The current situation and influencing factors of anxiety and depression among parents of children with autism - internal and external factors, which has a more significant impact?

doi:10.21203/rs.3.rs-4747323/v1

Objective: This study is aimed at examining the prevalence of anxiety and depression among parents of children diagnosed with autism spectrum disorder (ASD) and identifying potential influencing factors.

Method: A total of 411 children diagnosed with ASD and their parents were enrolled from the Department of Developmental Behavior at the Affiliated Children's Hospital of Zhejiang University School of Medicine between January and July 2022. Data on the mental health (specifically depression and anxiety) of these parents and the severity of ASD symptoms in their children were collected. Multiple linear regression was utilized to analyze the relationships between the mental health of the parents and factors such as psychological resilience (internal), demographic data, and the severity of ASD symptoms (external).

Results: Psychological resilience was identified as the most significant predictor of both depression and anxiety among the parents, surpassing the impacts of demographic variables or the severity of the children's symptoms (p<0.001). Furthermore, gender differences were found to significantly influence anxiety levels (p<0.05), while marital status was shown to have a noticeable impact on depression (p<0.05).

Conclusion: Attention to the mental well-being of parents with ASD children and enhancement of their psychological resilience are suggested to significantly improve the family's quality of life. This support is also indicated to facilitate better societal integration for children with autism.

Autism spectrum disorder

psychological resilience

anxiety

depression

ASD is a neurodevelopmental disorder marked by communication difficulties, limited interests, and repetitive behaviors. Recent data indicates that in the United States, one in every 40 children is diagnosed with ASD, maintaining a male-to-female ratio of approximately 3–4 to 1[1]. Similarly, the prevalence of ASD in China is on the rise [2]. Children with ASD often struggle with social interactions and self-care, presenting considerable challenges to their families [3]. Consequently, parents of children with ASD frequently report elevated stress and fatigue levels [4], which significantly impact their psychological well-being. Research has identified stress and the financial demands of caring for these children as key factors deteriorating parental mental health [5–6]. Particularly vulnerable are parents with lower education levels, those whose children exhibit severe symptoms such as non-functional language, and those dealing with children's behavioral issues or co-occurring conditions [7–8]. Notably, studies have highlighted that mothers caring for children with ASD often experience pronounced depressive symptoms [9]. Nonetheless, while these findings emphasize the correlation with autism symptoms and demographic factors, they tend to overlook other influential elements like parental psychological resilience.

The American Psychological Association defines psychological resilience as the ability to adapt effectively to adversity, trauma, tragedy, threats, or significant stress. This resilience is crucial for caregivers, potentially alleviating stress, anxiety, and depression. Diminished psychological resilience in parents, characterized by reduced optimism [11], mindfulness [12], acceptance [13], and self-compassion [14], may escalate parental stress and deteriorate their mental health. In the context of ASD, parents displaying higher psychological resilience experience fewer depressive symptoms [11], greater marital satisfaction [15], and enhanced life satisfaction [16]. Research on this resilience among parents of children with ASD remains scant in China. This study aims to assess the impact of typical symptoms (external factors) and parental psychological resilience (internal factors) on the psychological health of these parents. Identifying which factor exerts a more significant influence will inform strategies to bolster parental resilience or address children's symptoms, ultimately benefiting ASD families.

2.1 Research subjects

In this study, 411 children along with their parents, all diagnosed with ASD, were enrolled. These participants were recruited from the Developmental-Behavioral Pediatrics Clinic at the Affiliated Children's Hospital of Zhejiang University School of Medicine between January and July 2022. The inclusion criteria were as follows: (1) diagnosis according to the ASD criteria outlined in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) from the United States; (2) ages ranging from 3 to 17 years; and (3) absence of genetic metabolic disorders, Rett syndrome, fragile X syndrome, and other significant organic neurological and psychiatric disorders, such as tuberous sclerosis or epilepsy. The study received approval from the Ethics Committee of the Affiliated Children's Hospital of Zhejiang University School of Medicine (No. 2021-IRB-309).

2.2 Research Tools

2.2.1 Typical severity of ASD symptoms

This study employed the second edition of the Autism Diagnostic Observation Schedule (ADOS-2) to assess the severity of autism symptoms in children. ADOS-2 comprises five modules, each designed for individuals of varying ages and linguistic abilities. The diagnostic scores include a total score and a comparison score (D), with the total score derived from the sum of the communication and social interaction items. The comparison score, ranging from 1 to 10, is calculated based on the child's age, language skills, and total score, using the ADOS-2 norms. Based on the thresholds for total and comparison scores, patients can be classified as having classic autism, atypical autism, or non-autism spectrum disorder. A higher comparison score D indicates more typical symptoms of autism.

2.2.2 Parental mental health status

The Chinese versions of the Self-Rating Anxiety Scale (SAS) and the Self-Rating Depression Scale (SDS) are used to measure anxiety and depression symptoms in caregivers. The SAS consists of 20 items, scored on a four-point scale, with higher total scores indicating more severe anxiety. Similarly, the SDS includes 20 items, also scored on a four-point scale, with higher total scores indicating more severe depression.

2.2.3 Psychological resilience

The Connor-Davidson Resilience Scale (CD-RISC) comprises 25 items across five dimensions: tolerance of negative affect (7 items), competence (8 items), acceptance of change (5 items), spirituality (2 items), and control (3 items). Each item is scored on a five-point scale (0–4), with higher cumulative scores indicating stronger psychological resilience.

2.2.4 Statistical analysis

Firstly, we use descriptive analysis to report demographic variables of caregivers and children, including age, gender, educational background, family income, and marital status. In addition, we used multiple linear regression to estimate the self-reported mental health symptoms of caregivers based on psychological resilience (internal factors) and ASD symptom typicality (external factors), while controlling for five demographic variables (child age, parent gender, parent educational background, family income, marital status). We also reported the rough coefficients and significance tests of two predictive variables for predicting mental health symptoms.

3.1 Demographic Information

A total of 411 children diagnosed with ASD at the hospital were studied, comprising 352 boys (85.6%) and 59 girls (14.4%), with ages ranging from 3 to 17 years (M = 5.97, SD = 1.68). The children's Composite D scores varied from 4 to 10, with an average of 6.64 (SD = 1.31). The fathers had an average age of 36.90 years (SD = 4.94), while the mothers averaged 35.22 years (SD = 7.76). For further details on the demographic characteristics of the children, parents, and families, see Table 1.

Table 1 Demographic Information

		N (%)
Mother’s Educational Background
	Below Primary School	5(1.2)
	Middle School	36(8.8)
	High School	67(16.3)
	Voluntary college	122(29.7)
	Bachelor	160(38.9)
	Master and above	21(5.1)
Father’s Educational Background
	Below Primary School	2(0.5)
	Middle School	44(10.7)
	High School	82(20.0)
	Voluntary college	87(21.2)
	Bachelor	160(38.9)
	Master and above	36(8.8)
Marital Status
	Married	386(93.9)
	Divorced	11(2.7)
	Separated	4(1.0)
	Remarried	10(2.4)
	Lost one of their partners	/
Early Birth
	Early	49(11.9)
	Normal	362(88.1)
Birth Type
	Normal Delivery	211(51.3)
	Cesarean Section	200(48.7)
Care Provider
	Mother	334(81.3)
	Father	11(2.7)
	Grandparents	60(14.6)
	Babysitters	1(0.2)
	Others	5(1.2)
Abnormal during Mom’s Pregnancy
	Abnormal	50(12.2)
	Normal	361(87.8)
Family Income
	Below 50,000	17(4.1)
	50,000 – 100,000	58(14.1)
	100,000 – 15,0000	138(33.6)
	200,000 – 500,000	146(35.5)
	500,000 – 1,000,000	36(8.8)
	Above 1,000,000	16(3.9)

3.2 Anxiety and Depression Symptoms of Parents

From Table 2, it can be seen that about 20% and 40% of people self-reported symptoms of anxiety and depression. Moreover, most parents self-report mild symptoms of anxiety/depression.

Table 2 Anxiety and Depression Symptoms of Parents

Self-report mental health symptoms		N (%)
Anxiety
	Serious Anxiety Symptoms	4(1.0)
	Middle-level Anxiety Symptoms	27(6.6)
	Mild Anxiety Symptoms	49(11.9)
	No Symptoms	331(80.5)
Depression
	Serious Depression Symptoms	9(2.2)
	Middle-level Depression Symptoms	60(14.6)
	Mild Depression Symptoms	85(20.7)
	No Symptoms	257(62.5)

Note: Based on Chinese norm, scores higher than 70 were classified as “Serious Anxiety Symptoms”, and scores lower than 50 were classified as “No Symptoms”.

3.3 Regression analysis

In the second phase of analysis, the addition of Group D into the regression model did not result in any notable changes in the R^2 values for either anxiety or depression, suggesting that psychological resilience is a more critical predictor of these symptoms among parents of children with ASD than are demographic factors or the typicality of ASD symptoms in their children. The findings, presented in Table 3, also highlighted significant differences based on respondent gender and family and marital status in predicting anxiety and depressive symptoms, respectively, with p-values below 0.05.

Table 3 Hierarchical regression analysis of self-reported anxiety and depression among parents

Variables		Anxiety				Depression
Variables		β	R²	F	t	β	R²	F	t
Step 1			.29	20.65^***			.48	45.56^***
	Resilience	-6.81			-11.20^***	-.11			-17.73^***
Covariates
	Child’s Age	.14			.53	.00			.66
	Participant Gender	-2.72			.01^*	-.03			.01
	Mother’s Education	-1.19			.30	-.00			.72
	Father’s Education	-.20			.86	-.01			.36
	Family Income	-.77			.09	-.00			.35
	Marital Status	3.07			.09	.04			.04^*
	Diagnosis Time	.35			.52	.00			.45
Step 2			.29	18.33^***			.48	40.46^***
	Compare D	.09			.78	.00			.60

* p < 0.05, ** p < 0.01, *** p < 0.001

Our research results reveal that approximately 20% of parents exhibit anxiety symptoms, whereas about 40% demonstrate signs of depression, underscoring a prevalent mental health concern among caregivers of children with ASD. These findings align with earlier research, which indicates that one-fifth to over one-third of parents with ASD-diagnosed children may report clinically significant depressive symptoms, as referenced in studies [17]. Furthermore, a recent meta-analysis by Schnabel et al. [18] determined a 31% overall prevalence of depression among this demographic. Contrasting these outcomes, a 2017 large-scale study in the United States by Cohs and Leslie reported a lower prevalence of depression at 12.5% [19]. Additionally, Davis and Carter utilized the Beck Anxiety Scale in a U.S. study, noting a 12% prevalence of anxiety symptoms among parents, which escalated to 47.8% when assessed with the DASS-21 tool [20]. These variances likely stem from differences in measurement scales and possibly the diverse socio-cultural backgrounds of the study populations. In summary, the mental health status of parents caring for children with ASD presents significant concerns.

This study finds that parental psychological resilience significantly predicts anxiety and depression symptoms in parents of children with ASD, surpassing the influence of demographic factors and typical ASD symptoms. Consistent with previous research on the mental health of mothers of children with chronic developmental disorders, including autism [21], this study confirms that psychological resilience and challenging parenting experiences are primary predictors of depressive symptoms. Furthermore, research on anxiety symptoms reveals similar findings [22]. A randomized trial also examined the AMOR (Acceptance, Mindfulness, Optimism, Resilience) method, an eight-week intervention aimed at enhancing parental psychological resilience [23]. Significant improvements were noted in stress management and mental health symptoms among parents post-intervention, which in turn benefitted family functioning and the well-being of children with ASD. This underscores the positive impact of psychological resilience interventions on ASD families. Moreover, meta-analyses suggest that interventions based on psychological education, mindfulness, and cognitive-behavioral therapy enhance caregiver resilience. However, no substantial evidence supports the effectiveness of expressive writing in boosting psychological resilience [10].

Moreover, gender differences among parents significantly influence anxiety levels. Research indicates that four-fifths (80%) of mothers experience higher levels of depression and anxiety compared to fathers of children with ASD. This disparity may stem from mothers assuming greater caregiving responsibilities or could reflect a reporting bias, as men are less likely to report symptoms of depression and anxiety [24]. Additionally, recent studies suggest that psychological resilience and the challenges of parenting mediate the anxiety experienced by mothers of children with ASD [25]. This finding aligns with longitudinal studies, which have consistently shown that mothers, typically the primary caregivers, face significant parenting challenges. Notably, research from Türkiye reveals that fathers often disengage from familial duties, interacting less with their children and focusing more on the financial aspects of family care, while mothers predominantly manage the caregiving and other domestic responsibilities [26]. Interestingly, younger mothers report greater stress, possibly due to poorer mental health in this demographic [27]. Conversely, studies indicate that older mothers may face increased challenges in raising children with ASD [28]. The correlation between parental age and psychological stress, however, remains unclear.

Significant disparities were observed in predicting parental depression symptoms across different marital statuses. The marital status of a family is a primary determinant of the economic and psychological pressures faced by parents. Previous research has extensively documented that divorce detrimentally impacts parents' mental health [29–30]. Furthermore, separation or divorce tends to exacerbate financial difficulties for parents of children with ASD, restricting their access to necessary services and treatments [31]. Notably, a longitudinal study revealed that children with ASD from divorced families exhibit heightened mental health challenges and display reduced psychological resilience [32]. Therefore, marital status plays a pivotal role in shaping parental psychological well-being.

This study presents several limitations. Initially, the reliance on parental self-report scores to evaluate psychological states restricts the generalizability of the findings. A more robust evaluation would encompass diverse methodologies and multiple informants, including clinical assessments and spouse reports. Moreover, the small sample size of the survey may fail to capture all pertinent changes in the measured variables, suggesting the need for future studies to engage a broader participant base. Additionally, the fact that nearly 80% of participants identify as full-time caregivers may limit the applicability of the results to varied family dynamics.

This study has revealed that psychological issues among parents of children diagnosed with ASD are widespread and demand urgent societal attention. Among various factors, psychological resilience has emerged as the most significant predictor of depressive and anxiety symptoms in parents. This factor surpasses the influence of both demographic variables and typical symptomatology associated with ASD in children. Enhancing psychological resilience could therefore be a strategic approach to ameliorating the mental well-being of these parents, which in turn, could enhance their quality of life and positively impact the prognosis for children with ASD.

Ethics approval：This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of the Affiliated Children's Hospital of Zhejiang University School of Medicine (No. 2021-IRB-309).

Consent to participate：Informed consent was obtained from all individual participants included in the study.

Consent for publication: Not applicable.

Availability of data and materials: The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

Competing interests: The authors have no competing interests to declare that are relevant to the content of this article.

Funding: This research was supported by Zhejiang Provincial Natural Science Foundation of China under Grant No. LTGY24H090005 and Autism Research Special Fund of Zhejiang Foundation For Disabled Persons（No.2023006）.

Authors' contributions: The corresponding author of this manuscript is Chao Song and contribution of the author as mentioned below with the responsibility in the research.

1. Ting Han wrote the first manuscript under the supervision of Chao Song and participated in study design, collection and analysis of data.

2. Cheng Mian Zhang participated in analysis of data

3. Xiao Lin Liu, Yan Jin, Ze Peng Wang participated in collection of data.

4. Chao Song participated in study concept and design.

5. All authors commented on previous versions of the manuscript and approved the final manuscript.

Acknowledgements: Not applicable.

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No competing interests reported.

The current situation and influencing factors of anxiety and depression among parents of children with autism - internal and external factors, which has a more significant impact?

Status:

Version 1

Abstract

1 Preface

2 Methods

3 Results

4 Discussion

5 Conclusion

Declarations

References

Additional Declarations

Status:

Version 1