**5. Managing family stress**

Until the 1980's, the diagnosis of autism was generally not well-known and most children diagnosed with autism were eventually institutionalized. Today, the majority of these chil‐ dren live with their families, who face enormous challenges in planning for and providing a lifetime of care. Families often experience significant financial burden [26], insecurity re‐ garding long-term family planning, and stress related to the child's social impairments and adverse behaviors that often interfere with family functioning [27, 28]. Because additional care giving has been shown to predict parental distress [29] and parents of children with au‐ tism may experience greater stress than parents of children with other disabilities, interven‐ tions and techniques that can reduce stress are needed [30-34].

Although caring for a child with ASD can adversely affect quality of life for both parents [35], most research related to parental stress has focused on mothers [36] who have reported higher stress levels than fathers [31, 37-40]. However, in two other studies comparing moth‐ ers' and fathers' stress levels, no differences were found [32, 41]. The author and team also found that both mothers and fathers scored very high, over the 90th percentile on the Parent‐ ing Stress Index pre-intervention with no statistical significance between the mothers' and fathers' scores [14].

In 2008, Davis and Carter provided more insight regarding how mothers and fathers may react to their child's autism. They noted that although mothers had a higher rate of stress and depression, fathers reported more difficulty interacting with the children. In addition, mothers were more involved with everyday activities and thus, more often affected by their child's inability to perform activities of daily living and self-regulate emotions. In contrast, fathers reacted more to overt behaviors such as tantrums, aggression, and/or loud/peculiar vocalizations, which are particularly difficult to manage and can be embarrassing in public settings. Because the core disability associated with autism is social, it can be stressful for parents to deal with a child who may not like to be held, will not respond to their affection, or even make eye contact.

Although only a few studies have explored effects of child intervention on changes in paren‐ tal stress levels, [14, 28, 42, 43] results are promising. Parent involvement that results in im‐ proved child outcomes can empower parents and lower stress in both mothers and fathers. Also, it is important to consider that although fathers may not appear to be as overtly stressed as mothers, there is evidence that they also experience high levels of stress; there‐ fore, interventions should include both mothers and fathers. Finally, although little is known about stress in siblings, it is likely that their stress is also high and that they could benefit from being included in an intervention.
