Behavioral and emotional profile and parental stress in preschool children with autism spectrum disorder

Highlights

• Preschooler autistic children show more behavioral problems than controls.

• Specific preschooler autistic children behavioral problems predict parental stress.

• Severity of autistic symptoms do not predict parental stress.

• Adaptive skills and cognitive ability are associated with specific parenting stress.

• Parents of autistic children experience more stress than parents of controls.

Abstract

Parents of children with autism spectrum disorder (ASD) were shown to experience more stress than parents of typically developing peers, although little is known about risk factors predicting stress in this population. The aim of this study was to evaluate parental stress levels and behavioral and emotional problems in a sample of preschool children with ASD as compared to typically developing (TD) peers and to investigate the role of several factors, including the severity of autistic symptoms, adaptive skills, cognitive abilities and behavioral and emotional problems, on parental stress. Results confirmed that parents of children with ASD experience higher stress levels than parents of TD and that children with ASD show more behavioral and emotional problems than controls. Moreover, our results showed that behavioral and emotional problems are strong predictors of parental stress, while stress related to a parent–child dysfunctional relationship was associated with daily living and communication skills as well as cognitive abilities. Findings revealed different behavioral and emotional problems affecting parental stress in ASD and TD samples. No association between the severity of autism symptoms and parental stress was detected. These results suggest that dysfunctional behaviors in preschool children with ASD have a strong impact on parental stress, profoundly affecting the well-being of the entire family. Therefore, strategies aimed at the early detection and management of these behavioral and emotional problems are crucial in order to prevent parental stress and to develop the most appropriate treatment interventions.

Introduction

Autism spectrum disorder (ASD) is a neurodevelopmental disorder with a lifelong impact on multiple domains of functioning, characterized from a profound impairment in social communication and social interaction and restricted and repetitive behavior, interest and activities (APA, 2013). The everyday management of children with ASD is a big challenge for parents, especially during early childhood. A considerable number of studies reported higher levels of stress in parents of young children with ASD as compared to typically developing peers or to children suffering from other pathologies, including down syndrome, cerebral palsy, intellectual disability (ID), developmental delay and cystic fibrosis (Baker-Ericzen et al., 2005, Blacher and McIntyre, 2006, Bouma and Schweitzer, 1990, Dabrowska and Pisula, 2010, Eisenhower et al., 2005, Estes et al., 2009, Estes et al., 2013, Hayes and Watson, 2013, Mugno et al., 2007, Sanders and Morgan, 1997, Wolf et al., 1989, Zablotsky et al., 2013). Furthermore, stress experienced by parents of children with ASD seems to be greater during the early childhood and the preschool age as compared to older ages (Schieve, Blumberg, Rice, Visser, & Boyle, 2007). Higher parental stress levels were also shown to reduce the effectiveness of early teaching intervention programs, thereby impairing the clinical improvement in intellectual and educational skills, adaptive behavior and social functioning (Osborne, McHugh, Saunders, & Reed, 2008). Several studies investigated the predictors of stress in parents of school-aged children and adolescents with autism, identifying crucial factors, including diagnosis of autism, behavioral problems, social interaction impairment, coping strategies of parents and family-related variables (Duarte et al., 2005, Falk et al., 2014, Firth and Dryer, 2013, Hastings et al., 2005, Huang et al., 2013, Johnson et al., 2011, Lecavalier et al., 2006, McStay et al., 2014). However, so far, only few studies have investigated the predictors of parental stress in children with ASD during the very early childhood (Davis and Carter, 2008, Estes et al., 2009, Estes et al., 2013, Hastings and Johnson, 2001, Hill-Chapman et al., 2013, Rivard et al., 2014). In one of these studies, evaluating parental stress in a sample of 141 parents of young children with autism conducting home-based behavioral interventions, Hastings and Johnson (2001) reported a significant positive correlation between severity of autistic symptoms severity and parental stress, suggesting that the severity of autistic traits could also be related to parental stress (Baker-Ericzen et al., 2005, Hastings and Johnson, 2001, Hastings et al., 2005, Hill-Chapman et al., 2013, Osborne and Reed, 2009). On the other hand, other researches highlighted the everyday management of behavioral problems and the child's characteristics (i.e. adaptive behavior, intelligence, gender, age, etc.) as a relevant source of parental stress (Dabrowska and Pisula, 2010, Davis and Carter, 2008, Estes et al., 2009, Estes et al., 2013, Hastings et al., 2005, Rivard et al., 2014). Indeed, Rivard and colleagues (2014) reported that levels of parental stress were significantly correlated with the child's age, intellectual abilities, and adaptive behaviors as well as with the severity of autistic symptoms. Another study addressing the relationships between child, partner, and parent variables in 48 parents of preschool children with autism showed that stress was strongly predicted by the child's behavioral problems, but not by the autistic symptoms or adaptive behavior (Hastings et al., 2005). Taken together, all of these studies indicate that the available data on predictors of parental stress in preschool aged children with ASD are very inconsistent and that the role played by autistic symptoms, intelligence quotient, adaptive skills, and behavioral problems on parental stress onset has not been clarified yet.

Furthermore, behavioral problems in young children with ASD include several maladaptive behaviors, such as sleep problems, attention problems, hyperactivity, self-injuries and aggressiveness. However, it remains unclear how each of them exactly should impact on parental stress. Indeed, many studies have investigated the interaction between behavioral problems and parental stress in families with children with ASD simply evaluating the total score of a questionnaire, without dissecting which factors are typically implicated (Eisenhower et al., 2005, Estes et al., 2009, Estes et al., 2013). An extensively used measure for the assessment of a wide range of emotional and behavioral disorders is the Child Behavior Checklist (Achenbach & Rescorla, 2000), which has been used in several research studies in order to investigate behavioral and emotional problems on school aged children and adolescents (Bolte et al., 1999, Duarte et al., 2005, Mazefsky et al., 2011, Ooi et al., 2011). Nonetheless, only few studies have applied the CBCL for ages 1½–5 (CBCL/1½–5) to explore behavioral and emotional problems in preschool aged children with ASD, describing a behavioral and emotional profile characterized from high scores on the CBCL subscales related to withdrawal problems, attention problems and emotionally reactive problems as compared to typically developing children (Georgiades et al., 2011, Hartley et al., 2008, Muratori et al., 2011, Myers et al., 2013, Pandolfi et al., 2009, Rescorla et al., 2014, Sikora et al., 2008). Moreover, Muratori and colleagues reported that the same CBCL subscale scores were also significantly different between children with ASD and peers suffering from other psychiatric disorders (Muratori et al., 2011). However, none of these studies has evaluated the influence that these behavioral and emotional problems may have on parental stress.

The aim of the present study was to investigate the prevalence of maladaptive behaviors and parental stress in a sample of preschool aged children with ASD with respect to a group of healthy controls. Moreover, we wanted to investigate the impact of behavioral and emotional problems, autistic symptoms, intellectual abilities and adaptive behaviors on parental stress in both ASD and TD sample in order to identify potential predictors.