4. Methods
4.4. Statistical analysis
Statistical analyses were performed using the SPSS 17.0 (SPSS Inc., Chicago, IL, U.S.A.).
Two-sided p ≤ 0.05 was considered statistically significant.
(1) Descriptive statistical methods were used to characterize the demographic and clinical features of participants.
(2) Multiple linear regression models were fitted to identify the significant predictors of the parenting stress in mothers of children with ASD. The PSI-C short form as the dependent variable and the independent variables were all the observed variables in health condition, body functions and structures, and activity and participation, environmental and personal dimensions. To ensure the quality of analysis, model-fitting techniques for variable selection, goodness-of-fit (GOF) assessment, and regression diagnostics was used in regression analyses. Specifically, the stepwise variable selection procedure was applied to obtain the candidate final regression model. All the univariate significant and
non-significant relevant covariates were put on the variable list to be selected and the significance levels for entry (SLE) and for stay (SLS) were set to 0.15.
CHAPTER 5
RESULTS
5.1 Characteristics of the participants
Table 4 presents the demographic data of participants. The participants for the study included 89 children aged 36-71 months old (mean age= 54.53, SD=9.73). The mean age at diagnosis was 33.48 months (SD=10.32, range 13.2-60.0). Eighty-two percent of the children were male. Most children (76.1%) were diagnosed as Autistic disorder and few were
Asperger’s Syndrome (7.9%) or PDD-NOS (16%). Most of them were diagnosed by child psychiatrists (80.9%). The most common co-morbidity was ADHD (11.2%). Over half (n=52, 58.4%) of participants attended regular kindergarten, 18 (20.2%) children in special education kindergarten, 14 (15.7%) children in developmental center, 4 (4.5%) children in hospitals for day care, and one child was unschooled.
Descriptive statistics of independent variables as presented in Table 5. The mean score of CARS were 29.29 (SD = 6.68) which was within the range of non-autistic diagnostic category.
However, 5.62% (n = 5) of children were at the range of mild to moderate autism, and 16.85%
(n = 15) at the range of severe autism. About the child’s emotional and behavior, the mean of T scores in Internalizing problems was 64.28 (SD = 8.77) which within the clinical range (≥ 63), but the mean of T scores in Externalizing problems was 57.93 (SD = 11.51) which within the normal range. As to the temperament, the mean of each behavioral category was within
±1SD, except the threshold in female participant was exceeded +1SD. Higher threshold
means that female participants need higher amount of sensory stimulation to elicit a response.
In Short Sensory Profile-Chinese version, the mean of scores in underresponsive, auditoty filtering, and low energy sections were within definite difference range and others were within probable difference range. In CPEP-3, the mean age equivalent in each subtest was within 31.79 month to 41.11 month. In VABS-C, the mean age equivalent in each domain was within 18.5 month (socialization) to 52.98 month (motor).
5.2 Parenting stress in mothers of children with ASD
Scores of parenting stress were displayed in Table 5. Despite the fact that the mean total stress score was 101.09 (SD= 17.49, range 47-142) which was below the Clinically
Significant range (=115), nearly one quarter of mothers (n=20, 22.5%) rated their total stress level in the Clinically Significant range. Thirty-seven mothers (41.6%) rated their stress level in the Clinically Significant range on the Difficult Child subscale, 27.0% on the Parental Distress subscale, and 7.9% on the Parental-Child Dysfunctional Interaction subscale. No group differences (t = .286, p = .594) were noted in the mean total stress scores between mothers of girls and boys.
5.3 Correlations between potential predictors and maternal parenting stress
As Table 5, the severity of symptoms was significantly and positively correlated with maternal parenting stress. Both Internalizing problems and Externalizing problems were significantly and positively correlated with maternal parenting stress level. As to the temperament, child’s higher activity level and higher response intensity were positively correlated with maternal parenting stress level. Child’s higher rhythmicity, higher approachability, higher adaptability, more stable mood, and lower distractibility were all significantly negatively correlated with maternal parenting stress. With regard to sensory processing ability, all subscales were significantly and negatively correlated with maternal parenting stress level except movement sensitivity and low energy.
About the activity and participation dimension, only child’s cognitive verbal and
expressive language subtests in the CPEP-3 were significantly and negatively correlated with maternal parenting stress level. Four domains (communication, daily living skills,
socialization, and motor) in the VABS-C were significantly and negatively correlated with maternal parenting stress level. Lastly, mothers’ positive affect was significantly and negatively correlated with their parenting stress level.
5.4 The predictors of parenting stress
As shown in Table 6, multiple regression analysis revealed that child’s Internalizing Problems, severity of symptoms, rhythmicity, and mother’s positive affect were the significant
predictors of parenting stress in mothers of children with ASD, and accounted for 54% of the variance. That is, maternal parenting stress would be higher when children with ASD scored higher on internalizing problems or symptom severity. However, maternal parenting stress would be lower when children with ASD scored higher on rhythmicity or mother had higher scores on the PAI.
CHAPTER 6
DISCUSSION
This study investigated parenting stress in 89 mothers of preschoolers with ASD who were between 3 and 6 years old. Furthermore, this study examined the predictors of parenting stress, considering the possible factors from the entire scope of the ICF.
Our results showed that although the average maternal parenting stress in this sample was within the Normal range (i.e., below 80th percentile), there were still nearly one-quarter of mothers rated their total stress in the Clinically Significant range, indicating a relatively high stress level. Among the three subscales of PSI-CSF, nearly half of mothers presented a Clinically Significant level on the Difficult Child subscale, which assessed the characteristics of the child that made him/her easy or difficult to manage. According to the Chung et al.’s (2012) study, children with ASD had a higher activity level, were more withdrawn, less adaptable, had more negative mood, were less persistent, had lower distractibility, and higher threshold than typically developing children. The temperament or behavior characteristics of children with ASD may easily make their mothers feel that their children were difficult to manage . Our study showed that child’s temperament was related to maternal parenting stress and was consistent with the McBride, Schoppe, and Rane’s study (2002) found that higher maternal parenting stress was significantly and positively correlated with child’s higher activity level and higher emotional intensity. Therefore, providing individualized parenting or
caring skills for mothers based on child’s temperament or behavior characteristics may decrease parenting stress. In addition, one-quarter of mothers showed a Clinically Significant level on the Parent Distress subscale, indicating an impaired sense of competence in the parenting role, lack of social support, role-restriction, depression, and conflict with one’s spouse. Therefore, improving mother’s confidence in parenting is a critical issue. Lastly, less than ten percent of mothers scored their stress level at the Clinically Significant range on the Parental-child Dysfunctional Interaction subscale, indicating some children were unable to meet their mothers’ expectations or mother felt disappointing in interacting with the child.
Thus, providing parenting knowledge and skill training may help mothers have suitable expectations for their child and thereby improve parenting function.
The present study lends partial support to the hypothesis that the factors from all dimensions of the ICF-CY were associated with parenting stress in mothers of children with ASD. The discrepancies of the results between univariate and multivariate analysis were due to the confounding effects of the other uncontrolled variables in the univariate analysis.
Therefore, the discussions were primarily based on the results of the multivariate analysis.
The significant predictors of parenting stress in mothers of preschoolers with ASD were child’s internalizing problems, rhythmicity, severity of symptoms, and mother’s positive affect, which encompassed the dimensions of the body function, the environmental factors, and the health condition in the ICF-CY model. Our findings were consistent with previous
studies that mothers had increased parenting stress when their child with ASD showed more internalizing problems behaviors (Dumas et al., 1991; Hastings et al., 2005; Konstanatareas &
Homatidis, 1989; Konstanatareas & Papageorgiou, 2006; Matthew, 2010; Tomanik, 2004) or had severer autism symptoms (Hastings et al., 2005; Hoffman et al., 2009; Honey et al., 2005;
Konstanatareas & Homatidis, 1989; Matthew, 2010). The core symptoms of children with ASD usually cause an increased burden of caregivers (Hastings et al., 2005; Honey, et al., 2005). Internalizing problems behaviors and autism symptoms may not only affect children’s functioning (Lecavalier, 2006) but also have a great influence on maternal parenting stress in everyday life (Davis & Carter, 2008).
Findings of the study showed that higher rhythmicity of preschoolers with ASD and more positive affect of mothers toward their children were related to decreased maternal parenting stress. Rhythmicity describes the regularity of physiological functions, such as sleeping or toileting. It is usually easier for parents to take care of children with higher
rhythmicity in daily life and such that parenting stress may decrease accordingly. Furthermore, before this present study, no studies have investigated the relationship between that mothers’
positive affect towards their ASD children and parenting stress. Based on the theoretical model of the relative probability of effective parental functioning in all possible conditions of parenting system (Belsky, 1984), parents function most effectively when each subsystem (i.e.
parental personality and psychological well-being, contextual subsystems of support, child
characteristics) operates in the supportive mode and least competently when each subsystem operates in the stressful mode. In our study, we had demonstrated the relationship that mother showed more positive perceptions to their ASD children, or more understanding, trust,
fairness, respect, and affection they feel about their ASD children, or more positive interaction with their ASD children, then the stress decreased.
This study had several limitations. First, cross-sectional data provide some understanding of the potential factors for parenting stress in mothers of preschoolers with ASD, but
longitudinal measures would provide more precise and robust conclusions. Second, although we included the possible factors in the ICF-CY model for parenting stress in mothers of preschoolers with ASD, further research is needed to identify additional possible factors such as parenting styles or family and social support.
CHAPTER 7
CONCLUSION
This is the first study investigating the parenting stress in mothers of preschoolers with ASD adopting the conceptual framework of the ICF-CY. Our study found that when children with higher rhythmicity and mother with more positive affect toward children, mothers would have decreased parenting stress. Furthermore, when children had more internalizing problems behaviors and severer symptoms in ASD, mother would have increased parenting stress.
Findings of the study highlighted the importance of early diagnosis and intervention, and the need of providing coping strategies and parent support group to mothers with preschoolers with ASD to decrease stress levels in parenting children with ASD.
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Table 1. Studies investigating factors associated with parenting stress in children with ASD
Authors & titles Participants Statistical methods Dependent variables Independent variables Results Limitations
1. (Holroyd, with autistic children (28 mothers and 22 fathers),
29 autistic patients’
mean age were 10.5Y (SD=4.4, 1-18Y &
24Y), 78% were male, Inclusion:
Diagnosed as autistic by one of the author with following characteristics (1) bizarre, stereotyped self-stimulation, social amenities or self care,
(5) unusual patterns of play, and
(6) isolation from others.
The relationship between QRS scales and the interview rating of family stress: t test
The stress of parents of institutionalized and
noninstitutionalize d children matched for children’s age:
t test
The Questionnaire on Resources and Stress (QRS): parent report, 285 items to assess 15 variables pertinent to families caring for chronically ill or handicapped individuals, three
Interview ratings of Stress: interviewer (two social worker) estimated a family’s functioning in three levels:
High Stress: top 25%
of all the families on current stress level
Medium Stress: adult autistic case was removed, older vs.
younger
Relationships between the QRS and Interview ratings of Stress
Interviewer classified 14% of the families as High Stress, 59% as Medium Stress, and 24% as Low Stress.
Mothers of families classified as High Stress families scored higher on five QRS scale than mothers of Low Stress families. Five scales were in the area of Parents Problems (Scale 5 & 7) and Family Problems (Scale 8, 9, &10).
None of the scales reflecting severity of impairment in the child (Scale 11-15). Family stress level may be independent of the severity of the child’s problems, as measured by the QRS.
Only one father from High Stress families and could not compared with fathers from Low Stress Families.
Parents of Institutionalized vs. Parents of Noninstitiutionalized Children
It is no difference in distribution of interviewer stress ratings between families of institutionalized and noninstitutionalized children matched for age distribution of the autistic child. (Home vs.
Institutionalized with H/M/L Stress: 1/7/1:2/8/2)
Mother of institutionalized autistic children scored higher than mothers with children at home on three scales: Scale 7, 11, & 15.
Father on institutionalized children scored higher than fathers of children at home on three scales:
Scale 11, 13, & 15.
Except Scale 7, parents of institutionalized children reported more problems related to the severity of the child’s problems.
Parents of Older Children vs. Parents of Young Children
Most families (4 of 7) with young autistic children were rated Low Stress while none with older group.
Mothers of older children only scored higher on the Financial Problems Scale of the QRS.
Inter-rater reliability was not ascertained for the stress level judgments.
Small sample in comparison between High and Low Stress.
The range in age of the children was broad.
(Konstantareas stress in parents of Autistic Children
Journal of child Psychology and Psychiatry, 30, 459-470.
mean age 6Y10M (2Y4M-12Y7M), 32 (73%) were boys and 12 (27%) were girls, 18 were firstborn or only children and 26 were later-born, Inclusion:
Diagnosed based on DSM-III by a child psychologist and a child psychiatrist.
Maternal age: mean 34.7Y(23-46Y). One mother attempted to commit suicide by an
Maternal age: mean 34.7Y(23-46Y). One mother attempted to commit suicide by an