Parent Stress and Its Relation to Parent Perceptions of Communication Following Parent-Coached Language Intervention

Abstract

The effects of a parent-coached language intervention on parent stress and its relation to parent perceptions of communication development were examined in 60 parents of toddlers with developmental delays. Results indicated that overall parent stress was not high prior to or following language intervention. Parents’ perceptions about the severity of their children’s communication deficits partially mediated the relationship between expressive language at preintervention and parent stress at postintervention. Parents of children who had better expressive language at the beginning of intervention perceived their children’s communication difficulties as less severe and had less parent stress following language intervention.

Keywords

disabilities and developmental delays early language intervention parent stress parent perceptions

Parents raising a child with a disability face challenges that may not be shared by parents of typically developing children (Stoneman, 1997). They generally report more stress within the family system as compared to parents of typically developing children (Baker et al., 2003; Byrne & Cunningham, 1985; Crnic, Friedrich, & Greenberg, 1983; Dyson, 1991; Hauser-Cram, Warfield, Shonkoff, & Krauss, 2001; Orr, Cameron, Dobson, & Day, 1993). For children with developmental disabilities, communication impairments are quite common and may magnify the stress experienced by parents, yet this issue is rarely addressed in the parent stress literature. Additionally, it is relatively rare that parents actively participate in the language intervention process for their children with disabilities. Children with communication impairments usually receive speech and language interventions that occur without direct parent involvement. Even though early language intervention often takes place at the home, the parent is not typically involved directly in the intervention. It is possible that more parent participation in the child’s language interventions may have an effect on parent stress. If parents feel more confident in their ability to communicate with their child, it is possible that there could be positive outcomes for parents as well as for the child. In the present study, we examined stress in parents of children with disabilities who encountered significant difficulty acquiring speech and language and how this parent stress changed following a parent-coached language intervention.

Parent Stress

When elevated levels of stress are found, it is often due to the additional caregiving demands that parents of children with disabilities face as compared to parents of typically developing children. Some of these stressors include adjustment of family routines due to participation in interventions and therapies, medical and financial costs, and time spent away from other family pursuits. Tunali and Power (1993) reviewed existing literature on stress and coping in families of children with disabilities. They found that greater levels of stress were related to increased financial strains due to the need for medications, hospitalizations, intervention services, and specialized equipment. They also found that there was the potential for strained emotional relationships in the family due to less available time for other family members, overprotection of the child, and feelings of blame for possibly being genetically responsible for their child’s disability. Finally, they found that families may feel socially isolated due to negative reactions from extended family, friends, and neighbors; potential embarrassment about how the child looks or acts; fear of accidents; and limited mobility.

Although focusing research on the negative outcomes of parent stress is understandable, some researchers have noted that parents also report many positive experiences. There has been a shift in the perspective of researchers, from a pathological view of families to a view that focuses on positive adaptation and effective coping in families (Turnbull & Turnbull, 1993). This shift has resulted in an increased interest in the positive experiences and perceptions of having a child with a disability as well as the role of these experiences and perceptions on parents’ stress level. Family members often report a range of positive perceptions and experiences that occur jointly with stressful experiences. In fact, families report similar or higher levels of positive perceptions and experiences as compared to families raising children without disabilities despite reporting generally higher levels of stress (Baker, Blacher, Crnic, & Edelbrock, 2002; Blacher & Baker, 2007; Hastings, Allen, McDermott, & Still, 2002; Hastings & Taunt, 2002). Holding more positive perceptions may function as a mechanism for coping with the stresses and strains of caring for children with disabilities.

There has been relatively little research on the stress level of parents as a function of the communication abilities of children with disabilities. In a sample of 48 children aged 2 to 14 years, Frey, Greenberg, and Fewell (1989) found that parents reported more stress when their child’s communication skills were relatively low as measured by the standardized communication score from the Vineland Adaptive Behavior Scales (Sparrow, Balla, & Cicchetti, 1984). In a more recent study, Robertson and Weismer (1999) found that, in addition to increasing their communication skills, early language intervention resulted in decreased child-related parent stress for parents of late-talking toddlers. They suggested that early language intervention served to increase children’s communicative proficiency, which in turn facilitated positive changes in parents’ perceptions about their children’s skills and behaviors, leading to lower levels of child-related stress. Although the children in this sample had diagnoses of expressive language delay, the finding that early language intervention resulted in decreased parent stress has implications for children with developmental disabilities. It is possible that early language intervention for children with developmental disabilities also may result in positive outcomes for parents.

Intervention

The increased focus on positive adaptation is also evident in the changing nature of interventions. The recent shift in treatment models from an exclusive focus on the child to a consideration of the entire family system in intervention has helped parents feel more competent and efficacious in their ability to interact successfully with their child and bring about positive outcomes on their own (Bernheimer, Gallimore, & Weisner, 1990). Many interventions for children with developmental disabilities have focused exclusively on the child without much direct involvement from the parents. Brookman-Frazee (2004) asserted that for interventions to be successful, parents should take an active role not only in implementing the intervention but also in developing an intervention that will fit well into the families’ daily routines.

There has been some concern that involving parents closely in interventions with their children with disabilities could bring more stress into the lives of parents who are already dealing with additional demands. Brinker, Seifer, and Sameroff (1994) found that for parents who initially exhibited high levels of parent stress, more intensive interventions targeting communication between parent and child led to less child improvement and increases in parent stress. Contrary to these findings, Fey et al. (2006) found that parent stress levels did not increase or decrease following a combination of a parent education program and a prelinguistic milieu teaching program. In fact, levels were comparable to those of parents of typically developing children. Although this study had a parent education component, parents were not involved directly in implementing the intervention with their child with a disability. In the past, many language interventions have been implemented without involving parents even though the transactional nature of communication suggests that appropriate parent involvement will result in positive child outcomes (Koegel, 2000). Part C of the Individuals with Disabilities Act requires the inclusion of parents in early intervention. For communication skills in particular, Part C requires that early intervention professionals assist in teaching parents and other caregivers strategies to enhance their children’s communication and language development (Hebbeler et al., 2007). Although the level of implementation varies by state, the inclusion of parents in communication interventions is becoming more common and therefore is an important area for study since communication skills are essential for many aspects of successful functioning in early childhood (Kaiser, 1993). Additionally, communication problems are widespread among children receiving early intervention as 52% of the children participating in the National Early Intervention Longitudinal Study were receiving speech-language services (Hebbeler et al., 2007). The communication abilities of children with developmental disabilities are often delayed and, in some children, significantly impaired. In addition to the stress that comes along with a child with a disability, the inability of the child to communicate effectively with the parent may magnify the stress experienced by parents.

A concern about involving parents in language interventions has been that they themselves will not be able to implement the intervention strategies successfully. However, there is increasing evidence that supports parents as effective communication partners. Specifically, teaching parents new skills to support their child’s language development can in fact improve child developmental outcomes, reduce problem behavior, and improve the quality of the parent–child relationship (Kaiser & Hancock, 2003). Kaiser and her colleagues have demonstrated that parents can indeed learn to deliver naturalistic language intervention strategies successfully and to generalize these strategies to the home environment, resulting in positive effects on children’s language skills and parent–child interactions (Hemmeter & Kaiser, 1994; Kaiser & Hancock, 2003; Kaiser, Hancock, & Hester, 1998). Romski, Sevcik, Adamson, Cheslock, and Smith (2007) found that parents were consistently able to implement interventions successfully using language strategies that included a speech-generating device. How the parent perceived the communication abilities of the child also influenced the parent stress. As part of a larger early language intervention study for toddlers with developmental delays, Romski et al. (in press) reported that parent perceptions of success in influencing their child’s communication increased over the course of the intervention.

In the present study, we examined the role of communication ability on the level of stress perceived by parents of young children with developmental delays and significant communication impairments and addressed four questions. First, how does parent stress change following participation in a parent-coached language intervention? We expected that overall parent stress would decrease from pre- to postintervention. Second, how does children’s communication ability, specifically their expressive language skills at preintervention, relate to parent stress at both pre- and postintervention? We expected that the child’s expressive language at preintervention would be inversely associated with parent stress at both pre- and postintervention. Third, and relatedly, when children’s expressive language skills increase from pre- to postintervention, do parents’ stress scores decrease? We expected that children whose expressive language scores increased would have parents whose stress scores decreased. Finally, do parents’ perceptions about their child’s language development mediate the association between the child’s expressive language and parent stress? We expected that the association between child’s expressive language preintervention and parent stress postintervention would be mediated by parents’ perception assessed both pre- and postintervention.

Method

Participants

Sixty-two toddlers completed a language intervention study for children with developmental delays and 10 or fewer intelligible spoken words (Romski et al., 2010). The goal of this larger study was to determine the relative effects of three parent-coached language interventions on the communication skills, adaptive behavior, and educational placement of toddlers. Parent–child dyads were recruited from the metro Atlanta area through various early intervention services sites, including physicians, psychologists, and speech-language pathologists. Interested parents contacted the project about their participation.

Prior to beginning the intervention, each parent–child dyad completed a preintervention battery of tests that characterized the way the child understood and used language. The parents also completed measures about parent stress, parents’ perception of their child’s language development, the child’s daily living skills, and intervention history. As part of the larger study, the parents completed the Parent Stress Index–Short Form (PSI-SF; Abidin, 1995) and Parent Perception of Language Development (PPOLD; Romski, Sevcik, Adamson, & Bakeman, 2000) prior to beginning intervention and at the end of the last intervention session. Of the 62 parents, two did not complete the PSI at both pre- and postintervention and were excluded. An additional 7 parents did not complete the PPOLD at both pre- and postintervention (5 because the measure was being developed and not yet available)—thus, N = 60 for the analyses reported here and n = 53 for analyses using the PPOLD.

At the beginning of the study, all 60 children had, at most, 10 intelligible spoken words as observed during assessment and a score of less than 12 months on the Expressive Language Scale of the Mullen Scales of Early Learning (Mullen, 1995). Demographic characteristics for the children and their participating parent are presented in Table 1. Medical etiologies included genetic syndromes (e.g., Down syndrome), seizure disorders, cerebral palsy, or unknown medical etiology. All children had hearing and vision within normal limits as described in intake reports. At the onset of the study, 74% of the children were enrolled in state-funded Part C early intervention services, and 87% of the children received individual speech therapy services. None of the children participated in a parent-coached language intervention.

Table 1

Demographic Characteristics for Children and Participating Parent

Characteristic	Child	Parent
Age^a
M (SD)	30 (5)	37 (5)
Range	21–40	30–45
Mullen Early Learning Composite
M (SD)	59 (13)	—
Range	48–97	—
Gender
Male	41	4
Female	19	56
Race
Caucasian	37	39
African American	16	17
Asian	6	4
Education
High school	—	6
Some college	—	8
Graduated college	—	24
Graduate/professional degree	—	21

Age for children is in months; age for parents is in years.

Procedure

Intervention

As described in Romski et al. (2010), each parent–child dyad took part in a 24-session parent-coached language intervention and was randomly assigned to one of three interventions: Spoken Communication, which focused on spoken interaction, or one of two augmented language interventions—Augmented Communication–Input or Augmented Communication–Output. In all three interventions, the goal was to teach parents effective ways to communicate with their child. Each parent and child completed two 30-minute intervention sessions per week for a total of 24 sessions. The first 18 sessions took place at the Toddler Language Intervention Lab at Georgia State University. The final 6 sessions took place at the child’s home. Each 30-minute intervention session consisted of three 10-minute segments focused on play, book reading, and snack, in that order. An individualized set of target vocabulary appropriate to the three activities was chosen for each child through collaboration between the parent and research speech-language pathologist.

Each intervention had four components: Target Vocabulary, Parent Coaching, Mode, and Strategies (Romski et al., 2010). Table 2 shows the three interventions across these components and includes examples for each. Although these three interventions each had distinct language components, they all shared a common protocol. For the purposes of this study, all interventions were grouped. All three interventions encouraged the use of basic language stimulation techniques, such as modeling, expansions, and sabotage to encourage interaction and communication from the child. As part of all three interventions, the interventionist provided coaching and feedback to the parents and answered any questions about the sessions. The project’s speech language pathologist, who was certified by the American Speech-Language-Hearing Association and had 13 years of early intervention clinical experience, supervised six female interventionists (mean age = 25.6 years). The interventionists had at least bachelor’s degrees in psychology or communication and were taught to deliver all three interventions across the study. They could not be masked to the intervention assignment but were masked to the research questions to be evaluated. A minimum of 30% of the intervention sessions were supervised as per guidelines for supervision of speech language pathologist assistants (American Speech-Language-Hearing Association, 2004). All parents received the same training and instruction, using the same manual and across the same number of sessions.

Table 2

Components of Three Interventions

Component	Augmentedcommunication–input	Augmentedcommunication–output	Spoken communication
Target vocabulary	Individualized target vocabulary of visual–graphic symbols + spoken words with use of all target vocabulary during each session; I/P has a card with all target vocabulary listed.	Individualized target vocabulary of visual–graphic symbols + spoken words with use of all target vocabulary during each session; I/P has a card with all target vocabulary listed.	Individualized target vocabulary of spoken words with use of all target vocabulary during each session; I/P has a card with all target vocabulary listed.
Mode	I/P uses SGD to provide communication input to child.	Child uses SGD to communicate.	I/P and child use speech to communicate.
Strategies	I/P provides vocabulary models to child using the device; symbols are positioned in the environment to mark referents; I/P reinforces the child’s productive communications.	I/P provides verbal and/or hand-over-hand prompts so that the child produces communication using the SD.	I/P provides verbal prompts so that the child produces spoken words.
Parent coaching	I provides coaching for P.	I provides coaching for P.	I provides coaching for P.
Sample interaction	Adult and Child (Emily) are having snack.	Adult and Child (Johnny) are playing with blocks.	Adult and Child (Lem) are playing.
	A MmmA Now what do you want?A COOKIE or CRACKERC vocalizes unintelligible and holds out handA Cookie or cracker?C CRACKERA Good. You want a cracker A Ok. (A gives the cracker to Emily)A That tastes good	A Look JohnnyA Here are the blocks A Tell mama buildC PLAYA Yep, we’re playin’A Tell mama build (A taps on SGD)A Tell me build C BUILD (A provides hand over hand assistance)A All right	A Let’s play with the truckA Look (A points to mouth)A LookA /t/ /t/C XX A TruckC XX A Right? A Look at my face

Note. Components of the three interventions as described in Romski, M. A., Sevcik, R. A., Adamson, L. B., Cheslock, M., Smith, A., Barker, R. M., & Bakeman, R. (2010). Randomized comparison of augmented and non-augmented language interventions for toddlers with developmental delays and their parents. Journal of Speech, Language, and Hearing Research, 53, 350-364. I = interventionist, P = parent, A = adult, SGD = speech-generating device, words in CAPS indicate SGD use, and XX = unintelligible vocalization. The interventionist treatment implementation manual is available upon request from the authors.

Treatment Implementation Rating Scale

As described in Romski et al. (2010), the Treatment Implementation Rating Scale (Romski et al., 2007) was developed to ensure that the three interventions were implemented reliably across interventionists and time. It assessed how accurately each intervention was implemented across participants and included 13 yes/no items that encompassed common components across the three interventions, components specific to each intervention, and a scoring key specific to each intervention condition. The features of the interventions were implemented appropriately across both session type (interventionist only, .94; parent supported, .94; and parent-led, .91) and intervention (.93 for Augmented Communication–Input, Augmented Communication–Output, and Spoken Communication). Detailed information about treatment fidelity has been described by Romski and colleagues (Romski et al., 2007; Romski et al., 2010).

Measures

Three measures were used to address the questions in this study. Parent stress was assessed using the PSI-SF, which measured the impact that the parenting role had on an individual’s stress level; it has a long history of being used to evaluate stress experienced by parents of children with developmental disabilities (Lessenberry & Rehfeldt, 2004). The PSI-SF consisted of 36 items taken from the full-length questionnaire that provided a measure of total stress that a parent was experiencing, as well as three subscales: Parent Distress evaluated the distress that a parent was experiencing in his or her role as a parent; Parent–Child Dysfunctional Interaction focused on the parent’s perception that his or her child did not meet the parent’s expectations; and Difficult Child focused on behavioral characteristics of the child that made one easy or difficult to manage. Internal consistency alphas for the PSI-SF in the sample were .93 and .92 for pre- and postintervention, respectively. This measure correlates well with the full-scale PSI, which has constructive and predictive validity as well as widespread use with special populations (Abidin, 1995).

The second measure, the PPOLD, measured parent perception of early communication development and intervention in children who have severe communication delays. Although the PSI addressed parent stress at a general level, it did not provide an indication of parent stress as it related to the child’s communication abilities. Consequently, the PPOLD was used to address more specific questions relating to parent perceptions of communication development, as well as the stress that parents feel related to their child’s communication. This measure addresses topics such as the child’s language development, the child’s use of language, influences on the child’s language development, and stresses related to the child’s language development. The PPOLD is a 20-item questionnaire; each item is rated 1 (strongly disagree) to 5 (strongly agree). The items included in the questionnaire are shown in Table 3. Factor analyses identified two factors: success, which measured parents’ perceptions about how well they were affecting their child’s communication development; and difficulty, which measured parents’ perceptions about the severity of their child’s communication deficits. Internal consistency alphas were .86 and .91 for success and .71 and .79 for difficulty for pre- and postintervention data, respectively. Information about the development and psychometrics of this measure can be found in Romski et al. (in press).

The third measure, the Sequenced Inventory of Communication Development–Revised (Hedrick, Prather, & Tobin, 2000), assessed receptive and expressive language skills. It was designed to evaluate language skills in young children aged 4 months to 4 years and included a receptive and expressive scale, each of which yielded an age in months. The inventory has been shown to be an effective way to measure communication abilities of young children with and without developmental disabilities. It was administered during the study’s preintervention assessment and following completion of the intervention.

Table 3

Parent Perception of Language Development Items

Item
Factor 1: Success
Therapy has helped my child communicate.
My child’s language development has progressed well during the last three months.
My child and I have developed ways to communicate that I find satisfying.
Being in structured programs has helped my child communicate.
My child has made great strides in understanding what other people are trying to communicate.
I am increasingly confident that I can help my child develop ways of communicating.
My child has made great strides in expressing his/her needs and wants.
My child seems eager to communicate with me.
My efforts working on communication with my child seem to be paying off.
My child is trying very hard to learn language.
Factor 2: Difficulty
It is often difficult to find the time to make special efforts to help my child learn to communicate.
Helping my child learn to communicate is more work than I thought it would be.
Therapy related to communication development puts an added stress on our family.
My child still has a long way to go before he/she communicates as well as other children his/her age.
My child misbehaves because s/he does not have a way to tell me what he/she wants.
My child’s expressive language skills hamper his/her ability to communicate needs and wants.
Not included in either factor
I want my child to talk more than he/she currently does.
When it comes to language development, my child is a late bloomer who will eventually acquire adequate skills.
Computer technology has provided my child with help to communicate.
My child’s language development is about where I expect it to be given his/her level of motor and cognitive development.

Note: Factor 1 consists of items with loadings at least .40 at one time and at least .30 at the other; likewise for Factor 2.

Results

Means and standard deviations for all measures are displayed in Table 4. Only three standardized skews exceeded 1.96 absolute—3.29, 3.11, and −4.96 for pre- and postreceptive language and postsuccess, respectively. Correlations for all measures are displayed in Table 5. Pre- and postcorrelations were significant: p < .01 for parent stress, PPOLD difficulty, receptive, and expressive language and p = .052 for PPOLD success, indicating consistency across time.

We used repeated measures t tests to test the first prediction that overall parent stress would decrease from pre- to postintervention. On the total stress scale of the PSI, parents received a mean score of 74 at preintervention and 72 at postintervention. Results indicated that total parent stress did not change significantly following language intervention, t(59) = 1.14, p = .26, pη² = .02. Although the sample decreased its total stress score by an average of 2.1 points, this decrease may be due to the expected error variance associated with measurement.

Table 4

Descriptive Statistics for Key Variables

	Pre	Post
Variable	M(SD)	M(SD)
Total parent stress	74 (21)	72 (20)
Parent distress	24 (7)	23 (7)
P-CDI	21 (6)	21 (6)
Difficult child	28 (10)	27 (9)
PPOLD success	3.63 (0.69)	4.05 (0.73)
PPOLD difficulty	3.34 (0.75)	3.25 (0.81)
SICD-R receptive language	19 (7)	22 (8)
SICD-R expressive language	13 (4)	16 (7)

Note: N = 53 for PPOLD factors; N = 60 otherwise. P-CDI = Parent–Child Dysfunctional Interaction; PPOLD = Parent Perception of Language Development; SICD-R = Sequenced Inventory of Communication Development–Revised (scores are age equivalents in months).

Table 5

Correlations for Key Variables

Variable	1	2	3	4	5	6	7	8	9
1. Pre–total parent stress	—
2. Post–total parent stress	.75**	—
3. Pre–PPOLD success	−.28*	−.25	—
4. Post–PPOLD success	−.24	−.29*	.27	—
5. Pre–PPOLD difficulty	.57**	.68**	−.36**	−.48**	—
6. Post–PPOLD difficulty	.51**	.59**	.32*	−.63**	.77**	—
7. Pre–receptive language	−.07	−.06	.20	.16	−.18	−.23	—
8. Post–receptive language	.00	.03	.26	.26	−.20	−.23	.85**	—
9. Pre–expressive language	−.18	−.35**	.15	.23	−.35*	−.27*	.31*	.32*	—
10. Post–expressive language	−.03	−.14	.24	.34*	−.23	−.25	.41**	.57**	.70**

Note: N = 53 for Parent Perception of Language Development (PPOLD) correlations; N = 60 otherwise.

p < .05. **p < .01.

We used correlation to test the second prediction. As expected, the correlation between expressive language preintervention and parent stress both pre- and postintervention was negative (–.18 and –.35, p = .17 and .006), but only the postintervention correlation was significant. Children who had higher expressive language preintervention tended to have parents who exhibited lower levels of parent stress postintervention and vice versa.

We used an odds ratio to test the third prediction. As expected, the odds that children whose expressive language scores increased had parents whose stress scores decreased were twice as great as the odds for children whose expressive language scores did not increase (odds ratio = 2.10, 95% confidence interval = 0.71–6.22, p = .18). However, although in the expected direction, this result did not reach a conventional level of significance

We used regression analyses to examine whether parent perceptions mediated the relationship between expressive language preintervention and parent stress postintervention (see Table 6). The indirect effect of expressive language on parent stress mediated by success was weaker than its direct effect; the mediated effect was 10% and 16% of the total effect when assessed pre- and postintervention, respectively. In contrast, the indirect effect of expressive language on parent stress mediated by difficulty was stronger than its direct effect; the mediated effect was 69% and 46% of the total effect when assessed pre- and postintervention, respectively. Expressive language accounted for 10% of the variance in parent stress; adding success accounted for an additional 4% and 5% (p = .12 and .092), whereas adding difficulty accounted for an additional 36% and 27% (p < .001 for both).

Table 6

Mediation Analysis

Mediator	Total effect	Direct effect(β expressive language)	Indirect effect via mediator	r Expressive language–mediator	β Mediator
Success pre	−.32	−.29	−.03	.15	−.21
Success post	−.32	−.27	−.05	.23	−.23
Difficulty pre	−.32	−.10	−.22	−.35	.64
Difficulty post	−.32	−.18	−.15	−.27	.54

Note: N = 53. The total effect is the correlation between child expressive language preintervention and parent stress postintervention. The regression coefficients are for parent stress regressed on expressive language and the mediator. The indirect effect is the product of the last two columns.

Although it was not the focus of the current study, there were no intervention group effects for either total parent stress or language gains.

Discussion

In this study, we examined the effects of a parent-coached language intervention on parent stress in a sample of very young children with developmental delays and 10 or fewer spoken words. Additionally, we investigated whether there was a relationship between children’s expressive language ability and parent stress and whether parent perceptions about their child’s communication development mediated this relationship. Although parent stress did not show a significant decrease from pre- to postintervention, there was a relationship between expressive language and parent stress. Specifically, parents’ perceptions about the severity of their child’s communication deficits partially mediated the relationship between expressive language at preintervention and parent stress at postintervention.

Although total stress scores on the PSI-SF decreased from pre- to postintervention, the change was not significant, and the effect size was minimal. In fact, the mean total stress score at preintervention was in the normative range and suggested that, overall, parents who participated in this study were not very stressed at the beginning of the intervention. With the growing number of community-based early intervention services, parents of young children may have greater access to resource supports, social supports, and information and services. Access to services and supports may in turn contribute to parents’ confidence in their ability to be successful caretakers to their child with a disability (Guralnick, 2000). Having an early intervention system in place may bring about more positive developmental outcomes for the children and can in turn mitigate the psychological distress of families. In this sense, it is encouraging that the present sample of parents did not exhibit high stress levels; thus, it is reasonable that PSI scores would not decrease by a significant amount following intervention.

The finding that parent stress was in the normative range also addresses the concern that involving parents closely in interventions with their young children with disabilities could bring more stress and undue demands into the lives of these families (Mahoney & Powell, 1988). This finding adds very modest support to previous intervention research findings that clinician-implemented early language intervention involving a parent education component does not increase parent stress (Fey et al., 2006; Robertson & Weismer, 1999; Shonkoff, Hauser-Cram, Krauss, & Upshur, 1992). For parent-training programs specifically, this finding supports that of previous research showing that when parents are taught to change their interaction style with their child to promote language development, there are positive effects for both children and parents as children can exhibit positive language outcomes and parents can learn to provide clearer linguistic models while maintaining stress levels in the normative range (Tannock, Girolametto, & Siegel, 1992).

Parent stress was almost twice as likely to decrease when expressive language increased as compared to when expressive language decreased or stayed the same. Prior to beginning the language intervention, there was not a significant relationship between expressive language and total parent stress. The significant correlation at postintervention showed that parents of children who exhibited higher expressive language skills following intervention, relative to other children in the sample, showed less parent stress overall. This may suggest that parents experience greater amounts of stress when their child makes modest progress in expressive language. Participating in a child’s language intervention may sensitize parents to their child’s communication skills and could contribute to the association between parent stress and language skills.

Parents’ perceptions about their success in affecting their children’s communication development were not related to parent stress since the relationship between preintervention expressive language and postintervention parent stress remained significant when success was added to the model. How well parents perceived their child to be communicating may have made the greatest contribution to parent stress. Not only did parents who perceived their child’s communication difficulties as more severe exhibit greater parent stress, but their perceptions of difficulty at both pre- and postintervention partially mediated the relationship between expressive language at preintervention and parent stress at postintervention. This finding suggests that improving a child’s expressive language may decrease parents’ perceptions about their child’s communication difficulties, which may then have positive effects on parent stress.

Limitations

A main limitation to our study involves the composition of the sample. Although the present sample was ethnically diverse, with 39% of the families identifying themselves as minority, the sample consisted of middle-class families who all had at least a high school education. Families had to initiate contact with the project and commit to bringing their child to the intervention site twice a week for 18 half-hour sessions until the sessions were generalized to the home. Although child care, parking, and other transportation costs were provided as needed, the commitment required for participation may have been too much for families who did not have at least a high school education in that they may not have been able to commit approximately 2 hours of time every week for 12 weeks to participate in the intervention.

A second limitation to our study is the use of parent report on measures of both stress and child behavior. Response bias is always a concern with self-report measures since parents may respond to items more favorably than how they actually feel about their stress or the actual behavior of the child. It will be important for future studies to include objective measures of both parent stress and child behavior along with parent report.

Implications for Research

Our findings about parent stress are encouraging and suggest that additional research is needed to examine the role that parent-coached language interventions play in parent stress levels for families of children with disabilities. Although past research has addressed concerns about negative effects of early language interventions on parent stress, this is the only study to date that has examined parent stress in interventions that specifically coach the parent to take on the primary interaction role. The role of communication on parent stress longitudinally is also important. We found that parent stress remained in the normative range, but it is unknown how this may change over time as children get older and enter school. Future research should also continue to examine how parent perceptions of their child’s communication development influence their interactions with their child, including how stressful they are. When parents perceive that their child’s communication difficulties are less severe and when they feel successful in affecting their children’s communication development, there may be positive changes in parent stress.

Another area for future research is etiology of disability and how that relates to parent stress. Smith and Romski (2007) explored etiological differences in parent stress and parent perceptions of communication in parents of children with Down syndrome as compared to parents of children with mixed etiologies. In the current sample, parents of children with Down syndrome had significantly lower parent stress scores than parents of children with mixed etiologies both before and after the intervention. They also perceived that their children’s communication difficulties were less severe, despite the fact that their performance on standardized tests of language did not differ from the other children. This finding for etiological differences remained strong as these children entered preschool and elementary school (Smith & Sevcik, 2008). This underscores the important role that parent perceptions can play for families of children with disabilities.

Implications for Practitioners

Our findings suggest that including parents in early language intervention is a viable early intervention strategy that does not increase their stress levels beyond what they are presently exhibiting. Specifically, part of our intervention focused on teaching parents strategies to improve communication with their young child using augmentative and alternative communication—the inclusion of which is rare in very early language intervention and could be very useful to parents of children for whom developing speech may be difficult. Giving parents a means to successfully communicate with their children may help reduce stress associated with communication difficulties.

Conclusions

In conclusion, the findings of this study extend research in the area of parent stress as it relates to children’s early communication development—specifically in the area of parent perceptions of their child’s communication development and the role that parent-coached interventions play in that process. There are clear benefits gained by parents participating in early parent-coached interventions in which they learn new strategies to communicate more successfully with their young children. Learning these strategies does not lead to increases in parent stress and may serve to reduce parent stress, especially for parents who are already highly stressed. Targeting parents’ perceptions about their child’s communication development can serve an important function in reducing parent stress. If parents perceive that their children are not making adequate gains in their communication skills or do not feel that they can communicate effectively with their children, it may be more difficult for them to implement language intervention strategies adequately. Changing these perceptions may optimize parents’ participation in language interventions for their child.

Footnotes

Ashlyn L. Smith, Department of Psychology, Georgia State University; Mary Ann Romski, Departments of Communication and Psychology, Georgia State University; Rose A. Sevcik, Department of Psychology, Georgia State University; Lauren B. Adamson, Department of Psychology, Georgia State University; Roger Bakeman, Department of Psychology, Georgia State University. This article is from a master’s thesis done under the direction of the second author and is part of a larger study that was supported by the National Institutes of Health, DC-03799.

References

Abidin

R. R.

(1995). Parent Stress Index Manual (3rd ed.). Odessa, FL: Psychological Assessment Resources.

American Speech-Language-Hearing Association. (2004). Guidelines for the training, use, and supervision of speech-language pathology assistants. Available from http://www.asha.org/policy

Baker

B. L.

Blacher

Crnic

K. A.

Edelbrock

(2002). Behavior problems and parenting stress in families of three-year-old children with and without developmental delays. American Journal of Mental Retardation, 107, 433-444.

Baker

B. L.

McIntyre

L. L.

Blacher

Crnic

K. A.

Edelbrock

Low

(2003). Preschool children with and without developmental delay: Behavior problems and parenting stress over time. Journal of Intellectual Disability Research, 47, 217-230.

Bernheimer

Gallimore

Weisner

(1990). Ecocultural theory as a context for the individual service plan. Journal of Early Intervention, 14, 219-233.

Blacher

Baker

B. L.

(2007). Positive impact of intellectual disability on families American Journal of Mental Retardation, 112, 330-348.

Brinker

R. P.

Seifer

Sameroff

A. J.

(1994). Relations among maternal stress, cognitive development, and early intervention in middle- and low-SES infants with developmental disabilities. American Journal of Mental Retardation, 98, 463-480.

Brookman-Frazee

(2004). Using parent/clinician partnerships in parent education programs for children with autism. Journal of Positive Behavior Interventions, 6, 195-213.

Byrne

E. A.

Cunningham

C. C.

(1985). The effect of mentally handicapped children on families: A conceptual review. Journal of Child Psychology and Psychiatry, 26, 847-862.

10.

Crnic

K. A.

Friedrich

W. N.

Greenberg

M. T.

(1983). Adaptation of families with mentally retarded children: A model of stress, coping, and family ecology. American Journal of Mental Deficiency, 88, 125-138.

11.

Dyson

L. L.

(1991). Families of young children with handicaps: Parental stress and family functioning. American Journal of Mental Retardation, 95, 623-629.

12.

Fey

M. E.

Warren

S. F.

Brady

Finestack

L. H.

Bredin-Oja

S. L.

Fairchild

. . . Yoder

P. J.

(2006). Early effects of responsivity education/prelinguistic milieu teaching for children with developmental delays and their parents. Journal of Speech, Language, and Hearing Research, 49, 526-547.

13.

Frey

K. S.

Greenberg

M. T.

Fewell

R. R.

(1989). Stress and coping among parents of handicapped children: A multidimensional approach. American Journal of Mental Deficiency, 94, 240-249.

14.

Guralnick

M. J.

(2000). Early childhood intervention: Evolution of a system. Focus on Autism and Other Developmental Disabilities, 15, 68-79.

15.

Hastings

R. P.

Allen

McDermott

Still

(2002). Factors related to positive perceptions in mothers of children with intellectual disabilities. Journal of Applied Research in Intellectual Disabilities, 15, 269-275.

16.

Hastings

R. P.

Taunt

H. M.

(2002). Positive perceptions in families of children with developmental disabilities. American Journal of Mental Retardation, 107, 116-127.

17.

Hauser-Cram

Warfield

M. E.

Shonkoff

J. P.

Krauss

M. W.

(2001). Children with disabilities: A longitudinal study of child development and parent well-being. Monographs of the Society for Research in Child Development, 66, 1-131.

18.

Hebbeler

Spiker

Bailey

Scarborough

Mallik

Simeonsson

. . . Nelson

(2007). Early intervention for infants and toddlers with disabilities and their families: Participants, services and outcomes. Menlo Park, CA: SRI International.

19.

Hedrick

D. L.

Prather

E. M.

Tobin

A. R.

(2000). Sequenced Inventory of Communication Development Manual–Revised Edition. Los Angeles, CA: Western Psychological Services.

20.

Hemmeter

M. L.

Kaiser

A. P.

(1994). Enhanced milieu teaching: Effects of parent-implemented language interventions. Journal of Early Intervention, 18, 269-289.

21.

Kaiser

A. P.

(1993). Parent-implemented language intervention: An environmental system perspective. In Kaiser

Gray

(Eds.), Enhancing children’s communication: Research foundations for intervention (pp. 63-84). Baltimore: Brookes.

22.

Kaiser

A. P.

Hancock

T. B.

(2003). Teaching parents new skills to support their young children’s development. Infants and Young Children, 16, 9-21.

23.

Kaiser

A. P.

Hancock

T. B.

Hester

(1998). Parents as co-interventionists: Research on applications of naturalistic language teaching procedures. Infants and Young Children, 10, 4-12.

24.

Koegel

L. K.

(2000). Interventions to facilitate communication in autism. Journal of Autism and Developmental Disorders, 30, 383-391.

25.

Lessenberry

B. M.

Rehfeldt

R. A.

(2004). Evaluating the stress levels of parents of children with disabilities. Exceptional Children, 70, 231-244.

26.

Mahoney

Powell

(1988). Modifying parent–child interaction: Enhancing the development of handicapped children. Journal of Special Education, 22, 82-96.

27.

Mullen

E. M.

(1995). Mullen Scales of Early Learning. Circle Pines, MN: American Guidance Service.

28.

Orr

R. R.

Cameron

S. J.

Dobson

L. A.

Day

D. M.

(1993). Age-related changes in stress experienced by families with a child who has developmental delays. Mental Retardation, 31, 171-176.

29.

Robertson

S. B.

Weismer

S. E.

(1999). Effects of treatment on linguistic and social skills in toddlers with delayed language development. Journal of Speech, Language, and Hearing Research, 42, 1234-1248.

30.

Romski

M. A.

Sevcik

R. A.

Adamson

L. B.

Bakeman

(2000). Parent Perception of Language Development. Unpublished measure, Department of Communication, Georgia State University, Atlanta, GA.

31.

Romski

M. A.

Sevcik

R. A.

Adamson

L. B.

Cheslock

Smith

(2007). Parents can implement AAC interventions: Ratings of treatment implementation across early language interventions. Early Childhood Services, 1, 100-115.

32.

Romski

M. A.

Sevcik

R. A.

Adamson

L. B.

Cheslock

Smith

Barker

R. M.

Bakeman

(2010). Randomized comparison of augmented and non-augmented language interventions for toddlers with developmental delays and their parents. Journal of Speech, Language, and Hearing Research, 53, 350-364.

33.

Romski

M. A.

Sevcik

R. A.

Adamson

L. B.

Smith

Cheslock

Bakeman

(in press). Parent perceptions of language development before and after participation in parent-coached language interventions for toddlers with developmental delays. American Journal of Speech-Language Pathology.

34.

Shonkoff

J. P.

Hauser-Cram

Krauss

M. W.

Upshur

C. C.

(1992). Development of infants with disabilities and their families: Implications for theory and service delivery. Monographs of the Society for Research in Child Development, 57(6, Serial No. 230).

35.

Smith

Romski

M. A.

(2007, March). Examining parental stress and parental perceptions of toddler’s communication development following language intervention: A comparison between children with and without Down syndrome. Paper presented at the 40th annual Gatlinburg Conference on Research and Theory in Intellectual and Developmental Disabilities, Annapolis, MD.

36.

Smith

Sevcik

R. A.

(2008, March). Examining parent stress and parent perception of language development over time in children who are non-speaking as toddlers. Paper presented at the 41st annual Gatlinburg Conference on Research and Theory in Intellectual Disabilities, San Diego, CA.

37.

Sparrow

S. S.

Balla

D. A.

Cicchetti

D. V.

(1984). Vineland Adaptive Behavior Scales (Survey Edition). Circle Pines, MN: American Guidance Service.

38.

Stoneman

(1997). Mental retardation and family adaptation. In McLean

W. E.

(Ed.), Ellis’ handbook of mental deficiency, psychological theory, and research (3rd ed., pp. 405-427). Mahwah, NJ: Erlbaum .

39.

Tannock

Girolametto

Siegel

L. S.

(1992). Language intervention with children who have developmental delays: Effects of an interactive approach. American Journal of Mental Retardation, 2, 145-160.

40.

Tunali

Power

T. G.

(1993). Creating satisfaction: A psychological perspective on stress and coping in families of handicapped children. Child Psychology and Psychiatry, 34, 945-957.

41.

Turnbull

A. P.

Turnbull

H. R.

(1993). Cognitive coping, families, and disability. Baltimore: Brookes.