Parental Competence in Parents of Children with Autism Spectrum Disorder: A Systematic Review

Abstract Objective. This work aimed to define and assess the parental competence of parents with autistic children. Methods. This study was conducted through a systematic review. The search was done in databases, including Cochrane Library, PubMed, CINAHL, Science Direct, Wiley Scopus, Pro Quest, Web of Science, Elsevier, Google Scholar, and Ovid by using keywords, like “children, autism, parenting, competence, and scale” from 1974 to 2019. Inclusion criteria were that the article should be quantitative, qualitative, and mixed-method studies in nursing, psychology, and medicine; the full text of the article should be available and the article should be in English or Persian. Results. Competence among these parents was affected by more factors and they reported lower competence compared to other parents. Moreover, only two instruments were available to assess parenting competence, which were not designed for parents of autistic children. Variables and factors affecting parenting competence has not been examined well in parents of children with autism, and no specialized instrument is available to evaluate parenting competence in parents with autistic children either. Conclusion. Although parental competence has been known as the main element to improve the quality of care, it has been studied restrictively from the viewpoints of the parents of children with autism. Therefore, the development of this concept is highly essential for clinical application and investigating its outcomes support.


Introduction
A utism is one of the most important developmental disorders, which severely affects both parents and children. (1) This disorder imposes great physical, mental, and social pressures on families, particularly parents, (2) and affects various dimensions of their lives. (3) These parents, especially mothers, try to adapt with the painful events and the care burden and seek support from various resources. (4) Hence, the healthcare providing is required to identify the needs and problems of these parents and help them to do their parenting roles well. (5) In order to identify the problems of parents of children with autism, in recent years many studies have focused on the assessment of stress level and compatibility strategies in parents of autistic children. (6) These studies, in fact, aimed to find strategies for reducing the impacts of these children on other family members, particularly mothers (7) The results of these studies indicated that such mothers had lower health status, higher levels of stress, and lower self-efficacy and parenting competence compared to mothers with healthy children as well as those with children suffering from other disorders. (8,9) Although some studies have examined parental self-efficacy among parents of children with autism, parental competence is more comprehensive and broader than parental selfefficacy. (10) Some studies have attempted to define the concept of parental competence in parents of children with normal growth and development, (11,12) however the systematic review revealed that this concept is not explained in the parents of children with autism; when parents face their children's severe conditions, their competence will be significantly affected by their children's sickness and other background factors. (13,14) Also according to several studies, parental competence in these parents are influenced by more factors than the normal children's parents. (13)(14)(15) It is important that nurse's awareness of the effective factors in parenting competence among parents of autistic children that they can take basic steps in identifying the problems of these parents, promoting parenting competence and subsequently promote the quality of life of parents and the child with autism. In addition, definition, dimensions, and effective factors of parenting competence are not established well in such parents. The aim of the present study is to answer the question, which is to define and assess the parental competence of the parents with autistic children?

Methods
The present study is a comprehensive systematic review of the available literature on parental competence among parents of autistic children. The applied approach to systematic review is based on Cochrane's guideline which consists of topic selection, inclusion criteria, search strategy, selection of studies, evaluation of the quality of articles, data collection, analysis and conclusion. (16) The entire articles related to parental competence were published over the past forty years, from 1974 to 2019, and were checked electronically. The collected resources based on publication year, country of origin, type, research type and domains have been summarized in Table 1.

Variable n (%)
Year of Publication

Results
Out What is the meaning of parenting competence?
Review of the literature indicated that competence is an expanded concept (17) with various meanings depending on backgrounds, conditions, domains, and individual characteristics. (18) Therefore, no global definition can be presented for competence. (17,18) Indeed, studies on assessment of parenting competence have provided various definitions for this concept. (11,19) For instance, Nair et al. (20) defined parenting competence as parents' ability to provide care without asking others for help. In addition, Montigny et al. (21) conducted a study on analysis of maternal self-efficacy and stated that competence and self-efficacy were inter-related but different. Shin et al. (11) also disclosed that maternal sensitivity was related to, but different from maternal competence.
From psychological point of view, competence is defined as sufficient knowledge and skills for successful and effective performance of tasks. (19,22) On the other hand, Pridham et al. (23) defined parenting competence as the knowledge, skills, problem solving ability, and activity for child care, with knowledge and skills being more important compared to other dimensions. Mercer (24,25) also defined maternal competence as the ability to perform maternal roles through interaction with microsystems, particularly the family. Mondell et al., (26) too, defined parenting competence as selfefficacy, trust in interpersonal relationships, and compatibility with parental roles. However, no studies have been conducted on this concept in parents of autistic children.
What factors affect parenting competence in parents with autistic children?
The results of the studies demonstrated that parenting competence could vary depending on parents' and children's characteristics. (27) However, it was affected by interaction with professionals, (28) acquiring skills in child care, (28,29) ability to recognize the child's reactions, (29,30) parents' childhood experiences, (29) mental health, (29,31) age, (29,32) self-efficacy, (33,34) and parents' self-confidence. (23) Among these factors, parents' self-efficacy and self-confidence were two important predictors of parenting competence. (23,35,36) The findings of the studies on parents with autistic children revealed that stress, depression, familial and social support, parents' mental and physical health, feeling of guilt due to child's disease, participation in care programs, and being supported by professionals were effective in selfefficacy and subsequently parental competence of parents with autistic children. (37,38) On the other hand, other studies indicated that parents' self-efficacy had an impact on their parenting behaviors. It is evident that parents' behaviors and competence could, in turn, affect children's social, emotional, and educational growth and development. (2,32,39) Accordingly, parents with higher self-efficacy showed more responsibility, kindness, sympathy, and attempt for developing appropriate behaviors in their children and, as a result, were more competent to take care of their children. (40)(41)(42) What are appropriate and reliable instruments for the evaluation of parenting competence?
To evaluate each concept, it is essential that there be a valid instrument (43) Since self-efficacy is one of the main predictors of parenting competence, (23,35,36) parental self-efficacy questionnaires were used to assess parenting competence in most studies. (30,43,44) However, parenting competence is rather wider in comparison to parental self-efficacy (21) and cannot be judged by the mere assessment of self-efficacy. The findings revealed three main scales for the evaluation of parenting competence, namely Parenting Sense of Competence Scale, Sense of Competence Scale of the Parenting Stress Index and parental competence scale in parents of children with autism. (40,45,46) Gibaud-Wallston et al. (40) designed Parenting Sense of Competence Scale in 1977. This scale contains two dimensions, namely self-efficacy, knowledge, and skills (8 items); and satisfaction, comfort, and worthiness (9 items). The items can be answered through a 6-point Likert scale ranging from completely agrees to completely disagree. It should be noted that all items receive equal scores, and higher scores represent higher competence and self-confidence. This scale was first used in 100 parents to 10-week-old neonates born through natural vaginal delivery. The reliability coefficient was reported to be 0.80 for the whole scale and 0.69 and 0.80 for self-efficacy and satisfaction dimensions, respectively.
Mohammadi et al. (2) designed mixed-method study that developed and psychometrically of parental competence scale in parents of children with autism in 2018. This scale has two dimensions including: adapting with the present situation (9 items) and excellence in care (16 items). The parental competence scale demonstrated acceptable psychometric properties. Therefore, this scale can be used for assessing parental competence in parents of children with autism. (46) What instruments have been used to evaluate parental competence in parents of children with autism?
According to the results, seven articles had evaluated parenting competence in parents with autistic children using Parenting Sense of Competence Scale and Sense of Competence Scale of the Parenting Stress Index. (43,(47)(48)(49)(50)(51) The findings of these studies indicated that autistic children's behavioral problems affected the parents' satisfaction regarding parental roles, selfefficacy, social interactions, fatigue, and parenting competence. However, none of these factors could predict parents' satisfaction level, self-efficacy, and parenting competence ( Table 2). Results: Parenting stress was affected by the relationship between children's behavioral problems and parents' self-efficacy. On the other hand, parents' self-efficacy was associated with the relationship between parental stress and depression and anxiety. Accordingly, behavioral problems increased parents' stress levels, decreased their self-efficacy, and increased their anxiety and depression.

Discussion
The present study aims to define parenting competence and determine an appropriate instrument for its evaluation among parents with autistic children. The results indicated that competence was quite an expanded concept depending on backgrounds, conditions, and individual characteristics. Therefore, no global definition could be provided for this concept. (17,18) However, the results indicated that a few studies have explained parenting competence in parents with normal children (11,(19)(20)(21)(23)(24)(25)(26) These studies have defined parenting competence as skills, knowledge, comfort, and satisfaction regarding the successful and effective performance of parenting roles. (19,22) However, parental competence is not defined for the parents of children with autism.
This study has also demonstrated that more factors affected parental competence in parents with autistic children, compared to those with normal children, because behavioral problems children with autism cause their parents to experiencing more. (23,52,53) Parents' stress, anxiety, depression and fatigue levels were increased by behavioral problems, whereas their self-efficacy was decreased. (40,54) Therefore, acquiring child care skills and the ability to recognize children's reactions play a critical role in promoting parenting competence. (29,30) Evidence has revealed selfefficacy, self-confidence, participation in care, and professional relations as predictors of parenting competence. (23,35,36) Accordingly, parents' selfefficacy affects their parental behaviors, and this improved behavior influences their parenting competence as well as their children's growth and development. (55) Indeed, parents' participation in child development programs plays a key role in the promotion of parenting competence, because the parents acquire skills for organizing children's behaviors and benefit from professional support. (56,57) Since self-efficacy is one of the main predictors of parenting competence, most studies had utilized parental self-efficacy questionnaires in order to assess parenting competence. (29,44) The study results indicated that some studies involved designing instruments for the evaluation of parental self-efficacy in parents of children with other diseases. However, parenting competence has a far wider definition compared to parental selfefficacy. (21) Thus, parenting competence cannot be judged by the mere assessment of parents' self-efficacy, Therefore this study identified only three scales are available in this regards, namely Parenting Sense of Competence Scale, Sense of Competence Scale of the Parenting Stress Index and parental competence scale in parents of children with autism. (40,45,58) Parenting Sense of Competence Scale is a general instrument for determining parenting competence in parents with normal children. (59) Sense of Competence Scale of the Parenting Stress Index is one sub scale with 13 items for evaluating parenting competence. (59) Although this questionnaire is a reliable scale for assessing parental stress, it is not comprehensive enough to be utilized for the evaluation of parental competence. (45) Review of the related literature revealed that parental competence scale in parents of children with autism is only specialized instrument for the assessment of parenting competence in parents of children with autism. This scale was designed in 20019; therefore this scale has not been used by other authors. (57) Nonetheless, 7 articles were found to evaluate parental competence in parents of children with autism, in which they had used these two non-specialized instruments to determine parenting competence and self-efficacy in parents of children with autism. The results of these seven studies with those of the two nonspecialized scales for the parents of children with autism revealed that parents' quality of life was significantly associated with stress, adaptation strategies, and demographic features, but it showed no significant difference between mothers and fathers of autistic children regarding physical, mental, and social health. (60) One of the limitations of the present study was that the Literature about explaining the concept of parental competence of children with autism and its standard tools are few, the reason for its scarcity can be the absence of a comprehensive definition of the concept of parental competence and the lack of an appropriate scale for its measurement. Furthermore, most of the studies found on the subject were carried out in developed countries.
Since the level of health care and services in developed countries is higher and social welfare is generally better compared to developing countries, the findings cannot be generalized to developing countries (such as Iran).

Conclusion.
Although parental competence has been proposed as the main element in improving the quality of life among parents with autistic children, there have been few empirical studies and research; however, as parental competence is one of the key features among parents, it should be defined in parents with autistic children. An appropriate instrument should also be developed to evaluate parenting competence in such parents.
The findings of the present study can develop the knowledge and attitude of researchers and healthcare providers regarding the evaluation of parenting competence of parents with autistic children and subsequently, improve families' and children's health status. Thus, based on our findings, it can be said that the development and definition of parental competence concept among parents of autistic children, as well as the promotion and development of assessing the parental competence will be an important aspect of nursing care and clinical performance. Therefore, the development of this concept is highly essential for clinical application and investigating its outcomes support. In order to understand parental competence of parents with autistic children, it is suggested that mixed research be used to define this concept, then development and psychometric scale for assessing parental competence of such parents in different cultures.