International Journal of Developmental Disabilities

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/yjdd20

Health-related quality of life in caregivers of

children with and without neurodevelopmental
disorders during the COVID-19 pandemic

Cristina Sinziana Trofin & Claudia Iuliana Iacob

To cite this article: Cristina Sinziana Trofin & Claudia Iuliana Iacob (2023): Health-related
quality of life in caregivers of children with and without neurodevelopmental disorders
during the COVID-19 pandemic, International Journal of Developmental Disabilities, DOI:
10.1080/20473869.2023.2236797

To link to this article: https://doi.org/10.1080/20473869.2023.2236797

View supplementary material

Published online: 18 Jul 2023.

Submit your article to this journal

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=yjdd20
Health-related quality of life in caregivers of
children with and without
neurodevelopmental disorders during the
COVID-19 pandemic
Cristina Sinziana Trofin and Claudia Iuliana Iacob
Department of Applied Psychology and Psychotherapy, Faculty of Psychology and Educational Sciences,
University of Bucharest, Bucharest, Romania

Background: Family caregivers face health issues that affect their quality of life, especially during the COVID-
19 pandemic, which challenges people’s resilience resources.
Methods: This cross-sectional design study investigated the health-related quality of life (HRQOL) of family
caregivers of children with and without neurodevelopmental disorders (N1 ¼ 129, N2 ¼ 126), focusing on
four domains: physical, psychological, social, and environmental. Also, we explored the differences between
caregivers, considering the child’s comorbidities and disorder severity.
Results: Participants in group one had lower HRQOL than group two, especially in the social and psycho-
logical areas. In addition, as expected, caregivers of children with severe disorders had a more negative per-
ception of HRQOL’s social domain than caregivers of children with mild conditions. Finally, there were
differences between HRQOL depending on comorbidities in psychological, social and environmental
domains.
Conclusions: Caregivers of children with neurodevelopmental disorders (especially if the disorder is severe
and there are comorbidities) are more vulnerable than other caregivers regarding HRQOL, which conveys the
message that social support policies should pay more attention to them.
Keywords: health-related quality of life; familial caregivers; neurodevelopmental disorders; HRQOL; physical and mental health

A familial caregiver of a child with disabilities invests
effort, time, and other resources in supporting the
child’s development and rehabilitation (Beach et al.
2005). However, in this process, the caregivers often
sacrifice their life-related interests (e.g. career, interper-
sonal relationships, leisure activities, holidays) and neg-
lect aspects concerning physical and emotional health
(Benjak 2011, Arora et al. 2020). As a result, the care-
giver compromises to help the person in need. In the
long term, this leads to a psychological burden, distress
(Mugno et al. 2007), anxiety, and depression (Khanna
et al. 2011).
Health-related quality of life (HRQOL) describes the
person’s subjective perceptions about her own physical
and mental health (Awick et al. 2015). This construct
includes relationship and environmental dimensions,
Correspondence to: Claudia Iuliana Iacob, Department of Applied
Psychology and Psychotherapy, University of Bucharest, Street
Panduri, no. 90, District 5, Bucharest, Romania. E-mail: claudia-
iuliana.iacob@fpse.unibuc.ro
Supplemental data for this article can be accessed online at https://
doi.org/10.1080/20473869.2023.2236797.
such as interpersonal interactions, received support, and
social facilities (Schmidt and Kober 2010). HRQOL is
a significant predictor of mortality and morbidity in the
general population and populations at risk of health
problems (e.g. people with chronic diseases, the elderly,
and their caregivers). Essential aspects of HRQOL were
the energy levels, daily activities during leisure, sub-
jective perception of health status, and the social sup-
port group in the general population (Saxena et al.
2001). The literature emphasizes that there are factors
that could contribute to the perceived mental and phys-
ical health of caregivers: the perceived quality of emo-
tional and practical support, characteristics of the
environment, and resources that brace the care process
(Mugno et al. 2007, Allik et al. 2006, Ji et al. 2014,
Tung et al. 2014, Khanna et al. 2011, Adams et al.
2020, Darla and Bhat 2021).
Neurodevelopmental disorders (i.e. NDs) are defined
in the DSM-5 as ‘a group of conditions occurring dur-
ing development‘ characterised by functional impair-
ments in the personal, social, educational, or

# The British Society of Developmental Disabilities 2023

DOI 10.1080/20473869.2023.2236797 International Journal of Developmental Disabilities 2023 VOL. 0 NO. 0 1
Cristina Sinziana Trofin and Claudia Iuliana Iacob HRQOL in familial caregivers
professional field (e.g. learning and controlling execu-
tive functions, social skills, intelligence) (American
Psychiatric Association 2013). The main categories are
intellectual disorders (e.g. intellectual disabilities,
Down Syndrome), autism spectrum disorders (i.e.
ASD); attention deficit hyperactivity disorder (i.e.
ADHD); communication disorders (language deficits in
communication and speech), specific learning disorders
(e.g. dyslexia), and motor disorders (disorders related to
the development of coordination, stereotypical move-
ments, ‘tic disorders’).
The prevalence of NDs is rapidly increasing. Thus,
according to global statistics from 2016, about 1 in 6
children (i.e. 17%) had an ND, compared to 2009–
2011, when the prevalence of these disorders was
16.2% (Centers for Disease Control and Prevention
2020). In addition, statistics also show that health status
negatively influences approximately 53% of caregivers
(e.g. they feel anxious or depressed and frequently use
psychoactive or sedative medications to reduce fatigue
and pain) (Centers for Disease Control and Prevention
2019). Thus, caregivers could face problems related to
their own physical and mental health or have a negative
perception of it, regardless of their medical status
(Mugno et al. 2007, Khanna et al. 2011).
The negative perception of physical health and low
psychological well-being are common findings in the
majority of family caregiving studies (i.e. caregivers of
children with neurodevelopmental disorders, such ASD
or intellectual disabilities; Adams et al. 2020, Allik
et al. 2006, Darla and Bhat 2021, Khanna et al. 2011,
Mugno et al. 2007, Tung et al. 2014). However, to our
knowledge, the literature does not cover self-assessed
HRQOL (Adams et al. 2020, Khanna et al. 2011) in
terms of its dimensions (i.e. psychological, environmen-
tal, and social aspects; Tung et al. 2014).
Lin et al. (2009) found that using the WHOQOL-
BREF scale (WHOQOL Group 1995) on a sample of
familial caregivers of children with intellectual disabil-
ities, three aspects emerge: (1) the negative perception
of global health, (2) the declared degree of stress, and
(3) the insufficient physical and emotional help from
the family. These factors are often ubiquitous and are
implicitly associated with a lower QOL. Thus, care-
givers who reported poor quality help (i.e. physical
help) from others and declared a lack of emotional sup-
port from family (Kim et al. 2021) and public services
(Vasilopoulou and Nisbet. 2016) also reported a lower
QOL. On the other hand, a healthy functioning and
positive relationship between family members was asso-
ciated with a higher QOL even when the care burden
was overwhelming (Kim et al. 2021). The authors state
the need to investigate further the aspects related to
social relations and the perceived external help, which
will be followed and investigated in the present study
2 International Journal of Developmental Disabilities 2023
through the domain of social support from the
WHOQOL-BREF.
Moreover, it is important to observe how caregivers
perceive their HRQOL depending on disorder severity
(Huang et al. 2014, Tung et al. 2014, Pisula and
PoreR bowicz-D€orsmann 2017) and child comorbidities
(Darla and Bhat 2021), aspects that could impact the
perceived HRQOL domains as previous studies showed.
These connections lead to a deeper understanding of
caregivers of children with neurodevelopmental disor-
ders, a population prone to various clinical challenge-
s(e.g. stress, fatigue, and chronic pain, anxiety,
depression; Padden et al. 2019, Sharpley et al. 1997)
and difficulties to enjoy leisure activities or perform
daily tasks (Ji et al. 2014, Arora et al. 2020).
The parents of children with ASD report a much
lower HRQOL, the most affected area being physical
health, compared to parents of children with typical
development (Allik et al. 2006, Mugno et al. 2007) and
the general population (Khanna et al. 2011). In add-
ition, the disorder’s severity and the child’s behaviour
challenges contribute to the parents’ negative perception
of their health (Tung et al. 2014, Khanna et al. 2011).
The families of children with ASD reported a much
lower level of HRQOL (i.e. physical activity domain,
social support, and perception of global health) com-
pared to caregivers of young people with intellectual
disabilities (Arora et al. 2020), cerebral palsy, epilepsy,
including children with typical development (Mugno
et al. 2007). Arora et al. (2020) explain the results by
the fact that children with ASD, especially those with
low-functioning autism, have many behavioural chal-
lenges and require more attention and care from care-
givers. Consequently, parents neglect their relationships
with others due to insufficient time or physical and
emotional exhaustion. Likewise, mothers of children
with ASD reported lower HRQOL than the general
female population in the USA, especially regarding
physical pain, vitality, social functioning, overall health,
mental health, and emotional state. Furthermore, when
the researchers compared mothers of children with
ASD with people with clinical depression, the results
showed similarities between the two populations
(Khanna et al. 2011).
Parents of children with Down Syndrome reported
poorer physical and mental health, lower levels of psy-
chological well-being, and more significant psycho-
logical distress than parents of neurotypical developing
children (Hedov et al. 2000). Similar results were
reported for caregivers of children with ADHD (Liang
et al. 2021). Child comorbid diagnoses were also asso-
ciated with negative changes in caregivers’ QOL or
mental health status (Darla and Bhat 2021). Another
factor investigated in relation to caregivers’ QOL is
child age or age category. Some studies reported lower
caregiver QOL when their children reached adolescence
VOL. 0 NO. 0

compared to previous developmental stages. At the
same time, other studies did not find age, but rather
symptom severity and externalising behaviours to pre-
dict the caregiver’s QOL (Baghdadli et al. 2014, Patel
et al. 2022).
As a result, QOL is currently a relevant field of
study concerning caregivers of children with ASD
(Bohadana et al. 2019, Padden et al. 2019) and other
disorders (Kim et al. 2021, Pokharel et al. 2021), with
implications related to the current COVID-19 pan-
demic. For example, caregivers describe high distress,
anxiety, and depressive symptomatology associated dir-
ectly with fears regarding access to rehabilitation inter-
ventions and proper education for their child during the
COVID-19 pandemic (Folostina and Iacob 2021, Grumi
et al. 2021). Moreover, research shows that the care-
givers of children with ASD felt more distress and
higher anxiety levels (Corbett et al. 2021). However,
only the perceived distress was associated directly with
the current pandemic (Friesen et al. 2022). Studies
showed that female caregivers experienced post-trau-
matic stress symptomatology (Wade et al. 2021) or
other mental health problems during the COVID-19
pandemic (e.g. psychological suffering, persistent fear,
concerns about family health and economic status)
(Friesen et al. 2022, Grumi et al. 2021).
Most quantitative research on HRQOL in familial
caregivers of children with NDs focused primarily on
ASD, intellectual disorders, genetic syndromes, and
ADHD, giving little information about caregivers of
children with communication or motor disorders
(Schoemaker and Houwen 2021). This research will
also take into account communication and motor disor-
ders. Additionally, the data will be collected from
Romania, an eastern European country, providing
national policy-makers with arguments supporting this
vulnerable population. To our knowledge, previous
studies did not consider samples from this country.
Even though we do not expect to find different results
from other samples regarding HRQOL domains, we
believe the study will help national stakeholders assist
these caregivers.
Study aim
This study investigates the HRQOL of family care-
givers of children with NDs compared to caregivers of
typical developing children. Analyses of HRQOL will
be performed depending on the child age category, pri-
mary diagnosis, child’s disorder severity, and the pres-
ence of comorbidities (i.e. children with comorbid
diagnoses versus children with one ND).
First, we assume that caregivers of children with
NDs have a more negative perception of HRQOL than
caregivers of children with typical development.
Specifically, we expect the most affected areas to be
physical and mental health, given the COVID-19
International Journal of Developmental Disabilities
Cristina Sinziana Trofin and Claudia Iuliana Iacob HRQOL in familial caregivers
restrictions imposed by the authorities at the time of
data collection. Second, we expect caregivers of teen-
agers with NDs to report lower HRQOL compared to
caregivers of younger children with NDs, due to the
rise of behavioural challenges in teenage years. Third,
we assume that there will be differences in HRQOL
between caregivers of children with NDs depending on
the child’s diagnosis. Fourth, caregivers of children
with moderate and severe disabilities will report a lower
HRQOL compared to caregivers of children with mild
disabilities. Finally, we anticipate that caregivers of
children with comorbid NDs will describe a more nega-
tive perception of their physical and psychological
health than caregivers of children with one diagnosis.
Methods
Study design and participants
The present study is based on a convenience sample of
255 family caregivers (Mage ¼ 37.14, SDage ¼ 8.05) of
children aged between 1 and 17 years old. We analysed
two groups: group 1 - caregivers of children with NDs
(N1 ¼ 129, Mage ¼ 37.36, SDage ¼ 8.46), and group 2 -
caregivers of children with typical development
(N2 ¼ 126, Mage ¼ 36.93, SDage ¼ 7.48). In group one,
the questionnaire was filled in by 111 females and 18
males, of whom 115 were parents and 14 grandparents.
The main inclusion criteria for this group were caring
for a child with a neurodevelopmental disorder. Group
two consisted of 116 females and 10 males, of whom
121 were parents and 5 grandparents. We included in
this group caregivers of children without a neurodeve-
lopmental disorder. In both groups, the children had
similar ages and their gender was unknown. The socio-
demographic and disease characteristics of caregivers
and children are provided in Supplementary material
Table SM1. We included familial caregivers (i.e.
parents, grandparents) actively attending to children,
excluding formal caregivers (e.g. doctors, nurses).
There was no minimum duration of care needed to par-
ticipate in the current research if the caregivers were
not the parent of the children (i.e. if they were
grandparents).
Ethical considerations
The Research Ethics Committee of the University of
Bucharest approved this study (notification no.
52/14.08.2021). All procedures were carried out follow-
ing the Declaration of Helsinki.
Procedure and data collection
All participants completed the entire series of question-
naires in an online survey created in Google Forms.
There were no missing data because all questions in the
survey were checked as mandatory. At first, they read
an informed consent on the purpose of the research, the
time allotted for completion, the processing of personal
2023 VOL. 0 NO. 0 3
Cristina Sinziana Trofin and Claudia Iuliana Iacob HRQOL in familial caregivers
data, and the confidentiality of the information they
provide. The Google Forms survey was active for com-
pletion between December 2020 and March 2021, when
COVID-19 restrictions were still in place in Romania.
The survey was distributed only to Romanian partici-
pants and all of the questionnaires were completed by
familial caregivers (e.g. mothers and grandmothers). In
terms of data collection, the survey was shared in
online groups for caregivers of children with special
needs and by e-mail to centres, institutions, organisa-
tions, and specialists (e.g. psychologists, speech thera-
pists, social workers) from Romania, who shared the
questionnaire with caregivers. For the second group,
primary and secondary school teachers distributed the
questionnaire to the respondents. Therefore, we used
convenience sampling with ‘snowball‘ or ‘network‘
sampling.
The power analysis of the test was performed using
GPower 3.1 software (Faul et al. 2007), both a priori
and post hoc. For a test power of 95% and an effect of
.50, using a ¼ .05, a priori analysis suggested 105 par-
ticipants in each group. In the post hoc analysis, we
obtained statistical power of 99% in the present
research (N1 ¼ 129, N2 ¼ 126, a ¼ .05, d ¼ .5).
Measures
Health-related quality of life
To measure the health-related quality of life (HRQOL),
we used the WHOQOL-BREF scale (WHOQOL Group
1998). This self-reported scale covers four domains as
follows: (a) physical health, which includes facets such
as daily activities, drug/medication addiction/depend-
ence, mobility, energy, fatigue, discomfort, pain, hours
of sleep, opportunities for relaxation and fitness self-
reported work; (b) the psychological domain that inte-
grates subfields such as body image perception, positive
and negative emotions felt, self-perceived self-esteem,
spirituality/religiosity, personal beliefs, and cognitive
abilities (i.e. thinking, memory, learning, and concentra-
tion); (c) social relationships, domain that includes the
description of interpersonal relationships, the perceived
social support and the quality of sexual activity, (d) the
environment domain, relating to financial resources,
freedom, physical security and safety, perception of
public health services (i.e. accessibility and quality),
family environment, ability to access information and
learn new skills, opportunities for leisure activities (i.e.
recreational activities), physical environment (i.e. pollu-
tion, noise, traffic, climate) and transport services
(WHOQOL Group 1998).
The scale has 26 items scored on a 5-point Likert
scale, from 1 (not at all/never) to 5 (an extreme amoun-
t/always). Examples of items are: (1) for the physical
health domain – ‘To what extent do you feel that phys-
ical pain prevents you from doing what you need to
do?’; (2) for the psychological domain – ‘How much
4 International Journal of Developmental Disabilities 2023
do you enjoy life?’; (3) for the social domain – ‘How
satisfied are you with personal relationships?’; (4) for
the environment domain – ‘How safe do you feel in
your daily life?’. A Cronbach Alpha coefficient of .92
was obtained in the present research. Also, Cronbach
Alpha coefficient was calculated for each domain of
WHOQOL-BREF0 s scale: (1) physical health, a ¼ .77;
(2) psychological/mental health, a ¼ .80; (3) social, a
¼ .77; (4) environment, a ¼ .82.
Socio-demographic and health-related
characteristics questionnaire
All participants completed a socio-demographic ques-
tionnaire divided into two parts. The first part included
questions about themselves regarding gender, age, edu-
cation, employment status, marital status, medical diag-
nosis, and the relationship with the child (e.g. parent,
grandparent, legal guardian). The second part of the
questionnaire referred to the child’s characteristics: age,
medical diagnosis (where appropriate), and disorder
severity (i.e. mild, moderate, or severe disability).
Regarding diagnosis, caregivers could tick the diagnosis
based on the DSM-5 formulation and mark several dis-
orders simultaneously (i.e. associated comorbidities).
Then, caregivers reported the disorder’s severity.
Caregivers of children with neurotypical develop-
ment completed similar questions, except for the med-
ical diagnosis item. Instead, two questions were added
regarding a possible clinical condition of the child (e.g.
asthma, allergies) and the severity of that medical con-
dition (i.e. mild, moderate, severe impairment). As
mentioned above, the caregivers reported the name of
the medical condition and its severity.
Statistical analysis
The IMB SPSS Statistics Version 25 program (IMB
Corp 2017) was used to analyse the data from this
study. To investigate the HRQOL differences between
caregivers of children with NDs and caregivers of typ-
ically developing children, we used the independent
samples t-test, as there were no violations of the nor-
mality condition. As recommended, the skewness and
kurtosis indicators had values between 1.96 and
þ1.96. We reported the usual statistical indicators for
this type of analysis (t-test value, degrees of freedom,
p-value), including Cohen’s d effect size. A p-value
under .05 was considered the cutoff for statistical sig-
nificance. Cohen’s d values were interpreted using the
following benchmarks: small effect size (d  .02),
medium effect size (d ¼ .05), and large effect size (d
¼.08) (Cohen 1988).
Next, we compared the HRQOL of caregivers in the
first group (i.e. children with NDs), depending on the
child’s age: (1) 1 to 6 years old in the preschoolers’
subgroup; (2) 7 to 11 years old in small school child-
ren’s subgroup; (3) 12 to 17 years old group in the
VOL. 0 NO. 0
 Cristina Sinziana Trofin and Claudia Iuliana Iacob HRQOL in familial caregivers

teenagers’ subgroup. Differences between all the sub-
groups were analysed with Welch’s t-test. To approach
one of the most mentioned limitations in the research
literature, we compared the HRQOL of the first group
of caregivers by the child’s diagnosis, conducting the
non-parametric Kruskal-Wallis analysis of variance.
There were eight categories created by the diagnosis
criteria: (1) ASD (N ¼ 52); (2) ADHD (N ¼ 14); (3)
communication disorders (N ¼ 13); (4) learning disor-
ders (N ¼ 2); (5) motor disorders (N ¼ 2); (6) intellec-
tual disability (N ¼ 8); (7) others (i.e. comorbidities
with others disorders, like enuresis, hypoacusis or epi-
lepsy) (N ¼ 17); (8) multiple NDs (i.e. comorbidities
with another ND, like ASD or ADHD; N ¼ 21). Post
hoc Dunn analyses were used for significant results to
see the comparisons between the diagnoses. Given the
small sample sizes of the subgroups and their variety,
we chose to report the results of the adjusted p-value to
avoid possible false-positive results (Feise 2002,
Ludbrook 1998).
After that, we computed classic one-way ANOVA to
see whether the HRQOL of caregivers of children with
NDs differs depending on the disorder severity. The
Levene test showed that the score variances were
homogenous for all domains investigated: (1) the phys-
ical domain, F(2, 126) ¼ .54, p ¼ .570; (2) the psycho-
logical one F(2, 126) ¼ 1.16, p ¼ .312; (3) social
domain F(2, 126) ¼ .19, p ¼ .82; (4) that of the envir-
onment F(2, 126) ¼ .20, p ¼ .811. Lastly, HRQOL dif-
ferences depending on child comorbidities or single
diagnosis were analysed with Welch’s t-test, due to the
big difference in sample sizes.
Results
Descriptive statistics
The means, standard deviations, and minimum and
maximum values of the normality indicators (skewness
and kurtosis) for each group are provided in
Supplementary material Table SM2.
Between-group differences regarding HRQOL
domains
The independent samples t-test was statistically signifi-
cant, t(253) ¼  4.07, p < .001, Cohen0 s d ¼ 0.51.
Caregivers of children with NDs (M ¼ 15.54, SD ¼
2.97) reported lower scores on physical health than
caregivers of children with typical development
(M ¼ 16.88, SD ¼ 2.21). T-test analysis for independent
samples was statistically significant for the psycho-
logical domain (t(253) ¼  5.41, p <.001, Cohen’s
d ¼ 0.54). In the same way, caregivers of children
with NDs (M ¼ 15.03, SD ¼ 2.97) reported lower
scores on the mental health domain than those of chil-
dren with typical development (M ¼ 16.76, SD ¼ 2.04).
Statistical analyses also found significant differences
between the two groups regarding the social and
environmental domains. For the social domain, the
independent samples t-test was statistically significant
(t(253) ¼  5.11, p < .001, Cohen0 s d ¼ 0.64), with a
medium effect size. Similarly, for the environment
domain, the differences were also statistically signifi-
cant (t(253) ¼  3.14, p < .01, Cohen0 s d ¼ 0.39),
with a small effect size (see Table 1).
Differences between caregivers of children
with neurodevelopmental disorders,
depending on children’s age
Three groups were built according to the child’s age
with NDs. The first group included preschoolers
between 1 and 6 years old (N ¼ 74), the second group
had small school aged children between 7 and 11 years
old (N ¼ 30), and the last group was teenagers between
12 and 17 years old (N ¼ 25). There were no significant
differences between the caregivers’ HRQOL domains
according to the children’s age. The Supplementary
material Table SM3 has more information about the
statistical results. Therefore, the subsequent analyses
referred to the caregivers of children with NDs.
Differences between caregivers of children
with neurodevelopmental disorders,
depending on child’s primary diagnosis
We explored the differences between caregivers in the
first group depending on the child’s primary diagnosis.
Most children were diagnosed with ASD, followed by
ADHD and communication disorders (see Table SM1).
Kruskal-Wallis’s non-parametric analysis emphasised a
significant difference in the social support domain
(H ¼ 20.14; p ¼ .01) and the environmental domain
(H ¼ 15.64; p ¼ .03) between the caregivers, depending
on the child’s diagnosis. Pairwise comparisons using
Dunn’s post hoc test for the social support domain indi-
cated that the ND comorbidities subgroup scores were
significantly different from those of the communications
subgroup (adjusted p ¼ .01). In other words, caregivers
of children with communication disorders (M ¼ 16.77)
reported higher social support than caregivers of children
with comorbid NDs (M ¼ 12.24). No other significant
differences were found using the conservative adjusted
p-value approach. For the other two HRQOL domains,
there was no significant difference depending on the
Table 1. Overall between-group differences regarding
HRQOL domains.
Group 1 Group 2
HRQOL Cohen0 s
domain M SD M SD t(253) p d
Physical 15.54 2.97 16.88 2.21 4.07 .000 .51
Psychological 15.03 2.97 16.76 2.04 5.41 .000 .54
Social 13.7 3.84 15.9 3.00 5.11 .000 .64
Environmental 14.8 2.95 15.9 2.40 3.14 .002 .39
Note: Group 1 ¼ caregivers of children with neurodevelopmental
disorders; Group 2 ¼ caregivers of children with typical
development.

International Journal of Developmental Disabilities 2023 VOL. 0 NO. 0 5

Cristina Sinziana Trofin and Claudia Iuliana Iacob HRQOL in familial caregivers
child’s diagnosis: physical (H ¼ 10.15; p ¼ .18) and psy-
chological (H ¼ 9.52; p ¼ .22).
Differences between caregivers of children
with neurodevelopmental disorders,
depending on disorder severity
We analysed the possible differences between the care-
givers of children with NDs regarding HRQOL,
depending on the severity of the child’s condition.
Thus, three categories emerged based on the degree of
disability present in the child’s diagnosis: (1) mild dis-
ability (N ¼ 30); (2) moderate disability (N ¼ 58); (3)
severe disability (N ¼ 41). One-Way ANOVA analyses
showed non-significant differences for the physical
domain (F(2, 126) ¼ 2.97, p ¼ .052), the psychological
domain (F(2, 126) ¼ 2.28, p ¼ .100), and the environ-
ment domain (F(2, 126) ¼ 2.41, p ¼ .091). Only in the
social domain, we found significant between-group dif-
ferences (F(2, 126) ¼ 3.96, p ¼ .021, g2 ¼ .002), with
a small effect size. The Bonferroni post-hoc analysis
indicates a significant difference between the caregivers
of children with mild disorders and the caregivers0
group of children with severe disorders in describing
the quality of perceived social support (see Table 2).
Differences between caregivers of children
with neurodevelopmental disorders,
depending on comorbidities
We analysed the differences between caregivers of chil-
dren with comorbid NDs (N ¼ 38) and children with a
single ND diagnosis (N ¼ 91) in each HRQOL domain
(see Table 3). The differences were significant in the
following domains: psychological (t(67.2) ¼ 2.10, p <
.05, Cohen0 s d ¼ .41), social (t(67.2) ¼ 2.10, p < .05,
Cohen0 s d ¼ .41) and environmental (t(67.2) ¼ 2.58, p
< .05, Cohen0 s d ¼ .51). No significant differences
were obtained across the physical domain (t(67.2) ¼
1.27, p ¼ .208, Cohen0 s d ¼ .24). In other words, there
are no significant differences in how caregivers of chil-
dren with NDs perceive physical health depending on
the presence or absence of a comorbid diagnosis.
However, there are significant differences in the psy-
chological, social and environmental aspects associated
with HRQOL. Caregivers of children without a comor-
bid diagnosis report higher levels of HRQOL in the
domains mentioned above, with small to medium effect
sizes.
Table 2. Between-group differences regarding HRQOL domains, depending on disorder severity.
Group 1.1 (N ¼ 30)
HRQOL domain M SD
Physical 16.3 2.60
Psychological 15.9 2.55
Social 14.7 4.04
Environment 15.3 3.24
Note: Group 1.1 ¼ mild disability; Group 1.2 ¼ moderate disability; Group 1.3 ¼ severe disability;  p < .05.
6 International Journal of Developmental Disabilities 2023
Discussion
The present research aimed to investigate how family
caregivers of children with NDs perceive their HRQOL
compared to caregivers of typical developing children.
As expected, the caregivers of children with NDs report
lower HRQOL than the other group. These results con-
firm and complement comparative studies conducted on
familial caregivers of children with and without NDs
and their QOL (Adams et al. 2020, Bohadana et al.
2019, Darla and Bhat 2021, Khanna et al. 2011, Tung
et al. 2014).
Overall differences in HRQOL domains
The present study followed the four domains of
HRQOL (i.e. physical health, psychological, social sup-
port, and environment) described by the World Health
Organization (WHOQOL Group 1995, 1998).
Regarding the first two domains, caregivers of children
with NDs reported a lower quality of life than care-
givers of typical developing children. These results
reinforce the widespread and long-investigated hypoth-
esis that caregivers of children with NDs face various
negative feelings due to the many demands associated
with caring for a child with various conditions. The
caregiving process then reflects on their self-assessed
QOL, especially their physical and mental health. The
literature links the negative perception of QOL to bur-
den and stress, including how caregivers strive to cope
with the pressures and demands (Kim et al. 2021).
Differences regarding self-reported environmental
HRQOL between caregivers of children with and with-
out NDs were also found. So far, most studies did not
provide clear guidelines or conclusive information, as
most research emphasises the physical and psycho-
logical domains of HRQOL (Vasilopoulou and Nisbet
2016, Allik et al. 2006). The variations revealed in the
current study can be associated with the lockdown and
the restrictions imposed during the COVID-19 pan-
demic, especially in the environment and social
domains. In addition, the negative implications of the
restrictions on social interactions and outdoor activities
also could have impacted HRQOL. COVID-19-related
factors may have contributed to the respondents’ per-
ceptions: limiting or prioritising access to hospitals and
medical services, public transport safety and public
areas, and trust in state institutions.
Group 1.2 (N ¼ 58) Group 1.3 (N ¼ 41)
M SD M SD F(2, 126) g2
15.7 3.12 14.7 2.99 2.81 .043
15.0 3.10 14.4 2.91 2.39 .037
14.1 3.80 12.4 3.49 3.73 .056
15.1 2.75 14.1 2.93 1.95 .030
VOL. 0 NO. 0

Table 3. Between-group differences regarding HRQOL domains, depending on the presence of child comorbidities.
Group 1.1 (N ¼ 91)
HRQOL domain M SD
Physical 15.7 2.97
Psychological 15.4 2.77
Social 14.2 3.70
Environmental 15.3 2.68
Note: Group 1.1 ¼ Caregivers of children with neurodevelopmnent disorders and without a comorbid diagnosis; Group 1.2 ¼ Caregivers
of children with neurodevelopmnent disorders and with a comorbid diagnosis.
It is imperative to highlight that caregivers of chil-
dren with NDs had a lower QOL compared to care-
givers of children with typical development, mainly in
the social and psychological domains, followed by
physical health and environmental HRQOL. These
results are inconsistent with previous research showing
that physical health (Tung et al. 2014, Adams et al.
2020) and mental health (Khanna et al. 2011) matter
most. The current paper’s results could be explained by
the existence of ‘social restrictions‘ (i.e. legal regula-
tions, moral responsibility) faced in the COVID-19 pan-
demic. Thus, people seemed to prioritise social lifestyle
changes during the COVID-19 crisis (Zhang and Ma
2020). Future studies may deepen these issues regarding
QOL, both during the current COVID-19 pandemic and
after the pandemic.
In terms of physical health, studies showed that care-
givers of children with various disorders, especially
from the autism spectrum, describe severe pain (e.g.
migraines) and persistent fatigue as the leading indica-
tors of poor physical health quality (Allik et al. 2006,
Mugno et al. 2007, Adams et al. 2020, Tung et al.
2014). In contrast, in the present study, the domains in
which caregivers of children with NDs reported the
lowest scores compared to caregivers of typical children
were primarily the social and psychological ones.
Caregivers’ HRQOL and child’s primary
diagnosis
We compared the caregiver’s HRQOL on various
domains according to the child’s diagnosis, as indicated
by Schoemaker and Houwen (2021) recommendations.
We divided the group into multiple subgroups: ASD,
ADHD, communication disorders, learning disorders,
motor disorders, intellectual disability, multiple NDs
and others (i.e. comorbidities with a non-developmental
disorder, like enuresis, hypoacusis or epilepsy). Most
results were not significant, given the low sample sizes
in the subgroups. However, caregivers of children with
communication disorders reported higher social support
than caregivers of children with multiple NDs. This
finding may be explained by the fact that caregivers of
children with multiple NDs need more social support
more frequently than those of children with just one
condition or with higher levels of adaptive behaviour
(Carlson and Miller 2017, Drogomyretska et al. 2020,
Cristina Sinziana Trofin and Claudia Iuliana Iacob HRQOL in familial caregivers
Group 1.2 (N ¼ 38)
M SD t(67.2) p Cohen0 s d
15.0 3.08 1.27 .208 .24
14.1 3.21 2.10 .040 .41
12.6 3.99 2.10 .040 .41
13.7 3.29 5.58 .013 .51
McIntyre and Brown 2018), leading to the perception
that the support received is insufficient. In addition,
social support was higher for caregivers who offered
more attention to their child’s health status and lowered
for those who spent more time worrying about the men-
tal/physical health of the child (Wang 2021). Future
research may consider these directions to address less
studied NDs and validate the present study’s results.
Caregivers’ HRQOL and child disorder severity
There were differences between groups depending on
child disorder severity only in the social domain. Thus,
the caregivers of children with severe disabilities
reported lower social support compared with those of
children with mild disabilities. Previous studies
emphasised a dynamic link between perceived social
support, parental distress, quality of life aspects or
health status perception, and child behaviour character-
istics (Sharpley et al. 1997, Allik et al. 2006, Faw
2018). Thus, researchers explained that consistent help
from other family members (Sharpley et al. 1997) and
qualitative social support (Faw 2018) improve the
health perception of caregivers significantly in the case
of children with severe disorders (i.e. lower scores in
anxiety, depression, and distress scales).
Caregivers’ HRQOL and the presence of a
child comorbid diagnosis
The results showed that caregivers of children with a
single diagnosis had higher social, psychological and
environmental HRQOL scores compared to caregivers
of children with comorbidities. These findings are in
line with previous studies emphasising the role of
comorbid diagnosis in QOL perception. For example, in
their research about the caregivers of children with
ASD, with and without comorbid intellectual disability,
Vaz et al. (2021) show that there are several, but lim-
ited, implications of comorbidity over the caregiver0 s
QOL perception (e.g. they could declare less time for
leisure activities). Also, in children with Down
Syndrome, associated diagnoses (e.g. hypothyroidism,
heart problems, repeated respiratory infections, eczema)
were connected with lower QOL of their caregivers due
to more financial difficulties (e.g. multiple medical con-
sultations, various therapies and treatments) (Darla and
Bhat 2021).
International Journal of Developmental Disabilities 2023 VOL. 0 NO. 0 7
Cristina Sinziana Trofin and Claudia Iuliana Iacob HRQOL in familial caregivers
Limitations
Complementary to the contributions highlighted above,
this study has several limits, most deriving from the
cross-sectional nature of the research design. As such,
no timeline inferences can be made between the varia-
bles, and we cannot know how the HRQOL will modify
over time or depending on what factors.
Sample characteristics also can introduce some bias in
the results. The current study included grandparents and
fathers of children with NDs, an aspect proposed as a
research direction in the study conducted by Kim et al.
(2021); however, the percentage was low. Future studies
could consider targeting a more significant share of pri-
mary caregivers such as grandparents, fathers or other
relatives/legal guardians. We could not analyse the pos-
sible gender differences and the implications of the med-
ical history of the caregiver due to the imbalanced
sample (i.e. primarily female caregivers who participated
in this research). Females take on most caregiving tasks,
especially in collectivistic or developing countries
(Sharma et al. 2016, Pharr et al. 2014), such as
Romania. Furthermore, the subgroup with clinical health
conditions was small (i.e. 15 out of 129 for group 1 and
15 out of 126 for group 2), and we could not analyse the
HRQOL. Finally, socio-economic status and the particu-
larities of the children’s comorbid conditions (e.g. the
level of severity, the presence of additional treatment,
and the financial costs involved) were unknown in the
present study, which led to less control over this area of
investigation. Future studies may consider these aspects.
We could not observe differences between caregivers’
HRQOL according to the age of children with NDs. But
the sample consisted mostly from preschoolers, which
may have biased the results. Concerning caregivers, the
possible existence of medication treatment, including
sedatives or stimulants, or potential involvement in a
psychotherapeutic program was unknown, and these
aspects may have impacted their responses.
Conclusion
In the present research, caregivers of children with NDs
described lower HRQOL in all domains. The most sig-
nificant discrepancy between the main groups was
observed in the social domain, probably due to the
COVID-19 pandemic restrictions. There are significant
differences between caregivers of children with NDs
depending on the disorder severity, comorbidities, and
the child’s diagnosis. Above all, the current research
provides insight into how caregivers of children with
NDs coped during the COVID-19 pandemic compared
to caregivers of children with typical development.
Author contributions
Both authors contributed to the study’s conception
and design. Material preparation, data collection and
8 International Journal of Developmental Disabilities 2023
analyses were performed by Cristina Sinziana Trofin.
Cristina Sinziana Trofin wrote the first draft of the
manuscript, and Claudia Iuliana Iacob commented on
and reviewed the subsequent versions. Both authors
read and approved the final manuscript.
Disclosure statement
No potential conflict of interest was reported by the
authors.
Ethics approval
Ethical approval was waived by the Research Ethics
Committee of the University of Bucharest (notification
no. 52/14.08.2021).
ORCID
Claudia Iuliana Iacob http://orcid.org/0000-0001-
9508-4881
Data availability statement
The data that support the findings of this study are
openly available in the Mendeley repository at https://
data.mendeley.com/datasets/9c9tcxrmpx/1
References
Adams, D., Clark, M. and Simpson, K. 2020. The relationship
between child anxiety and the quality of life of children, and
parents of children, on the autism spectrum. Journal of Autism
and Developmental Disorders, 50, 1756–1769.
Allik, H., Larsson, J.-O. and Smedje, H. 2006. Health-related
quality of life in parents of school-age children with Asperger
syndrome or high-functioning autism. Health and Quality of Life
Outcomes, 4, 1.
American Psychiatric Association. 2013. Diagnostic and statistical
manual of mental disorders. 5th ed., Washington, DC.
Arora, S., Goodall, S., Viney, R., Einfeld, S. and The MHYPEDD
team. 2020. Health-related quality of life amongst primary care-
givers of children with intellectual disability. Journal of
Intellectual Disability Research : JIDR, 64, 103–116.
Awick, E. A., W ojcicki, T. R., Olson, E. A., Fanning, J., Chung,
H. D., Zuniga, K., Mackenzie, M., Kramer, A. F. and McAuley, E.
2015. Differential exercise effects on quality of life and health-
related quality of life in older adults: A randomised controlled trial.
Quality of Life Research : An International Journal of Quality of
Life Aspects of Treatment, Care and Rehabilitation, 24, 455–462.
Baghdadli, A., Pry, R., Michelon, C. and Rattaz, C. 2014. Impact of
autism in adolescents on parental quality of life. Quality of Life
Research : An International Journal of Quality of Life Aspects of
Treatment, Care and Rehabilitation, 23, 1859–1868.
Beach, S. R., Schulz, R., Williamson, G. M., Miller, L. S., Weiner,
M. F. and Lance, C. E. 2005. Risk factors for potentially harmful
informal caregiver behavior: Potentially harmful caregiver behav-
ior. Journal of the American Geriatrics Society, 53, 255–261.
Benjak, T. 2011. Subjective quality of life for parents of children
with autism spectrum disorders in Croatia. Applied Research in
Quality of Life, 6, 91–102.
Bohadana, G., Morrissey, S. and Paynter, J. 2019. Self-compassion:
A novel predictor of stress and quality of life in parents of chil-
dren with autism spectrum disorder. Journal of Autism and
Developmental Disorders, 49, 4039–4052.
Carlson, J. M. and Miller, P. A. 2017. Family burden, child disabil-
ity, and the adjustment of mothers caring for children with epi-
lepsy: Role of social support and coping. Epilepsy & Behavior :
E&B, 68, 168–173.
Centers for Diseases Control and Prevention. 2019. Caregiving.
Division of Population Health, National Center for Chronic
Disease Prevention and Health Promotion. Available at: https://
www.cdc.gov/aging/caregiving/index.htm
VOL. 0 NO. 0

Centers for Diseases Control and Prevention. 2020. Developmental
disabilities prevalence trends. National Center on Birth Defects
and Developmental Disabilities, Centers for Disease Control and
Prevention. Available at: https://www.cdc.gov/ncbddd/develop-
mentaldisabilities/features/birthdefects-dd-keyfindings.html
Cohen, J. 1988. Statistical Power Analysis for the Behavioral
Sciences (2nd ed.). Lawrence Erlbaum Associates, Publishers.
Corbett, B. A., Muscatello, R. A., Klemencic, M. E. and
Schwartzman, J. M. 2021. The impact of COVID -19 on stress,
anxiety, and coping in youth with and without autism and their
parents. Autism Research : official Journal of the International
Society for Autism Research, 14, 1496–1511.
Darla, S. and Bhat, D. 2021. Health-related quality of life and coping
strategies among families with Down syndrome children in South
India. Medical Journal, Armed Forces India, 77, 187–193.
Drogomyretska, K., Fox, R. and Colbert, D. 2020. Brief report: Stress and
perceived social support in parents of children with ASD. Journal of
Autism and Developmental Disorders, 50, 4176–4182.
Faul, F., Erdfelder, E., Lang, A.-G. and Buchner, A. 2007. GPower
3: A flexible statistical power analysis program for the social,
behavioural, and biomedical sciences. Behavior Research
Methods, 39, 175–191.
Faw, M. H. 2018. Supporting the supporter: Social support and psycho-
logical stress among caregivers of children with severe disabilities.
Journal of Social and Personal Relationships, 35, 202–223. 2018,
Feise, R. J. 2002. Do multiple outcome measures require p-value
adjustment? BMC Medical Research Methodology, 2, 1–4.
Folostina, R. and Iacob, C. I. 2021. Impact of COVID-19 lockdown
on children with developmental disabilities and their parents.
Cypriot Journal of Educational Sciences, 16, 1878–1892.
Friesen, K. A., Weiss, J. A., Howe, S. J., Kerns, C. M. and
McMorris, C. A. 2022. Mental health and resilient coping in care-
givers of autistic individuals during the COVID-19 pandemic:
Findings from the families facing COVID study. Journal of
Autism and Developmental Disorders, 52, 3027–3037.
Grumi, S., Provenzi, L., Gardani, A., Aramini, V., Dargenio, E.,
Naboni, C., Vacchini, V., Borgatti, R. and Engaging with
Families through Online Rehabilitation for Children during the
Emergency (EnFORCE) Group. 2021. Rehabilitation services
lockdown during the COVID-19 emergency: The mental health
response of caregivers of children with neurodevelopmental dis-
abilities. Disability and Rehabilitation, 43, 27–32.
Hedov, G., Anneren, G. and Wikblad, K. 2000. Self-perceived health
in Swedish parents of children with Down’s syndrome. Quality of
Life Research : An International Journal of Quality of Life
Aspects of Treatment, Care and Rehabilitation, 9, 415–422.
Huang, Y.-P., Chang, M., Chi, Y.-L. and Lai, F.-C. 2014. Health-
related quality of life in fathers of children with or without devel-
opmental disability: The mediating effect of parental stress.
Quality of Life Research : An International Journal of Quality of
Life Aspects of Treatment, Care and Rehabilitation, 23, 175–183.
IBM Corp. 2017. IBM SPSS Statistics for Windows. Armonk, NY:
IBM Corp. Available at:https://hadoop.apache.org
Ji, B., Zhao, I., Turner, C., Sun, M., Yi, R. and Tang, S. 2014.
Predictors of health-related quality of life in Chinese caregivers of
children with autism spectrum disorders: A cross-sectional study.
Archives of Psychiatric Nursing, 28, 327–332.
Khanna, R., Madhavan, S. S., Smith, M. J., Patrick, J. H., Tworek,
C. and Becker-Cottrill, B. 2011. Assessment of health-related
quality of life among primary caregivers of children with autism
spectrum disorders. Journal of Autism and Developmental
Disorders, 41, 1214–1227.
Kim, J., Kim, H., Park, S., Yoo, J. and Gelegjamts, D. 2021.
Mediating effects of family functioning on the relationship
between care burden and family quality of life of caregivers of
children with intellectual disabilities in Mongolia. Journal of
Applied Research in Intellectual Disabilities : JARID, 34, 507–
515.
Liang, S. H.-Y., Lee, Y.-C., Kelsen, B. A. and Chen, V. C.-H. 2021.
Health-related quality of life in mothers of children with attention
deficit hyperactivity disorder in Taiwan: The roles of child, par-
ent, and family characteristics. Research in Developmental
Disabilities, 113, 103944.
Lin, J.-D., Hu, J., Yen, C.-F., Hsu, S.-W., Lin, L.-P., Loh, C.-H.,
Chen, M.-H., Wu, S.-R., Chu, C. M. and Wu, J.-L. 2009. Quality
of life in caregivers of children and adolescents with intellectual
disabilities: Use of WHOQOL-BREF survey. Research in
Developmental Disabilities, 30, 1448–1458.
International Journal of Developmental Disabilities
Cristina Sinziana Trofin and Claudia Iuliana Iacob HRQOL in familial caregivers
Ludbrook, J. 1998. Multiple comparison procedures updates. Clinical
and Experimental Pharmacology & Physiology, 25, 1032–1037.
McIntyre, L. L. and Brown, M. 2018. Examining the utilisation and
usefulness of social support for mothers with young children with
autism spectrum disorder. Journal of Intellectual &
Developmental Disability, 43, 93–101.
Mugno, D., Ruta, L., D’Arrigo, V. G. and Mazzone, L. 2007.
Impairment of quality of life in parents of children and adoles-
cents with pervasive developmental disorder. Health and Quality
of Life Outcomes, 5, 22.
Padden, C., Concialdi-McGlynn, C. and Lydon, S. 2019.
Psychophysiological measures of stress in caregivers of individu-
als with autism spectrum disorder: A systematic review.
Developmental Neurorehabilitation, 22, 149–163.
Patel, A. D., Arya, A., Agarwal, V., Gupta, P. K. and Agarwal, M.
2022. Burden of care and quality of life in caregivers of children
and adolescents with autism spectrum disorder. Asian Journal of
Psychiatry, 70, 103030.
Pharr, J. R., Dodge Francis, C., Terry, C. and Clark, M. C. 2014.
Culture, caregiving, and health: Exploring the influence of culture
on family caregiver experiences. ISRN Public Health, 2014, 1–8.
Pisula, E. and PoreR bowicz-D€ orsmann, A. 2017. Family functioning,
parenting stress and quality of life in mothers and fathers of
Polish children with high functioning autism or Asperger syn-
drome. PLOS One, 12, e0186536.
Pokharel, R., Poudel, P. and Lama, S. 2021. Quality of life among
caregivers of children with epilepsy: A cross-sectional study at
Eastern Nepal. Epilepsia Open, 6, 120–126.
Saxena, S., Carlson, D. and Billington, R. 2001. The WHO quality
of life assessment instrument (WHOQOL-Bref): The importance
of its items for cross-cultural research. Quality of Life Research :
An International Journal of Quality of Life Aspects of Treatment,
Care and Rehabilitation, 10, 711–721.
Schmidt, M. and Kober, R. 2010. Quality of life of families with children
with intellectual disabilities in Slovenia. In: R. Kober, ed. Enhancing
the Quality of Life of People with Intellectual Disabilities. Vol. 41.
Springer Netherlands, Dordrecht, pp. 363–376.
Schoemaker, M. M. and Houwen, S. 2021. Health-related quality of
life in children with developmental disorders. Current
Developmental Disorders Reports, 8, 69–76.
Sharma, N., Chakrabarti, S. and Grover, S. 2016. Gender differences
in caregiving among family - caregivers of people with mental ill-
nesses. World Journal of Psychiatry, 6, 7–17.
Sharpley, C. F., Bitsika, V. and Efremidis, B. 1997. Influence of
gender, parental health, and perceived expertise of assistance
upon stress, anxiety, and depression among parents of children
with autism. Journal of Intellectual & Developmental Disability,
22, 19–28. 1997,
The WHOQOL Group. 1998. The World Health Organization quality
of life assessment (WHOQOL): Development and general psycho-
metric properties. Social Science and Medicine, 46, 1569–1585.
The World Health Organization quality of life assessment
(WHOQOL). 1995. Position paper from the World Health
Organization. Social Science and Medicine, 41, 1403–1409.
Tung, L.-C., Huang, C.-Y., Tseng, M.-H., Yen, H.-C., Tsai, Y.-P.,
Lin, Y.-C. and Chen, K.-L. 2014. Correlates of health-related
quality of life and the perception of its importance in caregivers
of children with autism. Research in Autism Spectrum Disorders,
8, 1235–1242.
Vasilopoulou, E. and Nisbet, J. 2016. The quality of life of parents
of children with autism spectrum disorder: A systematic review.
Research in Autism Spectrum Disorders, 23, 36–49.
Vaz, S., Thomson, A., Cuomo, B., Falkmer, T., Chamberlain, A. and
Black, M. H. 2021. Co-occurring intellectual disability autism.
Associations with stress, coping, time use, and quality of life in
caregivers. Research in Autism Spectrum Disorders, 84, 101765.
Wade, M., Prime, H., Johnson, D., May, S.S., Jenkins, J.M. and
Browne, D.T. 2021. The disparate impact of COVID-19 on the
mental health of female and male careguvers. Social Science &
Medicine (1982), 275, 113801.
Wang, C. 2021. Mental health and social support of caregivers of
children and adolescents with ASD and other developmental dis-
orders during COVID-19 pandemic. Journal of Affective
Disorders Reports, 6, 100242.
Zhang, Y. and Ma, Z. F. 2020. Impact of the COVID-19 pandemic
on mental health and quality of life among local residents in
Liaoning Province, China: A cross-sectional study. International
Journal of Environmental Research and Public Health, 17, 2381.
2023 VOL. 0 NO. 0 9