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\begin{document}


\def\RunningAuthor{Samira Mohamed Saleh and Sneha Pitre}
\firstPage{1136}
\articleType{Original Article}
\receivedDate{08 Feb 2021}
\acceptedDate{17 Mar 2021}
\revisedDate{10 Mar 2021}
\journalVolume{2021, 12}
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\journalDoi{ijrps.v12i2.4645}
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\title{Parental Beliefs about Child's Experience of Anxiety in Saqr Hospital Ras Al-Khaimah, U.A.E}
\author{Samira~Mohamed~Saleh, 
            Sneha~Pitre\textsuperscript{*}~\\[5pt]{Department of Nursing, Kalba Hospital, R.A.K. of Nursing, Rak Medical and Health Sciences University, Ras Al Khaimah, Sharjah-500001, United Arab Emirates }}

\begin{abstract}
Anxiety is a reaction of an individual to change or a stressful event. Separation anxiety, fear of darkness, stranger anxiety etc., are normal features of development during the initial part of life. However, if it persists and not identified at an early stage can lead to anxiety disorders in children. Parents play an important role in its identification at an early stage and management to protect the child from long term consequences of anxiety disorders. It imposes them to have an appropriate belief about the experience of their child's anxiety.  Cross sectional survey was conducted among 252 parents who visited Saqr hospital for various health care issues. Participants were selected using a convenience sampling technique. Data was collected with the use of a self-reported Parental Belief about child's anxiety questionnaire (PBA-Q). Majority (93.7\%) of parents had a moderate level and 5.6\% had a highly negative belief about the experience of their child's anxiety. No significant association was observed between Parental Belief about a child's anxiety and demographic variables like age, gender, education. However, a significant association was observed with the household income of the family. Parents being the primary and most influential caregiver, play a significant role in the emotional health of the children. Findings of the present study strongly recommend regular assessment of parents belief about the experience of anxiety in children and provide guidance to minimize anxiety disorders in children. PBA-Q is a simple tool that can be used in day to day practice.
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}Anxiety,\newline belief,\newline emotional health,\newline PBA-Q
\end{keywords}
\twocolumn[ \maketitle {\printKwdAbsBox}]
\makeatletter{\raggedright\textsuperscript{*}Corresponding Author\par Name:\ Sneha~Pitre~\\ Phone:\ +971527441296~\\  Email:\ pitresneha@gmail.com
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\section{Introduction}
\textbf{Background }

Anxiety, fear, phobia are some of the common feelings experienced by children at various stages of life. Separation anxiety is common among infants and toddlers, whereas preschoolers are scared of darkness, water, height, blood, school etc. It is considered as a part of normal development, however, if it persists can lead to anxiety disorders in children\unskip~\citep{1043850:21739336}. Approximately 8\% of all children and adolescents suffer from anxiety disorders\unskip~\citep{1043850:21739339}. The overall prevalence of anxiety disorders among school-aged adolescents in the U.A.E was also 28\%, which was higher than rates in other countries. Discoveries likewise showed that the predominance of uneasiness problems was higher in young ladies (33.6\%) than young men (17.2\%) (p \textless\ 0.0001). Members matured \textless\ 16 years had higher summed up tension, partition nervousness, and social uneasiness scores contrasted and those matured \ensuremath{\geq }16 years (p \ensuremath{\leq } 0.05)\unskip~\citep{1043850:21739331}. 

Anxiety disorders among children affect their personal and social life, which includes difficulty in attending school, high levels of distress, distorted cognition, impaired relationship with parents and siblings and more victimization\unskip~\citep{1043850:21739327,1043850:21739343}.\ensuremath{^{}}Parents being a primary caregiver play an important role in its identification at an early stage and protecting the child from lifelong consequences associated with these disorders.  

Parental psychopathology, including anxiety and depression\unskip~\citep{1043850:21739328} ; child rearing styles of parents and behaviors\unskip~\citep{1043850:21739329}, are some of the factors which have been found to be connected with anxiety disorders in children. It is also observed that a significant relationship exists between parent's beliefs about their child's anxiety, coping skills and parenting with the level of anxiety in their children\unskip~\citep{1043850:21739332}.

It is a known fact that both father and mother play a significant role in the physical, social and emotional development of their children. Many researchers have explored the impact of parent's emotions in the form of anxiety on their children. Anyway, there is still a scarcity of exploration where guardians are evaluated for the convictions about the experience of tension in their youngsters. Therefore, in the present study, Parental Beliefs about their child's experience of Anxiety was assessed with the use of the Parental Beliefs About Anxiety Questionnaire (PBA-Q). \textbf{\space }
    
\section{Methodology}
\textbf{Research design and setting }

Quantitative cross sectional survey design was used in the present study. It was conducted in the Saqr hospital, which comes under the Ministry of health and prevention U.A.E. This hospital provides health care services to adults and children. Approximately 100-200 parents visit this hospital daily for the management of various health care issues. 

\textbf{Ethical Considerations}

Ethical approval was obtained from the university and regional ethical (RAKREC.) committee. Informed consent was taken from the parents who were willing to participate in the study.  

\textbf{Sampling }

252 parents of the children between 1-18 years of age were selected using a convenient sampling technique for the study. Parents who were able to read and write English or Arabic and gave informed consent participated in the study.  

\textbf{Instrument }

Parental Beliefs About Anxiety Questionnaire (PBA-Q) was used in the study\unskip~\citep{1043850:21739337}.  It is a four point Likert scale having 17 items, ranging from 0 (strongly disagree) to 3 (strongly agree). Reverse scoring was done for question no. 6 \&14. Higher scores show more noteworthy degrees of parental negative convictions about the youngster's experience of uneasiness. 

\textbf{Data collection procedure }

After receiving ethical approval from RAKMHSU, RAK REC and Administrative authorities, parents who were visiting saqr hospital during data collection period were approached.  

\textbf{Protection of human subjects}

Study was conducted after receiving ethical approval. Anonymity of the data was maintained by using a system of coding. Access for the data is restricted to the investigator. Participants were ensured that data collected in this study would not be used for any other purpose. 
    
\section{ Results}

\begin{table*}[!htbp]
\caption{\boldmath {Demographic characteristics of the parents} }
\label{tw-4cd13d334266}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.4761\linewidth-2\tabcolsep}p{\dimexpr.2715\linewidth-2\tabcolsep}p{\dimexpr.25240000000000002\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Demographic characteristic  & Frequency & Percentage \\
\tblmidrule 
\multicolumn{3}{p{\dimexpr(1\linewidth-2\tabcolsep)}}{Age (years ) }\\
21-30 &
  26 &
  10.3\\
31-40 &
  78 &
  31.0\\
   41-50 &
  118 &
  46.8\\
 \ensuremath{\geq } 51  &
  30 &
  11.9\\
\multicolumn{3}{p{\dimexpr(1\linewidth-2\tabcolsep)}}{ Relationship with the child }\\
 Father  &
  118 &
  46.8\\
Mother  &
  134 &
  53.2\\
\multicolumn{3}{p{\dimexpr(1\linewidth-2\tabcolsep)}}{Marital status}\\
Married  &
  240 &
  95.23\\
Widow  &
  1 &
  0.4\\
Divorcee  &
  11 &
  4.4\\
\multicolumn{3}{p{\dimexpr(1\linewidth-2\tabcolsep)}}{Education Level}\\
Primary  &
  35 &
  13.88\\
Higher secondary  &
  130 &
  51.58\\
Under graduate  &
  63 &
  25\\
Graduate   &
  24 &
  9.52\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Level of Parental Beliefs about child's experience of anxiety } }
\label{tw-e4cff87b4a71}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.1136\linewidth-2\tabcolsep}p{\dimexpr.28639999999999997\linewidth-2\tabcolsep}p{\dimexpr.20\linewidth-2\tabcolsep}p{\dimexpr.20\linewidth-2\tabcolsep}p{\dimexpr.20\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor} Sl. No.  & Level of parental belief  & Score  & f &  \%\\
\tblmidrule 
1 &
  Highly negative &
  35 -51 &
  14 &
  5.6\\
2 &
  Moderately negative  &
  18 -34 &
  236 &
  93.6\\
3 &
  Slightly negative  &
  0 {\textendash} 17 &
  2 &
  0.8\\
 &
  Total  &
   &
  252 &
  100\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Item wise analysis of the statements as per PBA-Q} }
\label{tw-68e7da01e450}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.07749999999999998\linewidth-2\tabcolsep}p{\dimexpr.3894\linewidth-2\tabcolsep}p{\dimexpr.1346\linewidth-2\tabcolsep}p{\dimexpr.12100000000000005\linewidth-2\tabcolsep}p{\dimexpr.13749999999999998\linewidth-2\tabcolsep}p{\dimexpr.14\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Sl. No. & Item  & Strongly \mbox{}\protect\newline Agree \% & Agree  \mbox{}\protect\newline \% & Disagree \mbox{}\protect\newline \% & Strongly disagree \%\\
\tblmidrule 
1 &
  When my child is upset, it makes me very anxious. &
    6.0 &
  52 .0 &
  36.9 &
  4.4\\
2 &
  It scares me when I~notice that my child is short of breath.  \mbox{}\protect\newline  &
  13.1 &
  35.3 &
  47.6 &
  4.0\\
3 &
   I~feel like I~am a bad parent if my child becomes stressed out. &
  1.6 &
  47.2 &
  44.4 &
  6.7\\
4 &
   If my child gets too nervous, it could be really harmful. &
  4.8 &
  67.1 &
  23.8 &
  4.4\\
5 &
  My child should not have to feel afraid.   &
  9.5 &
  70.6 &
  18.3 &
  1.6\\
6 &
   My child will grow out of his/her fears.   \mbox{}\protect\newline  &
  12.7 &
  63.1 &
  23.0 &
  1.2\\
7 &
  When my child is nervous, I~worry that he/she might be  mentally ill.  \mbox{}\protect\newline  &
  8.3 &
  48 &
  38.5 &
  5.2\\
8 &
  I~get very anxious when my child is ill .  &
  9.1 &
  52.8 &
  35.7 &
  2.4\\
9 &
   I~do not like it when other people see my child is afraid.  \mbox{}\protect\newline  &
  6.3 &
  55.6 &
  35.7 &
  2.4\\
10 &
  When my child's stomach is upset, I~worry that he/she might be seriously ill. &
  8.3 &
  50.8 &
  35.3 &
  5.6\\
11 &
   When I~worry about my child, I~feel like I~am a good parent. &
  11.1 &
  46.8 &
  37.7 &
  4.4\\
12 &
   It scares me when my child is nervous.   &
  4.8 &
  38.1 &
  54.8 &
  2.4\\
13 &
   When I~feel worried that my child is not safe, it is important for me to trust those feelings no matter what anyone else says.   &
  5.6 &
  61.1 &
  31.3 &
  2.0\\
14 &
   I~do not get uncomfortable when my child is upset about something. &
  7.1 &
  61.5 &
  30.2 &
  1.2\\
15 &
  It scares me when my child says he/she feels faint.  \mbox{}\protect\newline  &
  4.0 &
  44.0 &
  51.6 &
  0.4\\
16 &
   It scares me when my child is nauseous.  \mbox{}\protect\newline  &
  4.0 &
  36.5 &
  59.5 &
  -\\
17 &
   It is important to me that my child not appears nervous. \mbox{}\protect\newline  &
  4.4 &
  90.1 &
  5.2 &
   0.4\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Association between Level of Parental Beliefs about child's experience of anxiety and selected demographic variables} }
\label{tw-f549a9e3dcdf}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.3758\linewidth-2\tabcolsep}p{\dimexpr.2838\linewidth-2\tabcolsep}p{\dimexpr.1916\linewidth-2\tabcolsep}p{\dimexpr.14879999999999997\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Demo Variable   & Chi-square(X\ensuremath{^{2}}) value & df & P value\\
\tblmidrule 
Age of the parents   &
  7.814 &
  6 &
  0.252\\
Gender   &
  1.888 &
  2 &
  0.389\\
Marital status   &
  1.236 &
  6 &
  0.975\\
 Education level   &
  14.677 &
  8 &
  0.066\\
Household income  &
  64.437 &
  6 &
  0.000\\
Religion   &
  0.137 &
  2 &
  0.934\\
Family history of chronic diseases  &
  2.972 &
  0.8 &
  0.936\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}
As per the data presented in Table~\ref{tw-4cd13d334266}, the majority of participants were in the age group of 41{\textendash}50 years, Muslim (99.2\%) and staying with spouse (93.3\%). However, 4.4 \% of mothers were divorcee staying with their children. Findings also indicated that in the majority of participants, family income was ranging between 11,000 - 20,000 per month. 

Results obtained from Table~\ref{tw-e4cff87b4a71}  indicates that a substantial number of parents (93.6\%) had a moderately negative belief about their child's experience of anxiety. Findings also suggest that 5.6 \% of parents have a high level of negative belief about their child's experience of anxiety. 

Data presented in Table~\ref{tw-68e7da01e450}  indicates that the majority of parents have misinterpreted the child's experience of anxiety. Substantial number (52\%) of parents agree that they become anxious when their children are upset, are nervous, having stomach upset and fainting attacks. Data also indicates that a considerable number of parents (47.2\%) feel that they are bad parent if their children are under stress and are good parent when they worry about their children. In addition to this majority of parents express that their child should not feel afraid (70.6\%) and grow out of his/her fears (63.1\%). 

As per the data presented in Table~\ref{tw-f549a9e3dcdf}, no significant association is observed between the Level of Parental Beliefs about a child's experience of anxiety and selected demographic variables except with the parent's household income (0.000).
    
\section{Discussion}
252 parents participated in the present study. Among the participants' majority (53.2\%) were mothers of children and between 41-50 years (46.8\%) of age. Maximum (96.5\%) number of parents were Muslims and educated up to a higher secondary level (51.8 \%).

When parents' belief about their child's anxiety was assessed by using the PBA-Q scale, the majority (93.7\%) of them had moderately high negative beliefs, whereas 5.6 \% had a highly negative belief about the experience of anxiety in their children. It was evident from the findings of the item-wise analysis, where the majority of parents perceived symptoms like stomach upset as a serious illness, feeling scared when a child has shortness of breath, nervousness in children as an indication of mental illness, and getting very anxious when a child is sick. The majority of parents (90\%) also believe that their child should not look nervous, grow out of fear and worry as it is harmful to their emotional health. According to Francis and Chorpita \unskip~\citep{1043850:21739337}, these beliefs are considered maladaptive, which do not indicates normal levels of concern about their children's experience of undesirable emotions. It was also evident from the findings of the study performed by these researchers in which significant association was observed between maladaptive parental belief and child anxiety. Hence, there is a need to consider this factor while assessing children for anxiety disorders\unskip~\citep{1043850:21739334}. 

Parents' perception of anxiety in their children plays an important role in the early identification and management of the child's anxiety. In the present study majority of parents were having a moderate level of negative belief about their child's experience of anxiety. These findings are in line with the observations done by \unskip~\citep{1043850:21739338}, where Father' and mother's beliefs about children's anxiety were assessed. Findings revealed that most of the parents perceived the child's anxiety as a permanent condition, attributing it to external and parental factors and considering that the anxiety problems have a negative impact on the child's well-being. In addition, parents who had previously sought professional help for the child's emotional problems believed that anxiety could improve with the child's or parents' efforts and with professional guidance, contrarily to those who had not. Finally, the researcher concluded that parental beliefs about their children's anxiety might influence their attitudes and decisions, for instance, to sought help from counselors.

The findings of this study also indicate the anxious raring behavior among parents. This behavior may reinforce avoidance response in their children and excessively warn them about experiencing dangers. Research has shown that parents who practice a high level of anxious raring have children who are more anxious than those who do not practice this behavior\unskip~\citep{1043850:21739330}.

Item wise analysis of the statements related to parent's belief about their children's experience of anxiety indicated that the majority of parents are very sensitive towards their child's emotional and physical discomfort, as evidence by 52\% agree that they become anxious when their children are upset, nervous, having stomach upset and fainting attacks. Data also indicates that a substantial number of parents (47.2\%) feel that they are bad parents if their children are in stress and good parent if they worry about their children. In addition to this majority of parents express that their child should not feel afraid (70.6\%) and grow out of his/her fears (63.1\%). 

In the present study, the association between the level of belief of the parents towards their child's experience of anxiety and selected demographic characteristics were assessed. No significant association was observed between the level of negative belief about parents experience of their child's anxiety and age, gender, level of education, and marital status except with monthly family income (.000). 

Item wise association with selected demographic variables was assessed in the present study. Significant (0.000) association was observed between gender and the response related to the item, "when my child is upset, it makes me very anxious". Surprisingly percentage of agreement was more in fathers (53.4\%) than mothers (46.6\%). It suggests that father and mother may have different perception about the anxiety in their children, which needs to be explored separately. It is observed that most of the studies related to parental behavior involve only mothers. However, there is a need to know how parental perception and parent-child interaction differs among father and mother\unskip~\citep{1043850:21739342}.

In addition to this, items stating "It scares me when I~notice my child is short of breath" and "My child should not have to feel afraid" showed Significant association (0.000) with gender, family history of chronic illness, religion, education, and family income. This association indicates an underlying concern about the child and anxiety among parents. Anxious parents are likely to exhibit anxious behavior and may impose restrictions on the behavior of their children, which may increase the risk of anxiety disorders among them\unskip~\citep{1043850:21739340}.

Facilitating the normal emotional development of children is an important responsibility of the parents. It depends upon the guidance and supports the child receives from the parents to regulate and express their emotions\unskip~\citep{1043850:21739333,1043850:21739335}. It necessitates that parents need to have an appropriate belief about the experience of various emotions in their children. 

Parent's emotional philosophy has shown a significant impact on the emotional state of their children. According to parental Meta emotion coaching philosophy, those parents who are aware about their own, as well as their children's emotions, are empathetic, view negative experience of emotions in their children as an opportunity to strengthen their bond with the child and prepare them to solve the problems with a positive attitude\unskip~\citep{1043850:21739341}. Whereas if parents have dismissive philosophy tend to avoid or dismiss the exposure of their children to any negative stimuli. These parents view negative emotions are harmful to their children and should be taken care of immediately. When the effect of these two philosophies on children was compared, it was observed that children of the parents with higher meta emotion philosophy had better emotional and physiological stability, self esteem, academic performance and less stress\unskip~\citep{1043850:21739335}. 

The findings of the present study on the basis of a review of relevant literature strongly suggest the need for counseling for the parents to improve their own beliefs and providing guidance for their children during periods of stress and anger. It will help in minimizing the chances of the development of anxiety disorders in children, which is found to be prevalent all over the world. These findings also indicate that parent's negative beliefs about their child's experience of anxiety may affect their decision about seeking help from counsellors, which is detrimental for the emotional health of the child\unskip~\citep{1043850:21739338}.
    
\section{Conclusions}
Anxiety is a contagious phenomenon. Therefore, the children of parents who have negative beliefs about anxiety may perceive any negative or traumatic event in their life as a threat. It may lead to impaired learning and development due to triggering anxious behavior. The findings of this study suggest there is a need to screen the parents for their beliefs about the experience of anxiety in their children and provide appropriate counselling to minimize the chances of the development of anxiety disorders in children.
\section*{Acknowledgement}Authors acknowledge the immense support received from Dr Azza Saad Zaghloul Ahmed and scholars whose articles are cited and included in references to this manuscript. Authors are also grateful to authors /editors /publishers of all those articles, journals, and books from which the literature for this article has been reviewed and discussed. 

\textbf{Funding Support}

The authors declare that they have no funding support for this study.

\textbf{Conflict of Interest}

The authors declare that they have no conflict of interest for this study. 
    

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