Internalization of stigma for parents of children with autism spectrum disorder in Hong Kong Winnie W.S. Mak * , Yvonne T.Y. Kwok Department of Psychology, The Chinese University of Hong Kong, Shatin, NT, Hong Kong article info Article history: Available online 12 March 2010 Keywords: Hong Kong Affiliate stigma Attribution model Social support Parents Autism spectrum disorder Children China abstract An attribution model was tested to explain the internalization of stigma among parents of children with Autism Spectrum Disorder (ASD). In the model, the internalization paths from courtesy stigma to affiliate stigma and the impact of three types of social support on affiliate stigma and psychological well-being were examined. The study was conducted in Hong Kong, China; one hundred and eighty-eight parents of children with ASD were recruited to complete the questionnaire. The model showed excellent fit to the data. Path analysis suggested three possible paths of internalizing courtesy stigma, including the direct path to affiliate stigma, through perceived controllability, or through perceived responsibility and self- blame. Support from family, significant others, friends, or professionals was found to be related to affiliate stigma and psychological well-being differentially. The internalization of stigma among parents of ASD children was severe. The path model sheds light on possible ways to reduce stigma in future services. Ó 2010 Elsevier Ltd. All rights reserved. Stigma not only impacts the discredited individuals them- selves; it can affect individuals who are closely associated with these stigmatized individuals (i.e., family members, caregivers, friends, or service providers). Previous studies have found family members encountering various forms of stigmatization and discrimination as a result of their children having autism (Gray, 2002), intellectual disability (Green, 2003), ADHD (Koro- Ljungberg & Bussing, 2009; Norvilitis, Scime, & Lee, 2002), schizophrenia or other mental illness (Angermeyer, Schulze, & Dietrich, 2003; Muhlbauer, 2002; Östman & Kjellin, 2002; Phelan, Bromet, & Link, 1998; Schulze & Angermeyer, 2003). These studies generally focused on the extent of courtesy stigma (Goffman, 1963) that the family members perceive from the general public towards themselves. To distinguish courtesy stigma from self-stigma experienced by the family members, we refer to this self-stigmatization of family members as affiliate stigma (Mak & Cheung, 2008). In the process of internalizing stigma, family members might develop negative self- evaluation, experience heightened negative emotions, and behav- iorally withdraw and conceal their stigmatized status from others (Corrigan & Watson, 2002). Although the concept of affiliate stigma has been proposed (Mak & Cheung, 2008), the process in which associates internalize courtesy stigma into affiliate stigma and its consequences remain unknown. The present study examined the internalization process of courtesy stigma using Weiner’s attribu- tion model (1993) and its impact on psychological well-being among parents of children with Autism Spectrum Disorder (ASD or simply autism) in Hong Kong. In addition, the effects of different types of social support on affiliate stigma and psychological well- being were also investigated. Stigmatized autistic features and the local context According to the DSM-IV-TR (APA, 2000), the diagnostic features of Autism Spectrum Disorder (ASD) include impaired social inter- actions, impaired communication, as well as restricted, repetitive, and stereotyped behavior patterns. Among people with mental illness, those who lack proper social skills and perform inappro- priate affective behaviors are considered impolite and dangerous (Pugliesi, 1987). As such, their parents are often subjected to stigma due to the public’s misconception of their lack of control or disci- pline over their children with mental illness (Penn, Kohlmaier, & Corrigan, 2000). In the case of children with autism, parental stress has been shown to become heightened when their children show behavioral oddities in the form of self-stimulation and inappropriate use of their bodies through flapping, smelling and mouthing objects, rocking and twirling and finger-gazing (Konstantareas & Homatidis, 1989). Their children’s display of behavioral oddities may expose parents to courtesy stigma, which in turn may become internalized as affiliate stigma. * Corresponding author. Tel.: þ852 2609 6577; fax: þ852 2603 5019. E-mail address: wwsmak@psy.cuhk.edu.hk (W.W.S. Mak). Contents lists available at ScienceDirect Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed 0277-9536/$ e see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2010.02.023 Social Science & Medicine 70 (2010) 2045e2051