Parental Distress Research Articles

Grief and bereavement support amidst palliative care in the paediatric intensive care unit

ABSTRACT In paediatric intensive care units (PICUs), advanced medical care meets deeply emotional human experiences. This review examines grief and bereavement support in PICUs, emphasising its significance in extending palliative care beyond end-of-life scenarios. A comprehensive literature search of PubMed and Google Scholar from 2014 to 2023 yielded 50 relevant studies. The findings illustrate the unique challenges in PICUs, such as children’s limited communication abilities, parental distress and emotional burden on healthcare providers. Our review revealed the multifaceted nature of grief in PICUs, including anticipatory and complicated grief, and its profound impact on families and siblings of PICU patients. We identified diverse emotional, psychological, cultural and spiritual support needs that underscored the importance of continuous bereavement care and access to resources. Current support practices, including counselling, support groups, memorial services and interdisciplinary teamwork, are explored. Challenges such as resource limitations, healthcare providers’ emotional toll and communication barriers are discussed. The study also highlights emerging trends such as digital tools, innovative therapies and policy changes to enhance holistic, family-centred care in PICUs.

The Course of Parental Psychological Distress in Childhood and Adolescent Depression

The Course of Parental Psychological Distress in Childhood and Adolescent Depression

Experiences of the Parents of Children Admitted to PICU.

A pediatric intensive care unit (PICU) is a highly technological and fast-paced setting in a hospital. To explore the experiences of the parents in the critical care area of a selected tertiary care facility. In a qualitative study, we interviewed 10 purposively selected parents of the children admitted to PICU using a pre-validated in-depth interview schedule. All parents, whose children were admitted to PICU for more than 5 days, who understood Hindi or English and were willing to participate in the study, were enrolled in the study. Parents of critically ill children having readmission to PICU or prolonged stay of more than 15 days and not accompanied by parents were excluded. Parents had unmet needs, such as the need for information, counseling and education from the healthcare team (HCT) members, having trusting relationship with the HCT, and expecting receiving orientation of the routines and the protocols of PICU, and empathy from the various levels of PICU team. The majority of subjects expressed the desire to talk to a dedicated person for their queries. The parents had multiple feelings of distress, hopelessness, helplessness, guilt, and the fear of losing the child and used various coping strategies. Parents of critically ill children in the PICU have unmet needs. Healthcare team members should take initiative in relieving parental distress and improving their coping abilities. Kichu S, Joshi P, Bhandari S, Lodha R, Jaykrishnan K. Experiences of the Parents of Children Admitted to PICU. Indian J Crit Care Med 2024;28(7):696-701.

Critical examination of ethical dimensions in prenatal and neonatal screening

Increasingly technologized face of reproductive medicine, in which artificial reproductive technology is thriving, and whole genome sequencing is accessible, faces a plethora of new ethical issues. Prenatal tests raise concerns about selective abortions, eugenics and privacy of genetic information, as well as equity and access, while neonatal screening programs are faced with issues concerning the diseases and conditions they cover, disclosure of carrier status and involvement of employers and insurance companies. Even if more and more conditions are identified through genetic screening and testing, many of them have no treatment and diagnosing such a disease has no apparent benefits. False positive results and the incidental discovery of other health issues during genetic testing can cause parental distress and lack of trust in the medical system. Education programs addressed to medical professionals and the public are needed regarding the benefits and the limits of genetic testing and screening.

Effectiveness of a positive psychology and mindfulness-based app on mental health for parents of children with a neurodevelopmental disorder: study protocol of a pragmatic international randomized controlled trial

IntroductionParents of children with a neurodevelopmental disorder (NDD) experience more stress than parents of typically developing children. In a cocreation process with experts and parents, a low-threshold application that uses exercises based on the principles of positive psychology and mindfulness was developed. This application, called “Adappt,” aims at enhancing the ability to adapt of the parents and caregivers of children with NDDs and at supporting their mental health. This protocol describes the evaluation study of the effectiveness of Adappt, its core working mechanisms and user experiences.MethodA pragmatic international multicenter randomized controlled trial will compare the effectiveness of Adappt with a (delayed) waitlist control condition. At least 212 parents or primary caregivers of children younger than 18 years diagnosed with or suspected of a NDD will be randomly assigned to the intervention or waitlist control condition. Participants are excluded if they have severe anxiety or depression levels or are in treatment for mental health issues. Measures will be collected online at baseline, post-intervention (1 month after baseline), and 4 and 7 months after baseline. The primary outcome is the improvement in generic sense of ability to adapt as measured with the Generic Sense of Ability to Adapt Scale (GSAAS; (Front Psychol 14:985408, 2023)) at 4-month follow-up. Secondary outcomes are mental well-being, (parental) distress, and client satisfaction with “Adappt.”DiscussionResults of this study will contribute to knowledge on the effectiveness of a low-threshold application for parents of children with a NDD in multiple countries. If the application is found to be effective in improving mental health, recommendations will be made for implementation in health care.Trial registrationThis study is registered on clinicaltrials.gov (NCT06248762) on February 8, 2024, and the Open Science Framework (https://osf.io/5znqv).

Parenting under pressure: a cross-sectional questionnaire study of psychological distress, parenting concerns, self-efficacy, and emotion regulation in parents with cancer.

As many as one in four adults with cancer have children under 18 years. Balancing parenting and cancer is challenging and can be a source of psychological distress. This study aimed to examine psychological distress in parents with cancer and its associations with parenting concerns, self-efficacy, and emotion regulation. This was a cross-sectional questionnaire study of 406 parents (aged 25-60 years) diagnosed with cancer within the last 5 years, with at least one dependent child (≤ 18 years). Parents completed questionnaires on psychological distress (DASS-21), parenting concerns (PCQ), self-efficacy (GSE), emotion regulation (ERQ), mental and physical health, and sociodemographics. Data were analysed using multiple logistic regressions on depression (yes/no), anxiety (yes/no), and stress (yes/no). Higher parenting concerns were associated with greater odds of depression (OR = 2.33, 95% CI: 1.64-3.31), anxiety (OR = 2.30, 95% CI: 1.64-3.20), and stress (OR = 3.21, 95% CI: 2.20-4.69) when adjusting for health and sociodemographic factors. Poorer self-efficacy was associated with increased odds of anxiety (OR = 0.94, 95% CI: 0.89-0.99, p < 0.05), whereas lower use of cognitive reappraisal and higher use of expressive suppression increased the odds of depression (OR = 0.76, 95% CI: 0.59-0.98 | OR = 1.46, 95% CI: 1.18-1.80). The findings highlight the complexity of parental well-being in relation to parenthood and cancer, stressing the need for interventions that address relevant psychological factors to improve overall mental health in this population.

Exploring the Unique and Interactive Effects Between Callous-Unemotional and Autistic Traits with Parental Practices, Care, and Distress in a Community Sample.

Parental practices and stress are associated with both CU and autistic traits, with parents of children with these traits facing challenges that other parents do not encounter. However, the majority of available studies focused mainly on the unique effects of CU and autistic traits with parental stress and practices without exploring their interaction. The current study examines the distinct associations and interactions between CU and autistic traits with parental practices (parental involvement, poor monitoring, inconsistent discipline, and corporal punishment), care, and distress after considering the effect of conduct problems (CPs), age and sex in a Greek-Cypriot sample (N = 146, Mage = 7.30, SD = 1.43). Hierarchical multiple regression analysis revealed that children with CU traits were more likely to experience negative parenting, while parents showed heightened levels of distress. Notably, the study found no association between CU traits and positive parental practices. Further analysis indicated no significant relation between autistic traits and interactions with the target variables, signifying that these traits are not associated with difficulties in parenting and distress. No sex differences were found in all analyses. Age was negatively significant only in relation to parental distress These findings provide valuable insights into the impact of CU traits and underscore the need for additional studies investigating the impact of autistic traits, possibly within clinical samples.

Household material hardship and distress among parents of children with advanced cancer: A report from the PediQUEST Response trial.

The prevalence and characteristics of household material hardship (HMH) in families of children with advanced cancer and its association with parent distress are unknown and herein described. Parents of children aged ≥2 years with advanced cancer at five cancer centers completed baseline surveys as part of the PediQUEST Response trial. HMH (housing, energy, and food) was operationalized as binary (≥1 HMH domains), ordinal (zero, one, or two or more HMH domains), and housing based (none, nonhousing [food and/or energy], only housing, or housing+other). Associations between HMH and parent distress measured by the State-Trait Anxiety Inventory-State and the 10-item Center for Epidemiologic Studies Depression Scale were estimated via linear models adjusting for confounders. Among 150 parents, 41% reported ≥1 HMH (housing, 28% [only housing, 8%; housing+other, 20%]; energy, 19%; food, 27%). HMH was more prevalent among Hispanic, other non-White race, Spanish-speaking, and single parents and those with lower education (associate degree or less) or who were uninsured/Medicaid-only insured. Parents endorsing HMH reported higher anxiety (mean difference [MD], 9.2 [95% CI, 3.7-14.7]) and depression (MD, 4.1 [95% CI, 1.7-6.5]) scores compared to those without HMH. Distress increased with the number of hardships, particularly housing insecurity. Specifically, parents experiencing housing hardship, alone or combined, reported higher distress (housing only: anxiety: MD, 10.2 [95% CI, 1.8-18.5]; depression: MD, 4.9 [95% CI, 1.3-8.6]; housing+other HMH: anxiety: MD, 12.0 [95% CI, 5.2-18.9]; depression: MD, 4.8 [95% CI, 1.8-7.8]). HMH is highly prevalent in pediatric advanced cancer, especially among historically marginalized families. Future research should investigate whether interventions targeting HMH, particularly housing stabilization efforts, can mitigate parent distress. In our cohort of parents of children with advanced cancer, household material hardship (HMH) was highly prevalent and significantly associated with higher parent distress. Housing hardship was the primary driver of this association. Families of children with advanced cancer may benefit from systematic HMH screening as well as targeted HMH interventions, especially stabilizing housing.

Immobilization during infant fluoroscopy: Pros and cons

This article explores the practice of immobilization during fluoroscopy procedures for infants, discussing its advantages and disadvantages. The authors examine contrasting policies and thoughts on immobilization across different medical institutions. While some advocate for its routine use to minimize patient motion, enhance imaging quality, and decrease radiation exposure, others question its necessity and raise concerns about patient consent and parental distress. Ethical dilemmas are also discussed regarding patient autonomy and psychological impact on families. The authors advocate for a balanced approach, recognizing the utility of immobilization in certain clinical scenarios while still emphasizing patient-centered care. Ultimately, the article underscores the importance of institutional policies that prioritize both patient safety and ethical principles in pediatric radiology practices.

Depression and parental distress among caregivers of autistic children: a serial mediator analysis in caregivers of autistic children

BackgroundThis study aimed to investigate the relationship between the severity of autism, emotional and behavioral problems of autistic children, internalized stigma, depressive symptoms, and primary caregiver parental stress. Specifically, we explored the mediating role of internal stigmatization and total difficulties of individuals with autism on parenting stress and depressive symptoms of the primary caregiver.MethodMothers of 93 children with autism were included in the study. The mothers were given the Beck Depression Inventory (BDI), The Internalized Stigma of Mental Illness Scale (ISMI), the Autism Behavior Checklist, the Parenting Stress Index-Short Form, Strength, and Difficulties Questionnaire -Parent Form (SDQ-P).ResultsAs a result of our study, the emotional and behavioral problems of the child and the internalized stigmatization felt by the parent played a mediator role in the relationship between the child’s autism severity and the parent’s stress and depressive symptoms.ConclusionsOur findings highlight that internalized stigmatization and behavioral characteristics of individuals with autism are among the most critical problems for their primary caregivers. These results have important implications for the development of interventions aimed at reducing the internalized stigma experienced by primary caregivers of individuals with autism and for improving their mental health outcomes.

Psychological Distress, Coping Strategies and Social Support in Parents of Children with Leukemia

Background: Leukemia poses significant distress for affected children and their families, necessitating extensive parental involvement in care. Parents must manage multiple clinic visits, medication administration, and provide emotional support during treatment, impacting their psychological well-being. Objective: To assess the levels of psychological distress, coping strategies, and social support among parents of children with leukemia. Methods: This analytical cross-sectional study was conducted at Bolan Medical Complex and Cenar Cancer Hospital in Quetta, Baluchistan. A total of 341 parents participated, with data collected via three standardized questionnaires: the Coping Health Inventory for Parents (CHIP), Kessler Psychological Distress Scale (K10), and Multidimensional Scale of Perceived Social Support. Ethical approval was granted by the Khyber Medical University Peshawar. Results: Among the participants, 36.1% were aged 25-35 years; 61.9% were male. Educational levels were 73.9% secondary and 23.8% primary. Psychological distress was reported as moderate by 86%, while 76% utilized fair coping strategies, and 95% experienced medium social support. There was no significant correlation between psychological distress and coping strategies; however, a negative association was noted between social support and psychological distress. Conclusion: The study reveals substantial psychological distress among parents, with prevalent fair coping strategies and medium social support. Enhanced social support is negatively associated with psychological distress, highlighting the need for targeted support interventions.

Predictors of children's headaches during the second COVID-19 pandemic wave in the country with long-lasting lockdown.

The current study examined the links and interactions among headaches, screen-based media use, physical activity, sleep, and the family environment in Lithuanian school-aged children during the second COVID-19 lockdown. The study comprised data of 541 children aged 7-14 years from different Lithuania regions, and without chronic health conditions or developmental disorders. Information about the child was provided by their parents or caregivers who filled questionnaire on child's screen time, sleep duration and quality, physical activity, parental distress, parent-child relationship, history of child's headaches and infectious diseases. During the study period, 54% of the children had headaches, and the frequency was positively associated with child's age, screen time and parental distress, as well as negatively related to physical activity (PA), sleep quality, and the parent-child relationship. Parental education was related to child's PA, screen time and sleep quality. The results of binary logistic regression analysis and path analysis revealed that sleep quality and parental distress were significant predictors of headaches in children. Family and child or adolescent education and lifestyle modification aiming to improve sleep hygiene and PA, and to reduce screen-based sedentary behaviour should be provided. Family centred approach for more effective coping with distress and improvement of parent-child relationship is also important in treating child and adolescent headache.

Preliminary development of a measure of parental behavioral responses to everyday pains in young children: the PREP.

Everyday pains are experienced frequently by young children. Parent responses shape how young children learn about and experience pain. However, research on everyday pains in toddlers and preschoolers is scarce, and no self-report measures of parent responses to their child's pain exist for this age group. The objective of this study was to develop a preliminary self-report measure of parent behavioral responses to everyday pains in the toddler and preschool years (the PREP) and examine its relationship with child age, sex, and parent and child distress. Items for the PREP were based on a behavioural checklist used in a past observational study of caregiver responses to toddler's everyday pains. Parents (N = 290; 93% mothers) of healthy children (47.9% boys) between 18 and 60 months (Mage = 34.98 months, SD = 11.88 months) completed an online survey of 46 initial PREP items, demographic characteristics, and their child's typical distress following everyday pains. An exploratory factor analysis was performed on the PREP items that describe observable actions parents may take in response to their young child's everyday pains. The final solution included 10 items across 3 factors: Distract, Physical Soothe, and Extra Attention and explained 60% of the model variance. All PREP subscales were related to child distress; only Physical Soothe and Extra Attention were related to parent distress. This study was a preliminary step in the development and testing of a new self-report measure of parental responses to everyday pains during early childhood.

The effect of an educational program on illness uncertainty in mothers of children with type 1 diabetes: a quasi-experimental study.

The mother is traditionally the primary caregiver for the child, and uncertainty is a major source of psychological distress for parents of sick children. As a result, the current study sought to investigate the impact of an educational program on illness uncertainty in mothers of children with insulin-dependent diabetes mellitus (IDDM). This is a quasi-experimental study with a pretest-posttest design, involving 40 mothers of children with IDDM. After visiting the research site and recruiting eligible mothers, the researcher used the purposive sampling method to randomly assign them to one of two intervention and control groups. Taking into account their needs and conditions, mothers were scheduled for at least three sessions, with a 30-minute interval every other day. The data analysis revealed no significant differences between the two groups in terms of child age and gender, mother age and education level, number of children, and duration of diabetes. There was a significant difference in the total score of uncertainty, total score of ambiguity, lack of clarity, lack of information, unpredictability, and their dimensions between mothers of diabetic children before and after the intervention (P=0.02). Based on the findings, it is recommended that the educational needs of children and their mothers be assessed upon admission and that educational content be prepared and taught accordingly, thereby helping to reduce illness uncertainty in mothers.

Extending the concept of moral distress to parents of infants hospitalized in the NICU: a qualitative study in Greece

BackgroundThe hospitalization of infants in the neonatal intensive care unit (NICU) is an ethically challenging situation. A limited number of studies have extended the concept of moral distress to parents of infants hospitalized in the NICU. This topic requires further investigation.MethodsThe present prospective qualitative study was conducted from February 2023 to May 2023. Data were collected through semistructured in-depth interviews, which were conducted in-person with fifteen parents of infants who were hospitalized in the NICU at the time of the interviews. Purposive sampling was used. The data were classified and analyzed using thematic analysis.ResultsThree themes emerged from the data analysis performed for this empirical study. One intrapersonal dimension featuring two aspects (one dynamic and one static) and another interpersonal dimension focusing on parental moral distress emerged from the data analysis. Furthermore, seven subthemes emerged across these themes: (1) self-directed negative feelings were experienced by parents due to their inability to fulfill their caregiving/parental roles; (2) intense internal conflict was experienced by parents in response to a moral dilemma that was difficult, which was perceived as irresolvable; (3) objectively unjustified, self-directed negative feelings of guilt or failure were experienced by parents; (4) parents experienced moral distress due to the poor image of the ill infants; (5) inadequate information may predispose parents to experience moral distress (6) neonatologists’ caring behaviors were unduly perceived by parents as paternalistic behaviors; (7) reasonable or justified institutional rules were unduly perceived by parents as constraint.ConclusionsIn general, the results of this study support the integrated definition of parental moral distress proposed by Mooney-Doyle and Ulrich. Furthermore, the present study introduces new information. The study distinguishes between the dynamic and static aspects of the intrapersonal dimension of the phenomenon of parental moral distress. Moreover, participants experienced moral distress because they unduly perceived certain situations as causing moral distress. In addition, inadequate information may predispose parents to experience moral distress. The findings of this study may contribute promote family-centered care in the NICU context.

Children born very or extremely preterm transitioning to school: a cross-sectional study examining predictors of school readiness, school adjustment, and support needs

ABSTRACT The transition to school is a sensitive developmental period for young children. Although children born very/extremely preterm have increased risk of health and developmental concerns, predictors of their school readiness and adjustment remain largely unexamined. Parents of very/extremely preterm-born children (aged 3–7 years; pre-transition n = 114, post-transition n = 112) completed an online survey assessing their perceptions of children’s school readiness (pre-transition) or adjustment (post-transition), support needs, child behaviour, parent distress, and parent confidence. Poorer school readiness and adjustment and greater needs for support correlated with child health/developmental condition/s; hyperactivity, peer problems, conduct problems, emotional symptoms, and less prosocial behaviour; and lower parent confidence. Using hierarchical linear regression, parent confidence emerged as the strongest common predictor of school readiness (pre-transition) and school adjustment (post-transition), followed by low hyperactivity, high parent education (tertiary), and no diagnosed child health/developmental condition/s. Results will be used to identify families needing support and develop tailored support strategies.

Linking child externalising problems to psychological distress in parents: Mobile phone use by children as a mediator.

Child externalising problems, such as acting out and hostility, have been found to be significant stressors for parents, leading to increased distress levels. This cross-sectional study examined the mediating role of parents' use of mobile phones to soothe or engage children in the association between child externalising problems and distress in parents. Altogether 937 parents of children aged 5-12 reported their child's externalising problems, child's mobile phone use, and their distress through an online survey. The findings indicated that parents of children with high externalising problems are more likely to use mobile phones to soothe their children and keep them engaged in daily activities, which, in turn, is associated with higher distress in parents. Child externalising problems and distress in parents remained significantly and positively associated even after accounting for the mediating effect. The results highlight the child-driven effect on distress in parents through parenting behaviours, indicating the importance of providing alternative parenting strategies to cope with child externalising behaviours, in order to promote parental emotional well-being.

Community and household-level incarceration and its association with mental health in a racially/ethnically diverse sample of families

This study examines the association between community incarceration rates, household incarceration, and the mental health of parents and children. Participant families had children ages 5–9 (n = 1307) from the African American, Latinx, Hmong, Somali/Ethiopian, Native American, and White communities in the Twin Cities, Minnesota. Linear mixed models were used to estimate associations between parent and child mental health, household incarceration exposure, and census tract race, ethnicity and gender-specific incarceration rates matched to the family's home address and race/ethnicity. Findings indicated that living in census tracts with elevated incarceration rates of men from your same racial or ethnic group was significantly associated with psychological distress in parents and externalizing behaviors in boys, regardless of household exposure to incarceration. The association between incarceration rates and externalizing behaviors was only observed among girls with exposure to household incarceration. Policies that deconstruct pervasive racism in penal systems are needed to improve population mental health.

Coping Styles among Parents of Children with Autism Spectrum Disorders

Introduction: Autism falls under the most common category of Pervasive Developmental Disorders (PDD). It is a lifelong neurodevelopmental disability characterized by persistent and pervasive impairments that include challenges with social understanding and communication, difficulty adapting to new situations, and exhibiting repetitive behaviors or interests. Caring for children diagnosed with Autism Spectrum Disorder (ASD) can be an arduous task for caregivers all around the globe. To tide through the various phases of development, certain coping mechanisms are applied by the parents of children with ASD. An impact on the level of parental distress can be evaluated being based on parental coping styles concerning developmental disabilities. Objective: To assess the coping among the parents of children with autism spectrum disorder and to measure the association of coping styles with selected background variables. Methods: A descriptive cross-sectional, questionnaire-based survey was carried out among 174 parents of children with ASD in selected autism care centers in Kathmandu, Nepal. The data was collected using a questionnaire developed by taking the reference from the Brief COPE questionnaire to evaluate the coping styles used by parents. Descriptive (mean and standard deviation) and inferential statistics (independent sample t-test) were used to analyze data in SPSS vs20. Results: The findings of the study revealed, the majority of the respondents were below 35 years of age (70.1%), female (55.2%), belonged to the Brahmin/Chhetri (63.2%) ethnic group, had a single child (62.1%), belonged to nuclear family (52.9%), were homemakers (34.5%), able to spend sufficiently economically (66.7%) and having a graduate or higher education (71.3%). Similarly, the majority of autistic children were aged between 1 to 5 years (93.1%), and were males (71.3%). In terms of birth order, the majority of children with autism were firstborns (72.4%), did not have any other illnesses (96.6%), and were diagnosed at the age of less than 3 years (62.1%). Overall, the majority of the parents used a problem-focused coping style with a mean of 3.2±0.3, followed by avoidant coping style (2.7±0.4) and emotion-focused coping style (2.5±0.5). Likewise, there was there was a significant association of avoidant coping style with the age of respondents and the number of children they have, emotion-focused coping with ethnicity, and occupation of respondents. Again, the sex of respondents, level of education of spouse, and level of autism of children of respondents were found to have a significant association with both avoidant and emotion-focused coping styles. Overall, the level of education of respondents was associated with overall coping strategies. Conclusion: Based on the findings of the present study, the study concludes that the majority of the respondents used problem problem-focused coping style, followed by avoidant and emotion-focused coping styles. Significant associations were found between various coping styles and demographic attributes such as age, gender, ethnicity, occupation, level of education of respondents as well as their spouse, and the level of ASD of their children. Understanding the coping styles is central to supporting the parents’ coping efforts. Providing parents with effective techniques to manage their emotions can greatly influence how they view their situation, the intensity of the symptoms of their children, and the psychological distress associated with it.

Polish Adaptation of the Coparenting Relationship Scale

Abstract: The Coparenting Relationship Scale (CRS) is a 35-item self-report measure used to assess subjective evaluation of the relationship between parents. Developed and applied in the United States, it was translated and adapted in other countries. The article presents a Polish adaptation of the CRS. The study included 802 respondents (514 mothers, 288 fathers). In comparison to the original 7-factor structure of the original CRS, in our case, we excluded the division of labor factor and achieved satisfactory goodness-of-fit criteria upon the inclusion of the method factor with reverse-worded (RW) items. We also attempted to test measurement invariance by gender and across two cultural contexts: comparing with the USA and Switzerland. In all cases, at least scalar invariance was achieved, allowing for comparisons between the mentioned groups. We also verified construct validity, which allowed us to demonstrate convergent validity when the CRS was correlated with the Enrich Marital Satisfaction Scale and Parental Distress Scale, as well as discriminant validity when the CRS was correlated with the Lie Scale from the Eysenck Personality Questionnaire-Revised. The results of statistical analyses show that the Polish CRS is a valid and reliable measure of the coparenting relationship.