1. Background
Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by persistent deficiencies in social communication, behavioral patterns, and repetitive and limited interests or activities (1). The global prevalence of autism has increased significantly in recent years (2, 3). A comprehensive review estimated a global prevalence of 17 per 10,000 carriers (2). While the main symptom of autism is social failure (4), some researchers believe that failure in executive functions constitutes the main disorder of those who suffer from autism (5, 6). Executive functions are a set of processes that enable individuals to consciously control their behavior and thoughts with respect to their future goals (7). As crucial nerve structures, these functions are generally referred to as the high psychological processes involved in controlling and regulating the cognition, thinking, goal-oriented behavior, and anticipation functions (8, 9). Executive functions include impulse control, self-regulation, initiation, working memory, mental flexibility, ability to deal with new things, social thinking, sustained attention, etc. (10, 11).
Emotion regulation (ER) is a construct that may provide explanatory power for understanding the observed emotional and behavioral problems in ASD (12). Impaired ER has been associated with several disorders, including anxiety, mood disorders, borderline personality disorder, and ASD (13, 14). ER is conceptualized as an executive function that plays a role in regulating and inhibiting behaviors. While this executive function has a neurobiological basis, parents play a central role in the development of ER via soothing, organizing, and refocusing. Indeed, they enhance the development of more independent regulatory strategies in typically developing children (15).
Previous findings suggested that adolescents who rely on reappraisal may have more cognitive resources to help them remain attentive and well-regulated in their daily lives. On the other hand, if better executive functions facilitate the use of reappraisal, adolescents’ ability to regulate their emotions could potentially be enhanced via supports for executive functions (16). Parenting is a cognitive, emotional, and behavioral endeavor; Shaffer and Obradovic (17) reported that direct assessment of parent inhibitory control was positively associated with sensitive/responsive behaviors, whereas parent self-reported difficulties in using emotion regulation strategies were associated with lower levels of positive and collaborative dyadic behaviors. In addition, Hinnant et al. (18) indicated that children from more co-operative dyads, who possessed higher executive function skills, had higher moral reasoning scores than other children. Besides, they reported that children lower in both emotion regulation and executive function had lower moral reasoning scores than other children (18).
Many children with autism suffer from impaired executive function (19, 20). Measuring the executive functioning in parents of children with autism is a way to indicate aspects of executive functions, which may play an important role in the development of this disorder (21). Bolte and Poustka (22) investigated and compared executive functioning in parents of children with autism and schizophrenia and mental retardation and parents of healthy children. They found no statistically significant differences in the executive functioning between parents of children with autism and other parents (22). Another study, which compared the executive functioning of parents and siblings of autistic children and those with normal children, mentioned some weaknesses in some executive functioning abilities (e.g., planning) in parents and siblings of autistic children (23). Also, Moazzen et al. (21) investigated executive functioning of first-degree relatives of autistic patients and reported difficulties in inhibition and cognitive flexibility functions.
2. Objectives
Accordingly, the current study aimed to compare the executive functioning in mothers of children with and without autism.
3. Methods
The current descriptive and case-control study is approved by the ethical committee of Zahedan University of Medical Sciences. Informed written consent was obtained from all participants (code no.: 7889). The study population included all parents with autistic children referred to welfare rehabilitation centers of Zahedan, South East of Iran, in 2017 (March to September). The study sample consisted of 60 mothers who were selected by convenience sampling technique (30 mothers with autistic children and 30 mothers without autistic children). Those with a history of psychiatric disorders, head injury, or brain tumor were excluded from the study. Furthermore, participants were matched in terms of age, education, and culture of mothers, the order of birth, gender, and age of children. Demographic characteristics of mothers of children with and without autism are presented in Table 1.
Table 1.Demographic Characteristics of Mothers of Children with and Without Autism
| Variable | No. (%) |
|---|---|
| Age, y | |
| Mothers | |
| 25 - 30 | 28 (46) |
| 31 - 35 | 16 (26) |
| 36 - 40 | 4 (6) |
| 41 - 45 | 8 (13) |
| 46 - 50 | 4 (6) |
| Children | |
| 2 - 5 | 24 (40) |
| 6 - 10 | 32 (53) |
| 11 - 15 | 4 (6) |
| Education | |
| Below high school diploma | 2 (3) |
| High school diploma | 4 (6) |
| Undergraduate | 44 (73) |
| Graduate | 10 (16) |
| Birth order of children | |
| First-born | 32 (53) |
| Second-born | 20 (33) |
| Third-born | 8 (13) |
| Child’s gender | |
| Boy | 48 (80) |
| Girl | 12 (20) |
3.1. Instruments
3.1.1. Wechsler Adult Intelligence Scale (WAIS-IV)
This test includes some subscales such as digit span, block design, and picture arrangement, which are explained below.
3.1.1.1. Digit Span
In this test, participants hear a series of numbers, which starts from three-digit numbers and ends with nine-digit numbers and should repeat them. Two-digit sequences with different numbers are given to the participants. The total score is equal to the number of correct repetitions. The test ends after one mistake. The other form of this test involves repeating the list of numbers in reverse order (24). In the present study, this test was used to measure working memory.
3.1.1.2. Block Design
This test features 9 colored cubes (white, red, and red-white). The participant must arrange the cubes at the specified time as required by Wechsler test. The sooner s/he makes the related arrangements, the greater will be the performance. This test is used to measure organization and problem-solving items (25).
3.1.1.3. Picture Arrangement
It contains 8 components arranged as a series of illustrated cards that tell a story when put in a certain order. The picture arrangement test intends to examine the social relationships (26).
These three tests are the subscale of the Revised Wechsler Adult Intelligence scale. The validity of these three subscales is reported between 0.76 and 0.97 (27).
3.2. Cognitive Emotion Regulation Questionnaire (CERQ)
This 36-item questionnaire intends to measure the subscale of cognitive-emotional regulation: self-blame, other-blame, rumination, catastrophizing, putting into perspective, positive refocusing, positive reappraisal, acceptance, and refocus on planning. In other words, it is designed to evaluate the cognitive strategies that each person uses after experiencing threatening events or life stresses (28). In Iran, reported Cronbach’s alpha coefficient for the subscales of this questionnaire range from 0.76 to 0.92; and the values reported for Kendal’s coefficient range from 0.81 to 0.92 (29).
The scoring method according to the Likert scale was as follows: never (1), rarely (2), sometimes (3), often (4), and always (5). The minimum score was 36, and the maximum score was 180. Based on the calculated scores, the cognitive emotion regulation rate was poor, medium, and strong (36 - 72, 72 - 108, and > 108, respectively).
3.3. Cognitive Flexibility Inventory (CFI) (Denis and Vander Wal)
The CFI contains two subscales and intends to measure cognitive flexibility. The alternatives and control subscale measures three aspects of cognitive flexibility: (A) the tendency to perceive difficult situations as controllable; (B) the ability to perceive multiple alternative explanations for life occurrences and human behavior; and (C) the ability to generate multiple alternative solutions to difficult situations. Each item is scored on a seven-point Likert scale (1 = strong disagree, 2 = disagree, 3 = slightly disagree, 4 = no idea, 5 = agree a bit, 6 = agree, and 7 = strong agree). The total score ranges from 20 to 140. The concurrent validity of the CFI was -0.39 as obtained by Beck Depression Inventory-II (BDI-II), and its convergent validity was 0.75 using the Cognitive Flexibility scale (CFS) proposed by Martin and Rubin (30). In Iran, Cronbach’s alpha coefficient for the subscales and the whole questionnaire are reported at 0.90 and 0.71, respectively (27).
3.4. Data Collection
The participants were tested individually in a quiet room. Each day two participants were examined. First, the respondents answered CFI and CERQ. Then, the respondents had a break for 5 to 15 minutes. After the break, the Wechsler subscales, including block design, digit span test, and picture arrangement, were administered.
3.5. Statistical Analysis
Analysis of variance (ANOVA) test was used to perform intra-group and intergroup comparisons of executive functions. Data were analyzed using SPSS version 16. Statistical significance was considered when P-value < 0.05.
4. Results
Mean executive functioning scores (organization, problem-solving, cognitive flexibility, emotional adjustment, working memory, and Social relations) of mothers of children with and without autism are shown in Table 2. The results showed no significant difference between the executive functioning scores of parents of children with and without autism, as shown in Table 3 (P > 0.05). However, the evaluation of the organization and problem-solving components between the two groups showed marginally insignificant differences (P = 0.083). A significant difference was found in one of the factors of emotional regulation (i.e. other-blame), in which parents without autistic children had a higher score (P = 0.048).
Table 2.Mean and Standard Deviation of Cognitive Emotion Regulation Variables for Both Groups (Mothers with Autistic Children (Case Group) and Mothers Without Autistic Children (Control Group))
| Cognitive Emotion Regulation Variables | Mean± SD |
|---|---|
| Organization | |
| Case | 23.37 ± 7.867 |
| Control | 26.80 ± 7.203 |
| Problem-solving | |
| Case | 23.37 ± 7.867 |
| Control | 26.80 ± 7.203 |
| Cognitive flexibility | |
| Case | 90.60 ± 14.642 |
| Control | 93.73 ± 11.659 |
| Positive emotional regulation | |
| Case | 46.37 ± 10.193 |
| Control | 47.30 ± 8.603 |
| Negative emotional regulation | |
| Case | 61.63 ± 12.732 |
| Control | 63.13 ± 11.181 |
| Working memory | |
| Case | 14.17 ± 3.705 |
| Control | 15.63 ± 3.605 |
| Social relations | |
| Case | 12.77 ± 4.546 |
| Control | 13.40 ± 5.117 |
Table 3.Results of ANOVA for Cognitive Emotion Regulation Variables Between Groups, Intergroup, and Total Participants
| Cognitive Emotion Regulation Variables | SS | df | MS | F | Sig |
|---|---|---|---|---|---|
| Organization | 3.108 | 0.083 | |||
| Between groups | 176.817 | 1 | 176.817 | ||
| Intergroup | 3299.767 | 58 | 56.893 | ||
| Total | 3476.583 | 59 | |||
| Problem-solving | 3.108 | 0.083 | |||
| Between groups | 176.817 | 1 | 176.817 | ||
| Intergroup | 3299.767 | 58 | 56.893 | ||
| Total | 3476.583 | 59 | |||
| Cognitive flexibility | 0.841 | 0.363 | |||
| Between groups | 147.267 | 1 | 147.267 | ||
| Intragroup | 10159.067 | 58 | 175.156 | ||
| Total | 10306.333 | 59 | |||
| Working memory | 2.414 | 0.126 | |||
| Between groups | 32.267 | 1 | 32.267 | ||
| Intragroup | 775.133 | 58 | 13.364 | ||
| Total | 807.400 | 59 | |||
| Social relations | 0.257 | 0.614 | |||
| Between groups | 6.017 | 1 | 6.017 | ||
| Intragroup | 1358.567 | 58 | 23.424 | ||
| Total | 1364.583 | 59 | |||
| Positive emotional regulation | 0.147 | 0.703 | |||
| Between groups | 13.067 | 1 | 13.067 | ||
| Intragroup | 5159.267 | 58 | 88.953 | ||
| Total | 5172.333 | 59 | |||
| Negative emotional regulation | 0.235 | 0.630 | |||
| Between groups | 33.750 | 1 | 33.750 | ||
| Intragroup | 8326.433 | 58 | 143.559 | ||
| Total | 8360.183 | 59 | |||
| Self-blame | 0.432 | 0.514 | |||
| Between groups | 6.017 | 1 | 6.017 | ||
| Intragroup | 807.633 | 58 | |||
| Total | 813.650 | 59 | 13.925 | ||
| Acceptance | 0.156 | 0.695 | |||
| Between groups | 1.667 | 1 | 1.667 | ||
| Intragroup | 620.733 | 58 | 10.702 | ||
| Total | 622.400 | 59 | |||
| Rumination | 0.184 | 0.669 | |||
| Between groups | 2.017 | 1 | 2.017 | ||
| Intragroup | 634.567 | 58 | 10.941 | ||
| Total | 636.583 | 59 | |||
| Positive refocus | 0.931 | 0.339 | |||
| Between groups | 11.267 | 1 | 11.267 | ||
| Intragroup | 701.667 | 58 | 12.98 | ||
| Total | 712.933 | 59 | |||
| Planning refocus | 0.005 | 0.947 | |||
| Between groups | .67 | 1 | 0.67 | ||
| Intragroup | 857.867 | 58 | |||
| Total | 857.933 | 59 | 14.791 | ||
| Positive reappraisal | 0.641 | 0.427 | |||
| Between groups | 9.600 | 1 | 9.600 | ||
| Intragroup | 868.733 | 58 | |||
| Total | 878.333 | 59 | 14.978 | ||
| Putting into perspective | 0.083 | 0.774 | |||
| Between groups | 1.067 | 1 | 1.067 | ||
| Intragroup | 744.933 | 58 | 12.844 | ||
| Total | 746.000 | 59 | |||
| Catastrophizing | 1.665 | 0.202 | |||
| Between groups | 20.417 | 1 | 20.417 | ||
| Intragroup | 711.233 | 58 | 12.263 | ||
| Total | 731.650 | 59 | |||
| Other-blame | 4.093 | 0.048 | |||
| Between groups | 64.067 | 1 | 64.07 | ||
| Intragroup | 907.867 | 58 | 15.653 | ||
| Total | 971.933 | 59 |
5. Discussion
The purpose of this study was to compare the executive functions (e.g. organization, problem-solving, cognitive flexibility, working memory, and social relations) in parents of children with and without autism. According to the findings, there was no significant difference between mothers of children with and without autism concerning executive functions, except for other-blame.
Numerous studies reported that families with autistic disorder experience more stress than parents with typically developing children (31). It has been shown that parents with poor emotion regulation tend to perceive parenting responsibilities as more stressful than those with better emotion regulation (32). This might be particularly true for parents of children with ASD as the stress associated with parenting these children is already overwhelming. In a study on parents of children with ASD, Ekas et al. (33) reported that mothers’ and fathers’ use of emotional support from their partners could highly predict their relationship satisfaction. Cognitive emotion regulation is useful when someone is confronted with unpleasant and stressful events. It is believed that the use of cognitive emotion regulation strategies such as rumination, thought suppression, reevaluation, and problem-solving may be an important diagnostic criterion in different forms of psychopathology (34). Salimi et al. (35) conducted a study to investigate the effectiveness of group-based acceptance and commitment therapy on cognitive emotion regulation strategies in mothers of children with autism. They asked the respondents to fill the cognitive emotion regulation questionnaire both before and after the intervention. Their results showed that group-based acceptance and commitment therapy had a significant effect on positive/planning strategy refocusing, positive reappraisal, self-blaming, and blaming others, considering a situation as disastrous, reception (35).
Kim et al. (36) reported an intergenerational association concerning the risk of ASD in executive function between mothers and children. In another study, Chico et al. (37) reported a significant correlation between the executive function of mothers and their children. Moreover, according to the literature, there is a gender-specific difference in the parent‐reported executive functioning and adaptive behavior in children and young adults with ASD (38). Furthermore, some studies suggested that parents of autistic children might have a range of autism problems (39, 40).
Moazzen et al. (21) found that the relatives of patients with autism had poorer performance in terms of cognitive flexibility and inhibition than the control group. Wong et al. (23) demonstrated that the relatives of patients with autism had poorer cognitive flexibility and performance than the control group, while there was no significant difference between the two groups concerning inhibition. In the same vein, Hughes et al. (41) also investigated planning, cognitive flexibility, and working memory in the parents and siblings of patients with autism and then compared the results with the control group as well as parents and siblings of people who had other developmental disorders. They concluded that relatives of autistic people had poorer planning and cognitive flexibility as compared with the two groups; however, they mentioned no difference between the three groups concerning the spatial working memory and the capacity of working memory (41). Our results are not consistent with the mentioned findings.
This discrepancy can be attributed to the differences in the methodology adopted by each study. In the present study, Wechsler test subscales, CFI, and CERQ were used to measure executive functions, while the other studies had employed Wisconsin and Stroop tests. Also, the above-mentioned studies have been conducted on first-degree relatives of autistic patients, including parents and siblings, but this study was carried out on mothers with autistic children.
Given the considerable effects of cultural differences on many aspects of human development and personality, the findings of the present study are not an exception, so that one may explain the higher level of ‘other-blame’ in parents without autistic children by reference to such variations (42). As mentioned before, this study was performed in the city of Zahedan, whose inhabitants generally have more solid spiritual beliefs and interpret events and life experiences from a spiritual perspective. Hence, it can be speculated that people who grow in this cultural community are less likely to accuse and criticize others for various problems. Because of the extreme and unusual nature of the incident or problem in question, they are less likely to hold others responsible, instead relate it to Providence.
It is necessary to mention some limitations of this study, including the small sample size. Besides, the current study was conducted in a homogenous population of Zahedan, in which the two groups (mothers with and without autistic children) were finely matched regarding the age, education, and culture of mothers, as well as the order of birth, gender, and age of children. Moreover, we evaluated six items of executive functions in the present study, while previous studies mostly used two or three items. Against some previous studies, we replaced the Denis and Vander Wal questionnaires instead of the Wisconsin card test. Because before the implementation of the study, we carried out a Wisconsin test on a group of students (medical, nursing, environmental health students, and staff of the Zahedan University of Medical Sciences) as well as uneducated people. We found that due to the complexity of test execution, the majority of participants were reluctant to take the test. Therefore in the current study, Denis and Vander Wal questionnaires were used in order to, firstly, avoid tiredness of participants tired and, secondly, interfering with the results of the test.
This study demonstrated that the parents (mothers) of children with autism did not have any impairment in their executive functioning abilities, and it is likely that parents who do not have an autistic child might experience such impairments because parents of children with autism had once children who did not have this disorder. As we could not find any similar study to compare the executive functions addressed in the present study (e.g. as organization, problem-solving, emotional regulation, and social relations), it is recommended to perform further studies in this field.
Future studies, with a larger sample size, are needed to extend our knowledge. Also, considering both parents will provide considerable biological-psychological-cultural information for assessing variations among study participants.
