Affiliate Stigma and Marital Satisfaction in Spanish Parents of Children With Intellectual Disabilities

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Affiliate Stigma and Marital Satisfaction in Spanish Parents of Children With Intellectual Disabilities

Fernando Molero, Patricia Recio, and Encarnación Sarriá

Online First Publication, September 7, 2023. https://dx.doi.org/10.1037/sah0000478

CITATION

Molero, F., Recio, P., & Sarriá, E. (2023, September 7). Affiliate Stigma and Marital Satisfaction in Spanish Parents of Children With Intellectual Disabilities. Stigma and Health. Advance online publication.

https://dx.doi.org/10.1037/sah0000478

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Af ﬁ liate Stigma and Marital Satisfaction in Spanish Parents of Children With Intellectual Disabilities

Fernando Molero

^{1, 2}

, Patricia Recio

^{2, 3}

, and Encarnacio ´n Sarriá

^{2, 3}

1Department of Social Psychology, Faculty of Psychology, National University for Distance Education (UNED)

2Joint Research Institute National University for Distance Education and Health Institute Carlos III (IMIENS)

3Department of Methodology of Behavioral Sciences, Faculty of Psychology, National University for Distance Education (UNED)

Parents tend to experience more stress when their children have intellectual disabilities (ID), and this stress often increases the frequency of family conflicts. Previous research has shown that disability in children negatively impacts marital relationships. The present study analyzes, with reference to the double ABCX model of family adaptation, the association between affiliate stigma (parents’internalization of the stigma borne for their children) as a stressor and the parents’marital satisfaction as an adaptation outcome variable, considering two mediating variables: parents’perceived social support and parents’self-efficacy. The study sample comprises 197 Spanish fathers (31%) and mothers (69%) raising children with ID. Most participants’children had been diagnosed with Down’s syndrome (37.1%) or autism spectrum disorder (ASD) with ID (34%). Our study shows that, as predicted, affiliate stigma is inversely associated with marital satisfaction in parents of children with ID and that perceived social support and self-efficacy play a significant mediational role in this association. Thesefindings may contribute to guiding practitioners and social services on how to enhance protective factors and mitigate risk factors influencing family adaptation.

Clinical Impact Statement

This research shows the important impact of affiliate stigma on marital satisfaction of parents who have children with intellectual disabilities. Specifically, it examines whether social support and self-efficacy may serve as protective factors by preventing the negative consequences of parental affiliate stigma on marital satisfaction. Thus, thefindings have implications for theory, research, and practice.

Keywords:intellectual disability, afﬁliate stigma, marital satisfaction, self-efﬁcacy, social support

Raising a child with intellectual disabilities (ID) entails practical, emotional, and ﬁnancial demands that may affect relationships between parents (Brobst et al., 2009). Parents of children with ID experience more stress than parents of children without disabilities, often exacerbating family conﬂicts and parents’ psychological distress (Scherer et al., 2019;Schilling et al., 1984). They experience numerous challenges as individuals and as couples, which can affect their daily lives in both the short and long terms. In addition to the stressors stemming from the increased daily care needs of their

children, the stigma and perceived discrimination associated with their children’s condition (Banga & Ghosh, 2017;Chiu et al., 2013) may limit opportunities for social life and negatively impact their psychological well-being (Mitter et al., 2019). Several studies have shown that good family adaptation to a signiﬁcant stressor, such as having a child with ID, is important for children’s emotional and behavioral aspects and for parents’psychological well-being (Friedrich, 1979; Greenlee et al., 2022; Hartley, Seltzer, et al., 2011;Sikora et al., 2013). From the family systems perspective, the ThisdocumentiscopyrightedbytheAmericanPsychologicalAssociationoroneofitsalliedpublishers. Thisarticleisintendedsolelyforthepersonaluseoftheindividualuserandisnottobedisseminatedbroadly.

Fernando Molero https://orcid.org/0000-0001-9789-9822 Patricia Recio https://orcid.org/0000-0002-0530-4404 Encarnacio´n Sarriá https://orcid.org/0000-0002-4775-4980

Our positionality statements follow: The authors wish to provide the reader with information about our backgrounds, recognizing that our identities can influence our approach to science. With respect to gender, two authors self- identified as female and one author self-identified as male. All of the authors self-identified as European White race.

This research received a grant from the Spanish Ministry of Economy and Industry, Ministerio de Economía y Competitividad PSI2017-88455-R awarded to Fernando Molero. The authors declare that they have no conﬂicts of interest to disclose.

The data that support theﬁndings of this study are available from the

corresponding author upon reasonable request.

Fernando Molero played a lead role in conceptualization and funding acquisition and an equal role in investigation, project administration, supervision, writing–original draft, and writing–review and editing. Patricia Recio played a lead role in data curation, formal analysis, funding acquisition, methodology, and software, a supporting role in conceptualization, and an equal role in investigation, supervision, writing–original draft, and writing–review and editing. Encarnacio´n Sarriáplayed a supporting role in conceptualization, formal analysis, and methodology and an equal role in investigation, supervision, and writing–review and editing.

Correspondence concerning this article should be addressed to Patricia Recio, Department of Methodology of Behavioral Sciences, Faculty of Psychology, National University for Distance Education (UNED), calle Juan del Rosal, 10, Madrid 28028, Spain. Email:[email protected]

Stigma and Health

ISSN: 2376-6972 https://doi.org/10.1037/sah0000478

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couple’s relationship is considered the core of family functioning and plays a fundamental role in maintaining a positive family environment (Minuchin, 1985). In families with a child with developmental disabilities, the couple’s relationship has been shown to be a critical factor for parents in dealing with stressful situations (García-Lo´pez et al., 2020).

The ABCX theory, proposed by Hill (1958) and further developed by Burr (1973) and McCubbin and Patterson (1983), is considered the most inﬂuential family stress theory since theﬁrst family stress theories emerged (Randall & Bodenmann, 2013). The ABCX model includes three variables that interact to predict the outcome variable (crisis X): the stressor event (A), which interacts with the family’s resources (B), and with their interpretation and meaning of the event (C), which are also interrelated. The double ABCX model of family stress and adaptation (McCubbin &

Patterson, 1983) aims to redeﬁne precrisis variables and incorporate postcrisis variables in order to explain: the accumulation of additional life stressors and strains after the crisis event (represented by the aA factor); the range of family adaptation processes’ outcomes in response to this accumulation of stressors, varying from maladaptation to bonadaptation (the xX factor); and the intervening factors (the bB and cC factors) that shape the adaptation process, such as family resources, family appraisal, and coping strategies.

The adaptive resources play a mediating role between the accumulation of life stressors and the family’s adaptation, either reducing the impact of demands on the family or assisting the family in adapting to necessary changes (Lavee et al., 1985).

The ABCX model (Hill, 1958) and its more advanced version, the double ABCX model (McCubbin & Patterson, 1983), have been shown to be useful to better understand the adaptation processes of families with children with ID (Orr et al., 1991;Saloviita et al., 2003) or with other developmental disabilities, such as autism spectrum disorder (ASD), with or without ID (Bristol, 1987;

Higgins et al., 2023;McStay et al., 2014;Meleady et al., 2020;

Pakenham et al., 2005;Pozo & Sarriá, 2014;Pozo et al., 2006,2014;

Yu et al., 2018).

In the present study, we analyze, with reference to the double ABCX model of family adaptation, the relationship between afﬁliate stigma (parents’ internalization of the stigma borne for their children) as a stressor (factor aA) and the parents’ marital satisfaction as an adaptation outcome variable (factor xX), considering two mediating variables: parents’ perceived social support (factor bB) and parents’self-efﬁcacy (factor cC).

Afﬁliate Stigma as a Parental Stressor (Factor aA) Research shows that people with ID are stigmatized and face consequent discrimination worldwide (Lovell & Wetherell, 2018;

Scior, 2016;Ting et al., 2018).Pachankis et al. (2018)extensively studied different kinds of stigmatized groups using the taxonomy proposed byJones et al. (1984). They found that the rankings of

“mental retardation” (i.e., ID) were high for visibility, persistent course, disruption, and unappealing aesthetics; moderate for peril;

and low for controllable origin. Based on these characteristics, Pachankis et al. (2018) included ID in the “awkward” cluster alongside autism, blindness, and facial scars.

Although the stigma rankings of Pachankis et al. (2018) are useful, it is important to consider that there are several kinds of ID. For instance, mixed reactions have been reported toward

people with Down’s syndrome. Although some forms of ID may induce compassion or sympathy, other forms can elicit negative stigmatizing emotions, such as pity, anxiety, or hostility, leading to the rejection and avoidance of people with ID (Scior, 2016). Experiences of stigmatization can be very detrimental to the psychological well-being of both children with ID and their parents (Ali et al., 2012). AsGoffman (1963) pointed out, stigma is not limited to the person with the stigmatizing characteristic but can also extend to people associated with them (especially relatives and friends). This phenomenon is referred to as stigma by association or, more recently, when the stigma by association is internalized, as afﬁliate stigma, and it has important consequences.

Perceived discrimination and stigma have been reported by parents of children with ID (Banga & Ghosh, 2017;Chiu et al., 2013). We assume that, in the same way, stigmatized individuals may accept or justify the public stigma against them, family caregivers will also justify the public stigma borne by their children;

for example, parents may feel guilty or embarrassed about their child’s behavior or disability. This process has been called the internalization of stigma (Bos et al., 2013). Subsequently,Mak and Cheung (2008)coined the term“afﬁliate stigma”to describe the self-stigma and corresponding psychological responses of the parents or caregivers of children belonging to stigmatized groups.

Since then, several studies have revealed in several countries the negative effects of afﬁliate stigma on parents’self-esteem, stress, psychological and emotional well-being, and subjective burden (Mak & Cheung, 2008,2012;Mitter et al., 2019;Recio et al., 2021;

Shi et al., 2019;Werner & Shulman, 2015).

Marital Satisfaction (Factor xX)

Systematic literature reviews showed that couples raising a child with ASD experience less relationship satisfaction than couples raising typically developing children (Hayes & Watson, 2013;Sim et al., 2016). Moreover,Risdal and Singer’s (2004) meta-analysis concluded that a child’s disability has an overall negative impact on marital adjustment. Part of the research on this topic has focused speciﬁcally on the negative impact of the child’s disability on the couple’s relationship, accumulating evidence of parenting burden, relationship dissatisfaction, and even increased risk of dissolution (Hartley, Barker, et al., 2011;Hartley et al., 2010). However, research is progressively shifting toward studying relationship satisfaction as a positive factor associated with individual and family well-being, highlighting the pivotal role of the couple’s relationship in managing the challenges associated with raising a child with developmental disabilities (García-Lo´pez, Sarriá, Pozo, & Recio, 2016; Hartley, Seltzer, et al., 2011). In this respect, Essex (2002) found that marital satisfaction was associated with both parents’feelings of closeness to the child with ID.

To the best of our knowledge, no study has explored the relationship between afﬁliate stigma and marital satisfaction.

However, Kwok et al. (2014)examined the relationship between perceived stigma (a precursor of afﬁliate stigma) and marital satisfaction in Chinese mothers of children with autism and ID and found a negative relationship between these factors. Theseﬁndings are relevant for the present study, as they suggest a negative effect of stigma on marital satisfaction.

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Mediating Variables: Perceived Social Support (Factor bB) and Self-Efﬁcacy (Factor cC)

Usually, social support is considered in the stigma literature as a buffering or protective mechanism against the negative effects of discrimination on the health and well-being of stigmatized people (Mak & Kwok, 2010). Social network support and high-quality interpersonal relationships are considered essential for reducing the stress produced by discrimination (Beals et al., 2009;Cantwell et al., 2015;Molero et al., 2017). In their meta-analysis,Pascoe and Smart Richman (2009)found that social support moderated the negative impact of perceived discrimination on mental health in various discriminated groups. The study ofMa and Mak (2016)revealed that perceived social support contributes to reducing afﬁliate stigma and preventing psychological distress in family caregivers of children with physical disabilities.

In addition, there is evidence that social support is an important external resource for positive psychological adaptation in parents of children with developmental disabilities. Speciﬁcally, social support has been associated with enhanced well-being and more positive attitudes in parents (Dunst et al., 1986), lower parental stress (Higgins et al., 2023;Pozo & Sarriá, 2014), better family quality of life (Higgins et al., 2023;Pozo et al., 2014), and has been identiﬁed as a protective factor for the psychological well-being of mothers of children with intellectual and developmental disabilities (Halstead et al., 2018). Regarding the association between social support and relationship satisfaction, the systematic review conducted bySim et al. (2016)shows that social support serves as a coping resource capable of enhancing both parental psychological well-being and relationship satisfaction among parents of children with ASD.

Self-efficacy is the set of beliefs a person holds about their ability to organize and execute courses of action to manage a given situation (Bandura, 1997). Research shows that self-efficacy is positively related to several aspects of psychological well-being in a wide range of stigmatized groups (Denton et al., 2014;Tucker et al., 2014;Watson et al., 2007). There is also evidence that parental self- efficacy is an important resource to promote parental adaptation for parents of children with ASD (García-Lo´pez, Sarriá, & Pozo, 2016;

Higgins et al., 2023;Rezendes & Scarpa, 2011).

Other studies have focused on the role of self-efficacy in protecting individuals from the negative effects of internalized stigma (Jahn et al., 2020).Li et al. (2019)explored the role of self- efficacy in the effects of parents’ affiliate stigma in families with children with developmental disabilities. They reported that parents’ self-stigma (i.e., affiliate stigma) was linked to fewer prosocial behaviors and more externalizing and internalizing behaviors in children, but also found that parents’ self-efficacy partially alleviated these associations.

Taken together, the research outlined above demonstrates the importance of parental social support and self-efﬁcacy for family adaptation, justifying their inclusion in the present study as possible mediating variables in the relationship between afﬁliate stigma and marital satisfaction.

Present Research

The main objective of the present study was to analyze the association between afﬁliate stigma and marital satisfaction among

parents of children with ID with reference to the double ABCX model. We considered afﬁliate stigma as a family stressor (factor aA). Regarding the outcome variable (i.e., marital satisfaction;

factor xX), we differentiated between dyadic satisfaction (satisfaction with the other partner) and familial satisfaction (concerning work distribution at home; Raffagnino & Matera, 2015). We analyzed the potential mediating roles of parents’ perceived social support (factor bB) and parents’ self-efﬁcacy (factor cC; seeFigure 1). We predicted the following relationships:

(a) direct negative associations between affiliate stigma and the two types of relationship satisfaction; (b) negative associations between affiliate stigma and both self-efficacy and social support; (c) positive associations between both self-efficacy and social support and both types of relationship satisfaction; and (d) mediating roles of self-efficacy and social support in the associations between affiliate stigma and both types of relationship satisfaction.

Method Participants

The sample comprises 197 Spanish fathers (31%) and mothers (69%) who were raising children with ID. The inclusion criteria were being a biological parent (mother or father) of a child with ID.

Only one of the two members of the couple was included. Six participants were excluded from theﬁnal sample because of missing data. The percentage of missing values did not exceed 5%, so no imputation was performed.

Participants’demographic characteristics are presented inTable 1.

The age of participants ranged from 26 to 71 years (M =45.77;

SD=8.16), while the age of their children ranged from 1 to 30 years (M=13.18;SD=7.40). According to the information reported by parents, most of the children had a diagnosis of Down’s syndrome (37.1%) or ASD with ID (34%). The other reported diagnoses were cerebral palsy, attention-deﬁcit/hyperactivity disorder, and unspeci- ﬁed ID.

Instruments

Affiliate stigma was measured using the Spanish translation (Recio et al., 2020) ofMak and Cheung’s (2008)Affiliate Stigma Scale. This instrument has 19 items for measuring the internalized stigma (i.e., affiliate stigma) of caregivers of children with disabilities (e.g.,“Having a child with a disability makes me feel ThisdocumentiscopyrightedbytheAmericanPsychologicalAssociationoroneofitsalliedpublishers. Thisarticleisintendedsolelyforthepersonaluseoftheindividualuserandisnottobedisseminatedbroadly.

Figure 1

Theoretical Model With Reference to the Double ABCX Model of Family Adaptation

MARITAL SATISFACTION IN PARENTS 3

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that I am incompetent compared with other people”). Participants rated the extent to which they agreed with each item on a 4-point Likert scale, ranging from 1 (not at all agree) to 4 (completely agree). The instrument’s Cronbach’sαwas .87 in this study.

To measure relationship satisfaction, we used the Spanish translation (Magallares et al., 2023) of the Couple Satisfaction Scale (Raffagnino & Matera, 2015). This instrument is composed of two subscales that respectively assess dyadic satisfaction (nine items) and familial satisfaction (ﬁve items). Sample items are

“How satisﬁed I am with the way in which my desires and needs are satisﬁed within my current relationship”(dyadic dimension) and

“How satisfied I am with responsibility and family commitment” (familial dimension). Participants responded to each item on a 4- point Likert scale, ranging from not satisfied at all (1) to very satisfied(4). In this study, Cronbach’sαvalues were .96 and .93 for the dyadic and familial subscales, respectively, indicating good internal consistency.

The Spanish adaptation (Bello´n et al., 1996) of the Duke-UNC Functional Social Support Questionnaire (Broadhead et al., 1989) was used to measure perceived social support. Participants responded to 11 items on a 4-point Likert scale, ranging from 1 (not at all agree) to 4 (completely agree). A sample item is“I get invitations to go out and do things with other people.” The instrument had good internal consistency in this study (Cronbach’s α=.92).

Self-efﬁcacy was measured using the Spanish adaptation (Sanjuán et al., 2000) of the General Self-Efﬁcacy Scale (Baessler & Schwarzer, 1996). Participants responded to 10 items on a 4-point Likert scale, ranging from 1 (not at all agree) to 4 (completely agree). A sample item is“I can solve most problems if I invest the necessary effort.”The instrument’s Cronbach’sαwas .93 in this study.

Procedure

Participants were recruited by psychology-major undergraduates at a Spanish university who voluntarily searched for parents of children with ID using a combination of convenience sampling and snowball sampling. The students contacted the target participants, namely fathers and mothers of individuals with intellectual

disabilities, to explain the study’s objectives and provide instructions on how to access the questionnaire.

The students were provided with written instructions to ensure consistent sample collection and facilitate participants’ access to the questionnaire. Additionally, the questionnaire itself included instructions for completion, thus ensuring uniformity in the completion process across all participants (Morgan et al., 1998).

Individuals accessing the online questionnaire were first presented with information about the study aims, informed they could withdraw from the study at any time, and assured that their responses would remain anonymous and confidential. Only those who then confirmed their consent to participate were able to proceed to the questionnaire. The survey was self-administered and took approximately 20 min to complete.

The study received approval from the National University of Distance Education Ethics Committee and was performed in accordance with the ethical standards of the Declaration of Helsinki.

Data Analysis

Descriptive statistics, mean differences, and Pearson’s correlation coefficients were calculated using SPSS software. A Multivariate Analysis of Variance was used to explore potential differences in the variables of affiliate stigma, self-efficacy, perceived social support, dyadic satisfaction, and familial satisfaction between fathers and mothers, as well as based on the types of disability in children.

The data were screened to check multivariate normality using Mardia’s (1970)measure of multivariate kurtosis. Path analysis with maximum likelihood estimation was used to test the proposed mediating model in AMOS 24. The required sample size in structural equation modeling depends primarily not only on model complexity but also on several other factors, such as missingness patterns and data normality. The most common recommendation is for a sample size of at least 10 cases per estimated parameter (see Kline, 2011, for an overview). Our model estimates 13 parameters, so the sample size of 197 participants exceeds the minimum recommendation.

Several indices were used to assess modelfit (Kline, 2011). The overallfit of the model to the data was examined using a chi-square test. A nonsignificant chi-square indicates that the modelfits the data well. However, because the chi-square statistic is influenced by sample size (Marsh et al., 1988), supplementaryfit indices were assessed: comparative fit index (CFI: >.90 acceptable, >.95 desirable), normedfit index (NFI:>.90 acceptable,>.95 desirable), standard root-mean-square residual (SRMR:<.08 acceptable,<.05 good), and root-mean-square error of approximation (RMSEA:

<.08 acceptable,<.06 good).

A bias-corrected bootstrapping procedure was used to assess the mediation effects, with 10,000 resamples generated from the original data set. If the interval between the lower and upper bounds does not include zero, the effect is considered statistically signiﬁcant atp<.05 (Shrout & Bolger, 2002). The direct effect was analyzed before and after introducing each mediator variable to determine whether that variable eliminates the direct path or reduces it signiﬁcantly (requirement for mediation).

The data that support theﬁndings of this study are available from the corresponding author upon reasonable request.

Table 1

Participants’Sociodemographic Characteristics

Characteristic Mothersn(%) Fathersn(%)

136 (69.0) 61 (31.0)

Age

26–35 15 (11.5) 3 (5.0)

36–45 59 (45.0) 25 (41.7)

46–55 47 (35.9) 20 (33.3)

≥56 10 (7.6) 12 (20.0)

Education level

Primary school 19 (13.9) 11 (18.0)

Secondary school 62 (45.6) 32 (52.5)

University grade 55 (40.4) 18 (29.5)

Employment

Employed 89 (65.4) 51 (83.6)

Unemployed 44 (32.4) 5 (8.2)

Retired 3 (2.2) 5 (8.2)

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Results

The scores on variables affiliate stigma, self-efficacy, perceived social support, and dyadic satisfaction did not significantly differ between fathers and mothers. However, familial satisfaction was significantly higher in men than in women (F=9.14,p=.003,η²= .062), consistent with earlier findings in the literature (see, e.g., Agus et al., 2021).

We also tested for differences in thefive study variables between children with different types of disability. No differences were significant (all ps > .05) except for affiliate stigma: parents of children with ASD with ID had higher affiliate stigma than parents of children with Down’s syndrome (F=6.57,p=.011,η²=.045).

This is also consistent with previous research (Meleady et al., 2020).

AsTable 2reports, bivariate Pearson correlation analysis showed that all the variables were significantly correlated. More specifically, affiliate stigma was highly negatively correlated with the other four variables, while self-efficacy and social support were significantly positively associated with both dyadic and familial satisfaction.

The model closelyﬁtted the data:χ²=3.22;p=.20; CFI=0.997;

NFI=0.980; SRMR=0.023; RMSEA=0.056. The results of the tested model are presented inFigure 2.

As Figure 2shows, afﬁliate stigma was negatively related to self-efﬁcacy (β = –.16, p = .023), which was itself positively

related to familial satisfaction (β = .21, p = .003) but not signiﬁcantly related to dyadic satisfaction (β=0.13, p=.051).

Afﬁliate stigma was also negatively related to social support (β= –.55,p=.000), which was itself positively related to both dyadic satisfaction (β=.57,p=.000) and familial satisfaction (β=.43, p=.000).

Before conducting mediation analyses using the bias-corrected bootstrapping method, we checked the mediation requirements.

In the absence of a relationship between self-efficacy and dyadic satisfaction, there could be no mediating effect of self-efficacy between affiliate stigma and dyadic satisfaction. There were three mediating effects on the relationship between affiliate stigma and relationship satisfaction (dyadic and familial). First, we found a significant indirect effect of affiliate stigma on familial satisfaction via self-efficacy (β=–.21,p<.001; 95% CI [–.29,–.12]). Second, affiliate stigma indirectly affected dyadic satisfaction via social support (β=–.35,p.001; 95% CI [–.45,–.26]). Third, we also found an indirect effect of affiliate stigma on familial satisfaction via social support (β=–.31,p<.001; 95% CI [–.40,–.21]). In addition, social support was found to mediate the relationship between affiliate stigma and self-efficacy (β=–.32,p<.001; 95%

CI [–.41, –.23]). The results of the mediation analyses are presented inTable 3.

Table 2

Descriptive Statistics and Pearson Correlation Coefﬁcients for the Variables in the Study

Variable M SD 1 2 3 4 5

1. Afﬁliate stigma 1.46 .37 — –.43** –.55** –.41** –.41**

2. Self-efﬁcacy 2.77 .60 — .58** .46** .46**

3. Social support 2.84 .61 — .65** .56**

4. Dyadic relationship satisfaction 3.05 .76 — .81**

5. Familial relationship satisfaction 3.01 .79 —

Note. Scores range from 1 to 4.

**p<.01.

Figure 2

Standardized Path Coefﬁcients Among Variables

*p<.05. **p<.01. ***p<.001.

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Discussion

The main objective of this research was to analyze the association between affiliate stigma in parents of children with ID and their marital satisfaction with reference to the double ABCX family adaptation model (McCubbin & Patterson, 1983). The theoretical model hypothesized the association between affiliate stigma as a family stressor and marital satisfaction as an adaptation outcome, considering the mediational role of two relevant variables: perceived social support and self-efficacy.

As predicted, our results show that affiliate stigma has direct negative associations with both measures of relationship satisfaction, dyadic and familial. Previous research has shown that caregivers who experience higher levels of stigma are more likely to have symptoms of anxiety or depression as well as negative emotional reactions, including sadness, embarrassment, shame, and guilt (Mitter et al., 2019). However, to the best of our knowledge, the association between parents’affiliate stigma and the quality of their marital relationship has not been investigated previously. Although more research is needed, it is not unreasonable to assume, as we have found in this study, that the psychological distress associated with affiliate stigma (Mak & Cheung, 2008,2012;Mitter et al., 2019;

Recio et al., 2021;Shi et al., 2019;Werner & Shulman, 2015) can negatively affect relationship satisfaction.

The results also show that affiliate stigma is negatively associated with both social support and self-efficacy. In the case of social support, previous research has reported similar results (Cantwell et al., 2015; Werner & Shulman, 2013), but the association between affiliate stigma and self-efficacy does not appear to have been investigated before. There is, however, earlier research showing a negative association between a similar variable (self-esteem) and affiliate stigma (Mitter et al., 2019). Our results also reveal a positive association between self-efficacy and familial satisfaction. This result is in agreement with existing literature.

Luszczynska et al. (2005) found that general self-efficacy was positively correlated with a number of behavior-specific self- efficacy elements and with several aspects of well-being.

Relatedly,Weiser and Weigel (2016)reported that self-efﬁcacy in romantic relationships was positively associated with relationship satisfaction. Regarding social support, prior studies have demonstrated its important effects on the quality of life and well- being of parents of children with ID (Ma & Mak, 2016;Schilling

et al., 1984); moreover, the systematic review bySim et al. (2016) shows that social support is an important coping resource to improve the relationship satisfaction in parents of child with ASD.

In our study, social support had a stronger impact than self- efficacy on both types of relationship satisfaction (dyadic and familial). It is also noteworthy that self-efficacy and social support were highly related in our model, consistent with previousfindings in studies of other social groups (Cheung & Sun, 2000;Major et al., 1990). However, more research is needed into what factors influence relationship satisfaction in parents of children with ID.

This study contributes to the literature in several aspects. It adds to the literature that reaffirms the usefulness of the double ABCX model for the study of family adaptation in stressful situations. The double ABCX model has proven useful in analyzing the role of affiliate stigma as a potential stressor in families with children with ID. The multidimensional perspective of the double ABCX model allows for a better understanding not just of the predictive capacity of selected variables but also the interrelationships among them. Thesefindings contribute to a greater understanding of the underlying psychological mechanisms behind the impact of affiliate stigma on families with children with ID. On the other hand, to the best of our knowledge, the stressor (affiliate stigma) and the dependent variable (parents’ relationship satisfaction) have not been analyzed previously using this model. Finally, the model considers social support and self-efficacy as variables that may explain (or prevent) the negative impact of parents’affiliate stigma on marital satisfaction.

Marital relationship quality is an important predictor of the health and functioning of families with children with ID (Abbot & Meredith, 1986). Moreover, for parents coping with the challenges of caring for these children, when marital satisfaction is high, spouses will likely be a key support for one another (García-Lo´pez, Sarriá, Pozo, & Recio, 2016; Hartley, Seltzer, et al., 2011). Our findings may guide practitioners and social services on how to enhance protective factors and mitigate risk factors. It seems important to reduce family stressors, especially the affiliate stigma perceived by parents, and to increase self-efficacy and social support provided to families.

Health professionals and services should contemplate the development and implementation of tailored programs aimed at reducing afﬁliate stigma among parents of children with ID.

Encouraging outcomes from other experiences, such as the SOLACE program for parents of children with ASD (Lodder et al., 2020), are promising. The SOLACE program is a ThisdocumentiscopyrightedbytheAmericanPsychologicalAssociationoroneofitsalliedpublishers. Thisarticleisintendedsolelyforthepersonaluseoftheindividualuserandisnottobedisseminatedbroadly.

Table 3

Results of Mediational Analysis Mediational

analyses

Directβwithout mediator

Directβwith

mediator Standard indirectβ Standard

error Mediation type

AS→SE→FS −.41*** −.07 −.20***

[−.29;−.12]

.04 Full mediation

AS→SS→DS −.41*** .03 −.35***

[−.45;−.26]

.05 Full mediation

AS→SS→FS −.41*** −.16* −.31***

[−.40;−.21]

.05 Partial mediation

AS→SS→SE −.43*** −.09 −.32***

[−.41;−.23]

.05 Full mediation

Note. AS = affiliate stigma; SE =self-efficacy; FS= familial relationship satisfaction; SS= social support; DS=dyadic relationship satisfaction. Bold formatting indicates statistically significant values.

*p<.05. ***p<.001.

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multicomponent intervention that employs psychoeducation, cog- nitive restructuring strategies, and compassion-focused techniques.

It encompasses a range of techniques, such as lectures, group discussions, guided activities, and sharing of experiences. This program was effective in reducing stigma and improving mental health indicators among parents with children with ASD (Lodder et al., 2020). Thus, adapting this or similar programs for addressing afﬁliate stigma among parents of children with ID could be a valuable resource to consider within health support interventions.

Likewise, professionals should consider the messages they convey to parents and the public. These messages have the potential to shape how parents perceive and process their child’s condition (Bagatell, 2007). The language used by professionals can inﬂuence how parents integrate their child’s condition into their thoughts and emotions. It is important for professionals to reﬂect carefully on their communication to ensure that they are providing accurate and supportive information that promotes positive attitudes and understanding.

Professionals working with families should also assist in identifying the needs of these parents and connecting them with appropriate sources of support. The responsibility of locating and obtaining formal support should not fall solely on parents (Weiss, 2002). Providing families with information about their rights and access to social services can be crucial to mitigating stress.

Additionally, families often report that informal support, such as that provided by extended family, friends, neighbors, and other parents facing similar challenges, is the most critical source of support (Lounds, 2004). Therefore, professionals should encourage parents to seek and accept help from their social network and provide them with information about parent associations. Engaging in group activities offered by the associations may promote a sense of community and increase the perception of social support, thereby serving as a protective factor against the negative effects of stigma.

Moreover, from a psychological perspective, increasing parents’ self-efficacy may contribute to the familial balance, enhancing marital satisfaction. Parental self-efficacy can be a key target for prevention and intervention programs, as it encompasses dynamic cognition, emotions, and behaviors that can be improved through training. Evidence supports the effectiveness of training programs aimed at increasing parental self-efficacy (Sofronoff & Farbotko, 2002). Indeed, using measures of parental self-efficacy could be a useful tool for clinicians to assess family strengths and weaknesses.

This study has some methodological limitations that need to be considered when interpreting its results. The sample used in this research consisted of voluntary parents who were motivated to participate in the study. Although participation in the study only requires 20 min of dedication, we cannot determine if there were any relationships between certain variables included in the study, such as the intensity of the experience of affiliate stigma or the level of self- efficacy, and the participants’motivation to participate. Therefore, we should be careful when generalizing these results. Moreover, self-report measures can introduce bias that may influence the results. Despite these limitations, the strength of path analysis lies in its ability to allow simultaneous examination of structural relationships between direct and indirect paths (e.g.,Schumacker &

Lomax, 2004). Another limitation is that we only recruited one parent in each family unit. For two members of a couple, each individual’s outcomes cannot be assumed independently and are likely a function of both their own characteristics (actor effects) and

their partner’s characteristics (partner effects). Collecting the perceptions of both parents in a family unit would have allowed for the study of actor and partner effects with a dyadic analysis (García-Lo´pez et al., 2021). Future research should investigate larger samples of couples parenting children with ID in order to study these effects. Finally, our model may omit other potential mediators of the relationship between afﬁliate stigma and relationship satisfaction, such as parents’self-esteem or subjective burden. Future research should also consider certain sociodemographic variables, such as socioeconomic status, educational level, age of children with disabilities, or some disability characteristics, such as severity or duration. Moreover, the validity of our results should be tested by expanding the target group from parents of children with ID to parents of children with other kinds of disabilities, such as physical disabilities or ASD without ID.

Despite these limitations, this study contributes to the literature by demonstrating the important impact of affiliate stigma on the marital satisfaction of parents of children with ID. Ourfindings also show that there are external (social support) and internal (self-efficacy) resources that may contribute to preventing the effect of affiliate stigma on marital quality.

References

Abbot, D. A., & Meredith, W. H. (1986). Strengths of parents with retarded children. Family Relations, 35(3), 371–375. https://doi.org/10.2307/

584363

Agus, M., Puddu, L., & Raffagnino, R. (2021). Exploring the similarity of partners’love styles and their relationships with marital satisfaction: A dyadic approach.Sage Open,11(4).https://doi.org/10.1177/215824402 11040785

Ali, A., Hassiotis, A., Strydom, A., & King, M. (2012). Self stigma in people with intellectual disabilities and courtesy stigma in family carers: A systematic review.Research in Developmental Disabilities,33(6), 2122– 2140.https://doi.org/10.1016/j.ridd.2012.06.013

Baessler, J., & Schwarzer, R. (1996). Evaluacio´n de la autoeﬁcacia:

Adaptacioń española de la escala de Autoeficacia General [Measuring self- efficacy: Spanish adaptation of the general self-efficacy scale].Ansiedad y Estrés,2, 1–8.https://psycnet.apa.org/record/1999-00958-001 Bagatell, N. (2007). Orchestrating voices: Autism, identity and the power of

discourse.Disability & Society,22(4), 413–426.https://doi.org/10.1080/

09687590701337967

Bandura, A. (1997).Self-efﬁcacy: The exercise of control. W.H. Freeman.

Banga, G., & Ghosh, S. (2017). The impact of afﬁliate stigma on the psychological well-being of mothers of children with speciﬁc learning disabilities in India: The mediating role of subjective burden.Journal of Applied Research in Intellectual Disabilities, 30(5), 958–969. https://

doi.org/10.1111/jar.12311

Beals, K. P., Peplau, L. A., & Gable, S. L. (2009). Stigma management and well-being: The role of perceived social support, emotional processing, and suppression.Personality and Social Psychology Bulletin,35(7), 867– 879.https://doi.org/10.1177/0146167209334783

Bello´n, J. A., Delgado, A., Luna del Castillo, J. D., & Lardelli, P. (1996).

Validity and reliability of the Duke-UNC-11 questionnaire of functional social support.Atencion Primaria,18(4), 153–156.https://Pubmed.ncbi .nlm.nih.gov/8962994/

Bos, A. E. R., Pryor, J. B., Reeder, G. D., & Stutterheim, S. E. (2013).

Stigma: Advances in theory and research. Basic and Applied Social Psychology,35(1), 1–9.https://doi.org/10.1080/01973533.2012.746147 Bristol, M. M. (1987). Mothers of children with autism or communication

disorders: Successful adaptation and the double ABCX model.Journal of ThisdocumentiscopyrightedbytheAmericanPsychologicalAssociationoroneofitsalliedpublishers. Thisarticleisintendedsolelyforthepersonaluseoftheindividualuserandisnottobedisseminatedbroadly.

(9)

Autism and Developmental Disorders,17(4), 469–486.https://doi.org/10 .1007/BF01486964

Broadhead, W. E., Gehlbach, S. H., deGruy, F. V., & Kaplan, B. H. (1989).

Functional versus structural social support and health care utilization in a family medicine outpatient practice. Medical Care, 27(3), 221–233.

https://doi.org/10.1097/00005650-198903000-00001

Brobst, J. B., Clopton, J. R., & Hendrick, S. S. (2009). Parenting children with autism spectrum disorders: The couple’s relationship. Focus on Autism and Other Developmental Disabilities, 24(1), 38–49. https://

doi.org/10.1177/1088357608323699

Burr, W. R. (1973). Theory construction and the sociology of the family. Wiley.

Cantwell, J., Muldoon, O., & Gallagher, S. (2015). The inﬂuence of self- esteem and social support on the relationship between stigma and depressive symptomology in parents caring for children with intellectual disabilities.Journal of Intellectual Disability Research,59(10), 948–957.

https://doi.org/10.1111/jir.12205

Cheung, S. K., & Sun, S. Y. K. (2000). Effects of self-efﬁcacy and social support on the mental health conditions of mutual-aid organization members. Social Behavior and Personality, 28(5), 413–422. https://

doi.org/10.2224/sbp.2000.28.5.413

Chiu, M. Y., Yang, X., Wong, F. H. T., Li, J. H., & Li, J. (2013). Caregiving of children with intellectual disabilities in China: An examination of afﬁliate stigma and the cultural thesis.Journal of Intellectual Disability Research,57(12), 1117–1129.https://doi.org/10.1111/j.1365-2788.2012 .01624.x

Denton, F. N., Rostosky, S. S., & Danner, F. (2014). Stigma-related stressors, coping self-efﬁcacy, and physical health in lesbian, gay, and bisexual individuals.Journal of Counseling Psychology,61(3), 383–391.https://

doi.org/10.1037/a0036707

Dunst, C. J., Trivette, C. M., & Cross, A. H. (1986). Mediating inﬂuences of social support: Personal, family, and child outcomes.American Journal of Mental Deﬁciency,90(4), 403–417.

Essex, E. L. (2002). Mothers and fathers of adults with mental retardation:

Feelings of intergenerational closeness.Family Relations,51(2), 156–165.

https://doi.org/10.1111/j.1741-3729.2002.00156.x

Friedrich, W. M. (1979). Predictors of coping behavior of mothers of handicapped children.Journal of Consulting and Clinical Psychology, 47(6), 1140–1141.https://doi.org/10.1037/0022-006X.47.6.1140 García-Lo´pez, C., Pozo, P., & Sarriá, E. (2020). Role of Relationship

satisfaction in parental coping. In F. R. Volkmar (Ed.),Encyclopedia of autism spectrum disorders(pp. 1–6). Springer.https://doi.org/10.1007/

978-1-4614-6435-8_102395-1

García-Lo´pez, C., Recio, P., Pozo, P., & Sarriá, E. (2021). Psychological distress, disorder severity, and perception of positive contributions in couples raising individuals with autism.Frontiers in Psychology, 12, Article 694064.https://doi.org/10.3389/fpsyg.2021.694064

García-Lo´pez, C., Sarriá, E., & Pozo, P. (2016). Parental self-efﬁcacy and positive contributions regarding autism spectrum condition: An actor- partner interdependence model.Journal of Autism and Developmental Disorders,46(7), 2385–2398.https://doi.org/10.1007/s10803-016-2771-z García-Lo´pez, C., Sarriá, E., Pozo, P., & Recio, P. (2016). Supportive dyadic coping order: The role of relationship satisfaction.Journal of Autism and Developmental Disorders, 46(11), 3434–3447. https://doi.org/10.1007/

s10803-016-2883-5

Goffman, E. (1963).Stigma: Notes on the management of spoiled identity.

Prentice Hall.

Greenlee, J. L., Piro-Gambetti, B., Putney, J., Papp, L. M., & Hartley, S. L.

(2022). Marital satisfaction, parenting styles, and child outcomes in families of autistic children.Family Process, 61(2), 941–961.https://

doi.org/10.1111/famp.12708

Halstead, E. J., Grifﬁth, G. M., & Hastings, R. P. (2018). Social support, coping, and positive perceptions as potential protective factors for the well-being of mothers of children with intellectual and developmental

disabilities.International Journal of Developmental Disabilities,64(4–5), 288–296.https://doi.org/10.1080/20473869.2017.1329192

Hartley, S. L., Barker, E. T., Seltzer, M. M., Floyd, F., Greenberg, J., Orsmond, G., & Bolt, D. (2010). The relative risk and timing of divorce in families of children with an autism spectrum disorder.Journal of Family Psychology,24(4), 449–457.https://doi.org/10.1037/a0019847 Hartley, S. L., Barker, E. T., Seltzer, M. M., Greenberg, J. S., & Floyd, F. J.

(2011). Marital satisfaction and parenting experiences of mothers and fathers of adolescents and adults with autism. American Journal on Intellectual and Developmental Disabilities, 116(1), 81–95. https://

doi.org/10.1352/1944-7558-116.1.81

Hartley, S. L., Seltzer, M. M., Barker, E. T., & Greenberg, J. S. (2011).

Marital quality and families of children with developmental disabilities.

International Review of Research in Developmental Disabilities,41, 1–29.

https://doi.org/10.1016/B978-0-12-386495-6.00001-1

Hayes, S. A., & Watson, S. L. (2013). The impact of parenting stress: A meta- analysis of studies comparing the experience of parenting stress in parents of children with and without autism spectrum disorder.Journal of Autism and Developmental Disorders,43(3), 629–642.https://doi.org/10.1007/

s10803-012-1604-y

Higgins, L., Mannion, A., Chen, J. L., & Leader, G. (2023). Adaptation of parents raising a child with ASD: The role of positive perceptions, coping, self-efﬁcacy, and social support. Journal of Autism and Developmental Disorders,53(3), 1224–1242. https://doi.org/10.1007/

s10803-022-05537-8

Hill, R. L. (1958). Generic features of families under stress.Social Casework, 39(2–3), 139–150.https://doi.org/10.1177/1044389458039002-318 Jahn, D. R., Leith, J., Muralidharan, A., Brown, C. H., Drapalski, A. L.,

Hack, S., & Lucksted, A. (2020). The inﬂuence of experiences of stigma on recovery: Mediating roles of internalized stigma, self-esteem, and self- efﬁcacy. Psychiatric Rehabilitation Journal, 43(2), 97–105. https://

doi.org/10.1037/prj0000377

Jones, E. E., Farina, A., Hastorf, A. H., Markus, H., Miller, D. T., & Scott, R. A. (1984).Social stigma: The psychology of marked relationships. W.

H. Freeman.

Kline, R. B. (2011).Principles and practice of structural equation modeling.

Guilford Press.

Kwok, S. Y. C. L., Leung, C. L. K., & Wong, D. F. K. (2014). Marital satisfaction of Chinese mothers of children with autism and intellectual disabilities in Hong Kong.Journal of Intellectual Disability Research, 58(12), 1156–1171.https://doi.org/10.1111/jir.12116

Lavee, Y., McCubbin, H. I., & Patterson, J. M. (1985). The double ABCX model of family stress and adaptation: An empirical test by analysis of structural equations with latent variables.Journal of Marriage and Family, 47(4), 811–825.https://doi.org/10.2307/352326

Li, X., Lam, C. B., Chung, K. K. H., & Leung, C. (2019). Linking parents’ self-stigma to the adjustment of children with disabilities. American Journal of Orthopsychiatry, 89(2), 212–221. https://doi.org/10.1037/

ort0000386

Lodder, A., Papadopoulos, C., & Randhawa, G. (2020). SOLACE: A psychosocial stigma protection intervention to improve the mental health of parents of autistic children-a feasibility randomised controlled trial.

Journal of Autism and Developmental Disorders,50(12), 4477–4491.

https://doi.org/10.1007/s10803-020-04498-0

Lounds, J. (2004). Family stress and coping. In T. L. Whitman (Ed.),The development of autism: A self-regulatory perspective (pp. 233–278).

Jessica Kingsley Publishers.

Lovell, B., & Wetherell, M. A. (2018). Caregivers’characteristics and family constellation variables as predictors of afﬁliate stigma in caregivers of children with ASD.Psychiatry Research,270, 426–429.https://doi.org/10 .1016/j.psychres.2018.09.055

Luszczynska, A., Scholz, U., & Schwarzer, R. (2005). The general self-efﬁcacy scale: Multicultural validation studies.The Journal of Psychology,139(5), 439–457.https://doi.org/10.3200/JRLP.139.5.439-457