Coparenting in Caregivers of Children With Cerebral Palsy

The Brazilian Association of Cerebral Palsy defines Cerebral Palsy (CP) as a group of disorders of development and posture, which cause limitations in an individual activity. The birth of a child with CP generates an impact, which brings a new reality for the family, mainly parents and others caregivers. The goal of the present work was to describe coparenting relationships in parents of children with CP, comparing between main and secondary caregivers, and still, the relationship between coparenting pair. Data was obtained from 12 coparenting pairs (24 individuals) caregivers of children with CP. Were used the instruments: Coparenting Questionnaire (COPQ), to evaluate the coparenting relationships, Socio Demographic Inventory (SDI), to describe information about the main and secondary caregivers and the Gross Motor Function Classification System (GMFCS) for to measure the children’s gross motor function. The data was treated through the software SPSS (version 20.0), the statistic calculated was frequency, descriptive, and still, a parameter of scores was fixed for the classification of coparentality factors (cooperation, triangulation and conflict). The results indicated that secondary caregivers exhibited higher average in the factors of analysis of cooperation and triangulation (21 and 5,2). The mainly caregivers indicated the bigger average in conflict factor, (11, 3). In general, the coparenting pairs exhibited high cooperation (19-25 points), high triangulation (4-8 points) and low conflict (5-11 points). The establishment of a good coparenting relationship, expressed in the mutual support and commitment of the dyads is fundamental for the family functioning and for the child’s global welfare.

The Associação Brasileira de Paralisia Cerebral (ABPC) (Brazilian Association of Cerebral Palsy) defines CP as a group of disorders of development and posture, which cause limitations in an individual's activities (ABPC, 2015).Thus, they are considered as non-progressive disorders that happen to the brain in development, being in several cases, followed by sensory, perceptual, cognitive, communicational and behavioral alterations, being sometimes followed by convulsive crises.
For Dantas, Pontes, Assis, and Collet (2012), the classification of Cerebral Palsy is made through quality analysis of muscle tone, pattern of the motor expression, quality and cerebral compromising area.The type of alteration of movement observed is related to the location of the injury in the brain and its severity depends on the extension of the injury.The diagnosis of CP usually involves retardation or delay in the motor development, persistence of primitive movements, presence of abnormal reflexes, and the failure of the development of protector reflexes.
Interpersona | An International Journal on Personal Relationships interpersona.psychopen.eu | 1981-6472 There are several classifications used for the alterations of CP, one of the most accepted is still the one from American Academy for Cerebral Palsy and Developmental Medicine (AACPDM, 1956).This classification does not take in account the etiology or the pathology of a problem, but it characterizes the type of motor damage present and summarizes the findings in terms of motor and topographical characteristics if the damages and the clinical manifestations of the impairment (Gianni, 2003;Mancini et al., 2004).
The topographical description refers to the physical extension of sequelae, namely in three forms: tetraparesis, diparesis and hemiparesis.Tetraparesis is considered the most serious type of CP, in which the inferior and superior members are affected in asymmetrical manner.These characteristics might be observed in the first months of life, being accentuated progressively as the child develops (Baladi, Castro, & Morais Filho, 2007).
Diparesis is characterized by the accentuated impairment of inferior members over the superior members, caused by the spasticity of the extension and adductor muscles of legs.The deficiency is commonly observed around the second semester, when the child begins to use well the superior members, but cannot walk (Gianni, 2003;Mancini et al., 2004).
Hemiparesis is a type of CP evidenced around the 4-5 months when the child starts to manipulate objects.In such cases there is the involvement of only one hemibody and, frequently, there is the presence of feet in equinovarus pattern (Baladi et al., 2007).
Regarding the clinical manifestations, CP can be classified in four modalities: athetosis, ataxic, spastic and mixed.This last one occurs in 75% of cases and is characterized as a deficit syndrome of pyramid liberation with exacerbation of deep tendinous reflexes, clonus and Babinski sign, being the muscle hypertension its main manifestation (Gianni, 2003;Mancini et al., 2004).
The child with CP has a delay in the neuropsychomotor development, which might cause impairment in the motor, sensory and/or cognitive area, implying in alteration muscle tone, movement quality, perceptions and capacity to apprehend and to interpret the environmental stimuli.In several cases, the sequelae from CP are aggravated by the difficulties these children have in exploring the environment and communicating with the external world.The alterations presented vary since the light to the most severe level.Many of them become dependent in the activities of daily life and in the performance of functional activities in practical life.The motor and/or cognitive implications cause limitations of experiences that might compromise even more the development of these children.
The birth of a child with CP generates an impact, which brings a new reality for the entire family.The chronic alterations in the children condition the majority of family tasks, they adjust the responsibilities and bring additional concerns (Wong, 2006).Despite these aspects generally impacting every member participating in the family, parents and caregivers are in the front line of care destined to these children, because they are very present in their routines.
The arrival of a disabled child in the family has been highlighted by literature as a transition lived in peculiar manner by each family core (Amaral, 1995;Buscaglia, 1997).Depending on its structure and arrangement, these situations might be motive of limitation or overcoming of the family potentialities.Taking in consideration such affirmations, Minuchin (1998) affirms that inside a systemic perspective, family, or a family group follows a pattern or configuration according to the demands provided by the environment, which allows that in each family the subsystems will present a specific dynamics.Among these subsystems, the parental one constitutes the central axis once it consists in the support base of the children subsystem as it offers specific resources that enable the development of the younger generation.
The potential of the parental dyad while subjects generating development is associated to support relationship established between them.This aspect has been considered by studies that investigate coparentality.For McHale (1995), coparentality is a process in which father and mother divide the leadership and mutually support themselves in their parental roles.It is about an intergame of roles that relates to the global care of the child, including values, ideas, expectations directed to them.Thus, this concept involves, among others, the processes of cooperation and antagonism.
Coparentality can be considered a variable that measures the marital relationship and parentality, once the collaboration between the couple members might influence the way they interact with the child, evidencing how much marital relationships affect the relationships between parents and children (Margolin, Gordis, & John, 2001).
According to Feinberg (2002), coparentality refers to the manner parental figures relate or work together.In other words, it goes beyond simply being a father and a mother of a child, but describes how maternal and paternal figures perform such roles in an organized way.Authors as McHale (1995) declare that in a coparenting relationship the essence is in the mutual support and commitment in raising a child, emphasizing that it is not needed to exist consanguineous bonds between child and caregiver in this relation.Some works about coparentality have shown several ways this concept is used in the scientific field, and among these studies the one developed by Frizzo, Kreutz, Schmidt, Piccinini, e Bosa (2005), which mapped between 1996 and 2004 this diversity.The data revealed that 35,6% of works appear in form of empirical articles, 30% in book chapter, 22% in doctoral thesis and 37% associated to the concept of divorce and child custody dispute.
In Brazil, Sinfuentes (2007) and Schmidt (2008) investigated the phenomenon of coparentality in the context of families constituted by a member diagnosed with autism.Sinfuentes (2007) investigated the coparentality in five couples that had from 4 to 7 years old children, presenting diagnosis of autism, through a semi structured interview.Besides the dimensions of the concept presented by McHale (1995), their results suggest that the perception of parents about the child (personal characteristics, potentiality X commitment) and about the partner (positive and negative) are important for the comprehension of coparentality.Schmidt (2008) investigated the characteristics of coparenting relationships, the family adaptation and the occurrence of aggressive behaviors in fraternal relationships of teenagers diagnosed with autism.The analysis revealed that the dimensions of coparentality were present independent of the presence of aggressiveness, being fundamental the role exerted by the father in direct care with the child.

Method Delimitation
This study has descriptive character and was developed under a quantitative approach.12 coparenting pairs participated (24 individuals), caregivers of children in age group of 0 to 12 years old, diagnosed with cerebral palsy, treated in University Hospital from Belém.The environment of collection was the waiting room of one of the services provided by the hospital.

Instrument Sociodemographic Inventory (SDI)
It is constituted of four sessions, in other words, about the treatment, the family composition extended to the child, the main and secondary caregivers and economic and house characteristics.However, for this study only information concerning the main and secondary caregivers of the child and some clinical data from this one were used.

The Gross Motor Function Classification System (GMFCS)
This instrument is part of the GMFM, which is a scale of measure of the gross motor function and evaluates the changes corresponding to these functions in the child with cerebral palsy (CP) emphasizing the movements of sitting and walking.The GMFCS is constituted of five motor levels, being each level subdivided for age groups 0 to 2 years old, 2 to 4 years old, 4 to 6 years old and 6 to 12 years old.In Level I the individual walks without restriction, presenting limitations to run and jump; in Level II the child walks without the aid of equipment and crutches; in Level III the child can walk with the aid of walkers or crutches, having difficulties to walk outside the house and in the community; in Level IV the child walks with external aid, with limitations and needs wheelchair to walk outside the house and in the community and, for last, in Level V the child presents mobility severely limited, even with equipment and adaptations.

Coparenting Questionnaire (COPQ)
Used to evaluate the coparenting relationships, the Coparenting Questionnaire (Margolin, Gordis, & John, 2001) was adapted from an initial group of 27 items, being used in this research the version constituted of 14 items of closed answer distributed in three factors: cooperation (Items 1 to 5), triangulation (Items 6 to 9) and conflict (Items 10 to 14).The sum of items is performed considering the participants' answers, however for the factor of triangulation, besides having an affirmative less, the counting is inverted, in other words, bigger the score, smaller the intensity in the factor.

Ethical and Collection Procedure
This study is part of bigger project called "health of families of children with cerebral palsy", which was submitted and approved in the institution ethics committee, under the advice no.473.140.After the formal acceptance from the institution, the participants were selected from the diagnosis of cerebral palsy of their child and then approached in the dependencies of the waiting room, from the service offered by a University Hospital.The participants were invited to participate in the research and, after there was an explanation about the general objectives and procedures of study.The interviews were performed respecting the availability of each participant and the frequency in the treatment of each child.After reading and approving the participation

Data Analysis
After the collection, the data was treated through the software SPSS (The Statistical Package for Social Science for Windows, version 20.0).For the data referring to the instrument SDI the statistic calculated was frequency whose completion enabled the obtaining of percentage for each sociodemographic category.For the questionnaire of coparentality the data was analyzed as it follows: descriptive statistical mensuration of data, obtaining the values of averages, medians and standard deviation for the three factors that make the instrument used.
Besides the descriptive statistical calculation, a parameter of scores was fixed for the classification of coparentality factors.This strategy of analysis was performed once it was not found parameters in the literature that supported the calculation for the sample used, being built from the data obtained.This way it was possible to classify the scores obtained for each coparenting pair in each one of the suggested factors.Thus, for the cooperation and conflict the following parameters were calculated: low = 5-11 points, medium = 12-18 points, high = 19-25 points.For the levels of triangulation, the scores obtained are lower and the levels number of points is inverted.In this sense, participants achieving a score between 4-8 points, present high triangulation in the relation, from 9-14 points medium triangulation and 15-20 points low triangulation in the relation.

Participant's Characterization
In this study 12 main caregivers and 12 secondary caregivers of children with palsy took part.Regarding the main caregivers 83,3% of these were biological mothers of the children and 16,6% foster mother and step mothers, with ages between 23 to 43 years old (medium = 36,17%).33,3% of the mothers studied until high school, without completing it and had as occupation, in 75% of the cases, the function of performing domestic tasks in the own house, named as "home".Considering the secondary caregiver, 66,7% were of biological fathers of the children, followed by step fathers, maternal grandmothers, cousins and foster parents, 8,3% each.The age of the secondary caregiver was between 15 and 52 years old (medium = 38,58%).33,3% of these participants presented education level in the incomplete high school, exerting in 58,2% of the cases, extra household remunerated activities.
Concerning the children characteristics, 58,3% (5 children) was between 7 and 10 years old during the period of interviews.The bigger part of them was feminine gender (7 girls), occupying in the majority of families (5 families) the number 1 position in the offspring.Regarding the motor impairment obtained by the Gross Motor Function Classification System (GMFCS), the most frequent level found between the children was Level 5, characterized by severe impairment of the motor locomotion.

Caregivers Coparenting
Table 1 shows the results referring to the caregivers coparenting, taking as basis the three factors of analysis that make the instrument: cooperation, triangulation and conflict in the coparenting relationship.The results are Dourado, França, Cardoso et al. exhibited relating the descriptive statistics (average, median and standard deviation) from both people responsible for the cares with the child (main and secondary).between 19 and 25 points, demonstrating high perception of cooperation by the coparenting pair.Among the caregivers that achieved high level of cooperation, it was noticed that the great part of them ( 12) was composed of the coparenting pair and that three of them obtained the maximum score possible, corresponding to 25 points.In 8 dyads it was observed the highest coparentality for the secondary caregiver.
Regarding the triangulation in the parenting relation, Figure 2 illustrates the levels achieved between the participants.In this factor, bigger the score is lower is the level of triangulation between the pairs, consequently lower the score achieved higher the level of triangulation in the relation.Finally, the levels of conflict factor were examined.Figure 3 exposes the scores achieved by the participants, according to the score of each one of the 24 caregivers.The perception of conflict in low level was noticed in seventeen caregivers, among these, two caregivers (1pco = CS and 3pco = CP) achieved the minimum score for this dimension.Still considering the low level of conflict, the coparenting pairs, 6cpo and 8cpo, obtained the same scores, 9 and 10 points respectively, suggesting that they are possibly agreeing about the degree of discordance in what concerns the care with the child.The score corresponding to the medium level of conflict was present in the answers of the other caregivers interviewed (7 coparenting pairs).There were not scores between the participants that characterizing high levels of conflict between the pairs.

Discussion
The objective of this work was to describe the relation of coparenting between caregivers of children with cerebral palsy.For that the coparenting dyads, which divide the responsibility for tasks and global care for the child (main and secondary caregiver), were investigated.
The data revealed that the majority of the dyads was composed of mothers -main responsible for the care with the child -and biological parents, step fathers, grandmothers, cousins and foster parents, performing the role of secondary caregiver.It is noticeable from this that the parenting figures found in this study were very different and despite the majority being constituted of spouses, the presence of individuals such as grandmothers and cousins was also important.This diversity of coparenting configurations are supported by McHale (1995) and Margolin et al. (2001) when they consider that coparenting can be applied to any situation in which two adults share the parentality towards a child and yet that in coparenting relation the essence is in the mutual support and commitment in raising her, not being necessary consanguineous bond between child and caregiver.
The quality of coparenting relation seems to be very important for the child development, it being with or without alterations (Schoppe, Mangelsdorf, & Frosch, 2001).For the family that has a member with development alteration, such as cerebral palsy, the balance of this relation is especially important to promote conditions of development for this individual.Coparenting was investigated in this research under the perspective of cooperation, triangulation and conflict factors, suggested by Margolin et al. (2001).From this, it was noticed that secondary caregivers present higher indexes about the factor of cooperation and triangulation in comparison to main caregivers.These higher indexes concerning cooperation represent a positive perception of these caregivers in sharing parenting responsibilities and the appreciation of the parenting pair considering respect and mutual support between them.However, these elevated values might be related to the fact that these individuals help only in the child's care, the task demanding more effort, attention and time being for the main caregivers to perform who, in this study, are predominantly mothers.França, Cardoso, Moraes, and Silva (2014) in research about the characteristics of caregivers of children with cerebral palsy had already pointed the mother as the main caregiver of children with cerebral palsy, as well as they are the ones that give away the exercise of activities outside home to answer for the children's necessities.
In this sense, cooperation according to Margolin et al. (2001) is the key element for an effective coparenting union, but for the impact to be positive in this relation it is necessary that both caregivers share this vision, revealing a common effort in caring for the child and emotional and instrumental availability in parenting themes.
Nevertheless, if for one side the higher indexes in cooperation reflect a positive perspective towards coparenting relation, in triangulation factor these ones allow to infer that, probably, the secondary caregivers with highest mediums found in this study have an unsatisfied perception about the union behaviors existing between one of the caregivers and the child.According to Margolin et al. (2001), triangulation is permeated by elevated levels of conflict in the relation, existing the possibility of being bonded to the fact of bigger connection of one caregiver and the child, but this happening in a disadvantaged manner, existing manipulation of the child by the partner/caregiver, promoting rejection in the child for the other member of the coparenting dyad.Frizzo et al. (2005) consider that father/mother can be excellent in management with the child and very responsive, but yet he/she can denigrate the partner in front of the child in these processes of veiled coparenting, possibly indicating conflict in the coparenting relation.
The main caregivers presented more elevated levels in the factor parenting conflict, which might indicate that the relation between parental figures is affected as frequent and severe disagreements happen between the caregivers when concerning the child, and yet it is affected by the inflexibility and disagreements about educational principles used in the child's education (Margolin et al., 2001).Then considering that all the main caregivers in this research referred to feminine gender individuals, this dissatisfaction might be justified by the overload of roles taken by these women, once the maternal figures, in most of times, are exempt of activities and social roles to take care of the child's needs.Thus, this conflict in higher levels identified in the analysis allow saying that this group of main caregivers possibly believes in the existence in the relation of parenting roles sharing disagreements between spouses and perhaps some mutual devaluation.
In general manner, the results also demonstrated that coparenting is noticed differently between the pairs.Secondary caregivers reveal the perception of high cooperation and low conflict, while both main and secondary caregivers notice the triangulation in high levels.The positive indexes of cooperation might be justified due to the context in which these families are inserted, context that demands from its participants a more intense complicity, which must be adjusted when facing the particularities of the care with the child with cerebral palsy.On the other hand the elevated levels of triangulation are very curious, because being the majority of coparenting pairs in this research formed of espouses that share a stable union, these results are commonly expected in situations of recent divorce (Verças, 2012).
Finally, the data in this research demonstrated that even in situations where cooperation could be negatively affected, such as in the context of cerebral palsy, this one was positively reflected in the caregivers answers.It is understood that despite all the particularities involving the cares with a child with cerebral palsy, the relationship between individuals that take on the roles of parenting figures might have multifactorial influences, and that the quality in these relations are implied in the manner the caregiver represent his/her importance in the child's life.

Final Considerations
This research made possible to investigate the coparenting relations between the main and secondary caregivers of a child with cerebral palsy.It was noticed that these pairs see coparenting different manner, and that main caregivers demonstrated good cooperation, but high conflict, while secondary caregivers demonstrated good cooperation and high triangulation in the relation.Facing that, it is understood that, despite this difference towards the vision of coparenting, the establishment of a good coparenting relationship, expressed in the mutual support and commitment of the dyads is fundamental for the family functioning and for the child's global welfare, mainly when it is a context with specific needs, such as the families of children with cerebral palsy.
The study is limited regarding the reduced number of coparenting dyads investigated, once this condition restricts the analysis to less refined statistics, and also for not aggregating with the instrument used a complementary way of coparenting investigation.
This research takes on scientific relevance once it investigates coparenting in very peculiar conditions, such as cerebral palsy.Despite the existence of several studies about coparenting and child development, it is observed the lack of studies about this construct in families where one of the members presents some deficiency.In this sense, for future researches it is suggested the investigation to be extended to families of children with development alterations, for the amplification of the knowledge about the functioning of the relations between pairs that divide roles, tasks and cares so important for the development of a child with deficiency.