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Journal of Intellectual Disability Research


442

doi: 10.1111/jir.12042

volume 58 part 5 pp 442458 may 2014

Family quality of life and psychological well-being in


parents of children with autism spectrum disorders:
a double ABCX model
P. Pozo, E. Sarri & A. Brioso
Faculty of Psychology, UNED: National University for Distance Education, Madrid, Spain

Abstract
Background This study examined family quality of
life (FQOL) and psychological well-being from a
multidimensional perspective. The proposed model
was based on the double ABCX model, with severity of the disorder, behaviour problems, social
support, sense of coherence (SOC) and coping
strategies as components.
Method One hundred and eighteen parents (59
mothers and 59 fathers) with a child diagnosed with
autism spectrum disorders (ASD) participated in
the study. Separate path analyses were performed to
evaluate models of FQOL and psychological wellbeing for mothers and fathers.
Results In all models, behaviour problems had a
negative indirect effect on adaptation (FQOL and
psychological well-being) through SOC. For both
mothers and fathers, the severity of the disorder
and social support played significant roles in FQOL
models. Coping strategies were related with adaptation, active avoidance coping with FQOL for fathers
and positive and problem-focused coping with psychological well-being for mothers.

Correspondence: Dr Encarnacin Sarri, Faculty of Psychology


UNED, C/ Juan del Rosal, 10, Madrid 28040, Spain (e-mail:
esarria@psi.uned.es).

Conclusions The results of this study highlight the


value of the multidimensional approach. The specific patterns of results for mothers and fathers contribute to comprehension of the psychological
adaptation of parents. Findings could be taken into
account in interventions with families.
Keywords autism spectrum disorders, coping strategies, double ABCX model, family quality of life,
psychological well-being, sense of coherence

Introduction
Parents of children with autism spectrum disorders
(ASD) confront daunting challenges and multiple
demands in their daily life. Compared with parents
of children with other disabilities or to parents of
typically developing children, parents of children
with ASD exhibit higher levels of stress (Belchic
1996; Baker-Ericzn et al. 2005), anxiety
(Konstantareas & Homatidis 1989; Baxter et al.
2000; Hastings 2003; Hastings et al. 2005a) and
depression (Olsson & Hwang 2002; Phetrasuwan
2003; Singer 2006; Feldman et al. 2007).
Characteristics of children with ASD play an
important role in parental adaptation. Several
studies have found that the severity of the disorder
is positively related to parenting stress (Bebko et al.

2013 The Authors. Journal of Intellectual Disability Research 2013 John Wiley & Sons Ltd, MENCAP & IASSIDD

volume 58 part 5 may 2014

Journal of Intellectual Disability Research


443
P. Pozo et al. Family quality of life and psychological well-being

1987; Konstantareas & Homatidis 1989; Szatmari


et al. 1994; Kasari & Sigman 1997; Hastings &
Johnson 2001; Bravo 2006; Pozo et al. 2006; Pozo &
Sarri, in press). However, studies have identified
behaviour problems, such as aggressive and selfinjurious behaviour, as the leading contributor to
parental stress in parents of children with autism
(Donenberg & Baker 1993; Tomanik et al. 2004;
Lecavalier et al. 2006).
Despite having a child with severe intellectual disabilities (ID) and behaviour problems, some families are resilient and adapt well (Gerstein et al.
2009). Characteristics of children are not the only
variables that influence adaptation; other factors
have been demonstrated significantly related to
adaptation processes.
Social support appears to be a protective factor
that alleviates parental stress (Dyson 1997; Sharpley
et al. 1997) and improves personal well-being and
positive attitudes towards the child (Dunst et al.
1986). Coping strategies in response to stress are
related to parental adaptation. Parents who adopt
active avoidance coping strategies report more stress
and mental health problems, whereas those who
adopt positive reframing strategies report less stress
(Dunn et al. 2001; Hastings et al. 2005b). Compared with parents of typically developing children,
parents of children with ASD more frequently
employ escape-avoidance coping strategies (Sivberg
2002; Twoy et al. 2007; Pisula & Kossakowska
2010). The perception of the problem is an important predictor of adaptation in parents of children
with ASD or ID. The strongest predictor of parental
stress is parents negatively defining the situation as
a catastrophe (Bristol 1987; Saloviita et al. 2003).
However, positive factors, such as a strong sense of
coherence (SOC) (Olsson & Hwang 2002; Oelofsen
& Richardson 2006; Mak et al. 2007), appear to
protect the family from stress and reduce the impact
of the disability on the family.
SOC is conceptualised by Antonovsky (1987) as
a global orientation that expresses the extent to
which one has a pervasive, enduring though
dynamic feeling of confidence that: (1) the stimuli
deriving from ones internal and external environments in the course of living are structured, predictable and explicable; (2) the resources are available
to meet the demands posed by these stimuli; and
(3) these demands are challenges worthy of invest-

ment and engagement (p. 19). These three theoretical components are identified as comprehensibility,
manageability and meaningfulness, although SOC is
considered a unitary construct (Antonovsky 1993;
Frenz et al. 1993). SOC is conceived as a personality characteristic or coping style. SOC, as stable
trait, may be adversely affected by a crisis, but over
time it can be reset and restored to its previous
values (Antonovsky 1987). Studies focused on
family resilience across different contexts and disorders found that SOC is positively related to psychological health and well-being (Cohen & Dekel 2000;
Pallant & Lae 2002; Ericksson & Lindstrm 2006).
Regarding the adaptation variables, research on
parental adaptation in families with a child with ID
has generally focused on negative outcomes such as
stress, anxiety and depression. However, in the last
decade, there has been a tendency to also study
positive factors (Dykens 2005) such as positive perception (Hastings & Taunt 2002) or psychological
well-being (Phetrasuwan 2003). Psychological wellbeing, a concept developed by Ryff (1989), is composed of the six domains of self-acceptance, positive
relations, autonomy, environmental mastery,
purpose in life and personal growth. Phetrasuwan
(2003) found that satisfaction with the family and
family support significantly predicted psychological
well-being.
An emerging area of study in the field of developmental and ID is family quality of life (FQOL).
Diverse research groups work to develop theoretical
frameworks and survey instruments (Brown et al.
2003; Poston et al. 2003; Summers et al. 2005;
Isaacs et al. 2007). FQOL is defined as a dynamic
sense of well-being of the family, collectively and
subjectively defined and informed by its members,
in which individual- and family-level needs interact
(Zuna et al. 2010). Although researchers have recognised the need to study FQOL as a positive family
outcome, previous research has primarily focused
on exploring the factor structure of the FQOL construct (Wang et al. 2004; Jokinen & Brown 2005;
Verdugo et al. 2005; Shu 2009). In a study of
parents of children with autism, Bayat (2005) examined how parental perception of the childs disability affected FQOL. The results indicated that family
perception of the positive effects of autism (e.g.
autism made the family closer and stronger) most
strongly predicted FQOL.

2013 The Authors. Journal of Intellectual Disability Research 2013 John Wiley & Sons Ltd, MENCAP & IASSIDD

volume 58 part 5 may 2014

Journal of Intellectual Disability Research


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P. Pozo et al. Family quality of life and psychological well-being

Another issue detected in the review of studies


about the psychological adaptation of families with
children with ASD is that most of these studies
were carried out using partial analysis of variables
that predict adaptation. However, a multidimensional and holistic approach must be adopted to
simultaneously examine the influence of different
factors. The few studies that have adopted this
approach to investigate the adaptation of parents
with children with ASD (Bristol 1987; Jones &
Passey 2005; Pakenham et al. 2005; Pozo et al. 2006;
Siman-Tov & Kaniel 2011; Pozo & Sarri, in press)
or parents of children with ID (Orr et al. 1991;
Saloviita et al. 2003) have analysed stress as the
adaptation variable. Most of these studies have
found that the double ABCX model of stress and
adaptation (McCubbin & Patterson 1983) effectively
predicts adaptation.
The application of the double ABCX model for
the study of psychological adaptation of parents of
children with ASD (Pozo et al. 2006, 2011) suggests
that the adaptation outcome (xX factor) depends on
interrelations among several factors: stressors or
child characteristics (aA factor), social support (bB
factor), perception or definition of the situation (cC
factor), and coping strategies (BC factor). The
review of research provided information to determine the variables that make up the factors in the
model. The severity of the disorder and behaviour
problems integrate the aA factor. Social support and
SOC equate with the bB and cC factors, respectively. Two main types of coping strategies, positive
and problem-focused coping and active avoidance
coping, were introduced as variables of the BC
factor to consider the type of coping strategy instead
of the global measure of coping. The adaptation
outcome (xX factor) was evaluated with FQOL and
psychological well-being. The model postulates that
the bB, cC and BC factors play mediating roles. In
this sense, child characteristics variables have two
different effects on adaptation: (1) a direct and
negative association with adaptation, and (2) an
indirect effect on adaptation through the mediating
variables.
Some studies of parents of children with developmental disorders, have found that mothers experience the effects on the family differently from
fathers (Krauss 1993; Pelchat et al. 2003; Keller &
Honing 2004). Maternal stress is related more to

childcare demands and needs, whereas acceptance


of the disability and attachment are more important
for fathers. Wang et al. (2006) evaluated whether
mothers and fathers had similar views of FQOL and
found no difference in their responses. However, the
current study explores the FQOL models for
mothers and fathers.
The present study carries out a multidimensional
analysis of positive adaptation in parents of children
with ASD. Based on the double ABCX theoretical
model, we examine FQOL and psychological wellbeing models for both mothers and fathers. This
research has three main aims: (1) to evaluate the fit
of the empirical models to the theoretical model,
(2) to identify the relevant variables in the models
and their relationships, and (3) to explore similarities and differences between mothers and fathers.
The hypotheses of the study are presented in
Fig. 1, which identifies the hypothesised relationships among the factors of the theoretical double
ABCX model for the analyses of FQOL and psychological well-being. The hypothesised relationships between variables are as follows:
(H1) Severity of the disorder and behaviour problems are directly and negatively related to FQOL
and psychological well-being.
(H2) Severity of the disorder and behaviour problems indirectly influence adaptation through three
pathways. Social support, SOC and coping strategies each have a mediating effect on the adaptation
variables.
(H3) Social support and SOC are directly and
positively related to FQOL and psychological wellbeing. Different coping strategies are related to
adaptation variables such as positive relations in the
case of positive and problem-focused strategies and
negative relations in the case of active avoidance
strategies.
(H4) Social support and SOC are related to each
other and to two types of coping strategies.

Methods
Participants
Fifty-nine couples from Spain (n = 118), who were
the biological parents of children diagnosed with
ASD, participated in the present research. All of
couples spoke Spanish as their primary language,

2013 The Authors. Journal of Intellectual Disability Research 2013 John Wiley & Sons Ltd, MENCAP & IASSIDD

volume 58 part 5 may 2014

Journal of Intellectual Disability Research


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P. Pozo et al. Family quality of life and psychological well-being

Figure 1 The theoretical model of family


quality of life and psychological well-being.

had created two-parent families and resided


together in the family home. The data presented in
Table 1 indicate that mothers and fathers were
similar in age and level of education. A significant
difference appears in employment (c2 = 31.67,
P < 0.01) with 49.1% (29) of the mothers and
88.1% (52) of the fathers gainfully employed.

Procedure
Initially, the heads of schools were contacted
through the Professional Association of Autism in
Spain and informed of the aims of the research.
Parents received a letter inviting them to participate
in the study. Participation was voluntary and confidential. Parents participated by completing a series
of questionnaires that they received either through
the school or by mail, depending on their preference. Further instructions included with the questionnaires stated that they should be completed
individually without consultation or discussion with
the spouse.
A total of 161 parents (96 mothers and 65
fathers) completed the questionnaires. To standardise the groups of mothers and fathers in family

context factors, the inclusion criterion for the final


sample was that both parents of the same family
had completed the questionnaires. In the end, 118
parents (59 mother-father couples from two-parent
families) were included as participants.

Measures
A brief questionnaire was used to obtain demographic information for families. In addition, seven
questionnaires administered in Spanish evaluated
the factors of the double ABCX model. One of
these questionnaires (the Childhood Autism Rating
Scale) was completed by the professionals, and the
mothers and fathers completed the other six questionnaires individually. Some questionnaires were
previously adapted for Spanish by other authors. We
translated the following measures into Spanish: the
Behaviour Problems Inventory, the Checklist of Support
for Parents of the Handicapped and the Sense of
Coherence Questionnaire. We adopted the backtranslation technique to ensure translation accuracy.
Two bilingual experts were invited to translate the
Spanish versions back to English to correct differences between the two versions.

2013 The Authors. Journal of Intellectual Disability Research 2013 John Wiley & Sons Ltd, MENCAP & IASSIDD

volume 58 part 5 may 2014

Journal of Intellectual Disability Research


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P. Pozo et al. Family quality of life and psychological well-being

Table 1 Demographic characteristic of parents, family and children


with ASD

Demographic information
Mothers (n = 59)
Age (years) range 2869
Education level
Primary school
Secondary school
University grade
Employed
Fathers (n = 59)
Age (years) range 3272
Education level
Primary school
Secondary school
University grade
Employed
Family (n = 59)
Family composition
3 members
4 members
5 members
Family income (euros)
<500
500850
8501200
12001800
18002000
>2000
Child (n = 59)
Age (years) range 438
Gender
Male
Type of ASD
Autistic disorder
Aspergers syndrome
Retts syndrome
PDD-NOS
Education centre
Ordinary school
Especial education school
Autism-specific school
Day centre

% (n)

Mean (SD)

44.6 (7.9)
22.0 (13)
35.6 (21)
45.9 (25)
49.1 (29)
46.7 (9.1)
22.0 (13)
37.3 (22)
40.7 (24)
88.1 (52)

23.7 (14)
61.0 (36)
19.3 (9)
15.3 (9)
37.3 (22)
20.3 (12)
18.6 (11)
1.7 (1)
6.8 (4)

ured the severity of the disorder. The CARS is a


15-item behaviour scale with scores ranging from 1
(age-appropriate behaviour) to 4 (severe or profoundly abnormal behaviour). The present study
used the total score. The internal consistency of
original scale is high, with an alpha reliability coefficient of 0.94. The Spanish adaptation of the CARS
presents both good internal consistency (a = 0.98)
and concurrent validity (Kappa coefficient = 0.78).
The current study also exhibited good reliability
(a = 0.91).
The Behaviour Problems Inventory (BPI; Rojahn
et al. 2001) was used to assess the behaviour problems of children with ASD. This is a 52-item scale
with three sub-scales (self-injurious, stereotyped and
aggressive/destructive behaviour). Each item is
scored on a 4-point severity scale ranging from 0
(no problem) to 3 (a severe problem). The BPI has
been found to be a reliable and valid instrument for
behaviour problems in individuals with ID and
developmental disabilities (Rojahn et al. 2001). The
Cronbachs a for the total scale was 0.83 in the
original study and 0.89 in this study.

Assessment of social support (bB factor)

12.4 (7.9)
79.7 (47)
72.9 (43)
1.7 (1)
8.5 (5)
16.9 (10)
25.4 (15)
12.2 (6)
55.9 (33)
8.5 (5)

The Checklist of Supports for Parents of the Handicapped (CSPH; Bristol 1979) was used to evaluate
the useful social support available to parents caring
for a child with a disability. It is a 23-item rating
scale using a 5-point item scale ranging from 0
(nothing useful) to 4 (very useful). The total score
was the measure used in this study. There was no
information regarding the internal consistency of
the original scale, but in the present study, Cronbachs a was 0. 82.

Assessment of perception of the situation (cC factor)


Family income: monthly income per family member.
SD, standard deviation; ASD, autism spectrum disorders; PDDNOS, pervasive developmental disorder not otherwise specified.

Assessment of child characteristics (aA factor)


The Childhood Autism Rating Scale (CARS;
Schopler et al. 1988; adapted for Spanish by
Garca-Villamisar & Polaino-Lorente 1992) meas-

The Sense of Coherence Questionnaire (SOC;


Antonovsky 1987) was used to assess the SOC. It
measures the extent to which individuals find life to
be comprehensible, manageable and meaningful.
This is a 29-item scale rated using a 7-point item
scale, with higher scores indicating a stronger SOC.
The Cronbachs a of the original questionnaire was
0.88 (Antonovsky 1993). The alpha coefficient for
the present sample was 0.90.

2013 The Authors. Journal of Intellectual Disability Research 2013 John Wiley & Sons Ltd, MENCAP & IASSIDD

volume 58 part 5 may 2014

Journal of Intellectual Disability Research


447
P. Pozo et al. Family quality of life and psychological well-being

Assessment of coping strategies (BC factor)


The Brief Coping Orientation of Problems Experienced
(Brief-COPE; Carver 1997; adapted to Spanish by
Crespo & Cruzado 1997) is the brief form of the
original COPE questionnaire (Carver et al. 1989),
which was used to obtain information on coping
strategies used by parents. It is a 28-item scale that
measures 14 different coping strategies. Response
options range from 0 (I havent been doing this at
all) to 3 (Ive been doing this a lot). Following the
methodology used by Hastings et al. (2005b), a
principal component factor analysis was performed
to explore the structure of the coping strategies and
to reduce the number of strategies. Two factors
explained 28% of the variance. Factor 1, positive
and problem-focused coping strategies, included
items from the sub-scales for active coping, planning, seeking instrumental and emotional social
support, positive reframing and humour. Factor 2,
active avoidance coping strategies, consisted of
seven items from the sub-scales for denial, behaviour disengagement, distraction and self-blame. In
this study, only two factor scores were used. Reliability was good for both the positive and problemfocused coping strategies (a = 0.79) and active
avoidance coping strategies (a = 0.71).
Assessment of adaptation (xX factor)
The Beach Center Family Quality of Life Scale
(FQOL; Poston et al. 2003; adapted for Spanish by
Sainz et al. 2005) was used to assess parents perceived satisfaction with their quality of life. This is a
25-item scale with five sub-scales (family interaction, emotional well-being, parenting, physical/
material well-being and disability-related support).
This scale has two different response formats: satisfaction and importance. This study used the total
score of satisfaction format. The items are rated on
a 5-point scale ranging from 1 (very dissatisfied) to
5 (very satisfied). Cronbachs a for the FQOL subscale rating of Satisfaction was 0.88 in the original
study and 0.95 in this study.
The Brief Psychological Well-being Spanish Version
(Daz et al. 2006) is a brief version of the original
Psychological Well-being Scale (Ryff 1989). It is a
29-item scale with a 6-point item scale ranging from
1 (completely disagree) to 4 (completely agree).
The 29 items are organised into six dimensions

(self-acceptance, positive relations, autonomy, environmental mastery, purpose in life and personal
growth). However, the measure of psychological
well-being in this study was the total score. The
internal consistency of the brief version of the scale
is good (a = 0.84). In the present study, Cronbachs
a was 0.87.

Results
First, Pearsons correlations were used to explore
bivariate associations between all of the variables
that operationalise the double ABCX model factors
in this study. Correlations were calculated separately
for mothers and fathers (Table 2) and demographic
variables were included in this analysis. The data
show that the severity of disorder is negatively associated with the two adaptation variables in mothers.
In the case of fathers the other characteristic of the
child variable (behaviour problems) is negatively
associated with the two adaptation variables. For
both samples active avoidance coping strategies are
negatively correlated with psychological well-being.
At the same time, SOC is positively associated with
the two adaptation variables, and social support is
only positively associated with FQOL. Psychological
well-being and FQOL are positively associated,
which is also true for the two characteristics of the
child variables. The behaviour problems variable is
positively correlated with active avoidance coping
strategies, and SOC is negatively associated with
behaviour problems and active avoidance coping
strategies. The two types of coping strategies are
positively associated only in the case of mothers. In
addition only in mothers the age of the child
presents significant correlations. The age of the
child is negatively associated with behaviour problems and positive and problem-focused coping
strategies. The family income presents significant
correlations with behaviour problems in mothers. In
the case of fathers, family income is positively associated with education level, SOC and psychological
well-being. The parents educational level does not
present any significant correlation with the variables
of the study.
To control the threat of a demographic variable
confounding the relationship between the predictor
and criterion variables, we calculated the partial

2013 The Authors. Journal of Intellectual Disability Research 2013 John Wiley & Sons Ltd, MENCAP & IASSIDD

volume 58 part 5 may 2014

Journal of Intellectual Disability Research


448

0.136
0.116
0.256*
-0.220
-0.361*
0.124
0.748**
0.032
-0.461**
0.412**

0.108
0.128
0.007
-0.013
-0.269*
0.270*
0.477**
-0.122
-0.156

0.542**
-0.020
-0.181
-0.133
0.065
0.276*
-0.151
-0.686**
0.131

-0.154
-0.292*
-0.159
0.063
0.129
-0.051
0.062
0.167
-0.126

0.340**
0.009
0.184

Table 3 Couple correlations in child characteristics variables, social


support, sense of coherence (SOC), coping strategies and adaptation variables

-0.144
-0.256*
-0.163
0.168
-0.094
0.081
0.051
0.083
0.219
0.131
-0.034
-0.121
0.066
-0.063
0.041
-0.049
0.045

-0.176
-0.061
-0.109
0.414**

-0.042
-0.275*
0.198
0.265*
-0.223
-0.187
-0.130
0.020
-0.144

0.423**
0.028
-0.256*
-0.005
0.193
-0.417**
-0.335**
0.174
0.293*
0.005

** P < 0.01, * P < 0.05.

-0.082
0.174
-0.130
-0.283*
-0.141
0.038
-0.296*
0.090
-0.119
0.014
Age of child
Education level
Family income
Severity of disorder
Behaviour problems
Social support
SOC
Positive and problem- focused coping
Active avoidance coping
Family quality of life
Psychological well-being
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

Variables

Couple
correlations

Severity of disorder
Behaviour problems
Social support
SOC
Positive and problem-focused coping
Active avoidance coping
Family quality of life
Psychological well-being

1.00**
0.63**
0.44**
0.38**
0.11
-0.05
0.17
0.35**

** P < 0.01, * P < 0.05.

-0.034
-0.040
-0.217
-0.044
-0.109

0.205
0.181
-0.076
0.296*
0.233

0.120
0.147
0.263*
-0.239
-0.335*
0.155

-0.026
-0.395**
0.444**
0.767**

11
10
9
8
7
6
5
4
3
2
1

Table 2 Correlations between demographic variables, child characteristics variables, social support, sense of coherence (SOC), coping strategies and adaptation variables in fathers (above
diagonal) and mothers (below diagonal)

P. Pozo et al. Family quality of life and psychological well-being

correlation between SOC and psychological wellbeing in fathers and controlled for the effects of
family income. The partial correlation remains significant (0.730, P < 0.01). This result allows us to
reject family income as a confounder of this relation. The age of the child is negatively associated
with behaviour problems as well as positive and
problem-focused coping strategies, but there is no
significant relation between these variables. Thus, a
potential confounder is not relevant in this case.
The analysis of bivariate correlations between
measurements of the two members of a couple,
father and mother, shows significant positive correlations in SOC, perceived social support, child
behaviour problems and psychological well-being
(see Table 3). The severity of the disorder has a
perfect correlation because the evaluation is conducted by professional. There are no significant
correlations in coping strategies and FQOL.
Path analysis was carried out using the AMOS
Graphic 5 statistics program, and all of the variables
were introduced in each model. Separate models
were carried out for each outcome variables,
because of the small sample size. Data for mothers
and fathers were analysed separately, resulting in
four empirical models (two models of FQOL and
two models of psychological well-being). Demographic data were used basically to provide descriptive information on the characteristics of the sample
and to control possible confounders. None of these
variables was included in the path analysis. There
were no missing values for the total scores of any of

2013 The Authors. Journal of Intellectual Disability Research 2013 John Wiley & Sons Ltd, MENCAP & IASSIDD

volume 58 part 5 may 2014

Journal of Intellectual Disability Research


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P. Pozo et al. Family quality of life and psychological well-being

the scales. Missing values were limited to specific


items of the questionnaires and were not always the
same. We applied average values from existing
values in these items. The rates of all missing data
were less than 1%.
The specification and assessment of models were
generated in several stages. In the first stage, the
hypothetical models were designed to follow the
framework of the double ABCX theoretical model
(see Fig. 2). The initial model tested is more
complex than recommended in relation to sample
size (participants: parameters ratio), but we considered that it was necessary to accurately reflect the
factors and the relations of double ABCX theoretical model, including the relevant observed variables
to evaluate their usefulness in explaining the psychological adaptation of parents.
Graphic paths were constructed while ensuring
that the variable relationships were linear.
Maximum likelihood methods were used to estimate all models. A different fits index was used to
test the goodness of fit of the proposed models.
Chi-square (c2) is suitable for small samples, such
as our research. The model shows a good fit when
its probability is not significant (P > 0.05). Nevertheless, considering the complexity of the initial
model and the small sample size the primary fit

statistic used was chi-square degree ratio (c2/d.f.).


This ratio in the range of 3 to 1 is indicative of an
acceptable fit between the hypothesised and the
sample data (Carmines & McIver 1981). We also
considered the normed fit index (NFI) which
values greater than 0.90 are considered acceptable,
the comparative fit index (CFI), in which values
greater than 0.95 represent a good model fit, and
a root mean square error of approximation
(RMSEA) in which values lower than 0.08 are
considered acceptable and values lower than 0.05
are considered very good. However, these last fit
statistics are uninformative if the chi-square degree
ratio is below 1. Post hoc model modifications
were performed trying to develop a better fitting
model. Below, we describe the process of estimating the models, specifying the criteria by which the
models were trimmed and reporting the fit indices
and the participants to parameters ratio (p:p ratio)
of each analysis.

Family quality of life results


Separate path analysis for mothers and fathers was
calculated. The hypothesised model for FQOL was
tested for mothers [c2 (2) = 8.32, P = 0.015;
c2/d.f. = 4.17; NFI = 0.88; p:p ratio = 2.27:1]. Post

Figure 2 The initial tested model of family


quality of life and psychological well-being.
FQOL, family quality of life.

2013 The Authors. Journal of Intellectual Disability Research 2013 John Wiley & Sons Ltd, MENCAP & IASSIDD

volume 58 part 5 may 2014

Journal of Intellectual Disability Research


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P. Pozo et al. Family quality of life and psychological well-being

hoc model modifications were performed in an


attempt to develop a better fitting and possibly
more parsimonious model. First, non-significant
relationships were dropped to re-estimate the
model. Because the relation of active avoidance
coping strategies with FQOL was non-significant,
this variable was dropped. The goodness of
fit of this model was: c2 (4) = 1.95, P = 0.74;
c2/d.f. = 0.48; NFI = 0.97 (p:p ratio = 5.90:1).
Second, because the regression weight of the social
support and SOC relation was no significant this
relation was eliminated and the model re-estimated.
This model was a good fit (c2 (3) = 4.17, P = 0.24;
c2/d.f. = 1.34; NFI = 0.91; CFI = 1.00;
RMSEA = 0.00; p:p ratio = 6.56:1). The final model
is illustrated in Fig. 3.
The hypothesised model for FQOL was tested for
fathers [c2 (3) = 2.18, P = 0.54; c2/d.f. = 0.73;
NFI = 0.98; p:p ratio = 2.27:1]. Post hoc model
modifications were performed. Non-significant
relationships were dropped to re-estimate the
model. The goodness of fit of this model was:
c2 (7) = 4.68, P = 0.70; c2/d.f. = 0.67; NFI = 0.95
(p:p ratio = 4.54:1). The model was again
re-estimated dropping the behaviour problems
and FQOL non-significant relation. This new
model (Model 2) was a good fit [c2 (6) = 7.18,
P = 0.31; c2/d.f. = 1.20; NFI = 0.92; CFI = 1.00;

RMSEA = 0.00; p:p ratio = 4.92:1]. The final


model is presented in Fig. 4.
Although the empirical models show a good fit
for the theoretical parameters, they do not reproduce the complete theoretical model. The significant variables and their direct and indirect effects
on FQOL for mothers and fathers are presented in
Table 4. Fundamentally, the empirical models do
not include positive and problem-focused coping
strategies as a relevant variable. The direct effect of
behaviour problems on FQOL is not significant,
and neither are the relations between the characteristics of child and social support. In particular,
active avoidance coping strategies variable does not
play a relevant role in the model for mothers.
The two FQOL models exhibit both commonalities. For both models, behaviour problems had a
negative indirect effect on FQOL through SOC.
Behaviour problems had a negative relation to SOC,
whereas SOC had a positive relation to FQOL.
Another shared relationship was the social support,
which had a direct and positive effect on FQOL.
With regard to differences observed in graphic
models, SOC exhibited an indirect effect on FQOL
through active avoidance coping strategies in the
model for fathers. The severity of the disorder had
a direct influence on FQOL for mothers and
fathers, but the sign was different. It had a negative

Figure 3 The family quality of life model


for mothers with standardised b
coefficients. SOC, sense of coherence.

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P. Pozo et al. Family quality of life and psychological well-being

Figure 4 The family quality of life model


for fathers with standardised b coefficients.
SOC, sense of coherence.

Table 4 Direct, indirect and total effects of variables on family


quality of life for mothers and fathers

Effect
Variable
Mothers
Severity of disorder
Behaviour problems
SOC
Support
Fathers
Severity of disorder
Behaviour problems
SOC
Support
Active avoidance
coping strategies

Direct

Indirect

-0.34
-0.09
0.31
0.25
0.15
0.73
0.22
0.37

-0.19
-0.20

Total

-0.34
-0.09
0.31
0.25
0.15
-0.19
0.53
0.22
0.37

SOC, sense of coherence.

effect on FQOL for mothers and a positive effect


for fathers.

Psychological well-being results


Separate path analysis for mothers and fathers were
calculated. The hypothesised model for psychologi-

cal well-being was tested for mothers [c2 (1) = 8.31,


P = 0.01; c2/d.f. = 8.31; NFI = 0.92; p:p
ratio = 2.27:1]. Post hoc model modifications were
performed in an attempt to develop a better fitting
and possibly more parsimonious model. Nonsignificant relationships were dropped to re-estimate
the model. The goodness of fit of this model was:
c2 (4) = 2.73, P = 0.60; c2/d.f. = 0.68; NFI = 0.97
(p:p ratio = 5.90:1). The model was again
re-estimated dropping the two non-significant relations. The goodness of fit of the final model was:
c2 (3) = 2.70, P = 0.44; c2/d.f. = 0.90; NFI = 0.96;
CFI = 1.00; RMSEA = 0.00; p:p ratio = 8.43:1. The
final model is illustrated in Fig. 5.
The hypothesised model for psychological wellbeing was tested for fathers [c2 (3) = 2.11, P = 0.55;
c2/d.f. = 0.70; NFI = 0.98; p:p ratio = 2.27:1]. Post
hoc model modifications were performed. Nonsignificant relationships were dropped to re-estimate
the model. The goodness of fit of the final model
was good [c2 (1) = 1.81, P = 0.12; c2/d.f. = 1.81;
NFI = 0.97; CFI = 1.00; RMSEA = 0.00; p:p
ratio = 11.80:1]. The final model is presented in
Fig. 6.
The two well-being models are simpler than the
theoretical model. The significant variables and
their direct and indirect effects on psychological

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P. Pozo et al. Family quality of life and psychological well-being

Figure 5 Psychological well-being model


for mothers with standardised b
coefficients. SOC, sense of coherence.

Figure 6 Psychological well-being for


fathers with standardised b coefficients.
SOC, sense of coherence.

well-being for mothers and fathers are presented in


Table 5. The empirical models of mothers and
fathers do not include the severity of the disorder,
the social support and active avoidance coping strategies as relevant variables. In addition, there is not
direct effect of behaviour problems on well-being. In
particular, positive and problem-focused coping
strategies variable does not play a relevant role in
the model for fathers.
The variables of behaviour problems and SOC
played a significant role in both psychological wellbeing models. For mothers and fathers, behaviour
problems had a negative, indirect effect on psychological well-being through SOC. This indirect influ-

ence occurred because behaviour problems, which


were negatively related to SOC, reduced the positive
effect that SOC had on psychological well-being.
Another notable finding was the role of positive and
problem-focused coping strategies in the model for
mothers. This type of coping strategy exhibited a
direct and positive effect on psychological wellbeing, indicating that more frequent use of positive
and problem-focused strategies was associated with
higher levels of psychological well-being.
Finally, a comparative analysis of mean differences of variables was performed. Only the positive
and problem-focused coping strategies variable
differed significantly for mothers and fathers

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Table 5 Direct, indirect and total effects of variables on psychological well-being for mothers and fathers

Effect
Variable
Mothers
Behaviour problems
SOC
Positive and problem-focused
coping
Fathers
Behaviour problems
SOC

Direct

Indirect

Total

-0.23

-0.23
0.77
0.16

-0.25

-0.25
0.75

0.77
0.16

0.75

SOC, sense of coherence.

[t (118) = -3.56, P = 0.001]. The analysis indicated


that mothers used this type of coping strategy more
often than fathers (mean = 17.78 and mean = 14.53,
respectively).

Discussion
In the present study, the double ABCX model proposed by McCubbin & Patterson (1983) was tested.
Separate path analyses examined FQOL and psychological well-being in mothers and fathers of children with ASD, and the resulting empirical models
exhibited a partial fit to the theoretical model.
We can observe shared patterns of relationships.
First, behaviour problems did not show any direct
effect on adaptation variables. It is necessary to note
that the measure of behaviour problems was rather
specific (focused on self-injury, stereotypies, aggression and destructive behaviour) compared with
other instruments of measure used in other studies
referenced in the introduction. Behaviour problems
exhibited an indirect effect on adaptation in all the
empirical models.
This pattern of relationships was very clear and
consistent. SOC had a positive relation with both
FQOL and well-being. Parents with a high level of
SOC were more satisfied with their FQOL and had
a higher level of psychological well-being. At the
same time, behaviour problems had negative relation with SOC. This supports the view that the high
level of stress related with raising a child with

autism has a negative effect on parental SOC. When


behaviour problems are more severe, parents may
perceive the situation as less predictable, manageable and meaningful. These findings are consistent
with the results of other studies (Oelofsen &
Richardson 2006; Pozo et al. 2006; Mak et al. 2007;
Pozo & Sarri, in press). In addition, Olsson &
Hwang (2002) and Pisula & Kossakowska (2010)
found that mothers of children with autism have
lower levels of SOC than mothers of children with
ID and mothers of typically developing children.
For both mothers and fathers, social support had
a positive relation with FQOL. Parents who perceived that they had adequate social support to
cope with the demands of caring for their children
were more likely to report a better FQOL. Receiving useful and appropriate support in daily life
would arguably improve the perception of a better
FQOL among parents of individuals with ASD.
For mothers, the severity of disorder had a negative relation to FQOL. Mothers of a child who was
more severely affected by the disorder were less satisfied with FQOL. A child whose disorder is more
severe will be less able to independently carry out
the activities of daily life and will place more care
demands on the mother. This specific effect of the
severity of the disorder in mothers FQOL models
is probably related to their experience as primary
caregivers and to the degree of responsibility for
parenting. In this study, a division of childcare
responsibilities was assumed because only 49.1% of
the mothers were employed outside the home compared with 88.1% of the fathers.
Curiously, for fathers the severity of disorder had
a positive relation to FQOL. Previous studies of
stress in parents of children with ID have found that
while maternal stress was related to childcare
demands, fathers stress was more related to their
relationship and attachment to the child (Krauss
1993; Pelchat et al. 2003; Keller & Honing 2004).
This difference in the experience of the childs disorder in parents could explain this finding. Greater
severity of the disorder may facilitate the adjustment of fathers expectations about childs development and acceptance of the disorder, with positive
consequences for their relationship and their perception of FQOL.
With regard to differences in FQOL graphic
models, the model for fathers particularly included

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active avoidance coping strategies like explanatory


variable positively related to FQOL. At the same
time SOC is negatively related to active avoidance
coping strategies. This findings report that fathers
with lower SOC are more oriented to use coping
strategies based in denial, self-blame, behaviour
disengagement or distraction, and these coping
strategies favoured their positive perception. The
particular value of this type of coping strategies in
fathers might be related to the higher proportion
of employment outside the home, which would
provide more opportunities for behaviour disengagement or distraction. However, the novelty of
these findings should lead us to treat them with
caution. There is always the risk of being simply an
artefact of the model. More research is needed to
examine its accuracy, relevance and interpretation.
For mothers, positive and problem-focused
coping strategies predicted psychological well-being.
This finding is consistent with the results of Smith
et al. (2008) that found that problem-focused strategies were associated with the personal growth
domain. Other studies indicated that coping strategies that involve seeking support are associated with
more positive mood (Pottie & Ingram 2008) and
parental subjective well-being (Glidden et al. 2006).
The different role of coping strategies in the path
models for mothers and fathers is consistent with
the results of correlation analysis of couples. The
only explanatory variables in which the measurements of the two members of a couple did not
present any significant correlation are precisely the
two types of coping strategies. In addition, the comparative analysis of mean differences of variables
between mothers and fathers reported only one
significant difference. Mothers used positive and
problem-focused coping strategies more often than
fathers. A similar result was obtained in the study of
Essex et al. (1999) in parents of adults with ID.
Hastings et al. (2005b) found that mothers of children with autism reported more frequent use of
two coping strategies than fathers. These authors
explain that these findings could be a result of the
stressor experienced by mothers and consequently
an increased need to engage in coping efforts compared with fathers.
Several limitations of the present study must be
taken into account. The main limitation is the small
sample size in relation to the complexity of the

model (participants : parameters ratio). There is


little consensus on the recommended sample size
for structural equation models (Sivo et al. 2006).
Nevertheless, Bentler (1989) and other authors
propose a minimum ratio of 5:1 participants to
parameters, and the analysis of this study does not
always fit this criterion. Many authors warn that an
inadequate sample size could affect the accuracy
and stability of the model estimation. The small
sample size could also complicate the interpretation
of associations between factors in the models. The
magnitude of associations described by the models
needs to be taken into account as well as statistical
significance. For low sample sizes even with good
model fits it is necessary large loadings to suggest
an association on a factor or between factors. Hair
et al. (1998) suggest standardised betas of at least
0.55 are needed to demonstrate an association
between pairs of factors. In our results the SOC
relations to the psychological well-being, FQOL and
active avoidance coping strategies meet this criterion. Other relationships have magnitudes less than
this value so it should be considered as trends.
Then further research with larger sample size is
necessary to verify the findings.
Another limitation is that all of the measures in
the model, except the severity of disorder, are collected from self-report questionnaires. Further
research with cross-reported analysis and multigroup modelling is necessary. The cross-sectional
nature of the data is also a limitation for answering
questions about the direction of effect between variables. The direction of effects may not be possible
to test in the models, and it is important to recognise that many of the relationships could be bidirectional rather than unidirectional. Further research
with longitudinal studies is necessary to deepen the
knowledge of the direction of effects.
Despite its limitations, the study provides results
that may provide suggestions for research and for
interventions with families of children with ASD.
The results of this study highlight the informativeness of the multidimensional approach and the
utility the use of path analysis to examine the relationships among variables. To design and provide
crucial support for parents, it is important to identify the factors implied in their adaptation and to
take differences between mothers and fathers
needs and perceptions into account. One of the

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P. Pozo et al. Family quality of life and psychological well-being

main findings is the significant role of SOC in all


of the examined models of adaptation. For both
mothers and fathers the SOC has a positive relation
with the adaptation variables. These results are
consistent with other studies that identify positive
relationships between SOC and psychological
well-being in mothers of children with disabilities
(Gottlieb 1998), in married and divorced mothers
(Cohen & Dekel 2000), in elderly (Sagy et al. 1990),
and in general population (Pallant & Lae 2002;
Nilsson et al. 2010).
Professionals could work with families to improve
parents SOC through its three components: comprehensibility, manageability and meaningfulness.
Providing parents with clear and consistent information about the characteristics of ASD and steps
to take over the life cycle could increase the comprehensibility of the problem. By informing parents
about the resources can be developed to manage
family demands and to empower families to acquire
feelings of control and manageability over their
lives. Finally, parents can learn that demands can be
perceived as challenges, which can lead to the redefining of future goals and the reframing of negative
concerns. Parents can learn to emphasise the positive aspects of their situation and to consider their
familys strengths and opportunities for growth.
On the other hand, professionals should pay
attention to the coping strategies that parents use to
confront family demands and be aware that mothers
and fathers may adopt different coping strategies.
Professionals need to work with families to identify
their needs and the appropriate sources of support.
Finally, it is important to study family adaptation
from a positive perspective to identify factors that
promote psychological well-being and enhance perceived FQOL. Research in this area is only beginning, and much more work is needed.

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