Role of Externalizing Children Problem Behaviors in the Relationship between Autism and Parenting Stress: A Primary School Based Case-Control Study

Background: Identifying the sources of parenting stress (PS) is important to improve well being of parents and their child. Although PS has been consistently reported higher among parents of children with autism spectrum disorders (ASD) than parents of typically developing (TD) children, the findings of the relationship between severity of ASD and PS among parents of children with ASD are not consistent suggesting PS can be independent from ASD. While children problem behaviors (CPB) are known to be a major source of PS, little is known about the relationship between ASD, CPB, and PS.

Objectives: (1) To compare PS between parents of children with ASD and TD children; (2) To examine factors associated with PS; and (3) To examine the role of CPB, including externalizing and internalizing problem behaviors, in the relationship between the symptoms and severity of ASD and PS.

Methods: A cross-sectional survey was conducted in 5 public primary schools and 2 special education programs in 2015. A total of 731 parents (177 ASD children and 554 TD) completed the survey (M=41.5 years old, SD=6.4). Age by gender of children was matched between the children with ASD and TD children groups (M=8.6 years old, SD=1.6). The measures included parent and child characteristics, Childhood Autism Spectrum Test (CAST) assessing symptoms and severity of autism characteristics, Strengths and Difficulties Questionnaire (SDQ) assessing externalizing and internalizing CPB, pro-social behavior, and parenting stress (PS; the Parental Distress subscale of Parenting Stress Index Short Form). Pilot survey checked preliminary validity and reliability in the study sample. Multiple regression models were used to examine the associations between the study variables and outcome variable of PS, direct and indirect effects of CAST on PS mediated by SDQ, controlling for diagnosis of ASD (i.e., children with ASD and TD children groups).

Results: Compared to parents of TD children, those of children with ASD reported higher scores on CAST, externalizing and internalizing CPB, and PS and lower score on pro-social behavior (all p<.001). In multiple regression models, in the sample of ASD cases, PS was significantly associated with the number of children with ASD, externalizing CPB and less pro-social behaviors. In TD controls, PS was significantly associated with lower household income, larger household size, lower birth order, externalizing and internalizing CBP. The significant indirect effect was found between CAST and PS, mediated by SDQ in both groups: .34* (.12) in ASD case and .50***(.066) in TD control. In examining the both groups in one model, the effect of externalizing CPB was found as well: .42***(.081), and diagnosis of ASD entered but was not significant for PS.

Conclusions: The mediation effect of CPB on the association between CAST and PS suggests a primary stress source for PS was not the severity and symptoms of ASD but externalizing problem behaviors. Children’s labeling with ASD was not a primary parenting stressor either. Psychological interventions should focus on skills and efficacy in coping with their children’s externalizing behaviors rather than autism-oriented characteristics in order to alleviate PS.