Qom University of Medical Sciences Journal

Introduction
The parents with disabled children have more physical and psychological disorders compared to the parents of healthy children. They have more depression, anxiety, and stress and lower self-confidence and quality of life. During the COVID-19 pandemic, the lockdown and the closure of schools and rehabilitation centers forced millions of disabled children to stay at home for months, and their parents, especially mothers, had to take on multiple roles, including parenting, child education, and child rehabilitation, which can increase their anxiety and stress and cause psychological problems.
Families, especially mothers, use coping strategies to tolerate and minimize anxiety and stress. Although some parents make behavioral and cognitive efforts to manage the stressful conditions, others struggle to get their lives back to normal. In this research, we seek to answer the question, “Is there a difference in stress and anxiety caused by COVID-19 and the coping strategies between the mothers of children with disabilities and the mothers of healthy children in Iraq?
Methods
This descriptive-analytical study was carried out in 2021 on 120 mothers, 60 mothers with normal children and 60 mothers of children with special needs (intellectual disability, deafness, hard of hearing, and physical-motor impairment) in Kirkuk city, Iraq. They were selected using a convenience sampling method from among those visiting public places such as educational centers, parks, sports clubs, etc. The entry criteria for mothers of children with disabilities were residence in Kirkuk city, having at least one disabled child under home care, minimum literacy to understand the questions, no history of acute physical or mental disorder, the child living with both parents, and consent to participate in the study. After assuring them of the confidentiality of their information and obtaining their consent, the required data were collected using a demographic form (surveying mothers’ education, mothers’ occupation, and the number of children in the family), the corona disease anxiety scale (CDAS), Cohen’s perceived stress scale (PSS) and Endler and Parker’s multidimensional coping inventory (MCI).

The CDAS was designed by Alipour et al. [13] in Iran. It has 18 items measuring two domains of mental symptoms (items 1-9) and physical symptoms (items 9-18), rated on a four-point Likert scale from 0 (never) to 3 (always). Therefore, the total score ranges from 0 to 54. The PSS was developed in 1983 by Cohen et al. [14] and has 14 items measuring perceived psychological stress in the past month. The scoring is based on a 5-point Likert scale from 0 (never) to 4 (very often). The total score ranges from 0 to 56. A score of 0-18 indicates low stress, a score of 18-36 indicates moderate stress and a score above 36 shows high stress. The MCI was developed by Endler and Parker in 1990 to evaluate three coping styles in stressful situations. It has 48 items rated on a Likert scale from 1 (never) to 4 (very much). The first 16 items measure task-oriented coping. The second 16 items measure emotion-oriented coping and the third 16 items measure avoidance-oriented coping. The total score ranges from 16 to 80. Data analysis was done using descriptive statistics (Mean±SD, frequency and percentage) and inferential statistics (independent t-test and analysis of variance) in SPSS software, version 22. The significance level was set at 0.05.
Results
In the present study, about 74% of mothers had lower than high school education or high school diploma, 80% were housekeepers, and about 47% had ≥3 children. The levels of stress (P=0.002) and anxiety (P<0.001) caused by COVID-19 were significantly higher in mothers of children with disabilities than in mothers of normal children. There was no significant difference between the scores of task-oriented (P=0.064) or emotion-oriented (P=0.051) coping styles between the two groups of mothers, but the difference between the two groups was significant in avoidance-oriented coping (P=0.030).
Conclusion
Due to the higher level of stress and anxiety caused by COVID-19 in mothers of children with special needs compared to the mothers of normal children in Kirkuk, Iraq, timely parental support is necessary to strengthen parent-child relationships and reduce mothers’ mental health problems. Future research should focus on effective coping strategies and use them as a basis for parent education. Online counseling and web-based parenting skills programs can also be used for mothers of disabled children who need professional support and guidance during the pandemic.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Research Ethics Committee of Kermanshah University of Medical Sciences, Iran (Code: IR.KUMS.REC.1400.638). For ethical considerations, the participants’ information was kept confidential and their informed consent was obtained.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for profit sectors.
Authors contributions
Conceptualization, writing, editing & review: All authors; Methodology and sampling: Nooshin Salimi and Akram Ali Bagher; Data analysis: Nooshin Salimi and Masoumeh Heydarian.
Conflicts of interest
The authors declare no conflict of interest.
Acknowledgements
The authors would like to thank all the mothers who participated in this study for their cooperation.