Post-traumatic growth in mothers of children with autism: A phenomenological study

Abstract

While the adverse effects of raising a child with autism are well demonstrated, there have been few reports of the post-traumatic growth of mothers of children with autism. The purpose of this research was to explore dimensions of post-traumatic growth in this population in Mainland China and identify the factors facilitating post-traumatic growth. A total of 11 mothers of pre-school children were recruited from five rehabilitation centres of children with disabilities in Shanghai. The semi-structured interviews were conducted between August 2012 and October 2012 and analysed using thematic analysis. The data partially confirmed Tedeschi and Calhoun’s model of post-traumatic growth. A new philosophy of life, appreciation of life, relating to others, personal strength and spiritual change were five domains of post-traumatic growth in mothers of children with autism. Perceived social support, peer example, effective coping style and self-efficacy enhancement were facilitating factors of post-traumatic growth. Further studies are needed to understand how to promote the post-traumatic growth of mothers of children with autism.

Keywords

Autism caregiver mental health mothers post-traumatic growth

Introduction

Recently, the prevalence of children with autism spectrum disorders (ASD), herein referred to as autism, has increased dramatically. Between 2000 and 2010, the number of children with autism in Europe and North America has increased from 5–9 to 90–110 per 10,000 (Matson and Kozlowski, 2011). The number has also increased from 1.9 in the 1980s to 14.8 in 2010 per 10,000 individuals in Asia (Sun and Allison, 2010). While there are no national statistics, the prevalence rate in Mainland China is estimated to be 1.53 per 1000 children, resulting in a population of more than 1 million children with autism (Beijing Disabled Persons’ Federation and Municipal Health Bureau, 2006). As the primary caregivers, mothers play an essential role in the treatment and daily care of children with autism. Because of the higher incidence of mental health morbidity, Firat et al. (2002) recommended that the assessment of children with autism should include a psychological assessment of their mothers.

Importance of focus on post-traumatic growth

Having a child with autism often exposes mothers to greater stress, which can impact their mental health (Gaspar de Alba and Bodfish, 2011; Ludlow et al., 2012; Pottie and Ingram, 2008). The negative impact of rearing a child with autism on mothers is widely acknowledged, namely, parental stress (Dabrowska and Pisula, 2010), a lower quality of life (Kheir et al., 2012), coping and adaptation problems (Hastings et al., 2005a), and a variety of psychological symptoms, including depression (Davis and Carter, 2008), anxiety and pessimism (Hastings and Brown, 2002). Casey et al. (2012) have also reported post-traumatic stress symptoms (PTSSs) such as intrusive recollections, avoidant symptoms and hyper-arousal symptoms in 20% of their sample of parents of children with autism (n = 265, 92% were mothers).

While rearing a child with autism can result in marked psychological distress and mental health problems for mothers, there is increasing evidence that parents of children with disabilities demonstrate considerable strength, articulating the positive contributions of their child’s disability to their lives and well-being (Bayat, 2007; Benson, 2010; King et al., 2006). Tedeschi and Calhoun (2004) defined this phenomenon as post-traumatic growth (PTG) and identified a five-domain model comprising ‘new possibilities’, ‘appreciation of life’, ‘personal strength’, ‘relating to others’ and ‘spiritual/religious change’. Phelps et al. (2009) noted that ‘Traumatic losses, such as the realization that your child will not develop typically, may lead parents to find new insights in life and develop a greater sense of spirituality and strength’ (p. 135). Bayat (2007) found evidence of both spiritual and personal growth as an outcome of caring. Phelps et al. (2009) surveyed 80 caregivers (97.5% were mothers) using the Post-Traumatic Growth Inventory (PTGI; Tedeschi and Calhoun, 1996) and found that enrichment and growth occurred to varying degrees in their sample.

Since it is recognized that concepts with a ‘positive flavour’ link to multiple processes likely to influence health outcomes (Aspinwall and Tedeschi, 2010) such as less emotional distress (Ickovics et al., 2006) and more health-related behaviours (Gingerich and Eisengart, 2000), focusing on positive accomplishments may help to promote positive family outcomes (Hastings et al., 2005b). The identification of positive emotions and thoughts may assist professionals in recognizing and amplifying possible strengths, thereby establishing a platform for building psychosocial health and the development of support programmes. Thus, the facilitation of PTG within the psychological support of mothers of children with autism may be beneficial to the recovery and development of maternal well-being. This is important because mothers play a crucial role in the progress of their children’s development (Smith et al., 2008), and mothers’ mental health affects the outcomes of their children’s treatment (Breevaart and Bakker, 2012; Shine and Perry, 2010), thereby contributing to their children’s rehabilitation.

Chinese culture–related factors

The socio-cultural environment plays an essential role in the formation of positive change (Brennan, 2001). Before the establishment of People’s Republic of China in 1949, women had a low social status with total responsibility for housework and childcare instead of working outside, and although this situation has changed in recent decades, the traditional division of domestic labour is common in mothers caring children. In Mainland China, there is a widespread lack of knowledge of autism and treatment is relatively under-developed and characterized by limited financial and institutional support (Wang et al., 2011). Additionally, the Chinese culture places a high value on perfection and achievement (Wang et al., 2011), and mothers of children with autism may feel greater stress, isolation and shame in response to the social and behavioural problems associated with autism. This may be compounded by the ‘one-child’ policy where high expectations are invested by families into a single child (Miu, 2004). To date, there has been no investigation of PTG in Chinese mothers, which is an important gap, as it cannot be assumed that they experience PTG in the same way as mothers in different cultural and social contexts.

This study aimed to explore the evidence of PTG in Chinese mothers of children with autism residing in Mainland China. The specific objectives were as follows: (a) to explore PTG among mothers of children with autism and to hear how they articulated and described this growth and (b) to explore the facilitating factors of PTG.

Methods

Design

A phenomenological approach was chosen in the absence of existing research relating to the PTG in mothers of children with autism in Mainland China. This study design enables individuals to relay their unique experiences, be understood and represented (Benner, 1994).

Participants

Participants were purposefully recruited through five centres providing services for pre-school children (before primary school) with a developmental disability in the Shanghai metropolitan area. This approach was used because the centres provided access to both mothers who have a child diagnosed with autism and also users of specialist services. Thus, the centres offered access to the key informants required to meet the study aims.

To be included in the study, the mothers had to have at least one biological child over the age of 3 years with a formal diagnosis of autism according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR; American Psychiatric Association, 2000) diagnostic criteria. Mothers were excluded if they had received, or were receiving, mental health services or any psychological treatment. Information about the study was given to potential participants via centre brochures, emails and newsletters, and face-to-face contact between centre users and centre staff. Mothers interested in participating were initially asked to contact the first author (W.Z.) to learn more about the study prior to arranging a time and place for the interview. After interviews with 11 mothers, no new information relevant to the study purpose emerged and data saturation had been achieved. The participants were aged 33.55 years (standard deviation (SD) = 4.63 years) and of various education levels (high school to master’s level). Eight mothers had given up their careers, and one was divorced. Sample details, including those of the children, are given in Table 1.

Table 1.

Biographical data of research participants (n = 11).

Participant	Age (years)	Level of education	Occupation	Marital status	Child with autism
Participant	Age (years)	Level of education	Occupation	Marital status	Gender	Age (years)	Diagnosis (years)^a	Siblings
A	36	Bachelor’s degree	Accountant	Married	M	4	1	0
B	29	Associate degree	None	Married	M	5	2	0
C	29	High school	None	Married	M	7	3	0
D	33	Bachelor’s degree	None	Married	M	5	1.5	0
E	36	High school	None	Married	M	4	1	1 older sister
F	32	Associate degree	None	Married	M	7	4	0
G	27	Associate degree	None	Married	M	5	2	0
H	40	Bachelor’s degree	Self-employed	Married	M	6	3	0
I	33	Bachelor’s degree	None	Divorced	M	8	4.5	1 younger brother
J	32	High school	None	Married	F	6	2	0
K	42	Master’s degree	Teacher	Married	F	8	5	0

‘Diagnosis’ represents ‘years since formal diagnosis of autism’.

Data collection

Data were collected between August 2012 and October 2012. The five-member research team developed the topic guide of primary questions and follow-up probes based on the literature. The topic guide was assessed for face validity by an expert in caring for children with autism based at one of the centres. Trained volunteers cared for the participants’ children during the one-to-one interviews. W.Z. conducted all the interviews in the meeting rooms of the centres. The primary questions asked were the following:

How did you feel about being told your child’s diagnosis?

How have your feelings changed over time?

What do you think brings about these changes in your feelings?

How are you now?

Is there anything that you currently do in your life that affects how you feel about having a child with autism?

On the basis of mothers’ responses, W.Z. used follow-up probes to clarify comments and elicit in-depth explanations. The mothers were encouraged to share any information that they felt would help the researchers understand their experiences. The interviews lasted 70–150 min (mean = 100 min).

Ethical consideration

The study was approved by the Ethical Review Board of the Second Military Medical University in Shanghai. Prior to each interview, the author obtained written consent from the participating mothers. Each interview was audio-recorded with permission, and this was given by all participants.

Data analysis

The audiotaped interviews were transcribed verbatim by W.Z. and checked by T.T.Y. to ensure accuracy. During the initial coding, the researchers started with the key components of the PTG model and noted where the data did not match the PTG model. Data analysis followed three major steps (Creswell et al., 2007): (a) initial within-case coding – each transcript was coded to identify key data within each single transcript (horizontalization); (b) identifying clusters of meaning across cases – researchers clustered similar quotes and phrases across the different transcripts looking for similarities and (c) thematic analysis – researchers collapsed initial codes into broader categories related to the guiding questions. The team discussed the categories, eliminated irrelevant data and identified overlapping categories.

Inter-rater reliability and credibility

Three researchers independently coded each transcript, clustered similar meanings across cases and generated themes. The percentages of coding agreement between each pair of researchers across the 11 transcribed interviews were 81%, 84% and 85%. Weekly meetings were held to discuss the emerging results and draw consensus regarding coding and themes related to the research objectives. Once consensus between the researchers had been achieved, each participant was presented with a summary of the interpretations of her interview which they confirmed (signed or sent email) as representing what they wanted to express. All the mothers confirmed that the interpretations were correct.

Results

Two categories and nine subcategories were identified from the data. Categories reported by each participant and the numbers of statements in each category are set out in Table 2. First, the evidence and domains of PTG are described followed by its facilitating factors.

Table 2.

Categories and subcategories identified.

Categories	Subcategories	Statement count	Participants
Domains of PTG	New philosophy of life	16	A, B, C, D, H, I and G
	Appreciation of life	5	D, H and I
	Personal strength	18	A, B, C, D, E, F, G, H, I and K
	Relating to others	23	A, B, C, D, E, F, G, H, I, J and K
	Spiritual change	3	C and G
Facilitating factors	Perceived social support	20	A, B, C, D, E, F, G, H, I, J and K
	Peer example	9	B, C, D, E, G, I and J
	Effective coping style	17	A, B, C, D, E, F, G, H, I and J
	Self-efficacy enhancement	10	A, C, E, F, G and K

PTG: post-traumatic growth.

Evidence of PTG

A new philosophy of life

In the original PTG model, ‘new possibilities’ is a separate domain, representing the individual’s identification of new ways for achievement (Tedeschi and Calhoun, 2004). In this sample, while most of the mothers had given up their careers, they identified new possibilities for their lives. For example, Mother B felt that her developing expertise on the management of autism provided new career opportunities: ‘I plan to be a teacher in an agency …’ and described it as a new journey that she would not have experienced otherwise.

However, one theme emerged which could not be described as ‘new possibilities’ but rather ‘changed priorities’, which refers to changes in the goals and activities that the mothers felt were most important (King et al., 2006). A typical change emerged with mothers placing more emphasis on the health and happiness of their children, and they often contrasted this with the high expectations placed on children within Chinese culture. Almost all the mothers except for Mother C, who stated that her current as well as previous goal was to let her child live happily, gave priority to their children’s future before the diagnosis. A changed emphasis from career to family was also detected, exemplified by the following quotation (Mother H): ‘My family is most important for me, power and career success are meaningless for me now’.

Thus, we expanded the original domain of ‘new possibilities’ by adding ‘changed priorities’ to the domain as this better reflected the data from the participants.

Appreciation of life

Appreciation of life was a less pervasive dimension but was articulated by three mothers (Mothers D, H and I). It was characterized by an increased gratitude for life. In these cases, the mothers found themselves loving life more, and in this sample, ‘being so lucky to have such a child’ was not an uncommon sentiment even among those who did not specifically express a greater appreciation of life.

Personal strength

Personal strength conveys a sense of survival through the negative consequences of an event and reflects the notion that the event was the trigger for new-found advantage (Shakespeare-Finch and Copping, 2006). Becoming less judgmental, less selfish, more compassionate, more caring, more patient and more mindful of individual differences were the most frequently mentioned attributes gained by raising a child with autism. Mother K described her changed attitudes in these terms:

I have come to realize that my daughter is my teacher. She is teaching me to be patient; and I have never discovered I am an outgoing person … I forced myself to communicate with the doctors, nurses, other mothers, and the headmasters of elementary schools, I can label myself as sociable now … much more adamant than I thought before.

Relating to others

‘Improved relationships’ and ‘relating to others experiencing adversity’ were identified as two themes in this sub-category. Improved relationships included greater marital or family unity and closer relationships with friends, neighbours or related others. Mother F described the impact on her marriage in the following way: ‘We argued occasionally about little things … because of him [the child]. We have a better relationship and seldom waste time quarrelling, rather, he combined us together’. Additionally, the mothers described stronger relationships with others, as Mother H commented, ‘My friends always invite me to take my child out with their children, it seems we are closer now’.

Relating to others experiencing adversity refers to ‘an increased sense of compassion for other persons who suffer’ (Calhoun and Tedeschi, 2006: 5). The experience of being mother of a child with autism engendered greater compassion and sensitivity to the feelings and needs of others and enabled the mothers to reach out and help others who had experienced similar losses or traumas (Tedeschi and Calhoun, 1996). The mothers described how they were better able to disclose feelings and reactions to others, as Mother B commented,

I comfort other mothers who are new comers to this agency, when I saw them, it seems like I saw myself 1 year ago [frown] … I shared my experience with them, and it did help them a lot [smile].

Spiritual change

Spiritual development was not as evident as the other dimensions in the data. No mothers experienced spiritual awakening as such, although one mother (G) felt that her sense of spiritual awareness had deepened: ‘Autism has increased my previous belief that all lives are intended to be here. No life or disabilities are mistakes’. None of the mothers described undertaking religious activities in response to the diagnosis of autism except for one (Mother C) who mentioned that she had gone to the temple twice to ask for a blessing from the Buddha: ‘Life is not easy, I feel God meant to make my child, and he will balance us in other fields’.

Facilitating factors of PTG

Receiving the diagnosis is a traumatic experience, which disrupts the mothers’ world as commonly illustrated by ‘my whole world collapsed’. The process of PTG involves cognitive reframing and finding meaning out of adversity. Factors affecting a positive transformation are likely to be multi-dimensional. The findings suggested that perceived social support, peer example, effective coping style and self-efficacy enhancement are the positive factors that may make PTG more likely.

Perceived social support

Social support is important in facilitating ‘cognitive processing and self-disclosure in supportive environments’ (Bray, 2010), which enabled the process of PTG. In the early stages, the family and significant friends were viewed as ‘emotional partners’ through the support that they provided. Their verbal persuasion and comfort affected the mothers’ attitudes towards their experience and understanding of the effects of autism. Health worker support as an ‘expert companion’ played an important role in the PTG process. As Mother H stated, ‘I appreciate what Doctor X has done, he is patient … he even calls us occasionally … I feel more determined with his help’. The mothers also perceived the special education system, early intervention services and community services as helpful. The support of other mothers raising children with autism was seen as especially valuable because the mothers believed that they could more readily appreciate their problems since they ‘seem like battle companions with the same goal’ (Mother A). The presence of a person who would listen to the mother’s problems and offer emotional or practical support was often felt to be extremely important.

Peer example

Some mothers considered the examples of ‘successful’ parents raising children with autism as a source of inspiration to help them move forward. They admired mothers in the same situation who were coping well and viewed it as a hopeful picture of themselves and sought to follow their examples to ‘live splendidly’. As Mother I said,

I met the headmaster and Teacher X, I was surprised that they were all mothers [of children with autism], they were so optimistic … Why their lives were so different from mine, I would like to communicate with them so that they can give me the positive energy.

Effective coping

Coping processes are important, and although PTG is not simply coping, coping success is probably crucial in the process of growth (Tedeschi and Calhoun, 1995). Effective coping could help mothers reduce negative emotions. In this sub-category, downward comparison and a problem-focus coping style were the two themes identified (Table 3).

Table 3.

Categories and evidence of effective coping.

Downwards comparisons	Although autism, my child is very kind hearted. Some children have learnt to bully others, my child will never. (Mother A)
	There are so many people fighting with tragedy, they may lost their children because of cancer, or car accident, after they have instilled so much love in these children, comparing with them, what I am suffering now is not a big deal. (Mother H)
Problem-focus coping style	Before going out, I am well aware of my son’s probable reactions. (Mother D)
	I tend to try and get him to do a bit more of the activity type things. (Mother F)

When people compare themselves to others who are seen as more unfortunate or unlucky, they often conclude that they are doing better. This downward comparison may not explain PTG, but could facilitate the process of PTG because downward comparisons tend to comfort, reduce time spent mourning loss and encourage mothers to realize the positive aspects of their children. In this study, the most common effective coping methods reported by mothers was anticipating the difficulties that were likely to arise and planning an appropriate response to deal with them if they happened. Despite the large number of problems faced by the mothers, those who adopted the problem-focus coping style found ‘resolutions are always more than problems’ (Mothers G, H and J), which made them more optimistic and more likely to gain PTG.

Self-efficacy enhancement

Mothers expressed that self-efficacy enhancement occurred in the process of rearing a child with autism, giving them positive feelings as well as confidence in the caregiving. Mother G commented, ‘I have learnt a lot of knowledge, I make progress everyday with my child … this indeed produces a sense of achievement’ and Mother K recalled, ‘Every step is filled with tears and sweat, when I look back occasionally, it has been a big improvement …’ Although exhausting, these experiences empowered the mothers and made them feel that they had overcome great obstacles on behalf of their children. Self-efficacy enhancements tended to help them derogate ‘past selves’ to maintain a favourable view of ‘current selves’.

Discussion

Discussion on the findings

This study provides evidence that, despite the extraordinary challenges faced by mothers of children with autism, a number of the sample mothers showed PTG supporting the favourable findings of studies of mothers rearing children with autism in other countries (Kayfitz et al., 2010; Keen et al., 2010; Kuhaneck et al., 2010; Markoulakis et al., 2012; Phelps et al., 2009). And this was within the context of the more stressful Chinese culture which values achievement very highly alongside the less widespread understanding of autism and the one-child policy. The study data displayed three of the five domains of PTG proposed by Tedeschi and Calhoun (2004). The domain of ‘new possibilities’ was expanded and re-named ‘a new philosophy of life’ since an emergent theme of ‘changed priorities’ was incorporated. Growth in spiritual change was not strong, and religious growth was not clearly articulated. While one participant described undertaking religious activities, they made no reference to an underpinning religious belief or faith. This contrasts with the findings of Taunt and Hastings (2002) in the United Kingdom, who reported that some parents experienced a strengthening of their religious faith in the face of raising a child with a disability, and Ekas et al. (2009) in the United States, who also reported that religious beliefs and spirituality were associated with better positive parental outcomes. This phenomenon may reflect the different cultural context of religious practice and discourse in Mainland China. However, many aspects of behaviour were reported regarding personal strength, such as to be compassionate, to do good and help others, which might be seen as ‘spiritual’ within Western countries.

Relating to others, especially improved relationships such as stronger marital attachment and closer personal relationships with friends, was emphasized more in these data. Since the majority of the participants perceived improved relationships as an important part of their enrichment, it could also explain why all participants mentioned their social support as important in their process of growth. This domain could explain the static divorce rate in families rearing a child with autism reported by Freedman et al. (2012) and other studies (Ekas et al., 2009, 2010; Lickenbrock et al., 2011).

In the process of PTG, perceived social support, learning from a peer example, applying effective coping and self-efficacy enhancement were facilitating factors, confirming the two key factors in the model of PTG, namely, social support and coping strategy. This study also confirmed existing research reporting the positive contributions of social support (Bayat, 2007; Dickie et al., 2009; Ekas et al., 2010) and the favourable outcome of an effective coping style (Luong et al., 2009; Pisula and Kossakowska, 2010) to maternal well-being. Peer example and self-enhancement were listed as underpinning factors facilitating the process of PTG. However, why this may be the case is difficult to explain from this interview data. It may be that the impact of self-enhancement on PTG can be explained by the findings of Kuhn and Carter (2006) where the mothers’ self-efficacy gave them a greater sense of control and more confidence in their parental role, thereby influencing their cognitive reframing.

Finally, growth was especially pronounced regarding a greater sense of personal strength and enhancement of relationships with others. To a somewhat lesser extent, participants reported a new philosophy of life, appreciation of life and spiritual change, indicating that mothers of children with autism may differ in the areas of growth, which may be related to the different experiences of individuals.

Implications for the theory

The findings from this study resonate with recent theories of PTG, for example, the participants’ transformation to growth can be understood in terms of the cognitive model of PTG. That is, mothers were able to appraise their experience so as to manage the perception of current challenges or ‘mental depression’. Our different findings on ‘new possibilities’ and ‘spiritual/religious change’ suggest that caution should be exercised in applying the PTG model directly to non-Western populations from different cultures.

Implications for the practice

While the stress and challenges of having a child diagnosed with autism cannot be eradicated, understanding the PTG that a mother potentially experiences may improve the effectiveness of the clinician in working with a family. This study’s findings lend support for the use of ‘acceptance and commitment therapy’ as described by Blackledge and Hayes (2006). They recommended that clinicians work to reframe the perspectives of families as an important way to promote the growth of family members. At the very least, healthcare workers should be sensitive about the possible occurrence of PTG when working with mothers to identify their own potential and strength in order to encourage and stimulate PTG, rather than focus on the application of psychiatric labels.

It may be helpful to encourage mothers to adopt an effective way to deal with their problems and maximize their strong support network comprising family, friends and helping professionals to provide emotional or practical support. In addition, promoting self-efficacy enhancement in the process of PTG, therapists or other professionals may seek to involve mothers directly in a child’s therapy, helping the mother develop more rational beliefs and guide the mothers to realize that they can help their children grow and develop. Finally, this research highlights the growth in relationships with others and the potential growth involved in learning from peers. Providing contact with other families rearing children with autism may help everyone to normalize and appraise their own experience and give them a chance to gain growth together. It may be beneficial to direct mothers to support groups comprising other parents of children with autism.

Limitations and future studies

This study has several limitations. First, the participants were recruited from special centres and excluded mothers receiving (or who had received) mental health services or psychological treatment. The findings therefore do not reflect those of all mothers of children with autism, and it is acknowledged that the excluded population could provide alternative perspectives on PTG. Second, the small sample size limits the comparison of PTG difference across sub-groups such as duration of formal diagnosis. A third limitation relates to longitudinal data collection since mothers may think differently about growth in their lives while still immersed in the caregiving experience. Future studies should recruit various samples and have multi-stage designs to better understand PTG in this population. Additionally, this study neither explored the perspective of fathers or other family members and their PTG nor the relationship between the PTG of each couple, both of which need further exploration.

Conclusion

Although PTG is a growing field of inquiry, the topic has seldom been explored in mothers with children who have autism, especially in non-Western settings. This study found evidence of PTG in the study sample in Mainland China. The findings partially supported the theory of PTG reflecting the different context of Chinese mothers’ experience of rearing a child with autism. Although the theory of PTG may still be useful in understanding these experiences, further research is needed to establish how the specific culture of parenting plays a role in the process of PTG. Furthermore, the mechanism of how PTG takes place and the contribution of each factor should continue to be explored in order to develop a comprehensive understanding of maternal growth in parents of children with autism.

Footnotes

Acknowledgements

We thank Ya-song Du of Shanghai Mental Health Centre for his helpful suggestions. We also thank the staff of college of pre-school and special education of East China Normal University, Shanghai Loving Children Rehabilitation Training Centre, Shanghai Qing Cong Quan Children Intelligence Training Centre, Shanghai Xingyu Children Healthy Hospital and Xi Er Sen Company for their support and assistance in data collection in this study.

Declaration of conflicting interests

No conflict of interest has been declared by the authors.

Funding

This work was supported by Key Project of Shanghai Science and Technology Commission (grant number 11411952401).

References

American Psychiatric Association (2000) Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4th ed. Text revision. Washington, DC: American Psychiatric Association.

Aspinwall

Tedeschi

(2010) The value of positive psychology for health psychology: progress and pitfalls in examining the relation of positive phenomena to health. Annals of Behavioral Medicine 39: 4–15.

Bayat

(2007) Evidence of resilience in families of children with autism. Journal of Intellectual Disability Research 51: 702–714.

Beijing Disabled Persons’ Federation and Municipal Health Bureau (2006). Sampling Survey Report of 0–6 Years Old Children with Disabilities in Beijing. Beijing: China Three Gorges Press.

Benner

(1994) Interpretive Phenomenology: Embodiment, Caring, and Ethics in Health and Illness. Thousand Oaks, CA: SAGE.

Benson

(2010) Coping, distress, and well-being in mothers of children with autism. Research in Autism Spectrum Disorders 4: 217–228.

Blackledge

Hayes

(2006) Using acceptance and commitment training in the support of parents of children diagnosed with autism. Child & Family Behavior Therapy 28: 1–18.

Bray

(2010) A broader framework for exploring the influence of spiritual experience in the wake of stressful life events: examining connections between posttraumatic growth and psycho-spiritual transformation. Mental Health, Religion & Culture 13: 293–308.

Breevaart

Bakker

(2012) The influence of job and parental strain on typically and atypically developing children: a vicious circle? Community, Work & Family 15: 173–188.

10.

Brennan

(2001) Adjustment to cancer: coping or personal transition? Psycho-oncology 10: 1–18.

11.

Calhoun

Tedeschi

(eds) (2006) Handbook of Posttraumatic Growth: Research and Practice. Mahwah, NJ: Lawrence Erlbaum Associates.

12.

Casey

Zanksas

Meindl

. (2012) Parental symptoms of posttraumatic stress following a child’s diagnosis of autism spectrum disorder: a pilot study. Research in Autism Spectrum Disorders 6: 1186–1193.

13.

Creswell

Hanson

Clark Plano

. (2007) Qualitative research designs: selection and implementation. Counseling Psychologist 35: 236–264.

14.

Dabrowska

Pisula

(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: 266–280.

15.

Davis

Carter

(2008) Parenting stress in mothers and fathers of toddlers with autism spectrum disorders: associations with child characteristics. Journal of Autism and Developmental Disorders 38: 1278–1291.

16.

Dickie

Baranek

Schultz

. (2009) Parent reports of sensory experiences of preschool children with and without autism: a qualitative study. The American Journal of Occupational Therapy 63: 172–181.

17.

Ekas

Lickenbrock

Whitman

(2010) Optimism, social support, and well-being in mothers of children with autism spectrum disorder. Journal of Autism and Developmental Disorders 40: 1274–1284.

18.

Ekas

Whitman

Shivers

(2009) Religiosity, spirituality, and socioemotional functioning in mothers of children with autism spectrum disorder. Journal of Autism and Developmental Disorders 39: 706–719.

19.

Firat

Diler

Avci

. (2002) Comparison of psychopathology in the mothers of autistic and mentally retarded children. Journal of Korean Medical Science 17: 679–685.

20.

Freedman

Kalb

Zablotsky

. (2012) Relationship status among parents of children with autism spectrum disorders: a population-based study. Journal of Autism and Developmental Disorders 42: 539–548.

21.

Gaspar

Alba

Bodfish

(2011) Addressing parental concerns at the initial diagnosis of an autism spectrum disorder. Research in Autism Spectrum Disorders 5: 633–639.

22.

Gingerich

Eisengart

(2000) Solution-focused brief therapy: a review of the outcome research. Family Process 39: 477–498.

23.

Hastings

Brown

(2002) Behavior problems of children with autism, parental self-efficacy, and mental health. American Journal on Mental Retardation 107: 222–232.

24.

Hastings

Kovshoff

Brown

. (2005a) Coping strategies in mothers and fathers of preschool and school-age children with autism. Autism 9: 377–391.

25.

Hastings

Kovshoff

Ward

. (2005b) Systems analysis of stress and positive perceptions in mothers and fathers of pre-school children with autism. Journal of Autism and Developmental Disorders 35: 635–644.

26.

Ickovics

Meade

Kershaw

. (2006) Urban teens: trauma, posttraumatic growth, and emotional distress among female adolescents. Journal of Consulting and Clinical Psychology 74: 841–850.

27.

Kayfitz

Gragg

Orr

(2010) Positive experiences of mothers and fathers of children with autism. Journal of Applied Research in Intellectual Disabilities 23: 337–343.

28.

Keen

Couzens

Muspratt

. (2010) The effects of a parent-focused intervention for children with a recent diagnosis of autism spectrum disorder on parenting stress and competence. Research in Autism Spectrum Disorders 4: 229–241.

29.

Kheir

Ghoneim

Sandridge

. (2012) Quality of life of caregivers of children with autism in Qatar. Autism 16: 293–298.

30.

King

Zwaigenbaum

King

. (2006) A qualitative investigation of changes in the belief systems of families of children with autism or Down syndrome. Child: Care, Health and Development 32: 353–369.

31.

Kuhaneck

Burroughs

Wright

. (2010) A qualitative study of coping in mothers of children with an autism spectrum disorder. Physical & Occupational Therapy in Pediatrics 30: 340–350.

32.

Kuhn

Carter

(2006) Maternal self-efficacy and associated parenting cognitions among mothers of children with autism. The American Journal of Orthopsychiatry 76: 564–575.

33.

Lickenbrock

Ekas

Whitman

(2011) Feeling good, feeling bad: influences of maternal perceptions of the child and marital adjustment on well-being in mothers of children with an autism spectrum disorder. Journal of Autism and Developmental Disorders 41: 848–858.

34.

Ludlow

Skelly

Rohleder

(2012) Challenges faced by parents of children diagnosed with autism spectrum disorder. Journal of Health Psychology 17: 702–711.

35.

Luong

Yoder

Canham

(2009) Southeast Asian parents raising a child with autism: a qualitative investigation of coping styles. The Journal of School Nursing 25: 222–229.

36.

Markoulakis

Fletcher

Bryden

(2012) Seeing the glass half full: benefits to the lived experiences of female primary caregivers of children with autism. Clinical Nurse Specialist 26: 48–56.

37.

Matson

Kozlowski

(2011) The increasing prevalence of autism spectrum disorders. Research in Autism Spectrum Disorders 5: 418–425.

38.

Miu

G-Z

(2004) Only-child families are essentially risky families. Population Research 28: 33–37.

39.

Phelps

McCammon

Wuensch

. (2009) Enrichment, stress, and growth from parenting an individual with an autism spectrum disorder. Journal of Intellectual & Developmental Disability 34: 133–141.

40.

Pisula

Kossakowska

(2010) Sense of coherence and coping with stress among mothers and fathers of children with autism. Journal of Autism and Developmental Disorders 40: 1485–1494.

41.

Pottie

Ingram

(2008) Daily stress, coping, and well-being in parents of children with autism: a multilevel modeling approach. Journal of Family Psychology 22: 855–864.

42.

Shakespeare-Finch

Copping

(2006) A grounded theory approach to understanding cultural differences in posttraumatic growth. Journal of Loss & Trauma 11: 355–371.

43.

Shine

Perry

(2010) The relationship between parental stress and intervention outcome of children with autism. Journal on Developmental Disabilities 16: 64–66.

44.

Smith

Greenberg

Seltzer

. (2008) Symptoms and behavior problems of adolescents and adults with autism: effects of mother-child relationship quality, warmth, and praise. American Journal on Mental Retardation 113: 387–402.

45.

Sun

Allison

(2010) A review of the prevalence of autism spectrum disorder in Asia. Research in Autism Spectrum Disorders 4: 156–167.

46.

Taunt

Hastings

(2002) Positive impact of children with developmental disabilities on their families: a preliminary study. Education and Training in Mental Retardation and Developmental Disabilities 37: 410–420.

47.

Tedeschi

Calhoun

(eds) (1995) Trauma and Transformation: Growing in the Aftermath of Suffering. Thousand Oaks, CA: SAGE.

48.

Tedeschi

Calhoun

(1996) The Posttraumatic Growth Inventory: measuring the positive legacy of trauma. Journal of Traumatic Stress 9: 455–471.

49.

Tedeschi

Calhoun

(2004) Posttraumatic growth: conceptual foundations and empirical evidence. Psychological Inquiry 15: 1–18.

50.

Wang

Michaels

Day

(2011) Stresses and coping strategies of Chinese families with children with autism and other developmental disabilities. Journal of Autism and Developmental Disorders 41: 783–795.