Chen et al.

BMC Public Health (2024) 24:226 BMC Public Health

https://doi.org/10.1186/s12889-024-17731-7

RESEARCH Open Access

Factors predicting depressive symptoms

in parents of children with autism spectrum
disorder in eastern China
Xu Chen1†, Jiao Tong1†, Weijing Zhang2,3,4†, Xin Wang1, Shan Ma1, Dongdong Shi1, Dongmei Yan1* and Yan Liu2,3,4*

Abstract
Background Parents of children with autism spectrum disorder (ASD) are at a higher risk of depression than parents
of typically developing children and those of children with other developmental disorders. Depression affects the
well-being and quality of life of parents of children with ASD and has serious consequences for the long-term health
outcomes of children with ASD. Therefore, this study explored the current status of depressive symptoms in parents of
children with ASD in eastern China and further analyzed multiple aspects of the predictors of depressive symptoms.
Methods A multicenter cross-sectional survey was conducted among parents of children with ASD in the
rehabilitation department of a large specialized hospital and 10 rehabilitation centers for children with special needs
in Lianyungang, Jiangsu Province, Eastern China. A structured questionnaire that focused on child-related factors,
parent-related factors, depressive symptoms, courtesy stigma, and social support was used to obtain data. Binary
logistic regression was used to identify the independent predictors of depressive symptoms in parents of children
with ASD.
Results A total of 409 parents of children with ASD were recruited, of whom 18.8% had depressive symptoms.
Parents of children with ASD who raised a child who spoke few to no words (odds ratio [OR]: 2.747, 95% confidence
interval [CI]: 1.026–7.357), claimed a high economic burden (OR: 3.215, 95% CI: 1.234–8.379), reported no change or
increased severity of ASD in their children (OR: 2.518, 95% CI: 1.108–5.720), and those with a higher courtesy stigma
score (OR: 1.189, 95% CI: 1.093–1.294) were more likely to have depressive symptoms. Conversely, parents of children
with ASD who were employed (OR: 0.427, 95% CI: 0.201–0.907), satisfied with their current marital status (OR: 0.429,
95% CI: 0.221–0.834), and those with a higher social support score (OR: 0.973, 95% CI: 0.950–0.996) were less likely to
have depressive symptoms.

†
Xu Chen, Jiao Tong and Weijing Zhang contributed equally to this
work.
*Correspondence:
Dongmei Yan
[email protected]
Yan Liu
[email protected]
Full list of author information is available at the end of the article

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Chen et al. BMC Public Health (2024) 24:226 Page 2 of 11

Conclusions Depressive symptoms are common in parents of children with ASD in eastern China. Therefore,
screening and intervention for depressive symptoms in parents of children with ASD is necessary, especially for those
with high-risk factors.
Keywords Depressive symptoms, Parents, Children, ASD, Predictors, China

Background symptoms such as depression using psychotherapy or

Autism spectrum disorder (ASD) is a complex neurode- other helpful resources may result in a better response
velopmental disorder characterized by limited, repetitive to treatment in children with ASD [20]. In addition,
behavioral patterns or interests, limited social inter- severe depressive symptoms in parents were risk factors
action, and communication impairment [1, 2]. In the for increased psychiatric problems in children with ASD
United States, ASD is reported in approximately 1 in 59 during the COVID-19 pandemic [21]. Therefore, there is
children [3]. This has drawn increasing attention to chil- an urgent need to study the status and influencing fac-
dren with ASD. It is worth noting that parents of children tors of depressive symptoms in parents of children with
with ASD encounter a variety of challenges in caring for ASD so as to develop targeted and effective intervention
their children, such as behavioral problems, sleep prob- measures to reduce depressive symptoms. This may not
lems, emotion regulation deficits, and cognitive impair- only improve the mental health of parents of children
ment, which often lead to higher mental health risks, with ASD and family well-being but may also have flow-
including an increased risk of depression [4, 5]. Parents through effects that ultimately improve children’s devel-
of children with ASD generally have worse psychological opmental outcomes [22].
bonding outcomes than parents of typically developing In recent years, an increasing number of studies have
children and those of children with other developmental focused on depressive symptoms in parents of children
disabilities [6–8]. with ASD. Foreign studies have shown that children’s age,
Studies have shown that 12.5–34.2% of parents of time of diagnosis, comorbidity, time interval since diag-
children with ASD have clinically significant depressive nosis, poor language function, sleep problems, and the
symptoms, and mothers of children with ASD are more severity of symptoms are significantly associated with
than three times more likely to suffer from depression depressive symptoms in parents of children with ASD
than normal adult population [9–11]. However, screen- [14, 23–26]. Parents’ education level, occupation, mari-
ing and treatment of depressive symptoms in parents of tal quality, knowledge, perceived stigma, family function,
children with ASD is often neglected, and few parents social support, self-efficacy, subjective burden, and chal-
are able to access or actively seek the required health lenging parenting experience significantly predict depres-
care services [12]. Depressive symptoms in parents of sive symptoms in parents of children with ASD [5, 11, 22,
children with ASD have potentially negative impacts on 24, 27–31]. Chinese studies have shown that mothers of
the individual and have serious consequences for the children with ASD in the low-functioning group have a
long-term health outcomes of children with ASD [5, 13, significantly higher incidence of depressive symptoms
14]. The role of parents of children with ASD as advo- than those of children in the high-functioning group
cates for children, coordinators of services, and inter- [32]. The educational level of mothers of children with
veners plays a crucial role in the treatment of children ASD is associated with depressive symptoms [33]. Most
[4, 15]. Interventions for children with ASD often need of the previous studies only analyzed a few aspects of
to be implemented consistently in school and home set- the factors associated with depressive symptoms in par-
tings, requiring parents to change their own behavior ents of children with ASD, and the literature in China is
and increase the time spent playing and communicating very limited. Notably, analysis of the Chinese caregivers
with their children [5]. However, this may be very diffi- of children and adolescents with ASD and other devel-
cult for a parent with depressive symptoms. Depressive opmental disorders showed that caregivers with higher
symptoms can lead to a deterioration in parental impa- family income had significantly lower levels of depres-
tience and emotional control, which can cause difficulties sive symptoms [34]. Income was also a predictor of qual-
in managing the child’s behavior and an inability to apply ity of life for mothers of children with ASD [35]. Recent
the skills learned during the treatment process to daily studies have found that exercise has a positive effect on
child care, thus, affecting the effectiveness of parental depression [36, 37]. However, few previous studies have
intervention, participation, and implementation as well explored the effects of these factors on depressive symp-
as child recovery [16–18]. Studies have demonstrated toms among parents of children with ASD. In addition,
that parental depression and other symptoms can mini- most studies have analyzed the effect of the severity
mize children’s response to treatment and make them of symptoms in children with ASD on parental depres-
benefit less from treatment [19]. Addressing parental sive symptoms [14, 25]. However, how changes in the
Chen et al. BMC Public Health (2024) 24:226 Page 3 of 11

condition of the disease affect depressive symptoms is about the purpose of the study, the process of the study,
unclear. In the Chinese collectivist culture, where social the confidentiality of their data, and their right to with-
identity and social acceptance are highly valued, many draw from the study at any time. Investigators distributed
parents of children with ASD may be more sensitive to questionnaires on site and were responsible for guidance
the social perceptions of their children with ASD [38]. and interpretation.
Moreover, because Chinese culture focuses on the family
roots of developmental disorders, many Chinese parents Sample size
of children with ASD may be blamed for causing their The minimum sample size required for this study was
children’s present condition [39]. These may make par- calculated using the single-population proportion for-
ents of children with ASD more prone to psychological mula. Due to the lack of previous relevant studies at the
problems. However, there are few studies on depressive study site, we used a prevalence of depressive symptoms
symptoms in parents of children with ASD in the Chi- of 50% (p = 50%), 95% confidence interval (CI), a margin
nese context. Insufficient awareness of depressive symp- error of 5%, and a non-response rate of 10% to obtain the
toms in the parents of children with ASD may hinder largest possible sample size. The sample size required for
efforts to intervene early in children with ASD in China the study based on the calculation was 423. Therefore, a
[32]. Therefore, we hypothesize that the above factors total of 430 parents of children with ASD were recruited
may be associated with depressive symptoms in Chinese into this study; 21 parents who did not completely fill out
parents of children with ASD. the questionnaire were excluded. Finally, a total of 409
We conducted a cross-sectional survey in Lianyun- parents of children with ASD were included in this study,
gang, Jiangsu Province, Eastern China. We aimed to with a participation rate of 95.1%.
assess the current status of depressive symptoms in par-
ents of children with ASD and to analyze the predictors Data collection
of depressive symptoms from multiple aspects, such as A structured questionnaire, developed through a litera-
child-related factors, parent-related factors, courtesy ture review and expert consultation, was used to collect
stigma, and social support. This will be beneficial for data. The questionnaire focused on child-related factors,
developing interventions for depressive symptoms in parent-related factors, depressive symptoms, courtesy
parents of children with ASD; furthermore, this will help stigma, and social support. Child-related factors included
children with ASD achieve the best treatment outcomes the child’s sex, age, comorbidities (referring to children
and improve the health of the entire family. who currently have other medical conditions), duration
of rehabilitation, and functional speech. Parent-related
Materials and methods factors included age, sex, place of residence, occupation,
Study design and participants educational status, family monthly income, satisfaction
A multicenter cross-sectional survey was conducted with marital status, challenges of caring for children with
from October 2022 to February 2023 in the rehabilita- ASD, economic burden, changes in a child’s disease sta-
tion department of a large specialized hospital and 10 tus, physical exercise, average time spent with the child
rehabilitation centers for children with special needs in per day, alcohol intake, and cigarette smoking. The term
Lianyungang, Jiangsu Province, Eastern China. Fathers economic burden refers to the economic costs of rehabili-
or mothers of children with ASD undergoing rehabili- tating children with ASD borne by the family. Changes in
tation in these institutions were invited to participate a child’s disease status refers to the changes in the disease
in this study. Only one parent was invited for per child status of children with ASD treated by rehabilitation.
with ASD. The inclusion criteria for participants were as Depressive symptoms were measured using the
follows: (1) age greater than or equal to 18 years; (2) be Patient Health Questionnaire-9 (PHQ-9) [40]. It is a
the mother or father of a child aged less than or equal to commonly used depression screening tool that assesses
12 years with a definite diagnosis of ASD; (3) be able to the frequency of depressive symptoms in the past two
understand the content of the questionnaire; and (4) be weeks. The PHQ-9 consists of nine items, each scored
living with a child with ASD. The exclusion criteria for on a 4-point Likert scale ranging from 0 (not at all) to 3
participants were as follows: (1) mental disorders with a (almost every day). Total scores range from 0 to 27, with
definite diagnosis; and (2) children with ASD had other higher scores indicating more severe depressive symp-
serious physical or neurological diseases. Parents of chil- toms. PHQ-9 total scores of 0–4, 5–9, 10–4, and 15–27
dren with ASD who met the criteria and agreed to partic- indicate no depression, mild depression, moderate
ipate in this study were asked to sign an informed consent depression, and severe depression, respectively [41]. The
form and anonymously complete a hard copy of the ques- recommended cutoff for positive results on the scale is 10
tionnaire. Before participating in the study, parents of points, and it has been validated in the primary care pop-
children with ASD were informed by the investigators ulation (sensitivity = 0.74, specificity = 0.91) and among
Chen et al. BMC Public Health (2024) 24:226 Page 4 of 11

pregnant women in the community (sensitivity = 0.95, differences in the means of continuous variables, t-tests
specificity = 0.89) [42–44]. Therefore, a cut-off value of were used. Variables that were statistically significant
10 was used in this study. The PHQ-9 has been validated in univariate analyses were included in a binary logistic
in healthcare settings in multiple countries, including regression model to assess the independent effect of each
among parents of children with ASD, and has good inter- variable after adjusting for potential confounders. Collin-
nal consistency, construct, and criterion-related validity earity between independent variables was tested before
[5, 33, 41–43, 45]. In the current study, it had a reliability performing binary logistic regression. The results showed
coefficient (Cronbach’s α value) of 0.910, and the internal that the variance inflation factor of each variable was less
consistency would not have improved with the deletion than 10, and the tolerance was much greater than 0.1.
of later scale items. Its validity was confirmed by explor- Therefore, collinearity between independent variables
atory and confirmatory factor analyses (comparative fit was not present. In the current study, all comparisons
index [CFI] = 0.931, goodness-of-fit index [GFI] = 0.913, were two-sided, and all tests of statistical significance
Tucker-Lewis index [TLI] = 0.905, and standardized root used a critical p value of 0.05.
mean square residual [SRMR] = 0.045).
Courtesy stigma was assessed using the Perceived Results
Courtesy Stigma Scale (PCSS), modified from the Deval- The status of depressive symptoms in parents of children
uation of Consumer Families Scale (DCFS) [46]. The with ASD
scale consists of seven items, each scored on a 4-point Based on their scores on the PHQ-9 scale, of the 409
Likert scale ranging from 0 (strongly disagree) to 3 parents of children with ASD, 130 (31.8%) had mild
(strongly agree). Total scores range from 0 to 21, with depressive symptoms, 40 (9.8%) had moderate depressive
higher scores reflecting greater stigma. The PCSS has symptoms, and 37 (9.0%) had severe depressive symp-
been validated for parents of children with ASD and has toms. Using the recommended critical significant depres-
good internal consistency [47, 48]. In the current study, it sive symptoms value of 10, the incidence of depressive
had a reliability coefficient (Cronbach’s α value) of 0.893. symptoms was 18.8% (Fig. 1).
The confirmatory factor analyses for it were CFI = 0.952,
GFI = 0.929, TLI = 0.923, and SRMR = 0.050. Child-related factors
Social support was measured using the Multidimen- The mean age of the children with ASD was 4.88 ± 2.30
sional Scale of Perceived Social Support (MSPSS) [49]. years, and approximately two-thirds (66.7%) of the chil-
The scale consisted of 12 items, including three dimen- dren were younger than 6 years. Most of the children
sions of family support, friend support and other sup- (69.7%) were male, and a few (6.6%) had other medical
port. Each item was scored using a 7-point Likert scale conditions. More than half of the children (52.6%) had
ranging from 1 (very strongly disagree) to 7 (very strongly been in rehabilitation for more than one year, and nearly
agree). Total scores range from 12 to 84, with higher total half (44.3%) spoke few to no words. Univariate analysis
scores indicating higher levels of perceived social support showed that the duration of rehabilitation and functional
for individuals. This scale has been widely used in sev- speech were significantly correlated with depressive
eral countries to assess the adequacy of perceived social symptoms (p < 0.05) (Table 1).
support by the parents of children with ASD [28, 32].
The reliability and validity of the Chinese version of the Parent-related factors
scale have also been confirmed in some studies [50, 51]. The mean age of the parents of the 409 children with ASD
In the current study, it had a reliability coefficient (Cron- was 33.30 ± 5.10 years, and a large proportion of parents
bach’s α value) of 0.955. The confirmatory factor analy- (65.3%) were 31–45 years old. Approximately two-thirds
ses for it were CFI = 0.952, GFI = 0.899, TLI = 0.932, and of the participants (63.8%) were mothers. More than half
SRMR = 0.044. the participants (53.5%) lived in urban areas, and approx-
imately half (49.9%) were currently employed. More
Data processing and analysis than two-fifths of the participants (41.8%) had a college
The completed questionnaires were coded and entered or higher degree, and only 17.8% of the participants had
into a database established using Epidata version 3.1 (Epi- an average monthly family income of more than 10,000
Data Association, Odense, Denmark) software. The data yuan. Nearly a quarter of the participants (24.4%) were
were exported to SPSS version 21.0 (IBM Corporation, not too satisfied with their current marital status, and a
Armonk, State of New York) software for statistical anal- large proportion (85.6%) believed that caring for children
ysis. Continuous data were described as means and stan- with ASD was a big challenge. Approximately one-third
dard deviations (SD), and categorical data as frequencies of the participants (34.2%) claimed that the economic
and percentages. Chi-square tests were used to assess dif- burden of rehabilitation for their child with ASD was
ferences in the proportions of categorical data. To assess low, and only 13.9% of the participants reported that
Chen et al. BMC Public Health (2024) 24:226 Page 5 of 11

Fig. 1 The status of depressive symptoms in parents of children with ASD

Table 1 Child-related factors and their association with exercised. More than one-fifth of the participants (22.2%)
depressive symptoms were current drinkers, and more than a quarter (26.9%)
Variable Total n (%) Depressive symp- χ2 p were current smokers. Univariate analysis found that
toms n (%)
place of residence, occupation, educational status, fam-
Yes No
ily income, satisfaction with marital status, challenges of
Child’s sex 0.207 0.649
caring for children, economic burden, changes in a child’s
Male 285 (69.7) 52 (18.2) 233 (81.8)
Female 124 (30.3) 25 (20.2) 99 (79.8)
disease status, physical exercise, and average time spent
Child’s age 1.393 0.238
with the child per day were significantly associated with
<6 years 273 (66.7) 47 (17.2) 226 (82.8)
depressive symptoms (p < 0.05) (Table 2).
≥6 years 136 (33.3) 30 (22.1) 106 (77.9)
Comorbidities 0.002 0.966 Courtesy stigma and social support
Yes 27 (6.6) 5 (18.5) 22 (81.5) The average scores of courtesy stigma and social support
No 382 (93.4) 72 (18.8) 310 (81.2) were 7.48 ± 4.13 and 57.22 ± 13.55, respectively. Different
Duration of 5.819 0.016 courtesy stigma scores and social support scores signifi-
rehabilitation cantly affected depressive symptoms in parents of chil-
≤1 year 194 (47.4) 27 (13.9) 167 (86.1) dren with ASD (p < 0.001) (Table 3).
>1 year 215 (52.6) 50 (23.3) 165 (76.7)
Functional 11.982 0.003 Predictors of depressive symptoms
speech Binary logistic regression analysis revealed that par-
Few to no 181 (44.3) 47 (26.0) 134 (74.0) ents of children with ASD who raised a child that spoke
words
few to no words were almost 2.747 times more likely to
Some words or 136 (33.3) 21 (15.4) 115 (84.6)
phrases
have depressive symptoms than parents of children with
Sentences 92 (22.5) 9 (9.8) 83 (90.2)
ASD who could speak sentences (odds ratio [OR]: 2.747,
Significant values are in bold 95% confidence interval [CI]: 1.026–7.357). Parents of
children with ASD who reported a high economic bur-
den were almost 3.215 times more likely to have depres-
their child’s condition did not change or became more sive symptoms than parents of children with ASD who
severe after treatment. More than half of the participants reported a low economic burden (OR: 3.215, 95% CI:
(55.0%) spent an average of 6 h or more with their chil- 1.234–8.379). Parents of children with ASD who reported
dren per day, and approximately one-fifth (20.3%) never that their child’s disease status was unchanged or became
Chen et al. BMC Public Health (2024) 24:226 Page 6 of 11

Table 2 Parent-related factors and their association with depressive symptoms

Variable Total n (%) Depressive symptoms n (%) χ2 p
Yes No
Age 0.633 0.729
≤ 30 127 (31.1) 21 (16.5) 106 (83.5)
31–45 267 (65.3) 53 (19.9) 214 (80.1)
>45 15 (3.7) 3 (20.0) 12 (80.0)
Sex 3.263 0.071
Mothers 261 (63.8) 56 (21.5) 205 (78.5)
Fathers 148 (36.2) 21 (14.2) 127 (85.8)
Place of residence 5.479 0.019
Urban 219 (53.5) 32 (14.6) 187 (85.4)
Rural 190 (46.5) 45 (23.7) 145 (76.3)
Occupation 15.189 < 0.001
Employed 204 (49.9) 23 (11.3) 181 (88.7)
Unemployed 205 (50.1) 54 (26.3) 151 (73.7)
Educational status 6.833 0.009
High school or below 238 (58.2) 55 (23.1) 183 (76.9)
College or above 171 (41.8) 22 (12.9) 149 (87.1)
Family income (RMB/month) 6.861 0.032
≤5,000 175 (42.8) 39 (22.3) 136 (77.7)
5,001–10,000 161 (39.4) 32 (19.9) 129 (80.1)
>10,000 73(17.8) 6 (8.2) 67 (91.8)
Satisfaction with marital status 28.606 < 0.001
Satisfaction 309 (75.6) 40 (12.9) 269 (87.1)
Not too satisfaction 100 (24.4) 37 (37.0) 63 (63.0)
Challenges of caring for children 4.835 0.028
Big 350 (85.6) 72 (20.6) 278 (79.4)
Small 59 (14.4) 5 (8.5) 54 (91.5)
Economic burden 26.628 < 0.001
Low 140 (34.2) 7 (5.0) 133 (95.0)
High 269 (65.8) 70 (26.0) 199 (74.0)
Changes in a child’s disease status 14.066 < 0.001
No change or more severe 57 (13.9) 21 (36.8) 36 (63.2)
Improvement 352 (86.1) 56 (15.9) 296 (84.1)
Physical exercise 11.101 0.004
Often 35 (8.6) 4 (11.4) 31 (88.6)
Sometimes 291 (71.1) 47 (16.2) 244 (83.8)
Never 83 (20.3) 26 (31.3) 57 (68.7)
Average time spent with the child per day 4.826 0.028
<6 h 184 (45.0) 26 (14.1) 158 (85.9)
≥6 h 225 (55.0) 51 (22.7) 174 (77.3)
Alcohol intake 0.070 0.792
Yes 91 (22.2) 18 (19.8) 73 (80.2)
No 318 (77.8) 59 (18.6) 259 (81.4)
Cigarette smoking 0.041 0.840
Yes 110 (26.9) 20 (18.2) 90 (81.8)
No 299 (73.1) 57 (19.1) 242 (80.9)
Significant values are in bold

more severe were almost 2.518 times more likely to have likely to have depressive symptoms (OR: 1.189, 95% CI:
depressive symptoms than parents of children with ASD 1.093–1.294). However, employed parents of children
who reported that their child’s disease was improving with ASD were almost 0.427 times less likely to have
(OR: 2.518, 95% CI: 1.108–5.720). Parents of children depressive symptoms than unemployed parents of chil-
with ASD with higher courtesy stigma scores were more dren with ASD (OR: 0.427, 95% CI: 0.201–0.907). Parents
Chen et al. BMC Public Health (2024) 24:226 Page 7 of 11

Table 3 Parental courtesy stigma, social support and their Table 4 Binary logistic regression analysis to determine the
association with depressive symptoms predictors of depressive symptoms
Variable Total Depressive symptoms t p Variables OR 95% CI p
(Mean ± SD) (Mean ± SD) Duration of rehabilitation
Yes No ≤1 year 0.598 0.313–1.143 0.120
Courtesy 7.48 ± 4.13 10.17 ± 4.40 6.85 ± 3.82 5.746 < 0.001 >1 year 1
stigma Functional speech
Social 57.22 ± 13.55 49.52 ± 13.03 59.00 ± 13.05 -6.104 < 0.001 Few to no words 2.747 1.026–7.357 0.044
support
Some words or phrases 1.778 0.657–4.815 0.257
Significant values are in bold
Sentences 1
Place of residence
of children with ASD who were satisfied with their cur-
Urban 1.012 0.519–1.974 0.972
rent marital status were almost 0.429 times less likely to
Rural 1
have depressive symptoms than the parents of children Occupation
with ASD who were not too satisfied with their current Employed 0.427 0.201–0.907 0.027
marital status (OR: 0.429, 95% CI: 0.221–0.834). Parents Unemployed 1
of children with ASD with higher social support scores Educational status
were less likely to have depressive symptoms (OR: 0.973, High school or below 1.363 0.648–2.868 0.415
95% CI: 0.950–0.996). Thus, children’s functional speech, College or above 1
parents’ occupation, satisfaction with marital status, eco- Family income (RMB/month)
nomic burden, perceived changes in a child’s disease sta- ≤5,000 0.730 0.230–2.317 0.593
tus, courtesy stigma, and social support were predictive 5,001–10,000 0.973 0.318–2.978 0.961
factors of depressive symptoms in parents of children >10,000 1
with ASD (Table 4). Satisfaction with marital status
Satisfaction 0.429 0.221–0.834 0.013
Discussion Not too satisfaction 1
Depression is a treatable mental health condition and Challenges of caring for children
should not be a barrier to parents optimally caring for Big 1.247 0.413–3.767 0.695
their children with ASD [12]. This study assessed depres- Small 1
sive symptoms in parents of children with ASD in east- Economic burden
ern China and analyzed its predictors from multiple Low 1
aspects. To the best of our knowledge, this study fills the High 3.215 1.234–8.379 0.017
gap in research related to depressive symptoms in par- Changes in a child’s disease status
ents of children with ASD in eastern China. The results No change or more severe 2.518 1.108–5.720 0.027
of this study showed that the incidence of depressive Improvement 1
symptoms in parents of children with ASD was 18.8%, Physical exercise
which was lower than that in Hong Kong (25.4%) and Often 0.508 0.133–1.933 0.320
Brazil (26.7%) and higher than that in the United States Sometimes 0.615 0.306–1.236 0.172
(12.5%) [9, 11, 14]. This may be due to differences in the Never 1
study design and the sociocultural context. Traditional Average time spent with the child
per day
Chinese culture emphasizes shame and honor, which
<6 h 0.686 0.347–1.355 0.278
may cause people to pay too much attention to the per-
≥6 h 1
ception and evaluation of others; this in turn leads to a
Courtesy stigma 1.189 1.093–1.294 < 0.001
higher incidence of depressive symptoms. Our findings Social support 0.973 0.950–0.996 0.021
suggest that depressive symptoms are common in par- Significant values are in bold
ents of children with ASD in eastern China. Effective and
targeted interventions to reduce depressive symptoms
in parents of children with ASD are urgently needed. predictive factors of depressive symptoms in parents of
Therefore, identifying individual or environmental fac- children with ASD. Regarding child-related factors, this
tors that may contribute to the alleviation of depressive study showed that sex, age, comorbidities, and duration
symptoms in the parents of children with ASD is very of rehabilitation were not significantly associated with
important. This study found that children’s functional depressive symptoms. Regarding parent-related factors,
speech, parents’ occupation, satisfaction with marital this study indicated that age, sex, place of residence, edu-
status, economic burden, perceived changes in a child’s cational status, family income, challenges of caring for
disease status, courtesy stigma, and social support were children, physical exercise, average time spent with the
Chen et al. BMC Public Health (2024) 24:226 Page 8 of 11

child per day, alcohol intake, and cigarette smoking were satisfaction may buffer the effect of parental stress on
not significantly associated with depressive symptoms. depressive symptom; a good marital relationship may
mitigate the effect of parental stress on depressive symp-
Effect of child-related factors on depressive symptoms toms; and a poor relationship may exacerbate the effect of
The current study showed no significant association parental stress on depressive symptoms [4]. In addition, a
between the sex of children with ASD and parental positive marital relationship facilitates effective commu-
depressive symptoms, which is consistent with the find- nication, facilitates problem solving, and increases the
ings of previous studies [9, 23]. In addition, the cur- level of mutual support. Therefore, rehabilitation service
rent findings suggest that parents of children with ASD providers for children with ASD should consider a fam-
who raised a child who speaks few to no words are ily-centered approach to caring for children with ASD
more likely to experience depressive symptoms. This is and how to improve parental relationships.
similar to the findings in previous studies that show an Parents of children with ASD have a substantial finan-
association between severe symptoms in children with cial burden in terms of the costs of rehabilitation training
ASD and a higher incidence of maternal or caregiver and treating medical illnesses [55]. A survey conducted
depressive symptoms, and a lack of functional language in China showed that children with ASD required higher
is particularly important in this regard [33, 52]. Moth- costs to raise them than those with physical or men-
ers of children with ASD often have great expectations tal disabilities [56]. In China, it was estimated that each
for their child’s language development and are likely to family with a child with ASD spent at least RMB 30,000
be depressed by the lack of language development [25]. per year on services for the child in rehabilitation insti-
The absence or lack of language function in children with tutions [33]. The current study showed that parents
ASD may also cause parents to be overwhelmed by their who perceived that the cost of rehabilitation for their
children’s behavior while caring for them, which may pro- children with ASD was a high economic burden on the
mote the occurrence of depressive symptoms. Previous family were more likely to have depressive symptoms.
studies paid more attention to the relationship between This is consistent with the findings in previous literature
the severity of children’s symptoms and parental depres- on the health-related effects of financial stress factors,
sive symptoms [14, 25] and rarely analyzed the effect of which showed that financial hardship predicted anxiety
functional speech on parental depressive symptoms. This in mothers of children with ASD [22]. Thus, financial
study fills this lack of knowledge. Therefore, special atten- support may play an important role in reducing depres-
tion should be paid to the parents of children with ASD sive symptoms in the parents of children with ASD. At
who have no or little language function when developing present, China has expanded its medical insurance cover-
interventions to reduce depressive symptoms in parents age and optimized its reimbursement policy. It includes
of children with ASD. the treatment and rehabilitation of children with ASD
in the medical insurance coverage and has increased the
Effect of parent-related factors on depressive symptoms reimbursement proportion and limit. However, the reha-
Caregiver occupation status was significantly associated bilitation and treatment of children with ASD requires
with depressive symptoms [34]. Unemployment is an long-term investment and support, and the joint efforts
important predictor of depressive symptoms in parents and support of all sectors of society are still required.
or caregivers of children with ASD [29]. This study sup- Previous studies have shown that children’s behavioral
ports previous studies that found that parents of children problems are reliable predictors of depressive symptoms
with ASD who were employed were less likely to develop in mothers of children with ASD [57]. Severe behavioral
depressive symptoms. Because of caregiving responsibili- symptoms in children increase the likelihood of severe
ties for children with ASD, parents are often forced to depressive symptoms in parents by 35 times [14]. The
leave their jobs or to reduce their hours at work, which current study expands on previous findings that showed
reduces family income and, thus, increases stress, lead- that parents who perceived no change or more severe ill-
ing to depressive symptoms [4, 53]. Therefore, much ness in their children with ASD were more likely to be
attention should also be paid to the parents of children depressed than parents who perceived improvement in
with ASD who are unemployed. Relationship quality their children with ASD. Parents who perceived that their
may be an important factor to be explicitly considered child’s disease was unchanged or became more severe
in an intervention paradigm for children with ASD [4]. were more likely to be confused about the future of the
Low marital satisfaction is associated with higher nega- child and to have doubts about the care the child needs,
tive emotions in mothers of children with ASD [54]. which may in part increase the occurrence of depressive
This study also found that parents of children with ASD symptoms. Therefore, clinicians should increase com-
who were satisfied with their current marital status were munication with these parents to solve their confusion
more likely to be free from depressive symptoms. Marital and doubts, thereby reducing the incidence of depressive
Chen et al. BMC Public Health (2024) 24:226 Page 9 of 11

symptoms. In addition, compared with some Western depressive symptom interventions for parents of children
countries, there are relatively few ASD rehabilitation with ASD.
institutions and resources in China, which prevents some
children with ASD from receiving timely and effective Limitations and suggestions for future research
rehabilitation. This may affect the improvement of the Several limitations of the current study must be acknowl-
disease, and more resources should be made available. edged. First, a causal relationship between the variables
and outcome could not be established because this is a
Effect of courtesy stigma on depressive symptoms cross-sectional study. Future longitudinal studies are
Previous studies have found that vicarious and self- required to further evaluate the associations found. Sec-
stigma are positively correlated with depressive symp- ond, fathers and mothers were recruited separately, and
toms in parents of children with ASD, and internalized there were no matched parenting pairs. Future recruit-
stigma is significantly correlated with depressive symp- ment of both fathers and mothers of the same child with
toms in parents of children with ASD [11, 58]. The cur- ASD is needed for better comparative analyses. Third, the
rent study adds to previous research by clarifying that current study was conducted in only one city, and due
courtesy stigma is a risk factor for depressive symptoms to the influence of socio-economic and cultural back-
in parents of children with ASD. The Chinese culture ground, the results should be cautiously extrapolated to
emphasizes group harmony. Some families of children regions with different conditions. Future studies in dif-
with ASD may face social isolation due to their children’s ferent cultural contexts are needed. Finally, the measures
abnormal behavior and communication style, which may of variables such as depressive symptoms in the current
cause significant stigmatization of these Chinese parents study were all based on self-report, with the possibility of
[11, 59]. In addition, the parents of children with ASD bias. Multiple methods of data collection need to be con-
are also subject to unjustified criticism and accusations sidered in future studies.
that they are passing on bad genes or providing ineffec-
tive parenting because of their biology and closeness [38]. Conclusion
Qualitative studies conducted in China have also shown The results of this study showed that the prevalence of
that parents of children with ASD are criticized for fail- depressive symptoms in parents of children with ASD in
ing to discipline their children or for poor parenting [60]. eastern China was high, and children’s functional speech,
Therefore, there is an urgent need to develop effective parents’ occupation, satisfaction with marital status, eco-
anti-stigma interventions to reduce depressive symptoms nomic burden, perceived changes in a child’s disease sta-
in parents of children with ASD. Studies have shown tus, courtesy stigma, and social support were predictors
that knowledge interventions and contact interventions of depressive symptoms in parents of children with ASD.
can reduce the prejudice of community members and Interventions that focus on depressive symptoms in par-
improve the public’s attitude towards children with ASD ents of children with ASD need to be developed. In the
and their families, thereby reducing the stigmatization of formulation of intervention measures, efforts should be
parents of children with ASD [38]. focused on reducing the risk factors and strengthening
the protective factors of depressive symptoms to achieve
Effect of social support on depressive symptoms optimal effectiveness of the intervention and the healthy
Support and education should be provided to parents of development of children with ASD.
children with ASD on an ongoing basis throughout their
Abbreviations
child’s development [9]. Strengthening social support ASD Autistic spectrum disorder
can reduce depressive symptoms in mothers of children PHQ-9 Patient Health Questionnaire-9
with ASD. Support from family members is an impor- CFI Comparative fit index
GFI Goodness-of-fit index
tant component of social support, and interventions to TLI Tucker-Lewis index
improve family functioning may help address depres- SRMR Standardized root mean square residual
sive symptoms in mothers of children with ASD [5]. The PCSS Perceived Courtesy Stigma Scale
MSPSS Multidimensional Scale of Perceived Social Support
current study revealed that social support is a protective SD Standard deviation
factor against depressive symptoms in parents of chil- OR Odds ratio
dren with ASD. This is consistent with previous studies CI Confidence interval

in which social support was shown to be a significant Acknowledgements

predictor of depressive symptoms in both mothers and We would like to thank the data collectors and supervisors for their efforts and
fathers of children with ASD [31]. Social support is key support and assistance for this study. In addition, we deepest gratitude goes-
ahead to the study subjects for their willingness to participate in this study.
to improving parental adaptability in the management
of children with ASD [61]. Therefore, increasing social
support is an aspect of concern in the development of
Chen et al. BMC Public Health (2024) 24:226 Page 10 of 11

Author contributions 8. Zhang X, Kern ZG, Yun J. Physical activity and Mental Health of parents of
DMY, JT and XC carried out conceived the study. DDS, XW, SM, XC and children with Autism Spectrum Disorder. Adapted Phys Activity Quarterly:
JT collected the data. XC and JT participated in the statistical analysis, APAQ. 2023;40(4):649–63.
interpretation of data and manuscript preparation. All authors read and 9. Cohrs AC, Leslie DL. Depression in parents of children diagnosed with
approved the final manuscript. Autism Spectrum disorder: a claims-based analysis. J Autism Dev Disord.
2017;47(5):1416–22.
Funding 10. Gatzoyia D, Kotsis K, Koullourou I, Goulia P, Carvalho AF, Soulis S, Hyphantis T.
Funding Support for this study came from the Opening Foundation of The association of illness perceptions with depressive symptoms and general
NHC Contraceptives Adverse Reaction Surveillance Center, Jiangsu Health psychological distress in parents of an offspring with autism spectrum disor-
Development Research Center (Grant number: JSHD2022062). der. Disabil Health J. 2014;7(2):173–80.
11. Chan KKS, Leung DCK. Linking child autism to parental depression and
Data availability anxiety: the mediating roles of Enacted and Felt Stigma. J Autism Dev Disord.
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Ethics approval and consent to participate 14. Machado Junior SB, Celestino MI, Serra JP, Caron J, Pondé MP. Risk and protec-
The study was conducted in accordance with the criteria of the 1964 tive factors for symptoms of anxiety and depression in parents of children
Declaration of Helsinki and its later amendments. This study was approved by with autism spectrum disorder. Dev Neurorehabilitation. 2016;19(3):146–53.
the Ethics Committee of Lianyungang Maternal and Child Health Hospital. All 15. Burrell TL, Borrego J. Parents’ involvement in ASD Treatment: what is their
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The authors declare no competing interests. early intervention: a call for an integration of services. Infants and Young
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Author details 19. Wergeland GJ, Fjermestad KW, Marin CE, Bjelland I, Haugland BS, Silverman
1
Lianyungang Maternal and Child Health Hospital, 669 Qindongmen WK, Öst LG, Bjaastad JF, Oeding K, Havik OE, et al. Predictors of treatment
Street, Haizhou District, 222000 Lianyungang, Jiangsu, China outcome in an effectiveness trial of cognitive behavioral therapy for children
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National Health Commission Contraceptives Adverse Reaction with anxiety disorders. Behav Res Ther. 2016;76:1–12.
Surveillance Center, NO.277 Fenghuang west Street, Gulou District, 20. Reid M, Fesalbon M, Mendoza E, Alvord MK, Rich BA. Examining the relation-
210036 Nanjing, Jiangsu, China ship between parental symptomatology and treatment outcomes in children
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Jiangsu Health Development Research Center, Nanjing, Jiangsu, China with Autism Spectrum Disorder. J Autism Dev Disord. 2019;49(11):4681–5.
4
Jiangsu Provincial Medical Key Laboratory of Fertility Protection and 21. Vasa RA, Singh V, Holingue C, Kalb LG, Jang Y, Keefer A. Psychiatric problems
Health Technology Assessment, Nanjing, Jiangsu, China during the COVID-19 pandemic in children with autism spectrum disorder.
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