An-Najah National University Faculty of Graduate Studies MARITAL QUALITY AND ITS RELATIONSHIP TO SYMPTOMS OF PSYCHOLOGICAL DISORDERS AMONG MOTHERS OF AUTISTIC CHILDREN IN NABLUS GOVERNORATE By Lama Yousef Nasrallah Supervisors Dr. Shadi Abualkibash Dr. Filasteen Nazzal This Thesis is Submitted in Partial Fulfillment of the Requirements for the Degree of Master of Clinical Psychology, Faculty of Graduate Studies, An-Najah National University, Nablus - Palestine. 2025 ii MARITAL QUALITY AND ITS RELATIONSHIP TO SYMPTOMS OF PSYCHOLOGICAL DISORDERS AMONG MOTHERS OF AUTISTIC CHILDREN IN NABLUS GOVERNORATE By Lama Yousef Nasrallah This Thesis was defended successfully on 16/07/2025 and approved by: iii Dedication To the children with autism, whose unique perspectives and boundless potential inspire me every day, may this work, in some small way, help foster a world that embraces your individuality with understanding, compassion, and respect. To the families and caregivers who, with unwavering love and dedication, support these children on their journey, your strength and resilience are a continual source of inspiration. And to the researchers, educators, and advocates striving to build a more inclusive world, this thesis is for you, a testament to the progress we can achieve when united by a shared purpose. iv Acknowledgments I would like to express my sincere gratitude to my supervisors, Dr. Shadi Abualkibash and Dr. Filasteen Nazzal, for their continuous guidance, valuable insights, and unwavering support throughout the research process. I am also thankful to the faculty members and staff of the [Department of Clinical Psychology] at [Najah University] for their encouragement and assistance during my academic journey. Special thanks go to the mothers who participated in this study. Your openness and willingness to share your experiences made this research possible. This work is, in many ways, a reflection of your resilience and strength. I would like to extend my heartfelt thanks to my mother and father, my husband, my dear family, my precious daughter, and my colleagues at work. Your patience, encouragement, and unwavering support have been the driving force behind the completion of this thesis. v Declaration I, the undersigned, declare that I submitted the thesis entitled: MARITAL QUALITY AND ITS RELATIONSHIP TO SYMPTOMS OF PSYCHOLOGICAL DISORDERS AMONG MOTHERS OF AUTISTIC CHILDREN IN NABLUS GOVERNORATE I declare that the work provided in this thesis, unless otherwise referenced, is the researcher’s own work, and has not been submitted elsewhere for any other degree or qualification. Student's Name Lama Yousef Nasrallah Signature: Date: 16/07/2025 vi List of Contents [ Dedication ......................................................................................................... iii Acknowledgments..............................................................................................iv Declaration .......................................................................................................... v List of Contents ..................................................................................................vi List of Tables .................................................................................................. viii List of Appendices .............................................................................................ix Abstract ............................................................................................................... x Chapter One: Introduction and Theoretical Background ..................................... 1 1.1 Introduction ................................................................................................... 1 1.2 Literature Review .......................................................................................... 8 1.2.1 Psychological Disorder ............................................................................ 10 1.2.2 Multiple Causes of Mental Disorder ........................................................ 11 1.2.3 Depression ............................................................................................... 13 1.2.4 Anxiety .................................................................................................... 15 1.2.5 Stress ........................................................................................................ 17 1.2.6 Autism Spectrum Disorder ....................................................................... 21 1.3 Study Terms ................................................................................................ 24 1.4 Problem statement and study question ........................................................ 26 1.5 Objectives of the study ................................................................................ 28 Chapter Two: Methodology .............................................................................. 30 2.1 Study design ................................................................................................ 30 2.2 Study population ......................................................................................... 30 2.3 Study sample ............................................................................................... 30 2.4 Instruments of study and validation indicators ............................................ 32 2.4.1 Marital Quality Scale ............................................................................... 32 2.4.2 Depression anxiety stress scale (DASS-21) ............................................. 33 2.5 Study procedures ......................................................................................... 34 Chapter Three: Results ...................................................................................... 36 3.1 Introduction ................................................................................................. 36 3.2.1 Results Related to the First Question ....................................................... 36 3.2.2 Results Related to the Second Question ................................................... 39 3.2.3 Results Related to the Third Question ...................................................... 42 vii 3.2.4 Results Related to the Fourth Question .................................................... 43 3.2.5 Results Related to the Fifth Question ....................................................... 45 Chapter Four: Discussion of Results and Recommendations ............................ 46 4.1 Discussion of Results .................................................................................. 46 4.1.1 Discussion of the results related to the first research question ................. 46 4.1.2 Discussion of the results related to the second research question ............. 47 4.1.3 Discussion of the results related to the third research question ................ 49 4.1.4 Discussion of the results related to the Fourth research question ............. 50 4.1.5 Discussion of the results related to the fifth research question ................. 51 4.2 Recommendations ....................................................................................... 53 References......................................................................................................... 54 Appendices ....................................................................................................... 62 ب ................................................................................................................. الملخص viii List of Tables [ Table 1: Severity levels for autism spectrum disorder....................................... 23 Table 2: Distribution of the study sample based on its independent variables... 31 Table 3: The correlation coefficients of each item with the total score ............. 33 Table 4: The correlation coefficients of each item with the total score ............. 34 Table 5: Means, standard deviations, percentages and estimations of the items and domains of the level of psychological disorders among mothers of autistic children in Nablus Governorate ................................................. 37 Table 6: Results of the One Sample t-Test for the difference between the sample means and the population mean the level of psychological disorders among mothers of autistic children in Nablus Governorate (n = 97) .................. 38 Table 7: Means, standard deviations, percentages and estimations of the items and domains of the level of marital quality among mothers of autistic children in Nablus Governorate .............................................................. 40 Table 8: Results of the One Sample t-Test for the difference between the sample means and the population mean the level of marital quality among mothers of autistic children in Nablus Governorate (n = 97) ................................ 41 Table 9: Results of Pearson Correlation Test between marital quality and psychological disorders among mothers of autistic children in Nablus Governorate among mothers of autistic children in Nablus Governorate (n = 97) ....................................................................................................... 42 Table 10: Descriptive statistics of the level of psychological disorders among mothers of children with autism in Nablus Governorate according to the variables (child's gender, mother's age, child's age, educational qualification, marital status) (n = 97) ...................................................... 44 ix List of Appendices [ Appendix A: 62 ................................................................ استبيان الملعلومات اديمغرافية Appendix B: 63 ................................................................... مقياس االضطرابات النفسية Appendix C: 64 ........................................................................... مقياس جودة الزوارج Appendix D: Tables .......................................................................................... 65 Table D.1: Results of Wilks' Lambda Test for differences in the means of psychological disorder levels based on certain classification variables among mothers of children with autism in Nablus Governorate (N = 97) ............................................................................................................... 65 Table D.2: Descriptive statistics of the level of marital quality among mothers of children with autism in Nablus Governorate according to the variables (child's gender, mother's age, child's age, educational qualification, marital status) (n = 97) ...................................................... 65 Table D.3: Results of Wilks' Lambda Test for differences in the means of marital quality levels based on certain classification variables among mothers of children with autism in Nablus Governorate (N = 97) .......... 66 x MARITAL QUALITY AND ITS RELATIONSHIP TO SYMPTOMS OF PSYCHOLOGICAL DISORDERS AMONG MOTHERS OF AUTISTIC CHILDREN IN NABLUS GOVERNORATE By Lama Yousef Nasrallah Supervisors Dr. Shadi Abualkibash Dr. Filasteen Nazzal Abstract The study aimed to identify marital quality and its relationship to symptoms of psychological disorders among mothers of autistic children in Nablus Governorate. In addition to examine the effect of demographic variables of (child's gender, mother's age, child's age, educational qualification, severity of autism diagnosis, and marital status) on marital quality and its relationship to symptoms of psychological disorders. To achieve the study purpose, marital quality and psychological disorders scales were used. The indicators of the validity and reliability of the study tools were confirmed, and the study sample consisted of (97) mothers of autistic children, and the descriptive correlational approach was used. The results indicated the presence of an inverse relationship, meaning that the higher the marital quality, the lower the psychological disorders. Marital quality was average, and psychological disorders (anxiety, depression, stress) were low. There were no differences in the study sample’s attitudes towards marital quality and its relationship to psychological disorders according to the variables of the child’s gender, mother’s age, child’s age, educational qualification, and marital status. Based on the results reached by the study, a number of recommendations were made, including conducting more research on other psychological and social factors that may have an impact and increase marital quality and reduce psychological disorders among mothers of children with autism spectrum disorder. Keywords: marital quality, psychological disorders, autism spectrum disorder. 1 Chapter One Introduction and Theoretical Background 1.1 Introduction The family plays a crucial role in shaping the personality and social upbringing of its members, with children reflecting the values and customs of their society. However, when there is a child with special needs, particularly autism, the family’s dynamic changes. Their initial reactions often involve shock and denial, stemming from the challenge of adjusting to the new situation. This is often followed by feelings of guilt, as they believe they may have contributed to the child's condition through neglect or a lack of attention to the child or mother's health. States that the presence of a child with autism spectrum disorder in the family constitutes a great challenge, as autism is one of the most difficult categories of special needs. It requires a lot of effort due to the duties of caring for the child as it is not an easy task, in addition to other challenges, including long-term financial affairs, as autism spectrum disorder it is inherent to the child for life, there are challenges in how to communicate and interact with the child, in addition to the social stigma inherent in the child and the family (Marukyan V. , 2023). Autism spectrum disorder is defined according DSM5 as a neurodevelopmental disorder, “Symptoms are typically recognized during the second year of life (12-24 months of age) but may be seen earlier than 12 months if developmental delays are severe, or noted later than 24 months if symptoms are subtler” (American Psychiatric Association, 2013, p. 55). According to DSM5, the diagnostic criteria for autism spectrum disorder as follows: “1- Persistent deficits in social communication and social interaction across multiple con­ texts. 2- Restricted, repetitive patterns of behavior, interests, or activities. 3- Symptoms must be present in the early developmental period. 4- Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning” (American Psychiatric Association, 2013, p. 50). 2 Autism spectrum disorder (ASD) affects individuals from all backgrounds, with a prevalence four times higher in boys than girls. Additional conditions like epilepsy often accompany the diagnosis of girls with ASD (Hodges, Fealko, & Soares, 2020). The increasing prevalence of ASD necessitates a focus on the challenges faced by parents, particularly in managing their children’s special needs, which also affect other family members. Parents of children with ASD face stressors like behavioral issues, difficulty accessing services, and social isolation (zhao, kendrick, & duan, 2024) . Mothers of children with ASD often experience higher levels of stress and lower overall well-being compared to mothers of children with other disabilities. Additionally, raising a child with ASD can lead to financial strain, feelings of guilt, and challenges in marital relationships ( Farzad, Mansour, Elham, Behnaz, & Narges, 2021). Research indicates that mothers of children with ASD often experience a decline in marital satisfaction, primarily due to the elevated stress involved in raising a child with autism (papadopoulos, 2021). The demands of intensive childcare, chronic stress, and persistent fatigue place significant strain on spousal relationships. These challenges are more prevalent among mothers of children with ASD compared to those raising children with other disabilities. Moreover, frequent parental conflicts over managing the child's communication, social, and behavioral difficulties further contribute to the decline in marital quality (benson & kersh, 2011). Parents and caregivers of children with autism face numerous challenges, including communication difficulties, sensory sensitivities, and limited access to specialized services (papadopoulos, 2021). These challenges can be emotionally, physically, socially, and financially overwhelming. A holistic approach—encompassing social, educational, and specialized interventions—is essential to effectively address the needs of children with autism. Identifying the key caregiving challenges, their underlying causes, and strategies for overcoming them is crucial for delivering meaningful and effective support to children with autism spectrum disorder (Marukyan, 2023) Parents of children with autism spectrum disorders (ASDs) often experience significant stress due to the complex social, emotional, and behavioral challenges associated with their children's condition. This elevated stress can increase the risk of mental health 3 issues, such as depression and anxiety. Ineffective coping strategies—such as self-blame or emotional venting—may further exacerbate stress levels. Additionally, persistent behavioral problems in children can lead to parental fatigue, compounding the overall emotional burden (seymour, wood, giallo, & jellett, 2013) Research consistently shows that parents of children with autism spectrum disorder (ASD) experience higher levels of stress, depression, and anxiety compared to parents of typically developing children. Although most studies on parental stress have been conducted in Western and European contexts, similar findings from Southeast Asia and Arab countries also reveal elevated stress levels and negative impacts on the mental health of these parents ( Alibekova, et al., 2022). Parenting children with autism spectrum disorders (ASD) results in significantly higher stress levels compared to parents of typically developing children or those with other disabilities. Common stressors include unpredictable behavior, concerns about the child’s future, and educational challenges. The constant demands of caregiving can leave many parents feeling overwhelmed (Yesilkaya & Magallón-Neri , 2024). ASD-specific challenges, such as impaired communication and social difficulties, add further strain on parents' well-being. These parents often face greater caregiving burdens, experience limits on family and social activities, and may be more likely to quit jobs due to childcare needs. Additionally, they report lower family cohesion, adaptability, and marital satisfaction, with mothers being more affected than fathers. Marital difficulties tend to persist as children with ASD grow into adolescence and adulthood (Harper, Dyches, Harper, Roper, & South, 2013). Research indicates that individuals with autism spectrum disorders (ASDs) display behaviors that create unique stressors for their families, particularly through externalizing behaviors that negatively impact overall family functioning and contribute to parental stress (Mills, 2014). Higher frequency and severity of these behaviors are associated with decreased parental well-being and increased levels of stress, anxiety, and depression. Parents often report chronic stress and exhaustion due to caregiving demands linked to their child's characteristics, a lack of resources, and negative societal attitudes (Yesilkaya & Magallón-Neri , 2024). Mothers typically experience higher levels of stress and lower 4 well-being than fathers, who often focus on economic responsibilities and feel stress indirectly through their partners. Despite the overall trend of increased stress, some parents report positive experiences, emphasizing that their perceptions of their child's disability significantly influence their reported levels of distress (McDonnell & Gracia, 2024). Marital quality is essential for the well-being of parents raising children with developmental disabilities, as it helps reduce depression and parenting stress and improves parenting efficacy. Couples raising a child with ASD tend to report lower marital satisfaction compared to other couples. About 16% of these parent's experience marital distress, similar to levels seen in medical patients. Support systems outside the family, particularly respite care, significantly impact marital quality (Harper, Dyches, Harper, Roper, & South, 2013) Families raising children with a developmental disability experience varying level of stress. However, marital satisfaction serves as a protective factor, helping parents adapt to stress, reducing depression and parenting stress, and improving their efficiency in parenting (Al-Shirawi , 2018). Mothers, especially those with disabled children, often take on the primary caregiving role. Raising a child with a disability can affect the marital relationship either positively or negatively. However, marital satisfaction serves as a protective factor, helping parents adapt to stress, reducing depression and parenting stress, and improving their efficiency in parenting (O’Sullivan, et al., 2022). Therefore, the detection of symptoms of psychological disorders for the mothers of children with disabilities, and their relationship to marital quality, is a very important issue, especially for mothers with children with autism spectrum disorder, and this study comes in its quantitative part to understand more deeply the marital quality and its relationship to the symptoms of psychological disorders among mothers of children with autism spectrum disorder in Nablus. Marital Quality John Gottman's research shows that marital conflicts fall into two categories: resolvable and perpetual. Since most conflicts are perpetual, the Gottman Method focuses on helping 5 couples learn healthier ways to manage these ongoing issues. This method addresses various relationship problems, from frequent arguing to infidelity, by teaching couples to manage perpetual conflicts (gottman & gottman, 2008). The therapy is inclusive and effective for couples at any relationship stage and of any race, class, or cultural identity. These skills help couples long-term, preventing them from reverting to negative patterns (Carr, 2025). The Gottman method of therapy consists of three main components (Meunier, 2017): 1. Friendship 2. Ability to manage conflict 3. Creating shared goals Therapy helps couples improve interactions, shift from negative to positive, and deepen their emotional connection. Gottman Method therapists also educate couples about healthy relationships, providing insights and tools for long-term relationship maintenance (Meunier, 2017). Marital quality is a complex concept defined by various terms such as marital happiness, satisfaction, stability, success, adjustment, and friendship. Researchers often use these terms interchangeably, leading to diverse interpretations and confusion (Nurhayati, Faturochman, & Helmi, 2019). Marital satisfaction refers to a subjective evaluation of one's marriage, while marital happiness indicates the level of happiness felt by a couple (Abreu-Afonso, Ramos, Leal, & Queiroz-Garcia , 2022). Marital adjustment involves agreement on important issues, effective communication, joint activities, minimal conflict, and overall satisfaction. Separation or divorce indicates the continuity and success of a marital bond. The overlapping of terms complicates the establishment of a clear definition of marital quality (Meunier, 2017). Some experts acknowledge the inadequate conceptualization of marital quality, noted that although numerous studies exist, most conceptualizations are simplistic and a theoretical, relying mainly on emotional satisfaction reports from spouses ( Fowers & Owenz, 2010). 6 Despite these inadequacies, two definitions are commonly referenced (Spanier & Lewis, 1980) defined marital quality as a subjective evaluation of the relationship across various dimensions, while ( Bradbury, Fincham, & Beach, 2004)focused on couples' subjective and evaluative judgments of their marriage or partners. Both emphasize subjective evaluations from spouses ( Fowers & Owenz, 2010). also defined marital quality as an individual's subjective evaluation of the marriage condition, using the marriage's purpose as the evaluation criteria (Nurhayati, Faturochman, & Helmi, 2019). Ledermann, Bodenmann, Rudaz, & Bradbury (2010) defined marital quality as the perceptions and evaluations individuals have of their marriage, including key factors such as satisfaction, stability, and overall functioning. Contemporary approaches to marital quality recognize that positive and negative aspects can coexist within the same relationship, providing a more nuanced understanding of how spouses experience their marriage (Ledermann, Bodenmann, Rudaz, & Bradbury, 2010). Delatorre and Wagner (2020) define marital quality as the way individuals evaluate their relationships, emphasizing factors such as satisfaction, happiness, and adjustment (Delatorre & Wagner, 2020). Marital quality is a dynamic concept shaped by evolving societal definitions of marital ideals. Its interpretation varies over time and across cultural or regional contexts. Marital quality can be conceptualized as either unidimensional or multidimensional, encompassing intrapersonal factors—such as satisfaction, happiness, personality, religiosity, and gender—as well as interpersonal factors, including intimacy, agreement, communication, and economic status) (Nurhayati, Faturochman, & Helmi, 2019) The factors affecting marital quality are as follows: 1. Personality: A couple's personality significantly impacts marital quality, with traits such as neuroticism, extraversion, agreeableness, conscientiousness, and positive expression playing crucial roles. Specifically, high levels of neuroticism, low agreeableness, low conscientiousness, and a lack of positive expression are associated with marital dissatisfaction (Sayehmiri, Kareem, Abdi, Dalvand, & Gheshlagh, 2020). Additionally, attachment style—originally related to the 7 caregiver-child bond—has been studied in the context of romantic relationships and also reveals a correlation with marital quality. Satisfaction within a marriage can be predicted by individual and combined attachment styles, with anxious attachment linked to a decrease in marital quality ( Johnson & Levy , 2024). 2. Religiosity and spirituality: Beliefs and participation in religious activities are widely related to marital quality. Current research confirms that religiosity is positively related to marital adjustment. Furthermore, both religiosity and attendance at religious services are associated with higher marital quality and a lower likelihood of infidelity, domestic violence, and divorce (Yaden, et al., 2022). 3. Gender Role Attitude: that gender role attitudes significantly impact marital quality. Conservative attitudes promote a division of labor where men work outside the home and women handle unpaid household tasks, while egalitarian attitudes advocate for equal roles for both genders (Çetinkaya & Gençdoğan, 2014) that marital quality improves when both spouses hold egalitarian views, leading to greater flexibility, harmony, and fewer disagreements, Husbands who hold egalitarian beliefs report higher levels of marital happiness compared to those with more conservative attitudes (Nurhayati, Faturochman, & Helmi, 2019). 4. Coping Strategy: The way couples manage challenges plays a crucial role in shaping marital quality. Elevated stress levels are often associated with reduced marital happiness, whereas effectively navigating moderate difficulties can foster resilience and improve marital adjustment (Timothy-Springer & Johnson, 2018). Dyadic coping—how couples manage both individual and shared stressors—plays a crucial role in marital dynamics. Couples who openly communicate about stress, employ positive coping strategies, and minimize negative behaviors generally report higher levels of marital quality. Notably, common dyadic coping, which reflects harmony and cooperation in addressing challenges, is strongly associated with greater marital satisfaction (Landolt, Weitkamp , Roth, Sisson, & Bodenmann, 2023). 5. Communication: Communication is a critical factor influencing marital quality, with both positive and negative communication behaviors impacting couples' satisfaction. Effective communication about parenting contributes to higher marital satisfaction, and expressing positive emotions, especially from husbands, can mitigate negative 8 interactions during difficult times (Khezri, Hassan, & Nordin, 2020). Additionally, feeling understood is essential for maintaining marital quality; partners may feel less understood when one withdraws from conflict, even though this understanding correlates positively with marital satisfaction (Gordon & Diamond, 2023). 6. Relationship maintenance behavior: encompasses the everyday actions that promote a satisfying and healthy relationship, significantly influencing marital quality. Key components of this behavior include positivity, openness, assurance, network utilization, and task management (Ogolsky & Stafford, 2023). Positivity involves enjoyable and non-critical interactions between couples, while openness refers to candid discussions about the relationship and the expression of desires for it. Assurance consists of affirming words that emphasize commitment. Network utilization involves engaging with and relying on family and friends for support, and task management entails fulfilling shared responsibilities, such as household chores. Additionally, gratitude plays a vital role in sustaining intimate relationships (Stafford, 2011). 7. Economy and Finance: Socioeconomic status, particularly economic and financial issues, plays a crucial role in marital quality research. that economic problems and financial dissatisfaction are significant predictors of divorce, often more so than disagreements over other issues like division of responsibilities (Friedline, Chen , & Morrow , 2020). Couples' materialistic attitudes influence their perceptions of financial problems, which can negatively affect marital satisfaction. As materialism rises, so do perceptions of financial stress, leading to lower marital satisfaction. Additionally, couples who collaborate on financial planning tend to have higher marital quality compared to those who engage in independent financial planning (LeBaron, Allsop, Hill, Willoughby, & Britt-Lutter, 2017). 1.2 Literature Review He, Wongpakaran, Wongpakaran, & Wedding (2022) conducted a study examining the factors influencing marital satisfaction among parents of children with autism spectrum disorder. The study explored how perceived family support, severity of autistic behaviors, and complementarity between partners' coping styles influence marital satisfaction. The 9 results indicated that perceived family support significantly influenced marital relationships, differing between husbands and wives. Spousal satisfaction was closely related to perceived family support, while severity of autistic behaviors was the primary influencer on relationship satisfaction. Interpersonal complementarity negatively impacted marital satisfaction, and time spent caring for children negatively impacted relationship quality, especially for women (He, Wongpakaran , Wongpakaran , & Wedding, 2022). In a phenomenological study by ( Farzad, Mansour, Elham, Behnaz, & Narges, 2021), the experiences of families raising children with autism spectrum disorder (ASD) were explored to understand the challenges these families face. the study identified 54 conceptual codes that fell into two major categories: family-related issues (financial, psychological, and relationship struggles) and education and treatment challenges (such as schooling, transportation, and the quality of available facilities). The study concluded that these parents require more comprehensive support systems, including emotional, societal, and governmental interventions, to enhance their coping strategies and overall quality of life. This highlights the ongoing need for better resources and assistance for families of children with autism. Al-Shirawi conducted a study titled A Comparison of Marital Satisfaction of Mothers Raising a Child with Intellectual Disability versus a Child with Autism in Bahrain. the results indicated that 70% of the mothers reported high levels of marital satisfaction, with no significant difference between the two groups. Social support was identified as a significant predictor of marital satisfaction, while factors such as income, child characteristics, and years of marriage were found to be insignificant. Qualitative analysis showed that most mothers received strong support from their husbands, families, in-laws, and professionals (Al-Shirawi , 2018). In a study titled Respite Care, Marital Quality, and Stress in Parents of Children with Autism Spectrum Disorders (Harper, Dyches, Harper, Roper, & South, 2013) investigated how respite care influences these dynamics, the study found that increased hours of respite care were positively associated with improved marital quality for both parents. Specifically, an additional hour of weekly respite care significantly enhanced marital 10 quality by reducing stress and increasing daily positive experiences. Furthermore, families with more children reported higher stress levels and lower marital satisfaction. These results emphasize the importance of developing interventions that provide respite care to support families raising children with ASD. In a study by ( Kersh, Hedvat, Hauser-Cram, & Warfield, 2006), the impact of marital quality on the well-being of parents with children who have developmental disabilities was examined. The study highlights the importance of marital quality in reducing parenting stress and depressive symptoms for both mothers and fathers of children with developmental disabilities. While marital quality enhanced parenting efficacy for mothers, fathers' efficacy was more affected by social support. Child behavior also played a significant role in parental well-being. All studies consistently underscore the critical role of support systems—whether familial, societal, or professional—in maintaining marital satisfaction among parents of children with autism spectrum disorder (ASD) or developmental disabilities. From family support and respite care to government policy and marital therapy, the collective findings advocate for a holistic approach to supporting affected families. In my view, future efforts should prioritize gender-sensitive and culturally appropriate interventions while also ensuring access to practical support services such as respite care, inclusive education, and couple-focused therapy models. 1.2.1 Psychological Disorder Mental disorders were defined based on DSM5 as " A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities" (American Psychiatric Association, 2013, p. 20). According to DSM5, the diagnosis of a mental disorder should guide clinicians in determining prognosis, treatment plans, and potential outcomes, but it does not automatically indicate the need for treatment. Treatment decisions involve a complex 11 clinical assessment, considering factors such as symptom severity, the presence of distressing symptoms (e.g., suicidal thoughts), the patient's distress, disability caused by symptoms, and the risks and benefits of treatments. Even if individuals do not meet the full diagnostic criteria for a disorder, they may still require care, and a lack of full symptoms should not limit access to appropriate treatment (American Psychiatric Association, 2013, p. 20). 1.2.2 Multiple Causes of Mental Disorder Mental disorders arise from a complex interplay of biological, social, and psychological factors. The biopsychosocial model, introduced by Engel in 1977, underscores the importance of examining these interconnected dimensions to fully understand health and illness (Engel, 1977). This model aligns with the view that mental disorders result from both internal factors, like physical and psychological elements, and external influences, including environmental and social aspects (Remes, Mendes, & Templeton, 2021). Original Causes: These are factors that set the stage for the potential development of mental disorders, making an individual more vulnerable to the onset of such conditions when combined with additional, triggering factors. Predisposing causes are varied and can impact an individual over extended periods, sometimes lasting for years. Examples include genetic predispositions, physical disorders, adverse situations in childhood, and social instability (Newman, et al., 2016). Precipitating Causes: These are recent or preceding events and factors that directly accelerate the onset of psychological disorders in individuals who are already predisposed. These causes do not create the disorder but trigger its symptoms. Examples include crises like economic hardship, emotional trauma, and major life transitions such as puberty, aging, marriage, parenthood, or environmental changes ( Pigeon, Bishop, & Krueger , 2017). Biological causes: often arise from physical or organic factors throughout an individual’s developmental history. These causes include physiological disorders, such as defects in body systems, hereditary physiological changes, and structural or compositional imbalances that affect physical and psychological well-being (Renzi, et al., 2018). 12 Additional contributors include genetic predispositions, biochemical imbalances, neuroanatomical abnormalities, and variations in brain structure, all of which are linked to mental health conditions like depression, bipolar disorder, and schizophrenia (Remes, Mendes, & Templeton, 2021). Social factors: social factors play a significant role in contributing to mental disorders. Conditions like poverty, inadequate housing, and unemployment create environments that heighten mental health risks. Additionally, life events such as trauma, bullying, and impactful interpersonal experiences increase an individual’s vulnerability to mental health issues (Alegría, NeMoyer, Bagué, Wang , & Alvarez, 2018). Psychological causes: encompass factors rooted in psychological development, particularly in childhood, such as unmet needs and disrupted personal and social relationships. Contributing elements also involve conflict, frustration, deprivation, aggression, and psychological stress (Remes, Mendes, & Templeton, 2021). Additionally, individual processes, such as personal interpretation and event processing, further shape mental health outcomes ( Gross & Medina-DeVilliers, 2020). External and Environmental Causes: These factors encompass influences within the individual's environment, including cultural disruptions and socialization processes in family, school, and society ( Bush, et al., 2020). External factors interact with predisposing and precipitating causes to contribute to mental disorder symptoms. that strong predisposing causes may allow minor events to trigger a disorder, while weaker predispositions require more substantial precipitating factors. Notably, challenges that may destabilize one person could, for another, foster resilience and character growth (Warren, et al., 2024). Interactions among these factors also influence mental disorder development, where genetic predispositions might heighten vulnerability to environmental stressors, and social support can moderate the effects of adverse experiences. Therefore, a holistic approach that considers the complex interplay between biological, social, and psychological factors is necessary for understanding and addressing mental disorders comprehensively (Assary, Vincent , Keers, & Pluess, 2018). 13 The diathesis-stress model proposes that mental disorders result from an interaction between genetic vulnerabilities and environmental stressors, explaining variations in individuals' susceptibility to mental disorders and responses to stressful events (Organization, World Health, 2001). Adverse experiences, including abuse, social stress, and traumatic events, can strongly impact mental health, though the exact pathways to specific disorders are not fully understood. Community factors like employment issues, socioeconomic inequality, and migration challenges also contribute to mental health risks. Managing mental stress, a common trigger for mental illness, is crucial, with coping strategies such as yoga, exercise, and medication offering stress relief (Thurston, Murray, Franchino-Olsen, & Meinck, 2023). 1.2.3 Depression The DSM-5 defines depression as a group of disorders marked by persistent feelings of sadness, emptiness, or irritability, accompanied by cognitive and physical (somatic) changes that significantly impair an individual's functioning. These disorders differ in duration, timing, and underlying causes (American Psychiatric Association, 2013). Major depressive disorder, for example, involves episodes lasting at least two weeks with notable changes in mood, cognition, and physical state (Otte, et al., 2016). while persistent depressive disorder (dysthymia) presents as a chronic mood disturbance spanning years (Walter, et al., 2023). Other forms, such as premenstrual dysphoric disorder and depression associated with substance use or medical conditions, are classified based on specific triggers or patterns related to underlying health factors (American Psychiatric Association, 2013). Symptoms of Depression Symptoms of depression extend beyond persistent sadness and encompass a wide range of effects on mood, sleep, and physical health, as well as cognitive and behavioral functioning (Frank, 2024). Mood: Depression can affect mood in various ways. Beyond sadness, individuals may experience anhedonia—a loss of interest in previously enjoyable activities—making life 14 feel dull and unfulfilling. Feelings of hopelessness or excessive guilt over minor issues may also emerge, accompanied by a general sense of apathy that diminishes motivation for work, hobbies, and daily responsibilities (Remes, Mendes, & Templeton, 2021). Anxiety often coexists with depression, adding persistent worry and rumination to symptoms such as low mood, anhedonia, and hopelessness, resulting in an exhausting combination of distressing emotions (Gustavson , Pont , Whisman, & Miyake , 2018). Sleep: A significant aspect of depression is its impact on sleep patterns, which can manifest as either oversleeping or insufficient sleep. Common issues include 'early awakening,' where individuals wake up in the early morning and struggle to fall back asleep, as well as insomnia and restless sleep, marked by difficulty falling asleep or frequent awakenings. These disturbances are particularly troubling, as adequate and restful sleep is essential for managing depression (Riemann, Krone, Wulff , & Nissen , 2020). Body: Depression can significantly impact appetite, leading to behaviors that may be out of character. Some individuals may experience increased hunger, feeling as though they can never eat enough, while others may lose their appetite entirely. These changes can result in significant, often unintentional, weight fluctuations. Additionally, physical symptoms of depression can include either fatigue or restlessness, with individuals feeling excessively tired or, conversely, overly energized (Simmons, et al., 2020). Cognition and Behavior: Depression can significantly impair cognitive function, making thinking feel slow and burdensome. Maintaining attention becomes difficult, turning routine tasks at work or school into major challenges. You may also experience increased irritability, frequent crying spells, and feelings of agitation that arise without clear triggers. As a result, you might withdraw from friends and family, finding social interactions particularly overwhelming during depressive episodes (LeMoult & Gotlib , 2019). Suicidal Ideation: One of the most severe symptoms of depression is suicidality, characterized by feelings of worthlessness or an overwhelming urge to die. These emotions can be difficult to express, especially to those who haven't experienced them, 15 often leading to feelings of shame or fear of burdening loved ones. It's essential to understand that suicidal thoughts are a treatable symptom of depression, and seeking help immediately is crucial (Pompili, 2019). 1.2.4 Anxiety In the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition), anxiety is defined as an emotional state marked by feelings of worry, nervousness, or unease, often related to an impending event or uncertain outcome. Anxiety disorders in the DSM-5 include various specific conditions, such as generalized anxiety disorder, panic disorder, social anxiety disorder, and specific phobias, each with its own set of diagnostic criteria (American Psychiatric Association, 2013). 1. Generalized Anxiety Disorder (GAD) People with GAD experience persistent, pervasive feelings of anxiety or dread without a specific focus. Unlike anxiety that arises in response to a stressful situation and dissipates afterward, GAD involves a general sense of worry that may impact many areas of daily life. Individuals with GAD often worry about various things and may find it difficult to relax or get to sleep (Mishra & Varma , 2023). 2. Panic Disorder People with panic disorders experience frequent and unexpected panic attacks. These attacks may have specific triggers, or they may occur without any identifiable cause (Cackovic, Nazir, & Marwaha, 2023). 3. Specific phobia Specific phobias involve an intense fear of a particular object or situation, like heights or spiders, and are focused on a single, specific trigger—unlike other anxiety disorders, which may have broader concerns. Even though individuals with phobias often recognize that their fear is irrational or extreme, they may still find it very challenging to control their response when faced with the triggering object or situation ( Samra, Torrico , & Abdijadid , 2024). 16 4. Social anxiety disorder Social anxiety is characterized by the fear of negative judgment from others, leading individuals to feel as though their every action is being scrutinized and that they risk embarrassment or humiliation in social situations (Alomari, et al., 2022). This overwhelming fear can result in the avoidance of social interactions or specific scenarios, such as speaking with strangers. Additional signs of social anxiety may include intense self-consciousness, difficulty making eye contact, speaking in a quiet or soft voice, and experiencing moments where their mind feels as though it has “gone blank” during social encounters ( Rose & Tadi , 2022). 5. Symptoms Anxiety can present as either chronic (or generalized) anxiety, which consists of persistent daily symptoms that negatively affect quality of life, or as acute anxiety, characterized by brief episodes of intense panic attacks. The symptoms of anxiety vary in number, intensity, and frequency among individuals, although most people do not experience chronic anxiety (Szuhany & Simon, 2022). Behavioral effects Behavioral effects of anxiety can include avoiding situations associated with past anxiety or negative emotions, as well as changes in sleep, daily habits, food intake, and increased motor tension like foot tapping ( Gautam, Mittal, Gautam, & Rawat, 2022). Emotional effects The emotional effects of anxiety can include feelings of apprehension, difficulty concentrating, tension, anticipating the worst, irritability, restlessness, and hypervigilance. Other symptoms may involve nightmares, obsessions about sensations, déjà vu, a sense of mental blankness, feeling trapped in one’s mind, and an overall sense of helplessness (Sendzik, Schäfer, Samson, Naumann, & Tuschen-Caffier , 2017). 17 Cognitive effects The cognitive effects of anxiety may involve thoughts of perceived dangers, such as an irrational fear of dying or having a heart attack, even when experiencing only mild chest pain, for example (Park & Moghaddam, 2017). Physiological effects Physiological symptoms of anxiety can affect various systems in the body (Testa, 2013). Neurologically, individuals may experience headaches, paresthesia's, fasciculation's, vertigo, and presyncope. Digestive symptoms can include abdominal pain, nausea, diarrhea, indigestion, dry mouth, or a sensation of a lump in the throat, with stress hormones potentially exacerbating conditions like irritable bowel syndrome (IBS). Respiratory symptoms often manifest as shortness of breath or sighing, while cardiac symptoms may involve palpitations, tachycardia, or chest pain (M.A., N., & S., 2018). Muscularly, fatigue, tremors, or tetany can occur, alongside cutaneous symptoms like perspiration or itchy skin. Additionally, urogenital symptoms may include frequent urination, urinary urgency, dyspareunia, impotence, or chronic pelvic pain syndrome (Chu, Marwaha , Sanvictores , Awosika, & Ayers , 2024). 1.2.5 Stress Stress can be defined as a state of worry or mental tension caused by a difficult situation. It is a natural human response that prompts us to address challenges and threats in our lives. While everyone experiences stress to some degree, the way we respond to stress significantly affects our overall well-being (Organization, World Health ;, 2023). Stress-related disorders are a category of mental disorders characterized by maladaptive biological and psychological responses to physical or emotional stressors, whether short- or long-term. The National Institute of Environmental Health Sciences classifies both obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD) as stress-related disorders (Halbreich, 2021). However, the World Health Organization's ICD-11 excludes OCD from this category while including PTSD, Complex Post-Traumatic Stress Disorder (CPTSD), and adjustment disorder as stress-related disorders (World Health Organization , 2024). 18 According to (Ghasemi, Beversdorf, & Herman, 2024), recognizing stress can be challenging, as it may not always have an obvious cause and can build up over time from everyday pressures at work, school, or home. Stress affects both the mind and body, and certain signs may indicate you’re under excessive strain. Key indicators - Cognitive signs: difficulty focusing, persistent worry, anxiety, and forgetfulness. - Emotional signs: irritability, anger, fear, and mood swings. - Physical signs: increased blood pressure, headaches, sweaty or clammy hands, neck tension, changes in weight, frequent colds, teeth grinding, digestive issues, and shifts in menstrual cycle or sex drive. - Behavioral signs: reduced self-care, neglect of enjoyable activities, or increased reliance on substances like alcohol or drugs for coping (Crosswell & Lockwood, 2020). Types of stress - Acute stress: This type of stress is brief and intense, often triggered by sudden, traumatic events such as car accidents, assaults, or natural disasters (Ouagazzal, Bernoussi , Potard, & Boudoukha, 2021). - Chronic stress: persistent and ongoing, chronic stress often arises from difficult, long-term situations, like an unhappy marriage or a demanding job, and may feel inescapable (Mariotti, 2015). - Episodic acute stress: When acute stress becomes frequent and ingrained in everyday life, it leads to episodic acute stress. Examples include recurrent illness, enduring domestic violence, child abuse, or living in conflict zones (Villarreal, et al., 2021) - Eustress: Known as "positive stress," eustress is exciting and motivating, often accompanied by adrenaline surges. It’s experienced in activities like skiing, racing against a deadline, or taking on new challenges (Kloidt & Barsalou, 2024). The study Longitudinal Pathways Between Parent Depression and Child Mental Health in Families of Autistic Children by Piro-Gambetti, Greenlee, Bolt, Litzelman, and Hartley 19 (2024) investigates the interconnected mental health challenges faced by autistic children and their parents. The study revealed that father depression played a significant mediating role, linking child mental health concerns to both critical and positive behaviors by fathers, whereas no similar mediation effects were observed for mothers. These findings underscore the reciprocal impact of mental health within families of autistic children, suggesting that interventions aimed at enhancing parent-child relationship quality— particularly in father-child interactions—may help mitigate the mutual psychological toll on both parents and children (Piro-Gambetti, Greenlee, Bolt , Litzelman, & Hartley , 2024). This study, "Psychological Stress and Perceived Self-Efficacy in Mothers of Autistic Children," examines the relationship between psychological stress and perceived self- efficacy in mothers and fathers of autistic children. the study highlights that the stress of parenting children with disabilities significantly impacts the psychological well-being of mothers of autistic children ( Mubarak, 2022). Wahdan evaluated the effectiveness of the Incredible Years Autism Spectrum Disorder (IY-ASD) program in reducing family stress and improving parenting skills—specifically in communication, socialization, and problem-solving—among parents in Palestine. The results revealed a significant reduction in the Parental Stress Index. Furthermore, the total stress score decreased post intervention. Notably, fathers demonstrated lower levels of negative behavior compared to mothers, who reported increased discipline scores after the intervention (wahdan, 2018). In a study examining the stress levels of parents of children with autism spectrum disorder (ASD) at the onset of their children's Early Intensive Behavioral Intervention (EIBI) program, it was found that fathers reported higher stress levels than mothers. identified that both parents' stress levels correlated with their child's age, intellectual quotient, severity of autistic symptoms, and adaptive behaviors. Notably, paternal stress was specifically predicted by the severity of the child's symptoms and gender. These findings underscore the need for targeted services and early interventions to support parents facing these challenges (Rivard, Terroux, Parent-Boursier, & Mercier , 2014) 20 A study investigating the buffering effects of psychological resilience on stress, anxiety, and depression among parents of children with autism spectrum disorder (ASD) found that mothers reported significantly higher levels of anxiety and depression than fathers, often feeling overwhelmed. Both groups exhibited clinically significant rates of anxiety and depression, with levels up to five times higher than those in the general adult population. Notably, psychological resilience was identified as a protective factor, with even low levels of resilience helping to alleviate the severity of anxiety and depression associated with parenting stress (Bitsika, Sharpley, & Bell , 2013). In a study conducted by Merkaj et al. (2013), the psychological well-being of parents of autistic children was compared to that of parents of typically developing children. The research aimed to assess symptoms of stress, depression, and anxiety using the DASS 42 scale. Parents of children with autism reported higher levels of stress, depression, and anxiety than those of typically developing children. Notably, mothers of children with autism exhibited more pronounced symptoms of these psychological issues compared to fathers. The findings suggest a need for institutions that work with autistic children to offer counseling and stress management programs for parents, as their well-being is crucial for the overall family system (Merkaj, Kika , & Simaku , 2013). A study conducted in Heilongjiang Province, China, investigated parenting stress among mothers of children with autism spectrum disorders ( Wang, et al., 2013). collecting data on demographics, parenting stress, anxiety, depression, child behavioral issues, coping strategies, and social support. The results indicated elevated levels of parenting stress among mothers, which were significantly associated with their depression, anxiety, and the severity of their child's behavioral symptoms. Studies consistently highlight the profound psychological impact of raising a child with autism on both parents, with mothers often reporting higher levels of stress and emotional strain. Fathers’ mental health also plays a crucial role in overall family dynamics. Protective factors such as psychological resilience and parental self-efficacy can help buffer stress, while structured intervention programs have proven effective in improving parenting skills and alleviating family burden. These findings underscore the need for gender-sensitive, family-centered mental health support. 21 In my view, future research and clinical programs should expand their focus to more fully include fathers, whose contributions to family adjustment and child development are often overlooked yet vital. 1.2.6 Autism Spectrum Disorder "Autism," originating from the Greek word "autos," meaning "self," was introduced by Swiss psychiatrist Eugen Bleuler in the early 20th century to describe a detachment from social interaction and an inward focus. Over time, it has expanded to encompass a wide range of behavioral and developmental variations ( Goldstein & Lancy , 1985). In 1943, American psychiatrist Leo Kanner published a pivotal paper introducing the term "early infantile autism," emphasizing children's social and communication challenges, repetitive behaviors, and intense focus on specific interests. His work was fundamental in recognizing autism as a distinct developmental disorder, paving the way for further research (kanner, 1943). Around the same time, Austrian pediatrician Hans Asperger independently identified a condition he termed "autistic psychopathy," characterized by social and communication challenges, specific interests, and motor coordination difficulties. His work eventually led to the adoption of the term "Asperger's syndrome" to describe individuals with higher-functioning autism. As research on autism evolved, so did the diagnostic terminology (Asperger, 1944). Initially classified under "pervasive developmental disorders" (PDD) in the Diagnostic and Statistical Manual of Mental Disorders (DSM), autism was redefined as "autism spectrum disorder" (ASD) in the DSM-5 published in 2013, to better capture the diversity of characteristics and functioning levels in the autism community (American Psychiatric Association, 2013). Autism Spectrum Disorder (ASD) is defined by the American Psychiatric Association as a neurodevelopmental disorder characterized by persistent deficits in social communication, social interaction, speech, and nonverbal communication, along with restricted, repetitive behaviors. The effects of ASD and the severity of symptoms vary from person to person (American Psychiatric Association, 2013). 22 Criteria for Diagnosis of Autism Spectrum Disorder Criteria for Diagnosis of Autism Spectrum Disorder by the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (American Psychiatric Association, 2013): A. “persistent deficits in social communication and interaction: - Deficits in social-emotional reciprocity (e.g., abnormal social approach, reduced sharing of interests/emotions)”. - Deficits in nonverbal communication (e.g., poor eye contact, body language, lack of facial expressions). - Deficits in developing, maintaining, and understanding relationships (e.g., difficulty in making friends, lack of interest in peers). B. Restricted, repetitive patterns of behavior, interests, or activities: - Stereotyped or repetitive motor movements, use of objects, or speech (e.g., lining up toys, echolalia). - Insistence on sameness and inflexible adherence to routines (e.g., distress at small changes, rigid thinking patterns). - Highly restricted, fixated interests (e.g., strong attachment to unusual objects). - Hyper- or hypo reactivity to sensory input or unusual interest in sensory aspects of the environment (e.g., excessive smelling or touching of objects). C. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life). D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning. E. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. intellectual disability and autism spectrum disorder frequently co-occur, to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below 23 that expected for general developmental level (American Psychiatric Association, 2013). The severity of social communication difficulties and repetitive restrictive behaviors is categorized separately according to the DSM-5 as follows: Severity levels for autism spectrum disorder The severity of social communication difficulties and repetitive restrictive behaviors are classified separately according to the DSM-5 as follows (American Psychiatric Association, 2013): Table 1 Severity levels for autism spectrum disorder Severity level Social communication Restricted, repetitive behaviors Level 3 Requiring very substantial support Individuals experience severe deficits in verbal and nonverbal communication, leading to significant functional impairments. They initiate social interactions infrequently, respond minimally to others, and use limited, often need-based approaches. Individuals exhibit inflexible behavior, extreme difficulty coping with change, and other repetitive behaviors that interfere with functioning in all areas, causing significant distress and difficulty in shifting focus or actions Level 2 Requiring substantial support Even with support, individuals have marked deficits in verbal and nonverbal communication, showing limited initiation of interactions and abnormal responses. They might speak in simple sentences and focus on narrow interests, with notably odd nonverbal behavior. Behavioral inflexibility and difficulty coping with change are obvious and interfere with functioning across contexts, causing distress and challenges in shifting focus or action. Level 1 Requiring support Without support, deficits in social communication cause noticeable impairments. Individuals struggle to initiate interactions, respond atypically to others, and may seem less interested in socializing. They can speak in full sentences but have ineffective back- and-forth conversations and unsuccessful attempts at making friends. Behavioral inflexibility significant interfere with functioning in various contexts. Individuals have difficulty switching between activities, and problems with organization and planning hinder their independence. 24 1.3 Study Terms Marital Quality Marital quality is a multifaceted concept that encompasses various dimensions of a marital relationship. Based on John Gottman's research, which distinguishes between resolvable and perpetual conflicts and the Gottman Method’s focus on managing these conflicts, marital quality can be defined through several key aspects. This includes the effectiveness of managing conflicts, the strength of friendship, and the ability to create shared goals (Meunier, 2017). Marital quality reflects the overall satisfaction and health of a marriage, incorporating elements such as marital happiness, satisfaction, stability, and adjustment. Researchers often use terms like marital happiness, satisfaction, and adjustment interchangeably, which can create confusion. For instance, marital satisfaction involves a subjective evaluation of one’s marriage, while marital happiness pertains to the level of joy experienced within the relationship. Marital adjustment refers to effective communication, agreement on important issues, and overall satisfaction, while stability can be indicated by the continuity of the marital bond ( Fowers & Owenz, 2010). In the current study, marital quality will be operationally defined as the score achieved by mothers of children with autism spectrum disorder on the study questionnaire. Autism spectrum disorder The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) defines autism spectrum disorder (ASD) as a neurodevelopmental disorder characterized by persistent deficits in social communication and social interaction, and restricted and repetitive patterns of behavior, interests, or activities. In 2013, in the DSM-5, ASD was expanded to include the previous diagnoses (DSM-IV-TR) of autism, Asperger syndrome, pervasive developmental disorder not otherwise specified (PDD-NOS), and childhood disintegrative disorder (American Psychiatric Association, 2013). 25 In the current study, autism spectrum disorder will be defined procedurally as children who receive rehabilitation services in their rehabilitation centers in Nablus Governorate and who have been diagnosed through diagnostic tools for autism spectrum disorder. Psychological disorders It refers to an individual's difficulty in adapting to themselves and their surrounding environment, often leading to feelings of anxiety, despair, and frustration. This condition is typically accompanied by emotional, cognitive, and behavioral disturbances (Volkmar, 2021). A mental disorder is a clinically significant disturbance in an individual’s cognition, emotional regulation, or behavior, arising from dysfunctions in underlying psychological, biological, or developmental processes. It is typically associated with substantial distress or impairment in social, occupational, or other essential areas of functioning (Organization, World Health, 2024) In the current study, psychological disorders will be operationally defined as the score achieved by mothers of children with autism spectrum disorder on the study questionnaire. Depression Depression is a prevalent mental disorder characterized by persistent sadness, loss of interest in activities, and impaired daily functioning. It affects approximately 5% of adults worldwide, with women experiencing higher rates than men. Depression can arise from stressful life events, trauma, or significant losses and may negatively impact relationships, work, and overall well-being (World Health Organization , 2024). Depression, also known as major depressive disorder or clinical depression, is a serious mood disorder characterized by persistent sadness, hopelessness, and a loss of interest in previously enjoyable activities, It can cause significant emotional and physical symptoms, including disruptions in sleep, appetite, and daily functioning. In addition to emotional distress, individuals with depression may experience physical symptoms such as chronic 26 pain or digestive issues. Depression can affect people of all ages, backgrounds, and socioeconomic statuses (American Psychiatric Association, 2013). Anxiety Anxiety is a natural emotional response to real or perceived threats, often accompanied by physical symptoms like shaking, sweating, and an increased heart rate. It activates the body's stress response, commonly known as freeze, which helps individuals react to danger. However, anxiety can also arise in non-threatening situations. While occasional anxiety is normal, persistent, excessive anxiety may indicate an anxiety disorder, a treatable mental health condition that can significantly impact daily life (felman, 2024). Anxiety is a common emotion, but anxiety disorders involve persistent, excessive fear and worry that are difficult to control. These disorders often cause physical tension, cognitive symptoms, and significant distress, interfering with daily life, relationships, and work or school performance. Without treatment, symptoms can persist and severely impact overall well-being (World Health Organization , 2024). Stress Stress is a state of mental tension or worry triggered by challenging situations. It is a natural human response that helps individuals navigate difficulties and threats. While everyone experiences stress to some extent, the way one manages it significantly impacts overall well-being (World Health Organization , 2024). Stress is a natural response to daily pressures but can become harmful when it disrupts daily functioning. It affects nearly every system in the body, influencing emotions, behavior, and overall well-being. By triggering mind-body changes, stress can contribute to both psychological and physiological disorders, impacting mental and physical health and reducing quality of life (American Psychiatric Association, 2013). 1.4 Problem statement and study question The lack of research that addressed marital quality and its relationship to symptoms of psychological disorders among mothers of autistic children in Nablus Governorate in particular and Palestine in general, prompted the researcher to conduct this research. In 27 addition to the researcher's work as a rehabilitation specialist with children with autism spectrum disorder for 9 years, she noticed the need to work on the marital quality among mothers of children with autism spectrum disorder, due to its positive impact on the child. The better the marital quality, the more improvement is observed in the child's behavior, social interactions, and communication with peers and the environment. The presence of a child with autism spectrum disorder in the family has an impact on marital quality. According to previous studies, parents of children with autism spectrum disorder experience higher levels of stress compared to parents of children with typical development. This stress affects relationships among family members and their interactions with the external environment, in addition to its impact on marital quality ( Zuckerman, Lindly, Bethell, & Kuhlthau, 2014). This prompted the researcher to address the topics of the current study closely by using the quantitative research method to reach a deeper understanding of the study topics. The main question of the study: " What is the relationship between marital quality and symptoms of psychological disorders among mothers of autistic children in Nablus Governorate?" The following sub-questions branch out from this question: Questions related to the quantitative method: 1. What is the level of psychological disorders among mothers of autistic children in Nablus Governorate? 2. What is the level of marital quality among mothers of autistic children in Nablus Governorate? 3. Does the level of psychological disorders among mothers of autistic children in Nablus Governorate vary based on variables such as (child's gender, mother's age, child's age, educational qualification, severity of autism diagnosis, and marital status)? 4. Does the level of marital quality among mothers of autistic children in Nablus Governorate vary based on variables such as (child's gender, mother's age, child's age, educational qualification, severity of autism diagnosis, and marital status)? Importance of the study The importance of the study lies in the importance of the target group in the current study, which is children with autism spectrum disorder, which is one of the most difficult 28 disorders and requires special care, in addition to mothers of children with autism spectrum disorder, especially since they live in Palestine, which suffers from the Zionist occupation that stifles any opportunity for prosperity and achieving sustainable development. The importance of the study also stems from the importance of the topics it addresses, which are marital quality and its relationship to symptoms of psychological disorders among mothers of autistic children in Nablus Governorate. The importance of the current study stems from the fact that it provides information that will be revealed using the quantitative approach, which will provide us with information about autistic children and their mothers in Palestine in general and the city of Nablus in particular. The researcher hopes that the current study will come out with a set of recommendations and suggestions that may find practical application and be taken into consideration in light of the results by specialists working with autistic children and their mothers in order to improve their reality in Palestine in general and the city of Nablus in particular. 1.5 Objectives of the study 1. To know is the relationship between marital quality and symptoms of psychological disorders among mothers of autistic children in Nablus Governorate. 2. To know is the level of psychological disorders among mothers of autistic children in Nablus Governorate. 3. To know the level of marital quality among mothers of autistic children in Nablus Governorate. 4. To know Does the level of psychological disorders among mothers of autistic children in Nablus Governorate vary based on variables such as (child's gender, mother's age, child's age, educational qualification, severity of autism diagnosis, and marital status). 29 5-To know Does the level of marital quality among mothers of autistic children in Nablus Governorate vary based on variables such as (child's gender, mother's age, child's age, educational qualification, severity of autism diagnosis, and marital status). 30 Chapter Two Methodology This chapter outlines the methods and procedures used in the study, including the chosen methodology, study design, population, and sample. It also details the steps involved in developing the study tools, their characteristics, and the statistical tests applied to analyze the study data. 2.1 Study design To address the study objective of examining marital quality and its relationship to symptoms of psychological disorders among mothers of autistic children, a cross- sectional research design was employed. This design was chosen based on the nature of the research and the type of information required. Specifically, a descriptive correlational approach was utilized, as it is the most appropriate method for achieving the study's objectives. The descriptive correlational approach allows for a thorough understanding and accurate description of the phenomenon by drawing on previous research and literature. Beyond merely collecting data, this approach analyzes and establishes relationships between the study variables, enabling the study to derive meaningful conclusions (Wang & Cheng, 2020). 2.2 Study population A total of 97 mothers of children diagnosed with ASD were selected from centers specializing in supporting them in the Nablus Governorate to participate in this study. The questionnaire was distributed both electronically and in paper form, and all 97 participants successfully completed it. 2.3 Study sample A convenience sample of mothers of children with autism spectrum disorder (ASD) from the Nablus Governorate was selected for this study. Data were collected using an electronic questionnaire via the Google Forms platform, as well as paper questionnaires distributed through various centers. The study sample consisted of 97 mothers of children 31 formally diagnosed with ASD in the Nablus Governorate, all of whom completed either the electronic or paper version of the questionnaire. Table 2 Distribution of the study sample based on its independent variables Variable Level Number Percentage Mother's age Less than 19 0 0% 19-25 8 8.2% 26-35 54 55.7% 36 and over 35 36.1% Total 97 100.0 Child's gender Male 62 63.9% Female 35 36.1% Total 97 100.0 Child's age 3-6 39 40.6% 7-12 44 45.8% 13-18 10 10.4% 18 and over 4 3.2% Total 97 100.0 Mother's educational qualification Tawjihi and below 34 35.1% Diploma 10 10.3% Bachelor's 49 50.5% Master's and above 4 4.1% Total 97 100.0 Marital status Married 92 95.8% Divorced 5 4.2% Widow 0 0% Total 97 100.0 The severity of autism that your child was diagnosed with? Mild 28 29.2% Moderate 41 42.7% Severe 8 7.3% Unsure 20 20.8% Total 97 100.0 32 2.4 Instruments of study and validation indicators To achieve the study objectives and address its questions, two data collection tools were utilized after a thorough review of relevant previous studies. These tools are: - Marital Quality Scale: I used the Marital Quality Scale for mothers of children with ASD, using the Marital Quality Scale developed by (Lamphun, 2021). - Depression anxiety stress scale (DASS-21): questionnaire, an internationally validated tool used to assess an individual’s mental health based on negative emotional states of depression, anxiety, and stress experience over the past week (Shrivastava & Rajan, 2018) 2.4.1 Marital Quality Scale The Marital Quality Scale for Mothers of Children with Autism Spectrum Disorder developed by Lamphon (2021) was used to determine the nature and type of marital quality in the presence of a child diagnosed with ASD. The marital quality scale consists of 30 items, each measured on a five-point Likert scale, ranging from 0 ("very unsatisfactory") to 4 ("very good"). 1. Construct Validity The construct validity of the scale was assessed by applying it to a pilot sample of 30 mothers of children with autism spectrum disorder in Nablus. The correlation coefficients between each item and the total score of the scale were calculated. The finalized scale comprised all 30 items, as no item was removed due to a lack of significant correlation with the total score of the Marital Quality Level Scale at the significance level of α = 0.05. This demonstrates that the scale possesses appropriate construct validity. The coefficients ranged between (0.135-0.877). 33 Table 3 The correlation coefficients of each item with the total score Item Number Correlation with the total score Item Number Correlation with the total score Item Number Correlation with the total score 1 0.767** 11 0.584** 21 0.843** 2 0.702** 12 0.595** 22 0.868** 3 0.636** 13 0.877** 23 0.798** 4 0.694** 14 0.387** 24 0.747** 5 0.758** 15 0.480** 25 0.867** 6 0.526** 16 0.688** 26 0.704** 7 0.834** 17 0.400** 27 0.135** 8 0.790** 18 0.688** 28 0.841** 9 0.866** 19 0.812** 29 0.340** 10 0.822** 20 0.786** 30 0.402** **Statistically significant at (α = 0.01), *Statistically significant at (α = 0.05). 2. Reliability of the Marital Quality Level Scale The internal consistency of the Marital Quality Level Scale was assessed using Cronbach's Alpha. The reliability coefficient was found to be (0.955) indicating a high level of reliability and confirming the scale's suitability for measuring marital quality. 2.4.2 Depression anxiety stress scale (DASS-21) questionnaire, an internationally validated tool used to assess an individual’s mental health based on negative emotional states of depression, anxiety, and stress experience over the past week (Shrivastava & Rajan, 2018), the scale was modified to incorporate a five-point Likert scale to better align with the objectives of the study. The DASS consists of 21 items divided into three subscales, each containing seven questions. The depression subscale assesses hopelessness, devaluation of life, self- deprecation, lack of interest, and rigidity. The anxiety subscale assesses panic attacks, musculoskeletal effects, and subjective experience of anxious affect. The stress subscale assesses levels of chronic difficulty in relaxing, nervous arousal, easily upset, irritability, and impatience. Each question is measured on a five-point Likert scale ranging from 0 (“never”) to 4 (“Always”). 34 1. Construct Validity The construct validity of the Psychological Disorders Scale was evaluated by administering it to a survey sample of 30 mothers of children with autism spectrum disorder in Nablus. Correlation coefficients were calculated between each item and the total score of the scale. The final scale comprised 21 items, as no item was removed, indicating that the tool demonstrates appropriate construct validity. The correlation coefficients between the items and the total score of the Psychological Disorders Scale ranged between (0.590-0.826). Table 4 The correlation coefficients of each item with the total score Item Number Correlation with the total score Item Number Correlation with the total score Item Number Correlation with the total score 1 0.590** 8 0.698** 15 0.808** 2 0.684** 9 0.826** 16 0.753** 3 0.765** 10 0.657** 17 0.722** 4 0.752** 11 0.738** 18 0.704** 5 0.662** 12 0.681** 19 0.725** 6 0.698** 13 0.756** 20 0.799** 7 0.687** 14 0.682** 21 0.668** **Statistically significant at (α = 0.01), *Statistically significant at (α = 0.05). 2. Reliability of the Psychological Disorders Scale The internal consistency of the Psychological Disorders Scale was assessed using Cronbach's alpha. The reliability coefficient was calculated to be (0.955) indicating a high level of reliability and confirming the scale's suitability for measuring psychological disorders. 2.5 Study procedures This study was conducted sequentially according to the following steps: • Defining and delimiting the study population. • Determining the sample size and selecting the sampling method. 35 • Distributing the preliminary study tool to a pilot sample using both electronic and paper questionnaires. • Calculating validity and reliability coefficients and finalizing the study tools. • Administering the finalized study tools to the main sample using electronic and paper questionnaires. • Collecting and organizing the data using the SPSS program. • Analyzing the data and addressing the study questions. • Interpreting the results, discussing findings, and providing recommendations. 36 Chapter Three Results 3.1 Introduction Chapter three presents the results of the questions and hypotheses of the study to achieve the purpose of the study by using the Statistical Package for Social Sciences (SPSS). The data were gathered from the tools of the study. Additionally, findings and conclusions addressed the outcomes of data analysis. The statistical analysis revealed the following results: 3.2 Results of study 3.2.1 Results Related to the First Question What is the level of psychological disorders among mothers of autistic children in Nablus Governorate? In order to answer this question, the researcher calculated the means, standard deviations, percentages of the items in the psychological disorders Scale and its domains were calculated. The researcher determined three intervals to distinguish between high, moderate, and low levels. The range was calculated as (5-1 = 4) and then divided into three intervals (4/3 = 1.33), resulting in an interval length of (1.33). Accordingly, the researcher adopted the following classification for the scores as following: 1. The arithmetic mean ( 1.00 – 2.33) has a low degree. 2. The mean (2.34 – 3.67) has a moderate degree. 3. The mean (3.68 – 5.00) has a high degree. 37 Table 5 Means, standard deviations, percentages and estimations of the items and domains of the level of psychological disorders among mothers of autistic children in Nablus Governorate No. M SD % Level 1 2.90 1.056 58 Moderate 2 2.19 1.112 43.8 Low 3 2.89 1.069 57.8 Moderate 4 2.27 1.271 45.4 Moderate 5 2.78 1.139 55.6 Moderate 6 2.87 1.124 57.4 Moderate 7 2.20 1.222 44 Low 8 3.35 1.100 67 Moderate 9 2.08 1.256 41.6 Low 10 2.56 1.099 51.2 Moderate 11 3.11 1.079 62.2 Moderate 12 3.11 1.075 62.2 Moderate 13 3.10 1.110 62 Moderate 14 2.65 1.104 53 Moderate 15 2.10 1.271 42 Low 16 3.04 1.127 60.8 Moderate 17 2.08 1.311 41.6 Low 18 3.20 1.272 64 Moderate 19 2.67 1.289 53.4 Moderate 20 2.65 1.354 53 Moderate 21 2.59 1.305 51.8 Moderate Total score 2.68 0.848 53.6 Moderate Table 5 shows that the level of psychological disorders among mothers of autistic children in Nablus Governorate achieved a mean of (2.68), which means that there is medium level of psychological disorders among mothers of autistic children in Nablus Governorate. In addition, the results of the previous table indicate that the level of psychological disorders among mothers of autistic children in Nablus Governorate from low to moderate. The highest-rated item was item (8), which stated, " I felt that I was using a lot of nervous energy" receiving a medium estimation with a mean of (3.35) and a standard deviation of (1.1), with a percentage of (67%). On the other hand, the lowest-rated item were items (9, 38 17), which stated, I was worried about situations in which I might panic and make a fool of Myself ", and “I felt I wasn’t worth much as a person” receiving a low estimation with a mean of (2.08) and a standard deviation of (1.272), with a percentage of (41.6%). In reality, it is not possible to make an accurate judgment about the levels of psychological disorders among mothers of autistic children in Nablus Governorate based solely on arithmetic means. This judgment does not take into account standard deviations. A more precise estimation of psychological disorders levels can be achieved using the (One Sample t-Test), which is used to compare the sample mean with the theoretical or hypothesized population mean. Since the correction system used is the five-point Likert scale, the benchmark value (3) is considered the dividing point between high and low estimations. Accordingly, the sample means in the Psychological Needs Satisfaction Scale were compared with the benchmark value (3), as shown in the following table. Table 6 Results of the One Sample t-Test for the difference between the sample means and the population mean the level of psychological disorders among mothers of autistic children in Nablus Governorate (n = 97) No. Domain M SD T- Value D.F Sig. 1 Anxiety Disorder 2.31 1.018 5.328 - 96 0.000 2 Stress Disorder 3.04 0.817 7.037 - 96 0.000 3 Depressive Disorder 2.73 0.889 6.891 - 96 0.000 Total Scores of psychological disorders 2.68 0.848 -6.071 96 0.000 According to the results shown in the table above, the arithmetic mean of psychological disorders among mothers of autistic children in Nablus Governorate was (2.68) with a standard deviation of (0.848). When comparing this mean with the benchmark value (3), the calculated t-value was found to be negative and statistically significant (t = -6.071, α < .001). This indicates that the level of psychological disorders among mothers of autistic children in Nablus Governorate was significantly lower than the hypothetical mean, suggesting that the sample does not suffer from psychological disorders. The arithmetic mean for anxiety disorder was (2.31) with a standard deviation of (1.018). When comparing this mean with the benchmark value (3), the calculated t-value was 39 found to be negative and statistically significant (t = -5.328, α < .00). This indicates that the level of anxiety disorder among mothers of autistic children in Nablus Governorate was significantly lower than the hypothetical mean, meaning that the sample does not suffer from anxiety disorder. The arithmetic mean for stress disorder was (3.04) with a standard deviation of (.817). When comparing this mean with the benchmark value (3), the calculated t-value was found to be negative and statistically significant (t = -7.037, α < .00). This indicates that the level of stress disorder among mothers of autistic children in Nablus Governorate was significantly lower than the hypothetical mean, meaning that the sample does not suffer from stress disorder. Moreover, the arithmetic mean for depressive disorder was (2.73) with a standard deviation of (.889). When comparing this mean with the benchmark value (3), the calculated t-value was found to be negative and statistically significant (t = -6.891, α < .00). This indicates that the level of depressive disorder among mothers of autistic children in Nablus Governorate was significantly lower than the hypothetical mean, meaning that the sample does not suffer from depressive disorder. 3.2.2 Results Related to the Second Question What is the level of marital quality among mothers of autistic children in Nablus Governorate? In order to answer this question, the researcher calculated the means, standard deviations, percentages of the items in the marital quality Scale and its domains were calculated. The researcher determined three intervals to distinguish between high, moderate, and low levels. The range was calculated as (5-1 = 4) and then divided into three intervals (4/3 = 1.33), resulting in an interval length of (1.33). Accordingly, the researcher adopted the following classification for the scores as following: 1. The arithmetic mean ( 1.00 – 2.33) has a low degree. 2. The mean (2.34 – 3.67) has a moderate degree. 3. The mean (3.68 – 5.00) has a high degree. 40 Table 7 Means, standard deviations, percentages and estimations of the items and domains of the level of marital quality among mothers of autistic children in Nablus Governorate No. M SD % Level 1 3.31 1.185 66.2 Moderate 2 2.76 1.203 55.2 Moderate 3 3.02 1.322 60.4 Moderate 4 3.57 1.322 71.4 Moderate 5 3.85 1.074 77 High 6 3.94 1.478 78.8 High 7 3.57 1.155 71.4 Moderate 8 3.10 1.081 62 Moderate 9 3.35 1.267 67 Moderate 10 3.65 1.234 73 Moderate 11 3.17 1.063 63.4 Moderate 12 3.22 1.103 64.4 Moderate 13 3.74 1.394 74.8 High 14 3.43 1.274 68.6 Moderate 15 2.94 1.375 58.8 Moderate 16 3.77 1.335 75.4 High 17 3.79 1.151 75.8 High 18 3.22 1.317 64.4 Moderate 19 3.32 1.380 66.4 Moderate 20 3.21 1.421 64.2 Moderate 21 3.25 1.299 65 Moderate 22 3.07 1.307 61.4 Moderate 23 3.19 1.332 63.8 Moderate 24 3.77 1.192 75.4 High 25 3.66 1.383 73.2 Moderate 26 4.03 1.350 80.6 High 27 2.77 1.418 55.4 Moderate 28 3.49 1.248 69.8 Moderate 29 3.94 1.303 78.8 High 30 3.90 1.183 78 High Total score 3.40 0.874 68 moderate 41 Table 7 shows that the level of marital quality among mothers of autistic children in Nablus Governorate achieved a mean of (3.40), which means that there is moderate level of marital quality among mothers of autistic children in Nablus Governorate. In addition, the results of the previous table indicate that the level of marital quality among mothers of autistic children in Nablus Governorate from moderate to high. The highest-rated item was item (26), which stated, " The idea of divorce from my partner crosses my mind" receiving a high estimation with a mean of (4.03) and a standard deviation of (1.350), with a percentage of (80.6%). On the other hand, the lowest-rated item were items (2), which stated, “I talk with my partner about our intimate relationship”, receiving a medium estimation with a mean of (2.76) and a standard deviation of (1.203), with a percentage of (55.2%). In reality, it is not possible to make an accurate judgment about the levels of marital quality among mothers of autistic children in Nablus Governorate based solely on arithmetic means. This judgment does not take into account standard deviations. A more precise estimation of marital quality levels can be achieved using the (One Sample t- Test), which is used to compare the sample mean with the theoretical or hypothesized population mean. Since the correction system used is the five-point Likert scale, the benchmark value (3) is considered the dividing point between high and low estimations. Accordingly, the sample means in the Psychological Needs Satisfaction Scale were compared with the benchmark value (3), as shown in the following table. Table 8 Results of the One Sample t-Test for the difference between the sample means and the population mean the level of marital quality among mothers of autistic children in Nablus Governorate (n = 97) Domain M SD T- Value D.F Sig. Total Score of marital quality 3.40 0.873 2.297 96 0.024 According to the results shown in the table above, the arithmetic mean of marital quality among mothers of autistic children in Nablus Governorate was (3.40) with a standard deviation of (0.873). When comparing this mean with the benchmark value (3), the calculated t-value was found to be positive and statistically significant (t = 2.297, 42 α < 0.05). This indicates that the level of marital quality among mothers of autistic children in Nablus Governorate was significantly lower than the hypothetical mean, this indicates that the marital quality of the sample participants was moderate. 3.2.3 Results Related to the Third Question What is the relationship between marital quality and symptoms of psychological disorders among mothers of autistic children in Nablus Governorate? In order to answer this question, the researcher calculated using Pearson Correlation Test to determine the relationship between marital quality and symptoms of psychological disorders among mothers of autistic children in Nablus Governorate. Table 9 Results of Pearson Correlation Test between marital quality and psychological disorders among mothers of autistic children in Nablus Governorate among mothers of autistic children in Nablus Governorate (n = 97) Psychological disorders Domains Marital quality Sig. Correlation Coefficient Psychological disorders and marital quality 0.006 -0.276 Anxiety Disorder 0.023 -0.231 Stress Disorder 0.040 -0.212 Depressive Disorder 0.001 -0.346 According to the results shown in the table above, It is evident that the value of (α = 0.006) is smaller than 0.05, meaning that the null hypothesis is rejected and there is a significant correlation between psychological disorders and marital quality. Given the correlation coefficient of -0.276, which is negative, this indicates an inverse relationship -meaning that as marital quality increases, psychological disorders decrease-. Examining the three dimensions of the scale separately, the results remain consistent, the table shows that anxiety disorder has a value of (α = 0.006), which is smaller than 0.05, indicating a significant correlation. With a correlation coefficient of -0.231, the relationship is inverse. Similarly, stress disorder has a value of (α = 0.040), which is smaller than 0.05, indicating a significant correlation, with a correlation coefficient of - 43 0.212, signifying an inverse relationship. Lastly, depression disorder has a value of (α = 0.001), which is also smaller than 0.05, indicating a significant correlation, with a correlation coefficient of -0.346, the relationship is also inverse. 3.2.4 Results Related to the Fourth Question Does the level of psychological disorders among mothers of autistic children in Nablus Governorate vary based on variables such as (child's gender, mother's age, child's age, educational qualification, severity of autism diagnosis and marital status)? To answer this question, the means and standard deviations of psychological needs were calculated according to the variables of child's gender, mother's age, child's age, educational qualification, and marital status. The following table presents these results. 44 Table 10 Descriptive statistics of the level of psychological disorders among mothers of children with autism in Nablus Governorate according to the variables (child's gender, mother's age, child's age, educational qualification, marital status) (n = 97) Variables NUM Psychological disorders Anxiety Disorder Stress Disorder Depressive Disorder M SD M SD M SD M SD Child's gender Male 62 2.669 0.734 2.299 0.870 3.004 0.746 2.723 0.790 Female 35 2.691 1.031 2.322 1.251 3.099 0.943 2.735 1.056 Mother's age 19- 25 years 8 2.821 1.045 2.535 1.152 3.089 0.887 2.839 1.151 26- 35 years 54 2.778 0.883 2.394 1.036 3.153 0.847 2.835 0.938 36 years and more 35 2.487 0.729 2.122 0.958 2.839 0.733 2.542 0.732 Child's age 3- 6 years 39 2.920 0.985 2.578 1.162 3.270 0.924 2.941 0.975 7-12 years 44 2.580 0.710 2.185 0.916 2.955 0.671 2.647 0.816 13- 18 years 10 2.266 0.619 1.885 0.594 2.685 0.746 2.269 0.648 18 years and more 3 2.746 0.650 2.333 1.109 2.952 0.644 2.952 0.577 Educational qualification Ta