Caregiver stress: The crucial, often unrecognized byproduct of chronic disease

September 11, 2019

Science Daily/Elsevier

There is growing evidence that caregivers of patients with cardiovascular disease (CVD) are vulnerable to developing their own poor cardiovascular health. Investigators report in the Canadian Journal of Cardiology, published by Elsevier, on a proof-of-concept couples-based intervention in a cardiac rehabilitation setting. This intervention has shown potential for reducing caregiver distress, and future studies are evaluating its impact on both caregivers' and patients' cardiovascular health.

Nearly half of Canadians have been in caregiving roles to family and friends, with similar figures in the United States and Europe. A caregiver is broadly defined as someone who provides informal or unpaid work to a family member or friend with a chronic condition or disability. Caregivers provide crucial, rarely remunerated support to sick family members or friends. About 40 per cent of caregivers, of whom more than half are women, report high psychological, emotional, physical, social, and financial stresses imposed by the caregiving role. These factors can contribute to a higher risk of CVD among caregivers themselves. However, despite an appreciation of these issues, few approaches have been effective in reducing caregiver stress. This need is expected to increase because pressures on "cardiac" caregivers are projected to rise in the next decade as the population ages, length of hospital stays decline, and CVD and associated risk factors continue to increase.

"It is abundantly clear that caregivers need to be better supported!" said lead investigator Heather Tulloch, PhD, Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute (UOHI), and University of Ottawa, Ottawa, ON, Canada. First author, Karen Bouchard, PhD, postdoctoral fellow in behavioral medicine at UOHI added, "Caregivers are critical for patients' cardiovascular health management and are an invaluable healthcare resource, contributing enormously to the Canadian healthcare system. Individuals who care for their partners may experience additional cardiovascular risk -- a risk that should be recognized and to which we should respond."

In this narrative review, investigators look at evidence from the fields of health psychology and relationship science and highlight the direct (e.g., physiological) and indirect (e.g., behavioral, emotional) factors that link caregiver distress with caregivers' own cardiovascular risk. For example, caregivers are more likely to continue to smoke and less likely to be physically active than individuals who provide no or low levels of care; their diets tend to be high in saturated fat intake leading to greater body mass indexes; they spend less time engaging in self-care activities and report poor preventive health behaviors; they experience less or disordered sleep; and demonstrate poor adherence to medication. Spousal caregivers have higher levels of depressive symptoms, physical and financial burden, relationship strain, and lower levels of positive psychological wellbeing compared to adult children caregivers, for example.

The researchers report that the risk of hypertension and metabolic syndrome may be directly related to high-intensity caregiving, defined as providing more than 14 hours of caregiving per week over two consecutive years. They also report findings that estimate the economic contribution of caregivers' unpaid labor to be $26 billion annually in Canada, which is projected to increase to $128 billion by 2035 (likely translating to over a trillion dollars each in the USA and Europe).

The investigators contend that the cardiovascular health of both patient and caregiver could be improved by enhancing the quality of the patient-caregiver relationship. They describe a proof of concept testing of Healing Hearts Together, a relationship-enhancement and educational program for patients and partners. Based on attachment theory, which states that close emotional bonds are essential when faced with a threat such as a cardiac event, the program guides couples through conversations in which they review information on heart health and attachment; share their unique experiences with heart disease with partners and peers; and learn to clearly communicate their need for connection and reassurance. This connection enhances couple satisfaction and problem solving. Participants reported improvements in relationship quality, mental health, and select quality of life measures. A controlled evaluation of the impact of the program on cardiovascular risk factors is underway.

"The aim of Healing Hearts Together is to increase emotional accessibility and responsiveness in couples facing CVD," explained Dr. Tulloch. "Taken together, couples-based interventions in a cardiac rehabilitation setting may be a timely and appropriate approach to reduce caregiver distress and enhance caregivers' comprehensive health outcomes. There is an emerging opportunity to care for those who care for their partners and enhance the health of both. It is important that healthcare professionals recognize the burden of caregiving and act sensitively and strategically to address these challenges."

"Detrimental effects of the caregiving experience are greater among middle-aged caregivers, those known as the 'sandwich generation,' because they balance paid work commitments and interpersonal relationships with care delivery tasks for parents, children, and/or partners," commented Monica Parry, NP-Adult, MEd, MSc, PhD, University of Toronto, Toronto, ON, Canada, in an accompanying editorial. She points out that men and women deal differently with caregiving and, as the landscape of heart disease in women is changing, so must our approach and understanding of the caregiving experiences of men. For example, male caregivers may struggle with the societal views of caring; feel invisible at times; and may be unsure how to assimilate the caring role, masculinity, and accessing help for themselves. "We are facing an epidemic of caregiver burden. Caregivers cannot remain under-researched, under-diagnosed, under-treated and/or under-supported," she concluded.

https://www.sciencedaily.com/releases/2019/09/190911091400.htm

How parenting affects antisocial behaviors in children

October 11, 2018

Science Daily/University of Pennsylvania

In a recent study of the parental caregiving environment, researchers found that within identical twin pairs, the child who experienced harsher behavior and less parental warmth was at a greater risk for developing antisocial behaviors.

Less parental warmth and more harshness in the home environment affect how aggressive children become and whether they lack empathy and a moral compass, a set of characteristics known as callous-unemotional (CU) traits, according to findings from the University of Pennsylvania, the University of Michigan, and Michigan State University. The work was published in the Journal of the American Academy of Child and Adolescent Psychiatry.

In a study of 227 identical twin pairs lead by Penn psychologist Rebecca Waller, the research team analyzed small differences in the parenting that each twin experienced to determine whether these differences predicted the likelihood of antisocial behaviors emerging. They learned that the twin who experienced stricter or harsher treatment and less emotional warmth from parents had a greater chance of showing aggression and CU traits.

"Some of the early work on callous-unemotional traits focused on their biological bases, like genetics and the brain, making the argument that these traits develop regardless of what is happening in a child's environment, that parenting doesn't matter," says Waller, an assistant professor in Penn's Department of Psychology. "We felt there must be something we could change in the environment that might prevent a susceptible child from going down the pathway to more severe antisocial behavior."

The work is the latest in a series of studies from Waller and colleagues using observation to assess a variety of aspects of parenting. The initial research, which considered a biological parent and child, confirmed that parental warmth plays a significant role in whether CU traits materialize.

A subsequent adoption study, of parents and children who were not biologically related, turned up consistent results. "We couldn't blame that on genetics because these children don't share genes with their parents," Waller says. "But it still didn't rule out the possibility that something about the child's genetic characteristics was evoking certain reactions from the adoptive parent." In other words, a parent who is warm and positive may have a hard time maintaining those behaviors if the child never reciprocates.

Knowing this led Waller and University of Michigan psychologist Luke Hyde to team with S. Alexandra Burt, co-director of the Michigan State University Twin Registry. Using 6- to 11-year-old participants from a large, ongoing study of twins that Burt directs, the team turned its attention to identical twins.

For 454 children (227 sets of identical twins), parents completed a 50-item questionnaire about the home environment. They also established their harshness and warmth levels by rating 24 statements such as "I often lose my temper with my child" and "My child knows I love him/her." The researchers assessed child behavior by asking the mother to report on 35 traits related to aggression and CU traits.

"The study convincingly shows that parenting -- and not just genes -- contributes to the development of risky callous-unemotional traits," says Hyde, an associate professor in Michigan's Department of Psychology. "Because identical twins have the same DNA, we can be more sure that the differences in parenting the twins received affects the development of these traits."

According to Waller, a potential next step is to turn these findings into useable interventions for families trying to prevent a child from developing such traits or to improve troubling behaviors that have already begun.

"From a real-world standpoint, creating interventions that work practically and are actually able to change behaviors in different types of families is complicated," Waller says. "But these results show that small differences in how parents care for their children matters. Our focus now is on adapting already-successful parenting programs to include specific interventions focused on callous-unemotional traits as well."

Though an intervention with parents could succeed, Hyde and colleagues stress that the work isn't blaming parents for their child's CU or aggressive behaviors. "Our previous work with adopted children also showed that genes do matter, and so there is a back and forth," he says. "Some children may be more difficult to parent. The most important message is that treatments that work with parents likely can help, even for the most at-risk children."

The researchers acknowledge some limitations to the study, for example that it skews heavily toward two-parent families, meaning the findings may not be as generalizable to single-parent homes. It also assesses parenting measures and twin behaviors based solely on parenting reports.

Yet despite these drawbacks, the researchers say the work broadens the understanding of how different forms of antisocial behavior, like aggression and callous-unemotional traits, emerge. "This provides strong evidence that parenting is also important in the development of callous-unemotional traits," Hyde says. "The good news is we know that treatments can help parents who may need extra support with children struggling with these dangerous behaviors."

https://www.sciencedaily.com/releases/2018/10/181011173131.htm