The Role Of Stressful Coping Styles İn Depression And Anxiety Levels On Parents Of Children With Autism Spectrum Disorder
Abstract
Aim: The purpose of this research is the determination of depression and anxiety levels and their impact on the style of coping with
stress of parents of children with Autism Spectrum Disorder (ASD).
Material and Methods: Research was conducted with parents of 73 children with ASD, who come to the rehabilitation center.
Personal Information Form, Stress Coping Styles Scale, Beck Depression Inventory and State and Trait Anxiety Scale were used to
the relational screening method.
Results: It was found that the mean state and trait anxiety scores of parents was high and parents chose one of the self-confidence
confidence approach to cope with stress.The self-confident approach alone reduced the despair negatively by -49.9%, but the
submissive approach did not affect variables.
Conclusion: It was found that the despair of the family members decreased when they preferred the self-confident coping approach.
INTRODUCTION
Autism spectrum disorder (ASD) is a developmental
disorder with lack of social and communicative behavior
and the presence of restricted and repetitive patterns
of behaviors, interests, and activities (1). In terms of
family members, ASD is an uncontrollable, unchangeable
condition that may lead to deterioration of emotions, such
as anxiety, depression and stress. Research shows that
parents of children with ASD have higher levels of stress,
and their quality of life is poor (2,3,4). Family members
who care for a child with ASD may feel stressed, anxious
and helpless, and they are at high risk for a condition of
exhaustion, anger, rage, or guilt (5). Increasing evidence
suggests that the parents of the child with ASD have higher
rates of depression and anxiety (6,7). Family members can
try many different methods to cope with the situation that
causes stress (8,9). Methods used by families are mostly
aimed at solving problems, doing things, trying to reduce
or manage their emotions (10,11). It is important in which
situation; coping styles are used and repeated for the
formation of coping attitudes. Cognitive and behavioral
strategies develop as the information about individuals
coping with stress increases. In addition, coping
mechanisms protect parents from depression and other
psychiatric disorders (12,13). The sociodemographic
characteristics of the family, age and gender of the child,
and behaviors related to ASD affect the well-being and
coping of parents of children with ASD (2). Determining
the approaches of family members and examining the
factors that affect their attitudes and behaviors are also
important to become socialized for individuals with ASD
and also important for their special education. As known,
it is important to support families to be mentally healthy
and It is possible to increase the quality of life of parents
with effective mental health support systems (14). In their
study, Da Paz et al. investigated the relationship between
2870
Ann Med Res 2019;26(12):2870-5
maternal adaptation and distress measures in mothers of
children with autism (15). At the beginning of the study,
high acceptance rates of the mother were associated with
less psychological stress, especially less depression and
perceived stress. Increased acceptance over time has
also been associated with decreases in the symptom
of depression during the same period. Coping with the
negative situation of families of children diagnosed with
ASD affects their levels of depression and anxiety and
thus their physical and emotional well-being. In this study,
based on the previous research, we planned to reveal the
relationships between the coping styles and levels of
depression and anxiety of family members. In the light
of other studies, our hypothesis is that, coping with the
negative situation of families with children diagnosed
with ASD leads to higher levels of depression and anxiety.
We considered that there was a significant relationship
between the coping styles and depression levels, state
and trait anxiety levels of the family members of children
with ASD.
MATERIAL and METHODS
Participants
The sample for this pilot study consisted of 73 children
previously diagnosed with ASD and their family members
was drawn from a special education center located in
Istanbul that provides services to children with ASD.
At the beginning of the study, 80 children who were in a
special education program in a special education center
were randomly selected. Three of these children were
excluded from the study because of chronic medical
illness (epilepsy) and 4 of them due to other psychiatric
illness (ADHD). A history of chronic medical illness was
obtained from the family.
A total of 73 participants were included.The children and
their families who agreed to participate in the study. The
parents were informed about the purpose of the study
and informed consent was obtained from all parents
before the examination. Children with chronic diseases
(e.g., diabetes, cardiovascular, autoimmune, history of
stroke, brain injury, cancer, endocrine disorders) were
excluded.Parents meeting criteria for another psychiatric
disorder including psychosis and bipolar disorder, alcohol
or substance use disorder, current posttraumatic stress,
bipolar, or eating disorders were also excluded. 73 children
with ASD had not been diagnosed with ASD in different
Child and Adolescent Psychiatry Clinics in Istanbul by
other child and adolescent psychiatrist and they were in
special education program.
Diagnosis verification of ASD was based on the interviews
with parents and detailed developmental anamnesis
according to DSM 5 criteria by a child and adolescent
psychiatrist in our study. In the research, Personal
Information Form, Stress Coping Styles Scale (SCSS),
Beck Depression Inventory (BDI) and State and Trait
Anxiety Scale (STAI) were used with a relational screening
method. The scales were filled by the researchers as
a result of clinical interview with the children and their
family.
The results were evaluated by psychiatrist, child
psychiatrist and psychologist. The study protocol was
reviewed and approved by the non interventional research
ethics committee of Üsküdar University.
Instruments of data collection
Personal Information Questionnaire: The Personal
Information Questionnaire Form prepared by the
researchers is an interview form which includes the gender,
age, level of education, economic status of participants
and gender and age of children with ASD.
Stress Coping Styles Scale (SCSS) was developed by
Folkman and Lazarus to measure the stress levels of
individuals in the face of events and to investigate the
ways of coping with stress (16). SCSS is 4-point Likerttype
scale of the stress situation of individuals. In this
study, a 30-item short form of SCSS, which the reliability
and validity study of the Turkish version was done by
Şahin and Durak, was used (17).
Beck Depression Inventory (BDI): Beck Depression
Inventory (BDI) is one of the most used scales in the
world to measure the depression level of individuals. The
scale was developed by Beck and consists of 21 items
aimed at measuring the emotional, somatic, cognitive
and motivational causes of depression (18). Each item
determining a behavioral feature regarding depression
under the scale is assigned a score between 0 (never) to 3
(frequently) and as a result the person receives a score of
0-63 and high scores demonstrate increase in depression
symptoms. The validity and reliability study of the scale
was conducted by Hisli and Tegin (19,20). In the validity
and reliability analysis of the scale adaptations validity
were found to be 0.650 to 0.680 coefficient of 0.740.
Each item determining a behavioral feature regarding
depression under the scale is assigned a score between
0 (never) to 3 (frequently) and as a result the person
receives a score of 0-63 and high scores demonstrate
an increase in depression symptoms. The validity and
reliability study of the scale was conducted by Hisli and
Tegin (19,20). In the validity and reliability analysis of the
scale adaptations validity was found to be 0.650 to 0.680
coefficients of 0.740]
A high total score indicates a high level of depression or
severity.
State and Trait Anxiety Scale (STAI): State and Trait
Anxiety Scale (STAI) was developed by Spielberg et al. to
measure continuous and state anxiety levels of normal
and abnormal individuals and was adapted into Turkish
by Öner and Le Compte (21,22). The STAI has 40 items,
20 items allocated to each of the state anxiety and the
trait anxiety subscales. The total score obtained from
both scales ranges from 20 to 80. A high score indicates
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Ann Med Res 2019;26(12):2870-5
a high level of anxiety and a small score indicates a low
level of anxiety. The average score level determined in
the applications ranged from 36 to 41. In reliability and
validity analyzes, the reliability coefficient was found to be
between 0.830 and 0.870 for the Trait Anxiety Scale and
between 0.940 and 0.960 for the State Anxiety Scale. Their
reliability ranged from 0.710 to 0.860 for the Trait Anxiety
Scale and 0.260 to 0.680 for the State Anxiety Scale.
Analysis of the data: The collected data were entered into
a worksheet and analyzed by SPSS-19 statistical software
(IBM Corporation, USA).Categorical variables were
analyzed using chi square tests and data were expressed
as frequency of observed and expected. All numerical
variables were initially tested for normal distribution
using Kolmogrov–Smirnov test. Variables with normal
distribution were then compared with paired t-tests and
those without a normal distribution were analyzed with
an equivalent non-parametric Wilcoxon Sum Ranks.In the
interpretation of the results, p <0.05 significance level was
taken into consideration.
RESULTS
The frequency and percentage distributions of the
sociodemographic information of 73 participants that are
the sample of the study are presented in Table 1.
Table 1. Demographic Characteristics of Participants
Frequency Percentage (%)
Age of parents
25-35 Years 31 42.5
36-45 Years 29 39.7
46 Years and over 13 17.8
Gender of parents
Total 73 100
Female 57 78.1
Male 16 21.9
Gender of children
Total 73 100
Female 19 26
Male 54 74
Age of children
Total 73 100
Under 3 Years 26 35.6
3-4 Years 16 21.9
4-5 Years 6 8.2
5-6 Years 10 13.7
6 Years and over 15 20.5
Level of Education
(Parents)
Total 73 100
Secondary School 10 13.7
High School 19 26
Undergraduate 19 26
Graduate 8 11
Socioeconomic
Level of Parents
Total 73 100
Low 15 20.5
Middle 32 43.8
High 26 35.6
Total 73 100
The mean and standard deviation of SCSS, BDI and STAI
subdimensions and subcales applied to the participants
are shown in Table 2.
Table 2. Mean and standard deviation of the sub-dimensions of the
scales
Sub Dimensions and Scales Mean STD
Self-confident Approach 2.92 0.671
Submissive Approach 2.30 0.682
Hopelessness 2.25 0.728
Physiological problems 2.21 0.725
State Anxiety 48.45 10.488
Trait Anxiety 52.57 10.005
When the findings of the relationship between stress and
anxiety levels and coping styles of parents, the correlation
test results to determine the relationships between
dependent and independent variables in accordance with
the research problem are shown in Table 3. According to the
findings, the participants’ self-confidence and submissive
approach subscale of SCSS scores were found to be
negatively correlated with a low level (r= -0.340, p=0.003),
self-confident approach scores and hopelessness
dimension of BDI scores were found to be negatively
correlated with moderate level (r=0.541 p= 0.003). There
was also a negative correlation with a low level between
self-confident approach and physiological problem
dimension (r=-0.277 p=0.018), between self-confident
approach and state anxiety scores (r=-0,321 p =0.006) and
between trait anxiety scores (r=-0.410, p = 0.000) (Table 3).
It can be said that the self-confident approach subscale
scores affect the BDI hopelessness dimension by 28.3%
and the remaining part is determined by other factors,
besides the hopelessness of family members with children
diagnosed with ASD will decrease by 54.1% when the selfconfident
approach scores increases one unit (Table 4).
As can be seen in Table 5, the self-confident approach
subscale scores decrease the BDI hopelessness
dimension by -49.9% negative.
Table 6 shows the relationship between the submissive
approach subscale, hopelessness and physiological
problem`s dimensions and state and trait anxiety according
to the findings. There is no statistically significant
relationship between submissive approach subscale and
hopelessness (t=1.568 p=0.122), physiological problems
dimensions (t=0.638 p=0.526), and state and trait anxiety
(t=-0.507 p=0.614; t=1.88 p=0.064 respectively).
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Ann Med Res 2019;26(12):2870-5
Table 4. Findings related to the relationship between self-confident
approach and dependent variables
Model R R2 Corrected R Prediction Std
Error
1 0.541 0.293 0.283 0.56831
Table 5. The Results of the Regression Model of Means of Hopelessness
and Self-Confident Approach
Model 1 Unstandardized Standardized
B Std. error Beta t Sig. (p)
(Constant) 4.048 0.218 -0.541 -18.604 0.001
-0.499 0.092 0.001
Table 3. Correlation findings for the relationship between dependent and independent variables
Self-confident
Approach
Submissive
Approach Hopelessness Physiological
problems State Anxiety Trait Anxiety
Self-confident Approach
1
73
Submissive Approach
-0.340** 1
0.003 73
Hopelessness
-0.541** 0.443** 1
0.001 0.001 73
Physiological problems
-0.277*- 0.312** 0.404** 1
0.018 0.007 0.001 73
State Anxiety
-0.321** 0.363** 0.654** 0.339** 1
0.006 0.002 0.001 0.003 73
Trait Anxiety
-0.410** 0.477** 0.674** 0.488** 0.776** 1
0.001 0.001 0.001 0.001 0.001 73
Table 6. The results of the regression model of dependent variables mean by submissive approach
Unstandardized Coefficients Standardized Coefficients
B Std. error Beta t Sig. (p)
Constant 0.748 0.369 2.025 0.047
Hopelesness 0.218 0.139 0.233 1.568 0.122
Physiological problems 0.074 0.115 0.077 0.638 0.526
State Anxiety -0.104 0.205 -0.088 -0.507 0.614
Trait Anxiety 0.447 0.237 0.350 1.885 0.614
DISCUSSION
In this study, we determined that the parent’s of children
with ASD chose one of the self-confidence approachs
and the submissive approach to cope with stress, and the
average state and trait anxiety was high. In our study, the
anxiety levels of the families are high, as seen in previous
studies showing that parents of children with ASD have
higher levels of stress relative to parents of children with
other types of developmental disabilities (2, 23).
When the literature is systematically examined, it is seen
that the studies about the parents of children with ASD
are focused on parenting stress and quality of life (24).
Bozkurt et al.studied the burden and stress coping styles
of parents of 131 children with ASD by using the “Caregiver
Strain Index” and “Ways of Coping Questionnaire.” In their
study, parents with children with ASD had a high caregiver
burden. In their study, parents of 3-year-olds scores of
the ‘self-confident approach’ and the ‘optimistic approach
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Ann Med Res 2019;26(12):2870-5
were found to be lower than those of other ages and
mothers’ scores of ‘submissive approach’ and the ‘seeking
social support’ were significantly higher as compared
with the fathers, In our study, the self-confident approach
and the submissive approach scores of the families
of children with ASD were above the average (25). The
average of the self-confident approach was higher than
the submissive approach. Family members are looking
for scientific solutions with the emotional acceptance
of child with ASD after showing rejecting attitudes and
behaviors. Considering that the children of the families
participating in our study are receiving special education.
The fact that children with ASD are brought into special
education and that the average of the self-confident
approach scores of the family members are higher than
the submissive approaches seem to be compatible with
each other. Furthermore, it can be said that the number
of female participants is high in our study because of the
fathers are working and therefore the mothers are mostly
interested in the care of the child. These results are in line
with the results of studies showing that mothers have
more difficulties and burn out because they take care of
their children on their own, and seek more social support
(26,27).
In a meta-analysis, Yirmiya and Shaked found that parents
of children with ASD had higher psychiatric symptoms
of depression and anxiety (28). Previous studies have
shown that parents of children with autism have more
mental health problems than parents of children with
other diseases (29,30). When the studies are examined,
it is expected that the parents of children with ASD have
more stress, depression and anxiety (25, 31). In our
study, we found that the state and trait anxiety mean
scores of the family members were above the average.
These results are consistent with previous findings that
depression and anxiety are the strongest determinants
of mothers with low social support (32, 33). It can be
said that the mother’s and father’s concerns about what
kind of future is expected for their children are long-term
and continue with the development of the child. Benson
reported a significant reduction in maternal stress
proliferation and psychological distress regarding change
in maternal adjustment over the 7-year period examined.
In that study the effect of cognitive reframing on distress
(defined as anxiety and depressive mood) was examined.
Nevertheless, detailed studies are needed to understand
psychopathology of parents of children with ASD parents
and how their relationship with coping strategies (34).
CONCLUSION
It was found that the despair of the family members
decreased when they preferred the self-confident coping
approach. The findings may help inform the design of
effective interventions aimed at reducing burden among
the parents of children with ASD.For this reason, it
will be beneficial to provide trainings that can support
the individual development of family members with
children diagnosed with ASD, such as coping with stress,
awareness, decision making techniques.
LIMITATION
This study is limited to a sample of 73 parents of ASD. It is
thought that more meaningful results can be obtained for
the depression and anxiety levels experienced by family
members by increasing the number of participants’ first
and geographical differentiation. All applied scales are
self-report scales. ASD cases were taken from a special
education center avoiding generalization of the results.
The sample size is relatively low. Future studies may be
helpful by including the control group in the studies and
including a larger sample set or study group.
Competing interests: The authors declare that they have no conflict of
interest.
Financial Disclosure: There are no financial supports.
Ethical approval: The study protocol was reviewed and approved by the
non interventional research ethics committee of Üsküdar University.
Gülin Yazkan ORCID: 0000-0003-1649-7237
Melek Gozde Lus ORCID: 0000-0002-0430-9289
Habib Erensoy ORCID: 0000-0002-4278-2739
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Ann Med Res 2019;26(12):2870-5
Aim: The purpose of this research is the determination of depression and anxiety levels and their impact on the style of coping with
stress of parents of children with Autism Spectrum Disorder (ASD).
Material and Methods: Research was conducted with parents of 73 children with ASD, who come to the rehabilitation center.
Personal Information Form, Stress Coping Styles Scale, Beck Depression Inventory and State and Trait Anxiety Scale were used to
the relational screening method.
Results: It was found that the mean state and trait anxiety scores of parents was high and parents chose one of the self-confidence
confidence approach to cope with stress.The self-confident approach alone reduced the despair negatively by -49.9%, but the
submissive approach did not affect variables.
Conclusion: It was found that the despair of the family members decreased when they preferred the self-confident coping approach.
INTRODUCTION
Autism spectrum disorder (ASD) is a developmental
disorder with lack of social and communicative behavior
and the presence of restricted and repetitive patterns
of behaviors, interests, and activities (1). In terms of
family members, ASD is an uncontrollable, unchangeable
condition that may lead to deterioration of emotions, such
as anxiety, depression and stress. Research shows that
parents of children with ASD have higher levels of stress,
and their quality of life is poor (2,3,4). Family members
who care for a child with ASD may feel stressed, anxious
and helpless, and they are at high risk for a condition of
exhaustion, anger, rage, or guilt (5). Increasing evidence
suggests that the parents of the child with ASD have higher
rates of depression and anxiety (6,7). Family members can
try many different methods to cope with the situation that
causes stress (8,9). Methods used by families are mostly
aimed at solving problems, doing things, trying to reduce
or manage their emotions (10,11). It is important in which
situation; coping styles are used and repeated for the
formation of coping attitudes. Cognitive and behavioral
strategies develop as the information about individuals
coping with stress increases. In addition, coping
mechanisms protect parents from depression and other
psychiatric disorders (12,13). The sociodemographic
characteristics of the family, age and gender of the child,
and behaviors related to ASD affect the well-being and
coping of parents of children with ASD (2). Determining
the approaches of family members and examining the
factors that affect their attitudes and behaviors are also
important to become socialized for individuals with ASD
and also important for their special education. As known,
it is important to support families to be mentally healthy
and It is possible to increase the quality of life of parents
with effective mental health support systems (14). In their
study, Da Paz et al. investigated the relationship between
2870
Ann Med Res 2019;26(12):2870-5
maternal adaptation and distress measures in mothers of
children with autism (15). At the beginning of the study,
high acceptance rates of the mother were associated with
less psychological stress, especially less depression and
perceived stress. Increased acceptance over time has
also been associated with decreases in the symptom
of depression during the same period. Coping with the
negative situation of families of children diagnosed with
ASD affects their levels of depression and anxiety and
thus their physical and emotional well-being. In this study,
based on the previous research, we planned to reveal the
relationships between the coping styles and levels of
depression and anxiety of family members. In the light
of other studies, our hypothesis is that, coping with the
negative situation of families with children diagnosed
with ASD leads to higher levels of depression and anxiety.
We considered that there was a significant relationship
between the coping styles and depression levels, state
and trait anxiety levels of the family members of children
with ASD.
MATERIAL and METHODS
Participants
The sample for this pilot study consisted of 73 children
previously diagnosed with ASD and their family members
was drawn from a special education center located in
Istanbul that provides services to children with ASD.
At the beginning of the study, 80 children who were in a
special education program in a special education center
were randomly selected. Three of these children were
excluded from the study because of chronic medical
illness (epilepsy) and 4 of them due to other psychiatric
illness (ADHD). A history of chronic medical illness was
obtained from the family.
A total of 73 participants were included.The children and
their families who agreed to participate in the study. The
parents were informed about the purpose of the study
and informed consent was obtained from all parents
before the examination. Children with chronic diseases
(e.g., diabetes, cardiovascular, autoimmune, history of
stroke, brain injury, cancer, endocrine disorders) were
excluded.Parents meeting criteria for another psychiatric
disorder including psychosis and bipolar disorder, alcohol
or substance use disorder, current posttraumatic stress,
bipolar, or eating disorders were also excluded. 73 children
with ASD had not been diagnosed with ASD in different
Child and Adolescent Psychiatry Clinics in Istanbul by
other child and adolescent psychiatrist and they were in
special education program.
Diagnosis verification of ASD was based on the interviews
with parents and detailed developmental anamnesis
according to DSM 5 criteria by a child and adolescent
psychiatrist in our study. In the research, Personal
Information Form, Stress Coping Styles Scale (SCSS),
Beck Depression Inventory (BDI) and State and Trait
Anxiety Scale (STAI) were used with a relational screening
method. The scales were filled by the researchers as
a result of clinical interview with the children and their
family.
The results were evaluated by psychiatrist, child
psychiatrist and psychologist. The study protocol was
reviewed and approved by the non interventional research
ethics committee of Üsküdar University.
Instruments of data collection
Personal Information Questionnaire: The Personal
Information Questionnaire Form prepared by the
researchers is an interview form which includes the gender,
age, level of education, economic status of participants
and gender and age of children with ASD.
Stress Coping Styles Scale (SCSS) was developed by
Folkman and Lazarus to measure the stress levels of
individuals in the face of events and to investigate the
ways of coping with stress (16). SCSS is 4-point Likerttype
scale of the stress situation of individuals. In this
study, a 30-item short form of SCSS, which the reliability
and validity study of the Turkish version was done by
Şahin and Durak, was used (17).
Beck Depression Inventory (BDI): Beck Depression
Inventory (BDI) is one of the most used scales in the
world to measure the depression level of individuals. The
scale was developed by Beck and consists of 21 items
aimed at measuring the emotional, somatic, cognitive
and motivational causes of depression (18). Each item
determining a behavioral feature regarding depression
under the scale is assigned a score between 0 (never) to 3
(frequently) and as a result the person receives a score of
0-63 and high scores demonstrate increase in depression
symptoms. The validity and reliability study of the scale
was conducted by Hisli and Tegin (19,20). In the validity
and reliability analysis of the scale adaptations validity
were found to be 0.650 to 0.680 coefficient of 0.740.
Each item determining a behavioral feature regarding
depression under the scale is assigned a score between
0 (never) to 3 (frequently) and as a result the person
receives a score of 0-63 and high scores demonstrate
an increase in depression symptoms. The validity and
reliability study of the scale was conducted by Hisli and
Tegin (19,20). In the validity and reliability analysis of the
scale adaptations validity was found to be 0.650 to 0.680
coefficients of 0.740]
A high total score indicates a high level of depression or
severity.
State and Trait Anxiety Scale (STAI): State and Trait
Anxiety Scale (STAI) was developed by Spielberg et al. to
measure continuous and state anxiety levels of normal
and abnormal individuals and was adapted into Turkish
by Öner and Le Compte (21,22). The STAI has 40 items,
20 items allocated to each of the state anxiety and the
trait anxiety subscales. The total score obtained from
both scales ranges from 20 to 80. A high score indicates
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Ann Med Res 2019;26(12):2870-5
a high level of anxiety and a small score indicates a low
level of anxiety. The average score level determined in
the applications ranged from 36 to 41. In reliability and
validity analyzes, the reliability coefficient was found to be
between 0.830 and 0.870 for the Trait Anxiety Scale and
between 0.940 and 0.960 for the State Anxiety Scale. Their
reliability ranged from 0.710 to 0.860 for the Trait Anxiety
Scale and 0.260 to 0.680 for the State Anxiety Scale.
Analysis of the data: The collected data were entered into
a worksheet and analyzed by SPSS-19 statistical software
(IBM Corporation, USA).Categorical variables were
analyzed using chi square tests and data were expressed
as frequency of observed and expected. All numerical
variables were initially tested for normal distribution
using Kolmogrov–Smirnov test. Variables with normal
distribution were then compared with paired t-tests and
those without a normal distribution were analyzed with
an equivalent non-parametric Wilcoxon Sum Ranks.In the
interpretation of the results, p <0.05 significance level was
taken into consideration.
RESULTS
The frequency and percentage distributions of the
sociodemographic information of 73 participants that are
the sample of the study are presented in Table 1.
Table 1. Demographic Characteristics of Participants
Frequency Percentage (%)
Age of parents
25-35 Years 31 42.5
36-45 Years 29 39.7
46 Years and over 13 17.8
Gender of parents
Total 73 100
Female 57 78.1
Male 16 21.9
Gender of children
Total 73 100
Female 19 26
Male 54 74
Age of children
Total 73 100
Under 3 Years 26 35.6
3-4 Years 16 21.9
4-5 Years 6 8.2
5-6 Years 10 13.7
6 Years and over 15 20.5
Level of Education
(Parents)
Total 73 100
Secondary School 10 13.7
High School 19 26
Undergraduate 19 26
Graduate 8 11
Socioeconomic
Level of Parents
Total 73 100
Low 15 20.5
Middle 32 43.8
High 26 35.6
Total 73 100
The mean and standard deviation of SCSS, BDI and STAI
subdimensions and subcales applied to the participants
are shown in Table 2.
Table 2. Mean and standard deviation of the sub-dimensions of the
scales
Sub Dimensions and Scales Mean STD
Self-confident Approach 2.92 0.671
Submissive Approach 2.30 0.682
Hopelessness 2.25 0.728
Physiological problems 2.21 0.725
State Anxiety 48.45 10.488
Trait Anxiety 52.57 10.005
When the findings of the relationship between stress and
anxiety levels and coping styles of parents, the correlation
test results to determine the relationships between
dependent and independent variables in accordance with
the research problem are shown in Table 3. According to the
findings, the participants’ self-confidence and submissive
approach subscale of SCSS scores were found to be
negatively correlated with a low level (r= -0.340, p=0.003),
self-confident approach scores and hopelessness
dimension of BDI scores were found to be negatively
correlated with moderate level (r=0.541 p= 0.003). There
was also a negative correlation with a low level between
self-confident approach and physiological problem
dimension (r=-0.277 p=0.018), between self-confident
approach and state anxiety scores (r=-0,321 p =0.006) and
between trait anxiety scores (r=-0.410, p = 0.000) (Table 3).
It can be said that the self-confident approach subscale
scores affect the BDI hopelessness dimension by 28.3%
and the remaining part is determined by other factors,
besides the hopelessness of family members with children
diagnosed with ASD will decrease by 54.1% when the selfconfident
approach scores increases one unit (Table 4).
As can be seen in Table 5, the self-confident approach
subscale scores decrease the BDI hopelessness
dimension by -49.9% negative.
Table 6 shows the relationship between the submissive
approach subscale, hopelessness and physiological
problem`s dimensions and state and trait anxiety according
to the findings. There is no statistically significant
relationship between submissive approach subscale and
hopelessness (t=1.568 p=0.122), physiological problems
dimensions (t=0.638 p=0.526), and state and trait anxiety
(t=-0.507 p=0.614; t=1.88 p=0.064 respectively).
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Ann Med Res 2019;26(12):2870-5
Table 4. Findings related to the relationship between self-confident
approach and dependent variables
Model R R2 Corrected R Prediction Std
Error
1 0.541 0.293 0.283 0.56831
Table 5. The Results of the Regression Model of Means of Hopelessness
and Self-Confident Approach
Model 1 Unstandardized Standardized
B Std. error Beta t Sig. (p)
(Constant) 4.048 0.218 -0.541 -18.604 0.001
-0.499 0.092 0.001
Table 3. Correlation findings for the relationship between dependent and independent variables
Self-confident
Approach
Submissive
Approach Hopelessness Physiological
problems State Anxiety Trait Anxiety
Self-confident Approach
1
73
Submissive Approach
-0.340** 1
0.003 73
Hopelessness
-0.541** 0.443** 1
0.001 0.001 73
Physiological problems
-0.277*- 0.312** 0.404** 1
0.018 0.007 0.001 73
State Anxiety
-0.321** 0.363** 0.654** 0.339** 1
0.006 0.002 0.001 0.003 73
Trait Anxiety
-0.410** 0.477** 0.674** 0.488** 0.776** 1
0.001 0.001 0.001 0.001 0.001 73
Table 6. The results of the regression model of dependent variables mean by submissive approach
Unstandardized Coefficients Standardized Coefficients
B Std. error Beta t Sig. (p)
Constant 0.748 0.369 2.025 0.047
Hopelesness 0.218 0.139 0.233 1.568 0.122
Physiological problems 0.074 0.115 0.077 0.638 0.526
State Anxiety -0.104 0.205 -0.088 -0.507 0.614
Trait Anxiety 0.447 0.237 0.350 1.885 0.614
DISCUSSION
In this study, we determined that the parent’s of children
with ASD chose one of the self-confidence approachs
and the submissive approach to cope with stress, and the
average state and trait anxiety was high. In our study, the
anxiety levels of the families are high, as seen in previous
studies showing that parents of children with ASD have
higher levels of stress relative to parents of children with
other types of developmental disabilities (2, 23).
When the literature is systematically examined, it is seen
that the studies about the parents of children with ASD
are focused on parenting stress and quality of life (24).
Bozkurt et al.studied the burden and stress coping styles
of parents of 131 children with ASD by using the “Caregiver
Strain Index” and “Ways of Coping Questionnaire.” In their
study, parents with children with ASD had a high caregiver
burden. In their study, parents of 3-year-olds scores of
the ‘self-confident approach’ and the ‘optimistic approach
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Ann Med Res 2019;26(12):2870-5
were found to be lower than those of other ages and
mothers’ scores of ‘submissive approach’ and the ‘seeking
social support’ were significantly higher as compared
with the fathers, In our study, the self-confident approach
and the submissive approach scores of the families
of children with ASD were above the average (25). The
average of the self-confident approach was higher than
the submissive approach. Family members are looking
for scientific solutions with the emotional acceptance
of child with ASD after showing rejecting attitudes and
behaviors. Considering that the children of the families
participating in our study are receiving special education.
The fact that children with ASD are brought into special
education and that the average of the self-confident
approach scores of the family members are higher than
the submissive approaches seem to be compatible with
each other. Furthermore, it can be said that the number
of female participants is high in our study because of the
fathers are working and therefore the mothers are mostly
interested in the care of the child. These results are in line
with the results of studies showing that mothers have
more difficulties and burn out because they take care of
their children on their own, and seek more social support
(26,27).
In a meta-analysis, Yirmiya and Shaked found that parents
of children with ASD had higher psychiatric symptoms
of depression and anxiety (28). Previous studies have
shown that parents of children with autism have more
mental health problems than parents of children with
other diseases (29,30). When the studies are examined,
it is expected that the parents of children with ASD have
more stress, depression and anxiety (25, 31). In our
study, we found that the state and trait anxiety mean
scores of the family members were above the average.
These results are consistent with previous findings that
depression and anxiety are the strongest determinants
of mothers with low social support (32, 33). It can be
said that the mother’s and father’s concerns about what
kind of future is expected for their children are long-term
and continue with the development of the child. Benson
reported a significant reduction in maternal stress
proliferation and psychological distress regarding change
in maternal adjustment over the 7-year period examined.
In that study the effect of cognitive reframing on distress
(defined as anxiety and depressive mood) was examined.
Nevertheless, detailed studies are needed to understand
psychopathology of parents of children with ASD parents
and how their relationship with coping strategies (34).
CONCLUSION
It was found that the despair of the family members
decreased when they preferred the self-confident coping
approach. The findings may help inform the design of
effective interventions aimed at reducing burden among
the parents of children with ASD.For this reason, it
will be beneficial to provide trainings that can support
the individual development of family members with
children diagnosed with ASD, such as coping with stress,
awareness, decision making techniques.
LIMITATION
This study is limited to a sample of 73 parents of ASD. It is
thought that more meaningful results can be obtained for
the depression and anxiety levels experienced by family
members by increasing the number of participants’ first
and geographical differentiation. All applied scales are
self-report scales. ASD cases were taken from a special
education center avoiding generalization of the results.
The sample size is relatively low. Future studies may be
helpful by including the control group in the studies and
including a larger sample set or study group.
Competing interests: The authors declare that they have no conflict of
interest.
Financial Disclosure: There are no financial supports.
Ethical approval: The study protocol was reviewed and approved by the
non interventional research ethics committee of Üsküdar University.
Gülin Yazkan ORCID: 0000-0003-1649-7237
Melek Gozde Lus ORCID: 0000-0002-0430-9289
Habib Erensoy ORCID: 0000-0002-4278-2739
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Ann Med Res 2019;26(12):2870-5
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