Behavior Problems and Parenting Stress in Families of Three-Year ...

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AMERICAN JOURNAL ON MENTAL RETARDATION

Behavior Problems and Parenting Stress in Families of Three-Year-Old Children With and Without Developmental Delays Bruce L. Baker University of California, Los Angeles Jan Blacher University of California, Riverside Keith A. Crnic and Craig Edelbrock The Pennsylvania State University

Abstract Children and adolescents with mental retardation are at heightened risk for mental disorder. We examined early evidence of behavior problems in 225 three-year-old children with or without developmental delays and the relative impact of cognitive delays and problem behaviors on their parents. Staff-completed Bayley Behavior Scales and parent-completed Child Behavior Checklists (CBCLs) showed greater problems in children with delays than in those without delays. Children with delays were 3 to 4 times as likely to have a total CBCL score within the clinical range. Parenting stress was higher in delayed condition families. Regression analyses revealed that the extent of child behavior problems was a much stronger contributor to parenting stress than was the child’s cognitive delay.

Adults with mental retardation are at heightened risk for mental disorder, a phenomenon termed dual diagnosis. The limited literature on dual diagnosis in children, derived mainly from the study of adolescents with mental retardation, indicates a higher incidence as well (Gillberg, Persson, Grufman, & Themner, 1986; Jacobson, 1990). Two recent population-based studies extended the age limit downward. Stromme and Diseth (2000), examining all children ages 8 to 13 years born during a 5-year period in a county in Norway, found that 37% of those with mental retardation met International Classification of Diseases–10th ed. (ICD-10) criteria for psychiatric disorder. Steffenburg, Gillberg, and Steffenburg (1996) found that 59% of children 8 to 16 years of age who had mental retardation and epilepsy had at least one psychiatric disorder. We do not know yet, however, whether even younger chilq American Association on Mental Retardation

dren with delays are at the same heightened risk as these older children and adolescents. Despite high prevalence rates, dually diagnosed children have been among the least understood and most underserved of any group with disabilities (M. Campbell & Malone, 1991; Pfeiffer & Baker, 1994; Reiss, Levitan, & McNally, 1982). Dual diagnosis presents unique diagnostic and treatment challenges and leaves children at particular risk for unfavorable long-term life outcomes. Placement is more likely when children with mental retardation have serious maladaptive behaviors that challenge the family’s capacity to manage the child or adolescent effectively (Blacher, 1994; Borthwick-Duffy & Eyman, 1990; Bromley & Blacher, 1989; McIntyre, Blacher, & Baker, 2001). Beyond placement considerations, serious maladaptive behavior among persons with mental retardation predicts academic problems, failure in 433

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Behavior problems and parenting stress

community living arrangements, frequent moves, social isolation and rejection, and reduced employment prospects (Borthwick-Duffy & Eyman, 1990; Bruininks, Hill, & Morreau, 1988; Pearson et al., 2000). Clearly, dual diagnosis is of serious concern. The overall aim of our research program is to derive a better understanding of this heightened risk in children with developmental delays. To track problem development, we have begun assessment of problem behaviors when children are 3 years old. Our focus in this paper is on mothers’ and fathers’ reports of problem behaviors exhibited by young children with and those without delays. Moreover, we have considered the impact that child problem behaviors have on parents’ experience of stress. We would not expect to find much diagnosable mental disorder per se during the preschool years. However, longitudinal studies of typically developing children have found high continuity for behavior problems across the childhood years; this is especially true for externalizing problems, such as aggression, noncompliance, conduct problems, and hyperactivity (S. Campbell, 1994; S. Campbell, Breaux, Ewing, & Szumowski, 1984; Egeland, Kalkoske, Gottesman, & Farrell-Erickson, 1990; Heller, Baker, Henker, & Hinshaw, 1996). Thus, our primary question is: What, if any, problem behaviors already differentiate young children with and without cognitive delays? There is little known about how early in life children with delays evidence heightened problem behaviors. Studies of typically developing preschoolers have found a modest negative relationship between child cognitive ability and behavior problems. Hay and coworkers (1997), studying a sample of 93 typically developing 4-year-olds in South London, reported negative correlations between child IQ and mothers’ and fathers’ Child Behavior Checklist (CBCL) behavior problem scores. Similarly, Dietz, Lavigne, Arend, and Rosenbaum (1997), studying typically developing children ages 2 to 5, found that lower verbal or performance IQ predicted higher externalizing and internalizing CBCL scores. On the other hand, Feldman, Hancock, Reilly, Minnes, and Cairns (2000a) in their study of 2-year-olds with intellectual delays did not find elevated problems on this measure relative to published norms, although the delays were mild and in some cases questionable. Researchers comparing preschoolers with and 434


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without delays have found more problem behaviors in those with delays. Kopp, Baker, and Brown (1992) reported social deficits in 15 children with delays who were 4 years old (range 5 3 to 5), contrasted with 15 playmates without delays. Play was observed in triads of 1 child with delays and 2 without delays; the child without delays closest in age to the child who had delays was chosen for comparison. Observations showed significantly more ‘‘no-play’’ intervals for children with delays. Within intervals where play took place, delay group children engaged in solitary play (rather than parallel or social play) 33% of the time versus 12% for children without delays. Moreover, children with delays showed much disruptive entry (53% vs. 0%), and only 53% of children with delays at some time smiled and/or laughed to their peers in contrast to 93% of children without delays. On the Behavioral Screening Questionnaire (Richman, Stevenson, & Graham, 1982), parents of children with delays reported significantly higher behavior problem scores. Merrell and Holland (1997) found similar differences in a large survey study of 398 children ages 3 to 5 years. Half of these children were categorized by teachers as delayed, although no criteria were reported; measures were completed by ‘‘parents or teachers,’’ without further specification. Social skills deficit and behavioral–emotional problem excesses were each 4 to 5 times as likely in those children with delays. The greatest differences were in the social domain: social interaction and independence skills and socially withdrawn behavior patterns. There is some evidence, then, of increased problem behaviors in children with delays by age 3, although there is a need for further study with better defined assessment procedures and child delay status. There has been considerable study of families raising a child with mental retardation (Baker, Blacher, Kopp, & Kraemer, 1997). At a practical level, these families experience excessive caretaking demands, financial burden, and restrictions on leisure activities and social lives as well as disruptions of family plans (Gunn & Berry, 1987; Rodrique, Morgan, & Geffken, 1992). Not surprisingly, parents experience increased stress, especially in domains related to childrearing (Baker et al., 1997; Crnic, Friedrich, & Greenberg, 1983; Fidler, Hodapp, & Dykens, 2000; Orr, Cameron, Dobson, & Day, 1993; Minnes, 1988), Parental stress, in turn, is one domain of family risk and protecq American Association on Mental Retardation

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tive factors that may be relevant to the emergence of psychiatric problems in children with mental retardation (Crnic & Greenberg, 1987; Margalit, Shulman, & Stuchiner, 1989). A lingering question is whether the heightened stress represents a chronic reaction to intellectual disability per se or a reaction to the often associated behavioral challenges that families face. Our second question, then, is: Do parents of 3-year-olds with delays already experience heightened child-related stress, and, if so, what are the relative contributions of cognitive delay versus problem behaviors to parental stress levels? Although negative impact has garnered the largest share of research attention, there has been a recent trend to also consider the more positive or growth-promoting effect that a child with mental retardation can have on the family. The potentially positive impact on families may operate through specific positive contributions of disability on family members (Turnbull et al., 1993) as well as through promoting positive coping strategies and adaptation (Crnic et al., 1983; Hawkins, Singer, & Nixon, 1993). We also examined the influence of child behavior problems on parents’ positive views of childrearing. Assessment of child behavior problems relies heavily on informants’ opinions, usually through checklists. Most studies of young children have relied on mothers as informants. Yet, mothers and fathers have different relationships with their child and different opportunities to observe their child’s behavior; moreover, any informants’ responses are to some degree influenced by his or her own personality (Achenbach, McConaughy, & Howell, 1987; Hay et al., 1999; Phares, 1996). Studies in which mothers and fathers have both completed CBCLs have reported significant but modest correlations (Baker & Heller, 1996; Hay et al., 1999). For example, in the Hay and colleagues study just noted, although the mean scores for mothers and fathers did not differ on any scale, the correlation between mothers and fathers was .32 for Total score and .42 for Externalizing; the correlation for Internalizing problems did not reach significance. There has been little study of how fathers of children with delays perceive problem behaviors or of how these behaviors affect their experience of parenting stress. Our third questions, then, is: Do fathers and mothers differ in their perception of problem behaviors in children with and without delays and/ or in their experience of parenting stress? q American Association on Mental Retardation

Method Participants Participants were 225 families with a 3-yearold child. These families had been recruited to participate in a 2-year longitudinal study of young children from ages 3 to 5 years, with samples drawn from Central Pennsylvania and Southern California. The children were classified as having delays (n 5 92) or not having delays (n 5 133). Delayed condition families were recruited primarily through community agencies that serve persons with developmental disabilities. The selection criteria were that the child (a) be between 30 and 39 months of age; (b) receive a score on the Bayley Scales of Infant Development II (see below) between 30 and 85; (c) be ambulatory, and (d) not be diagnosed with autism. Nondelayed condition families were recruited primarily through preschools and daycare programs. The selection criteria were that the child (a) be between 30 and 39 months of age; (b) receive a score on the Bayley Scales of 85 or above; (c) not be born prematurely or have a developmental disability. Table 1 shows the demographic characteristics of this sample by group status (delayed, nondelayed). The intake assessment was conducted, on average, just before the child’s third birthday (35.2 months; standard deviation [SD] 5 3.0). In the combined sample, there were more boys than girls (57%), and 61% of the children were Caucasian. Recruitment initially focused on intact families, so most participants (86%) were married (defined here as legally married or living together at least 6 months). The socioeconomic status (SES) was generally high, with 51% of mothers and 51% of fathers having graduated from college, and 53% of families having an annual income of $50,000 or more. The two conditions did not differ on the child attributes shown in Table 1. The conditions differed on the parent and family attributes that indicated SES; these were significantly higher in the nondelayed families, with a greater percentage of mothers and fathers graduating from college and more families with incomes at $50,000 or more. We covaried SES indicators in subsequent analyses where these correlated significantly with the dependent variable.

Assessments The data considered in this study were obtained in two ways. The measures of child’s de435

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Table 1. Demographics by Group Delayed (n 5 92)

Nondelayed (n 5 133)

t or chi squared

Child Age at testing (months) Gender (% boys) Race (% Caucasian) Siblings (% only children) Bayley Scales: MDIa

35.6 64.1 60.9 30.4 57.9

35.0 51.9 60.9 29.3 104.6

1.59 2.85 0.00 0.00 29.58***

Parent and family Marital status (% married) Mother educ. (% college degree) Mother employment (%) Father education (% college degree)b Family income (% $50K1)c

80.4 31.5 52.2 34.6 43.5

89.5 61.7 61.7 58.4 59.8

2.94 18.57*** 1.63 9.94** 5.20*

Variable

Mental Development Index. bN 5 203. cN 5 224. *p , .05. **p , .01. ***p , .001.

a

d

The ts are in boldface.

velopmental level and problem behaviors were obtained at the home intake assessment session, conducted when the child was between 30 and 39 months of age. Prior to this session, parents had completed a telephone intake interview with our staff and had received project descriptions and the informed consent form. Two trained researcher assistants visited the family for a 2-hour assessment session. After reviewing procedures, answering questions, and obtaining informed consent, the staff administered the Bayley Scales of Infant Development to the child. During this testing, mother, and father if present, completed a demographic questionnaire and the CBCL (see below). Measures that were not completed during the assessment session were mailed to us soon thereafter. Immediately following the home assessment session, the two staff members completed the Bayley Behavior Problems Scales together. The measure of the child’s impact on the family was part of a measure packet completed prior to a home observation, conducted at 36 months or soon after the intake, if the intake was later than 36 months.

Measures Bayley Scales of Infant Development II (Bayley, 1993). The Bayley Scales are a widely used assessment of mental and motor development of children ages 1 to 42 months. This instrument was administered in the child’s home, with the mother present. In most cases, there was a primary ex436

aminer and an assistant. Only mental development items were administered; the Mental Development Index (MDI) is normed with a mean of 100 and an SD of 15. Bayley (1993) reported high short-term test–retest reliability for the MDI, r 5 .91. Also, with children ages 36 to 42 months, the MDI related to the Full-Scale IQ of the Wechsler Preschool and Primary Scale of Intelligence–Revised (WPPSI–R), r 5 .73 (Bayley, 1993). Behavior Rating Scale. The examiner completes this checklist following the testing session. The scale has three dimensions: Orientation/Engagement (12 items), Emotion Regulation (10 items), and Motor Quality (8 items). We only included the first two dimensions in the present study. Examiners scored collaboratively, discussing any disagreements and arriving at a joint rating. To determine interjudge reliability, for a subsample of 25 protocols, the two examiners completed the scale separately and then arrived at consensus ratings. For each pair, the examiner with the most experience using Bayley Scales was designated as the standard. There was very high agreement between raters, r (23) 5 .96, p , .001. CBCL for Ages 1.5–5 (Achenbach & Rescorla, 2001). This is a new version of the widely used CBCL (Achenbach, 1991), aimed at the preschool years. It has 99 items that indicate child problems, listed in alphabetical order (from ‘‘aches and pains without medical cause’’ to ‘‘worries’’). The respondent indicates, for each item, whether it is not true q American Association on Mental Retardation

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(0), somewhat or sometimes true (1), or very true or often true (2), now or within the past 2 months. This CBCL yields a Total problem score, broadband Externalizing and Internalizing scores, and narrow-band scales (Emotionally Reactive, Depressed/Anxious, Withdrawn, Somatic, Sleep Problems, Attention, and Aggression). Scale sum scores were used in analyses. Alphas for the present sample were rs of .94 for both mothers and fathers. The CBCL also yields T scores, with the mean set at 50 and an SD of 10. We report these for the Total scale, where the mean is set at 50 and SD is 10; T scores for the narrow-band scales are truncated at 50 and, thus, are not as valid for correlational analyses. Family Impact Questionnaire (Donenberg & Baker, 1993). This instrument is a 50-item questionnaire that is used to measure the ‘‘child’s impact on the family compared to the impact other children his/her age have on their families’’ (e.g., Item 1: ‘‘My child is more stressful’’). Parents endorse items on a 4-point scale, ranging from not at all to very much. Five scales are used to measure negative impact on Feelings About Parenting (9 items), Social Relationships (11), Finances (7), and, if applicable, Siblings (9) and Marriage (7). One scale measures impact on positive feelings about Parenting (7). A combined score (negative impact) is the sum of the first two negative impact scales. Alphas in the present sample for negative impact were .92 for mothers and .90 for fathers; for positive impact, both alphas were .81.

Results Child Behavior Problems Mother and Father CBCL scores. In the combined sample there was high agreement between mothers’ and fathers’ CBCL scores. Pearson correlations for Total, Internalizing, and Externalizing problem scores were .68, .68, and .67, respectively. Agreement on the narrow-band scales ranged from .50 (Anxious/Depressed) to .68 (Attention Problems). All correlations were significant at the .001 level. Moreover, mothers’ and fathers’ mean scores were highly similar; mean differences did not approach significance for any broad-band or narrow-band scale. Table 2 shows parents’ agreement by delay status; parents in the delayed condition had higher agreement on every scale than did parents in the nondelayed condition. The differences between correlations were significant for the Total, q American Association on Mental Retardation

Table 2. Correlations of Mother and Father Child Behavior Checklist Scores by Group Score Total Score Internalizing Externalizing Emotional Reactivity Anxious/Depressed Somatic Withdrawal Sleep Attention Aggression

Delayeda

Nondelayedb

.75 .75 .71 .61 .52 .73 .67 .71 .71 .68

.57c .57c .63 .38c .47 .58 .57 .61 .59 .58

Note. All correlations were significant at the .001 level. a N 5 75. bN 5 126. cDifference between delay and nondelay correlations significant at p , .05.

Internalizing, and Emotionally Reactive scores. In the delayed condition, mothers’ and fathers’ mean scores did not differ on any scale. In the nondelayed condition mothers’ reported significantly higher Attention and lower Aggression scores than fathers did, p , .05. Child Behavior Scores by Delay Status. We contrasted the two status group (delayed and nondelayed) on the CBCL and the Bayley Behavior Scale scores. Analyses were conducted as 2 (status) 3 2 (gender) analyses of variance (ANOVAs). Education and family income, on which the delay status groups differed, were related to some of the dependent variables for mothers and fathers and, thus, were covaried for all analyses. Mothers’ CBCL scores and Bayley Behavior scores are shown in Table 3. On mothers’ CBCL scales, children in the delayed condition were reported to have significantly higher Total and Internalizing scores as well as higher scores on Attention and Withdrawal problems. There were several significant gender effects; boys scored higher than did girls on problems with Emotional Reactivity and Aggression as well as the Externalizing and Total scores. Boys with delays scored highest on every scale (except Sleep Problems), resulting in several significant Delay 3 Gender interactions. Children with delays were scored significantly lower on the Bayley Behavior Scales of Emotional Regulation and Orientation/Engagement; there were no gender or status by gender effects on the Bayley Behavior Scales. Fathers’ CBCL scores are also shown in Table 437

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Table 3. Child Behavior Scores by Group, Gender, and Parent Scores Delayeda Test score Mothers’ CBCL Total Score Internalizing Externalizing Emotional Reactivity Anxious/Depressed Somatic Withdrawal Sleep Attention Aggression Bayley Behavior Scales Emotional Regulation Orient./Engagement Fathers’ CBCL Total Score Internalizing Externalizing Emotional Reactivity Anxious/Depressed Somatic Withdrawal Sleep Attention Aggression

Nondelayedb

F

Boys

Girls

Boys

Girls

Status

Gender

S 3 Gc

50.3 13.2 18.5 3.6 3.1 2.9 3.5 3.7 4.4 14.2

39.6 10.1 14.3 2.3 2.9 1.8 3.1 2.8 3.8 10.5

34.1 7.7 13.7 2.3 2.2 1.5 1.6 3.4 2.4 11.3

34.1 8.4 12.6 2.3 2.6 1.9 1.6 4.1 2.1 10.5

6.73** 5.82* 3.53 0.70 0.38 1.90 23.12*** 2.03 28.88*** 0.31

5.18* 2.63 7.27** 5.13* 0.67 2.11 0.75 0.23 2.51 7.23**

5.59* 6.25* 2.77 5.74* 0.15 9.36** 0.90 4.60* 0.21 3.55

32.9 32.6

34.6 31.2

41.9 37.7

42.6 36.6

59.90*** 27.80***

1.09 1.51

0.07 0.06

45.8 11.3 17.4 2.9 2.8 2.3 3.2 3.0 4.0 13.3

40.7 10.5 14.4 2.5 2.9 2.0 3.2 3.5 3.6 10.8

29.7 6.1 12.1 1.5 2.0 1.2 1.4 3.1 2.6 9.5

34.9 9.2 12.5 2.2 2.9 2.2 1.8 4.0 2.6 9.9

9.43** 8.80** 6.28* 4.80* 0.52 1.65 21.69*** 0.76 11.33*** 4.02*

0.06 0.93 1.57 0.06 2.09 0.82 0.35 2.43 0.88 1.52

4.39* 6.04* 2.84 3.67 3.10 8.61** 0.66 0.44 0.76 3.15

Note. Analyses were run as 2 (group) 3 2 (gender) ANOVAs, covarying for mother education and family income. a Ns 5 59 and 33 for boys and girls, respectively. bNs 5 69 for boys and 63 for girls, respectively. cStatus 3 Gender. d Child Behavior Checklist. *p , .05. **p , .01. ***p , .001.

3. Fathers reported the same status group differences as mothers did, but in addition reported significantly higher scores for children with delays on Externalizing, Aggression, and Emotional Reactivity scales. Fathers did not report gender differences, but reported status by gender effects similar to mothers. Children meeting criteria for clinical range. We determined the number of children in each status group who were at or above the clinical cut-off, T score 5 64, on the Total CBCL (Achenbach & Rescorla, 2001). For mothers, the CBCL Total T score was in the clinical range for 8.3% of children without delays and 26.1% of children with delays, a ratio of 1:3.1, continuity corrected x2(1, N 5 225) 5 11.82, p , .01. For fathers, the CBCL 438

Total T score was in the clinical range for 5.6% of children without delays and 24% of children with delays, a ratio of 1:4.3, continuity corrected x2(1, N 5 201) 5 13.04, p , .001.

Family Impact For the combined sample, Family Impact Questionnaire scores were similar for mothers and fathers. On the Negative Impact Scale, parental agreement was r 5 .66; mothers’ mean score was 13.9 and fathers, 12.8 The only significant difference was on positive impact, where fathers scored higher (M 5 16.7) than did mothers (15.7), t 5 2.54, p , .05. Family impact and child status groups. We contrasted the two status group (delayed and nondeq American Association on Mental Retardation

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Table 4. Correlations of IQ and Behavior Problems With Parents’ Stress (FIQ Negative Impact) Stressa Test Bayley Mental Development Index Emotional Regulation Orientation-Engagement Child Behavior Checklist Externalizing scale Internalizing scale Total

Mothers’

Fathers’

2.34 2.41 2.23

2.29 2.37 2.29

.70 .51 .69

.65 .54 .65

Note. FIQ 5 Family Impact Questionnaire. All correlations were significant at the .001 level. a N 5 225 mothers and 198 fathers.

layed) on the Family Impact Questionnaire scales. Analyses were conducted as 2 (status) 3 2 (gender) ANOVAs, with education covaried. Parents of delayed group children reported higher negative child impact than did parents of nondelayed group children. Delayed group mothers scored higher than did nondelayed group mothers on the combined negative impact variable, F(1, 220) 5 13.76, p , .001, as well as negative impact on finances, F(1, 220) 5 21.70, p , .001. There was no status group effect for negative impact on siblings or marriage or for positive impact on feelings about parenting. Mothers of delayed boys reported the greatest negative impact. There was a significant gender effect for negative impact, F(1, 220) 5 10.99, p 5 .001, and Status 3 Gender interactions for negative impact, F(1,220) 5 7.66, p , .01, and impact on siblings, F(1,148) 5 6.19, p , .05. Fathers’ scores showed a similar pattern, although differences were not as strong. Delayed group fathers scored higher on negative impact than did nondelayed group fathers, F(1,188) 5 4.76, p , .05, as well as on negative impact on finances, F(1, 189) 5 18.08, p , .001. Fathers of delayed boys also reported the greatest negative impact; there was a significant Status 3 Gender interaction for negative impact, F(1,188) 5 6.10, p , .05. No other comparison reached significance. Parenting stress, child delay, and behavior problems. Table 4 shows the correlations between mother and father Negative Impact (stress) scores and two domains of child functioning: cognitive functioning (Bayley MDI) and behavior (CBCL and Bayley Behavior Scales). Although stress scores related significantly to the child’s cognitive functioning, the relationships with behavior problems were considerably higher. To examine this q American Association on Mental Retardation

relationship another way, we divided CBCL total scores into thirds, yielding a high, medium, and low behavior problem group. We conducted a 2 (status) 3 3 (behavior problem group) ANOVA on mother’s combined Family Impact Questionnaire Negative Impact score, with mother’s education as a covariate. Figure 1 shows mothers’ Negative Impact scores by status group and behavior problem group. Status group was significant, F(1, 218) 5 11.67, p , .01, but behavior problems group had a considerably stronger effect, F(2, 218) 5 43.62, p , .001. For the variables positive impact, negative impact on marriage, and negative impact on siblings, status group was not significant, but there were significant behavior problem group effects. For negative impact on finances, there were significant main effects for status and behavior problems as well as the only significant interaction, with delayed group high behavior problems associated with highest stress by far. We repeated these analyses for fathers’ Family Impact Questionnaire scores. The behavior problem group variable was significant for every Family Impact Questionnaire scale for our primary measure of stress, Negative Impact, F(2, 189) 5

Figure 1. Mothers stress by delay status and behavior problems (BP) group. 439

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42.62, p ,.001. Delay status was associated significantly only with Negative Impact on Finances. We examined the relationship between child characteristics and parent stress further, using hierarchical multiple regression. We considered the relative contributions of child cognitive functioning (Bayley MDI) and behavior problems (CBCL Total score; Bayley Behavior Scales of Emotional Regulation and Orientation/Engagement). The CBCL total score was modestly related to the Bayley Behavior Scale scores for mothers and fathers, rs 5 .27 to .34. We also entered the status variable (delayed, nondelayed) to detect variance in stress attributable to having a child with delays over and above the actual level of cognitive functioning. In the first analysis, we entered MDI (Step 1), status (Step 2), and behavior problems (Step 3). As shown in Table 5, these variables explained 52% of the variance in mothers’ stress, with behavior problems accounting for an additional 40% of the variance after the MDI score was accounted for; status per se did not account for variance. Each of the three behavior problem indicators was significant in the final model. To examine the extent to which cognitive functioning predicted stress after accounting for behavior problems, we conducted a further regression analysis with behavior problems entered first (Step 1), followed by MDI

(Step 2), and status (Step 3). Behavior problems accounted for 52% of the variance, with MDI and status not accounting for significant variance. Each of the three behavior problem indicators was significant in the final model. Regressions on father negative impact produced similar results, with the variables combined accounting for 46% of the variance. With MDI entered first, it accounted for 8% and behavior problems accounted for an additional 38%; the CBCL score and the Bayley Emotional Regulation score were each significant in the final model. When variables were entered in the reverse order, behavior problems accounted for 46%, with MDI and status not accounting for significant variance. Here too, the CBCL score and the Bayley Emotion Regulation score were each significant in the final model. The thrust of all of the above analyses is that child behavior problems contributed to parental stress far more than did the level of cognitive functioning.

Discussion We examined the extent of behavior problems in 3-year-old children with and without delays and the relative impact on their parents of cognitive delays and problem behaviors. Our first

Table 5. Hierarchical Multiple Regression, Predicting Parental Stress From Child’s Mental Development and Behavior Problems R

R

R change

F change

Sig F change

Mother (n 5 224) Bayley MDIa Delay status Behavior problems Behavior problems Bayley MDI Delay status

.34 .34 .72 .72 .72 .72

.12 .12 .52 .52 .52 .52

.12 .00 .40 .52 .00 .00

29.28 0.80 61.49 78.42 2.87 0.38

.000 .371 .000 .000 .092 .846

Father (n 5 193) Bayley MDI Delay Status Behavior problems Behavior problems Bayley MDI Delay status

.28 .30 .68 .68 .68 .68

.08 .09 .46 .46 .46 .46

.08 .01 .38 .46 .00 .01

17.17 1.31 44.75 54.12 0.08 2.44

.000 .254 .000 .000 .782 .120

Negative impact

3

2

Note. Behavior problems variables were: (a) CBCL total score, (b) Bayley Behavior Scales Emotional Regulation score, and (c) Bayley Behavior Scales Orientation/Engagement score. a Mental Development Index.

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question was, Do children with and without delays already show differential extent of problem behaviors by age 3? Parents of children with delays reported higher Total CBCL scores and higher broad-band Internalizing Problem scores than did parents of children without delays; indeed, children with delays were 3 to 4 times as likely to have a Total score within the clinical range. On the narrow-band scales, children with delays were most different from their peers without delays on Social Withdrawal and Attention Problems. Although fathers’ scores were higher for children with delays on Aggression and Emotional Reactivity problems, mothers’ scores were not. The groups did not differ on either parents’ scores on Anxious/Depressed, Somatic, or Sleep Problems. The strong difference in social behavior is consistent with the behavioral observations of Kopp et al. (1992) and the survey findings of Merrell and Holland (1997), discussed earlier. As children with delays grow older, this social domain may take on added importance as a moderator of other types of problems. Children with poor social interaction skills may be particularly at risk for problems with anxiety, depression, or aggression because social demands become more complex as children with delays become more aware of their differences and as peers become more rejecting. Kopp et al. (1992) found that 3-year-olds without delays were already demonstrating a higher rate of rejecting responses (80% of children) than their playmates with delays. Lang, Baker, and Henker (2001) found that among nonaggressive preschoolers, poor social skills predicted those children who subsequently became aggressive by third grade. Thus, although CBCL scores for typically developing children have been found to be reasonably stable across several early school years (Achenbach, 1991; Heller et al., 1996), we anticipated that for children with delays, there may be a tendency for behavior problems, especially externalizing ones, to increase over time with increasing cognitive and social demands, resulting in an even greater differentiation of the two groups. Our second question was, Do parents of 3year-olds with delays experience heightened stress relative to parents of children without delays, and, if so, is this stress primarily related to the children’s cognitive delay or behavioral challenges? Both mothers and fathers of children with delays reported greater negative impact of the child on the family (the variable we refer to as stress) as well q American Association on Mental Retardation


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as greater negative impact on family finances. Positive impact did not differ by delay status. Thus, parents of children with delays expressed positive feelings similar to those of parents with nondelayed children, while at the same time acknowledging more negative ones. Although many researchers have found heightened stress in families of children with disabilities, the measures commonly used to assess parental stress have a number of items tapping the child’s limitations, and these items are included in the summary score purporting to measure the parent’s stress. It is a given, therefore, that stress will appear to increase with increasing disability. The measure employed here, the Family Impact Questionnaire (Donenberg & Baker, 1993), does not ask about child functioning and then make inferences about parental stress. Rather, it was designed to avoid this problem by directly asking parents about their child’s impact on the family, relative to the impact they perceive other children having on their families. Yet the association of child delay and parental stress was still found. The experience of child-related stress, however, was related much more strongly to the presence of behavior problems than to intellectual delay. In regression analyses, for mothers and fathers, child behavior problems explained most of the variance in reports of negative impact. These analyses support the conclusion that problem behaviors, much more than the fact or extent of intellectual delay, account for the parents’ stress level. We realize, however, that two alternative explanations, where the direction of influence goes from parent to child, must be entertained. The first is that very stressed parents misperceive and misreport their children as having more behavior problems, thus creating the apparent relationship between these domains. The second is that very stressed parents, through their parenting, actually create more problem behaviors in their children. We can address the first hypothesis within our data set, as the Bayley Behavior Scales were completed not by parents but by staff members, following the in-home cognitive assessment. Although the Bayley Behavior Scales does not measure the same constructs as does the CBCL, there is a conceptual and modest statistical relationship between these scores. In the regression analyses, although the CBCL scores accounted for considerably more variance, the Bayley Behavior Scale scores also entered significantly. When we ran these same regressions with CBCL scores omitted, 441

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the pattern of findings was similar, albeit attenuated; the Behavior Scales, even without the CBCL, explained more variance in parent stress than did the MDI. Thus, we are reasonably confident that the relationship between child problems and parent stress is not spurious, based on stressed parents misreporting their child’s difficulties because we found it with variables reported by others. The second hypothesis, that stressed parents create greater problems in their children, cannot be ruled out in this data set and must await repeated assessment of these variables over time. Even if parental stress has an effect on children’s behavior and there is evidence that it does (Heller et al., 1996) it is not likely that this accounts in full for the relationships found here. Mothers and fathers appeared to be viewing their child’s behavior problems in similar ways. Their CBCL scores were highly correlated, and neither parent scored consistently higher on any scale. Moreover, mothers and fathers reported similar degrees of child-related stress, and their CBCL scores related in a similar way to their stress. The parent agreements found here were high, especially for parents of children with delays. Achenbach (1991) reported mother and father agreement on CBCL Externalizing and Internalizing scores for boys 4 to 11 to be .86 and .71, respectively; and for girls, .70 and .57. Researchers focusing on 4-year-olds with no delays, however, have reported considerably lower agreements, for example, .42 and .18, respectively (Hay et al., 1999) and .55 and .12 (Baker & Heller, 1996). Our agreements between parents of children with delays, .71 and .75, were similar to Achenbach’s correlations with children who were, on average, older. It is possible that the scales on this new 1.5to 5-year version of the CBCL will reflect better parent agreements and/or that parents of delayed children are especially attuned to their children’s behavior and more likely to communicate about it. It appears that the roots of dual diagnosis are taking hold at least by age 3. This finding has two clear implications for early intervention programs. First, developers of child programs should make social skill development and behavior problem management a central focus of the curriculum. Second, parent program personnel should share this focus on ameliorating child problem behaviors, but also work with families on strategies for coping with stress. Successful child behavior problem reduction may result in reduced parenting 442

stress as well as in reduced child risk for later mental disorder.

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ges, B. A., & Cleveland, L. A. (2000). Patterns of behavioral adjustment and maladjustment in mental retardation: Comparison of children with and without ADHD. American Journal on Mental Retardation, 105, 236–251. Pfeiffer, S. I., & Baker, B. L. (1994). Residential treatment for children with dual diagnosis of mental retardation and mental disorder. In J. Blacher (Ed.), When there’s no place like home: Options for children living apart from their natural families (pp. 273–298). Baltimore: Brookes. Phares, V. (1996). Fathers and developmental psychopathology. New York: Wiley. Reiss, S., Levitan, G. W., & McNally, R. J. (1982). Emotionally disturbed mentally retarded people: An underserved population. American Psychologist, 37, 361–367. Richman, N., Stevenson, J., & Graham, P. J. (1982). Preschool to school: A behavioural study. London: Academic Press. Steffenburg, S., Gillberg, C., & Steffenburg, U. (1996). Psychiatric disorders in children and adolescents with mental retardation and active epilepsy. Archives of Neurology, 53, 904– 912. Stromme, P., & Diseth, T. H. (2000). Prevalence of psychiatric diagnoses in children with mental retardation: Data from a population-based

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study. Developmental Medicine and Child Neurology, 42, 266–270. Turnbull, A. P., Patterson, J. M., Behr, S. K., Murphy, D. L., Marquis, J. G., & Blue-Banning, M. J. (Eds.) (1993). Cognitive coping, families, and disability. Baltimore: Brookes. Received 5/7/01, accepted 8/14/01. This article is based on activities of the Collaborative Family Study, supported by National Institute of Child Health and Human Development Grant 34879-1459 (K. A. Crnic, principal investigator, B. L. Baker, J. Blacher, & C. Edelbrock, co-principal investigators). The Collaborative Family Study is conducted at three sites: The Pennsylvania State University, University of California, Los Angeles, and University of California, Riverside. We are indebted to our staff members at these settings and very much appreciate the assistance of Carolyn Christensen, Kelly Dulan, Catherine Gaze, Juan Gomez, Casey Hoffman, Christine Low, Christopher Macauley, Laura Lee McIntyre, Sandra Minassian, Michael Rothman, and Araksia Trmrian. We especially acknowledge Lesley Keeler’s early contributions to this paper. Requests for reprints should be sent to Bruce L. Baker, Department of Psychology, UCLA, Los Angeles, CA 90095. E-mail: [email protected]

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