Coping Strategies as Mediators and Moderators

RESEARCH ARTICLE

Coping Strategies as Mediators and Moderators between Stress and Quality of Life among Parents of Children with Autistic Disorder Latefa A. Dardas*† & Muayyad M. Ahmad The University of Jordan, Amman, Jordan

Abstract The purpose of this cross-sectional study was to examine coping strategies as mediators and moderators between stress and quality of life (QoL) among parents of children with autistic disorder. The convenience sample of the study consisted of 184 parents of children with autistic disorder. Advanced statistical methods for analyses of mediator and moderator effects of coping strategies were used. The results revealed that ‘accepting responsibility’ was the only mediator strategy in the relationship between stress and QoL. The results also revealed that only ‘seeking social support’ and ‘escape avoidance’ were moderator strategies in the relationship between stress and QoL. This study is perhaps the first to investigate the mediating and moderating effects of coping on QoL of parents of children with autistic disorder. Recommendations for practice and future research are presented. Copyright © 2013 John Wiley & Sons, Ltd. Received 4 February 2013; Revised 15 June 2013; Accepted 19 June 2013 Keywords mediators; moderators; coping; quality of life; autistic disorder *Correspondence Latefa A. Dardas, The University of Jordan, Amman 11942, Jordan. † Email: [email protected] Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/smi.2513

Introduction Coping with stressful situations that exceed one's abilities is one of the greatest challenges of life. According to Lazarus and Folkman's Transactional Model of Stress and Coping (1984), coping is defined as the cognitive and behavioural efforts that are constantly changing to master, reduce or tolerate a specific stressor appraised as exceeding one's available resources and abilities. A striking point in the model is that coping strategies are considered the intermediate process between stressors and health outcome. Indeed, Folkman, Lazarus, Dunkel-Schetter, DeLongis, and Gruen (1986) found that the process of coping can change the relationship between life stressors and health. Coping is considered to be of critical importance in determining whether a stressful event results in adaptive or maladaptive outcomes. To a parent, having a new child is considered a stressful situation. However, when the child is born with disability, parents bear greater stressors and demands that can disrupt the whole family's life, requiring a wide range of coping strategies (Gray, 2006). Autistic disorder is considered one of the pervasive developmental disorders. Children with autistic Stress Health (2013) © 2013 John Wiley & Sons, Ltd.

disorder show complex behaviours, which can create chaos in the parents' life. Particularly, those children are characterized by significant qualitative impairment in social interaction and communication, and restricted patterns of repetitive and stereotyped behaviour, interests and activities (the American Psychiatric Association (APA), 2000). Compared with parents of typical children and parents of children with other developmental disabilities, parents of children with autistic disorders have been found to experience significantly higher levels of parenting stress and psychological distress (Ericzon, Frazee, & Stahmer, 2005; Weiss, 2002). Further, poor quality of life (QoL) levels have been documented for those parents (Mungo, Ruta, Arrigo, & Mazzona, 2007; Yamada et al., 2012). Therefore, parents of children with autistic disorder are expected to be in vital need to develop ongoing effective coping responses to deal with their children's lifelong disability and to maintain their QoL. Indeed, the types of coping strategies used by parents of children with disability were found to have more decisive effect on their level of stress than the stressors itself (Beresford, 1994).

Coping Strategies as Mediators and Moderators

Despite the practical importance of studying coping, there has been a dearth of information available on this concept and its influences on parenting stress and QoL among parents of children with autistic disorder. Parenting stress is considered an aversive psychological reaction to the demands of being a parent that stems from a complex combination related to the child, the parent and the child–parent interactions (Abidin, 1995). The concept of QoL is defined as ‘individuals' perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns’ (WHO, 1996, p. 5). Although there is a growing awareness of the need to integrate the concept of QoL in the support services provided for children with chronic disabilities and their parents, the factors contributing to the QoL of those parents (e.g. their style of coping with life stressors) have received relatively little attention. Among the few studies that have investigated the interactions between the concepts of stress, coping strategies and QoL among parents of children with autistic disorder (e.g. Dabrowska & Pisula, 2010; Gray, 2006; Smith, Seltzer, Tager-Flusberg, Greenberg, & Carter, 2008), links between the types of coping strategies used by the parents and their levels of stress and QoL were revealed. It was inferred from these studies that parents who are able to develop effective coping strategies are likely to experience satisfactory levels of QoL and wellbeing and functional levels of parenting stress. In particular, active problem-focused strategies were associated with positive outcomes. Meanwhile, the reliance on passive, avoidant coping strategies was associated with negative outcomes. While drawing attention to the studies that investigated the concepts of stress, coping and QoL among parents of children with autistic disorder, two main methodological limitations can be argued. First, authors made their interpretation of the results in terms of the two general categories of coping strategies (emotion focused and problem focused). It has been argued by Folkman and Moskowitz (2004) that relying on this classification for the synthesis of findings may run the risk of distorting important differences within categories. In addition, classifying coping strategies into two distinct sets has the expectation that problem and emotion-focused strategies are independent of one another. However, different types of coping seem to overlap and facilitate each other. For example, emotion-focused strategies relieve emotional distress and, consequently, may encourage the person to engage in problem-focused coping. Conversely, effective problem-focused coping can lead to relieving the stressor-associated distressing feelings. Fortunately, Folkman and Lazarus (1988) adapted their work on coping classification and derived new eight classifications, including positive reappraisal, confrontive coping, planful problem solving, seeking social support, distancing, self-control,

L. A. Dardas and M. M. Ahmad

escape avoidance and accepting responsibility. Those categories provide a clear description for the thoughts and actions an individual uses to cope with a specific stressful encounter. A second limitation for the previous studies that investigated the concepts of stress, coping and QoL among parents of children with autistic disorder is that it presented these concepts through bivariate relationships. However, relationships among variables are often considered more complex than simple bivariate relationship such as between an independent variable and an outcome variable. Rather, these relationships may be modified by a third variable such as mediator and moderator (Baron & Kenny, 1986; Bennett, 2000). Mediators provide information about how or why two variables are strongly related, whereas moderators answer why a weak or strong association between two variables occurs (Lindley & Walker; 1993; Moore, Biegel, & Mcmahon, 2011). The importance of investigating mediation and moderation effects has been recognized in literature (Connor-Smith, & Compas, 2002; Littleton, Horsley, John, & Nelson, 2007). If researchers fail to consider the possibility of a mediator or moderator effect in the data, inappropriate explanation for the outcome may be reached. Unfortunately, few studies have tested coping strategies as mediators or moderators between life stress and health outcome. Further, no studies have been conducted on coping as a moderator and mediator in the relationship between stress and QoL among parents of children with autistic disorder. The purpose of this study was to examine coping strategies as mediators and moderators between stress and QoL among parents of children with autistic disorder.

Methods Sample To determine the sample size based on power analysis, Cohen's technique (1988) for power analysis was used. The estimated sample size needed for this study was 114 participants, based on α level of 0.05, power of 0.80, relatively small effect size (0.10) and three predictors in regression analysis. The convenience sample of the study was composed of 184 parents of children with autistic disorder. Parents were included in the study if (1) they had a child under the age of 12 years with a clinical diagnosis of autistic disorder and (2) they were able to read and write in Arabic. Parents were contacted individually through the special education centres where their children have been diagnosed with autistic disorder by licensed professionals. Participants were provided with simple incentives. The diagnosis was made on the basis of the Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR (fourth edition, text revision) provided by the American Psychiatric Association (APA, 2000). Stress Health (2013) © 2013 John Wiley & Sons, Ltd.


Measures The Parenting Stress Index—Short Form (Abidin, 1995) The Parenting Stress Index—Short Form (PSI-SF) is a 36-item self-reported questionnaire designed to measure stress associated with parenting among parents of children younger than 12 years (Abidin, 1995). The PSI-SF scale is one of the most commonly used measures across many different samples including parents with a range of income and education levels and parents of children with a broad range of ability levels (Dardas & Ahmad, 2013). The items of the scale range from 1 (strongly disagree) to 5 (strongly agree). Higher scores indicate greater levels of parenting stress (Abidin). The total stress score has been used for this study. The internal consistency reliability coefficient for the total stress was 0.91 (Abidin, 1995). In this sample, Cronbach's α for the total stress scale was 0.91. The Revised Ways of Coping Checklist (Folkman & Lazarus, 1988) The revised ways of coping is a 66-item questionnaire that contains eight different cognitive and behavioural strategies used to cope with stressful encounters, including confrontive coping (six items; describes active effort to alter a situation, sometimes associated with some degree of aggression, hostility and risk taking), distancing (six items; refers to cognitive efforts made to detach oneself from a stressful situation and minimize its significance), self-controlling (seven items; describes an individual's active effort to regulate their feelings and actions), seeking social support (six items; refers to efforts to seek informational, tangible and emotional support), accepting responsibility (four items; refers to the acknowledgment of one's contribution to the problem and trying to fix things out), escape avoidance (eight items; includes wishful thinking and behavioural efforts to avoid facing the problem), planful problem solving (six items; covers deliberate focus on altering the situation using careful analyses to solve the problem and generate possible solutions) and positive reappraisal (seven items; describes efforts that focus on personal growth and some religious aspects to create a positive meaning for a situation). Participants were required to respond to a specific stressor, raising a child with autistic disorder and subsequently respond to each statement in the scale by expressing the extent to which they used the strategy in coping with that stressful situation on a four-point scale from 0 (not used) to 3 (used a great deal). The internal consistency reliability coefficients ranged from 0.68 to 0.79 for the eight subscales (Folkman & Lazarus, 1988). In this sample, Cronbach's alphas for the eight subscales ranged from moderate to high. Stress Health (2013) © 2013 John Wiley & Sons, Ltd.


The World Health Organization Quality of Life Assessment–Bref self-administered instrument (WHO, 1996) The World Health Organization Quality of Life Assessment–Bref (WHOQOL-BREF) contains a total of 26 questions that were developed in an attempt to provide a QoL measure that would be applicable cross-culturally (WHO, 1996). It produces a profile with four physical, psychological, social and environmental domain scores and two individually scored items about an individual's overall perception of QoL and health. Items of the scale range from 1 to 5 with higher scores denoting higher QoL. The total QoL score has been used for this study. The WHOQOL-BREF is a cross-culturally valid and reliable assessment of QOL. In this sample, Cronbach's α for the total QoL scale was 0.93. Ethical considerations The Academic Research Committee at the Deanship of the Academic Research at the University of Jordan granted the ethical approval for conducting this study. The purpose, methods, risks and benefits of the study were explained to the participants before they decided to participate. The participants were assured that their participation would be completely voluntary and that they would have the right to quit their participations at any stage if they did not feel comfortable in continuing the process. The researchers assigned identification number to the participants to assure the confidentiality of the data obtained.

Results A total of 184 parents participated in the study. Of them, 62% (n = 114) were mothers. The mean age for the sample was 37 years [standard deviation (SD) = 7.6] ranging from 21 to 69 years. The majority of the parents (96.7%, n = 178) were married. In relation to the parents' level of education, 46.2% (n = 85) of them had secondary school or less (ranging from 9th grade to 12th grade), 23.9% (n = 44) had diploma and 29.9% (n = 55) had baccalaureate degree or higher. Overall, 56% (n = 103) of the parents were not working. All the parents had only one child diagnosed with autistic disorder. All children in this study were diagnosed with autistic disorder using the DSM-IV criteria (APA, 2000). The criteria of the DSM-IV are considered a standardized diagnostic procedure for autistic disorder in the country. About 84% (n = 155) of children were male. The mean age for children was 6.3 years (SD = 3) ranging from 2 to 12 years. The mean age of symptoms was 2 years (SD = 1). The mean age of diagnosis was 3 years (SD = 1). Regarding the level of parental stress, the analysis showed that the mean of the total stress score was 118 (SD = 23), which indicates a clinically significant high



levels of stress. The most frequently used coping strategy among the parents was ‘positive reappraisal’ (mean = 74.30, SD = 12.97), whereas ‘distancing’ was the least used coping strategy (mean = 55.19, SD = 13.56). The mean scores for the other six coping strategies ranged from 55 to 68. The mean of the total QoL score was 80 (SD = 16). Tests of mediated models Several steps were performed to examine the mediating effect of coping strategies on the relationship between stress and QoL using the Statistical Package for Social Sciences (IBM Corp., 2012). Eight sets of regressions were tested, with each set exploring mediation of the relationship between stress and QoL by one of the eight coping strategies. Following standard procedures, each mediated model was tested in three steps (Baron & Kenny, 1986; Warner, 2008). In the first step, associations of the independent variable (stress) with the possible mediator (the eight coping strategies) were examined. Stress was able to predict significantly two types of coping strategies: escape avoidance (t = 6.40; P < 0.001) and accepting responsibility (t = 4.55; P < 0.001). Thus, the other six types of coping were dropped from next steps of examinations (Table I). In the second step, the dependent variable (QoL) was regressed on the possible mediators (escape avoidance and accepting responsibility) of coping strategies. The two sets of regression demonstrated that escape avoidance and accepting responsibility had significant negative relationships with QoL (Table II). In the third step, the association of stress and QoL reduced significantly when ‘accepting responsibility’ was added to the hierarchical equation. The coping strategy ‘escape avoidance’ in the second step of regression remained significant predictor; thus, it was not considered as a mediator (Table III). Therefore, the

QoL R

R

2

Escape avoidance 0.366 0.134 Accepting responsibility 0.236 0.056

t

β

Significance

5.314 3.271

0.366 0.236

0.001 0.001

only mediator variable in this study, which fulfilled all the required criteria, was accepting responsibility (Figure 1).

R

t

Significance

0.007 0.135 0.138

0.092 1.838 1.874

0.927 0.068 0.063

0.013

0.181

0.856

Discussion

0.070 0.092 0.429 2 (R = 0.184) 0.320 2 (R = 0.102)

0.948 1.245 6.401 (β = 0.429) 4.551 (β = 0.320)

0.344 0.215 0.001

Dependent variables

Accepting responsibility

Independent variables

Tests of moderated models Moderated models of regression analyses were used to test the hypothesis that the relationship between stress and QoL occurs primarily under certain conditions, with coping serving either as an amplifier or as a buffer (Warner, 2008). Following a standard procedure, measures of coping and stress were centred in tests of coping moderation to maximize interpretability and minimize potential problems with multicollinearity (Aiken & West, 1991). Moderation was examined by constructing eight hierarchical regression equations that included stress, eight coping strategies and a multiplicative term representing the interaction between each of the coping strategies and stress. As with tests of the mediated models, a separate set of regression analyses was used for each of the eight coping strategies with all regressions controlling for stress as stress is entered first in the analysis on the basis of the Lazarus and Folkman model. In these models, a significant interaction term with a negative beta would suggest that a coping strategy is buffering the relationship between stress and QoL. A significant interaction term with a positive beta would indicate that a coping strategy is amplifying the relationship (Aiken & West, 1991; Baron & Kenny, 1986; Warner, 2008). The model with ‘seeking social support’ coping strategy accounted for 39% of the variance in QoL, with the interaction between coping and stress indicating that seeking social support served as amplifier. Similarly, the model with escape avoidance coping strategy accounted for 41% of the variance, with escape avoidance serving as amplifier (Figure 2). All other coping strategies did not show moderating effects between stress and QoL (Table IV).

Table I. Association of the independent variable with possible mediators

Positive reappraisal Confrontive coping Planful problem solving Seeking social support Distancing Self-control Escape avoidance

Table II. Association of the possible mediators with the QoL

Stress (independent variable)

0.001

Investigating the mediation and moderation effects of the variables is of great importance in providing explanations for the outcomes. The examination of mediators and moderators in descriptive studies can clarify why or how a direct association occurs between an independent variable and an outcome variable. To the best of our knowledge, no previous studies have yet Stress Health (2013) © 2013 John Wiley & Sons, Ltd.



Table III. Hierarchical regression testing for coping strategies as mediators Steps

1 2 1 2

Independent variables

Stress Stress Escape avoidance Stress Stress Accepting responsibility

QoL 2

R

R

0.608 0.619

0.370 0.383

0.608 0.610

0.370 0.372

examined coping as a moderator and mediator in the relationship between stress and QoL among parents of children with autistic disorder. In this study, mediated and moderated models were examined to explore the role of coping in the relationship between stress and QoL. The results of this study showed that accepting responsibility was the only mediator strategy in the relationship between stress and QoL among parents of children with autistic disorder. The other seven types of coping did not show a mediating effect. This indicates that only accepting responsibility was able to explain the relationship between stress and QoL among

t

β

Significance

10.332 8.551 2.007 10.332 9.541 0.739

0.608 0.552 0.139 0.608 0.593 0.046

0.001 0.001 0.046 0.001 0.001 0.461

the parents. According to Folkman and Lazarus (1988), accepting responsibility entails the acknowledgment of one's contribution to the problem and trying to correct the situation. In this study, it can be inferred that accepting responsibilities for the problems that parents face due to having a child with autistic disorder can explain the higher levels of QoL they reported. Accepting responsibility does not entail that parents should believe that the problems they have are their fault, rather what this means is that parents need to accept that they have the problem and they are the only ones who can fully determine the outcome. By taking responsibility for their life problems, parents will find

Figure 1 Accepting responsibility as mediator between stress and QoL. Note: The coefficient 0.05 represents the strength of linear association between QoL and stress when accepting responsibility is controlled by including it as another predictor of QoL; the coefficient 0.59 represents the linear association between QoL and stress when accepting responsibility is not statistically controlled

Figure 2 Coping strategies as moderators in the association between stress and QoL Stress Health (2013) © 2013 John Wiley & Sons, Ltd.



Table IV. Moderated model regression analyses for the eight coping strategies (QoL is dependent variable) Steps 1 Stress Positive reappraisal 2 Stress Positive reappraisal Stress × Positive reappraisal 1 Stress Confrontive coping 2 Stress Confrontive coping Stress × Confrontive coping 1 Stress Planful problem solving 2 Stress Planful problem solving Stress × Planful problem solving 1 Stress Seeking social support 2 Stress Seeking social support Stress × Seeking social support 1 Stress Distancing 2 Stress Distancing Stress × Distancing 1 Stress Self-control 2 Stress Self-control Stress × Self-control 1 Stress Escape avoidance 2 Stress Escape avoidance Stress × Escape avoidance 1 Stress Accepting responsibility 2 Stress Accepting responsibility Stress × Accepting responsibility

R

2

0.384 0.386

0.370 0.377

0.398 0.402

0.374 0.391

0.382 0.382

0.371 0.374

0.383 0.406

0.372 0.373

β

T

0.607 0.120 0.612 0.118 0.039 0.609 0.008 0.988 0.483 0.664 0.584 0.171 0.851 0.126 0.376

10.409*** 2.059* 10.391*** 2.017* 0.662 10.227*** 0.130 3.603*** 1.373 1.416 10.042*** 2.938** 3.327*** 0.444 1.071

0.609 0.065 1.265 0.736 1.050 0.616 0.109 0.500 0.263 0.202 0.612 0.042 0.914 0.247 0.440 0.552 0.130 1.033 0.863 1.045 0.593 0.046 0.732 0.241 0.277

10.351*** 1.099 4.207*** 2.019* 2.225* 10.506*** 1.861 2.210* 0.885 0.529 10.339*** 0.707 2.658** 0.750 0.891 8.551*** 2.007* 5.263*** 2.970** 2.587** 9.541*** 0.739 3.579*** 0.858 0.712

*P ≤ 0.05, **P ≤ 0.01, ***P ≤ 0.001.

a greater sense of control and will quickly progress in recovery rather than dwelling on the past or blaming the problem on an outside factor. The results indicate that accepting responsibilities need to be encouraged through equipping parents with the needed skills and support services that could help them adapt with their responsibilities and develop positive outcomes for their acceptance. The results also further support investigation of the role that coping strategies play in the relationship between stress and QoL.

On the other hand, the results of this study showed that only seeking social support and escape avoidance were moderator strategies in the relationship between stress and QoL among parents of children with autistic disorder. All other coping strategies did not show moderating effect between stress and QoL. Given the difficulty of detecting moderator effects in non-experimental studies, interactions between stress and seeking social support explained 1.7%, as well as stress and escape avoidance explained 2.3% of the variance, which can be meaningful (Yip, Rowlinson, & Siu, 2008). This indicates that when parents of children with autistic disorder use more seeking social support or escape avoidance coping strategies to alter stressful encounters, these strategies are able to improve significantly the QoL of the parents. In contrast to Kashdana, Barriosb, Forsyth, and Stegerc (2006) and Hastings et al. (2005) who reported that avoidance strategy has been linked to increases in intrusive thoughts, anxiety and depression, our study found escape avoidance as a buffer for stress. It is important to note that although avoidance strategy may be helpful in the short term (Heckman et al., 2004), it is found to adversely affect the mental health of individuals when used on the long run when dealing with chronic stressors such as raising a child with a lifelong disability (Holahan, Moos, & Bonin, 2004). Since people who do not deal with their stressors directly are more likely to suffer health problems, researchers believe that avoidance coping strategy is not as efficient as confrontive strategies (Folkman & Moskowitz, 2004; Lazarus & Folkman, 1984). Regarding seeking social support, the result was consistent with the logical interpretation and previous findings in reducing stress. McCubbin and Patterson's (1983) viewed seeking social support to be the most important for parents experiencing stress. Gray (2006) supported this finding and reported that seeking social support is one of the popular effective strategies that parents of children with autistic disorder use when dealing with their stressors. Moreover, McConkey, Truesdale-Kennedy, Chang, Jarrah, and Shukri (2008) reported that families in different cultures utilize different coping strategies when caring for a child with chronic disability. The sample of this study was in part from the Arab world. Arabs are united in a shared culture that is considered substantially different from their western counterparts (Retso, 2002). According to Fakhr El-Islam (2008), many educational, economic and cultural factors affect mental health perceptions and practices in the Arab world. Social support is considered a valued Arabic tradition that plays a prophylactic role in the development of mental health problems. The extended family system in the traditional Arab cultures was found to significantly help individuals deal with their life stressors (Fakhr El-Islam, 2008; Kandel, Morad, Vardi, Press, & Merrick, 2004). This explanation may also be supported by the fact that the vast majority of the parents (96.7%) were married. Stress Health (2013) © 2013 John Wiley & Sons, Ltd.


Confrontive coping, planful problem solving, selfcontrolling and positive reappraisal coping strategies did not show any mediation or moderation effect in the relationship between parental stress and QoL. It is worth noting that the mentioned strategies were among the most commonly used strategies by the parents. However, it had no effect on the relationship between their perceived parental stress and QoL. These findings warrant further investigations for the actual application of coping and the meaning that coping has for the parents. For example, confrontive coping includes fighting for what is wanted, expressing anger to the cause of the problem and letting feelings out somehow (Folkman & Lazarus, 1988). Failure to employ confrontive coping in an adaptive style can lead to adverse effects and higher levels of parental stress. On the other hand, distancing coping was the least reported parental coping strategy in this study and showed no effect on the relationship between parental stress and QoL. Although distancing coping, which was defined by Folkman and Lazarus (1988) as undertaking cognitive efforts to detach oneself from a stressful situation and minimize its significance, was found to be correlated with negative outcomes (Smith et al., 2008), it has been argued by some researchers that distancing is considered a significant moderator in the relationship between stressors and mental health (Dunn, Burbine, Bowers, & Tantleff-Dunn, 2001; Sivberg, 2002). In other words, for parents of children with chronic disabilities (e.g. autistic disorder), being unable to detach themselves from their children-related problems may lead to exaggerate their distress and as a result negatively affect their mental health. Therefore, it may be beneficial to encourage parents with chronic stressors to distance themselves appropriately from their stress-provoking situations. In this study, having distancing the least reported coping strategy with no effects on the relationship between parental stress and QoL may indicate that parents are enmeshed in their relationship with their children with autistic disorder and, as such, are at high risk for developing negative outcomes for their parenting experience. Another area in this study deserving special consideration is related to gender differences in regard to coping reactions to life stressors. Discussion on gender-related issues is unsettled. Research on gender and coping has traditionally assumed that men and women perceive stressors similarly. In addition, the traditional perception was that men are more likely to suppress their feelings, whereas women are more likely to vent their feelings and use social support as a means of dealing with their distress. However, this assumption was refuted by Lazarus (1996) who reported that men and women do not experience the same problems when exposed to the same stressful life events. Lazarus also maintained that differences in the coping strategies used by men and women are related to the different roles they assume in their societies and cultures, and not to their gender per se. Therefore, in Stress Health (2013) © 2013 John Wiley & Sons, Ltd.


this study, we considered mothers and fathers together rather than separately as we were unable to identify the different roles and responsibilities that the fathers and mothers actually assumed. Referring to the Lazarus and Folkman model (1984), the relative use of coping strategies varies significantly among individuals. The stress coping process is influenced by antecedent person characteristics and environmental variables (Folkman & Lazarus, 1988). In addition, Gray (2006) argued that coping among parents of children with autistic disorder appears to be a complex process incorporating a variety of strategies that change over time. Thus, although correlations between stress and most coping strategies were low in this study, it is possible that personality characteristics influenced this relationship. It is also possible that events that would be perceived as stressors for some individuals were irrelevant events for others. Implications, limitations and recommendations One should consider variations in coping strategies among individuals across cultures. In particular, health professionals and researchers should be alerted about making false generalizations that are not based on specific research findings in a specific culture. The results of this study also indicate that professionals who work with parents of children with autistic disorder need to be aware of the coping strategies that the parents use to deal with the demands of parenting and the associations between coping, and parental stress and mental health. The focus need to be on increasing their use of healthy coping, perhaps by enhancing positive perceptions and acceptance of raising a child with autistic disorder. In addition, health professionals need to provide parents of children with autistic disorder with adequate formal support. This would be especially beneficial in developing countries where formal support is almost nonexistent. There are some methodological issues that should be considered when interpreting the results of this study. The psychometric properties of the PSI-SF were previously examined in parents of children with typical development. Thus, findings related to this measure should be carried with caution when it is used across populations with pervasive chronic disabilities. Further, considering the limitations associated with the use of meditational analyses in cross-sectional samples, we recommend replicating this study in a variety of distressed samples using longitudinal designs. The sample of this study was convenience; nevertheless, the heterogeneity and the size of the sample are assumed to be strength for the purpose of the analyses. However, it is recommended for future studies in this field to follow the probability sampling. It is also noteworthy to consider the sensitivity of the measures when carrying out crosscultural research.



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