Parenting Stress and Hypertension in Parents of Mental Retardation Children

Parents with mental retardation children experience higher parenting stress than parents with other types of disability. Differences in responses to stressors indicate a level of parenting stress that is influenced by the characteristics of children, family, parents, and the environment. Parenting stress that is not managed and occurs in a long time can cause physical disorders of hypertension. The purpose of this study was to describe the parenting stress and the incidence of hypertension in the parents of children with mental retardation aged 12-15 years. This research is a descriptive research with quantitative approach. The sample of this study was the father and mother of mental retardation students aged 12-15 years of 59 respondents who met the criteria of inclusion and exclusion. The result of this research is most of the hypertension respondent have high parenting stress level of 53,6% in fathers and

Based on preliminary studies that have been conducted by researchers with interviewing techniques, it was concluded that many parents with mental retardation children of 12-15 years old showed the symptoms of stress. The parents mentioned that there are some burdens when their children enter adolescence. In addition for having to accept the condition of children, parents must face child behavior problems, such as child mischief, differences in attitudes and uncontrolled sexual behavior. Parents found it difficult to monitor and educate the children, considering that mental retardation children have low IQs, making it difficult to receive new information.
The presence or absence of stress symptoms shown by parents indicates a level of stress. The level of stress is caused by differences in responses between individuals against stressors (Viaene et al, 2017). The difference in responses is influenced by several factors, such as the characteristics of parents, children, family and the environment (Lestari, 2016). Parenting stress that occurs should be overcome because if it is not addressed it can cause negative impact on children, parents, and parentchild relationships. In terms of health, the impact that can arise in the parents is rising blood pressure (hypertension). Based on data from Probolinggo City Health Office, hypertension became the highest non-communicable disease and entered into 15 most diseases in the last 5 years. This research aimed to describe the parenting stress and the incidence of hypertension in the parents with mental retardation children aged 12-15 years old in SDLB Sinar Harapan, SDLB PGRI Wonoasih, and SMPLB Sinar Harapan Probolinggo City.

METHODS
This was a descriptive research with quantitative approach that was performed in SDLB Sinar Harapan, SDLB PGRI Wonoasih and SMPLB Sinar Harapan Probolinggo City, Central Java, Indonesia. The study began in July 2017 until August 2017. The population of this study was all the fathers and mothers who take care of mental retardation children aged 12-15 years old of 102 respondents. The sample of this study was the entire population who met the inclusion and exclusion criteria of 59 respondents. The inclusion criteria of this study were parents of

INTRODUCTION
Parenting stress is a natural thing that every parent feels because parenting is not an easy task and a stressful process. Parenting stress is a process that leads to unpleasant psychological and physiological reactions and arises from attempts to conform to the demands of being parents (Holub et al, 2017, Argumedes et al, 2018. Parents are often preoccupied with managing work-related schedules, household chores and raising their children. These demands sometimes lead to stress. The stress is associated with being parents (Huang et al, 2014, Holden & Banez, 2016. Parenting stress is associated with parenting behaviors and child self-adjustment. Parents who report higher levels of parenting stress tend to be authoritarian, abusive and negative in interacting with their child (Cates et al, 2016;Moreland et al, 2016). Some studies indicated the correlation between stress and some disorders like hipertention and coronary heart disease (Yulistina et al, 2017;Agustina & Raharjo, 2015;Farahdika & Azam, 2015).
Having a normal child is the hope of all parents, but not all children are born normal (Lestari, 2016). Parents who have children with special needs will experience higher parenting stress (Ong et al, 2010;Huang et al, 2015). The prevalence of children with special needs in Indonesia reached 4.2 million where East Java Province ranked second with the prevalence of 1,052,548 people (Irwanto et al., 2010). Purwandari (2013) stated that parents with mental retardation children experience higher parenting stress than parents with other types of disabilities. In Indonesia, mental retardation ranked fourth from all other types of disability and became the most common type of mental disorder of 135,376 people (Irwanto et al., 2010). Based on data from the Probolinggo City Social Service, the prevalence of mental retardation was 240 people and became the second highest type of disability after body disabilities.
Parents of children that diagnosed with behavioral disorders or developmental disabilities are at risk of parenting stress (Brei et al, 2015). Parents of children with autism spectrum disorders or developmental abnormalities reported had higher levels of parenting stress than parents of children whose development tended to be normal (Hutchison et al, 2016).
Parents with mental retardation children are susceptible to stress due to the physical, psychological, and social burdens (Saleh, 2014;Seke, 2016). Parents with children aged 12-17 years old will experience higher parenting stress than parents with children aged 0 -5 years. Parenting stress can be known by the emergence of symptoms of stress. Based on data from Probolinggo City Education Of-mental retardation students aged 12 -15 years old in 2017-2018 and domiciled in Probolinggo City, while exclusion criteria was parents who live saparetely with their mental retardation children (live in different house).
Variables of this study were the characteristics of children, family, parents, the incidence of parenting stress, and hypertension. Primary data of this research was all data that based on research variables obtained through interview and blood pressure measurement. Secondary data in this research was case data of hypertension and data of 15 most diseases in Probolinggo City, data of Probolinggo's disability people, data of children with special needs in special needs school in Probolinggo city. The data were collected with interview, observation and documentation. Instruments in this study were questionnaire and digital sphygmomanometer. The analysis used was univariate analysis.

RESULTS AND DISCUSSION Characteristic of Respondents
The respondents of this research were the father and mother of mental retardation children aged 12-15 years in SDLB Sinar Harapan, SDLB PGRI Wonoasih, and SMPLB Sinar Harapan Probolinggo City of 59 respondents. The distribution of child and family characteristics can be seen in Table 1.
Respondents were parents who mostly have mental retardation children aged 12 -15 years of male sex (52.54%), have mild and moderate mental retardation children (67.80%), biological parents (96.61 %), not single parents (91.52%), parents with two adults in one house (84.75%), have more than two normal children (47.46%), have one child with special needs (96, 61%), and income <Rp. Respondents were dominated by respondents with age category >35 years (100% in fathers and 74.2% in mothers), low education level (39.3% in fathers and 54.8% in mothers), working status (100% in fathers and 74.2% in mothers), and low social support (60.7% in fathers and 58.1% in mothers).

Parenting Stress
Parenting stress is a natural thing that parents feel, but the perceived parenting stress will be different for parents who have mental retardation children.
The highest level of parenting stress experienced by respondents of 71.4% in the fathers and 80.5% in the mothers. Parenting stress level of mother is higher than father. Ma'mun and Prameswarie (2016) study indicated that many respondents from mothers experienced high levels of parenting stress. The number of mothers who experienced high levels of stress is due to the existence of cultural factors that cause the mothers to take care of the whole. This makes mothers face the problem of children's behavior with higher frequency.
The results also showed that most respondents experienced high levels of parenting stress. This result is in line with the study by Purwandari (2013) which stated that parents who have mental retardation children experience higher levels of parenting stress compared with parents with other types of disabilities. The presence of stress levels in fathers and mothers indicates the difference of responses (individual differences) to stressors that are influenced by the characteristics of children, family, parents, and the environment.

Parenting Stress based on Characteristics of Respondents
According to the theory of daily hassles, parenting stress is caused by several factors, including the characteristics of children, family, parents, and the environment.
The high level of parenting stress based on the characteristics of the child was found in respondents who have male mental retardation children aged 12 -15 years (35.7% in fathers and 41.9% in mothers). This result is in line with research by Ma'mun and Prameswarie (2016) where parents who have mental retardation children tend to experience higher levels of parenting stress. There is still no literature related to the influence of the child sex to parenting stress. Mental retardation male children are more active than the female ones. It caused the parents of mental retardation male children had higher parenting stress.
Respondents in this study mostly experienced high levels of parenting stress in respondents who have mild and moderate mental retardation children of 46.4% in fathers and 58.1% in mothers. There were still no results that match this study due to differences in categorization of types of mental retardation in previous studies. Number of respondents with high levels of parenting stress in children with mild and moderate retardation due to the nature of the child's temperament and hyperactivity. Based on the family structure, many respondents who experienced high levels of parenting stress as biological parent status (71.4% in fathers, 67.9% in mothers), not single parents (67.9% in fathers, 67.7% in mothers), two adults in one home (60.7% of fathers, 61.3% in mothers), have more than two children in normal conditions (35.7% in fathers, 48.4% in mothers), and have one child with special needs (67.9% in fathers, 77.4% mother). There is still no research on the parenting stress associated with family characteristics. However, the high parenting stress experienced by respondents due to many children and the existence of children with special needs shows the amount of burden by the respondent and this affects the parenting process. In addition, there are other driving factors, namely low income, other burdens such as parents or relatives who live in one house but do not work, and a source of income only from one person.
Respondents with income <Rp. 1,735,247.50 many experienced high levels of parenting stress by 53.6% in fathers and 54.8% in mothers. This result is in line with the research by Chairini (2013) where the lower the income, the higher the level of parenting stress. This is because respondents with low incomes were faced with high demand for life.
Characteristics of parents who experienced high levels of parenting stress were dominated by respondents aged >35 years (71.4% in fathers and 54.8% in mothers). Oktafiani et al (2014) stated that the respondents aged >35 years would experience a decrease in physical condition so that the parenting process is not optimal. Studies of Purwandari (2013) and Ma'mun & Prameswarie (2016) showed that high level of parenting stress was found in respondents aged 42-49 years old. The parents of mental retardation children were faced with decreasing physical conditions of their bodies in the same time with facing their children's special needs and worrying their mental retardation children's future.
Respondents with low levels of education experienced a high level of parenting stress (35.7% in fathers and 58.1% in mothers). It was in line result with study of Yeni et al (2014), which stated there is a relationship between the levels of education with parenting stress, where parents with low levels of education are easy to experience stress. This is because parents with low levels of education have difficulty in dealing with child behavior problems due to lack of knowledge related to how to take care the children so that the parenting process is fulfilled with pressure. The result of this study is not in line with research by Maulina (2017) and Ma'mun & Prameswari (2016) where high level of parenting stress was found in respondents with high education level.
There were 71.4% of working fathers who experienced high level of parenting stress. Parents who have a lot of work pressure, generally feel overloaded and tend to have lower acceptance of and frequently happened conflicts (Lestari, 2016). The fathers in this study did not take total care, but there was one father respondent who performed total care due to single parent status. When the workload exceeds capacity and caring for children with uncontrolled mental retardation behavior problems, fathers tend to foster with unstable emotional conditions so that the parenting process is fulfilled with stress. Mostly non-working mother (58.1%) experienced high level of parenting stress in this study. It was caused by the more frequency and the longer time of facing the mental retardation children.
Most respondents experienced high level of parenting stress with low social support (39.3% in fathers and 45.2% in mothers). This result is in line with research by Chairini (2013) which stated that the lower the social support, the higher the level of parenting stress. Social support is related to psychological conditions, moods, beliefs in parenting, and reduces depression. The absence of social support leads a person to feel lonely and mistrustful, thus reducing psychological conditions, depression, mood swings, and decreasing beliefs so that parenting is under stress and leads to stress. In contrast to someone with high social support, they will feel loved and appreciated and perceived in their environment.

Hypertension Incidence
Hypertension can occur in all people with various risk factors. One of the risk factors that can cause hypertension is parenting stress. Respondents who experienced hypertension were 53.6% from fathers group and 71% from mothers group. This result is in line with data from the Probolinggo City Health Office where hypertension has become one of the 15 most diseases in the last 5 years. Hypertension can be caused by various factors, but currently, the dominant factor in hypertension is the unhealthy lifestyle. Stress indirectly can be the cause of the occurrence of hypertension where stress changes the pattern of life becomes unhealthy. Stress directly can cause physical disturbance of hypertension if it is not managed properly and lasted for a long time. This is due to stress can lead to a physiological response to stressors that cause increased stimuli such as heart rate, blood pressure, increased muscle tension, and increased stomach acid production (Huang et al, 2015).

Hypertension Incidence and Parenting Stress
Stress is one factor causing hypertension. Respondents with hypertension mostly also experienced high level of parenting stress (53.6% in fat-hers and 64.5% in mothers). Psychological factors, especially stress, can cause high blood pressure. This is because strong emotions and sustained anxiety are transformed into direct somatic reactions of the circulatory system affecting heart rate, blood circulation, and blood pressure. Unmanaged-stress will give an impact on physical health where a person with high emotional stress tends to experience a higher blood pressure increase. If the emotional tension lasts for long periods of time and is chronic and cannot be reduced by adjustment and other effective mechanisms, it will definitely lead to high blood pressure (hypertension) disease. It remains uncertain whether the parenting stress that occurs in the respondents of this study is the main cause of hypertension. This is because there is still no research that proves the relationship between parenting stress with the incidence of hypertension, given that there are many types of stress (Huang et al, 2015).

CONCLUSION
Characteristic of children was dominated with parents who have mental retardation male children aged 12-15 years and parents with children with mild and moderate mental retardation type. The characteristics of the family were dominated by biological parental status and not a single parent, parents with two adults in one house, have more than two normal children, have one child with special needs, and income <Rp. 1,735,247.50. Characteristics of parents were dominated by respondents aged >35 years, low level of education, and still working. Environmental characteristic was dominated by respondents with low social support. Many father and mother experienced high levels of parenting stress.
High level of parenting stress on fathers and mothers was dominated by respondents with age category >35 years old, low education level, working father and non-working mother, having male mental retardation child, having mild and moderate mental retardation children, respondents with biological parent status and not single parents, two adults in one house, having more than two normal children, having one child with special needs, income <Rp.1,735,247.50, and low social support. Many fathers and mothers experienced hypertension. Respondents who experienced hypertension were dominated by respondents who experienced high levels of parenting stress.