The Couple’s Congruence of Child’s Illness Perception and the Quality of Marital Relationship

The spouses’ congruence regarding perceptions about the disease was usually analyzed in the context of intimate partner physical illness and the results showed that couple’s congruence of disease perception positively correlated with patients’ quality of life, adjustment to illness, and relationship satisfaction. In the same time, some studies consider that a strong perception on the child's illness causes psychological distress. The study aims to test whether couple’ congruence regarding child's illness perception has an influence on the quality of marital relationship, operationalized by couple satisfaction, parental stress, dyadic coping and resilience family. This research involved 106 parents of children with Autism Spectrum Disorder (ASD) (53 of maried couples). The results show a significant effect of couple’ congruence of child's illness perceptions on marital satisfaction F (2.103) = 3.61, p = .03, parental stress F (2.103) = 17.89, p <.001, dyadic coping F (2.103) = 9.23, p <.001 and family resilience, F (2.103) = 10.43, p <.001.The results indicate a decreasing trend of marital satisfaction, family resilience and dyadic coping and an increasing trend of parenting stress when the couple congruence of illness perception grows. Our results are discussed in the context of their relevance for the therapy of families with children who suffer from Autism Spectrum Disorders.


Introduction
Illness perceptions and their meaning in terms of adjustment to illness have often been studied in the scientific literature (Filipp & Aymanns, 1997;Petrie & Weinman, 2012;Salewski, 2010). Illness perceptions are thought to contain and organize people's information and beliefs on illnesses, symptoms, medical treatments or health-threatening factors. In other words, these perceptions represent the way in which people subjectively explain their illness and its circumstances (Benyamini, 2011).
Illness perceptions have generally been explained using the selfregulation model of response to illness proposed by Leventhal, Nerenz and Steele (Leventhal, Nerenz & Steele, 1984). This model views health-and illness-related behaviours as a repetitive process, through which the individual integrates the information received from internal and external stimuli within the existing cognitive structures, in order to guide the coping behaviours, whose outcomes are evaluated; this evaluation is used to reestimate the interpretation of illness and to plan the future methods of coping (Leventhal et al., 1984). This model posits that illness perceptions are based on five elements: illness identity, illness consequences, illness time-line and illness cause and illness controllability (Leventhal et al., 1984;Lau, Bernard & Hartman, 1989;Barrowclough, Lobban, Hatton & Quinn, 2001).
Besides studies that have focused on the effects of illness perception on an individual level, it is worth noting studies that use a systemic approach to the examination of illness perceptions, within families (Salewski, 2003;Sim & Matthews, 2013) or romantic dyads (Kaptein et al, 2007;Yorgason et al., 2010). Therefore, illness perceptions -mostly in the case of chronic disorders -reportedly affect not only the patient but also the members of his/her family. Most of these studies show the impact of a couple's illness perceptions, especially when one of the partners suffers from a chronic disease (Karademas & Giannousi, 2013;Berg & Upchurch, 2007;Kaptein et al., 2007;Yorgason et al., 2010).
Illness perceptions in a couple must not be understood as two independent cognitive-emotional representations, because they develop a specific dynamic based on concordance (similarity) or discordance (dissimilarity). In this sense, Figueiras and Weinman (2003) examined illness perceptions in couples where one person had suffered a heart attack. Concordant perceptions were found to be positively associated with a wide range of effects necessary for a patient to recover (Figueiras, & Weinman, 2003). Sterba and his collaborators (2008) report similar outcomes also concerning couples where one of the spouses suffers from arthritis (Sterba et al., 2008). Karademas, Zarogiannos and Karamvakalis (2010) found that dyadic concordance related to illness perceptions is associated with certain coping strategies. In a study analyzing couples who struggle with infertility issues, Benyamini, Gozlan and Kokia (2009) found that illness perceptionsassessed from a dyadic perspective -have an effect upon couple distress and wellbeing.
A few studies have focused on the investigation of parental perception of the child's Autism Spectrum Disorder (ASD) (Al Anbar, Dardennes, Prado-Netto, Kaye & Contejean, 2010;Gatzoyia et al., 2014;Hagger & Orbell, 2003;Baines, & Wittkowski, 2013;Baker, Blacher & Olsson, 2005). Learning that your own child has a disability or a chronic disease is a trauma for any parent; through the information and experiences related to his/her own child, each parent changes his/her system of beliefs, expectations and perceptions (Pianta & Harbers, 1996). Al Anbar and his colleagues (2010) conclude that, in the case of children with autism, parental illness perception influences decision making concerning the treatment of choice. For instance, parents with higher perceived control are more open to discussing with other parents of children with autism, to talking with a psychologist or to getting information from books. Furthermore, high beliefs concerning unpredictable evolution predict low parental adherence to various training programs. In addition, parents who make internal attributions to the illness are less likely to talk with other parents or with specialists about the child's disorder or to look for additional information. Hence, hereditary beliefs are associated with attendance to training programs (Al Anbar et al., 2010). Gatzoyia and his collaborators (2013) indicated that a high percentage of parents of children with ASD feature significant symptoms of depression and, in their turn, these are associated with their perception of disease consequences and chronicity. Other studies have reported that certain beliefs about the controllability and consequences of a disease are associated with depression, quality of life, coping and overall function (Hagger & Orbell, 2003;Baines & Wittkowski, 2013;Saloviita, Itaelinna & Leinonen, 2003). Baker, Blacher and Olsson (2005) found that parents who care for children with developmental disorders and who report strong beliefs concerning the chronic nature of the disease actually have a more pessimistic approach, which may lead to depression. Other studies have shown that a perceived negative situation and guilt concerning the child's issues are main predictors of stress for parents of children with intellectual disabilities (Saloviita, Itaelinna & Leinonen, 2003). In the same line, some parental beliefs related to their effectiveness as parents act like mediating variables of the relationship among various psychological variables, such as depression, stress and parental competence (Coleman & Karraker, 1997;Teti & Gelfand, 1991;Teti, O'Connell & Reiner, 1996). Thus, identifying parental perceptions and beliefs concerning their child's illness may represent an important step in the elaboration of an intervention targeting the family -namely stress reduction and wellbeing increase (Al Anbar et al., 2010).

Current study
Previous studies featuring the relationship between parental illness perceptions of the child with ASD and adjustment to the illness (Al Anbar et al., 2010;Gatzoyia et al., 2013;Hagger & Orbell, 2003;Baines & Wittkowski, 2013;Baker, Blacher & Olsson, 2005) have analyzed only individual data, but they did not focus on investigating the dynamic in terms of concordance/congruence with both parents' perception of the child with ASD. The studies concerning dyadic congruence in relation to illness perception (Figueiras & Weinman, 2003;Sterba et al., 2008;Karademas, Zarogiannos & Karamvakalis, 2010;Benyamini, Gozlan & Kokia, 2009; failed to consider the situation when the child is actually the patient.
Therefore, based on a systemic perspective, our aim is to cover this gap through this study and to analyze the extent to which couple's congruence of the child's ASD has an impact upon parental stress, couple satisfaction, family resilience and dyadic coping.

Participants
This study comprised 106 parents (53 heterosexual Romanian couples) who care for a child with ASD aged between 4 and 17 (M = 9.45; AS = 4.06). The age of the subjects ranges between 26 and 51 (M = 43.05, AS = 5.15). Other demographic data taken into account are as follows: background (83% of the participants are urban and 17% are rural); level of education: high school diploma (n = 68) and college degree (n = 38); marriage duration (for this series, it ranges between 8 and 25 years) (M = 18.81, AS = 5.14).

Procedure
The participants were recruited from two day-care centres and from an inclusive education centre. The inclusion criterion was for every parent to have a child diagnosed with ASD .The diagnosis was based on DSM-IV criteria for an autistic disorder and made by board-certified child psychiatrists and clinical psychologists. Before the study, the participants were presented the purpose of study and they had to give their consent in order to partake in this study. They were assured that their answers would remain anonymous and confidential and that all data would be used for research purposes only. The assessment instruments were applied during one session.

Parenting Stress Index-Short Form (PSI-SF)
This instrument contains 36 items, and it represents the abridged form of Parenting Stress Index (PSI) (Loyd & Abidin, 1985). Stress is measured using PSI-SF on a Likert scale from (1) strongly agree to (5) strongly disagree. PSI-SF generates a total stress score and scores on three subscales: parental distress, dysfunctional interaction between parent and child and difficult child (Abidin, 1995). For this study, we used only the total score of the scale -Cronbach's alpha for all items is .89.

Couples Satisfaction Index (CSI)
This scale contains 32 items and was designed to measure one's satisfaction in a relationship. The scale has a variety of items with different response scales and formats (Funk, & Rogge, 2007). The internal consistency coefficient in this current study is .96.  Leventhal et al. (1980Leventhal et al. ( , 1998. The questionnaire is comprised of items classified on several subscales, in order to evaluate the five elements of illness perception (identity, consequences, time-line, cause and controllability). The internal consistency coefficients for all subscales of the instrument range between .62 and .86. For the analyses conducted in this study, the total illness perception score was used, which means that a higher illness perception score involves a rich system of beliefs and cognitions related to the circumstances of the illness (identity, consequences, controllability, time-line and causes), while a lower score entails a reduced and vague system of beliefs and cognitions related to the circumstances of the illness (identity, consequences, controllability, time-line and causes). Cronbach's alpha for the entire scale is .76.

Dyadic Coping Inventory (DCI)
This instrument includes 37 items, rated on a 5-point scale (from 1 = very rarely to 5 = very often) on 9 subscales (Bodenmann, 2008). For the analyses in this present study, two specific subscales of positive dyadic coping were used: Supportive dyadic coping (self-perceptions), with an internal consistency coefficient of .76 after eliminating item 20 and Supportive dyadic coping (the partner's perception), with an internal consistency coefficient of .67 after eliminating item 8. In addition, two specific subscales of negative dyadic coping were used: Negative dyadic coping (self-perceptions),with an internal consistency coefficient of .71 and Negative dyadic coping (the partner's perception) with an internal consistency coefficient of .81. After reversing the negative items, the total score of dyadic coping for the entire scale was calculated by adding together the results of items 1 to 35. Hence, a high score of total dyadic coping suggests a high level of positive dyadic coping, while a low score in total dyadic coping involves a low level of positive dyadic coping. For total dyadic coping, an internal consistency coefficient of .85 was obtained after eliminating items 31 and 7.

Family Resilience Assessment Scale (FRAS)
This scale contains 66 questions, the last of which is an open one (not used in the current study) (Sixbey, 2005). It uses a Likert-point scale, where 4 means strongly agree, while 1 -strongly disagree. A high score from this instrument represents strong family resilience, while a low score suggests weak family resilience. This instrument contains six subscales: Making Meaning of Adversity; Family Communication and Problem Solving; Utilizing Social and Economic Resources; Family Connectedness; Family Spirituality; Maintaining a Positive Outlook. The internal consistency values for each subscale range between .79 and .97, while for the total score, Cronbach's alpha is .89.

Preliminary analyses
After analyzing the distribution normality for the variables taken into account in this study by using the Kolmogorov-Smirnov test, the results confirm that it is possible to use the parametric tests within the analyses necessary to test the hypothesis, because the data are normally distributed (Table 1). The T tests for independent samples shows that the gender of parents does not significantly influence the total scores of the variables investigated (parental stress, couple satisfaction, perception of child's illness, dyadic coping, family resilience) ( Table 2). The absence of gender differences allows us to consider, in our future analyses, that subjects make up one group (thus we may not take into account the gender of the subjects).  Table 3 features the means, standard deviations as well as correlation coefficients for the variables illness perception, parental stress, couple satisfaction, dyadic coping and family resilience. The results of the correlation analysis show that the scores for illness perceptionassociated positively and significantly with the total score forparental stress (r = .46, p < .001) and dyadic coping (r =.22, p = .02). On the other hand, the results for parental stress associated negatively and significantly with couple satisfaction (r = -.46, p<.001) and dyadic coping (r = -.19, p = .04). The results of correlation analysis also show that family resiliencecorrelates positively and significantly with couple satisfaction (r =.50, p<.001) and dyadic coping (r = .50, p<.001), while couple satisfaction associates positively and significantly with dyadic coping (r = .67, p<.001).

Effect of couple's congruence of illness perception upon the variables: couple satisfaction, parental stress, dyadic coping and family resilience
For the statistical processing of the data during this stage of the study, we used the Anova One Way. Hence, we tested the influence of the independent variable couple's congruence of illness perception, comprised of three levels: incongruence (one partner features strong illness perception, while the other partner weak illness perception), congruent weak illness perception (both partners have weak illness perception), congruent strong illness perception (both partners have strong illness perception) upon the dependent variables: parental stress, couple satisfaction, family resilience, dyadic coping (in the analyses, only total scores for the dependent variables were considered). It is necessary to mention that strong illness perception iscomprised of a clear and rich system of beliefs and cognitions related to the circumstances of the disease (identity, consequences, controllability, time-line, causes), while weak illness perception suggests a reduced and vague system of beliefs and cognitions related to the circumstances of the disease (identity, consequences, controllability, timeline, causes). We conducted these analyses precisely to highlight the way in which a couple's congruence of their child's autism leaves traces in certain aspects of family life, conceptualized through the following: parental stress, couple satisfaction, family resilience and dyadic coping.

Table4.
Results for the variables for parental stress, couple satisfaction, dyadic coping and family resilience in couples with strong illness perception congruence, weak illness perception congruence and incongruent illness perception These findings show a significant effect of illness perception congruence upon couple satisfaction F(2,103) = 3.61, p = .030. Furthermore, parents who feature couple incongruence of illness perception (M = 129.68) score significantly higher in couple satisfaction (p = .027), compared to parents with a congruence of strong illness perception (M = 112.16). Thus, after comparing the score means in couple satisfaction depending on the aforementioned three levels of congruence, we found that couple satisfaction decreases as illness perception increases ( Figure 2).
As for parental stress, the findings show a significant effect of illness perception congruence (F(2,103) = 17.89, p <.001). After analyzing the results on each congruence level, we found that parents who feature congruence of strong illness perception (M = 111.95) scored significantly higher in the parental stress assessment (p <.001) compared to parents with an incongruent perception of a child's illness (M = 93.75) but also compared to parents with congruent weak illness perception (M = 90.75, p <.001) (Figure 1).
Concerning the impact of illness perception congruence upon dyadic coping, the data suggest a significant effect (F(2,103) = 9.23, p <.001). Upon analyzing the results on each congruence level, we found that parents involved in this study who feature weak illness perception (M = 109.39) score significantly lower in dyadic coping, compared to parents who feature an incongruent illness perception (M = 124.24, p<.001) but also compared to those with congruent strong illness perception (M = 124.50, p = .002) (Figure 3).
Finally, the findings also show a significant effect of illness perception congruence on family resilience, F(2,103) = 10.43, p <.001. Upon analyzing the results on each congruence level, we found that parents who feature incongruent illness perception (M = 184.05) score significantly higher in family resilience compared to parents with congruent weak illness perception (M = 175.57, p = 001) but also compared to parents featuring a congruent strong perception of child's illness (M = 174.70, p = .001) ( Figure  4).

Discussions
The purpose of this research was to test the influence of a couple's perception of their child's ASD upon the quality of their marital relationship, operationalized through couple satisfaction, parental stress, dyadic coping and family resilience.
The findings show that the couple's congruence/concordance concerning the strong perception of their child's ASD has a negative impact upon couple satisfaction, dyadic coping and family resilience, but it amplifies parental stress. Whereas the scientific literature considers a couple's congruence (in families with children suffering from chronic diseases) a factor improving marital function, such data refer to the congruence of coping used (Barbarin, Hughes, & Chesler, 1985), not to illness perception, as it occurs in this current study.
On the other hand, a couple's congruence of illness perceptions has usually been analyzed in the context of physical disorders from which one of the partners suffered, and the findings have shown that a couple's congruence of illness perception correlates positively with petient's quality of life (Green, Wells & Laakso, 2011;Sneeuw, Albertsen & Aaronson, 2001), with coping strategies (Green et al. 2011) adjustment to the illness (Romero et al., 2008) and relationship satisfaction (Langer et al., 2008). Whereas the findings of our study show a decreasing trend of couple satisfaction, family resilience and dyadic coping as well as a concomitant increase of couple congruence, the data do not contradict the previous studies, because couple congruence is analyzed from the perspective of illness perception in the case of children with autism. At the same time, Gatzoyia et al. (2014) shows that a strong perception of the child's illness causes psychological distress. Under such circumstances, it is easy to explain the findings of our study, which show that a couple's congruence concerning the strong perception of the child's ASD augments psychological distress and reduces couple satisfaction, family resilience and dyadic coping. Moreover, the positive effects concerning marital and family function are mostly significant when the partners have different perceptions of the child's autism or when congruence includes weak perception of the child's illness.

Conclusions
Parents' concerns related to the child's illness and their perceptions reflect on a personal level, but they also have an impact upon a couple's dynamic. Most of the time a couple's concordance or congruence concerning a certain topic is considered a beneficial phenomenon, because it provides harmony and a favouring environment for problem solving, decision making and for developing psychological wellbeing and coping abilities (Fletcher, Miaskowski, Given & Schumacher, 2012). When a couple's congruence concerns illness perception considering that one of the partners is the patient, studies report that a couple's congruence features positive characteristics, leading to lower distress (Karademas, 2014;Karademas, Zarogiannos & Karamvakalis, 2010;Benyamini, Gozlan & Kokia, 2009) and to improved patient status (Heijmans, de Ridder & Bensing, 1999), compared to the situation involving discordant illness perception. In such a situation, it is worth noting that the difficulty or illness that motivates perception is part of the couple's system, meaning that one of the spouses is the patient, and the couple's resources and energy remain at the level of the spousal dyad. If the patient is a child with ASD, the issue is different. Illness -that motivates perception and beliefs -develops outside the dyad because the child is the one impaired. In general, previous studies have reported that a strong parental perception and intense concerns for the child's ASD -for all dimensions involved (symptoms, causes, consequence, controllability, time-line) -are associated with increased psychological distress, lower wellbeing and the emergence of marital trouble (Gatzoyia et al., 2014). Especially when both partners have a complex perception of the child's ASD, there is a negative impact characterized by a decrease in couple satisfaction, in family resilience, in dyadic coping and by an increase in parental stress. In this sense, psychotherapists who deal with families caring for children with ASD should take into account the manner in which both partners explain their child's illness, the way they have adjusted to the disease and the impact of this phenomenon on the couple's dynamic.
This study has several limits, which actually help us outline future research directions. First, there are no data on the quality of spousal relationship and on the psychological function of the parents before learning of the child's diagnosis. For this reason, such an aspect should be investigated using qualitative methods, such as interviews with both partners. Another limit would be the investigation of illness perception as a unique variable, even though it is based on several elements. Future studies should analyze, on a dyadic level, all elements of illness perception and their impact upon the couple's relationship.
Despite the aforementioned limits, this study highlights the importance of the parents' beliefs regarding the illness child's ASD and the methods used by the couple to regulate their dynamic by taking into account these perceptions.