A longitudinal examination of the relation between parental expressed emotion and externalizing behaviors in children and adolescents with autism spectrum disorder

Differing relationships between parenting stress, parenting practices and externalising behaviours in autistic children

There is limited literature on the association between parenting practices, parenting stress and externalising behaviours in autistic children. We investigated whether parenting practices mediate the association between parenting stress and externalising behaviours. Parents of school-aged autistic children (n = 138) completed an online survey on parenting practices, parenting stress and child externalising behaviours. Higher levels of parenting stress were associated with higher levels of externalising behaviours. In contrast to prior literature, parenting practices were not associated with child externalising behaviours and did not have mediating effects on the association between parenting stress and child externalising behaviours. However, higher levels of parenting stress were associated with lower levels of mindful parenting and higher levels of permissive and authoritarian parenting practices. Together, findings suggest that targeting parenting stress can impact parenting practices. Limitations of the study are acknowledged including the cross-sectional design, which limits causality-based inferences, given parent-child associations could occur over time. Implications for research and clinical practice in designing parent-informed programmes focused on reducing parenting stress via parenting practices are discussed.Lay abstractThere is much research on parenting stress and child behaviours of autistic children. However, researchers have rarely explored whether how parents raise their children (called 'parenting practices') links to parenting stress and child behaviours. This is important, as if we know which parenting practices lead to better outcomes, parents can be supported to use parenting practices that are most helpful to them and/or their child. We asked parents of school-aged children to complete a survey on parenting stress, parenting practices and child behaviours. We found that parents who reported being more stressed (i.e. high levels of parenting stress) reported their children showed more observable behaviours that others find challenging such as aggression. Parents who were more stressed also reported lower mindful parenting (i.e. a style of parenting characterised by being present, non-judgementally in the moment) and were more permissive (e.g. giving in) in their parenting. However, these parenting practices did not impact the link between parenting stress and child behaviours. Results suggest we should focus on ways to reduce parents' stress, which could include changing parenting practices which is consistent with strengths-based, neurodiversity-affirming approaches.

Harsh Parenting and Trajectories of Emotional and Behavioural Difficulties in Autistic Children

Autistic children show higher rates of co-occurring emotional and behavioural difficulties compared to other children in the general population. However, the environmental factors which contribute to the development of emotional (internalising) and behavioural (externalising) difficulties in autistic individuals are poorly understood. This study sought to investigate the association between harsh parenting (smacking, shouting, telling off) and the trajectories of emotional and behavioural difficulties in autistic children from ages 3 to 7. A sample comprising of 349 autistic children participated from the UK's Millennium Cohort Study. Associations between harsh parenting and child emotional and behavioural difficulties were modelled using multilevel growth curve models. In autistic children, harsh parenting was associated with total emotional and behavioural difficulties and behavioural (but not emotional) problems concurrently. Moreover, harsh parenting was not associated with changes in emotional and behavioural difficulties over time. Harsh parenting may have an important role in externalising problems in young autistic children indicating the need for public health strategies which educate parents on its effects.

Parent Facilitation of Child Emotion Regulation in ASD: An Ecological Momentary Assessment Study

Parents play a substantial role in their children's emotion regulation (ER) abilities. Children with autism spectrum disorder (ASD) often have difficulties regulating their emotions, which can manifest as externalizing behavioral issues. Parents of children with ASD facilitate their children's ER development in response to unique challenges and stressors, often developing resiliency but other times contributing to their children's dysregulation and behavioral challenges. It is unclear how much momentary stress attenuates parents' emotional facilitation of child ER and its effect on child behavioral functioning. Using an ecological momentary assessment approach, the current study explores this process by considering how parents of children with ASD facilitate child ER through (1) parent ER ability, (2) emotion socialization style, and (3) expressed emotion. Multilevel models explored the relative influences of parent ER facilitation on the association between momentary parent stress and behavioral intensity. Results suggest that parent ER abilities and specific emotion socialization styles interact with momentary parent stress and child behavior, whereas emotional climate of the home impacts child behavior more directly. The role of parent ER facilitation in the context of parent stress and children with ASD and behavioral problems is complex and multifaceted. Implications for further supporting children's emotional development via parent involvement are discussed.

Protective factors for children with autism spectrum disorder during COVID-19-related strict lockdowns: a Shanghai autism early developmental cohort study

BACKGROUND

COVID-19 lockdowns increased the risk of mental health problems, especially for children with autism spectrum disorder (ASD). However, despite its importance, little is known about the protective factors for ASD children during the lockdowns.

METHODS

Based on the Shanghai Autism Early Developmental Cohort, 188 ASD children with two visits before and after the strict Omicron lockdown were included; 85 children were lockdown-free, while 52 and 51 children were under the longer and the shorter durations of strict lockdown, respectively. We tested the association of the lockdown group with the clinical improvement and also the modulation effects of parent/family-related factors on this association by linear regression/mixed-effect models. Within the social brain structures, we examined the voxel-wise interaction between the grey matter volume and the identified modulation effects.

RESULTS

Compared with the lockdown-free group, the ASD children experienced the longer duration of strict lockdown had less clinical improvement (β = 0.49, 95% confidence interval (CI) [0.19-0.79], p = 0.001) and this difference was greatest for social cognition (2.62 [0.94-4.30], p = 0.002). We found that this association was modulated by parental agreeableness in a protective way (-0.11 [-0.17 to -0.05], p = 0.002). This protective effect was enhanced in the ASD children with larger grey matter volumes in the brain's mentalizing network, including the temporal pole, the medial superior frontal gyrus, and the superior temporal gyrus.

CONCLUSIONS

This longitudinal neuroimaging cohort study identified that the parental agreeableness interacting with the ASD children's social brain development reduced the negative impact on clinical symptoms during the strict lockdown.

Parenting Practices and Externalizing Behaviors in Autistic Children: A Systematic Literature Review

There is limited recent research on the association between parenting practices and externalizing behaviors in autistic children. To address this gap, the current systematic review examined the associations between parenting practices and externalizing behaviors in autistic children, along with the mediating and moderating effects of parent and child variables (PROSPERO registration number CRD42022268667). Study inclusion criteria were (1) Peer-reviewed journals, (2) Participants included parents of autistic children and their children, (3) Quantitative measures of both parenting practices or behaviors/style and child externalizing behaviors, (4) Cross-sectional or longitudinal studies only, and (5) Studies published in English. Study exclusion criteria were: (1) Qualitative studies, (2) Published in a language other than English, (3) Participants included non-human participants, (4) Participants that did not include parents and their autistic children as participants or did not report this group separately, (5) Systematic review and meta-analyses, and (6) No quantitative measures of parenting practices and/or child externalizing behaviors. Quality appraisal and risk of bias were conducted using the McMaster Tool and results were synthesized in Covidence and Excel. Thirty studies were included in the review. Results demonstrated that mindful parenting was associated with fewer or lower levels of externalizing behaviors; positive parenting practices had non-significant associations with externalizing behaviors; specific parenting practices had differing associations with externalizing behaviors; and negative parenting practices were associated with higher levels of externalizing behaviors. We are unable to draw causal relationships due to focus on cross-sectional and longitudinal articles only. The potential for future research to target specific parent practices to support children's externalizing behaviors is discussed.

The Relation of Parental Expressed Emotion, Parental Affiliate Stigma, and Typically-developing Sibling Internalizing Behavior in Families with a Child with ASD

Caregivers of children with autism spectrum disorder (ASD) experience greater stress, expressed emotion (EE), and affiliate stigma than caregivers of children without ASD. Siblings of children with ASD often experience greater negative functioning than siblings of individuals without ASD. The current study found significant interrelations among symptom severity and externalizing behavior in children with ASD; parental stress, affiliate stigma, and EE; and TD sibling internalizing behavior. In addition, certain subcomponents of affiliate stigma predicted unique variance in EE and TD sibling internalizing behavior. Findings may increase understanding of psychosocial functioning in families with children with ASD and allow clinicians to improve outcomes for all family members. Limitations of the study included self-report data, limited sample diversity, and a cross-sectional design.

Exploring Bidirectional Relationships: Child Sleep Duration, Child Behavior Problems, and Parenting Stress in Families of Children with Autism Spectrum Disorder

Background

Youth with Autism Spectrum Disorder (ASD) are at-risk for sleep and behavior problems, and their parents are at-risk for high stress. Child sleep duration, behavior problems, and parenting stress are interrelated; however, directionality of these associations is unclear and research including youth with ASD is lacking. Using a day-to-day, within-person design, this study explores the directionality of these relationships in families of children with ASD.

Method

Twenty-six children (ages 3-5, 73.1% male, 65.4% Hispanic/Latino) with ASD and their mothers participated in a 14-day study. Child sleep duration (parent-report and actigraphy), behavior problems, and parenting stress were measured daily. Constructs were decomposed into their within- and between-person components and analyzed with random intercept cross-lagged panel models.

Results

While between-person relationships were directionally expected in that shorter sleep, more behavior problems, and greater parenting stress were associated, within-person relationships were complicated. Better-than-average child behavior was associated with less next-day parenting stress, yet more parenting stress than average was associated with better next-day child behavior. As expected, longer-than-average child sleep was associated with less next-day parenting stress, while greater child behavior problems were associated with less sleep that night.

Conclusions

Understanding the directionality of associations between child and parent factors allows for the optimization of interventions to improve the quality of life for families of children with ASD. Interventions that target child behavior and/or help parents manage stress while maintaining effective parenting strategies for sleep and behavior may be useful.

The effectiveness of an attention-based intervention for school-aged autistic children with anger regulating problems: A randomized controlled trial

Anger regulation is a challenge for children with autism spectrum disorders (ASD). We investigated if attention-based cognitive behavioral treatment, based on mindfulness cognitive therapy (MBCT) and dialectical behavior therapy (DBT), reduces aggressive behavior and improves anger coping in school-aged autistic children (n = 51). Children were randomized to an active-control or a treatment condition. The treatment included nine weekly sessions attention-based individual therapy. Parents in both conditions received three weekly psychoeducation group sessions to heighten awareness of expressed emotion (EE). For aggressive behavior, treatment reduced temper tantrums and arguing. No effect was found on destroying things and physical violence. For anger coping, treatment increased adaptive coping strategies of diffusion and social support seeking, but had no effect on assertion, rumination, and maladaptive coping direct anger out and avoidance. Treatment did not impact secondary outcome measures concerning children's quality of life (QoL) and parental stress-levels and psychological well-being. In conclusion, school-aged autistic children are able to acquire self-regulation skills reducing temper tantrums and arguing and increasing the use of adaptive anger coping strategies. The intervention shows potential to improve behavior and regulation, but little transfer to other domains. Limitations and future directions involving the child's social environment, including parents, siblings, and teachers are discussed. LAY SUMMARY: Children on the autism spectrum often show aggressive behavior. Treatment can train children to be more aware of their emotions. This study found that this can help reducing temper tantrums and arguing and increasing some coping skills, though no impact was found on several other domains of aggression and coping.

Clinical and individual features associated with maternal stress in young adolescents with autism spectrum disorder

Parents of people with autism spectrum disorder experience both negative stressful and positive events. Several clinical and socio-demographic features of children on the autism spectrum have been associated with parenting stress in their families. However, there have been few studies that focus on adolescents and the role of cognitive impairment has rarely been addressed. The main aim of the present research is to explore associations between autism symptoms, cognitive impairment, emotional and behavioral problems, socio-demographic features, and maternal stress in a sample of young adolescents with Autism Spectrum Disorder with and without cognitive impairment. Cognitive impairment and emotional and behavioral problems are associated with maternal stress, while autism symptoms seem to play a minor role. Maternal education and occupation are only associated with maternal stress in the group with cognitive impairment, while maternal age is stress-associated in the group of adolescents without cognitive impairment. Age-related implications for intervention and future research directions are discussed. LAY SUMMARY: Parents of individuals on the autism spectrum are exposed to both negative stressful and enriching experiences during their parenthood. While the influence of several child characteristics and socio-demographic features on parental stress during childhood has been widely explored in past studies, studies on teenagers are limited. The aim of the present research is to explore the influence of several characteristics on maternal stress levels in families with teenagers on the autism spectrum. We found that cognitive impairment and emotional and behavioral problems are associated with maternal stress, while autism symptoms seem to play a minor role. Socio-demographic features are not associated with maternal stress. Broadly speaking, the subjective perception of parental distress in both groups is less related to teenagers' characteristics then the perception of having a difficult interaction with the teenagers. We divided our participants into two groups (one group with cognitive impairment and the other group without). We found that mothers of teenagers with cognitive impairment are generally more stressed compared to the other group. Furthermore, we confirm that emotional and behavioral problems seem to play a major role in maternal stress (especially in the group without cognitive impairment), while autism symptoms seem to play a minor role. Furthermore, we found that maternal education/occupation and maternal age are associated with maternal stress in the group with and the group without cognitive impairment respectively. This research highlights the association between several variables and stress in mothers of adolescents on the spectrum. Results are discussed in the framework of previous findings highlighting the lack of adequate care and support services for families, especially for those of adolescents on the spectrum with cognitive impairment.

Negative Controlling Parenting and Child Personality as Modifiers of Psychosocial Development in Youth with Autism Spectrum Disorder: A 9-Year Longitudinal Study at the Level of Within-Person Change

This nine-year longitudinal study addresses the joint contribution of parent-rated negative controlling parenting and child personality on psychosocial outcomes in 141 families of children with autism spectrum disorder (83% boys, mean age Time 1 = 10.1). Latent change modeling revealed substantial variation in within-person change in parenting and psychosocial outcomes across a six- and three-year-interval. Over time, negative controlling parenting and child personality were consistently related to externalizing problems, whereas child personality was differentially related to internalizing problems and psychosocial strengths. Three personality-by-parenting interactions were significant, suggesting that children with less mature personality traits show more externalizing behaviors in the presence of controlling parenting. This study identified both parenting and child personality as important modifiers of developmental outcomes in youth with autism.

Emotion Control Predicts Internalizing and Externalizing Behavior Problems in Boys With and Without an Autism Spectrum Disorder

Children and adolescents with Autism Spectrum Disorder (ASD) often show comorbid emotional and behavior problems. The aim of this longitudinal study is to examine the relation between emotion control (i.e., negative emotionality, emotion awareness, and worry/rumination) and the development of internalizing and externalizing problems. Boys with and without ASD (N = 157; age 9–15) were followed over a period of 1.5 years (3 waves). We found that baseline levels of worry/rumination was a specific predictor of later externalizing problems for boys with ASD. Furthermore, the developmental trajectory of worry/rumination predicted the development of internalizing and externalizing problems in both groups. Our findings suggest that worry/rumination may constitute a transdiagnostic factor underlying both internalizing and externalizing problems in boys with and without ASD.

Parental criticism and behavior problems in children with autism spectrum disorder

Associations between parent critical attitudes (a component of the Expressed Emotion construct) and behavior problems have been relatively well established in adolescents and young adults with autism spectrum disorder, but use of systems adapted for children with autism spectrum disorder and additional investigations with younger samples are needed. This study examined parental criticism, derived from a population-specific coding system, as related to behavior problems in children with autism spectrum disorder between the ages of 4 and 11 years, and considered parental warmth and children's psychophysiological reactivity as statistical moderators of these associations. In all, 40 children with autism spectrum disorder and their primary caregivers attended a visit involving collection of child electrodermal activity, parent-child interaction, a parent interview from which critical attitudes and warmth were coded, and parent report of child behavior problems. Criticism was directly related to higher child externalizing but not internalizing problems. Parental criticism interacted with warmth in the prediction of internalizing problems such that criticism was only associated with more problems in the context of moderate but not high warmth. Criticism was positively associated with externalizing problems under conditions of moderate and high, but not low, child electrodermal activity reactivity. Implications for conceptualizations of parental criticism in autism spectrum disorder, for understanding comorbid behavior problems in this population, and for intervention are discussed.

The Association Between Emotional and Behavioral Problems in Children with Autism Spectrum Disorder and Psychological Distress in Their Parents: A Systematic Review and Meta-analysis

This review (Prospero Registration Number: CRD42017057915) aimed to systematically identify and summarize existing research on the relationship between additional emotional and behavioral problems (EBP) in children with autism, and parenting stress (PS) and mental health problems (MHP) in their parents. Sixty-seven studies met criteria for inclusion in the review, 61 of which were included in the meta-analysis. Pooled correlation coefficients were in the low to moderate range ([Formula: see text]). Some evidence for moderation by measurement characteristics was found. Narrative review of concurrent adjusted associations showed some evidence for shared relationships with other factors, most notably ASD severity and parent perception of own parenting. Longitudinal studies showed mixed evidence for bidirectional predictive relationships between child EBP and parent psychological distress variables.

Parental Burden and its Correlates in Families of Children with Autism Spectrum Disorder: A Multicentre Study with Two Comparison Groups

BACKGROUND

The effects of having a child with Autism Spectrum Disorder (ASD) on parents are multifaceted and pervasive. While ample evidence has been provided that these families are under severe stress, there are still several knowledge gaps and unresolved questions.

OBJECTIVE

This study aimed at quantifying the subjective and objective burden of ASD in mothers and fathers, and at improving the understanding of the interplay between parental burden, child's characteristics, and parents' coping resources and strategies.

METHODS

The parents of 359 children/adolescents with ASD were compared to parents of age-matched patients with Down syndrome (N=145) and Type 1 diabetes mellitus (N=155). Child's clinical characteristics and parents' caregiving burden, psychological distress, coping resources and strategies were assessed.

RESULTS

The parents of children with ASD reported higher objective and subjective burden, more frequent psychological distress, lower social support. Mothers reported greater subjective burden than fathers. Structural equation modeling showed that the most consistent positive and negative predictors of objective and subjective burden were ASD symptom severity and social support, respectively. Other positive predictors were engagement, distraction and disengagement coping, intellectual disability, and adaptive functioning. Other negative predictors were spiritual wellbeing and hardiness. Some effects were indirect through social support and coping strategies.

CONCLUSION

This study confirmed that parents of children with ASD carry a huge caregiving burden, and added to our understanding of the factors associated with burden. The findings may help inform the design of effective interventions aimed at reducing burden among the parents of children with ASD.

The relationship of parental expressed emotion to co-occurring psychopathology in individuals with autism spectrum disorder: A systematic review

Expressed emotion is a construct of the affective relationship between two people, with domains measuring criticism, hostility, warmth, relationship and emotional over-involvement. This review focuses on studies of Expressed Emotion in families of individuals with autism spectrum disorder and its association with co-occurring psychiatric disorders. A systematic search used the Psych-Info and Medline databases to identify articles available at or before September 2016. Eleven studies met the inclusion criteria. The included studies suggest that high levels of expressed emotion, including criticism, are associated with behavioural problems. However, the relationship between expressed emotion and emotional problems is presently unclear because findings were mixed. Also, there is presently little evidence regarding the impact of other components of expressed emotion on co-occurring disorders.

Predicting Internalizing and Externalizing Symptoms in Children with ASD: Evaluation of a Contextual Model of Parental Factors

Parental adjustment, parenting behaviors, and child routines have been linked to internalizing and externalizing child behavior. The purpose of the present study was to evaluate a comprehensive model examining relations among these variables in children with ASD and their parents. Based on Sameroff's Transactional Model of Development (Sameroff in: The transactional model of development: How children and contexts shape each other, American Psychological Association, Washington, DC, 2009), researchers hypothesized that these factors would collectively predict child behavior. Parents (n = 67) completed measures of parental adjustment, parenting behaviors, child routines, and child behavior using the Hopkins Symptom Checklist, Alabama Parenting Questionnaire, Child Routines Inventory, and Child Behavior Checklist, respectively. Results indicated that parental adjustment predicted harsh/disengaged parenting (B = 0.17, p < .01) and internalizing behavior (B = 0.32, p < .01). Harsh/disengaged parenting and warm/supportive parenting predicted externalizing behavior (B = 0.59, p < .01) and internalizing behavior (B = - 0.49 p < .01), respectively.

Examining bidirectional relationships between parenting and child maladjustment in youth with autism spectrum disorder: A 9-year longitudinal study

Longitudinal bidirectional effects between parents and children are usually studied in samples of typically developing children, but remain understudied in families with a child with autism spectrum disorder. This three-wave longitudinal study examined how parents and children with autism spectrum disorder influence one another, relying on parent reports of parenting behaviors and children's problem behaviors across 9 years, in a sample of 139 youngsters (M age Time 1 = 10.2 years, 83% boys). Cross-lagged analyses indicated that children's externalizing problems at Time 1 predicted negative controlling parenting 6 years later (Time 2) that in turn predicted externalizing problems 3 years later (Time 3). Negative parental control at Time 1 also increased the risk for internalizing problems at Time 2. It was surprising that externalizing problems at Time 2 also predicted positive parental involvement at Time 3. Thus, although results indicate that externalizing problems generally elicit maladaptive reactions in parents, this study also suggests that parents adjust their way of reacting to externalizing child problems as their child reaches adolescence/emerging adulthood. Implications for future research on parenting dynamics in families with a child with autism spectrum disorder are discussed.

Stress, anxiety, and depression among parents of children with autism spectrum disorder in Oman: a case-control study

Previous studies carried out in Euro-American populations have unequivocally indicated that psychological disorders of the CASD (caregivers of children with autism spectrum disorder) are marked with high levels of stress, anxiety, and depression. This finding has been attributed to the reaction of having to care for a child with neurodevelopmental disorders. While there have been reports on autism spectrum disorder in Arab/Islamic countries such as Oman, there is no study from this region, to our knowledge, reporting the performance of indices of stress, anxiety, and depression among CASD. This study aimed to examine whether there is variation in the performance of indices of stress, depression, and anxiety explored via Depression, Anxiety and Stress Scale 21 among CASD, caregivers of children with intellectual disabilities, and caregivers of typically developing children. All indices of stress, depression, and anxiety were higher in CASD compared to other caregivers in the control group. This study corroborates with other studies carried out in other populations that caring for children impacts the mental health status of caregivers. Therefore, there are strong grounds to contemplate the mechanism to help such a vulnerable group of family caregivers.

A longitudinal examination of the relation between parental expressed emotion and externalizing behaviors in children and adolescents with autism spectrum disorder

The current study explored the longitudinal relation between parental expressed emotion, a well-established predictor of symptom relapse in various other disorders (e.g., schizophrenia) with externalizing behaviors in 84 children, ages 8-18 (at Time 2), with autism spectrum disorder (ASD). It was found that parental expressed emotion, specifically criticism/hostility at Time 1, significantly related to a change in externalizing behaviors from Time 1 to Time 2, even after controlling for Time 1 family income, ASD symptom severity, parental distress, and parenting practices. That is, higher levels of parental criticism/hostility at Time 1 predicted higher levels of child externalizing behaviors at Time 2. However, the reverse was not found. This finding of a unidirectional relation has important clinical implications.