Health, Spirituality and Medical Ethics

Introduction

Mothers raising children with intellectual disabilities report significantly higher rates of health issues, depression, anxiety, and stress than mothers of typically developing children, often coupled with lower self-esteem and increased isolation [1, 2]. Intellectual disability, characterized by substantial limitations in both intellectual functioning and adaptive behavior originating before age 18 [3], places unique and often chronic psychological burdens on families [4, 5]. While fathers also experience stress, mothers typically assume the primary caregiving role, bearing the brunt of extensive responsibilities and facing multifaceted challenges that can significantly diminish their psychological well-being [6, 7]. The cumulative impact of navigating caregiving tasks, managing the child’s specific needs, and coping with societal factors can lead to adverse mental health outcomes, ranging from feelings of shame and guilt [8] to clinically significant anxiety and depression [9-11].

While these challenges are well-documented, the specific psychological factors that buffer or exacerbate distress in this population warrant deeper investigation. The existing literature highlights several potentially influential variables but often examines them in isolation, leaving gaps in our understanding of their interplay. Parental self-efficacy, a parent’s belief in their capacity to manage challenges related to their child [12], is a significant factor. Lower self-efficacy is associated with reduced parenting persistence, higher maternal depression, and poorer role satisfaction [13], suggesting it is crucial for maternal adjustment. Concurrently, spiritual intelligence, defined as adaptive mental capacities drawing on non-material and transcendent aspects of reality to foster coherence and problem-solving [14, 15], has been positively linked to psychological well-being in various populations [16-18]. It may represent a vital internal resource for coping with chronic stress.

However, the mechanisms through which these internal resources (self-efficacy and spiritual intelligence) translate into better psychological well-being for these mothers have not been fully elucidated. This study proposes that alexithymia, a personality construct involving difficulties in identifying, describing, and processing one’s emotions [19, 20], may play a critical mediating role. Alexithymia is consistently linked to diminished psychological well-being [8], as impaired emotional competence hinders effective coping with stressors [21]. We theorize that chronic stress and potential feelings of helplessness associated with low parental self-efficacy [12, 13] could overwhelm a mother’s capacity for emotional processing, thereby increasing alexithymic traits. These difficulties in recognizing and articulating distress may contribute directly to poorer psychological outcomes [19]. Similarly, lower spiritual intelligence might mean fewer resources for finding meaning or employing transcendent coping strategies when facing caregiving demands [14-16], potentially making mothers more vulnerable to developing alexithymic responses as a maladaptive way of managing overwhelming emotions, consequently impacting their well-being [17, 18].

Understanding these potential pathways is crucial for developing targeted interventions. While direct links between self-efficacy, spiritual intelligence, alexithymia, and well-being have been suggested [8, , the specific mediating function of alexithymia within the complex stress context faced by mothers of children with intellectual disabilities remains largely unexplored. This study aims to fill this gap by examining the interplay between these variables. Therefore, this study investigates the following hypotheses: Parental self-efficacy is positively associated with psychological well-being among mothers of children with intellectual disabilities. Spiritual intelligence positively affects the psychological well-being of mothers of children with intellectual disabilities. Alexithymia is negatively associated with psychological well-being among mothers of children with intellectual disabilities. Alexithymia mediates the relationship between parental self-efficacy and psychological well-being. Alexithymia mediates the relationship between spiritual intelligence and psychological well-being.

Methods

The present study adopted a descriptive and correlational research design, employing structural equation modeling (SEM) to examine the interrelationships among parental self-efficacy, spiritual intelligence, alexithymia, and psychological well-being. The target population comprised mothers of children with intellectual disabilities residing in Tehran City in 2024. An a priori power analysis was conducted using G*Power software, version 3.0 to determine an adequate sample size, targeting a medium effect size (f2=0.15), α=0.05, and power=0.80 for a structural equation model with four latent variables. This analysis indicated a minimum sample size of 250. Accounting for potential attrition, a convenience sampling method was used to recruit 290 mothers from three special education schools in Tehran, selected based on accessibility and cooperation with school authorities.

Mothers were approached through school-organized meetings, where researchers provided detailed information sheets outlining the study’s purpose, procedures, voluntary nature, and confidentiality measures. Verbal explanations supplemented the sheets to ensure comprehension, and mothers were given time to ask questions before providing written informed consent. Participation was explicitly framed as voluntary to minimize coercion, with no incentives offered, and mothers were assured they could withdraw without consequences. Of the 290 mothers recruited, 269 provided complete responses to the questionnaires and were included in the final analysis.

The inclusion criteria required participants to be biological mothers of a child with a diagnosed intellectual disability (verified by school medical records based on DSM-5 criteria) enrolled in the selected Tehran special education schools during data collection, and to have provided informed consent. The exclusion criteria included mothers of children with co-occurring disabilities (e.g. severe autism spectrum disorder or profound physical impairments) that could significantly confound psychological outcomes, as determined by school records and consultations with school psychologists. Additionally, mothers with severe, unstable psychiatric conditions (e.g. active psychosis or untreated bipolar disorder), assessed via self-report and confirmed by school counselors, were excluded, as were those unable to comprehend the questionnaires due to language or cognitive barriers. These criteria were applied consistently to ensure methodological rigor and ethical participant selection for the study of maternal psychological well-being.

Measure

Psychological well-being scale

Ryff’s [22] Psychological Well-being Scale, comprising 18 items, was utilized to assess participants’ psychological well-being. Responses are recorded on a six-point Likert scale, where one indicates ‘completely disagree’ and six signifies ‘completely agree.’ The scale yields scores for six dimensions: Autonomy, environmental mastery, personal growth, positive relationships with others, purpose in life, and self-acceptance. A total score is derived by summing the scores across all six dimensions, ranging from 18 to 108. The psychological well-being scale has demonstrated acceptable reliability, with Bayani et al. [23] reporting a test-retest reliability coefficient of 0.82. In the current study, the scale exhibited a Cronbach’s α coefficient of 0.85, indicating strong internal consistency within this sample.

Parental self-agency measure (PSAM)

Developed by Dumka et al. [24], the 10-item PSAM assesses parents’ overall confidence in their maternal or paternal role. The questionnaire comprised five positive and five negative statements, utilizing a Likert scale ranging from 1 (rarely) to 7 (always). The total score ranges from 10 to 70, with higher scores indicating greater self-efficacy. In Iran, Abarashi et al. [25] documented a Cronbach’s α of 0.71 and confirmed content validity through expert review by three psychology professors. While content validity has been established, specific validity data for the PSAM within a population of mothers raising children with intellectual disabilities are not detailed. The PSAM demonstrated a Cronbach’s α of 0.78 in the current study, indicating acceptable internal consistency within this sample.

Spiritual intelligence questionnaire

Designed by Abdollahzadeh et al. [26], considering cultural characteristics of Iranian society, the Spiritual Intelligence questionnaire consists of 29 items and two micro variables called “perceiving and connecting to the source of creation” (12 items) and “spiritual life” (17 items). This questionnaire is scored on a seven-point Likert scale (i.e. 1=“completely disagree,” 2=“disagree very much,” 3=“slightly disagree,” 4=“neutral,” 5=“slightly agree,” 6=“agree very much,” and 7=“completely agree”). The minimum and maximum scores are 29 and 203, respectively. Total score ranges of 1–100, 100–160, and 160–203 refer to low, average, and high levels of spiritual intelligence, respectively. Abdollahzadeh et al. [26] reported a Cronbach’s α of 0.87 for the spiritual intelligence questionnaire, indicating good internal consistency. Although the questionnaire was developed considering the cultural context, specific validity data for its use with mothers raising children with intellectual disabilities were not provided. In the current study, the Spiritual Intelligence Questionnaire demonstrated a Cronbach’s α of 0.84, suggesting acceptable internal consistency within this sample.

The toronto alexithymia scale (TAS)

The TAS, a 20-item self-report questionnaire developed by Bagby et al. [27], measures alexithymia. The TAS comprises three subscales: “Difficulty identifying feelings,” which assesses the challenge individuals face in recognizing and labeling their own emotions; “difficulty describing feelings,” which evaluates the difficulty individuals experience in communicating their emotions to others; and “externally oriented thinking,” which measures the tendency to focus on external factors rather than internal emotional states. Items are scored using a 5-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree). Total scores range from 20 to 100, with ≤51 indicating low alexithymia and scores ≥61 indicating high alexithymia. Notably, items 4, 10, 18, and 19 were reverse-scored. The total score was calculated by summing the scores of all items. Besharat [28] reported a Cronbach’s α coefficient of 0.75 for the Persian version, demonstrating acceptable internal consistency. While the reliability of the Persian version has been established, specific validity data for the TAS within a population of mothers raising children with intellectual disabilities is not discussed. The TAS exhibited a Cronbach’s α coefficient of 0.82 in the present study, indicating strong internal consistency within this sample.

Statistical analyses

The data were analyzed using descriptive and inferential statistics. Descriptive statistics, including Mean±SD, were used to describe the distribution of research variables. Pearson’s correlation coefficient assessed the bivariate linear relationships between psychological well-being, parental self-efficacy, spiritual intelligence, and alexithymia. To examine the hypothesized relationships among these variables, specifically the direct effects of parental self-efficacy and spiritual intelligence on psychological well-being and the mediating role of alexithymia in these associations, SEM was employed. The tested model posited that parental self-efficacy and spiritual intelligence positively predicted psychological well-being and negatively predicted alexithymia. Furthermore, the model hypothesized that alexithymia would negatively predict psychological well-being, thus mediating the relationships between the independent variables (parental self-efficacy and spiritual intelligence) and the dependent (psychological well-being) variables. No control variables were included in the tested models. Initial data exploration was conducted using SPSS software, version 27.0, and SEM analysis was performed using SmartPLS software. The specific estimator used in SmartPLS for the SEM analysis was the partial least squares SEM (PLS-SEM) algorithm.

Results

Findings related to demographic variables indicated that the mothers’ mean age was 41.22±3.16 years. Educational attainment was distributed as follows: 18 participants (6.7%) held a high school diploma, 72(26.8%) an associate’s degree, 123(42.7%) a bachelor’s degree, and 56(20.8%) a master’s degree. Additionally, 222(82.4%) were married, 33(12.3%) divorced, and 14(5.2%) widowed. regarding employment status, 131(48.7%) were employed full-time, 60(22.3%) part-time, and 78(29.0%) were housewives. Household income levels were reported as low 77(28.6%), middle 142(52.8%), and high 50(18.6%), based on Tehran’s socioeconomic standards.

Table 1 presents the Mean±SD, and Pearson correlation coefficients for the research variables: Psychological well-being, parental self-efficacy, spiritual intelligence, and alexithymia. Psychological well-being had a Mean±SD of 39.37±12.42. Parental self-efficacy showed a Mean±SD of 111.86±35.24. Spiritual intelligence had a Mean±SD of 61.20±14.16. Alexithymia had a Mean±SD of 60.66±19.71. The correlation matrix revealed several significant relationships: Parental self-efficacy was positively correlated with psychological well-being (r=0.18) and spiritual intelligence (r=0.15), but negatively correlated with alexithymia (r=−0.23). Spiritual intelligence was positively correlated with psychological well-being (r=0.36) and negatively correlated with alexithymia (r=−0.47). Alexithymia was negatively correlated with psychological well-being (r=−0.45). These correlations suggest complex interrelationships between the variables, with higher parental self-efficacy and spiritual intelligence associated with higher psychological well-being. In contrast, higher alexithymia was associated with lower psychological well-being. Figure 1 shows the initial model proposed in this study.

Table 2 presents the model fit results for the structural equation model, comparing the saturated and estimated models using two key indices: The standardized root mean square residual (SRMR) and normed fit index (NFI). The SRMR was 0.07 for the saturated model and 0.08 for the estimated model, indicating a good fit, as both values were below the desirable threshold of 0.08. The NFI was 0.79 for both the saturated and estimated models, suggesting a moderate fit to the data, as it surpassed the moderate fit threshold of 0.7 but did not reach the good fit threshold of 0.9. These fit indices suggest that the estimated model provides an acceptable representation of observed data. However, the NFI value indicates room for potential enhancements to the model’s explanatory power.

Table 3 presents the path coefficients for the direct relationships among the research variables. The path from parental self-efficacy to psychological well-being was insignificant (β=0.08, t=1.68, P=0.090). However, alexithymia had a significant relationship with psychological well-being (β=-0.52, t=9.67, P<0.001), as did spiritual intelligence (β=0.14, t=2.38, P=0.020). Spiritual intelligence also demonstrated a significant relationship with alexithymia (β=-0.45, t=10.48, P<0.001), and parental self-efficacy showed a significant relationship with alexithymia (β=-0.20, t=3.97, P<0.001). Spiritual intelligence was indirectly related to psychological well-being through the mediating role of alexithymia (β=0.22, t=6.80, P<0.001). Similarly, parental self-efficacy was indirectly related to psychological well-being through the mediating role of alexithymia (β=0.10, t=3.34, P<0.001). Figure 2 shows the final structural model in this study.

A multi-group analysis was conducted to examine the moderating role of gender within the proposed model. Table 4 presents the results of this study. The table displays path coefficients (β), t, and P for both girls and boys. No significant sex differences were observed across all pathways (P>0.05). Specifically, the relationships between alexithymia and psychological well-being, spiritual intelligence and psychological well-being, spiritual intelligence and alexithymia, parental self-efficacy and psychological well-being, and parental self-efficacy and alexithymia did not significantly differ between girls and boys. These findings suggest that the direct relationships between these variables are consistent across genders within the study sample.

Discussion

This study aimed to elucidate the relationships between parental self-efficacy, spiritual intelligence, alexithymia, and psychological well-being among mothers of children with intellectual disabilities in Tehran City. This study tested a model in which alexithymia mediates the pathways from parental self-efficacy and spiritual intelligence to psychological well-being. The findings offer nuanced insights into the psychological dynamics experienced by this population, contributing to the existing literature and highlighting areas needing further investigation.

A primary, somewhat unexpected, finding was the lack of a significant direct relationship between parental self-efficacy and psychological well-being. This contrasts with several studies reporting a positive association [29, 30] and general theories emphasizing self-efficacy’s role in adaptive functioning [12, 13]. Several interpretations warrant consideration. First, methodological differences, including variations in sample characteristics (cultural context, socioeconomic range), sample size limitations, or the specific psychometric properties of the instruments used in this study compared to others [29, 30], may contribute to this discrepancy. Second, and perhaps more substantively, the overwhelming and multifaceted nature of the challenges inherent in raising a child with an intellectual disability [4, 5] might attenuate the direct protective effect of self-efficacy beliefs alone. In high-stress contexts, internal beliefs about capability (parental self-efficacy) may only translate into enhanced well-being when coupled with other crucial resources, such as robust social support networks, adequate financial resources, accessible support services, or effective practical coping strategies–factors not controlled for in this study. It is plausible that these external resources or other internal characteristics (e.g. dispositional optimism, baseline stress levels) mediate or moderate the parental self-efficacy-psychological well-being link more strongly than alexithymia alone in this population. This finding does not dismiss the importance of parental self-efficacy. However, this suggests that its direct impact on well-being might be contingent upon a broader constellation of factors in highly demanding caregiving roles [13]. Future research, potentially using mixed methods or larger, more diverse samples, could further explore the conditions under which parental self-efficacy impacts the well-being of this group.

Conversely, consistent with prior research [16, 18, 21], spiritual intelligence demonstrated a significant positive direct relationship with psychological well-being. This supports conceptualizing spiritual intelligence as a vital internal resource [14, 15]. For mothers facing chronic caregiving stress, spiritual intelligence may foster well-being by enabling them to find meaning and purpose amidst adversity, cultivating a sense of connection to something larger than themselves (reducing isolation), promoting virtues, such as tolerance and resilience, and offering transcendent frameworks for interpreting hardship [14]. These components likely enhance coping capacity and buffer against the psychological toll of demanding circumstances, contributing directly to higher psychological well-being.

This study also confirmed a significant negative relationship between alexithymia and psychological well-being, aligning with previous findings [15, 18, 19]. Individuals who struggle to identify, understand, and articulate their emotions often experience heightened negative affect, reduced positive affect, and lower life satisfaction [19, 20]. For mothers of children with intellectual disabilities, the chronic, complex, and often ambiguous emotional landscape (encompassing grief, frustration, chronic worry, joy, and love) may be particularly difficult to navigate. Difficulty processing these intense emotions (alexithymia) can hinder adaptive coping, impede supportive communication within the family, and directly contribute to poorer mental health outcomes [9, 21]. These findings underscore the relevance of emotional processing skills for resilience in this population.

The mediation model results indicated that alexithymia significantly mediated the relationship between parental self-efficacy and psychological well-being. Although parental self-efficacy did not directly predict psychological well-being, an indirect pathway emerged: Higher parental self-efficacy was associated with lower alexithymia, which was linked to higher psychological well-being. While the study noted a lack of directly comparable research on this specific mediation pathway, this finding suggests a potential mechanism: Mothers who feel more capable in their parenting role (higher parental self-efficacy) may feel less overwhelmed by their emotional experiences, allowing for better emotional processing and expression (lower alexithymia), subsequently improving their well-being. This interpretation posits that enhancing self-efficacy might indirectly bolster psychological well-being by improving emotional regulation capacities. This highlights alexithymia as a potentially crucial intervention target, suggesting that interventions aiming to boost psychological well-being might be more effective if they concurrently enhance self-efficacy and address difficulties in emotional processing.

Furthermore, alexithymia also mediated the relationship between spiritual intelligence and psychological well-being, but in a complex manner. While spiritual intelligence directly predicted higher psychological well-being, the indirect pathway through alexithymia was unexpectedly negative (higher spiritual intelligence predicted higher alexithymia, which predicted lower psychological well-being). This paradoxical finding suggests that while spiritual intelligence generally promotes well-being [14, 16], certain facets or expressions of spirituality might, for some individuals in this high-stress context, inadvertently encourage emotional suppression or avoidance (contributing to alexithymia). For instance, strong beliefs emphasizing acceptance or stoicism may discourage processing difficult negative emotions. This aligns with literature suggesting potential “dark sides” or maladaptive forms of spiritual coping. This complex result underscores the need to consider individual differences and cultural contexts [15], suggesting that the way spiritual intelligence is manifested and utilized is crucial. This implies that interventions leveraging spiritual intelligence should foster transcendent connections, meaning, and healthy emotional awareness and expression.

A principal limitation of this study is the utilization of convenience sampling. This non-probability technique inherently restricts the generalizability of the findings to the wider population of mothers caring for children with intellectual disabilities, both within Tehran and more broadly, as the sample may lack representativeness. Convenience sampling introduces potential selection bias, meaning participants might systematically differ from non-participants (e.g. regarding motivation, access to services, or the severity of challenges faced), compromising the results’ external validity. Consequently, the specific focus on mothers residing in Tehran City necessitates careful consideration when applying these findings to diverse geographic or cultural contexts. Further limitations include reliance on self-reported instruments. While conventional, such measures are susceptible to biases, notably social desirability, which could compromise the veracity of participant responses concerning sensitive topics, such as personal well-being or perceived efficacy. Additionally, the exclusive focus on mothers precludes the extrapolation of findings to fathers or other primary caregivers, who may experience these dynamics differently. Finally, the study did not control for several potentially confounding variables, including socioeconomic status, specific type and severity of the child’s intellectual disability, and the availability and quality of family or social support. These unmeasured factors could have influenced the observed relationships between parental self-efficacy, spiritual intelligence, alexithymia, and psychological well-being.

Conclusion

This study elucidates the intricate interplay between alexithymia, spiritual intelligence, parental self-efficacy, and psychological well-being in mothers of children with intellectual disabilities. The findings revealed significant negative associations between alexithymia and psychological well-being, while spiritual intelligence demonstrated a positive relationship with maternal well-being. Furthermore, spiritual intelligence, parental self-efficacy, were significantly and inversely related to alexithymia. Notably, alexithymia emerged as a significant mediator in the relationship between spiritual intelligence and parental self-efficacy and psychological well-being. The absence of a moderating effect of child gender suggests the consistency of these findings across the sampled gender of children with intellectual disabilities. These results have significant clinical implications for supporting the psychological well-being of mothers raising children with intellectual disabilities. Interventions addressing alexithymia could incorporate acceptance and commitment therapy, facilitating emotional awareness and expression through mindfulness and value-driven activities. Support groups led by trained therapists could provide a valuable platform for mothers to process their emotions, thereby mitigating the negative impacts of alexithymia. Interventions might include guided spiritual retreats or workshops centered on existential reflection and meditative practices to foster spiritual intelligence. By specifically targeting alexithymia and promoting spiritual intelligence and parental self-efficacy, such interventions hold the potential to significantly enhance maternal psychological well-being, with positive cascading effects on family outcomes. Future research should aim to validate these findings in more diverse populations and rigorously evaluate the efficacy of the proposed interventions to optimize support strategies for this specific maternal group.

Ethical Considerations

Compliance with ethical guidelines

The study was approved by the Ethics Committee of the Islamic Azad University, Shahrekord Branch, Shahrekord, Iran (Code: IR.IAU.SHK.REC.1403.347).

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Authors' contributions

Data collection, literature review, and manuscript drafting: Mahnaz Talebi; Supervising, studt design, data analysis, interpretation, and final manuscript revision: Ahmad Ghazanfari; final approval: All authors.

Conflict of interest

The authors declared no conflicts of interest.

Acknowledgments

The authors sincerely thank all mothers who participated in this study for their time, trust, and openness in sharing their experiences. We also thank the staff at the psychology centers and institutions for their valuable assistance with data collection. Special appreciation is extended to Islamic Azad University, Shahrekord Branch, for supporting this research.