Behavior problems among school-aged children with autism spectrum disorder: Associations with children's communication difficulties and parenting behaviors

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Highlights

  • Child- and family-level predictors of behavior problems in children with ASD were examined.

  • Communication difficulties and parenting behaviors contributed uniquely to behavior problems.

  • Pragmatic language difficulties were associated with externalizing and internalizing problems.

  • Negative controlling parenting behavior was predictive of externalizing problems.

  • ASD adapted parenting behavior was related with internalizing problems.

Abstract

Research has clearly demonstrated that behavior problems are common among children with ASD. These co-occurring behavior problems place children with ASD and their families at risk for a range of negative outcomes. This questionnaire study aimed to investigate whether and how age, gender, and communication difficulties at the child level and parenting behaviors at the family level are associated with externalizing and internalizing problems among children with ASD (n = 206) and without ASD (n = 187) aged 6–12 years. Results indicated that pragmatic language difficulties of the child and negative controlling parenting behaviors both made a significant and unique contribution to externalizing behavior problems for the ASD group. In the control group, chronological age and pragmatic language difficulties were the most robust concurrent predictors of externalizing problems. With regard to internalizing problems, pragmatic language difficulties and ASD adapted parenting behaviors were significant predictors for both the ASD and control group.

Introduction

Autism spectrum disorders (ASD) are characterized by persistent impairments in reciprocal social interaction and communication across multiple contexts, along with the presence of restricted, repetitive and stereotyped behaviors and interests (American Psychiatric Association, 2013). Current evidence suggests that children with ASD often exhibit high levels of co-occurring behavior problems (Bauminger et al., 2010, Gray et al., 2012, Hartley et al., 2008, Kanne and Mazurek, 2011, Mazurek and Kanne, 2010). Both internalizing (e.g., depressed/anxious affect, somatic complaints, and withdrawal) and externalizing (e.g., aggression, hyperactivity, and property destruction) problems are frequently present in children with ASD. Bauminger, Solomon, and Rogers (2010), for example, found that children with ASD aged between 8 and 12 years showed higher levels of externalizing and internalizing behaviors measured through the Child Behavior Checklist compared to typically developing children, with 21% of the ASD group meeting the clinical criteria for externalizing behaviors and 26% for internalizing behaviors. Prevalence figures vary, depending on the population, definition, and methods used to measure behavior problems.

These co-occurring behavior problems place children with ASD and their families at risk for a range of negative outcomes. Behavior problems can interfere with the child's daily functioning, instruction, and intervention outcomes, thereby hindering improvement across various developmental domains (Kanne and Mazurek, 2011, Matson and Wilkins, 2007, Taylor and Seltzer, 2011). Moreover, behavior problems among children with ASD can affect parents’ psychological well-being, possibly contributing to elevated levels of parenting stress (Estes et al., 2013, Hastings et al., 2005, Lecavalier et al., 2006, McStay et al., 2013, Tomanik et al., 2004), depression and anxiety (Carter et al., 2009, Herring et al., 2006), beyond and above the effect of the core ASD symptoms. Furthermore, research has indicated that externalizing problems are associated with poorer family functioning, particularly with increased negativity in parenting perceptions and poorer social functioning (Sikora et al., 2013). Given the significant impact of behavior problems on the functioning and well-being of children with ASD and their families, it is important to understand which factors contribute to the emergence and maintenance of such difficulties. This knowledge can inform health care providers in the development and delivery of prevention programs and effective interventions. The present study aims to investigate whether externalizing and internalizing problems among school-aged children with ASD are associated with children's communication difficulties and parenting behaviors.

There is a large body of empirical literature on the presence and the various functions that behavior problems or challenging behaviors can fulfill among children with ASD (Gavidia-Payne and Hudson, 2002, Repp and Horner, 1999). By contrast, only a small amount of studies have investigated risk factors for the development and maintenance of such difficulties. From a developmental psychopathology framework, it is recognized that there are multiple possible pathways in the development of behavior problems, and that multiple factors may contribute to these pathways. Therefore, researchers have examined the role of various risk and protective factors in predicting trajectories of behavior problems among children and adolescents from the general population. Several factors that can influence the risk for adaptive or maladaptive outcomes are identified at the child, family and contextual level (Calkins, Blandon, Williford, & Keane, 2007). At the individual child level, for example, the temperamental dimension of negative emotionality and early deficits in self-regulatory processes have been found to predict both internalizing and externalizing behavior problems (Calkins and Fox, 2002, Calkins et al., 2007). Moreover, early language delays have been shown to increase the risk for aggression, especially when combined with impulse control and emotion regulation difficulties (Calkins, 1994, Dionne et al., 2003). Gender is also identified as an important child characteristic, with boys in general being at greater risk for the development of externalizing behavior problems (Lahey et al., 2000, Tremblay, 2000). Regarding age of the child, research has indicated that aggressive behaviors show a significant decline across childhood for most children (Tremblay, 2000). At the family level, a large amount of research has focused on the effect of different aspects of the parent-child relationship on the development and maintenance of child behavior problems. Specific parenting behaviors, such as harsh, inconsistent, or negative parental control strategies (Kawabata et al., 2011, Smith et al., 2004), love withdrawal or guilt induction (Barber et al., 2005, Finkenauer et al., 2005), or limited positive involvement (Caron et al., 2006, Pettit et al., 1993) have been identified as risk factors for the development of externalizing problems in children. With regard to internalizing problems, studies have indicated that excessive parental control (Caron et al., 2006, Wood et al., 2003) or love withdrawal (Barber et al., 2005) are associated with internalizing problems among children. Research has shown that parenting behaviors can serve not only as a risk factor, but also as a protective factor in the development of behavior problems. Positive parenting behaviors, such as parental involvement and support, may protect children from developing maladaptive behavior outcomes (Barber et al., 2005, Finkenauer et al., 2005, Kawabata et al., 2011). At the contextual level a range of socio-economic risk factors are identified, such as family income, maternal education and parental employment (Hartas, 2011).

In the autism field, studies investigating risk factors for the development and maintenance of behavior problems have mainly focused on individual child characteristics, such as age, gender, cognitive functioning, adaptive behaviors, receptive and expressive language, and severity of ASD symptoms. Lower cognitive and adaptive functioning and more severe ASD symptomatology have been identified as important predictors for maladaptive behavior outcomes (Dominick et al., 2007, Hartley et al., 2008, McTiernan et al., 2011). With regard to language ability, receptive and expressive language levels have been shown to be negatively associated with behavior problems (Dominick et al., 2007, McTiernan et al., 2011, Park et al., 2012). However, Kanne and Mazurek (2011) found that level of intellectual functioning and language ability were not predictive of aggressive behaviors in children and adolescents with ASD. Park and colleagues (2012) also found no significant association between structural language skills and behavior problems. Concerning age effects, mixed findings have been reported. For example, Kanne and Mazurek (2011) highlighted age-related changes in aggressive behaviors, with aggression being reported more often in younger children with ASD. Matson, Mahan, Hess, Fodstad, and Neal (2010), however, found no significant differences between young children (3–6 year olds), school-aged children (7–10 year olds), and young adolescents (11–14 year olds) with ASD in challenging behaviors such as physical aggression and property destruction. Discrepancies in the findings of some of these studies can be due to methodological differences, such as varying developmental levels and chronological ages, and the inclusion or exclusion of children with a co-occurring intellectual disability.

To our knowledge, only a few studies have investigated risk factors on the family level. In a study of Bauminger, Solomon and Rogers (2010) parenting stress was identified as a significant predictor for both externalizing and internalizing behavior problems among high functioning children with ASD. Osborne, McHugh, Saunders, and Reed (2008) found a negative correlation between limit setting and child behavior problems. Furthermore, limit setting was shown to mediate the relationship between parenting stress and subsequent child behavior problems. Midouhas, Yogaratnam, Flouri, and Charman (2013) investigated whether home organization and maternal warmth and involvement could buffer the effect of family poverty on psychopathology trajectories of young children with ASD. Although they found no evidence to suggest that warmth, involvement, and home organization buffered the effect of poverty on psychopathology, their study indicated that maternal warmth was associated with fewer conduct problems and less hyperactivity, and with an annual decrease in peer and conduct problems.

According to developmental psychopathology, multiple factors can influence the risk for maladaptive behavior outcomes among children. However, regarding ASD, research investigating risk factors at both the child and family level is rather scarce. Therefore, the first objective of this study is to investigate the role of child and family factors in the prediction of behavior problems among school-aged children with ASD. At the child level, we will investigate whether and how child age, gender, and communication difficulties are associated with both externalizing and internalizing problems. Contrary to previous studies, which often used wide age and IQ ranges, the present study focusses on children aged 6–12 years without intellectual disability. These children often exhibit communication difficulties, especially with regard to pragmatic language. Although the association between communication difficulties and behavior problems has been documented in studies from the general population, research examining the influence of structural and pragmatic language difficulties on behavior problems among children with ASD is limited. At the family level, we aim to investigate the contribution of parenting behaviors in the prediction of children's behavior problems. Research in the general population has clearly shown that parenting behaviors can serve both as a protective and risk factor in the development of behavior problems. In autism research, however, little attention has been paid to the role of parenting behaviors in the development of behavior problems among children with ASD.

A second objective of the present study is to examine possible moderator effects between the child and family variables. A moderator effect occurs when one predictor affects the strength and/or direction of the relation between another predictor and the outcome variable. For example; children with more communication problems could be more vulnerable for the effects of the environment (i.e., parenting behaviors). Given the complex nature of behavior problems, it is important to investigate whether moderator effects occur. This could give us insight into possible interaction effects between children's communication difficulties and parenting behaviors in predicting behavior problems among children with and without ASD.

Section snippets

Participants

The total sample included 393 Dutch children aged between 6 and 12 years. Children with ASD (n = 206) were compared with a control group of children without ASD diagnosis (n = 187). Children with intellectual disability (IQ below 70), as reported by the parents, were excluded from the sample. For the ASD group, parents indicated on a questionnaire whether their child had received a clinical ASD diagnosis based on DSM-IV-TR criteria for Autistic Disorder, Asperger syndrome, or PDD-NOS by qualified

Child behavior problems

Significantly more behavior problems, both externalizing and internalizing, were reported in the ASD group compared to the control group (Externalizing: t(390) = 15.63, p < .001; Internalizing: t(389) = 20.65, p < .001). In the ASD group, a large amount of children had a clinically significant score on the SDQ subscales measuring externalizing problems and internalizing problems (Table 2).

Behavior problems and their association with child characteristics and parenting behaviors

Pearson correlations (see Table 3) indicated that in the ASD group pragmatic language difficulties, positive

Discussion

Although a multitude of studies have identified various risk factors for the emergence and maintenance of behavior problems among children in the general population at the child, family and contextual level, in the autism field most studies have only focused on the role of child characteristics. The present study extends previous findings and contributes to our knowledge about possible predictors for behavior problems in ASD by focusing on the predictive value of both child and family

Acknowledgements

This research was funded by the Marguerite-Marie Delacroix Support Fund (GV/B-167) and the Research Fund Katholieke Universiteit Leuven. Furthermore, we thank all the participating families and schools, as well as the Dutch parent association for ASD.

References (59)

  • D. Sikora et al.

    The relationship between family functioning and behavior problems in children with autism spectrum disorders

    Research in Autism Spectrum Disorders

    (2013)
  • American Psychiatric Association

    Diagnostic and statistical manual of mental disorders

    (2013)
  • B.K. Barber et al.

    Parental support, psychological control, and behavioral control: Assessing relevance across time, culture, and method

    Monographs of the Society for Research in Child Development

    (2005)
  • N. Bauminger et al.

    Externalizing and internalizing behaviors in ASD

    Autism Research

    (2010)
  • D.V.M. Bishop

    The children's communication checklist-2

    (2003)
  • J. Boucher

    Research review: Structural language in autistic spectrum disorder – characteristics and causes

    Journal of Child Psychology and Psychiatry

    (2012)
  • S.D. Calkins

    Origins and outcomes of individual differences in emotion regulation

    Monographs for the Society for Research on Child Development

    (1994)
  • S.D. Calkins et al.

    Biological, behavioral, and relational levels of resilience in the context of risk for early childhood behavior problems

    Development and Psychopathology

    (2007)
  • S.D. Calkins et al.

    Self-regulatory processes in early personality development: A multilevel approach to the study of childhood social withdrawal and aggression

    Development and Psychopathology

    (2002)
  • A. Caron et al.

    Parenting behavior dimensions and child psychopathology: Specificity, task dependency, and interactive relations

    Journal of Clinical Child and Adolescent Psychology

    (2006)
  • A.S. Carter et al.

    Stability and individual change in depressive symptoms among mothers raising young children with ASD: Maternal and child correlates

    Journal of Clinical Psychology

    (2009)
  • R.J. Coplan et al.

    Shy and soft-spoken: Shyness, pragmatic language, and socio-emotional adjustment in early childhood

    Infant and Child Development

    (2009)
  • S.S.W. De Pauw et al.

    How temperament and personality contribute to the maladjustment of children with autism

    Journal of Autism and Developmental Disorders

    (2011)
  • G. Dionne et al.

    Physical aggression and expressive vocabulary in 19-month-old twins

    Developmental Psychology

    (2003)
  • J. Fagan et al.

    The relationship between fathers’ and children's communication skills and children's behavior problems: A study of Head Start Children

    Early Education and Development

    (2000)
  • A. Field

    Discovering statistics using SPSS

    (2009)
  • C. Finkenauer et al.

    Parenting behavior and adolescent behavioral and emotional problems: The role of self-control

    International Journal of Behavioral Development

    (2005)
  • S. Gavidia-Payne et al.

    Behavioural supports for parents of children with an intellectual disability and problem behaviours: An overview of the literature

    Journal of Intellectual and Developmental Disability

    (2002)
  • H.M. Geurts

    CCC-2-NL: Children's Communication Checklist-2

    (2007)
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