http://informahealthcare.com/pdr ISSN: 1751-8423 (print), 1751-8431 (electronic) Dev Neurorehabil, Early Online: 1–8 ! 2014 Informa UK Ltd. DOI: 10.3109/17518423.2014.925519

ORIGINAL PAPER

Risk and protective factors for symptoms of anxiety and depression in parents of children with autism spectrum disorder Samuel Bezerra Machado Junior1, Meline Ivone Oliveira Celestino1, Juliane Penalva Costa Serra1, Jean Caron2, & Milena Pereira Ponde´1 1

Interdisciplinary Research Laboratory on Autism (LABIRINTO), BAHIANA School of Medicine and Public Health, Salvador, Bahia, Brazil, and Douglas Mental Health Institute, McGill University, Montreal, Quebec, Canada

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Abstract

Keywords

Objective: The severity of symptoms of anxiety and depression was evaluated in 102 parents of children with autism spectrum disorders (ASD) and correlated with the severity of their child’s behavioral symptoms. Design: An observational, cross-sectional study. Methods: The Portuguese versions of the Hospital Anxiety and Depression Scale and the Aberrant Behavior Checklist were used to assess symptoms in the parents and in their children. Main outcomes and results: Depression was present in 26.7% of parents and anxiety in 33.7%. Severe behavioral symptoms in the child increased the likelihood of severe anxiety and depression symptoms in the parents by a factor of 35. If the child had severe behavioral symptoms and the father lived in the family home, the likelihood of severe symptoms of anxiety and depression in the parents was 95.2% lower. Conclusion: The presence of the father living in the family home acted as a buffer against parents’ symptoms.

Anxiety, autism, depression, parents

Introduction Autism spectrum disorders (ASD) are a genetically and phenotypically heterogeneous group of neurodevelopmental disorders that involve persistent deficits in social communication and social interaction across multiple contexts, and restricted, repetitive patterns of behavior, interests or activities [1]. Their severity is based on impairments in social communication and on restricted, repetitive patterns of behavior. Symptoms must be present in the early developmental period, but may not fully manifest themselves until social demands exceed limited capacities, or symptoms may be masked by strategies learned later in life [2]. Early symptoms begin to be noted from the first months of life and impact the child’s development [3, 4]. On one hand, adjustment disorder symptoms such as anxiety and depression are associated with biological and environmental factors [5]. Environmental events or experiences that are positively associated with fewer emotional symptoms are referred to as protective factors. On the other hand, risk factors are those associated with the presence of more emotional symptoms [6]. Therefore, the protective factors promote an improvement in mental health (fewer emotional symptoms), whereas the risk factors cause mental health to deteriorate (more emotional symptoms) [7].

Correspondence: Milena Pereira Ponde´, Av. D. Joa˜o VI, 275, Brotas, 40290-000 Salvador, Bahia, Brazil. Tel: 55 71 32768200. Fax: 55 71 32768200. E-mail: [email protected]

History Received 26 December 2013 Revised 11 May 2014 Accepted 13 May 2014 Published online 19 June 2014

Studies conducted in different cultural contexts indicate a greater prevalence of symptoms of anxiety and depression in the parents of children with autism spectrum disorders compared with the parents of children with typical development or the parents of children with Down syndrome. In a study conducted in the United States using a semi-structured, investigator-based version of the Schedule for Affective Disorders and Schizophrenia – Lifetime Version, Piven et al. [8] found that the lifetime prevalence rate of anxiety disorder was significantly greater in parents of children with autism compared with the parents of children with Down syndrome. In Saudi Arabia, Almansour et al. [9] compared the parents of children diagnosed with ASD and the parents of a child with typical development using the Hospital Anxiety and Depression Scale (HADS). Both the mean depression score and the mean anxiety score were significantly higher in the parents of children with ASD [9]. In China, Ou et al. [10] evaluated the mental health of the parents of children with autism and the parents of healthy children using the Symptom Checklist-90 (SCL-90). The SCL-90 scores for depression and anxiety were significantly higher in the parents of children compared with those of the parents of healthy children. Some studies have been conducted to understand why the parents of children with ASD are more likely to suffer from stress. Some authors have suggested that emotional and behavioral problems in children with ASD are the aspects that most contribute towards parental stress [11–13]. Herring et al. [11] conducted a study in which parents

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completed a checklist on child behavioral and emotional problems, and also individual questionnaires on family functioning, their own mental health and stress in relation to parenting their child. This study compared behavioral and emotional problems in young children with ASD with those of children with delayed development but without ASD. Emotional and behavioral problems in the child contributed significantly more to stress in the mother, to mental health problems in both parents, and to perceived family dysfunction than the child’s diagnosis (ASD/non-ASD). Estes et al. [12] used parent self-reports of parenting-related stress and psychological distress. These investigators showed that the parents of toddlers with ASD experienced greater parentingrelated stress compared with the parents of toddlers with a developmental delay or typical development. However, there was no significant difference in psychological distress between the groups. Child behavior problems, but not daily living skills, emerged as a significant predictor of parentingrelated stress and psychological distress. This was true both for the mothers of children with ASD and for the mothers of children with a developmental delay. In the study conducted by Firth and Dryer [13], parents completed selfreport questionnaires on measurements of anxiety, depression, stress, and parenting-specific stress, as well as rating scales on the characteristics of their child’s ASD. According to that study, the child’s behavioral and emotional impairments predicted the parents’ overall levels of distress (i.e., stress/tension, anxiety and depression), but not the stress associated with parenting. Although the studies indicate that parents’ stress and symptoms of anxiety and depression correlate with behavioral symptoms in the children, the authors did not compare groups of children with ASD whose behavioral symptoms differed in intensity. Thus, it was impossible to conclude whether more severe behavioral symptoms in the children are more strongly associated with emotional symptoms in their parents. The objective of the present study was to evaluate whether the parents of children with autism with more severe behavioral symptoms are more likely to have symptoms of anxiety and depression than the parents of children with autism and less severe behavioral symptoms. If there are aspects that aggravate the risk of anxiety and depression in the parents of children with autism, there are factors that reduce this risk and that may buffer the effect of stressors. Some studies have attempted to identify factors associated with a reduction in stress in the parents of children with developmental problems. Feelings of selfefficacy were shown to mediate the effect of the child’s behavior on the mother’s symptoms of both depression and anxiety, and on the father’s symptoms of anxiety [14]. For mothers of children with developmental problems, social support proved to be a predictor of better adaptation [15]. In contrast, Shu et al. [16] found that symptoms of psychological disorders decreased in the mothers of children with developmental problems as a function of the mother’s education level, i.e., the higher her education level, the fewer the symptoms. The aforementioned studies indicate that a feeling of self-efficacy, the presence of social support, and a higher education level may constitute protective factors for the emotional health of the parents of children

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with autism. Specifically, a feeling of self-efficacy may buffer the effect of behavioral symptoms in the child in relation to symptoms of anxiety in the parents and depression in the mothers. Those studies show the importance of trying to identify individual factors that may help the parents of children with autism and behavioral disorders reduce their symptoms of anxiety and depression. By seeking to identify factors that may strengthen parents’ mental health, this study also aimed to investigate individual or environmental factors that could contribute to reducing the symptoms of anxiety and depression in the parents of children with autism. On the other hand, evidence suggests that the parents’ behavior may affect the prognosis of autism from the child’s early years until adulthood [17–21]. Parental mental disorders may have a major impact both on the family dynamics and on the behavior of the child with autism [22]. Accordingly, studies have suggested that maternal stress is associated with behavioral problems in the child [23, 24], while mood changes in the mother are also associated with problems of a behavioral nature and internalization in the children [23]. Therefore, identifying emotional symptoms in the parents is important, not only for improving their own health, but also because these symptoms may affect the prognosis of children with autism. Considering that an association may exist between behavioral disorders in children with ASD and greater anxiety and depression symptoms in their parents, the design of the present study included three objectives. (1) The first was to estimate the prevalence of symptoms of anxiety and depression in the parents of children with a diagnosis of ASD. (2) Second, the study aimed to correlate the severity of the parents’ symptoms with the severity of their child’s behavioral symptoms, as perceived by the parents. (3) And finally, this study sought to identify factors that could affect this correlation so as to increase or to reduce the likelihood of symptoms of anxiety and depression in the parents of children with ASD.

Methods Sample This was an observational, cross-sectional study of children attending a specialist school for children with autism in Bahia, Brazil. This school is a not-for-profit, non-governmental organization (Public Interest Civil Society Organization) providing specialist, individualized education free of charge for children with a diagnosis of autism or another ASD. The target population consisted of the parents of the 130 children currently enrolled in the specialist school. Of those, 110 were selected for the study because the children already had a confirmed diagnosis of ASD, while 20 were excluded because they did not have a formal psychiatric diagnosis. Of the 110 parents initially selected, four were excluded because they failed to complete the evaluation tools adequately (as a result of their poor schooling, they were unable to comprehend the questions in the questionnaires). Since the study objectives concerned the children’s parents specifically, four guardians were excluded because they were the children’s grandparents.

DOI: 10.3109/17518423.2014.925519

Therefore, the final sample consisted of 102 parents: 84 mothers and 18 fathers.

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Participants The majority of the 102 parents evaluated were mothers (n ¼ 84; 82.4%), while 17.6% (n ¼ 18) were fathers. The mothers ranged in age from 26 to 56 years, with a mean age of 40 years (SD 6.4). The fathers were 29–62 years of age, with a mean of 43.3 years (SD 7.5). With respect to schooling, 1% of the mothers had only primary school education, while 72% had completed high school and 27% were college educated. Of the fathers, 1.1% had only primary school education, while 98.9% had completed high school. All the children lived with their mothers and in 71.6% of cases the father was also living in the family home. In 21.6% of cases, at least one sibling also lived with the family, and in 2% of cases, the sibling also had ASD. In addition, 31.1% of those interviewed stated that someone else also lived with the family. Most of the children were boys (n ¼ 86; 84.3), with only 15.7% (n ¼ 16) being girls. The age of the children ranged from 3 to 21 years, with a mean of 10.3 years (SD 5.3). Overall, 65.7% of the mothers had experienced complications during pregnancy and 24.5% had suffered complications during childbirth. Around 10% of the mothers admitted consuming alcohol or drugs during pregnancy and around 5% reported having taken some form of medication to try to provoke an abortion. With respect to the children’s health, 20.6% had another concomitant health problem including epilepsy, asthma, rhinitis, sinusitis, a food allergy, an intestinal parasite infection, and/or blindness. Overall, 36.4% had required hospitalization in the past, 24.5% had required surgery in the past, 7.8% had suffered at least one accident, 41.2% had been prescribed some form of psychopharmacological medication, and 85.3% were undergoing some form of treatment. The different therapies consisted of regular school, physiotherapy, occupational therapy, equine therapy, and treatment with a psychologist and/or an educational psychologist, in addition to attending this specialist school. Evaluation instruments Previously trained medical students collected the data confidentially at the school between August 2011 and April 2012. As the study population consisted of individuals with little schooling, the interviewers asked each individual question verbally and wrote down the responses. The interviews were conducted in a private room at the school. Each interview lasted on average 45 min. The instruments applied to the parents included a sociodemographic form, the Portuguese version of the Hospital Anxiety and Depression Scale (HADS) [25], which was used to assess symptoms in the parents, and the Portuguese version of the Aberrant Behavior Checklist (ABC) [26], which was used to assess the severity of the children’s behavioral symptoms. In all cases, the children had a previous psychiatric diagnosis of ASD according to the DSM-IV. Data collected at the sociodemographic interview included the age of the parents and child; parents’ schooling, religion, and profession; the number of people living in the home and

Parents’ anxiety and depression & autism symptoms in children

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who they were, whether the father was living in the family home; what therapeutic resources the parents and/or children had received since diagnosis; and the medical histories of both child and parent. The HADS consists of 14 items, 7 of which are used to evaluate anxiety (HADS-A) and 7 to evaluate depression (HADS-D). Each item receives a score that ranges from 0 to 3, resulting in a maximum overall score of 21 points for each subscale and 42 for the entire scale. The alpha coefficient of internal consistency was reported to be 0.68 for the anxiety subscale and 0.77 for the depression subscale [27]. The HADS has been translated into Portuguese and validated for use in this language, with sensitivity and specificity of 93.7% and 72.6%, respectively, for anxiety and 84.6% and 90.3%, respectively, for depression [25]. To evaluate the frequency of anxiety and depression, the cut-off points recommended for both subscales were applied, with scores of 0–8 indicating no anxiety or depression and scores 9 indicating the presence of anxiety or depression [25, 27]. The ABC scale is mainly used to evaluate the severity of behavior symptoms [26]. It consists of 58 items divided into five subscales: (I) irritability, agitation, and crying (15 items); (II) lethargy, social withdrawal (16 items); (III) stereotypic behavior (7 items); (IV) hyperactivity (16 items); and (V) inappropriate speech (4 items). Each item receives a score that ranges from 0 to 3, resulting in a maximum overall score of 174 points. The ABC was translated into Portuguese and cross-culturally adapted for use in Brazil. It was chosen not only because the translation had been adapted for populations comparable with that of the present sample but also because the majority of the participating children had some form of cognitive deficit. Statistical analysis Prevalence rates of depression and anxiety symptoms in the parents were estimated based on a cut-off point of 8 for both subscales. The variable ‘symptoms of anxiety and depression’ was then dichotomized into mild and severe, symptoms being considered severe when above the 80th percentile in the distribution of scores. Therefore, parents with a score 20 were considered to have severe symptoms and those scoring 520 were considered to have mild symptoms. Based on the ABC score that ranged from 0 to 174 points (the higher the score, the more severe the symptoms), the children’s symptoms were dichotomized into mild or severe. In accordance with the established cut-off point, symptoms were considered severe if they were above the 80th percentile in the distribution of scores; hence, behavioral symptoms were considered severe when children scored 89 points. The co-variables were distributed in accordance with the effect variable to check for differences between the group of parents with mild symptoms of anxiety and depression and those with severe symptoms. Significance was determined using the Pearson chi-square test and Fisher’s exact test [28]. Crude measures of effect were calculated for

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the association between severe behavioral symptoms in the children and severe symptoms of anxiety and depression in the parents, and to verify the measure of association for the different strata of each co-variable. The crude effect estimate was the prevalence ratio (PR). The 95% confidence intervals (95% CI) were calculated both to estimate precision and for statistical inference. Stratified analysis was used to calculate the presence of an interaction. An interaction was considered to be present when the prevalence ratio for the association between the predictor variable and the effect of one of the strata was not contained within the confidence interval of the other and vice-versa [29]. Logistic regression was used to identify variables associated with the ABC using a backward deletion procedure [30]. First, all the variables associated with symptoms of anxiety and depression at a significance level of 0.10 were entered into the analysis [31]. Interactions identified with the stratified analysis were also entered into the logistic regression model. After completion of the first regression analysis, the next step was to remove the variables that failed to reach a significance level of 0.10 until all the variables in the model were found to be statistically significant at 0.05 or a tendency was established at 50.10. Correlations between predictors and criterion variables were assessed using the phi-coefficient for dichotomous variables [32]. A post-hoc power analysis [33] was conducted to ensure that the size of the sample in this study had sufficient power to detect effects with desirable effect sizes. Given the sample size (102), the power of the sample is sufficient (80%) to detect significant p50.05 effects with odds ratios 3.4. Parameters for calculating the power were obtained from a previous study in which the prevalence of depression was estimated as 36% and the prevalence of anxiety as 46% in the parents of children with autism [16]. Ethical and legal aspects The internal review board of the Bahia Foundation for the Development of Science (Fundac¸a˜o Bahiana para o Desenvolvimento das Cieˆncias) approved the protocol (reference # 008/2008). All the participating parents signed an informed consent form.

Results Prevalence of symptoms of anxiety and depression in the parents The mean HADS score for the parents was 13.05 points. Considering a cut-off point of 8 for both subscales, 42 individuals (41.2%) showed some signs of having a psychiatric disorder: 27 (26.7%) of depression, 34 (33.7%) of anxiety, and 20 (18.9%) of both. There was no statistically significant difference between the mothers and the fathers with respect to the prevalence of symptoms of anxiety and depression. According to the ABC scale, the mean score for the children’s behavioral symptoms was 59.8, with 81 children (79.4% of the sample) scoring 89 points, the score

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established as the cut-off point separating mild from severe symptoms. Accordingly, 21 children (20.6%) were considered to have severe behavioral symptoms, with scores of 490 points. The correlation between the severity of the parents’ symptoms and the severity of their child’s behavioral symptoms Table I lists the characteristics of the study population in accordance with the intensity of the parents’ symptoms of anxiety and depression. The severity of symptoms in the parents was not associated with their gender, schooling, or religious practice, or with the child’s age, previous hospitalization or the presence of other siblings at household. Severe anxiety/depression symptoms were significantly more common in parents whose children had severe behavioral symptoms compared with the parents of children with mild symptoms (43% vs. 16%). Symptoms of severe anxiety and depression were also significantly more common in the parents of children with comorbidities (38.1%) compared with the parents of children with ASD alone (17.3%). There was an inverse association between parent’s age and anxiety/ depression scores, with scores being higher in the group of mothers 30 years of age. Of these, 57.1% had severe anxiety/depression symptoms compared with 16% in the 30–45 year age group and 30% in the 445-year age group (p50.01). In both mothers and fathers, there was a positive association between a history of psychiatric problems and severe anxiety/depression symptoms. Of the mothers with a history of psychiatric problems, 45.5% had severe symptoms of anxiety/depression compared with only 17.8% of the mothers who had no history of psychiatric problems. A similar situation was found for the fathers: 57.1% of the fathers with a history of psychiatric problems had severe anxiety/depression symptoms compared with 18.3% of those with no history of psychiatric problems. Severe symptoms of anxiety and depression were found in 17.2% of the parents of children undergoing some form of treatment compared with 42.9% of the parents whose children were not undergoing treatment. Non-significant trends were identified with respect to the gender of the child and the mother’s use of substances during pregnancy. Severe anxiety/depression symptoms were found in 37.5% of the parents of girls compared with 18.6% of the parents of boys. With respect to whether or not the mother had used substances during pregnancy, 23.1% of the mothers who had not used substances during pregnancy had severe symptoms of anxiety/depression, whereas none of the mothers who had used substances during pregnancy had severe anxiety/depression symptoms. With a prevalence ratio of 4.2 and a 95% confidence interval of 1.4–11.8, stratified analysis indicated a threefold greater chance of more severe symptoms of anxiety/ depression in the parents of children with more severe behavioral symptoms. Of the variables analyzed as being possible effect modifiers of this association, the presence of the father living in the family home appeared as a possible factor of interaction in the stratified bivariate analysis. Therefore, the presence of the father living in the family

Parents’ anxiety and depression & autism symptoms in children

DOI: 10.3109/17518423.2014.925519

Table I. Distribution of the population according to the severity of symptoms of anxiety and depression in parents of children with autism spectrum disorders. Symptoms of anxiety and depression

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n ¼ 102

Severe symptoms

Mild symptoms

N

%

N

%

2

21.4 22.2

66 14

78.6 77.6

60

0 19.4 25.9

1 58 20

100 80.6 74.1

77

0 18.7

1 74

100 81.3

73

16 42.9

68 12

84 57.1

7.09*

20.3 25.9

47 20

79.7 74.1

57.1 16 30

3 63 14

42.9 84 70

7.45*

23.2 19.6

43 37

76.8 80.4

20

38.1 17.3

13 67

61.9 82.7

4.27

18.6 37.5

70 10

81.4 62.5

2.85#

25.9 15.9

43 37

74.1 84.1

1.47

24.6 16.2

49 31

75.4 82.8

98

0 23.1

10 70

100 76.9

2.91#

45.5 17.8

6 74

54.5 82.7

4.56*

57.1 18.3

3 76

42.9 81.7

5.93

17.2 42.9

72 8

82.8 57.1

4.81*

Gender of caregiver Female 84 18 Male 18 4 Mother’s education level Only primary school 1 0 High school 72 14 College 27 7 Father’s education level Only primary school 1 0 High school 91 17 ABC* score Mild symptoms 81 13 Severe symptoms 21 9 Mother’s attitude towards religion Religious 59 12 Not religious 27 7 Age* 30 years 7 4 30–45 years 75 12 445 years 20 96 Another sibling Yes 56 13 No 47 9 Child has comorbidities Yes 21 8 No 81 14 Child’s gender Male 86 16 Female 16 6 Child’s age 12 years 58 15 412 years 44 7 Child has been hospitalized Yes 65 16 No 37 6 Use of substances during pregnancy Yes 10 0 No 91 21 Mother has history of psychiatric problems Yes 11 5 No 90 16 Father has history of psychiatric problems Yes 7 4 No 93 17 Child undergoing treatment Yes 87 15 No 14 6

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symptoms in the child (high ABC score), a history of psychiatric problems in the mother, the child undergoing some form of treatment, the child’s comorbidities, and the child’s gender (Table II). Of these risk factors, severe behavioral symptoms in the child increased the likelihood of severe symptoms of anxiety/depression in the parents by a factor of 35, while a history of psychiatric problems in the mother increased the likelihood by a factor of 9.2, and comorbidities in the child increased the likelihood by a factor of 4.7. Protective factors included the child being male, which reduced the likelihood of severe anxiety/depression symptoms in the parents by 77.7%, and the child undergoing some form of treatment, which reduced the likelihood by 64%. The presence of the father living in the family home did not appear to have any direct effect on anxiety/depression scores in the parents (Table II); nevertheless, logistic regression confirmed an interaction between this variable and severe behavioral symptoms in the children. If the child had a high ABC score (severe behavioral symptoms) and the father was living in the family home, there was a 95.2% lesser likelihood of severe symptoms of anxiety/depression in the parents (Table II). Logistic regression analysis confirmed that the presence of the father living in the family home acts as a buffer against the stress of having to care for a child with autism and severe behavioral symptoms. Intercorrelations between predictors identified in the logistic regression analysis and high anxiety and depression scores in the parents are shown in Table III.

Discussion

n is the number of subjects. #p50.10. *p50.05.

home may represent a protective factor against the greater risk of severe symptoms of anxiety/depression in the parents of children with more severe behavioral symptoms. Factors affecting the correlation between the severity of symptoms of anxiety and depression in the parents of children with ASD and the severity of behavioral symptoms in their children In the logistic regression analysis, the variables identified as being significantly associated with severe symptoms of anxiety/depression in the parents were severe behavioral

Prevalence of symptoms of anxiety and depression in the parents According to the results of the present study, there was a prevalence of symptoms of depression in the parents of children with ASD of 26.7%, a prevalence of symptoms of anxiety of 33.7%, and a prevalence of 18.9% for both together. The rates in the general population are around 5% for depression and 4.5% for anxiety disorders [34–36]. The high rate of symptoms found in this study is in agreement with the results of a study conducted with the mothers of children with ASD in Thailand, showing depression in 36% and anxiety in 46%, while 9% had both disorders [16]. The correlation between the severity of the parents’ symptoms and the severity of their child’s behavioral symptoms Severe symptoms of anxiety and depression were significantly more prevalent in the parents of children with severe behavioral symptoms compared with the parents of children whose behavioral symptoms were milder. Severe behavioral symptoms in children were strongly associated with symptoms of anxiety/depression in their parents, with severe symptoms in the child increasing the likelihood of the parents suffering from anxiety/depression by a factor of 35. These findings are in agreement with previous studies suggesting an association between symptoms of anxiety and depression in the parents and behavioral problems in children with

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Table II. Logistic regression analysis to identify the variables associated with high anxiety and depression scores. 95% CI for Exp (B)

High ABC score History of psychiatric problems in the mother Child under treatment Child has comorbidities Child’s gender Father living in the family home High ABC score vs. father living in the family home Constant

A

SE

Wald

Sig.

Exp (B)

Lower

Higher

3.56 2.28 1.02 1.55 1.50 0.63 3.03 1.45

1.25 0.92 0.41 0.75 0.73 0.91 1.54 1.66

8.07 6.12 6.15 4.24 4.25 0.48 3.89 0.76

0.01 0.01 0.01 0.04 0.04 0.49 0.05 0.38

35.10 9.73 0.36 4.70 0.22 1.88 0.05 4.26

3.01 1.61 0.03 1.08 0.05 0.32 0.00

408.69 58.91 0.65 20.52 0.93 11.19 0.98

A is the unstandardized B regression coefficient; SE is the standard error of the regression coefficient; Wald is the chi-square test value; Sig. is the p value of the Wald chi-square test; Exp (B) is the exponential of the regression coefficient, odds ratio.

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Table III. Intercorrelations between predictor and criterion variables.

High anxiety and depression scores High ABC score Mother has history of psychiatric problems Child under treatment Child has comorbidities Child’s gender Father living in the family home

High anxiety and depression scores 1 0.26** 0.21* 0.22* 0.21* 0.17# 0.04

High ABC score

Mother has history of psychiatric problems

Child under treatment

Child has comorbidities

Child’s gender

1 0.15 0.02 0.04 0.15 0.06

1 0.05 0.01 0.15 0.20*

1 0.13 0.06 0.19#

1 0.05 0.00

1 0.03

**p50.01. *p50.05. #p50.10.

neurodevelopmental disorders but not with their diagnosis [13]. These findings are also in agreement with those of Barker et al. [17], who evaluated the parents of adolescents with autism over a 10-year period and found that during times in which the child’s behavioral problems were more severe, the symptoms of depression in the mothers were also more intense. An association was identified between the need to increase the amount of care and attention given to a child with any chronic disease and psychological suffering in the caregivers [37]. Notwithstanding, when the disease is associated with alterations marked by cognitive deficits, behavioral disturbances and/or difficulties with daily living, the effect of the illness is potentiated. A strong association has been found, for example, with states of depression [38]. Factors affecting the correlation between the severity of symptoms of anxiety and depression in the parents of children with ASD and the severity of behavioral symptoms in their children Risk factors for symptoms of anxiety and depression in parents The fact that mothers comprised 82.4% of the sample contributed to a history of psychiatric problems in the mother being the second variable most strongly associated with the parents’ symptoms, increasing the likelihood of severe symptoms in the parents by a factor of 9. Various explanations are possible. On one hand, mothers with a history of psychiatric problems are more susceptible to a recurrence of depression [39] or anxiety disorders [40]

compared with those with no prior history of mental disorder. It is also possible that some of the mothers may still have had symptoms of anxiety or depression when they filled out the questionnaire on their current symptoms. Of those who were in remission, the burden of their child’s severe behavior may also have contributed towards triggering a relapse. Furthermore, comorbidities in the child increased the risk of high anxiety and depression scores in the parents by a factor of 5. This may be explained by the additional burden, increasing stress levels in the parents. Protective factors for symptoms of anxiety and depression in parents Logistic regression analysis also identified the variables that reduced the likelihood of severe symptoms of anxiety and depression in the parents. If the child was a boy, this risk decreased by 77.7%. It is possible that in the particular cultural context of this study, deviant behavior is more acceptable in boys; therefore, when the child with ASD is a girl, the symptoms of anxiety and depression in the parents may be greater. The fact that the child was receiving some form of treatment from the healthcare services reduced this likelihood by 64%. Being under treatment may, on one hand, improve severe behavior in autism and, on the other hand, may provide the parents with a better understanding of their children, since counseling and practical advice on how to deal with the child, in addition to reassurance, may reduce their symptoms of anxiety and depression.

DOI: 10.3109/17518423.2014.925519

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The presence of the father acts as a buffer The presence of the father living in the family home did not appear to be directly associated with anxiety and depression scores in the parents; however, if the child had severe behavioral symptoms and the father lived in the family home, the likelihood of symptoms of anxiety and depression in the parents was 95.2% lower. Since this is a cross-sectional study in which the direction of causality is not determined by the antecedence of one factor in relation to another, this finding could be interpreted in two ways: one, that the presence of the father living in the family home may act as a buffer against the stress of caring for a child with more severe symptoms of autism; and, two, that the child’s severe symptoms may have played a role in the breakup of the family and that the separation may have contributed towards the mother’s symptoms of anxiety and depression. Most of the studies conducted with the families of children with autism were carried out with the mothers [41, 42]. In the present study, the majority of the population also consisted of mothers. It has been suggested that stress may be related to the different responsibilities designated to each caregiver [43, 44]. Barker et al. [17] suggested that symptoms of anxiety in the mothers were more intense when their social support network was weaker and when they had experienced more environmental stressors. Moreover, Essex and Hong [45] considered the marital relationship to be a determining factor in the quality of the parent–child relationship, balancing the mental burden in families with an adolescent or adult with an autism spectrum disorder. Limitations of the study Since this was a cross-sectional study, it is impossible to determine the direction of causality, i.e., it cannot be established whether more severe behavioral symptoms in the children worsen the symptoms of anxiety and depression in the parents or whether parents with more mental symptoms unbalance their children with ASD, aggravating their behavioral symptoms. The actual situation probably consists of a cycle in which deterioration in the child’s symptoms generates an increase in adaptive symptoms of anxiety and depression in the parents, which in turn worsens the child’s behavioral symptoms. Only prospective studies will be able to confirm this hypothesis.

Conclusions and practical implications There is a strong association between the greater severity of behavioral symptoms in children with an ASD and the presence of more intense symptoms of anxiety and depression in the parents, even after adjustment for other risk factors. The comorbidity of autism symptoms with another health issue in the child also increases the probability of more intense symptoms of anxiety and depression in the parents. In contrast if the child is receiving treatment, this reduces the risk of these symptoms in the parents. If the child had severe behavioral symptoms and the father was living in the family home, the likelihood of severe symptoms of anxiety and depression in the parents was lower. Here, the presence of the

Parents’ anxiety and depression & autism symptoms in children

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father living in the family home acted as a buffer. This study shows that it is crucial to look not only for risk factors in the parents of children with autism but also to identify protective factors that may improve the mental health of parents, thus allowing them to care more easily for their child. Future studies should try to evaluate why the presence of the father in the family home acts as a buffer, whether it is because of his financial support, social support, or his help in caring for the child. The results of this study indicate that more attention should be paid to symptoms of anxiety and depression in the parents of children with autism whose behavioral symptoms are more severe, since these parents are more likely to develop these symptoms.

Declaration of interest The authors declare that there are no conflicts of interest associated with this study.

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Risk and protective factors for symptoms of anxiety and depression in parents of children with autism spectrum disorder.

The severity of symptoms of anxiety and depression was evaluated in 102 parents of children with autism spectrum disorders (ASD) and correlated with t...
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