Personality and Individual Differences 186 (2022) 111351
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Personality and Individual Differences
journal homepage: www.elsevier.com/locate/paid
Coping, social support, and family quality of life for caregivers of
individuals with autism: Meta-analytic structural equation modeling
Ruodan Wang a, Qing Liu a, *, Wenjuan Zhang b
a
b
College of Education and Technology, Zhejiang University of Technology, Hangzhou, China
Mental Health Education Center, Xidian University, Xi'an, Shaanxi, China
A R T I C L E I N F O
A B S T R A C T
Keywords:
Caregivers of individuals with autism
Coping
Social support
Family quality of life
Meta-analysis
This study used the meta-analysis structural equation modeling (MASEM) method to explore the relationship
between coping (positive and negative), social support, and family quality of life for caregivers of individuals
with autism. Through a meta-analysis of 29 studies (N = 4864), the following results were found: (1) Positive
coping by caregivers significantly positively predicted social support (β = 0.27) and family quality of life (β =
0.12). Negative coping significantly negatively predicted social support (β = − 0.18) and family quality of life (β
= − 0.18). The social support of caregivers significantly positively predicted family quality of life (β = 0.30). (2)
Positive coping and negative coping by caregivers had significant indirect effects on their family quality of life
through social support (β = 0.08, β = − 0.05, respectively). It can be seen from the results that social support of
caregivers of individuals with autism partially mediates the relationship between coping (positive and negative)
and family quality of life. In addition, the results of the moderator analyses showed that caregivers with spouses
were more likely to reduce social support when they adopted negative coping than caregivers without spouses (p
= .022).
1. Introduction
Autism spectrum disorder (ASD) is an early neurodevelopmental
disorder characterized by social communication deficits, language
development disorders, an intense preoccupation with a narrow range of
subjects, and stereotypic behavior (American Psychiatric Association,
2013). In addition, the external manifestations of ASD are complex,
including sleep problems, aggression, hyperactivity, self-injury
behavior, impulsive behavior, and (lower or higher) sensitivity to
stimuli. The problem behaviors of children with ASD have brought great
challenges to their caregivers (usually parents). In the caring process,
caregivers of individuals with ASD face pressure and difficulties from
employment, financial crisis, alienation, irregular life, social stigma, and
mental and physical exhaustion, which greatly reduce their family
quality of life (FQOL) (Stanojević et al., 2017; Weiss et al., 2014). In
1983, some researchers proposed a double ABCX model for the adjust­
ment and adaptation of families facing stressors (Fig. 1), in which family
adaptation (xX) is affected by the pile-up of demands (aA), adaptive
resources (bB), family perception (cC), and coping (BC) (McCubbin &
Patterson, 1983). Many studies have found that various predictors of
FQOL and family adaptation are consistent, such as children's behavioral
problems, social support, coherence, and mental health (McStay et al.,
2015; Predescu & Şipoş, 2017). The double ABCX model can be suc­
cessfully applied to the study of FQOL in caregivers of people with ASD
after continuous revision. The revised double ABCX model consists of
four parts (aA stressors, bB external support, cC appraisal and coping,
and xX family adaptation). Specifically, stressors, external support,
appraisal, and coping all directly affect the FQOL, and external support,
appraisal, and coping play a moderating role in the process of stressors
affecting the FQOL (*Meleady et al., 2020).
Some studies based on the double ABCX model found that coping and
social support of caregivers of individuals with ASD have a significant
predictive effect on their FQOL (*Ji et al., 2014; Ghanimi et al., 2018;
Mourya & Singh, 2016), where positive coping is significantly positively
correlated with social support and FQOL, and negative coping is
significantly negatively correlated with social support and FQOL
(*Cappe et al., 2018; *Lin et al., 2011). However, some studies have
found that the correlation between positive coping and FQOL is not
significant (*Pozo et al., 2014). Moreover, the correlation between
negative coping and social support was not significant (*Khanna et al.,
2011). Currently, there are few studies on the mediating role of social
support for caregivers in coping with FQOL. At the same time, the results
* Corresponding author at: Zhejiang University of Technology, Hangzhou 310014, China.
E-mail address: psylq@zjut.edu.cn (Q. Liu).
https://doi.org/10.1016/j.paid.2021.111351
Received 21 August 2021; Received in revised form 5 October 2021; Accepted 15 October 2021
Available online 23 October 2021
0191-8869/© 2021 The Authors.
Published by Elsevier Ltd.
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R. Wang et al.
Personality and Individual Differences 186 (2022) 111351
related quality of life and well-being. Social support can be used as a
potential intervention point to alleviate the inner pain of caregivers, and
it has a significant impact on the satisfaction of FQOL (Garrido et al.,
2020). At present, meta-analyses of the relationship between social
support and FQOL for caregivers of people with ASD are rare. Schiller
et al. (2021) showed through a meta-analysis that different types and
sources of social support have a protective effect on caregivers' mental
health. This study will use a meta-analysis to illustrate the impact of
social support as a mediator variable on the FQOL for caregivers of
children with ASD in the structural equation model.
of the relationships between existing variables are also different.
Therefore, it is necessary to discuss the relationship between the coping,
social support and FQOL for autistic persons' caregivers, as well as
whether there is a mediating and potential moderator effect among
them.
1.1. Does social support of caregivers of ASD affect their family quality of
life?
Family quality of life (FQOL) refers to the degree to which family
needs are met, the time that family members enjoy life together, and the
opportunity to do things of great significance to the family together
(Park et al., 2003), including physical and mental health, family inter­
action, nurturing, and support related to disability (Hoffman et al.,
2006). Studies have shown that the quality of life of parents of children
with ASD is lower than that of parents of normally developing children,
and the parenting burden of mothers with children who have ASD is
greater than that of mothers of normally developing children (Wang
et al., 2018). Caregivers of autistic children are more likely to experience
psychological distress and lower quality of life (Bromley et al., 2004;
Pastor-Cerezuela et al., 2021). In general, although the improvement of
caregivers' FQOL is helpful for the treatment and rehabilitation of per­
sons with ASD (Ghanimi et al., 2018), this group's material life, physical
function, psychological function, and social function are significantly
lower than those of normal developing children's parents (Perumal et al.,
2014). At the same time, their emotional health satisfaction is even
lower than other aspects of FQOL (Schlebusch et al., 2017; Smith, 2018).
Marsack and Samuel (2017) explained the importance of support from
social relationships to the happiness, health, and FQOL of caregivers of
ASD. Social support refers to individuals who feel the care, love, and
respect provided by the social network and receives the help provided by
the social network (Cobb, 1976). Social support can generally be divided
into formal and informal support. Formal support usually refers to the
support that needs to be paid for, such as support from health care in­
stitutions, rehabilitation centers, etc.; informal support usually refers to
the support obtained without compensation, such as support from peers,
religious groups, friends, and family (Ault et al., 2021). In the context of
collectivist culture, mothers of autistic children report higher stress
levels than mothers of healthy children (Ueda et al., 2020), but the
combination of formal and informal support is of greater help to their
families (McIntyre & Brown, 2018).
Many studies have shown that social support has a positive effect on
improving the FQOL of caregivers of individuals with ASD (BishopFitzpatrick et al., 2018; Ekas et al., 2016; Lei & Kantor, 2021; Obeid &
Daou, 2015). McGrew and Keyes (2014) found that perceived social
support can buffer the impact of stress on individuals, reduce the burden
and depression level of caregivers of ASD, and improve their health-
1.2. Does coping of caregivers of ASD affect their social support?
Coping refers to the use of cognitive and behavioral efforts to control,
tolerate, and reduce internal and external needs and conflicts generated
by stressful situations (Folkman, 1984). The coping style is similar to the
coping strategy, which is the specific form of coping and refers to the
main behavior mode and reaction state tendency adopted by individuals
in facing the stress process (Craig et al., 2020; Spady, 1993). Different
studies divide coping in different ways (Algorani & Gupta, 2021). The
most common division is currently split into two dimensions: problemfocused coping and emotion-focused coping (Benson, 2010; Bozkurt
et al., 2019). Problem-focused coping is generally seen as adaptive
behavioral tendency, which produces more positive results than
emotion-focused coping (*Khanna et al., 2011). Emotion-focused coping
is considered as a maladaptive behavior tendency (Herman & Tetrick,
2009). Adaptive and maladaptive coping are usually regarded as posi­
tive and negative coping, respectively (Ward et al., 2021). Positive
coping includes active responses, planning, active reconstruction,
acceptance, humor, religion, the use of emotional support, and instru­
mental support, while negative coping includes self-distraction, denial,
venting, substance abuse, behavior disengagement, and self-blame
(Meyer, 2001). Brown et al. (2020) have shown that the avoidance
dimension in negative coping is related to higher stress levels of parents
of children with ASD, and positive coping is related to lower levels of
depression. According to them, in terms of marital satisfaction, female
caregivers tended to benefit more than male caregivers in positive
coping. Lai et al. (2015) found that parents of children with ASD are
more likely to adopt maladaptive coping than parents of normally
developing children.
Regarding the relationship between coping and social support,
China's research and analysis has concluded that coping has a significant
predictive effect on social support (a mediator variable) in the process of
influencing mental health, with an effect coefficient of 4.887 (Jing et al.,
2017). Positive coping dimensions such as seeking social support and
being action-oriented are significantly positively correlated with the
support index, while negative coping dimensions such as avoidance are
Fig. 1. The double ABCX model of family adjustment and adaptation (McCubbin & Patterson, 1983).
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Personality and Individual Differences 186 (2022) 111351
significantly negatively correlated with the social support index
(*Whitehead et al., 2015). However, some studies on the relationship
between the two have shown that some positive or negative dimensions
of coping are not significantly associated with social support (Novara
et al., 2015). Therefore, given the inconsistency of the research results,
this study used a meta-analysis based on the structural equation model
to explain the relationship between the two variables.
status” as a moderator variable to observe whether it has an impact on
the relationship between caregivers' coping, social support, and FQOL.
1.4.3. Sex of caregivers
Mothers of children with ASD are more likely to use emotion-focused
coping than fathers, which will increase their depression and anxiety
problems and become one of the factors that reduce their FQOL (Dab­
rowska & Pisula, 2010; Meral et al., 2013). In contrast to the above
conclusions, Ghanouni and Hood (2021) concluded in their article that
there is no significant difference in coping ability between mothers and
fathers of children with ASD, and mothers will use more support from
family, friends, and spouses. This type of support tends to improve
family happiness. In response to the above different views, this article
will incorporate “sex of caregivers” into the potential moderator
variables.
1.3. Does social support of caregivers of ASD mediate the relationship
between coping and family quality of life?
Stuart et al. described that positive coping could reduce the burden
on all levels of the family system, and that negative coping has a
negative effect on individual stress levels, and physical and mental
health (Stuart & McGrew, 2009). Numerous studies have also discovered
the importance of adopting positive coping for caregivers, which is
related to increased happiness and decreased depression (McKee et al.,
2020). According to Tajrishi's experiment, some scholars have
concluded that the use of positive dimensional problem-focused coping
strategies by caregivers of individuals with ASD can significantly
improve their quality of life (Lovell & Wetherell, 2015; Pourmohama­
dreza-Tajrishi et al., 2015).
According to the amended double ABCX model (*Meleady et al.,
2020), coping and social support have a direct effect on FQOL, and they
play a moderating role in the process of stressful events faced by care­
givers. As to whether social support acts as a mediator variable between
coping and FQOL, some research supports this view. Social support has
been found to play a mediating role in the relationship between coping
and mental health (Jing et al., 2017), while other studies are mostly
regression analyses about coping and social support of caregivers of
people with ASD on FQOL. For example, Khanna et al. (2014) believe
that caregivers fully perceive support from friends and family, and
adopting positive coping will lead to higher FQOL. In general, in view of
the unclear mediating role of caregivers' social support on the impact of
coping on FQOL in previous studies, this article will further confirm this.
1.4.4. Age of persons with ASD
Kousha et al. (2016) found that the age of autistic children strongly
affects their mothers' mental health and quality of life. According to
them, the older the children, the worse the parents' ability to use
reasonable coping strategies and useful external resources, and the more
obvious symptoms of anxiety and depression. However, some studies
have shown that the FQOL perceived by caregivers of autistic in­
dividuals is unrelated to their age (Dardas & Ahmad, 2014; Robinson &
Weiss, 2020). This may be caused by poor coping strategies and social
support that did not meet the needs and expectations of these families.
Based on the inconsistency of some research results, this article will use
the “age of persons with ASD” as a moderator variable to explore its
influence on the variables in the structural equation.
1.4.5. Family financial status
Through research, some scholars believe that family income affects
the satisfaction of children with ASD. If there is no satisfaction, it dis­
rupts family life order and increases the stress of caregivers, thus
reducing FQOL (*Cappe et al., 2018; Alenazi et al., 2020; Alhazmi et al.,
2018; Omar et al., 2017). Gagat-Matula (2021) also supports this view.
In his research, he found that compared with families with ordinary
economic conditions, families with poorer finances prefer to adopt
emotion-focused coping, lack vitality in seeking social support, and thus
have a lower quality of life. However, some studies have pointed out that
the social support received by families of individuals with ASD is not
affected by financial status, which may be due to the lower cost of
available support (Al-Tal et al., 2021). Therefore, in view of the different
results of different studies on family financial status, this study will
incorporate it into potential moderator variables to explore its impact.
In summary, current research on the mediating role of social support
between coping and FQOL is still unclear, and the results of the rela­
tionship between the two are still controversial. Therefore, this research
will use the meta-analysis structural equation modeling (MASEM)
method to explore the relationship between coping (positive and nega­
tive), social support, and FQOL for caregivers of individuals with ASD,
and whether social support has a mediating effect on the pooled sam­
ples. If there is a mediating effect, what is the specific impact mechanism
of the mediating effect? Do potential moderator variables affect the
relationship between the three? Specifically, the hypotheses of this
meta-analysis are as follows:
1.4. Do moderator variables affect the relationship between coping, social
support, and family quality of life of caregivers of individuals with ASD?
We considered several potential moderator variables that affect the
relationship between variables in the structural equation model,
including caregivers' age, marital status, sex of caregivers, age of persons
with ASD, and family financial status.
1.4.1. Age of caregivers
Studies have shown that as the age of parents increases, the fre­
quency of positive coping strategies decreases (*Salas et al., 2017). The
use of negative coping strategies that accompany the above situation is a
risk factor for quarrels in families, which can lead to social isolation and
is detrimental to the FQOL (Vernhet et al., 2019). However, Schlebusch
et al. (2017) found that regardless of the age of fathers or mothers, it
does not affect disability-related support and does not affect the FQOL.
In view of this, we will examine whether the “age of caregivers” affects
the relationship between coping, social support, and FQOL.
1.4.2. Marital status
The partner effect will influence fathers to adopt distracting coping
strategies (negative), and avoiding social support and responsibilities,
which makes mothers take on more challenges and subsequently have a
poorer quality of life (Özgür et al., 2018; Wang et al., 2020). McAuliffe
et al. (2017) compared married mothers and single mothers and found
that although single mothers have a lower quality of life in the envi­
ronmental field, there is no difference in the physical, psychological, and
social relations fields. Single mothers use more adaptive coping
(acceptance), which is a positive coping style. From the above, based on
the diversity of the research results, this article will include “marital
1) Positive coping of caregivers of individuals with ASD has a signifi­
cant positive impact on social support, while negative coping has a
significant negative impact on social support.
2) Positive coping of caregivers of individuals with ASD has a signifi­
cant positive impact on FQOL while negative coping has a significant
negative impact on FQOL.
3) The social support of caregivers of individuals with ASD positively
predicts their FQOL.
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Personality and Individual Differences 186 (2022) 111351
4) Social support plays a mediating role in the relationship between
coping (positive and negative) and FQOL.
5) The relationship between coping, social support, and FQOL for
caregivers of individuals with ASD was not affected by the potential
moderator variables (age of caregivers, marital status, sex of care­
givers, age of persons with ASD, and family financial status).
1997) is mostly used; for the mediating variable “social support”, the
Multidimensional Scale of Perceived Social Support (Zimet et al., 1988)
is more used; for the dependent variable “family quality of life”, the
WHOQOL-BREF (Whoqol Group, 1995) and the Beach Center Family
Quality of Life Scale (Hoffman et al., 2006) are often used. The specific
data collection for the above variables comes from cross-sectional
studies.
2. Methods
2.1. Participants
2.3. Procedure
After screening literature (see “Section 2.3. Procedure” for details), a
total of 4864 caregivers of autistic persons were pooled. Most caregivers
were recruited from special schools, clinics, and the Internet. The
diagnosis of their children's autism was confirmed by authorities. In the
collected samples, the age of caregivers ranged from 35.22 to 47.49
years (M), the married rate exceeded 50%, female caregivers accounted
for more 50% (ranging from 50% to 100%), and the age of autistic
persons ranged from 3.24 to 18.04 years (M). The research process of
this meta-analysis has been approved by the local ethics committee and
conforms to the ethical standards of the Helsinki declaration.
2.3.1. Literature search
We used the electronic databases Web of Science, PsycINFO,
PubMed, and MEDLINE to conduct literature searches. The date of the
last search ended on June 15, 2021. Specifically, the search terms'
combination for caregivers of ASD was set as autis* OR asperger OR
ASD, and care* OR parent* OR mother* OR father*, the search term for
coping was set as coping, the search terms' combination for social sup­
port was set as social support OR society support, and the search terms'
combination for FQOL was set as quality of life OR living quality.
2.3.2. Inclusion and exclusion criteria
The literature search and screening process followed the PRISMA
guidelines (Moher et al., 2009); the specific process is shown in Fig. 2.
We established the following criteria to determine whether studies
should be included in the meta-analysis of structural equation modeling:
on one hand, studies should quantitatively report effective information
2.2. Variables and instruments
In the pooled research, for the independent variable “coping” of
caregivers of individuals with autism, the Brief COPE scale (Carver,
Fig. 2. PRISMA flow diagram.
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Personality and Individual Differences 186 (2022) 111351
such as correlation coefficients and sample sizes about the relationship
between the constructs (i.e., coping, social support, and FQOL of care­
givers of ASD); on the other hand, studies should simultaneously mea­
sure the relationship between the three variables, or coping (positive
and negative) should be measured before other variables to ensure the
accuracy of directions in the model. Studies that had nothing to do with
the subject or caregivers of ASD were excluded; theoretical reviews,
conceptual articles, or qualitative studies were excluded; non-English or
non-Chinese literature was excluded; the best of different articles of the
same data source were retained according to the quality after compar­
ison, and the others were eliminated.
moderating effect to explain possible heterogeneity in this research (Jak
& Cheung, 2020).
Publication bias refers to the fact that studies with statistically sig­
nificant results are more likely to be published, resulting in small-study
effects (Griffin et al., 2021). There are many ways to test publication
bias, and the Egger test was used in this study (Egger et al., 1997). The
Egger test, also called the Egger linear regression method, was used to
test the degree of symmetry of the funnel distribution. If the test is sig­
nificant (p < .05), it means that the funnel is asymmetrical and there is
publication bias (Yu et al., 2021).
3. Results
2.3.3. Selection and coding of studies
Two authors discussed the relevant content of articles together
during the selection process to determine whether the articles should be
included in the meta-analysis. After that, the two authors separately
coded and checked the information required for the selected articles. In
the case of very few data deviations, the two authors made a final de­
cision after reviewing and discussing them. Each study was coded using
Microsoft Excel spreadsheets according to the following sample char­
acteristics: author information, sample size, country of sample, publi­
cation time, measurement tools of variables, reliability of measurement
tools, correlations between variables, sex of caregivers (the proportion
of females), family financial status (the percentage of the lowest income
level in a research), marital status (married rate), age of caregivers
(average age of caregivers of individuals with ASD), and age of persons
with ASD.
This study collected 29 different studies from 28 articles, with a total
of 4864 participants. The positive coping and FQOL (20 studies, n =
3046), negative coping and FQOL (16 studies, n = 2512), positive coping
and social support (19 studies, n = 3351), negative coping and social
support (16 studies, n = 3086), social support and FQOL (15 studies, n =
2703) were analyzed by MASEM, and a total of 106 effect sizes related to
r were extracted.
3.1. Heterogeneity of structural equation model and test of mediation
effect
Table 1 shows the first-stage pooled correlation matrix based on the
random effects model. After the heterogeneity test, the results showed
high heterogeneity among the studies (Q test was significant and I2 was
greater than 50%). The TSSEM results are listed in Table 2. Table 2
shows that the direct effects of the hypothetical structural equation
model were all significant (confidence interval does not include 0).
Positive coping with caregivers had a positive impact on social support
and FQOL (β = 0.27, β = 0.12, respectively), while negative coping had a
negative impact on social support and FQOL (β = − 0.18 and β = − 0.18,
respectively). Increasing social support can improve FQOL (β = 0.30). In
addition, positive coping of caregivers had a significant positive impact
on their FQOL through social support (β = 0.08), and negative coping of
caregivers had a significant negative impact on their FQOL through
social support (β = − 0.05), showing that social support partially
mediated the relationship between coping (positive and negative) and
FQOL. Fig. 3 shows the assumed and verified the structural equation
model.
2.3.4. Calculation of effect size
This study used the Pearson correlation coefficient “r” as the effect
size to analyze the strength and direction of the relationship between
structural variables. If a study reports correlation coefficients between
different dimensions of a variable and other variables, the mean value is
taken as the final correlation coefficient index; when multiple mea­
surements are taken, the index of the first measurement is used (Deng
et al., 2016; Roorda et al., 2011; Tehrani & Yamini, 2020). According to
the above two previous experiences, combined with “Section 2.3.2. In­
clusion and exclusion criteria”, 28 full-text articles were included in the
analysis, of which 29 were independent studies, and the total number of
subjects was 4864. All included articles followed the relevant ethical
standards.
2.3.5. Statistical analysis
The data collected in this study was processed using the meta for
package and meta SEM package in R (Cheung, 2014; Viechtbauer,
2010). Meta-analysis structural equation modeling (MASEM) was used
to examine the relationships between variables and fit the structural
equation model. To verify the mediating effect of a variable in the
structural equation model, we used the two-stage method of metaanalysis structural equation modeling (TSSEM) proposed by Cheung
and Chan (2005). In the first stage, the correlation coefficients of various
studies were combined into a correlation matrix. In the second stage, a
combined correlation matrix was used to verify the proposed structural
equation model. Since the research data came from samples with
different conditions, after considering sampling errors and different
variations between studies (heterogeneity), we used the random effects
model to draw more general conclusions.
There are two methods for quantitative analysis of heterogeneity:
Cochran's Q test, if it is significant, there is obvious heterogeneity
(Cochran, 1954; Hedges & Olkin, 2014); the other is statistical value I2;
specifically, I2's low-, medium-, and high- classification standards are
25%, 50%, and 75% (Higgins et al., 2003). The latter judgment of het­
erogeneity is currently more popular. The information characteristics of
the moderating variables included in this study were all continuous
variables. Therefore, we used one-stage meta-analysis structural equa­
tion modeling (OSMASEM) to test moderator variables to analyze the
3.2. Analysis of the moderating effect of a structural equation model
OSMASEM was used to test the moderating effects of the moderator
variables (age of caregivers, marital status, sex of caregivers, age of
persons with ASD, and family financial status). After standardizing the
moderator variables, this study analyzed whether they had any influ­
ence on all paths involved in the structural equation model. The results
Table 1
Stage 1: pooled correlations (and I2) among the variables in the mediation based
on the random effects model.
Variable
Positive
coping
Negative
coping
Social
support
Family quality
of life
Positive coping
1
20 (88.52%)
20 (83.22%)
Negative
coping
Social support
Family quality
of life
0.06
1
0.26***
0.18***
− 0.16***
− 0.22***
19
(72.39%)
16
(75.92%)
1
0.36***
16 (55.28%)
15 (77.30%)
1
Note. The upper diagonal of the matrix contains the number of studies involved
in the analyses for each pair of correlation and homogeneity indices (I2). Each
pair of correlations is listed in parentheses, and the lower diagonal of the matrix
contains correlations among the variables in the mediation model. *** p < .001.
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Personality and Individual Differences 186 (2022) 111351
increase their degree of social support, while adopting negative coping
decreases their degree of social support (Hypothesis 1 is supported). This
outcome further supports previous empirical research (Jing et al., 2017;
Pisula & Banasiak, 2020; Ruiz-Robledillo et al., 2014; Schneider-Matyka
et al., 2018). It is worth noting that despite their significant predictive
power, positive coping has a stronger correlation with social support
than negative coping. This may indicate that caregivers can obtain more
social support from the outside world through positive strategies such as
actively seeking help and cognitive reconstruction, thereby perceiving
the availability and usefulness of the support they receive. However, by
adopting negative coping strategies such as avoidance and disengage­
ment, caregivers feel fewer social support changes, and therefore the
association is less.
Second, both coping and social support have predictive effects on the
FQOL of caregivers of people with ASD (Hypothesis 2 and Hypothesis 3,
respectively, supported). By accepting the ASD's facts, looking for
treatments, and adopting correct coping strategies (such as positive
cognitive reappraisal and reasonable emotional venting), caregivers can
improve the mental health aspect of the FQOL. Instead, negative coping
strategies such as self-closure and avoiding reality will adversely affect
their physical and mental health, thereby decreasing their overall
quality of life. This result is consistent with the revised double ABCX
model (*Meleady et al., 2020) and the conclusions drawn from previous
studies (*Pyszkowska & Wrona, 2021; Chowdhury et al., 2019; Siah &
Tan, 2016; Vaz et al., 2021). However, when Dardas and Ahmad (2015)
studied the role of fathers' coping with ASD between parenting stress
and quality of life, they found that coping had no significant impact on
the father's quality of life. The reasons discussed may be due to factors
such as male-related personal styles, family characteristics, and culture,
which have led to weaker coping effects.
Finally, when analyzing the constructed structural equation model,
we found that social support plays a role in mediating the relationship
between coping and FQOL (Hypothesis 4). This shows that coping of
caregivers of individuals with ASD can indirectly impact their FQOL
through social support. It can also directly impact FQOL, regardless of
the impact of social support. The verification of this structural equation
model further explores the double ABCX model (*Meleady et al., 2020;
McCubbin & Patterson, 1983), which illustrates the relationship and
influence path between coping, social support, and FQOL. Through
analysis of the moderating effect, we concluded that marital status has a
moderating effect on the model (Hypothesis 5 is not supported). Spe­
cifically, caregivers with spouses were more likely to reduce social
support when they adopted negative coping strategies than caregivers
without spouses. This may be because caregivers with spouses adopt a
series of hostile emotional vents, escape, avoidance, excessive selfblame, and other negative coping, making the other one in the mar­
riage and closest family members more emotional (“one disaster after
another”). Hence, this situation greatly reduces social support from
other spouses and families.
This study verified the overall relationship between coping (positive
and negative), social support, and FQOL for caregivers of individuals
with ASD through meta-analysis structural equation modeling
(MASEM). This extended and expanded the double ABCX model. The
results show that the methods and interventions that combine coping
(internal provision) and social support (external provision) are effective
in improving family quality of life for autistic persons' caregivers. This
not only illustrates the importance of adjusting and changing negative
coping, but also explains the significance of cognitive acuity of social
resources (Ghanimi et al., 2018). It provides a reference for related
medical service personnel, community workers, and other important
persons in the social network of caregivers (Mourya & Singh, 2016).
Professionals can cooperate with caregivers to help them develop
parenting plans and teach positive coping strategies to manage various
difficult problems they may encounter (Marsack-Topolewski & Wilson,
2021). Relevant experts can provide caregivers with telemedicine and
mutual assistance platforms, and encourage family members and friends
Table 2
Stage 2: Standardized Parameter Estimates (β) and 95% Confidence Intervals.
Parameter estimates
Coefficient
95% CI
Lower
Upper
Direct effect, positive coping–social support
Direct effect, negative coping–social support
Direct effect, social support–family quality of life
Direct effect, positive coping–family quality of life
Direct effect, negative coping–family quality of
life
Indirect effect, positive coping–family quality of
life
Indirect effect, negative coping–family quality of
life
Correlation, positive coping and negative coping
Residual variance, social support
Residual variance, family quality of life
0.27
− 0.18
0.30
0.12
− 0.18
0.20
− 0.26
0.21
0.01
− 0.25
0.34
− 0.09
0.40
0.23
− 0.11
0.08
0.05
0.12
− 0.05
− 0.09
− 0.03
0.06
0.90
0.83
− 0.04
0.85
0.76
0.17
0.94
0.88
Note. Variance, positive coping, and variance, negative coping is equal to 1 by
definition (because of analyzing a correlation matrix analysis). CI = confidence
interval.
Fig. 3. Meta-analysis structural equation model in this research.
showed that the moderating effect of marital status was significant
(χ2(5) = 13.135, p < .05) after omnibus tests, with a statistically sig­
nificant impact on the path of negative coping affecting social support.
When the marriage rate increased by one standard, the direct effect of
negative coping on social support increased by 0.12. Thus, caregivers
with spouses were more likely to reduce social support when they
adopted negative coping strategies than caregivers without spouses.
3.3. Publication bias tests
Egger's linear regression test showed that the relationship between
positive coping and negative coping was Z = − 1.79, p = .07; the rela­
tionship between positive coping and social support was Z = 0.77, p =
.44; the relationship between positive coping and FQOL was Z = 1.79, p
= .07; the relationship between negative coping and social support was
Z = 0.51, p = .61; the relationship between negative coping and FQOL
was Z = − 1.20, p = .23, and the relationship between social support and
FQOL was Z = 0.25, p = .80. It can be seen from the above that p-values
were not significant, and therefore there was no publication bias or
small-study effect.
4. Discussion
The objective of this study was to use TSSEM and OSMASEM
methods of meta-analytical structural equation modeling (MASEM) to
test the hypotheses of the relationship between coping, social support,
and FQOL for caregivers of individuals with ASD by collecting multiple
sample data. Results demonstrated that coping (positive and negative)
and social support significantly affect FQOL in caregivers of individuals
with ASD, and in the structural equation model constructed by the three,
social support plays a partial mediating role. In addition, marital status
plays a significant moderating role in the path of negative coping that
affects social support.
First, caregivers of ASD individuals adopting positive coping can
6
R. Wang et al.
Personality and Individual Differences 186 (2022) 111351
of caregivers to provide instrumental and emotional support in order to
reduce parenting pressure and improve FQOL (Ault et al., 2021; Yan
et al., 2021).
drafting, revising, or critically reviewing the article; gave final approval
of the version to be published; have agreed on the journal to which the
article has been submitted; and agree to be accountable for all aspects of
the work.
4.1. Limitations of the present study and future directions
Declaration of competing interest
On one hand, although the path relationships of the structural
equation model were proved, the collected data all came from crosssectional studies. Therefore, the sequence of occurrences between var­
iables is still worth exploring with longitudinal research methods for
later researchers to form meta-analyses of longitudinal studies. This will
make the results more realistic and reliable. Furthermore, this study did
not consider the relationship between different dimensions of each
variable, and therefore future research should refine related research
between different dimensions of the three variables to clarify the in­
fluence mechanism and size of effects between dimensions.
On the other hand, many studies have shown that compared with
fathers and other caregivers of ASD, mothers have a higher level of
caregiving involvement, and their mental health status should be paid
more attention to by researchers (Al-Kandari et al., 2017; Cetinbakis
et al., 2020; Papadopoulos, 2021; Singh et al., 2017). Therefore, in the
future, when researchers study and analyze various psychological con­
structs of ASD caregivers, they can target the mothers of ASD, so that this
group has more strategies for improving FQOL, and the research also has
more unique research meaning.
In addition, because of Chinese and English language restrictions, the
included sample sizes were small; individual moderator variables' in­
formation provided in some articles was incomplete and not included,
which made us lose the opportunity to explore the role of other
moderator variables; when screening and coding literature as well as
resolving inconsistencies, in addition to two of the authors' co-screening
and independent coding, a third or more authors can also rule on dis­
agreements and participate in screening and coding; the method of
testing publication bias only used Egger's test, which may affect the
accuracy of the results. Therefore, future research can integrate the
strengths of different scholars to include more samples, use more testing
methods, and flexible and comprehensive ideas to explore more scien­
tific research facts.
The author has declared that no competing interests exist.
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This study used the TSSEM method in the meta-analysis structural
equation modeling to determine if the social support of caregivers of
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Consent for publication
Not applicable.
Availability of data and materials
All data, models, and codes generated or used during the study
appear in the submitted article.
Authors' contributions
All authors made a significant contribution to the work reported,
whether that is in the conception, study design, execution, acquisition of
data, analysis and interpretation, or in all these areas, took part in
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