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Mothers' Parenting Responsibility After Divorce.

Diabetes mellitus type 1 is one of the most commonly diagnosed chronic illnesses among U.S. children and is predicted to triple within the next 30 years (Imperatore et al., 2012). Families have difficulty meeting the daily challenges of managing diabetes mellitus type 1, placing children at increased risk for acute and chronic complications (Helgeson, Escobar, Siminerio, & Becker, 2010). Over 30% of children live in a household with a divorced mother. Different life stressors of divorced families may compound the difficulties of managing diabetes for children (United States Census Bureau, 2014).

Family structure has not been well studied in relation to children with chronic illness (McBroom & Enriquez, 2009). Research has been conducted with children diagnosed with diabetes mellitus type 1 and living in two-parent families, but few diabetes mellitus type 1 studies have explored the responses of divorced mothers of children (Main et al., 2015; Markowitz et al., 2012). Research that ignores family context, other family structures. or culturally diverse families does not accurately assess the experiences of mothers and children, and does not inform healthcare practice to improve family-centered care for all types families.

Divorced and married mothers experience a difference in co-parenting, and the relationship interactions of raising children between mothers and fathers. Physical custody arrangements, maintaining separate households, blended families, and economic strain complicate parent-child and co-parental relationships for divorced parents (Zimnitzky, 2011). Coleman, Ganong, and Leon (2006) discovered that couples with conflict during their marriage found it difficult to parent with each other after marriage dissolution. Conflict in the co-parental relationship is a strong detrimental influence on children's adjustment and may have a long-term effect on parents and their parenting ability (Coon & Fine, 2012). Divorce stress in mothers has been associated with the onset or progression of diabetes mellitus type 1 in children (Sepa, Frodi, & Ludvigsson, 2005). Divorce families parenting children diagnosed with diabetes may experience high stress at periods or throughout family life contributing to poor diabetes control due to co-parenting factors. Research related to how divorce families interact may improve health outcomes.

With increasing populations experiencing divorce and little known how divorced parents co-parent, understanding how divorced mothers manage co-parenting for their children with chronic illness may help nurses support divorce families, help the father understand the mother's perspectives, and improve outcomes for children.

Aim

The purpose of this study was to use grounded theory method to explain the processes of co-parenting through the perception of divorced mothers caring for children who have a diagnosis of diabetes mellitus type 1.

Methods

Strauss and Corbin's (1998) grounded theory methods were used to analyze narrative data and identify psychosocial processes of co-parenting from divorced mothers' perspectives. A purposeful sample was recruited of divorced mothers who were age 18 years or older, have a child who has had diabetes mellitus type 1 for at least one year, were divorced from the child's father, and were proficient in English.

Twelve mothers from a pediatric endocrinology clinic affiliated with a major medical center in the Midwest volunteered to be part of the study. Mothers agreeing to be interviewed gave their contact information to the clinic nurse practitioner who passed the mother's information to the researcher. Mothers were given a choice of interviews: in-person or by phone. All mothers chose telephone interviews. Institutional Review Board approval was granted. The first author conducted minimally structured interviews with mothers by phone using a semi-structured interview guide. The interviews lasted approximately one hour. Mothers were asked about family history, co-parenting experiences, and diabetes management. Interviews were recorded and transcribed verbatim. The transcribed data were coded to protect the mother's identity and confidentiality.

Data Analysis

Both authors read all the transcripts, independently developed codes and categories, and discussed them monthly. Nvivo software was used to store codes and categories. Interviews continued until both authors agreed that the categories were well saturated, and additional interview data did not provide new data. Coding procedures described by Corbin and Strauss (2008) began with open coding. Open coding was done line by line. Initially, codes were labeled with participants' own words (in vivo), resulting in 175 codes. Identification of the phenomena was accomplished through axial and selective coding (Corbin & Strauss, 2008). The initial step in selective coding was explicating the core phenomenon or most striking aspect of the study, around which all other categories were linked. Once identified, this core category allowed us to consider conditions, context, strategies, and consequences.

Validity and Rigor

To ensure scientific rigor, credibility, and trustworthiness, we conducted ongoing member checks of the sample. One author is a family nurse practitioner with expertise in managing diabetes and working with families. The other author is an expert in family studies with the main focus on divorced families and co-parenting issues. The authors' experiences aided the development and analysis of the study. To seek validation of the findings, the interview guide and study outcomes were also shared with an expert panel of two nurses and two family therapists. We also shared the emerging findings during the analytic process with participants and asked them to give feedback about the developing model. The second author reviewed the field notes and memos the first author used to record the development of the categories and to leave an audit trail. Both authors agreed with the outcome of the research.

Results

Description of Sample

Mothers' ages ranged from 36 to 55 years (M = 42.25). One of the 12 mothers had two children diagnosed with diabetes. Eleven mothers described themselves as white; one mother described herself as black. They designated themselves as either working class or middle class. Two had high school degrees, five had attended some college, three had college degrees, and two reported having graduate degrees. Most mothers shared legal and physical custody of children with fathers; only one had sole legal and physical custody. Average time since divorce was six years. Ten mothers perceived their relationships with co-parenting fathers as cooperative, one was cooperative with "times of conflict," two were described as a conflict relationships, and two were disengaged. Nine mothers were single, two were remarried, and one was cohabiting.

Responsible for the Co-Parenting Relationship

The central phenomenon for divorced mothers in co-parenting with their former spouse is the sense of being solely responsible for the relationship. Divorced mothers thought co-parenting was one of the most difficult parts of managing diabetes for their children. One mother described trying to co-parent with her ex-husband being like "a salmon trying to swim up Niagara Falls." Although mothers felt they were solely responsible for their children's treatment regimen and the daily management of diabetes, they also believed they were responsible for the relationship between themselves and their ex-spouse because most mothers believed children "need both parents." Mothers recognized the divorce occurred "partly because we didn't agree," and co-parental disagreements continued after the divorce, but they also worked hard at trying to keep the fathers engaged with the children and cooperative with them despite disagreements and the challenges of getting along with the fathers. This sense of responsibility for the co-parenting relationship involved three interactional processes occurring simultaneously. Those interactional processes were working together, keeping them informed, and encouraging relationships. Working together with the father, keeping the father informed about the disease, and encouraging the father-child relationship were seen by mothers as essential to a co-parenting relationship with their ex-spouse to manage their children's diabetes. They also believed these duties were the mothers' responsibilities of the co-parenting relationship.

Working together. Mothers perceived they were solely responsible to work together with the divorced father so that the child's blood sugars were under control. Working together is seen in this quote: "It takes everybody working together, or the child is not probably going to do well." Mothers believed they needed to cooperate with fathers for the sake of the children: "I am trying really, really, really hard to be civil to him because it does upset her if we ever argue or fight." Another mother explained: "You really have to work together on making sure you manage your child's diabetes regardless of whether or not you're going to be married together." These mothers considered cooperating to be their responsibility and essential in diabetes management.

Divorced mothers tried to get along even when there were anger and disagreements between the co-parents. Differences in household rules and routines were a source of conflict: "Their priorities aren't always the same as ours." Another mother explained her view of co-parental working together even when there are differences:
They [the children] have rules and guidelines at my house, and then
they have rules and guidelines at his house. The [rules] don't
necessarily mesh, so it is kind of difficult, but we've tried very hard
to make the best decisions for the kids.


Another mother discussed cooperating for the children: "Most of the time, we get along just for the simple reason that it's not fair to the kids." One mother noted that even though she believed the father does not get the "big picture" or "really understands what it [diabetes] is really like," she knows that "when it comes to diabetes...we have always cooperated and worked together." Cooperating was an important part of the co-parenting relationship, and mothers believed they were responsible in working with the ex-husbands to help their children.

Keeping the father informed. Keeping the father informed, like getting along, was an important part of co-parenting to manage the disease.
When you're divorced, and you have a diabetic child, I think it's
really important to have good communication and cooperation with the
other parent because if you don't, it can be very hard trying to treat
the disease when you don't share, blood sugar readings back and forth.


Mothers initiated communication with fathers most of the time: "I do most of the calls, probably 98% of the calls, to try to keep him updated. Oh, he always thanks me when I call him, but he could call too." Mothers believed they were responsible for communicating to fathers about healthcare appointments, trends of blood sugar readings at fathers' households, and how to control the children's diabetes when children were with the fathers:
I'll give him feedback, Like if I pick her up three times in a row and
her blood sugar's like over 250 each time, I'll be like the last three
times I picked her up her blood sugars have been high.


Some fathers did not attend diabetes education classes or healthcare appointments, so mothers often decided they were the fathers' only sources of information about the disease for the father: "His dad doesn't have really any kind of role in managing diabetes for him." Mothers also communicated to the father how to manage diabetes: "I have told him how to calculate the insulin, but I don't think he has ever." One mother talked about how she educated her ex-spouse: "We talked all the time. He had questions about what she could eat and what she couldn't eat.but now it is just about blood sugars.or if she is symptomatic." Mothers also thought their communications helped fathers stay involved: "I think it helps him stay in the program since he is not quite as diligent as I am."

All mothers communicated to fathers face-to-face, and most also called, texted, and mailed notes. Mothers also indirectly communicated by talking to their ex-spouse's current romantic partner. One ex-husband told the mother of his child he preferred the mother speak with his current wife instead of him. Face-to-face discussions occurred with fathers or the fathers' current partners mostly when children were being picked up or dropped off from a visit to the father's household: "We talk on the phone. I send notes in his blood kit. I talk to his wife whenever she comes to pick up the kids."

Mothers' beliefs about the importance of communication in the co-parental relationship focused on the child. As one mother explained in the context of the co-parenting relationship:
Just the importance of maintaining communication with the father, if at
all possible... But I think that the most important thing is to
maintain some type of communication or to have somebody that can be an
intermediary to keep the communications open for the sake of the child.


This process was important to the mother because to mothers, it was their children's "health and life," similar to the reasons why they got along with their ex-spouse.

Encouraging relationships. Mothers' responsibilities included facilitating the children's relationships with members of the fathers' households. In particular, mothers were responsible for being the intermediaries for relationships between children and their fathers. One mother described her experience growing up in a divorced family as the reason why she felt responsible for aiding the relationship between her children and their father:
I had trouble getting to know my dad because I lived with my mom full
time, and I would hear these things about my dad, but when I would go
and visit my dad...they didn't quite jive...so I know there was
bitterness there. I didn't want my children to feel that way.


One mother facilitated the father-child relationship by "trying to get [her son] to share those things [i.e., blood sugars, healthcare information] with his dad." She also initiated phone calls between her son and his father. Another mother did most of the calling to the father to set up visitation times for her adolescent daughter because visitation was sporadic: "I call a month in advance." Mothers also communicated to children their "father loves them" to build the relationship between the father and child. Mothers encouraged the relationship by including the father in healthcare appointments as well: "Sometimes we schedule them on a Wednesday because he has every Wednesday off."

Encouraging relationships also meant mothers worked at helping the child have a relationship with the father's new romantic partner. "I try to push my kids to respect their dad's new wife. And that is kind of difficult seeing that I don't care for her, but it's not the kids' fault." Encouraging relationships was how mothers assisted their children to develop and maintain new relationships in their father's household.

As in the other processes, one motivation for mothers to encourage relationships was to help manage their child's diabetes. Blood sugar readings influenced mothers' decisions about the relationships. One mother confided there was a time when she had to stop letting her daughter go to her father's home because her daughter argued with her stepmother frequently and "it would make her blood sugar go up." The mother also reported the father brought her daughter back to the mother's home once because of a father-daughter fight and "the blood sugar shot up to over 500." When the child was ready to go back, "I just made sure that she felt comfortable going back over there."

Mothers believed they were responsible for working together with the father, keeping the father informed about the disease, and encouraging relationships in the divorced families. The mothers believed it was their responsibility to cooperate with the father, communicate information about blood sugars, and facilitate relationships to help manager their children's diabetes.

Discussion

This study described the perceptions of divorced mothers about the co-parenting relationship they have with their ex-spouses in relation to raising children with diabetes. The mothers believed maintaining the co-parenting relationship was their responsibility. Mothers' feelings of overwhelming responsibility are documented in the literature. Gayer and Ganong (2006) found that single mothers caring for children with cystic fibrosis had a sense of being overwhelmed with responsibilities, including the many healthcare treatments, earning a living, and others. This study describes the added responsibility of maintaining a co-parenting relationship with their ex-spouse includes working together, keeping the father informed, and encouraging relationships all for the sake of the child. Participants reported having a cooperative co-parenting relationship with the fathers of their children despite their disagreements and/or lack of father involvement in diabetes-related tasks.

Social desirability may have played a role with these responses, or mothers may have such a strong need to see themselves as effective parents after divorce they gloss over problems when evaluating co-parental relationships. Markham and Coleman (2012) found most mothers in their study believed they had cooperative relationships with their ex-spouses or the relationship became cooperative over time. Mothers' expectations and the expectations of others also predicted how well mothers co-parented (Markham, Ganong, & Coleman, 2007). Supporting the mother to work together with the father may be an important area for intervention for divorced mothers in the healthcare system to aid families in managing health and chronic illnesses.

Mothers reported they kept the father informed by communicating information to the father about the child's health status in relation to diabetes. Mothers also acted as educators in communicating how to manage diabetes for children, such as information about insulin. They also expressed concerns about fathers' lack of knowledge about diabetes and treatment regimens, which may have led them to operate as educators for the father. Some mothers may act as gatekeepers if they believe the father cannot manage the diabetes or children are not able to independently manage diabetes in their fathers' home. This concern for lack of knowledge or ability of the father may lead to exert control over visitation more than the mothers would have if the children did not have diabetes.

This study also found that mothers used several means to communicate with fathers. Ganong, Coleman, Feisman, Jamison, and Markham (2012) found cooperating co-parents used a variety of technology to help communicate and improve the co-parenting relationship. Nurses seeking interventions to involve fathers in diabetes education may help mothers reduce the need to be the main communicator of the children's health. Nurses may need to continue to focus on diabetes education to ensure accurate information is being passed along to the father.

Mothers reported encouraging the relationship between their children and their father. Studies have shown the success or failure of divorced co-parenting relationships significantly affects fathers' involvement with their children (Wu et al., 2010), and fathers' involvement is a facilitating factor in social-emotional development and well-being for children post-divorce (Castillo, Welch, & Sarver, 2011). Mothers in this study portrayed themselves as having an active role in facilitating the relationship among children and their fathers. These mothers saw value in the father's involvement with children, and so they facilitated father-child communications and visits. Other researchers reported mothers overall wanted their children to have a positive view of their father (Cohen, Leichtentritt, & Volpin, 2014). Trying to facilitate a relationship can be positive, but it could also be somewhat negative and stressful for mothers, especially if there is lack of cooperation or communication on the fathers' or children's part. Interventions focused on facilitating father involvement or children's ability to enable their father's relationship, which may help reduce mother's perceived responsibilities in this area. Nurses can act as intermediaries to support mothers' cooperation, communication, and facilitation with their ex-spouses (Russell, Coleman, Ganong, & Gayer, 2016).

Limitations

The study shared the perspectives of a small, relatively homogenous group of mothers willing to talk about their ex-spouse, which may have limited the study. This group was from one clinic and may limit the study because of representing only the culture and environment in the Midwest. Parental management of children, at the very least, is a dyadic process. Divorced mothers only providing one perspective limit the study. Understanding the perspectives of fathers and children may provide further insight into post-divorce treatment of children with chronic illness and address different family dynamics.

Implications for Future Research

A review of family interventions for children with diabetes mellitus type 1 found little research focused on the children who live in diverse family structures (McBroom & Enriquez, 2009). With so few studies recognizing family structure as a variable, factors could be overlooked that may affect family functioning, interventions, and health outcomes for children. More studies should be completed to include family structure with children living with chronic illness, especially families representing divorced and diverse households.

Studying fathers in divorced families and other family structures could gain further insight. Fathers would add greater insight into the social dynamics of managing diabetes mellitus type 1 in divorced families and the co-parenting relationship. Research to discover how divorced parents of children with chronic illness can develop cooperative co-parenting relationships may be important in improving health outcomes for children. Hypothesis testing of the theory may potentially lead to interventions in areas described in this model. Diabetes support for divorced mothers should be studied to find interventions that promote cooperative co-parenting, encourage father involvement, and facilitate parent-child relationships.

Clinical Implications

The management of diabetes for children in a divorced family is a complex and stressful endeavor for mothers. Parental collaboration for and management of diabetes is important for glycemic control and improving metabolic outcomes (Wilson, DeCourcey, & Freeman, 2009). This grounded theory model of divorced mothers' perception of co-parenting has the potential to improve clinical practitioners' abilities to understand, communicate, and collaborate in partnership with divorced mothers (Kars, Duijnstee, Pool, van Delden, & Gypdonck, 2008). Recognizing that divorced mothers manage diabetes for their children in a unique context will help healthcare providers address their specific needs. Divorced mothers may need assistance (e.g., education, facilitation) to help them build cooperative relationships, maintain and/or improve communication with their ex-spouses, and facilitate relationships in a divorced family. Equipping mothers with strategies, such as how to communicate and cooperate with their former spouses, will help them improve health outcomes for children with diabetes mellitus type 1. Increasing awareness of the unique needs of divorce families may ultimately benefit children and improve their health.

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Leesa A. McBroom, PhD, APRN, FNP-C, is an Associate Professor and Chair of Nursing, William Jewell College, Liberty, MO.

Lawrence Ganong, PhD, is a Professor, Human Development and Family Science, University of Missouri, Columbia, MO.
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Author:McBroom, Leesa A.; Ganong, Lawrence
Publication:Pediatric Nursing
Article Type:Report
Date:Nov 1, 2017
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