Faculty of Social and Behavioural Sciences
Graduate School of Childhood Development and Education
Do families of children with different clinical
diagnoses differ in child and parental
psychopathology, quality of life, and parental
stress?
Research Master Educational Sciences
Thesis 1
Liesbeth Telman
Supervisors: dr. F.J.A. van Steensel, prof. dr. S.M. Bögels
July, 2013
Abstract
This study compared 251 children (mean age = 11.62) with Autism Spectrum Disorder (ASD), Attention-Deficit Hyperactivity Disorder (ADHD), Anxiety Disorders (AD), and Disorder Not Otherwise Specified (NOS) on their quality of life, emotional and behavioural problems, parental psychopathology, and parental stress. Multilevel analyses showed that children with AD were reported to have more internalizing problems than children with ADHD and disorder NOS, and less externalizing problems than all other groups. Children with ASD were reported to be more withdrawn than all other groups and to have more thought problems than all other groups. Quality of life was reported to be higher for children with ADHD than children with ASD and disorder NOS on the domains psychological and social functioning. Analyses of parental stress showed that parents of children with AD had less stress than parents of children with ASD, ADHD and NOS. No differences in parental psychopathology were found between children from different disorders subgroups. In sum, results suggest that the four clinical groups differ significantly on child psychopathology symptoms, quality of life, and parental stress. It is therefore important to acknowledge that these children might need a different approach in parenting as well as in clinical treatment.
Key words: quality of life, emotional and behavioural problems, child psychopathology, parental stress, parental psychopathology
Introduction
The prevalence of clinical disorders in children is estimated at around 9.5% (Ford, Goodman, & Meltzer, 2003; Cartwright-Hatton, McNicol, & Doubleday, 2006). Studies have shown that children with a clinical diagnosis have more behavioural problems than normally developing children (Thaulow & Jozefiak, 2012). These problems can lead to deviant behaviours and problems in social interactions with adults and peers. Child problem behaviours can be divided into internalizing problems which may include withdrawal and anxiety, and externalizing problems which may include aggression and rule-breaking behaviour (Fanti & Henrich, 2010). Internalizing and externalizing problems can co-occur in children and can lead to deviant behaviours and social problems. Several studies have examined internalizing and externalizing problems in children with psychopathology. Compared to a control group of typically developing children, children with attention deficit hyperactivity disorder (ADHD) as well as children with emotional disorders related to anxiety and depression had a significantly higher total behavioural problem score on the Child Behavior Check List (CBCL, Achenbach & Rescorla 2001; Thaulow & Jozefiak, 2012). Moreover, children with ADHD had a higher total problem score than the anxiety/depression group. The authors suggest that this is due to the often observed co-morbidity of ADHD with other (developmental) disorders. In terms of internalizing and externalizing problems, the anxiety/depression group reported significantly more internalizing problems than the ADHD group, while the latter reported more externalizing problems than the first group. Another study found that children with major depressive disorder experienced more emotional problems, as measured by the Child Health Questionnaire (CHQ, HealthActCHQ, 2008), while children with ADHD experienced more behavioural problems, as reported by parents (Sawyer et al., 2002). The study of Holtmann, Bölte, and Poustka (2007) showed that children with autism spectrum disorder (ASD) and comorbid attention problems exhibited a higher degree of internalizing and externalizing problems than children with ASD only. Moreover, the children with ASD and comorbid attention problems showed more social interaction problems, as measured by the CBCL, than the children with ASD only. Children with ASD also had a clinical score on thought problems of the CBCL (Holtmann, Bölte, & Poustka, 2007).
(Wiegand-Greve et al., 2012). The concept quality of life encompasses multiple domains, such as physical well-being, psychological well-well-being, and social functioning (Bastiaansen, Koot, & Ferdinand, 2005). Children who are diagnosed with a psychiatric disorder generally have a considerably poorer quality of life than children from the general population (Bastiaansen et al., 2005; Watson & Keith, 2002). The study by Bastiaansen, Koot, Ferdinand, and Verhulst (2004) compared the quality of life between children with different psychiatric diagnoses: ADHD, anxiety disorders (AD), ASD, mood disorders, and other disorders. The comparison between clinical groups showed that children with AD had a poorer emotional functioning than children with ADHD. In contrast, no significant differences in quality of life were found between children with ADHD and children with anxiety/depression in the study by Thaulow and Jozefiak (2012) when parents reported about their child’s quality of life. However, it should be noted that self-reports of the children revealed a higher quality of life for the ADHD group. Regarding children with ASD, there is some evidence that these children have a poorer quality of life compared to other children. That is, the study by Kuhlthau et al. (2010) found that the quality of life of children with ASD was significantly lower than that of the normal population, and in the study of Lee, Harrington, Louie, and Newschaffer (2008) parents reported children with autism to have a lower quality of life than children with ADHD. According to clinician’s ratings, children with ASD had a poorer overall quality of life than children with other clinical diagnoses (Bastiaansen et al., 2004). The authors suggest that the severity of problems might influence quality of life more than the presence of the clinical disorder. In accordance, a comparison between children with ASD and comorbid anxiety disorders, and clinically anxious children revealed that a lower quality of life was related to more severe autistic behaviour and a higher anxiety severity (Van Steensel, Bögels, & Dirksen, 2012). Also in line, Klassen, Miller, and Fine (2004) found that a poorer psychosocial quality of life is correlated with more severe symptoms of ADHD. According to the review of Danckaerts et al. (2010), there is a considerable amount of research suggesting that quality of life impairment increases as the severity of ADHD increases, and/or where comorbidity or psychosocial stressors are present.
Another factor that is associated with child psychopathology is parental psychopathology. The study of Humphreys, Mehta and Lee (2012) revealed that (1) parental depression is specifically
associated with child internalizing problems and (2) parental ADHD is related to broader child psychopathology. In addition, it has been reported that parents of a child with ASD showed elevated levels of anxiety and depression when compared to the normal population (Sharpley, Bitsika, & Efremidis, 1997). In a meta-analysis by Yirmiya and Shaked (2005), it was found that parents of children with ASD have more psychiatric difficulties compared to other parents (parents of typical developing children and children with other diagnosis than autism combined). The authors suggest that these psychiatric problems cannot solely be the result of environmental effects (the burden of having a child with ASD); however, genetic vulnerability is likely to play a role.
Parenting a child with a clinical diagnosis often raises parental stress, and feelings of being less competent in parenting than other parents. Parental stress is an increasingly important construct which may contribute independently to the clinical portrait of clinic-referred families (Costa, Weems, Pellerin, & Dalton, 2006). Parents of children with ASD report higher levels of parental stress when compared to parents of normally developing children (Lyons, Leon, Roecker Phelps, & Dunleavy, 2010). The study of Lyons et al. (2010) found that autism severity is the strongest and most consistent predictor of stress across all of the parental stress domains. For parents of children with ADHD, parental stress levels were not found to differ from that of parents from control children (Podolski & Nigg, 2001). In addition, Baker (1994) found that that both mothers and fathers of children with ADHD experience the same levels of parental stress; however, the findings indicated that the stress for mothers and fathers can be evoked by different child behaviour. For mothers, child inattention and oppositional-conduct problems but not hyperactivity contributed uniquely to parenting role distress. For fathers, parenting role distress was associated uniquely with child oppositional or aggressive behaviours but not with ADHD symptom severity (Podolski & Nigg, 2001).
In sum, a considerable amount of research suggests that there are differences in behavioural problems between children with different clinical diagnoses. For example, children with ADHD have a higher total problem score than children with AD where children with ASD are found to have a lower quality of life than children with ADHD. In addition, parents of children with ASD are found to have more psychiatric problems compared to parents with typically developing children. These studies mostly have compared two clinical groups on either child behavioural problems or parenting
stress. However, a comparison that takes into account several clinical groups seems to be missing, especially in studies about parental psychopathology and stress. The aim of this study is to compare children with different psychiatric diagnoses on their quality of life and on their emotional and behavioural problems. Moreover, the characteristics of the parents of these different clinical groups will be examined by comparing parents’ self-reported emotional and behavioural problems and their perceived parental stress. Children are categorized in groups according to their primary diagnosis: ADHD, ASD, AD, and Disorder Not Otherwise Specified (NOS). This study adds to the available evidence a comparison of several clinical groups on different aspects in order to examine to which extent children with different clinical diagnoses possess the same characteristics. Moreover, the clinical relevance of this study lies in taking into account parental psychopathology and stress. When it is known that certain clinical groups are associated with more parental psychopathology or stress, clinicians can consider this information in their treatment. In addition, this study will add to the possibilities of screening whether a child is at higher risk to develop specific behavioural problems, concerning their diagnosis.
Method
Participants
Participants eligible for this study were children aged 6-24 years (M = 11.62, SD = 3.05) referred for clinical treatment to an academic treatment centre in Amsterdam. Participants were included in this study when (1) at least one of the parents had completed all questionnaires, and (2) children had a clinical diagnosis of ASD, ADHD, AD or Disorder NOS. In total, 251 children were included, of which 248 (98.8%) mothers and 210 (83.7%) fathers participated. Of 207 (82.5%) children, both parents had filled in the questionnaires.
The sample consisted of 177 boys (70.5%) and 74 girls (29.5%). There were 39 (15.5%) children diagnosed with a primary diagnosis of ASD, 128 (51.0%) with ADHD, 63 (25.1%) with AD and 21 (8.4%) children with Disorder NOS. Of the total group, 89 children (35.5 %) had a comorbid disorder (see Table 1). Parents’ average age was 45.04 (SD = 5.36) years for mothers and 47.86 (SD = 6.05) years for fathers. Most of the children had a Dutch background (76.2%). Nearly all reports were
from biological parents (98.2%). Table 2 displays the demographics of the four groups. A group difference was observed between the ASD and ADHD group; children in the ASD group were significantly older than children in the ADHD group (t = 2.18, p = .031). Moreover, groups differed significantly in gender (χ2 (3, N = 251) = 12.04, p = .007); there were relatively more girls in the AD group than in the ASD and ADHD group (p’s < .05).
Table 1
Comorbidity with other disorders Primary diagnosis Percentage comorbidity ADHD AD Mood Disorder ODD Learning Disorder Other Disordera ASD (n=39) 46.2 (n=18) 11 5 0 1 3 0 ADHD (n=128) 34.4 (n=44) 0 17 1 4 19 12 AD (n=63) 34.9 (n=22) 0 8 2 0 5 9 Disorder NOS (n=21) 23.8 (n=5) 0 0 0 0 3 2 a
This category included parent-child relational problems, adaptation disorders, enuresis, pavor nocturnus, selective mutism, and Gilles de la Tourette.
Table 2
Demographics of Sample Categorized by Diagnosis TOTAL (n=251) ASD (n=39) ADHD (n=128) AD (n=63) NOS (n=21) Gender boys (n, %) 177 70.5 32 82.1 96 75.0 34 54.0 15 71.4 Age child (M, SD) 11.62 3.05 12.51 0.59 11.27 0.26 11.86 0.36 11.67 0.69 Age mother (M, SD) 45.04 5.36 45.47 0.80 45.10 0.51 45.00 0.63 44.48 1.25 Age father (M, SD) 47.86 6.05 47.91 0.88 47.83 0.63 47.88 0.77 48.19 1.65 Marital status: married (n, %) 173 68.9 29 74.4 89 69.5 42 66.7 13 61.9 Educational level mothera (M, SD) 5.68 1.34 5.85 0.17 5.75 0.12 5.44 0.19 5.67 0.34 Educational level fathera (M, SD) 5.56 1.58 5.91 0.21 5.66 0.15 5.16 0.24 5.38 0.39 a
Procedure
The sample is part of a larger study examining treatment efficacy at the academic treatment centre UvA minds situated in Amsterdam. Data was collected from May 2012 to May 2013. Data was collected by online questionnaires that parents need to fill in at intake in the treatment centre. All measures are using parent-report which is policy at the treatment centre (in order not to burden the children). Children were excluded when one of their siblings had participated in the study (14 children were excluded for this reason). Moreover, when more than two parents were involved, only data from the biological parents was used (four respondents were excluded). Primary diagnosis was obtained from the clinician, based on DSM-IV-TR criteria, and often the diagnosis was confirmed by a
diagnostic instrument, such as the ADIS-C and P, or the ADI-R. All participants were informed about the study, and ethical approval for the study as well as informed consent was obtained. Parents of three children did not agree with the informed consent and were therefore excluded from this study.
Instruments
Behavioural Problems. Behavioural problems were assessed with the Child Behaviour Check List (CBCL). The CBCL is a widely used questionnaire that measures a broad range of behavioural problems in children (CBCL, Achenbach, & Rescorla, 2001). The questionnaire consists of 113 items, which are rated on a 3-point scale; a rate of zero indicates that the item is not true and a rate of two indicates that the item is often true. An example item is ‘My child acts too young for his/her age’. A total problem scale is calculated from the summing the scores of all items. A distinction can be made in two broad-band syndrome scales, namely internalizing and externalizing behaviour problems. The scale internalizing behaviour problems consists of three subscales: anxious/depressed,
withdrawn/depressed, and somatic complaints. The scale externalizing behaviour problems consists of two subscales: rule breaking behaviour, and aggressive behaviour. Other syndrome subscales of the CBCL that are not part of the two broadband syndrome scales internalising and externalising are: social problems, problematic thoughts, and attention problems. Internal consistency values in this study range between .70 and .90 for the syndrome subscales and values between .88 en .94 were obtained for the total scale and broad-band syndrome scales.
Quality of Life. Quality of life was measured with the KIDSCREEN-27 quality of life questionnaire. The KIDSCREEN-27 was designed to address generic health-related quality of life (HRQoL) in a standardized format and is applicable to healthy and chronically ill children and adolescents from 8-18 years (Ravens-Sieberer et al., 2006). This study used the proxy report, designed for parents. The KIDSCREEN-27 measures five HRQoL dimensions: Physical Well-being (5 items); Psychological Well-being (7 items); Autonomy and Parent Relations (7 items); Social Support and Peers (4 items); and School Environment (4 items). An example of a question is: ‘Did your child have the chance to talk to his/her parents when he/she wanted to?’ (item of the Autonomy and Parent Relations scale). The items are scored on a 5-point scale ranging from ‘never/not at all’ to ‘always’. Item intra-class correlation between self-reported scores and scores from parents filling out the KIDSCREEN-27 proxy-version range from .44 and .61 (Ravens-Sieberer et al., 2006). Internal consistency values in this study range between .72 and .91.
Parental psychopathology. Parental psychopathology was assessed with the Adult Self Report (ASR, Achenbach & Rescorla, 2003). The ASR measures a broad range of behavioural problems in adults and contains 123 questions which are rated on a 3-point scale, just like the CBCL. An example item is ‘I cannot get along with other people’. A total problem scale is created by summing the score of all items. The ASR consists of two broad-band syndrome scales: internalizing and externalizing
problems. The scale internalizing problems consists of three syndrome subscales; anxious/depressed, withdrawn/depressed, and somatic complaints. The scale externalizing problems also consists of three subscales; aggressive behaviour, rule-breaking behaviour, and intrusive behaviour. Two other
syndrome subscales that are included in the ASR are thought problems, and attention problems. High scores on the syndrome scales indicate clinically important deviance, with scores on the total problem scale above 68 (women) or 69 (men) indicating clinically elevated levels of behaviour problems. For internalizing and externalizing problems, the cut-off scores respectively are 23 and 16 (women), and 19 and 14 (men). Internal consistency values in this study range between .83 en .96 for the total scale and broad-band syndrome scales, values between .57 and .90 were obtained for the syndrome subscales.
Stress Index-Short (NOSI-K) and the Nijmeegse Parenting Stress Index – Subscale Competence (NOSI-C, de Brock, Vermulst, Gerris, & Abidin, 1992). The NOSI-K consists of 25 items, which are rated on a six-point scale, ranging from ‘I completely disagree’ to ‘I completely agree’. The NOSI-K is a short version of the NOSI (123 items), and is constructed by combining the 25 items that had the highest loading on the scale ‘general parenting stress’. An example item is ‘My child is more
demanding to me than most other children’. A higher score on the NOSI-K indicates higher feelings of parenting stress. The competence subscale consists of 13 items, from which six items are also part of the NOSI-K. A higher score on the NOSI-C indicates higher feelings of stress concerning the parents’ perceived capabilities in raising their child. An example item of the NOSI-C is: ‘While being a parent, I’m in doubt whether I can handle most situations’. For both the competence subscale and the total NOSI-K, norm scores are available to interpret the scores for both mothers and fathers. Scores on the competence subscale indicated as above average (above 31 for mothers and above 30 for fathers) are interpreted as clinically relevant. Elevated levels of clinical significance on the NOSI-K totalscale are also indicated with an above average score (above 61 for mothers and above 53 for fathers). Internal consistency values in this study range between .86 and .95 for the competence scale, and between .87 and .93 for the total stress scale.
Statistical analyses
Prior to analysis, several univariate outliers were detected for each dependent variable (-3.29 > z > 3.29, p < .001), however there were no differences in outcomes when analysing with and without outliers. Therefore the decision was made to conduct the analyses including outliers. Mahalanobis distance was calculated in order to detect multivariate outliers. With all variables included in the model, three multivariate outliers were detected beyond the critical χ2
of 76.154, for 50 df at α=.001. The analyses were run with and without those outliers, which showed only one small difference on the p-value of AD concerning child internalizing problems (multivariate outliers included p = .049; multivariate outliers excluded p = .051). It was decided to keep multivariate outliers in analyses. Assumptions were checked for the residuals of the different models. Inspection of residual plots showed a normal distribution for the different variables.
Multilevel analyses using maximum likelihood estimation procedures were used to examine group differences in child psychopathology, quality of life, parental psychopathology, and parental stress. Multilevel data analysis was used to analyse a repeated-measures design, with reports of mothers and fathers treated as repeated measures. An advantage of multilevel data analysis is that it does not require complete data over measures, nor is there a need for equal numbers of cases in each group (Tabachnick, & Fidell, 2012). Therefore, all available data is used in analysis, including those cases of which one parent did not participate. Moreover, multilevel takes into account the dependency among respondents, as both respondents in this study are nested within one child (grouping variable). Each (sub)scale of the different measures (CBCL, KIDSCREEN-27, ASD, NOSI-K, NOSI-C) was used separately as a dependent variable in analysis. Clinical groups were treated as dichotomous measures, by creating dummy variables and the variables ASD, ADHD, and AD were used as predictors. The reference group in each analysis is the Disorder NOS group. When a significant difference was found, additional analyses were conducted with the predictor that showed a significant difference treated as the new reference group. This approach was taken to be able to compare the other subgroups. The continuous variables were transformed into standardized scores. In this way the parameter estimates of the dummy variables can be interpreted as a measure of effect size (Cohen’s d). Age of the child was added as a covariate; however this did not account for any differences and was therefore left out of analysis. Moreover, when adding ‘respondent’ to the analyses, no interactions with respondent and diagnosis were found and this variable was dropped from the final models that are presented in this paper. Lastly, chi-square analyses were conducted to examine whether there were differences between clinical groups on the parental measures (psychopathology and stress) with regards to clinically relevant scores.
Results
Child Psychopathology
In order to examine whether there are differences between the groups on child psychopathology, group differences were examined using the CBCL (sub)scales. Mean scores and standard deviations
are shown in Table 3; mean scores of the subscales are presented in Figure 1. No group differences were found for the total problem scale. Therefore, the broadband subscales were examined next. A difference was found on the scale internalizing problems, where both children with ASD and children with AD had a significantly higher score than children with Disorder NOS (respectively β = .570, p = .015, and β = .428, p = .049). Additional analyses revealed that children with ASD (β = .700, p < .001) and children with AD (β = .558, p < .001) also had a significantly higher score than children with ADHD on internalizing problems. On the scale externalizing problems, a difference was found for children with AD, who had a significantly lower score than the reference group (β = -.662, p = .004). In addition, children with AD had a significantly lower score on externalizing problems than children with ASD (β = -.627, p = .001) and ADHD (β = -.461, p = .002).
Next, the subscales of the CBCL were inspected. Differences were found on the subscale anxiety problems, with children with AD reporting higher anxiety problems than children with Disorder NOS (β = .488, p = .031). Additional analyses revealed that children with AD also had significantly more anxiety problems than children with ADHD (β = .565, p < .001). The ASD group had a higher score on the withdrawn/depressed subscale, reporting higher scores than children with Disorder NOS (β = 1.032, p < .001), as well as higher scores than children with AD (β = .765, p < .001) or ADHD (β = 1.181, p < .001). No differences were found between groups on the subscale somatic complaints. Children with AD had significantly lower scores than children with Disorder NOS on rulebreaking behaviour and aggressive behaviour (respectively β = .732, p = .001, and β = -.560, p = .016). Additional analyses revealed that children with AD also had lower levels of rule-breaking behaviour and aggressive behaviour than children with ASD (respectively β = -.623, p = .001 and β = -.562, p = .004), and children with ADHD (β = -.494, p < .001 and β = -.396, p = .007). Children with ASD had significantly more thought problems than the reference group (β = .817, p = .001), and more thought problems than children with AD (β = .462, p = .013) and ADHD (β = .600, p < .001). The subscale attention problems showed differences for children with ADHD, who exhibited more attention problems than children with disorder NOS (β = .669, p < .001), and more attention problems than children with AD (β = 1.109, p < .001) and ASD (β = .370, p = .015). Additional
analyses revealed that children with AD exhibited significantly less attention problems than all other groups (β values range from -.441 to -1.109 and p values range from p < .001 to p = .030). With respect to social problems, it was found that AD children seem to have slightly less social problems than children with disorder NOS (β = -.420, p = .064). In addition, children with ASD had
significantly more social problems than children with AD (β = .666, p < .001) and ADHD (β = .590, p = .001).
Quality of Life
Children with ADHD were reported to have a higher score than children with Disorder NOS on the KIDSCREEN-27 subscale psychological functioning (β = .451, p = .031). Additional analyses revealed that children with ADHD also had a higher score than children with ASD (β = .693, p < .001), and borderline significantly higher than children with AD (β = .270, p = .056). In addition, children with ADHD had a higher score than children with Disorder NOS on the subscale social functioning (β = .456, p = .027). Further, it was found that children with ASD are reported to have lower scores on social functioning than children with AD (β = -.563, p = .003) and ADHD (β = -.671, p < .001). Children with ADHD had a significantly lower score on school functioning than children with AD (β = -.310, p = .032). Mean scores and standard deviations are shown in Table 4, and visualized in Figure 2. There were no significant differences between the groups on the subscales physical functioning, and autonomy and parent-child relation.
Table 3
Means (M) and Standard Deviations (SE) of scores on CBCL and KIDSCREEN, Classified by Diagnosis
ASD ADHD AD NOS
M (SE) M (SE) M (SE) M (SE)
CBCL Total 62.80 (2.92) 50.40 (1.55) 47.05 (2.20) 53.32 (4.03) Internalizing 18.65 (1.08) 12.18 (0.59) 17.79 (0.89) 14.12 (1.40) Externalizing 15.59 (1.08) 13.12 (0.59) 9.15 (0.70) 15.34 (1.51) Anxious 7.57 (0.54) 5.74 (0.31) 8.86 (0.50) 6.61 (0.79) Withdrawn 7.26 (0.42) 3.25 (0.18) 4.61 (0.31) 3.83 (0.46) Somatic 3.83 (0.38) 3.19 (0.21) 4.31 (0.29) 3.68 (0.51) Social 7.03 (0.48) 4.75 (0.23) 4.62 (0.33) 6.20 (0.56) Thought 7.10 (0.52) 4.71 (0.24) 5.49 (0.40) 4.15 (0.45) Attention 8.96 (0.48) 10.54 (0.23) 6.00 (0.38) 7.83 (0.61) Rule-breaking 4.14 (0.36) 3.53 (0.20) 2.00 (0.18) 4.22 (0.61) Aggressive 11.45 (0.83) 9.59 (0.46) 7.15 (0.57) 11.12 (1.01) KIDSCREEN Physical 46.03 (1.50) 52,87 (0.78) 47.68 (1.16) 49.34 (1.78) Psychological 38.67 (1.07) 45.54 (0.65) 42.87 (1.10) 40.78 (1.11) Autonomy 50.04 (0.94) 50.34 (0.54) 51.43 (0.81) 49.20 (1.32) Social 44.61 (1.42) 51.79 (0.58) 50.21 (1.00) 46.61 (1.53) School 44.58 (1.09) 43.62 (0.57) 46.73 (0.95) 45.03 (1.25)
Figure 1. Mean scores of clinical groups on the eight syndrome subscales of the CBCL. Higher scores indicate higher levels of behavioural problems on each subscale.
2 3 4 5 6 7 8 9 10 11 12 Me an sco re ASD ADHD AD NOS
Figure 2. Mean scores of clinical groups on the five quality of life dimensions of the KIDSCREEN-27. Higher scores indicate a higher quality of life on each dimension.
Parental Psychopathology
Results of the multilevel analyses of parental psychopathology did not reveal any significant differences between the groups. Additional analyses showed that approximately 8% of the mothers had a score in the clinical range on the total problems scale of the ASR (10.5% internalizing problems; 7.3% externalizing problems). For fathers these numbers were 5.3% for total problems, 11.1% for internalizing problems, and 6.8% for externalizing problems. When including scores in the subclinical range, 16.7% of the mothers obtained a score in the (sub)clinical range for total problems (18.2% internalizing problems, and 18.7% externalizing problems). For fathers, the percentages of scores in the (sub)clinical range were 13.0% for total problems, 21.3% for internalizing problems, and 16.9% for externalizing problems. Additional chi-square analyses did not reveal significant
differences between the four groups on (sub)clinical scores of parents on the ASR. 35 37 39 41 43 45 47 49 51 53 55
Physical Psychological Autonomy Social School
Me an sco re ASD ADHD AD NOS
Parental Competence and Stress
There were no differences between the groups on self-reported feelings of parental competence (NOSI-C). However, differences were present on the total stress scale (NOSI-K): parents of AD children reported significantly lower feelings of stress than parents of the reference group (β = -.470, p = .031). Additional analyses revealed that parents of children with AD also had lower scores of parental stress than parents of children with ASD (β = -.632, p = .001) and ADHD (β = -.304, p = .027).
For both parental competence and parental stress, it was examined which percentage of the parents obtained a score in the clinical range. Table 5 shows that 32.4% of both mothers and fathers had an above average score on parental competence. Additional chi-square analyses showed that the groups differed significantly from each other when compared on elevated levels of clinical
significance on parental feelings of competence for mothers (χ2 (3, N = 247) = 8.43, p = .038), but not fathers (χ2 (3, N = 207) = 1.76, p = .623). Inspection of results showed that mothers of children with AD had significantly less scores in the above average range than mothers of the other groups (p’s < .05). Table 5 shows that 48.5% of the mothers and 52.7% of the fathers had an above average score on parental stress. Groups differed significantly on above average levels of parental stress reported by mothers (χ2 (3, N = 241) = 14.80, p = .002), but not fathers (χ2 (3, N = 201) = 5.66, p = .130). Results indicated that mothers of children with AD showed less elevated levels of parental stress than the other mothers (p’s < .05).
Table 4
Means (M) and Standard Deviations (SE) of scores on ASR and NOSI, Classified by Diagnosis and Respondent (M=Mother; F=Father)
ASD ADHD AD NOS
M F M F M F M F
M (SE) M (SE) M (SE) M (SE) M (SE) M (SE) M (SE) M (SE)
ASR Total 32.59 (4.01) 34.03 (4.02) 35.59 (2.26) 33.09 (2.18) 32.78 (3.31) 28.61 (3.64) 29.90 (4.57) 32.05 (4.26) Internalizing 10.86 (1.64) 9.03 (1.27) 11.65 (0.86) 9.78 (0.80) 11.74 (1.37) 10.43 (1.57) 9.75 (1.65) 9.95 (1.45) Externalizing 6.90 (1.16) 9.62 (1.40) 7.84 (0.59) 8.87 (0.61) 7.26 (0.79) 6.15 (0.87) 6.35 (1.25) 7.90 (1.24) Anxious 6.17 (1.06) 4.34 (0.74) 6.68 (0.57) 4.79 (0.48) 6.65 (0.87) 4.80 (0.84) 5.75 (1.11) 4.90 (0.84) Withdrawn 2.03 (0.40) 2.97 (0.48) 1.83 (0.22) 2.77 (0.25) 1.76 (0.30) 3.09 (0.45) 1.75 (0.52) 3.20 (0.57) Somatic 2.66 (0.43) 1.72 (0.35) 3.14 (0.26) 2.22 (0.25) 3.33 (0.44) 2.54 (0.43) 2.65 (0.53) 1.85 (0.39) Thought 1.41 (0.34) 2.10 (0.40) 1.47 (0.16) 1.39 (0.18) 1.43 (0.25) 1.50 (0.27) 1.35 (0.35) 1.50 (.394) Attention 6.41 (0.95) 5.97 (0.78) 7.34 (0.57) 6.72 (0.51) 6.13 (0.80) 4.87 (0.70) 4.75 (1.22) 6.30 (1.08) Aggressive 4.17 (0.67) 5.03 (0.81) 4.87 (0.36) 4.68 (0.38) 4.76 (0.58) 3.37 (0.59) 4.35 (0.76) 3.65 (0.61) Rule-breaking 1.48 (0.27) 2.59 (0.48) 1.96 (0.24) 2.61 (0.23) 1.54 (0.20) 1.89 (0.33) 1.60 (0.33) 2.95 (0.52) Intrusive 1.24 (0.39) 2.00 (0.48) 1.01 (0.15) 1.59 (0.20) 0.96 (0.19) 0.89 (0.18) 0.80 (0.27) 1.30 (0.47) NOSI Competence 28.14 (2.17) 28.79 (1.82) 28.31 (1.09) 26.51 (1.02) 26.09 (1.43) 26.30 (1.62) 28.95 (2.17) 28.35 (2.33) Stress 73.79 (4.58) 71.00 (4.40) 63.90 (2.36) 58.73 (2.38) 58.00 (3.10) 55.63 (3.17) 71.95 (5.67) 61.65 (5.27)
Table 5
Percentages of Mothers (M) and Fathers (F) with Scores in the Clinical Range on the ASR and NOSI, Classified by the Child’s Diagnosis
TOTAL ASD ADHD AD NOS
ASR M N=247 F N=207 M n=39 F n=32 M n=127 F n=103 M n=59 F n=51 M n=21 F n=21 Total 8.1 5.3 7.7 3.1 8.7 6.8 8.5 5.9 4.8 0 Internalizing 10.5 11.1 12.8 6.2 9.4 14.6 15.0 9.8 0 4.8 Externalizing 7.3 6.8 10.3 9.4 8.7 5.8 3.4 5.9 4.8 9.5 NOSI Competence 32.4 32.4 28.2 34.4 37.3 28.8 19.7 34.0 47.6 42.9 Stress 48.5a 52.7b 59.5 67.7 53.3 53.5 27.9 40.8 61.9 55.0 a N=241, bN=201 Discussion
This study showed that children with ASD, ADHD, AD, and Disorder NOS differed from each other on behavioural problems, quality of life, and parental stress. Children with ASD and children with AD were reported by their parents to have higher scores on internalizing problems than children with ADHD and children with NOS. Children with AD had less externalizing problems than children with ASD, ADHD, and NOS. This finding is in line with the criteria for the diagnosis AD; these children show symptoms of internalizing problems. Also in line, children with AD have less externalizing problems than all other groups. Children with ADHD were found to have more attention problems than all other groups, which is in line with their diagnosis and the high correlation of .80 between this subscale of the CBCL and DSM criteria for ADHD (Verhulst & van der Ende, 2013). An important finding is that children with ASD have higher internalizing problems, and mainly on the subscale withdrawn/depression. Moreover, it was found that children with ASD have a higher score on the subscale thought problems than all other groups, which includes strange behaviours and repeated acts. These findings are in line with Bölte, Dickhut, and Poustka (1999), who state that these scales reflect behaviours that can be interpreted as typical autistic symptoms.
The results of this study support the finding that children with ADHD had a higher self-reported quality of life than children with other disorders (Thaulow & Jozefiak, 2012). The results on
the quality of life measure revealed that children with ADHD had a higher quality of life than children with ASD and NOS on both psychological functioning and social functioning. Moreover, children with AD have a higher score on social functioning than children with ASD. This is also in line with the finding that children with ASD have a poorer quality of life than other children (Bastiaansen et al., 2004). Differences found on the subscale school functioning revealed that children with AD had higher scores than children with ADHD. It is interesting that children with ADHD have a higher psychological and social functioning, but not a higher school functioning. This indicates that it is important to measure quality of life on several domains, as this reveals that despite of their lower school functioning, children with ADHD do have a higher psychological and social functioning than the other children. It might be that the different disorders have a different impact on various domains of functioning: for example, ADHD would be more likely to affect school functioning, while anxiety problems may be more likely to affect psychological and social functioning. This is an important finding with regards to further treatment directions.
In contrast with previous studies, no differences were found on measures of parental
behaviour problems between the child diagnosis groups. An explanation for the lack of differences on parental behaviour problems is that parents of children with a clinical diagnosis are more alike than other parents; however, further research is necessary to examine this statement. Moreover, inspection of the clinical levels of parental responses showed that only 6-11% of the parents reported above the cut-off score for internalizing or externalizing problems. It is unclear whether the relatively highly educated sample of parents in the current study, influenced these results.
This study does support the finding that levels of parental stress are elevated at parents of children with different clinical diagnoses. Parents of anxious children reported less stress than parents of the other groups. In addition, analyses of maternal stress revealed that the least clinical responses were reported by mothers of anxious children. This finding might be explained by the internalizing behaviour of children with AD, which might raise less feelings of stress than the externalizing
behaviour of the other groups. Further research is needed to investigate this assumption, as research to date only indicates that maternal stress is associated with children’s both anxious and depressive symptoms (Rodriguez, 2011) as well as externalizing problems (Barry et al., 2005), but no previous
studies that the authors know of have compared parental stress levels between clinical groups with internalizing or externalizing behaviour problems.
One limitation of this study is the lack of a control group of typically developing children. Therefore, results of the present study can only be generalized to the clinical groups that are included in this sample. It would be interesting to examine whether these clinical groups also differ from typically developing children on these measures, especially with respect to parental psychopathology. Moreover, not all clinical diagnoses were confirmed with a structured diagnostic interview, which can influence the external validity of this study, as clinicians might interpret DSM criteria differently when diagnosing a child. A third limitation is that only parent reports were used; parents tend to underestimate internalizing behaviour of their child, and studies have shown that discrepancies exist between reports of different informants (Achenbach, McConaughy, & Howell, 1987, De Los Reyes & Kazdin, 2005). Moreover, it is unclear whether parents in the current study reported socially desirable on their psychopathology and stress, which might have influenced results.
This was one of the first studies to compare four clinical groups on both child and family factors. It was found that children with ASD, ADHD, AD, and Disorder NOS have different patterns of behavioural problems, quality of life, and parental stress. No differences were found in parental behavioural problems, and only a small amount of parents reported clinically relevant levels of their behavioural problems. The findings imply that children with these diagnoses need a different
approach in both parenting and clinical treatment, as they exhibit different behavioural problems and other domains of quality of life are affected. Moreover, parents of children with ADHD, ASD, and Disorder NOS might experience elevated levels of parental stress, which should be addressed in treatment. Additional research is needed to examine whether these findings remain when compared to a control group of typically developing children.
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