NH!UHWWU11NHNMMlHWNIWIWWI . 133 348 .THS THESlS met-mm“, ll’l’lll’lllllllllllll” University This is to certify that the thesis entitled PARENTS WITH A CHRONICALLY ILL CHILD: THE HASSLES AND UPLIFTS 0F EVERYDAY LIFE presented by Susan C. Aula has been accepted towards fulfillment of the requirements for Master of Science degree in Nursing Major professor Date /0//[p/49 0-7639 MS U is an Affirmative Action/Equal Opportunity Institution PLACE IN REIURN BOX to remove this chedtout from your record. TO AVOID FINES return on or before date due. MAY BE RECALLED wim earlier due date if requested. DATE DUE DATE DUE DATE DUE 11% W14 PARENTS WITH A CHRONICALLY ILL CHILD: THE HASSLES AND UPLIFTS OF EVERYDAY LIFE BY Susan C. Aula A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE IN NURSING College of Nursing 1998 ABSTRACT PARENTS WITH A CHRONICALLY ILL CHILD: THE HASSLES AND UPLIFTS OF EVERYDAY LIFE BY Susan C. Aula This study was a secondary data analysis of a study by Carla Barnes, Patty Peek and Linda Spence, College of Nursing faculty at Michigan State University. This was a cross sectional, descriptive, quasi-experimental study to examine the frequency of reported hassles and uplifts of parents of chronically ill children (CIC) compared to those with healthy children (BC). The sample consisted of 28 families with a CIC between the ages of 8-12 years and 17 comparison families with BC of the same age group. The families of CIC were recruited through the MSU, Department of Pediatrics and Human Development. Families with a CIC were required to have had the diagnosis of the chronic illness for at least one year to avoid the period of initial adaptation to the diagnosis. The families with BC were recruited through university, neighborhood and community agency announcements and matched to chronic illness families from each diagnostic category by age, sex, and birth order of the target child. The respondents were asked to report whether an experience occurred from a list of hassles and uplifts as defined by the given tools. Results of the study show that there is no significant difference in the number of hassles and uplifts in parents of CIC compared to those with RC. ACKNOWLEDGMENTS I would like to thank my thesis chairperson, Dr. Linda Spence for her data and guidance throughout the project and committee members Sharon King and Mary Jo Arndt for their understanding and willingness to participate. I would like to thank my study partner and colleague Sherrie Lynn Roth for moral support and friendship throughout the entire graduate school experience. Thank you to my sister Lynn Aula for companionship, moral support and laughter in our years at school together, and my father Gordon Aula for reassurance and moral support. Additionally, a special thank you to the Kanitz/Krukemyer crews, the Olsons, and the Lampears: Jill, Richard, Joshua, Lindsey and Matthew for allowing me in their lives and homes and offering never ending support and encouragement throughout graduate school. I would like to dedicate this project to my brother Steven Aula and his wife, Jane Marie Sexton Aula, 31 year old survivor of Cystic Fibrosis, who inspired my interest in families of chronically ill children and provided me with moral support and weekend lodging throughout graduate school. iii TABLE OF CONTENTS LIST OF TABLES . . . . . . . . . . . . . . . LIST OF FIGURES O O O O O O O O O O O O O O 0 INTRODUCTION . . . . . . . . . . . Background of the Research Problem Purpose of the Study . . . . . . . Rationale . . . . . . . . . . . . . Conceptual Definition of Terms . . THEORETICAL FRAMEWORK . . . . . . . . . . . . REVIEW OF LITERATURE . . . . . . . . . . . . Hassles and Uplifts/Demands . . . . . . Parental coping with chronic illness . . Parental coping with cystic fibrosis . . Parental coping with asthma and diabetes METHODS . . . . . . . . . . . . . . . . . . Research Design . . . . . . . . . . . . . . Sample . . . . . . . . . . . . . . . . . . Data Collection Procedures/Instrumentation Operational Definitions . . . . . . . . . Limitations of Design . . . . . . . . . . . Scoring and Data Summarizing Procedures . . . Protection of Human Subjects/UCRIHS Approval Data Processing and Analysis . . . . . . . . RESULTS . . . . . . Hassles . . . . . . Perceived Hassles . Uplifts . . . . . . Perceived Uplifts . Family Adaptation Model . DISCUSSION . . . . . . . . . . . . . . . . . Methods . . . . . . . . . . . . . . . . . . . Current Literature . . . . . . . . . . . . . Implications for Advanced Practice Nursing . Implications for Further Research . . . . . . Implications for Nursing Education . . . . . Summary . . . . . . . . . . . . . . . . . . . LIST OF REFERENCES . . . . . . . . . . . . . APPENDICES . . . . . . . . . . . . . . . . . UCRIHS approval letter . . . . . . . . . Hassle tool . . . . . . . . . . . . . . Uplift tool . . . . . . . . . . . . . . Page 0... UNNI-‘H 10 11 13 17 17 17 18 20 20 21 21 21 22 22 23 23 24 25 26 26 27 27 28 29 29 . 33 . 33 . 34 LIST OF TABLES Page Table 1: Number of Hassles . . . . . . . . . . . . . . . 23 Table 2: Number of Perceived Hassles . . . . . . . . . . 24 Table 3: Number of Uplifts . . . . . . . . . . . . . . . 24 Table 4: Number of Perceived Uplifts . . . . . . . . . . 25 LIST OF FIGURES Figure 1: Family Adaptation . . . . . . . Figure 2: Application of Family Adaptation vi Page 0 5 . 7 INTRODUCTION Background of the Research Problem With the life expectancy of chronically ill children increasing with the assistance of modern treatments and technology, improving quality of life for the chronically ill child and their families needs to be considered by the health care providers (Ievers & Drotar, 1996). Stress and physiologic illness has been associated since the times of Hippocrates (Boyce, Chesney, Alkon, Tschann, Adams, Chesterman, Cohen, Kaiser, Folkman & Wara, 1995). Studies cited by Boyce et al. (1995) have documented the association of successive stressful life events with increased risk for physical disorders, chronic illnesses, injuries, as well as psychiatric and behavioral disorders. Others comment on how important everyday stresses are and that the “multiplier effect7 AI 838 E33 .5 2mm“: .8 cosh—outed AI mop—SOmONm 32.: 3:25 5? 250 a oocomn< to 8:035 £3: ea 2%: _ Figure 2 . overall functionality. Adaptation is the process by which the family learns to function in response to the demands using perception of demands, resources and coping mechanisms in order to maintain the most stable level of functioning of which the family is capable (Spence, 1992). In the application of this model to the present study, hassles and uplifts are defined as demands on parents. Examples of demands that occur in the lives of parents with a chronically ill child include: treatments, doctor's appointments, grocery shopping, cooking, having lunch with a friend and other everyday events. For the purpose of this study, perception of demands refers to the perception of the hassle or uplift (Figure 2). In other words does the parent define the event as a hassle or uplift and to what extent was the event defined as severe or pleasurable to the individual or the family as a whole. As hassles and uplifts occur within the family and the family utilizes the resources it has available, the hassles and uplifts are perceived across a continuum from severe to very pleasurable. The family's coping mechanisms are utilized according to the perceived intensity of the event and result in a level of functioning within the family. REVIEW OF LITERATURE Overall family function is strongly related to the parents' level of function within the family (Hamlett, Pellegrini & Katz, 1992), therefore, research on coping of parents of children with chronic illness has an important role. Understanding stressors such as hassles and uplifts 8 and their impact helps to define, develop and guide interventions related to coping mechanisms for parents of children with chronic illness. Many studies related to parents of chronically ill children and their coping mechanisms use families of children with cystic fibrosis. Also to be reviewed in this section will be literature on parental coping of children with asthma and diabetes and demands of parents with children who have chronic illness. Wands Kanner, Coyne, Schaefer and Lazarus (1981) compared measurement of stress with daily hassles and uplifts to major life events.. The study used the Hassles and Uplifts scales that were administered once a month for ten months consecutively to middle aged adults. The Hassles Scale was found to be a more reliable predictor of concurrent and subsequent psychological symptoms than the life events scores. Uplifts were positively related to symptoms for women, but not for men and the Hassles and Uplifts Scales were related to positive and negative affect which allowed the investigators to conclude that assessing daily hassles and uplifts would help to predict adaptational outcomes more accurately than the life events approach usually used. DeLongis, Folkman and Lazarus (1988) studied the psychological and somatic effects of stress on adults. Using a revised version of the Hassles and Uplifts Scales, 75 married couples completed questionnaires monthly for six months. The investigators found a significant relationship between daily stress and health problems such as the flu, 9 sore throats, headaches and back problems. In the area of mood, this study suggests that individuals with poor psychosocial support and lower self-esteem are more prone to have an increase in both psychological and somatic problems following stressful days as measured by hassles and uplifts. E l J . 'll 1 . .1] Cadman, Rosenbaum, Boyle and Offord (1991), in a descriptive epidemiologic study, used data from 1869 families in the Ontario Child Health Study to compare psychosocial characteristics of parents and families of chronically ill children with families of healthy children. No differences were found between the groups related to number of single parent families, social isolation, alcohol problems or family dysfunction. Parents of chronically ill children were found to have increased rates of treatment for “nerves” and a higher incidence of psychosocial problems themselves. Silverstein and Johnson (1994) discuss ways that parents of diabetic children cope with the child's illness. Feelings of guilt about hereditary aspects of the disease may lead the parents to overindulge, overprotect or be extremely permissive with the child. Fear, anxiety and anger related to the long-term complications and potential shortened life span along with sadness and grief related to the loss of expectations to have a healthy child are some emotions parents experience. This may lead some parents to be controlling and expect perfection from the child while at the other extreme, some parents hand over responsibility and 10 expect the child to be responsible for management of the disease possibly before the child is ready. E l J . 'II I' E'l . In a 1996 review of articles related to the functioning of families and parents of children with cystic fibrosis (CF) compared to families with healthy children (Ievers & Drotar), commonalties were found in that parents of the chronically ill children expressed concerns regarding treatment regimen, terminal illness and the disruption of familial relationships. Parents of the children with CF seemed to experience greater stress and burdens, higher levels of distress, an avoidant coping style and low levels of family support which led to poorer psychological adjustment than the parents of healthy children. In another study that compared twenty mothers of children with cystic fibrosis and twenty matched control mothers, the parents of chronically ill children were found to spend more time tending to the child's medical care and less time engaging in activities involving play and recreation (Quittner, Opipari, Regoli, Jacobsen & Eigen, 1992). This study specifically found that mothers of chronically ill children spend twice as much time in child care activities as parents of healthy children and significantly less time interacting with their husbands. The study looked at role strain by using a Behavioral Role Strain Index which assessed a range of daily activities such as medical care, meals and household responsibilities and 11 found the mothers in the cystic fibrosis group reported more role strain than the control group. Hymovich and Baker (1985) examined the perceptions of parents of children with cystic fibrosis and the impact of their child's illness on the family. The sample was taken from those who visited a CF center between November 1982 and February 1983. Mothers and fathers (161 total) were asked to complete the Chronicity Impact and Coping Instrument: Parent Questionnaire, an instrument which measures concerns, needs and coping strategies. Parents were most concerned about the future of the child and making the child happy or comfortable. One half of the parents wanted information about the child's condition, physical care, diet and nutrition, growth and development related to the child. One-third of the parents were interested in child-rearing issues related to the siblings of the child with CF. Of the 124 parents responding to a question regarding spousal relationships, 60% were “very satisfied" and 26% were somewhat satisfied. Coping strategies included: talking with nurses and physicians and praying. There were no significant differences found between the responses of the fathers and the mothers. Patterson and McCubbin (1983b) surveyed 100 families from the cystic fibrosis Pediatric Outpatient Clinic at the University of Minnesota Hospital. A questionnaire mailed to families asked about family life events and changes experienced by the family during each six month period of the past year. Clinic records of height, weight and 12 pulmonary function were reviewed and compared with the survey questionnaire to conclude that a decline in pulmonary functioning could be associated with family stress related to: “family development and relationships, family management and decisions and family finances? (p. 255). The investigators of this study applied the “Double ABCX pile up of stressors”‘theory to predict a decline in the chronically ill child's health when the family undergoes stressful life changes. Using the same sample from the above investigation, McCubbin, McCubbin, Patterson, Cauble, Wilson and Warwick (1983) evaluated behavior related items on the Coping Health Inventory for Parents.(CHIP) to describe parental coping patterns. Important patterns noted in this study were: “maintaining family integration, cooperation and an optimistic definition of the situation; maintaining social support, self esteem, and psychological stability; and understanding the medical situation through communication with other parents and consultation with the medical staff” (p. 359). Mother's coping tended to be toward family integration and social/emotional stability where the father's coping was more in supporting the mother in a broader sense. E l J . 'll ll 1 i' l l Hamlett, Pellegrini and Katz (1992), interviewed mothers of children with asthma or diabetes and compared their responses to mothers of healthy children of the same age to evaluate the impact of childhood chronic illness and 13 its impact on the family. The study's findings supported that childhood chronic illness and family functioning are related to maternal perception of behavioral adjustment for the child. Also noted in this study was: an increase in internalizing behaviors in children with asthma; less adequate perceived social support for the parent; and a greater number of reported stressful events. The level of family functioning and available resources were found to directly influence coping capabilities for parents with chronically ill children (Hamlett et al., 1992). Rubin and Peyrot, (1992) reviewed literature related to psychosocial problems in diabetes and cited multiple sources which emphasize that a diagnosis of diabetes does affect non-diabetic family members and especially mothers of children with diabetes. Hauser, Jacobson, Wertlieb, Weiss-Perry, Follansbee, Wolfsdorf, Herskowitz, Houlihan and Rajapark (1986) reported after one year of a four year longitudinal study on children with diabetes that diabetic children and their parents expressed more:“focusing, problem solving and active understanding" (p. 274) than parents and children with other chronic conditions, but also noted that fathers and children in the diabetes group engaged in more devaluing interactions. Additionally noted is the thought that family members reactions, particularly parents, influence the child's adaptation and attitude toward the illness. This leads to the conclusion that parental influence based on the 14 parents' perception can determine the course and eventual prognosis of a child diagnosed with diabetes. Schulz, Dye, Jolicoeur, Cafferty and Watson (1994) studied parents of asthmatic children in two nonrandom groups obtained from one asthma and allergy specialist's practice and parents who wrote letters to Mother's of Asthmatics, Inc./The National Allergy and Asthma Network (MA), a national support and information organization. The parents were organized into focus groups to discuss concerns and quality of life issues. Common concerns among parents were related to job maintenance and security, feelings of emotional distress including feeling alone, frustrated, doubt and depression. .Family issues common to parents were *being on pins and needles, living in a roller coaster household and being turned upside down? Cp. 212). Parents also commonly felt that needs of the child and the parent themselves could not be met at the same time as well as financial strains and loss of freedom. In summary the authors found once again that the illness of a child in the family does not just affect the ill child, it also affects and often changes the life of the parents. Schwam (1987) suggests ideas to consider in helping parents of children with asthma cope more effectively. Importance is placed on support from health care providers, spouse, extended family and friends as well as having accessible resources, being organized and planning ahead, and being able to help others with similar problems. Understanding each parent's style of coping and helping the 15 parents to understand each other's coping is noted as being vital so that there is not a breakdown in “parental alliance? (p. 51). Support and validation of the parent of the asthmatic child is the key to helping the parent make decisions regarding discipline, school issues, athletic participation, helping the child to develop autonomy, manage the illness and prevent the parent from becoming overwhelmed. The findings from these studies indicate a need to address health care strategies not only for chronically ill children but also for the parents of these children and to recognize what is stressful to the parents who have children with chronic illness in order to help the parents recognize stressful experiences and develop adequate coping mechanisms. The studies discussed are limited by small sample size, use of convenience samples and lack of longitudinal follow up. Longitudinal follow up would be helpful in that the data obtained is subjective and therefore may not be an accurate portrayal of the norm if the subject responded to data during a particularly stressful or eventful time. Strengths with the literature reviewed are related to the specific coping mechanisms of the parents related to children with specific diseases. Parental issues related to children with cystic fibrosis may differ from those related to parents of children with diabetes or another disease. It is recognized throughout the literature that parenting a chronically ill child is stressful and that there is a need to address this 16 population's concerns and educational needs related to coping with problems specific to having a child with chronic illness. METHODS Research Design This study consisted of a secondary analysis of data collected by Carla Barnes, Patricia Peek and Linda Jan Spence, College of Nursing faculty at Michigan State University. This is a cross-sectional, descriptive, quasi- experimental study to examine the frequency of reported hassles and uplifts of parents of chronically ill children compared to parents with healthy children. Sample The sample consisted of 28 families with a chronically ill child between the ages of 8—12 years and 17 comparison families with healthy children of the same age group. The families of chronically ill children were recruited through Michigan State University, Department of Pediatrics and Human Development and were limited to these clinics to maintain control of medical management philosophy of their diseases (asthma, congenital heart disease, cystic fibrosis and insulin dependent diabetes mellitus). Families with a chronically ill child were required to have had the diagnosis of the chronic illness for at least one year to avoid the period of initial adaptation to the diagnosis (Spence, 1993). All families coming to the clinics were asked to participate due to the low incidence of some of the chronic illnesses. The families with healthy children were 17 recruited through university, neighborhood and community agency announcements. Thirteen comparison families were matched to chronic illness families randomly selected from each diagnostic category by: age, sex and birth order of the target child; number of parents in the home, family size and family income. The remaining four comparison families were matched to non-randomly selected chronic illness families. In the 28 target families there were 47 parents (28 mothers, 19 fathers) and in the 17 comparison families there were 28 parents (17 mothers, 11 fathers) (Spence, 1992). Families meeting the criteria received a letter explaining the study and an invitation to participate. Interested subjects returned a postcard that prompted the investigator to call the subjects by telephone to set up a home visit/interview. Data Collection Procedures/Instrumentation In the primary study, the home visit allowed the investigator to explain the study, answer questions and obtain informed consent. Socioeconomic information was obtained from parents at this home visit and family members were asked to complete a series of questions including the Hassles and Uplifts Scales (Kanner et al., 1981) that assesses positive and negative experiences in daily life. The respondents were asked to report whether an experience occurred and if so, indicate if it was perceived as a hassle or uplift. If an experience was perceived as a hassle or uplift, the respondent was then asked to rate the experience on a 3 point scale from “somewhat hassled" to “very hassled" 18 (Hassles Scale) or “somewhat pleasurable” to “very pleasurable” (Uplifts Scale) (Spence, 1992). Reliability for these scales was done in Kanner's (1981) original studies on adults. The original study generated lists of 118 hassles and 134 uplifts related to: “work, health, family, friends, the environment, practical considerations, and chance occurrences" (Kanner et al., 1981, pp. 8-9). The scales were administered during a one year longitudinal study once each month for nine consecutive months. Test-retest correlations from these test administrations were calculated relative to frequency and intensity. The average test-retest correlation for frequencies was .79 and the average test-retest correlations for intensities was .48 on the Hassles Scale. The Uplifts Scale correlation for frequencies was .72 and for intensity was .60. The Hassles and Uplifts Scales were also found to be positively related to each other with frequencies correlating .51 and intensities .28. Face, content, construct, predictive and discriminant validity of the Hassles and Uplifts Scale were also examined (Kanner et al., 1981). The frequency of hassles related to negative affect and psychological symptoms more than the uplifts scale related to positive affect. Reported intensity of hassles and uplifts did not appear to be related to affect, but women tended to report higher intensity than men when data were examined by gender. The findings suggested that uplifts do contribute to stress level in women. Kanner et al. (1981) also found the Hassles and Uplifts scales to be 19 related to each other which suggests that respondents either have a common response style or a tendency for those who experience many uplifts to also experience, or perceive to experience, many hassles. Operational Definitions Hassle as measured by the Hassles Scale (Kanner et al., 1981) is events or situations indicated by parents as having occurred. Perceived Hassle measures whether or not the event which has been indicated as having occurred was perceived as a negative event by the parent. Uplift as measured by Uplift Scale (Kanner et al., 1981) is the events or situations identified by parents as having occurred. Perceived Uplift measures whether or not the event which has been indicated as having occurred was perceived as a positive event by the parent. Limitations of Design Obvious limitations to the primary study are related to the small sample size and the use of one style of medical management from the clinics. Data collected was retrospective therefore the information obtained infers how the family is coping with stress in the past and present, but is not able to look into how the parents will cope in the future related to events occurring now. The “multiplier” effect discussed by Kanner et al. (1981), is an important consideration. The sequence of events occurring for a family in the given time frame in which the study was 20 conducted has an impact on how a family member perceives and responds to questions. A longitudinal study design would help reduce this effect. Looking at intensity of reported hassles and uplifts might improve this investigator's ability to distinguish more stressful experiences from those that have occurred but not been perceived as intense. Scoring and Data Summarizing Procedures Data obtained was evaluated by comparing the number of reported items on each of the Hassles and Uplifts scales as occurring and the number of events identified as being either a Hassle or Uplift for parents who have a chronically ill child and parents who do not have a chronically ill child. Protection of Human Subjects/UCRIHS Approval The participants of the primary study all were volunteers who gave informed consent. The original study was approved by the University Committee on Research Involving Human Subjects (UCRIHS) (IRB# 89-174). The present study was also approved by UCRIHS (IRB# 98-282). The data was received on computer disc with no identifying information about the family. Data Processing and Analysis Descriptive statistics and t-test analysis were used to examine the responses of the parents with and without chronically ill children to the Hassles and Uplifts Scales and determine whether there was a significant difference between the two groups on frequency of Hassles and Uplifts and frequency of perceived Hassles and Uplifts. 21 RESULTS The results of this study are the product of 75 parents self reported answers to hassles and uplifts defined by the designated tools. The 75 parents were from two groups: 47 parents of chronically ill children (28 mothers, 19 fathers) and 28 parents of healthy children (17 mothers, 11 fathers). The original study found no significant differences between the chronic illness families and comparison families on target child characteristics (age, sex and birth order), family characteristics (number of parents, number of children, and income) or characteristics of fathers (education, occupation, or full/part time work). Mothers in the comparison families had significantly more education, were significantly more likely to work outside the home and in graduate professional positions and to work full time compared to the mothers of chronically ill children (Spence, 1992). Hassles T-test was performed comparing the number of events having occurred listed on the hassles tool. It was not designated whether or not the event was defined as a hassle, rather did it occur (Table 1). No significant differences were found between the groups of parents related to number of events defined as hassles having occurred p > 0.05 (M=31.07 and M=3l.04). 22 Table 1. We: Barent :1 mean SttLdexiation chronic 46 31.07 15.72 healthy 28 31.04 15.63 T-test for equality of means I dfi ‘ Signifil_12:Iailedl 0.008 72 0.994 Perceived Hassles T-test was performed comparing the number of reported hassles between parents of chronically ill children and parents of healthy children (Table 2). No significant differences were found between the two groups of parents relating to reported hassles p > 0.05 (M=20.76 and M=20.54). Uplifts T-test was performed comparing the number of events having occurred listed on the uplifts tool. It was not designated whether or not the event was defined as an uplift, rather did it occur (Table 3). No significant differences were found between the groups of parents related to the number of events defined as uplifts having occurred p > 0.05 (M=65.24 and M=62.82). 23 Table 2. Nnmber_ef_2ereeixed_flassles Parent n mean Std_deyiatien chronic 46 20.76 13.02 healthy 28 20.54 10.66 T-test for equality of means 1 df Signifl_lz:lailedl 0.077 72 0.939 Table 3. Number_ef_nnlifts tzarent n mean Std_deviatien chronic 46 65.24 24.77 healthy 28 62.82 24.44 T-test for equality of means t df Signifl_12:Tailedl 0.409 72 0.684 Perceived Uplifts T-test was performed comparing the number of reported uplifts between parents of chronically ill children and parents of healthy children (Table 4). There were no 24 Table 4. H l E E . i u J'E! Parent n mean Std_dexiatien chronic 46 55.98 23.76 healthy 28 53.29 23.35 T-test for equality of means I df Signif1_12:tailedl 0.476 72 0.636 significant differences found between the two groups of parents relating to uplifts p > 0.05 (M=55.98 and M=53.29). The results of this study suggest that there is no significant difference in the number of reported hassles and uplifts between parents of chronically ill children and parents of healthy children. Family Adaptation Model The conceptual model of adjustment and adaptation would suggest that parents of chronically ill children would experience daily hassles and uplifts at a higher rate than those of healthy children. The presence of a child with chronic illness in the family, perception of daily hassles and uplifts and available resources are impacted as the chronic illness is an ever present demand of its own often at the center of family activities and plans. In families of children with chronic illness, attention directed toward 25 the illness, treatments of the illness, and limitations on activity, may deplete resources available for coping with the daily hassles and uplifts thus altering the perception of the event occurring. In turn this could effect coping mechanisms and overall functioning within the family over time. The results of this study do not support that common belief. DISCUSSION Methods There are multiple characteristics of the methodology that may influence the data interpretation. The sample size is small and the demographics of families are relatively homogenous, therefore, the findings cannot be generalized to all populations. The subjects were all volunteers and it can be assumed that the subjects had enough time and emotional resources to participate and complete the study. Significant differences in the educational level of the mothers may also influence the results, however, no specific data relating to educational level and coping was found. Another issue related to the findings of the study is that the tools used identified specific events and labeled them as hassles or uplifts. These may or may not be a stressor to an individual or family. Additionally, other events in an individual's life may be perceived as a hassle or uplift but not be designated as one on the tools. Another issue in evaluating the data is the cross sectional nature of data collection. Data was collected at one period in time, the sequence and timing of events could have an impact on the 26 perception of the event at the time of self reporting for this study. Current Literature The current literature suggests that parents of children with chronic illness experience more stress and have more tasks and burdens relating to the illness in daily life, but the literature is scarce relating to parental perception of hassles and uplifts in daily life. The findings of this study indicate that in spite of the added burdens related to having a chronically ill child, parents of these children do not perceive hassles and uplifts of daily life any more frequently than parents of healthy children. This suggests that parents learn to cope and find a balance of adjustment within the family whatever the list of burdens. Implications for Advanced Practice Nursing Implications for Advanced Practice Nursing are to continually assess the family's coping and adjustment skills both in healthy families and in those with children with chronic illness. As families develop and change over time, the equilibrium of adjustment and coping skills acquired will also continue to change and find new balance. By allowing parents opportunity to discuss issues and concerns, the Advanced Practice Nurse can facilitate the development of these coping and adjustment skills through teaching and counseling. Acknowledging stresses related to hassles and uplifts in the lives of parents and the disruption they bring to families, will help parents to see that through 27 communication and work within the family, another level of equilibrium in the area of adjustment and coping will be achieved as the family continues to develop. Advanced practice nurses can also be involved in educating the public, developing support programs and advocating on behalf of families of children with chronic illness. With increased public awareness and understanding, support and programs available will add to the available resources to families with chronically ill children. Legislative bills such as the family leave act recently signed and implemented is a start to public understanding and awareness. Other laws such as this one will help facilitate support and coping amongst families who must deal with chronic illness and thus increase overall functionality amongst families in the United States. Implications for Further Research Further research related to hassles and uplifts could be conducted on a larger sample and increase the ability to generalize the findings to a broader population. Evaluating perceived intensities of hassles and uplifts would also be helpful in determining whether the parents of chronically ill children experience them differently from parents of healthy children. Adapting a tool that allowed subjects to identify events perceived as a hassle or uplift which did not appear on the given tool may give a more accurate account as to the number of significant events. A longitudinal study would be more effective in evaluating the long term level of stress and the “multiplier effect" 28 related to hassles and uplifts in everyday life. Another important consideration in evaluating the data would be to consider the number of parents and stage of the family development related to the number of reported hassles and uplifts. Implications for Nursing Education This study is relevant in nursing education at all levels. Considering families as holistic, interacting, and ever-changing systems allows nurses to provide nursing care at different levels according to the level of the family's readiness and ability to accept information. As the family develops and experiences different levels of stress, the nurse can guide the family to and through various levels of coping. It is important for the nurse to understand the ever changing needs as a family develops as well as how individual perceptions differ within and between families experiencing similar situations. Summary In summary, though every family unit has individual ways of coping with stresses related to hassles and uplifts in everyday life, there continues to be a common thought that those families with chronically ill children experience them differently than their counterparts with healthy children. The advanced practice nurse can facilitate healthy growth and development and encourage the acquisition of effective coping skills amongst all families. Through acknowledgment and awareness that events in everyday life, whether a hassle or an uplift, stressors can be tools the 29 family uses to develop the next level of adaptation in the process of family development. 30 LI ST OF REFERENCES LIST OF REFERENCES Boyce, W.T., Chesney, M., Alkon, A., Tschann, J.M., Adams, S., 8., Cohen, F., Kaiser, P., Folkman, S. & Wara, D. (1995). Psychobiologic reactivity to stress and childhood respiratory illness: Results of two prospective studies. 2sxcbesematic_nedie1ne1_51 411- 422. Cadman, D., Rosenbaum, P., Boyle, M. & Offord, D.R. (1991). Children with chronic illness: Family and parent demographic characteristics and psychosocial adjustment. Bediatr1esl_al(6). 884- -889- Cohen, M. H. (1993). The unknown and the unknowable: Managing sustained uncertainty. Western_JQurnal_Qf_Nnrsing Researeh1_15(1), 77- -96. Cohen, S. (1990). Social support and physical illness. Advances_l(1), 35-47. DeLongis, A., Folkman, S. & Lazarus, R. S. (1988). The impact of daily stress on health and mood: PSychological and social resources as mediators. 1Qurnal_gf_2ez§gnality_and Seeial_25¥cheleg¥1_54(3). 436 495- Folkman, S., & Lazarus, R.S. (1988). Mannal_fgr_way§_gfi ' ' (research ed.). Palo Alto, CA: Consulting Psychologist Press. Gibson, C. (1988). Perspective in parental coping with a chronically ill child: The case of cystic fibrosis. Issues 1n_Cemnrehens1xe_2ed1atr1e_Nnrsingl_11 33- 41. Hamlett, K. W., Pellegrini, D. S. & Katz, K. S. (1992). Childhood chronic illness as a family stressor. 1gnzna1_gf Bediatrie_zs¥eheleg¥1_11, 33- 47. Hauser, S.T., Jacobson, A.M., Wertlieb, D., Weiss- Perry, 8., Follansbee, D., Wolfsdorf, J.I., Herskowitz, R.D., Houlihan, J. & Rajapark D.C. (1986). Children with recently diagnosed diabetes: Interactions within their families. Health_25¥cheles¥1_§(3). 273-296- Heaman, D.J. (1995). Perceived stressors and coping strategies of parents who have children with developmental disabilities: A comparison of mothers with fathers. Journal of.£ediatr1c.flnrs1ngl_10(5), 311-320. Hill, R. (1958). Generic features of families under stress. Seeial_§aeeuerk1_12. 32-52- 31 Hymovich, D. P. & Baker, C. D. (1985). The needs, concerns and coping of parents of children with cystic fibrosis. Family—Relat1ensl_14 91- 97. Ievers, C. E. & Drotar, D. (1996). Family and parental functioning in Cystic fibrosis. Jeurnal_ef_Deyelonmental_and Behayier_2ediatr1esl_1l(1). 48- 55 Kanner, A.D., Coyne, J.C., Schaefer, C. & Lazarus, R.S. (1981). Comparison of two modes of stress measurement: Daily hassles and uplifts versus major life events. Journal_gf Behayieral_nedicine1_4(1). 1- -39. Kanner, A. D. & Feldman, S. S. (1991). Control over uplifts and hassles and it's relationship to adaptational outcomes. Jenrnal_0f_Behayieral_Medie1ne1_4(2). 187- 201- Lavigne, J. V. & Burns, W. J. (1981). The impact of a chronic illness on the family. In Ped1atz1g_£§yghglggy1_An Intreduct1en_f0r_2ed1atrieians_and_Es¥ehelogiets. New York: Grune & Stratton, Inc. pps. 331-353. Lazarus, R S- (1966) Eexehelegieal_strees_and_the Qgp1ng_prggess. New York: McGraw Hill. McCubbin, H.I., McCubbin, M.A., Patterson, J.M., Cauble, A.E., Wilson, L.R. & Warwick, W. (1983a). CHIP- Coping health inventory for parents: An assessment of parental coping patterns in the care of the chronically ill child. Ieurnal_9f_Marr1age_and_the_Eamil¥1_484 359- 370. McCubbin, H.I. & Patterson, J.M. (1983b). The family stress process: The double ABCX model of adjustment and adaptation. In H. I. McCubbin, M. A. Sussman, & J. M. Patterson (Eds. ). ' See1al_Strese_and_the_Eam11¥1_Ad!anees_1n_Eam11¥ Stress_Theorx_and_Beseareh. New York: The Haworth Press, pp 7- 37. Patterson, J. & Blum, R. W. (1996). Risk and resilience among children and youth with disabilities. Argh1ye§_gf Eed1atr1c_and_Adeleseent_Med1e1ne1_150 692- 698. Patterson, J.M. & McCubbin, H.I. (1983a). Chronic Illness: Family stress and coping. In C.R. Figley, & McCubbin, H.I. (Eds.). ' ' ' . New York: Brunner/Mazel, Publishers, pp. 21-36. Patterson, J. M. & McCubbin, H. I. (1983b). The impact of family life events and changes on the health of a chronically ill child. Eam11y_Relat1Qn§1_1z, 255- -64. 32 Quittner, A.L., Opipari, L.C., Regoli, M.J., Jacobsen, J. & Eigen, H. (1992). The impact of caregiving and role strain on family life: Comparisons between mothers of children with cystic fibrosis and matched controls. Rehab111tatien_ns¥ehelogxl_31, 275- 290. Rubin, R. R. & Peyrot, M. (1992). Psychosocial problems and interventions in diabetes: A review of the literature. Diabetes.§are1_15(11), 1640- 1657. Schulz, R.M., Dye, J., Jolicoeur, L., Cafferty, T. & Watson, J. (1994). Quality of life factors for parents of children with asthma. Journa1_gf_asthm11_11(3), 209-219. Schwam, J.S. (1987). Assisting the parent of a child with asthma. Jen:nal.ef_Asthmal_24(1). 45-54. Silverstein, J. H. & Johnson, 8. (1994). Psychosocial challenge of diabetes and the development of a continuum of care. Eediatrie_Annalel_23(6). 300- 305- Spence, L. J. (1992). gh11dhggd_111nes§. Unpublished doctoral dissertation, Michigan State University, East Lansing, MI. Spirito, A., Stark, L.J., Gil, K.M. & Tyc, V.L. (1995). Coping with everyday and disease-related stressors by chronically ill children and adolescents. lgnzna1_gf Amer1can_Aeademx_ef_Cn1ldland_Adeleseent_zs¥sh1atr¥1_31(3). 283-290. U. S. Department of Health and Human Services (1992). 0‘00 7 IOI’ \. .09. .7. g 0 on. .0. .Q. 0. -. - preyent1gn_gbjegt1yes. Boston: Jones & Bartlett. VanSciver, M.M., D'Angelo, E.J., Rappaport, L. & Woolf, A.D. (1995). Pediatric compliance and the roles of distinct treatment characteristics, treatment attitudes, and family stress= A Preliminary report Dexelenmental_and_Behax1oral Pediatriesl_1§(5). 350- 358- 33 APPENDIX A UCRIHS.Approval Letter unnaunhda human) unmade-unauu aeaaaenanaaan “MW muons suntan» FR SWIG-"fl hmbm “film” mam Wham MICHIGAN STATE 0 N I v E a s l T Y May.ll. 1990 TO: Linda 3 e A230 Li a Sciences RI: 123.: 98-203 um: Y ILL CHILD: m wrrn a cnaowrcann 3730133 nun UPLIFTS or svrnrnav LIFE asvrsrow asoussrsnz na . - cassooav1-7 aspnovan mass: 05 00/90 The university Committee on Research Involving Human Sub ects'tUCRIHSI review of thistproject is complete. I am pleased to adv se that the rights and wel are of the ”subjects appear to be a mtected and me Mrmed ta prie? store, the UCRIHS approved this project” any mreggs one listed nauswan: UCIIISa roval is valid for one calendarm with the capprgeal datec shown above. Investigators mplgzgigsing cent a project ygtrm the green renewal fora1n (enclosed with origins a roval letter or when an p::1:3: is renewed) to se Mtifition.1hen of four such expedit renewals sible. Investigators fishing to continue a roject beyond tha time need to submit it agam or complete rev ew. navzsxoms: rocedures involving human intge change. If this is done at moggeen renewal tore. er time duringm UCRIHS must w231m subjects. °prior to tiation of ThT1Em renewal. pleas: uze rev e an a roved ro oco a an year send yourw wtten rgquest to ir, requesting revised I§?r°v‘1 raqiaigt'rdaicr .131’523282'3h123 .1336 ctCI'éi :3:l“:' a e an re s insz:::ents, consent forge or advertisements that {re applicable. 33031.38] cannons: Should either of the toll work, investi ators must noti ”I romptlytm mgroblees (unexpecteds de effects aints, e c. subjects or .2 es incoup the research enn ronment or new info mtion cating greater risk to the hm sub ects than existed when the protocol was previously reviewed roved arise during& If we can be of any future help please do not hesitate to contact us at 353- 2100 or sax (517)4 2 171. A U! 3.0 d av bed cc:t‘::hn C. hula :34 APPENDIX B Hassle Tool SUBJECT, mu ; mmssusm 1881110611083: _ mg day people experience irritating. fruatrating.’ or distressing evente that vacuum. Hasslescanrangafrusincranncyancestcasjcrpresstn-es. prohleas. or difficulties. hesles can occur few or eany tines. Metedbelowereseveralwe'ysinwhichaperscncanfeelhassled. Pleaseread eachevent. Iftheeventhappenedtcycuan'ingthepesteonth.ciroletheword m.§1ftheeventdidnotcootn'.dcnotcircleIIBandgccntothenert event. Iftheeventccmed,thenindioatewtethertbeeventwaseheeslefcryouby oirclingeitbernscrlo. Iftheeventwasaha'ssleUBwasciroled)fienretetheseverityofthehessle byoirclingeither1or2or3. 1ummszumm1mrm; m3ummxsrvm. Ifeventwesshassle, ,indicateseverity me If as. . event was event mu MM! WI . ocoufl l m m m m M MI Get Mt in tb rain...... ”C m 1 2 3 WMeeeeeeeeeeeeeeeeeee' m IE '0 1 2 3 “Meeeeeeeeeeeeeee m m IO 1 2 3 1. Hisplecing u.- lcaing. ‘ Weeeeeeeeeeeeeeseeeeeee m m '0 1 2 3 2. houblescae neighbors.....3. us as .0 1 2 3 3e W “m‘meeeeeeeesee m m 1 2 3 4e Wderate .Ohneeeeeeee m m IO 1 2 . 3 5. Mling thoughts about ' m Meeeeeeeeeeeeeeeeee m m m 1 2 3 6e Wt. M “.t’heeeeeeee m m m 1 2 3 .7. waddfmmouom m m 1 2 3 0. lot enough sons: for Chmeeeeeeeeeeeeeeeeeeeee m m '0 1 2 3 9. lot enough acne: for Weeeeeeeeeeeeeeeeeeeeee m m IO 1 2 3 10. Concerns about owing myeeee'eeeeeeeeeeeeeeeeeeee m 138 '0 1 2 3 11. Soeeone cwes'you aoney....... 128 IS NO 1 2 3 35 Haselee-P Page 2 "If event was a hassle. indicate severity 12. (batting down on elec- trinity. water. Cueeeeeee m 13s W too ”beseeeeeeee m 14c Use 0: “mleeeeeeeeeeee m 15. 16. too aany responsibilities. 17. “-10.11! ”lb.“ 11'“; in m ”meeeeeeeeeee 18s Care for ”teeeeeeeeeeee 19c am "heeeeeeeeeeee 20. Concerned about the m 0‘ luCeeeeeeeeeee 21o M1. “Inn‘eee.eeeeeee 22o WWI. m «Wee 23. Probleas getting along nth fellow workers....... 24. Inside hcee maintenance... 25. Concerns about job Wheeeeeeeeeeeeeeeeee 26. Laid-off or out or work... 27. Do not libs etc-rent work duties.................... 28. Do not like fellow mueeeeeeeeeeeeeeeeeee- 29. lot enough noney for m mmuCIeeeeeeeee 30. lot enotgh aoney for food. 31. therpected company........ - 32. too mob ties on hands.... ”e mm to mteeeeeeeeeeee 34. Concerns about socidents.. 35c Being lonely.............. 36s I.“ O: matheeeee 37s 81.11, mm “Use 38. Inability to express mueeeeeeeeeeeeeeeeee 39o W illness.......... 40. Side effects of sedioetion 41. Concerns about aedical muteeeeeeeeeeeeeeeee 42. mm appearance....... ‘3e 8..” O: "J”uaeeeeeeeee 44. Concerns about heelth in Mleeeeeeee'eeeeeeee E g Add dub-b Jul-Ida. cub-I dd .8 d-DJ-bd-IJ-l-I 0.3-... 8 888 888 88888888888 88 88 888 888 88888 do... cl 1 e i e an. 36 N ”NM ”NM NNNNNNNNN N N NM NM NM” ”NM NNNNN .90 UV“ \IIUUO UUUUUUUUU u U UH UV UUU UN!“ “0101““ Resales-P ' Pt:- 3 .Ifeventwasahessle. indicateseverity' Did If as. event was event mm mm mm: occur? an m arm: m m 45. lot seeing enth people.. as :13 IO 1 2 3 46. friends or relatives too , fl: Inyee'eeeeeeeeeeeeeeee m m m 1 2 3 47s mm uu'eeeeeeeeeee m m '0 1 2 3 “a Hosting tine.............. 123 m m .1 2 3 49. Probleas with aployeesu . 123 as m 1 2 3 50. Declining pmsical ' abilitien................. m m m 1 2 3 ’10 hm ”lumeeeeeeeneee m _ m '0 1 2 3 52. met-as about bodily ‘ ' - mumeeeeeeeeeeeeeeeee m 1” IO 1 2 3 53. Rising prices of connon Meeeeeeneeeeeeeeeeeeee m m m 1 2 3 54. Hot getting enough rest... 38 IE ’2 1 2 3 55. lot getting enough sleep.. IRS 13 no 1 2 3 56¢ Problens with 1810‘ mueeeeeeeeeeeeeeeeeee 133 m m 1 ’ 2 3 57. Problens with persons younger than yourself"... no 88 I0 1 2 3 58. Problens with your lover.. as 123 no 1 2 3 59. Difficulties seeing or hé‘D‘eeeeeeeeeeeeeeeeeee m m m 1 2 3 60. Overloaded with fully “CMbmu..eeeeeeeeee m m m 1 2 3 61. Too new things to do..... m IE so 1 2 3 62s WW ”theeeeeeee m _ m n 1 . 2 3 63. Concerns about nesting high . . .Weeeeeeeeeeeeeenee m m m- 1 2 3 64s JOb diuatinteotim....u m m '0 1 2 3 65. worries about decisions to ’ m Joueeeeeeeeeeeeeee m m m 1 2 3 66. Trouble with reading, ' writing. or spelling .MnuCIeeeeeeeeeeeeeeeee m m '0 1 2 3 67. Problens with divorce or ° separation................ m m '0 1 2 3 58. M10 with arittnetic - wheeeeeeeeeeeeeeeeeeee m m '0 1 2 3 69s Mpeeeeeeeeeeeeeeeeeeee m m m 1 2 3 7°. 1““ mblmeeeeeeeeeeee IIS 13 m 1 2 3 71o mm m “Weeeee m m n 1 2 3 72. lot .0013!) til. to a ti. things you need to do..... 128 as no 1 2 3 73a l'elevision..............u ' m m m 1 2 3 74. lot enomh personal Clergy I38 m IO 1 2 3 37 Hessles-P PIC. 4 i - eventues a hessle. indicste severity Did It 133. . event wss event comm: mm: W! occur? an “8813? mm mm ' m 75.0oncerne about inner conllicts................. 113 m m 1 2 3 '76J'eel conflicted over what to doesseeesessseeseeeeees as m m 1 2 3 77.3.9.1:- over past decisions as as '0 1 2 3 78.W (period) problens m m m 1 2 3. 79.3. mmreeeeeeeeeeeeeee m m '0 1 2 3 80.!ighhres................ m m D 1 2 3 81.6oncerns about getting Meeeeeeeeeeeeeeeeeesee m m m 1 2 3 82.meales tron boss or ' Weeeeeeeeeeeeeeee 128 m .0 1 2 3 83.m£ticulties Vith m. m 133 ‘0 1 2 3 “Jot enough tine tor tenily m ms '0 1 2 3 85.1raneportatim probless... 123 m '0 1 2 3 86Jot enough none: for - - muoneeeeeeeeeeee 133 m ‘0 1 2 3 87.Ilot enough noney tor enter- - taiueent and recreation... as m '0 1 2 3 ”emceeeeeeeeeeeeeeeee m m I0 1 2 3 _ 89.?!031‘3“ CM tin M omueeeeeeesee 228 123 IO 1 2 3 90.Iot enough tine for enter- teiuent dad recreation... 83' 138 I) 1 , 2 3 91.!ardwcrk or outside hose Weeeeeeeeeeeeeee -m m '0 1 2 3 92.Concerns about news events as as no 1 2 3 QBeWeeeeeeeeeeeeeeeeeeeee . m , m .0 1 2 3 94.Crine..................... m m m 1 2 3 ”.Mic................... m m I) 1 2 3 96.hhuflm................. m m m 1 2 3 97.6oncerns about scneyttor WUeeeeeeeeesseeee m 138 m 1 2 3 98.Deoisions about heving Weeeeeeeeeeeeeeeeee IRS m IO 1 2 3 99.0.:stcsers or clients give ' you . M Meeeeeeeeeee m . ‘3 IO 1 2 3 100.1'oc new interruptions.... 118 as IO 1 2 3 101.!ot enough none: for ”a“ ”sesseeeeeeeeeee m m m 1 2 3 38 flassles Page 5 7f event was a hassle. indicate severity Did If YES. event was event Satin-MT MMTELY EXTREIELY occur? an MSSLE? SEVERE. SEVERE seven: 102v F1".M‘.1 mur1‘ye'eeeeeeeeee YES YES m 1 2 3 103. Sexual problems that result from physical ‘ prw‘mOOOOOOOOOOOOOOOOOCOOI YES “3 m 1 2 3 104. Sexual problems other than.those resulting fro. physical problens'....... YES YES no 1 2 3 105. Auto naintenance............. YES YES no 1 2 3 t“. F“"ng Wt femOOOOOOOOOOOO YES YES m 1 z 3 ~10? Neighborhood deterioration... YES YES in 1 2 3 108. Problees on Job due to ' being a woman or Ian......... YES YES 110 1 2 3 109. Financial dealings with friends or acquaintances.... YES YES 110 1 2 3 110. Too eany ueetings........... YES YES 110 1 2 3 111. Concerns about getting ‘ 1 cru1t...00.000300000000000. YES YES m 1 2 3 112. Financial responsibility ' for someone who does not _ I‘V. with NOOOOOOOOOOOOOOO YES YES 3 1 2 3 113. Concerns out retiruent... YES YES 1 2 3 119. Difficulties with getting . prflnmtOOO0.000.000.0000... '3 YES m 1 2 3 115. Financing children's .duc‘t'on.OOOOOOOOOOOOOOIOOO YES YES m 1 z 3 116. Problems with your children. YES YES 110 1 2 3 117. Property. investments. or , m.s0000OOOOOOOOOOOOOOOOOOO YES YES '0 1 2 3 118. 8.1” msp‘t‘I‘zfieeeeeeeeee YES YES m 1 2 a Have we eissed any of your hassles? If so. please write the: in below. Irsw 18619:? 5119/8 39 APPENDIX C Uplift Tool SUBJECT DAT! 1'83me 13811100110”: Every day people experience evente that eeloe thee (eel good. lie cell theee eventeUPLms. Uplift-onheouroeeotpeace.eatieteotion.pleeeure.or Joy. 8oneupli£teocc1rotten.othereererere. Lietedbelouereeeverelmeinwhichaperecncanteeluplitted. 21......“ 'eechevent. cheeventoocmedtoyouinthepeeteonthcirolethewondm. litheeventdidnotoccgn'.donotcirolewendgo.tothenextevent. i Ittheeventoocurredindioatewhethertheeventweeorwaenotanuplitt.- Ittheeventwaeenuplittthuretethepleamottheuplittbyoiroling. eitheriorZos-S. 1nmmmm.zummmm.m summ. TL?» event wee en upliRT indicate how pleasureble. Did It as. event wee event 30mm HOW mm m Wummmm' m. aegiaq '.a 2. 3. 4. 5. 6. 7. a. 9. 1o. 11. .12. 13. 14. Received a letter m . Meeeeeeeeeeeeee m ilon the daily lottery. no romd a dine in the .mteeee m al.-L Practicing your hobby. no hm Meeeeeeeeeee m. am my.......... m Mowing “Meeeeeee Liking an... wot-here. no lot working (on . "0.“ng m)eee m Gouipings 'ehootihg t). bull."............ m 3.1" neted.......... 1” 3.01138 hnweeeeeee m finding eoeething WM 10lteeeeeeee IE Recovering tron lllneu.............. m Staying or getting in good meicel ehepe... no km with “Moe m Jul-L ' O .a N” N N NNN N NNNNNT N N” uu u u wow: u uuuuu11 u on» a. 40 Uplifts-P Page 2 It the event wee an uplitt. indicate how pleaeureble. Did nus, event weeevent W. W! m, ccouflanm mmmmm_ 13. filing eceething of? getting away with . .mmn‘eeeeeeeeeee m m 30 1 2 3 16. Vieiting, phoning. .or “in“ .mmeeeeeee m m 30 1 2 3 17. Relating well with your 'epouee or lover.. as as 30 1 2 3 18c MOW . Meeeee m m m 1 2 3 19. 6171113 I ocuplinent... 123 m '0 1 2 3 20. fleeting £8.11! ”Whinu..eeeeee m m '0 ‘ 2 3 21. Relating well with ‘uMeeeeeeeeeeeee m m '0 1 2 3 22. 301113 etticient..."u m as 30 1 2 3 23. fleeting your reeponeibilitiee...... m as l0 1 2 3 24. mitting or cutting can a l1¢0h01....... 133 m m 1 2 3 25. Mtting or matting . don a: Meeeeeee m :3 I0 1 2 3 26. Solving an ongoing ‘ . ' pmtiod mb1-eeeee m m m 1 2 3 27o -Ihydrelaing........... m m '0 1 2 3 28. Deeired weight gain or 1m............. m m '0 1 2 3 ”emu” "MWeeee m . m '0 1 2 3 30. Having enough tine to - do 'ht I“ mteeeeee m ' m '0 ‘ 2 3 31. Getting a divorce or neperating............ m m D 1 2 3 32o Eeting cut............. m m I0 1 2 3 33. Having enough pereonal energy................ m m 1 2 3 34. Resolving inner oonflicte........... m m n 1 2 3 35. Being with .14.: . mpheeeeeeeeeeeeee m m '0 1 2 3 36. Finding no prejudice or diecrieinaticn when . ’0“ .mt iteeeeepeee m m m 1 2 3 Ne “Meeeeeeeeeeeeeee m m '0 1 2 3 38. Capitalieing on an mexpected opportunity YB 13 IO 1 2 3 39. lining druge or alcohol ID no IO 1 2 3 40. “I. being DIM. n: m .0 1 2 3 41 Uplitta-P Pta- 3 Did event ooou? 41 e 42. ' 430 “e 45. um “uWMeee m hting................ m ”I‘Meeeeeeeeeeeeee m lhving the WW amount of thinga t0 dCeeeeeeeeeeeeeee *1“ “am. M. or “at C I'Meeeeee IE Enjoying the weather" no hinting about the “meeeeeeeeeeeeee m spending tine with £anily.............. m none (inside) pleaaing “ Meeeeeeeeeeeeeeee Being with younger mp10eeeeeeeeeeeeee m haying thinga tor the houne............... “Meeeeeepeeeeeeee m Shopping.............. 13 hueeeeeeeeeeeeee m haying ClOMeeeeeeee IE 56 “'13; . ”Meeeeee m 67. 69. 70. Getting . ”mteeeee m Traveling or oouatingdm Doing yardwork u «abide mmwrkeeeee m haalth of a tanily nenher inpi-oving...... m ieaolving oontliota over what to “eeeeeee m Thinking about health. no Being a 'good' lintaner............ m Sociolising (going to parties heing with . m eeeeeeeeeeeeee m m I Weeeeeo :3 Sharing aonething..... 113 Having aoneone linton to Meoeeeeeeeeeeoeee m You yard or outaide ot houao in planing...” as thving enough honey tor entertain-ant and rooroation........... IRS Entertain-ant (noviea. cmrtl. ")eeeeooeee ’3 Hi3 HEEHE EHEEEEEEEHMEEEHEEEE 333 55353353 3': 3 fl 0 3'8 IO IO IO 42 Jule-I dub-8.8.5.3.... .3 cl .3 .3 dd ,3 dub-Id cl .3 a. dent-B N NN N N NNNNNNNN N N N N NN N N N NNN N U UV U U UUUUUUUU U U u U HUI on UN“ U U HUI“ U Uplifts-P hn4 E?” $ to pleasurable. Did If 123, t was an uplift, event. was event SOHEURAI RODERAIEfl! RIIREIEL! occur? an UPLIPT? PLEABGRARLB PLILSGRARLE ELIASURARLE 71. Good news on local or World 1".1eeeeeeeeeee m 113 ‘0 1 2 72. Getting good advicc... YES 123 R0 1 2 73. Recreation (sports. 8..., M)eeeeeeee YES m IO 1 2 74. Using skills well at "Orkeeeeeeeeeeeeeeeee m 113 HO 1 2 75. Growing as a person... YES 128 NO 1 2 76. Being coeplinented.... YES YES R0 1 2 W.&fiugwdm«su ”theeeeeeeeeeeeeeee YES m 110 1 2 7&InmuuorpmMg n." lkilll............ YES YES NO 1 2 79o “M I". theeeeee YES YES '0 1 2 80. RXpressing yourself “lleeeeeeeeeeeeeeee m IE 30 1 2 81e Bumseeeeeeeeeeeeee m 133 HO 1 2 &.huummguwwt spouss or children.... IRS YES R0 1 2 830 um work duti...... 133 m "0 1 2 abbuuuutouphnu m mueeeeeeeeeeee m m ”0 1 2 BLGuumumnuhd my......'......... YES NO 1 2 86e M8138 hb‘eeeeeeeee YES YES 130 1 2 87e mullaeeeeeeeeeeeeee m m .0 1 2 88s “V138 Meeeeeeeeeeee YES YES NO 1 2 89. Going sceeplace that is m:.mteeeeeeeeeeeee YES TESS ‘0 1 2 9mEMngmrnnk _, uwusuuuinnu ' - Weeeeeeeeeeeeeeeee m YES '0 1 2 91s “71.38 ”ueeeeeeeeeee m YES NO 1 2 92. Neighborhood isproving.!£s YES NO 1 2 93. Things going well filth 0.910,..(C)eeeeeeeeeee “3 IE '0 1 2 94e'Pl....nt -‘11‘eeeeeee 138 ES '0 1 2 95e am 10".......... 133 m '0 1 2 96c mm mm«:....... YES 13 NO 1 2 ”.mmnulhfltb mteeeeeeeeeeeeee'eeee ’3 IE IIO 1 2 98. 017138 3906 ld!1¢0.... YES YES ‘0 1 2 99e Praying............... YE YES NO 1 2 100emUh meeeeeeeeeeeee m YES NO 1 2 101.Con£ronting soeecns or .mm‘eeeeeeeeeeeee m m 310 1 2 102.801“ QOOCPMeeeeeeee YES YES NO 1 2 43 u uuuu u um um um u uuu u uu UlUl UUUU UUUU UUU Uplifts-P Page 5 i? tho event was an uplift, indicate how pleasurable. Did If 128, event occur? 103.61.th 10vo........... m 104.Boss pleased with your work.................. 105eh138 .lmeeeeeeeeeee 106.!‘ccling ”Ceeeeeeeeee 107.Horking well with fellow workers............... 108.Knowing your Job is secure.............. 109.?eeling sate in your neighborhood.......... 110.Doing volunteer work.. 111.Ccntributing to a ChaitYeeeeeeeeeeeee 112.Learning sosething.... 113.Being ”one“ with th. world............... 114.?ixing/repairing sosething (besides at YO“ 30b)eeeeeeeeeee 115.Haking something (besidesat your Job).. 116eEXOl-‘0181n8eeeeeeeeeeee 117.Heeting I omlweee 118.Hugging and/or kissing. 119.Plirtmg.............. 120.Having sexual rellumeeeeeeeeeee 121.Having enough soney for health “meeeeeeeeeee 122.Having enough soney for umflpomuoneeee m 123ehym Off domeeeeee m 124.Pest decisions “panning out.”................. 15 125.Job satisfying despite discrininaticn due to you BC‘eeeeeeoeeeeeee 13$ 126.Deciding to hIVO WIMeeeeeeeeeeee IRS 127.Car working/running “lleeeeeeeeeeeeeeee 128.8uccesstully avoiding or dealing with bureaucracy or mttwtimeeeeeee YES 129.“d1fltm‘............ m 335 a aaaaa a 5 aa aa a a 53 a a 5' a 53 a a aaaaa a a aa aa a E aaa a NO NO NO NO NO NO HO ”O NO NO NO NO NO “0 IO 41% N NN NN N N NNN N N NN N N NNNNN N N U UH WU U U UUUI U U UV bl U UUUUU U U Uplifts-P Pege 6 If the event was an uplift. indicate how pleasurable. Did If 238, event was event 80mm MODERATE! mam: occur? an OPLIFT? PLEASURADLE PLEASURARLE PLEASURADLB 130.8uccessful financial dialing...u......... YES 13 '0 1 2 3 131.?inancially supporting soseone who does not 11'. with Meeeeeeeee m m .0 1 2 3 132.Looking forward to ‘ retireunt............ m m .0 1 2 3 133.Having good credit....'!RS IRS IO 1 2 3 134.2n3cying your children's acccsplishsents....... IRS IRS IO 1 2 3 Have we sissed any of your uplifts? If so, please write thee in below. 45 "‘filflifliflnflflmflilmflflfiwmfiflfifiES