A longitudinal examination of interactions between autism symptom severity and parenting behaviors in predicting change in child behavior problems

Highlights

• Caregiver distress, caregiver sex, and negative parenting each predicted change in child behavior problems.

• More negative parenting predicted higher behavioral problems especially for children with less severe ASD symptoms.

• Less negative parenting predicted lower behavioral problems especially for children with less severe ASD symptoms.

• Negative parenting was not related to behavioral problems when considering only those with more severe ASD symptoms.

Abstract

Background

Children with autism spectrum disorder (ASD) often exhibit behavior problems, with more severe ASD symptomatology relating to more severe behavior problems. Behavior problems are correlated with parenting behaviors; however, less research has investigated the relations among specific parenting behaviors and change in child behavior problems, particularly among children with ASD.

Method

This study examined the interactions among Time 1 ASD symptom severity and parenting behaviors (positive and negative) when predicting Time 2 child internalizing and externalizing behaviors (analyzed separately), when accounting for Time 1 child behavior, caregiver distress, caregiver sex, and child age. The sample included 129 caregivers of a child with ASD (ages 4–10 years) who completed two online questionnaires one year apart, which included measures assessing ASD symptom severity, child behavior problems, parenting behaviors, and caregiver distress.

Results

Across two hierarchical multiple regression analyses, Time 1 child behavior, caregiver distress, caregiver sex, and negative parenting predicted unique variance in Time 2 child externalizing and internalizing behaviors. The interactions between ASD symptom severity and negative parenting predicting externalizing behaviors and ASD symptom severity and negative parenting predicting internalizing behaviors were significant.

Conclusions

Examination of plots of the significant interactions suggested higher levels of negative parenting may exacerbate later behavioral problems and lower levels of negative parenting may protect against later behavioral problems for children with less severe ASD symptoms but not for those with more severe ASD symptoms. Results have implications for interventions targeting parenting practices for children with ASD.

Introduction

Children with autism spectrum disorder (ASD) often exhibit externalizing (e.g., aggression, hyperactivity) and internalizing (e.g., anxiety, depression) behavior problems (e.g., Horner, Carr, Strain, Todd, & Reed, 2002; Ming, Brimacombe, Chaaban, Zimmerman-Bier, & Wagner, 2008), and research has consistently demonstrated that more severe ASD symptomatology is related to more severe behavior problems (e.g., Jang, Dixon, Tarbox, & Granpeesheh, 2011). A review of the literature found that behavioral problems in individuals with ASD are associated with an array of repercussions including social rejection, exclusion from settings, admission to residential facilities, use of psychotropic medication, and distress for these individuals, their caregivers, and treatment or educational providers (Didden et al., 2012). Although research on this subject is somewhat limited, a recent review found a relation between parenting behaviors and child behavior in families of a child with ASD, with more effective parenting strategies relating to better outcomes for children (e.g., Crowell, Keluskar, & Gorecki, 2019). We hope to expand these findings between parenting behaviors and child behaviors, such that they may be informative to future clinical or intervention efforts. To fill this gap, the current study evaluated the interaction between ASD symptom severity and parenting behaviors when predicting change in child behavior problems over one year.

A wealth of literature supports the association between parenting behaviors and typically-developing (TD) child outcomes, including social skills, independence, effortful control, as well as externalizing and internalizing behaviors (e.g., Boeldt et al., 2012; Baumrind, 1966; Eisenberg et al., 2005). For example, lower levels of positive parenting (e.g., warmth, involvement) and higher levels of negative parenting (e.g., inconsistent, harsh discipline) have been consistently related to child behavior problems (e.g., Boeldt et al., 2012; Frick et al., 1992). In general, positive parenting involves types of behaviors that have been described in the literature as warm, sensitive, responsive, involved, and directive, all of which have been closely related to the authoritative parenting style (Waters, 2017). For the purposes of the current study, positive parenting is defined as a combination of the positive parenting (e.g., use of praise and rewards) and parental involvement (e.g., talking with child, spending time with child) subscales from the Alabama Parenting Questionnaire (APQ; Essau, Sasagawa, & Frick, 2006; Shelton, Frick, & Wootton, 1996).

In the same vein, negative parenting behaviors, such as inconsistent discipline, hostile interactions, and punitive punishment, have also been directly linked to child behaviors. For example, negative parenting has been shown to relate to higher levels of both internalizing (e.g., McLeod, Weisz, & Wood, 2007) and externalizing behaviors (e.g., Hoeve et al., 2009; Kawabata, Alink, Tseng, Van Ijzendoorn, & Crick, 2011) in samples of TD children. Specifically, lack of parental warmth has been linked to higher levels of oppositionality in children, and higher parental aggression has been related to more severe child aggression (Stormshak, Bierman, McMahon, & Lengua, 2000). For the purposes of the current study, negative parenting is defined as a combination of the poor monitoring/supervision (e.g., being unsure where your child is, not supervising child in the home) and inconsistent discipline (e.g., parent’s mood dictates punishment given, threatens to punish but does not follow through) subscales from the APQ (Essau et al., 2006; Shelton et al., 1996). The use of the APQ in operationalizing both positive and negative parenting allowed an examination of specific parenting behaviors, rather than a parenting style, which could inform more exact behavioral intervention strategies.

Compared to the vast literature on the impact of parenting on the behavior of TD children, much less research has investigated the relation between positive and negative parenting practices and child outcomes for families of a child with ASD. Further, the literature is more mixed regarding the relation between positive parenting and behavior problems for children with ASD. A meta-analysis examining 14 studies of families with a child with a developmental disability, including families of a child with ASD, found a moderate relation between positive parenting and child behavior, which mirrors the relation found in TD samples (Dyches, Smith, Korth, Roper, & Mandleco, 2012). A study investigating behavioral problems in school-aged children with ASD demonstrated a positive relation between positive parenting and externalizing behaviors; however, no relation between positive parenting and internalizing behaviors was found (Boonen et al., 2014). Additionally, a study investigating correlates of behavior problems in children with ASD did not find a relation between maternal positive parenting with either externalizing or internalizing behaviors (Maljaars, Boonen, Lambrechts, Van Leeuwen, & Noens, 2014). Although one study demonstrated a significant, negative relation between rule setting and general behavioral problems, the relations between parental involvement and communication with behavior problems was nonsignificant (Osborne, McHugh, Saunders, & Reed, 2008). Importantly, a systematic review of studies investigating parenting behaviors in families of a child with ASD found that results often evaluated changes in language development and social skills rather than general behavior problems (Brookman-Frazee, Stahmer, Baker-Ericzen, & Tsai, 2006). For example, one study examining various correlates of outcomes in children with ASD from early to middle childhood, including how parenting behaviors impact development, found that more responsive parenting behaviors during play were associated with better developed language skills across time (Siller & Sigman, 2008). As studies investigating positive parenting are largely mixed, more research is needed to better understand the relation between positive parenting and child behavior for families of a child with ASD.

Although still relatively understudied, the relation between negative parenting and child behavior problems for families of a child with ASD more closely mirrors that found in samples of TD children. Specifically, behavior problems exhibited by children with ASD are positively related to negative parenting behaviors; however, this relation appears stronger for externalizing behavior when compared to internalizing behavior. For example, two studies found a positive relation between negative parenting and externalizing behaviors but no relation between negative parenting and internalizing behaviors (Boonen et al., 2014; Maljaars et al., 2014). Another set of studies found that negative parenting (specifically expressed emotion) predicted externalizing behaviors in children with ASD, above and beyond ASD symptom severity (Bader, Barry, & Hann, 2015), including when examining a change in externalizing behaviors two years later (Bader & Barry, 2014). Importantly, parents of children with developmental disabilities, including caregivers of a child with ASD, are more likely to display negative parenting behaviors compared to parents of TD children (Blacher, Baker, & Kaladjian, 2013; Brown, McIntyre, Crnic, Baker, & Blacher, 2011). Overall, the literature suggests that an examination of both positive and negative parenting behaviors when considering behavioral outcomes in children with ASD is warranted.

An examination of parenting behaviors and their associations with the behavioral problems of children with ASD would not be complete without a discussion of bidirectional effects. As described in Patterson and Fisher’s (2002; p.63) review, we must acknowledge parenting practices as both "products and as causal mechanisms;” specifically, they note certain (negative) parenting behaviors, such as harsh discipline-setting, may be largely attributed to the child as the parent responds to the child’s prior problematic behaviors. It is also conceivable, however, for parenting to take a more driving role in the reduction or increase of the child’s problematic behaviors through positive or negative contingencies. More recent studies have documented the bidirectional relation between parenting behaviors and problematic behaviors in children with ASD. For example, a nine-year longitudinal study found that child externalizing behavior predicted higher negative control, which then led to increased externalizing problems; higher negative control predicted higher internalizing problems; and higher externalizing problems predicted higher positive parenting (Dieleman, De Pauw, Soenens, Beyers, & Prinzie, 2017). Further, child behaviors have been found to relate to daily variation in parenting behaviors (e.g., more controlling or more autonomy-supportive), which further depended on daily satisfaction of maternal psychological needs (Dieleman et al., 2019).

De Clercq et al. (2019) demonstrated the influence of maternal psychological variables on children with ASD’s externalizing behaviors, in that higher levels of negative parenting (i.e., more controlling) was related to greater externalizing behaviors in children. Greenberg, Seltzer, Hong, and Orsmond (2006) examined the effects of expressed emotion on children with ASD in a sample of 149 mothers. Results indicated a longitudinal relation between maternal expressed emotion and increasing levels of internalizing, externalizing, and asocial behaviors in children with ASD. Additionally, the authors found a reciprocal effect of internalizing behavior problems on levels of maternal expressed emotion, in that higher levels of internalizing behaviors were associated with decreased expressed emotion. Related to emotion, one study examining parenting behaviors and child externalizing behaviors in children with ASD found that higher levels of respiratory sinus arrhythmia (RSA) reactivity (i.e., a hypothesized biomarker for emotional regulation) affected the positive relation between negative parenting and externalizing behaviors but not with positive parenting (Baker et al., in press). Baker et al. (in press) posited that either lower negative parenting allowed for lower RSA reactivity and thus greater regulation of the child’s behaviors or higher RSA reactivity magnified effects of higher negative parenting on child behaviors. Their study underscores the need to examine potential moderators in predicting externalizing behavior in children with ASD.

It is important to note the complexity of factors that influence parenting behaviors, including factors that may be specific to caregivers of a child with ASD. For example, there is some evidence that caregivers of a child with ASD more often demonstrate higher levels of aggravation when parenting and report more serious challenges related to caring for their child compared to parents of children with developmental disabilities other than ASD (Schieve, Blumberg, Rice, Visser, & Boyle, 2007). Importantly, parenting stress and maladaptive parenting strategies have been demonstrated to have a bidirectional relation. Specifically, higher levels of parenting stress predict future negative parenting behaviors and more severe negative parenting predicts higher levels of parenting stress (Mackler et al., 2015). It has been theorized that parents experiencing elevated levels of stress may lack the adequate energy and resources to effectively respond to both appropriate behavior and behavioral problems, which may result in their children displaying more severe behavioral difficulties in an attempt to receive attention (e.g., Bauminger, Solomon, & Rogers, 2010). Further, higher levels of depression have also been linked to more maladaptive parenting strategies (Lovejoy, Graczyk, O’Hare, & Neuman, 2000). As parents of a child with ASD consistently report higher levels of stress and depression compared to parents of TD children and children with other disabilities (e.g., Abbeduto et al., 2004; Hayes & Watson, 2013), it is possible that these caregivers are also at-risk to exhibit more maladaptive parenting behaviors. Importantly, gender differences among parents have been inconsistently reported in the literature. For example, the majority of studies report that mothers tend to have elevated stress and depression compared to fathers (e.g., Davis & Carter, 2008; Hastings et al., 2005; Herring et al., 2006). Therefore, investigating gender differences in both level of distress and parenting behavior may be warranted.

Further, demographic factors, such as child age have been shown to relate to parenting behaviors. One study investigating parenting behaviors in mothers of school-aged children and adolescents with ASD found that positive parenting and material rewarding was more frequently endorsed by mothers of younger children compared to older children (Maljaars et al., 2014). A longitudinal study found that negative parenting observed in mothers of preschool-aged children with ASD decreased over the course of two years during both structured activities and unstructured play while positive parenting increased during structured activities but decreased during unstructured play (Blacher et al., 2013). Thus, parenting behaviors may also change as a result of a child’s age, suggesting that child age may be an important variable to account for when investigating parenting behaviors.

Due to the consistently demonstrated impact of parenting behaviors on child behavior problems in samples of TD children, research has begun to investigate this relation for families of a child with ASD (e.g., Osborne et al., 2008). However, few studies have investigated these relations using a longitudinal study design (e.g., Dieleman et al., 2017). Further, the impact that parenting behaviors may have on the relation between ASD symptoms and child behavior problems over time (see Greenberg et al., 2006)—and if parenting behaviors serve as a protective factor against future behavior problems in children with ASD—warrant further investigation, as specific parenting behaviors in families of a child with ASD are relatively understudied. From a theoretical perspective and prior literature showing the effects of parenting on trajectories of externalizing behavior with TD children (Galambos, Barker, & Almeida, 2003), there is reason to suspect that the tailored behavioral contingencies implemented by parents may lead to change in child’s behavioral patterns in a clinical sample.

The current study examined the interactions among ASD symptom severity and parenting behaviors (positive and negative parenting) when predicting changes in child behavior problems (internalizing and externalizing behaviors, examined separately) one year later while accounting for caregiver distress, caregiver sex, and child age. It was hypothesized that more severe ASD symptomatology at Time 1 would predict higher levels of both internalizing and externalizing behaviors at Time 2, while accounting for child behavior at Time 1, caregiver distress at Time 1, caregiver sex, and child age. Second, it was expected that Time 1 parenting behaviors would moderate the relation between Time 1 ASD symptom severity and Time 2 child behaviors, such that higher levels of positive parenting would attenuate the relation and higher levels of negative parenting would exacerbate the relation.