Parenting Stress Index (PSI) Update 3/7/2018

Mar 07 2018

Parenting Stress Index (PSI) Update 3/7/2018

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Parenting Stress Index Update:

Cost: Kit- $262, Answer sheet (pack of 25)- $92, Profile form (pad of 25)- $32, Item Booklet (pack of 10)- $86, Manual- $92, Continuing Education Materials-$26


Information found at:


Research Article:

Li, S. T., Chiu, N. C., Kuo, Y. T., Shen, E. Y., Tsai, P. C., Ho, C. S., . . . Chen, J. C. (2017). Parenting stress in parents of children with refractory epilepsy before and after vagus nerve stimulation implantation. Pediatrics and Neonatology,58(6), 516-522. doi:10.1016/j.pedneo.2017.03.001


Literature shows that vagus nerve stimulator (VNS) implantation can decrease seizure frequency. However, parenting stress associated with VNS stimulation has not been considered. The purpose of this study was “to evaluate changes in the parenting stress level in parents of children with refractory epilepsy before and after VNS implantation.” Thirty children with refractory epilepsy who underwent VNS implantation were included in the study based on the following inclusion criteria: having received a diagnosis of refractory epilepsy from a pediatric neurologist, having undergone VNS implantation after refractory epilepsy was diagnosed, aged from 1-12 years, and parents having completed the PSI before and at least one year after VNS implantation. In regard to comorbidities, 21 patients had mental retardation, five patients had cerebral palsy, and five patients had autism.  Prior to VNS, five patients received 2 types of anticonvulsants, 15 patients received 3 types of anticonvulsants, and 10 patients received 4 or more types of anticonvulsants.  Regarding seizure frequency, eight patients had less than 10 seizures per month, 17 patients had 10-100 seizures per months, and five patients had more than 100 seizures per month.

To measure parenting stress, the authors used the Parenting Stress Index long-form (PSI), which is a 94-item questionnaire assessing parenting stress levels.  It includes a parent and child domain.  The parent domain contains 50 items on seven subscales (competence, role restriction, attachment, depression, health, social isolation, and spouse).  The child domain contains 44 items on six subscales (adaptability, mood, distractibility/hyperactivity, demandingness, reinforces parent, and acceptability).  Parents respond on a 5-point scale, with 5 representing the most stress.

The initial PSI was completed within the month pre-VNS implantation.  The second PSI was given at least 12 months post-VNS implantation. Mean time interval between first PSI measurement and VNS implantation was 14.9 days. Mean time interval between VNS implantation and second PSI measurement was 18.2 months. The highest mean scores for parent domain subscales were for spouse, role restriction, and health. The highest mean scores for the child domain subscales were for acceptability, demandingness, and distractibility/hyperactivity.  The mean total PSI scores decreased from 282.1 (which is higher than the 90th percentile of Taiwan validation sample) to 272.4 (less than 90th percentile).  This decrease was not statistically significant (p=0.193).  Scores for all parent domain subscales decreased except for competence.  Scores for four of six child domain subscales decreased. The most noticeable changes were in spouse (p = 0.034) and role restriction (p = 0.149) subscales, but did not achieve statistical significance. PSI scores decreased most in parents of males, parents of children without autism, and parents of children who did not taper off the number of anticonvulsant types.  However, no predictive factor was found for PSI score change for child’s gender, autism comorbidity, or tapering of anticonvulsants after MANOVA analysis.  After analysis, no association was found between tapering off number of anticonvulsant types and seizure reduction rate. Ratio of seizure frequency pre- to post-VNS implantation achieved a significant difference (p = 0.037), with fifteen patients having 50-100% seizure frequency reduction rate, and a 42.6% overall seizure frequency reduction rate.

Strengths of this study include the fact that it was a longitudinal prospective study, and that it provides data for changes in parental stress following VNS implantation.  This study was limited by the sample size being too small to analyze types and etiology of epilepsy. Furthermore, no association was found between reduction of seizure frequency and tapering off of anticonvulsants, as anticipated. Finally, this version was validated in 1362 Taiwanese children and may not be as applicable to western countries, as parent-child relationships and upbringings may vary.

Although not significantly different, overall PSI scores decreased 12 or more months after VNS implantation, implying that overall parental stress decreased following implantation.  This decrease in stress was seen especially in parents of: boys, children without autism, and children who did not reduce the number of anticonvulsant types used.  For the parents whose stress did not decrease as much, comorbidities or tapering off of medication types may act to negate the positive stress effects of VNS implantation. Furthermore, seizure frequency decreased following VNS implantation, leading one to believe the VNS implantation is a safe and effective method for resolving refractory epilepsy.

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4 Responses to “Parenting Stress Index (PSI) Update 3/7/2018”

  1. mhinshaw4 Says:

    Thought this was a really interesting article, I can see why the stress on parents would be really high when worrying about their child and the seizures, especially with all of the comorbidities many of the children had. Although the parent’s PSI scores did drop, the difference was not significant and I wonder if that amount of change is even notable from the parents point of view? I was surprised to see that the amount of seizures dropped that much without much reduction in parent stress, I wonder why that wouldn’t result in less stress? I was also thinking that the mean length of time they re-tested the parents with the PSI was 18 months, I wonder if going through such a stressful experience such as your child having such a surgery would actually increase parent stress significantly in the short term surrounding the surgery due to fears of complications and their children’s recovery? Although the support for reducing patient stress through implantation of the VNS was not strong, it was a good use of the test and an interesting topic.

  2. hhawkins Says:

    You make some very good points, Matt. I think it would be helpful in the future to do a third PSI a few years after the surgery once medications have been normalized and complications were resolved. Also, they did not mention the parents’ perceptions of the stress (whether they noticed the change) specifically, but I think that is a very valid question.

  3. smoree Says:

    This was really interesting to read about! I had no idea there was a measure that included the stress on parents. However, it is obviously a huge factor in the treatment of the patient. If the stress of the parent can be addressed early and provide strategies to minimize the stresses, the patient will have better outcomes. I am curious to know if there is a similar outcome measure related to caregivers of older adults? If not, I think the implementation of a similar outcome measure would be very helpful to the rehab of all patients.

  4. hhawkins Says:

    That’s a great question, Shannon. I am currently unaware of caregiver stress outcome measures for those that care for older individuals, but agree that it would be very helpful to expand the caregiver stress measures to that population as well!

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