See

discussions, stats, and author profiles for this publication at:

https://www.researchgate.net/publication/303438009

Multilevel approach to gender differences

in adaptation in father-mother dyads
parenting individuals with Autism
Spectrum Disorder

Article in Research in Autism Spectrum Disorders August 2016

Impact Factor: 2.96 DOI: 10.1016/j.rasd.2016.04.003

READS

3 authors:

Cristina Garca-Lpez Encarnacin Sarri

Hospital Sant Joan de Du National Distance Education University
6 PUBLICATIONS 15 CITATIONS 46 PUBLICATIONS 124 CITATIONS

SEE PROFILE SEE PROFILE

Pilar Pozo
National Distance Education University
13 PUBLICATIONS 66 CITATIONS

SEE PROFILE

All in-text references underlined in blue are linked to publications on ResearchGate, Available from: Encarnacin Sarri
letting you access and read them immediately. Retrieved on: 06 June 2016
 Research in Autism Spectrum Disorders 28 (2016) 716

Contents lists available at ScienceDirect

Research in Autism Spectrum Disorders

journal homepage: http://ees.elsevier.com/RASD/default.asp

Multilevel approach to gender differences in adaptation in

father-mother dyads parenting individuals with Autism
Spectrum Disorder
Cristina Garca-Lpeza,b,* , Encarnacin Sarria , Pilar Pozoa
a
Faculty of Psychology, National University of Distance Education (UNED), Madrid, Spain
b
Learning Disabilities Unit (UTAE), Neuropediatrics Department, Hospital Sant Joan de Du, Barcelona, Spain

A R T I C L E I N F O A B S T R A C T

Article history: Background: Most studies of gender differences in the ASD literature present methodologi-
Received 30 December 2015 cal limitations regarding the treatment of dyadic data. This work explored gender
Received in revised form 18 April 2016 differences in the psychological adaptation of a sample of Spanish fathers and mothers of
Accepted 20 April 2016
individuals with Autism Spectrum Disorder (ASD) using a multilevel modeling approach
Available online xxx
(MLM) that accounts for nested data.
Method: Questionnaires including different adaptation measures were completed by 120
Keywords:
father-mother dyads raising individuals with ASD. We designed a two-level model (parents
Autism severity
Parental adaptation
nested in dyads) with three predictor variables at level 1 (parent gender, parent age, and
Gender perception of childs behavior problems) and four predictor variables at level 2 (child age,
Multilevel modelling family income, ASD severity, and time since diagnosis) to examine the inuence of these
variables on negative and positive psychological outcomes (stress, anxiety, depression, and
psychological well-being).
Results: Mothers experienced higher levels of stress and anxiety than fathers, even after
controlling for interdependence and sociodemographic factors. ASD severity was a
signicant predictor of both progenitors stress and well-being, and family income was also
related to psychological well-being, although no gender differences were observed in the
way these variables are related to parental outcomes.
Conclusions: Professionals should offer parents support to adjust expectations according to
their childs ASD severity given its relationship to parental stress and well-being.
Considering that mothers experience higher levels of stress and anxiety than fathers,
clinicians should encourage maternal protective factors. Finally, governments should
consider new policies aiming to support ASD families treatment expenses.
2016 Elsevier Ltd. All rights reserved.

1. Introduction

Autism Spectrum Disorder (ASD) is a pervasive neurodevelopmental impairment characterized by social communication
decits along with stereotyped behavior, interests and activities (American Psychiatric Association [APA], 2013). Given these
difculties, parenthood is expected to be a challenging experience for mothers and fathers of individuals with ASD. In fact,

* Corresponding author at: Learning Disabilities Unit (UTAE), Neuropediatrics Department, Hospital Sant Joan de Du, c/Entena 154, 08029 Barcelona,
Spain.
E-mail addresses: cgarcialo@hsjdbcn.org (C. Garca-Lpez), esarria@psi.uned.es (E. Sarri), ppozo@psi.uned.es (P. Pozo).

http://dx.doi.org/10.1016/j.rasd.2016.04.003
1750-9467/ 2016 Elsevier Ltd. All rights reserved.
8 C. Garca-Lpez et al. / Research in Autism Spectrum Disorders 28 (2016) 716

studies have consistently demonstrated that parents of individuals with ASD manifest more psychological problems than
parents of typically developing children and parents of children with other disabilities (Dabrowska & Pisula, 2010;
Eisenhower, Baker, & Blacher, 2005; Hayes & Watson, 2013; Totsika, Hastings, Emerson, Berridge, & Lancaster, 2011). With
regard to gender, past research has suggested that mothers and fathers raising individuals with ASD report different patterns
of both negative and positive psychological adaptation.
Traditionally, stress has been one of the more widely studied variables in the literature on negative parental outcomes.
Most researchers have found that mothers of individuals with ASD are more likely to experience higher levels of stress than
fathers (Dabrowska & Pisula, 2010; Hastings, 2003; Little, 2002). Similarly, research indicates that both depression and
anxiety levels are higher in mothers than in fathers (Gau et al., 2012; Hastings, 2003; Hastings & Brown, 2002; Hastings et al.,
2005; Lee, 2009). This discrepancy has been linked to the fact that mothers are usually the primary care-givers (Tehee,
Honan, & Hevey, 2009). However, some studies of families of individuals with ASD have not observed gender differences in
the levels of parental stress, anxiety or depression (Davis & Carter, 2008; Epstein, Saltzman-Benaiah, O'Hare, Goll, & Tuck,
2008; Pozo & Sarri, 2014a; Rimmerman, Turkel, & Crossman, 2003). In fact, Rivard, Terroux, Parent-Boursier, and Mercier
(2014) recently found that fathers report signicantly higher stress levels than mothers do.
Beyond the many studies that focus on negative adaptation, there is evidence that some ASD families experience positive
outcomes (Bayat, 2007; Hastings & Taunt, 2002; Pakenham, Sofronoff, & Samios, 2011). The results of various studies indicate
that mothers present higher levels of positive perceptions as a result of raising their children with ASD than fathers do
(Hastings et al., 2005; Kaytz, Gragg, & Orr, 2010; Sarri & Pozo, 2015).

1.1. Predictors of parental outcomes

Research suggests that some factors associated with raising an individual with ASD can explain the different patterns
observed in these families when compared with other clinical and control groups. To determine these factors, researchers
have examined a number of predictors of negative and positive adaptation, among which sociodemographic and child
factors have been found to be relevant.
Some of the sociodemographic variables that have been proposed as predictors of parental adaptation include parent and
child age, family income, the presence of other family members with a disability, and the size of the social network (Hartley,
Seltzer, Head, & Abbeduto, 2012; Jones, Totsika, Hastings, & Petalas, 2013; Smith, Greenberg, & Seltzer, 2012). Child variables
that have been associated with parental adaptation measures include child age, the severity of social-communication
decits, behavior problems, cognitive impairment, eating and sleeping problems, and emotional deregulation (Bebko,
Konstantareas, & Spinger, 1987; Davis & Carter, 2008; Pozo, Sarri, & Brioso, 2014). In this category, the positive association
between both behavior problems and disorder severity with parental stress has been one of the most widely documented
ndings in families of children with ASD and developmental disabilities (Estes et al., 2013; Hastings & Brown, 2002; Pozo &
Sarri, 2015; Rezendes & Scarpa, 2011; Tomanik, Harris, & Hawkins, 2004; Zaidman-Zait et al., 2010).
As for gender differences, fathers and mothers levels of psychological adaptation seem to be affected by different child
variables. For instance, Allen, Bowles, and Weber (2013) determined that a childs social skills predicted stress in mothers,
whereas fathers stress was predicted by problems in the childs sensory and cognitive skills. In a sample of parents of
individuals with Asperger Syndrome, Epstein et al., 2008 showed that a childs executive dysfunction and sensory
sensitivities were signicantly and positively correlated to the mothers stress but not to the fathers stress. Herring et al.
(2006) also found that childrens emotional and behavioral problems contributed signicantly more to mothers stress than
to fathers stress. However, support for hypotheses for gender differences is difcult to test because neither fathers
representation nor interdependence within couples has been appropriately addressed in the autism research eld so far
(Jones et al., 2013). In most ASD research, fathers tend to be underrepresented, and thus, the ndings yield partial
conclusions (Braunstein, Peniston, Perelman, & Cassano, 2013; Flippin & Crais, 2011). In addition, most studies about
predictors of psychological adaptation do not use statistical methods that take into account that couples mutually inuence
each other and tend to share beliefs and feelings, which could explain similarities in the experience of parenting an
individual with ASD. Pottie and Ingram (2008) are an exception to this trend, as they explored ASD parents experiences and
subsequent subjective well-being through a daily diary method using a multilevel modeling (MLM) approach that accounts
for the interdependence of data. Their results show no gender differences in the use of effective coping responses. Another
representative study that considered interdependence was conducted by Jones et al. (2013), who used an MLM approach to
examine gender differences in 161 couples raising children with ASD. These authors showed that mothers experienced more
emotional distress and higher levels of positive gain than fathers. When these researchers controlled for demographic
characteristics and child factors, all outcome measures remained statistically signicant, except for positive gain, for which
gender differences disappeared. However, the researchers found little support for gender patterns in predictors of
adaptation: Compared with fathers, mothers anxiety was signicantly more affected by more severe behavior problems and
less adaptive skills in the child.
In view of the methodological limitations that characterize most studies addressing gender differences in the ASD
literature and the inconsistency of the ndings, we considered it relevant to conduct a new study on the predictors of
mothers and fathers psychological adaptation in order to better understand the specic needs of parents of individuals with
ASD. We adopted an MLM approach on a sample with a wide range of parental and child ages. Moreover, following the
methodological suggestions of Jones et al. (2013), to improve the research approach, our ratings of child characteristics were
 C. Garca-Lpez et al. / Research in Autism Spectrum Disorders 28 (2016) 716 9

based on professionals (who rated ASD severity) and both progenitors (fathers and mothers rated childrens behavior
problems separately).

1.2. Aims and hypothesis

The purpose of the present study is to examine gender differences when parenting individuals with ASD and the inuence
of child variables on parental psychological adaptation while controlling for the interdependence of dyadic data and
sociodemographic factors. We posed the following research questions: First, are there signicant differences in mothers and
fathers levels of stress, anxiety, depression and psychological well-being when we control for the interdependence of data?
Second, do child variables differently inuence fathers and mothers adaptation measures when we control for the
interdependence of data and for sociodemographic variables? On the basis of the gender differences found in previous
research (Dabrowska & Pisula, 2010; Gau et al., 2012; Hastings, 2003; Hastings & Brown, 2002; Jones et al., 2013; Little,
2002;), we hypothesized that mothers would experience more emotional maladjustment than fathers would. We also
predicted that the parental adaptation of fathers and mothers would be affected by different child factors (Allen et al., 2013;
Epstein et al., 2008).

2. Methods

2.1. Participants

The participants in the present study included 240 parents nested in 120 dyads. Their age ranged from 28 to 72 years.
Every dyad (n = 120) had at least one biological child aged 338 years who had been diagnosed with ASD. The inclusion
criteria were having a son or daughter diagnosed with ASD and having all family members living in the same home. Families
who participated in this study provided previous diagnoses given by licensed psychologists or neuropediatricians with
extensive ASD training and clinical experience. Parents had a clinical report specifying their childs diagnosis according to the
DSM-IV-TR (APA, 2000) or updated criteria (DSM-5; APA, 2013), depending on the current criteria at the time of the
diagnosis. Diagnostic evaluations included in all cases an interview with the parents and the ASD individual about early

Table 1
Participants sociodemographic characteristics.

Characteristic Fathers Mothers Family

% (n) % (n) % (n)
Education level
Primary school 13.3 (16) 13.3 (16)
Secondary school 40.0 (48) 33.4 (40)
University grade 46.7 (56) 53.3 (64)
Employment
Full time 85.0 (102) 50.0 (60)
Part time 1.7 (2) 8.3 (10)
Unemployed 3.3 (4) 10.8 (13)
Freelance 4.2 (5) 4.2 (5)
House 0.8 (1) 22.5 (27)
Retired 5.0 (6) 4.2 (5)
Family incomea (euros)
<500 14.2 (17)
500850 32.5 (39)
8501200 20.8 (25)
12001800 19.2 (23)
>1800 13.3 (16)
ASD Diagnosis
ASD (DSM-5 criteria) 26.7 (32)
Autistic Disorder 42.5 (51)
Asperger Syndrome 9.2 (11)
Rett Syndrome 4.2 (5)
PDD-NOS 17.5 (21)
Type of Education Center
Ordinary school 56.7 (68)
Special education school 7.5 (9)
Autism specic school 30.8 (37)
Day-care Centre 5.0 (6)
Age M (SD) M (SD) M (SD)
Parent 44.88 (7.62) 43.23 (6.75)
ASD individual 11.14 (6.65)

ASD: Autism Spectrum Disorder; PDD-NOS: Pervasive Developmental DisorderNot Otherwise Specied.
a
Family income: monthly income per number of family members.
10 C. Garca-Lpez et al. / Research in Autism Spectrum Disorders 28 (2016) 716

history and current symptoms and a rating scale based on clinical observation completed by the professional. The formal
diagnosis of ASD is necessary to access autism-specic services in Spain, and some local authorities may require a
reassessment and conrmation of the diagnosis before they will provide special services. In our sample, the mean time since
the last diagnosis (based on clinical reports date) was 6 years.
The age of the mothers and fathers and their education levels were similar (see Table 1). However, the results showed a
signicant difference in employment (x2 = 45.22, p < 0.001): Most fathers were employed full time (85%), whereas 50% of
mothers had a full-time job. Most individuals had the diagnosis of autistic disorder, as described in the DSM-IV criteria
(42.5%), followed by those diagnosed with ASD according to the DSM-5 criteria (26.7%). We also measured the involvement
of each parent in the care of their son or daughter according to their partners perception using a 10-point scale ranging from
0 (not at all involved in the sons or daughters care) to 10 (fully involved in caregiving tasks). Fathers perceived mothers
involvement to be signicantly higher (M = 9.39, SD = 0.88) than mothers perceived fathers involvement in caregiving tasks
(M = 7.30, SD = 2.18; t = 9.81, p < 0.001).

2.2. Instruments

Data for sociodemographic variables were gathered through a brief questionnaire specically designed for this
investigation. Given that the Behavior Problems Inventory had not been translated into Spanish, we adopted the back-
translation technique to ensure translation accuracy. The remaining instruments had been previously adapted into Spanish
by other authors.
Childhood Autism Rating Scale (CARS; Schopler, Reichler, & Reisner, 1988; adapted for Spanish by Garca-Villamisar &
Polaino-Lorente, 1992). The psychologists who worked with the individuals with ASD administered this tool. The CARS
comprises 15 items, with scores ranging from 1 (age-appropriate behavior) to 4 (severe or profoundly abnormal behavior).
Total scores range from 15 to 60; scores higher than 30 indicate the presence of ASD. The Spanish adaptation of the CARS has
good internal consistency (a = 0.98) and concurrent validity (Kappa coefcient = 0.78). For the purposes of our study, we used
the global score as a measure of ASD severity. The level of internal consistency was good in our study (a = 0.94). It should be
noted that not all participants met the cut-off criteria of above 30. However, no participants were excluded considering past
research comparing clinical diagnostic criteria with CARS scores. In particular, Garca-Lpez and Narbona (2014) found that
the CARS cut-off (30) was appropriate to detect Autistic Disorder (according to the DSM-IV-TR criteria) but not to screen for
mild forms of ASD, such as Asperger Syndrome or PDD-NOS. In this study, the authors concluded that CARS is a suitable tool
to monitor for ASD symptoms and to estimate severity of the disorder. Further studies have found that individuals presenting
mild forms of clinically diagnosed ASD score in a range from 19 to 34.5 in the CARS-2 (Mayes et al., 2014). In our study, the
range in CARS total scores was 20.5-57.5 (M = 34.46, SD = 9.1).
Behavior Problems Inventory (BPI; Rojahn, Matson, Lott, Svensen, & Smalls, 2001). This inventory comprises 52 items
grouped into three subscales (self-injurious, stereotyped, and aggressive/destructive behavior). Parents must score items on
a 4-point severity scale ranging from 0 (no problem) to 3 (a severe problem). In this study, we used the aggressive/destructive
behavior subscale (11 items) of this inventory. Items on this subscale are rated on a 4-point severity scale (03), and global
scores can range from 0 to 33. The internal consistency in the original study was 0.82. In our study, this subscale showed good
reliability (a = 0.83). To avoid overloading families with overly lengthy questionnaires, we decided on the aggressive/
destructive behavior subscale, which we considered to be the most informative for our study. Tomanik et al. (2004) found
that mothers of children with autism reported the greatest stress when their children were more irritable, lethargic/socially
withdrawn, or hyperactive/non-compliant, whereas the other two domains of the Aberrant Behavior Checklist (ABC),
stereotypic behavior and inappropriate speech, failed to show a signicant relationship with maternal stress. Aggressions
and disruptions to the environment place children with ASD and others around them at risk of physical injury while limiting
their involvement in community activities (Sigafoos, Arthur, & OReilly, 2003). Following the recommendation of Jones et al.
(2013), we incorporated two different ratings of behavior problems by asking fathers and mothers to score this inventory
separately. Parents in our sample reported very low levels of aggressive/destructive behavior problems in their children
(M = 3.55, SD = 4.45).
Parental Stress Index (PSI/SF; Abidin, 1995). To measure parental stress levels, we used the Spanish version of the Parental
Stress Index Short Form (PSI/SF), which is a self-administered scale composed of 36 items scored on a 5-point Likert scale from
1 (completely disagree) to 5 (completely agree). The internal consistency of the global scale was 0.91 (Daz-Herrero, Brito de
la Nuez, Lpez-Pina, Prez-Lpez, & Martnez-Fuentes, 2010). In addition to global stress, the scale offers three other
measures: (a) parental distress, (b) dysfunctional parent-child interaction, and (c) a difcult child. According to Zaidman-Zait
et al. (2010), items in the parent distress subscale are useful to assess the severity of distress among parents of individuals
with ASD. However, items in the parent-child dysfunctional interactions and difcult child subscales function less well
because they were not developed considering the specic behavioral prole of children with ASD. Consequently, following
Zaidman-Zait et al.s (2010) recommendations, we used the parental distress scale, which showed good internal consistency
(a = 0.87).
Anxiety and Depression Scale (HADS; Zigmond & Snaith, 1983). Adapted and validated by Tejero, Guimer, and Farr (1986).
This 14-item self-administered questionnaire includes two subscales for anxiety and depression measured using a 4-point
Likert scale ranging from 0 to 3. Scores of 12 or higher indicate clinically signicant levels of anxiety or depression. In a
literature review of the validity of the HADS (Bjelland, Dahl, Haug, & Neckelmann, 2002), the Cronbach's alpha for HADS-A
 C. Garca-Lpez et al. / Research in Autism Spectrum Disorders 28 (2016) 716 11

(anxiety subscale) varied from 0.68 to 0.93 (mean 0.83), and that for HADS-D (depression subscale) ranged from 0.67 to 0.90
(mean 0.82). In the present study, the reliability data were good for both HADS-A (a = 0.90) and HADS-D (a = 0.90).
The Brief Psychological Well-being (Ryff, 1989; Ryff & Keyes, 1995). Adapted and validated in Spanish by Daz et al. (2006).
The original version of the Ryff consists of 120 items grouped into six dimensions. Daz et al. (2006) proposed a reduced
version that was translated into Spanish and composed of 29 items. Answers are given on a 6-point scale from 1 (completely
disagree) to 6 (completely agree). The internal consistency of the brief version of the original scale is good (a = 0.84). In our
study, we analyzed the global score, and the level of internal consistency was 0.92.

2.3. Procedure

The participants were recruited from the Learning Disabilities Unit (UTAE) at Hospital Sant Joan de Du in Barcelona,
education centers in Madrid (ALEPH, CEPRI, PAUTA, Antonio Gala and Enrique Tierno Galvn), parents associations (PROTGD,
Autismo Burgos) and the Spanish Professional Association of Autism. Parents received a presentation letter from these
institutions that explained the aims and characteristics of the study. They could voluntarily choose to participate by
completing a booklet of questionnaires on paper or via e-mail. Informed consent was obtained from both parents, and
anonymity and condentially was guaranteed. We offered participants the opportunity to receive the results of their
personal psychological adaptation proles after completing the questionnaires.

2.4. Analysis plan

We used an MLM approach because these statistical procedures are capable of handling data when the observations are
not independent, modeling correlated errors, and allowing the adjustment of observation-level predictions based on the
clustering of measures at some higher level or by some grouping variable (Raudenbush & Bryk, 2002). The data structure
comprises two levels. The rst level (level 1) contains within-person measures (parent gender, parent age, and behavior
problems) representing the variation in outcome measures between individuals, whereas the second level (level 2) contains
shared dyad factors (child age, time since diagnosis, ASD severity, and family income) representing variation between dyads
(Fig. 1). It should be noted that the behavior problems variable is considered a level 1 variable because we rated both fathers
and mothers perceptions of their sons or daughters challenging behaviors, as proposed by Jones et al. (2013). Grouping
variables (being nested in the same dyad) were modeled as random factors, whereas predictors at any level (1 or 2) were
included as xed factors in the different models. Prior to the analysis, predictor variables were centered on their mean, as
recommended by Kenny, Kashy, and Cook (2006), to minimize multicollinearity. The entire MLM analysis was conducted
with SPSS v.22 using the Mixed Models command (Pardo, Ruiz, & San Martn, 2007). We constructed the different models
(stress, anxiety, depression and well-being) using the following approach.
The rst step was to calculate the intraclass correlation (ICC) to estimate the within-dyad correlation. This value indicates
the relationship between the within-dyad variability relative to the within-person variability. As the ICC increases, so does
the number of similarities between the members of the dyad, which justies the use of this type of statistical approach. To
test whether mothers and fathers experience different psychological adaptation levels, we introduced the parents gender as
a xed effect in each model. Then, we introduced potential confounding variables, such as parent age, family income, child
age and time since diagnosis, to examine their inuence on parental adaptation. After conducting these analyses, we retained
only variables that were signicantly associated with the outcome measures in the nal models, adopting a parsimonious
approach. In the nal models, we introduced child factors (ASD severity and behavior problems) in the different models to
test the main and interaction effects on parental adaptation measures while controlling for the confounding variables that
had been previously identied in each model.

[(Fig._1)TD$IG]
PREDICTORS OUTCOMES

Child age
Time since diagnosis
Level 2
ASD severity
Dyadic Family income

Level 1 Parent gender Stress

Individual Parent age Anxiety

Child behavior problems Depression

Well-being

Fig. 1. Data structure including predictor and outcome variables in two levels (individual and dyadic).
12 C. Garca-Lpez et al. / Research in Autism Spectrum Disorders 28 (2016) 716

Table 2
Descriptive statistics on parental adaptation measures, and gender xed effects.

Variable Mothers (n = 120) Fathers (n = 120) Parent gender xed effect

Mean SD Mean SD b SE P
Stress 33.40 9.49 30.58 8.53 2.82** 0.88 0.002
Anxiety 7.83 3.59 6.88 3.68 0.98* 0.40 0.020
Depression 5.41 3.61 4.82 3.53 0.61 0.39 0.120
Psychological well-being 121.16 21.49 121.00 1.80 0.16 2.10 0.940
**
p < 0.01.
*
p < 0.05.

3. Results

First, the unconditional random-effects model was tted, and the ICC values showed that a statistically signicant
amount of variance was attributable to within-dyad variability (stress: 39%, p < 0.001; anxiety: 26%, p < 0.001, depression:
31%, p < 0.001, well-being: 44%, p < 0.001), which justies the use of the MLM approach. When we introduced gender as a
xed effect in each model, we found that mothers showed signicantly higher levels of stress and anxiety than fathers. No
signicant differences in depression and well-being were found (see Table 2). The following step involved identifying
potentially relevant confounding variables to use as control variables in the nal models. We found family income to be
signicantly associated with psychological well-being (p = 0.006), whereas time since diagnosis was signicantly associated
with stress (p = 0.022) and psychological well-being (p = 0.038). We included these signicant control variables in the
corresponding nal models that analyzed the main and interaction effects of child variables on parental psychological
adaptation (Table 3).

3.1. Final psychological adaptation models

The stress model controlled for the amount of time since diagnosis. As main effects, gender and ASD severity were
relevant predictors of stress levels. Mothers reported higher stress levels than fathers, and as the childs presented severity of
ASD increased, so did the stress his or her parents experienced. None of the interaction terms were signicantly associated
with parental stress. The anxiety model did not control for any confounding variables because none of them had been
signicantly associated with anxiety in the previous analysis. Gender was signicantly related to parental anxiety, with
mothers experiencing greater anxiety. We did not nd interaction effects. Similarly, we did not introduce any confounding
variables in the nal depression model, and we encountered no main or interaction effects after including child variables.
Finally, the psychological well-being model controlled for family income and time since diagnosis. When we introduced the
child variables, the results showed that family income continued to be signicantly predictive of parental well-being, but
time since diagnosis was no longer a signicant predictor of well-being. As family income increased, so did the levels of
psychological well-being. Moreover, higher levels of ASD severity were found to be signicantly associated with lower well-
being in parents. None of the interaction terms were signicantly associated with psychological well-being.

Table 3
Final multilevel models of stress, anxiety, depression, and psychological well-being, controlling for the confounding variables previously identied as
signicantly associated to outcome measures.

Stress Anxiety Depression Psychological well-being

b SE b SE b SE b SE
Intercept 30.64*** 0.79 6.89*** 0.33 4.84*** 0.33 112.14*** 3.44
CONTROL VARIABLES Parent gender (L1) 2.70** 0.89 0.93* 0.40 0.57 0.39 0.31 2.13
Parent age (L1)
Family income (L2) 2.99** 0.99
Child age (L2)
Time since diagnosis (L2) 0.02 0.11 0.23 0.25
CHILD VARIABLES ASD severity (L2) 0.28** 0.09 0.01 0.04 0.04 0.04 0.66** 0.22
Behavior problems (L1) 0.24 0.17 0.13 0.07 0.11 0.07 0.18 0.40
INTERACTION EFFECTS Parent gender  ASD severity 0.01 0.10 0.08 0.04 0.03 0.04 0.22 0.24
Parent gender  Behavior problems 0.11 0.21 0.04 0.09 0.11 0.09 0.43 0.49

Variables not included in the nal models.

L1: level 1; L2: level 2.
*
p < 0.05.
**
p < 0.01.
***
p < 0.001.
 C. Garca-Lpez et al. / Research in Autism Spectrum Disorders 28 (2016) 716 13

4. Discussion

The current study compared the levels of psychological adaptation in a sample of Spanish mothers and fathers of
individuals with ASD and their association with child factors using MLM.
Our rst research question concerned whether there would be gender differences in the levels of stress, anxiety,
depression and psychological well-being after controlling for the interdependence of data between members of the same
dyad. The MLM results showed gender differences in the stress and anxiety levels of parents of individuals with ASD, even
after controlling for the interdependence of data. As we had hypothesized, and consistently with previous ndings, mothers
presented higher stress and anxiety levels than fathers (Dabrowska & Pisula, 2010; Gau et al., 2012; Hastings, 2003; Hastings
& Brown, 2002; Little, 2002). This nding indicates that despite the mutual inuence recognized between mothers and
fathers in terms of cognitive, emotional and behavioral interdependence, their adaptation outcomes are divergent. One
possible explanation for this pattern concerns the role of care-giving: Fathers in our sample perceived mothers involvement
in care-giving to be signicantly higher than mothers perceived fathers involvement. Consequently, these results suggest
that parental roles could be a relevant factor that could elucidate the differing experiences reported by fathers and mothers
of individuals with ASD, as other authors have suggested (Tehee et al., 2009).
As for predictors of adaptation, previous studies have consistently found a negative relationship between childrens
behavior problems and successful parental adaptation (Estes et al., 2013; Hastings & Brown, 2002; Pozo & Sarri, 2015;
Rezendes & Scarpa, 2011; Tomanik et al., 2004; Zaidman-Zait et al., 2014), but in this study, when we focused on aggressive/
destructive behavior problems, we did not nd this relationship. This discrepancy could be due to the low mean level of
challenging behaviors exhibited by the individuals of the present sample. However, the ndings showed that as the severity
of the childs presented ASD increased, so did the stress both progenitors experienced. Regarding positive outcomes, we
found that parents psychological well-being was positively predicted by family income and negatively predicted by the
severity of the disorder, in contrast with previous ndings reporting no association between child characteristics and
positive perceptions of raising a child with ASD (Jones et al., 2013). Methodological variations could explain the different
results encountered; in particular, we used psychological well-being as a measure of positive adaptation, which involves a
more comprehensive measure of positive outcome and seems more sensitive to ASD characteristics (particularly ASD
severity) than positive perceptions.
Our second research question was whether child variables inuenced fathers and mothers adaptation outcomes
differently after we controlled both for the interdependence of data and for possibly confounding variables. Our prediction
that parental adaptation would be affected by different factors for fathers and mothers was not supported, as we found no
interaction effects of gender or other relevant variables. By contrast, Jones et al. (2013) found child behavior problems and
adaptive behaviors to be strongly associated with maternal but not paternal anxiety. This difference could be attributed to
the fact that they measured child variables primarily through the reports of mothers (the primary care-givers) and did not
consider fathers perceptions of their childs behaviors. In contrast, our evaluations were based on both progenitors (i.e.,
mothers and fathers rated behavior problems separately), yielding a more representative picture of both progenitors
experiences regarding the effect of ASD characteristics on adaptation.
A further issue to discuss is the fact that, despite the broad age range analyzed, parent and child age had no association
with adaptation outcomes, which suggests that every period (from childhood to adulthood) poses new challenges for
families who need to struggle to adapt positively. These results are consistent with previous research showing sustained
levels of stress in parents of children with ASD (Pozo & Sarri, 2014b; Seltzer et al., 2010). According to the ndings of
previous research, although the severity of autism symptoms and behavior problems tend to decrease with age (Esbensen,
Seltzer, Lam, & Bodsh, 2010; Shattuck et al., 2007), these characteristics continue to affect the lives of individuals with ASD
and the well-being of their parents (Barker et al., 2011; Pozo & Sarri, 2015). Therefore, professionals and family members
should consider rethinking how to offer additional support to t family needs over the lifespan.
The limitations of the present study include the use of cross-sectional measures and the reliance on self-report
instruments, excluding the ASD severity evaluation, which was applied by professionals, and the measurement of parental
involvement in care-giving, which was measured through partner reports. Another limitation refers to the lack of previous
validation of the Spanish version of one of the instruments used (BPI). Future research should examine longitudinal
outcomes, consider both informant reports and self-reports, and continue to include both positive and negative outcome
measures.
However, the inclusion of fathers adds value to our study, considering that they are typically less represented in the
literature. As other authors have also stated (Braunstein et al., 2013; Mc Stay, Trembath, & Dissanayake, 2015), including
fathers is particularly relevant given that their role in intervention programs affects not only their well-being but also their
childrens outcomes (Flippin & Crais, 2011). Furthermore, evidence supports the need to focus not only on the childs
functioning but also on whole-family adaptability because outcomes in individuals with ASD are inuenced by the family
system (Baker, Seltzer, & Greenberg, 2011), which includes parents, siblings and other family members (Cridland, Jones,
Magee, & Caputi, 2013). The application of an MLM approach is also a positive aspect of this study, especially considering its
limited use in the ASD eld.
In conclusion, the ndings of this study suggest that mothers experience more stress and anxiety than fathers. ASD
severity is related to both progenitors stress and well-being. Gender differences in adaptation outcomes are not associated
14 C. Garca-Lpez et al. / Research in Autism Spectrum Disorders 28 (2016) 716

with the child variables here explored, but they might be related to other variables of the family system, among which care-
giving involvement emerges as a probable candidate.
In the clinical eld, professionals should be aware that ASD severity is negatively associated with both progenitors
psychological adaptation and thus offer support to adjust developmental expectations and to promote consciousness about
the positive contributions of disability. Furthermore, being aware that mothers, as main care-givers, experience more stress
and anxiety than fathers, professionals should encourage maternal protective factors. In addition, taking into account that
lower levels of family income are related to diminished well-being, governments should consider new policies aimed to
support ASD families treatment expenses. In Spain, publicly nanced treatments are limited in terms of number of hours,
which drives families to fund private services, adding an extra nancial burden to the already challenging situation they
experience. Therefore, nancial help for ASD families is necessary not only to help them pay for treatments but also to
support their well-being. All in all, in an era where parental involvement in treatment programs is pivotal, it has become
crucial to minimize parental distress and to stimulate well-being in order to optimize intervention outcomes.

Conict of interest

All authors declare they have no conicts of interest.

Ethical approval and informed consent

This study was approved by the Bioethics Committee for Research of the National University of Distance Education
(UNED). Written informed consent was obtained from both parents, and participants were guaranteed anonymity and
condentiality.

Acknowledgments

We are extremely grateful to all the families who generously participated in this study and to the Learning Disabilities Unit
at Hospital Sant Joan de Du, Parent and Professional Associations of Autism and the education centers that took part in this
research, for facilitating the recruitment process.

References

American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders: text revision. Washington: American Psychiatric Association.
American Psychiatric Association (APA) (2013). Diagnostic and statistical manual of mental disorders 5. Washington: American Psychiatric Association.
Abidin, R. R. (1995). Parenting stress index manual. Odessa, FL: Psychological Assessment Resources.
Allen, K. A., Bowles, T. V., & Weber, L. L. (2013). Mothers and fathers stress associated with parenting a child with autism spectrum disorder. Autism Insights,
5, 111. http://dx.doi.org/10.4137/AUI.S11094.
Baker, J. K., Seltzer, M. M., & Greenberg, J. S. (2011). Longitudinal effects of adaptability on behaviour problems and maternal depression in families of
adolescents with autism. Journal of Family Psychology, 25(4), 601609. http://dx.doi.org/10.1037/a0024409.
Barker, E. T., Hartley, S. L., Seltzer, M. M., Floyd, F. J., Greenberg, J. S., & Orsmond, G. I. (2011). Trajectories of emotional well-being in mothers of adolescents
and adults with autism. Developmental Psychology, 47(2), 551561. http://dx.doi.org/10.1037/a0021268.
Bayat, M. (2007). Evidence of resilience in families of children with autism. Journal of Intellectual Disability Research, 51(9), 702714. http://dx.doi.org/
10.1111/j.1365-2788.2007.00960.x.
Bebko, J. M., Konstantareas, M. M., & Spinger, J. (1987). Parent and professional evaluations of family stress associated with characteristics of autism. Journal
of Autism and Developmental Disorders, 17(4), 565576. http://dx.doi.org/10.1007/BF01486971.
Bjelland, I., Dahl, A. A., Haug, T. T., & Neckelmann, D. (2002). The validity of the hospital anxiety and depression scale. An updated review. Journal of
Psychosomatic Research, 52, 6977. http://dx.doi.org/10.1016/S0022-3999(01)00296-3.
Braunstein, V. L., Peniston, N., Perelman, A., & Cassano, M. C. (2013). The inclusion of fathers in investigations of autistic spectrum disorders. Research in
Autism Spectrum Disorders, 7, 858865. http://dx.doi.org/10.1016/j.rasd.2013.03.005.
Cridland, E. K., Jones, S. C., Magee, C. A., & Caputi, P. (2013). Family-focused autism spectrum disorder research: a review of the utility of family systems
approaches. Autism, 18(3), 213222. http://dx.doi.org/10.1177/1362361312472261.
Daz, D., Rodrguez-Carvajal, R., Blanco, A., Moreno-Jimnez, B., Gallardo, I., Valle, C., et al. (2006). Adaptacin espaola de las escalas de bienestar psicolgico
de Ryff. Psicothema, 18(3), 572577.
Daz-Herrero, A., Brito de la Nuez, A. G., Lpez-Pina, J. A., Prez-Lpez, J., & Martnez-Fuentes, M. T. (2010). Estructura factorial y consistencia interna de la
version Espaola del parenting stress index-short form. Psicothema, 22, 10331038.
Dabrowska, A., & Pisula, E. (2010). Parenting stress and coping styles in mothers and fathers of pre-school children with autism and Down syndrome. Journal
of Intellectual Disability Research, 54(3), 266280. http://dx.doi.org/10.1111/j.1365-2788.2010.01258.x.
Davis, N. O., & Carter, A. S. (2008). Parenting stress in mothers and fathers of toddlers with autism spectrum disorders: associations with child
characteristics. Journal of Autism and Developmental Disorders, 38(7), 12781291. http://dx.doi.org/10.1007/s10803-007-0512-z.
Eisenhower, A., Baker, B., & Blacher, J. (2005). Preschool children with intellectual disability: syndrome specicity, behaviour problems, and maternal well-
being. Journal of Intellectual Disability Research, 48, 657671. http://dx.doi.org/10.1111/j.1365-2788.2005.00699.x.
Epstein, T., Saltzman-Benaiah, J., O'Hare, A., Goll, J. C., & Tuck, S. (2008). Associated features of Asperger syndrome and their relationship to parenting stress.
Child: Care, Health and Development, 34, 503511. http://dx.doi.org/10.1111/j.1365-2214.2008.00834.x.
Esbensen, A. J., Seltzer, M. M., Lam, K., & Bodsh, J. W. (2010). Age-related differences in restricted repetitive behaviors in autism spectrum disorders. Journal
of Autism and Developmental Disorders, 39(1), 5766. http://dx.doi.org/10.1007/s10803-008-0599-x.
Estes, A., Olson, E., Sullivan, K., Greenson, J., Winter, J., Dawson, G., et al. (2013). Parenting-related stress and psychological distress in mothers of toddlers
with autism spectrum disorders. Brain and Development, 35, 133138. http://dx.doi.org/10.1016/j.braindev.2012.10.004.
Flippin, M., & Crais, E. R. (2011). The need for more effective father involvement in early autism intervention A systematic review and recommendations.
Journal of Early Intervention, 33(1), 2450.
Garca-Lpez, C., & Narbona, J. (2014). Clinical usefulness of IDEA and CARS: concordance with DSM-IV-TR in children and adolescents with suspicion of PDD.
Anales De Pediatra, 80(2), 7176. http://dx.doi.org/10.1016/j.anpedi.2013.05.012.
 C. Garca-Lpez et al. / Research in Autism Spectrum Disorders 28 (2016) 716 15

Garca-Villamisar, D., & Polaino-Lorente, A. (1992). Evaluacin del autismo infantil: una revisin de los instrumentos escalares y observacionales. Acta
Pediatrica Espanola, 50(6), 383388.
Gau, S. S., Chou, M. C., Chiang, H. L., Lee, J. C., Wong, C. C., Chou, W. J., et al. (2012). Parental adjustment, marital relationship, and family function in families of
children with autism. Research in Autism Spectrum Disorders, 6, 263270. http://dx.doi.org/10.1016/j.rasd.2011.05.007.
Hartley, S. L., Seltzer, M., Head, L., & Abbeduto, L. (2012). Psychological well-being in fathers of adolescents and young adults with down syndrome, fragile X
syndrome and autism. Family Relations, 61, 327342. http://dx.doi.org/10.1111/j.1741-3729.2011.00693.x.
Hastings, R. P., & Brown, T. (2002). Behaviour problems of children with autism, parental self-efcacy, and mental health. American Journal on Mental
Retardation, 107(3), 222232. http://dx.doi.org/[157_TD$IF][610.1352/0895-8017(2002)107<0222:BPOCWA>2.0.CO;2.
Hastings, R. P., & Taunt, H. M. (2002). Positive perceptions in families of children with developmental disabilities. American Journal on Mental Retardation, 107,
116127. http://dx.doi.org/10.1352/08958017(2002)107<0116:PPIFOC>2.0.CO;2.
Hastings, R. P., Kovshoff, H., Ward, N. J., Espinosa, F. D., Brown, T., & Remington, B. (2005). Systems analysis of stress and positive perceptions in mothers and
fathers of pre-school children with autism. Journal of Autism and Developmental Disorders, 35(5), 635644. http://dx.doi.org/10.1007/s10803-005-0007-
8.
Hastings, R. P. (2003). Child behaviour problems and partner mental health as correlates of stress in mothers and fathers of children with autism. Journal of
Intellectual Disability Research, 47, 231237. http://dx.doi.org/10.1046/j.1365-2788.2003.00485.x.
Hayes, S. A., & Watson, S. L. (2013). The impact of parenting stress: a meta-analysis of studies comparing the experience of parenting stress in parents of
children with and without autism spectrum disorder. Journal of Autism and Developmental Disorders, 43(3), 629642. http://dx.doi.org/10.1007/s10803-
012-1604-y.
Herring, S., Gray, K., Taffe, J., Tonge, B., Sweeney, D., & Einfeld, S. (2006). Behaviour and emotional problems in toddlers with pervasive developmental
disorders and developmental delay: associations with parental mental health and family functioning. Journal of Intellectual Disability Research, 50, 874
882. http://dx.doi.org/10.1111/j.1365-2788.2006.00904.x.
Jones, L., Totsika, V., Hastings, R. P., & Petalas, M. A. (2013). Gender differences when parenting children with autism spectrum disorders: a multilevel
modeling approach. Journal of Autism Developmental Disorders, 43(9), 20902098. http://dx.doi.org/10.1007/s10803-012-1756-9.
Kaytz, A. D., Gragg, M. N., & Orr, R. R. (2010). Positive experiences of mothers and fathers of children with autism. Journal of Applied Research in Intellectual
Disabilities, 23(4), 337343. http://dx.doi.org/10.1111/j.1468-3148.2009.00539.x.
Kenny, D., Kashy, D., & Cook, W. (2006). Dyadic data analysis. New York: The Guilford Press.
Lee, G. K. (2009). Parents of children with high-functioning autism: how well do they cope and adjust? Journal of Developmental and Physical Disabilities, 21,
93114. http://dx.doi.org/10.1007/s10882-008-9128-2.
Little, L. (2002). Differences in stress and coping for mothers and fathers of children with Aspergers syndrome and nonverbal learning disorders. Pediatric
Nursing, 28, 565570.
Mayes, S. D., Calhoun, S. L., Murray, M. J., Pearl, A., Black, A., & Tierney, C. D. (2014). Final DSM-5 under identies mild autism spectrum disorder: agreement
between the DSM-5, CARS CASD, and clinical diagnoses. Research in Autism Spectrum Disorders, 8, 6873. http://dx.doi.org/10.1016/j.rasd.2013.11.002.
Mc Stay, R., Trembath, D., & Dissanayake, C. (2015). Raising a child with autism: a developmental perspective on family adaptation. Current Developmental
Disorders Reports, 2, 6583. http://dx.doi.org/10.1007/s40474-014-0037-z.
Pakenham, K. I., Sofronoff, K., & Samios, C. (2011). Finding meaning in parenting a child with Asperger syndrome: correlates of sense making and benet
nding. Research in Developmental Disabilities, 25(3), 245264. http://dx.doi.org/10.1016/j.ridd.2003.06.003.
Pardo, A., Ruiz, M., & San Martn, R. (2007). Cmo ajustar e interpretar modelos multinivel con SPSS. Psicothema, 19(2), 308321.
Pottie, C. G., & Ingram, K. M. (2008). Daily stress, coping, and wellbeing in parents of children with autism: a multilevel modeling approach. Journal of Family
Psychology, 22(6), 855864. http://dx.doi.org/10.1037/a0013604.
Pozo, P., & Sarri, E. (2014a). A global model of stress in mothers and fathers of individuals with autism spectrum disorders (ASD). Anales De Psicologa, 30,
180191. http://dx.doi.org/10.6018/analesps.30.1.140722.
Pozo, P., & Sarri, E. (2014b). Prediction of stress in mothers of children with autism spectrum disorder. Spanish Journal of Psychology, 17, . http://dx.doi.org/
10.1017/sjp.2014.6.
Pozo, P., & Sarri, E. (2015). Still stressed but feeling better: well-being in autism spectrum disorder families as children become adults. Autism, 19(7), 805
813. http://dx.doi.org/10.1177/1362361315583191.
Pozo, P., Sarri, E., & Brioso, A. (2014). Family quality of life and psychological well-being in parents of children with autism spectrum disorders: a double
ABCX model. Journal of Intellectual Disability Research, 58, 442458. http://dx.doi.org/10.1111/jir.12042.
Raudenbush, S. W., & Bryk, S. J. (2002). Hierarchical linear models: applications and data analysis methods, 2nd ed. Thousand Oaks, CA: Sage.
Associations between parental anxiety/depression and child behaviour problems related to autism spectrum disorders: the roles of parenting stress and
parenting self-efcacy. Autism Research and Treatment395190. http://dx.doi.org/10.1155/2011/395190.
Rimmerman, A., Turkel, L., & Crossman, R. (2003). Perception of child development, child-related stress and dyadic adjustment: pair analysis of married
couples of young children with developmental disabilities. Journal of Intellectual and Developmental Disability, 28, 188195. http://dx.doi.org/10.1080/
1366825031000147111.
Rivard, M., Terroux, A., Parent-Boursier, C., & Mercier, C. (2014). Determinants of stress in parents of chidlren with autism spectrum disoder. Journal of Autism
and Developmental Disorders, 44(7), 16091620. http://dx.doi.org/10.1007/s10803-013-2028-z.
Rojahn, J., Matson, J. L., Lott, D., Svensen, A., & Smalls, Y. (2001). The behaviour problems inventory: an instrument for the assessment of self-injury,
stereotyped behaviour, and aggression/destruction in individuals with developmental disabilities. Journal of Autism and Developmental Disorders, 31(6),
577588. http://dx.doi.org/10.1023/A:1013299028321.
Ryff, C., & Keyes, C. (1995). The structure of psychological well-being revisited. Journal of Personality and Social Psychology, 69, 719727.
Ryff, C. (1989). Happiness is everything, or is it? Explorations on the meaning of psychological well-being. Journal of Personality and Social Psychology, 57,
10691081. http://dx.doi.org/10.1037/0022-3514.57.6.1069.
Sarri, E., & Pozo, P. (2015). Coping Strategies and Parents positive perception of raising a child with autism spectrum disorder. In M. Fitzgerald (Ed.),
AutismRietja, Croatia: InTechOpen. http://dx.doi.org/10.5772/58966 pp. 5179.
Schopler, E., Reichler, R. J., & Renner, B. R. (1988). The Childhood Autism Rating Scale (C.A.R.S). Los Angeles: Western Psychological Services.
Seltzer, M. M., Greenberg, J. S., Hong, J., Smith, L. E., Almedia, D. M., Coe, C., et al. (2010). Maternal cortisol levels and behavior problems in adolescents and
adults with ASD. Journal of Autism and Developmental Disorders, 40(4), 457469. http://dx.doi.org/10.1007/s10803-009-0887-0.
Shattuck, P. T., Seltzer, M. M., Greenberg, J. S., Orsmond, G. I., Bolt, D., Kring, S., et al. (2007). Change in autism symptoms and maladaptive behaviors in
adolescents and adults with autism spectrum disorders. Journal of Autism and Developmental Disorders, 37, 17351747. http://dx.doi.org/10.1007/s10803-
006-0307-7.
Sigafoos, J., Arthur, M., & OReilly, M. F. (2003). Challenging behavior and developmental disability. London: Whurr Publishers.
Smith, L. E., Greenberg, J. S., & Seltzer, M. M. (2012). Social support and well-being at mid-life among mothers of adolescents and adults with autism
spectrum disorders. Journal of Autism and Developmental Disorders, 42(9), 18181826. http://dx.doi.org/10.1007/s10803-011-1420-9.
Tehee, E., Honan, R., & Hevey, D. (2009). Factors contributing to stress in parents of individuals with autistic spectrum disorders. Journal of Applied Research in
Intellectual Disabilities, 22, 3442.
Tejero, A., Guimer, E. M., & Farr, J. (1986). Uso clnico del HADS (Hospital Anxiety and Depression Scale) en poblacin psiquitrica: un estudio de su
sensibilidad: abilidad y validez. Revista Del Departamento De Psiquiatra De La Facultad De Medicina De Barcelona, 13, 233238.
Tomanik, S., Harris, G. E., & Hawkins, J. (2004). The relationship between behaviours exhibited by children with autism and maternal stress. Journal of
Intellectual and Developmental Disability, 29, 1626. http://dx.doi.org/10.1080/13668250410001662892.
16 C. Garca-Lpez et al. / Research in Autism Spectrum Disorders 28 (2016) 716

Totsika, V., Hastings, R. P., Emerson, E., Berridge, D. M., & Lancaster, G. A. (2011). Behaviour problems at 5 years of age and maternal mental health in autism
and intellectual disability. Journal of Abnormal Child Psychology, 39(8), 11371147. http://dx.doi.org/10.1007/s10802-011-9534-2.
Zaidman-Zait, A., Mirenda, P., Zumbo, B. D., Wellington, S., Dua, V., & Kalynchuk, K. (2010). An item response theory analysis of the parenting stress index
short form with parents of children with autism spectrum disorders. Journal of Child Psychology and Psychiatry, 51, 12691277. http://dx.doi.org/10.1111/
j.1469-7610.2010.02266.x.
Zaidman-Zait, A., Mirenda, P., Duku, E., Szatmari, P., Georgiades, S., Volden, J., et al. (2014). Examination of bidirectional relationships between parent stress
and two types of problem behaviour in children with autism spectrum disorder. Journal of Autism and Developmental Disorders, 44, 19081917. http://dx.
doi.org/10.1007/s10803-014-2064-3.
Zigmond, A. S., & Snaith, R. P. (1983). The hospital anxiety and depression scale (HADS). Acta Psychiatrica Scandinavica, 67, 361370. http://dx.doi.org/10.1111/
j.1600-0447.1983.tb09716.x.