Predictors of quality of life for fathers and mothers of children with ...

Research in Developmental Disabilities 35 (2014) 1326–1333

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Research in Developmental Disabilities

Predictors of quality of life for fathers and mothers of children with Autistic Disorder Latefa Ali Dardas *, Muayyad M. Ahmad Faculty of Nursing, The University of Jordan, Amman 11942, Jordan

A R T I C L E I N F O

A B S T R A C T

Article history: Received 24 December 2013 Received in revised form 28 February 2014 Accepted 6 March 2014 Available online

A constant challenge for Quality of Life (QoL) research is tapping the most predictive indicators for a specific population. This study has sought to examine predictors of QoL for fathers and mothers of children with Autistic Disorder. Two multiple regression analyses were performed for fathers (N = 70) and mothers (N = 114) of children with Autistic Disorder. Six predictors were entered into the regression equation: Parental Distress (PD), Parent–Child Dysfunction Interaction (PCDI), Difficult Child Characteristics (DC), Household income, and the child’s with Autistic Disorder age and number of siblings. The analyses revealed that only PD was a significant predictor for both parent’s QoL, whereas DC, household income, and number of siblings were able to predict only mothers’ QoL. To our knowledge, this is the first study to focus on predictors of QoL among both fathers and mothers of children with Autistic Disorder. The results from the current study can have several implications for professionals and researchers targeting the primary force contributing to the wellbeing of children with Autistic Disorder, the parents. ß 2014 Elsevier Ltd. All rights reserved.

Keywords: Quality of Life Predictors Parenting Autistic Disorder Caregiving

1. Introduction Autistic Disorder is a neurological pervasive developmental disorder that impacts children’s communication and social functioning. The disorder affects individuals from all ethnic groups and socioeconomic backgrounds and is considered the third most common developmental disability following intellectual disability and cerebral palsy (Centers for Disease Control and Prevention (CDC), 2010). Children with Autistic Disorder often show a pattern of complex behaviors that can significantly affect parents’ and family’s functioning. Parents of children with Autistic Disorder may find themselves burdened with a lifelong responsibility of caring for their children and diminished attention to their own health. Thus, those parents are deemed to be at risk for a significant deterioration in several domains of their lives. Indeed, parents of children with Autistic Disorder experience elevated stress (Davis & Carter, 2008), impaired physical and social functioning (Hartley et al., 2010), impaired mental health, and restricted family functioning. Therefore, studying the psychological functioning for parents of children with Autistic Disorder requires a holistic view for the factors that can potentially affect the parents’ health and wellbeing. The construct of Quality of Life (QoL) represents one of the comprehensive, multidimensional outcome measures that is based on the individual’s subjective perception regarding several aspects of life experiences (WHO, 1996). The integrative

* Corresponding author. Tel.: +962 6 5355000x23134; fax: +962 6 5300244. E-mail addresses: [email protected], [email protected] (L.A. Dardas), [email protected], [email protected] (M.M. Ahmad). http://dx.doi.org/10.1016/j.ridd.2014.03.009 0891-4222/ß 2014 Elsevier Ltd. All rights reserved.

L.A. Dardas, M.M. Ahmad / Research in Developmental Disabilities 35 (2014) 1326–1333

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definition of QoL incorporates the individual’s physical health, psychological state, social relationships, financial well-being, spiritual and cultural beliefs, and their interactions with salient features of the environment. Quality of Life is therefore a key variable to consider in the evaluation of parents’ adaptation to their child’s disability. According to the World Health Organization (1996), QoL can be defined as ‘‘individuals’ perceptions of their position in life in the context of culture and value systems in which they live and in relation to their goals, expectations, standards and concerns’’ (p. 5). It is reasonably well established that there are several factors which can impact either positively or negatively on an individual’s QoL. However, ongoing debate includes whether some indicators are more important than others and whether there are certain indicators in specific populations that are more predictive of QoL. For parents of children with Autistic Disorder, there is a distinct dearth of studies to inform about the factors that can predict their QoL. 1.1. Quality of Life of parents of children with Autistic Disorder, what we know and what we do not know Parenting a child with Autistic Disorder can have a significant impact on the parents’ life. Previous studies have uniformly found elevated levels of parenting stress among parents of children with Autistic Disorder compared to both parents of children with typical development (Ericzon, Frazee & Stahmer, 2005) and to parents of children with other developmental disabilities (Dabrowska & Pisula, 2010; Seltzer, Abbeduto, Krauss, Greenberg & Swe, 2004). Parenting stress can be defined as the negative strain related to the self, the child, and the parent–child interaction in the context of parenthood (Abidin, 1995). According to Lee, Harrington, Louie, and Newschaffer (2008) and Dardas and Ahmad (2014a), high levels of parenting stress can contribute to a lower overall QoL for parents of children with Autistic Disorder. These studies revealed that parents who experience elevated stress levels are in need for mental health support to help them address their psychological distress and as a result improve their QoL. The age of the child with Autistic Disorder was found to have a significant effect on parents’ stress and QoL. Relevant studies revealed better QoL and lower levels of parenting stress among parents of older children compared to those of younger children (Dardas & Ahmad, 2014b; Duarte, Bordin, Yazigi, & Mooney, 2005; Mungo, Ruta, Arrigo, & Mazzona, 2007), suggesting that the child age may be correlated with parents’ ability to adopt healthy coping and develop more realistic views of the child’s developmental outcome. Parents of children with Autistic Disorder experience a pile up of other stressors that are not necessarily related to Autistic Disorder but can intensify its demands. Such stressors were found to be related to parental employment and socioeconomic status, the lack of appropriate services and support systems, and if present, the caring responsibilities toward other children. For example, parents with higher socioeconomic status have been found to report lower levels of stress and better QoL (Dardas & Ahmad, 2014b; Hatton & Emerson, 2009; Parish, Seltzer, Greenberg, & Floyd, 2004). On the other hand, Lee et al. (2009) found that having more children in the family predicted a higher level of parent-reported physical health, hypothesizing that the presence of siblings may allow for some shared caretaking responsibilities. Another point worth mentioning is the differences between fathers and mothers in regard to their psychological reactions to the child’s disability. While some researchers found that mothers have higher levels of stress and demoralization than fathers, with increased rates of physical health problems and poorer QoL (Dabrowska & Pisula, 2010; Mungo, Ruta, Arrigo & Mazzona, 2007; Yamada et al., 2012); others revealed that mothers and fathers experience similar levels of parenting stress and QoL (Dardas & Ahmad, 2014a; Hastings, 2003). Apparently, more investigations are needed in this particular area of research. In sum, while perceived stress, social support, satisfactory economic status, and number of family members are considered reasonable predictors of QoL in general, it is important to dig deeper and find out whether these variables will predict QoL for parents of children with Autistic Disorder, and whether certain aspects of these variables are more predictive than others. It is also important to investigate whether the same variables will have similar prediction strength of the parent’s QoL based on gender. Therefore, the purpose of this study was to examine the predictors of QoL for fathers and mothers of children with Autistic Disorder. Specific research questions were: (1) Do parents who experience high level of parenting stress report low level of QoL?; (2) Do parents with low socioeconomic status report low level of QoL?; (3) Will the QoL of parents of children with Autistic Disorder be higher with more children in the family? and (4) Do parents of older children experience better QoL? 2. Methods 2.1. Procedure Ethical approval for conducting this study was granted by the academic research committee at the deanship of the academic research at the University of Jordan. The collection of the data was conducted over a period of five months (March– August, 2012). A list of the names of licensed special education centers for Autistic Disorder was obtained from the Ministry of Social Development in the country. The head of each recruited center was personally contacted by the first author and was provided with a full description regarding the study’s purpose, targets, benefits, procedures, and ethical considerations. The head of each center was asked to specifically invite the participants who met the study’s eligibility criteria to a meeting with the first author at their child’s center. Participants who agreed to participate in the study and attended the meeting were offered a detailed description of the study’s purpose, procedures, benefits, risks, duration, confidentiality and participants’

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rights. Participants were then provided with a package that contained three questionnaires on parenting stress, QoL, and parents’ and their children’s characteristics. Participation was regarded as tacit consent. Participants received simple incentives for their participation. None of the participants who agreed to participate left the study. Confidentiality of the data obtained was assured by assigning an identification number to the actual data rather than any other identifiers. Therefore, it was not possible to know how many of the participants were married to each other. Sample size was calculated using G* power 3.0 software (Faul, Erdfelder, Lang, & Buchner, 2007). Using a power level of .80, an alpha level of .05, and a relatively moderate effect size of .20 with six predictors, the estimated sample size needed for each regression equation was 75. Standard simultaneous regression was used in this study. Assumptions of multiple regression were tested by examining the normal probability plots of residuals and scatter diagrams of residuals versus predicted residuals. No violations of linearity, normality, homoscedasticity or residuals were detected. Furthermore, according to case-wise diagnostics, all cases were included in the analyses. The sample size consisted of 114 mothers and 70 fathers of children with Autistic Disorder. Statistical Package of Social Science (SPSS) Version 21 was used to analyze the data (IBM 21, 2012). 2.2. Participants The majority of the sample (84%) had a secondary school or higher. More than half of the participants (56%) were currently unemployed. Of them, 89% were mothers. All the employed participants were full-time workers. Mothers were the primary caregiver (84%) for children with Autistic Disorder. Mean household income for the participants was 648 Jordanian Dinars (JD) (USD = 915). Most of the participants were from urban areas and all had only one child diagnosed with Autistic Disorder. All children addressed in this study had been diagnosed with Autistic Disorder using the Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR (fourth edition, text revision) criteria (APA, 2000). The criteria of the DSM-IV were used across the regions from which children were recruited as it is considered a standardized diagnostic procedure for Autistic Disorder in the country. Children’s reports showed that the severity of the disorder ranged from moderate to severe. However, only one center adopted the multi-disciplinary diagnostic approach using two assessment tools, the DSM-IV and the Childhood Autism Rating Scale (CARS). About 84% (N = 155) of children were boys; the mean age was 6.3 years (SD= 3), ranging from 2 to 12 years; the mean age at first symptom appearance was 2 years (SD = 1), ranging from 6 months to 5 years; and the mean age at clinical diagnosis was 3 years (SD = 1), ranging from 19 months to 6 years. The characteristics of the study sample are described in Table 1. The frequencies, means, and standard deviations for the study’s variables are presented in the table as appropriate. 2.3. Measures 2.3.1. The World Health Organization Quality of Life Assessment-BREF self-administered instrument (WHOQOL-BREF) The WHOQOL-BREF measures individuals’ physical, psychological, social, and environmental health. In addition, it considers individuals’ overall perception of QoL and health (WHO, 1996). Items of the scale range from 1 to 5 with higher scores denoting higher QoL. The total QoL score was used in the analyses. A validated Arabic version for the WHOQOL-BREF with parents of children with Autistic Disorder (Dardas & Ahmad, 2014c) was used in this study. 2.3.2. The Parenting Stress Index-Short Form (PSI-SF) The PSI-SF is considered one of the most commonly used self-reported questionnaires that aims to measure parenting stress (Abidin, 1995). Items included in the measure are divided into three subscales: Parental Distress (PD); Parent–Child Dysfunctional Interaction (PCDI); and Difficult Child (DC) (Abidin). The PD subscale evaluates parents’ judgment of their own behavior such as marital conflict, perceived competence, and life restrictions due to the parenting demands. The PCDI subscale evaluates the parents’ anticipations and interactions with their child. The DC subscale examines the parents’ perceptions of their child’s compliance, demandingness, and temperament. The items of the scale range from 1 (strongly disagree) to 5 (strongly agree) and has a 5th grade reading level. Raw scores above 33 on the PD and DC sub-scales and above 27 on the PCDI sub-scale are considered clinically elevated. Raw total scores above 90 indicate clinically significant high level of stress scores (Abidin). The expected time to complete the questionnaire is between 10 and 15 min. A validated Arabic version for the PSI-SF with parents of children with Autistic Disorder (Dardas, 2014; Dardas & Ahmad, 2013a) was used in this study. 3. Results The means and standard deviations for fathers and mothers on the stress and WHOQOL scales are presented in Table 2. MANOVA test did not show any significant differences between fathers and mothers in these scales. The theoretical importance and the correlation between the variables guided the selection of the predictors for the QoL in this study. Pearson’s product moment correlation coefficients for predictor and QoL are presented in Table 3. The authors chose the three stress subscales (Parental Distress; Parent–Child Dysfunctional Interaction; and Difficult Child), household income, number of children, and child’s with Autistic Disorder age as predictors.


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Table 1 Characteristics of the study variables. Characteristics

Fathers (N = 70) Frequency (%)

Education 11th grade Tawjihi (high school) Diplom BSc and above Occupation Not working Working Primary caregiver Mother Father Both Others Marital status Married Divorced Widow Separated

13 19 16 22

(18.6) (27.1) (22.9) (31.4)

Mothers (N = 114) Frequency (%)

17 36 28 33

(14.9) (31.6) (24.6) (28.9)

11 (15.7) 59 (84.3)

92 (80.7) 22 (19.3)

55 (78.6) 0 10 (14.3) 5 (7.1)

99 1 9 5

(86.8) (.9) (7.9) (4.4)

69 (98.6) 0 0 1 (1.4)

109 3 1 1

(95.6) (2.6) (.9) (.9)

Number of siblings Number of children diagnosed with ADb Age of the child with AD First symptoms’ appearance age (years) Diagnosis’ age (years) Monthly payment for the child’s treatment (JD) Household income a b

Total sample N = 184 M (SD)a

3.51 (1.58) 1.00 (.10) 6.04 (3.05) 1.96 (1.12) 2.85 (1.17) 193.3 (233.9) 648.2 (636)

M = mean; SD = standard deviation. AD = Autistic Disorder.

Table 2 WHOQOL-BREF and PSI-SF Scales Description and MANOVA test. Scales

PSI-SF Scales PD PCDI DC Total scale WHOQOL-BREF Total scale

Number of items

Range

12 7 11 30

12–60 7–34 15–55 35–145

24

32–114

Fathers

Mothers

MANOVA statistics

M (SD)

M (SD)

F value

Significance

39.1 38.5 39.3 116.9

41.1 37.2 40.3 118.6

1.58 .98 .74 .25

.21 .32 .39 .62

.91 .86 .87 .92

1.62

.21

.93

(10.3) (8.6) (7.8) (22.5)

58.2 (9.2)

(10.5) (8.8) (7.9) (22.6)

83.2 (8.8)

Cronbach’s alpha

Table 3 Pearson correlation of QoL for fathers and mother of children with Autistic Disorder with the study predictors. Variables

Fathers N = 70

Mothers N = 114

PD PCDI DC Household income Number of siblings Child’s age (years)

.57** .42** .48** 10 .01 .16

.65** .32** .55** .28* .17 .10

* p .01. ** p .001.

Two multiple regression analyses were performed based on the parenting relationship (Fathers, Mothers) with the children with Autistic Disorder. These analyses revealed that the model among mothers (F = 21.58, p < .001; R2 = .55) was able to predict high proportion of variance in QoL. The same regression equation among fathers gave a significant proportion of variance (F = 6.54, p < .001; R2 = .38). From the three stress subscales, only the PD was a significant predictor in both


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Table 4 Predictors of QoL among parents of children with Autistic Disorder. Variable

Fathers N = 70

Mothers N = 114

by PD PCDI DC Household income Number of siblings Child’s age (years) R2 Adjusted R2 F

t **

.45 .03 .20 .09 .02 .07

3.76 .23 1.34 .85 .16 .63 .38 .33 6.54**

by

t

.50 .13 .33 .22 .13 .10

6.37** 1.52 3.61** 3.37** 1.96* 1.45 .55 .52 21.58**

* p .01. ** p .001. y b = the Standardized beta.

regression equations. On the other hand, the PCDI and child’s age were not significant predictors in either of the regression equations. Table 4 displays the standardized regression coefficients (b), and t statistics for each predictor (t). 4. Discussion The QoL of children with Autistic Disorder relies heavily on the QoL of their parents (Burgess & Gutstein, 2007). Any disruption in the health of the parents may have direct negative effects on the children, their siblings, and the whole family system (Brown, MacAdam-Crisp, Wang, & Iarocci, 2006). Therefore, it is crucial to consider the QoL of the parents when designing the care plans for their children. The purpose of this study was to examine predictors of QoL for fathers and mothers of children with Autistic Disorder. In particular, the study investigated the prediction effect of the following variables: PD, PCDI, DC, household income, and the child’s with Autistic Disorder age and number of siblings. The following sections discuss the contribution of each of the selected variables to the prediction formula (Table 4). 4.1. Parenting stress 4.1.1. Parental distress The PD subscale evaluates parents’ judgment of their own behavior such as marital conflict, perceived competence, and life restrictions due to the parenting demands. Explaining the results that the PD level could predict the QoL for both fathers and mothers of children with Autistic Disorder may be a straightforward task. The stress of rearing children with Autistic Disorder comes from a variety of factors and can present itself in all aspects of the parents’ life. The child with Autistic Disorder was found to be a significant source of stress on parents because of the ambiguity of diagnosis, the severity and chronicity of the disorder, and the peculiarity of the child’s behavior that interfere with developing normal functioning and learning (Lecavalier, Leone, & Wiltz, 2006). In addition, care-taking demands may intensify the levels of stress among the parents and negatively affect the marital relationship and family’s activities and spontaneity (Hartley et al., 2010; Hastings, 2003). The prolonged nature of parenting stress experienced by parents of children with Autistic Disorder was also found to have significant short and long term effects on the parents’ mental, psychological, and physical health. Further, chronic parenting stress can significantly affect the parents’ work performance, home and social life, and ultimately their personal relationships and own self-worth and motivation (Parish, Seltzer, Greenberg, & Floyd, 2004). High levels of parenting stress can also adversely affect disabled children’s cognitive, behavioral and social development (Crnic, Gaze, & Hoffman, 2005). Therefore, targeting parenting stress in the interventions aimed at enhancing parents’ QoL is a critical step. The results that parenting stress was significantly elevated and predictive for both fathers’ and mothers’ QoL need to be highlighted. Traditional studies have generally shown that stressful life events cause less psychological distress in men than in women (Gadzella, Ginther, Tomalca, & Bryant, 1991; Thoits, 1995). In the case of the fathers and mothers of children with Autistic Disorder, available studies revealed mixed results. For example, Yamada et al. (2012) found that mothers experience poorer QoL than fathers in several mental domains and this was correlated with high care scores and low control scores. On the other hand, the study of Hastings (2003) and Dardas and Ahmad (2014a) revealed similar levels of parenting stress and QoL among both parent. The results come from this study add to a large body of research documenting high levels of parenting stress among mothers raising a child with Autistic Disorder but also, provide evidence that fathers are sharing the negative parenthood strain and hence, they are at risk of poor QoL. Our data suggest that parents of children with Autistic Disorder may benefit from family-centered interventions where the stress of both fathers and mothers is assessed comprehensively recognizing its impacts on parents’ wellbeing and QoL.


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4.1.2. Difficult child characteristics The results in this study showed that the child’s with Autistic Disorder difficult characteristics were able to predict mothers’ QoL but not fathers’. Relevant studies frequently report that mothers of children with Autistic Disorder are most often the primary caregiver for their children (Dardas & Ahmad, 2013b; Gray, 2002; Hoffman, Sweeney, Hodge, LopezWagner, & Looney, 2009). In this study, mothers were the primary caregivers in almost 84% of the sample. Only one participant reported that the father was the primary caregiver, while only 19 participants reported that both fathers and mothers shared the caregiving responsibilities. Therefore, mothers are more likely than fathers to be adversely affected by the negative emotional, social, physical and psychological impacts associated with their children’s disability. The highly challenging and difficult behavioral profile that children with Autistic Disorder exhibit require mothers to provide constant attention to their children and thereby, may have less time to meet their own health needs. Indeed, it has been reported that the level of emotional distress among mothers of children with Autistic Disorder is positively associated with the level of challenging behavior in the child and is negatively associated with the child’s ability to communicate functionally (Ello & Donovan, 2005). On the other hand, some studies suggest that the high parental stress for mothers is related to poor social support, conflicts in the dyadic relationship, and personality characteristics like vulnerability and anxiety proneness (Saisto, Salmela-Aro, Nurmi, & Halmesma¨ki, 2008). There is a significant dearth of studies similar to the current with which comparisons can be made. However, a study by Wang et al. (2004) showed partially similar results in that the severity of a child’s disability was a negative significant predictor for parents’ ratings of their family’s QoL. 4.1.3. Parent–child dysfunctional interaction The PCDI subscale measures the parents’ view of expectations and interactions with their child, (e.g. ‘My child rarely does things for me that make me feel good’; ‘My child smiles at me much less than I expected; It takes a long time and it is really hard for my child to get used to new things). Our analyses showed that PCDI was not a significant predictor for the parents’ QoL. In fact, the PCDI had low beta scores in comparison to the PD and DC scales. The finding can have statistical as well as theoretical explanations. In multiple regression equation, the first variable enters the equation exerts all its relationship with the dependent variable, while ignoring the influence of other variables in the prediction (zero-order correlation) (Polit, 2010). In our study, although we used the simultaneous method of entering the predictors, the variables other than the first predictor only contributed with the semi-partial correlation. This could explain why the PCDI turned to be not a significant predictor in the regression equations. From a theoretical point of view, Abidin (1995) has theorized that the stress experienced by parents stem from factors related to the self, the child’s characteristics, and interactions between the parent and their child. However, our review of the literature that specifically targeted parenting stress among parents of children with Autistic Disorder revealed that those parents are more concerned about their children’s difficult behavioral repertoire than about the style of their interaction with the children. In particular, parents experience stressors that are often related the child’s language and cognitive deficits, stereotyped behaviors, social isolation, difficulties in self-care, and lack of community understanding (Ello & Donovan, 2005; Hoffman et al., 2009). 4.2. Household income This study revealed that higher household income can predict better QoL for mothers of children with Autistic Disorder. The result is partially consistent with Brown et al. (2006) who found that financial well-being is particularly important for the QoL of parents of children with Autism Spectrum Disorder. Further, the results of Hatton and Emerson (2009) linked higher incomes with better QoL for mothers of children with Autistic Disorder; suggesting that higher levels of income can equip the mothers with better support services to deal with their stressors. Moreover, in their study on family QoL in the presence of a child with disability, Wang et al. (2004) found that family income was a significant positive predictor of the mothers’ but not fathers’ ratings of their family’s QoL. Financial challenges are considered one of the most common concerns for parents of children with pervasive developmental disabilities. Having a child with Autistic Disorder is associated with higher rates in work-loss and medical costs than unaffected families (Hecimovic & Gregory, 2005; Parish et al., 2004). In this study, parents reported that they pay around 200 Jordanian Dinar (JD) monthly for their child’s care services (1 JD = 1.4 US Dollar). This monthly amount is considered relatively high when compared to the parents’ household monthly income which is about 650 JD. According to Gray (2002), mothers of children with Autistic Disorder were more likely than fathers to experience a significant negative impact on their careers as a result of caring for their children. Many of the mothers decreased their works hours or were not able to work at all. The lack of suitable employment and/or its difficulty were associated with greater degrees of psychological distress, with increased reports of depression, anxiety, and anger among these mothers. It is also insightful to consider other variables that may be associated with the parents’ income and can affect their health and wellbeing. Coupled with individuals’ income, level of education reflect the socio-economic status. Socio-economic status and the resulting resource availability are reported to have positive impacts on individuals’ health and wellbeing. Furthermore, socio-economic status has been found to act as a moderator between QoL for caregivers and problematic behaviors in their children (Emerson, 2003; Hatton & Emerson, 2009). Although education can broaden individuals’ knowledge and provide them with better access to specialized medical and therapeutic services and thereby, may enhance

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individuals’ QoL, previous relevant studies did not support the assumption that the level of education for parents’ of children with Autistic Disorder is associated with their QoL (Dardas & Ahmad, 2014a; Wang et al., 2004). Another variable that can be relevant to the parents’ income is their occupational status. Although it may be true that mothers who are working may be able to improve their income (Dardas & Ahmad, 2014a) and therefore better QoL can be predicted, only 19.3% of the mothers were working. The high percentage of unemployed mothers was parallel with their high level of education. These paradoxical results can be explained by the children’s disturbing and disruptive behaviors which mandate consistent home caregiving. Previous studies reported that it is not uncommon for mothers of children with Autistic Disorder to quit their job and stay at home (Parish, Seltzer, Greenberg, & Floyd, 2004). Future research is advised to focus on the interactions between work and family’s stability among working parents of children with Autistic Disorder. 4.3. Number of siblings Research findings regarding effects of having siblings for the child with Autistic Disorder on parents are mixed. Some studies suggest that parents may face extra burdens as siblings themselves may be at increased risks for behavioral and social adjustment problems because of their exposure to stressful life conditions and decreased interaction with their parents (Kaminsky & Dewey, 2002). On the other hand, Lee et al. (2009)found that the presence of siblings for the child with Autistic Disorder may help parents with the care responsibilities and thereby, predicted better parent-reported physical health. Our results corroborate the work of Lee and colleagues in that having more children predicted better QoL for mothers of children with Autistic Disorder. Our explanation can be also supported by shedding some light on the cultural background for the participants. The sample of this study was in part from the Arab world (Jordanians). Arabs are united in a shared culture where loyalty to one’s extended family takes precedence over individual needs and goals (Nydell, 2005). Arab culture traditionally emphasizes that older siblings (especially sisters) are expected to help with caring for younger children. 4.4. Child’s age Several previous studies have highlighted that the age of the child with Autistic Disorder is considered an important factor in shaping parents’ QoL and wellbeing. As the child grows, parents are expected to develop more realistic view of the child’s outcome, experience reduced degree of psychological distress, and adopt more adaptive coping skills (Crnic, Gaze, & Hoffman, 2005; Dardas & Ahmad, 2014b; Duarte, Bordin, Yazigi, & Mooney, 2005). However, the results from this study showed that the age group of children included was not a significant predictor for the parents’ QoL. 5. Conclusion Examining parents’ QoL can help us gauge the impact of Autistic Disorder on the parents. The current study has provided some support to previous research that found the QoL of parents of children with Autistic Disorder affected by their stress levels and socioeconomic status. However, it did not support the notion that the style of parents’ interactions with their children and the age of children can have impact on parents’ QoL. Our study provides initial information about aspects in parents’ of children with Autistic Disorder lives that can predict their QoL. It should be noted that the six predictors in the regression equation used in this study accounted for high percentage of variance in mothers’ QoL and a relatively high percentage of variance in fathers’ QoL. Educators and clinicians can utilize the results of this study by designing comprehensive intervention plans that can better recognize and meet the needs of children with Autistic Disorder and their parents. Indeed, research results have highlighted that the most successful interventions are multidimensional; that is, it addresses multiple stressors and potential factors that can predict caregivers’ health and well-being (Brookman-Frazee, 2004; Tonge et al., 2006). This study utilized data from a relatively large number of parents which provides sufficient statistical power to predict the QoL of those parents. Yet, future studies would be advised to study the longitudinal course of QoL outcomes as developmental and environmental changes occur throughout the lifespan. It is also recommended to replicate this study with a larger number of fathers of children with Autistic Disorder so that their QoL predictors can be better revealed. As this study sheds light on how parenting roles and having siblings for the child with Autistic Disorder can impact on parents’ QoL, it is of importance for health professionals working with children with Autistic Disorder and their parents to ensure that care plans are set to target the family system rather than focusing on individual subsystems like the parents or their children. Ensuring professional partnerships between health care providers and families of children with Autistic Disorder can be a key component in the QoL experienced by the parents and eventually by the children. Acknowledgment The authors acknowledge the partial funding for this study provided by The University of Jordan. References Abidin, R. R. (1995). Parenting stress index (3rd ed.). Odessa, FL: Psychological Assessment Resource.


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