Parenting stress among parents of children with Neurodevelopmental Disorders

Psychiatry Research 242 (2016) 121–129

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Parenting stress among parents of children with Neurodevelopmental Disorders Francesco Craig a, Francesca Felicia Operto a, Andrea De Giacomo a, Lucia Margari a, Alessandro Frolli c, Massimiliano Conson c, Sara Ivagnes b, Marianna Monaco c, Francesco Margari b,n a

Child Neuropsychiatry Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari “Aldo Moro”, Italy Psychiatry Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari “Aldo Moro”, Italy c Neuropsychology Laboratory, Department of Psychology, Second University of Naples, Caserta, Italy b

art ic l e i nf o

a b s t r a c t

Article history: Received 25 January 2016 Received in revised form 6 May 2016 Accepted 12 May 2016 Available online 1 June 2016

In recent years, studies have shown that parents of children with Neurodevelopmental Disorders (NDDs) experience more parenting stress than parents of typically developing children, but the relation between the type of disorders and parenting stress is far from clear. The purpose of this study was to compare the parenting stress experienced by parents of 239 children with Specific Learning Disorders (SpLD), Language Disorders (LD), Autism Spectrum Disorder (ASD), Attention Deficit Hyperactivity Disorder (ADHD), and typical development (TD). Parents of children with NDDs experience more parenting stress than those of children who have TD. Although, parents of children with ASD or ADHD report the most high scores of parenting stress, also the parents of children with SpLD or LD report higher parental stress compared with parent of children without NDDs. Another interesting finding was that IQ level or emotional and behavioral problems are associated with the higher levels of parenting stress. This study suggest that parent, both mothers and fathers, of children with different type of NDDs should be provided with interventions and resources to empower them with the knowledge and skills to reduce their stress and to enhance their quality of life. & 2016 Elsevier Ireland Ltd. All rights reserved.

Keywords: Parenting stress Specific learning disorders Language disorders Autism spectrum disorder Attention deficit hyperactivity disorder

1. Introduction Neurodevelopmental Disorders (NDDs) are a group of conditions with onset in the developmental period, often before the child enters grade school, and are characterized by developmental deficits that produce impairments of personal, social, academic, or occupational functioning (American Psychiatric Association, 2013). Raising a child with a NDDs puts a greater strain on parenting skills than that of raising typically developing children. In fact, in parents of children with NDDs, high levels of parenting stress have been detected clear (Baker et al., 2002; Hauser-Cram et al., 2001; Johnston et al., 2003; Ricci and Hodapp, 2003), but the relation between the type of disability and parenting stress is far from. Parenting stress is defined as the aversive psychological reaction to the demands of being a parent (Liles et al., 2012), typically when the demands of being a parent are not matched with the perceived resources available to the parent. While all parents may experience a low degree of parenting stress, high levels of parenting n

Corresponding author. E-mail address: [email protected] (F. Margari).

http://dx.doi.org/10.1016/j.psychres.2016.05.016 0165-1781/& 2016 Elsevier Ireland Ltd. All rights reserved.

stress may have serious negative effects on the family and the parent's psychological health and overall well-being. Several theories suggests that parenting stress is multiply determined by child, parent, family, and ecological characteristics reciprocally influencing one another and contributing to outcomes (McCubbin and McCubbin, 1989; Lazarus and Folkman, 1984). Abidin developed the transactional model of parenting behaviors that describes the interplay between psychological, sociological, and environmental factors (Abidin, 1995). The author proposed three major domains of parental stress: parent characteristics, child characteristics, and situational/life demographics. These domains are reflected in Abidin's Parenting Stress Index (PSI), which is designed to measure the various sources and aspects of parental stress (Abidin, 1995). The theoretical framework used for this study was Abidin's Parenting Stress Theory, focusing mostly on child characteristics. Recent developments in the field of parenting stress have led to a renewed interest in the bidirectional relationship between parental stress and NDDs. The presence of maternal stress during pregnancy may explain 10–15% of childhood disorders of the neuro-development (Glover, 2014) and similarly stressful parenting patterns are found in families with children with NDDs.

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F. Craig et al. / Psychiatry Research 242 (2016) 121–129

Research suggests that offspring of mothers who experience high levels of stress during pregnancy are more likely to have problems in neurobehavioral development and intellectual disabilities (Bergman et al., 2007; Ronald et al., 2010). Ramchandani et al. (2010) investigated the influence of prenatal maternal stress on subsequent behavioral problems of children (four years of life) and found that the transmission of stress to their offspring is mediated by high levels of maternal hormones secreted by hypothalamicpituitary-adrenal (HPA) axis involved in the response to stress, hormones that can affect fetal brain development (Ramchandani et al., 2010). According to this study, fetal neural development would depend essentially on the duration of exposure to stress rather than by the specific type of stressful event, the timing of the stress, the time in which the fetus is exposed to prenatal stress, is an element critic could lead to a dysregulation the sense neurofetal development (Dipietro, 2012). On the other hand, child behavior problems consistently have been shown to predict parental stress (Baker et al., 2005), particularly autism (Abbeduto et al., 2004; Estes et al., 2009) and Attention Deficit Hyperactivity Disorder (ADHD) (Theule et al., 2013) have been reported as important correlates. Parents of children with autism experience a condition of elevated stress and are more vulnerable to potential negative outcomes compared to parents of children who have other disability forms (Dunn et al., 2001), and the severity of Autism Spectrum Disorder (ASD) symptoms is an important predictor of mother’s parenting stress (Mahoney, 2009). In the same way, parents of children with ADHD very often experience considerable stress in their parenting roles. A review study confirmed that parents of children with ADHD experience more parenting stress than parents of nonclinical controls and that severity of ADHD symptoms was associated with parenting stress (Theule et al., 2013). Multiple comorbid conditions such as emotional and behavioral problems are profound contributor to parental stress and family instability, because these can compounded functional impairments such as life skill, school performances, ability to work, and ability to independent. Previous studies have reported that parents of children with ASD experience higher stress levels than parents of typically developing children (TD) and that children with ASD show more behavioral and emotional problems than controls suggesting that behavioral and emotional problems are strong predictors of parental stress (Davis and Carter, 2008; Giovagnoli et al., 2015; Hastings, 2002; Huang Chien-Yu et al., 2014; Lounds et al., 2007). In a meta-analyses study, examining the association between parenting stress and ADHD, some authors reported that child co-occurring externalizing behaviors, in particular conduct problems, predicted parenting stress (Theule et al., 2013). Another potential child characteristic that may contribute to increased parent stress is cognitive dysfunction. Parents of children with lower intelligence quotient (IQ), may face increased child-rearing responsibilities. For example, children with lower IQ need greater assistance with a range of basic activities, from dressing, to bathing, to toileting. These increased demands may lead to increased parenting stress or psychological distress (Kennedy, 2012). Recently, some authors reported that in children with ASD, child's verbal and performance IQ were a significant predictor of parental stress (Pastor-Cerezuela et al., 2015), on the contrary others authors showed that in children with ADHD, IQ does not have an impact on parental stress but the severity of ADHD symptoms is an important predictor of parenting stress (Grizenko et al., 2015). Studies that have investigated the parental stress in children with SpLD or LD which also presented emotional and behavioral problems and/or intellectual disability are lacking. The elevated parental stress emanates directly from the presence of NDDs, given the increased caretaking demands that children with NDDs impose on their parents. Parents of these

children often find themselves involved in resolving various school, peer, and sibling difficulties. Although, research on parenting stress in parents of children diagnosed with ASD or ADHD has indicated that the characteristics of these two disorders make child raising especially stressful, study that has compared the stress experienced by parents of children with other NDDs, such as Specific Learning Disorders (SpLD), Language Disorders (LD) and intellectual and developmental disabilities are lacking. Understanding what contributes to stress will then lead to more targeted interventions to support families and facilitate family functioning. Therefore, the main objective of the present study was to compare the parenting stress of children and adolescents affected by different NDDs and TD. A strong point of the study is that we conducted a comparison between mothers and fathers. Higher levels of parenting stress and psychological distress were mainly reported in mothers of children with ASD (Dabrowska and Pisula, 2010; Tehee et al., 2009) or ADHD (Margari et al., 2013; Theule et al., 2013) or SpLD (Brock and Shute, 2001; Karande et al., 2009) or LD (Chaffee et al., 1991), moreover fathers of children with NDDs experience higher levels of parenting stress than fathers of TD children (Davis and Carter, 2008; Lach et al., 2009; Podolski and Nigg, 2001). However, very few studies have been conducted to compare parenting stress in mothers and fathers of children with different NDDs. An additional purpose of the study was to examine the association of parental stress with levels of emotional and behavioral problems and intellectual disability to have a better understanding of the parental stress. It was hypothesized that the level of parental stress is linked with emotional and behavioral problems or intellectual disability in these children.

2. Method The clinical sample consisted of 186 children/adolescents, aged from 3 to 12 years old, consecutively referred to Child Neuropsychiatry Unit-University-Hospital of Bari during the period from December 2014 to December 2015. Participants were divided into four groups: SpLD group, LD group, ASD group and ADHD group. The SpLD group comprised 60 children/adolescents, the LD group comprised 34 children/adolescents, the ASD group comprised 45 children/adolescents, the ADHD group comprised 47 children/adolescents. The diagnoses were made by clinical experts according to DSM-5. The diagnoses were based on the developmental histories of the children, taken from clinical interviews with the parents, observations and extended neuropsychological testing of the children themselves. The control group consisted of 53 TD children/adolescents, that was randomly recruited, based on the availability of parents or subjects to participate in the study, from schools located in Puglia and Campagnia. Exclusion criteria were the presence of other medical condition or mental disorders and medical/psychiatric illness of parents. Written informed consent was obtained for all participants after providing all the details of the study procedure. 2.1. Assessment The assessment included the administration of IQ test and clinical standardized scales such as the Parenting Stress Index (PSI) and Child Behavior Checklist (CBCL). 2.2. IQ test The IQ was assessed according to the age through Wechsler Intelligence Scale for Children (WISC-III) (Wechsler, 1991), Wechsler Preschool and Primary, Scale of Intelligence (WPPSI) (Wechsler, 2002), and Leiter International Performances Scale

F. Craig et al. / Psychiatry Research 242 (2016) 121–129

Revised (Leiter-R) (Roid and Miller, 1997) alternatively to WISC-III, in nonverbal subjects. The control group was not assessed for IQ. 2.3. Parenting Stress Index(PSI): short form The PSI Short Form (PSI/SF) is a direct derivative of the Parenting Stress Index (PSI) full-length test (Abidin, 1995). All 36 items on the Short Form are contained on the Long Form with identical wording and are written at a 5th-grade reading level, for parents of children 12 years and younger. Each item requires the parent/caregiver to rate the degree to which s/he agrees with a statement on a five-point Likert scale (1 ¼Strongly Agree, 2 ¼Agree, 3 ¼Not Sure, 4 ¼Disagree, and 5 ¼Strongly Disagree). This self-report uses a three factors model to measure parenting stress, to which correspond the three subscales: parenting distress (PD) scale, dysfunctional interaction parent-child (P-CDI) scale, difficult child (DC) scale. The PD scale defines the level of distress which a parent perceives in his parenting role, linked to personal factors directly involved in this role. The P-CDI scale values the parenting perception of a child that doesn’t respond to the family expectations and of an interaction neither reinforcing nor rewarding with the child. The DC scale values how much the parent perceives his child as easy/difficult to manage, considering some of his behavioral characteristics. The PSI-SF produces subscale raw scores ranging from 12 to 60 and an overall parenting stress total score that ranges from 36 to 180; a higher score indicates a greater level of stress. A score above 85 (at the 90th percentile) indicates clinically significant parenting stress (Abidin, 1995). The total stress (TS) scores, obtained by the sum of the scores of the 3 subscales, can be interpreted as a stress index related to the only parenting role. The test includes also a Defensive Responding (DF) scale, useful to control the validity of the protocol, which indicates if the parent tends to give a better self-image, minimizing the problems and the perceived stress in the relationship with the child. In this study, the Cronbach's alpha reliability coefficient of this measure is 0.91 for mothers and 0.88 for fathers.

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2.5. Statistical analysis All demographic and clinical variables were subjected to statistical analysis. Descriptive analysis was conducted for sociodemographics featuring of the four samples. Raw scores obtained from each subscale of the CBCL and PSI were transformed into t-scores to allow for consideration of how an individual's response compares with that of the population norms. For CBCL, the borderline (t-score 465) and clinical (t-score 470) scores were put together. For each group a clinical cutpoint for the domain specific syndrome scales and broadband scales is determined as the minimum raw score corresponding with T-score Z65. The Chisquare tests (χ2) was used to determine the significance of differences in frequencies (gender) between diagnostic groups. Due to the small sample size and nonnormatively distributed data, the nonparametric Kruskal-Wallis test was used to compare the mean score of the IQ, age (chidren, mothers and fathers), CBCL and PSI scores among groups. To evaluate significant differences between groups, post hoc analysis of Tamhane was conducted. The nonparametric Wilcoxon Signed Rank test was performed to evaluate differences in continuous variables (PD, P-CDI, DC, DF, and TS) of PSI between mothers and fathers of each group. The nonparametric Spearman rank correlation test was used to measure relationships between TS scores (mothers and fathers) and age of children, IQ, age of mothers, age of fathers, externalizing, internalizing and total problems. Spearman’r can vary in magnitude from  1 to 1, with  1 indicating a perfect negative linear relation, 1 indicating a perfect positive linear relation, and 0 indicating no linear relation between two variables. For non-parametric tests, the effect size is interpreted as 0.1 ¼ small, 0.3 ¼ medium, and 0.5 ¼ large. A p-value of less than 0.05 was considered as statistically significant. For statistical processing, we used the data processing program the Statistical Package for Social Science version 20.0.

3. Results 2.4. Child Behavior Checklist (CBCL) The CBCL (Achenbach, 2001) is a common tool used to assess emotional and behavioral problems in children. The first section of the scale includes 20 items related to the child's social competency, as rated by parents. These items address the child's participation in sports, hobbies, games, activities, organizations, jobs, chores, friendships, social interactions during play, independent work, and school functioning. The second section consists of 120 items on behavior or emotional problems during the past 6 months as rated on a three-point scale. The main areas of this construct are aggression, hyperactivity, bullying, conduct problems, defiance, and violence. The following behavioral and emotional problems are also measured: aggressive behavior, anxious/depressed, attention problems, delinquent rule-breaking behavior, social problems, somatic complaints, thought problems, withdrawal, externalizing, internalizing, and total problems. Responses are recorded on a Likert scale: 0 ¼Not True, 1 ¼Somewhat or Sometimes True, 2 ¼Very True or Often True. Lower scores indicate lower functioning on the academic performance and adaptive functioning scales. Higher scores indicate higher levels of maladaptive behavior on the syndrome, total problems, externalizing and internalizing scales. In order to verify the mean differences between groups, we took into account only the common scales between CBCL/6-18 and CBCL/1 ½-5. The instrument has an internal validity of 0.90–0.91 for the scales of internalizing disorders and of 0.95–0.96 for externalizing disorders. Cronbach's coefficient alpha was 0.95 and 0.96, respectively.

Socio-demographic characteristics of SpLD, LD, ADHD, ASD and TD groups are summarized in Table 1. No statistical differences among groups in gender (p ¼0.32) were found. However, we found a significant difference in the age between the groups (p ¼0.005). In particular, the LD group showed a lower chronological age compared with SpLD (p o0.001), ASD (p o0.001), ADHD (p o0.001) and TD (p o0.001) groups. A statistically significant difference was found between the groups in IQ mean score (p o 0.001). The post-hoc analysis showed that ASD group had lower IQ mean score, compared with SpLD (p o0.001), LD (p o0.001), and ADHD (p o0.001) groups. No statistical difference was found in IQ mean score between SpLD, LD, and ADHD groups. Although the definition of SpLD includes a normal intelligence level, we found a mild intellectual disability in the 5% of SpLD group but the specific learning difficulties markedly overcome the IQ's reduction. Two hundred and thirty fourth mothers (60 SLD, 34 LD, 47 ADHD, 42 ASD, 51 TD) and two hundred and third fathers (48 SpLD, 31 LD, 42 ADHD, 39 ASD, 43 TD) were in agreement to participate in the study. The greater number of mothers in comparison to that of the fathers was a result of different circumstances: it was either a single parent household or in a two-parent household one parent refused to participate. The mothers of children with ASD showed a higher chronological age than the parents of children with LD (p ¼0.14). The fathers of children with SpLD showed a higher chronological age than the parents of children with LD (p ¼0.007).

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Table 1. Sociodemographic characteristics and IQ of SpLD, LD, ASD, ADHD groups. Post hoc analysisb

SpLD N ¼60

LD N ¼34

ADHD N¼ 47

ASD N¼ 45

TD N ¼53

Ha

P-Value

65% 35% 10.3 7 2.1 87.4 7 10.3 75% 20% 5% 60 41.5 7 5.8 48 43.93 7 6.2

80% 20% 4.8 7 1.2 88.9 7 17.1 50% 40% 10% 34 37.8 75.9 31 39.8 7 5.2

80% 20% 9.3 7 2.1 82.6 7 12.3 45% 28% 27% 47 40.7 7 3.4 42 41.5 7 3.4

66% 34% 8.3 7 3.6 61.4 7 13.2 30% 27% 43% 42 41.8 7 4.8 39 43.17 4.2

77% 22% 8.3 7 2.5 – – – – 51 40.6 7 6.4 43 41.2 7 3.2

– – 66.2 74.5 – – – – 14.5 – 10.2

0.32c – – o0.001* o0.001* – – – – 0.06* – 0.04*

Gender (child) male female Age (child) IQ Level (child) normal borderline mild intellectual disability Mothers N Age (Mothers) Fathers N Age (Fathers)

– – – LDo *other gropus ASD o *other gropus – – – – ASD 4 *LD – LDo *SLD

Specific Learning Disorders (SpLD), Language Disorders (LD), Autism Spectrum Disorders (ASD), Attention-Deficit/Hyperactivity Disorder (ADHD), Typically Developing Children (TD), Intelligence Quotient (IQ), normal (IQ Z85), borderline (IQ 71-84), mild (IQ 50–70). a b c *

Kruskal–Wallis test (H). Tamhane test. Chi-square test. p o0.05.

3.1. Parenting stress The analysis conducted to evaluate the differences in parenting stress among the SpLD, LD, ASD, ADHD and TD groups revealed statistically significant differences in all the PSI variables (Table 2). The mothers of SpLD and LD children reported higher PD (p ¼0.001; p¼ 0.002), P-CDI (p o0.001), DC (p o0.001), DF (p o0.001; p ¼0.001) and TS (p o0.001) scores compared with the TD group. 3.1.1. Differences in PSI scores between mothers among groups The mothers of ADHD children reported higher PD scores compared with the SpLD (po0.001), LD (p¼0.002), TD (po0.001) groups; higher P-CDI scores compared with the LD (p¼0.009) and TD (po0.001) groups; higher DC scores compared with TD (po0.001) group; higher DF scores compared with the SpLD (po0.001), LD (p¼0.001) and TD (po0.001) groups; higher TS compared with the SpLD (po0.001), LD (p¼0.006), TD (po0.001) groups. The mothers of ASD children reported higher PD scores compared with the SpLD (p o 0.001), LD (p ¼0.001), TD (p o0.001) groups; higher P-CDI scores compared with the SpLD (p ¼0.001), LD (p ¼0.002), TD (p o0.001) groups; higher DC scores compared with TD (p o0.001) group; higher DF scores compared with the SpLD (p o0.001), LD (p ¼0.001), TD (p o0.001) groups; higher TD scores compared with the SpLD (p o0.001), LD (p o0.001), TD (p o0.001) groups. 3.1.2. Differences in PSI scores between fathers among groups The fathers of SpLD children reported higher P-CDI scores compared with the LD (p ¼0.01) and TD (p o0.001) groups; higher TS scores compared with the LD (p ¼0.04) and TD (p o0.001) groups. The fathers of LD children reported higher DC (p o0.001) and TS (p o0.001) scores compared with the TD groups. The fathers of ADHD children reported higher PD scores compared with the SpLD (p o0.001), LD (p o 0.001), TD (p o0.001) groups; higher P-CDI scores compared with the SpLD (p ¼ p o0.001), LD (p o0.001) and TD (p o0.001) groups; higher DC scores compared with the SpLD (p o0.001), LD (p ¼ 0.021) and TD (p o0.001) groups; higher DF scores compared with the SpLD (p o 0.001), LD (p o0.001)and TD (p o 0.001) groups; higher TS scores compared with the SpLD (p o 0.001), LD (p o0.001) and TD (p o0.001) groups. The fathers of ASD children reported higher PD scores compared with the SpLD (p o0.001), LD (p o 0.001) and TD (p o0.001) groups; higher P-CDI scores compared with the SpLD

(p ¼0.02), LD (p o0.001) and TD (p o0.001) groups; higher DC scores compared with the SpLD (p ¼0.041) and TD (p o0.001) groups; higher DF scores compared with the SpLD (p o0.001), LD (p o0.001) and TD (p o 0.001) groups; higher TS scores compared with the SpLD (p o0.001), LD (p o0.001)and TD (p o0.001) groups. 3.2. Parenting Stress of mothers and fathers within groups Considering the differences between parents (Table 3), the mothers of SpLD children showed significantly higher rates of PD (p ¼0.018) and DF (p o 0.001) than fathers. In ADHD children, the mothers of showed significantly higher rates of DC (p o0.001) than fathers. However, no significant difference between mothers and fathers of LD, ASD and TD children were found in all the PSI variables. 3.3. Emotional and behaviors problems The analysis of emotional and behaviors problems showed a statistically significant difference between the groups in all the CBCL variables (Table 4). The SpLD group showed higher Total problems scores compared with the TD (p ¼ 0.002) group; the ADHD group showed higher Total problems scores compared with the SpLD (p o0.001), LD(p o0.001), ASD(p o0.001), TD(p o0.001) groups; the ASD group showed higher Total problems scores compared with the TD (p ¼0.013) groups. 3.3.1. Externalizing problems The ADHD group showed higher Externalizing problems scores compared with the SpLD (p o0.001), LD (p o 0.001), ASD (p o0.001), TD (p o0.001) groups. The ADHD group showed higher Attention deficit problems scores compared with the SpLD (p o0.001), LD (p o 0.001), ASD (p o0.001), TD (p o0.001) groups; while the SpLD (p o0.001), LD (p ¼0.01) and ASD (p o0.001) groups showed higher Attention deficit problems scores compared with the TD group. The ADHD group showed higher ADHD problems scores compared with the SpLD (p o0.001), LD (p o 0.001), ASD (p o 0.001), TD (p o0.001) groups; while the SpLD (p ¼0.01) and ASD (p ¼0.02) groups showed higher ADHD problems scores compared with the TD group. The ADHD group showed higher Oppositional defiant disorder (ODD) scores compared with the SpLD (p o0.001), LD (p o 0.001),

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ASD (p o 0.001), TD (p o0.001) groups, while the SpLD groups showed higher ODD scores compared with the TD group (p ¼0.01). 3.3.2. Internalizing problems The SpLD group showed higher Internalizing problems scores compared with the TD (p ¼0.002) group; the ADHD group showed higher Internalizing problems scores compared with the ASD (p ¼0.02), LD (p o0.001) and TD (p o0.001) groups; while the ASD group showed higher Internalizing problems scores compared with the LD (p ¼0.031) and TD (p ¼ 0.013) groups. The SpLD group showed higher Anxious/Depressed problems scores compared with the LD (p ¼0.001), ASD (p o0.001), TD (p ¼0.023) groups; while the ADHD group showed higher Anxious/Depressed problems scores compared with the SpLD (p ¼0.001), LD (p o0.001), ASD (p o0.001), TD (p o0.001) groups. The ASD (p o0.001), SpLD (p ¼0.001), LD (p ¼0.005) and ADHD (p o0.001) groups showed higher Social Withdraw problems scores compared with the TD group. The SpLD (p o0.001), and ADHD (p o0.001) groups showed higher Somatic Complain problems scores compared with the TD group. The ADHD group showed higher Depression scores compared with the SLD (p ¼0.007), LD (p o0.001), ASD (p o0.001), TD (p o0.001) groups; while the SLD (p o0.001), and ASD (p ¼ 0.002) groups showed higher Depression scores compared with the TD group. The SpLD group showed higher Anxiety scores compared with the LD (p o 0.001) and TD (p o0.001) groups; the ADHD group showed higher Anxiety scores compared with the LD (p o 0.001), ASD (p ¼0.002), TD (p o0.001) groups; the ASD group showed higher Anxiety scores compared with the LD (p ¼0.024) and TD (p ¼0.033) groups.

*

b

Kruskal–Wallis test (H). Tamhane test. p o0.05. ** Cut-off 460.

3.4. Correlational analyses between parental stress with demographic characteristics, child emotional and behavioral problems and intelligence quotient

a

Specific Learning Disorders (SpLD), Language Disorders (LD), Autism Spectrum Disorders (ASD), Attention-Deficit/Hyperactivity Disorder (ADHD), Typically Developing Children (TD), Parenting Distress (PD), Dysfunctional Interaction Parent-Child (P-CDI), Difficult Child (DC), Defensive Responding (DF), Total Stress (TS).

ADHD, ASD 4 *SpLD, LD, TD ADHD, ASD 4 *SpLD 4 *LD, TD; LD4 *TD, ADHD 4 *SpLD, LD, TD; ASD 4 *LD, TD ADHD, ASD 4 *SpLD, LD, TD ADHD, ASD 4 *SpLD 4 *LD4 *TD o 0.001 o 0.001 o 0.001 o 0.001 o 0.001 31.9 7 4.6 98.3 40.2 7 2.7 78.1 30.6 7 1.2 107.2 30.17 1.3 102.3 627 2.3 122.8 30.4 7 25.1 69.44 729.4 98.3 7 3.3 28.5 7 31.1 88.3 7 7.9 20% 25% 45% 15% 30% Fathers PD P-CDI DC DF TS

30% 15% 50% 21% 26%

32.9 7 24.2 42.5 7 21.7 97.6 7 4.3 27.5 7 23.3 82.3 7 5.3

84% 82% 90% 91% 93%

90.2 7 26.1 87.2 7 16.1 957 2.1 88.5 7 25.9 97.4 7 4.1

46% 73% 86% 67% 87%

807 23.7 9% 907 27.5 18% 96.1 73.6 30% 83.5 7 25.3 15% 96.5 7 5.6 45%

o 0.001 o 0.001 o 0.001 30.5 7 1.2 30.17 1.3 62.8 7 1.9 85% 52% 70% 93.4 7 11.2 57.5 7 29.7 89.17 7.3 70% 30% 55% DC DF TS

86.17 29.9 72% 58.6 7 34.3 83% 87.5 710.5 91%

87.3 7 17.9 89.4 7 18.8 95.5 7 4.1

80% 73% 93%

60% 45% 75% 88.9 7 17.9 88.9 7 18.9 96.7 7 6.8

118.3 119.5 151.6

o 0.001 o 0.001 113.1 94.6.9 32.2 7 4.5 40.4 7 3.1 88.5 7 23.2 39% 907 69 49% 67% 74% 88.2 7 17.3 83.6 7 16.3 59.4 7 35.2 83% 66.17 30 85% 53% 52% 507 28.5 71.8 7 25.8 Mothers PD 25% P-CDI 45%

% 4Cut-off** M7 SD % 4Cut-off** M 7SD % 4Cut-off** M 7 SD % 4 Cut-off** M 7 SD

% 4 Cut-off** M 7 SD

TD LD SpLD

Table 2. Significant differences in PSI scores between groups.

ADHD

ASD

Ha

p value

Post hoc analysisb

ADHD, ASD 4 *SpLD, LD4 *TD SpLD, LD 4 *TD; ADHD 4 *LD, TD ASD 4 *SpLD, LD, TD ADHD, ASD, SpLD, LD 4 *TD; SpLD, LD 4 *TD; ASD, ADHD4 *SpLD, LD, TD ADHD, ASD 4 *SpLD, LD4 *TD

F. Craig et al. / Psychiatry Research 242 (2016) 121–129

We found statistically significant correlation between parental total stress with demographic characteristics, child emotional and behavioral problems and intelligence quotient in mothers and fathers of children with NDDs. These result are summarized in Table 5. In the mothers of SpLD children, we observed a negative relationship between total stress and IQ (p o0.001). In the fathers of SpLD children we observed a negative relationship between total stress and IQ (p ¼0.009). In the mothers of LD children, we observed a positive relationship between total stress and children's age (p ¼ p o0.001), externalizing (p ¼0.004), and internalizing (p ¼0.007); while we observed a negative relationship between total stress and IQ (p ¼.03). In the fathers of LD children we observed a negative relationship between total stress with IQ (p o0.001), age of mothers (p o0.001) and age of fathers (p ¼0.02). In the mothers of ADHD children, we observed a positive relationship between total stress with externalizing (p ¼0.002) and total problems (p ¼0.01); while we observed a negative relationship between total stress and IQ (p ¼ 0.004). In the fathers of ADHD children we observed a positive relationship between total stress with children's age (p o0.001) internalizing (p ¼0.01) and total problems (p ¼0.01); while we observed a negative relationship between total stress and father's age (p ¼ 0.001). In the mothers of ASD children, we observed a positive relationship between total stress and mother's age (p ¼0.003) and father's age (p ¼0.005). In the fathers of ASD children we observed a positive relationship between total stress and externalizing (p ¼0.005), internalizing (p ¼ 0.006) and total problems (p ¼0.001).

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Table 3. Significant differences in PSI scores between mothers and fathers. SpLD

PD P-CDI DC DF TS

LD

Z

Effect size Mothers vs Fathers p-valuea

 2.37  0.69  0.96 0.3.8.  0.72

0.35 0.03 0.29 0.87 0.06

0.018* 0.48 0.33 o 0.001* 0.45

ADHD

ASD

Z

Effect size Mothers vs Fathers p-valuea

Z

Effect size Mothers vs Fathers p-valuea

 0.79  0.85  0.69  1.5  0.69

0.98 0.97 0.9 0.98 0.72

 0.26  1.24  3.18  0.12  1.6

0.36 0.61 0.84 0.19 0.21

0.42 0.39 0.48 0.12 0.48

 0.79 0.21 0.001* 0.9 0.1

Z

Effect size Mothers vs Fathers p-valuea

 1.79  0.81  1.7 0.77  1.08

0.89 0.11 0.6 0.35 0.07

0.07 0.41 0.07 0.43 0.27

Specific Learning Disorders (SpLD), Language Disorders (LD), Autism Spectrum Disorders (ASD), Attention-Deficit/Hyperactivity Disorder (ADHD), Typically Developing Children (TD), Parenting Distress (PD), Dysfunctional Interaction Parent-Child (P-CDI), Difficult Child (DC), Defensive Responding (DF), Total Stress (TS), Mothers (MD), Fathers (FD), a *

Wilcoxon signed-rank test. p o0.05.

4. Discussion There is considerable understanding that parents of children with developmental disabilities experience increased levels of stress, often related to the severity of their child's behavior (Feizi et al., 2014; Hayes and Watson, 2013; Huang et al., 2014). However, the experience of stress is dependent on how individuals perceive their situation and what are the coping strategies (i.e., problemfocused, emotion focused, and appraisal- or perception-focused coping) that are used to manage stress. The first question in this study sought to determine the levels of parenting stress experienced by parents of children with different NDDs and TD children to define the profile of parenting stress in each group. The most obvious finding to emerge from the analysis is that the parents of the children in the clinical groups perceived greater parenting stress than that of the parents of typically developing children. This result would respond to the behavioral manifestation that usually occurs in NDDs, producing greater difficulties in fulfilling the parental role and greater tension in the parent–child relationship. In addition, we found some significant differences among the clinical groups in parenting stress. Our finding seem to be consistent with other research which found that the mothers of the ADHD and ASD groups reported elevated levels of parenting stress (Baker et al., 2005; Harrison and Sofronoff, 2002; Walker et al., 1999). However, our study shows high levels of parental stress also in mothers of children with SpLD or LD. These findings are consistent with those of Karande et al. (2009) who showed that mothers of children with SpLD reported high stress levels by the time this hidden disability is diagnosed (Karande et al., 2009). A possible explanation for this might be chronic poor school performance adversely impacts the child’s peer and family relationships and social interactions. Parents, especially the mother, may lose confidence in the child’s ability to ever achieve academic competence, get frustrated, and develop aggressive behavior towards the child. In the present study, also mother of children with LD reported higher levels of parenting stress than TD group. These results are in agreement with those obtained by Spiliotopoulou (2009) that suggested that some parents report constant conflict with their child and noncompliance, which may be a result of the frustration that the child feels because of his inability to express himself (Spiliotopoulou, 2009). Although, it has been widely demonstrated previously that the mothers of children with NDDs have significantly higher levels of stress than mothers of children with TD, few authors have investigated the parental stress of fathers. In the present study, we detected higher level of parenting stress in the fathers of children with ASD or ADHD compared to other groups examined. Nevertheless, fathers of children with SpLD or LD reported more parental stress than children with TD. This shows that parents, both

mothers and fathers, of children with NDDs express anxiety, discomfort and an altered sense of parental competence of their role. Although there are no statistically significant differences between mothers and fathers in the TS scale, however there are differences in the way mothers and fathers perceive stress (PD, DC, DF scales) with regards to their own and child characteristics. This could probably be because both mothers and fathers face their own individual types of challenges and stressors when caring for their child with ND For example, mothers may be overburdened by looking after the adaptive needs of their child while fathers may feel stressed owing to the overburden of making more money to meet the increased financial needs to look after the medical and rehabilitation expenses of the child with NDDs (Feizi et al., 2014). In addition, we evaluated the impact of demographic characteristics (i.e. parent age, child age), emotional and behavioral problems and intellectual disability on parenting stress of parent of children with NDDs. The most frequent association was found between parent stress and IQ, both in mothers and fathers. This result suggest that cognitive dysfunctions of the child would be significantly associated with parental stress. This result may be explained by the fact that cognitive dysfunctions result in impairment of adaptive functioning, such that the individual fails to meet standards of personal independence and social responsibility in one or more aspect of daily life, including communication, social participation, academic functioning and personal independence at home. Thus, these characteristics of children diagnosed with NDDs may account for increased parental stress. However, we found that cognitive functioning was not associated with parental stress in ASD children. A plausible explanation for our results is that, in these children, parenting stress is more directly associated with severity of cardinal symptoms than IQ level (Hastings and Beck, 2004; Hastings and Johnson, 2001; McStay et al., 2014). Another interesting finding was that emotional and behavioral problems of the children were significantly associated with the overall parental stress. As expected, in our clinical population we found higher levels of internalizing and externalizing behavioral problems compared with healthy children. In particular, we found that ADHD children reported more externalizing behavioral problems than others groups. These results are in accord with previous studies indicating that ADHD frequently co-occurs with externalizing disorders; 30–50% of individuals meeting the criteria for ADHD also fulfill the criteria for Conduct Disorder (CD) or Oppositional Defiant Disorder (ODD) (Angold et al., 1999; Biederman et al., 1991; Singh, 2008), and population-based studies suggest that ADHD-like and externalizing traits show considerable covariation in the general population (Costello et al., 2003). It is interesting to note that we observed a positive relationship between parental total stress and externalizing problems. This result are consistent with those of Anastopoulos (1992) who showed that

Table 4. Significant differences in CBCL symptom scores between groups. LD

ASD

ADHD

TD

% 4Cut-off** M 7 SD

% 4Cut-off** M 7 SD

% 4Cut-off** M 7 SD

% 4 Cut-off** M 7 SD

% 4Cut-off** M7 SD

a

p value

b

H

Post hoc analysis

55% 40% 50% 20%

56.6 7 11.1 61.3 7 11.9 60.9 7 12.4 62.6 7 8.7

12% 23% 12% 12%

55.3 7 13.2 40% 53.7 7 10.7 13% 55.6 7 12.2 46% 55.6 7 12.2 28%

54.4 7 9.6 60.7 7 9.2 61.17 9.1 57.5 7 5.9

74% 78% 83% 55%

68.6 7 7.8 66.5 7 7.6 70.9 7 6.9 69.2 7 7.9

13% 9% 11% 6%

52.3 77.9 53.9 77.6 53.6 77.5 54.5 76.7

49.06 69.03 72.07 83.8

o0.001 o0.001 o0.001 o0.001

ADHD4 *ASD, LD, TD; SpLD4 *TD ADHD4 *SpLD, LD, ASD, TD ADHD4 *SpLD, ASD 4 *LD, TD ADHD4 *SpLD4 *ASD, LD, TD

10% 15% 20% 30% 20% 35% 3%

61.25 7 8.2 59.65 7 7.2 64.95 711.2 63 79.3 62.8 7 7.6 62.65 7 8.4 56.9 7 5.5

9% 11% 32% 12% 11% 23% 12%

61.4 7 8 56 76.5 63.2 7 12.7 59.5 7 10.6 55.4 7 9.1 60.2 7 10.7 55.5 7 8.7

66.6 712.6 56.17 5.6 65 77.3 617 8.3 60 77.3 59.3 7 6.3 54.93 7 4.9

9% 8% 55% 34% 57% 53% 73%

62.2 7 10.2 59.6 7 8.9 74.6 711.6 68.8 7 8.4 66.9 7 6.6 70.5 7 8.7 67.7 7 7.8

2% 9% 9% 6% 9% 4% 3%

54.3 75.6 53.6 75.5 55.8 77.6 54.3 76.5 56.17 7.9 54.4 76.3 53.2 75.8

40.3 30.08 68.06 62.6 58.8 74.7 83.07

o0.001 o0.001 o0.001 o0.001 o0.001 o0.001 o0.001

SpLD, ADHD, ASD, LD 4 *TD SpLD, ADHD 4 *TD ADHD4 *SpLD, LD, ASD4 *TD ADHD4 *SpLD, LD, ASD, TD;SpLD, ASD4 *TD SpLD, ASD 4 *LD, TD, ADHD4 *LD, ASD, TD ADHD4 *SpLD, ASD 4 * LD, TD ADHD4 *SpLD, LD, ASD, TD; SpLD 4 *TD

46% 19% 36% 20% 26% 9% 7%

Child Behavior Checklist (CBCL), Specific Learning Disorders (SpLD), Language Disorders (LD), Autism Spectrum Disorders (ASD), Attention-Deficit/Hyperactivity Disorder (ADHD), Typically Developing Children (TD), Oppositional Defiant Disorder (ODD), **

Cut-off 465. p o0.05. Kruskal–Wallis test (H). b Tamhane test. *

a

Table 5. a Correlational analyses of parental total stress with demographic characteristics, child emotional and behavioral problems and intelligence quotient. Total Stress SpLD

Age (child) IQ Age (Mothers) Age (Fathers) Externalizing Internalizing Total Problems

LD

ADHD

F. Craig et al. / Psychiatry Research 242 (2016) 121–129

Internalizing Externalizing Total Problems Anxious/ Depressed Social Withdraw Somatic Complain Attention deficit Depression Anxiety ADHD ODD

SpLD

ASD

Mothers (N ¼60)

Fathers (N¼ 48)

Mothers (N¼ 34)

Fathers (N ¼31)

Mothers (N¼ 47)

Fathers (N¼ 42)

Mothers (N ¼42)

Fathers (N¼ 39)

r

p

r

p

r

p

r

p

r

p

r

p

r

p

r

p

0.31  0.48** 0.3 0.77  0.009 0.15 0.18

0.051 0.001 0.51 0.61 0.95 0.28 0.21

 0.31  0.49**  0.23  0.12 0.06 0.13 0.86

0.11 0.009 0.24 0.24 0.75 0.48 0.67

0.75**  0.38*  0.032 0.17 0.36* 0.47** 0.34**

o 0.001 0.03 0.863 0.35 0.04 0.007 0.057

 0.2  0.83**  0.94**  0.54* 0.22 0.42 0.16

0.91 o 0.001 o 0.001 0.03 0.39 0.08 0.52

 0.05  0.41**  0.04  0.05 0.44** 0.14 0.35*

0.72 0.004 0.74 0.71 0.002 0.31 0.015

0.64** 0.21  0.17  0.48** 0.13 0.61** 0.37*

o 0.001 0.15 0.25 0.001 0.36 0.001 0.01

0.2 0.18 0.32* 0.42** 0.04 0.19 0.2

0.21 0.24 0.03 0.005 0.21 0.2 0.19

 0.08  0.07  0.01  0.013 0.44** 0.42** 0.4**

0.58 0.64 0.91 0.93 0.005 0.006 0.01

Specific Learning Disorders (SpLD), Language Disorders (LD), Autism Spectrum Disorders (ASD), Attention-Deficit/Hyperactivity Disorder (ADHD), Typically Developing Children (TD), intelligence quotient (IQ), Spearman’s rho(r). * **

p o0.053. po 0.01.

127

128

F. Craig et al. / Psychiatry Research 242 (2016) 121–129

secondary behavioral features such as ODD and aggressive behaviors were strong associated with parental stress in parent of ADHD children (Anastopoulos et al., 1992). However, when compared on internalizing disorders, the SpLD, ADHD and ASD groups reported higher levels of social withdrawal and anxiety/depression symptoms compared with the LD and TD groups. Although, studies comparing internalizing disorders in different NDDs are lacking, some researchers have highlighted the presence of emotional problems in ADHD, ASD and SpLD (Rizzutti et al., 2015). These findings suggest that child emotional and behavioral problems are significant sources of general parental stress. What cannot be ascertained, however, due to the correlational nature of this investigation, is whether these same child and parent factors directly cause parenting stress. Additional research, therefore, must be conducted. Certain methodological limitations inherent in this study should be noted. The first limitation is related to the stress evaluation procedure used. Although the PSI has very good psychometric properties and high reliability and validity in the constructs that it measures, it is a subjective self-report measure that can lead to possible biases. Nevertheless, self-reports are crucial when assessing internalized states such as stress. Another limit of this study is that not provide consistent findings about the relationships between parental stress and relevant child characteristics such as severity of symptoms and developmental level that could significantly affect the parenting stress associated to each NNDs. Further, although this study utilized a fairly representative range of predictors, it did not include certain variables (e.g., marital dysfunction, socioeconomic status, skill of resilience, parents’ coping styles, outside support for parenting, parent emotional and behavioral problems) which prior research has shown to be related to parenting stress (Derguy et al., 2016).

5. Conclusion Findings of this study suggest that parents of children with NDDs experience more parenting stress than those of children who have TD. Although a lot of attention over the years has given to parents of children with ASD and ADHD, our findings suggest that also parent of children with SpLD and LD experienced higher parental stress than parent of children without NDDs. Therefore, parent of children with different type of NDDss should be provided with interventions and resources to empower them with the knowledge and skills to reduce their stress and to enhance their quality of life. In addition, considering the results of the present study, both mothers as well as fathers need equal support and guidance to be equipped with such coping so as to enhance their physical and psychological well-being. Through intervention efforts, researchers can aim to promote positive or adaptive appraisals and coping with stressors, and increase appropriate personal resources in the parental role. These efforts to improve cognitive and behavioral responses to stress may lead to better parental well-being, which can ultimately impact multiple functional domains in the family. Another interesting finding was that child characteristics such as cognitive dysfunction or emotional and behavioral problems are associated with the higher levels of parenting stress found among SpLD, LD, ADHD and ASD populations. This finding suggest that the characteristics common to children with a range of neuro-developmental disabilities, such as the presence of emotional and behaviors problem and cognitive dysfunction, may increase levels of stress in parent of children with NDDs.

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