Over the recent decades, resiliency has been considered as one of the components of a person's ability to cope with mishaps and hardships of life. Resiliency is the process of persons’ empowerment during stressful situations. There-fore, in most cases, it prevents negative behavior and thinking which would result in positive outcomes (1). It is also known as a protective factor in the science of behavior. Individuals with resilience ability, will often return to their normal behavior after pressurizing situ-ations (2). This concept also applies to family, which is defined as the ability of families to return from crises(3). To understand the basic concept of resilience in this case, resilience is the reason why some families collapse after facing disasters such as the illness, disability or the loss of family members, but others adapt themselves to the new circumstances(4).
From the systemic perspective, a person’s illness-/disability has an impact on the whole family which can cause them to make  some decisions over time(5). One of these conditions is autism, a disorder characterized by repetitive restricted behaviors and deficits in communi-cation and social skills. Symptoms, based on diagnostic criteria of DSMV, are deficits in social interaction, comm-unication skills, restricted behavior, movements, and interests(6,7,8).
In general, social interactions and the ability to interact with others is not strong in autistic children, so their families are under challenging circumstances, mental pressure and anxiety caused by having children with disabilities(9, 10). Mothers of these children experience much severe anxiety in a chronic way, which could lead to depression in the long-term(11). This state of depression and anxiety can reduce the mental health of parents, which can lead to ineffective family function-ing(12, 13). One of the acquired psychological charac-teristics that can reduce family anxiety is resiliency. Given the importance of the role of resilience as a protective factor in living conditions of families with autistic children against depression and anxiety, getting to know the families’ psychological conditions can play an important role in improving their quality of life. As has been proven in previous studies, psychotherapy can increase resilience which can be used to improve burnout, compassion fatigue, and the mental health of autistic patients (14). So, we decided to examine the resilience of families with autistic children and its relationship with anxiety, depression, and stress.
 

This study was carried out to review and assess the impact of Family Resilience on depression, anxiety and stress. 137 members of the families of autistic children were enrolled in our study, whose average age ranged from 40 to 67 years. (± 9.12). Participants included 80 females (58.4%), and 57 males (41.6%), most of whom had at least a bachelor’s degree (51.7%), and were generally married and lived with their families (78.8%), with no chronic physical (84.7%) or psychological (95.6%) conditions. Most of the participants (42.3%) had approximate income of 10 to 30 million IRR. Based on data from the Statistical Center of Iran, the average income of an urban household in the years 2016 and 2017 was approximately 37 million IRR in Tehran(17). Given the current economic conditions of Iran in 2018, the average income of our study participants was  estimated as below-average, and low income.
The number of family members (who are now living together) ranged from 2 to 7 most of whom were married and lived with their families, and did not have chronic medical/psychological conditions. The distributions were as follows (table 1):

Table 1. Distribution of chronic medical/psychological conditions

Regarding parents’psychological status, 48.2% had depression (mild to severe), 54% had anxiety, and 56.2% had stress. DASS-21 questionnaires results are collected in table 2

Table 2. DASS-21 questionnaires results

To test the parametric characteristics of our varia-bles, we used Kolmogorov-Smirnov test, which repor-ted that only the family resilience score questionnaire had normal distribution (P=0.2). To analyze the relationship among qualitative variables, depression, anxiety, and stress, Chi-square test was used.

 
Table 3. Chi-Square test of DASS-21 questionnaire with qualitative variables

In addition, neither age nor sex had any significant correlation with family resilience score according to Kendall's (P=0.562), Spearman's test (P=0.616), and Independent Sample t test (P=0.701), respectively. Due to normal distribution of the family resilience score, One Way ANOVA test was used to determine its relationship with qualitative variables. The analysis of variance is a set of statistical models that can investigate the difference between mean groups (more than three groups) and categories, so the average can be compared. Since in this test, if  P value is less than 0.05, it is possible to find a significant relationship between variables, according to the results in the table, it seems that anxiety and depression was highly correlated with resiliency(P=0/000), with mild to moderate resilience rates which is higher among higher groups.(Table 4).

Table 4. One Way ANOVA test of the family resilience score

Discussion

According to Sadeghirad’s study, income, psycholo-gical conditions, educational degree, and gender were risk factors for both depression and stress. Regarding the age range of the participants, there was a similarity between this study and ours. Also, Sadeghirad’s results were corroborated by ours regarding the educational status effects (18). This study was conducted to measure the prevalence of depression, and its results are more reliable because it was carried out among a larger population. Also, Altemus stated that gender is an important factor for depression, so that the probability of this disorder in women is higher and in the event of illness they show more severe symptoms from the onset (19). Family size, education, income, and psychological conditions had a significant effect on people's anxiety. Other studies such as Mcleen’s et al., and Altemus et al., observed that the ratio of male and female in all of the anxiety disorders was not close to each other, which disagrees with the current study results(19,20). In addition, Verma’s study stated that stress and stress response differs between men and women(21). In the study of the prevalence of psy-chiatric disorders in Iran, conducted by Sharifi et al., anxiety disorders were the most prevalent disorders with 15.6% frequency(22), which is much less than our sample statistics. However, due to the fact that the sample size in this study was much higher, it may be more accurate to examine the prevalence in this volume. Also, because the study population were the families of autistic patients who are exposed to various types of stress, the level of anxiety in them is expected.
 Sareen et al., also reported that low income or reduction in income can directly lead to mental disorders such as depression and anxiety(23).
Furthermore, our findings showed that family resilie-ncy average score was 193 (±25). There was no significant correlation between age and gender, which is in contrast with Kavaliotis study, indicating that sex has a different relation with the family resilience levels, as men show lower scores in comparison with women(24). However, depression, anxiety and stress were related to the level of resilience, in a way in which normal groups got higher scores than abnormal groups. It appears that having more powerful resilience ability contributes to lower depression, anxiety and stress. In confirmation, Bekhet  et al., found that ASD children’s parents who have the resiliency indices are able to solve problems associated with child care better than the others(25). In this regard, Duca results showed that families of ASD children experience high levels of stress, but resilient families had lower levels(26). Plus, another study noted resilience as a protective factor for depression or bitter experiences(27).
Finally, one limitation in this research was limited accessibility to sample family members. Nevertheless, the measurements of the variables were based on self-assessment, which makes it less controlled and stand-ardized. We propose the use of different kinds of assessment such as interview for future studies. In addition, this study recommends that future curricula should be designed to increase the level of resilience of individuals with before-after training tests for depre-ssion, anxiety and stress to determine their changes. It is also essential to assess family function when resilience increases.

 

Conclusion

From the results of this study, we can conclude that family resilience is one of the important factors that directly affects the level of depression, anxiety and stress among the family members of the autistic children. Therefore, we recommend ameliorating this ability in family members by various means such as training, counseling, supporting groups, etc.

 

Acknowledgements

The authors thank Ms. Fahimeh Mousavinejad, Director of Aeen Mehrvarzi Elementary School, for her cooperation in data gathering from the parents of children with autism

 

Conflicts of Interest

The authors declare that they have no competing interests.


 

Funding Sources

This research received no specific grants from any funding agencies in the public, commercial, or not-for-profit sectors. There is no role for any funding bodies in the design of the study, collection, analysis, and interpretation of data as well as writing the manuscript.