**2. Method**

#### *Participants and Procedure*

During the years 2014–2015, in the heart of the economic crisis, 62 parents of children with ASD completed a set of questionnaires on parenting stress, depressive symptomatology, quality of life, and coping strategies, participating in a research project on the needs, burdens, quality of life, and coping strategies of families with children with ASD [2,3]. The primary caregiver was asked to complete the questionnaires. All parents were attending the ASD Outpatient Clinic of a University Department and constituted consecutive cases coming for follow-up assessments. Their children or adolescents had received an ASD

diagnosis according to DSM-5 criteria [53] in the past and had undergone a standard psychometric evaluation. Exclusion criterion was the inability of parents to read or write adequately in Greek.

During the first phase of the COVID-19 pandemic, two months after the implementation of restrictive measures by the Greek Government, the same parents were asked to respond to a web-based survey, including a questionnaire on demographics and other characteristics of the sample (Table 1) and the same battery of instruments they had completed during the economic crisis period.

**Table 1.** Sample characteristics.


Out of 62 parents, 50 mothers and six fathers agreed to participate in the survey. The DSM-5 level of functioning of the youngsters during the two periods remained the same except for the case of one subject, whose level of functioning deteriorated from level 2 to level 3.

## **3. Instruments**

*Demographic Characteristics and COVID-19 related Questionnaire.* This questionnaire was developed for the needs of the current study and covers the caregivers' and children's demographic characteristics and information on the impact of the COVID-19 pandemic on the family (Table 1).

*Center for Epidemiologic Studies Depression Scale (CES-D)* [54]. This is a short selfreporting scale designed to measure depressive symptoms in the general population. It consists of 20 items, measuring the presence of depressive symptoms in the past week, on a four-point scale ranging from 0 (rarely) to 3 (most of the time). The possible range of scores is zero to 60. A score of 16 or higher indicates risk of clinical depression. It has been validated in the Greek population, showing a very good internal consistency (Cronbach's alpha: 0.95) [55,56].

*Family Crisis Oriented Personal Scales (F-COPES)* [57]. It is a 30-item, self-reporting instrument measuring a family's coping style. It includes two levels of interaction: (a) the ways a family internally handles difficult situations and problems and (b) the ways the family externally handles problems that emerge outside its boundaries. The responses range from 1 (strongly agree) to 5 (strongly disagree) and produce a total score and five subscales scores referring to: (a) acquiring social support, (b) reframing, (c) seeking spiritual support, (d) mobilizing family to acquire and accept help, and (e) passive appraisal. It is a reliable and valid tool that measures coping strategies and level of adaptation. The Greek version 0f F-COPES has shown a Cronbach's alpha of 0.86 and a test–retest reliability of 0.81 [58].

*Parenting Stress Index Short-Form (PSI-SF)* [59]. It consists of 36 items deriving from the Parenting Stress Index [60] and is a measure of the stresses that a parent is experiencing in his/her role. It comprises three subscales labeled Parental Distress (PD), Parent-Child Dysfunctional Interaction (PCDI), and Difficult Child (DC). The PD subscale measures the level of distress due to personal factors related to demands of parenting; the PCDI subscale assesses parents' dissatisfaction with their interactions with their children, and the DC subscale measures parents' perceptions of the characteristics of their child's behavior and how difficult it can be to manage. It also includes a Defensive Responding scale indicating parents' denial or minimization of problems. Participants use a 5-point Likert scale indicating the degree to which they agree with each statement. The Total Stress score is a composite score of the subscale scores. In our study, PSI-SF showed a very good internal consistency both for the total scale (Cronbach's α = 0.91) and all subscales (0.91: Parenting Distress; 0.82: Parent–Child Dysfunctional Interaction; 0.73: Difficult Child; 0.85: Defensive Responding).

*World Health Organization Quality of Life-BREF (WHOQoL-BREF)* [61]. The WHO QOL-BREF is an abbreviated version of WHOQOL-100, developed by the World Health Organization [62]. WHOQOL-BREF consists of 24 items corresponding to 24 QOL (thematic) facets, and two items comprising an overall quality of life/general health facet. Items are organized into four domains: (1) physical health, (2) psychological health, (3) social relationships, and (4) environment. The WHOQOL-BREF Greek version has demonstrated satisfactory psychometric properties [63].

#### **4. Statistical Analysis**

Quantitative variables were expressed as mean (Standard Deviation) or as median (interquartile range). Qualitative variables were expressed as absolute and relative frequencies. Paired students' *t*-tests were used for comparisons in all study scales between measurements occurring during the economic and pandemic crisis. The Benjamini-Hochberg procedure was applied to control the false discovery rate for independent tests. In order to examine the differences in all study scales between measurements after adjusting for parental educational level, income after the pandemic, DSM-5, and child's age, repeated measures ANOVA were conducted. Pearson's correlations coefficients were used to explore the association of all understudy scales during the pandemic crisis. Multiple linear regression was conducted, in a stepwise method (p for entry 0.05, p for removal 0.10) to find factors associated with the total PSI score. As independent variables, sample characteristics as well as F-COPES subscales were used. All reported *p* values are two-tailed. Statistical significance was set at *p* < 0.05 and analyses were conducted using SPSS statistical software (version 22.0).
