In China, approximately 4.04 million (6.65%) children are diagnosed with developmental disabilities (Olusanya et al., 2018). “Developmental disability” is an umbrella term that contains a group of conditions resulting from impairments that affect a child’s physical, learning, or behavioral functioning (Centers for Disease Control and Prevention (CDC), 2018, p.1). Affected children typically have cerebral palsy, autism spectrum disorder (ASD), attention deficit/hyperactivity disability (ADHD), intellectual disability, or other language/speech disabilities (American Psychiatric Association, 2013). In recent years, the impact of a diagnosis of developmental disabilities in children on primary caregivers has become better understood (Ribeiro et al., 2016). Caregiving for children who have been diagnosed with developmental disabilities leads adverse psychological health effects such as stress (Meadan et al., 2010; Zaidman-Zait et al., 2017), depression (Davis and Carter, 2008; Picardi et al., 2018), and anxiety (Al-Farsi et al., 2016; Sohmaran and Shorey, 2019) and has physical health impacts such as frequent challenges sleeping (Levin and Scher, 2016), eating (Bouma and Schweitzer, 1990) or communicating and behavioral and health complications (Ying et al., 2021). In addition, when caring for a child with developmental disabilities, caregivers can also experience posttraumatic stress symptoms (PTSSs), such as intrusive recollections, avoidant symptoms and hyperarousal symptoms (Wijesinghe et al., 2015; Masefield et al., 2020). Most studies have focused on the burdens (Alnazly and Abojedi, 2019; Hong et al., 2020; Liao and Li, 2020). Recently, under the influence of positive psychology, researchers have shifted their research focus to positive changes in individuals, such as posttraumatic growth (Hefferon et al., 2009), resilience (Aburn et al., 2016), positive coping style and self-efficacy (Luque Salas et al., 2017) and other similar concepts.

Our goal in this study was to extend our understanding of the relationship of resilience, positive coping style, self-efficacy and PTG among the primary caregivers of children with developmental disabilities. Specifically, we hypothesized that resilience directly or indirectly predicted the generation of PTG among primary caregivers through positive coping styles and self-efficacy. Our results confirmed the hypothesis: (1) higher resilience was associated with higher levels of PTG, consistent with previous findings (Kalisch et al., 2015; Qin et al., 2021), and the primary caregivers with higher resilience were more likely to actively seek multiple ways of solving problems, to take the initiative to obtain relevant knowledge and more easily accept their reality, to face their children with optimism, and to try to return to a normal life (Owens, 2016); (2) for the mediating role of self-efficacy, primary caregivers with higher resilience acquired a sense of achievement when handling pressure-related problems, which enhanced their sense of self–efficacy and thus promoted more PTG; and (3) positive coping style played a stronger mediating role in the relationship between resilience and PTG. The higher the resilience of caregivers was, the more active they were in exploring solutions to problems, calmly coping with stressful events in life, and improving their psychological growth, consistent with previous research results (Kuhn and Carter, 2006; Stephenson et al., 2016). Moreover, resilience also plays a key role when caregivers are confronted with adverse events in their lives. For instance, they will actively seek help, such as asking family members and friends for solutions, searching about relevant issues on the internet, and supporting their “companions” who have similar experiences. These actions can lead them to achieve a certain inner growth, hence promoting more PTG behaviors.

Consistent with previous findings (Qin et al., 2021), our study revealed that the primary caregivers of children with developmental disabilities experienced moderate PTG. We also found statistically significant differences in PTG across the education levels of the primary caregivers. According to the results of our study, subjects with a college education or higher (accounting for 58.1% of the sample) generally had higher PTG scores than subjects with a lower educational level. As we assume, perspective and the way in which life events are processed vary with level of education, hence affecting PTG (Stockton et al., 2011; Magallón-Neri et al., 2017). The different levels of PTG resulting from both area of residence and monthly income, which are rarely mentioned in previous articles, have also been shown in this study. There was a progressive decrease in PTG scores from urban areas to rural areas. This variation may have been caused by the differences in living conditions (economic level), educational concepts and social support in various areas of residence, concerning both caregivers and children. For instance, the socioeconomic status of people who live in rural areas may be lower than that of people who live in urban areas. Low-income families may be under greater pressure to pay for their children’s rehabilitation, which negatively affects PTG. Moreover, in traditional Chinese culture, disability is viewed as a punishment for the disabled person’s sins in the past life or the sins of the person’s parents (Huang et al., 2009; Holroyd, 2016), so primary caregivers consider the disabilities to be stigmatic. Furthermore, social support for caregivers may also be insufficient in rural areas, where more negative public attitudes could lead to lower expectations and more discriminatory behaviors and marginalization of families with disabilities than in the suburbs and urban areas (Zheng et al., 2016). Our study also found non-significant marital status and child diagnosis differences in PTG. PTG did not differ significantly in dependence on the marital status, mainly because there were only 8 (4%) divorced primary caregivers in our sample size, which accounted for a small part of the sample size. PTG did not differ in dependence on the child’s diagnosis. We suspect that developmental disabilities, regardless of the diagnosis, pose a great challenge for the primary caregiver. For example, developmental disabilities need rehabilitation treatment, which is a long process that requires considerable time, energy and money (Blachera et al., 2005; Wayment et al., 2019). Therefore, targeted psychological intervention is particularly important for caregivers.

The families of children with developmental disabilities face great economic, life, and other pressures. Thus, the primary caregivers of children with developmental disabilities might have significant psychological problems, gradually resulting in a public health problem. Most previous studies are limited to the exploration of PTG and the adverse factors (Alnazly and Abojedi, 2019; Bravo-Benítez et al., 2019; Naheed et al., 2020) and protective factors (Blackledge and Hayes, 2006; Young and Kleist, 2010; Wayment and Bauer, 2018) of PTG in the parents of ASD children. This study included the primary caregivers of ASD children and children with other developmental disabilities, such as ADHD, intellectual disability and other developmental delays. While exploring the protective factors of the primary caregivers of children with developmental disabilities, we found that resilience directly and indirectly affected the production of PTG through positive coping styles and self-efficacy, and that some sociodemographic characteristics significantly affected PTG. The results also improve our understanding of PTG among the primary caregivers of children with developmental disabilities.

The mental health of caregivers will affect the future treatment and rehabilitation of their children, so it is critical to provide psychological intervention on primary caregivers (Sohmaran and Shorey, 2019). In addition, an interesting finding of our study is that some of the preschool children’s grandparents became their primary caregivers, which should be closely related to China’s unique cultural background. However, there are only very few studies (Hillman and Anderson, 2019) abroad that examined the positive psychology of the grandparents of children with developmental disabilities, and no such studies are found in China for the time being. This paper may provide a new idea: It may be helpful to encourage mental health personnel to provide substantial care not only to parents but also to grandparents when focusing on the mental health of the primary caregivers of children with developmental disabilities. Certain psychological interventions may be needed for grandparents to improve the psychological health of the whole family. While focusing on the improvement in PTG, psychological workers should also pay attention to the assessment and intervention of resilience, coping style and self-efficacy level, and the subsequent influence on PTG, to more effectively help the families deal with pressure, seek professional help, and improve family and children’s life quality and treatment. Finally, the progress of children with developmental disabilities requires the joint efforts of medical staff and primary caregivers, so it is necessary for the staff of medical rehabilitation institutions and special education institutions to focus on the primary caregivers of children with developmental disabilities.

The results of this study should be considered in light of the following three limitations. First, as the study relies on cross-sectional self-reported data with a relatively small sample size, it does not allow the identification of causality or generalization. Second, this research is based on a field survey conducted in two children’s rehabilitation institutions in the city of Chongqing; therefore, caregivers who did not apply for medical care or treatment in the institutions were excluded due to possible negligence or unawareness of the children’s situation and economic deprivation of the family, which could lead to sampling bias. Third, self-reported measures were used to assess resilience, positive coping style, self-efficacy and PTG; therefore, the results could have been impacted by common method variance. Future studies should include more samples of grandparents among primary caregivers and independently explore their PTG and the differences between grandparents and parents in detail, adding the third-person estimations apart from the self-reports so data have a meaning to the clinical practitioner. Moreover, this population can be followed longitudinally to examine causality. In addition, personality traits (optimism, self-awareness, and sense of responsibility, etc.) were not included in this study and should be explored in more dimensions in future studies.

Our study showed that the primary caregivers of children with developmental disabilities experienced PTG, while the education background, monthly income and residence of caregivers also had a significant impact on their PTG. Additionally, resilience directly and indirectly had a positive predictive effect on the PTG of the primary caregivers of children with developmental disabilities through a positive coping style and self-efficacy. This study further confirmed the important role of resilience in PTG generation. It enables primary caregivers to positively deal with stress and difficulties and increase their self-efficacy. Our research provides a scientific basis for the psychological and behavioral intervention of primary caregivers by clinical psychology and social workers, which can help primary caregivers to better cope with stress and traumatic events, and promote the emergence of PTG, which may be very important for their mental health (Gori et al., 2021).

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.

The studies involving human participants were reviewed and approved by the Medical Ethics Committee of Army Medical University, PLA (2020 NO.035-03). The patients/participants provided their written informed consent to participate in this study.

WL contributed to the experiment design, did the experiment, analyzed the data, and contributed to article writing and editing. CX did the experiment and data analysis. XH did the experiment. JL and QZ contributed to article language revision. LP edited the article. ML contributed to the experimental design, supervision of the experiment, and project funding acquisition. WZL dealt with unexpected situations and experiment supervision in the study. All authors contributed to the article and approved the submitted version.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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