Introduction

Autism spectrum disorder (ASD) is a heterogeneous neurodevelopmental condition marked by persistent deficits in social communication and interaction, along with restricted and repetitive behaviors (American Psychiatric Association, 2013). In recent years, the rising prevalence of ASD has drawn global attention as a major public health concern. According to 2024 data from the Centers for Disease Control and Prevention, ASD affects 2.76% of children aged 8 in the United States (1 in 36), up from 2.27% in 2021. This increase has not only raised public awareness but also intensified concern for the mental health of individuals closely connected to children with ASD, particularly their parents.

Children with ASD often show communication difficulties, repetitive behaviors, self-injury, aggression, hyperactivity, and impulsivity. Due to the chronic and incurable nature of ASD, parents frequently face long-term caregiving responsibilities. This leads to significant emotional and financial stress, often affecting their mental health. Yet most research has focused on the children, with limited attention to parental wellbeing. To address this gap, World Autism Awareness Day 2023 adopted the theme: “Caring for autistic children, carers, and professionals who support autistic people,” highlighting the importance of supporting parents’ mental health.

The growing awareness of parental mental health in families with children diagnosed with ASD has broadened the focus of both empirical research and theoretical exploration. Studies indicate that parents often experience anxiety, confusion, fear, and even despair following their child’s diagnosis (Da Paz et al., 2018). Throughout the stages of diagnosis, treatment, and progress, they face persistent stress. In addition to the emotional toll, they must invest considerable time, energy, and financial resources, all while coping with the uncertainty of their child’s developmental trajectory. Moreover, parents often face challenges including strained relationships, social stigma, and difficulties with family education, all of which negatively affect their mental health (Han et al., 2023; Kinnear et al., 2016). Meta-analyses reports a global median prevalence of anxiety and depressive symptoms among these parents at approximately 33% and 31%, respectively (Schnabel et al., 2020). Additionally, parents frequently experience loss, frustration, and reductions in marital satisfaction, self-esteem, subjective well-being, and overall psychological health, significantly diminishing their quality of life (Brennan et al., 2024; Shepherd et al., 2024).

Parental mental health in families of children with ASD not only affects parents’ quality of life and subjective well-being but also plays a crucial role in the healthy development of their children. Longitudinal research reveals a complex bidirectional relationship between parental stress, psychological distress, and children’s behavioral problems: parental psychological states and parenting styles influence children’s behaviors, while children’s behavioral issues in turn impact parental mental health and stress (Zaidman-Zait et al., 2014). Studies show that children’s emotional and behavioral difficulties correlate more strongly with family quality of life and parental well-being than with core ASD symptom severity (Jones et al., 2014; Pozo et al., 2014). One study reports that parenting stress prevalence averages 78%, with 91% attributable to core ASD symptoms, 77% to comorbid behavioral problems, and 65% to comorbid physical issues (Nadeem et al., 2024).

Globally, parental mental health has been identified as a major barrier to the progress and rehabilitation effectiveness of children with ASD (Kulasinghe et al., 2023). Insufficient screening and treatment of parental mental health may hinder timely and effective interventions for children, increase the economic and social burdens of ASD care, compromise children’s overall outcomes, and reduce the efficacy of early interventions (Osborne et al., 2008). As primary caregivers, parents’ well-being is essential to optimal child care (Benjak et al., 2009). Recent research highlights the importance of prioritizing parental mental health as a key measure of intervention success (Kamis, 2021).

In summary, the emotional and behavioral symptoms of children with ASD not only hinder their development but also impose substantial physical and psychological burdens on their parents. These strains can negatively influence parenting and parent–child interactions, potentially reinforcing difficulties for the child. Therefore, while supporting autistic children remains essential, equal attention should be paid to the mental health of their caregivers. Although this study offers meaningful insights into influencing factors and potential interventions for parental mental health, previous reviews and meta-analyses have tended to address isolated issues without a holistic perspective. To fill this gap, the present study employs bibliometric analysis to systematically map the current research landscape and emerging trends in this field.

Bibliometrics is an interdisciplinary approach that applies mathematical and statistical methods to quantitatively assess research activities and uncover patterns within a specific field. Through the use of tools like CiteSpace, researchers can visualize the intellectual structure and developmental trends of a domain, enabling a systematic and multi-dimensional review of the literature (Chen, 2004). CiteSpace, in particular, facilitates the construction of knowledge maps that reveal research hotspots and evolving themes intuitively.

In this study, CiteSpace is employed to conduct a bibliometric analysis of literature related to the mental health of parents of children with ASD, covering the period from 2000 to 2024. While bibliometric methods offer objective insights into research structures, they are sometimes critiqued for lacking reflection on the epistemic significance of emerging topics. To address this, our study not only maps intellectual themes but also interprets them through the lens of Granular Interaction Thinking Theory (GITT), which posits that the value of knowledge emerges conditionally from the interactions among informational elements (Vuong & Nguyen, 2024). This theoretical framework supports a more reflective understanding of how research in this area has evolved.

This study aims to address the following questions:(1) How have publication trends in this field evolved over time? (2) Which countries and institutions are leading in this area? (3) Who are the most influential authors and journals? (4) What are the primary research hotspots?

Answering these questions will clarify the developmental trajectory of the field, offer a clearer picture of its current status and emerging themes, and assist future researchers in identifying relevant topics, thereby promoting collaboration and contributing to a more integrated knowledge base.

Data and methods

Data source and search strategies

All data were obtained from the Web of Science (WoS) database on November 6, 2024. WoS is a daily updated database covering an abstract index of multidisciplinary literature that exports complete citation data. Using the “Advanced Search” function in the WoS database, the search query was set as TS = (“Autism Spectrum Disorder” OR “Autism Spectrum Disorders” OR “Autistic Spectrum Disorder” OR “Autistic Spectrum Disorders” OR “Autistic Disorder” OR Autism OR Autistic OR “Kanner’s Syndrome” OR “Kanner Syndrome” OR “Kanners Syndrome” OR “Asperger syndrome” OR “infantile autism” OR “childhood disintegrative disorder” OR “Heller’s syndrome” OR “disintegrative psychosis” OR “pervasive developmental disorder” OR “pervasive developmental disorder not otherwise specified” OR “PDD-NOS”) AND TS = (parent* OR mother* OR maternal OR father* OR paternal OR caregiver) AND TS= (((mental* OR psych*) AND (health OR wellbeing OR well-being OR illness OR disease OR disorder)) OR depress OR anxiety). The publication date of the literature is from January 1, 1998, to November 6, 2024. The language is limited to English. By excluding non-articles, reviews, and literature not related to the research topic, a total of 2778 documents were exported, and the retrieved documents would be exported in the form of all records and references. The process of data extraction is presented in Fig. 1.

Fig. 1
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Flowchart of the screening process.

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Bibliometric analysis and visualization

This study uses the Java-based CiteSpace visualization software developed by Professor Chen Chaomei. CiteSpace can visually and clearly analyze the distribution, hot spots, and trends of a certain research field through the knowledge map, which can effectively help scholars grasp the research hot spots and frontier issues in this field in recent years (Chen et al., 2012). Today, CiteSpace is widely used in many research fields such as psychology, medicine, and management. In this study, the number of published articles, authors, countries, institutions, and journals will be analyzed using CiteSpace to provide an overview of the research on the mental health of parents of children with ASD. Additionally, an analysis of keywords and cited references will be conducted to identify the primary research hotspots in the field.

Results

Annual publications

The annual volume of publications offers a clear view of the developmental trajectory and research activity in this field. From 2000 to 2024, a total of 2778 publications were retrieved, including 2515 articles and 263 reviews. Based on yearly frequency data, the publication trend related to the mental health of parents of children with ASD was visualized (Fig. 2).

Fig. 2
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The annual number of publications related to mental health of parents of children with ASD.

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Since 2000, relevant studies have steadily emerged. The publication trend can be divided into three distinct phases: Embryonic stage (2000–2010): Annual output ranged from 1 to 47 publications. During this period, awareness of ASD and its impact on families was gradually increasing. Stable development stage (2011–2019): Research output rose to 72–177 publications per year, reflecting growing academic and societal attention to the topic. Rapid growth stage (2020–2024): Annual publications surged to 192–393. This sharp increase may be partially attributed to the COVID-19 pandemic, which exacerbated challenges for families of children with ASD and intensified scholarly focus on parental mental health.

Overall, research in this field has shown sustained growth in recent years and has entered a phase of dynamic expansion.

Author analysis

Author co-occurrence analysis helps identify prolific contributors, influential researchers, and the structure of collaboration within the field. Two key indicators—publication volume and centrality—reflect author productivity and academic influence. As shown in Table 1, the top three authors by publication count are Weiss J.A. (31), Charman T. (25), and Hastings R.P. (18). In terms of centrality, the leading authors are Hastings R.P. (0.02), Adams D. (0.02), and Rodgers J. (0.02).

Table 1 The top 10 authors related to mental health of parents of children with ASD based on publications and centrality.
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The author collaboration network generated using CiteSpace (Fig. 3) reveals several clusters of collaboration, often centered around highly prolific authors. Notably, scholars such as Uljarevic M. serve as bridges across multiple collaborative groups, linking teams led by researchers like Hardan A.Y., Adams D., and Charman T. In addition, distinct peripheral clusters exist, such as those led by Lecavalier L. and Seltzer M.M., indicating relatively independent collaborative structures within the broader research community.

Fig. 3
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The collaboration network of authors related to mental health of parents of children with ASD.

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National and institutional analysis

To identify the core countries, academic institutions, and research hubs in the field of parental mental health related to children with ASD, this study employed CiteSpace to analyze publication outputs by country and institution. The top 10 most productive countries and institutions are presented in Table 2.

Table 2 The top 10 countries and institutions related to mental health of parents of children with ASD based on publications.
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The United States (1060), England (391), Australia (326), and Canada (225) rank as the top four publishing countries, collectively contributing 72.07% of the total publications. Notably, five of the top ten institutions are based in the United States, four in England, and one in Canada. Among them, the University of London (149) and the University of California System (121) stand out with over 120 publications each, underscoring their leading influence in this field.

Journal analysis

CiteSpace was used to analyze the top 10 journals in this field, as summarized in Table 3. Among them, five journals—Journal of Autism and Developmental Disorders (2438 citations, 307 articles), Autism (1833, 167), Research in Autism Spectrum Disorders (1391, 114), Research in Developmental Disabilities (1275, 84), and Autism Research (813, 65)—ranked highly in both citation frequency and publication volume. These journals represent key outlets for research on parental mental health in the context of ASD and should be closely monitored by scholars for current developments.

Table 3 The top 10 journals related to mental health of parents of children with ASD based on citation and publications.
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A total of 2278 relevant articles were published across 551 journals. Journal of Autism and Developmental Disorders led with 307 publications, followed by Autism (167) and Research in Autism Spectrum Disorders (114). In terms of impact, Autism Research had the highest impact factor (5.3) among the top publishing journals.

For citation impact, Journal of Autism and Developmental Disorders ranked first (2438), followed by Autism (1833) and Journal of Child Psychology and Psychiatry (1440). Notably, five journals had impact factors exceeding 5, including Journal of the American Academy of Child and Adolescent Psychiatry (9.2), Journal of Child Psychology and Psychiatry (6.5), Pediatrics (6.2), Autism Research (5.3), and Autism (5.2).

Keywords analysis

Keyword co-occurrence analysis

Keywords represent a concise abstraction of a paper’s core content. Keyword co-occurrence refers to the frequency with which two keywords appear in the same document, and it serves as a useful tool for identifying research hotspots within a specific field. In this study, keywords with high frequency and centrality are considered indicators of major thematic focuses in the literature. A total of 2778 articles were imported into CiteSpace. The node type was set to “Keyword,” with a time span from 2000 to 2024 and a 1-year time slice. The resulting keyword co-occurrence network is shown in Fig. 4. To clearly highlight the research hotspots, we extracted keyword frequency and centrality data from CiteSpace and listed the top 10 keywords in Table 4. Keyword frequency typically indicates common or high-interest topics in the field, pointing to the main directions of research. In contrast, centrality reflects the structural importance of a keyword within the co-occurrence network—keywords with high centrality are more strongly connected to other terms and often play a bridging role across subfields. Notably, frequency and centrality are not always positively correlated; thus, both metrics are essential for a nuanced understanding of the research landscape.

Fig. 4
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Keyword co-occurrence network.

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Table 4 Top 10 high-frequency and centrality keywords in the field of Mental Health of Parents of Children with ASD.
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In terms of frequency, “autism spectrum disorder” emerged as the most frequent keyword, reflecting the central focus on various dimensions of ASD. High-frequency keywords such as “mental health,” “children,” “family,” and “parents” underscore a growing scholarly emphasis on the mental well-being of parents of children with ASD. These parents face substantial psychological, financial, and caregiving burdens, positioning them as a vulnerable group deserving of greater societal and academic attention. The prominence of keywords like “stress” and “parenting stress” indicates increasing recognition of the profound emotional, economic, and social pressures these parents endure, highlighting the urgent need for targeted intervention research. Notably, the frequent appearance of “mother” as a keyword suggests a particular concern with the disproportionate caregiving responsibilities and psychological strain often borne by mothers in families with children with ASD. Furthermore, the presence of terms such as “adolescents” and “young children” suggests that researchers are not only considering children across developmental stages, but are also exploring how these stages uniquely affect parental mental health. This points to a growing understanding that parenting challenges and mental health needs may vary significantly over time.

From the perspective of centrality, “behavior” ranks highest among all keywords, suggesting its pivotal role in linking key concepts within the literature network. It connects terms such as “children,” “parents,” and “difficulties questionnaire,” reflecting a major research focus on the bidirectional relationship between the behavioral characteristics of children with ASD and parental mental health. The presence of “mental retardation” as a high-centrality keyword points to the impact of comorbid conditions, which can complicate treatment and exacerbate parental psychological stress. The keyword “age” emphasizes the developmental variability in parental experiences, indicating that the psychological impact of raising a child with ASD may shift across different stages of the child’s growth. Furthermore, “attachment” emerges as a central concept, suggesting growing scholarly interest in applying attachment theory to ASD research. This perspective may provide valuable insights into the parent-child emotional bond and its influence on parental mental health outcomes.

Keyword cluster analysis

Keyword cluster analysis helps simplify complex co-occurrence networks by grouping related terms into distinct thematic clusters. Using the log-likelihood ratio (LLR) algorithm, 17 clusters (#0 to #16) were identified (Fig. 5), with clustering metrics indicating strong structural significance (Q = 0.7462, S = 0.8836). All clusters had silhouette scores above 0.7, suggesting high internal consistency (see Table 5). Lower-numbered clusters represent larger volumes of associated literature.

Fig. 5
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Time zone view of keywords.

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Table 5 Detailed information of each cluster.
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A review of the literature within each cluster reveals that current research on the mental health of parents of children with ASD is primarily concentrated in four thematic areas:(1)Parental Psychological Symptoms (#0, #5, #9, #13, #15): including parenting stress, anxiety, and depression. (2)Child-Related Factors (#1, #6, #8, #10, #11, #12): such as intellectual disability, behavioral issues, and comorbid conditions like oppositional defiant disorder, which negatively impact parental well-being. (3)Social Context (#4, #14): covering external influences like peer support, stigma, and societal attitudes. (4)Intervention Strategies (#2, #3, #7, #16): which include both child-centered approaches (e.g., early intervention, inclusive education) and parent-focused therapies (e.g., acceptance and commitment therapy, parent training).

These clusters collectively outline a multifaceted research landscape that addresses both the sources of parental mental health challenges and potential pathways for support and intervention.

Reference analysis

Highly cited references analysis

Each scholarly article typically cites multiple references, which are represented as nodes within a co-citation network in CiteSpace. The links between nodes reflect the frequency with which two references are cited together in the same publication. A high co-citation frequency suggests a conceptual or thematic connection between the references. Prior research indicates that such networks effectively reveal the core intellectual structure and research focus within a scientific community (Chen et al., 2010).

As shown in Table 6, the top ten co-cited references are listed, with five cited more than 50 times and the rest over 40 times. These highly cited works mainly address themes such as parenting stress, psychological functioning, and quality of life. The top three references are briefly summarized below.

Table 6 Top 10 highly co-cited references related to mental health of parents of children with ASD.
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The most frequently cited reference is The impact of parenting stress: A meta-analysis of studies comparing the experience of parenting stress in parents of children with and without autism spectrum disorder by Hayes et al. This study confirmed that parents of children with ASD experience significantly higher parenting stress than those with typically developing children or other disabilities. It also highlights the importance of incorporating family strengths and resilience factors into future research on parental stress.

The second most cited reference is Lai et al.’s Prevalence of co-occurring mental health diagnoses in the autism population: a systematic review and meta-analysis. Analyzing 96 studies covering eight mental disorders, it demonstrates the elevated risk of comorbid psychiatric conditions—including OCD, depression, bipolar disorder, and schizophrenia—among individuals with ASD. The authors argue for integrated and individualized support systems that go beyond treating single diagnoses, noting the implications of these comorbidities for both diagnosis and parental mental health burden.

Ranked third is The association between emotional and behavioral problems in children with autism spectrum disorder and psychological distress in their parents: A systematic review and meta-analysis by Yorke et al. This meta-analysis found that children’s emotional and behavioral issues are more strongly associated with parental distress than core ASD symptoms. The study also emphasizes the moderating role of parental factors such as age, coping strategies, and perceived parenting efficacy, and calls for more longitudinal research to better understand these complex bidirectional dynamics.

Cited reference burst analysis

Citation bursts indicate references that experience a sharp increase in citation frequency over a specific time period, reflecting emerging trends and research frontiers in a given field.

CiteSpace identified the top 25 references with the strongest citation bursts (Fig. 6). As of 2024, six references remain in an active burst phase. These studies primarily cluster around three major themes: (1) the prevalence and characteristics of ASD—including comorbidities, demographic variations, and monitoring data (Lai et al., 2019; Maenner et al., 2023); (2) the relationship between children’s emotional and behavioral problems and parental psychological distress (Barroso et al., 2018; Yorke et al., 2018); and (3) the psychological impact of COVID-19 on individuals with ASD and their families (Asbury et al., 2021; Colizzi et al., 2020).

Fig. 6
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The top 25 most cited references.

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Notably, four of the six burst references also rank among the most highly cited, underscoring the continued relevance of these topics. The sustained attention to ASD epidemiology, child behavior-related parental stress, and post-pandemic challenges highlights their centrality in current research on parental mental health in ASD contexts.

Discussion

Basic research profile

From 2000 to 2024, the number of research articles on the mental health of parents of autistic children showed an overall upward trend, which indicates that the mental health of parents has been paid more and more attention by researchers and may continue to be a research hotspot in the future. Weiss, Jonathan A. from York University in Canada, has published the most in this area of research, focusing on the well-being and mental health of people with developmental disabilities and their family members. In addition, the field has formed a cooperative network radiating outwards mainly with high-yield authors as the core. The USA leads the way in terms of number of publications, with five of the top ten organizations coming from the USA. In terms of co-cited journals, the top three journals are the Journal of Autism and Developmental Disorders, Autism, and the Journal of Child Psychology and Psychiatry. In terms of the number of Journal publications, the Journal of Autism and Developmental Disorders, Autism, and Research in Autism Spectrum Disorders has the most. Overall, these findings will help researchers quickly and accurately identify journals that are appropriate for the latest advances in the field of mental health for parents of children with ASD.

Research hotspots

Research hotspots refer to interconnected research questions or themes that receive considerable attention within a specific period. Keywords, as concise representations of a study’s core themes, are essential indicators for identifying these hotspots. Based on co-occurrence analysis, clustering, and burst detection, research on the mental health of parents of children with ASD can be categorized into three major themes: (1) symptoms and psychological manifestations, such as stress, depression, and anxiety; (2) influencing factors, including child behavioral problems, stigma, and social support; and (3) intervention strategies, such as mindfulness-based interventions, cognitive behavioral therapy (CBT), and parent training programs.

From the perspective of GITT, initial research focused on psychological symptoms. These studies align well with clinical paradigms and are easily quantifiable, which gives them strong “knowledge survivability.” Over time, scholarly attention has shifted toward underlying psychosocial mechanisms, marking a deepening of the epistemic trajectory—from individual symptoms to broader contextual influences. According to GITT, this evolution reflects conditional interactions between informational content and external knowledge demands, such as policymaking and family-centered care.

Research on intervention strategies—like mindfulness, CBT, and social support groups—has emerged as a response to the value-laden issues identified in the earlier themes. These studies aim to convert real-world concerns, such as parental psychological distress, into actionable knowledge, thus bridging the gap between understanding and application. GITT suggests that such work gains epistemic legitimacy because it meets both academic and societal expectations.

Overall, the three research themes are not isolated fragments but represent a coherent developmental pathway—from problem identification, to mechanism exploration, to solution implementation. The following sections will provide a detailed discussion of each thematic cluster.

Mental health symptoms and manifestations of parents of autistic children

Parents of children with ASD are primary resources for their children’s rehabilitation and play a crucial role in daily care and therapy. They are not only the early identifiers of ASD in their children but also have a significant impact on the child’s growth and development. The physical and mental well-being of parents directly influences the effectiveness of the child’s rehabilitation and is a key factor in ensuring the child receives optimal care (Osborne et al., 2008). However, parents also experience significant psychological stress, which can hinder their ability to effectively engage in their child’s progress. Families with ASD face various challenges, including limited resources, financial burdens, and emotional strain, all of which can influence parenting styles, the management of challenging behaviors, and overall family functioning and relationships.

Cluster and co-occurrence analysis also reveal that parental stress and anxiety are key symptoms and manifestations of the mental health of parents of children with ASD. Parental stress is an anxiety closely linked to the parenting role. For parents of children with ASD, this role often begins immediately after the child is diagnosed, with many parents experiencing feelings of surprise, sadness, shock, and rejection, which contribute to a range of emotional stresses. Research indicates that parents of children with ASD experience more psychological distress, including depression, anxiety, as well as decreased family cohesion and increased physical symptoms, than parents of children with intellectual or other developmental disabilities (Vasilopoulou and Nisbet, 2016). The prevalence of moderate to severe anxiety and depression was 13.8% and 13.1% in mothers, and 9.9% and 8.0% in fathers, respectively (Li et al., 2022). In addition, parents often experience negative emotions such as self-blame, guilt, and stigmatization (Papadopoulos et al., 2019). Mothers are more likely to feel negative events and tension, but they are also more active than fathers in seeking help (Grebe et al., 2022). Compared to parents of children without ASD, the prevalence of depression is twice as high, with mothers experiencing rates 3.5 times higher (Chen et al., 2024). A survey of 645 parents of children with ASD in China found that 34.6% of parents were at high risk of suicide. Additionally, 49.8% reported suicidal ideation in the past year, while 11.9% had made suicide plans and 2.5% had attempted suicide (Wang et al., 2024b).

The above issues suggest that paying attention to the subjective emotional burden of parents of children with ASD, providing them with professional guidance and intervention, and helping them to establish multiple channels of social and emotional support are important for the overall well-being of families with ASD.

Influencing factors of mental health of parents of autistic children

Clustering, co-occurrence analysis, and citation analysis revealed that problem behaviors, co-morbidities, stigma, social support, and the impact of COVID-19 are the key factors influencing the mental health of parents of children with ASD.

Problem behaviors

The problem behaviors of children with ASD have a significant impact on their parents’ mental health. Due to social communication difficulties and communication barriers, these children struggle to express their needs and emotions in conventional ways. As a result, they often manifest their feelings through unique behaviors, leading to a significantly higher frequency of problem behaviors (e.g., temper tantrums, self-injury, hostility, stereotypical behaviors, destructive behaviors) compared to typically developing children (Campbell, 2003; Grebe et al., 2022). Research has shown that these behaviors not only exacerbate parents’ psychological distress and emotional regulation difficulties but also lead to social misunderstandings, conflicts, and isolation (Lounds Taylor et al., 2017). This occurs due to a lack of social understanding and coping skills in handling social situations. Additionally, parents are often affected by affiliate stigma, which further exacerbates their psychological conditions.

Problematic behaviors in children with ASD can affect parental mental health in several ways. First, these behaviors tend to weaken the parent-child relationship and increase parental psychological burden and distress. Second, they trigger parental self-doubt and insecurity by decreasing parenting efficacy (Davis and Carter, 2008; Weiss et al., 2012). In addition, compared with parents of children with TD, parents of children with ASD have a significantly lower health-related quality of life (HRQOL) in terms of both physical health and mental health (Yorke et al., 2018). Network analyses further reveal that child age, externalizing behaviors, and parenting stress were significant predictors of parental HRQOL (Shepherd et al., 2024). It has been shown that although the problematic behaviors of children with ASD are closely related to their autistic traits, they are also influenced by the personality traits and parenting psychology of their parents (Teague et al., 2020). This suggests that the problematic behaviors of the children and the psychological and behavioral performance of their parents work in a bidirectional and dynamic relationship. Therefore, future research and interventions should start from a bidirectional perspective, focusing on both the child’s behavioral problems and the parents’ mental health, to achieve the goal of comprehensive improvement.

Co-morbidities

74% of patients with ASD have at least one comorbidity (Khachadourian et al., 2023). The characteristics of ASD comorbidities can significantly influence the course and prognosis of the disorder, as well as the patient’s quality of life across the lifespan. Given the highly heterogeneous character of ASD, comorbid psychiatric disorders may have overlapping risk factors, and the pattern of comorbidity itself may constitute a therapeutic subtype. Therefore, assessing ASD comorbidities through population-based studies not only has practical value for developing individualized interventions targeting the distribution of mental health burden in different populations but also has important scientific significance for deepening the understanding of psychiatric comorbidities.

The prevalence of ADHD in individuals with ASD varies across studies, ranging from 28% to 83%. Compared to parents of children with either ADHD or ASD alone, parents of children with comorbid ADHD and ASD report higher rates of intellectual disability (5.37%), oppositional defiant disorder (20.13%), anxiety (38.93%), depression (6.71%), and genetic disorders (3.36%) in their children (Mellahn et al., 2022). Sleep problems are also common comorbidities in children with ASD. Studies have found that parents of children with ASD who experience sleep difficulties report higher levels of anxiety and depression, as well as a lower quality of life, including poorer physical health, mental well-being, and environmental well-being, compared to parents of children without sleep problems (Iwamoto et al., 2023). In addition, a dynamic association exists between sleep problems and parenting stress. Specifically, children who slept longer were associated with reduced parenting stress the following day, whereas sleep deprivation on one night was strongly linked to more severe problem behaviors the next day. Sleep problems are especially prevalent in children with ADHD comorbid with ASD (Thomas et al., 2018). The severity and complexity of these symptoms can make it difficult for both clinicians and caregivers to choose appropriate support or intervention for the child and also place additional pressure on the mental health of parents. Therefore, future research is needed to further explore the multi-layered impact of comorbidity patterns on family systems, while developing targeted interventions to alleviate parental psychological stress and improve the overall well-being of families.

Stigma

Although most children with ASD have normal physical characteristics, they often exhibit inappropriate social behaviors such as sudden laughter, spinning, waving, beating others, screaming, and destructive behaviors, which often lead to public criticism or avoidance of their parents due to lack of awareness of ASD. So the stigma doesn’t just happen to children with ASD, it also happens to parents of children with ASD. This suggests that stigma affects not only individuals with stigmatized traits but also those who are closely associated with them. These individuals have a stigmatized social identity by sharing relationships with the stigmatized person, a stigma known as the “affiliate stigma.” This social bias has a significant negative impact on the mental health of parents of children with ASD. Affected by the associated stigma, these parents experience heightened emotional distress, including guilt, resentment, anxiety, and depression. As a result, their quality of life is diminished, and their overall happiness is lower.

Research shows that 95% of parents feel shame when their children with ASD misbehave in public, and 41% report experiencing social discrimination (Kinnear et al., 2016). In addition, stereotyping, negative labeling, and peer bullying in schools and communities increase parental stigma, affect self-esteem and self-efficacy, and increase the risk of suicide, anxiety, depression, and social fear (Lu et al., 2024; Ng and Ng, 2022; Wang et al., 2024a, b; Yip and Chan, 2022). Stigma not only impairs the mental health of parents but also significantly affects family life and social relationships (Chan and Lam, 2017). According to the study, 40.4% of parents isolate themselves from relatives and friends due to their children’s behavior, while 31.7% of parents are frequently excluded from activities. In addition, 55.4% of parents have reduced their working hours to care for their children, which exacerbates economic pressure and negatively impacts the quality of family life (Kinnear et al., 2016; Nadeem et al., 2024). The psychological burden caused by stigma can also increase intra-family conflicts, including parent-child conflicts and marital tensions (Chan et al., 2023).

Given the negative impact of affiliate stigma on the mental health of parents of children with ASD, other researchers have examined strategies to mitigate its detrimental effects. Some researchers have used social education to change the public’s stereotypes of ASD and enhance acceptance and support for children with ASD and their families. While changing society’s attitudes and behaviors toward individuals with ASD is crucial, this process can be slow. Therefore, there is also a need for support to help individuals with ASD cope with and challenge stigma (Han et al., 2023). As a result, some researchers have directly helped parents improve their mental health through psychological interventions. For example, it has been shown that improving parents’ self-esteem, parenting self-efficacy, and level of positive thinking, reducing shame, and enhancing family functioning can be effective in alleviating affiliate stigma (Chan et al., 2023; Chan and Lam, 2017; Zhou et al., 2018).

Although research on affiliate stigma has provided an important reference for reducing prejudice against parents of children with ASD, there are still limitations. The main ones include: the lack of scales specifically assessing parental affiliate stigma, studies ignoring the psychological feelings of other family members, and research designs that are mostly cross-sectional analyses. Future studies should focus on developing specialized scales for assessing affiliate stigma and conducting reliability tests. Additionally, exploring the affiliate stigma experienced by other family members and examining the long-term effects of affiliate stigma through longitudinal studies would provide valuable insights. Meanwhile, a multilevel approach is needed to promote broad societal change, addressing both individual and systemic levels to transform attitudes toward ASD.

Social support

Social support, as an important external resource in the adaptation process of parents of children with ASD, plays a positive role in alleviating parenting stress and enhancing self-efficacy. It is also a significant protective factor influencing the psychological health of these parents. A study of 6,120 parents of children with ASD in China showed that social support was a positive predictor of quality of life, and in particular, participation in an online support group significantly increased parents’ self-efficacy and positive affect (Yen and Valentine, 2023). Social support, including respect, emotional support, and companionship, helps caregivers better cope with stress and negative emotions, thereby enhancing their well-being and subjective quality of life. Research has also shown that social support increases parental life satisfaction and mitigates negative reactions during stressful situations (Gage and Christensen, 1991; Wang et al., 2023). An analysis of 379 mothers’ trajectories of emotional well-being over 10 years found that those mothers who had smaller social support networks typically exhibited higher levels of anxiety when experiencing more stressful events at home (Barker et al., 2011). This may be due to the lack of adequate emotional and practical support, which makes it more difficult for them to manage caregiving stress, thereby exacerbating feelings of anxiety.

However, the level of social support received by parents of children with ASD is generally lower than that received by parents of children with TD or other developmental disorders (Heiman and Berger, 2008). In particular, there is insufficient formal support received and a lack of awareness of where to seek help. The social support received was mainly from informal social support networks, especially emotional support (88.8%) and information support (67.5%) (Woodgate et al., 2008). Psychiatric services (48.8%), counseling (40.6%), and financial assistance (39.7%) were the most common types of formal social support (Marsack-Topolewski, 2020). It has also been found that while formal support is less effective in providing emotional and financial assistance, informal support (e.g., spousal support and social media networks) plays a crucial role in alleviating parental stress and offering emotional support (Shepherd et al., 2020). This suggests that parents of children with ASD still have limited awareness of and access to formal social support, while informal social support networks play a more significant role in their lives.

In conclusion, social support has a significant impact on the physical and mental health and coping abilities of parents of children with ASD, and informal support in particular plays a key role in providing emotional and informational support. To enhance the quality of life for these parents, it is essential to promote robust social support systems, which should include improving the accessibility and effectiveness of formal support services, while also strengthening informal support networks.

COVID-19

During the COVID-19 pandemic, children with ASD and their families faced unprecedented challenges. School closures prevented children with disabilities from accessing vital special education services, and many specialized service providers were forced to discontinue face-to-face services. This disruption in daily support had a particularly severe impact on families of children with ASD, who rely heavily on consistent services for their children’s development and well-being. In addition, individuals with ASD often have concomitant mental and physical health problems and are more likely to become seriously ill after contracting COVID-19, which further increases caregiver stress and anxiety (Eshraghi et al., 2020). Research has shown that parents of autistic children have significantly higher levels of psychological distress during COVID-19 than parents of non-autistic children (Lee et al., 2021). They experience higher levels of depression, lower quality of life, more family conflict, increased use of psychotropic medications by their children, and interruptions in their children’s treatment (Pondé et al., 2023; Wang et al., 2021). Data and research from this period reveal the vulnerability of ASD populations in the face of public health emergencies. In addition, despite the gradual easing of COVID-19 restrictions, parents’ mental health issues, including mental resilience, anxiety, and depression, have not shown significant improvement. (Isensee et al., 2022; Wang et al., 2022). The effects of COVID-19 extend beyond its physical impact, with profound effects on mental health and cognitive functioning (Taquet et al., 2024). Even after the epidemic subsides, it is important to remain concerned about its long-term consequences. Research on the recovery trajectories and support needs of families with children on the ASD can provide more targeted and sustained mental health support and contribute to more resilient family support systems.

The pandemic has accelerated the development of telemedicine and online support systems, providing new solutions for ongoing intervention for individuals with ASD. Telemedicine has become one of the practical solutions to provide interventions and diagnostic services for children with ASD and their families. This model is typically the delivery of telemedicine care through electronic communications and information technology. Through telemedicine, caregivers have the flexibility to participate in training sessions via video platforms or independently use online resources to effectively deliver interventions in the home environment. The study found that telemedicine interventions were comparable to traditional face-to-face treatments in terms of effectiveness and were less costly (Micai et al., 2024). These interventions not only actively engage parents but also provide broader support for children with ASD. This shift is not only a temporary response to COVID-19 but also provides a new model and approach to long-term support for the ASD community. However, there are still some challenges in telemedicine due to barriers in terms of technology, medical privacy, policies and regulations, and quality of care. Despite the widespread adoption of telemedicine during the pandemic, a full understanding of its long-term effectiveness, benefits, and costs is still not fully established. In the post-epidemic era, optimizing the telemedicine model and verifying its effectiveness in a diverse population is of great significance for making up for problems such as uneven resource distribution and geographical restrictions.

Although the COVID-19 pandemic has passed, it has a long-term impact on individuals with ASD and their families. A public health crisis or social emergency may recur in the future. The experience and data from the COVID-19 period will provide a scientific basis and important reference for telemedicine and intervention, family mental health support, and optimization of social emergency response mechanisms.

Interventions to alleviate the mental health of parents of children with ASD

Research on interventions for parents of children with ASD primarily employs two approaches: one focuses on early detection, intervention, and inclusive education to reduce the parenting burden, while the other emphasizes parental education or training from the parents’ perspective.

Early detection and intervention play a crucial role in improving core and concomitant symptoms in children with ASD as well as reducing the burden of care on parents. Currently, intervention methods that have been widely used and have empirical support include motor interventions, sensory integration training, video demonstration methods, applied behavior analysis, play interventions, music therapy and social-emotional interaction support models (Freud, 1946; Hardy and Lagasse, 2013; Miller, 2014; Reid et al., 1988; Schertz et al., 2013; Wang et al., 2019; Yakubova et al., 2015). Each method has its advantages and limitations. Therefore, in actual interventions, it is important to combine different approaches to achieve the maximum effectiveness. In addition, when children have the basic ability to go to school, they can choose to enter ordinary primary schools for classes, that is, integrated education. This will give parents psychological support to relieve psychological pressure, help parents to participate in various educational activities for children with a more positive attitude, and provide protection for the more comprehensive development of special children. The meta-analysis found that there was a strong demand from parents for a more inclusive ASD education system as well as social services (Shorey et al., 2020). Inclusive education provides children with ASD with more opportunities to communicate with others and helps to improve their social and imitative skills. However, its implementation faces significant challenges due to the unique and unpredictable behaviors often exhibited by children with ASD. Interviews with parents revealed negative attitudes towards integrated education for children with ASD in mainstream education. Parents generally believe that children face social exclusion and mental health problems in mainstream schools and that these problems stem from a lack of effective inclusion strategies and resources (McKinlay et al., 2022). Thus, the path to inclusive education remains a challenging and long-term endeavor.

In addition to implementing early detection and intervention for ASD and promoting inclusive education to reduce the psychological burden on parents, interventions that directly target the mental health of parents are particularly critical (Isensee et al., 2022). Long-standing research and practice have shown that helping parents manage their own emotions and coping strategies, through support and professional training, is an integral part of the early care of children with ASD. This approach is effective in reducing parental stress, depressive symptoms, and feelings of distress while improving children’s behavioral problems and parent-child relationships.

Intervention strategies are divided into two main categories: parent education and parent training. Psychoeducational interventions designed specifically for parents are intended to enhance parental well-being by providing knowledge about ASD and their children’s behaviors, while also helping parents optimize coping strategies and reduce psychological distress. Parent training interventions, on the other hand, focus more on the child as the primary beneficiary, guiding parents to modify their behaviors and to change and enhance their interactions with their children in order to more effectively manage their children’s challenging behaviors. These interventions emphasize parent-child interactions and may be an important way to empower parents. They provide families with a more cost-effective and practical way to support their children’s development, especially when resources are limited.

Numerous parents are actively accessing information, seeking support, and participating in workshops and parent support groups to enhance their self-education or to gain emotional comfort (Shorey et al., 2020). Empirical research confirms that psychological interventions targeting the primary caregiver of a child with ASD are effective in enhancing the parent’s emotional well-being and parenting skills, which in turn have positive effects on children’s well-being (Lovell and Wetherell, 2024). One study showed that 18 parent-child pairs participated in a 14-week judo program, which not only reduced parental stress but also increased their physical activity (Garcia et al., 2024). Another eight-week study of a writing-based gratitude intervention showed that it improved mothers’ well-being, parenting self-efficacy, positive mothering traits, and Parent-child relationship quality (Timmons and Ekas, 2018). Additionally, a group-based psychoeducational program led to “moderate” improvements in parental psychological symptoms, “low” effects on social skills, and “high” effects on well-being (Abouelseoud et al., 2022). Parent training programs enhanced their knowledge and enabled them to cope with behavioral challenges more independently and confidently. It is important to note that these studies have limitations in terms of intervention duration length and sample size. More rigorously designed randomized controlled trials should be conducted in the future to provide insight into the factors and mechanisms of action that influence the effectiveness of these interventions.

The researchers also designed mental health interventions specifically for parents, with acceptance commitment therapy (ACT) proving to be an effective way to alleviate parental stress and depressive symptoms. ACT is an empirical behavioral psychotherapy developed by American psychologist Stephen Hayes and colleagues in the 1990s and is theoretically grounded in relational frame theory and functional contextualist philosophy. Studies have shown that ACT significantly improves anxiety, depression, psychological flexibility, achievement of personal goals, experiential avoidance, psychological distress, and caregiver burden in parents of children with ASD and that these improvements persist after four months (Cañón et al., 2023; Maughan et al., 2024).

ACT applies to both parents and children with ASD because it encourages the development of broad and flexible patterns of behavior. Parents can use ACT to change their relationship with personal events, such as negative thoughts and emotions that may arise when parenting a child with ASD, and to move away from limiting thought patterns. ACT promotes open and meaningful lifestyles, such as identifying one’s core values and taking value-based action to support the child (Prevedini et al., 2020). The approach guides parents to accept rather than eliminate negative emotions, reduce over-attention to these emotions, and focus on the core values of parenting, thereby improving the quality of parent-child interactions (Hayes et al., 2006).

Although ACT has shown positive effects in enhancing the mental health of parents of children with ASD, existing studies have limitations in terms of sample size, control group setting, follow-up duration, and variable control, which affect the generalizability and persuasiveness of the findings. In addition, the studies mainly focused on mothers and neglected the perspectives of fathers and other family members. Future studies should aim to establish standardized intervention procedures, conduct large-sample randomized controlled trials, systematically assess key variables, and attract more family members to participate. Additionally, it is essential to explore the mediating mechanisms of the dimensions of ACT and examine the potential impact of parental involvement in interventions on children with ASD. To address the lack of specialized resources in low- and middle-income countries, online training platforms tailored to different linguistic and cultural contexts should be developed. These platforms would provide comprehensive, evidence-based, and sustainable support for families affected by ASD (Çiçek Gümüş and Öncel, 2023).

While psychosocial interventions have shown improvements in the social interactions of children with ASD in the short term, their effectiveness in the wider social context and the long-term development of ASD remains to be challenged. The long-term effects of such interventions are critical to the mental health of parents of children with ASD. Parents may experience anxiety, stress, and depression as they face their child’s long-term social and developmental challenges. Therefore, interventions that demonstrate real effects in the long-term progression of ASD will not only help the child’s development but also significantly enhance the mental health of the parents. Currently, while early interventions targeting biological targets show promise, the lack of large-scale effectiveness trials limits parents’ expectations for long-term support and positive outcomes. Therefore, research and implementation of more effective interventions are critical to support the mental health of parents of children with ASD (Bitsika et al., 2017; Green and Garg, 2018; Warreman et al., 2023).

In summary, ASD research has evolved from an initial focus on diagnosis and scientifically effective training methods, to a focus on improving the home environment, and more recently to exploring the entire life course and its meaning from an ecological perspective. This shift is an important milestone in the field. Effective interventions now depend on maximizing family resources and exploiting systemic synergies. A multifaceted, integrated approach helps families cope with challenges by preventing isolation and fostering reliance on well-functioning support systems.

Knowledge evolution and value formation in the field

While the current bibliometric analysis successfully delineates the thematic evolution and intellectual structure of research on the mental health of parents of children with ASD, it is essential to go beyond reporting patterns and explore the epistemological implications underlying these findings.

According to Vuong and Nguyen (2024), GITT emphasizes that knowledge production is not merely the accumulation of data or the repetition of dominant narratives. Rather, knowledge is conditionally constructed through dynamic interactions among informational elements—such as context, institutional acceptance, cultural framing, and systemic reinforcement. From this perspective, the value of knowledge is not intrinsic but emerges when specific configurations of information align to meet epistemic or societal needs.

In our study, the persistent centrality of clusters such as “parental stress,” “burden,” and “depression” reflects not only research interests but also the conditional amplification of these topics due to their practical, clinical, and policy relevance—particularly during crisis periods like the COVID-19 pandemic. The information environment during that time shaped what became urgent and fundable, thus conditionally increasing the value and visibility of certain research directions.

Conversely, the underrepresentation of themes such as paternal mental health, non-Western caregiver experiences, or longitudinal resilience outcomes suggests the operation of rejection mechanisms (Vuong & Nguyen, 2024)—where certain knowledge fragments, although potentially valid, fail to be integrated into the field due to sociocognitive filters or epistemic blind spots. These omissions highlight that bibliometric structures are not neutral but shaped by ongoing value negotiations among the academic community.

Incorporating the GITT framework thus enables a richer interpretation of bibliometric results by situating keyword co-occurrences and citation clusters within a broader system of conditional knowledge interactions. This perspective contributes to a more reflexive and critical understanding of how knowledge in this field evolves, consolidates, and—importantly—what it overlooks.

Conclusion

This study utilized CiteSpace to synthesize the mental health literature on parents of children with ASD from 2000 to 2024. A growing number of publications in this area suggests that parental mental health issues are becoming increasingly prominent as ASD diagnosis and treatment rates rise. Parental mental health is not only vital for the well-being of the parents themselves but also plays a crucial role in the effectiveness of interventions for children with ASD and the overall functioning of the family. These insights have drawn the attention of researchers and policymakers, and with the support of funding agencies and interdisciplinary collaboration, the field has gained momentum.

Current research hotspots focus on three major areas: parental mental health symptoms, influencing factors, and intervention strategies. These focus areas also point to several important directions for future research. As societal awareness of ASD continues to grow, research on parental mental health is expected to deepen and diversify. Future studies should aim to establish more systematic intervention and support systems. Innovative approaches such as telemedicine and virtual reality are expected to be employed to improve parental psychological well-being and enhance their caregiving capacity. At the same time, interdisciplinary collaboration may further optimize ASD family support systems and help develop more comprehensive intervention models.

As research advances, more tailored strategies for families from different cultural, geographical, and economic backgrounds will be needed to promote equitable and accessible ASD support services globally. Future studies should explore how parental caregiving burdens evolve as children with ASD grow, and how psychological interventions for parents can be integrated into rehabilitation programs to reduce subjective caregiving stress and improve child outcomes. Additionally, more attention should be paid to the bidirectional interactions between parental mental health and children’s behavioral problems, as well as the needs of autistic parents themselves.

However, one limitation of the present study is the lack of analysis on cross-cultural differences in ASD research. Since the bibliometric data were derived solely from English-language publications indexed in the Web of Science, cross-cultural comparisons could not be systematically conducted. Given that cultural attitudes toward ASD, mental health service availability, and family support structures vary significantly across regions, future research should incorporate multilingual databases and culturally sensitive analytical frameworks. Such efforts will help generate a more comprehensive understanding of the global landscape of ASD research and contribute to the development of culturally responsive family support strategies.