1.1. Caregiver burden in ECI

In a broad sense, caregiver burden has been used in the field as a construct that groups together the physical, emotional, social, or financial problems experienced by family members in the caregiving situation. In a more operational sense, this construct is defined, from a multidimensional approach, around self-efficacy expectations, the impact of caregiving and interpersonal relationships [8,14,15] and is the result of the caregiver’s perception and cognitive appraisal to adapt to the stressors derived from the parenting situation of a child with special needs [6].

In the early years of life of children with support needs (i.e., children with a disability, developmental delay or at-risk situation who experience needs of support), families face numerous unforeseen situations characterized by uncertainty, anxiety, parental stress or caregiving demands [16]. Families must select ECI services that meet their needs, determine the supports their children require, and identify the most suitable schooling. Additionally, it is essential to assess the nature of support needs and any potential developmental concerns. Collectively, these factors influence the perception and cognitive assessment of caregiver burden [4]. This fact is highly relevant given that research has shown a very close relationship between caregiver burden and FQoL [17–19]. Different research has studied this relationship showing that perceived caregiver burden negatively predicts FQoL [7,20]. In parallel, other research has reflected a negative relationship between family burden and “life satisfaction” of parents who have children with disabilities [19]. These results indicate that family confidence and caregiver burden are two variables that significantly affect FQoL. ECI services should strengthen their programs to increase family confidence and reduce the impact of caregiver burden [7].

In this context, a greater sense of parental self-efficacy is related to a lower level of stress caused by the burden [21]. Parental self-efficacy was found to increase as the collaboration between the professional and the family strengthens, especially showing greater improvement when the collaboration is closer and when caregivers are more involved in the intervention. In addition, ECI practices, have been shown to have a positive impact on the perception of caregiver burden in early childhood [22,23]. Among other service features, home visits by professionals have evidenced a decrease in caregiver burden resulting from family visits to centers [24].

1.2. Family confidence and competence in ECI

Confidence and competence are both dimensions of family capacity [25]. Family confidence, a result of support-based services, is a key aspect of self-efficacy, reflecting caregivers’ belief in their ability to promote their child’s development. Through capacity-building approaches in ECI, parental competencies are developed, and family confidence in these skills predicts how effectively they implement interventions [26]. This leads to better child and family outcomes such as child functioning and development and reduced parenting stress [2,15].

In the context of our study with families in ECI, family confidence can be seen as the sense of mastery and efficacy in carrying out daily parenting tasks [27,28]. Other authors state that it refers to both the primary caregiver’s perceived confidence in helping the family with routines and dynamics and the perceived confidence in helping the child with functioning in routines and social participation spaces [7,20,29–33]. From this approach, family confidence is a construct that is directly associated with a significant improvement in interactions between primary caregivers and children with special needs [2,5].

In this context, parenting competences, and the family’s confidence in those competences, are directly related to a higher family quality of life [5]. These authors found that certain characteristics of ECI services, such as multiple professionals involved in the family life, are related to lower family confidence and a worse perception of the child’s functioning [5]. In this sense, a transdisciplinary approach, through a primary service provider connecting the family with other professionals can contribute to reducing the impact of stressors and perceived caregiver burden [34]. Thus, promoting the confidence and competence of primary caregivers constitutes an indicator of achievement and success of family-centered support programs [34,35] especially with the presence of a primary service provider [36–38].

Other studies have demonstrated that lower family confidence and competence among parents are associated with greater difficulties in managing problematic behaviors in their children [1,39]. In addition, greater parental confidence contributes to generate more opportunities for social participation and greater management of daily routines, which allows expecting a lower caregiver burden and greater overall well-being [26]. Family confidence was found to mediate the negative effect that caregiver burden or the child’s level of support needs had on FQoL [7]. This effect also extends to other sociodemographic variables such as family income or caregiver gender, modulating their impact on family well-being and quality of life in early childhood [7].

Ultimately, it should be noted that, among other objectives, ECI services aim to increase family confidence by providing the necessary supports at this early stage of the child’s life [4]. Family confidence and competence can therefore be understood as an expected outcome of ECI services [1,19].

1.3. Child functioning and sociodemographic variables

In addition to family-level variables, there are child-related factors that can impact caregiver burden. Several studies found that child variables such as the child’s degree of social participation, functioning in routines, age or supports needs have a direct impact on caregiver burden and family quality of life [7,40,41]. Likewise, support needs, behavioral problems, and the need for intensified supports impact the primary caregiver’s perception of caregiving overload [35,42,43].

The relationship between child functioning, family confidence, and caregiver burden has also been partially investigated. For example, different authors have established an inverse relationship between child functioning -severity of the disability or amount of need for supports- and family well-being and quality of life [18,42,44]. Other studies have concluded that child support needs (level of child functioning) do not predict family quality of life by themselves but are positively related to caregiver burden [7].

On the other hand, research also shows that if ECI services contribute to increased family competence and confidence, coupled with greater perceived parental support, there is a significant improvement in child functioning [45,46]. This strong association between the child’s level of functioning and lower perceived caregiver burden has been widely described [47].

Likewise, family-level sociodemographic variables such as being employed [18,42], a greater family income [43,48,49], the presence of two adults living in the household [17,50], greater caregiver education level [35] or more family-centered supports provided by ECI services [40] have been shown to be variables that significantly impact positive child functioning, and greater FQoL.

In contrast, enhanced child functioning and age have been positively correlated with more elevated levels of caregiver burden, which signifies a more dynamic familial environment and the responsibilities that must be undertaken [51], as this often necessitates increased care and attention as children develop and interact [52].

Conversely, time spent by fathers with the child has been associated with a reduction in the perceived parenting burden within the family, concurrently resulting in an enhancement of the child’s functioning perception [51].

Building on these premises, this study positions family confidence as a cornerstone in ECI. A confident family is better equipped to support their child’s development in daily life. Family confidence, as a predictor of FQoL, has the potential to mitigate the adverse effects of caregiver burden. Additionally, while a child’s level of functioning is known to enhance FQoL directly, the demands of caregiving can impose significant strain on families. By examining the interplay between these variables, particularly how family confidence can mediate the impact of caregiver burden on FQoL, this research aims to identify pathways to support families more effectively in ECI contexts [2,4,7].

The focus of the present study challenges the traditional assumptions in ECI research by demonstrating that child functioning does not directly predict caregiver burden but instead operates through its impact on parental confidence. This highlights the need for implementing a capacity-building approach within ECI that emphasize the empowerment of parents.

Within the framework described above, the study presented here has two research objectives:

- To analyze the relationship between family confidence and child functioning as predictors of caregiver burden.

- To analyze the influence of the child’s level of functioning on caregiver burden with and without the mediating influence of family confidence.

2.1. Participants

A total of 169 Spanish families with children from birth to age six experiencing disability, developmental delay, or at risk of disability or biopsychosocial vulnerability participated in Early Childhood Intervention (ECI) services across five Autonomous Communities (Regions). The majority of families lived in Valencian Community (85.6%), followed by Canary Islands (6.6%), Andalusia (3.3%), and La Rioja (2.6%).

Regarding the family-level variables, the majority of respondents were mothers, (73.97%), followed by fathers (15.75%). Grandparents represented the smallest group at 1.37%. Regarding employment status, the largest portion of respondents are employed full-time (47.54%), with part-time employees comprising 24.59%, and the unemployed -but looking for a job- representing the smallest group at 9.84%. An 18.03% of respondents were homemakers or pension recipients. The monthly salary of each family unit was less than €1800 in 21.19% of cases, while in 78.81% of cases it was higher than €1800 per month.

Among child-level variables (age M = 36.72 months, SD = 7.51), 63.93% of the children did not have a diagnosed disability at the moment, rather, they had developmental delays or were at-risk due to bio-psycho-social factors. A total of 17.21% were in the process of being diagnosed, and 16.39% had a low level of disability. Only 1.64% had severe level of disability followed by 0.82% with moderate level of disability. There was only one missing case (0.82%) that did not report the disability condition. Over 78% percent of the families reporting marital status were married or living with a partner, whereas the 18.48% were single and 3.36% were divorced.

Regarding the service-level variables, the most frequent weekly sessions was once a week (70.25%), followed by every other week 15.70% and only 4.13% of families received more than two sessions per week.

Participants were contacted via email through their early childhood intervention programs with a link to the anonymous on-line survey. It took about 20 minutes to complete and the survey included the questionnaires listed in the instruments section. A written informed consent was embedded at the beginning of the survey and was a required field to access the questionnaires. Only the researchers could access, download, code and analyze the data. Any family receiving services from the participating ECI program was eligible. The link was available from October 1 to December 31, 2023. The study was conducted in accordance with the Declaration of Helsinki an Institutional Review Board approval was obtained from the Ethics Committee of the Catholic University of Valencia (protocol code CEI/UCV/2018–2019/111).

2.2. Instruments

2.3. Data analysis

Descriptive analyses were conducted to characterize the participants and to evaluate the scoring patterns of the measures used. This included calculating means, standard deviations, and the range of scores (minimum and maximum) at both the overall and dimension levels. For this purpose, we used SPSS v.25 (IBM, 2019). To calculate the internal consistency of the scores, alongside Cronbach’s alpha, McDonald’s omega (ω) was also used due to the ordinal nature of the Likert-type scores.

Furthermore, ANOVA and t tests were conducted to describe the scores for family confidence, child functioning, and caregiver burden based on sociodemographic variables of interest such as income and employment. A 95% confidence interval was used, with statistical significance accepted at p < .05. Effect sizes were calculated using Cohen’s d, with values of.20,.50, and.80 indicating small, medium, and large effect sizes, respectively [55]. Analyses of the relationships between continuous variables in the study were conducted using Pearson correlations. Finally, in order to address our second objective, a mediation analysis was carried out in which child functioning was the predictor, family confidence the mediator variable, and caregiver burden was the outcome variable. Specifically, we analyzed the direct effect of child functioning on caregiver burden, as well as the indirect effect through family confidence. We also calculated the total effect considering the impact of the predictor on the dependent variable without removing the effect of the moderator in the equation. We used a robust mediation method in JASP v.0.16.4 JASP Team, 2024, following the procedures of similar work on the topic [7]. Finally, a multiple mediation analysis (two mediators) was conducted for a deeper detail and understanding of how each of the three caregiver burden factors -dependent variables- (Impact of Care, Interpersonal Relationships and Self-efficacy) are predicted by child functioning -predictor- through the two dimensions of family confidence -mediators- (Confidence in Helping the Child -CHC-, and Confidence in Helping the Family -CHF-). In other words, we tested how child functioning predicts all three domains of caregiver burden individually and through each of the dimensions of family confidence.

4.1. Limitations

The present study should acknowledge some limitations. First, the sample size could be considered a limitation due to the unequal representation of participants in different regions. Some regions, such as the Valencian Community, had greater participation. Thus, this could affect to the generalization of results. However, the procedures and statistical techniques that were used —robust and appropriate for these cases— and the pattern of results were similar to those found in the literature on caregiver burden and family confidence (i.e., [7]), making this study an interesting contribution. The results should be taken as a promising first step in analyzing the mediating role of family confidence between child-related variables and caregiver burden. We encourage researchers to replicate this study in different contexts with a larger sample size. Furthermore, the analysis did not account for cultural disparities and variations in regional policies. This may be regarded as a limitation and could influence practical implications, particularly in terms of building family confidence implementing family-centered practices. While other studies have analyzed burden as the predictor of variables such as quality of life, the present study has put the attention in caregiver burden as the outcome, and we analyzed the role of family confidence as a buffer variable against this negative effect of the impact of a low child functioning.

4.2. Implications

The most significant implication is the need for services to measure and monitor family confidence and caregiver burden. Regularly monitoring these constructs can help programs identify potential areas of need, thereby serving not only as a final evaluation metric but also as a tool for planning and reviewing processes.

The consequences on support services of our results have a clear direction towards the implementation of collaborative practices and family empowerment. Reducing family burden is a relevant outcome of ECI settings. Research indicates that specific activities such as mindfulness can be beneficial, and services could encourage family participation in these activities. Such activities have proven effective in reducing stress among parents of children with disabilities [73,74].

However, because or results identified family confidence as a complete mediator between child functioning and caregiver burden we can recommend services to implement a collaborative capacity-building approach, with special attention to building family confidence. The influence of family confidence in helping the family functioning was even more relevant to the confidence in helping the child. This has a clear implication towards paying special attention to addressing family needs and priorities. This could be implemented in different stages of the intervention process (considering family priorities during needs assessment, evaluation processes, functional planning and also implementation of interventions). As [75] found, addressing more family-level goals (whether related to the child or not), have been related to better child performance.

Additional results from our study, such as the association between more weekly sessions and lower self-efficacy, and the finding that families with lower income feel less confident, suggest that services could, first, avoid overloading families with multiple weekly sessions. In addition, implementing a primary service provider (PSP) could help with both reduce the number weekly sessions and improve coordination to reduce parental stress [76] and improve child functioning and family quality of life [34]. A PSP is the main professional who provides support to the family and is the link between the family and the rest of ECI team specialists if needed, according to the needs. Second, services could also identify families who are more vulnerable and build their confidence not only with helping their child but also in enhancing overall family functioning. Given that insufficient economic resources can exacerbate caregiver burden, it is crucial for services to ensure strong connections with community resources tailored to each family’s needs. Furthermore, targeted interventions should be developed to support these families, addressing both their immediate and long-term challenges. By fostering a holistic approach, services can help mitigate the stressors associated with economic hardship and enhance the overall well-being of the family unit. Ultimately, implementing a family-centered approach (i.e., focusing on families’ identified needs and priorities, building their capacity, establishing positive and collaborative family-professional partnerships, designing functional participation-based intervention plans, and supporting families in natural environments rather than in multiple visits to the clinic), could help services have an important impact in both reducing caregiver burden and increasing family confidence and overall wellbeing.