Exploring Marital Quality in Parents of Children with Autism: Identifying Barriers and Facilitators

: The current study aims to examine the factors that facilitate or act as barriers to the marital relationships of parents of children with ASD. In total, 150 parents of children with ASD participated in this study. An online qualitative survey tool was utilized to collect data, which were subsequently subjected to thematic analysis. Through qualitative analysis, three major themes emerged: (1) Psychological and Emotional Experiences, (2) Sense of Partnership, and (3) The Rich get Richer, including sub-themes such as formal support systems, a strong marital relationship prior to ASD diagnosis, and limited family resources. The findings suggest that elements of the marital relationship can serve as valuable resources for parents of children with ASD in coping with the challenges of parenthood. Conversely, the study highlights certain factors that act as barriers to the marital relationship.


Introduction
The Diagnostic and Statistical Manual of Mental Disorders,Fifth Edition, from 2022 defines Autism Spectrum Disorder (ASD) as a neurodevelopmental disorder characterized by persistent deficits in social communication and social interaction across multiple contexts, as well as restricted, repetitive pa erns of behavior, interests, or activities.These symptoms must be present in the early developmental period and cause clinically significant impairment in social, occupational, or other important areas of functioning.Additionally, the DSM-5-TR specifies that the symptoms are not be er explained by intellectual disability or global developmental delay (American Psychiatric Association 2022).The World Health Organization has determined that 1% of children in the world have ASD (World Health Organization 2021).
Raising a child with autism spectrum disorder (ASD) can significantly impact family functioning, couple relationships, and parental well-being.A systematic review by Desquenne Godfrey et al. (2024) found that families of children with ASD experience more problematic general family functioning and less satisfaction compared to families with typically developing children.Parents of children with ASD typically experience higher levels of stress, anxiety, depression, and caregiver burden than other parents (Bonis 2016;Bozkurt et al. 2019;Khusaifan and El Keshky 2022).In addition, studies have shown that parents of children with ASD use more inefficient coping strategies (Vernhet et al. 2019) and report lower parental competence (Mohammadi et al. 2019).
The challenges of raising a child with ASD are not limited to the relationship between the parent and the child but also affect the relationship between the parents (Hock et al. 2012).The stress of raising a child with ASD can significantly impact couple relationships and parenting dynamics.Systematic reviews have found negative associations between relationship satisfaction and stressors, such as life events, parenting burden, and elevated parental stress levels (Sim et al. 2016).Saini et al. (2015) conducted a scoping review focused specifically on couple relationships among parents of children and adolescents with ASD.Their findings highlighted predominant themes of strain and disruption in marital relationships, stemming from stresses associated with meeting the needs of the child with ASD.Such stresses included accommodations and lifestyle adjustments, disagreements over treatment and care plans, limited opportunities for quality time or communication between partners, differing approaches to care, and lack of access to needed services.Limited time for the couple relationship was commonly reported by participants across the reviewed studies (Saini et al. 2015).
The severity of ASD symptoms in children does not appear to be a direct predictor of couple relationship quality or marital satisfaction for parents.Research by Desquenne Godfrey et al. (2024) and Saini et al. (2015) did not find a clear link between autism severity itself and poorer family functioning or reduced marital adjustment among parents.However, associated difficulties commonly seen in ASD, such as challenging behaviors, anxiety, and intellectual disability, do correlate with lower family cohesion, adaptability, and overall poorer family functioning (Desquenne Godfrey et al. 2024).Regarding relationship satisfaction specifically, a study by Sim et al. (2016) found no significant association between cognitive functioning in children with ASD and parental relationship satisfaction.The findings on the impact of ASD symptom severity were mixed across studies, with some reporting an inverse correlation with relationship satisfaction while others did not identify a significant relationship.
Research indicates that challenging behaviors exhibited by children with ASD can significantly strain couple and marital relationships.Multiple studies have found more severe behavior problems in children with ASD to be directly related to lower marital satisfaction and relationship quality for parents (Saini et al. 2015;Sim et al. 2016).Parents reporting more intense behavior problems, particularly externalizing behaviors, in their children also tended to experience higher personal stress levels.This elevated parental stress was associated with reduced relationship satisfaction, less spousal support, and lower commitment in the relationship-an effect that was especially pronounced among mothers (Saini et al. 2015).However, some studies did not find a significant difference between relationship satisfaction and the presence of either challenging or adaptive child behaviors (Sim et al. 2016).
Research examining the role of a child's age has yielded mixed findings regarding impacts on couple relationship quality and satisfaction.While some studies found having older children with ASD correlated with lower marital happiness and feeling less closeness in the relationship (Saini et al. 2015;Sim et al. 2016), others reported higher marital satisfaction with older children (Saini et al. 2015).Marital dissatisfaction was more prevalent when children were aged 5-9 years compared to 10-12 years (Saini et al. 2015).
The couple relationship can serve as an important source of support for parents raising a child with ASD.High-quality family relationships and social support have been positively linked to be er general family functioning, satisfaction, and cohesion (Desquenne Godfrey et al. 2024).Specifically examining couple dynamics, greater partner support has been shown to positively impact relationship satisfaction among these parents (Sim et al. 2016).The dyadic relationship provides a stage for spouses to support each other through the unique challenges of raising a child with ASD (Brien-Bérard and des Rivières-Pigeon 2023).This spousal support can play a protective role, as relationship satisfaction has been found to moderate the impact of emotional and behavioral difficulties in children with ASD on parental anxiety levels (Khusaifan and El Keshky 2022;Jose et al. 2021).
The aim of this qualitative study was to explore the experiences of the marital relationships among parents of children with ASD.Specifically, the primary objective was to elucidate the factors that undermine the quality of marital relationships in parents of children with ASD, as well as those that promote the preservation and enhancement of spousal relationships.The study sought to gain insight into the unique challenges faced by couples in this situation and to uncover strategies that may help them maintain a strong and healthy marital bond.To the best of our knowledge, no such study has been conducted in Israel; in that sense, this study may add unique insight into the facilitators and obstacles of marital relations of parents of children with ASD.Through this research, the study aims to contribute to the existing body of knowledge on ASD and its impact on families, as well as to provide practical guidance for families and professionals who work with this population.

Participants
Of the 150 parents who responded to the survey questions, a majority were women (82.7%).The average age of parents was 50.19 years.The average age of their children with ASD was 11.65 years.All participants in the study identified as Jewish, with 61.3% selfidentifying as secular, 24% as traditional, and 12.7% as religious.The severity of the child's ASD symptoms was reported by their parents; more than half of the children were reported to have mild ASD (53.1%), approximately one-fifth mild-moderate symptoms (19.0%), 9.5% moderate symptoms, 9.5% had severe ASD, and 8.8% were reported to demonstrate profound symptoms.

Measures
In the current study, we used a self-created online qualitative survey with two questions, one an open-ended question (Braun et al. 2021) that allowed participants to describe their experiences and perspectives regarding their spousal relationship.
The first question asked how having a child with ASD affected their spousal relationship, on a scale of 1-5 (1-significantly harmed the relationship; 5-significantly strengthened the relationship).The second question was an open-ended question encouraging the participants to further elaborate on their response to the first question ("Why does raising a child with ASD affect your relationship with your spouse in the manner you stated?").The items included in the survey were designed to collect information about facilitators of and barriers to the quality of the marital relationship.

Procedure
The study was approved by the Ethics Committee of the School of Social Work, Bar Ilan University (No. 092003).The online qualitative survey, based on two questions on a Qualtrics platform, was distributed via social networking, such as Facebook and WhatsApp.A convenience sampling was used to recruit parents of children with ASD for participation in the current study.To enhance transparency and address sample selectivity concerns, it is important to note that while social networking platforms were utilized for recruitment, efforts were made to ensure diversity within the sample.Specifically, recruitment messages were shared across various ASD-related groups and forums on these platforms to reach a broader audience.Additionally, the inclusion criteria for participation were clearly communicated to potential respondents, emphasizing that individuals with diverse backgrounds and experiences were encouraged to participate.Furthermore, the survey introduction provided participants with essential information about the study, including its purpose, voluntary nature, and assurance of confidentiality.Participants were also informed that their responses would be anonymized and used solely for research purposes.

Data Analysis
Thematic analysis was employed to identify major themes in response to an openended question (Braun and Clarke 2012).Initially, the authors independently conducted a thorough reading and coding of all the answers.The generated initial codes were then organized and categorized into potential themes.In the subsequent stage, the two researchers engaged in collaborative discussions to address any coding discrepancies and achieve consensus on the themes.Concurrently, a third researcher with expertise in disability research, who was not involved in the current study, independently reviewed the codes and provided valuable insights and revisions to the coding and themes.Following deliberation between the third researcher and the authors, a consensus on the themes was reached.Finally, the authors grouped the main themes to present the findings in a clear and comprehensive manner

Results
The first question asked participants to rate the way having a child with ASD affected their marital relationship.A minority of participants (25.2%) stated that having a child with ASD negatively harmed their relationship, and 7.2% cited significant harm (18%).Another 34.5% maintained that having an ASD child strengthened their relationship, and 15.1% noted significant strengthening of their marital relationship.The remaining 18% of participants stated that having a child with ASD did not affect their relationship.
No significant associations were observed between various personal characteristics and the perceived impact of ASD on spousal relationships.These characteristics included the age of the child and parents, parent gender, severity of the child's disability, and religiosity.
The analysis of responses to the open-ended question yielded three main themes: (1) psychological and emotional experiences, (2) a sense of partnership, and (3) the rich get richer (see Figure 1).These themes and their sub-themes are presented here.

Psychological and Emotional Experiences
Many parents mentioned and detailed their psychological and emotional challenges as parents of children with ASD.These fall under four sub-themes: (1) growth from adversity, (2) feeling pressure, (3) feeling hopelessness, and (4) tension between spouses.

Growth from Adversity
Participants spoke of the emotional process they underwent following the diagnosis of their child with ASD, and the subsequent personal and marital growth as a result of experiencing a new perspective to life.Participants felt that this strengthened the meaning of their marital relationship, placing it at the center as an important and significant source of support.As one participant stated: "New challenges mainly in everything that is related to children and dealing with these challenges, empowers and strengthens the relationship."(Participant 73) Another example was: "Caring for the child makes you look for solutions and strengthen the marital relationship."(Participant 68)

Feeling Pressure
Participants shared that the pressure that accompanied the diagnosis of ASD contributed to damaging the marital relationship.For example, one participant described: "The load, the pressure, the worry, the disappointment, the day-to-day difficulties damage the relationship."(Participant 22) Similarly, another participant stated: "Greater pressure creates a pressure cooker and nerves that come out on each other."(Participant 33)

Feeling of Helplessness
The third sub-theme of psychological and emotional barriers to the marital relationship referred to the sense of helplessness stemming from the child's ASD diagnosis.For example, in the context of marital relationships, one participant describes how the diagnosis affected her marital relationship: "Depression, dissatisfaction, lack of joy, lack of hope, lack of trust."(Participant 59)

Tension between Spouses
A few participants felt that the child's diagnosis with ASD weakened the marital relationship due to tensions that arose around having a child with ASD.One participant described a scenario where: "One side accepts and accommodates, and the other side still does not."(Participant 69).
Another example can be seen in the following quote: "… [having a child with ASD] increased the disputes and the tension between us."

Sense of Partnership
Many participants spoke of elements of their relationship that be er equipped them to handle the challenges of parenting children with ASD, as well as those elements that threatened their relationship.These included the sub-themes: (1) complementary parenting, (2) common goal, (3) breaking the marital alliance, (4) differences in a itudes, and (5) uneven distribution of responsibility.

Complementary Parenting
This theme describes couples who effectively distribute responsibilities between them of caring for the child with ASD.These couples aim to fulfill the many roles required of parents of children with ASD; each spouse takes on a role, and together they try to meet all the requirements of raising their child.As one participant remarked: "I learned to trust him (the husband) more because there are things in which he has more emotional abilities than me and also physical and vice versa-it's quite mutual."(Participant 56)

Common Goal
The participants contended that a mutual motivation to take care of their ASD child strengthened the marital relationship: "Difficulty makes us stronger, we do everything together in order to give the child as many tools as possible."(Participant 83) Another participant stated: "We both understood that we needed to act on a common front so that our child would be be er, ready to accept him as he is and work together to promote him in cooperation."(Participant 100) The first two sub-themes of the sense of partnership theme addressed positive factors that facilitated be er marital relationships.The following three sub-themes address barriers to the marital relationship addressed by parents.

Breaking the Marital Alliance
Some participants felt that raising and caring for a child with ASD had created a rift that weakened the marital alliance.This may occur when the child with ASD takes the place of the spouse within the relationship and makes it difficult for a marital relationship to exist.For example: "Because of his lack of independence (the child with ASD) and the need to sleep with him, my husband and I do not spend evenings together."(Participant 22) As well as: "I mediated the world to my daughter as much as was needed, in an instinctive manner.My husband felt that a symbiosis was created between us that left him and the other children on the outside."(Participant 55)

Differences in A itudes
Participants expressed how differences in a itudes and opinions created tension between spouses.As one participant stated: "The differences of opinion, the differences in views of life, different education methods, the feeling of the burden of taking responsibility and worrying about the child's advancement, zero free time for myself and of course for our relationship, more taking control, less trusting that the other party will do it, and do it the way I believe it should be done.These revealed the gaps and reduced the cohesion that existed before."(Participant 32) Similarly, one participant described how the marital relationship was damaged due to the diagnosis of the child with ASD: "Because of the differences of opinion, the being ignored and the denial."(Participant 44)

Uneven Distribution of Responsibility
Participants discussed the strain in the marital relationship caused by a lack of partnership in tasks related to raising and caring for the child with ASD.As one participant shared: "We sometimes had fights because only I take him (the child with ASD) to treatments and my husband is not willing to get involved."(Participant 4) Another said: "Because most of the burden is on me, there is no consideration of me or understanding that the child has special needs."(Participant 1)

The Rich Get Richer
The theme "The Rich Get Richer" highlights how the presence or absence of resources, such as formal support systems, a strong pre-existing marital bond, and adequate family resources, can significantly impact the way couples cope with the challenges of parenting a child with Autism Spectrum Disorder (ASD).The availability of these resources can provide couples with the necessary tools and support to effectively navigate the demands of raising a child with ASD, potentially strengthening their marital relationship.Conversely, a lack of resources can strain the relationship, as couples struggle to meet their child's needs while neglecting their own as a couple.This theme comprises three sub-themes: (1) formal support systems, (2) a strong marital relationship prior to ASD diagnosis, and (3) limited family resources.

Formal Support Systems
The importance of a formal support system as a resource that contributes to the strengthening of the marital relationship was presented by some of the participants.Many study participants recalled the multitude of formal support systems that assisted them after their child's diagnosis and have provided support in dealing with complex situations that arise from caring for a child with ASD.One participant said: "[In] Special education there is someone to talk to, there is support, there is availability, there is more coordination between the school and the home-therefore it is also easier to be in a healthy relationship because everything is clear."(Participant 49)

A Strong Marital Relationship Prior to ASD Diagnosis
The first sub-theme addressed couples who had a strong initial marital foundation, that is, those who enjoyed a prosperous and meaningful relationship before their child was diagnosed with ASD and maintained these qualities after the ASD diagnosis.One participant noted: "Our partnership was excellent and strong before, so the child with ASD strengthened it to a certain extent because the relationship was already strong before he was born.Our child affected our partnership in that we now share struggles that are only ours, and only we feel and understand.Even if the environment accommodates and supports us, at the end of the day it's our pain and coping together and we can really share it only with one another."(Participant 54) Another example of this was the following observation from a participant: "Our relationship is strong, and even if at first it (the relationship) took a slight hit, later on we got stronger and talked more openly about taking care of what is needed."(Participant 53)

Limited Family Resources
Some couples shared that lack of resources in the face of the growing demands required in raising a child with ASD adversely affected the marital relationship.These participants stated that they gave preference to the needs of the child before the needs of the marital relationship.For example, one participant stated: "Since it requires a lot of physical and mental resources, time and dedication to allow the child to become an independent adult who can reach his potential and find his place socially.There is not much room left for anything else." (Participant 8) This is also evident from the words of another participant: "We think about the needs of the child and less about ours as a couple, and most of the resources are directed to him, including mental strength."(Participant 19)

Discussion
This study identified and explored the factors that may facilitate or act as barriers to the marital relationships of parents of children with ASD.The examination of the marital relationship holds significance due to its potential as a valuable resource in coping with the challenges associated with parenting a child diagnosed with ASD (Brien-Bérard and des Rivières-Pigeon 2023; Brown et al. 2020).
As noted by Saini et al. (2015), there is a need for comprehensive investigation pertaining to the marital relationship among parents of children diagnosed with ASD, encompassing diverse populations characterized by variations in cultural backgrounds, socioeconomic status, ethno-racial composition, and structural factors.In this context, our study contributes to the existing body of research by offering cultural insights specific to the Israeli population.
The study's findings can be understood through the lens of the Conservation of Resources (COR) theory (Hobfoll 1989).The theory offers a comprehensive framework for understanding the relationship between stress and managing personal resources.The central premise of this theory is that individuals strive to acquire, maintain, and protect their valued resources.Stress occurs when individuals experience or anticipate a threat to their resources, an actual loss of resources, or a lack of resource gain following an investment of resources.Conversely, well-being is achieved when individuals have access to sufficient resources and can effectively manage these resources.
One interesting finding in our study was that almost 50% of participants stated that having a child with ASD strengthened their marital relationship.This finding might appear unexpected given that some studies suggest higher divorce rates among parents of children with ASD compared to the general population.Other research suggests that parents of children with ASD were more likely to be married compared to parents of children with other disabilities, and children with multiple disabilities were more likely to live in single-parent families (Saini et al. 2015).However, this finding of the potential for a positive effect on the quality of the relationship supports previous articles in the academic literature indicating that having a child with ASD can improve parental growth, resiliency, enrichment, compassion, and emotional maturity (King et al. 2012;Meleady et al. 2020).
The first theme in the current study concerned the psychological and emotional experience of parents of children with ASD.Negative experiences expressed by participants, including feeling pressure, hopelessness, and tension between the spouses, were countered by expressions of positive effects on the marital relationships, such as growth from adversity.Previous studies have also shown that parenting children with ASD can produce elements of growth, including empowerment and personal strength, existential perspective, spiritual-emotional experience, interpersonal growth, and professional growth (Phelps et al. 2009;Waizbard-Bartov et al. 2019).These findings align with COR theory, which posits that during challenging life circumstances, individuals can experience concurrent processes of resource loss and resource gain (Hobfoll 1989(Hobfoll , 2011)).
The second theme found in this study was that a sense of partnership can be a key factor in the quality of the marital relationship.When parenthood is complementary and parents have a common goal, the sense of partnership can facilitate a higher quality of marital relationship.On the other hand, when spouses struggle to maintain the marital alliance, when they exhibit differing a itudes, and when there is an uneven distribution of responsibilities between them, the lack of a shared sense of partnership can potentially damage the quality of the relationship between parents of ASD children.This supports previous studies on parents of children with ASD that reported the communication between the couple to be a key factor in maintaining a marriage (Gupta et al. 2023).Likewise, dyadic coping of parents of children with disabilities, which includes facing the challenges as a team, can have an important role in preserving the marital relationship (Brien-Bérard and des Rivières-Pigeon 2023).
The findings from this theme highlight how the presence or absence of a unifying parental partnership acts as either a resource protective factor or a risk factor for resource depletion, respectively, aligning with the COR theory's principles regarding the conservation and investment of key resources during challenging life circumstances (Hobfoll 2011).
A strong marital partnership with shared goals and responsibilities can be viewed as a vital interpersonal resource for parents navigating the challenges of raising a child with ASD.When spouses exhibited a complementary parenting approach with common objectives and an equitable division of responsibilities, this fostered a sense of partnership-a dynamic the theory suggests represents a crucial resource gain that can help offset resource losses experienced by these parents.
Conversely, when parents struggled to maintain a cohesive marital alliance due to differing attitudes or an imbalance in caregiver duties, this undermined their interpersonal resource of partnership.The theory posits that such resource loss begets further depletion, potentially exacerbating other losses and hampering parents' ability to cope effectively.
The final theme maintained that formal support systems and having a strong relationship before the child's ASD diagnosis can be the facilitator of a higher quality of marital relationship.On the other hand, having limited mental, emotional, and/or physical resources can be a barrier to the marital relationship.Other studies have also found that formal support systems, such as support from professionals, can help preserve a positive marital relationship (Brien-Bérard and des Rivières-Pigeon 2023; Solomon and Chung 2012), and that good communication and having a previously strong marital foundation based on common expectations can help parents of children with ASD keep their marriage strong (Ramisch et al. 2014).
This theme exemplifies the gain spiral and loss spiral concepts central to COR theory (Hobfoll 2011).The finding that formal support systems and strong pre-existing relationships facilitated marital quality represents initial resource gains that enabled further resource accrual-the gain spiral dynamic.Conversely, limited personal resources acting as a barrier to marital quality reflects how initial resource deficits can precipitate cascading loss spirals across life domains like relationships.
It is surprising that social support was not mentioned as a facilitator for marriage quality in the examined studies, given the substantial impact it has been shown to have on parents of children with ASD.For instance, Marsack and Samuel (2017) found that informal social support partially mediated the relationship between caregiver burden and parents' quality of life.Similarly, He et al. (2022) identified perceived family support as a significant predictor of relationship satisfaction among parents of children with ASD.

Limitations and Directions for Future Research
The current study has several limitations.First, as with all qualitative research, there is also always a possibility for human error in the data analysis; these errors may be a result of fatigue, erroneous interpretation, and personal bias (Bengtsson 2016).While the qualitative data offer valuable insights, they may lack the robustness and generalizability of quantitative approaches.A follow-up study utilizing quantitative data is recommended to supplement these findings.
In the current study, we used an online qualitive survey, and participants were asked to answer two questions, one of them in written detail.This data collection method, although useful in the sense that it allows the potential for a rich amount of data, has several limitations.For example, this method does not allow for follow-up questions.In addition, this platform may create a bias against people who find it difficult to express themselves through written text and may, therefore, opt not to participate in the study (Braun et al. 2021).
Another limitation is that a high percentage of participants in this study were female.Fathers are often underrepresented in studies that examine parents of children with ASD (Desmarais et al. 2018;Gerow et al. 2018;Ilias et al. 2018;Martin et al. 2019); this is also true specifically in the context of the marital relationship (Sim et al. 2016).Our study faced the same limitation; therefore, we suggest that future research focus on marital relationships from the perspective of fathers.
The Israeli population is characterized by many cultural differences.Consequently, the dynamics of parenthood are expected to be perceived and practiced divergently across these distinct groups.Thus, while this study of the general population allows it to be projected on the diverse populations of other countries, it does not delve deeply into any one specific culture.Hence, it is recommended that forthcoming research endeavors in Israel direct their a ention towards investigating particular subpopulations, specifically, the Arab and ultra-Orthodox communities.
Our study did not specifically address the involvement or impact of stepparents, which may influence the dynamics of caregiving and familial relationships in parents of children with ASD.Further research considering the role of stepparents is needed to fully explore the factors affecting marital quality in these families Additionally, future research should explore the longitudinal trajectory of marital satisfaction over time, particularly in comparison to families with children with other disabilities or without disabilities.Longitudinal studies would offer valuable insights into how marital satisfaction evolves in response to various factors over the course of family life.Lastly, future research should more closely examine the nuanced associations among parents' age and gender, the child's age and gender, and the severity of ASD symptoms in relation to relationship quality and divorce risk, as well as how having both affected and unaffected children within the same family impacts marital dynamics.

Practical Implications
The implications of this study point to the need for policymakers to adopt a familycentered approach when a empting to assist parents of children with ASD.The familycentered approach is based on the premise that all family members, and the dynamic between those family members, are affected by the child's situation.For that reason, all family members should be taken into account when offering services and interventions (Franck and O'Brien 2019;Kokorelias et al. 2019).In the context of our study, in addition to granting services to parents of children with disabilities as individuals, social support should be offered to help parents in preserving and strengthening their marital relationship.As shown in this study and others, the marital relationship can act as a resource in itself for handling the challenges that come with parenthood to children with ASD (Brien-Bérard and des Rivières-Pigeon 2023).
Within the focus on parents of children with ASD as couples, we suggest that interventions focus on their communication abilities with each other.As shown in the current study, discussion of many issues, such as mutual expectations and the distribution of responsibility, may resolve miscommunication and thus benefit these parents.

Conclusions
Parenting children with ASD can have unexpected effects on the quality of marital relationships.Many factors may help parents leverage their relationship as a tool to be er handle the challenges faced by parents of children with ASD, while other elements can adversely affect the marital relationship.Knowing this, we can be er work to enhance the quality of the marital relationship for parents of children with ASD.