Abstract
Asian immigrant parents raising children with developmental disabilities experience frustration, stress, social isolation, and poor health outcomes. Based on data collected from 55 Chinese American parents of children with developmental disabilities, this study examined the relationships between individual characteristics, parents’ perceptions of developmental disability, social support, severity of disability, and parents’ self-reported physical health and depressive symptoms. The findings showed that Chinese American parents exhibited different pathways for better health outcomes. Overall social support, specific support from family and friends/co-workers, and community involvement were significant correlates of maternal self-reported physical health and depressive symptoms. Fear of stigmatization was significantly and positively associated with maternal depressive symptoms. Similarly, education and employment status correlated with paternal self-reported physical health and depressive symptoms. The ages of parents and their children were found to be negatively correlated with paternal depressive symptoms. The child’s disability severity level was not associated with parents’ self-reported physical health and depressive symptoms. The findings also confirmed that parents’ self-reported physical health status was significantly and negatively associated with their own depressive symptoms. Chinese American mothers experienced poor physical health and greater depressive symptoms compared to Chinese American fathers. The study’s clinical implications and limitations are discussed.
Keywords: Chinese American parents, developmental disabilities, parents’ perceptions of development disability, social support, severity of disability, self-reported physical health, depressive symptoms
Introduction
Data from National Health Interview Surveys (NHIS) from 1997 to 2017 showed an increasing prevalence of developmental disabilities (DD) among children aged 3 to 17 years in the United States (US). From 1997 to 1999, the incidence of DD among US children in that age range was 12.8%. This rate increased to 17.8% from 2015 to 2017, up 39% (Zablotsky et al. 2019). In the NHIS, DD includes autism spectrum disorder (ASD), blindness, cerebral palsy, moderate to profound hearing loss, learning disabilities, intellectual disabilities, seizures, stuttering or stammering, and other developmental delays.
It is difficult to determine the exact number of Asian Americans (AA) diagnosed with DD because AAs are a small share of the nation’s population distribution. However, according to data collected from the National Survey of Children’s Health (NSCH) from 2018 to 2019, when parents were asked if any child aged 3–17 years had a mental, emotional, developmental, or behavioral problem, 9.4% of AA parents reported in the affirmative. This figure is significantly lower compared to other racial and ethnic groups (non-Hispanic White, 24.5%; Hispanic, 19.2%; Black, 21.9%). As for the prevalence of children diagnosed with ASD, the percentage of AA children was also lower (2%) versus their counterparts (non-Hispanic White, 2.8%; Hispanic, 3.2%; Black, 3.3%). AA children were also less likely to receive special services to meet their developmental needs, such as speech, occupational, or behavioral therapy (Asian, 4.2%; Non-Hispanic White, 7.2%; Hispanic, 6.8%; Black, 8.9%; Data Resource Center for Child and Adolescent Health 2020). Notably, the lower prevalence rate and service utilization of AA children with DD may be a manifestation of underreporting by AA families due to immigrant status and cultural and structural barriers (Cho and Gannotti 2005, Jegatheesan 2009, Hwang et al. 2020, Rossetti et al. 2020). Hence, more studies are required to fully understand the life experiences of AA families raising children with DD.
The existing literature includes several studies examining the experiences of non-Asian parents raising a child with DD; however, studies on the experiences of AA parents with a DD child are limited. Specifically, the literature lacks studies examining the experience of AA fathers with DD children. We found only two studies examining gender differences in Asian parents’ responses to their child’s ASD diagnosis and the impacts of their child’s diagnosis on the quality of family life. The first study collected qualitative data from six native Mandarin-speaking AA immigrant families and confirmed AA mother and father differences in cognitive responses to their child’s ASD diagnosis. Compared to fathers, mothers tended to detect atypical signs earlier and in more detail, and responded to the ASD diagnosis with more acceptance. Mothers also quickly found problem-focused coping strategies, made personal sacrifices, and devoted time to care-giving activities (Wang and West 2016). Another study conducted in Mainland China confirmed that fathers’ involvement in care of their children with ASD positively affected their own and their partners’ satisfaction with family quality of life (Wang et al. 2020). These results suggest that with effort, fathers could play a more important role in caring for children with ASD and reduce mothers’ care burden and stress. More studies are needed examining AA fathers’ experiences of caring for children with DD based on data collected from larger and more representative samples.
In addition, a one-size-fits-all approach is not applicable to different AA subgroups because AAs are exceptionally diverse in terms of their culture, national origin, language, and economic and immigration status (López et al. 2017). Therefore, this study attempts to address the gap in the literature by examining the unique experiences of first-generation Chinese immigrant parents who have children with DD and live in the greater Houston area. Specifically, this study examined the 1) relationships between parents’ and children’s individual characteristics and health outcomes, and 2) the relationships between parents’ perceptions of DD, social support, and health outcomes while controlling for parents’ and children’s individual characteristics. The following section summarizes the results of prior studies that examined the experiences of Asian parents of children with DD in both Asia and the United States.
Parenting experience among AA parents of children with DD
AA are the fastest growing among all racial and ethnic groups in the US, increasing 92.4% between 2000 and 2018 from 11.9 million to 22.9 million. In 2018, Chinese formed the largest Asian group (22.42%, n = 5,143,982), followed by Asian Indians (20.0%), Filipinos (19.6%), Vietnamese (9.4%), Korean (8.2%), and Japanese (6.7%) (López et al. 2017, U.S. Census Bureau 2018). This study uses a broader definition of Chinese Americans (CA), which may include people whose ancestors are from China, Taiwan, Hong Kong, Singapore, Malaysia, and Thailand.
According to the NSCH, between 2018 and 2019, 42.2% of Asian parents with children aged 3 to 17 years spoke a language other than English at home, and 82.1% of children had at least one parent born outside the US. In other words, the majority of AA families with young children are first-generation immigrant families (Data Resource Center for Child and Adolescent Health 2020). Many AA parents who have children with DD experience a “double minority” status (they are a racial minority and have a child with developmental disability; Waldman et al. 2016). They are a part of two disparate cultural systems, the Asian culture in which they grew up and the Western culture in which they are currently living. Hence, their parenting experiences of raising a child with DD are diverse because of religion, acculturation, and other individual characteristics such as age, education, and income level (Cooc and Yang 2017).
Several cross-cultural studies have confirmed that Asian caregivers of children with ASD or other DD, specifically mothers, experience higher depressive symptoms, parenting stress, and dissatisfaction with life than caregivers of typically developing children (Lee and Chiang 2018, Lei 2018, Millau et al. 2019, Porter and Loveland 2019, Zhou et al. 2018). Several factors contribute to AA parents’ stress, depressive symptoms, and quality of life: cultural burden and stigma (having a DD child is considered to be the result of sins, karma, and reincarnation; feelings of shame, embarrassment, and despair; Chan and Leung 2021, Chiu et al. 2013, Chou et al. 2010, Hwang et al. 2020, Zhou et al. 2018, Waldman et al. 2016, Zechella and Raval 2016), limited English proficiency (Hwang et al. 2020, Waldman et al. 2016), lack of awareness about DD, lack of familiarity with government or community support services, different communication styles, and various cultural expectations concerning the role of parents in children’s development and education (Porter and Loveland 2019, Waldman et al. 2016).
Social support and health outcomes
Social support has direct and mediating effects on reducing parenting stress and depressive symptoms and in increasing life satisfaction among parents of children with DD (Johnson et al. 2011, Wang et al. 2013, Yan et al. 2021). Prior research has not defined or measured the concept of social support consistently or universally; instead, it is considered a multidimensional construct. Overall, social support has generally been divided into two categories: informal/internal (within the family and social network system) and formal/external (within the community and government system). Several studies have examined the efficacy of social support in terms of positive family functioning and cohesion, including establishing supportive social relationships among parents, family members, friends, and community members (Chou et al. 2010, Johnson et al. 2011, Lee and Emmett Gardner 2015, Li-Tsang et al. 2001, Park et al. 2018, Thuy and Berry 2013, Wang et al. 2013). Other studies have examined the instrumental or informational dimensions of social support received from formal institutions, such as financial security, schools, service providers, and government benefit programs (Hwang et al. 2020, Thuy and Berry 2013, Wang et al. 2013).
Empirical results for the impact of social support on the health outcomes of Asian parents of children with DD have shown mixed results, with most lending at least partial support for a positive effect (Chou et al. 2010, Hwang et al. 2020, Johnson et al. 2011, Kimura and Yamazaki 2016, Lei 2018, Kimura 2018, Porter and Loveland 2019, Singh et al. 2017). Nevertheless, certain studies have failed to confirm this assertion. For example, in their South Korean study, Park et al. (2018) did not find that social support played a significant role in reducing caregivers’ stress. According to another study conducted in China, personal support from friends and family was not a major contributing factor in reducing maternal parenting stress, but government financial support was (Wang et al. 2013). Lei found that strengthening financial support and material benefits helped Chinese families cope with the challenges and stress of raising children with DD (2018). Similarly, Kimura (2018) reported that poor financial situations were strongly related with poor self-rated health among Japanese mothers of children with DD. Social support other than peer support was not statistically significant in relation to poor self-rated health.
Researchers have explained that Asian cultural beliefs that focus on collectivistic cultural values emphasizing group harmony and the presence of a strong cultural stigma in Asian culture toward people with DD could actually deter caregivers from engaging sources of social support. The need to protect the family honor and balance harmony within the family system, and the fear associated with the shame of having a child with DD, may discourage parents from seeking informal social support or discussing issues related to the caregiving burden and stress either within the family or in social networks (Park et al. 2018, Wang et al. 2013).
Severity of disability, child–parent age, and parental stress
Prior studies have confirmed that conditions related to the severity level of a specific disability, the child’s behavioral problems, and the caregiving burden significantly contributed to parenting stress in parents of children with DD (Chou et al. 2007, Kimura 2018, Lee and Chiang 2018, Park et al. 2018, Porter and Loveland 2019, Wang et al. 2013). Instead of direct effects, a study of Korean mothers of children with DD reported that child behavioral problems were indirectly related to chronic maternal stress through decreased acceptance of the disability and increased parenting stress (Kim et al. 2018).
The results regarding the effect of a DD child’s age on parental health status were inconclusive. A DD child’s age had a different impact on different subgroups. In DeLambo et al. (2011) study, non-AA parents reported having lower levels of parental stress as their children with DD grew older, whereas for AA parents no significant relationship was found between the age of DD children and parental stress levels. Instead, a significant negative correlation was found between the parental age and stress for AA parents of children with DD, perhaps because AA parents from collectivist cultures tend to be protective and are actively involved in their children’s lives; consequently, AA parents’ stress level does not diminish as their children with DD grow older. Hwang et al. (2020) conducted a meta-analysis of 11 qualitative studies and found that Asian immigrant parents in the US took different actions to support their child’s development depending on the child’s age (Hwang et al. 2020). Another study conducted in Scotland confirmed that age interacted with parenting style: parents of older children with DD used authoritative parenting less than parents of younger children with DD, and authoritative parenting contributed to higher levels of parental distress among parents of children with DD (Woolfson and Grant 2006). No such studies have been done with AA parent populations, however.
Conceptual framework
This study advances understanding of how parents’ and children’s individual characteristics, parents’ perception of DD, social support, and child’s disability severity factors impact the self-reported physical health and depressive symptoms of AA parents of children with DD in the CA cultural context. Figure 1 shows the conceptual framework developed based on the results of prior studies related to Asian parents of children with DD.
Figure 1.
Conceptual framework depicting the effects of parents’ and children’s individual characteristics, parental perceptions of developmental disabilities, and social support factors on self-reported physical health and depressive symptoms of Chinese American (CA) parents of children with developmental disabilities.
Materials and methods
This study formed part of a larger four-year project conducted from 2015 to 2019 by the Light and Salt Association-Special Needs Caring Center (LSA-SNCC), a community-based organization. The larger project was funded by the Texas Council for Developmental Disabilities and aimed to establish culturally and linguistically competent family support programs for about 100 AA families impacted by DD in the greater Houston area. The parents of the program participants were invited to complete the baseline questionnaire, before which the project team explained the study purpose and obtained informed consent. After one year, the parents were invited to participate in the focus group meeting and were asked to complete follow-up questionnaires to measure program impact. Upon completion of each survey, a $10 gift card was provided to parents to compensate them for their time. The Sam Houston State University Institutional Review Board reviewed and approved the larger project on August 4, 2016.
The study data were compiled from baseline surveys distributed between August 2016 and January 2019, depending on the time of each family’s entry into the program. A total of 57 parents completed the baseline survey. Two parents were excluded from the data analysis because they were interracial couples involving non-Asian fathers. The final sample included 55 parents (24 couples and 7 mothers). The seven mothers included a divorced woman and a widow, and five fathers chose not to participate in the survey because they worked in China or had concerns about privacy. In the parent sample, 61.3% had an autistic child, 12.9% had a child with Down syndrome, and 25.8% had a child with another type of disability, such as traumatic brain injury, attention deficit hyperactivity disorder, cerebral palsy, and blindness.
Among the 19 children with autism, three had an IQ below 70, and 13 had low-adaptive behavior as assessed by a state-licensed psychiatrist. Those 16 students showed intellectual disability, characterized by severely restricted low intellectual function and adaptive behavior. In addition, their STARR tests (State of Texas Assessments of Academic Readiness, which place students in Special Education programs) did not meet the annually tested standard. The other three children with autism were high-functioning Asperger patients with no behavioral problems. In addition, because IQ tests are expensive, above $4,000, parents often wait until their child is approved to receive the state waiver program for the IQ test. At that time, the state agency conducts IQ evaluation at no cost.
Measurements
Self-reported physical health and depressive symptoms
The dependent variables measured parents’ self-reported physical health and depressive symptoms. Participants were asked to rate their self-rated physical health with scores ranging from 1 (very bad) to 5 (very good). A Chinese version of the short form of the Center for Epidemiologic Studies Depression (CES-D) scale was used to assess parents’ overall levels of depressive symptoms (Andersen et al. 1994, Boey 1999). The participants were asked to report how often they had experienced ten symptoms associated with depression during the past week, such as restless sleep and feelings of hopelessness, fear, and loneliness. There were four possible responses for each condition: never/less than one day (coded 0), sometimes/1–2 days (coded 1), often/3–4 days (coded 2), and always/5–7 days (coded 3). The final overall self-rated depressive symptom score was calculated from the ten individual item scores. High scores indicate higher levels of depression. The short-form CES-D yielded a Cronbach’s alpha of 0.90, indicating high internal reliability among parents in this sample.
Social support
The concept of social support was measured based on the level of support received from different sources. Based on prior literature, six variables were developed in three categories. The first category, consisting of three variables, measured parents’ perceived support from family and informal social networks, such as spouse, other family members, and friends/coworkers. The level of support from each group ranged from 0 (no support) to 10 (strongest support). The second category, consisting of two variables, measured parents’ self-rated overall social support and community involvement. Both variables were developed using the Comprehensive Inventory of Thriving (CIT) scale, which measures a broad range of psychological well-being constructs and represents a holistic view of positive functioning (Su et al. 2014). The overall social support variable comprised three items: “There are people I can depend on to help me”; “There are people who give me support and encouragement”; and “There are people who appreciate me as a person.” The variable for community involvement included the following three items: “I pitch in to help when my local community needs something done”; “I invite my neighbors to my home”; and “I look for ways to help my neighbors when they are in need.” All items were coded on a 5-point Likert scale of 1 (strongly disagree) to 5 (strongly agree), and the final score for each variable was created by summing the individual scores from the respective three items. Higher scores indicate greater levels of overall social support and community involvement. The variables yielded a Cronbach’s alpha of 0.94 and 0.68, respectively. The last category of social support variables measured the number of government benefit programs received by a child with DD, including Medicaid, Medicare, Food Stamps, Social Security Disability Insurance (SSDI), Social Security Income (SSI), and seven different waivers. Higher scores indicated that children with DD used more benefit programs.
Parents’ perceptions of developmental disabilities
Two variables were adopted to measure parents’ perceptions of DD: 1) level of acceptance of a child’s learning disability, and 2) fear of stigmatization. The two variables were coded on a scale ranging from 0 to 10, with higher scores indicating high levels of parental acceptance regarding their child’s learning disabilities and high levels of fear of stigmatization attached to DD.
Children’s characteristics
Two variables were measured: the child’s age (in years) and their disability severity level. Disability severity level was assessed by the LSA-SNCC director, who holds a Master’s in Special Education and has worked as a therapeutic consultant/behavior specialist for more than 19 years. Following the guidelines provided by the International Classification of Functioning, Disability, and Health: Children and Youth Version (World Health Organization 2007), the director assessed DD-impacted children’s mobility, verbal ability, vision, comprehension, functional capacity, and behavioral problems, based on a scale ranging from 1 (performs this function well) to 4 (cannot perform this function). The total disability severity score for each child with DD was calculated by summing the individual functioning scores; a higher total score indicates high disability severity. The disability severity index yielded a Cronbach’s alpha of 0.70, indicating internal consistency and reliability.
Parents’ individual characteristics
Seven parental characteristics were recorded: age, educational level, annual household income, employment status, religion, birthplace, and years lived in the US. Detailed measurements and categories of these variables are listed in Table 1.
Table 1.
Results of descriptive statistics and paired sample t-tests between mother and father samples.
| Mothers | Fathers Paired Sample | ||
|---|---|---|---|
| Variables | (n = 31) | (n = 24) | T-Test/P Values |
| Parents’ Characteristics | |||
| Age (36–79 years old) | 50.55a (11.22b) | 53.71 (12.61) | −4.54/.00** |
| 40 and younger | 12.90% | 16.67% | |
| 40–49 | 48.39% | 29.17% | |
| 50–59 | 16.13% | 25.00% | |
| 60 and older | 22.58% | 29.17% | |
| Education (6–20 years) | 15.52 (3.93) | 17.88 (3.51) | −3.06/.00** |
| Birthplace | |||
| China | 74.55% | ||
| Taiwan | 21.82% | ||
| Hong Kong | 3.64% | ||
| Annual household income (1–5) | |||
| Less than $25,000 | 25.45% | ||
| $25,000 to $49,999 | 3.64% | ||
| $50,000 to $74.999 | 14.55% | ||
| $75,000 to $99,999 | 7.27% | ||
| $100,000 and more | 49.09% | ||
| Employment status (0–2) | |||
| Full-time | 19.35% | 75.00% | |
| Part-time | 25.81% | 0.00% | |
| Unemployed | 54.84% | 25.00% | |
| Religion | |||
| Christian | 45.16% | 50.00% | |
| Buddhist | 6.45% | 8.33% | |
| Catholic | 3.23% | 4.17% | |
| No religion | 45.16% | 37.50% | |
| Years lived in the US (1–53 years) | 18.37 (11.47) | 21.46 (13.78) | −3.79/.00** |
| Less than 10 years | 19.35% | 16.67% | |
| 10–20 | 38.71% | 33.33% | |
| More than 20 years | 41.94% | 50.00% | |
| Child’s Characteristics | |||
| Child’s age (3–48 years old) | 17.16 (12.23) | ||
| 3–9 | 35.48% | ||
| 10–19 | 29.03% | ||
| 20–29 | 16.13% | ||
| 30 and older | 19.35% | ||
| Disability severity score (6–20) | 10.62 (3.23) | ||
| Parents’ Perceptions of DD | |||
| Acceptance of child’s learning | |||
| disability (0–10) | 6.81 (3.27) | 6.29 (4.09) | 0.10/.92 |
| Stigmatization (0–10) | 2.03 (2.74) | 1.13 (1.87) | 1.52/.14 |
| Social Support | |||
| Overall social support (6–15) | 13.61 (2.51) | 12.71 (2.16) | 2.62/.02* |
| Spousal support (0–10) | 8.13 (2.78) | 9.29 (1.37) | −0.91/.37 |
| Family support (2–10) | 8.48 (2.25) | 8.21 (2.25) | 1.48/.15 |
| Friend/co-worker support (2–10) | 7.55 (2.53) | 7.04 (2.69) | 1.25/.22 |
| Community involvement (7–15) | 12.81 (2.23) | 12.54 (2.25) | 0.74/.47 |
| # of government benefit received (0–5) | 1.44 (1.55) | ||
| Health Outcomes | |||
| Self-reported physical health (1–5) | 3.35 (0.88) | 3.83 (0.87) | −2.30/.03* |
| Depressive symptoms (0–26) | 8.90 (5.98) | 6.88 (5.14) | 1.13/.27___ |
Mean.
Standard deviation.
p <.05.
p <.01.
Because this was an exploratory study with a small sample size, we used descriptive statistics and bivariate techniques such as paired sample t-tests, correlation, and partial correlation analysis. The alpha level for testing statistical significance was set at .10; although alpha (α) =.05 has been the dominant cut-off level for testing statistical significance, the .10 level has often been used for small sample sizes (Schumm et al. 2013). The analysis was performed using SPSS and STATA 14. Parent samples were analyzed separately to examine if mothers and fathers had different parenting experiences.
To examine the relationships between parents’ and children’s individual characteristics, parents’ perceptions of DD, social support, children’s disability severity level, and parents’ health outcomes, we performed Pearson (zero-order) correlation analysis to identify the significant correlates of parental health outcomes. Then we performed partial correlation analysis to reexamine the significant relationships found in Pearson correlation analysis while controlling for the effects of individual characteristics such as child’s age and parental age, education, total household income, and employment status.
Results
Table 1 summarizes the results of descriptive analysis and paired sample t-tests between the mother and father samples. Overall, fathers in the sample were older, more educated, likely to hold a full-time job, and had been living in the United States for longer than mothers. Both mothers and fathers were highly educated, with mean years of schooling at 15.5 and 17.9 years, respectively. The families in this sample had relatively higher family income, with 49.1% reporting total annual household income of $100,000 or more. The majority of them were born in China (74.6%); 21.8% were born in Taiwan, and 3.6% were born in Hong Kong. The majority were either Christian or had no religious preference. Neither fathers nor mothers in the sample reported significant differences in their perception of their child’s learning disability or fear of stigmatization about having a child with DD. There were no significant differences between the mother and father samples except for perceived overall social support. Mothers reported significantly higher levels of perceived overall social support than fathers did. Mothers reported significantly poorer physical health than did fathers. Mothers also reported higher levels of depressive symptoms compared to fathers. However, that difference was not statistically significant. The majority (64.5%) of the sampled children were less than 20 years old, and the mean disability severity score was 10.6.
Results of correlation and partial analysis
Table 2 summarizes the results of the Pearson correlation analysis. Table 3 summarizes the results of the partial correlation analysis. Several interesting findings can be observed in the results shown in Tables 2 and 3.
Table 2.
Results of the Pearson correlation analysis between selected variables and health outcomes (mothers, n = 31; fathers, n = 24).
| Self-Reported Physical Health Depressive Symptoms |
||||
|---|---|---|---|---|
| Variables | Mothers | Fathers | Mothers | Fathers |
| Parents’ Characteristics | ||||
| Age (35–79) | -.06a (.73b) | .05 (.81) | -.01 (.98) | -.42 (.04)* |
| Education (6–20 years) | .15 (.43) | .72 (.00)** | -.15 (.41) | -.45 (.03)* |
| Annual household income (1–5) | .33 (.07)+ | .26 (.22) | -.25 (.17) | -.32 (.13) |
| Employment status | .08 (.68) | -.34 (.10)+ | .06 (.75) | .37 (.08)+ |
| (0 = not employed, 1 = employed) | ||||
| Years living in the US (1–53 years) | .06 (.74) | -.02 (.93) | -.17 (.36) | -.26 (.23) |
| Child’s Characteristics | ||||
| Child’s age (4–48) | -.00 (.99) | 13 (.55) | -.03 (.89) | -.38 (.07)+ |
| Disability severity score (6–20) | .09 (.63) | 09 (.66) | -.01 (.94) | .10 (.64) |
| Parents’ Perceptions of DD | ||||
| Acceptance of child’s learning disability (0–10) | .33 (.07)+ | .42 (.04)* | -.16 (.38) | -.22 (.30) |
| Stigmatization (0–10) | -.28 (.12) | -.15 (.49) | .48 (.01)** | .40 (.05)+ |
| Social Support | ||||
| Overall social support (9–15) | .55 (.00)** | .46 (.02)** | -.76 (.00)** | -.27 (.19) |
| Spousal support (0–10) | .12 (.53) | -.18 (.41) | -.19 (.31) | -.11 (.60) |
| Family support (2–10) | .33 (.07)+ | .35 (.09)+ | -.46 (.01)** | -.07 (.73) |
| Friend/co-worker support (2–10) | .50 (.01)** | .49 (.02)* | -.66 (.00)** | -.29 (.17) |
| Community involvement (9–15) | .51 (.00)** | .58 (.00)** | -.37 (.04)* | -.18 (.40) |
| # Government benefits (0–5) | .01 (.97) | -.02 (.91) | -.10 (.59) | -.28 (.18) |
| Health Outcomes | ||||
| Self-rated physical health (1 = very bad, 5 = very good) | n/a | n/a | -.51 (.00)** | -.57(.00)** |
| Depressive symptoms (0-26) | -.51 (.00)** | -.57(.00)** | n/a | n/a |
Pearson correlation coefficient.
Significance/p value.
p values <.10.
p values <.05.
p values <.01.
Table 3.
Results of the partial correlation analysis between selected significant variables and health outcomes after controlling for variables related to parents’ and child’s individual characteristicsa (mothers, n = 31; fathers, n = 24).
| Self-Reported Physical Health |
Depressive Symptoms |
|||
|---|---|---|---|---|
| Variables | Mothers | Fathers | Mothers | Fathers |
| Parents’ Perceptions of DD | ||||
| Acceptance of child’s learning | ||||
| disability (0–10) | .23b (.27c) | -.00 (.99) | -.02 (.92) | -.15 (.53) |
| Stigmatization (0–10) | -.27 (.18) | -.29 (.23) | .45 (.02)* | .21 (.40) |
| Social Support | ||||
| Overall social support (9–15) | .52 (.01)** | 17 (.48) | -.74 (.00)** | -.12 (.62) |
| Family support | (2–10) .36 (.07)+ | .03 (.90) | -.45 (.02)* | .23 (.35) |
| Friend/co-worker support (2–10) | .50 (.01)** | .36 (.13) | -.64 (.00)** | -.01 (.98) |
| Community involvement (9–15) | .53 (.01)** | .42 (.08)+ | -.33 (.10)+ | .14 (.56) |
| Health Outcomes | ||||
| Self-reported physical health (1 = very bad, 5 = very good) | n/a | n/a | -.45 (.02)* | -.39 (.10)+ |
| Depressive symptoms (0–26) | -.45 (.02)* | -.39 (.10)+ | n/a | n/a |
aVariables that were controlled include parents’ age, educational level, total household income, employment status, and child’s age.
Partial correlation coefficient.
Significance/p value.
p values <.10.
p values <.05.
p values <.01.
Relationship between parents’ self-reported physical health and depressive symptoms
As shown in Table 2, both mothers’ and fathers’ self-reported physical health significantly and negatively correlated with their own depressive symptoms (-.51, mothers and −.57 for fathers, respectively, at a significance level of .01). Parents with higher levels of depressive symptoms reported lower levels of physical health. This negative and significant relationship weakened, although it remained significant (-.45 for mothers at .05 level and −.39 for fathers at .10 level), after controlling for parental and children’s individual characteristics (see Table 3).
Significant correlates of self-reported physical health
Examining the Pearson correlation coefficients presented in Table 2, the variables that showed a significant relationship with mothers’ and fathers’ self-reported physical health were acceptance of children’s learning disabilities and four variables measuring social support. The important social support variables included overall social support and support from other family members, friends/coworkers, and community. CA parents were physically healthier when they willingly accepted their child’s learning disability, received support from family members (other than their spouse) and friends/coworkers, and were more involved in community activities. Spousal support and government benefits were not significantly correlated.
In the context of parents’ and children’s individual characteristics, only annual household income correlated positively and significantly with mothers’ self-reported physical health. Mothers with higher annual household income reported better physical health. For fathers, education and employment status were correlated with physical health; CA fathers with higher educational levels and who were unemployed reported better physical health.
After controlling for the effects of parents’ and children’s individual characteristics (see Table 3), parental acceptance of children’s learning disabilities was no longer a significant correlate of parents’ self-reported physical health. In addition, for self-reported physical health, four social support variables remained major correlates for mothers but not for fathers. For fathers, only community involvement showed a substantial correlation with their self-reported physical health.
Correlates of parental depressive symptoms
Various significant correlates of mothers’ and fathers’ depressive symptoms were observed in the Pearson correlation coefficients shown in Table 2. For mothers, the significant correlates were fear of stigmatization and four social support variables (overall social support, support from other family members and friends/coworkers, and community involvement). Among CA mothers, those who seriously experienced fear of stigmatization for having a child with DD reported higher levels of depressive symptoms. CA mothers who perceived overall social support and social support from other family members and friends/co-workers and were involved in the community reported lower levels of depressive symptoms. None of the mothers’ or children’s individual characteristics were significantly correlated with mothers’ depressive symptoms.
For fathers, only individual characteristics (such as parents’ age, educational attainment, employment status, child’s age, and fear of stigmatization) were found to be significantly correlated with depressive symptoms. None of the variables measuring social support correlated with fathers’ depressive symptoms. Fathers’ age and education were negatively correlated with their depressive symptoms. Younger and less educated CA fathers had greater depressive symptoms than older and highly educated CA fathers. CA fathers working part-time or full-time reported higher levels of depressive symptoms. The child’s age was found to be significantly and negatively related to fathers’ depressive symptoms, and fathers with a younger child with DD were reported to have greater depressive symptoms. CA fathers with higher levels of fear of stigmatization toward DD reported higher levels of depressive symptoms.
After controlling for parents’ and children’s individual characteristics, fear of stigmatization and four social support variables remained significant correlates of mothers’ depressive symptoms (see Table 3). However, none of those variables, including fear of stigmatization, were significantly correlated with fathers’ depressive symptoms. The important relationship between fear of stigmatization and fathers’ depressive symptoms that was recorded in the prior Pearson correlation analysis was diminished after controlling for the individual characteristics of the father and child.
Discussion
Using data collected from 55 CA immigrant parents of children with DD, this study examined the relationships between parents’ and children’s individual characteristics, parents’ perceptions of DD, social support, and health outcomes in the CA cultural context. Table 4 summarizes the important findings generated from the Pearson and partial correlation analyses.
Table 4.
A summary of the effects of parents’ perceptions of DD and social support on parents’ self-reported physical health and depressive symptoms.
| Self-Reported Physical Health |
Depressive Symptoms |
|||
|---|---|---|---|---|
| Mothers | Fathers | Mothers | Fathers | |
| Acceptance of child’s learning disabilities | Indirecta | Indirect | Noneb | None |
| Fear of stigmatization | None | None | Directc | Indirect |
| Social support | Direct | Indirect | Direct | None |
| Depressive symptoms | Direct | Direct | N/A | N/A |
a‘Indirect’ indicates that the significant relationship diminished after controlling for parents’ and child’s individual characteristics.
‘None’ indicates that the relationship was not significant in either Pearson or partial correlation analysis.
‘Direct’ means the relationship remained meaningful after controlling for parents’ and child’s individual characteristics.
Parents’ self-reported physical health and depressive symptoms
For both mothers and fathers, self-reported physical health correlated significantly and negatively with their own depressive symptoms. This result was consistent with the study conducted by Chou et al. (2010) on older female caregivers of adults with intellectual disabilities in Japan. In addition, the descriptive analysis results indicated that CA mothers of children with DD experienced significantly poor physical health and high levels of depressive symptoms compared to CA fathers of children with DD. These results are consistent with prior studies on CA and non-CA populations (Lei 2018, Millau et al. 2019, McStay et al. 2014, Porter and Loveland 2019, Zhou et al. 2018). The division of household chores based on traditional gender roles, a division embedded in most Asian cultures, places mothers in child-rearing tasks, whereas fathers focus on wage-earning responsibilities. In this study, 55% of mothers were not employed but only 25% of fathers were unemployed. Accordingly, mothers carried a greater parenting burden in caring for children with DD, which seems to have caused depressive symptoms and detrimental effects on maternal physical health.
Different pathways to better health outcomes for CA immigrant mothers and fathers of children with DD
Another major finding was that CA parents of children with DD did not exhibit the same pathways to better physical health and depressive symptom outcomes. Social support from informal social networks, such as family members and friends/co-workers, overall social support, and more community involvement were found to have direct and significant effects on CA mothers’ self-reported physical health and depressive symptoms. However, these variables had spurious effects on CA fathers’ self-reported physical health but did not affect their depressive symptoms. These results are consistent with previous studies (Altiere and Kluge 2009, Chou et al. 2010, Kimura and Yamazaki 2016, Lee et al. 2020, Singh et al. 2017, Thuy and Berry 2013). Support from one spouse was not found to be significantly correlated. A possible explanation is that both parents were already rated high in terms of spousal support scores, which potentially decreased its explanatory power among the health status variables.
The results failed to confirm that formal support from various government programs would help improve parental physical health and depressive symptoms. This result is not consistent with the findings of Wang et al. (2013) or Kimura (2018). This is attributable to the fact that the US provides more government benefit programs to support people with DD compared with Asian countries such as China, which depend heavily on the private sector to provide supportive services (Lee et al. 2020, Wang et al. 2013). Furthermore, the sampled parents were considered to have relatively better economic resources. Almost half of them (49.1%) reported a total annual household income of more than $100,000, which is well above the US average family income of $64,324 in 2018 (Semega et al. 2020). Therefore, parents in this sample were able to afford extra treatment costs for their children with DD.
For CA fathers of children with DD, individual characteristics such as the child’s age and the father’s age, education, and employment status were important correlates of fathers’ self-reported physical health and depressive symptoms. Self-reported physical health was higher among CA fathers with higher levels of educational attainment, while CA fathers’ work outside the home played a detrimental role in their self-reported physical health. Similar results were reported regarding the impact of education and employment status on fathers’ depressive symptoms. Unemployed CA fathers with higher education levels reported lower levels of depressive symptoms. In addition, older fathers with grownup children with DD reported lower levels of depressive symptoms. These findings are consistent with DeLambo et al. (2011) and Woolfson and Grant (2006). DeLambo et al. (2011) confirmed a significant and negative relationship between parental age (not the age of the child with DD) and stress. Woolfson and Grant’s (2006) study asserted that parents of older children with DD used an authoritative parenting style less than parents of younger children with DD, and authoritative parenting contributed to higher levels of parental distress.
The initial significant correlations between social support variables and paternal self-reported physical health diminished after controlling for parents’ and children’s individual characteristics. Similarly, social support variables did not have any direct significant relationship with fathers’ depressive symptoms. In Iwamoto et al.’s (2010) study of factors associated with depressive symptoms in Asian men, they found that adherence to masculine norms such as competition, dominance, and avoidant coping strategies were associated with depressive symptoms, while the endorsement of Asian cultural values, self-reliance, and emotional control were not associated with depressive symptoms. These results, combined with the results of our study, suggest the merits of a thorough investigation of the effects of Asian cultural values and masculine norms on the physical health and depressive symptoms of CA fathers of children with DD. Perhaps such masculine norms or other aspects of Asian cultural values, such as focusing on group harmony and “saving face,” discouraged CA fathers of children with DD from engaging with sources of support from informal and formal social networks.
The results of this study partially support the link between parents’ perceptions of DD and health outcomes. Fear of stigmatization had direct effects on mothers’ depressive symptoms but a spurious relationship with CA fathers of children with DD. This result is partially consistent with Zhou et al. (2018) findings that the stigma affiliated with DD was positively associated with the caregivers’ depression. In addition, initial acceptance of the child’s learning disability had a significant and positive relationship with both mothers’ and fathers’ self-reported physical health. However, the significant relationship diminished after controlling for parents’ and children’s individual characteristics.
The average number of years living in the US for mothers and fathers in the sample were 18 and 21 years, respectively, and that did not correlate significantly with parents’ self-reported physical health and depressive symptoms. Most of these parents were not recent immigrants and had probably adapted to Western cultural beliefs and social systems, which are more open and accepting of people with DD. The study results do not support a linkage between the child’s disability severity level and parents’ health status, as reported by Kimura (2018). This study did not include data from children’s medical records; thus, the measurement of a child’s disability severity level may not be complete.
Study limitations
This study contributes to the literature by clarifying the life experiences of CA parents of children with DD in the US. Nevertheless, caution must be exercised when interpreting the findings, because this study has several shortcomings that may limit its generalizability. First, the sample size was small and not nationally representative. The small sample size limited us from performing more advanced statistical analysis, such as structural equation modeling, to directly test the mediated effect of social support. A larger and more nationally representative sample could enhance the generalizability of the findings to a larger population with a smaller significant alpha level. Second, the data were collected using self-report questionnaires, which may threaten measurement reliability and validity. The participants may have exaggerated their answers or be too embarrassed to provide accurate information about their true opinions. Third, the data analysis did not include variables measuring the dynamics within the family system, such as interaction between spouses and family functioning or cohesiveness, as suggested by Johnson et al. (2011), Lei (2018), Theodore et al. (2018), and Wang et al. (2020). Future studies that include variables measuring dynamics within the closed family system may provide a better perspective on the factors that contribute to physical health and lower levels of depressive symptoms among CA immigrant parents, particularly fathers of children with DD.
Conclusion and clinical implications
The findings showed that CA mothers and fathers of children with DD had different pathways to better health outcomes. These results may inform practitioners and local community stakeholders in developing programs to help CA immigrant families with children with DD. In light of the study results, community programs that promote help through informal social relationship networks, greater community engagement, and the reduction of affiliated stigma may be important ways to improve physical health and depressive symptoms among CA immigrant mothers of children with DD. Young, less educated working CA fathers of young children with DD were least likely to use informal social support to improve their physical health and depressive symptoms. Thus, practitioners can use age, education, employment status, and child age as screening tools to identify potential risk factors and the service needs of subgroups of fathers to develop programs or services that meet their specific needs.
Acknowledgements
The author(s) disclose receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by a grant award from the Texas Council for Developmental Disabilities (2015–2019) and the Sam Houston State University, Office of Research and Sponsored Programs, 2017 Internal Grant Programs.
Funding Statement
This work was supported by the Texas Council for Developmental Disabilities and Sam Houston State University, Internal Grant Programs.
Disclosure statement
No potential conflict of interest was reported by the authors.
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