Journal of Autism and Developmental Disorders (2021) 51:3690–3706

https://doi.org/10.1007/s10803-020-04826-4

ORIGINAL PAPER

Interventions to Improve the Mental Health of Mothers of Children

with a Disability: Systematic Review, Meta‑analysis and Description
of Interventions
Helen M. Bourke‑Taylor1   · Den‑Ching Angel Lee2 · Loredana Tirlea3 · Kahli Joyce1 · Prue Morgan4 ·
Terrence P. Haines2

Accepted: 1 December 2020 / Published online: 3 January 2021

© The Author(s), under exclusive licence to Springer Science+Business Media, LLC part of Springer Nature 2021

Abstract
To investigate the effectiveness of interventions that aim to improve the mental health of mothers of children with disabilities.
Seven databases were searched. Interventions incorporated primarily cognitive-behavioural, psychoeducation, mindfulness or
support-group approaches. The Template-for-Intervention-Description-and-Replication guided descriptions. Meta-analyses
using a random effect model of randomized controlled trials assessed intervention effects on parenting stress and mental
health. Of the 1591 retrieved papers, 31 met criteria to be appraised and 17 were included in the meta-analysis. Cognitive-
behavioural approaches reduced parenting stress [2 studies, n = 64, pooled Standardized-Mean-Difference (SMD) = 0.86,
95% CI (0.43, 1.29)] and improved mental health [3 studies, n = 186, pooled SMD = 1.14, 95% CI (0.12, 2.17)], psychoe-
ducation approaches improved mental health [2 studies, n = 165, SMD = 0.60, 95% CI (0.17, 1.03)]. Cognitive-behavioural
and psychoeducation interventions are effective. Further research and clinical guidelines are warranted.

Keywords  Mothers · Childhood disability · Mental health · Wellbeing

Introduction

Raising a child with a lifelong disability requires time,

Supplementary information  The online version of this article
(https​://doi.org/10.1007/s1080​3-020-04826​-4) contains
supplementary material, which is available to authorized users.
* Helen M. Bourke‑Taylor
helen.bourke‑taylor@monash.edu
1
Occupational Therapy Department, School of Primary
and Allied Health Care, Faculty of Medicine Nursing
and Health Sciences, Monash University, Peninsula Campus,
Building G, Level 4, McMahons road, Frankston, VIC 3199,
Australia
2
School of Primary and Allied Health Care, Faculty
of Medicine Nursing and Health Sciences, Monash
University, Peninsula Campus, Building G, Level 3,
McMahons road, Frankston, VIC 3199, Australia
3
Faculty of Health, Arts, and Design, Swinburne University
of Technology, PO Box 218, Hawthorn 3122, Australia
4
Physiotherapy Department, School of Primary and Allied
Health Care, Faculty of Medicine Nursing and Health
Sciences, Monash University, Peninsula Campus, Building B,
McMahons road, Frankston, VIC 3199, Australia
attention and development of skills to assist the child to be
healthy and participate in usual childhood activities (Bourke-
Taylor et al. 2010; Green 2007). Types of higher care needs
may include: provision of medical care; parents adopting
the roles of teacher and therapist; managing equipment and
technology on the child’s behalf; navigating a separate ser-
vice system to typically developing children; and managing
the impact of childhood disability on other family members
(Bourke-Taylor et al. 2010). Childhood disability refers to
any lifelong condition or diagnosis that results in atypical
care needs and activity limitations or participation restric-
tions. An international forum of experts from medicine, dis-
ability, education and policy, advised on future services for
children with a disability globally. Recommendations were
made for a more inclusive and healthy future for children
with disabilities and their families through provision of psy-
chosocial interventions to support families and programs to
support long term parental mental health. Importantly, the
forum acknowledged that “family mental health influences
the developmental trajectory of children” and that “ensuring

13
Vol:.(1234567890)
Journal of Autism and Developmental Disorders (2021) 51:3690–3706 3691
that parents and caregivers have access to affordable, quality
mental health services helps to prevent poor outcomes for
children.”(p. 1) (Collins et al. 2017).
The mental health status and stress experienced by moth-
ers of children with disabilities has been studied extensively
and action to better support mothers has been prioritised as
a target area for research to policy translation (Collins et al.
2017). In studies, mental health may refer to a diagnosed
mental health condition, or a person’s subjective emotional,
psychological, or social well-being. Stress can refer to per-
ceived daily stress or stress related specifically to parenting
(Hayes and Watson 2013) and is a basis to the caregiver pro-
cess stress model (Raina et al. 2004). Distress and subjective
mental health status are also reported in studies, depending
on the measurement tool used in data collection (Minnes
et al. 2015). In addition to mental health disparity, there is
also evidence that mothers experience higher rates of physi-
cal health difficulties including chronic medical conditions
(Brehaut et al. 2009; Chambers and Chambers 2015). In such
research, ‘health’ may be specific to conditions such as back
pain or cardiovascular disease, or mothers’ subjective health
status. Mental health, health, stress and parenting stress are
interrelated concepts that are reported to occur with high
frequency in this population (Masefield et al. 2020).
Estimates of the incidence of mental health conditions are
reported to be higher among mothers of children with a dis-
ability, than the general population. Recent estimates from
an administrative dataset of mothers of children with devel-
opmental disabilities in Canada found that rates of depres-
sion ranged from 74% (N = 6999, in period 1990–1995)
to 63% (N = 5956, in period 2000–2005) (Marquis et al.
2020a). So-described “mental health problems other than
depression” (p. 174) were similarly as prevalent with 65%
and 51%, respectively (Marquis et al. 2020a). Another Cana-
dian population based administrative sample of over 25,000
mothers of children with developmental disabilities deliv-
ered findings about the prevalence of mental health condi-
tions. The researchers found that 83% of mothers had been
diagnosed with depression or another mental health condi-
tion, that mothers of children with foetal alcohol syndrome
had the highest risk and that mothers of girls with develop-
mental disabilities had a higher risk for depression (Marquis
et al. 2020b). A population based study of mothers of chil-
dren with autism in the USA found that mothers (n = 364)
reported feeling more stressed and were more likely to report
“poor or fair” mental health, than mothers without a child
with autism (N = 61,772) (Montes and Halterman 2007).
In the same study, mothers of children with autism agreed
that their child was harder to care for and that mothers had
‘given up her life to meet the child’s needs’ at higher rates
(p < 0.001), (Montes and Halterman 2007, p. e1043).
Research about maternal stress and mental health has
been conducted within childhood disability groupings such
as mothers of children with cerebral palsy (Raina et al. 2005;
Sawyer et al. 2011), intellectual disability (Fairthorne et al.
2015) or autism (Montes and Halterman 2007). Childhood
disability refers to any condition acquired or present in child-
hood that results in greater dependence on adults for care,
health, safety and participation compared to other similar
aged children. A recent systematic review investigated psy-
chopathology related to parents of children with autism and
found higher incidence of depression (31%), anxiety (33%)
and obsessive compulsive disorder (OCD, 10%) (Schnabel
et al. 2020). The proportion estimations for depression and
anxiety were deemed to be significantly higher than the
global prevalence and OCD was higher than the national
prevalence in the USA and Australia. Fairthorn et al. (2015,
2016) and Marquis et al. (2020b) found that mothers of chil-
dren with Down Syndrome had lower incidence of psychiat-
ric diagnoses compared to mothers of children with intellec-
tual disability and autism. Research in the UK, investigated
the relationships between parental (N = 888) mental health
and parenting a child with intellectual disability. The study
found that parents had significantly higher emotional dis-
tress compared to the UK general population, and that child
factors such as emotional and social difficulties impacted
parental distress (Baker et al. 2020).
The aforementioned research is evidence that the health,
stress and wellbeing of mothers of children with a disability
is extensive. The evidence of health and wellbeing disparity
is irrefutable, indicating that such mothers of children with
high care needs require supports or interventions that can
ameliorate stress and support overall health, mental health
and wellbeing. Outcomes for mothers include many inter-
related and often interchangeable concepts, (i.e. distress
stress, parenting stress, emotional distress, poor mental
health, subjective mental health). Therefore, investigating
what is effective, for whom and for which outcomes needs
to include all such terms.
Currently, there is no available synthesis of effective
programs that improve maternal outcomes. Certainly, the
type, timing, efficacy of interventions and nature of services
(i.e. provided within paediatric or associated with paediatric
13

3692
services), remains under-developed (Lindo et al. 2016). Due
to the current lack of guidelines and evidence about pro-
grams that primarily aim to support better outcomes for
mothers, there is a need to gather and synthesise the avail-
able body of evidence to understand both how previous pro-
grams have been designed and how effective the programs
were. Therefore, the aims of this systematic review and
metanalysis are twofold:
Aim 1. To describe the content of empirically researched
intervention programs that primarily aim to reduce stress
and improve health, mental health and wellbeing of mothers.
Aim 2 To synthesise the available evidence examin-
ing whether interventions evaluated in studies that have
employed randomised controlled trial or a group compara-
tive design, have an impact on maternal stress, health, men-
tal health and wellbeing outcomes.
Methods
The protocol was registered with PROSPERO registration
number CRD42020110965.
Design and Procedure
This study is a systematic review and meta-analysis. Spe-
cifically, the research question was: For mothers of children
with disability, what is the most effective intervention com-
pared to no or an alternative intervention, for stress reduc-
tion, improved health, mental health and wellbeing?
Search Approach
A database search using Ovid Medline, PsychINFO,
Embase, Emcare, Cochrane central register of controlled
trials, CINAHL Plus and Proquest was undertaken for this
systematic review, with a most recent update on March 11,
2020.
Search terms were developed collaboratively following
consideration of known research and identifying terms and
collective agreement among authors). MeSH keywords were
used in the search strategy based on a PICO (Participant,
Intervention, Control, Outcome) model (see Appendix 1).
Preferred Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA) guidelines were followed for the
literature searching process. In addition, the reference list
of articles were hand checked for relevant studies. A grey
literature search was not performed for this review.
Study Selection Criteria and Process
Informed by the variability in terms already present in cur-
rent literature (see introduction), we selected a study for
13
Journal of Autism and Developmental Disorders (2021) 51:3690–3706
inclusion if it: (a) primarily reported maternal mental health
or health outcomes measured by validated instruments; (b)
primarily reported well-being outcomes of mothers of chil-
dren with a disability, for example quality of life, stress, life
satisfaction, self-efficacy/empowerment, coping styles, posi-
tive health behaviors or perceived social support measured
by validated instruments; (c) was an intervention study of
any quantitative research design; (d) was published in Eng-
lish. A study was excluded if it: (a) examined interventions
that were pharmacological agents; (b) examined interven-
tions that were primarily focused on the children with dis-
abilities; (c) included outcomes that were primarily meas-
uring child-related factors; (d) was a protocol or theoretical
paper; (e) included mothers who had typically developing
children only; or (f) if the dataset was incomplete or inad-
equate, including after contacting the authors and receiving
no additional data.
The process of searching and identification of stud-
ies followed a five step process: (1) Systematic search of
data bases; (2) All retrieved articles were saved to Endnote
reference manager and imported into an online screening
and data extraction tool (Covidence 2020); (3) Two authors
separately reviewed all titles and abstracts to exclude papers
clearly not meeting inclusion criteria with conflicts resolved
through discussion; (4) Two authors separately reviewed
full text articles to apply inclusion and exclusion criteria
and record reasons for exclusion of study (main reasons
listed). Conflicts were resolved through discussion and a
third reviewer; and (5) Two authors checked the research
design of all remaining papers. Papers were checked for suf-
ficient and adequate data, with authors contacted and papers
excluded if authors did not respond, or if data were deemed
incomplete or inadequate. Firstly, papers were collated for
the descriptive aspect of this review (aim 1). Secondly, only
papers with randomised control trials (RCTs) and group
comparative design studies were identified for inclusion
in the metanalysis or sensitivity analysis (aim 2). For con-
sistency, group comparative design studies were classified
according the dictionary from the Effective Public Health
Practice Project (EPHPP) (Armijo-Olivo et al. 2012), as the
tool was utilised for the assessment of methodological qual-
ity (see section below).
Categorisation of Interventions in all Studies in this
Review
Retrieved studies were categorised in several ways to
align with aims 1 and 2 of this review. Firstly, data were
extracted using conventional categories and tabulated (i.e.
study design, population, interventions received by groups
or control group, length of intervention etc.). Interventions
were reviewed closely and then classified by the approach
used for the intervention. The approach was derived through
Journal of Autism and Developmental Disorders (2021) 51:3690–3706 3693
consideration of the type of intervention, and the nature and
theoretical underpinnings of the intervention. Four authors
from three allied health disciples (psychology, occupational
therapy, physiotherapy) agreed on the classification of the
different approaches. For the purposes of this review, the
approaches with abbreviated titles were defined as:
1. Cognitive-behavioural approach: Cognitive-behavioural
and other psychological approaches referred to any form
of psychotherapy that operated under the principle that
thoughts, feelings and behaviours are interconnected and
uses cognitive strategies to influence behaviour change.
2. Psychoeducation approach: Psychoeducation or other
education approaches referred to programs providing
education about health (including health promotion),
mental health, stress, anxiety, coping, etc. to educate or
facilitate client’s knowledge and understanding about
thought patterns, emotions, health and coping strategies.
3. Mindfulness approach: Mindfulness and other relaxation
techniques referred to relaxation, breathing, meditation,
creativity, or movement techniques aimed specifically
at stress reduction and emotional control through mind
body connection.
4. Support group approach: Support groups referred to
approaches that relied on peer engagement and group
interactions with discussions around supports, coping
and information sharing.
Based on the intervention described in the design,
papers were then classified and allocated to an approach
by two authors independent of each other. Any disagree-
ment was resolved through discussion with a third author
who also verified allocation of all papers to the intervention
approaches (researcher with a PhD in psychology). After
consensus was reached, studies were then classified as using
one single approach if the majority of the described interven-
tion fit with the definitions. If interventions blended several
approaches but were more than 75% one approach, the study
was described as using a single approach. This was achieved
by reviewing the intervention descriptions and time alloca-
tion in activities in each paper. When the study described an
intervention that was more equally distributed between two
or more types of approaches, the intervention was classified
as a combined approach. To address aim 1 of this review,
all papers were classified under the main approach used in
the intervention and as single or combined. Tables were then
configured to display aforementioned study characteristics:
characteristics of the study; approach used in the interven-
tion; and whether single or combined.
Description of Interventions and Designs for all
Studies in this Review
The Template for Intervention Description and Replication
(TIDieR) checklist (Hoffmann et al. 2014) was used to guide
extraction of the characteristics of interventions in order to
collate an overview (aim 1 of this review). According to
TIDieR, the key characteristics of studies include where the
intervention was provided (location/setting), what was pro-
vided (content), how it was provided (medium of delivery),
who delivered the intervention (facilitators), when/length
of intervention (duration) and How well the intervention
was delivered (fidelity). Extracted information was used
to provide a descriptive overview of interventions only, as
outcomes were considered inadequate for reporting if they
were not rigorous enough for inclusion in the metanalyses.
All interventions from the included studies were included in
a TIDieR table to address aim 1 of this review.
Assessment of Methodological Quality for all
Studies in this Review
All papers were appraised for methodological quality. Two
authors performed the quality assessment using the Qual-
ity Assessment Tool for Quantitative Studies (QATQS) and
dictionary from the Effective Public Health Practice Project
(EPHPP, see https:​ //www.ephpp.​ ca/qualit​ y-assess​ ment-​ tool-
for-quanti​ tativ​ e-studie​ s/) (Armijo-Olivo et al. 2012). Step by
step instructions as described for the EHHPS were applied
to the quality ratings. The components of the tool included:
sample selection (selection bias), study design, identification
and treatment of confounders, blinding of outcome assessors
and of participants, reliability and validity of data collec-
tion methods, and withdrawals and dropouts. Two authors
rated studies as either strong, moderate, or weak using a
standardized guide and dictionary ratings provided by tool
authors. Disagreements were resolved through discussion
until consensus was reached with 100% agreement on the
QATQS categories. The EPHPP dictionary was used to clas-
sify all studies including the group comparative studies, in
this review.
Data Synthesis for Studies Used in the Metanalysis
To address aim 2 of this review, data were extracted and
synthesized from studies set aside for the metanalysis or
sensitivity analysis.
13

3694
Data Extraction Procedure from Randomised
Controlled Trials and Comparative Effectiveness
Studies
Inverse variance random effect meta-analyses were per-
formed for outcomes of randomized controlled trials where
data were available. Separate analyses were undertaken for
mode of intervention based on if they were single or multiple
interventions in these studies. Data from comparative effec-
tiveness studies (studies that did not have a control group or
compared effectiveness of two interventions) were described
separately and were not pooled with RCT studies. The con-
sistency in results between studies in the meta-analyses was
assessed using ­I2 where a value of 0% indicates no heteroge-
neity and larger values show increasing heterogeneity (Hig-
gins et al. 2003).
Measurement of Intervention Effects
Measurement of intervention effects on each outcome where
available were expressed as a standardized mean difference
(SMD) in order that effects from different scales measuring
each outcome could be combined. SMD of “post-test score”
Fig. 1  PRISMA flowchart
representing selection of studies
for research aims 1 and 2
13
Journal of Autism and Developmental Disorders (2021) 51:3690–3706
was defined as the between-group difference in mean values
post-intervention divided by the standard deviation pooled
across intervention and control groups (pooled SD). SMD
of the “change score” was defined as the difference between
within group change scores (pre-minus post) between the
intervention and control group divided by the pooled SD of
the change score. If these data were not presented, but effect
estimates such as regression coefficients and 95% confidence
intervals were reported, a SMD would be calculated based
on these data combined with the sample size. Authors were
contacted directly if all these data were omitted.
To maximize pooling of data, “post-test scores” reported
in these studies were used to calculate a pooled SMD when-
ever possible. This decision was guided by data extraction
because the majority of randomized controlled trials studies
had reported post-test scores. If “post-test scores” were not
reported, data for “change scores” were used to calculate
a pooled SMD. Meta-analyses were conducted separately
for studies that reported “post-test scores” versus “change
scores” consistent with recommendations from the Cochrane
Handbook for conducting meta-analyses (Higgins and Green
2011). Intervention effects at (or as close to) three months
for all reported outcomes were analyzed. For studies that did
Journal of Autism and Developmental Disorders (2021) 51:3690–3706 3695
not have a follow-up assessment at three months, the closest
assessment time point to three months was used.
Meta-analyses were performed to generate pooled effect
estimates for interventions using data from randomized
controlled trials where possible. Sensitivity analyses were
conducted to pool results inclusive of non-randomized con-
trolled trials wherever available to check for potential dif-
ference when adding results from research designs of lower
scientific quality. STATA (version 15) was used for meta-
analyses and whenever possible for sensitivity analyses.
Results
Search terms yielded 4719 papers of which 1560 were
retained for step 3 of the search procedure (see Fig.  1).
Two authors completed necessary full text reviews apply-
ing inclusion criteria and classifying common reasons for
rejection (see Fig. 1). Papers and theses were checked for
sufficient data in the relevant outcomes and trial authors con-
tacted via email for further information on the studies. One
response for further data was received. Overall, 869 papers
investigated mental health/stress in mothers, 792 papers
(91% of papers) used cross sectional or qualitative designs
and 77 papers (9%) included interventions to improve mater-
nal outcomes. Only 31 papers (4%) met inclusion criteria for
aim 1. Figure 1 PRISMA flowchart representing selection of
studies for research aims 1 and 2.
Research designs included 10 RCTs; 4 clinical controlled
trials (CCT); 4 cohort analytic studies; 11 cohort studies and
2 case studies (see Appendix S2). Three papers included in
the review used mixed methods to evaluate the interven-
tion, although only quantitative data were extracted from
the papers. The characteristics of all 31 included studies are
described in Appendix S3.
Description of Characteristics of Studies
The interventions originated from 16 countries: 6 from the
USA (Bazzano et al. 2013; Dykens et al. 2014; Feinberg
et al. 2014; Kirkham et al. 1986; Kirkham and Schilling
1990; Magana et al. 2015); 4 from Australia (Bourke-Taylor
et al. 2019; Lovenfosse and Viney 1999; Osborn et al. 2018;
Wong and Poon 2010); 3 from Taiwan (Hu et al. 2010; Shu
and Lung 2005; Wei et al. 2012a, b); 3 from Iran (Barog
et al. 2015; Izadi-Mazidi et al. 2015; Pourmohamadreza-
Tajrishi et al. 2015); 2 from Sweden (Anclair and Hiltunen
2014; Anclair et al. 2017); 2 from the UK (Arakkathara and
Bance 2019; Lovell et al. 2016) and 2 from Spain (Gonzalez-
Fraile et al. 2019; Lopez-Liria et al. 2019), and one from
South Korea (Lee 2017), India (Thenu & Natesan, 2013),
China (Zhang, Yan, Du, & Liu), Japan (Niinomi et al. 2016),
Hong Kong (Lo et al. 2017), Mexico (Fernández Sánchez
et al. 2020), Kenya (Bunning et al. 2020), Philippines (Arak-
kathara and Bance 2019) and Turkey (Yıldırım and Karakurt
2013) (see Appendix S3 Tables 1–4).
Participants
All studies provided interventions for mothers of children
with a disability (see Appendix S3). Overall, the 31 studies
included 1928 mothers. Nine studies included fathers and
22 included only mothers. Of the studies including fathers,
fathers were the minority of the sample size as follows: 5%
(Wong and Poon 2010); 6% (Lo et al. 2017); 9% (Bunning
et al. 2020); 11% (Malin Anclair et al. 2017); 15% (Lovell
et al. 2016); 23% (Bazzano et al. 2013; Wei et al. 2012a, b);
26% (Hu et al. 2010); and 29% (Thenu and Natesan 2013).
Seven interventions were specifically for mothers of chil-
dren with autism (Anclair and Hiltunen 2014; Feinberg et al.
2014; Izadi-Mazidi et al. 2015; Lovell et al. 2016; Niinomi
et al. 2016; Shu and Lung 2005; Zhang et al. 2014); one
intervention was for mothers of children with cerebral palsy
(Barog et al. 2015); one intervention was for mothers of
children with Down syndrome (Pourmohamadreza-Tajrishi
et al.); twenty-one interventions were for mothers of children
with development or intellectual disabilities (Arakkathara
and Bance 2019; Bazzano et al. 2013; Blake et al. 2019;
Bourke-Taylor et al. 2019; Bunning et al. 2020; Dykens
et al. 2014; Fernández Sánchez et al. 2020; Gonzalez-Fraile
et al. 2019; Hu et al. 2010; Kirkham and Schilling 1990;
Lee 2017; Lo et al. 2017; Lopez-Liria et al. 2019; Loven-
fosse and Viney 1999; Magana et al. 2015; Osborn et al.
2018; Thenu and Natesan 2013; Wei et al. 2012a, b; Wong
and Poon 2010; Yıldırım et al. 2013); and one intervention
included mothers of children with a wider range of health
issues (diabetes, cancer, autism, ADHD) (Anclair et  al.
2017). Although no studies provided specific interventions
directed towards the child (an exclusion criterion in this
systematic review), one study showed a single video about
autism with no follow-up child focused content (Niinomi
et al. 2016).
All studies recruited participants through a paediatric
facility/organisation or were associated with services for
children with a disability. Diverse inclusion and exclusion
criteria were evident (see Appendix S3). All studies included
mothers of children with a disability, although six studies
included mothers who had a mental health condition or
met a criterion on a scale, 5 studies excluded mothers with
a known mental health condition, and 2 studies excluded
mothers with physical health conditions.
Intervention Approaches
Twenty four of the 31 studies implemented a single approach
in the intervention. Three studies implemented single
13

3696
approach interventions in group comparative studies, i.e.
one approach for one group and one approach for the other
group. These studies were Dykens et al. (2014), and Anclair
et al. (2017) both implementing one intervention based in
a cognitive behavioural approach and one intervention
based in a mindfulness approach, Anclair et al. (2017), and
Kirkham et al. 1990 consisting of one intervention based in
a psychoeducation approach and one intervention based in a
parent support group approach. The final four studies amal-
gamated two approaches into a single intervention. Barog
et al. (2015), and Osborn et al. (2018) combined both cog-
nitive-behavioural and mindfulness interventions. Lo et al.
(2017) and Niinomi et al. (2016) combined psychoeducation
and mindfulness interventions.
Studies (n = 24) implementing a single intervention with
a control, waitlist or usual care group included: 8 cogni-
tive-behavioural interventions (Anclair and Hiltunen 2014;
Feinberg et al. 2014; Izadi-Mazidi et al. 2015; Lovell et al.
2016; Lovenfosse and Viney 1999; Thenu and Natesan 2013;
Wong and Poon 2010; Zhang et al.); 11 psychoeducation
interventions (Arakkathara and Blance 2019; Bourke-Tay-
lor et al. 2019; Bunning et al. 2020; Gonzalez-Fraile et al.
2019; Hu et al. 2010; Lee 2017; Lopez-Liria et al. 2019;
Magana et al. 2015; Pourmohamadreza-Tajrishi et al. 2015);
2 mindfulness interventions (Bazzano et al. 2013; Fernán-
dez Sánchez et al. 2020); and 3 support group interventions
(Blake et al. 2019; Shu and Lung 2005; Wei et al. 2012a, b).
Tables 1 to 4 in Appendix S3 present the characteristics of
studies classified by approach.
TIDieR Summary
Detailed descriptions of each study are included in
Tables 1–4 in Appendix S4. To collate a description of the
interventions retrieved from the review, relevant TIDieR
categories (Why, Where, What, How, Who, When, How
well) informed the aggregated summary (see Appendix S4).
Twenty-five interventions were group based (group sizes
ranged from 3 to 50) and six interventions were delivered
one on one. No interventions were online or used telehealth.
Interventions were delivered to mothers with the primary
outcome of stress reduction, improved health and mental
health, wellbeing and coping strategies. All outcome meas-
ures were self-report questionnaires. A range of activities
within the different approaches included therapeutic art-
work, health education or health promotion packages, mas-
sage, dancing, cognitive behavioural therapy and support
groups designed to enable mothers to discuss, disclose, share
emotions and strategies. Interventions were delivered by a
range of practitioners: physicians, psychiatrists, psycholo-
gists, nurses, occupational therapists, and social workers; or
peer mentor mothers (of children with a disability). Interven-
tions ranged in duration from one session only to a series of
13
Journal of Autism and Developmental Disorders (2021) 51:3690–3706
45 to 90 min sessions. Most interventions included groups
of 10 to 12 mothers, delivered 6 to 8, 60 or 90 min sessions
either weekly for 6–8 weeks or spread across a 3–6 month
period.
Approaches included different activities, strategies
or interventions. Examples of the cognitive-behavioural
approach included: groups for role play, modelling, psycho-
therapy, cognitive-behavioural therapy, positive solutions
finding, reframed thinking and individual sessions of writ-
ten emotional disclosure. Examples of the psychoeducation
approach included: group led health education, health pro-
motion and skills training, building skills to problem solve,
stress management, therapeutic artwork to explore feel-
ings, creative artwork alongside psychoeducation, healthy
lifestyle habits, life training skills, social and interpersonal
communication techniques, conflict resolution techniques
and economic empowerment and health. Examples of the
mindfulness approach included: guided relaxation, breath-
ing techniques, massage and dancing, yoga, salsa dancing,
meditation, mindful stretching, mindful sitting and mindful
eating. Examples of the support group approach included:
exploring family relationships, group discussion, sharing of
resources, and mutual support. Approaches are described in
more detail in Supplementary Appendix 4.
Quality Ratings of All Included Studies
The EPHPP tool revealed a range of ratings. Six RCT stud-
ies received a global rating of ‘strong’ (see Appendix S2)
indicating a low risk of bias (Feinberg et al. 2014; Gonzalez-
Fraile et al. 2019; Magana et al. 2015; Wei et al. 2012a, b;
Wong and Poon 2010; Yıldırım et al. 2013). Three RCTs had
a global rating of moderate (Lo et al. 2017; Lopez-Liria et al.
2019; Lovell et al. 2016) and one was appraised as weak
(Pourmohamadreza-Tajrishi et al. 2015). Only two studies
were rated ‘strong’ in every category (Magana et al. 2015;
Yıldırım et al. 2013) and six studies were rated ‘strong’ in
four or more of the seven categories (Dykens et al. 2014;
Feinberg et al. 2014; Lo et al. 2017; Lopez-Liria et al. 2019;
Lee 2017; Wong and Poon 2010). All other studies received
weaker ratings suggesting higher risk of bias. Seventeen
studies were suitable for the metanalysis or sensitivity analy-
sis including all RCTs, all CCTs, and three cohort analytic
studies.
Meta‑analysis of Outcomes in Randomised
Controlled Studies, Controlled Clinical Trials
and Cohort Analytic Studies
Outcome Measures
Instruments that measured the outcomes for mothers of chil-
dren with disabilities were extracted from each study where
Journal of Autism and Developmental Disorders (2021) 51:3690–3706 3697

available. Scales were examined to determine and confirm
the construct measured. The outcome measure used for data
analyses from each study is presented and scoring details
are included in Appendix S5. Outcomes were measured by
various scales in the areas: mental health; quality of life;
parenting stress; life satisfaction; self-efficacy; health related
self-efficacy; coping styles; positive health behaviour; and
social support.
Effect of Interventions Using Single Approaches
Effects of Interventions with a Single Approach
on the Outcome of Parenting Stress (Parent Domain Only)
Post-test scores of parenting stress were reported by two
RCT studies (Lovell et al. 2016; Wong and Poon 2010) and
a non-RCT study (Lovenfosse and Viney 1999) across the
cognitive-behavioural approach in a single intervention, one
RCT study (Lopez-Liria et al. 2019) and a non-RCT study

Fig. 2  Effects of single
intervention using a cognitive
behavioural approach on parent-
ing stress (parent domain scores
only)

Fig. 3  Sensitivity analysis
of studies that used single
intervention using a cognitive
behavioural approach on parent-
ing stress

13

3698
Fig. 4  Sensitivity analysis of
studies with a single interven-
tion using a psychoeducation
approach on parenting stress
(Lee 2017) across the psychoeducation approach in a single
intervention.
Pooled data from Wong and Poon (2010), and Lovell
et al. (2016) showed an effect of their intervention in reduc-
ing parenting stress among mothers of children with disabili-
ties [SMD = 0.86, 95% CI (0.43, 1.29)] (see Fig. 2).
A sensitivity analysis was conducted to include the data
reported by Lovenfosse et al. 1999, (see Fig. 3). This did
not change the results substantially [SMD = 0.83, 95% CI
(0.43, 1.24)].
Lopez-Liria et al 2019 was the only RCT included that
used a psychoeducation approach and reported a parent-
ing stress outcome [ES = 0.54, 95% CI (0.23, 0.86)] and
hence no meta-analysis could be conducted. However, a
sensitivity analysis was possible to incorporate the results
from Lee 2017, a cohort analytic study (non-RCT, with
an intervention group and a control group) study report-
ing this intervention and the outcome with that of Lopez-
Liria et al. 2019. Sensitivity analysis showed an effect of
their interventions using the psychoeducation approach on
parenting stress [SMD = 0.54, 95% CI (0.23, 0.86)], see
Fig. 4.
Effects of Interventions Using a Single Approach
on the Outcome of Mental Health
Post-test scores of mental health were reported by three RCT
studies (Feinberg et al. 2014; Lovell et al. 2016; Wong and
Poon 2010) across single interventions using a cognitive-
behavioural approach, three RCT studies (Magana et al.
2015; Pourmohamadreza-Tajrishi et al.; Yıldırım et al. 2013)
and two non-RCT studies (Hu et al. 2010) across the single
13
Journal of Autism and Developmental Disorders (2021) 51:3690–3706
interventions using a psychoeducation approach, and one
non-RCT study across the single intervention using a sup-
port group approach (Shu and Lung 2005).
Pooled data using depression subscale scores from Lovell
et al. (2016) indicated an effect of the cognitive-behavioural
approach in improving mental health among mothers of chil-
dren with disabilities [SMD = 1.14, 95% CI (0.12, 2.17)]
(Fig. 4). This result remained relatively unchanged when
the anxiety subscale scores from Lovell et al. (2016) was
substituted in the meta-analysis [SMD = 1.13, 95% CI (0.10,
2.16)] (analysis not shown).
Pooled data indicated an effect of the intervention using
the psychoeducation approach in improving mental health
among mothers of children with disabilities [SMD = 0.60,
95% CI (0.17, 1.03)] (see Fig. 5). Insufficient data were
reported by Pourmohamadreza et al. (2015) to enable pool-
ing with that of Magana et al. (2015) and Yildirim and Kara-
cut (2013). However, this study reported an effect of their
intervention using a psychoeducation approach on improv-
ing mental health of mothers of children with disabilities.
A sensitivity analysis was performed to include Hu et al.
2010 and Lee (2017) with that of Magana et al. (2015) and
Yildirim and Karacut (2013). The pooled results showed an
effect of interventions using a psychoeducation approach
on mental health of mothers of children with disabilities
[SMD = 0.44, 95% CI (0.14, 0.73)] (sensitivity analysis not
shown). This is consistent with that of the meta-analysis.
Shu and Lung (2005) reported no effect of their interven-
tion using a support group approach on mental health of
mothers [SMD = 0.35, 95% CI (− 0.48, 1.18)].
Change scores of mental health were reported by a RCT
study (Wei et al. 2012a, b) across the single intervention
Journal of Autism and Developmental Disorders (2021) 51:3690–3706 3699
Fig. 5  Comparison of effects
of different types of single
interventions on mental health
(using depression scores of
Lovell et al. 2015)
using a support group approach and a RCT (Gonzalez-Fraile
et al. 2019) across the single intervention based in the psych-
oeducation approach. Wei et al (2012a, b) reported an effect
of their intervention using a support group approach on men-
tal health of mothers [SMD = 1.17, 95% CI (0.81, 1.52)]
while Gonzalez-Fraile et al. (2019) also reported an effect
of their intervention using a psychoeducation approach on
mental health of mothers [SMD = 0.42, 95% CI (0.12, 0.72)].
Effects of Interventions Using a Single Approach
on the Outcome of Quality of Life in Mothers
Post-test scores of quality of life of mothers were reported by
a RCT (Wong and Poon 2010) across the single interventions
using a cognitive-behavioural approach, and by a non-RCT
(Shu and Lung 2005) across the single intervention using a
support group approach.
Wong and Poon (2010) reported an effect of their cog-
nitive behavioral intervention on quality of life in mothers
of children with disabilities [SMD = 0.88, 95% CI (0.34,
1.42)] Shu and Lung 2005. reported no effect of their sup-
port groups on quality of life in mothers [SMD = 0.42, 95%
CI (− 0.42, 1.25)].
Effects of Interventions Using a Single Approach
on the Outcome of Life Satisfaction of Mothers
Post-test scores of life satisfaction of mothers were
reported by a non-RCT (Lovenfosse and Viney 1999)
across the single intervention using a cognitive-behav-
ioural approach. This study reported no effect of their
intervention on life satisfaction in mothers [SMD =  − 0.66,
95% CI (− 1.82, 0.51)].
Effects of Interventions Using a Single Approach
on the Outcome of Health‑Related Self‑efficacy
Post-test scores of health-related self-efficacy of mothers
were reported by a RCT (Magana et al. 2015) across the
single intervention using a psychoeducation approach.
This study reported an effect of their intervention on
health-related self-efficacy of mothers [SMD = 1.15, 95%
CI (0.70, 1.60)].
Effects of Interventions Using a Single Approach
on the Outcome of Positive Health Behavior
Post-test scores of positive health behaviour of mothers
were reported by a RCT (Magana et al. 2015) across the
single intervention using psychoeducation approach. The
study reported an effect of their intervention on positive
health behaviours of mothers [SMD = 0.86, 95% CI (0.42,
1.29)].
Effects of Interventions Using a Single Approach
on the Outcome of Coping Styles of Mothers
Post-test scores of different coping styles of mothers were
reported by a RCT (Feinberg et al. 2014) across the single
intervention using a cognitive-behavioural approach, and
13

3700
a RCT (Lopez-Liria et al. 2019) across the single interven-
tion using a psychoeducation approach.
Feinberg et al. reported no effect of their cognitive-
behavioural intervention on improving problem-focussed
coping style of mothers [SMD = 0.06, 95% CI (− 0.31,
0.44)], no effect in reducing avoidant-focussed coping
style of mothers [SMD =  − 0.33, 95% CI (− 0.71, 0.05)]
but reported an effect of improving social coping style of
mothers [SMD = 0.55, 95% CI (0.17, 0.93)].
Lopez-Liria et al. (2019) reported an effect of their psy-
choeducation intervention on improving problem-focussed
coping style of mothers [SMD = 0.53, 95% CI (0.09, 0.97)]
but no effect in reducing avoidant-focussed coping style of
mothers [SMD = 0, 95% CI (− 0.44, 0.44)].
Effects of Interventions Using a Single Approach
on the Outcome of Self‑efficacy
Post-test scores of self-efficacy in mothers were reported
by a non-RCT (Zhang et al.) across the single interven-
tion using a cognitive-behavioural approach. It reported
an effect of their intervention on self-efficacy of mothers
[SMD = 1.77, 95% CI (1.06, 2.49)].
Effect of Interventions Using a Single Approach
on the Outcome of Perceived Social Support
Post-test scores of perceived social support were
reported by a RCT (Lopez-Liria et al. 2019) and a non-
RCT (Lee 2017) across the single intervention using a
Fig. 6  Sensitivity analysis of
studies of single interventions
using psychoeducation approach
on perceived social support
13
Journal of Autism and Developmental Disorders (2021) 51:3690–3706
psychoeducation approach, and a RCT (Wei et al. 2012a,
b) across the single intervention using a support group
approach.
Sensitivity analysis of Lopez-Liria et  al. (2019)
and incorporating data reported by Lee (2017) showed
no effect of their intervention using psychoeducation
approaches on perceived social support [SMD = 0.53,
95% CI (− 0.82, 1.88)] (see Fig. 6).
Wei et al. (2012a, b) (a RCT study) reported an effect
of intervention using a support group approach on per-
ceived social support [SMD = 0.85, 95% CI (0.49, 1.20)].
Effect of Interventions with Combined Approaches
Effects of Interventions with Combined Approaches
on the Outcome of Parenting Stress (Parent Domain Only)
Post-test scores of parenting stress were reported by a
RCT (Lo et al. 2017) across the combined approaches in
the interventions using mindfulness and psychoeducation.
The study had reported no effect of their interventions on
parenting stress among mothers of children with disabili-
ties [SMD =  − 0.02, 95% CI (− 0.31, 0.28)].
Effects of Interventions Using Combined
Approaches on the Outcome of Mental Health
Post-test scores of mental health were reported by a RCT
(Lo et al. 2017) across the combined interventions using
mindfulness and psychoeducation approaches. The study
had reported no effect of their interventions on mental health
Journal of Autism and Developmental Disorders (2021) 51:3690–3706 3701
of mothers of children with disabilities [SMD = 0.19, 95%
CI (− 0.10, 0.49)].
Comparative Effectiveness Studies (Interventions
Using Single Approaches)
There were two studies of this design. Dykens et al. (2014)
examined the effect of a two-group design comparing the
effect of an intervention based in a mindfulness approach
with an intervention based in a cognitive behavioral
approach. It reported both treatments had a significant effect
on reducing parenting stress (treatment slope =  − 0.08),
improving mental health (− 0.29 for depression and − 0.12
for anxiety) and life satisfaction (0.08) during the treatment
period. However, using an intervention approach based in
mindfulness appeared to have a greater effect on mental
health improvement than an intervention approach based
in a cognitive behavioral approach (mindfulness vs cogni-
tive behavioral approach: treatment slope =  − 0.2 for anxi-
ety, − 0.26 for depression).
Kirkham et al. (1990) compared the effect of an interven-
tion based in a psychoeducation approach with an active
control intervention using a support group approach. The
psychoeducation intervention was superior to the control
support group intervention in improving coping skills of
mothers [SMD = 0.41, 95% CI (0.12, 0.69)] and perceived
social support of mothers of older children with disabilities
using parent-role subscale of Inventory of Parent Experi-
ences [SMD = 0.09, (− 0.20, 0.37)].
Discussion
This review and meta-analysis synthesised the available
body of evidence to analyse program designs and deter-
mine how effective the programs were at reducing stress
and improving mental health and wellbeing for mothers
of children with a disability. Foremost, this paper reports
the first meta-analysis of intervention effects on parenting
stress and mental health. Meta-analysis of the effectiveness
of interventions using cognitive-behavioural and psychoe-
ducation showed positive effects. Meta-analysis of two stud-
ies (n = 64) implementing cognitive-behavioural approaches
reduced parenting stress. Meta-analysis of three studies
(n = 186) implementing cognitive-behavioural approaches
improved maternal mental health. Meta-analysis of two
studies (n = 165) implementing psychoeducation approaches
improved maternal mental health. Sensitivity analysis sup-
ported these metanalysis findings.
In this review, metanalysis of the effects of interventions
for studies using mindfulness or support group approaches
were not possible due to insufficient RCT studies. The
results of this systematic review and metanalysis indicate
that further RCTs utilizing all four approaches are war-
ranted. Some caution is advised in interpreting the findings
from the metanalysis of this review due to the low number
of studies available to be pooled for the meta-analysis, small
sample sizes in studies that were available, and the hetero-
geneity of the content of interventions as described in the
results of this review. Previously, a narrative review of the
content and types of interventions that targeted mental health
of parents of children with autism concluded that stress man-
agement and relaxation techniques, and mindfulness were
effective (Da Paz and Wallander 2017). The Da Paz et al.
findings, relate to one group of mothers (with a child with
autism), whereas the current metanalysis included mainly
mothers of children with various developmental disabilities.
In the current review 68% or 21 of the 31 appraised studies,
recruited mothers of a child with any disability. The meta-
analysis included three studies with mothers of children with
developmental disabilities (not otherwise specified) and two
studies with mothers of children with autism. Both studies
with mothers with autism were delivered within an autism
specific service and may be considered best practice when
provided alongside disorder-specific parenting interventions
that are important clinically when for example, addressing
a broad autism phenotype in families of autistic children.
Future studies might recognise mothers’ health and wellbe-
ing needs on merit, and consider whether a siloed approach
to grouping mothers according to their child’s diagnosis
is necessary or important. Such an approach to maternal
wellbeing is more inclusive and pertinent when maternal
outcomes are of primary concern.
Although numerous findings are presented in this meta-
analysis and may provide insights to better inform practition-
ers, service providers and policy makes, three main points
are prioritised for discussion: overall status of research on
mothers; salient findings about research designs; and aspects
of effective interventions for mothers. Together these dis-
cussion points summarise existing knowledge and identify
future focal points for program design and research in this
area that intersects childhood disability, mental health, and
carer/social services.
Overall Status of Research on Mothers
In this review, all retrieved studies were scanned and clas-
sified. Over one thousand cross sectional, qualitative and
other studies explored maternal stress, coping and mental
health. When examined, one hundred and thirty-three stud-
ies were excluded as the interventions primarily addressed
outcomes for children with disabilities, while outcomes for
mothers were considered secondary. Programs included par-
enting programs that address child outcomes such as behav-
iour, skill development and care (Barlow et al. 2014; Lindo
et al. 2016; Whittingham et al. 2014). Such interventions are
13

3702
important for families, although the current findings sup-
port the need for mothers to have their own programs with
maternal outcomes as the primary aim.
Only seventy-seven papers reported on intervention stud-
ies aimed primarily at improving outcomes for mothers.
Hence, over 90 percent of papers confirmed higher stress,
poorer mental health or health issues as well as factors asso-
ciated with stress. Only 9 percent of all papers focused on
responding to maternal needs and further implementing a
rigorous program to improve maternal outcomes. Hence, this
review recommends that the field be compelled to action
to design and evaluate interventions to improve health and
wellbeing outcomes (however operationalised) among moth-
ers of children with disabilities.
Salient Findings About Research Designs
In the current study, studies were appraised for quality and
the strongest research designs were included in the meta-
analysis. Conventional and TiDIER extraction of details
about interventions revealed a wide variance in inclusion cri-
teria, participants, length and nature of intervention, use of
outcome measures and follow-up measurement. The meta-
analysis grouped RCT studies according to approach and
therapeutic underpinnings. However, extraction and analysis
of the interventions revealed differences between the pooled
studies such as intervention duration, activities and profes-
sional facilitation. For example, when compared, the two
studies showing that the cognitive-behavioural approach was
effective revealed one intervention that was 30 h of group
based intervention delivered by professionals, and the other
involved 20 min of a positive psychology technique involv-
ing benefit finding called Written Emotional Disclosure at
home independently for three consecutive days. Similarly,
the psychoeducation based approach improved mental
health, although the pooled studies involved one intervention
with an eight week manualised health intervention delivered
by professionals and the second with 4 weeks of behavioural
and psychological education. A rigorous approach was
undertaken in the current paper, so that similar studies were
included in the meta-analysis. However future studies are
needed in all approaches to enable pooling and comparison
of more homogeneous studies. Differences in intervention
delivery raises the issue of cost effectiveness, another recom-
mendation for future research to consider.
Outcomes measures reflected the breadth of ways that
health, mental health, stress, and other like concepts were
operationalised. A strength of all studies included the use
of self-report questionnaires. However, the lack of consen-
sus on maternal outcome measurement and concepts asso-
ciated with different approaches suggests that consensus
about measurement of self-reported mental health symp-
tomatology and general health status would be appropriate.
13
Journal of Autism and Developmental Disorders (2021) 51:3690–3706
Pooling effects will continue to be difficult in future reviews
unless consensus is reached. Future research might include
a systematic review of instruments, including psychometric
properties, to determine the most applicable scales to enable
mothers to self-report mental and general health.
Participants were included in studies based on their par-
enting status. Some women were included in studies if they
had been diagnosed with a mental health or health condition
and other samples only included healthy mothers. Whilst
there is evidence that stress impacts mothers most substan-
tially in the early years (Estes et al. 2013; Minnes et al.
2015) and during transitions (Woodman 2014), few studies
intervened at these key times. Mothers with milder or no
mental health symptoms may benefit from a health educa-
tion approach and mothers who experience mental health
symptoms may benefit from a more intensive psychoeduca-
tion and cognitive behavioural approach.
A recent systematic review of health coaching for par-
ents of children with disabilities concluded that there are
insufficient programs and interventions that aim to support
parental health (Ogourtsova et al. 2019) and concluded that
parent-only targeted approaches are likely the best strategy
to advance both child and family outcomes. Future stud-
ies might also identify sub groups of mothers with differ-
ent health status when included within the one cohort (i.e.
mothers diagnosed or not diagnosed with depression) and
analyse outcomes as a separate group. Future research might
also better accommodate confounders to treatment outcomes
such as other treatments that are received simultaneously,
such as medications, counselling, or other psychiatric or psy-
chological care. Inclusion of mothers with identified condi-
tions is indicated because people with diagnosed conditions
can still experience improvements to health and wellbeing
and all intervention studies used self-reported scales that
measure health and wellbeing (or similar) change.
These important aspects around design of research,
characteristics of participants, timing of the interventions,
approach of the intervention and the type of outcome meas-
ure are all important for future research that enables pooling
of more homogeneous studies to determine what is most
effective, when it is effective, for whom it is effective, and
potentially what is most cost effective.
Salient Aspects of Interventions for Mothers
The interventions described in this review were mainly
locally designed by professionals to meet the cultural envi-
ronment within which mothers lived in 16 different coun-
tries. Numerous innovative programs were trialled, sug-
gesting that there is not a one size fits all solution to better
support mothers who have substantial care responsibilities.
Although excluded from this review, numerous other pro-
grams have been developed for mothers in other countries
Journal of Autism and Developmental Disorders (2021) 51:3690–3706 3703
such as Malawi (Masulani-Mwale et al. 2019) and Saudi
Arabia (Hemdi and Daley 2017). While rigorous evaluation
of such programs remains forthcoming, the international
attention on mother’s wellbeing demonstrates that it is a
priority where children with disabilities receive services.
The current paper highlights the need for complex inter-
ventions to be described in sufficient detail. The TiDIER
checklist was a useful tool to delineate the similarities
and differences between interventions that had com-
mon approaches. Future intervention studies might use
the TiDIER checklist to appraise fidelity and provide a
comprehensive description of the intervention for future
metanalyses. Studies in this review featured programs
that recruited mothers through paediatric clinics. Past
research has suggested that paediatric health practitioners
are not comfortable assisting mothers with mental health
and wellbeing (Gilson et al. 2018). However, one RCT in
this review trained paediatric focused health practitioners
to effectively deliver a one on one cognitive-behavioural
intervention that improved the mental health of mothers
(Feinberg et al. 2014). Therefore, it seems reasonable to
suggest that future programs might use a similar method to
rigorously train paediatric-focused professionals to imple-
ment individualised programs for mothers. Such a strategy
aligns with a family centred paradigm within the child’s
service system. Consideration may be given to including
mothers themselves as a strong resource in the co-design
and co-delivery of interventions.
Limitations within this review relate to the inclusion of
some fathers in the retrieved research, lack of comprehen-
sive definition of some constructs used in the outcomes of
interest, and lack of homogeneous participant groups for
interventions aimed at mental health and stress. The extent
to which these factors influenced findings is difficult to
ascertain. Future research should include more rigorously
designed RCT studies in all intervention approaches and
aim to extend outcomes to healthy behaviours and physical
activity if the overall health of mothers is to be enhanced.
This review has collated best evidence to date, and find-
ings can be extended to make clinical recommendations
including prioritisation of screening mothers, directing
mothers to local psychological and health profession-
als, and the development and implementation of effective
interventions for mothers/parents of children with dis-
abilities. Therapeutic approaches that include cognitive
behavioural and psychoeducation interventions are prefer-
able and outcomes measures should include self-reported
instruments related to mental health.
This review recommends that professionals and services
that work with children and young people with disabilities
include maternal health and wellbeing targets in family
level outcomes. Given the strong evidence about mater-
nal outcomes, aspirational targets such as screening every
mother, referring to a local evidence based program either
within the service or outside, are realistic and indicated.
Clinical guidelines are needed to support identification,
pathways to services and interventions options, and the
current review provides the first step by amalgamating cur-
rent research and identifying early findings about effec-
tive interventions. The challenge to produce much needed
clinical guidelines lies with both the fields of childhood
disability and mental health.
Acknowledgments  The authors completed this unfunded study
independently.
Author Contributions  HMB-T designed the search terms, identified
included studies via covidence via screening of tiles, abstracts and full
text reviews including classifying excluded studies; classified modes;
extracted intervention details via TIDieR; primary author of whole
manuscript. AL conducted the search and transferred retrieved stud-
ies to covidence; contributed to mode definitions and classifications;
extracted data for tabulated descriptions; conducted metanalysis and
sensitivity, and authored specific section of results. LT extracted study
data for tabulated descriptions; contributed to mode definitions and
classifications; conducted independent quality ratings; extracted and
described outcomes measures including tabulating; reviewed manu-
script; KJ conducted final search; extracted study data for tabulated
descriptions; contributed to mode definitions and classifications; con-
ducted independent quality ratings; PM assisted with search design
and systematic review planning; reviewed drafts of manuscript; TH
conducted independent review of titles and abstracts in Covidence and
reviewed drafts of the manuscript.
Compliance with Ethical Standards 
Conflict of interest  All authors declare that they have no conflict of
interest.
Ethical Approval  All procedures performed in this study were in
accordance with the ethical standards of 1964 Helsinki declaration
and its later amendments or comparable ethical standards.
Appendix 1
See Table 1.
13

3704 Journal of Autism and Developmental Disorders (2021) 51:3690–3706

References

anxiety OR “anxiety disorders” OR “emotional health”

smoking OR “substance abuse” OR “substance-related

outcome*” OR “self care” OR employment OR career
OR “mental health” OR wellbeing OR depression OR

“maternal welfare” OR “behavio?r change” OR “etoh

disorders” OR “child abuse” OR “quality of life” OR

“social participation” OR “child* quality of life” OR
“empowerment OR adaptation OR psychological OR

“parent–child relations” OR “family relations” OR

coping OR stress OR “parent*stress” OR “parent*

abuse” OR “alcohol drinking” OR alcoholism OR

Anclair, M., & Hiltunen, A. J. (2014). Cognitive behavioral therapy

OR “physical health” OR “women’s health” OR

for stress-related problems: Two single-case studies of parents of
children with disabilities. Clinical Case Studies, 13(6), 472–486.
https​://doi.org/10.1177/15346​50114​52209​0.
Anclair, M., Hjarthag, F., & Hiltunen, A. J. (2017). Cognitive behav-
ioural therapy and mindfulness for Health-Related Quality of
Life: Comparing treatments for parents of children with chronic
conditions-A pilot feasibility study. Clinical Practice and Epide-
miology in Mental Health, 13, 1–9. https:​ //doi.org/10.2174/17450​
17901​71301​0001.

“family functioning””
Arakkathara, J. G., & Blance, L. O. (2019). Promotion of wellbeing,
resilience and stress management (POWER): An intervention
Field 3: Comparison Field 4: Outcome

ofor mothers of children with intellectual disability, a pilot study.

Indian Journal of Positive Psychology, 10(4), 294–299.
Armijo-Olivo, S., Stiles, C. R., Hagen, N. A., Biondo, P. D., & Cum-
mings, G. G. (2012). Assessment of study quality for systematic
reviews: A comparison of the Cochrane Collaboration Risk of
Bias Tool and the Effective Public Health Practice Project Qual-
ity Assessment tool: Methodological research. Journal of Evalu-
ation in Clinical Practice, 18(1), 12–18. https​://doi.org/10.111
Not applicable

1/j.1365-2753.2010.01516​.x.
Baker, K., Devine, R. T., Ng-Cordell, E., Raymond, F. L., & Hughes,
C. (2020). Childhood intellectual disability and parents’ mental
health: Integrating social, psychological and genetic influences.
The British Journal of Psychiatry. https​: //doi.org/10.1192/
bjp.2020.38.
support" OR "peer support" OR "cognitive behavio?r

Barlow, J., Smailagic, N., Huband, N., Roloff, V., & Bennett, C. (2014).
"health promotion" OR resilience OR coaching OR
services" OR "self maintenance" OR psychoeduca-
("health education" OR "health literacy" OR "health

Group-based parent training programmes for improving parental

mentoring OR "program evaluation" OR "social
""disabled children" OR "child development disorder*" tion OR "acceptance commitment therapy" OR
Table 1  Search strategy for interventions that influence outcomes for mothers of children with a disability

psychosocial health. Cochrane Database of Systematic Reviews.

https​://doi.org/10.1002/14651​858.CD002​020.pub4.
Barog, Z. S., Younesi, S. J., Sedaghati, A. H., & Sedaghati, Z. (2015).
Efficacy of mindfulness-based cognitive therapy on quality of life
of mothers of children with cerebral palsy. Iranian Journal of
therapy" OR "cognitive therapy")

Psychiatry, 10(2), 86–92.

Bazzano, A., Wolfe, C., Zylowska, L., Wang, S., Schuster, E., Barrett,
C., & Lehrer, D. (2013). Mindfulness Based Stress Reduction
(MBSR) for parents and caregivers of individuals with develop-
mental disabilities: A community-based approach. Journal of
Field 2: Intervention

Child & Family Studies, 22(8), 1–11. https​://doi.org/10.1007/

s1082​6-013-9836-9.
Blake, L., Bray, L., & Carter, B. (2019). “It’s a lifeline”: Generating
a sense of social connectedness through befriending parents
of disabled children or children with additional need. Patient
Education and Counselling, 102(12), 2279–2285. https​://doi.
org/10.1016/j.pec.2019.07.012.
Bourke-Taylor, H., Howie, L., & Law, M. (2010). Impact of caring for
"p?ediatric health condition*" OR "autistic disorder"
“mother* OR women OR "working women" OR car-

OR pervasive OR “developmental disabilities" OR

a school-aged child with a disability: Understanding mothers’

OR "cerebral palsy" OR "intellectual disability"

perspectives. Australian Occupational Therapy Journal, 57(2),

127–136. https​://doi.org/10.1111/j.1440-1630.2009.00817​.x.
Bourke-Taylor, H. M., Jane, F., & Peat, J. (2019). Healthy mothers
healthy families workshop intervention: A preliminary investi-
egiver* OR carer* OR parents" AND

gation of healthy lifestyle changes for mothers of a child with a

disability. Journal of Autism & Developmental Disorders, 49(3),
935–949. https​://doi.org/10.1007/s1080​3-018-3789-1.
Brehaut, J. C., Kohen, D. E., Garner, R. E., Miller, A., Lach, L.,
Klassen, A. F., & Rosenbaum, P. (2009). Health among caregiv-
ers of children with health problems: Findings from a Canadian
Population-Based Study. American Journal of Public Health,
Field 1: Person/s

99(7), 1254–1262. https​://doi.org/10.2105/AJPH.2007.12981​7.

Bunning, K., Gona, J. K., Newton, C. R., Andrews, F., Blazey, C.,
Ruddock, H., et al. (2020). Empowering self-help groups for
caregivers of children with disabilities in Kilifi, Kenya: Impacts

13
Journal of Autism and Developmental Disorders (2021) 51:3690–3706 3705
and their underlying mechanisms. PLoS ONE, 15(3), e0229851.
https​://doi.org/10.1371/journ​al.pone.02298​51.
Chambers, H. G., & Chambers, J. A. (2015). Effects of caregiving
on the families of children and adults with disabilities. Physical
Medicine & Rehabilitation Clinics of North America, 26(1),
1–19. https​://doi.org/10.1016/j.pmr.2014.09.004.
Collins, P. Y., Pringle, B., Alexander, C., Darmstadt, G. L., Hey-
mann, J., Huebner, G., et al. (2017). Global services and support
for children with developmental delays and disabilities: Bridg-
ing research and policy gaps. PLoS Medicine, 14(9), e1002393.
https​://doi.org/10.1371/journ​al.
Covidence. (2020). Covidence systematic review software. Mel-
bourne: Veritas Health Innovation.
Da Paz, N. S., & Wallander, J. L. (2017). Interventions that tar-
get improvements in mental health for parents of children
with autism spectrum disorders: A narrative review. Clinical
Psychology Review, 51(4), 1–14. https​: //doi.org/10.1016/j.
cpr.2016.10.006.
Dykens, E. M., Fisher, M. H., Taylor, J. L., Lambert, W., & Miodrag,
N. (2014). Reducing distress in mothers of children with autism
and other disabilities: A randomized trial. Pediatrics, 134, e454.
Estes, A., Olson, E., Sullivan, K., Greenson, J., Winter, J., Dawson, G.,
& Munson, J. (2013). Parenting-related stress and psychological
distress in mothers of toddlers with autism spectrum disorders.
Brain & Development, 35(2), 133–138. https​://doi.org/10.1016/j.
brain​dev.2012.10.004.
Fairthorne, J., Jacoby, P., Bourke, J., de Klerk, N., & Leonard, H.
(2015). Onset of maternal psychiatric disorders after the birth of
a child with intellectual disability: A retrospective cohort study.
Journal of Psychiatric Research, 61, 223–230.
Feinberg, E., Augustyn, M., Fitzgerald, E., Sandler, J., Ferreira-Cesar
Suarez, Z., Chen, N., et al. (2014). Improving maternal mental
health after a child’s diagnosis of autism spectrum disorder:
Results from a randomized clinical trial. JAMA Pediatrics, 168(1),
40–46.
Fernández Sánchez, H., Enríquez Hernández, B. E. E., Sidani, S.,
Hernández Osorio, C., Castellanos Contreras, E., & Salazar
Mendoza, J. (2020). Dance intervention for Mexican family car-
egivers of children with developmental disability: A pilot study.
Journal of Transcultural Nursing, 31(1), 38–44. https​://doi.
org/10.1177/10436​59619​83802​7.
Gilson, K. M., Johnson, S., Davis, E., Brunton, S., Swift, E., & Red-
dihough, D. (2018). Supporting the mental health of mothers of
children with a disability: Health professional perceptions of need,
role, and challenges. Child: Care, Health and Development, 44(5),
721–729.
Gonzalez-Fraile, E., Dominguez-Panchon, A. I., Berzosa, P., Costas-
Gonzalez, A. B., Garrido-Jimenez, I., Rufino-Ventura, D., et al.
(2019). Efficacy of a psychoeducational intervention in caregivers
of people with intellectual disabilities: A randomized controlled
trial (EDUCA-IV trial). Research in Developmental Disabilities,
94(6), 103458. https​://doi.org/10.1016/j.ridd.2019.10345​8.
Green, S. E. (2007). “We’re tired, not sad”: Benefits and burdens of
mothering a child with a disability. Social Science & Medicine,
64(1), 150–163. https:​ //doi.org/10.1016/j.socsci​ med.2006.08.025.
Hayes, S. A., & Watson, S. L. (2013). The impact of parenting stress:
A meta-analysis of studies comparing the experience of parenting
stress in parents of children with and without autism spectrum
disorder. Journal of Autism & Developmental Disorders, 43(3),
629–642. https​://doi.org/10.1007/s1080​3-012-1604-y.
Hemdi, A., & Daley, D. (2017). The effectiveness of a psychoeduca-
tion intervention delivered via whatsapp for mothers of children
with autism spectrum disorder (ASD) in the Kingdom of Saudi
Arabia: A randomized controlled trial. Child: Care, Health and
Development, 43(6), 933–941.
Higgins, J., & Green, S. (2011). Cochrane handbook for systematic
reviews of interventions version 5.1.0 [updated March 2011]. In
The Cochrane Collaboration (Ed.).
Higgins, J., Thompson, S. G., Deeks, J. J., & Altman, D. G. (2003).
Measuring inconsistency in meta-analyses. BMJ, 327(7414),
557–560.
Hoffmann, T. C., Glasziou, P. P., Boutron, I., Milne, R., Perera, R.,
& Moher, D. (2014). Better reporting of interventions: Template
for intervention description and replication (TIDieR) check-
list and guide. British Medical Journal, 348, 1687. https​://doi.
org/10.1136/bmj.g1687​.
Hu, J., Lin, J. D., Yen, C. F., Loh, C. H., Hsu, S. W., Lin, L. P., & Wu,
S. R. (2010). Effectiveness of a stress-relief initiative for primary
caregivers of adolescents with intellectual disability. Journal of
Intellectual & Developmental Disability, 35(1), 29–35.
Izadi-Mazidi, M., Riahi, F., & Khajeddin, N. (2015). Effect of cognitive
behavior group therapy on parenting stress in mothers of children
with autism. Iranian Journal of Psychiatry and Behavioral Sci-
ences, 9(3), e1900.
Kirkham, M. A., & Schilling, R. F. (1990). Life skills training with
mothers of handicapped children. Journal of Social Service
Research, 13(2), 67–87.
Kirkham, M. A., Schilling, R. F., II., Norelius, K., & Schinke, S. P.
(1986). Developing coping styles and social support networks: An
intervention outcome study with mothers of handicapped children.
Child: Care, Health and Development, 12(5), 313–323.
Lee, J. H. (2017). Group art therapy and self-care for mothers of chil-
dren with disabilities. Doctor of Philosophy electronic. Lesley
University. Retrieved from https​://digit​alcom​mons.lesle​y.edu/
expre ​ s sive ​ _ disse ​ r tati ​ o ns/49?utm_sourc ​ e =digit ​ a lcom ​ m ons.
lesle​ y.edu%2Fexp ​ r essi ​ ve_disse ​ r tati ​ o ns%2F49&utm_mediu​
m=PDF&utm_campa​ign=PDFCo​verPa​ges.
Lindo, E. J., Kliemann, K. R., Combes, B. H., & Frank, J. (2016).
Managing stress levels of parents of children with developmental
disabilities: A meta-analytic review of interventions. Family Rela-
tions, 65(1), 207–224. https​://doi.org/10.1111/fare.12185​.
Lo, H. H. M., Chan, S. K. C., Szeto, M. P., Chan, C. Y. H., & Choi,
C. W. (2017). A feasibility study of a brief mindfulness-based
program for parents of preschool children with developmental
disabilities. Mindfulness, 8(6), 1665–1673.
Lopez-Liria, R., Vargas-Muñoz, E., Aguilar-Parra, J. M., Padilla-Gón-
gora, D., Mañas-Rodriguez, M. A., & Rocamora-Pérez, P. (2019).
Effectiveness of a training program in the management of stress
for parents of disabled children. Journal of Child and Family Stud-
ies. https​://doi.org/10.1007/s1082​6-019-01665​-5.
Lovell, B., Moss, M., & Wetherell, M. A. (2016). Assessing the
feasibility and efficacy of written benefit-finding for caregivers
of children with autism: A pilot study. Journal of Family Stud-
ies, 22(1), 32–42.
Lovenfosse, M., & Viney, L. L. (1999). Understanding and helping
mothers of children with “special needs” using personal con-
struct group work. Community Mental Health Journal, 35(5),
431–442.
Magana, S., Li, H., Miranda, E., & Paradiso de Sayu, R. (2015).
Improving health behaviours of Latina mothers of youths and
adults with intellectual and developmental disabilities. Journal
of Intellectual Disability Research, 59(5), 397–410.
Marquis, S. M., McGrail, K., & Hayes, M. (2020a). Mental health
of parents of children with a developmental disability in Brit-
ish Columbia, Canada. Journal of Epidemiology and Community
Health, 74(2), 173. https​://doi.org/10.1136/jech-2018-21169​8.
Marquis, S. M., McGrail, K., & Hayes, M. (2020b). Mental health out-
comes among parents of a child who has a developmental disabil-
ity: Comparing different types of developmental disability. Dis-
ability and Health Journal, 13(2), 1–8. https​://doi.org/10.1016/j.
dhjo.2019.10087​4.
13

3706
Masefield, S. C., Prady, S. L., & Sheldon, T. A. (2020). The caregiver
health effects of caring for young children with developmental dis-
abilities: A meta-analysis. Maternal Child Health Journal, 24(2),
561–574. https​://doi.org/10.1007/s1099​5-020-02896​-5.
Masulani-Mwale, C., Kauye, F., Gladstone, M., & Mathanga, D.
(2019). Development of a psycho-social intervention for reducing
psychological distress among parents of children with intellectual
disabilities in Malawi. PLoS ONE, 14(2), e0210855. https​://doi.
org/10.1371/journ​al.pone.02108​55.
Minnes, P., Perry, A., & Weiss, J. A. (2015). Predictors of distress and
well-being in parents of young children with developmental delays
and disabilities: The importance of parent perceptions. Journal
of Intellectual Disability Research, 59(6), 551–560. https​://doi.
org/10.1111/jir.12160​.
Montes, G., & Halterman, J. S. (2007). Psychological functioning
and coping among mothers of children with autism: A popula-
tion-based study. Pediatrics, 119(5), e1040-1046. https​://doi.
org/10.1542/peds.2006-2819.
Niinomi, K., Asano, M., Kadoma, A., Yoshida, K., Ohashi, Y., Furu-
zawa, A., et al. (2016). Developing the “Skippu-Mama” program
for mothers of children with autism spectrum disorder. Nursing
& Health Sciences, 18(3), 283–291.
Ogourtsova, T., O’Donnell, M., De Souva Silva, W., & Majnemer,
A. (2019). Health coaching for parents of children with develop-
mental disabilities: A systematic review. Developmental Medicine
& Child Neurology, 61(11), 1259–1265. https​://doi.org/10.1111/
dmcn.14206​.
Osborn, R., Girgis, M., Morse, S., Sladakovic, J., Kneebone, I., Shires,
A., et al. (2018). Mindfulness-integrated cbt (micbt) for reducing
distress in parents of children with intellectual disability (id): A
case series. Journal of Developmental and Physical Disabilities,
30, 559–568. https​://doi.org/10.1007/s1088​2-018-9602-4.
Pourmohamadreza-Tajrishi, M., Azadfallah, P., Hemmati Garakani,
S., & Bakhshi, E. (2015). The effect of problem-focused cop-
ing strategy training on psychological symptoms of mothers of
children with down syndrome. Iranian Journal of Public Health,
44(2), 254–262.
Raina, P., O’Donnell, M., Rosenbaum, P., Brehaut, J., Walter, S. D.,
Russell, D., et al. (2005). The health and well-being of caregiv-
ers of children with cerebral palsy. Pediatrics, 115(6), e626-636.
Raina, P., O’Donnell, M., Schwellnus, H., Rosenbaum, P., King, G.,
Brehaut, J., et al. (2004). Caregiving process and caregiver bur-
den: Conceptual models to guide research and practice. BMC
Pediatrics, 4, 1. https​://doi.org/10.1186/1471-2431-4-1.
Sawyer, M. G., Bittman, M., La Greca, A. M., Crettenden, A. D., Boro-
jevic, N., Raghavendra, P., & Russo, R. (2011). Time demands of
caring for children with cerebral palsy: What are the implications
for maternal mental health? Developmental Medicine & Child
Neurology, 53(4), 338–343.
13
Journal of Autism and Developmental Disorders (2021) 51:3690–3706
Schnabel, A., Youssef, G. J., Hallford, D. J., Hartley, E. J., McGillivray,
J. A., Stewart, M., et al. (2020). Psychopathology in parents of
children with autism spectrum disorder: A systematic review and
meta-analysis of prevalence. Autism, 24(1), 26–40. https​://doi.
org/10.1177/13623​61319​84463​6.
Shu, B. C., & Lung, F. W. (2005). The effect of support group on the
mental health and quality of life for mothers with autistic children.
Journal of Intellectual Disability Research, 49(Pt 1), 47–53.
Thenu, C. T., & Natesan, H. (2013). Management of stress in parents
of special children through positive therapy. Indian Journal of
Health and Wellbeing, 4(6), 1310–1312.
Wei, K. C., Lee, C., Mahendran, R., & Lim, C. G. (2012a). Improv-
ing mental health care for people with an intellectual disability
in Singapore: Bridging the health-social care divide. Singapore
Medical Journal, 53(7), 428–432.
Wei, Y.-S., Chu, H., Chen, C.-H., Hsueh, Y.-J., Chang, Y.-S.,
Chang, L.-I., & Chou, K.-R. (2012b). Support groups for car-
egivers of intellectually disabled family members: Effects on
physical-psychological health and social support. Journal of
Clinical Nursing, 21(11/12), 1666–1677. https​://doi.org/10.111
1/j.1365-2702.2011.04006​.x.
Whittingham, K., Sanders, M., McKinlay, L., & Boyd, R. N. (2014).
Child quality of life and parent psychological adjustment can
be improved with Stepping Stones Triple P and ACT: An RCT.
Developmental Medicine and Child Neurology, 56, 75.
Wong, F. K., & Poon, A. (2010). Cognitive behavioural group treat-
ment for Chinese parents with children with developmental dis-
abilities in Melbourne, Australia: An efficacy study. Australian &
New Zealand Journal of Psychiatry, 44(8), 742–749. https​://doi.
org/10.3109/00048​67100​37697​69.
Woodman, A. C. (2014). Trajectories of stress among parents of chil-
dren with disabilities: A dyadic analysis. Family Relations, 63(1),
39–54. https​://doi.org/10.1111/fare.12049​.
Yıldırım, A., Hacıhasanoğlu, A. R., & Karakurt, P. (2013). Effects of
a nursing intervention program on the depression and percep-
tion of family functioning of mothers with intellectually disabled
children. Journal of Clinical Nursing, 22(1/2), 251–261. https​://
doi.org/10.1111/j.1365-2702.2012.04280​.x.
Zhang, W., Yan, T. T., Du, Y. S., & Liu, X. H. (2014). Brief report:
Effects of solution-focused brief therapy group-work on pro-
moting post-traumatic growth of mothers who have a child with
ASD. Journal of Autism and Developmental Disorders., 44(8),
2052–2056.
Publisher’s Note Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.