Mechanisms of Parental Stress Associated with Emotional and Behavioral Problems in Children with Autism Spectrum Disorder

Background: Emotional and behavioral problems (EBP) are common in autism spectrum disorder (ASD). There is ample research to show that EBP, particularly externalizing behaviors, are associated with negative impacts on the family system. Additional research is needed to clarify the underlying mechanisms of this relationship. Studies have shown that parental self-efficacy (PSE) is an important variable in terms of parental stress and has been hypothesized as a potential mediator between EBP and family distress. A limitation to extant research is the infrequent focus on underserved populations. Further investigation into how family resources affect PSE and family distress is needed.

Objectives: The purpose of the current study was to investigate the role of PSE as a mediator of the relationship between EBP and family distress in an underserved sample of children with ASD. We hypothesized that the mediation effect would be greater for externalizing (EBP-E) versus internalizing (EBP-I) behaviors. Additionally, we hypothesized that the amount of family resources would moderate the degree of mediation such that lower family resources would be associated with a stronger relationship between lower PSE and increased family distress. We predicted no significant differences after controlling for autism symptom severity and intellectual ability.

Methods: Participants included (98) families of children with ASD between the ages of 3 and 13 who were recruited as part of a larger study of improving dental care. Families exhibited racial (45% Non-Caucasian) and ethnic (41% Hispanic) diversity, and all were underserved as defined by Medicaid-eligibility. Children completed the Autism Diagnostic Observation Schedule–2nd Edition (ADOS-2) and Stanford-Binet–5th Edition, abbreviated battery (ABIQ). Parents completed questionnaire ratings of PSE, Family Resources, Family Distress, and Child EBP. We used the PROCESS macro (Hayes, 2018) to assess for the degree of moderated mediation of the hypothesized model for both EBP-E and EBP-I (see Fig. 1).

Results: All associations were in the hypothesized directions. Both EBP-E and EBP-I models were significant and accounted for 58% and 44% of the variance, respectively. There was a significant direct effect of EBP-E on parent stress (β=.48, p<.001) and PSE mediated this relationship. The index of moderated mediation was significant (β = -.07, CI = -.14 ‒ -.008) indicating that fewer resources was associated with greater mediation by PSE. Results for EBP-I were similar, albeit not as pronounced, as hypothesized (see Fig. 1). Results were unchanged after controlling for autism symptom severity and intellectual ability.

Conclusions: Our data suggest that EBP increase parent stress through a mechanism of decreased PSE, particularly when resources are limited. Increasing parents’ sense of self-efficacy, especially in underserved populations, may be a critical focus of interventions to decrease stress associated with emotional and behavioral problems in children with ASD. These results highlight the need to support families with limited resources including providing parents with tailored interventions and novel skills that can target specific areas of concern that they may not otherwise be able to address on their own.