ALSMADI MOHAMMAD LAST ONE

Recognising the critical role that family plays in the integration and provision of care for children living with complex disabilities such as CP has resulted in shifting from focusing on the child to considering the needs of the whole family (Johansson, Svensson, Stenström, & Massoudi, 2017). Therefore, family-centered care has become a cornerstone of rehabilitation services (Parisi, et al., 2016). Family-centered practice encompasses collaboration with families on child-related goals as well as the evaluation of family values, beliefs, and needs to design interventions targeted at positive family outcomes (Jankowska, Włodarczyk, Campbell, & Shaw, 2015; Tseng, Chen, Shieh, Lu, Huang, & Simeonsson, 2016). This means that each family can choose its own, optimal service delivery and should, for example, be given options with respect to their level of involvement (Ahmadizadeh, Rassafiani, Khalili, & Mirmohammadkhani, 2015). Different families will have different preferences when it comes to their involvement in their child’s care. This may be influenced by culture, and how parents think about their children and different disability diagnoses is likely to have different meanings for parents from different cultural backgrounds (Valicenti-McDermott, 2015). Moreover, the concept of “disability,” and what it means to live with a disability, is multifaceted, including social and cultural influences, traditional practices, and personal experiences (Fernández-Alcántara, et al., 2015; Newland, 2015). 2.3.4 Stress Management in Mothers of Children with CP It is of utmost significance to devise means and approaches of overseeing stress in mothers of children who are enduring and were brought into the world with Cerebral Palsy. As a basic methodology, this study means to adjust some intellectual, social treatment to alleviate and whitewash the impacts of mother's and parental figure's 84

pressure. A few specialists have created an arrangement of subjective systems that guide in overseeing excessive pressure restrained by mothers. Wellbeing and mental solidness characterize the best type of pressure taking care of, as indicated by (Kumar, Lakhiar, & Lakhair, 2016). Each individual keeps up a condition of parity which helps in adjustment until an impact is implanted into the condition of dependability. This was studied as an augmentation of the Adaptation Syndrome Theory (AST) (Newland, 2015). As indicated by the accommodation by Lee, Matthews, and Park, (2019) an individual will come back to the condition of equalization or give up to the pressure known as depletion. Subsequently, to oversee pressure, mothers need an inspirational treatment and a stable adapting condition to keep up their prosperity and guide the ideal method for tolerating the states of the youngsters. A portion of the administration procedures of abridging incorporate pressure time on the board. In an investigation by (Ahmadizadeh, Rassafiani, Khalili, & Mirmohammadkhani, 2015; Bourke-Taylor, & Jane, 2018; Bourke-Taylor, Jane, & Peat, 2019), it was discovered that a few guardians penance their optimal time in their everyday schedule to deal with the youngster having the handicap. Contingent upon the seriousness and level of the CP, guardians, particularly the closer individuals who are accused of the consideration offered, need to include the ideal opportunity for providing care into their everyday occasions and timetable. Stress and results on the mother who neglects to sort out her time in her calendar are far proportionate to the child experiencing a said disability. Parents put large measures of vitality in childrearing, and yet make the most of their parenting job. At the point when looked at thinking about a child with formative 85

inability, families stand up to some of the extra difficulties (enthusiastic, physical, and money related) over a significant period (Hashem, & El Aziz, 2018). Parents can encounter mental pressure and disillusionment when their youngster neglects to satisfy their expectations of having a sound posterity, or an ''immaculate child'' (Power, et al., 2019). In this manner, the pressure engaged with raising a child with formative incapacity can be comprehended as a blend of a more prominent requirement for care of a youngster with atypical advancement and the enthusiastic responses to the presence of inability inside the family (Ahmadizadeh, Rassafiani, Khalili, & Mirmohammadkhani, 2015;). Various investigations have affirmed that amazing, enthusiastic and physical requests of thinking about a child with a ceaseless wellbeing condition or developmental handicap can cause worry in parents (Valicenti-McDermott, 2015). Expanded requests for childcare with developmental handicaps, for example, Cerebral Palsy (CP), can have suggestions for the mental and physical prosperity of the parents (Lee, Matthews, & Park, 2019). The parents are dubious about the result of their children’s condition and the forecast for their future advancement as they are troubled with visit therapeutic tests. As the stressors calculated by expanded childcare requests become progressively broad, parents can feel progressively discouraged, vulnerable, or useless (Power, et al., 2019). They should confront the children’s findings, give that person sufficient mind and adjust their way of life likewise (Teachman, et al., 2019). Considerable varieties have been demonstrated to exist concerning how parents adjust to stressors and requests set upon them. Research has highlighted various elements including the parents, the children, and emotionally supportive networks that are accepted to underlie parental adjustment (Raphael-Leff, 2018; Veilleux, Pollert, Skinner, Baker, Chamberlain, & Hill, 2019). This paper embraces the point of view that parental adjustment is good with parental 86

goals of determination status. The goals infer parental intellectual and enthusiastic handling on the experience of learning the children findings. Intellectually, the parents should comprehend the importance and ramifications of their child's finding. Inwardly, they have to understand, acknowledge and express their sentiments of frustration, despondency, distress, outrage and blame to have the option to fathom the extent concerning their youngster with genuine impedance. Following the extraordinary negative feelings, parents who can acknowledge their children’s condition can encounter fulfillment, pride, happiness and a feeling of being associated with their child. This does not infer that they would never again feel troubled, however, necessarily that those sentiments would not be so robust or overpowering as they used to be at the hour of getting educated regarding the children’s medical issues (Jelinek, 2019). The idea of goals depends to a great extent on the Attachment Theory and look into, and speaks to a procedure during which guardians change their working models of the foreseen ideal child into originations that are progressively lined up with the real world, speaking to a child with explicit capacities and restrictions. On the off chance that guardians can incorporate the clashing internal working models of the youngster, those present when getting mindful of the analysis into another, practical model and if they can guide their focus toward present and future substances, they will think that it is more straightforward to determine their sorrow responses. The expression ''lamenting the loss of the ideal youngster'' is utilized to depict the procedure during which guardians change their models of an ideal child into those that speak to a child with an interminable wellbeing condition (Naeem, Arif, Asghar, & Mahmood, 2018). Emphasize that goals do not infer a total end of lamenting, taking into account the misery to become reactivated. Accordingly, the cyclic procedure of lamenting in guardians of children 87

with formative incapacities has been named interminable distress. In any case, the critical issue for accomplishing parental goals is ensuring that the force of despondency is not excessively overpowering as it was toward the start of the adjustment procedure; when the guardians initially found out about the child's conclusion. Misery manifestations are heightened and hence goals get more earnestly to accomplish when guardians re-experience the divergence between their real child and the admired, flawless youngster they wanted. One of the procedures adding to expanded manifestations of pain is experiential shirking, characterized as an endeavor to stay away from the structure, recurrence, or situational affectability of perception, recollections or feelings related to sadness (Jelinek, 2019). Kelly, (2019) made a tremendous leap forward in evaluating guardians' achievement in settling their child's analysis. They built up a traditional, dependable technique is a type of a semi-organized meeting known as the Reaction to Diagnosis Interview. The RDI evaluates whether a parent has prevailed with regards to conquering the injury brought about by getting mindful of their child's incessant medical issues and reorienting to the truth of the youngster's condition. The RDI has been demonstrated to be a substantial system for foreseeing the emotional connection status in a youngster. As a sign of legitimacy, offspring of guardians delegated settled were altogether more regularly safely appended to their folks than offspring of uncertain guardians. The exploration has indicated the goals rates to fluctuate somewhere in the range of 33.3% and 81.6% in guardians of youngsters with various wellbeing conditions (Hashem, & El Aziz, 2018); Dim, Edwards, & Gibbons, 2018); Ellery et al. 2018); Kuschmann, 2018); Sharan & Rajkumar, 2018); Mohamed Mandy & Aranda, 2019). 88

This fluctuation can recommend that specific wellbeing conditions are all the more trying for parental goals. By the by, notwithstanding the conclusion itself, it is not evident which specific variables lead to the expansion in parental pressure and in this manner, impede goals. The specialists here have stressed the requirement for additional research to perceive the hazard and strength factors that influence parental goals. The present research receives Wallander and Varni's Disability-Stress-Coping model of elements impacting parental adjustment, as the hypothetical directing structure (Mohamed Mandy & Aranda, 2019). This model endeavors to recognize significant hazard and opposition factors that straightforwardly or in a roundabout way influence adjustment of guardians bringing up children with developmental handicaps. It incorporates three classes of the hazard factors: (1) ailment/incapacity parameters (e.g., seriousness), (2) useful reliance, and (3) psychosocial stressors (inability related issues, significant life occasions, day by day bothers), just as three classifications of opposition factors: (1) intrapersonal factors, (2) socio-biological components, and (3) stress preparing factors. The model is perplexing and far-reaching and is, in this way hard to test the full model in solitary research. We depended on Wallander and Varni's model to address specific hazard factors (functional status of the youngster and the collection of upsetting life occasions in the family). Be that as it may, rather than this model which sees maternal psychological wellness; as a result, maternal sorrow is likewise viewed as an extra hazard factor influencing adjustment. This is following past research demonstrating parental melancholy to be a contributing element to parenting pressure (Mohamed Mandy & Aranda, 2019). Consequently, given 89

the expectation to cover factors from the three significant areas – child, mother-, and family-related – it is fascinating to dig into the three specific hazard factors: the youngster's useful status, maternal misery, and the amassing of upsetting life occasions in the family. Although the Disability-Stress-Coping model incorporates condition seriousness as a significant hazard factor, it is tough to operationalize it in children with CP. CP speaks to a condition characterized through its engine shortage, however, it is unequivocally connected with different impediments, for example, specific scholarly handicap, physical disabilities, just as intricate constraints in self-care capacities. Youngsters with CP can encounter troubles in performing day by day exercises, hence expanding the degree of care a parent needs to give past what is run of the mill to an offspring of a similar age. Accordingly, scientists have endeavored to research the weight-related with thinking about the youngster by estimating the functional autonomy of the child. Additionally, this study contemplated the useful status of the child as a proportion of parental impression of the child's physical, mental, and social working, and the effect of the youngster's condition on these capacities in regular exercises. The parental impression of the child's condition has been underlined as the critical segment ascribing to parental pressure, which thus, prompts broken parenting (Alkozei, et al., 2019). The subsequent hazard factor, applicable to this study, are psychosocial stressors. This factor is operationalized through the variable of aggregate pressure, viewed as a whole of standardizing (anticipated, formative changes in family life), non-regulating stressors (sudden and frequently horrendous changes) and intra-family strains. It has been demonstrated that some of the extra or irregular requests concerning the consideration for a child with handicap corresponds profoundly with the experience of parental pressure. In an audit of research directed on families bringing up a youngster 90

with CP, the challenges detailed generally by the guardians include extensive changes in family exercises, medical issues, therapeutic costs, the requirement for a specific consideration for the child, modified relations with companions, just as pressure inside the family emerging nearby regular day to day existence occasions imparted to other, increasingly commonplace families (Smith, 2019). Further stressors may remember ailment for other relatives, work changes, conjugal pressure, and maturing of the guardians, kin, and people with CP. The third hazard calculate incorporated this study is maternal despondency. Various stressors joined to parenting a child with an inability could bring about higher paces of sadness or burdensome symptomatology, particularly in mothers. Scientists are progressively mindful of the probability of perplexing and proportional relations among stress and misery. Notwithstanding the plausibility of gloom being a result of an expanded pressure introduction, wretchedness, thusly, likewise builds defenselessness to advance upsetting occasions. This gives an objective to investigating melancholy as an extra hazard factor for parental adjustment. It is additionally hypothesized that parental sorrow adds to useless parenting. Moreover, melancholy in mothers of youngsters with a rational conclusion has been appeared to affect the goals procedure contrarily (Sharan & Rajkumar, 2018). 2.4 Effects of the CP on Mothers and Children at Different Age Levels Parents' observations about the idea of their child’s handicaps have been a point of convergence among various social gatherings, including Mexican Americans, Chinese Americans, Africans, Turks, Iranians, Arabs, and Asians (Hashem, & El Aziz, 2018; Woolfenden, et al., 2019). These studies have discovered that in each culture, incapacity 91

is seen in an unexpected way. Also, these observations formed parental frames of mind toward their child with incapacities; the assets parents are eager to put resources into the treatment, preparing, and training of these children; and parental desires for the eventual fate of their childs with inabilities. Parents from some social foundations have been found to hold double biomedical and customary convictions concerning the nature, causation, and treatment of handicap (Zuurmond, et al., 2018; Petersen, et al., 2019). Likewise, numerous mothers may not see biomedical mediations as powerful or even vital, or may not see their child as \"handicapped\". Different mothers, particularly the individuals who have confidence in rebirth, see their child's condition as impermanent (Tonmukayakul, et al., 2018). In like manner, these mothers might be less inclined to look for treatment for their youngsters (Tonmukayakul, et al., 2018). In reality, social understandings of handicaps are vital. LaForme Fiss, et al., (2019) contends that individuals with inabilities are constrained not by hindrances or movement restrictions, yet rather by the social understandings of handicap. In this manner, understanding the social setting and what is regulating inside a specific social gathering is essential to the training, with various conclusions of inabilities that are probably going to have various implications to parents from various social foundations (Null, et al, 2019). Cerebral Palsy (CP) has most as of late, been characterized by Rosenbaum and his partners as \"a gathering of changeless issue of the improvement of developments and stance, causing movement restrictions that are ascribed to non-dynamic unsettling influences that happened in the creating foetal or new born child cerebrum.\" It is the most well-known reason for critical engine impedance in children with a pervasiveness of 2.0e2.5/1000 live births. These engine shortfalls together with intellectual, discourse, conduct and physical debilitations, are all things considered related to constraints in exercises of 92

everyday living and confinements in investment in relaxation, social and other favoured exercises. Behavioural challenges in children with developmental handicaps can influence family working and by and significant prosperity of the child and relatives. It is additionally realized that a more elevated level of Behavioural troubles in children s is related to more noteworthy parental stress in various populaces. Not many studies have depicted Behavioural issues in children with CP. Starter considers propose that social as well as passionate aggravations are profoundly common in this populace, going broadly from 26 to 80% crosswise over studies which have utilized diverse psychometric tests and strategies of ascertainment. The exact idea of these social aggravations, their association with characteristic or extraneous elements are merely starting to be investigated. Underlying issues revealed in concentrate to date include: troubles with peers, consideration issues, hyperactive Behavioural, enthusiastic issues, expanded reliance, withdrawal, unyieldingness and withdrawn attributes. Characteristic factors that have been appeared to associate with an improved probability of social issues in children with CP incorporate epilepsy constrained or no strolling capacities, hearing misfortune, scholarly weakness and agony. The SPARCLE study in Europe likewise recognised that being a single child, having a sibling(s) with an incapacity, living in a community, or going to an extraordinary school program were significant extraneous variables related with more serious hazard for Behavioural issues. A few elements are recognised on a few children related and natural variables related with Behavioural however conceivable and possibly modifiable associations with different factors, for example, parental pressure and movement impediments stay to be resolved in children with CP. 93

Proof is expected to gauge the pervasiveness of social troubles in children s with CP all the more absolutely, as this is at present overlooked clinically as a significant and essential dreariness that requires intercession and consideration. Besides, children and family factors that have all the earmarks of being related with a more noteworthy probability of social issues require approval in different examples. Adapting can be characterized as an extraordinary psychological way to deal with assessing the stressors which are either immediate or aberrant with the point of alleviating and whitewashing the level of pressure (Ma, Grogan-Kaylor, & Lee, 2018; Polack, et al., 2018). Adapting in this way includes various folds of human attributes as it identifies with psychological, compelling and Behavioural, passionate and physiological equalization. Adapting are generally restored through different branches: family and individual adapting. An adapting technique that influences the condition of the family's penances through the previously mentioned sets are known as family adapting idea while mental, passionate and mental dealing with is alluded to as individual adapting (Walsh, et al., 2018). It likewise identifies with how people approach issues and stress utilizing alternate points of view. Typically, it depends on studies and significant assets. In some cases, it tends to be driven along learning outskirts and passionate responses to the unevenness in stable personalities known as pressure. Therefore, it is fair to conclude that coping strategies are dealt with using: Emotional focus and handling, problem management and inevitably but some time avoidance. Coping strategies can therefore be themed as illustrated on the figure below: 94

Figure 2.1 Coping Summary (Micozzi, 2018; Jette, 2019; Teachman, et al., 2019) Thoughts about the stress and how to cope with it, resulting to what we think? Emotional stability which results in what we feel? And the behavioural influence that guides what we do? Cognitive measures and behaviours define the form of psychological therapy that established or laid to correct or improve the mental depression, stress and emotional instability of an individual (Micozzi, 2018; Jette, 2019; Teachman, et al., 2019). It is usually referred to as Cognitive Behavioural Therapy (CBT) which in comprises of behavioural, feelings and thoughts to handles depression, anxiety and the likes. This study yearns to incorporate important variables such as family resources, environmental influence, religiosity and coping mechanism as well as to investigate the relationship that exists between the effects of mothers handling the children with Cerebral Palsy. 95

2.5 Social Support There is evidence that mothers with high levels of social support reported low levels of depression and parental stress. Family-centred care is an important predictor for parents’ emotional well-being and satisfaction with formal support services. Both social network size and satisfaction with social support are positively related to parental mental health. However, a disturbing lack of availability of social support in many European regions has been found, and children with the most difficulty in walking had the worst access to physically supportive environments and social support. A web-based system to promote communication between parents and a large multi-professional team has been shown to be effective. The system facilitated rapid consultation with varied professionals and improved the effectiveness of communication and support. A family- centred approach to the care of children with cerebral palsy and their families is essential to ensure that both receive adequate care and support. Nurses are in the primary position to provide services for those experiencing psychological distress and to affect early interventions that promote health and quality of life. A multidisciplinary treatment team model has been recommended for the psychosocial care of children with chronic illness and their families to address the different life areas that may need attention. Such teams should include physicians, nurses, psychologists, social workers, teachers and other healthcare professionals. The coordinating role of nurses in multi-professional intervention requires further review. Two recent meta-analyses showed that lack of social support is one of the strongest predictors of the natural development and severity of posttraumatic stress disorder among other predictors such as peritraumatic dissociation and severity of the trauma (Brewin et al., 2000; Ozer, Best, Lipsey, & Weiss, 2003). Authors have proposed many different definitions of social support. For example, it has been described as the quality 96

of the interactions within an individual’s social network (Guay et al., 2011) and as a process through which help is provided to or exchanged between people in order to facilitate one or more adaptive goals (Dolbier & Steinhardt, 2000). Social support derives from the social network of a person and can be provided by many sources, such as family, friends, and spouse. People can provide different types of support, such as emotional, informational, practical, and distractive. Social support can also be measured with four different dimensions: quality versus quantity, specific versus global, perceived versus received, and positive versus negative. The role that social support may play in the development or severity of posttraumatic stress disorder is different depending on which aspect of social support is considered as well. The social support that individuals have can be described in terms of quality and quantity. Quality refers to the meaningfulness and significance of their relationships, whereas quantity refers to the number of people in their social network. Although these two concepts have been associated with positive effects on health (Dolbier & Steinhardt, 2000), the size of the social network has been found to be less strongly correlated to well-being than the quality of the social network (Zoellner, Foa, & Brigidi, 1999; Cohen & Wills, 1985), and to have no correlation with posttraumatic stress disorder severity (Whitehead, Perkins-Porras, Strike, & Steptoe, 2006). Another important distinction is perceived versus received social support. Perceived social support refers to an individual’s perception of available social support, whereas received social support refers to social support that is objectively received by the person (Dolbier & Steinhardt, 2000). Perceived social support is usually assessed with self-reported questionnaires, whereas the latter usually requires more objective observational measures. Finally, even though social support has generally been considered to have positive effects, recent 97

studies have suggested that it can also be deleterious despite people’s best intentions to support (Guay et al., 2011; Zoellner et al., 1999; Zwiebach, Rhodes, & Roemer, 2010). Positive social support refers to supporting behaviors such as listening, validating the other person, and proposing positive solutions (e.g., confiding in trustworthy people), whereas negative social support refers to non-supporting behaviors such as criticizing, being hostile toward the other person, and being dominant (Lehoux, Guay, Chartrand, & Julien, 2007; Pizzamiglio, Julien, Parent, & Chartrand, 2001). In the aftermath of a traumatic event, although social support can come from many sources, people tend to seek support mainly from their spouse. Moreover, it was found that the prevalence of psychiatric disorders was more associated with the quality of marital relationship than the quality of the relationships with relatives or friends (Whisman, Sheldon, & Goering, 2000). Hence, marital support is generally considered the most important source of social support (Denkers, 1999; Halford & Bouma, 1997). According to the resiliency model of family stress, when one person develops an illness, both partners tend to change their roles in order to accommodate the sick person (H. I. McCubbin & McCubbin, 1988; M. A. McCubbin & McCubbin, 2003). With posttraumatic stress disorder, the nonanxious partner could, for example, help the anxious person avoid reminders of the traumatic event. However, with time, the anxiety and reduction of the life quality associated with the symptoms of posttraumatic stress disorder can harm the quality of the marital relationship and with it the quality of the support offered (Baucom, Stanton, & Epstein, 2003). Marital support may also have an important influence on the outcome of therapy. As was mentioned earlier, people who suffer from post-traumatic stress disorder ER often turn to their intimate partner as a source of support. The partner can also act as a recuperation agent (Guay, Billette, St-Jean-Trudel, Marchand, & Mainguy, 2004). However, it has been found that individuals diagnosed with post- 98

traumatic stress disorder suffer from numerous intimate relationship problems, including a greater likelihood to divorce, up to three times greater perpetration of intimate aggression, and diminished intimacy and relationship satisfaction, as well as marital distress (Cook, Riggs, Thompson, Coyne, & Sheikh, 2004; Monson, Rodriguez, & Warner, 2005). Despite the potential influence of marital support on maintenance and severity of post-traumatic stress disorder symptoms, few studies have assessed its impact on treatment efficacy. Empirical studies from the past three decades have indicated that various CBT protocols effectively treat post-traumatic stress disorder symptoms. International clinical practice guidelines have unanimously identified trauma-focused cognitive – behavioural therapy as a first line treatment (Forbes & colleagues, 2012). However, no single intervention is universally effective, acceptable, and/or feasible, and many patients are left with residual symptoms (Bomyea & Lang, 2012; Foa, Keane, & Friedman, 2000). It is therefore important to examine which factors influence treatment outcome and focus on patients’ characteristics in order to provide optimized clinical care (Monson et al., 2005; Thrasher, Power, Morant, Marks, & Dalgleish, 2010). Although the link between social support and post-traumatic stress disorder symptomatology is well established in the literature (Brewin et al., 2000; King, King, Foy, Keane, & Fairbank, 1999; Ozer et al., 2003; Polusny et al., 2011; Stevens et al., 2013), the association between pre-treatment social support and the efficacy of CBT for post-traumatic stress disorder is less clear, because few studies have examined this relation. 99

Many studies have demonstrated the role of social support in the development and maintenance of post-traumatic stress disorder symptoms. However, social support may also have an impact on the outcome of therapy for post-traumatic stress disorder. For example, positive social support could influence the outcome of therapy by its impact on the therapeutic alliance. Meta-analytic studies have suggested a consistent relationship between good therapeutic alliance and better psychotherapy treatment outcomes (Horvath & Symonds, 1991; Karver, Handelsman, Fields, & Bickman, 2006; Martin, Garske, & Davis, 2000). Indeed, therapeutic alliance has been associated with positive outcomes such as better treatment engagement and better adherence as well as less dropouts. Post-traumatic stress disorder treatment and especially exposure techniques can be very demanding for patients. A strong early therapeutic alliance might be particularly important to facilitate treatment adherence for post-traumatic stress disorder (Keller, Zoellner, & Feeny, 2010). Interestingly, Keller et al. (2010) found that positive social support from the relatives in the aftermath of a trauma emerged as the sole predictor of a strong early alliance (B .23, p .05), above and beyond treatment modality. This suggests that a good pre-treatment social support would positively influence strong therapeutic alliance. Another possible impact of social support on treatment efficacy for post-traumatic stress disorder relates to the fact that these treatments often ask patients to continue exposing themselves outside of the therapeutic settings, which can be very distressing (Foa et al., 2000). Good social support might help patients to meet these demands (Tarrier & Humphreys, 2003). According to Foa and Rothbaum (1998), negative social support may also influence the therapeutic outcome. Indeed, negative social support from the relatives, such as negative criticism and emotional avoidance, could negatively influence the victim and contribute to the development of counterproductive behaviors in a therapeutic setting. Moreover, Joseph, 100

Williams, and Yule (1997) proposed that social support impacts post-traumatic stress disorder symptoms via its influence on the victim’s interpretation of the event. Indeed, other people’s points of view could influence the victims, positively or negatively. Moreover, victims often experience profound belief changes (e.g., “I cannot trust people”) as a result of the traumatic event. A lack of understanding and validation from relatives, which can be considered negative social support, could interfere with the therapeutic effort to modify dysfunctional beliefs and prevent generalization outside the therapeutic setting. It would thus be important to determine whether there is an association between social and marital support and the efficacy of CBT for post- traumatic stress disorder. In this case, clinicians would need to adjust the therapy so that social support for the patient is considered in the process, for example by integrating the spouse or a relative in the treatment. In line with this, in the last couple years, a few researchers have started to integrate the spouse in the therapeutic process (Billette, Guay, & Marchand, 2008; Monson, Schnurr, Stevens, & Guthrie, 2004). If the results of these studies are positive, this could be a great answer to the problem of pre-trauma social support affecting CBT efficacy. 2.6 Empirical Literature Naeem, Arif, Asghar, and Mahmood, (2018) investigated the connection between psychosocial stressors, burnout, and emotional well-being issues in parental figures of children with Cerebral Palsy. A cross-sectional research configuration was utilized in the ebb and flow look into. The example included 93 mothers of children with Cerebral Palsy chose from 3 establishments of a specialized curriculum in Lahore through a purposive testing system. They found a positive connection between the absence of self- 101

guideline, absence of social help, withdrawal, substantial issues, reactivity and misery, stress and nervousness in mothers of children with Cerebral Palsy. Also, Hashem, and El Aziz, (2018) affirmed that Cerebral Palsy is one of the most widely recognized pediatric neurological issue which incorporates a negative mental, passionate, social and physical results of giving consideration. Giving an elevated level of care for children with Cerebral Palsy may influence both the physical, social, and mental strength of the mothers who take care of those children. Mothers experience numerous stressors that influence their day by day lives. The impact of nursing meditation on stress and adapting methodologies among mothers of their children with Cerebral Palsy are assessed. A semi test configuration was utilized for this investigation, including 65 mothers thinking about their children with Cerebral Palsy. It was uncovered that the total mean score of mothers' anxieties was high before nursing intercession while the score was lower subsequent to nursing mediation. Dim, Edwards, and Gibbons, (2018) inspected levels of parenting stress in mothers of preterm and term babies when the children were 2 years of age; and decided the direction of stress more than three timespans and analyzed the relationship of maternal and neonatal elements with the formative results with parenting stress. They revealed that no relationship between parenting stress and maternal socioeconomics, neonatal elements or Bayley-III outcomes. Parenting stress in mothers of preterm babies being high levelled at 2 years has expanded after some time. Maternal emotional well-being issues and baby social issues add to the stress. 102

Also, Ellery et al. (2018) early life stress is identified with neurocognitive disability during the long-term line up in new born children with underlying ailment like untimely birth or cardiovascular breakdown because of inherent coronary illness. Early life stress can be estimated by norepinephrine plasma levels and study of pulse fluctuation (HRV). Their analysis confirmed that a focused-on treatment to avoid the negative impacts of early life stress appears to have long-lasting results on the autonomic sensory system estimated by pulse inconstancy in our little gathering of children after heart medical procedure. Kuschmann (2018) guaranteed that troubles describe the discourse of children with dysarthria because of Cerebral Palsy (CP) with respiratory and phonatory control. The discoveries recommend that the children with CP utilize acoustic parameters uniquely in contrast to their ordinarily creating friends to stamp questions and proclamations. Perceptual studies will set up to what degree this influences audience members' capacity to recognize questions and articulations. Furthermore, Sharan and Rajkumar (2018) found that while thinking about the child with Cerebral Palsy (CP), the guardians might be presented to stress and physical burden prompting musculoskeletal issues (MSDS). They found that lower back torment was the most widely recognized particular musculoskeletal manifestation (65%) trailed by knee torment (46%), neck torment (40%) and shoulder torment (36%). Musculoskeletal issues expanded the weakness levels as recorded by the Borg CR-10 scale. 103

Moreover, Mlinda, Leyna, and Massawe (2018) indicated that sustaining children with Cerebral Palsy (CP) is testing and can prompt unexpected weakness results.. Fortifying sustenance training and administrations for guardians of children with CP have incredible incentives being taken care of by youngsters with exceptional needs and may improve the wellbeing results of children just as decrease stress among guardians/parental figures. Pinquart, (2018) thought about the degrees of parenting stress in families with and without a youngster with a ceaseless physical condition and dissected the connection of parenting stress in families with a child with a persistent condition. Their outcomes helped with distinguishing guardians with the most significant requirement for mediations planned for diminishing parenting stress. The intercessions tended to the decrease of youngster conduct issues, the sustaining of parental psychological wellness, the expansion in conjugal quality and social help when all is said in done, and abilities for managing stressors. Also, Mohamed Mandy and Aranda, (2019) investigated the impression of handicap among Saudi mothers and to comprehend the ramifications of the significance for the mothers of children with incapacity. They uncovered genuinely necessary information and reveals insight into a theme, the subtleties of which are once in a while accessible in look into writing from the Middle East. The discoveries further embraced the requirement for clinicians to tune in to the mothers to think about their convictions and the effect of these convictions on their encounters. This, thusly, may give significant theoretical data to medicinal services experts to utilize the family-trotted model when working with Cerebral Palsy tormented children. 104

Additionally, Kuschmann and Lowit, (2019) inspected on how children with dysarthria and Cerebral Palsy (CP) acknowledge sentence stress acoustically, and how well audience members could recognize the situation of the focused-on word inside these expressions. Their outcomes recommended that children with CP can control transient discourse properties to check stress. This capacity to adjust acoustic prosodic highlights could be saddled in mediation to improve children's useful correspondence. Dieleman, Van Vlaenderen, Prinzie, and De Pauw, (2019) uncovered that bringing up a child with Cerebral Palsy (CP) has been appeared to influence guardians' prosperity unequivocally and is regularly depicted as trying or complicated. Notwithstanding, nine guardians of young people with CP, matured 10 to 18 years, took an interest in an inside and out meeting concerning their need-related encounters in bringing up their child or little girl with CP. The information was breaking down with a topical deductive analysis. In addition, Silva, and de Araujo, (2019) demonstrated that in pediatric recovery, Cerebral Palsy establishes one of the most analyzed clinical conditions, in any case, further research is as yet essential to improve the nature of care in Brazil. The study of the whole example uncovered low-feelings of anxiety. Restricted wellsprings of help were watched, with family support being dominating. It was conceivable to recognize a negative relationship between's social help and stress. Van, Myezwa, Potterton, and Stewart, (2019) decided the impact of a gathering based instructive intercession, Hambisela, on feelings of anxiety and QOL of essential 105

parental figures of children with CP in Mamelodi, a township in Gauteng, South Africa. Eighteen essential parental figures of children with CP took part in a semi trial pre-test–post-aircraft tester study. They showed that most essential parental figures in this pilot study experienced clinically huge feelings of anxiety. Hambisela, as an instructive mediation, was not viable in lessening the stress or improving the QOL in these essential parental figures of children with CP. Future studies with a more prominent example size are expected to research the high feelings of anxiety of essential parents of children with CP. Besides, Omole, Adegoke, Omole, Mbada, Adedeji, and Adeyemi (2019) found that Cerebral Palsy (CP) is a significant reason for physical handicap in youth. Guardians are regularly exposed to both pressure and weight because of delayed consideration. They evaluated levels, connections, and prescient variables of stress and guardian trouble among essential parental figures of children with CP. Notwithstanding, Kriti, Pradhan, and Tufel (2019) showed that Cerebral Palsy (CP) is the main source of ceaseless incapacity in children making them physically and simple- minded and socially detached. The seriousness of the child's incapacity had no impact on the level of parenting pressure. The all-out family pay was seen as pitifully and conversely corresponded with the level of parenting pressure. In any case, there was a solid connection between co-horribleness factors and parental pressure. Besides, Leonard et al., (2019) expressed that Cerebral Palsy (CP) is the consequence of a static cerebrum sore which causes spasticity and muscle contracture. Results show that CP muscle at its most decreased level (the myofibril) is progressively consistent 106

contrasted with ordinary, which is directly inverse to what is seen at higher basic levels (single filaments, muscle fiber packs and entire muscle). It is imperative that at the in vivo sarcomere length in CP, the detached powers are more noteworthy than typical, absolutely as an increasingly useful consistent sarcomeres working at long lengths. Titin isoforms were not distinctive among CP and non-CP adductor longus yet titin: nebulin was decreased in CP muscle, which might be expected to titin misfortune or an over- articulation of nebulin in CP muscles. Howard, Huntley, Graham, and Herzog, (2019) uncovered that in Cerebral Palsy (CP), the spastic engine type is generally healthy, related with a speed subordinate increment in muscle firmness that goes before the advancement of fixed muscle contracture – a lasting shortening of the muscle ligament unit in any event, when loose. Intra-solid infusions of botulinum poison type A (BTX-A) have gotten famous for the treatment of spastic muscle contractures however, lamentably, its utilization has not brought about long-haul practical advantages and, incomprehensibly, has been related with a relentless loss of contractile material. Late biomechanical work has demonstrated that the firmness of the CP muscle increments concerning add up to collagen content inside the perimysial extra-cell grid. In this manner, instead of the utilization of tone-lessening specialists, it is theorized that the central utilization of a specific collagenase, infused into spastic muscle at a suitable weakening and focus, may serve to diminish the degree of muscle contracture, improving clinical scope of movement and maybe sarcomere length. Rani, and Thomas, (2019) comprehended the pressure and saw disgrace among parent of youngsters with epilepsy looking for treatment at a tertiary referral community for 107

nervous system science in South India. Parent of sixty youngsters experiencing epilepsy in the age gathering of 4–15 years were met to investigate parental pressure and saw shame. They were selected continuously over a time of a half year in 2015. Parents are significant figures in the process by which children with epilepsy came to recognize themselves is not the same as other children. Parents regularly dreaded unveiling their youngster's epilepsy to their companions and family members since they encountered a feeling of disgrace, self-fault, and dismissal which likewise expanded their pressure. Liang, Chen, Cheng, Xue, and Wang, (2019) decided the similar impact of monosialoganglioside versus citicoline on the substance changes of serum apoptotic factors (PDCD5, sFas, and sFasL), neurological capacity records (BDNF, NSE, S100- and NGF) and oxidative pressure files (SOD, MDA and GSH-PX) in infants with hypoxic-ischemic encephalopathy (HIE). Their finding revealed that after treatment, the degrees of serum PDCD5, sFas, sFasL, MDA, NSE and S100- in the treatment bunch were lower than those in the benchmark group Donkor et al., (2019) indicated that Cerebral Palsy (CP) is the most widely recognized youth handicap around the world, and proof shows that youngsters with CP are at an expanded danger of failing health because of nourishing troubles. This subjective study investigates parental figure's encounters of encouraging when a community‐based preparing program in Ghana. Thirteen parents of children with CP, who were severely undernourished, were met at the beginning of the preparation program. Eleven of these were met again following a time of month to month bunch trainings and home visits, which remembered direction for nourishing. Four extra parental figures were met at end line. Meetings investigated parental figures' supper time encounters, just as a 24‐hr 108

dietary review and an organized nourishing perception agenda. Youngsters' wholesome status was surveyed by anthropometry. A parent discovered eating times upsetting because of time requests, untidiness, and the weight of giving enough quality nourishment. They felt that the preparation program had helped decreased this pressure and dietary review information recommended some improved dietary quality. 2.7 Conceptual Framework The description of the Double ABCX Model (McCubbin & Patterson, 1983) provides this study with a clearer understanding of the concept of stress management. STRESSOR A This defines the events and occurrences which can impact the social state of the family. It majorly defines the level and categories of stress as it affects family set goals and achievements. These include sickness, which may require a hefty sum of family’s resources to be sundered. EXISTING RESOURCES B This involves the existing resources of the family that could help in reducing the effects of stress and other related anxiety. These include the level of social status, educational stability, community respects and reservation. PERCEPTION OF THE STRESSOR C This defines the perception of the family as it relates to the crisis. It virtually includes the level of acceptability and the reality of understanding the degree of the problem. For this study, it defines the severity of the child's disability. 109

CRISIS X The crisis itself which is demanding and bound to adaptation or surrendering. This is a critical variable that defines the family's fall to disruptions, chaos and disunity/disorganization. According to the ABCX model, this returns the family level of inability to retain balance and equilibrium. CONCEPTUAL MODEL FOR BEHAVIOURAL THERAPY Figure 2.0.2 ABCX Model Model (McCubbin & Patterson, 1983) 110

B. STRESSOR C . Religiosity Figure 2.0.3 CBT-Stress Conceptual Model (Lavee, 1985; Lavee et al., 1985; McCubbin & Patterson, 1983) In this study, CBT shall be used to investigate the level of the stress on mothers of the children who are suffering from CP using religiosity as submitted by (Lavee, 1985; Lavee et al., 1985; McCubbin & Patterson, 1983). 2.8 Theoretical Model The study’s theoretical framework refers to the basis upon which the whole research project is based upon. It forms logically developed, explained and elaborated relationships among the independent, dependent, and moderating variables that are explained in light of theories and relevant studies in the literature to obtain the solutions to the problem statement. It also offers a platform on which the hypotheses and measurement instruments can be developed. 111

Social Support Cognitive Psychological Behavioural Stress Level among Therapy Program Mothers with Cerebral Palsy Figure 2.4: The Theoritical Model 2.9 Summary of the Chapter The chapter discussed the theoretical framework and concepts related to the present study. The study was based on five theories, Behaviourism Theory, Constructivism, Cognitive Behavioural Theory and Social Problem-Solving Theory. In the conceptualisation of the study, the framework encompassed these theories and the four independent variables including motivation, anxiety, L2 and feedback, with one dependent variable which is online writing performance. The chapter also discussed various concepts related to the study such as Cerebral Pal, Stress, Parental Stress, Distress and Eustress, Family Stress, Prevalence of Stress in Mothers of Children with CP, Causes of Stress in Mothers of Children with CP, and Stress Management in Mothers of Children with CP. This chapter also presented review on relevant empirical studies. 112

CHAPTER 3 METHODOLOGY 3.1 Introduction This chapter presents the methodology used in this study. It further discusses the overall research design in which an embedded quantitative analysis, quasi-experimental study approach is employed in this study. Furthermore, it describes the research design of the study with the aid of a diagram that illustrates the phases of the study which is the quantitative phase 1: quasi-experimental study. This chapter also presents the study area as it was carried out in Irbid City in Jordan The target population of this study comprises of all mothers of children with disabilities from Irbid City in Jordan. Furthermore, a purposive sampling will be used to select the participants of the study. Moreover, the chapter presents the process of data collection as a quantitative research instrument used as the main methods of data collection which involves pre-/post/delay distribution of questionnaires as a means of collecting quantitative data at quasi-experimental study. Henceforth, the chapter describes the method of data analysis to be employed in the present study. The analysis however is based on the nature of the data collected in the quantitative phase. In the quantitative phase, descriptive and inferential analysis were used to analyse the data using SPSS. The chapter later presents the theoretical perspectives employed to guide the process of the study. It also describes the general process of the study using diagrams. 113

3.2 Research Design Research design is one of the compulsory features in conducting research respective of the field of study. Moreover, research design offers the needed guidance for researchers in a systematic way as well as present the collection and analysis of data based on the research questions. Additionally, a research design includes a series of rational decision- making choices that contain numerous issues. For example, the purpose of the study, the background of study, and the unit of analysis. This study presented a hypothesis to describe certain relationships. An exploratory and empirical research was used in this study. An exploratory configuration is considered the most appropriate approach in providing the perspective of the explored issue. As Creswell (2012) construes that the purpose of the exploratory methods design is to collect data and use the results to understand the research problem. He reiterates that the basic rationale for this design is that the data collection can provide support to offset the weaknesses of the other forms and that a complete understanding of a research problem results from collecting quantitative data; as in the case of the present study. Finally, the set of quantitative data are collected from pre-test and post-test scores. The delay-test questionnaire data are obtained from the set questions and hypotheses are then formulated. Nevertheless, in order to conduct a research in academic fields, a researcher needs to follow a sequential plan to address a particular problem (Andrew, Pedersen, & McEvoy, 2019). This is what is known as research design. It is a planned process in which a researcher collects, analyse, and interpret data using either quantitative approach or qualitative research or both approaches (mixed-methods) (Creswell, 2012). The present study was in a form of quantitative in nature. In other words, this study employs a quantitative approach, which implies the collection of both quantitative data sets, 114

including series of analyses and mixing of data at different phases to answer the research questions (Peacock, et al., 2019). A structured questionnaire adapted and modified from the past research (Jackson, Presanis, Conti, & De Angelis, 2019) on the appropriation of adoption of organizations used as the fundamental data-gathering instrument. The research instrument used well-established measurement scales known from earlier studies. Changes were made in the selected items to make sure they would fit into the context of the study 3.3 Target Population of the Study The population of this study comprised of mothers of children with disabilities from Irbid City in Jordan. The total number mothers of children with disabilities from Irbid City in Jordan are 100. The population refers to an aggregate or the sum of all the objects, subjects or members that conform to a set of specifications (Krops, et al., 2019) or the larger group of people, events, or objects from which the generalisation is made (Huitfeldt, Swanson, Stensrud, & Suzuki, 2019). In other words, Creswell (2012) defines a population as a group of individuals who have the same characteristic. The population can be small or large. In practice, quantitative researchers’ sample from lists and people available. A target population (or the sampling frame) is a group of individuals (or a group of organisations) with some common defining characteristic that the researcher can identify and study. Moreover, Blaum, et al. (2019) defined population as the complete set or entities of interest. It can also be referred to as a set of all individuals, items or data of interest on which researchers will generalize (Tang, et al., 2018). The sample to be used for the study will be drawn from the population. When conducting a research, there may not 115

be a need to study every individual in the group or population. Rather, researchers selected a representative from the group or population to be studied and collected data from the small group. 3.3.1 Sample Size of the Study Researchers used various procedures in sampling populations. It is the through the conditions imposed upon the study and the crucial nature of the participants that determine which procedures are to be employed in sampling population (Tam, Lo, & Woo, 2020). The selection of samples of the participants may be random or non-random (Luedtke, Sadikova, & Kessler, 2019).). Examples of random sampling include simple random, stratified random, systematic random and non-random sampling techniques include purposive sampling, convenient sampling, and quota sampling (Branion-Calles, et al., 2019) In the case of the present study where a quantitative research design was utilized, the phase of data collection is based on the sampling and the purposes served by the participants. However, all the participants in the present study were selected using non- random sampling procedure. As this phase involves quasi-experimental study Ratcliffe, & Groff, (2019) construe that the sample in quasi-experimental are selected on the basis of need or purpose of the study rather than random assignment. The sample size comprised of 50 mothers of children with disabilities from Irbid City in Jordan. The group consisted of female mothers of children with disabilities. All of the participants are mothers of children with disabilities from Irbid City in Jordan. The participants were a single experimental group that were subjected to pre-test, post-test 116

and delay test with the aim of determining their psychological, behavioural and cognitive domains to reduce the stress among mothers of children with Cerebral Palsy. According to Creswell (2012), a sample is a subgroup of the target population that the researcher planned to study to generalise the target population. In an ideal situation, a sample can be selected from individuals who were the representatives of the entire population. Additionally, the sample in a research study can be defined as a group on which information is obtained while population refers to the larger group in which one hopes to apply the result (Omura, Levett‐Jones, & Stone, 2019). Also, Jiang, et al., (2019) argued that a good sample allowed researchers to make a reasonable judgment and assisted them to generalize on the population that they are studying. Similarly, Creswell (2012) suggested that the researcher must identify appropriate sampling frame, select appropriate sample size and identify the appropriate sampling techniques in order to improve the generalizability of the result from the research study. Moreover, software can also be used to determine the sample size that is appropriate for any population. An example of such software is the sample size calculator. 3.3.2 Sampling Technique The participants of this study were selected based on convenience sampling technique. All the participants were the children with disabilities. The term convenience sampling is a form of non-probability sampling. It refers to a statistical method from which data is drawing by selecting samples based on the ease of their volunteering, availability or easy to access. 117

3.4 Data Collection Procedure The researcher had collected a letter of permission from in the Faculty of Social Science which addressed to the mothers of children with Cerebral Palsy in Jordan. Thereafter, the researcher first approached the appropriate authority to solicit their support and assistance for data administration and collection. After the permission was granted, the researcher later contacted the children. Then, the researcher personally conducted the Program and administered the questionnaire three times. In addition, the researcher adopted a face-to-face method of questionnaire administration. This method is more effective in the sense that it enabled the researcher to provide appropriate answer to any question that may be raised by the participants and made clarifications where appropriate (Badu, O’Brien, & Mitchell, 2019). 3.5 Data Collection Instruments The instrument that was used to collect data in the present study was a Pre/post/delay distribution of the questionnaire (quasi experimental study). According to Merriam, and Grenier, (2019), information gathered by figures are quantitative. However, in another view by Whitmore, (2019) quantitative research method refers to a method used to analyse numeric information in the form of the statistical method. Measurement of variables or instrumentation is a tool or mechanism for describing specific properties of the variables of interest in a study by assigning numbers in a reliable and valid manner (Creswell, 2012). In essence, the adapted questionnaire is a combination of various past research instruments on the discussed phenomenon. These questionnaires were adapted in order to provide clear understanding of the phenomenon 118

and constructs of this research study in selected mothers of children with disabilities from Irbid City in Jordan. The questionnaire for this quantitative study will comprise of two major parts of Sections A and B respectively as contained in the Appendix section. Section A centered on demographic information of the participants and Section B focused on variables. Moreover, sections B of the questionnaire consisted of 58 items which aimed at answering the research hypotheses stated earlier in Chapter One of this study. Also, the questionnaire used five Likert Scales of Strongly Disagree to Strongly Agree (SA) in order to examine the opinion of the respondents on the variables. 3.5.1 Survey Instruments One questionnaire was used in this study, which was the main survey questionnaire. The questions had been adopted and adapted from different questionnaires. 3.5.1.2 Survey Questionnaire The main survey questionnaire used in the present study has eight sections, A, B, C, D, E, F, G and H based on constructs. Section A contained two statements about demographic information while the remaining seven sections were designed based on seven constructs. Some constructs contained ten statements and some constructs contained five. The total constructs were 58 including demographic information statements. All of the statements under sections B, C, D, E were devised in the form of closed-ended questions designed in five Likert scales as followed: 119

Section A: Demographic Information This section contained three statements about children demographic information, such as the age, gender and level of their education. Section B: Survey Information In addition, Table 3.1 listed the number of the items used to measure each construct. Nevertheless, the items were adopted and modified from (Taweel, 2007), Cheon, (2012), Alatebe, (2014) to fit the context of the current study. Code Table 3.1 Research Instrument Source Alatebe, d. (2014) Section B Statement CBTP1 Cheon, (2012) I have to keep a continuous control and guidance to my child. CBTP2 120 Is it easy to communicate with my child to correct his cognitive CBTP3 and psychological problems? CBTP4 CBTP5 Is the child able to communicate with other children easily? ESBT6 The child has a good self-confidence in the society. CBTP7 Is the child healthy in the perception of the cognitive issues? CBTP8 Taught me how to give care to my child. CBTP9 Helped me understand my child’s behaviour and reaction. Let me know I am doing a good job in helping my child. CBTP10 Included me in discussions when decisions were made about my Section C child’s care. CBTFD1 Told me about improvements in my child’s conditions. CBTFD2 Child's disease was the main reason for the family problems. CBTFD3 We suffered from financial/economic problems to afford the medical CBTFD4 treatment to my child. CBTFD5 I feel shy when someone starts talking about my child. CBTFD6 I feel shy because of my child’s behaviour in public CBTFD7 I feel shy about receiving any guests in my house. CBTFD8 I feel shy about participating in societal celebrations. CBTFD9 I feel shy about practising my hobbies. CBTFD10 Investing time and energy in my job. I suffer from anxiety. CBTCF1 Engaging in relationships and friendship which help me to feel CBTCF2 important and appreciated. CBTCF3 CBTCF4 The child's disease is a challenge that cannot be solved. CBTCF5 The child will not be able to practice his physical activities in the future. CBTCF6 There are no relationships between my child and his peers. Is the child not being able to understand others and react positively? The child is not accepted in the society.

CBTCF7 My child doesn’t seem to smile as much as most children. Taweel, 2007 CBTCF8 My child is not able to do as much as I expected. CBTCF9 My child is not able to adapt to new things. CBTCF10 My child is moody and easily upset. Section E: My child is violent when something happened that made him/her upset CBTIP1 CBTIP2 Child's performance in understanding and perception does not develop. CBTIP3 Can I let my child go to the street alone without control and escort? CBTIP4 Is my child able to take care of his personal hygiene? Section F My child expresses his needs, wishes, and feelings. CBTIIP1 My child asks for help when needed. CBTIIP2 CBTIIP3 There are no family groups for the families which have Children with Cerebral Palsy. CBTIIP4 The family feels loneliness in the society. CBTIIP5 I do not know charities or entities that present any support or services for my child. Section G I feel the stress that cannot be avoided. CBTPS1 There is no psychological support for the families which have children with Cerebral Palsy. CBTPS2 CBTPS3 There are no books or publications that give information to the families which have children with Cerebral Palsy. CBTPS4 There are no regular visits or committees to teach the families which have children with Cerebral Palsy on how to develop the perception CBTPS5 and behaviour of their children. Section H There are no special schools for the children with Cerebral Palsy. There are no effective program to take care of the children with CBTFDS1 Cerebral Palsy. The society does not give any importance to the perceptive and CBTFDS2 behavioural problems of the children with Cerebral Palsy. CBTFDS3 There are no serious Program to develop children's mental and physical CBTFDS4 performance. CBTFDS5 No appliances are available to help the child walk. There are no achievements that indicate an improvement in the child's CBTFDS6 independent performance. CBTFDS7 I do not know the ways to care for the disabled child. There are some emotions in the child’s performance but the child do CBTFDS8 not know the reasons. The Behavioural Cognitive Mentoring Program added awareness in CBTFDS9 helping the child's independent performance through the cooperation with friends. CBTFDS10 The Behavioural Cognitive Mentoring Program added awareness in helping the child's independent performance through the cooperation with relatives. The Behavioural Cognitive Mentoring Program added awareness in helping the child's independent performance through hospitals. 3.6 Data Collection Process Data collection is defined as the process of gathering or collecting and measuring information and facts on variables of interest in a systematic way and fashion that 121

enabled one to provide an answer to the stated hypotheses, evaluate outcomes, and research questions (Wright, Wahoush, Ballantyne, Gabel, & Jack, 2016). The components that make up data collection in research is common to all specializations of study which includes physical and social science, business and humanities and other fields while the methods also vary by specialty or discipline, the emphasis on ensuring honest and accurate collection of data remained the same. The objective of data collection is to get the quality evidence that translates into a more accurate result which allows for building a credible answer to questions that have been posed. Therefore, this study was conducted in Jordan, and the data was collected through a self-administered questionnaire where the participants were asked to complete the survey on their own. The purpose of choosing self-administered questionnaire in this study is that it reduces cost by eliminating the interviewer device and items such as computer software. Moreover, there is no interruption from the interviewer as the respondents could answer the questionnaire at their own time. The study used the structured questionnaire for both pilot test and actual survey to measure the research constructs. Moreover, in quantitative research, the credibility of the study is largely based on the development of the instrument used to measure the underlying concept (Leo, & Michael, 2019). Therefore, the pilot test questionnaire for this study is going to be adapted from previous studies. 3.6.1 Quasi-Experimental Study The quantitative data of this study collected from the quasi-experimental study which has three sections, pre-distribution of the questionnaire, intervention or training and delay. A quasi-experiment was employed in the present study to investigate the effectiveness of the Behavioural Cognitive Mentoring Program in reducing cognitive 122

and psychological problems of the child's independent performance among mothers of children with Cerebral Palsy in post-evaluation. Shadish and Luellen (2006) define quasi-experiment as a kind of study similar to all experimental studies, in a sense that they are used to test hypotheses about the effects of manipulative treatments. However, quasi-experiments lack the process of random assignment of study units to conditions. Rather, some non-random assignment mechanism is used. A non-equivalent controls group quasi-experimental design was used. This is a common quasi-experiment design using pre, post, delay and control group added that “the pre distribution of the questionnaires helps determine whether people changed from before to after treatment. The control group provides an estimate of the counterfactual (i.e., what would have happened to the same participants in the absence of treatment)”. Other types of quasi-experimental design include ‘the one-group post distribution of the questionnaires only’ which was considered as a weak design and the other type is the interrupted time-series design which can be powerful for assessing treatment impact but found not suitable for this study. 123

3.6.2 Design of the Quasi-Experimental Study Three sections of non-equivalent quasi-experimental study will be designed in this study as presented in the diagram below: Pre-test For all groups Intervention (6 week) With...For Exp. Training and activities groups Without … for Contr. groups Week1 Week2 Week3 Week4 Week5 Week6 Immediate Delayed Post-test Post-test For all groups Figure 3.1 Quasi-Experimental Design Diagram Figure 3.2 Quasi-Experimental Design Diagram This diagram represents the flow of the quasi-experimental design employed in this study. In shows the three stages of conducting the experimental studies, pre-test, intervention training and post-test. The behavioural cognitive mentoring model”, Exp. stands for “experimental group” and Contr. Stands for “control group”. 124

3.6.3 Pre-Test and Post-tests In the first week of the study, the first test administered to all controlled and experimental groups. This is the first stage of quasi-experimental study. However, before the beginning of the actual study a pilot study was conducted to ascertain the validity and reliability of the instrument and validate the general procedure of the study as presented in sub-section blow. The questionnaires were given to all groups. Meanwhile, a six-week intervention Program was followed after distributing the pre- questionnaires. At the middle of the training period, the second distribution (immediate post questionnaire) were disseminated followed by the delayed post distribution at the end of the training. Post-distribution was the test administered to the groups after the treatment to determine the effect of the treatment on the experimental groups and to observe the causes or changes among the variables being observed. The post- distribution was administered twice at the middle (immediate post-distribution) and at the end of the training session (delayed post-distribution) the rationale was to ascertain the reliability of the instrument by correlating the gain scores of the participants and to examine the respondents ‘ability to make inference based on the knowledge. 3.7 Validation and Reliability of the Research Instrument According to Noble, Wiseman-Orr, Scott, Nolan, and Reid, (2019), the term validity was defined as the degree of correctness and appropriateness of inferences conveyed by a researcher. It measures the situation where the instrument is designed to measure. It explains the degree of an instrument to measure what it was meant to measure. Similarly, the questionnaire for the quantitative aspect of this study was validated using factor analysis. Factor analysis was used in checking the internal arrangement of items in a questionnaire and examines the relationship between variables (Hong, & Kim, 125

2019) With factor analysis, the researcher was able to determine the loading of each of the items under their respective construct and showed how well the items explain their constructs (Moyano-Fuentes, Bruque-Cámara, & Maqueira-Marín, 2019). Before presenting the test, there were some assumptions that must be fulfilled when adopting factor analysis. These include: sample size, factorability of the correlation matrix, linearity and outliers (Moyano-Fuentes, Bruque-Cámara, & Maqueira-Marín, 2019). On the sample size, some scholars argued that the sample size to be considered for factor analysis must be 30 or above with a ratio of five cases for each variable. In addition, the second assumption on factorability of correlation matrix relates to the result of the correlation matrix, KMO and Bartlett’s test of Sphericity. To qualify for factor analysis, (Moyano-Fuentes, Bruque-Cámara, & Maqueira-Marín, 2019) suggested that the value of correlation matrix must be .3 or above with KMO of .6 and above and Bartlett’s test must be significant at p < .05. In addition, the researcher used Cronbach’s Alpha to determine the reliability of the research instrument for the quantitative aspect. Cronbach’s Alpha enabled the researcher to determine how well the items relate to the construct and measure the constructs appropriately. 3.8 Research Procedure This section presents the procedure to be followed in the process of data collection and data analysis in the present study. The procedure also discussed the data analysis once the raw data had been synthesised. 3.8.1 Intervention Training Program This is a training used as an intervention to the children’ problem. The Program was based on the Behavioural Cognitive Mentoring Program. However, only the 126

experimental group were given this intervention training. The details of the process as given in the schedule of class in the research procedure illustrated that prior to the intervention, a background questionnaire and pre-test was given to the participants. The mothers of children with Cerebral Palsy were given homework weekly. The details of the Program were as follows: First Step Before starting with a cognitive behavioural Program, the researcher had read deeply about the subject of the study. Besides, he focused on the main psychological, behavioural and cognitive domains to reduce the stress during application of the Program. Also, the researcher visited Cerebral Palsy associations in Irbid and met several administers. The researcher presented the Behavioural Cognitive Mentoring Program in reducing psychological stress among mothers of children with Cerebral Palsy and the researcher will receive a great response from association’s administers for applying the Program. Second Step The researcher prepared a module reflecting behavioural cognitive mentoring in reducing psychological stress among mothers of children with Cerebral Palsy after reviewing of guided Program then the design for guided sessions was devised. The Program consisted of 50 items in the first design, every session has specific objectives, procedures, strategies, duration and visual aids. The researcher had designed a questionnaire for arbitrative experts who judged the Program’s sessions according to its objectives and content. The researcher then distributed the questionnaire for 10 127

arbitrators who specialise in psychology, guidance and counselling to give their valuable comments. According to the arbitrators’ comments, the researcher modified items such as home- notes and reviewed mothers in previous sessions with a new session. Third Step In the first session, the researcher will apply the Behavioural Cognitive Mentoring Program after modification. The Program consisted of 12 session Table 3.2 Sessions of the Program Sessions Period Topic The first session The second session 90min Greeting The third session The fourth session 90min Defining the Cerebral Palsy The fifth session The sixth session 90min Defining the stress The seventh session The eighth session 90min Problem solving 1 The ninth session The tenth session 90min Problem solving 2 The eleventh session The twelfth session 90min Method of care 90min Emotional release 90min Emotional relax 90min Strategies of coping 1 90min Strategies of coping 2 90min Free discussion 90min The final session The Strategies used in the Program i. Brain storming ii. Group work iii. Critical thinking iv. Problem solving v. Free discussion vi. Home-note vii. Role play 128

viii. Humor strategy ix. Lecture 3.8.2 Pre-Test. It is vital to pre-test the instruments to ensure that the questions will be understood by the respondents i.e., there is no ambiguity in the questions and that there were no problems with the wording or measurement. Pretesting involved the use of a small number of experts or academician to test the appropriateness of the questions and their comprehension. This will help to rectify any inadequacies, in time, before administering the instrument orally or through a questionnaire to respondents, and thus reduce biases Sekaran (2003). Moreover, Rosenthal, (1978) have recommended two basic ways to pre-test and pilot test the instruments of the questionnaire. He suggested that the researcher can either do pre-test the questionnaire with the colleagues or with other research professionals. Hence, this study will select four (3) experts from the department of Business Administration, in four Universities in Jordan. These experts will check the suitability of the questions and their perception. They will correct any deficiencies, in time, before administering the instrument orally or through a questionnaire to respondents, and thus reduce biases 3.8.2.1 Face validity The essential task of any research is to reliably and accurately collect information. Face validation of an instrument or rather appearance validity is subject to judgment on the appearance and the extent to which a test is subjectively viewed. It refers to the 129

transparency of a test as it appears to test participants. The quality of research cannot be valid until the data collection instrument has some degree of reliability. In this study, the suggestions and opinions of experts were obtained on the appearance, wordings, arrangement, and nature of the items measuring the intended constructs. 3.8.2.2 Content validity This study utilised content validity techniques and looked at elements of the study instrument for the measurement procedure. These were highly relevant since they represent the construct that measured the research construct. Expert opinion is the basis for establishing content validity, not statistical analysis (Hair et al., 2016). (Kilne, 2011). Thus, the content validity in this study was achieved through the evaluation of the instrument by the supervisory committee and several experts in the field. This was done in order to ensure that the instrument items were related to the purpose of the study, the points were easily comprehended and represented their content source. All recommended changes and modifications were considered and advised by the supervisory committee which included advice on formatting and structure of the questionnaire for easy comprehension and legibility. 3.9 Pilot Study This was modified to fit the theoretical perspectives and methodology of this study. A pilot study was conducted to ascertain the validity and reliability of the questionnaires. To ascertain the internal validity of the construct and face validity, the researcher submitted the copies of the modified questionnaires to the supervisors for correction and observation. Some copies were sent to other two experts in the field for face validity. All the questions were subjected to factor analysis since some of the adopted 130

and adapted instruments were not tested, the rationale for using factor analysis was to reduce and check the variables that are reflected in the observed variables. This pilot study used 30 participants out of the 55 samples. To ascertain reliability, a pilot test was administered to 30 participants. According to Krejcie and Morgan (1970). The reliability coefficient of the scales from the survey questionnaire was computed using factor analysis and Cronbach’s Alpha to test the viability of the constructs in the questionnaire and to refine the items that need necessary improvement. 3.10 Normality Based on the measurement model, the study will examine the normality for the items with a view to assess the distribution for every item or variable involved in the measurement model. Normal curves can be added to histograms by double-clicking on them and using the button in the Chart Editor window. It is very unlikely that a histogram of sample data will produce a perfectly smooth normal curve like the one displayed over the histogram, especially if the sample size is small. As long as the data is approximately normally distributed, with a peak in the middle and fairly symmetrical, the assumption of normality has been met. The normal Q-Q plot is an alternative graphical method of assessing normality to the histogram and was easier to use when there were small sample sizes. The scatter should lie as close to the line as possible with no obvious pattern coming away from the line for the data to be considered normally distributed. Below are the same examples of normally distributed and skewed data. 131

There are also specific methods for testing normality but these should be used in conjunction with either a histogram or a Q-Q plot. The Kolmogorov-Smirnov test and the Shapiro-Wilk’s W test determine whether the underlying distribution is normal. Both tests were sensitive to outliers and are influenced by sample size: for smaller samples, non-normality is less likely to be detected but the Shapiro-Wilk test should be preferred as it is generally more sensitive. For larger samples (i.e. more than one hundred), the normality tests were overly conservative and the assumption of normality might be rejected too easily (see robust exceptions below). Any assessment should also include an evaluation of the normality of histograms or Q-Q plots as these are more appropriate for assessing normality in larger samples. For both of these examples, the sample size is 35 so the Shapiro-Wilk test should be used. For the skewed data, p = 0.002 suggesting strong evidence of non- normality. For the approximately normally distributed data, p = 0.582, so the null hypothesis is retained at the 0.05 level of significance. Therefore, normality can be assumed for this data set and, provided any other test assumptions are satisfied, an appropriate parametric test can be used. 3.11 Method of Data Analysis Data analysis procedure simply refers to the process and techniques employed by the researcher to scrutinize the collected data in order to extract the information from the data and give a summary description of the results based on the analysis of the data (Nwana, 1981). To test for normality of data distribution skew and kurtosis were performed using SPSS to double check if a distribution of scores significantly differed from a normal distribution. The data were sampled from a Gaussian distribution, i.e. not normally distributed data, the no-parametric test of Man Witney and Wilcoxon were 132

used to analyse the data collected through questionnaire. To ensure effective data representation, the researcher conducted data mining procedure before performing actual data analysis. The frequency distribution used to tabulate the number of responses for each question, and the descriptive analysis for each variable produced. 3.12 Summary The chapter presented the method implored by the researcher in conducting this research study. It also discussed the research design of the study. Additionally, it provided the comprehensive information about the population, sample and method of the sampling technique that adopted by the researcher in this study. It similarly highlighted and clarified the research instrument that used in this study. It presented adequate information on the design and development of the research instruments, validation process and method of assuring its reliability. Moreover, it specified the procedure of administering the research instrument and method of data collection. Finally, it showed the methods of data analysis. 133