Research in Developmental Disabilities 30 (2009) 1448–1458

Contents lists available at ScienceDirect

Research in Developmental
Disabilities

Quality of life in caregivers of children and adolescents with

intellectual disabilities: Use of WHOQOL-BREF survey
Jin-Ding Lin a,*, Jung Hu a, Chia-Feng Yen b, Shang-Wei Hsu c,
Lan-Ping Lin b, Ching-Hui Loh d, Mei-Hua Chen e, Sheng-Ru Wu f,
Cordia M. Chu g, Jia-Ling Wu e
a
School of Public Health, National Defense Medical Center, Taipei, Taiwan
b
Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan
c
Graduate Institute of Healthcare Administration, Asia University, Taichung County, Taiwan
d
Department of Community and Family Medicine, Tri-Service General Hospital, Taipei, Taiwan
e
Research Center for Intellectual Disabilities Taiwan, Chung-Hua Foundation for Persons with Intellectual Disabilities,
Taipei County, Taiwan
f
National Taichung Special School, Taichung City, Taiwan
g
Center for Environment and Population Health, Griffith University, Brisbane, Australia

A R T I C L E I N F O A B S T R A C T

Article history: The present study based on World Health Organization quality of
Received 24 June 2009 life (WHOQOL-BREF) scale to examine quality of life of the
Accepted 9 July 2009 caregivers caring for their children/adolescents with intellectual
disabilities in Taiwan, and the factors contributing to their quality of
Keywords: life. Structured interviews were conducted with 597 caregivers of
Caregiver children/adolescents with intellectual disabilities. The results
Intellectual disability found that the mean scores in each domain of WHOQOL-BREF of
Quality of life
the caregivers as the followings: physical capacity (PC) was
WHOQOL-BREF
13.71  2.35, psychological well-being (PW) was 12.21  2.55, social
relationship (SR) was 12.99  2.43 and environment (EN) was
12.32  2.38. These mean scores were lower than the general
population and slight higher than the caregivers of adults with
intellectual disabilities in Taiwan. Finally, multiple stepwise regres-
sions were conducted to examine the characteristics of caregiver and
children/adolescents with intellectual disabilities will more likely
explained the WHOQOL-BREF mean scores. The study found the
following three factors: self-perceived health status, household
income and stress from insufficient family support were significantly
correlated to all four domains in multiple stepwise regression

* Corresponding author at: School of Public Health, National Defense Medical Center, No. 161, Sec. 6, Min-Chun E. Rd., Nei-Hu,
Taipei, Taiwan. Tel.: +886 2 8792 3100x18447; fax: +886 2 8792 3147.
E-mail address: jack.lin1964@gmail.com (J.-D. Lin).

0891-4222/$ – see front matter ß 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ridd.2009.07.005
 J.-D. Lin et al. / Research in Developmental Disabilities 30 (2009) 1448–1458 1449

analyses. The results highlights that caregivers of children and

adolescents with intellectual disabilities seem to display a lower
WHOQOL-BREF mean score than the general population, probably for a
combination of stress, health and household income factors. These
finding must be taken into account in policy making to provide better
and more specific supports and interventions for the caregivers of
people with intellectual disabilities.
ß 2009 Elsevier Ltd. All rights reserved.

1. Introduction

Quality of life (QOL) is the sum of a range of objectively measurable life conditions experienced by
an individual which include physical health, personal circumstances, social relationships, functional
activities and pursuits, and wider societies and economic influences. Subjective response to such
conditions is the domain of personal satisfaction with life (Felce & Perry, 1995; Hsiao & Nixon, 2008;
Simon, Rosen, Grossman, & Pratowski, 1995). QOL has emerged as an important outcome of service
delivery for individuals with disabilities and their families (Park et al., 2003). Measures of QOL should
become part of the standard battery of tools used to assess a people’s health and well-being, and to
identify aspects of life, physical, psychological, or social, that could be improved with intervention for
the caregivers (Donohue, 2002). QOL assessments that are easily administered and which do not
impose a great burden on the respondent are needed for use in large epidemiological surveys, clinical
settings and clinical trials (Skevington, Lotfy, & O’Connell, 2004).
People with ID who are prevalent in diseases and higher healthcare utilization than the general
population (Hsu et al., 2009; Lin et al., 2006, 2007; Lin, Lin, Yen, Loh, & Chwo, 2009) and they need the
consistent help from caregivers in their daily livings. Caregivers, whether family members or paid,
seem to have a rewarding, but very difficult job (Holt et al., 2004). Many studies (Grant, Ramcharan,
McGrath, Nolan, & Keady, 1998; Todd & Shearn, 1996) found that caregivers of adults with intellectual
disabilities (ID) report the existence of pervasive rewards and gratifications, as well as stresses, as part
of their caregiving experience. Studies also highlighted the caregivers of people with ID bear higher
burden of stress and needed further help than the general population (Lee et al., 2009; Lin, Lee, Loh
et al., 2009; Lin, Lee, Yen et al., 2009). Compared with parents of healthy children, parents in the
pervasive developmental disorder group reported impairment in physical activity and social
relationships and worse overall perception of their quality of life and health (Mugno, Ruta, D’Arrigo, &
Mazzone, 2007). Therefore, the caregiver assessment should enable the caregiver consider her or
himself as a person with needs of her own (Williams & Robinson, 2001). The present study based on
World Health Organization quality of life (WHOQOL-BREF) scale to examine QOL of the caregivers
caring for their children and adolescents with ID in Taiwan, and the factors contributing to their QOL.
The WHOQOL-BREF is a 26-item self-administered generic questionnaire, a short version of the
WHOQOL—100-scale (Skevington et al., 2004). It emphasizes subjective experiences rather than
objective life conditions (Olusina & Ohaeri, 2003).

2. Method

The present study employed a cross-sectional questionnaire survey, with the entire participants
was composed of 1043 main family caregivers of children and adolescents with ID (age 6–18 years)
who studying in 3 special schools in Taiwan. The survey materials included an invitational letter, the
WHOQOL-BREF (Taiwan version) and a demographic and stress characteristic questionnaire.
Originally, the WHOQOL-BREF is a 26-item instrument consisting of four domains: physical capacity
(PC, 7 items), psychological well-being (PW, 6 items), social relationships (SR, 3 items), and
environmental health (EN, 8 items). The PC domain includes items on mobility, daily activities,
functional capacity and energy, pain, and sleep. The PW domain measures self-image, negative
thoughts, positive attitudes, self-esteem, mentality, learning ability, memory and concentration,
religion, and the mental status. The SR domain contains questions on personal relationships, social
1450 J.-D. Lin et al. / Research in Developmental Disabilities 30 (2009) 1448–1458

support, and sex life. The EN domain covers issues related to financial resources, safety, health and
social services, living physical environment, opportunities to acquire new skills and knowledge,
recreation, general environment, and transportation (WHO, 1996). The WHOQOL-BREF has good to
excellent psychometric properties of reliability and performs well in preliminary tests of validity
(Skevington et al., 2004).
All domains are independent of each other. Score for each item within domains uses a scale from 1
to 5, with a higher score indicating a higher quality of life. Domain scores are calculated by multiplying
the mean of all facet scores included in each domain by a factor of 4, and potential scores for each
domain vary from 4 to 20 (WHO, 1994). It has been translated into the Chinese language in Taiwan and
the WHOQOL-BREF-Taiwan version has put two more items (in SR and EN domains) in the scale (Yao,
2002, 2005). The authors have received the approval from professor Kai-Ping Yao, Department of
Psychology, National Taiwan University, agreed to use the WHOQOL-BREF-Taiwan version in the
study.
Data were collected by a structured questionnaire that was completed by the caregivers during
April and May, 2008. A total of 1043 questionnaires were mailed to 3 special schools and asked the
students with ID to delivery/collect the questionnaire to/from their main caregiver. A signed consent
form and completed questionnaires were returned by the caregivers. In an attempt to increase the
response rate, the response questionnaire was rewarded by the gift of a BMI calculator to thank
participants for filling the questionnaire. There were 597 valid questionnaires (80% completion) were
returned, with a response rate of 63.4%. The data were entered into a database and analyzed using SPSS
13.0 software.

3. Results

3.1. Characteristics of the caregivers and individuals with ID

Table 1 presents the characteristics of the respondents in the sample, 92% were parents of ID
individuals and there were more females than males (72.7% vs. 27.3%). Average age was 43.6  8.57
years, their household income mainly less than 60,000 NTD (70%) and most of the respondents was in level
IV (47.7%) and V (32.1%) social class (incline to be lower classes). With regards to the characteristics of the
children and adolescents with ID, Table 2 shows that 58.3% were boys and 41.7% were girls and the mean
age was 16  3.3 years. There were 50.7% children and adolescents reported have a moderate level of
disability and 30% were severe level, and 31% were multiple disabilities which ID accompanied with other
disabilities.

3.2. Social support/medical consultation and stress

Table 3 shows the stress and experience of seeking for medical consultation or social support
among the respondents. The results revealed that only 20% have even seeking for social resource
supports in the previous year, and 8.4% have used psychiatric consultations in the previous 3 years.
Most of the respondents reported their health as fair (46.6%) and good (39.3%), and the remaining
10% felt poor or bad health status. In term of perceived stress among the caregivers, we used a scale
from 1 to 5, with a higher score indicating a higher agree on the stress in their daily livings. The
main sources of stress were ‘‘children’s interaction difficulty with people (3.64  0.87)’’, ‘‘children’s
health problem (3.36  0.8), ‘‘children’s behavioral problems (2.85  0.82)’’, and ‘‘insufficient family
support (2.74  0.77)’’.

3.3. WHOQOL-BREF score of the caregivers

We used mean and SD to describe the quality of life among the caregivers. The mean scores of the
PC, PW, SR and EN are presented in Table 4. The mean of PC (13.71  2.35) was slightly higher than other
domains, PW was 12.21  2.55, SR was 12.99  2.43 and EN was 12.32  2.38.
Table 5 showed the relationship between WHOQOL-BREF mean score and the characteristics of the
respondents. Female caregivers were statistical higher in SR mean score than male caregivers
 J.-D. Lin et al. / Research in Developmental Disabilities 30 (2009) 1448–1458 1451

Table 1
Characteristics of the caregivers.

Characteristics N (%) Mean (S.D.)

Relation to children with ID (N = 588)

Parent 541 (92.0)
Other 47 (8.0)

Gender (N = 582)
Female 423 (72.7)
Male 159 (27.3)

Age (N = 556) 43.6 (8.57)

Social class (N = 545)a

I (score: 52–55) 5 (0.9)
II (score: 41–51) 56 (10.3)
III (score: 30–40) 49 (9.0)
IV (score: 19–29) 260 (47.7)
V (score: 11–18) 175 (32.1)

Marital status (N = 581)

Unmarried 15 (2.6)
Married 486 (83.6)
Divorce 54 (9.3)
Widow/widower 26 (4.5)

Household income; NTD (N = 569)

<20,000 98 (17.2)
20,000–39,999 183 (32.2)
40,000–59,999 121 (21.3)
60,000–79,999 42 (7.4)
80,000–99,999 19 (3.3)
100,000–119,999 17 (3.0)
120,000–149,999 15 (2.6)
3150,000 15 (2.6)
Unknown 59 (10.4)

Religion (N = 580)
No 84 (14.5)
Buddhism 214 (36.9)
Dao 259 (44.7)
Christian 15 (2.6)
Catholic 5 (0.9)
Other 3 (0.5)
a
Two factor index of social position; calculated by weighting the factors of education and occupation
(score range: 11–55).

(p = 0.004). The factors of household income and social class were significantly correlated to all the
four domains in ANOVA or Pearson’s correlation analyses. The other factors such as ‘‘relation to ID
individual’’, marital status, age and religion of the caregivers were not statistical related to their
WHOQOL-BREF mean score. In term of caregiver’s perceived stress to the WHOQOL-BREF mean score,
all of the stress sources ‘‘insufficient family support’’, ‘‘children’s behavioral problems’’, ‘‘children’s
health problem’’, ‘‘children’s interaction with people’’, and ‘‘other stress’’ were significantly correlated
to quality of life mean scores in four domains (p < 0.001; Table 6).

3.4. WHOQOL-BREF score, individuals with ID and seeking for social support

A one-way ANOVA or t-test was used to compare the caregiver’s WHOQOL-BREF mean score
separately for each characteristic of the ID individual. ‘‘Age’’ of the children and adolescents was the
sole factor to affect the PC, PW and SR (p < 0.05), while his/her gender, disability level and
accompanied with multiple disabilities were not found to affect the respondent’s quality of life mean
scores (Table 7). The experience of seeking for professional help among the respondents, results found
that those caregivers have used psychiatric consultations tend to be significant lower mean scores in
1452 J.-D. Lin et al. / Research in Developmental Disabilities 30 (2009) 1448–1458

Table 2
Characteristics of the children and adolescents with ID.

Characteristics N (%) Mean (S.D.)

Gender (N = 591)
Boys 346 (58.3)
Girls 247 (41.7)

Age (N = 542) 16.0 (3.3)

Disability level (N = 580)

Mild 47 (8.1)
Moderate 294 (50.7)
Severe 174 (30.0)
Profound 65 (11.2)

Multiple disabilities (N = 574)

Yes 178 (31.0)
No 396 (69.0)

Table 3
Stress and experience of seeking for medical consultation or social
support.

Characteristic N (%)

Social support in the previous year (N = 544)

No 435 (80.0)
Yes (1–3 times) 55 (10.1)
Yes (4–6 times) 11 (2.0)
Yes (7–10 times) 5 (0.9)
Yes (Unclear) 38 (7.0)

Psychiatric consultation in the previous 3 years (N = 569)

No 521 (91.6)
Yes 48 (8.4)

Self-perceived health status (N = 582)

Excellent 24 (4.1)
Good 229 (39.3)
Fair 271 (46.6)
Poor 54 (9.3)
Bad 4 (0.7)

Sources of stressa
Insufficient family support (N = 541) 2.74 (0.77)
Children’s behavioral problems (N = 552) 2.85 (0.82)
Children’s health problems (N = 551) 3.36 (0.80)
Children’s interaction with people (N = 563) 3.64 (0.87)
Other (N = 560) 3.70 (0.65)
a
Score for each source uses a scale from 1 to 5, with a higher score
indicating a higher stress.

Table 4
WHOQOL-BREF mean scores of the caregivers.

Domain/facet Mean (S.D.)

PC (N = 581) 13.71 (2.35)

PW (N = 572) 12.21 (2.55)
SR (N = 582) 12.99 (2.43)
EN (N = 584) 12.32 (2.38)

PC, physical capacity (score 4–20); PW, psychological

well-being (score 4–20); SR, social relationships
(score 4–20); EN, environment (score 4–20).
 J.-D. Lin et al. / Research in Developmental Disabilities 30 (2009) 1448–1458 1453

Table 5
Relationship between WHOQOL-BREF score and caregiver characteristics.

Characteristics PC PW SR EN

Relation to ID
Parent Mean 13.71 12.18 12.95 12.30
N (%) 526 (90.5) 518 (90.6) 526 (90.4) 528 (90.4)

Other Mean 13.78 12.53 13.45 12.50

N (%) 55 (9.5) 54 (9.4) 56 (9.6) 56 (9.6)

F-Value 0.213 0.977 1.463 1.463

p-Value 0.831 0.329 0.144 0.144

Gender
Male Mean 13.84 12.42 12.49 12.11
N (%) 156 (27.5) 153 (27.3) 156 (27.5) 157 (27.5)

Female Mean 13.65 12.09 13.15 12.35

N (%) 411 (72.5) 407 (72.7) 412 (72.5) 413 (72.5)

t-Value 0.882 1.369 2.914 1.079

p-Value 0.378 0.172 0.004 0.281

Marital status
Unmarried Mean 13.64 12.36 13.47 12.56
N (%) 15 (2.6) 15 (2.7) 15 (2.6) 15 (2.6)

Married Mean 13.73 12.22 13.01 12.37

N (%) 477 (84.1) 467 (83.7) 477 (84.0) 478 (84.0)

Divorce Mean 13.46 11.92 12.66 11.75

N (%) 49 (8.6) 51 (9.1) 50 (8.8) 50 (8.8)

Widow/widower Mean 13.68 11.49 12.50 11.68

N (%) 26 (4.7) 25 (4.5) 26 (4.6) 26 (4.6)

F-Value 0.613 0.847 0.865 1.675

p-Value 0.607 0.469 0.459 0.171

Household income; NTD

<20,000 Mean 12.98 11.14 12.18 11.13
N (%) 95 (19.2) 92 (18.8) 95 (19.2) 96 (19.3)

20,000–39,999 Mean 13.55 11.99 12.87 11.89

N (%) 178 (35.9) 175 (35.8) 178 (35.9) 178 (35.7)

40,000–79,999 Mean 14.13 12.75 13.31 13.01

N (%) 159 (32.0) 159 (32.5) 159 (32.0) 159 (31.9)

380,000 Mean 14.59 13.08 13.78 13.77

N (%) 64 (12.9) 63 (12.9) 64 (12.9) 65 (13.1)

F-Value 8.518 11.776 7.120 25.920

p-Value <0.01 <0.01 <0.01 <0.01

Religion
No Mean 13.82 11.80 12.88 12.28
N (%) 83 (14.7) 81 (14.6) 82 (14.5) 83 (14.6)

Yes Mean 13.70 12.28 13.04 12.34

N (%) 481 (85.3) 474 (85.4) 483 (85.5) 485 (85.4)

t-Value 0.436 1.553 0.543 0.209

p-Value 0.663 0.121 0.588 0.834

Age
N 542 537 543 544
Pearson’s r-value 0.055 0.031 0.047 0.044
p-Value 0.204 0.474 0.275 0.305
1454 J.-D. Lin et al. / Research in Developmental Disabilities 30 (2009) 1448–1458

Table 5 (Continued )
Characteristics PC PW SR EN

Index of social position

N 534 526 535 535
Pearson’s r-value 0.137 0.173 0.095 0.221
p-Value 0.001 <0.01 0.028 <0.01

four domains, while caregivers self-perceived healthier status were more likely to get higher quality of
life mean scores (p < 0.001) (Table 8).

3.5. Regression model of WHOQOL-BREF mean score

Finally, a multiple stepwise regression was conducted to examine which characteristics of

caregiver and ID individual will more likely explained the WHOQOL-BREF mean scores, with the
statistically significant factors listed in Tables 5–8 identified as independent variables (Table 9). The
model revealed that the factors of self-perceived health status, stress from insufficient family support,
other stress, household income, children age, experience of psychiatric consultation can predict 48.1%
variation of caregivers’ PC mean score. In the domain of PW, those factors of stress from insufficient
family support, self-perceived health status, other stress, household income, stress from children’s
behavioral problem, social class and children’s age can predict 42.2% variation of this domain. With
regards to the regression model in SR domain, factors of stress from insufficient family support, self-
perceived health status, female caregiver and household income can predict 30.4% variation of
caregivers’ SR mean score. The final prediction model of EN, factors of stress from insufficient family
support, household income, other stress, self-perceived health status, and social class can explain
45.7% variation of caregivers’ EN mean score.

4. Discussions

The main purposes of this study were to investigate the QOL and determine the risk factors for
caregivers of children and adolescents with ID. In term of QOL measures among the respondents, we

Table 6
Relationship between WHOQOL-BREF score and caregiver’s stress.

Source of stress PC PW SR EN

Insufficient family support

N 531 526 532 532
Pearson’s r 0.489 0.471 0.450 0.521
p-Value <0.001 <0.001 <0.001 <0.001

Children’s behavioral problems

N 542 535 542 542
Pearson’s r 0.345 0.379 0.289 0.328
p-Value <0.001 <0.001 <0.001 <0.001

Children’s health problems

N 541 535 541 541
Pearson’s r 0.368 0.339 0.246 0.350
p-Value <0.001 <0.001 <0.001 <0.001

Children’s interaction with people

N 552 545 553 553
Pearson’s r 0.290 0.309 0.240 0.312
p-Value <0.001 <0.001 <0.001 <0.001

Other stress
N 549 543 551 551
Pearson’s r 0.372 0.397 0.297 0.432
p-Value <0.001 <0.001 <0.001 <0.001
 J.-D. Lin et al. / Research in Developmental Disabilities 30 (2009) 1448–1458 1455

Table 7
Relationship between WHOQOL-BREF score and individuals with ID.

Characteristic PC PW SR EN

Gender
Boy Mean 13.61 12.14 12.86 12.22
N (%) 339 (58.6) 336 (59.1) 341 (58.9) 342 (59.0)

Girl Mean 13.88 12.31 13.19 12.47

N (%) 239 (41.4) 233 (40.9) 238 (41.1) 238 (41.0)

t-Value 1.354 0.75 1.611 1.206

p-Value 0.176 0.453 0.108 0.228

Age (years)
3–6 Mean 12.29 10.82 12.18 11.29
N (%) 22 (3.8) 22 (3.9) 22 (3.8) 22 (3.8)

7–12 Mean 13.89 12.54 13.98 12.72

N (%) 43 (7.4) 43 (7.6) 49 (8.5) 43 (7.4)

13–15 Mean 14.16 12.75 13.34 12.68

N (%) 52 (9.0) 53 (9.2) 53 (9.2) 53 (9.1)

>15 Mean 13.69 12.16 12.90 12.27

N (%) 461 (79.8) 451 (79.3) 461 (79.5) 463 (79.7)

F-Value 3.492 3.337 3.815 2.285

p-Value 0.016 0.019 0.010 0.078

Multiple disabilities
No Mean 13.82 12.32 12.98 12.36
N (%) 385 (69.0) 376 (68.2) 384 (68.7) 386 (68.8)

Yes Mean 13.47 12.02 13.01 12.17

N (%) 173 (31.0) 175 (31.8) 175 (31.3) 175 (31.2)

t-Value 1.584 1.306 0.096 0.904

p-Value 0.114 0.192 0.924 0.366

Disability level
Mild Mean 13.83 12.64 12.89 12.85
N (%) 45 (8.0) 45 (8.1) 45 (7.9) 45 (7.9)

Moderate Mean 13.81 12.24 12.97 12.35

N (%) 285 (50.5) 275 (49.5) 284 (50.3) 285 (50.3)

Severe Mean 13.58 11.98 13.05 12.13

N (%) 172 (30.5) 172 (31.0) 173 (30.6) 173 (30.5)

Profound Mean 13.70 12.39 13.08 12.42

N (%) 62 (11.0) 63 (11.4) 63 (11.2) 64 (11.3)

F-Value 0.353 1.029 0.087 1.154

p-Value 0.787 0.379 0.967 0.327

used WHOQOL-BEEF health survey to examine their perception on satisfaction to their living. The
WHOQOL-BREF was developed as a short version of the WHOQOL-100 for use in situations where time is
restricted, respondent burden must be minimized or fewer details are necessary (Skevington et al.,
2004). The Taiwan version of WHOQOL-BREF showed it has very good reliabilities and validities (Yao,
2002, 2005), and it is an appropriate health-related quality of life instrument for populations with special
needs in Taiwan (Chiu et al., 2006; Chou, Lin, Chang, & Schalock, 2007; Yang, Kuo, Wang, Lin, & Su, 2005).
Comparing the Taiwan national norms of WHOQOL-BREF (Yao, 2005), we found the mean scores in
four domains of the caregivers for children and adolescents with ID were lower than the general
population. Their mean scores in each domain of the study respondents to the general population in
Taiwan were: PC (13.71  2.35 and 15.31  1.93), PW (12.21  2.55 and 13.80  2.19), SR (12.99  2.43
1456 J.-D. Lin et al. / Research in Developmental Disabilities 30 (2009) 1448–1458

Table 8
Relationship between WHOQOL-BREF score and experience of seeking for medical consultation or social support.

Characteristic PC PW SR EN

Social support
Yes Mean 13.72 12.55 13.26 12.54
N (%) 105 (19.7) 106 (20.1) 106 (19.9) 106 (19.8)

No Mean 13.78 12.15 12.93 12.31

N (%) 427 (80.3) 422 (79.9) 428 (80.1) 429 (80.2)

t-Value 0.253 1.465 1.272 0.863

p-Value 0.800 0.144 0.204 0.389

Psychiatric consultation
Yes Mean 11.72 10.59 11.77 11.08
N (%) 47 (8.4) 46 (8.3) 47 (8.4) 47 (8.4)

No Mean 13.91 12.35 13.12 12.45

N (%) 510 (91.6) 506 (91.7) 511 (91.6) 513 (91.6)

t-Value 6.297 4.556 3.734 3.793

p-Value <0.01 <0.01 <0.01 <0.01

Self-perceived health
Healthy Mean 14.85 13.38 13.95 13.26
N (%) 248 (43.5) 243 (43.2) 247 (43.3) 248 (43.4)

Fair Mean 13.25 11.65 12.54 11.80

N (%) 266 (46.7) 266 (47.2) 268 (46.9) 268 (46.9)

Unhealthya Mean 11.01 9.80 11.30 10.82

N (%) 56 (9.8) 54 (9.6) 56 (9.8) 56 (9.7)

F-Value 93.978 70.066 43.465 42.799

p-Value <0.01 <0.01 <0.01 <0.01
a
Healthy: excellent + good; unhealthy: poor + bad.

and 14.22  2.05) and EN (12.32  2.38 and 13.33  2.05). The results were slight higher than the
caregivers of adults with ID which PC was 13.5  2.59, PW was 12.11  2.33, SR was 12.84  2.19 and EN
was 12.09  2.15 (Chou et al., 2007). The possible reason maybe the age effect, our study respondents
tended to be younger than the caregivers of adults with ID.
PW is the lowest satisfactory domain of the caregivers in the present study. Walden, Pistrang, and
Joyce (2000) indicated that PW may be particularly adversely affected by the years of caregiving. In
addition, there is a strong association between caregiver’s distress and the emotional and behavioral
needs of children with ID (Emerson, Robertson, & Wood, 2004). Lam, Giles, and Lavander (2003) recruited
47 carers of children with moderate to severe ID, a multiple regression analysis indicated that carers’
expressed emotion, psychological well-being, appraisal of their children’s behavior, their children’s
communication skills and respite usage predicted 62% of the variance in their perceived stress scores.
The study found the following three factors: self-perceived health status, household income and
stress from insufficient family support were significantly correlated to all four QOL domains in multiple
stepwise regression analyses. The results are similar to the study of Chou et al. (2007), which pointed out
the strongest predictors of caregivers QOL were the caregiver’s health status, their family income and the
disability severity of the adults with ID. Emerson et al. (2004) also found that elevated rates of
psychological distress of the caregivers of children and adolescents may be mediated by socio-economic
deprivations.
We also found many factors such as age of children and adolescents was slightly correlated to PC
and PW means scores of the caregivers. In addition to the age of the children with ID, we should pay
attention to the age of the caregivers. As Minnes, Woodford, and Passey (2007) concluded that
caregiver perceptions of ageing and stress emerged as significant mediators of the relationship
between caregiver health and depression. However, resources and appraisals did not emerge as
significant mediators in analyses using quality of life as a positive outcome.
 J.-D. Lin et al. / Research in Developmental Disabilities 30 (2009) 1448–1458 1457

Table 9
Multiple stepwise regression model of WHOQOL-BREF score in the caregivers.

Domain Variable R2 b B p-Value

PC Constant 13.120
Self-perceived health 0.302 0.383 1.208 <0.001
Family support 0.427 0.259 0.761 <0.001
Other stress 0.450 0.160 0.545 <0.001
Household income 0.468 0.127 0.177 0.001
Children age 0.475 0.092 0.058 0.016
Psychiatric consultation 0.481 0.082 0.664 0.039
Fitness test; F = 56.474, p < 0.001

PW Constant 12.779
Family support 0.242 0.175 0.560 0.001
Self-perceived health 0.331 0.283 0.972 <0.001
Other stress 0.377 0.227 0.843 <0.001
Household income 0.398 0.105 0.157 0.021
Children’s behavioral problems 0.409 0.122 0.361 0.013
Social class 0.416 0.101 0.022 0.022
Children age 0.422 0.081 0.056 0.044
Fitness test; F = 38.100, p < 0.001

SR Constant 11.288
Family support 0.214 0.339 1.057 <0.001
Self-perceived health 0.280 0.282 0.942 <0.001
Female caregiver 0.293 0.109 0.580 0.013
Household income 0.304 0.109 0.158 0.017
Fitness test; F = 39.660, p < 0.001

EN Constant 14.328
Family support 0.283 0.280 0.851 <0.001
Household income 0.359 0.227 0.324 <0.001
Other stress 0.415 0.242 0.861 <0.001
Self-perceived health 0.448 0.196 0.640 <0.001
Social class 0.457 0.099 0.020 0.016
Fitness test; F = 64.077, p < 0.001

The factor of social class was used as a predictor of QOL in the present study. It is significant
correlated to PW and EN in multiple stepwise regression models. We used the factors of education and
occupation to describe the respondent’s social class. This classification was based on assumption
which developed by Hollingshead and Redlich (1958), the index of social position was developed to
meet the need for an objective, easily applicable procedure to estimate positions individuals occupy in
the status structure in the society. They concluded that there was a significant relationship between
social class and mental illness both in type and severity of mental illness suffered as well as in the
nature and quality of treatment that is provided (Pole, 2007).
The results highlights that caregivers of children and adolescents with intellectual disabilities seem
to display a lower WHOQOL-BREF mean score than the general population, probably for a combination
of stress, health and household income factors. These finding must be taken into account in policy
making to provide better and more specific supports and interventions for the caregivers of people
with intellectual disabilities. In addition, the findings also call for a regular program of comprehensive
intervention of caregivers caring for people with ID, to address QOL domains and provide caregiver
education and supports, in order to enhance their quality of life. The initial intervention should be
easily accessible and user-friendly information resource was needed for caregivers of people with ID.

Acknowledgements

This research was financially supported by Bureau of Health Promotion, Ministry of Health, Taiwan
(DOH97-HP-1601). We would also like to thank all the caregivers who took part in the study. In addition,
the authors want to acknowledge the kindness of professor Kai-Ping Yao, Department of Psychology,
National Taiwan University, agreed to use the WHOQOL-BREF-Taiwan version in the study.
1458 J.-D. Lin et al. / Research in Developmental Disabilities 30 (2009) 1448–1458

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