The Role of Internalizing Symptoms on Family Functioning in Adolescents with ASD and Their Families

Background: Families of children with autism spectrum disorder (ASD) report higher stress than parents of children with chronic medical illness and other developmental disabilities, and their level of stress is associated with their child’s level of externalizing behaviors. However, less is known about internalizing symptoms, such as anxiety, depression, and somatization, as they relate to family outcomes. Given the high rates of internalizing disorders in children with ASD and the dynamic relationships among child, parent, and family variables, this relationship warrants attention.

Objectives:  The impact of anxiety and depression on family functioning was evaluated in adolescents with autism spectrum disorder (ASD).

Methods:  This study was done as a secondary analysis of data collected for a multi-site clinical trial of a school-based social skills intervention. We evaluated the predictive value of internalizing symptoms in 69 adolescents with ASD (ages 11 to 18) on family functioning, after controlling for IQ and externalizing symptoms. Self- reported anxiety and depression were entered into the model together to evaluate the contribution of internalizing symptoms in general as well as the unique contribution of their distinct symptom presentations. Additionally, we examined the correspondence between parent and child ratings of these symptoms.

Results:  The results indicated that internalizing symptoms predict family functioning over and above IQ and externalizing symptoms, ΔR² = 0.013, p = 0.03, although the effect was small. Anxiety did not contribute a significant amount of unique variance to the model. However, depression significantly predicted more positive family functioning (p=.003). Parent ratings of internalizing symptoms were significantly higher than adolescent ratings (p=.0005).

Conclusions:  The results are contrary to our initial predictions, and we offer several explanations for this difference. Depressive symptomatology may suppress externalizing behaviors, which strongly interfere with family functioning. In addition, family characteristics that contribute to parents’ perceptions of family functioning (e.g., family outings, frequent social interactions) may be difficult for teens with ASD and therefore fuel depressive symptoms. Differences between parent and child ratings of internalizing symptoms is particularly interesting because although adolescent self-report measures were included in the analyses, parents reported even more internalizing symptoms than did the teens. One potential explanation is the overlap between internalizing symptoms and ASD symptoms that appear similar on the surface (e.g., social withdrawal, low motivation); parents may attribute these behaviors to internalizing disorders when they are actually more related to ASD. The differences between parent and adolescent perceptions of internalizing symptoms and the relationship between depression and family functioning suggest that internalizing behavior should be an important target of ongoing treatment. Clinicians should routinely ask specifically about anxiety and depression in their clients with ASD. Psychoeducation for families on assessing for internalizing behavior and how these symptoms may impact their family functioning is also indicated.