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Moderators of Stress in Parents of Children with Autism

Article  in  Community Mental Health Journal · March 2001

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Community Mental Health Journal, Vol. 37, No. 1, February 2001

Moderators of Stress in Parents

of Children with Autism

Michael E. Dunn, Ph.D.

Tracy Burbine, M.S.
Clint A. Bowers, Ph.D.
Stacey Tantleff-Dunn, Ph.D.

ABSTRACT: Parents of children with autism experience more stress and are more
susceptible to negative outcomes than parents of children with other disabilities. The
present work examines the relationship between stressors, social support, locus of
control, coping styles, and negative outcomes (depression, social isolation, and spousal
relationship problems) among parents of children with autism. Fifty-eight parents
completed surveys. Results indicated that several coping styles corresponded to negative
outcomes. Furthermore, the relationship between stressors and negative outcomes was
moderated by social support and coping style. Results are discussed in relation to
applications for clinical practice.

KEY WORDS: autism; parents; stress.

Parents who have children with autism endure more stress than
parents with non-disabled children (McKinney & Peterson, 1987) and
parents of children with other disabilities (Holroyd & McArthur, 1976;
Bouma & Schweitzer, 1990), heightening negative health outcomes like
depression and marital dissatisfaction (DeMyer, 1979). In addition,
mothers of children with autism report less parenting competence, less
marital satisfaction, and less family adaptability than mothers of chil-
dren with Down’s syndrome or mothers with typically developing chil-

Michael E. Dunn, Tracy Burbine, Clint A. Bowers, and Stacey Tantleff-Dunn are affiliated with
the Department of Psychology, University of Central Florida.
Address correspondence to Michael E. Dunn, Ph.D., Department of Psychology, P.O. Box 161390,
University of Central Florida, Orlando, FL 32816-1390; e-mail: mdunn@pegasus.cc.ucf.edu.

39  2001 Human Sciences Press, Inc.

40 Community Mental Health Journal

dren (Rodrigue, Morgan, & Geffken, 1990). Mothers with an adolescent

with autism report more parent and family problems, more behavior
difficulties, and more limitations of physical abilities and self-help skills
than mothers with adolescents with mental retardation (Donovan,
1988). The most stressful symptoms appear to be impairment in verbal
communication, unevenness in cognitive functioning, and impairments
in human relations (Konstantantareas & Homatidis, 1989). It is not
surprising, then, that the marriage is often adversely affected (DeMyer,
1979). Parents of children with autism report greater levels of stress
and depression and lower levels of marital intimacy than parents of
children with typical development, or parents of children with Down’s
syndrome (Fisman, Wolf, & Noh, 1989). Other work has found parents
of autistic children to be at high risk for marital discord (DeMyer, 1979;
Rodrigue et al., 1990; Donovan, 1988), depression (DeMyer, 1979) and
social isolation (Marcus, 1977). The more severe the child’s symptoms,
the greater the degree of parental stress.
Many factors can exacerbate stress levels. Mothers of adolescents
with autism are less likely to cope by maintaining their social support
system, self-esteem and psychological stability, and are less able to cope
than mothers of adolescents with mental retardation (Donovan, 1988).
Feelings of incompetence are common (Rodrigue et al., 1990), and par-
ents often choose isolation over the frustrations of taking their child
out in public. Mothers appear to be the most severely affected member
of the family, with almost one-third exhibiting depressive symptoms
(DeMyer, 1979).

COGNITIVE APPROACHES TO STRESS REDUCTION

Cognitive mediation plays a significant role in stress reactions

(Grinker & Spiegel, 1945; Janis, 1954; Lazarus, 1993a, 1993b) and can
be conceptualized in terms of two interacting processes: appraisal and
coping (Holroyd & Lazarus, 1982). Because appraisal may determine
whether or not a situation or encounter is personally stressful, altering
one’s cognitive appraisal can reduce stress (Lazarus & Alfret, 1964). The
impact of events still perceived as stressful can be minimized through
effective coping skills (Lazarus & Alfert, 1964; Speisman, Lazarus,
Mordkoff, & Davidson, 1964).

SOCIAL SUPPORT, STRESS, AND PERSONALITY FACTORS

Social support is one type of coping mechanism that has been found to
be a buffer against stress (Bailey, Wolfe, & Wolfe, 1994; Bowers &
 Michael E. Dunn, Ph.D., et al. 41

Gesten, 1986; Bristol & Schopler, 1983; Chay, 1993). Social support has
differentiated high and low stressed mothers of children with autism
(Bristol & Schopler, 1983), and mothers who perceive social support
as more accessible report fewer stress-related somatic problems and
depressive symptoms (Gill & Harris, 1991). Gray and Holden (1992)
found social support to be inversely related to depression and anxiety.
Support within the marital relationship has been found to be related
to better personal and marital adaptation in families with young devel-
opmentally disabled boys (Bristol, Gallagher, & Schopler, 1988) and to
life satisfaction among parents of children with autism (Milgram &
Atzil, 1988).
While social support has typically been related to positive outcomes,
there are some findings to the contrary (e.g., Hynes, Callan, Terry, &
Gallois, 1992). Efforts to resolve the discrepancies have found that sup-
port may be moderated by personality factors. For example, Type A
personality has been found to moderate the relationship between coro-
nary artery disease and social support, and hardiness has been found
to moderate the relationship between social support, stress, and illness
(Blumenthal, Burg, Barefoot, Williams, Haney, & Zimet, 1987; Kobasa &
Puccetti, 1983). In both cases, external locus of control corresponded to
a failure to benefit from social support.

LOCUS OF CONTROL AND STRESS

Locus of control may help explain the complex effects of social support.
Non-depressed mothers with an internal locus of control reported fewer
parent and family problems (Friedrich, Wilturner, & Cohen, 1985). Simi-
larly, families who used an internal approach to coping were less
stressed by raising a child with a disability (Bristol & Schopler, 1983).
In contrast, external locus of control correlates with job stress (Cooper,
Kirkcaldy, & Brown, 1994), and has been linked to depression and
anxiety in response to negative life changes (Johnson & Sarason, 1978).
Reminiscent of learned helplessness, individuals who experience stress
and view themselves as having no control over events may be most
susceptible to the influences of life stress.

PURPOSE AND HYPOTHESES

The present work attempted to assess the relationship between stress-

ors, social support, locus of control, coping style, and negative outcomes
42 Community Mental Health Journal

in parents of children with autism. It was hypothesized that lack of

social support, external locus of control, and ineffective coping styles
would predict negative outcomes. Furthermore, it was hypothesized
that the relationship between stressors and negative outcomes would be
moderated by social support, locus of control, and coping style. Finally, it
was hypothesized that locus of control would moderate the relationship
between social support and negative outcomes. Hypotheses were tested
in relation to three outcome measures: depression, social isolation, and
spousal relationship difficulties.

METHOD

Participants
Participants were recruited from southeast divisions of both the Florida Autism Society
and Autism Societies of America. All parents with an autistic child between the ages
of 3 and 15 years were asked to participate. Those who completed measures included
39 mothers and 19 fathers ranging in age from 25 to 67 years (mean = 36.84, SD =
9.21). Mean age of children was 7.47 years, SD = 3.31. Parents were 81% Caucasian,
8% African American, 8% Hispanic, and 3% percent “other.” Education level of parents
was 3% partial high school, 21% high school graduate, 30% partial college, 33% college
graduate, and 13% partial or completed graduate school.

Measures

The Inventory of Socially Supportive Behaviors (ISSB). The ISSB (Barrera, Sand-
ler, & Ramsay, 1981) is a 40-item self-report questionnaire that was used to assess the
type and amount of social support received by parents. Test-retest reliability for the
ISSB = .88, internal consistency (alpha) = .93. The ISSB has been found to correlate
significantly with the Arizona Social Support Interview Schedule (Barrera et al., 1981).

Ways of Coping Questionnaire—Revised (WOC). The WOC (Folkman & Lazarus,

1985) is a 66 item coping style checklist that consists of eight subscales: Confrontive
Coping, Distancing, Self-controlling, Seeking Social Support, Accepting Responsibility,
Escape-Avoidance, Planful Problem-solving, and Positive Reappraisal. Internal consis-
tencies for the subscales ranged from alpha = .61 to .79 (Folkman & Lazarus, 1985).

Parenting Stress Index (PSI). The PSI (Abidin, 1995; Loyd & Abidin, 1985) is a 120-
item self-report measure that assesses negative outcomes associated with the parent-
child relationship and identifies the source of the stress. Three subscales of the parent
domain were selected for the present study: parental depression, social isolation, and
spousal relationship. Test-retest reliability ranged from .69 to .96 for the total stress
score and .69 to .91 for the parent domain. Alpha internal consistency coefficient = .95
for the total stress score. The total score on the PSI significantly correlated with trait
anxiety (r = .84) and state anxiety (r = .71), as measured by the State-Trait Anxiety
Inventory (Loyd & Abidin, 1985).
 Michael E. Dunn, Ph.D., et al. 43

Internal-External Locus of Control Scale (LOC). The Rotter LOC Scale (Rotter, 1966)
is a 29-item self-report questionnaire that was used to measure locus of control. Internal
consistency for the LOC Scale ranged from alpha = .69 to .73. Test-retest correlations
ranged from .55 to .78 (Rotter, 1966).

Life Experiences Survey (LES). The LES (Sarason, Johnson, & Siegel, 1978) is a 57-
item self-report questionnaire that assesses the desirability and impact of events that
have occurred over the previous year. Ten items pertaining only to students were not
employed. Test-retest correlations were .19 and .53 for the positive change score, .56
and .88 for the negative change score, and .63 and .64 for the total change score. Negative
change scores were computed and used as a measure of stressors for the present analyses
because they have been found to predict state and trait anxiety (Sarason et al., 1978).

Procedure
After presenting the intent of the research, parents were given a packet containing the
measures listed above and an addressed stamped return envelope. All forms were in
the same order in each packet. Participants were given five days to complete the packet.

Analysis
Analyses were conducted in three steps. First, correlations were computed between
each IV (stressors, social support, locus of control, & eight coping styles) and each
DV (depression, social isolation, & spousal relationship problems) to assess simple
relationships. Second, stepwise regressions were conducted with all IV’s predicting each
DV to assess the degree to which the IV’s predict common variance. Third, moderator
analyses were conducted using the procedure described by Baron and Kenny (1986).
They asserted that moderation should be established by assessing the direct effects of
a predictor (in this case stressors or social support), a potential moderator (social support,
locus of control, or coping style), and the interaction product of the predictor and modera-
tor. The moderator hypothesis is supported if the interaction term is significant. They
also asserted that main effects for the predictor and the moderator may be significant,
but are not directly relevant to testing the moderator hypothesis. Sample sizes vary
among analyses due to incomplete data provided by some participants.

RESULTS

Correlations

Three variables correlated significantly with depression: locus of control

(r = −.30, p = .03), Ways of Coping—Distancing (r = .32, p = .02), and
Ways of Coping—Escape (r = .50, p = .00). Therefore, external locus of
control, and use of distancing and escape as coping tools corresponded
to increased depression. Locus of control (r = −.36, p = .01), and Ways
of Coping—Escape (r = .38, p = .00) correlated significantly with social
isolation. Therefore, external locus of control and use of escape as a
coping tool corresponded to increased social isolation. Three variables
44 Community Mental Health Journal

correlated significantly with spousal relationship problems, receipt of

social support (r = −.27, p = .04), Ways of Coping—Seeking Social Sup-
port (r = −.27, p = .04), and Ways of Coping—Escape (r = .43, p = .00).
Therefore, failure to receive and failure to seek social support, and use
of escape to cope corresponded to increased levels of spousal relationship
problems.

Stepwise Regressions

Three stepwise regressions were completed with ten IV’s (social support,
locus of control, and eight subscales of the coping measure) and three
DV’s (depression, social isolation, and spousal relationship difficulties).
In predicting depression, the only IV’s to enter the equation were the
Ways of Coping subscales Escape-Avoidance and Confrontive Coping,
R (2,44) = .64. Escape-Avoidance had a positive relationship with de-
pression such that increased use of escape and avoidance as coping
methods corresponded to increased depression (see Table 1). Confrontive
Coping had a negative relationship with depression such that increased
use of confrontive approaches to coping corresponded to decreased de-
pression. Although locus of control and distancing as a coping tool had
significant correlations with depression, they did not enter the equation.
It is logical to conclude that escape-avoidance might account for variance
shared by distancing as they are conceptually similar coping styles. In
fact, the correlation between them was r = .50, p = .00. Although locus
of control did not significantly correlate with either escape-avoidance
or confrontive coping, these variables appeared to account for common
variance to the extent that locus of control was not a significant predictor
after the coping methods entered the equation.

TABLE 1

Stepwise Multiple Regression Predicting Depression

Step Predictor b Error β t p Cum. R F p

1 Escape- .81 .19 .54 4.19 .00 .54 17.52 .00

Avoidance
2 Escape- .92 .18 .61 5.06 .00 —
Avoidance
Confrontive −.77 .26 −.36 −2.98 .01 .64 14.80 .00
Coping
 Michael E. Dunn, Ph.D., et al. 45

In predicting social isolation, results were similar to the depression

analysis in that the first IV to enter the equation was the Ways of Coping
Escape-Avoidance subscale. The only other IV to enter the equation was
the Positive Reappraisal subscale of the Ways of Coping measure, R
(2,44) = .72. The relationships were such that increased use of escape
and avoidance as coping approaches corresponded to increased social
isolation and increased use of positive reappraisal corresponded to de-
creased social isolation (see Table 2). Again, locus of control had a
significant correlation with social isolation, but did not enter the regres-
sion equation. Therefore, it is likely that it accounted for common vari-
ance with the coping methods.
It is interesting to note that some criterion contamination may have
been present in this analysis due to the attempt to use measures of
seeking and receiving social support to predict social isolation. One
would logically expect a significant negative relationship to exist be-
tween these variables. Neither social support measure entered the equa-
tion, however. Furthermore, the correlation between the Seeking Social
Support subscale and social isolation was only r = .03. The correlation
between receiving social support and isolation was higher, r = −22, but
not significant (p = .11). There are several possible interpretations of
this result. First, the experience of social isolation may not be directly
related to the seeking of social support or the receipt of social support
as tapped by the Inventory of Socially Supportive Behaviors. Second,
social support may moderate the relationship between stressors and
isolation. A hierarchical regression testing this hypothesis is described
in the section on moderator analyses. The interaction product of stres-
sors and social support was significant. Third, the relationship between
isolation and social support may be moderated by a third variable,

TABLE 2

Stepwise Multiple Regression Predicting Social Isolation

Step Predictor b Error β t p Cum. R F p

1 Escape- .77 .21 .48 3.61 .00 .48 13.03 .00

Avoidance
2 Escape- 1.21 .19 .75 6.23 .00 —
Avoidance
Positive −.83 .17 −.60 −4.92 .00 .72 22.11 .00
Reappraisal
46 Community Mental Health Journal

such as locus of control. Fourth, the relationship between isolation and

seeking support might by moderated by actually receiving social sup-
port. Finally, the relationship between isolation and receiving support
might by moderated by seeking support. To investigate this issue, three
hierarchical regressions were conducted. In two analyses, receiving so-
cial support and locus of control were assessed as possible moderators
of the relationship between seeking social support and social isolation.
The interaction products of the predictor and moderators were not signif-
icant in either analysis. Therefore, receiving social support and locus
of control did not moderate the relationship between seeking social
support and isolation. Locus of control was assessed as a possible moder-
ator of the relationship between receiving social support and isolation
(the product of seeking and receiving social support was assessed in the
first moderator analysis). The product of receiving social support and
locus of control was not significant indicating a lack of moderation.
In predicting spousal relationship problems, the Ways of Coping Es-
cape-Avoidance subscale again entered first, followed by the Positive
Reappraisal and the Seeking Social Support subscales, R (3,48) = .69.
The relationships were such that increased use of escape-avoidance,
decreased use of positive reappraisal, and less seeking of social support
corresponded to increased spousal relationship problems (see Table 3).

TABLE 3

Stepwise Multiple Regression Predicting

Spousal Relationship Problems
Step Predictor b Error β t p Cum. R F p

1 Escape- .56 .17 .44 3.34 .00 .44 11.18 .00

Avoidance
2 Escape- .87 .17 .66 5.19 .00 —
Avoidance
Positive −.57 .14 −.51 −3.97 .00 .63 15.23 .00
Reappraisal
3 Escape- .88 .16 .67 5.62 .00 —
Avoidance
Positive −.50 .14 −.44 −3.60 .00 —
Reappraisal
Seeking −.34 .13 −.30 −2.66 .01 .69 13.87 .00
Social Support
 Michael E. Dunn, Ph.D., et al. 47

Although actually receiving social support had a significant correlation

with spousal relationship problems, it failed to enter the equation. Re-
ceiving social support had significant correlations with seeking social
support (r = .51, p = .00) and positive reappraisal (r = .37, p = .01) sug-
gesting that common variance accounted for prevented receiving social
support from entering the regression equation.

Moderator Analyses

Following the Baron and Kenny (1986) approach, three sets of regres-
sions were conducted to evaluate the hypothesis that ten variables (so-
cial support, locus of control, and eight coping styles) might moderate
the relationship between stressors and negative outcomes (depression,
social isolation, and spousal relationship difficulties). In addition, locus
of control was evaluated as a potential moderator of the relationship
between social support and negative outcomes. Moderator analyses were
conducted using hierarchical regression as described previously. When
predicting depression and spousal relationship problems, none of the
ten potential moderator-predictor interaction products were significant.
When predicting social isolation, however, two moderator-predictor in-
teraction products including Ways of Coping—Distancing subscale (t =
−2.48, p = .016, see Table 4) and social support (t = −2.91, p = .005, see
Table 5) were statistically significant. The moderator-predictor interac-
tion product was not significant in any of the analyses assessing locus
of control as a moderator of the relationship between social support and
negative outcomes. Therefore, locus of control did not appear to moderate
this relationship.

TABLE 4

Hierarchical Regression Assessing Moderation of the

Relationship Between Stressors and Social Isolation
by the Coping Style of Distancing. Variables are Listed
in Order of Entry
Predictor R2 Change F Change df Sig. F Change

Stressors .02 1.18 1,51 .28

Distancing .01 .65 1,50 .43
Product of Stressors
and Distancing .11 6.17 1,49 .02
48 Community Mental Health Journal

TABLE 5

Hierarchical Regression Assessing Moderation of the

Relationship Between Stressors and Social Isolation by
Social Support. Variables are Listed in Order of Entry
Predictor R2 Change F Change df Sig. F Change

Stressors .02 1.09 1,52 .30

Social Support .05 2.46 1,51 .12
Product of Stressors
and Social Support .14 8.46 1,50 .01

DISCUSSION

Social Support

Our hypotheses regarding social support were supported by a correlation

that indicated that higher levels of social support corresponded to fewer
spousal problems. In regression analyses, however, coping styles were
a more powerful predictor of spousal problems while social support
was not significant. It is interesting to note that there was no direct
relationship between social support and isolation suggesting that some
of these parents feel isolated despite receiving social support. In fact,
reliance on escape and avoidance and failure to use positive reappraisal
corresponded to feelings of isolation more than seeking or receiving
social support. Moderator analyses, however, indicated that the relation-
ship between social support and isolation is complex. Social support
was found to be a significant moderator of the relationship between
stressors and isolation such that decreasing social support corresponded
to an increased likelihood that stressors would correspond to isolation.
Therefore, it may be particularly important for these parents to receive
social support in more difficult times. Further research on the types of
support that are most helpful and on the relationship between support
and isolation is clearly warranted. Despite the analyses that supported
the importance of social support, coping styles were found to be more
directly related to isolation than seeking or receiving social support.
Therefore, while receipt of social support is clearly important, it may
be secondary to methods of coping. Practitioners would be well-advised
to facilitate social support for these parents, particularly in times of
 Michael E. Dunn, Ph.D., et al. 49

increased stress, but other types of coping should be emphasized as

well.

Locus of Control

In support of our hypotheses, internal locus of control corresponded to

lower levels of depression and isolation, but like social support, locus
of control was overshadowed by coping styles in the regression analyses.
Locus of control did not moderate the relationship between stressors
and negative outcomes or the relationship between social support and
negative outcomes. Therefore, locus of control did not buffer the effects
of stress or enhance the effects of social support. Again, the relationship
between social support and negative outcomes appears to be complex.
Encouraging an internal locus of control may not enhance the positive
effects of social support, but there is certainly reason to believe locus
of control is important. The direct relationship between internal locus
of control and fewer negative outcomes suggests that making the en-
hancement of parents’ sense of control a therapeutic goal would be
beneficial.

Styles of Coping

The emotion-focused coping style of escape-avoidance was found to corre-

spond to increased depression, isolation, and spousal relationship prob-
lems. Therefore, it may be particularly beneficial to discourage use of
escape-avoidance including hoping for miracles, having fantasies, using
food or drugs, and avoiding others. Distancing, another emotion-focused
style that includes going on as if nothing has happened, trying to forget
the situation, and making light of the situation, also corresponded to
increased depression. Distancing was also a significant moderator, how-
ever, in the relationship between stressors and isolation. Less use of
distancing corresponded to a greater likelihood that stressors would
correspond to isolation. It may be that parents who fail to use some
distancing strain their social relationships. If one is not able to talk
about any other subject or be interested in someone else’s life, isolation
may result from friends being less willing to provide social support.
Parents may benefit from being encouraged to distance themselves ap-
propriately from their situation when spending time with others to
facilitate interpersonal relationships.
Failure to employ several coping styles corresponded to negative out-
comes. Failure to use the emotion-focused style of positive reappraisal
50 Community Mental Health Journal

corresponded to isolation and spousal relationship difficulties. Failure

to use the problem-focused style of confrontive coping corresponded to
depression and failure to seek social support corresponded to spousal
relationship difficulties. Therefore, it might be beneficial to encourage
parents to use positive reappraisal, confrontive coping, and to seek
social support. Positive reappraisal includes such things as growing as
a person, finding new faith, rediscovering the important things in life,
and being inspired to be creative. Confrontive coping includes fighting
for what is wanted, expressing anger to the cause of the problem, letting
feelings out somehow, and taking chances.

Summary

It was the intent of this study to assess the simple and complex relation-
ships between stressors, social support, locus of control, coping styles,
and negative outcomes in parents of children with autism. Stressors
were not a direct predictor of negative outcomes, but their influence
was moderated by social support and coping style. Although locus of
control was correlated with negative outcomes, it was overshadowed by
coping styles in regression analyses. First and foremost, these data
indicated that it would be beneficial to discourage parents from using
escape and avoidance as a coping style. Encouragement of more appro-
priate coping and receipt of social support should also be beneficial in
buffering the effects of stressors and reducing negative outcomes.
It must be noted that coping behavior might be a short-term mecha-
nism, thus warranting further research on the long-term effects of coping
styles. In addition, the most critical period of adjustment and coping
may occur before the age of three and different relationships among
these variables may be observed in this time frame. Further research
with a narrower range of the child’s age may be warranted. Finally,
participants in this study were members of autism societies. There may
be a substantial number of parents who do not participate in these
societies. These parents may be coping effectively with different methods
or may be experiencing a higher rate of negative outcomes. Future work
should target this population.

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