The socio-emotional behavioural problems of children with cerebral palsy according to their parents' perspectives

Abstract

This study aimed at identifying the behavioural difficulties facing the children with cerebral palsy (CP) in Jordan. In addition, it attempted to determine the differences between those children according to certain variables such as gender, age, level of family income, and level of disability. Besides, the sample of the study consisted of 96 students with CP aged between six and 16 years. Moreover, two scales were developed to achieve the study goals. The results revealed that children with CP on average, according to their parents' reports, had a moderate degree of overall behavioural problems across internalised problems that were composed of subscales such as shyness, depression, anxiety, and social isolation; and across externalised problems composed of the aggressiveness scale. There were significant differences due to the gender variable on the overall scale and on the anxiety dimension in favour of male children. Moreover, there were significant differences on the shyness and isolation dimensions due to the level of disability in favour of children with CP and mental retardation. Also, there were statistically significant differences due to the child's age in overall behaviour problems in both the anxiety and the aggressive dimensions. Finally, based on the findings, appropriate recommendations were suggested.

Keywords:

• social and emotional behavioural problems
• children with cerebral palsy
• parents' perspectives

Introduction

Cerebral palsy (CP) is considered to be the most common developmental and physical disability. It is described as a congenital, life-long, and non-progressive motor disability of movement and posture. It is caused by an injury in the immature brain (Sandstrom, 2007). The movement disorder of CP is expressed in a variety of ways and degrees for each individual (Mayston, 2001). CP can lead to limit a child's ability to perform his/her daily living activities, and to engage in age-appropriate activities, mobility, cognitive, functioning, social, and emotional development, sensory, body functions, and communication (Heward, 2006). As a consequence of these limitations, children can impose limits by themselves to attain success and accomplishments they need in order to develop a positive view of themselves (Schuengel et al., 2006), to affect various developmental characteristics and to complete psychological systems through a direct and an indirect way (Heller, Alberto, Forney, & Schwartzman, 1996; Sandstrom, 2007; Toombs, 1992).

Previous literature reported the CP impacts on physical as well as psychological performances. Therefore, some children with physical disabilities –including those who have CP – may consider dealing emotionally with their disability a major problem that, in turn, poses a major barrier which sometimes hinders their success (Boeraerts & Roeder, 1999). One of the problems that some children with CP face is to maintain the peer relationship and sense of belonging to a group, which seems difficult for them when they find themselves obliged to leave the classroom to have supportive services and feel anxious about fitting in at schools (Olsen & Sutton, 1998). In this field, Sexson and Dingle (2001) also point out that children with physical disabilities often identify concerns about their physical appearance as reasons for emotional and social problems and feelings of depression.

Heward (2006) added that children with CP might experience fear and anxiety from others' view, the sense of being different, frustrations caused by poor control over one's body, inability to communicate their thoughts and needs, and inability to feed themselves. Moreover, as a result of the visibly noticeable physical symptoms of CP such as incontinence, these children might also feel embarrassed in any setting, and social interaction with peers or adults could be at risk because of their easy emotional pain. In addition, different treatments they take could reinforce their feeling of being different by reducing their abilities to carry out certain activities at school or in their community (Sandstrom, 2007).

According to many researchers' points of view, there are other conditions forcing such children to experience the suffrage of social and emotional (S-E) behavioural problems; that is, CP being associated with a spectrum of developmental disabilities such as mental retardation (Heward, 2006; Scope, 2007; Wajid, Javead, Parvez, & Shafat, 2006).

In spite of the fact that many of the previous researchers support that CP affects presenting some of the emotional and social behavioural problems (Boeraerts & Roeder, 1999; Sandstrom, 2007; Scope, 2007; Sexson & Dingle, 2001), others do not support the assumption that there are a personality type and behavioural problems associated with CP (Llewellyn & Chung, 1997), but they support the hypothesis that children adapt to their physical limitations and respond to social–interpersonal situations in ways that are strongly related with parents, siblings, teachers, peers, the public perception, and reactions to them (Bigge, Best, & Heller, 2001; Heller, Alberto, & Meagher, 1996). Accordingly, effective parents and teachers can play a key role to encourage these children to determine how to think about themselves, how to see their disability, strength aspect, and needs, and finally how to enable them to live a healthy life that is full of achievement according to their abilities (Heward, 2006).

The findings of some studies have suggested that an increasing risk for having adjustment problems with children with CP themselves and others suffering syndromes of depression (Aasland & Diseth, 1999; Coster & Haltiwanger, 2004; Manuel, Balkrishnan, Camacho, Smith, & Koman, 2003; McDermott et al., 2005), anxiety (Aasland & Diseth, 1999; Harvey & Greenway, 1984; Hourcade & Parette, 1984; Manuel et al., 2003; McDermott et al., 1996), shyness, withdrawal (Aasland & Diseth, 1999; Manuel et al., 2003; Schuengel et al., 2006), and aggression (Schuengel et al., 2006) are associated with presenting motor disabilities like CP (Lavigne & Faier-Routman, 1993). Other variables include other disabilities like mental retardation (MR) (McDermott et al., 1996). Moreover, there are few studies of diagnosis-specific S-E behavioural problems among children with chronic non-progressive disability (Reijneveld et al., 2006). Therefore, it is important first to determine whether the children with CP suffer from a variety of emotional and social behavioural problems, and to identify these problems especially such as emotional and social behaviour problems that have not received much attention with respect to children with CP in Jordan (Ministry of Education, 2009) By this knowledge, we are more able to assess the emotional and social behavioural problems and develop comprehensive prevention and intervention programmes for children suffering from CP (Surveillance of CP in Europe, 2002) by taking into account the variable that may affect prevention of emotional and social behaviour problems to make the child live a healthy life during his or her growth.

Significance of the current study

Recent literature and follow-up studies emphasise the idea that children with CP face increased pressure to cope with their disability (Boeraerts & Roeder, 1999), which may influence development of all aspects including emotional and social ones and their academic performance during school age and adolescence. Moreover, there has been little research conducted to examine whether these children with CP have an increased rate of emotional and social behavioural problems, and to explore to what degree the children with CP may suffer (Reijneveld et al., 2006). In fact, the present study was conducted to address this issue. Therefore, it is important to deal with emotional and social behavioural problems among children with CP in order to understand them well. The recent study focused on two standpoints.

First, by a practical standpoint, S-E behavioural problems are considered one of the key factors that influence directly the quality of life of the child and their achievement. Moreover, S-E behavioural-problem research plays a key role in the progress and design of preventing intervention programmes. Indeed, identifying behavioural problems among children with CP could describe the impact of disability and the outcome of intervention programmes. In this regard, findings of this study can help schools and centres to present adequate services to these children and their families in order to be able to remove obstacles that affect their health development. In addition, the study findings guide decision-makers to set social and educational policies that help children with CP to participate effectively within their society (Colver, 2007).

Second, at the theoretical level, there is lack of research in this area (Heward, 2006). In Jordan, there is little evidence on the occurrence of these problems among children with CP (Ministry of Education, 2009). Further evidence is needed to be guided for suitable intervention programmes. In addition, further research efforts may shed more light on factors that can play a role in the development of the S-E behavioural problems and show its relation.

Therefore, it is necessary to investigate the behavioural problems among these children, include internalising and externalising problems and the factors that might influence the occurrence of such problems.

Research objectives and questions

The goal of the current work is to gain deeper understanding of S-E behavioural problems associated with CP, to examine the influence of general cognitive ability of the type and level of S-E behavioural problems, demography and family factors that affect children with CP. More specifically, this paper will address the following questions:

1.	What are the main emotional and social behaviour problems among children with cerebral palsy from their parents' perspectives?
2.	Are there any significant differences among emotional and social (S-E) behavioural problems dimensions according to the following demographic variables: child's gender, age, and intellectual level?

Theoretical framework

A number of papers have reviewed the prevalence of S-E behavioural problems among children with physical disabilities including those who have CP, its nature and degree of occurrence. For over 20 years, according to McDermott et al. (1996), researchers reported a positive association between childhood chronic disabilities and S-E behavioural problems. McDermott et al. (2002) reported that 30–80% of children with CP had emotional and social behavioural problems in some way and at a different level and degree. Coster and Haltiwanger (2004) reported also that classroom teachers and other school professionals stated that more than 40% of the 62 elementary students with CP performed below the grade-expected level on six of seven social–behavioural tasks that are necessary for optimal functioning and learning at school. They reported that students with CP could identify concerns about their physical appearance, and consider their physical appearance as a reason for the feeling of depression and emotional difficulties. Indeed, Harvey and Greenway (1984) found that children with physical disabilities had a lower sense of self-esteem, greater anxiety, and less integrated view of themselves more than those without disabilities.

In addition, Heward (2006) reported that the performance of children with physical disabilities, including CP, was under the average of social–behavioural skill measures. A number of researchers have reviewed the occurrences of emotional and social behavioural problems in children with CP, and have shown that some of these children increase risk to have adjustment problems, and they have poor social skills (Lavigne & Faier-Routman, 1993), and internalising problems (Hinton, Nereo, Fee, & Cyrulnik, 2006). For school-age children with CP, Blum, Resnick, Nelson, and Germaine (1991) reported also that isolation and dependence could be problematic for children with CP. Besides, Hourcade and Parette (1984) found that these children at school age had S-E behavioural problems including passivity, immaturity, and anxiety.

Presently, children with physical limitation like CP need to be encouraged in order to be independent (Enright, 2000; McGill & Vogle, 2001). In this field, many researchers like Howe, Feinstein, Reiss, Molock, and Berger (1993) reported that children with CP tended to be dependent and stubborn, had low self-concept, and did not feel much better about themselves. Many researchers emphasised that children with physical disabilities, including those who have CP, may reinforce passivity and dependency (Campbell, 1997; Giangreco, Edelman, Luiselli, & Macfarland, 1997). Shield, Murdoch, Loy, Dodd, and Taylor (2006) examined these results and showed that adolescent females have a lower global self-concept compared with these without disabilities, and this low self-concept is related to physical appearance, confidence interval, social acceptance, athletic competence, and scholastic competence. Manuel et al. (2003) found that self-esteem in pre-adolescence and adolescence stages with CP is associated with their feminine gender, and better physician-assessed functional ability.

In general, McDermott et al. (1996) reported that behavioural problems were five times more likely to occur in children with CP, in comparison with those having no health problems, and that children with CP who had MR showed higher risk of problems such as anti-social anxiety, hyperactivity, and peer-conflict behaviour. Other studies indicated that children with various disabilities had poorer quality of life and psychosocial health when compared with their typically developing peers (Feekes et al., 2000; Social Welfare Department, 2004).

However, other empirical studies stated that children with CP had a moderate or low degree of S-E behavioural problems. For example, Fox (2002) and Andren and Grimby (2004) show that children with CP are similar to the average population in S-E aspects and in life satisfaction; they have also found little evidence proving a difference between children with physical disabilities and normal children at the same age on measures of behavioural problems. Similarly, Colver (2007) pointed out that most children with CP had similar quality of life to other normal children.

According to previous studies that examine the level and nature of emotional and social behavioural problems among children with CP, we can conclude that the causal pathway for the development of emotional and social behavioural problems is not clear among children with chronic non-progressive disability; some of these studies revealed that some of these children suffered from emotional and social behavioural problems in some way (Hinton et al., 2006; McDermott et al., 1996), but other studies pointed out that these children might have the same degree and nature of S-E behavioural problems as other children with no disabilities (Andren & Grimby, 2004; Colver, 2007; Fox, 2002). The difference, based on the study results, invites us to search for the key variables that play an essential role for some of these problems among children with CP.

Based on written literature in this area, a number of researchers have found that emotional and social behavioural problems are sometime associated with the degree of functional limitations experienced by the child and the severity of their disability. For example, Arnaud et al. (2008) reported that great severity of disabilities was not always associated with poor quality of life, emotions, self-perception, social acceptance, and school environment domains. In addition, McDermott et al. (2005) found that the relative risk for depression was significantly lower than normal in many individuals with life-long disabilities such as CP and MR.

Similarly, Miyahara and Piek (2006) found that the major physical disabilities like CP do not seem to affect more generally self-esteem than minor physical disabilities do. Indeed, Hinton et al. (2006) reported that boys with chronic progressive disabilities like Duchenne muscular dystrophy encountered more social and behavioural problems than children with non-progressive disabilities like CP.

Other factors may play a role and are associated with present S-E behavioural problems among these children. Jan et al. (2006) point out that those S-E behavioural problems can be a response to challenges of the environment, and the availability of integrated services they need. Sandstrom (2007) also showed that adults with CP had the same perceptions and strategies followed to cope with challenges as other adults did. Besides, negative perceptions of the physical body, perceptions of difference and restricted autonomy are relevant to the appearance of emotional and social behavioural problems and the negative self-image of this group. Schuengel et al. (2006) indicated also that internalising problems were negatively associated with all perceived competence scales and self-worth, whereas aggression was positively associated with perceived motor competence, physical appearance, and self-worth. Shield, Loy, Murdoch, Taylor, and Dodd (2007) supported this result since they found that there had been no difference between children with CP and those with no disability in global self-worth, physical appearance, or behavioural conduct even though they might feel less competent in certain aspect of their daily life activities. Moreover, females with CP scored lower on social acceptance, whereas males with CP had lower scores due to scholastic competence.

Other studies (Aasland & Diseth, 1999; Manuel et al., 2003) found that functional ability, female gender, perceived parental over-protectiveness, and perceived impact of the disability are all associated with the emotional aspect including self-worth and with internalised behaviour problems (depression, anxiety, withdrawal, somatisation) in children with chronic physical diseases, including those with CP. Wiegerink, Roebroeck, Donkervoort, Stam, and Cohen-Ketteniss (2006) found that social relationships for those with CP were less active than their counterparts.

Previous literature showed that many researchers had developed data based on S-E behavioural problems among children with disability (Chavira, Lopez, Blacher, & Shapiro, 2000; Dekker, Nunn, Einfeld, Tonge, & Koot, 2002), and some were interested in investigating behavioural problems among children with physical disability in general and with CP in particular (McDermott et al., 1996; Jan et al., 2006; Sandstrom, 2007). Nevertheless, due to my knowledge, few of these studies surveyed a broad array of the problem, or were interested in exploring the question of whether children with CP experience E-S behavioural problems or not and its level according to parents' reports. In addition, studying the effect of some factors that can contribute to some behavioural problems in these children is essential (Gray, O'Callaghan, & Poulsen, 2007; Hinton et al., 2006; McDermott et al., 1996; Schuengel et al., 2006).

Limitations of the study

The study is restricted by some limitations that hinder the generalisation of its findings:

1.	The number of children with CP was relatively low since CP is a rare event. Therefore, I am still hesitant to generalise the interpretation of this analysis since the number of children with CP in each behaviour is small.
2.	The study sample includes parents of children with CP from only one city in Jordan (Zarqa).
3.	The study uses mainly the questionnaire as a research instrument, whereas other instruments such as interviews and observation reports were not used.
4.	Data were collected using a survey model.

Methodology

Population and sample

The population targeted in this study were all parents of children with CP enrolled in eight centres and schools that consist of 200 children in Zarqa city (considered the second largest city in Jordan, and represent the local community to the university research beyond), during the academic year 2008/09. A list of numbers of all children with CP and their schools in Zarqa city was provided by Ministry of Education to the researchers in Jordan to determine the population frame for the study.

The study sample was randomly selected from five centres and schools representing 50% of the school and centre populations. Ten males and five females (this difference in rate is due to the rates of males being larger in centres compared with females) were selected from each school/centre and their parents received two questionnaires. Then, the researcher contacted the children's mothers and informed them about the study and assured them that their responses should be kept confidential and anonymous.

Consequently, 96 parents were involved in the present study, 11 of whom were fathers while 85 were mothers. With regard to gender of the child, 61 children were males, 28 of them were females, and seven of them were unknown. Also, for child age, 27 children were aged 6–8, 29 were aged 9–11, 28 were aged 12–14, while 10 were aged between 15 and 16, and the age of the last two was unknown. With regard to the level of disability, 79 children have only CP while 15 of them have multi-disabilities (CP and MR at the same time).

Instruments

Social and Emotional Behavioral Problematic Scale

To achieve the study objectives, the researcher developed the Social and Emotional Behavioral Problematic (SEBP) scale, which is used to identify and measure the emotional problems connected with children who have CP based on parents' reports according to the following steps,

Step 1: reviewing the theoretical and experimental literature

The scale was developed by the researcher, based on a survey in which parents of children with CP were asked to answer an open question: ‘What are the essential E-S behavioural problems faced by your child with CP?’ Participants had to write down all the emotional and social behavioural problems their children with CP showed. The researcher benefited from the parents' answers to develop the research tool and in validating the findings of this study. Then, the researcher reviewed the theoretical and experimental literature related to emotional and social behavioural problems of disabilities faced by children in general, and the children with CP in particular, identified the items and sections of the instrument, and distributed the items on the sections. Then, the researcher rewrote the responses in her own words, so each of them was designed to identify the emotional and social behavioural problems that may occur in children with CP according to experimental literature.

The instrument used to collect data in this study consisted of 80 items in the primary frame and composed of two sections. The first section included a demographic questionnaire inquiring about characteristics of family members, income level of the family, the highest level of education, in addition to characteristics of the person with CP including age and gender. Section two used was rated using a Likert-type scale that ranged as follows: 5 = ‘strongly agree’, 4 = ‘agree’, 3 = ‘neutral’, 2 = ‘disagree’, 1 = ‘strongly disagree’. These sections also included five scales: Shyness/Withdrawal (15 items); Depression (12 items); Worrying and Nervousness (Anxiety) (13 items); Social Isolation (10 items); and Aggressiveness (20 items)

Correct the scale

The scale used in rating the participant caring parents' performance is a five-point scale (one to five). Since a value 3 forms the midpoint of this scale, the half-degree ranged between 2.5 and 3.49 and represented the mean degree on the scale and lies in the category of average degree of problems, so we identified one category lower than this, and other categories are higher than this category (5–3.5 represent a high degree of problems, 2.49–1 represent a low degree of problems).

Step 2: validity and reliability of the instrument

The researcher translated the questionnaire into Arabic after preparing it in English since the respondents were native Arabic speakers, and most of them did not have adequate knowledge of English. Therefore, both the English and Arabic copies were proofread by a language specialist who made some modifications on a number of items included in the questionnaire. In order to ensure the validity of the questionnaire, only the Arabic version was tested on a group of six special education professionals at some universities in Jordan, and also on 20 professionals providing services to children with disabilities. Their role was to confirm whether the content of the questionnaire is accurate and adequate in terms of language clarity to check the relevance of each item of the main section in the questionnaire and to provide any additional comments or corrections. In the light of their modifications, some items were added to the questionnaire and others were excluded or refined. So, changes necessitated changing the number of items to 70 instead of 80 distributed on the previous five measuring subscales, and parents, mostly mothers, completed the questionnaire. Each item describes a board range of childhood emotional and social behavioural problems (from three to 16 years). The researcher used a broad band scale for internalising problems that are composed of the subscales Shyness/Withdrawal (e.g. avoiding talking face to face with others), Depression (e.g. feeling that they cannot achieve anything, Anxiety (e.g. getting nervous when asked to talk about or express his or her feelings), Social Isolation (e.g. tending to be lonesome most of the time), and Aggressiveness (e.g. speaking bad language with siblings).

The researcher also ensured the validity of the study questionnaire by ensuring the inference of discriminative validity by computing the total degree of the experimental sample. The first application of the instrument was conducted on the experimental sample that consisted of 50 mothers and fathers who had children with disabilities. Then, the total degree of the experimental sample was placed in descending order. Next, it dealt with the top 25% from the total degree, and considered the individuals who took these degrees as members who had the higher rank group; at the same time, the individuals who achieved the least 25% from the total degree were considered as individuals who had a lower rank group. Then, the t-test was used for the independent samples to examine the difference between the average of the two groups divided by the total degree as an indicator of the discriminative validity of the instrument, as shown in Table 1.

Table 1 Results of t-test for the average of higher and lower rank groups.

	Rank	n	Mean	Standard deviation	t	p
Total degree for the questionnaire	Higher rank group	25	2.82	0.314	12.74	0.000*
	Lower rank group	25	1.76	0.274
Note: *Significant at p <  0.05.

Table 1 shows that there are statistically significant differences < 0.05 for the total degree of the questionnaire between the ratings of higher categories of individuals and the rating of lower categories of individuals in favour of individuals of higher rank. This means that the questionnaire could discriminate between the individuals of higher and lower ranks. So, the researcher could consider the validity of the questionnaire, and it is enhanced by the evidence of discrimination/distinguished validity.

The reliability of the questionnaire was estimated by calculating the internal consistency, using the Cronbach alpha method for each scale. Thus, the Shyness behaviour scale scored 0.76, the Depression behavioural scale 0.76, the Anxiety behavioural scale 0.83, the Social Isolation behaviour scale 0.71, the Aggressiveness behaviour scale 0.83, and the total scale 0.83. This result means that the reliability coefficient has been satisfactory for the purpose of this study.

Also the researcher used the test–re-test method to estimate the reliability of the questionnaire by applying it for the first time on a prospective sample, consisting of 50 fathers and mothers in 12 February 2008. After two weeks from that data collection the application of the sample was reapplied on the same sample, and then the correlate score of coefficients was computed on second administration of a test with the score from the first administration, which was 0.77.

Before being distributed to the study sample, the instrument was piloted in three care centres of children with CP chosen from the study population who were outside the original study sample. This was necessary since the research instrument had been translated into Arabic after being prepared initially in English. The questionnaire, which had validated and reliability tested, was distributed to a group of 10 parents in three centres. The aim was to have a preliminary judgement of the questionnaire items and to clarify their meanings, so that it would be more possible to carry out necessary changes in order to make each item more effective. The participants were asked to respond to the questionnaire and to express their opinion and reactions. During all times the participants were involved in responding the questionnaire, which was tested as well.

Data collection

Data were collected from 96 mothers of children with CP at the public and private schools during the academic year 2008/09.

Data analysis

The survey questionnaire was quantitatively analysed by utilising the Statistical Package for the Social Sciences (SPSS). The collected data were analysed and expressed by means and standard deviations (SDs). The t-test for the independent sample and one-way analysis of variance (ANOVA) were used as the main statistical techniques in the study. The t-test was used to determine any statistically significant differences caused by children's gender and level of their disability, whereas ANOVA was employed to determine any statistically significant differences among parents with regard to their financial levels and child's age.

Findings

Results pertaining to the first research question

The first research question addressed the main emotional and social behavioural problems among children with CP from parents' perspectives. In order to answer this research question, mean, standards deviations and rank were calculated and used.

As shown in Table 2, the most serious problem with children with CP was shyness. This problem had the higher mean score 2.58, SD = 0.52, followed by the depression dimension, which ranked second with a mean score of 2.38. Next, aggressiveness and isolation had mean scores of 2.34, SD = 0.57 and 2.24, SD = 0.62 respectively. On the other hand, emotional and social behavioural problems related to anxiety were ranked as the least serious problems that children with CP face according to their parents' perspectives with a mean score of 1.96, SD = 0.61.

Table 2 Mean and standard deviations of five dimensions of the SEBP scale.

Dimension	Mean	Standard deviation	Rank
Shyness	2.58	0.52	1
Depression	2.38	0.55	2
Isolation	2.24	0.62	4
Anxiety	1.96	0.61	5
Internalising problems	2.29	0.46
Aggressiveness	2.34	0.57	3
Total	2.30	0.44

It is also obvious from Table 2 that the mean of participants' ratings on emotional and social behavioural problems of children with CP for the overall scale is 2.3. In particular, the mean of participants' ratings on internalising problems in children with CP was 2.29, SD = 0.46, and 2.34, SD = 0.57 for the externalising problems, represented by aggressive behaviour.

Table 3 displays the items of five dimensions in which parents have been asked to report the extent to which they have rated them as emotional and social behavioural problems of their children with CP. The table illustrates that the most serious problems were viewed as being related to shyness where parents regarded ‘Depending on others he is familiar with’ as the biggest problem with mean of 3.72 and SD = 1.14. With regard to the emotional and social behavioural problems for children with CP related to depression, the results show that the most serious problem of children with CP according to their parents' perspectives with mean of 2.86, SD = 1.06, was the ‘Feeling guilty when things don't do right’. Regarding social isolation, the data indicate that the most serious problem for children with CP was ‘Making individual decisions’ and ‘not expressing on himself eloquently’ with a mean of 3.6 and SD = 1.02, 1.17 respectively.

Table 3 Distribution of S-E behavioural problems among children with CP according to their parents' perspective.

Number	Domain/item	Rank	Mean	Standard deviation
Domain 1. Shyness behaviour
7.	Depending on others he is familiar with.	1	3.72	1.14
14.	Being unable to express his feelings clearly.	2	3.13	1.23
15.	Feeling sensitive when dealing with others.	3	2.87	1.12
2.	Avoiding interaction with others.	9	2.4	0.96
3.	Appearing shy at school not at home.	9	2.4	0.96
6.	Selecting individual activities.	9	2.4	1.03
4.	Avoiding talking face to face with others.	10	2.3	1.10
10.	Believing that he can't achieve.	10	2.33	1.08
5.	Being not intimate with others.	11	1.92	0.93
Domain 2. Depression behaviour
19.	Feeling guilty when things don't do right.	1	2.86	1.06
20.	Crying quickly for any reason.	2	2.85	1.12
26.	Complaining a lot.	3	2.55	1.08
25.	Getting hesitant and nervous quickly.	10	2.27	1.0
22.	Feeling hated by others.	11	2.06	1.02
27.	Appearing to be afraid or in pain without a concrete reason.	12	1.79	0.86
Domain 3. Worrying and Nervousness (Anxiety) behaviour
39.	Getting nervous when asked to talk about or express his feelings.	1	2.26	0.97
38.	Becoming hesitant when going to school.	2	2.19	1.13
32.	Forgetting easily what he wants to say.	3	2.17	1.11
35.	Seeming preoccupied and stressed.	9	1.82	0.9
31.	Getting nauseated and dizzy when facing a situation.	10	1.78	0.99
29.	Having a headache before and after doing a task.	11	1.72	0.92
Domain 4. Aggressiveness behaviour
49.	Getting upset in rage when he doesn't get what he wants.	1	3.12	1.4
48.	Not feeling guilty when misbehaving.	2	2.87	1.15
45.	Hitting his siblings.	3	2.66	1.02
47.	Destroying his own belongings.	15	2.28	1.24
44.	Hitting friends of his own age.	16	2.05	1.08
42.	Speaking bad language with his peers.	17	1.77	1.0
Domain 5. Social Isolation behaviour
62.	Not expressing himself eloquently.	1	2.6	1.17
65.	Making individual decisions.	1	2.6	1.02
60.	Not interacting with others.	2	2.35	1.08
70.	Not taking responsibility.	3	2.29	1.1
69.	Not cooperating with his peers.	7	2.13	1.1
67.	Not appearing glad when he finds someone that shares the same interests and hobbies as him.	8	1.84	0.99
66.	Complaining from people trying to avoid him.	9	1.76	0.80

Furthermore, the more serious emotional and social behavioural problem related to the domain concerning aggressiveness was that ‘Getting upset in rage when he doesn't get what he wants’ with a mean of 3.12, SD = 1.14. Emotional and social behavioural problems concerning the dimension of anxiety were not serious compared with others, and they were ranked as being the least serious problems. The main problem listed here was ‘Getting nervous when asked to talk about or express his feelings’, with a mean score of 2.26, SD = 0.95.

Results pertaining to the second research question

The second research question examined the statistically significant differences among emotional and social behavioural problem dimensions among children with CP. The demographic variables that were investigated were child's gender, age, and level of disability.

The t-test for independent sample was used to examine the difference in mean between female and male children with CP according to their level of disability (CP, or CP and MR). On the other hand, one-way ANOVA was utilised to identify whether the variances of the four levels of age of children with CP (6–8, 9–11, 12–14, 15–17) on participant's ratings to behavioural problems measured by study scale were significantly equal or different.

Table 4 shows that there were significant differences at the 0.05 level between females and males with CP according to the ratings of parents participated in study on the anxiety dimension and internalising problems in general. This difference was in favour of males. Moreover, Table 5 reports that there have been significant differences at the 0.05 level between children with CP and children with both CP and MR as rated by the participants of the study of the Shyness dimension, Isolation dimension, and internalising problems dimensions, which were in general in the favour of children with CP and MR.

Table 4 Difference between male and female children with CP on each dimension of the SEBP scale.

Dimension	Gender	n	Mean	Standard deviation	t	Degrees of freedom	p
Anxiety	Male	61	2.07	0.68	2.513	87	0.014*
	Female	28	1.71	0.47
Isolation	Male	61	2.33	0.65	2.702	87	0.008*
	Female	28	1.97	0.46
Internalising problems	Male	61	2.36	0.48	2.37	67	0.02*
	Female	28	2.11	0.39
Total	Male	61	2.37	0.45	2.457	87	0.016*
	Female	28	2.12	0.43
Note: *Significant at α = 0.05.

Table 5 Difference between intellectual ability (CP, and CP with MR) on each dimension of the SEBP scale.

Dimension		n	Mean	Standard deviation	t	Degrees of freedom	p
Shyness	CP	79	2.52	0.48	− 2.150	92	0.046*
	CP with MR	15	2.90	0.65
Isolation	CP	79	2.17	0.58	− 2.359	92	0.020*
	CP with MR	15	2.58	0.76
Internalising problems	CP	79	2.24	0.42	− 2.29	92	0.024*
	CP with MR	15	2.53	0.59
Note: *Significant at α = 0.05.

Utilising one-way ANOVA, as Table 6 records, shows that there are statistically significant differences in the ratings of participating parents for the behavioural problems in their children with CP at the 0.05 level among the four levels of age of the variable of children with CP in overall behaviour problems, in internalising problems in general, in the Anxiety dimension and in the Aggressiveness dimension.

Table 6 Differences among the age of children with CP (7–9, 10–12, 13–15, 16–18) in each dimension of the SEBP scale.

Dimension		Sum of square	Degrees of freedom	F	p
Anxiety	Between groups	4.127	3	3.895	0.011*
	Within groups	31.782	90
	Total	35.909	93
Internalising problems	Between groups	2.504	3	4.363	0.006*
	Within groups	17.217	90
	Total	19.72	93
Aggressiveness	Between groups	2.798	3	2.987	0.035*
	Within groups	28.102	90
	Total	30.900	93
Total	Between groups	2.477	3	4.682	0.004*
	Within groups	15.874	90
	Total	18.352	93
Note: *Significant at α = 0.05.

To determine what levels of age of children with CP contribute to the statistical difference in each dimension, post-hoc comparison was carried out using the least-significant difference test. Table 7 shows the results of the post-hoc comparisons of the Anxiety dimension with respect to the age of children with CP. According to the results, it is obvious that statistically significant differences (at alpha = 0.05) exist among the different age levels of children with CP. Having a look at Table 7, it can be noticed that parents who participated in the study report that their children with CP at age 7–9 have more degree of anxiety more than those at 10–12 years, and those at 12–15 years.

Table 7 Post-hoc comparisons for anxiety behaviour, aggressiveness behaviour, internalising problems, and overall behaviour problems with respect to age of children with CP.

Dimension	Age of children/mean				Mean difference (I-J)	Standard error	p value
Anxiety	7–9	2.27	10–12	2.31	0.4214	0.15892	0.009*
	7–9	2.27	13–15	2.23	0.5150	0.16028	0.002*
Aggressiveness	7–9	2.89	13–15	2.14	0.4479	0.15072	0.004*
Internalising problems	7–9	2.52	10–12	2.18	0.3454	0.11697	0.004*
	7–9	2.52	13–15	2.14	0.3796	0.11797	0.002*
Overall behaviour problems	7–9	2.54	10–12	2.21	0.3282	0.11231	0.004*
	7–9	2.54	13–15	2.14	0.3932	0.11328	0.001*
Note: *Significant at α = 0.05.

Table 7 shows results of the post-hoc comparisons in the Aggressiveness dimension regarding children with CP age. As noted from Table 7, parents' ratings show statistically significant differences in the aggressiveness level between the age groups of 7–9 and of 13–15 years in favour of children in the age group of 7–9-years-old.

Moreover, Table 7 shows the post-hoc comparisons for internalising problems with respect to the age of children with CP. With respect to the overall internalising problems (Anxiety, Shyness, Depression, Isolation), it is clear from Table 6 that there exist some statistically significant differences between participants' ratings due to age level among their children with CP (between 7–9 years and 10–12 years and between 7–9 years and 13–15 years). Having a look at the mean in Table 6, it is noticed that children with CP in the age group of 7–9-years-old according to parents report appearing to have more degree of behavioural problems than those in the groups of 10–12 years and 13–15 years have.

Table 7 also shows the post-hoc comparisons of overall behavioural problems regarding the age of children with CP. With respect to the overall behaviour (internalising problems, aggressiveness), it is noted from Table 6 that there is a statistically significant difference among participants ratings due to age level of their children with CP (between 7–9 years and 10–12 years and between 7–9 years and 13–15 years). Having a look at Table 7, it is noticed that the children with CP in the group of 7–9-years-old according to parents' report appear to have a greater degree of behavioural problems more than those in the age group of 10–12-years-old and 13–15-years-old have. However, this difference does not exist in participants' ratings between the age groups of 7–9 and 16–18, between 10–12 and 13–18, between 10–12 and 16–18, and between 13–15 and 16–18.

Discussion and conclusion

The data collected from parental reports of S-E behavioural problems of children with CP demonstrate and help us find out if children with CP have behavioural problems at different levels: gender, age, income level, or overall general estimates of intellectual level that add significantly to the report of behavioural problems.

The findings of the current study indicate that children with CP, on average, have a moderate degree of S-E behavioural problems according to their parents' report, which is lower than previous estimations (30–80%) (McDermott et al., 2002). These results could attend special schools or daycare centres for children with CP, MR, or for multi-disabilities due to that child in this study. All these alternative placements, including staff, dealt with these children and their parents in a positive way, were interested in developing a warm environment stimulating social interaction and adjustment with themselves, and focused fostering all developmental areas including emotional and social development in a healthy way that might prevent problems in this area of development, which can explain the modernity level of S-E behavioural problems of these children according to their parents' perspectives.

Differences are found in most types of problems but it is largest for shyness and anxiety behavioural problems, which probably resulted from the fact that there were many children with CP who performed well and received good care from their families, schools, medical care, and education services. Thus, the sample used in current studies is more likely to represent the wide array of children with CP. Indeed, our results agree with those of many previous studies (Andren & Grimby, 2004; Colver, 2007; Fox, 2002), which indicates that parents report that children with CP have a modern degree of S-E behavioural problems. Likewise, these results can be explained by CP being a life-long disability and that these children might cope with their situation, compared with children with progressive disabilities or those who have a mild degree of physical disability like cleft palate, as emphasised by many studies (for example, Arnaud et al., 2008; Hinton et al., 2006; McDermott et al., 2005; Miyahara & Piek, 2006), and so those CP children can behave like their peers with no disabilities.

As a group, CP children have a considerable risk for developing problems assessed by the shyness scale with a mean score of 2.58. Shyness is considered the first problem according to parents' reports. This can be resulted from parental practices, consistent disciplinary practices, lack of social skill, and communication with others. Lack of self-assertion or high perceived parent over-protectiveness are confirmed by many studies like Manuel et al. (2003), who ensured that these factors are able to develop emotional and social aspects of the child's character including self-view and self-worth, which are finally related to the emergence of internalising problems, including shyness as Aasland and Diseth (1999) and Schuengel et al. (2006) reported.

The second problem is related to depression according to parents' reports with a mean score of 3.05 to a moderate degree. The current result is similar to the findings of the majority of previous research indicating that individuals with CP have a moderate degree of depression like other people with no disability. This result could be due to physical appearance and depression due to the fact that they cannot be like their peers and do not have a normal body like them. This is explained and ensured by many studies like Sexson and Dingle (2001), who reported that the physical appearance was a reason for the feeling of depression. Several studies also reported that major physical disabilities like CP did not seem to cause the development of behavioural problems compared with mild physical disabilities (Andren & Grimby, 2004; Colver, 2007; Fox, 2002; McDermott et al., 2002; Miyahara & Piek, 2006). Orr (1989) reported that getting a positive perception from the parent presents some kind of physical and emotional support to their child with a disability.

Next, the problem related to aggressiveness gave a mean score of 2.34, with moderate degree. The explanation of this can be that these children have problems in motor competence. Schuengel et al. (2006) ensure that it is related positively to aggressiveness behaviour.

As a group, children with CP are least likely to develop problems assessed by isolation and anxiety scales with mean score of 2.24 and 1.96, respectively. In relation to anxiety behaviour, the current result is similar to Miller, Johann-Murphy, and Cate (1997) who found that anxiety decreases in children with CP over time. This result is not like the previous studies such as Harvey and Greenway (1984) who found that children with physical disabilities have a greater anxiety compared with children with no disabilities. In addition, it is interesting to speculate the possible antecedent conditions contributing to the development of problems in these behavioural dimensions. Such behavioural problems are quite possibly due to parental practice. Available school and community services present to these children and their family, in addition to the nature of disability that becomes part of their long life and stability of the level of disability across life-stages. All of these factors may force the parents and the child to cope with the situation and to be a normal person in their own and others' view. Clearly, future research should be undertaken to determine how parents' practice and interaction affect the development of emotional and social behaviour of children with CP. Also, they should compare children with CP who suffer from a long-life non-progressive disability and others who are affected by physical disabilities that can be considered progressive.

Otherwise, this result is not consistent with the research of Breslau and Marshall (1985) and Blum et al. (1991) who ensured that isolation is considered problematic for children with CP. These problems scores in this study are considerably less likely to be at risk for developing isolation problems. This could be due to the vast majority of these children living with their families, friends and relatives. Indeed, this social life could force these children to face other children their age at home and school, and this environment makes these children's life full of factors and people to encourage them to be interactive with others – especially because these children usually do not recognise the difference between them and their peers until others see it, and they are usually affected by others' attitudes and perspectives. Besides, their family and others deal with their child's conditions cautiously. So, they might see their child with CP as their peers and deal with him according to this perspective. Colver (2007) ensured this conclusion when reporting that most children with CP have a similar quality of life as other children. Furthermore, Andren and Grimby (2004) and Fox (2002) found that S-E life and satisfaction among children with CP are similar to the average of population.

Research should be interested also in examining if there is consistency within children's behaviour in each situation they encounter; at school and at home. There is also a need to conduct longitudinal design studies to provide information about the behavioural problems.

In addition, significant differences between males and females with CP were found for overall behavioural problems, anxiety, and isolation dimensions in favour of males. These findings combine with the result of numerous studies concerned with children in general (Weisz, Sigman, Wiess, & Mosk, 1993) to suggest that boys are more likely than girls to develop undercontrolled problems. This trend may be rather robust across different cultures and different socialisation practices, therefore; it may result in relatively culture-transcendent causal forces. This result also explained the expectation demand of males compared with females and pressure on them to be like other children, and the nature of responsibility they must have as males in family and community compared with females. Findings showed that children with CP and MR were reported to have more shyness and social isolation behaviour compared with children with CP only. This result is similar to the results of Breslau and Marshall (1985), who reported that social isolation is considered a significant problem for children with CP. This result could be due to shyness and social isolation being related to the interactive relation with others, and because the degree of a person's relationship with others depends on what range they possess in communication and social skills. So, children with CP and MR might need to learn communication skills to be able to deal with others and interact with them effectively. Some studies (McDermott et al., 1996) reported that these children with MR show higher risk for developing behavioural problems including anxiety and anti-social behaviour.

Besides, the results of the one-way ANOVA reveal that there were statistically significant differences in behavioural problems among children with CP, including anxiety and aggressiveness dimensions in favour of children 7–9-years-old. This means that children with CP aged 7–9 have higher level of behavioural problems compared with children aged 10–12 and 13–15 in general. This could be due to children of 7–9 years interacting with others out of their family, at school and in the community, and might face in this new situation of new stress and pressure. In this field, Jan et al. (2006) stated that, at this stage, children with CP see themselves different due to dependency on others' views. After this stage, peers and others who deal with them at school and community affect them, and they might adjust with others – as Colver (2007) showed that most children with CP aged 8–12 have similar quality of life compared with other children, and as Fox (2002), Andren and Grimby (2004), and Heward (2006) have shown that these children, in relation to S-E life and satisfaction, are similar to the average population of all children.

Finally, a reminder is needed that the information presented here was all derived from parents' reports on their child's S-E behavioural problems. Although parents' reports may be the best single source of information for children's problems, it is also true that parents' notes and what they see as significant problems in their child can be influenced by several factors like cultural ethos and social values of the parents' society. It will be important for future studies to assess children's problems from other sources (e.g. teachers and the children themselves) and consider the direct observation of a child's behaviour within their life activities.

Implications

Because the variety of development areas overlap, the present S-E behavioural problems influence not only their emotion and social behaviour areas but also the cognitive, academic, physical aspects of development, and their abilities to practice their life activities in the school, home, and community. Therefore, the findings of this study indicate that children with CP encounter a number of problems that hinder their actual participation in school activities, develop effective social interactive with their peers, and make them happy in their life and cope with their situation.

These problems have been classified into different domains of varied seriousness. Suggestions have been made on how we can enhance and overcome S-E behavioural problems that may present among children with CP. Although the current study reveals that children with CP have on average a moderate degree of S-E behavioural problems, these limit their ability to cope with themselves and others and to express their feelings. Such children simply need specific interventions to help themselves overcome problems they face to cope with their situation, overcome S-E behavioural problems they may have due to their physical appearance, others' attitudes and perspectives, develop communication skills, be self-assertive, and have social interaction with their peers and others. Moreover, there is a need to perform another piece of research that must focus on identifying protective factors related to children and their environments that help reduce the risk of onset of behavioural problems. These factors may include social support, school placement and the nature of services present for such children and their families. Likewise, there is a need to conduct additional research to address the effectiveness of intervention programmes, services, and counselling programmes that deal with these children and their families.

It is necessarily to recommend that care centres and school care of children with CP need to develop early intervention programmes to treat physical attendant symptoms to CP like drooling, communication disorders, and movement disability, which affect the prevention of S-E behavioural problems among these children.

Moreover, parents of children with CP need to train in order to develop their skills to cope with their child situation, develop reality expectation for their child, and train themselves to have specific skills to provide their child with positive environment that helps prevent him/her from having any serious level of S-E behavioural problems and skills to have awareness of problems that their child may have and how to treat it in collaboration with professionals.

Schools and daycare centres are the first setting where children have to concentrate on specific tasks for long periods and have continuous social interaction in a large group. So, targeted educational assistance for children with CP and their parents during school entrance might help them to overcome such S-E behavioural problems. Teachers and other professionals working with children with CP and their parents need also to be trained for routine screening for these problems, identifying its degree, and offering supportive treatment.

Parents also need training programmes in order to enhance their abilities to develop their strategies and skills that deal with their child's behaviour and increase his strength and maintain appropriate behaviour in addition to the skills that help decreasing behavioural problems. Furthermore, Jordanian universities that grant a bachelor's degree in the special education field should offer courses for trainee teachers on the home–school relationship, parental empowerment, and effective behavioural modification that can be used by parents in order to develop healthy growth for their children with CP.

So, when parents develop their ability to control their child's behaviour and master the abilities and knowledge to manage and modify his or her S-E behavioural problem, they can predict events that may lead to increase behavioural problems and modify the environment that support appropriate behaviour. Also, by attending training programmes, parents can develop their skills to cure behavioural problems through positive strategies, and when the parents are finally able to manage and decrease behavioural problems. This all contribute to help them to develop positive perception toward their child with CP and his competence. So, they can establish healthy relationships among family members as a whole and with one another effectively.

Much research is needed to try to replicate these findings in other samples and to establish valid scale cut-off scores that discriminate between children and adolescents in need of professional healthcare versus those who are not. Finally, there is a need to encourage parental involvement in every aspect of the policies and strategies relevant to the teaching and learning their children in a safe learning environment in order to enhance the mutual understanding of their child with CP.