Summary of Doctoral Thesis on Psychology: Stress in parents of children with autism spectrum disorder

MINISTRY OF EDUCATION AND TRAINING HANOI NATIONAL UNIVERSITY OF EDUCATION

NGUYEN THI MAI HUONG

STRESS IN PARENTS OF CHILDREN WITH

AUTISM SPECTRUM DISORDERS

Major: Psychology Code: 9.31.04.01

SUMMARY OF DOCTORAL THESIS ON PSYCHOLOGY

HÀ NỘI - 2020

The research project is completed at DEPARTMENT OF PSYCHOLOGICAL - EDUCATION – HANOI NATIONAL UNIVERSITY OF EDUCATION

Supervisors:

1. Associate Professor. Dr. TRAN THI LE THU

2. Associate Professor. Dr. PHAN THI MAI HUONG

Reviewer 1: Assoc.Prof. Dr. Le Van Hao

Institute of Psychology

Reviewer 2: Assoc.Prof.Dr Nguyen Thi Mai Lan

Academy of Social Sciences - Vietnam Academy of Social Sciences

Reviewer 3: Assoc.Prof.Dr. Truong Thi Khanh Ha

University of Science and Technology - VNU Hanoi

The thesis will be reviewed by the Council of Thesis Evaluation at the Department of Psychology – Education, Hanoi National University of Education at…..on....../…./ 2020

The thesis can be found at the National Library (Ha Noi) and

the Library of Hanoi National University of Education

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PREAMBLE

1. Reasons for choosing this topic

1.1 Over the past decades, the term „stress‟ has become increasingly popular in the fields of behavioral and health sciences; and many treatments have been applied in an attempt to address these complex health problems (Papathanasiou et al., 2015). Stress is how the body responds to any type of needs or threats. The stress response is also how the body protects us.

When functioning properly, it helps people stay focused, energetic, and alert. In emergencies, stress can save lives or give people more strength to protect or defend themselves (Segal et al., 2019), in which it is termed beneficial stress (Eustress). Issues around stress have been studied by many scientists, especially psychologists and medical researchers. However, stress that exceeds the threshold will cause physical, emotional, and psychological damage (Gregory Fricchione, 2016). Such excessive stress is called harmful stress (Distress); therefore, it is necessary to take pertinent remedies and minimize its adverse effects.

1.2 Autism and autism spectrum disorder are all terms that refer to a group of complex disorders in brain development, which is characterized by difficulties and deprivations in social interaction, verbal and non-verbal communication, and restricted repetitive behaviors and interests.

With defective social interaction and sensory disorders by nature, children with ASDs face many difficulties in all life aspects, such as learning to speak, communication, behavior, emotional adjustment and expression, studying, independent life, and working in adulthood. These difficulties in children with ASDs also cause numerous adversities and stress for their families, especially their direct caregivers (Sander et al., 2010). Children with ASDs almost merely receive the main support from their families, namely parents, grandparents, or charitable individuals and social organizations in different forms (Tran Van Cong, 2013).

Parents taking care of children with ASDs often report increased levels of harmful stress, depression, and anxiety. If these parents‟ needs for psychological, physical, and social health care are unmet, this will hinder the family's adaptive activities as well as the ability to intervene and support the children with ASDs (Catalano et al., 2018).

Mothers of children with ASDs can be four times more likely to suffer from harmful stress (Silva and Schalock, 2012) than mothers of children from other groups; and they can have twice as much stress as mothers of children with developmental delay (Estes et al., 2009; Rodrigue et al., 1990; Schieve et al., 2007; Silva and Schalock, 2012).

When detecting impairments in their children, parents commonly undergo tremendous changes in individual psychological states, psychological atmosphere in the family, and personal routines. Also, regarding these cases, there are more disquieting thoughts and disturbances in the emotional life among spouses, children, family members, and social relationships. This transition leads to certain moods when parents are not able to adapt or accept this new situation of themselves and their families (Nguyen Thi Quyen and Nguyen Thi Mai Lan, 2013).

1.3 Over the past years, with the advancement of science, many factors have been identified as sources of stress, such as biology, chemicals, microorganisms, psychology, social culture, and the environment. Each approach interprets stress differently, entailing deeming stress as a stimulus or as a reaction or interaction (Papathanasiou et al., 2015).

Stress has been studied by many domestic and foreign researchers with different approaches on different subjects. However, there is still a lack of research on stress in parents of children with ASDs. Therefore, the study of stress in parents of children with ASDs in

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Vietnam will bring theoretical as well as practical significance. The questions are: Do parents of children with ASDs experience harmful stress? If so, what are the levels and expressions of harmful stress in these parents? Which factors affect the stress found in parents of children with ASDs? How do parents of autistic children cope with stress and how this can relate to their stress status? Can psychological therapy help reduce parents' stress?

For these reasons, we chose to research on the topic "Stress in parents of children with autism spectrum disorder" to describe stress expression in parents of children with ASDs, detect stressors and how parents deal with stress, thereby apply psychological counseling to help mitigate stress in parents of children with ASDs. 2. Research purposes

This research aims at studying the theory and real situation of stress in parents of autistic children, based on which psychological interventions will be experimented to reduce harmful stress in parents of children with ASDs. 3. Research objects and research subjects 3.1. Objects of the study: Expression of stress in parents of children with disabilities in the aspects of entity, perception, emotion, and behavior; the relation between parents‟ stress and problems related to children with ASDs, and factors from parents themselves and their demographic and social characteristics; and how to deal with harmful stress in parents of autistic children. 3.2. Subjects of the study: The study surveyed 209 parents of autistic children. 4. Scientific hypotheses 4.1. The majority of parents of children with ASDs in the sample group experience harmful stress; and harmful stress appears heterogeneously among parents of children with ASDs regarding the aspect of entity, cognition, emotion, and behavior. 4.2. The main factors related to harmful stress in parents of children with disabilities include (1) Issues related to their children 's ASDs situations, (2) Demographic and social characteristics, (3) Gender and birth order of children with ASDs, (4) Parents‟ knowledge and skills to care for and educate children with ASDs, and (5) Family support to parents in their life and especially in educating children with ASDs. 4.3. How harmful stress is tackled in parents of children with ASDs is related to their status of harmful stress. 4.4. It is possible to help parents of children with ASDs to mitigate harmful stress through psychological counseling using Albert Ellis' rational emotional behavioral therapy (REBT). 5. Research tasks 5.1. Research the theoretical basis of stress in parents of children with ASDs from a psychological perspective. 5.2. Survey and analyze the status of stress expression, the relation between parents‟ stress and problems in children with ASDs, and factors from parents themselves as well as demographic and social characteristics; and how to deal with harmful stress in parents of children with ASDs. 5.3. Experiment psychological counseling using REBT to minimize harmful stress in parents of children with ASDs. 6. Limitations of the research 6.1. Limitations of research content

This study focused only on subjective assessments of parents of children with ASDs regarding the expression of harmful stress in certain aspects of entity, cognition, emotion and behavior; related factors, stressors and ways to deal with harmful stress; and Reasonable emotional behavioral therapy (REBT) in harmful stress intervening treatment.

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6.2. Limitations of research space This doctoral study researched on integrated diagnostic, integration, semi-integration,

and specialized facilities in Hanoi City and some neighboring provinces as follows.

- Sao Bien Center, Hanoi National University of Education (Hanoi) - Khanh Tam Center (Hanoi) - Gia An Center (Hanoi) - Uoc Mo Center (Bac Ninh) - Nang Mai Center (Hanoi) - Anh Sao Specialized Center (Hanoi) - Akira Center (Hanoi) - Thien Than Nho Center (Ninh Binh) - Tuong Lai Moi Center (Hanoi) 6.2. The limitations of survey subjects The study was conducted on 209 parents of children with ASDs at an early intervention age. 7. Research methodology 7.1. Approaching method

The study was conducted based on an integrated approach which entails - Approaching the mind - biology - society: Biological, psychological and social factors are closely connected. These factors all affect stress in parents of children with ASDs. Therefore, in proposing preventive and intervening activities to deal with stress, all these three factors need to be taken into consideration.

- Approaching developmental psychology: Studying stress in parents of children with ASDs should be based on the developmental psychological characteristics corresponding to the age of parents themselves and their children. Therefore, it is necessary to examine and experiment appropriate psychotherapy to minimize parents' stress at this stage of maturation and corresponding to children's age.

- Approaching social psychology: Research by applying the knowledge of social psychology to discern how the community, services, and social policies impact on stress in parents of autistic children and the ways they cope with their stress.

- Approaching counseling psychology: The study uses the knowledge of counseling psychology to apply REBT personal counseling therapy to reduce harmful stress in parents of children with ASDs.

- An interdisciplinary approach: The study of stress in parents of children with ASDs is conducted based on the inseparable relationship between psychology and special education and social work. Therefore, the application of interdisciplinary research is essential in researching and supporting parents of children with ASDs. 7.2. Specific research methods Regarding the nature and focus of this study, we applied a combination of the following methods:

- Document analysis method - Investigation via questionnaire method - In-depth interview method - Experimental method - Mathematical statistical methods

8. New contributions of the thesis 8.1. Theoretical contribution

The thesis has synthesized and pointed out research directions about stress and stress in parents of children with ASDs, which entails research on the manifestation of harmful stress, research on stressors, research on the stress response, and research on intervening

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remedies to deal with harmful stress in parents of children with ASDs.

The dissertation has synthesized relevant and updated literature related to ASDs including concepts, nature, issues about ASDs, and psychological characteristics of young parents having children with ASDs.

The thesis has contributed to clarifying some theoretical issues about stress, especially stress in parents of children with ASDs, which specifically entail criteria for assessing stress, expression of stress, stressors, ways to cope with stress, and intervening measures to minimize harmful stress in parents of children with ASDs. 8.2. Practical contribution In Vietnam, this research is one of the first studies on the topic of stress in parents of children with ASDs.

This research has indicated that most parents of children with ASDs in the sample group have exhibited fairly frequent stress since the diagnosis of their children‟s ASDs; and stress manifests itself in all four aspects of physical, cognitive, emotional, and behavioral conditions. Expression of the overall stress is associated with all four mentioned component aspects, among which the most evident expression is found in emotions and behaviors.

Based on statistical analysis, the thesis has found out that: The lower the education levels of parents are, the more their expression of stress is; the more family members support the care for and education of children with ASDs, the less stress in parents is found; and parents having an inadequate understanding of treatments of autism have higher stress levels than those with no or deep knowledge of the issue. The more skillful parents are at training their children‟s behavioral skills, the more often they experience stress. There is a significant positive correlation between autistic children's problems (communication, behavior, and social interaction) and the level of stress in parents. The manifestations or problems related to ASDs in children are the basic factors leading to parents' stress. The more continuously these problems occur, the more frequent parents‟ harmful stress becomes. The most common coping strategy used by parents is focusing on their children's positive points. The least used measures are meditation, yoga, or taking art courses. The more stressful parents are, the more likely they are to respond negatively.

This study has also pointed out the effectiveness and relevance of individual consultations based on REBT therapy for negatively-stressed-out parents of children with ASDs. Besides, the study has emphasized paying attention to individual characteristics, family culture, and clients‟ academic levels.

Based on the results of the whole thesis research, the author has proposed appropriate recommendations for parents of children with ASDs, young families, and experts of intervention and counseling for children and for young families to prevent and minimize harmful stress in parents of children with mental health; thereby simultaneously contribute indirectly to improving the quality of interventions and supports for children with ASDs. 9. Thesis structure

In addition to the introduction and overview, conclusions and recommendations, lists of published works, references, and appendices, this thesis is organized into three chapters including Chapter 1: Rationale for stress in parents of children with autism spectrum disorders; Chapter 2: Research organization and methods; Chapter 3: Research results of stress status in parents of children with autism

spectrum disorders.

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Chapter 1 RATIONALE OF STRESS IN PARENTS OF CHILDREN AUTISM UNIVERSAL DISORDERS

1.1. Overview of research topic 1.1.1. Studies on the expression and level of stress in parents of children with ASDs

Through researching relevant literature, it is revealed that, in the world, there have been in-depth studies on stress issues in parents of children with ASDs. The early years of a child's life can be a particularly stressful time for all parents; however, parents having children with ASDs may encounter additional sources of stress. 1.1.2. Studies on the causes/factors leading to stress in parents of autistic children

Regarding sources of stress in parents of children with ASDs, parents having autistic children can experience specific sources of stress related to the child – his/her autism, the parent themselves, and the social support. 1.1.3. Studies on response to harmful stress in parents with autistic children

A mission-oriented response is an indicator of parents of normally developing children, according to Dunleavy, A.M., Leon, S.C., Lyons, A.M., & Roecker Phelps, C.E. (2010). Severe symptoms and coping strategies of parents having autistic children can impact on their stress. Coping strategies involving duties, emotions, surrounding society, and avoidance are considered as indicators of four types of parental stress. Stressors include parenting and family issues, pessimism, children's characteristics, and lack of physical strength, according to Kaniel, S., Siman-Tov, A. (2011). 1.1.4. Studies on psychological interventions to reduce stress in parents of autistic children

Approaching awareness to reduce stress in parents having autistic children: awareness plays an important role in stress responses (Grinker & Spiegel, 1945; Janis, 1954; Lazarus, 1993a, 1993b) and assessment of changed awareness can reduce stress (Lazarus & Alfret, 1964). The view of events that are still deemed stressful can be mitigated through ineffective coping skills (Lazarus & Alfert, 1964; Speisman, Lazarus, Mordkoff, & Davidson, 1964). 1.2. Some theoretical issues about stress 1.2.1. Stress concept

Harmful stress (distress) is a state of psychological discomfort that occurs when an individual subjectively assesses events and external factors such as those that are physically or mentally threatening, beyond the coping ability, and are harmful. 1.2.2. Theoretical approach to stress

The literature analysis shows that there are three approaches to stress entailing (1) the physiological response of the body, (2) as a stimulus from the external environment, and (3) as an interaction. 1.2.3. Manifestations of stress Stress has a great influence on our mood, happiness, behavior, and health (Neil Schneiderman, Gail Ironson, and Scott D. Siegel, 2005). The manifestations of stress in specific areas are as follows:

Entity: Stiff or tight muscles, teeth grinding, sweating, stress headache, fainting sensation, feeling of suffocation, difficulty swallowing, abdominal pain, nausea, vomiting, constipation, frequency of urination, loss of excitement, tremor, weight loss or weight gain, and awareness of heart rate. Cognition: Anxious thoughts, fearful anticipation, poor concentration, and difficulty remembering. Emotion: Feelings of stress, irritability, restlessness, anxiety, inability to relax, and depression. Behavior: Eating too much or too little, sleeping too much or too little. 1.3. Some theoretical issues related to stress in parents of children with autism spectrum disorders 1.3.1 Concept 1.3.1.1 Definition of autism spectrum disorder

Autism spectrum disorder is a form of developmental disability characterized by three main defects of communication, social interaction, and having restricted repetitive behaviors, hobbies, or

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activities. Autism spectrum disorders include disorders that share common characteristics but vary in scope, severity, onset, and course of symptoms over time. 1.3.1.2 The concept of stress in parents of autistic spectrum disorder children

Based on the concept, expression of stress and harmful stress in parents of autistic children is understood as “the parents‟ reactions to problems arising from their children autism. These reactions are physically or/and mentally threatening, beyond their coping ability, manifested in the physical, cognitive, emotional, and behavioral aspects.”

* Stress in parents of children with ASDs can manifest itself via entities including - Headache, migraine - Forgetfulness * Stress in parents of children with ASDs can manifest itself via cognition including - Thinking slowly or not wanting to think about your child's conditions - Self-explanation, self-questioning about your child‟s problems * Stress in parents of children with ASDs can be expressed through emotions entailing - Being shocked when knowing that your child has ASDs - Being irritable, easy to get angry - Being sad and depressed when thinking of your child‟s future * Stress in parents of children with ASDs can be expressed through behaviors entailing - Being unable to focus on work - Being impatient when waiting - Being unable to accept something that hinders what you are doing

1.3.3 The stressors for parents arising from their children's problems with autism spectrum disorder

- Issues related to ASDs in children - Factors related to parents - Factors related to the child/children - External factors

1.3.4. Stress coping of parents having children with autism spectrum disorders

Responding is the way individuals show their reactions to certain circumstances, which is

corresponding to their own logic, meanings in their lives, and their psychic abilities.

In this study, with the criteria of reducing stress on an individual level, the responses can be divided into positive responses (proactive actions, affection, and positive thinking to escape the problem) and negative ones (showing negative emotions and having negative thoughts and actions). 1.3.5 Psychological developments in parents of children with disabilities

While some parents go through all these stages, others undergo only certain stages. These periods may come back, especially when new problems/ difficulties arise (Tran Thi Le Thu, 2009). This will be demonstrated through the following 5 stages.

+ Stage 1: Shock, disbelief, denial of the truth. + Stage 2: Anger, Self-blaming + Stage 3: Self-explaining and self-questioning + Stage 4: Felling undermined, depression. + Stage 5: Acceptance

1.4. Psychological interventions to reduce harmful stress in parents of children with disabilities 1.4.1. Psychological intervention therapies to reduce stress 1.4.2. Humanistic therapy 1.4.3. Cognitive therapy 1.4.4. Reasonable emotional behavioral therapy (REBT) 1.4.5. Group therapy 1.4.6. Mindfulness Therapy (mindfulness) 1.4.7. Community psychology (focusing on early identification and prevention) Conclusion of chapter 1

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Chapter 2 RESEARCH ORGANIZATION AND METHODS

2.1. Research organization 2.1.1. Research content

This research focuses on the following topics: - Examining the history of relevant literature, theoretical issues that are the basis for

researching on Expression of stress in parents of children with ASDs in terms of entity,

perception, emotion, and behavior; the relations between parents‟ stress and problems

stemming from their autistic children, and factors from parents themselves as well as

demographic and social characteristics; how to deal with harmful stress.

- Studying the situation of stress in parents of children with ASDs regarding the aspects

of physical, cognitive, emotional, and behavioral manifestations.

- Understanding the relationship between stress in parents and problems relating to

children with ASDs, and factors from parents themselves as well as demographic and social

characteristics.

- Experimenting with reasonable behavioral emotional counseling (REBT) to help

parents of children with ASDs reduce stress.

2.1.2. Characteristics of research subject samples

The mass sample consisted of 231 parents of children with ASDs. While processing

the data, we removed 22 parents because they failed to meet the requirements of the study

(those were parents having children with intellectual disabilities or delayed speech, not

children with ASDs). Therefore, the final sample size to draw scientific judgments was 209

parents. The characteristics of each target group are shown in the following table.

Table 2.1: Characteristics of the research sample

No. Characteristics Number Percentage%

Male 54 25,8

1 Sex Female 152 72,7

Missing 3 1,4

Intermediate or lower 55 26,4

2 Academic level College and higher levels 151 72,2

Missing 3 1,4

Under 30 years old 50 23,9

31 - 40 years old 81 38,7

3 Age Over 40 years old 30 14,4

Missing 48 23,0

Average: 35.9 Sig: 6,61

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2.2. Steps of research implementation 2.2.1. Progress of theoretical research (From March 2013 to September 2016)

2.2.2. Progress of practical research (From September 2016 to May 2018)

To collect information as the basis for developing the questionnaire, the following

resources were used:

Firstly, studies from domestic and foreign researchers about stress and how to deal with stress in parents of children with autistic spectrum disorders were synthesized. At the

same time, information on common issues with variables related to the manifestations of

autism was collected.

The second source was several relevant questionnaires that have been applied in

psychological studies in Vietnam and abroad to evaluate this content.

The third source was consultations with experts.

The fourth source was an exploratory survey with parents of children with autism

spectrum disorder in Hanoi.

Testing the questionnaire.

• Case counseling

The purpose of this step is to test ways to help parents overcome stress.

Selected sample: cases of parents who have a high frequency of stress hindering the

effectiveness of main activities and who have needs for support.

The case consultation was held at Gia An center, No. 35, Lane 7, Thai Ha, Dong Da

2.3. Research methods

2.3.1. Investigation via questionnaire method

2.3.2. In-depth interview method

2.3.3. Empirical method of counseling using rational emotional behavioral therapy

2.3.4. Mathematical statistical methods

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Chapter 3 RESULTS OF REAL SITUATION OF STRESS IN PARENTS HAVING CHILDREN WITH AUTISM 3.1. The situation of stress in parents having children with autism spectrum disorders 3.1.1. General assessment of stress in parents with children with autism spectrum disorders

These signs entail 4 groups which are physical, cognitive, emotional, and behavioral expression. Henceforth, we refer to these four groups as the entity group, cognitive group, emotional group, and behavior group.

Figure 3.1. Distribution of overall stress points

The research results showed that the mean value of stress was 2.60 with the standard deviation (SD) of 0.71. With a scale of 1 to 4 points and a median score of 2.5, the overall stress score was quite regular. The inclination of the Sk graph was <0, which revealed that the distribution was more inclined to the right, meaning that parents with autistic children had stress points that were more inclined to high points than to low ones. The data of the distribution showed that the percentage of people with 3 points or more (under fairly regular or regular stress level) accounted for more than 50%, while the proportion of people under 2 points (belonging to the level of rarely or never stressed) only accounted for 6.2%. The proportion of parents who were "quite often" stressed was 1.5 times higher than the figure for those having stress less frequently.

Stress manifestations Quite often (from 2.5 – 3.5 points) Never / rarely (< 1.5 points)

Table 3.1. Frequency of stress expression in parents by expression groups (%) Sometimes (from 1.5 - under 2.5 points) Often (from 3.5 points and above)

Synthetic 6,2% (n = 13) 40,2% (n = 84) 49,8% (n = 104) 3,8% (n = 8)

Entity 7,7% (n = 16) 32,1% (n = 67) 55,0% (n = 115) 5,3% (n = 11)

Awareness 6,2% ( n = 13) 26,3% (n = 55) 56,0% ( n= 117) 11,5% (n = 24)

Feeling 11,0% (n =23) 39,2% (n = 82) 34,4% (n = 72) 15,3% (n = 32)

42,6% (n = 89) 45,0% (n = 94) 3,8% (n = 8) Behavior

8,6% (n = 18) Note: n represents the number of parents

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Statistical results showed that more than 90% of parents suffered from stress at varying levels, of which more than 50% of parents having children with ASDs had stress at a fairly frequent rate or more, 40.2% of parents having autistic children had occasional stress. Thus, the proportion of parents of ASDs children having stress quite often or more frequently indicated in this study was of the same trend with rates already published in many other studies in Vietnam and over the world, such as the research of Catalano et al. (2018) which showed that caregivers having autistic children often reported increased stress levels, depression, and anxiety. 3.1.2. Manifestations of stress in parents having children with autism spectrum disorder 3.1.2.1. Physical manifestations

No. Opinions Mean SD Never/rarely (%) Sometimes (%) Often (%)

Table 3.2. Manifestations of physical stress Quite often (%) 48,3 18,0 20,2 13,5 2,71 1,015 1

2 12,4 15,7 49,4 22,5

2,89 2,56 0,901 0,990 3 19,3 20,5 43,4 16,9

4 5 6 13,6 18,4 24,1 17,0 23,0 37,9 45,5 23,9 44,8 13,8 27,6 10,3

2,76 2,47 2,27 2,46 0,935 0,920 0,943 0,988 7 23,5 29,4 27,1 20,0 I have a headache or migraine. I am forgetful. I have a decreased interest in sex. I feel tired. I lose appetite. I eat too much or too little. I have insomnia or do not sleep well.

(Min point = 1, Max point = 4) Above are the physical signs of stress in parents having children with ASDs. However, it is often uneasy for parents and those around them to recognize these symptoms, which are often considered to be physical problems, as external signs of stress. From a clinical psychology perspective, these are typical symptoms of stress. 3.1.2.2. Manifestations of cognitive stress

No. Opinions Mean SD Never/rarely (%) Sometimes (%) Often (%) Table 3.3. Manifestations of cognitive stress Quite often (%)

1 24,1 25,3 35,6 14,9 2,41 1,017

2 16,1 21,8 41,4 20,7 2,66 0,984

3 9,1 21,6 48,9 20,5 2,80 0,869

4 8,1 15,1 47,7 29,1 2,97 0,880

5 6,8 11,4 45,5 36,4 3,11 0,863

6 23,8 34,5 33,3 8,3 2,26 0,919 I find myself thinking slowly or not wanting to think about my child's conditions. I explain to myself or question myself about my child's problems. I often think back of the most recent worries. I have many anxious thoughts. I often have repetitive thoughts about my child's conditions. I see the negative side of every problem, overestimate difficulties, and underestimate myself.

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3.1.2.3. Expressing emotional stress Manifestations of emotional stress in parents of autistic children had quite high mean

value and percentage, as shown in Table 3.4.

Table 3.4. Manifestations of emotional stress

No. Opinions Mean SD Never/rarely (%) Sometime (%) Often (%) Quite often (%)

14,0 20,9 46,5 18,6 2,69 0,933 1

11,4 25,0 42,0 21,6 2,73 0,928 2

24,1 32,2 29,9 13,8 2,33 0,996 3

19,8 24,4 37,2 18,6 2,54 1,013 4

18,2 17,0 46,6 18,2 2,64 0,983 5 I was shocked to learn that my child had autism. I am irritable and become angry easily. I feel frustrated and unable to relieve stress. I often feel upset and depressed about my child's future. I feel guilty and incompetent when my child is autistic.

6 I feel lonely and isolated 28,2 29,4 31,8 10,6 2,24 0,986

36,5 23,5 29,4 10,6 2,14 1,036 7

The signs having the highest mean values were: " I am irritable and become angry easily" (M = 2.73, SD = 0.928), " I was shocked to learn that my child had autism" (M = 2.69, SD = 0.933), " I feel guilty and incompetent when my child is autistic" (M = 2.64, SD = 0.983), and " I often feel upset and depressed about my child's future" (M = 2.61 , SD = 0.90).

31,0 31,0 23,8 14,3 2,21 1,042 8 I easily fall into a negative state. I am often restless, worried, and scared.

In terms of percentage, 40.0% of parents often and quite often felt that they “easily fall

into a negative state”, 43.7% felt “frustrated and unable to relieve stress", and 38.1% often

felt “restless, worried and scared”.

Thus, experiencing negative emotions of parents having autistic children can be seen as warning signs that they may be facing stress. Knowledge of these signs needs to be

provided to parents of autistic children, thereby helping them to prevent or reduce stress.

3.1.2.4. Manifestations of behavioral stress

Survey results illustrating behavioral stress are summarized in Figure 3.5. According to Miller (2010), behavioral problems are considered as externalizing disorders of internal emotional disturbances.

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No. Opinions Mean SD Never/rarely (%) Sometime (%) Often (%) Table 3.5. Behavioral stress manifestations Quite often (%)

0,926 1 2,58 24,7 15,7 44,9 14,6

0,922 2 20,5 2,35 34,1 35,2 10,2

1,059 3 23,0 27,6 2,37 33,3 16,1

0,944 4 1,95 28,1 16,9 43,8 11,2

5 31,4 22,1 43,0 2,49 3,5 0,906

6 17,0 40,9 2,32 34,1 8,0 0,853

44,3 15,9 10,2 29,5 2,65 7 0,869

17,8 37,8 2,35 35,6 8,9 8 0,878

I cannot focus on the work I am doing. I find my working performance less efficient. I am not as active and flexible as usual. I am often confused by things that didn't work out. I often withdraw into myself and do not want to interact with others. I tend to overreact in every situation. I find myself impatient when waiting. I cannot accept something interfering with what I am doing. It can be seen that parents of autistic children experienced stress at different levels, and most signs of stress actually existed. In particular, in each group of physical, emotional, cognitive, and behavioral signs, the following manifestations were common (signs which appeared quite often or more frequently in over 50% of respondents). 3.1.3. Correlation between groups of stress manifestation 3.1.3.1. Correlation between groups of stress manifestation in parents of autistic children Examining the relation between groups of stress signals, we found a positive and very strong correlation between them. The results of the Pearson correlation between each group of stress expression and the overall stress are shown in Table 3.6 as below.

Table 3.6. Correlation between groups of stress expression in parents

Manifestations of stress Physical Emotional Cognitive Overall

1. Overall 0,897**

2. Emotional 0,917** 0,735**

3. Cognitive 0,949** 0,793** 0,847**

4. Entities 0,936** 0,804** 0,809** 0,858**

Note: ** p < ,01

Specifically, the overall stress had a positive correlation with physical stress (correlation coefficient r = 0.897, p <0.01); with cognitive stress (r = 0.949, p <0.01); with emotional stress (r = 0.917, p <0.01), and with behavioral stress (r = 0.936, p <0.01). Among these correlations, the overall stress correlated most closely with emotional expressions with r = 0.917 **, followed by behavioral expressions with r = 0.936 **. These very high correlation coefficients which were close to 1 showed that they were nearly equal and systematically agreed with each other among all the researched signs of stress.

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Thus, parents having stress at a "fairly regular" frequency will undergo stress expression in all aspects of entity, cognition, emotion, behavior, and other manifestations, among which the most pronounced manifestations are found in emotional and behavioral forms. Similarly, physical, cognitive, and behavioral signs are also closely correlated with the correlation coefficient r ranging from 0.78 to 0.91; p <0.01. 3.1.3.2. Characteristics of stress manifestations in parents of children with ASDs

The results of the discovery factor analysis showed that the matrix of the original components (without rotation) revealed that the items loaded on four factors could explain 62.37% of the variance, with eigenvalue > 1 and all the items had extraction rates on factor > 50%. The data showed that the first component explained over 49% of the variance, being the largest and accounting for the majority of the 4 factors. The matrix table also showed that all items were loaded on the first factor with all loading factors greater than 0.5. Several items are loaded at the same time on certain factors, but most of them had lower loading factors.

Thus, it can be concluded that the items on the stress scale used in this study are quite consistent, focusing on the same factor. Therefore, they can create a unified measurement area (common stress), rather than diverging into separate components.

This is a characteristic of stress in parents having children with ADSs: stress manifestations appear quite simultaneously with almost similar frequencies. When a group of stress manifestation appears, whether it is physical, cognitive, emotional, or behavioral, it goes hand in hand with other manifestation groups. Thus, the overload of stress in parents, which results from the occurrence of series of frequent stress manifestations, is predictable. If having stress regularly can lead to many negative consequences in life, parents of children with ASDs, in particular, will face many problems that affect their health, caring and parenting process, and relationships with family members and friends. 3.2. The correlation between parents’ stress and problems related to children with autism spectrum disorders 3.2.1. Problems of children with ASDs belonging to this research sample group

In this study, three groups of problems of autistic children were surveyed, including (1) Communication problems, (2) Behavioral problems, and (3) Social interaction problem. These are typical manifestations of autism spectrum disorder.

The average score of these 3 types of problems was as follows. (1) Communication problems had M = 2.79, SD = 0.77; (2) Behavioral problems had M = 2.64, SD = 0.76; and (3) Social interaction problems had M = 3.09, SD = 0.76. Thus, children‟s problems that cause the most stress for parents are those about social interaction.

Table 3.8. Problems of children with ASDs in the sample group

N

Real number Missing

Mean SD Communication problems 209 5 2,79 0,77 Behavioral problems 209 7 2,64 0,76 Social interaction problems 209 4 3,09 0,76

Note: Scale score has min = 1 (Never), max = 5 (Very often)

3.2.1.1. Communication problems

Social communication is considered a major flaw in children with autism spectrum disorders, and interventions aimed at social interaction are the focus of many studies (Anagnostou et al., 2015). The specific communication issues that lead to stress in parents of children with ASDs are shown in the table below.

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Table 3.9. Status of communication problems Problems

No. 1 The child does not understand what I say. 2 The child does not respond when I talk to him/her. 3 The child speaks weird language. 4 The child repeats certain questions. 5 The child interrupts others while they are talking. Mean 2,98 3,03 3,00 2,51 2,24 SD 0,883 0,875 1,025 1,098 1,017 Note: Scale score has min = 1 (Never), max = 5 (Very often)

3.2.1.2. Behavioral problems

For autistic children, difficulties in language, communication, and cognition may not be serious obstacles that they face. However, other difficulties associated with the mentioned disabilities have become challenging barriers to overcome in these children‟s integration process. One of the difficulties is problems with inappropriate behaviors or provocative behaviors of children. Behavioral problems leading to stress in parents of autistic children are shown in the following table.

Table 3.10. Behavioral problems of autistic children Problems No. 6 The child has self-harming behaviors (skin-pinching, biting, hair- Mean 2,13 SD 1,154 pulling, head-banging against the wall, etc.) 7 The child has repetitive behaviors (hand-flapping, moving hands towards the face and twisting them, finger-flicking, etc.)

8 The child only eats one specific type of food. 9 The child usually touches his/her genital parts. 10 The child does not stay focused on activities. 11 The child repeats a certain question. 12 The child attacks other people (pinching, biting, hitting, forcefully hugging others, etc.) 13 The child breaks surrounding objects. 2,67 2,39 2,59 3,43 2,60 2,32 2,22 1,214 1,189 1,056 0,991 1,197 1,153 1,093 Note: Scale score has min = 1 (Never), max = 5 (Very often)

Autistic children's behaviors are often a source of parents‟ anxiety (Myers et al., 2009); therefore, a necessary part of early intervention can be teaching parents the skills to deal with behavioral problems (National Research Council, 2001). 3.2.1.3. Social interaction problems

The characteristics of social interaction are manifested quite variously in autistic children, for instance, they have difficulty in interpersonal relationships, social contacts, and lack of eye contact. These children also do not care about sharing joy or dislike and often behave in a mechanical way. Problems of social interaction in autistic children leading to stress in parents are specifically characterized as shown in the table below.

Problems

No. 14 The child often plays alone. 16 The child moves things in his/her room without permission. 17 The child makes noise (screaming, crying for a long time, stomping his/her feet, wavering, kicking, jumping up and down, etc.)

18 The child climbs up dangerous places. 19 The child is restless, always wants to work, and does not stay still. 20 The child is playful, squirming, and wiggling. 21 The child is inactive. 22 The child is indifferent to the surrounding. 23 The child does not interact with other people (regarding eye contact, facial expressions, etc.)

Table 3.11. Social interaction problems in autistic children Mean 3,44 2,98 2,90 2,71 3,13 3,07 2,84 3,35 3,26 3,52 2,74 2,91 26 The child is slow to speak. 28 The child asks inappropriate questions. 29. The child plays inappropriate toys. SD 1,157 1,138 0,995 1,027 1,086 1,057 1,180 1,228 1,077 1,167 1,293 1,153

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The research results showed that the "slow-talking" characteristic had the highest mean value among all interaction problems leading to stress in parents of autistic children (M = 3.52, SD = 1,167); this characteristic belongs to the isolated group - the most common group in autism. Isolation occurs even when people around them find ways to draw them into socializing. Children do not come close when called and do not react when someone talks to them; or their faces may express nothing, which can really be a huge challenge for parents of autistic children. Therefore, this characteristic can easily lead to stress in parents having autistic children. 3.2.2. The correlation between parents’ stress and problems related to children with ASDs 3.2.2.1. Correlation between autistic children's problems and parents’ stress

The challenges of parenting of autistic children can be very different from parents of normal children or children with developmental delay. Difficult situations can occur daily as autistic children are often aggressive and tend to break objects, take off clothes at inappropriate times, and hurt themselves (Fodstad et al., 2012). These behaviors may be related to autistic children's characteristics such as impairments in communication or social interactions, mere attention on certain things, and repetitive behaviors (Delmolino and Harris, 2004). To better understand the correlation between autistic children's problems and their parents' stress, we used the Pearson correlation. Specific results are shown in the table below.

Table 3.12: Correlation between autistic children's problems and their parents' stress

Stress manifestations Overall Entity Emotion Cognition Behavior Communication problems 0,551** 0,473** 0,501** 0,520** 0,549** Behavioral problems 0,454** 0,377** 0,405** 0,426** 0,479** Social interaction problems 0,584** 0,476** 0,583** 0,544** 0,554**

Note: ** p < 0,01

The data showed that stress (including both overall stress and components) had a moderate to strong positive correlation with autistic children's problems. In particular, the correlation with problems of social interaction was the strongest, as compared to other components. This aspect had the highest correlation coefficient with emotional stress (R = 0.583, p <0.01) and the lowest with physical stress (R = 0.476, p <0.001). Stress had a lower correlation coefficient with behavioral problems, ranging from 0.377 to 0.479. The data above indicated that the more often the child's problems occurred, the higher the parent‟s stress level got.

Thus, the consistency between this research result and the results shown in the table above points out that there is a significant positive correlation between the problems of autistic children and overall stress, facets of stress manifestation, other research results (Bebko et al., 1987; Moes, 1995; Moes et al., 1992). In particular, overall stress is positively correlated with social interaction, followed by communication and behavior respectively. Regarding stress manifestation, physical stress is also most positively correlated with social interaction, followed by communication and behavioral problems respectively. Emotional stress is most closely positively correlated with social interaction, followed by behavior and communication respectively. Cognitive stress is most positively correlated with social interaction, followed by communication and behavior respectively. Behavioral stress is most positively correlated with social interaction, followed by communication and behavior respectively. Through interviews with 10 parents having autistic children, all parents said that their children had difficulty interacting, specifically as shared below by a parent.

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Sharing of Ms. T.T.N.V: “My child rarely makes eye contact; his language does not develop; his concentration is poor; his body is always active; when seeing strangers, he will yell loudly and cry. He cannot go to daycare because no teachers can look after him as (he will) affect other students in the classroom.”

“When he went to school, the teacher told me he didn't anything, then he, the teacher told me that he didn't eat at all, he didn't eat at all, and the teacher had to feed him. When I visited his class, and I sat in the classroom, I found out that other children were communicating with each other, but my child did not communicate with anyone. He just sat at one place playing and paying no attention at all, at that moment I decided to find a place to intervene in his condition.”

Behavioral problems of autistic children are positively correlated with overall stress and behavioral manifestation of stress. Behavioral problems of autistic children such as "children do not focus on activities", "children have self-harming behaviors", "children have repetitive behaviors", etc. lead to stress in parents. The results showed a positive linear correlation between the negative impacts of behavioral problems and overall stress (r = 0.474, p <0.001) and behavioral stress (r = 0.511, p <0.001). All interviewed parents reported that their children had typical behavioral problems of

autistic children. Sharing of Ms. N.T.T: “In the past, he went to a specialized school, after that he went to an integrated school but he was a bit disruptive because he was hyperactive. He still listened to his teacher but he was devastating, he was really devastating.”

Researches have shown that parents of children with ASDs are stressed by their children‟s characteristics including uneven intellectual development in children, disruptive behaviors, and enduring care cycles (Bebko et al., 1987; Koegel. et al., 1992; Moes, 1995; Moes et al., 1992). Thus, this research result is consistent with the results shown in the table above, which points out that there is a significant positive correlation between the problems of autistic children and overall stress and aspects of stress expression.

In particular, the overall stress is most positively correlated with social interaction, followed by communication and behavior respectively. Regarding stress manifestation, physical stress is also most positively correlated with social interaction, followed by communication and behavioral problems. Emotional stress is most positively correlated with social interaction, followed by behavior and communication. Cognitive stress is most positively correlated with social interaction, followed by communication and behavior. Behavioral stress is most positively correlated with social interaction, followed by communication and behavior. The results above show that, in this study, among problems of autistic children, social

interaction problems are the most influential factor causing stress in parents. 3.2.2.2. The impacts of autistic children's problems on their parents' stress

Table 3.13 shows the results of four linear regression models that predict stress from children's problems. In particular, models 1, 2, and 3 independently predict stress from each aspect, while model 4 is a prediction based on all three problems of children.

Research results showed that each issue of autistic children could directly predict the level of parental stress with the amplitude of influence ranging from 20.2% to 34.1% (p <0.001). In particular, social interaction appeared to have the strongest impact on parents' stress.

Considering the fourth model, when all three issues were affected at the same time, the amplitude of the influence could reach up to nearly 41%, which was significantly stronger than each model with its independent variables. However, in this model, behavioral problems had no statistical significance in predicting the level of parents‟ stress, and interaction was the factor that had the strongest impact on parents‟ stress.

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Table 3.13. The impact of autistic children's problems on their parents' stress

Model Independent variables R2 F P Beta (p)

0,303 0,202 0,341 87,959 51,919 105,205 <0,001 <0,001 <0,001 1 2 3

0,408 47,236 <0,001 4 Communication problems Behavioral problems Social interaction problems Communication problems Behavioral problems Social interaction problems 0,329 (<0,001) -0,026 (0,737) 0,419 (<0,001)

Thus, among the 3 problem groups of autistic children, social interaction problems had the strongest impact on parents' stress, then followed by communication problems. Behavioral problems were incapacitated to affect stress when being controlled by the other two aspects.

Therefore, it can be said that problems/manifestations related to autism are the basic factors leading to parents' stress. The more often these occurrences/expressions occur, the more frequent parents' stress becomes.

This result once again proves the difficulties parents face when having autistic children, and these problems are closely associated with the parents‟ mental health and the process of raising children with ASDs. 3.3. Measures to deal with stress in parents of autistic children and their relation with parents' stress 3.3.1. Coping measures

“Sharing with other family members” was particularly the measure that was loaded on both factors with the factor loadings being insignificantly different, indicating that this was a bipolar response, being both positive and negative. The extraction of the factor of each item showed that the majority were > 0.3. There were only 2 items with the extraction of <0.3, which were "pretend nothing happened" and "practice meditation/yoga". These are responses that clearly reflect neither positivity nor negativity or negative. 3.3.1.1. Positive responses Table 3.15. Positive responses of parents having children with ASDs

Mean SD Number Reality Missing

200 198 201 201 200 198 197 199 198 9 11 8 8 9 11 12 10 11 1,53 2,34 1,92 1,89 2,14 2,11 1,75 1,70 2,23 0,862 0,941 0,902 0,970 0,895 0,971 0,849 0,925 0,871

203 6 1,79 0,844 Focus on your child‟s positive points Join organizations that support autistic children Get enough sleep at night Accept your child‟s condition Seek experts to support for your child Take up a course or a type of art Manage and rearrange your time Eat properly regarding nutrition Practice meditation/yoga Listen to music, watch TV, watch movies, ror ead stories/books

Note: Scale score has min = 1 (Never), max = 4 (Very often)

The two least common coping measures adopted by parents having autistic children were meditation/yoga and taking up a course or a type of art course. This is possibly because focusing on caring for and raising their autistic children gives them little time to

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attend courses. Also, regarding the context of Vietnam, the option of handling stress by forms of art is still quite new to the people; so, this option is rarely chosen.

The measures of managing and rearranging time and joining organizations that support

autistic children are neutral responses selected by parents of autistic children. 3.3.1.2. Negative responses The survey results of negative responses are presented in Table 3.16 below.

Content No. Mean SD Table 3.16. Respond negatively in parents of children with ASDs Number Reality Missing 201 3,03 1,102 8

1 Vent your frustration on someone or something 2 Say angry, sarcastic, mocking, and scolding words 201 3,14 ,938 8 to other people

197 12 2,82 1,142

3 Dramatize your child‟s problems (by thinking of negative things that can happen to your child) Isolate yourself 200 3,06 1,040 9

4 5 Deduce unreasonably and to blame other people for 201 3,25 ,904 8 your child‟ problems

6 Blame yourself 7 Hurting someone innocent 8 Let go if everything 9 Cry, wail, scream and smash surrounding objects 10 Avoid meeting other people 200 199 198 201 199 2,59 1,113 3,65 ,591 2,84 1,043 2,37 1,037 2,62 1,046 9 10 11 8 10

Note: Scale score has min = 1 (Never), max = 4 (Very often)

3.3.2. The correlation between coping measures and stress Table 3.17. Correlation between coping measures and stress

There was a significant negative correlation between stress and negative responses: the higher the stress value was, the lower the value of negative responses was. This means that the more often parents experience stress, the more often they will adopt negative measures, and vice versa, the less stress they undergo, the less likely they are to respond negatively. The correlation coefficient was relatively strong, indicating a relatively strong correlation.

Coping measures/ Groups of stress manifestation Overall Entity Emotion Cognition Behavior Negative responses -0,575** -0,502** -0,609** -0,493** -0,519** Positive responses 0,207** 0,151* 0,206** 0,185** 0,224**

Between positive responses and groups of stress manifestation, there was a positive correlation, but the significance ranged from weak to very weak (below 0.225). Thus, it can be understood that the correlation between stress and positive responses is insignificant despite the statistical significance. Therefore, in parents of autistic children, stress seems to be associated with negative rather than positive responses whether they are evasive or seeking relevant resources. This suggests that it is essential to reduce stress and improve mental health for parents of autistic children.

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3.4. The correlation between stress and characteristics of parents and children with ASDs

The results mentioned above (sections 3.2 and 3.3) have provided clear evidence of the relationship between stress and autistic children's problems (related to their mental condition), and coping measures of parents. In particular, the more often children show signs of their illness, the more often parents encounter stress and strongly suffer from stress related to negative responses. This section will examine the relation between stress and other factors of parents and children. 3.4.1. Social and demographic factors of parents and stress 3.4.1.1. Stress and gender

In general, concerning the whole sample, the results showed that mothers of autistic children had higher mean values of overall stress as well as stress reflected in all 4 aspects than fathers (p <0.01). It can be seen that when children are sick, mothers tend to undergo more severe stress in all forms than fathers.

Mothers of children with ASDs had overall stress whose value was significantly higher than fathers whose p = <0.001. This result is also consistent with the mentioned previous studies; a study revealed that mothers underwent higher levels of stress than fathers, especially in child-rearing (Mose et al., 1992). The above studies indicate the need for comparative research on the stress level between mothers and fathers of children with ASDs (Stahmer et al., 2005). This can be explained by the fact that mothers are commonly the primary caretakers of children, who day by day deeply feel the development of their children. Most of the abnormalities in children are mainly discovered by mothers; the theory of attachment also partly explains the bonds between mothers and children. When a child shows abnormal signs, the mother is often the first person to find ways to examine and find intervention strategies for the child. 3.4.1.2. Stress and age

A review of the data about overall stress showed that the younger the age group was, the more frequent the stress occurred. If the error was 7%, this difference would be statistically significant (F = 2.76, p = 0.066). Research results showed that parents aged 30 and under had higher mean values of overall stress as well as stress of all 4 aspects of manifestation than parents aged 31 - 40 and those aged over 40 years old. This can be explained by the fact that people under 30 have less parenting experience than older parents. However, in general, this difference is statistically insignificant, even though younger parents tend to encounter stress more frequently. 3.4.1.3. Stress and education level The research results examining the manifestation of stress by education level are summarized in Table 3.20.

Table 3.20. Comparison of stress from the perspective of education level

Lower College level From Intermediate level p Manifestations of stress

Entity Emotion Cognition Behavior Overall Stress Mean 2,52 2,38 2,56 2,36 2,46 Mean 2,72 2,71 2,87 2,57 2,72 0,050 0,003 0,002 0,035 0,006 SD 0,68 0,74 0,72 0,66 0,65

SD 0,63 0,76 0,59 0,66 0,61 The research results showed that the lower the education level was, the more often stress occurred (p <0.05). Specifically, parents of autistic children with intermediate or lower qualifications had the mean value of 2.72 and SD = 0.61, while those with a college

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or higher qualifications had the mean value of = 2.46 and SD = 0.65. This may be explained by the fact that the higher education level a person has, the greater chances that person has to look for official and meaningful information on supporting his/her child, which may include seeking diagnostic services or intervention remedies for autistic children. People having higher levels of education also have more opportunities to access better parental support services, which results in lower levels of stress. 3.4.1.4. Stress and income

The results of data analysis showed that the lower income parents of autistic children had, the more often they underwent stress (p <0.05) (see Table 3 in the annex). Several studies indicated that parents of autistic children with worse socioeconomic disadvantages showed higher levels of stress and depression (Stanojević et al, 2017; Zaidman-Zait et al, 2018). Many studies also showed that financial concerns for basic needs would interfere with treatments and education (e.g. Sharpe and Baker, 2011; Vohra et al., 2014; Zablotsky et al., 2014; Thomas et al. (2016).

Table 3.21. Correlation between stress and income

Overall Stress

INCOME

Pearson Correlation SD (2-tailed) N -0,166* 0,038 157

Note: Some parents left a blank on information about family income

3.4.2. Parents’ stress and characteristics of autistic children

Gender of the children The comparison showed that parents of female children and those of male children had a relatively similar mean value of stress, with 2.54 for male children and 2.53 for female ones (p = 0.887> 0.05). Thus, parents having autistic children, regardless of the children‟s genders, have no difference in stress level.

Order of birth There was no significant difference found in the frequency of stress among parents having autistic children of different birth orders. An autistic child, whether he/she was the eldest, middle, or youngest, would have nothing to do with the parents' stress (p = 0.918> 0.05). 3.4.3. The correlation between stress and the time of detecting ASDs in children

The results showed that parents‟ stress was negatively correlated with the duration of experiencing the ASDs in their children, with R = - 0,304, p <0.01. Assuming that parents who are, for the first time, informed of their children‟s mental evaluation are all shocked and stressed, the longer the time passes by, the more their stress decreases and vice versa - the more recent their experience is, the more often they encounter stress.

The notion of adaptive stress was formulated in Hans Selye's theory of stress (1936). He also developed the theory of General Adaptive Syndrom (GAS). This model explains the physiological responses of the body to stress. According to him, these stress responses are divided into three phases: alarm, resistance, and exhaustion. In the alarm stage, the "fight or not" mechanism is activated to prepare the body for physical activities, thus allowing it to defend itself against a potential threat. The second stage is characterized by lower stress levels as the body distributes energy to damaged tissues. Therefore, stress responses in this phase are minimized. Lastly, during the exhaustion phase, the body cannot fight against stressors any longer because of the exhaustion of energy resources. Thus, if the cause of stress is not solved at once, health problems may happen. Selye's GAS theory presents a biological elaboration of the body‟s responses and adaptations to stressors. With this mechanism, the more an individual can adapt to the stressors, the less stress he/she will

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encounter. This study has shown evidence to support that view; however, the correlation coefficient <│0,3│ shows that the relationship is weak. Thus, it can be understood that the longer the parents‟ experience with the child's manifestations is, the less their stress will be, which can be attributed to adaptive stress as proposed by the stress theory above. At the same time, the weak correlation coefficients show that in order to adapt to stress, there are many other factors, both internal and external, to consider; however, these are not covered in the scope of this research. 3.4.4. Stress and the support of relatives in how parents' care for and educate their autistic children

The more relatives support parents' ways of caring for and educating their autistic children, the more the parents' stress is reduced, and vice versa - the less their relatives support, the more often stress occurs in parents (p = 0.00). In certain researches, social support is deemed a coping mechanism to help minimize stress for parents (Liwag, 1989; Foronda, 2000; Ting and Chuah, 2010; Callos, 2012; Moh and Magiati, 2012; Yeo and Lu, 2012; Wahyuni, 2013; Foo et al, 2014; Ha et al., 2014; Xue et al, 2014; Roffeei et al, 2015; Santoso et al, 2015; Chong and Kua, 2016). Specifically, social support has been achieved from various of sources, entailing direct support from families, schools, parents of children with ASDs, experts or extended family members (e.g. Foronda, 2000; Xue et al, 2014; Santoso et al, 2015; Chong and Kua, 2016)

Table 3.25. Correlation between stress and support from relatives

Support from relatives Pearson Correlation SD (2-tailed) N Overall Stress -0,345** 0,000 209

3.4.5. The relation between parents' stress and their knowledge and skills of autistic children's 3.4.5.1. The relation between stress and knowledge of ASDs

Research results show that, in general, parents who do not know or know deeply about the treatment of autism are not often stressed, while parents knowing little or knowing somewhat suffer higher stress levels. Thus, it can be concluded that having inadequate knowledge often causes stress at higher levels in parents, as compared to those having no or a lot of knowledge. 3.4.5.2. The relation between stress and parents' skills of behavioral training of their autistic children

In this study, parents‟ behavioral training skills of autistic children entail 3 aspects: in daily routine (referred to as living training skills), in communication (referred to as communication training skills), and in correcting behaviors of autistic children (referred to as adjustment skills for short). The combination of all these aspects is called general training skills. The description of each skill aspect is shown in the table below. Overall, the general training skills of parents in this study were relatively proficient with most items having a mean value > 2.5 (the median of the scale). Skills that had the highest mean values were "Teaching children to bring things" and "Teaching children to use the potty" with the mean value of 2.97, while the skill with the lowest mean value was "Teaching children".

The results of data analysis showed that stress was positively correlated with parents' communication training skills of autistic children with R = 0.174 and p = 0.012 <0.05. This

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means that the more skillful parents are at training their children‟s communication, the more stress they will experience, and vice versa - the less skillful they are, the less stress they have. However, the correlation coefficient <0.3 indicated that this is a weak correlation.

Examining the correlation between stress and different skill aspects, stress did not correlate with parents‟ skills of living training in daily life and managing autistic children‟s behaviors (p> 0, 05); however, it was positively correlated with parent‟s communication training skills, demonstrating a statistical significance. Thus, it can be concluded that the relation between parents' stress and their behavioral training skills for autistic children is actually the correlation with parents‟ communication training skills. 3.5. Experimenting with individual consultation for a case of a mother showing stress 3.5.1. General description of the case 3.5.2. Goal, therapies, process, and plan of individual consultation for Ms. S

The goal is to help the client recognize unhealthy thoughts/beliefs, emotions, and behaviors; proactively identify and gradually replace these with healthy and rational thoughts/beliefs, emotions, and behaviors. 3.5.3. Content and results of the 08 consultation sessions

The consultation for Ms. S lasted 8 sessions over 2 months (1 session per week for 60 minutes), and then short phone calls were maintained to ensure that Ms. S was stable mentally and physically. 3.5.4. Other conclusions drawn from the consultation case

- Evidence supporting the results of quantitative research: the measuring scale of stress manifestations developed by the Ph.D. researcher, the evaluation scale of DASS stress expression.

- New findings from the consultation case: the consultation showed that Ms. S could think fast, being suitable for the 06-step process of the therapy. Ms. S could understand herself and quickly identified her beliefs, emotions, and behaviors; then proactively replaced and adjusted her beliefs, emotions, and thoughts in each specific situation according to the A-B-C-D-E-F model of the REBT methodology throughout 2 months of her individual consultation (1 session per week).

- Research shows that parents' beliefs, thoughts, emotions, and rational optimistic behaviors are positively correlated with positive outcomes of children with ASDs (Bailey, 2008; Durand, 2014). Since Ms. S knew how to relieve stress in positive ways, created a happy harmonious home atmosphere, and involved her husband and other family members in supporting her child, the child has shown considerable improvements. Ms. S's family is a family of state-sector employees, in which all family members have a university or higher degree and healthy social relationships, and live in a high-class collective area. This living situation is also partly helpful for Ms. S's spiritual strength, although in the past, other members of the family had hesitations interacting with the surrounding.

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CONCLUSIONS AND RECOMMENDATIONS

1. Conclusions

Regarding the theory 1.1. Autism spectrum disorder is a form of developmental disability characterized by three main defects in communication; social interaction; and having restricted repetitive behaviors, hobbies, or activities. ASDs can be diagnosed based on the following criteria: (1) severe impairments of social communication and social interaction in many situations, with present or pre-existing symptoms; (2) limitations or stereotypes of behaviors, interests, and activities expressed in at least two manifestation aspects, with present pre-existing symptoms; (3) the signs mentioned above must be shown from an early age; (4) the signs mentioned above must impair social, occupational or other important functional areas; and (5) these disorders are not explained by intellectual disability or normal developmental delay.

1.2. Harmful stress in parents of children with ASDs is the parents' responses to problems arising from their children‟s autism. These reactions, which are expressed in physical, cognitive, emotional, and behavioral aspects, are physically and/or mentally threatening in ways that are beyond the parent‟s response ability.

1.3. Stress in parents of children with ASDs is expressed physically, emotionally, cognitively, or behaviorally, and is associated with subjective factors (beliefs, wills, and knowledge and skills of raising autistic children), and external factors (mass media, community bias, and family support) of parents having children with ASDs.

Regarding the practicality 1.4. Stress of parents having children with ASDs - In general, most of the parents in this research sample, when discovering the ASDs in their children, fell into the state of harmful stress. In particular, the proportion of parents having stress quite often or more frequently was large, while the percentage of parents having no or little stress was very small.

- Stress manifests itself in all the aspects of entity, emotion, cognition, and behavior; and these aspects are closely related. The manifestation of stress is highly convergent. Therefore, using the indicator of overall stress is qualified enough to display the stress level of parents having children with ASDs.

- Common signs of stress include (1) physical symptoms such as forgetfulness, fatigue, headache, migraine, decreased sexual interest, and poor appetite; (2) cognitive symptoms including wandering thoughts, anxious thoughts, self-explanation, self-questioning, thinking of sadness, and not wanting to think of the child's autistic situation; (3) emotional symptoms such as shock, sadness and depression, feeling guilty, irritability, and anger; (4) behavioral symptoms entailing being indecisive, losing focus, being impatient, decreased performance in work, and overreacting. The interview results in this research are also consistent with the quantitative results of these common signs.

1.5. Autistic children's problems are the main cause of their parents’ stress. - The research results have shown a significant positive correlation between the problems of autistic children (regarding communication, behavior, and social interaction) and their parents' stress. - The frequency of autistic children's problems, especially those related to social interaction, can predict the level of stress in their parents.

1.6. Adaptive stress - The research results have shown that the longer the parents experience their children‟s autism, the less frequent their stress is. Also, parents are more likely to encounter stress during the initial period when they, for the first time, are informed of their children‟s autism condition.

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1.7. Parents’ stress is associated with factors stemming from parents themselves. - The more often parents experience stress, the more often they adopt negative coping

measures; and the correlation between stress and positive responses is weak.

- Mothers of autistic children have higher stress levels in all aspects, as compared to fathers. The lower the parents‟ educational levels are, the more often their stress occurs. There is a correlation between the age of parents and stress, but this relationship is insignificant. The lower income the parents earn, the more often they undergo stress.

- Parents who are not fully knowledgeable about the treatment of their children‟s autism have higher levels of stress than those who have no or little knowledge of the problem. There is no correlation between parents' stress and understanding of the concept or causes of autism. - The more skillful parents are at training their autistic children‟s behaviors, the more often they experience stress and vice versa. 1.8. The correlation between parents’ stress and their autistic children’s demographic characteristics.

- The study results have found no correlation between the parents' stress and the characteristics of their children regarding gender and birth order.

1.9. There is a correlation between parents 'stress and support from their relatives. The more relatives support parents' methods of caring for and educating their autistic children, the less often these parents encounter stress and vice versa.

1.10. Parents’ stress can be improved by the REBT remedy. The results of the experimental consultation, which lasted for 2 months (8 sessions/ 480 minutes) and was based on the rational emotive behavior therapy (REBT), have shown that this remedy is effective for cases of mothers having stress quite often. The experimented mother's stress level has been reduced significantly by engaging in REBT experiences which aim at changing and adjusting her unfavorable emotions and behaviors (causing harmful stress) by changing negative beliefs/thoughts in the mother. Experiments conducted in this study have also suggested open space for future research on applying this therapy regarding cultural and personal aspects. 2. Recommendations

2.1. For parents of autistic children: they should proactively identify signs of stress, practice to reduce negative responses to stressful situations arising from problems of their autistic children, and when needed, look for consultation or advisory support from reliable agencies.

2.2. For family members and families of autistic children: Intervention agencies and counseling/advising specialists for children with ASDs should connect their family members with their parents. At the same time, family members and relatives, if possible, should also actively support parents of autistic children in caring for and providing relevant interventions to the children. Also, it is necessary to actively enhance the understanding of autistic children‟s needs and knowledge - skills of supporting these children in their families; to support parents financially; and to spend more time with parents of autistic children.

2.3. Individual counseling and advisory support for autistic children's parents should particularly focus on assisting these parents in preventing and dealing with harmful stress. Both parents with limited knowledge and those with a deep understanding of ASDs should be supported in intervening skills as well as education skills applied to their autistic children.

2.4. The REBT therapy should be applied in individual consultation for parents of autistic children suffering from stress, in consideration of their psychological characteristics, family culture, and academic levels. Meanwhile, flexibly combining this therapy with other relevant remedies is also recommended.

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LIST OF THE THESIS-RELATED PUBLISHED WORKS

BY THE AUTHOR

1. Nguyen Thi Mai Huong (2018),"Trends in studying stress in parents of children with autism spectrum disorder", Journal of Science, Hanoi National University of Education, Volume 63, Issue 9AB.

2. Do Thi Hoa, Tran Tuyet Anh, Nguyen Thi Mai Huong (2018), “The role of social workers in assisting autistic parents to improve their emotional management skills at counseling centers. and inclusive education in Gia An ”. Journal of Hanoi National University of Education, Volume 63, Issue 9AB.

3. Nguyen Thi Mai Huong (2019), "Stress and strategies for coping with stress in parents of autistic spectrum disorder children", Journal of Educational Equipment, Number 1, October 2019.

4. Nguyen Thi Mai Huong (2020),"The situation of stress in parents of children with

autism spectrum disorder", Journal of Psychology, No. 4/2020.

5. Nguyen Thi Mai Huong, Phan Thi Mai Huong (2020),"The problems of children with autism spectrum disorder and their relationship with stress in parents", Journal of Psychology, No. 7/2020 .