Relationship between Disorder Severity, Psychological Distress, and Quality of Life in Parents of Children with Autism Spectrum Disorder: Coping Strategies as a Mediator

Relationship between Disorder Severity, Psychological Distress, and Quality of Life in Parents of Children with Autism Spectrum Disorder: Coping Strategies as a Mediator | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Relationship between Disorder Severity, Psychological Distress, and Quality of Life in Parents of Children with Autism Spectrum Disorder: Coping Strategies as a Mediator Arslan Khalid, Khizra Iqbal, Mehwish Khan, Abdul Sattar Ghaffari, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7068894/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Purpose Raising a child with autism spectrum disorder leads to psychological distress and has a significant impact on the quality of life of parents. The present study was conducted to assess the mediating role of coping strategies in managing psychological distress and improving the quality of life in parents of children with autism. Method An analysis based on a descriptive cross-sectional design was conducted in various autism centers and special education centers of District Punjab. The study involved 266 parents (133 mothers and 133 fathers), recruited via purposive sampling. Data collection was completed by using the Childhood Autism Rating Scale (CARS-2), Brief COPE, Kessler Psychological Distress Scale (K10), and WHO-QOL Brief. Results Pearson correlation analysis revealed that ASD Severity is significantly correlated with psychological distress, quality of life, avoidant coping, and approach coping. Mediation pathway analysis showed that avoidant coping partially mediates the relationship between severity levels, quality of life and psychological distress overall for fathers and mothers of children and fathers of children, but does not mediate for mothers of children. Approach coping partially mediates the relationship between severity levels, quality of life, and psychological distress among fathers and mothers of children. The t-test showed that the difference in quality of life and coping approach is significantly higher in fathers of children as compared to mothers. Conclusion Findings concluded that effective use of coping strategies helps reduce psychological distress and enhances the quality of life for parents. Autism Spectrum Disorder Coping Strategies Quality of Life Psychological Distress Parents Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 Figure 12 Introduction Autism Spectrum Disorder (ASD) is a neurodevelopmental condition characterized by challenges in social interaction, communication, and repetitive behaviors. The severity levels and impact of ASD vary widely among individuals, influencing the level of support needed throughout their lives. While ASD is a lifelong condition, early intervention and tailored support can significantly improve quality of life and daily functioning [ 1 ]. Individuals with ASD may experience a broad range of cognitive abilities, from intellectual disability to exceptional skills in specific areas. The Centers for Disease Control and Prevention notes that ASD can be identified as early as 18 months, though diagnosis is often delayed until later in childhood or even adulthood. Early identification and intervention are crucial for maximizing developmental progress and access to supportive resources [ 2 ]. Parents of children with ASD often experience considerable psychological distress due to the challenges of caregiving, financial burdens, and social isolation. These stressors can significantly affect their overall well-being, with higher severity levels of ASD cases typically correlating with greater parental distress and reduced quality of life [ 3 ]. Multiple research studies have explored the pressure of raising a child with ASD, specifically, the impact it has on the parents, and the importance of supporting them. This is because these parents experience significant distress as a result of having a child who may face profound challenges in social communication, emotions, and behavior, and encounter difficulties in accessing the necessary services [ 4 , 5 ]. Psychological distress refers to the state of emotional strain resulting from the demands of parenting, particularly in the context of ASD. Research highlights that this stress is closely linked to child and parent characteristics, with behavioral difficulties and deficits in socialization and communication being the primary contributing factors [ 6 ]. Among families of children with ASD, parenting psychological distress is a well-documented issue, encompassing emotional, psychological, and practical challenges that can impact family dynamics and parental mental health. Research indicates that parents of children with ASD experience higher levels of anxiety, stress, and depression compared to parents of neurotypical children [ 7 ]. Numerous prior studies have indicated that parents of children with autism spectrum disorder experience a higher level of psychological distress than parents of children without any developmental disabilities and parents of children with other types of developmental disabilities [ 8 , 9 , 10 ]. Parenting stress is the psychological strain caused by the difficulties and expectations of parenting roles, which have a direct effect on parents’ emotional health, the parent-child relationship, and the child’s emotional and social growth [ 11 ]. Several studies have also found that mothers experience greater levels of parental stress than fathers. The level of stress experienced by fathers was associated with the intensity of the ASD in their children. The fathers of children with more serious ASD symptoms reported higher levels of parenting stress [ 12 ]. The severity levels of ASD symptoms are directly associated with increased parental psychological distress, which in turn significantly impacts their overall quality of life [ 13 ]. The caregiver significantly impacts the quality of life (QoL) demands linked with ASD. Research indicates that parents of children with more severe ASD symptoms tend to report lower Quality of life due to heightened caregiving responsibilities and social restrictions [ 14 ]. As primary caregivers, parents manage various aspects of their child's life, including diagnosis, healthcare, behavior, and daily activities, making it essential to assess how this role affects their overall well-being. QoL is a broad concept encompassing multiple aspects of an individual's functioning. QoL is defined as an individual’s perception of their position in life about their goals, expectations, standards, and concerns. Understanding the impact of caregiving on QoL can help in developing interventions to support parents in managing their responsibilities while maintaining their well-being [ 15 ]. Coping strategies play a crucial role in helping parents navigate the challenges of raising a child with ASD while also enhancing their overall quality of life [ 16 ]. Coping strategies play a vital role in shaping the experiences of parents of children with ASD. Coping is commonly defined as the ongoing cognitive and behavioral efforts individuals use to manage external and internal challenges that they perceive as overwhelming or exceeding their available resources. Implementing effective coping strategies is essential for reducing stress and promoting mental well-being. Research suggests that approach-oriented coping, which involves actively addressing stressors, is linked to more positive psychological outcomes, whereas avoidance-based coping may contribute to heightened distress [ 17 ]. Recognizing the significance of coping mechanisms can help in developing targeted interventions to support parents in managing stress effectively. Parenting a child with ASD can be difficult and have a negative effect on the health and well-being of parents. Coping strategies are essential for mitigating stress and maintaining mental health. Approach coping is associated with better psychological outcomes, whereas avoidance coping may lead to increased distress. Understanding the role of coping strategies can help in designing effective interventions for parents to enhance their quality of life by reducing psychological distress. Despite extensive research, gaps remain in understanding the specific effects of ASD severity levels on parental quality of life, including physical health and social relationships. Most studies focus primarily on mothers, overlooking the experiences of fathers and other caregivers. Additionally, little research has explored how socioeconomic and cultural factors influence parental well-being. Cultural perceptions of disability and healthcare accessibility can shape the challenges faced by families of children with ASD. The purpose of the current study is to explore how approach and avoidant coping mediate the relationship between autism severity levels and their effect on psychological distress and the quality of life of parents. Addressing these gaps is essential for developing targeted interventions based on the severity levels of a child’s ASD symptoms. The present study aimed to assess the association of Autism Spectrum disorder severity levels with psychological distress, quality of life, and coping styles in parents. The second objective is to investigate whether coping strategies mediate the relationship between Autism spectrum disorder severity levels and psychological distress and quality of life in parents and lastly to explore the differences in terms of demographic variables (i.e. parents' gender, severity levels, and socioeconomic class) on Autism severity levels, psychological distress, quality of life, and coping strategies in parents. Methods Participants and Procedure The sample comprised 266 parents (133 mothers and 133 fathers) aged between 25 and 50 years. Participants were selected using a purposive sampling technique from various Autism Centers, Special Education Centers, and Government Hospitals across multiple cities, including Rahim Yar Khan, Bahawalpur, Sadiqabad, Multan, Faisalabad, and Lahore. Children clinically diagnosed with ASD according to ICD-11 or DSM-5. Participants were primary caregivers of a child with ASD, living in the same household as the child, with no history of major psychiatric disorders (e.g., major depression, schizophrenia). Parents of children with other comorbidities and disabilities were excluded from the study. A cross-sectional correlational study design was employed. The authorities of the institutes were approached to gain permission to conduct the study within the institutes. Data was collected through in-person surveys using standardized questionnaire tools. Initially, parents were informed about the benefits of the study, and a consent form was introduced. Through that consent form, parents were informed that the information gathered would be confidential and that their refusal to participate in the study would not affect their status in Society. Their right to withdraw from the study at any time, without penalty, was discussed with them. Informed consent was obtained from the participants, the researcher established a rapport with the participants, and then all measures were administered to each family one by one. They were interviewed about the severity levels of the child using CARS-2 and requested to fill demographic sheet, Brief-Cope, Kessler Psychological Distress Scale (K10), and WHO-QOL BREF. The use of culturally adapted versions ensured that the tools were accessible and meaningful to the study population, enhancing the validity of the findings. Measures Childhood Autism Rating Scale (CARS-2). The severity levels of autism spectrum disorder (ASD) in children were assessed using the Childhood Autism Rating Scale, Second Edition CARS-2 is a behavior-based rating scale consisting of 15 items that evaluate key domains of ASD, including social interactions, communication, and repetitive behaviors. Each item is scored on a 4-point Likert scale, with total scores ranging from 15 to 60. Scores are categorized as non-autistic (15–29.5), mild to moderate ASD (30–36.5), or severe ASD (37–60). The reliability of the scale ranged from 0.90 to 0.95[ 18 ]. Brief-COPE. The Brief COPE inventory was used to assess coping strategies. The Brief COPE is a 28-item instrument that evaluates 14 coping strategies, including Approach Coping and Avoidant Coping. The reliability of the Urdu version of Brief COPE has good internal consistency, with Cronbach's alpha of 0.87. The translated Brief COPE was administered as a self-report questionnaire. Participants were asked to indicate how often they used each coping strategy in response to stress, using a 4-point Likert scale [ 19 ]. Kessler Psychological Distress Scale (K10). Kessler's Psychological Distress Scale (K10) was used to measure psychological distress. The K10 scale involves 10 questions about emotional states, each with a five-level response scale that assesses symptoms of anxiety and depression over the past 30 days. The measure can be used as a brief screen to identify levels of distress. Each item is scored from one ‘none of the time’ to five ‘all of the time’. Scores of the 10 items are then summed, yielding a minimum score of 10 and a maximum score of 50. Low scores indicate low levels of psychological distress, and high scores indicate high levels of psychological distress. The reliability of the Urdu version of K10 ranges from 0.85 to 0.90 [ 20 ]. WHO-QOL BREF . The World Health Organization Quality of Life-BREF (WHOQOL-BREF) was used to assess participants' quality of life. The WHOQOL-BREF is a 26-item instrument that evaluates four domains: physical health, psychological health, social relationships, and environment. The Cronbach's alpha values range from 0.65 to 0.92 for the Urdu version of WHOQOL-BREF [ 21 ]. Statistical Analysis Descriptive statistics (mean, standard deviations, variance, and standard error of the mean, confidence intervals), t-test, Pearson's correlation analysis, and multiple regression analysis to examine the coping strategies as mediators between severity levels of ASD, psychological distress, and QoL and ANOVA to see the comparison in the quality of life, severity levels of ASD, psychological distress, avoidant coping and approach cop. All statistical computation was done through the Statistical Package for Social Sciences SPSS, IBM, 21; 2012) and Process Macro in SPSS. Ethics Approval for the study was obtained from the Institutional Ethics Committees of the School of Foreign Languages and Literature, Shandong University (Ref No: ECSFLLSDU2025-10), and the Islamia University of Bahawalpur, Rahim Yar Khan Campus (Ref No: 5424/PSY/RYK). Ethical guidelines were rigorously followed, including obtaining informed consent and ensuring participant confidentiality. Results Table 1 Frequency and percentage of demographic variables of participants (n = 266) Demographic variables f % Parents Father 133 50.0 Mother 133 50.0 Severity Levels Mild 112 42.1 Moderate 102 38.4 Severe 52 19.5 Monthly Earnings (Parents) 150000 Rupees 16 6.0 Table 1 shows the frequencies and percentages of demographic variables of the study participants. Table 2 Correlation between quality of life, severity, psychological distress, avoidant coping, and approach coping Variables M ± SD 1 2 3 4 5 Quality of Life 80.48 ± 8.37 1 Severity 33.41 ± 3.58 − .870** 1 Psychological Distress 35.40 ± 2.21 − .932** .865** 1 Avoidant Coping 14.40 ± 4.17 − .792** .822** .820** 1 Approach Coping 58.22 ± 6.60 .926** − .784** − .838** − .658** 1 ** Significant at the 0.01 level (2-tailed). Table 2 , indicates the correlations between the levels of quality of life, severity, psychological distress, avoidant coping, and approach coping. The findings reveal that quality of life is significantly and negatively correlated with severity, psychological distress, and avoidant coping, while significantly and positively correlated with approach coping. Similarly, severity is significantly and positively correlated with psychological distress and avoidant coping, while significantly and negatively correlated with approach coping. Furthermore, psychological distress is significantly and positively correlated with avoidant coping, while it is significantly and negatively correlated with approach coping. The levels of avoidant and approach coping were significantly and negatively correlated with each other. Table 3 Regression analysis, using avoidant coping as a mediator, severity as an independent variable, and quality of life as an outcome among fathers and mothers of children Predictor Path Coefficients (95% CI) R 2 a b c c ′ Overall, fathers and mothers of children Severity .953 *** − .477 *** -2.015 *** -1.560 *** (-.736, − .186) .775 Only fathers of children Severity .927 *** − .809 *** -1.476 *** − .726 *** (-1.035, − .489) .829 Only mothers of children Severity 1.097 *** − .145 -2.552 *** -2.393 *** (-.566, .178) .762 Table 3 and Figs. 1 , 2 and 3 , shows the results of mediation analysis with avoidant coping as the mediator variable and quality of life as an outcome variable, with the aim of investigation the influence of avoid in the relationship between autism severity (as independent variable) and quality of life (dependent variable) among overall fathers and mothers of children, only fathers of children and only mothers of children. From the results, we see that severity was significantly and positively associated with avoidant (from path a ) overall, fathers and mothers of children, only fathers of children, and only mothers of children. Similarly, avoidant coping was significantly and negatively associated with quality of life among overall fathers and mothers of children, only fathers of children fathers but no association was found among mothers of children (from path b). For direct effect of severity was significantly and negatively associated with quality of life for overall fathers and mothers of children, only fathers of children, and only mothers of children (from path c ). When avoidant coping was involved in the model as a mediator, the indirect pathway between severity and quality of life remained statistically significant among overall fathers and mothers of children, only fathers of children and only mothers of children (from path c’ ) which showed that avoidant coping partially mediates the relationship between severity and quality of life overall fathers and mothers of children and fathers of children” but do not mediate for mothers of children. Table 4: Regression analysis, using the approach coping as a mediator, severity as an independent variable, and quality of life as an outcome among overall fathers and mothers of children, only fathers of children, and only mothers of children Predictor Path Coefficients (95% CI) R 2 a b c c ′ Fathers and mothers of children Severity -1.432 *** .805 *** -2.015 *** -.862 *** (-1.437, -.929) .911 Only fathers of children Severity -.887 *** .569 *** -1.476 *** -.976 *** (-.831, -.236) .861 Only mothers of children Severity -1.991 *** .974 *** -2.552 *** -.613 *** (-2.260, -1.632) .918 Table 4 and figures 4, 5 and 6, shows the results of mediation analysis with approach coping as the mediator variable and quality of life as an outcome variable, with the aim of investigation the influence of approach coping in the relationship between autism severity (as independent variable) and quality of life (dependent variable) among overall fathers and mothers of children, only fathers of children and only mothers of children. From the results, we see that severity was significantly and negatively associated with approach coping among overall fathers and mothers of children, only fathers and only mothers of children (from path a ). Similarly, the approach coping was significantly and positively associated with quality of life among overall fathers and mothers of children, only fathers and only mothers of children (from path b). For direct effect of severity was significantly and negatively associated with quality of life among overall fathers and mothers of children, only fathers and only mothers of children (from path c ). When approach coping was involved in the model as a mediator, the indirect pathway between severity and quality of life remained statistically significant among overall fathers and mothers of children, only fathers of children and only mothers of children (from path c’ ) which showed that approach coping partially mediates the relationship between severity and quality of life among overall fathers and mothers of children, only fathers of children and only mothers of children. Table 5: Regression analysis, using avoidant coping as a mediator, severity as an independent variable, and psychological distress as an outcome among overall fathers and mothers of children, only fathers of children, and only mothers of children Predictor Path Coefficients (95% CI) R 2 a b c c ′ Fathers and mothers of children Severity .953 *** .179 *** .536 *** .366 *** (.102, .234) .785 Only fathers of children Severity .927 *** .289 *** .471 *** .203 *** (.215, .315) .844 Only mothers of children Severity 1.093 *** .072 .633 *** .555 *** (-.012, .191) .720 Table 5 and figures 7, 8 and 9, shows the results of mediation analysis with avoidant coping as the mediator variable and psychological distress as an outcome variable, with the aim of investigation the influence of avoidant coping in the relationship between autism severity (as independent variable) and psychological distress (dependent variable) among overall fathers and mothers of children, only fathers of children and only mothers of children. From the results, we see that severity was significantly and positively associated with avoidant coping among overall fathers and mothers of children, only fathers of children, and only mothers of children (from path a ). Similarly, avoidant coping was significantly and negatively associated with psychological distress among overall fathers and mothers of children, and only fathers of children, but no association was found among mothers of children (from path b). For direct effect of severity was significantly and negatively associated with psychological distress among overall fathers and mothers of children, only fathers of children, and only mothers of children (from path c ). When avoidant coping was involved in the model as a mediator, the indirect pathway between severity and psychological distress remained statistically significant for among overall fathers and mothers of children and only fathers of children and only mothers of children (from path c’ ) which showed that avoidant coping partially mediates the relationship between severity and psychological distress among overall fathers and mothers of children and only fathers of children but do not mediate for mothers of children. Table 6: Regression analysis, using the approach coping as a mediator, severity as an independent variable, and psychological distress as an outcome among overall fathers and mothers of children, only fathers of children, and only mothers of children Predictor Path Coefficients (95% CI) R 2 a b c c ′ Fathers and mothers of children Severity -1.432 *** -.140 *** .536 *** .335 *** (.154, .252) .815 Only fathers of children Severity -.878 *** -.108 *** .471 *** .376 *** (.048, .158) .775 Only mothers of children Severity -1.991 *** -.189 *** .633 *** .258 *** (.266, .492) .804 Table 6 and figures 10, 11 and 12, shows the results of mediation analysis with approach coping as the mediator variable and psychological distress as an outcome variable, with the aim of investigation the influence of approach coping in the relationship between autism severity (as independent variable) and psychological distress (dependent variable) among overall fathers and mothers of children, only fathers of children and only mothers of children. From the results, we see that severity was significantly and positively associated with approach coping among overall fathers and mothers of children, only fathers of children, and only mothers of children (from path a ). Similarly, approach coping was significantly and negatively associated with psychological distress among overall fathers and mothers of children, only fathers and only mothers of children (from path b). For direct effect of severity was significantly and negatively associated with psychological distress among overall fathers and mothers of children, only fathers and only mothers of children (from path c ). When approach coping was involved in the model as a mediator, the indirect pathway between severity and psychological distress remained statistically significant among overall fathers and mothers of children, only fathers of children and only mothers of children (from path c’ ) which showed that approach coping partially mediates the relationship between severity and psychological distress among overall fathers and mothers of children, only fathers of children and only mothers of children. Table 7 : The comparison in the levels of quality of life, severity, psychological distress, avoidant and approach coping between fathers and mothers of children Variables M ± SD T p 95% CI Father (n=133) Mother (n=133) LL UL Quality of Life 84.42±6.01 76.75±8.46 5.930 .000 5.90 9.44 Severity 31.80±3.50 34.95±2.89 -5.630 .000 -3.92 -2.37 Psychological Distress 34.50±1.93 36.18±2.17 -4.703 .000 -2.17 -1.18 Avoidant coping 13.08±3.94 15.53±3.98 -3.790 .000 -3.41 -1.50 Approach coping 61.19±4.81 55.34±6.71 5.496 .000 4.44 7.26 ** Significant at the 0.01 level (2-tailed). Table 7 represents results for comparison in the levels of quality of life, severity, psychological distress, avoidant, and approach coping between fathers and mothers of children. From the results, we conclude that the levels of quality of life and approach are significantly higher in fathers of children than those of mothers of children, while the levels of severity, psychological distress, and avoidant coping are significantly higher in mothers of children than those of fathers of children. Table 8: The comparison in the levels of quality of life, severity, psychological distress, avoidant, and approach coping among different levels of severity ANOVA Table Variables SOV Sum of Squares df Mean Square F Sig. Quality of Life Between Groups 2218.545 2 1109.272 18.337 .000 Within Groups 15909.966 263 60.494 Total 18128.511 265 Psychological Distress Between Groups 101.139 2 50.570 11.113 .000 Within Groups 1196.729 263 4.550 Total 1297.868 265 Avoidant coping Between Groups 153.347 2 76.673 4.601 .011 Within Groups 4382.988 263 16.665 Total 4536.335 265 Approach coping Between Groups 1679.332 2 839.666 23.012 .000 Within Groups 9596.247 263 36.488 Total 11275.579 265 Table 8 shows the results of ANOVA for the levels of quality of life, severity, psychological distress, avoidant, and approach coping among different levels of severity. From the results, we conclude that the levels of quality of life, severity, psychological distress, avoidant, and approach coping significantly differ among different levels of severity. Furthermore, a maximum difference was found in the parents of children whose severity levels are “mild and high”. Table 9: The comparison in the levels of quality of life, severity, psychological distress, avoidant, and approach coping among different monthly family income levels ANOVA Table Variables SOV Sum of Squares df Mean Square F Sig. Quality of Life Between Groups Within Groups 1391.342 16737.169 2 263 695.671 63.639 10.931 .000 Total 18128.511 265 Psychological Distress Between Groups Within Groups 135.391 1162.478 2 263 67.695 4.420 15.315 .000 Total 1297.868 265 Avoidant coping Between Groups Within Groups 404.767 4131.567 2 263 202.384 15.709 12.883 .000 Total 4536.335 265 Approach coping Between Groups Within Groups 415.640 10859.939 2 263 207.820 41.293 5.033 .007 Total 11275.579 265 Severity Between Groups Within Groups 380.084 2998.322 2 263 190.042 11.400 16.670 .000 Total 3378.406 265 Table 9 shows the results of ANOVA for the levels of quality of life, severity, psychological distress, avoidant and approach coping among different monthly family income levels. From the results, we conclude that the levels of quality of life, severity, psychological distress, and avoidant significantly differ among different monthly family income levels, while no significant difference found in the level of approach among different monthly family income levels. Furthermore, a maximum difference was found whose monthly family income levels are “100000 rupees”. Discussion The present study examined the mediating role of coping strategies among the parents of children with Autism spectrum disorder. Low QoL among the parents of children with ASD can result in severe physical and psychological consequences, including anxiety, depression, social withdrawal, and fatigue, all of which may affect not only the parents themselves but also the quality of care being provided to the child. The study was first to explore the association of ASD severity levels on psychological distress and quality of life in parents of children with autism spectrum disorder, second to identify coping strategies among parents of children with ASD, and third to investigate whether coping strategies mediate the relationship between ASD severity levels, psychological distress and quality of life in parents of children with ASD in Pakistan. As the findings of our study indicate that quality of life is significantly and negatively correlated with severity, psychological distress, and avoidant coping, while significantly and positively correlated with approach coping. Similarly, severity is significantly and positively correlated with psychological distress and avoidance; on the other hand significantly and negatively correlated with approach coping. The results align with existing literature, which suggests that higher ASD severity levels are associated with increased psychological distress and reduced QoL among parents [ 22 , 23 ]. Another study conducted in an Asian country supports these findings, indicating that parents of children with severe ASD experience greater challenges in maintaining their well-being compared to parents of children with mild to moderate ASD [ 24 ]. Findings showed that avoidant coping partially mediates the relationship between severity and quality of life overall fathers and mothers of children and fathers of children but does not mediate for mothers of children. However approach coping partially mediates the relationship between severity and quality of life among overall fathers and mothers of children, only fathers of children, and only mothers of children. Findings also showed that avoidant coping partially mediates the relationship between severity and psychological distress among overall fathers and mothers of children, and only fathers of children, but does not mediate for mothers of children. On the other hand, approach coping partially mediates the relationship between severity and psychological distress among overall fathers and mothers of children, only fathers of children, and only mothers of children. A growing body of research suggests a strong link between the relationship between ASD severity levels and psychological distress is often mediated by coping strategies. Avoidant coping has been linked to higher levels of psychological distress, as it prevents parents from effectively addressing stressors [ 25 ]. Approach coping, although, has been shown to mitigate psychological distress by promoting adaptive responses [ 26 ]. Similar research findings showed that parents who utilized avoidant coping strategies experienced higher levels of psychological distress, like stress and depression, while those who engaged in approach coping reported lower psychological distress [ 27 ]. Results of the present study indicated that avoidant coping, characterized by strategies such as denial and behavioral disengagement, has been found to exacerbate the negative impact of ASD severity levels on psychological distress and quality of life of parents [ 28 ]. Conversely, approach coping, which includes problem-solving and seeking social support, has been associated with better QoL outcomes [ 29 ]. A study revealed that parents who relied on avoidant coping reported significantly lower QoL. At the same time, those who employed approach coping strategies demonstrated better adaptation to the challenges of raising a child with ASD, which supports the question of the present study[ 30 ]. Gender differences were also evident in coping strategies, QoL, and psychological distress among parents of children with ASD, with mothers reporting higher levels of psychological distress and lower QoL compared to fathers. This aligns with research, which suggests that there was an obvious gender difference in psychological distress for parents of children with ASD. However, this difference depended highly on the severity levels of the child's autistic symptoms [ 31 ]. Another study showed consistency with our findings that mothers of children with ASD experienced significantly higher levels of stress and lower QoL than fathers, highlighting the gendered nature of caregiving responsibilities. These findings underscore the need for targeted interventions that address the unique challenges faced by different groups of parents [ 32 ]. The current study also indicates that the severity levels of ASD significantly influence parental outcomes. Parents of children with severe ASD report higher levels of psychological distress, lower QoL, and greater reliance on avoidant coping strategies compared to parents of children with mild to moderate ASD [ 33 ]. A study found that parents of children with severe ASD faced greater challenges in maintaining their QoL and mental health, which supports the present study results [ 24 ]. Findings revealed that differences were found in socioeconomic status in severity of autism, quality of life, psychological distress, and avoidant coping, whereas no difference was found in approach coping. The result was consistent with the logical interpretation and previous findings in increasing psychological distress and quality of life. Socioeconomic status (SES) plays a critical role in shaping parental outcomes. Lower SES is associated with higher psychological distress, lower QoL, and limited access to resources for coping [ 34 ]. Another study also aligns with our findings that parents from lower SES backgrounds reported significantly higher levels of stress and lower QoL compared to those from higher SES backgrounds, highlighting the intersection of economic disadvantage and caregiving challenges that also supports the current study’s question [ 35 ]. Conclusion In conclusion, findings showed associations of ASD Severity levels with psychological distress and quality of life. However, quality of life improved as parents applied coping strategies in managing their stress levels. An inverse association between psychological distress and coping strategies indicates that more use of coping helps improve the quality of life in parents of autistic children. When parents use coping strategies such as avoidant coping and approach coping as a mediator partial effect is found between ASD severity levels and quality of life and psychological distress. Significant differences are obtained in fathers and mothers as the quality of life and approach are significantly higher in fathers of children, while the levels of severity, psychological distress, and avoidant coping are significantly higher in mothers of children as compared to fathers of children. Furthermore, the maximum difference was found in parents of children with ASD whose severity levels were mild and high. Socioeconomic status also differed on all variables. Limitations While this study contributes to understanding the mediating role of coping strategies in quality of life and psychological distress among parents of children with autism spectrum disorder (ASD) in Pakistan, several limitations must be acknowledged. First, the sample consists of only 266 parents from selected cities in Punjab, restricting the generalizability of findings to the broader Pakistani population. Second, reliance on self-reported measures for quality of life, psychological distress, and coping strategies may introduce bias due to social desirability or fluctuations in participants’ emotional states at the time of data collection. Incorporating objective assessments or multiple informants could mitigate this limitation. Future Recommendations Future research should broaden its focus to include older individuals with ASD and a more diverse range of caregivers to better understand their unique experiences and challenges. Further studies should also explore the factors that contribute to parental stress when raising children with ASD and identify effective strategies for reducing these stressors. Future studies should consider support programs and interventions for long-term benefits, such as parent-mediated therapy, mindfulness-based intervention, and parent-child relationship programs to incorporate both caregivers and children with Autism spectrum disorder. Declarations Data Availability The data supporting this study’s findings are available from the corresponding author, ( [email protected] ) upon reasonable request Author contributions Author A.K. designed and completed the manuscript. Authors K.I., M.K., and A.S.G. were involved in data collection, and author Y.S. reviewed and wrote the manuscript. Funding The authors declare that they did not receive support from any organization for the submitted work. Ethics approval and consent to participate Approval for the study was obtained from the Institutional Ethics Committees of the School of Foreign Languages and Literature, Shandong University (Ref No: ECSFLLSDU2025-10), and the Islamia University of Bahawalpur, Rahim Yar Khan Campus (Ref No: 5424/PSY/RYK). Ethical guidelines were rigorously followed, including obtaining informed consent and ensuring participant confidentiality. Competing interests The authors declare no competing interests. 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The association between autism spectrum disorder symptoms in high-functioning male adolescents and their mothers’ anxiety and depression. J Child Fam Stud. 2017;29:461–73. https://doi.org/10.1007/s10826-019-01608-7 . Vasilopoulou E, Nisbet J. The quality of life of parents of children with autism spectrum disorder: A systematic review. Res Autism Spectr Disord. 2016;23:36–49. https://doi.org/10.1016/j.rasd.2015.11.008 . World Health Organization. Autism spectrum disorders. 2024. https://www.who.int/news-room/fact-sheets/detail/autism-spectrum-disorders Papadopoulos A, Siafaka V, Tsapara A, et al. Measuring parental stress, illness perceptions, coping, and quality of life in families of children newly diagnosed with autism spectrum disorder. BJPsych Open. 2023;9(3):e84. https://doi.org/10.1192/bjo.2023.55 . Vernhet C, Dellapiazza F, Blanc N, Cousson-Gélie F, Miot S, Roeyers H, Baghdadli A. Coping strategies of parents of children with autism spectrum disorder: A systematic review. Autism Dev Lang Impair. 2023;7:1–8. https://doi.org/10.1177/23969415221142262 . Schopler E, Van Bourgondien ME, Wellman GJ, Love SR. Childhood Autism Rating Scale–Second Edition (CARS-2). Los Angeles: Western Psychological Services; 2010. Nisa A, Siddiqui S. Urdu translation and adaptation of Brief COPE scale. Pak J Psychol Res. 2020;35(1):1–21. https://doi.org/10.33824/PJPR.2020.35.1.1 . Ghaffar A. The relationship between resilience, psychological distress and subjective well-being among dengue fever survivors. Glob J Hum Soc Sci Arts Humanit Psychol 2014;14(10). Saqib Lodhi F, Raza O, Montazeri A, Nedjat S, Yaseri M, Holakouie-Naieni K. Psychometric properties of the Urdu version of the World Health Organization's quality of life questionnaire (WHOQOL-BREF). Med J Islam Repub Iran. 2017;31:129. https://doi.org/10.14196/mjiri.31.129 . Hayes SA, Watson SL. The impact of parenting stress: A meta-analysis of studies comparing the experience of parenting stress in parents of children with and without autism spectrum disorder. J Autism Dev Disord. 2013;43(3):629–42. https://doi.org/10.1007/s10803-012-1604-y . Karst JS, Van Hecke AV. Parent and family impact of autism spectrum disorders: A review and proposed model for intervention evaluation. Clin Child Fam Psychol Rev. 2012;15(3):247–77. https://doi.org/10.1007/s10567-012-0119-6 . Farooq A, Ahmed S. Impact of autism severity levels on parental quality of life in Pakistan. J Dev Behav Pediatr. 2020;41(5):345–52. Lazarus RS, Folkman S. Stress, appraisal, and coping. New York: Springer; 1984. Hastings RP, Kovshoff H, Brown T, Ward NJ, Degli Espinosa F, Remington B. Coping strategies in mothers and fathers of preschool and school-age children with autism. Autism. 2005;9(4):377–91. https://doi.org/10.1177/1362361305056078 . Ali S, Rehman R, Hussain A. Coping strategies and psychological distress among parents of children with autism spectrum disorder in Pakistan. J Autism Dev Disord. 2018;48(3):789–99. https://doi.org/10.1007/s10803-017-3365-0 . Smith LE, Seltzer MM, Tager-Flusberg H, Greenberg JS, Carter AS. A comparative analysis of well-being and coping among mothers of toddlers and mothers of adolescents with ASD. J Autism Dev Disord. 2008;38(5):876–89. https://doi.org/10.1007/s10803-007-0461-6 . Miranda A, Mira A, Berenguer C, Rosello B, Baixauli I. Parenting stress in mothers of children with autism without intellectual disability: Mediation of behavioral problems and coping strategies. Front Psychol. 2019;10:464. https://doi.org/10.3389/fpsyg.2019.00464 . Khan S, Hussain A. Coping strategies and quality of life among parents of children with autism in Pakistan. J Autism Dev Disord. 2019;49(8):3215–26. Li F, Tang Y, Li F, Fang S, Liu X, Tao M, et al. Psychological distress in parents of children with autism spectrum disorder: A cross-sectional study based on 683 mother-father dyads. J Pediatr Nurs. 2022;65:e49–55. Riaz N, Batool S. Gender differences in coping strategies and quality of life among parents of children with autism spectrum disorder in Pakistan. J Autism Dev Disord. 2021;51(4):1234–45. https://doi.org/10.1007/s10803-020-04609-9 . Benson PR. Coping strategies of parents of children with autism spectrum disorder: A systematic review. Eur Child Adolesc Psychiatry. 2018;28(6):747–58. https://doi.org/10.1007/s00787-018-1183-3 . Yesilkaya M, Magallón-Neri E. Parental stress related to caring for a child with autism spectrum disorder and the benefit of mindfulness-based interventions for parental stress: A systematic review. SAGE Open. 2024;14(1):1–22. Malik F, Haider S. Socioeconomic status and parental stress in families of children with autism spectrum disorder in Pakistan. J Autism Dev Disord. 2020;50(6):2145–56. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 21 Sep, 2025 Reviewers agreed at journal 14 Sep, 2025 Reviewers agreed at journal 09 Sep, 2025 Reviewers agreed at journal 03 Sep, 2025 Reviewers invited by journal 29 Aug, 2025 Editor invited by journal 23 Jul, 2025 Editor assigned by journal 23 Jul, 2025 Submission checks completed at journal 19 Jul, 2025 First submitted to journal 19 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7068894","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":510000462,"identity":"9ffa4acc-e00f-42a7-a91a-0fd1b9694ae1","order_by":0,"name":"Arslan Khalid","email":"","orcid":"","institution":"Shandong University","correspondingAuthor":false,"prefix":"","firstName":"Arslan","middleName":"","lastName":"Khalid","suffix":""},{"id":510000463,"identity":"6d73503d-7c7e-4100-84f8-30dea32f2797","order_by":1,"name":"Khizra Iqbal","email":"","orcid":"","institution":"Islamia University of 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children.\u003c/p\u003e","description":"","filename":"12.png","url":"https://assets-eu.researchsquare.com/files/rs-7068894/v1/3cf7523b9e4af2dd7d3457da.png"},{"id":90899616,"identity":"736d3ee6-4f49-493b-95ca-c9f05f3c89a9","added_by":"auto","created_at":"2025-09-09 12:01:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1645967,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7068894/v1/39a8595d-4dd6-4c30-bdab-612b84acc157.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Relationship between Disorder Severity, Psychological Distress, and Quality of Life in Parents of Children with Autism Spectrum Disorder: Coping Strategies as a Mediator","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAutism Spectrum Disorder (ASD) is a neurodevelopmental condition characterized by challenges in social interaction, communication, and repetitive behaviors. The severity levels and impact of ASD vary widely among individuals, influencing the level of support needed throughout their lives. While ASD is a lifelong condition, early intervention and tailored support can significantly improve quality of life and daily functioning [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Individuals with ASD may experience a broad range of cognitive abilities, from intellectual disability to exceptional skills in specific areas. The Centers for Disease Control and Prevention notes that ASD can be identified as early as 18 months, though diagnosis is often delayed until later in childhood or even adulthood. Early identification and intervention are crucial for maximizing developmental progress and access to supportive resources [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eParents of children with ASD often experience considerable psychological distress due to the challenges of caregiving, financial burdens, and social isolation. These stressors can significantly affect their overall well-being, with higher severity levels of ASD cases typically correlating with greater parental distress and reduced quality of life [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Multiple research studies have explored the pressure of raising a child with ASD, specifically, the impact it has on the parents, and the importance of supporting them. This is because these parents experience significant distress as a result of having a child who may face profound challenges in social communication, emotions, and behavior, and encounter difficulties in accessing the necessary services [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePsychological distress refers to the state of emotional strain resulting from the demands of parenting, particularly in the context of ASD. Research highlights that this stress is closely linked to child and parent characteristics, with behavioral difficulties and deficits in socialization and communication being the primary contributing factors [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Among families of children with ASD, parenting psychological distress is a well-documented issue, encompassing emotional, psychological, and practical challenges that can impact family dynamics and parental mental health. Research indicates that parents of children with ASD experience higher levels of anxiety, stress, and depression compared to parents of neurotypical children [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Numerous prior studies have indicated that parents of children with autism spectrum disorder experience a higher level of psychological distress than parents of children without any developmental disabilities and parents of children with other types of developmental disabilities [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Parenting stress is the psychological strain caused by the difficulties and expectations of parenting roles, which have a direct effect on parents\u0026rsquo; emotional health, the parent-child relationship, and the child\u0026rsquo;s emotional and social growth [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Several studies have also found that mothers experience greater levels of parental stress than fathers. The level of stress experienced by fathers was associated with the intensity of the ASD in their children. The fathers of children with more serious ASD symptoms reported higher levels of parenting stress [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The severity levels of ASD symptoms are directly associated with increased parental psychological distress, which in turn significantly impacts their overall quality of life [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe caregiver significantly impacts the quality of life (QoL) demands linked with ASD. Research indicates that parents of children with more severe ASD symptoms tend to report lower Quality of life due to heightened caregiving responsibilities and social restrictions [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. As primary caregivers, parents manage various aspects of their child's life, including diagnosis, healthcare, behavior, and daily activities, making it essential to assess how this role affects their overall well-being. QoL is a broad concept encompassing multiple aspects of an individual's functioning. QoL is defined as an individual\u0026rsquo;s perception of their position in life about their goals, expectations, standards, and concerns. Understanding the impact of caregiving on QoL can help in developing interventions to support parents in managing their responsibilities while maintaining their well-being [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eCoping strategies play a crucial role in helping parents navigate the challenges of raising a child with ASD while also enhancing their overall quality of life [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Coping strategies play a vital role in shaping the experiences of parents of children with ASD. Coping is commonly defined as the ongoing cognitive and behavioral efforts individuals use to manage external and internal challenges that they perceive as overwhelming or exceeding their available resources. Implementing effective coping strategies is essential for reducing stress and promoting mental well-being. Research suggests that approach-oriented coping, which involves actively addressing stressors, is linked to more positive psychological outcomes, whereas avoidance-based coping may contribute to heightened distress [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Recognizing the significance of coping mechanisms can help in developing targeted interventions to support parents in managing stress effectively.\u003c/p\u003e\u003cp\u003eParenting a child with ASD can be difficult and have a negative effect on the health and well-being of parents. Coping strategies are essential for mitigating stress and maintaining mental health. Approach coping is associated with better psychological outcomes, whereas avoidance coping may lead to increased distress. Understanding the role of coping strategies can help in designing effective interventions for parents to enhance their quality of life by reducing psychological distress. Despite extensive research, gaps remain in understanding the specific effects of ASD severity levels on parental quality of life, including physical health and social relationships. Most studies focus primarily on mothers, overlooking the experiences of fathers and other caregivers. Additionally, little research has explored how socioeconomic and cultural factors influence parental well-being. Cultural perceptions of disability and healthcare accessibility can shape the challenges faced by families of children with ASD. The purpose of the current study is to explore how approach and avoidant coping mediate the relationship between autism severity levels and their effect on psychological distress and the quality of life of parents. Addressing these gaps is essential for developing targeted interventions based on the severity levels of a child\u0026rsquo;s ASD symptoms. The present study aimed to assess the association of Autism Spectrum disorder severity levels with psychological distress, quality of life, and coping styles in parents. The second objective is to investigate whether coping strategies mediate the relationship between Autism spectrum disorder severity levels and psychological distress and quality of life in parents and lastly to explore the differences in terms of demographic variables (i.e. parents' gender, severity levels, and socioeconomic class) on Autism severity levels, psychological distress, quality of life, and coping strategies in parents.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cb\u003eParticipants and Procedure\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe sample comprised 266 parents (133 mothers and 133 fathers) aged between 25 and 50 years. Participants were selected using a purposive sampling technique from various Autism Centers, Special Education Centers, and Government Hospitals across multiple cities, including Rahim Yar Khan, Bahawalpur, Sadiqabad, Multan, Faisalabad, and Lahore. Children clinically diagnosed with ASD according to ICD-11 or DSM-5. Participants were primary caregivers of a child with ASD, living in the same household as the child, with no history of major psychiatric disorders (e.g., major depression, schizophrenia). Parents of children with other comorbidities and disabilities were excluded from the study. A cross-sectional correlational study design was employed.\u003c/p\u003e\u003cp\u003eThe authorities of the institutes were approached to gain permission to conduct the study within the institutes. Data was collected through in-person surveys using standardized questionnaire tools. Initially, parents were informed about the benefits of the study, and a consent form was introduced. Through that consent form, parents were informed that the information gathered would be confidential and that their refusal to participate in the study would not affect their status in Society. Their right to withdraw from the study at any time, without penalty, was discussed with them. Informed consent was obtained from the participants, the researcher established a rapport with the participants, and then all measures were administered to each family one by one. They were interviewed about the severity levels of the child using CARS-2 and requested to fill demographic sheet, Brief-Cope, Kessler Psychological Distress Scale (K10), and WHO-QOL BREF. The use of culturally adapted versions ensured that the tools were accessible and meaningful to the study population, enhancing the validity of the findings.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMeasures\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eChildhood Autism Rating Scale (CARS-2).\u003c/b\u003e The severity levels of autism spectrum disorder (ASD) in children were assessed using the Childhood Autism Rating Scale, Second Edition CARS-2 is a behavior-based rating scale consisting of 15 items that evaluate key domains of ASD, including social interactions, communication, and repetitive behaviors. Each item is scored on a 4-point Likert scale, with total scores ranging from 15 to 60. Scores are categorized as non-autistic (15\u0026ndash;29.5), mild to moderate ASD (30\u0026ndash;36.5), or severe ASD (37\u0026ndash;60). The reliability of the scale ranged from 0.90 to 0.95[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cb\u003eBrief-COPE.\u003c/b\u003e The Brief COPE inventory was used to assess coping strategies. The Brief COPE is a 28-item instrument that evaluates 14 coping strategies, including Approach Coping and Avoidant Coping. The reliability of the Urdu version of Brief COPE has good internal consistency, with Cronbach's alpha of 0.87. The translated Brief COPE was administered as a self-report questionnaire. Participants were asked to indicate how often they used each coping strategy in response to stress, using a 4-point Likert scale [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cb\u003eKessler Psychological Distress Scale (K10).\u003c/b\u003e Kessler's Psychological Distress Scale (K10) was used to measure psychological distress. The K10 scale involves 10 questions about emotional states, each with a five-level response scale that assesses symptoms of anxiety and depression over the past 30 days. The measure can be used as a brief screen to identify levels of distress. Each item is scored from one \u0026lsquo;none of the time\u0026rsquo; to five \u0026lsquo;all of the time\u0026rsquo;. Scores of the 10 items are then summed, yielding a minimum score of 10 and a maximum score of 50. Low scores indicate low levels of psychological distress, and high scores indicate high levels of psychological distress. The reliability of the Urdu version of K10 ranges from 0.85 to 0.90 [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cb\u003eWHO-QOL BREF\u003c/b\u003e. The World Health Organization Quality of Life-BREF (WHOQOL-BREF) was used to assess participants' quality of life. The WHOQOL-BREF is a 26-item instrument that evaluates four domains: physical health, psychological health, social relationships, and environment. The Cronbach's alpha values range from 0.65 to 0.92 for the Urdu version of WHOQOL-BREF [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eDescriptive statistics (mean, standard deviations, variance, and standard error of the mean, confidence intervals), t-test, Pearson's correlation analysis, and multiple regression analysis to examine the coping strategies as mediators between severity levels of ASD, psychological distress, and QoL and ANOVA to see the comparison in the quality of life, severity levels of ASD, psychological distress, avoidant coping and approach cop. All statistical computation was done through the Statistical Package for Social Sciences SPSS, IBM, 21; 2012) and Process Macro in SPSS.\u003c/p\u003e\u003cp\u003e\u003cb\u003eEthics\u003c/b\u003e\u003c/p\u003e\u003cp\u003e Approval for the study was obtained from the Institutional Ethics Committees of the School of Foreign Languages and Literature, Shandong University (Ref No: ECSFLLSDU2025-10), and the Islamia University of Bahawalpur, Rahim Yar Khan Campus (Ref No: 5424/PSY/RYK). Ethical guidelines were rigorously followed, including obtaining informed consent and ensuring participant confidentiality.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFrequency and percentage of demographic variables of participants (n\u0026thinsp;=\u0026thinsp;266)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDemographic variables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003ef\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e%\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParents\u003c/p\u003e \u003cp\u003eFather\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e133\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e50.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMother\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e133\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e50.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSeverity Levels\u003c/p\u003e \u003cp\u003eMild\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e112\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e42.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e102\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e38.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSevere\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e19.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMonthly Earnings (Parents)\u003c/p\u003e\u003cp\u003e\u0026lt;\u0026thinsp;80000 Rupees\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e14.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e80001\u0026ndash;150000 Rupees\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e211\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e79.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;150000 Rupees\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the frequencies and percentages of demographic variables of the study participants.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCorrelation between quality of life, severity, psychological distress, avoidant coping, and approach coping\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eM\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQuality of Life\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e80.48\u0026thinsp;\u0026plusmn;\u0026thinsp;8.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSeverity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e33.41\u0026thinsp;\u0026plusmn;\u0026thinsp;3.58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.870**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePsychological Distress\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e35.40\u0026thinsp;\u0026plusmn;\u0026thinsp;2.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.932**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.865**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAvoidant Coping\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e14.40\u0026thinsp;\u0026plusmn;\u0026thinsp;4.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.792**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.822**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.820**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eApproach Coping\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e58.22\u0026thinsp;\u0026plusmn;\u0026thinsp;6.60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.926**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.784**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.838**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.658**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e** Significant at the 0.01 level (2-tailed).\u003c/em\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, indicates the correlations between the levels of quality of life, severity, psychological distress, avoidant coping, and approach coping. The findings reveal that quality of life is significantly and negatively correlated with severity, psychological distress, and avoidant coping, while significantly and positively correlated with approach coping. Similarly, severity is significantly and positively correlated with psychological distress and avoidant coping, while significantly and negatively correlated with approach coping. Furthermore, psychological distress is significantly and positively correlated with avoidant coping, while it is significantly and negatively correlated with approach coping. The levels of avoidant and approach coping were significantly and negatively correlated with each other.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eRegression analysis, using avoidant coping as a mediator, severity as an independent variable, and quality of life as an outcome among fathers and mothers of children\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePredictor\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e\u003cp\u003ePath Coefficients\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e(95% CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eR\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003ea\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003eb\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003ec\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003ec\u003c/em\u003e\u003csup\u003e\u003cem\u003e\u0026prime;\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e\u003cp\u003eOverall, fathers and mothers of children\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSeverity\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.953\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.477\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-2.015\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-1.560\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e(-.736, \u0026minus;\u0026thinsp;.186)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.775\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e\u003cp\u003eOnly fathers of children\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSeverity\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.927\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.809\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-1.476\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.726\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e(-1.035, \u0026minus;\u0026thinsp;.489)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.829\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e\u003cp\u003eOnly mothers of children\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSeverity\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.097\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.145\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-2.552\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-2.393\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e(-.566, .178)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.762\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, shows the results of mediation analysis with avoidant coping as the mediator variable and quality of life as an outcome variable, with the aim of investigation the influence of avoid in the relationship between autism severity (as independent variable) and quality of life (dependent variable) among overall fathers and mothers of children, only fathers of children and only mothers of children.\u003c/p\u003e\u003cp\u003eFrom the results, we see that severity was significantly and positively associated with avoidant (from path \u003cem\u003ea\u003c/em\u003e) overall, fathers and mothers of children, only fathers of children, and only mothers of children. Similarly, avoidant coping was significantly and negatively associated with quality of life among overall fathers and mothers of children, only fathers of children fathers but no association was found among mothers of children (from path b). For direct effect of severity was significantly and negatively associated with quality of life for overall fathers and mothers of children, only fathers of children, and only mothers of children (from path \u003cem\u003ec\u003c/em\u003e). When avoidant coping was involved in the model as a mediator, the indirect pathway between severity and quality of life remained statistically significant among overall fathers and mothers of children, only fathers of children and only mothers of children (from path \u003cem\u003ec\u0026rsquo;\u003c/em\u003e) which showed that avoidant coping partially mediates the relationship between severity and quality of life overall fathers and mothers of children and fathers of children\u0026rdquo; but do not mediate for mothers of children.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4: Regression analysis, using the approach coping as a mediator, severity as an independent variable, and quality of life as an outcome among overall fathers and mothers of children, only fathers of children, and only mothers of children\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"580\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 4.3143%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePredictor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 15.4512%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePath Coefficients\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 6.3711%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e(95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 2.5585%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eR\u003csup\u003e2\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 4.0133%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ea\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.4113%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eb\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.1136%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ec\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.9631%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ec\u003csup\u003e\u0026prime;\u003c/sup\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" style=\"width: 29.0462%;\"\u003e\n \u003cp\u003eFathers and mothers of children\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 4.3143%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeverity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.0133%;\"\u003e\n \u003cp\u003e-1.432\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.4113%;\"\u003e\n \u003cp\u003e.805\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.1136%;\"\u003e\n \u003cp\u003e-2.015\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.9631%;\"\u003e\n \u003cp\u003e-.862\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.3711%;\"\u003e\n \u003cp\u003e\u0026nbsp; (-1.437, -.929)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.5585%;\"\u003e\n \u003cp\u003e.911\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" style=\"width: 29.0462%;\"\u003e\n \u003cp\u003eOnly fathers of children\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 4.3143%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeverity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.0133%;\"\u003e\n \u003cp\u003e-.887\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.4113%;\"\u003e\n \u003cp\u003e.569\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.1136%;\"\u003e\n \u003cp\u003e-1.476\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.9631%;\"\u003e\n \u003cp\u003e-.976\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.3711%;\"\u003e\n \u003cp\u003e\u0026nbsp; (-.831, -.236)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.5585%;\"\u003e\n \u003cp\u003e.861\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" style=\"width: 29.0462%;\"\u003e\n \u003cp\u003eOnly mothers of children\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 4.3143%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeverity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.0133%;\"\u003e\n \u003cp\u003e-1.991\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.4113%;\"\u003e\n \u003cp\u003e.974\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 4.1136%;\"\u003e\n \u003cp\u003e-2.552\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.9631%;\"\u003e\n \u003cp\u003e-.613\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6.3711%;\"\u003e\n \u003cp\u003e\u0026nbsp; (-2.260, -1.632)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2.5585%;\"\u003e\n \u003cp\u003e.918\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 4 and figures 4, 5 and 6, shows the results of mediation analysis with approach coping as the mediator variable and quality of life as an outcome variable, with the aim of investigation the influence of approach coping in the relationship between autism severity (as independent variable) and quality of life (dependent variable) among overall fathers and mothers of children, only fathers of children and only mothers of children.\u003c/p\u003e\n\u003cp\u003eFrom the results, we see that severity was significantly and negatively associated with approach coping among overall fathers and mothers of children, only fathers and only mothers of children (from path \u003cem\u003ea\u003c/em\u003e). Similarly, the approach coping was significantly and positively associated with quality of life among overall fathers and mothers of children, only fathers and only mothers of children (from path b). For direct effect of severity was significantly and negatively associated with quality of life among overall fathers and mothers of children, only fathers and only mothers of children (from path \u003cem\u003ec\u003c/em\u003e). When approach coping was involved in the model as a mediator, the indirect pathway between severity and quality of life remained statistically significant among overall fathers and mothers of children, only fathers of children and only mothers of children (from path \u003cem\u003ec\u0026rsquo;\u003c/em\u003e) which showed that approach coping partially mediates the relationship between severity and quality of life among overall fathers and mothers of children, only fathers of children and only mothers of children.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5: Regression analysis, using avoidant coping as a mediator, severity as an independent variable, and psychological distress as an outcome among overall fathers and mothers\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eof children, only fathers of children, and only mothers of children\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"551\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePredictor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 297px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePath Coefficients\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e(95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eR\u003csup\u003e2\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ea\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eb\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ec\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ec\u003csup\u003e\u0026prime;\u003c/sup\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" style=\"width: 551px;\"\u003e\n \u003cp\u003eFathers and mothers of children\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeverity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e.953\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e.179\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e.536\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.366\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u0026nbsp; (.102, .234)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e.785\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" style=\"width: 551px;\"\u003e\n \u003cp\u003eOnly fathers of children\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeverity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e.927\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e.289\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e.471\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.203\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u0026nbsp; (.215, .315)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e.844\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" style=\"width: 551px;\"\u003e\n \u003cp\u003eOnly mothers of children\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeverity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1.093\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e.072\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e.633\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 80px;\"\u003e\n \u003cp\u003e.555\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 116px;\"\u003e\n \u003cp\u003e\u0026nbsp; (-.012, .191)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e.720\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 5 and figures 7, 8 and 9, shows the results of mediation analysis with avoidant coping as the mediator variable and psychological distress as an outcome variable, with the aim of investigation the influence of avoidant coping in the relationship between autism severity (as independent variable) and psychological distress (dependent variable) among overall fathers and mothers of children, only fathers of children and only mothers of children.\u003c/p\u003e\n\u003cp\u003eFrom the results, we see that severity was significantly and positively associated with avoidant coping among overall fathers and mothers of children, only fathers of children, and only mothers of children (from path \u003cem\u003ea\u003c/em\u003e). Similarly, avoidant coping was significantly and negatively associated with psychological distress among overall fathers and mothers of children, and only fathers of children, but no association was found among mothers of children (from path b). For direct effect of severity was significantly and negatively associated with psychological distress among overall fathers and mothers of children, only fathers of children, and only mothers of children (from path \u003cem\u003ec\u003c/em\u003e). When avoidant coping was involved in the model as a mediator, the indirect pathway between severity and psychological distress remained statistically significant for among overall fathers and mothers of children and only fathers of children and only mothers of children (from path \u003cem\u003ec\u0026rsquo;\u003c/em\u003e) which showed that avoidant coping partially mediates the relationship between severity and psychological distress among overall fathers and mothers of children and only fathers of children but do not mediate for mothers of children.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6: Regression analysis, using the approach coping as a mediator, severity as an independent variable, and psychological distress as an outcome among overall fathers and mothers of children, only fathers of children, and only mothers of children\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"600\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 93px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePredictor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 329px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePath Coefficients\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e(95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eR\u003csup\u003e2\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ea\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eb\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ec\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ec\u003csup\u003e\u0026prime;\u003c/sup\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" style=\"width: 600px;\"\u003e\n \u003cp\u003eFathers and mothers of children\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeverity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e-1.432\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e-.140\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e.536\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e.335\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp; (.154, .252)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e.815\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" style=\"width: 600px;\"\u003e\n \u003cp\u003eOnly fathers of children\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeverity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e-.878\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e-.108\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e.471\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e.376\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp; (.048, .158)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e.775\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" style=\"width: 600px;\"\u003e\n \u003cp\u003eOnly mothers of children\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeverity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e-1.991\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e-.189\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e.633\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e.258\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp; (.266, .492)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e.804\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 6 and figures 10, 11 and 12, shows the results of mediation analysis with approach coping as the mediator variable and psychological distress as an outcome variable, with the aim of investigation the influence of approach coping in the relationship between autism severity (as independent variable) and psychological distress (dependent variable) among overall fathers and mothers of children, only fathers of children and only mothers of children.\u003c/p\u003e\n\u003cp\u003eFrom the results, we see that severity was significantly and positively associated with approach coping among overall fathers and mothers of children, only fathers of children, and only mothers of children (from path \u003cem\u003ea\u003c/em\u003e). Similarly, approach coping was significantly and negatively associated with psychological distress among overall fathers and mothers of children, only fathers and only mothers of children (from path b). For direct effect of severity was significantly and negatively associated with psychological distress among overall fathers and mothers of children, only fathers and only mothers of children (from path \u003cem\u003ec\u003c/em\u003e). When approach coping was involved in the model as a mediator, the indirect pathway between severity and psychological distress remained statistically significant among overall fathers and mothers of children, only fathers of children and only mothers of children (from path \u003cem\u003ec\u0026rsquo;\u003c/em\u003e) which showed that approach coping partially mediates the relationship between severity and psychological distress among overall fathers and mothers of children, only fathers of children and only mothers of children.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 7\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eThe comparison in\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ethe levels of quality of life, severity, psychological distress, avoidant and approach coping between fathers and mothers of children\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"644\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eM\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u0026plusmn; \u003cem\u003eSD\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eFather (n=133)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMother (n=133)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eUL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eQuality of Life\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e84.42\u0026plusmn;6.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e76.75\u0026plusmn;8.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.930\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9.44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSeverity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e31.80\u0026plusmn;3.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e34.95\u0026plusmn;2.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-5.630\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-3.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-2.37\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePsychological Distress\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e34.50\u0026plusmn;1.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e36.18\u0026plusmn;2.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-4.703\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-2.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-1.18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAvoidant coping\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13.08\u0026plusmn;3.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e15.53\u0026plusmn;3.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-3.790\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-3.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-1.50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eApproach coping\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e61.19\u0026plusmn;4.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e55.34\u0026plusmn;6.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.496\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7.26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cem\u003e** Significant at the 0.01 level (2-tailed).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTable 7 represents results for comparison in the levels of quality of life, severity, psychological distress, avoidant, and approach coping between fathers and mothers of children. From the results, we conclude that the levels of quality of life and approach are significantly higher in fathers of children than those of mothers of children, while the levels of severity, psychological distress, and avoidant coping are significantly higher in mothers of children than those of fathers of children.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 8:\u003c/strong\u003e \u003cstrong\u003eThe comparison\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ein the levels of quality of life, severity, psychological distress, avoidant, and approach coping\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;among different levels of severity\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"612\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"10\" valign=\"top\" style=\"width: 47.6833%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eANOVA Table\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 10.4953%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.0987%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSOV\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 8.5946%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSum of Squares\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 3.6362%;\"\u003e\n \u003cp\u003e\u003cstrong\u003edf\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.7682%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean Square\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5.7022%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eF\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.9667%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSig.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 9.5862%;\"\u003e\n \u003cp\u003eQuality of Life\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 9.5036%;\"\u003e\n \u003cp\u003eBetween Groups\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 8.5946%;\"\u003e\n \u003cp\u003e2218.545\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.1403%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.7682%;\"\u003e\n \u003cp\u003e1109.272\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 5.7022%;\"\u003e\n \u003cp\u003e18.337\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 3.4709%;\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 9.5036%;\"\u003e\n \u003cp\u003eWithin Groups\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 8.5946%;\"\u003e\n \u003cp\u003e15909.966\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.1403%;\"\u003e\n \u003cp\u003e263\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.7682%;\"\u003e\n \u003cp\u003e60.494\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 9.5036%;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 8.5946%;\"\u003e\n \u003cp\u003e18128.511\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.1403%;\"\u003e\n \u003cp\u003e265\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.7682%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 9.5862%;\"\u003e\n \u003cp\u003ePsychological Distress\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 9.5036%;\"\u003e\n \u003cp\u003eBetween Groups\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 8.5946%;\"\u003e\n \u003cp\u003e101.139\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.1403%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.7682%;\"\u003e\n \u003cp\u003e50.570\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 5.7022%;\"\u003e\n \u003cp\u003e11.113\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 3.4709%;\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 9.5036%;\"\u003e\n \u003cp\u003eWithin Groups\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 8.5946%;\"\u003e\n \u003cp\u003e1196.729\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.1403%;\"\u003e\n \u003cp\u003e263\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.7682%;\"\u003e\n \u003cp\u003e4.550\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 9.5036%;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 8.5946%;\"\u003e\n \u003cp\u003e1297.868\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.1403%;\"\u003e\n \u003cp\u003e265\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.7682%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 9.5862%;\"\u003e\n \u003cp\u003eAvoidant coping\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 9.5036%;\"\u003e\n \u003cp\u003eBetween Groups\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 8.5946%;\"\u003e\n \u003cp\u003e153.347\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.1403%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.7682%;\"\u003e\n \u003cp\u003e76.673\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 5.7022%;\"\u003e\n \u003cp\u003e4.601\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 3.4709%;\"\u003e\n \u003cp\u003e.011\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 9.5862%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 9.5036%;\"\u003e\n \u003cp\u003eWithin Groups\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 8.5946%;\"\u003e\n \u003cp\u003e4382.988\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.1403%;\"\u003e\n \u003cp\u003e263\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.7682%;\"\u003e\n \u003cp\u003e16.665\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 9.5862%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 9.5036%;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 8.5946%;\"\u003e\n \u003cp\u003e4536.335\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.1403%;\"\u003e\n \u003cp\u003e265\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.7682%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 9.5862%;\"\u003e\n \u003cp\u003eApproach coping\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 9.5036%;\"\u003e\n \u003cp\u003eBetween Groups\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 8.5946%;\"\u003e\n \u003cp\u003e1679.332\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.1403%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.7682%;\"\u003e\n \u003cp\u003e839.666\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 5.7022%;\"\u003e\n \u003cp\u003e23.012\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 3.4709%;\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 9.5036%;\"\u003e\n \u003cp\u003eWithin Groups\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 8.5946%;\"\u003e\n \u003cp\u003e9596.247\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.1403%;\"\u003e\n \u003cp\u003e263\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.7682%;\"\u003e\n \u003cp\u003e36.488\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 9.5036%;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 8.5946%;\"\u003e\n \u003cp\u003e11275.579\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 3.1403%;\"\u003e\n \u003cp\u003e265\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.7682%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 8 shows the results of ANOVA for the levels of quality of life, severity, psychological distress, avoidant, and approach coping among different levels of severity. From the results, we conclude that the levels of quality of life, severity, psychological distress, avoidant, and approach coping significantly differ among different levels of severity. Furthermore, a maximum difference was found in the parents of children whose severity levels are \u0026ldquo;mild and high\u0026rdquo;.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 9:\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eThe comparison in the levels of quality of life, severity, psychological distress, avoidant, and approach coping among different monthly family income levels\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eANOVA Table\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"612\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSOV\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSum of Squares\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003e\u003cstrong\u003edf\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean Square\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eF\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSig.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 126px;\"\u003e\n \u003cp\u003eQuality of Life\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eBetween Groups\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eWithin Groups\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e1391.342\u003c/p\u003e\n \u003cp\u003e16737.169\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e263\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e695.671 63.639\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e10.931\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003eTotal\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e18128.511\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 34px;\"\u003e\n \u003cp\u003e265\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 126px;\"\u003e\n \u003cp\u003ePsychological Distress\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003eBetween Groups\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eWithin Groups\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e135.391\u003c/p\u003e\n \u003cp\u003e1162.478\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 34px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e263\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 112px;\"\u003e\n \u003cp\u003e67.695 4.420\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e15.315\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 37px;\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eTotal\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e1297.868\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003e265\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 126px;\"\u003e\n \u003cp\u003eAvoidant coping\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003eBetween Groups\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eWithin Groups\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e404.767\u003c/p\u003e\n \u003cp\u003e4131.567\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 34px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e263\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e202.384 15.709\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e12.883\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eTotal\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e4536.335\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003e265\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 126px;\"\u003e\n \u003cp\u003eApproach coping\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 144px;\"\u003e\n \u003cp\u003eBetween Groups\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eWithin Groups\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e415.640\u003c/p\u003e\n \u003cp\u003e10859.939\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 34px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e263\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e207.820 41.293\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e5.033\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e.007\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 144px;\"\u003e\n \u003cp\u003eTotal\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 93px;\"\u003e\n \u003cp\u003e11275.579\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 34px;\"\u003e\n \u003cp\u003e265\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 126px;\"\u003e\n \u003cp\u003eSeverity\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eBetween Groups Within Groups\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e380.084\u003c/p\u003e\n \u003cp\u003e2998.322\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e263\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e190.042 11.400\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e16.670\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eTotal\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e3378.406\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003e265\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 112px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 9 shows the results of ANOVA for the levels of quality of life, severity, psychological distress, avoidant and approach coping among different monthly family income levels. From the results, we conclude that the levels of quality of life, severity, psychological distress, and avoidant significantly differ among different monthly family income levels, while no significant difference found in the level of approach among different monthly family income levels. Furthermore, a maximum difference was found whose monthly family income levels are \u0026ldquo;\u0026lt;50000 rupees and \u0026gt;100000 rupees\u0026rdquo;.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study examined the mediating role of coping strategies among the parents of children with Autism spectrum disorder. Low QoL among the parents of children with ASD can result in severe physical and psychological consequences, including anxiety, depression, social withdrawal, and fatigue, all of which may affect not only the parents themselves but also the quality of care being provided to the child. The study was first to explore the association of ASD severity levels on psychological distress and quality of life in parents of children with autism spectrum disorder, second to identify coping strategies among parents of children with ASD, and third to investigate whether coping strategies mediate the relationship between ASD severity levels, psychological distress and quality of life in parents of children with ASD in Pakistan.\u003c/p\u003e\u003cp\u003eAs the findings of our study indicate that quality of life is significantly and negatively correlated with severity, psychological distress, and avoidant coping, while significantly and positively correlated with approach coping. Similarly, severity is significantly and positively correlated with psychological distress and avoidance; on the other hand significantly and negatively correlated with approach coping. The results align with existing literature, which suggests that higher ASD severity levels are associated with increased psychological distress and reduced QoL among parents [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Another study conducted in an Asian country supports these findings, indicating that parents of children with severe ASD experience greater challenges in maintaining their well-being compared to parents of children with mild to moderate ASD [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFindings showed that avoidant coping partially mediates the relationship between severity and quality of life overall fathers and mothers of children and fathers of children but does not mediate for mothers of children. However approach coping partially mediates the relationship between severity and quality of life among overall fathers and mothers of children, only fathers of children, and only mothers of children. Findings also showed that avoidant coping partially mediates the relationship between severity and psychological distress among overall fathers and mothers of children, and only fathers of children, but does not mediate for mothers of children. On the other hand, approach coping partially mediates the relationship between severity and psychological distress among overall fathers and mothers of children, only fathers of children, and only mothers of children. A growing body of research suggests a strong link between the relationship between ASD severity levels and psychological distress is often mediated by coping strategies. Avoidant coping has been linked to higher levels of psychological distress, as it prevents parents from effectively addressing stressors [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Approach coping, although, has been shown to mitigate psychological distress by promoting adaptive responses [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Similar research findings showed that parents who utilized avoidant coping strategies experienced higher levels of psychological distress, like stress and depression, while those who engaged in approach coping reported lower psychological distress [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Results of the present study indicated that avoidant coping, characterized by strategies such as denial and behavioral disengagement, has been found to exacerbate the negative impact of ASD severity levels on psychological distress and quality of life of parents [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Conversely, approach coping, which includes problem-solving and seeking social support, has been associated with better QoL outcomes [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. A study revealed that parents who relied on avoidant coping reported significantly lower QoL. At the same time, those who employed approach coping strategies demonstrated better adaptation to the challenges of raising a child with ASD, which supports the question of the present study[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eGender differences were also evident in coping strategies, QoL, and psychological distress among parents of children with ASD, with mothers reporting higher levels of psychological distress and lower QoL compared to fathers. This aligns with research, which suggests that there was an obvious gender difference in psychological distress for parents of children with ASD. However, this difference depended highly on the severity levels of the child's autistic symptoms [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Another study showed consistency with our findings that mothers of children with ASD experienced significantly higher levels of stress and lower QoL than fathers, highlighting the gendered nature of caregiving responsibilities. These findings underscore the need for targeted interventions that address the unique challenges faced by different groups of parents [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe current study also indicates that the severity levels of ASD significantly influence parental outcomes. Parents of children with severe ASD report higher levels of psychological distress, lower QoL, and greater reliance on avoidant coping strategies compared to parents of children with mild to moderate ASD [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. A study found that parents of children with severe ASD faced greater challenges in maintaining their QoL and mental health, which supports the present study results [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFindings revealed that differences were found in socioeconomic status in severity of autism, quality of life, psychological distress, and avoidant coping, whereas no difference was found in approach coping. The result was consistent with the logical interpretation and previous findings in increasing psychological distress and quality of life. Socioeconomic status (SES) plays a critical role in shaping parental outcomes. Lower SES is associated with higher psychological distress, lower QoL, and limited access to resources for coping [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Another study also aligns with our findings that parents from lower SES backgrounds reported significantly higher levels of stress and lower QoL compared to those from higher SES backgrounds, highlighting the intersection of economic disadvantage and caregiving challenges that also supports the current study\u0026rsquo;s question [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, findings showed associations of ASD Severity levels with psychological distress and quality of life. However, quality of life improved as parents applied coping strategies in managing their stress levels. An inverse association between psychological distress and coping strategies indicates that more use of coping helps improve the quality of life in parents of autistic children. When parents use coping strategies such as avoidant coping and approach coping as a mediator partial effect is found between ASD severity levels and quality of life and psychological distress. Significant differences are obtained in fathers and mothers as the quality of life and approach are significantly higher in fathers of children, while the levels of severity, psychological distress, and avoidant coping are significantly higher in mothers of children as compared to fathers of children. Furthermore, the maximum difference was found in parents of children with ASD whose severity levels were mild and high. Socioeconomic status also differed on all variables.\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWhile this study contributes to understanding the mediating role of coping strategies in quality of life and psychological distress among parents of children with autism spectrum disorder (ASD) in Pakistan, several limitations must be acknowledged. First, the sample consists of only 266 parents from selected cities in Punjab, restricting the generalizability of findings to the broader Pakistani population. Second, reliance on self-reported measures for quality of life, psychological distress, and coping strategies may introduce bias due to social desirability or fluctuations in participants\u0026rsquo; emotional states at the time of data collection. Incorporating objective assessments or multiple informants could mitigate this limitation.\u003c/p\u003e\u003cp\u003e\u003cb\u003eFuture Recommendations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFuture research should broaden its focus to include older individuals with ASD and a more diverse range of caregivers to better understand their unique experiences and challenges. Further studies should also explore the factors that contribute to parental stress when raising children with ASD and identify effective strategies for reducing these stressors. Future studies should consider support programs and interventions for long-term benefits, such as parent-mediated therapy, mindfulness-based intervention, and parent-child relationship programs to incorporate both caregivers and children with Autism spectrum disorder.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data supporting this study\u0026rsquo;s findings are available from the corresponding author, ([email protected]) upon reasonable request\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthor A.K. designed and completed the manuscript. Authors K.I., M.K., and A.S.G. were involved in data collection, and author Y.S. reviewed and wrote the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they did not receive support from any organization for the submitted work.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eApproval for the study was obtained from the Institutional Ethics Committees of the School of Foreign Languages and Literature, Shandong University (Ref No: ECSFLLSDU2025-10), and the Islamia University of Bahawalpur, Rahim Yar Khan Campus (Ref No: 5424/PSY/RYK). Ethical guidelines were rigorously followed, including obtaining informed consent and ensuring participant confidentiality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdditional information\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCorrespondence and requests for materials should be addressed to Y.S\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAmerican Psychiatric Association. 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Eur Child Adolesc Psychiatry. 2018;28(6):747\u0026ndash;58. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00787-018-1183-3\u003c/span\u003e\u003cspan address=\"10.1007/s00787-018-1183-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYesilkaya M, Magall\u0026oacute;n-Neri E. Parental stress related to caring for a child with autism spectrum disorder and the benefit of mindfulness-based interventions for parental stress: A systematic review. SAGE Open. 2024;14(1):1\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMalik F, Haider S. Socioeconomic status and parental stress in families of children with autism spectrum disorder in Pakistan. J Autism Dev Disord. 2020;50(6):2145\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Autism Spectrum Disorder, Coping Strategies, Quality of Life, Psychological Distress, Parents","lastPublishedDoi":"10.21203/rs.3.rs-7068894/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7068894/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e\u003cp\u003e Raising a child with autism spectrum disorder leads to psychological distress and has a significant impact on the quality of life of parents. The present study was conducted to assess the mediating role of coping strategies in managing psychological distress and improving the quality of life in parents of children with autism.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e\u003cp\u003eAn analysis based on a descriptive cross-sectional design was conducted in various autism centers and special education centers of District Punjab. The study involved 266 parents (133 mothers and 133 fathers), recruited via purposive sampling. Data collection was completed by using the Childhood Autism Rating Scale (CARS-2), Brief COPE, Kessler Psychological Distress Scale (K10), and WHO-QOL Brief.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003ePearson correlation analysis revealed that ASD Severity is significantly correlated with psychological distress, quality of life, avoidant coping, and approach coping. Mediation pathway analysis showed that avoidant coping partially mediates the relationship between severity levels, quality of life and psychological distress overall for fathers and mothers of children and fathers of children, but does not mediate for mothers of children. Approach coping partially mediates the relationship between severity levels, quality of life, and psychological distress among fathers and mothers of children. The t-test showed that the difference in quality of life and coping approach is significantly higher in fathers of children as compared to mothers.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eFindings concluded that effective use of coping strategies helps reduce psychological distress and enhances the quality of life for parents.\u003c/p\u003e","manuscriptTitle":"Relationship between Disorder Severity, Psychological Distress, and Quality of Life in Parents of Children with Autism Spectrum Disorder: Coping Strategies as a Mediator","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-09 11:29:20","doi":"10.21203/rs.3.rs-7068894/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-09-21T15:21:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"301002277303011970420009176672693439812","date":"2025-09-14T07:05:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"33683364855889894893926824857717349795","date":"2025-09-09T05:02:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"128058860149189121080141308332762475981","date":"2025-09-03T13:48:59+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-29T08:16:54+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-23T16:18:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-23T16:10:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-19T20:10:04+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychology","date":"2025-07-19T20:06:57+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"280b34cc-12b4-4638-83e5-67d24fb0076c","owner":[],"postedDate":"September 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-09T11:29:20+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-09 11:29:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7068894","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7068894","identity":"rs-7068894","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}