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Parental perception of stress and emotional-behavioural difficulties of children with autism spectrum disorder and specific language impairment

Authors:
  • Institute of Ortophonology
  • Instutute of Ortophonology
  • Institute of Ortophonology, Rome, Italy
  • Institute of Ortophonology

Abstract and Figures

Background and aims: The daily challenges of caring for a child with autism spectrum disorder affect many areas of everyday life and parental well-being, as well as parents’ ability to manage the needs of the family and the child concerned. A better understanding of parents’ perception of their child’s characteristics can allow better support for them and individualize intervention protocols in a more accurate way. The main objective of this study is the evaluation of the perception of stress by parents of children with autism compared to parents of children with specific language impairment. Methods The parents of 87 children aged between 2 and 6 years were included in this study, 34 children with a specific language impairment diagnosis and 53 children with an autism spectrum disorder diagnosis (ASD) or at risk of developing it. They were asked to complete a self-report on perceived stress and rating scales on adaptive/problematic behaviours, executive functions and sensory profile of the child. Results The results reveal that parents of ASD children, compared to the control group, showed significantly higher levels of stress, mainly due to the difficulty of managing unexpected events, the feeling of loss of control over one's life and the fear of not being able to cope with the adversities they were experiences. The most critical area, both for ASD and control group, concern the executive function related to emotional reactions. Conclusions: Thus, we argue that the difficulties in self-control, sensory modulation and emotional regulation, represent an element of stress for parents of children with developmental disorders. Implications: Regarding the difficulties of children with ASD, supporting the ways in which caregivers adapt to the signals of children is an important strategy, which has now become a key element of treatments for autism mediated by parents.
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Research Article
Parental perception of stress and
emotional-behavioural difficulties of
children with autism spectrum disorder
and specific language impairment
Magda Di Renzo, Federico Bianchi di Castelbianco,
Elena Vanadia, Massimiliano Petrillo, Lidia Racinaro and
Monica Rea
Institute of Ortofonologia, Italy
Abstract
Background and aims: The daily challenges of caring for a child with autism spectrum disorder affect many areas of
everyday life and parental well-being, as well as parents’ ability to manage the needs of the family and the child
concerned. A better understanding of parents’ perception of their child’s characteristics can allow better support for
them and individualize intervention protocols in a more accurate way. The main objective of this study is the evaluation
of the perception of stress by parents of children with autism compared to parents of children with specific language
impairment.
Methods: The parents of 87 children aged between 2 and 6 years were included in this study, 34 children with a specific
language impairment diagnosis and 53 children with an autism spectrum disorder diagnosis (ASD) or at risk of developing
it. They were asked to complete a self-report on perceived stress and rating scales on adaptive/problematic behaviours,
executive functions and sensory profile of the child.
Results: The results reveal that parents of ASD children, compared to the control group, showed significantly higher
levels of stress, mainly due to the difficulty of managing unexpected events, the feeling of loss of control over one’s life
and the fear of not being able to cope with the adversities they were experiences. The most critical area, both for ASD
and control group, concern the executive function related to emotional reactions.
Conclusions: Thus, we argue that the difficulties in self-control, sensory modulation and emotional regulation, repre-
sent an element of stress for parents of children with developmental disorders.
Implications: Regarding the difficulties of children with ASD, supporting the ways in which caregivers adapt to the
signals of children is an important strategy, which has now become a key element of treatments for autism mediated by
parents.
Keywords
Autism spectrum disorder, emotional difficulties, parental perception, clinical symptoms
Introduction
Children with autism spectrum disorder (ASD) usually
have difficulty with social communication and interac-
tion, restricted interests, and repetitive behaviours;
often they also show impairment in understanding
others’ intentionality, in symbolic play and in imitation
skills (Hyman et al., 2020). To support the develop-
ment of these abilities, they are now introduced
Corresponding author:
Magda Di Renzo, Institute of Ortofonologia, Via Salaria 30, 00198 Rome, Italy.
Email: m.direnzo@ortofonologia.it
Autism & Developmental Language
Impairments
Volume 5: 1–12
!The Author(s) 2020
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increasingly early into treatment paths that should be
personalized, calibrated on the child’s level of develop-
ment and relevant to the objectives of the treatment;
treatments are mostly intensive, some more closely cen-
tred on the child, others mostly emphasizing parental
involvement (Granger et al., 2012; Lyra et al., 2017;
Weitlauf et al., 2014; Zwaigenbaum et al., 2015).
In addition to the line of research on autism’s core
symptoms and treatments, over the years studies have
investigated the impact that the characteristics of chil-
dren with ASD have on parental figures. Some have
found a higher incidence of psychopathological disor-
ders in parents (Bonis, 2016), including depression,
anxiety and stress-related symptoms, compared to
parents of children with typical development
(Ingersoll & Hambrick, 2011; Jones et al., 2013; Lau
et al., 2014; Silva & Schalock, 2012; Zablotsky et al.,
2013), with Down syndrome (Dabrowska & Pisula,
2010) or other disabilities (Hayes & Watson, 2013;
Reed & Osborne, 2013; Zablotsky et al., 2013).
With reference to stress, different studies have
shown higher levels of parental stress in families of
children with ASD than in children with typical devel-
opment or with other disabilities (Agazzi et al., 2017;
Hayes & Watson, 2013; Lecavalier et al., 2006).
Children with ASD exhibited more problematic behav-
iours than children without disabilities, and their
parents showed higher levels of stress. However,
stress seemed more related to the severity of problem-
atic behaviour or conduct disorder than to the type of
disability or severity of symptoms (Hill-Chapman
et al., 2013; Rivard et al., 2014; Schieve et al., 2011).
Such research shows that it is more difficult for parents
to take care of their child than most children of the
same age, even if they are less annoyed by the things
their children do and get less angry with them.
Falk et al. (2014) also highlighted a significant rela-
tionship between a child’s aggressive behaviour and
maternal depression, especially in parents with low
social support; while the severity of the symptoms of
autism seemed to correlate more with maternal anxiety,
especially in younger mothers.
These results suggest that the relationship between
‘child-centred variables’ (externalizing behaviours and
severity of autism symptoms) and parental psychopath-
ological symptoms may be mediated by other variables,
which need to be investigated. One of these variables is
the executive functioning (planning, working memory,
cognitive flexibility, response initiation and inhibition,
impulse control and self-monitoring of tasks and
actions) of ASD children (Hutchison et al., 2016),
which seems to be the basis of the management diffi-
culties that parents report, especially since executive
dysfunction seems to be closely related to the severity
of repetitive behaviours and restricted interests.
Specifically, the areas of cognitive flexibility and the
planning of actions during problem solving (Panerai
et al., 2014) seem to be more compromised, aspects
usually associated with reduced adaptability, in partic-
ular with socialization, and a lack of behavioural reg-
ulation capacity in everyday situations. These deficits,
in the study of Panerai et al. (2014) are present in all
ASD subgroups, both those with and without intellec-
tual disability; for this reason, they are described by the
authors as a typical feature of autistic disorders.
These authors have shifted the focus of their interest
on adaptive functioning, noting significant deficiencies
in all ASD children, identifying the presence of a deficit
especially in the social sphere.
The results described so far support the need to con-
sider the combination of the ‘objective’ severity of the
autistic symptomatology and the ‘perception’ that the
parent of the ASD child has of such severity, as this
could favour a better personalization of the path of
treatment, in which the parent is usually also involved.
This co-participation is based on Vygotsky’s (1934)
concept of proximal development zone: an area of
skills that is just beyond the child’s current ability,
but where the child can move through the involvement
of a caregiver.
As reported by Hutchison et al. (2016), the child’s
experiences in the surrounding environment, including
social and affective interactions, modify the child’s
behaviour and vice versa. These bidirectional influen-
ces, therefore, can determine changes over time both in
the child’s behaviour, in the parent’s representations of
the child and his or her disorder, and consequently
in the child-parent interactions, triggering a virtuous
circle.
The present study will therefore investigate the dif-
ficulties that preschool children with ASD could man-
ifest in executive functioning in daily life, assessed
indirectly through parenting reports, in adaptive
behaviour, in the sensory profile and in the
behavioural-relational profile, compared to children
without ASD who have specific language disorders.
The second objective will be to investigate the relation-
ship between the level of stress perceived by the parents
of ASD children, compared to the parents of children
with speech disorders, and the characteristics of the
child’s neurodevelopment, in order to better under-
stand how to better individualize the strategies of treat-
ment that will be proposed to these children.
Method
Participants
The study included 87 children aged between 2 and
6 years of age. At intake, 34 children (39%) have a
2Autism & Developmental Language Impairments
specific language impairment diagnosis (SLI); 20 chil-
dren aged between 31 and 49 months of age (23%) have
an autism spectrum disorder diagnosis; 33 children
between 18 and 30 months of age (38%) have a classi-
fication of “at risk” of developing a spectrum disorder.
This classification reflects the early diagnosis criteria of
ADOS-2 and Diagnostic and Statistical Manual of
Mental Disorders (DSM-5, APA_American
Psychiatric Association, 2013). Children with SLI rep-
resented the Control group, children with ASD or at
risk of ASD, represented the ASD group (see Table 1).
The two groups differ in the age of first diagnosis
(3.6 vs. 2.6 years old), but they do not differ in the
average time spent in therapy at the time of recruitment
in this research (14.7 vs. 16.5 months). 23.5% of the
control group and 26.4% of the ASD group started a
therapeutic path less than six months previously;
17.6% of the control group and 18.9% of the ASD
group started 6–12 months previously; 41.2% of the
control group and 30.2% of the ASD group started
12–23 months previously; 17.6% of the control group
and 20.8% of the ASD group started 24–42 months
previously. The two groups do not differ in terms of
gender (percentage of males: 85.3% vs. 88.7%), nor by
order of parentage or number of siblings. The general
distribution of the ASD sample is in line with the most
recent estimates indicating a prevalence of males in a 4:
1 ratio compared to females (ISS_ISTISAN Reports,
2013; Morbidity and Mortality Weekly Report, 2014).
Most children are first born and about 38% are an
only child. Fewer than a third had complications
during pregnancy (for example, placenta praevia,
maternal hypertension, gestational diabetes), but they
had no postnatal problems; the children of the two
groups do not differ in birth weight. In 13% of the
cases in the ASD group children have a twin and in
18% of cases familiarity is reported for spectrum dis-
orders, that is a percentage significantly higher than
that found in the control group (8.8%).
In terms of socio-economic status, the two groups
do not differ either by country of origin (mostly
Italian), or by parental marital status, in fact almost
Table 1. Characteristics of the sample.
Control group (N ¼34) ASD group (N ¼53) P
Diagnosis at Intake, N (%)
SLI 18 (53%) 14 (26.4%)
SLI & Emotional disorder 16 (47%) 6 (11.3%)
Autism 2 (3.8%)
Spectrum 6 (11.3%)
Low ASD Risk 25 (47.2%)
Moderate ASD Risk
High ASD Risk /
Age of first diagnosis in years, mean (sd) 3.6 (0.7); range 2.3–5.5 2.6 (.58); range 1.6–4.1 .01
Current age of child in years, mean (sd) 4.8 (0.9); range 2.8–6.2 3.9 (1.1); range 2.4–6 .01
Months of Therapy (ongoing) 14,7 (10.1) range 2.6–39.2 16.5 (12.4) range 0.4–42.9 .47
Gender of Child (male), N (%) 29 (85.3%) 47 (88.7%) .64
Firstborn, N (%) 19 (56%) 35 (66%) .39
One Child, N (%) 13 (38.2%) 21 (39.6%) .93
Pregnancy Problems, N (%) 6 (19%) 15 (28%) .26
Birth Weight, mean (sd) 3326 (554) 3107 (594) .09
Twin Birth, N (%) 0 7 (13%) .05
Familiarity for autism 3 (8.8%) 10 (18.8%) .05
Italian Origin, N (%) 30 (90%) 48 (88%) .70
Mother Age, mean (sd) 38.7 (5.3) 39.3 (5.8) .79
Marital Status
Married/Cohabiting 34 (100%) 52 (96%) .71
Years of Marriage, mean (sd) 9.1 (4.1) 8.4 (4.3) .18
Mother Title Study, N (%)
Middle School Diploma 2 (5.9%) 4 (7.5%) .45
Diploma 16 (47.1%) 28 (52.8%)
Degree 15 (44.1%) 16 (30.2%)
It does not Declare 1 (2.9%) 5 (9.4%)
Mother Profession, N (%)
Worker 25 (73.5%) 33 (61.1%) .27
Unemployed 9 (26.5%) 20 (38.9%)
Legend: SLI ¼Specific Language impairment.
Di Renzo et al. 3
all of them have been married or cohabiting on average
for eight-nine years; in both groups the majority
(between 47% and 52%) of mothers have a secondary
school diploma or a degree (between 30% and 44%);
finally, about two thirds of mothers are in stable
employment.
Procedures
Parents and children with certified diagnoses received
by health services delivered by the National Health
System through public hospitals, or private facilities
under contract with the National Health System were
recruited and included in this study. The data were
collected in the 2018–2019 period.
The exclusion criteria were as follows: (a) neurolog-
ical diseases or focal neurological signs; (b) severe sen-
sory impairments (e.g., blindness and deafness); (c)
history of severe perinatal asphyxia, head injury or epi-
lepsy; (d) positivity to the examination of the high-
resolution karyotype, DNA analysis for X-Fragile or
positive screening tests for metabolic disorders.
Neurodevelopmental disorder diagnoses were based
on DSM-5 criteria (APA_American Psychiatric
Association, 2013) and prepared following clinical
interviews, physical examinations and psychodiagnos-
tic assessments, carried out by the multidisciplinary
teams of the reference Centre.
Informed consent was obtained from all parents
(Helsinki Declaration). This research respected the eth-
ical guidelines and legal requirements of the country in
which it was conducted. The research also met the eth-
ical standards of the American Psychiatric Association
(APA).
At the time of recruitment for this study, all the
children were assessed in order to update an assessment
of their autistic symptoms, psychomotor development,
cognitive, linguistic and emotional functioning; their
parents were given rating scales and questionnaires
for assessing the adaptive skills, the executive func-
tions, the sensory and behavioural/relational profile
of the children, and for investigating parental stress.
Instruments
ADOS-2 – Autism Diagnostic Observation Schedule – Second
Edition. The ADOS-2 (Lord et al., 2012) is a semi-
structured, standardized assessment of communication,
social interaction, play and restricted and repetitive
behaviours which provides a series of activities
designed to elicit behaviours directly related to the
autism spectrum disorder diagnosis. The Toddler
Module, for children between 12 and 30 months of
age who do not consistently use phrase speech, pro-
vides ‘ranges of concern’ reflecting the extent to
which a child demonstrates behaviours associated
with ASD.
ABAS-II-Adaptive Behavior Assessment System – Second
Edition. The ABAS-II (Harrison & Oakland, 2003) is
a commonly used referenced tool designed to assess
adaptive skills in individuals from birth to 89 years of
age. The Parent Form used in this study measures nine
adaptive skill areas (M ¼10; SD ¼3) covering three
domains: Conceptual (CON:
Communication þFunctional Academics þSelf-
Direction), Social (SOC: Leisure þSocial), and
Practical (PR: Community Use þHome
Living þHealth and Safety þSelf-Care). The ‘General
Adaptive Composite’ (GAC) score that represents a
commonly referenced score for the individual
(M ¼100; SD ¼15) is also calculated from all nine
skill areas.
BRIEF-P-Behavior Rating Inventory of Executive Functions-
Preschool Version. The BRIEF-P (Gioia et al., 1996) is
a standardized rating scale developed to provide an
understanding of everyday behaviours associated with
specific domains of executive functioning (EF) in chil-
dren aged two to five years. The BRIEF-P consists of a
single Rating Form, designed to be completed by
parents, teachers, or other caregivers, with 63 items
on a three-point rating, each one rated as ‘Never’,
‘Often’, ‘Never’, depending on how often they observe
a specific behaviour, in five non-overlapping scales. The
scales form a Global Executive Composite (GEC) and
three overlapping summary indexes. The Inhibitory
Self-Control Index (ISCI) is composed of the Inhibit
and Emotional Control scales, the Flexibility Index
(FI) is composed of the Shift and Emotional Control
scales, and the Emergent Metacognition Index (EMI) is
composed of the Working Memory and Plan/Organize
scales.
SSP-Short Sensory Profile. The Short Sensory Profile
(McIntosh et al., 1999) is a caregiver questionnaire
which contains 38 items organized into seven subscales
reflecting responsiveness to sensory input across senso-
ry modalities including: tactile sensitivity, taste/smell
sensitivity, movement sensitivity, under-responsivity/
seeking sensation, auditory filtering, low energy/weak-
ness and visual/auditory. Parents indicate their percep-
tion of the frequency with which their child exhibits
atypical behaviour responses to sensory stimulation
on a five-point Likert scale ranging from 1 (always)
to 5 (never). Higher scores represent higher functional
performances. The SSP total score and the score on
each subscale can be used to classify children’s level
of sensory abnormality: Typical, Probably Difference,
or Definite Difference. The Sensory Profile was
4Autism & Developmental Language Impairments
standardized on more than 1200 children; the short
version derived from it has a reliability of .90 and a
discriminating validity >95% in identifying children
with and without atypical sensory processing patterns;
it has an internal consistency of the factors within the
scale ranging from .70 to .90.
ASDBI – ASD Behavior Inventory. The ASDBI (Cohen &
Sudhalter, 2005) is a standardized rating scale designed
for parents and teachers which allows one to make an
assessment of relational behaviour and some other
symptomatic aspects typical of children with ASD,
referring to different life contexts. Through 188 items,
it allows to evaluate the domain of contact/isolation
problems (Sensory/Perceptual Approach Behaviours,
Rituals/Resistance to Change, Social/Pragmatic
Problems, Semantic/Pragmatic problems, Arousal
problems, Fears, Aggressiveness) measuring the differ-
ence in the behaviour of typical children compared to
what is usually observed in ASD children. The ASDBI
was standardized on 369 parents and 277 teachers of
children with ASD. The reliability for the parent
sample ranged from .38 to .91. Clinical validity was
assessed through comparison with the ADOS.
Perceived Stress Scale (PPS). The PSS (Cohen et al., 1994;
Mondo et al., 2019) is a 14-item self-report measure
designed to assess the degree to which life situations
are appraised as stressful. Specifically, items are
designed to measure the extent to which one’s life is
perceived as unpredictable, uncontrollable and over-
loading. The questions are general in nature and there-
fore exempt from specific content of any subpopulation
and concern feelings and thoughts relating to the past
month. Each item is rated on a five-point Likert scale
ranging from 0 ¼Never to 4 ¼Very Often. The higher
the score, the greater the overload stress, as well as the
perceived discomfort. The validation sample consists of
2387 people over the age of 18, residing in the U.S.
Statistics
In order to evaluate the differences between groups,
analyses of the unifactorial (ANOVA) and multivariate
(MANOVA) variance were conducted. The effect size
was calculated using the partial eta squared whereby
g
2
¼0.02 is considered a small effect, 0.13 a medium
effect, and 0.23 a large effect (Pierce et al., 2004). In
order to analyze the changes in the time of the meas-
ures based on categorical variables, an analysis of the
Chi-square was carried out. To evaluate the correla-
tions between the scores obtained in different measure-
ments, correlational analyses were conducted. The level
of significance was set at p <0.05. All statistical
analyses were performed using the software version
21.0 of SPSS.
Results
Descriptive statistics
The differences between groups compared to the ages
(in months) of acquisition of the first stages of devel-
opment were analyzed. No significant differences
emerged between the control group and the ASD
group with respect to the age of achievement of the
control of sitting posture (5.7 1.8 months vs. 6.0
1.5 months; P ¼.38), of the movement on all fours
(8.1 1.9 months vs. 9.0 2.1 months; P ¼.07), the
first autonomous walking (13.9 3.1 months vs.
14.2 2.7 months; P ¼.60) and the appearance of the
first words (i.e mum or dad) (13.3 6.5 months vs.
16.1 9.7 months; P ¼.16) . However, a significant dif-
ference emerged in relation to the appearance of the
first sentences, which appeared later in the children of
the ASD group (23.5 8.0 months vs. 32.6 9.7
months; F
(1,85)
¼13.09; P <.001; ƞ
2
¼.21). In addition,
the parents of the control group declared that they
started to recognize the existence of a problem in the
development stages on average six months later than
the parents of the ASD group (26.8 6.9 months vs.
20.5 6.1 months; F
(1,85)
¼18.97; P <.001; ƞ
2
¼.19).
Symptomatological characteristics of the children
Adaptive skills (ABAS-II). Parents of children from both
groups completed the ABAS-II rating scale for assess-
ing the child’s adaptive skills in the Conceptual (CON),
Practical (PR) and Social (SO) domains. The scores of
each scale are expressed in weighted points (mean 10
and sd 3), so the higher the score, the better the adap-
tive skills of the child. The children of the ASD group
show significantly lower adaptive abilities than the chil-
dren of the control group (Wilks’ Lambda ¼5.48;
p<.001) in all the areas assessed (see Table 2); the
covariate ‘age of the child’ (P ¼.28), which was not
significant, and the covariate ‘months of therapy’
(P <.05), which has a significant effect on the areas
of the Practical domain were checked: as the months
of therapy increase, the scores in the Home Living
(F
(1,85)
¼7.695; P <.01), Health and Safety
(F
(1,85)
¼4.774; P <.05) and Self Care (F
(1,85)
¼6.305;
P<.05) improve.
Executive Functions (BRIEF-P). The scale assesses the
child’s executive functioning in the daily context of
home life. The scores of each scale are expressed in T
points (mean 50 and sd 10), thus scores T >65 indicate
the presence of difficulties in executive functioning. The
Di Renzo et al. 5
children of the ASD group show significantly more
impaired inhibition, shift, working memory and plan-
ning abilities than children in the control group (Wilks’
Lambda ¼0.85; p <.001) (see Table 2); however, there
are no significant differences between the groups in the
area of emotional regulation (F
(1,85)
¼2.348; P ¼.16);
the covariates ‘age of the child’ (P ¼.15) and ‘months
of therapy’ (P ¼.13) were not significant.
Sensory Profile (SSP). The parents of the children of both
groups completed the Sensory Profile Short Form
rating scale which assesses the child’s ability to modu-
late sensory inputs. The scores of each scale are
expressed in raw points; a higher score corresponds
to a more adequate ability of the child. The children
of the ASD group show a significantly lower regulation
of the sensory response than the children of the control
group in three areas assessed (See Table 2): Tactile
Sensitivity (F
(1,85)
¼5.203; P <.05), for which they
express greater discomfort during moments of personal
care or react excessively to physical contact; Hypo-
Responsivity/Seeking Sensation (F
(1,85)
¼9.569;
P<.01), for which they seek sensory stimulation,
manipulate objects and things in a more stereotyped
way; Auditory Filtering (F
(1,85)
¼9.893; P <.01), for
which for example they are more bothered by back-
ground noises, such as fan, refrigerator, etc. or by
sudden noises, in front of which they can show bizarre
reactions. The covariate ‘age of the child’ (P ¼.08) and
the covariate ‘months of therapy’ (P ¼.27) were
checked, but were not significant.
Symptomatology in the relational area (ASDBI). The scale
assesses the presence of problematic contact/isolation
behaviours, observed in the daily context by the
parents of both groups. The scale scores are expressed
either in T points (mean 50 and sd 10) or in percentile
points, so T scores>60 and percentile>75 indicate the
Table 2. Mean (sd) differences between groups on test scores.
Domains Subtest
Control Group
(N ¼34)
ASD
(N ¼53) F
(1,85)
P
Eta
squared
ABAS-II Conceptual Functional Academics 8.7 (4.5) 4.6 (3.3) 22.195 .001** .21
Self-direction 9.3 (4.3) 5.5 (3.1) 22.403 .001** .21
ABAS-II Practical Community Use 9.5 (4.1) 4.2 (3.5) 37.364 .001** .31
Home living 9.1 (3.4) 5.5 (3.8) 21.681 .001** .20
Health and Safety 8.7 (3.9) 4.2 (3.3) 32.809 .001** .28
Self-care 10.1 (3.8) 5.9 (3.3) 22.448 .001** .21
ABAS-II Social Leisure 9.3 (3.7) 5.5 (3.8) 17.014 .001** .17
Social 9.6 (4.1) 3.8 (3.4) 42.197 .001** .33
BRIEF-P Inhibitory Self-Control Inhibit 49.8 (11.6) 58.3 (11.9) 5.234 .05* .06
Emotional Regulation 52.3 (11.2) 55.3 (13.5) 2.348 .13 /
BRIEF-P Flexibility Shift 50.5 (11.6) 55.3 (12.9) 4.136 .05* .05
BRIEF-P Emergent Metacognition Working Memory 48.9 (8.9) 61.9 (13.4) 12.424 .001** .14
Plan/Organize 47.8 (8.4) 60.7 (17.1) 10.587 .01** .12
Sensory Profile Tactile Sensitivity 31.5 (3.4) 29.3 (4.7) 5.203 .05* .06
Taste/Smell Sensitivity 16.9 (3.5) 15.5 (5.3) 1.826 .18 /
Movement Sensitivity 13.6 (2.1) 12.9 (2.8) 1.065 .30 /
Hypo-responsivity/
Seeking Sensation
28.2 (4.9) 24.2 (6.4) 9.569 .01** .10
Auditory Filtering 25.7 (4.8) 22.2 (5.1) 9.893 .01 .10
Low Energy/Weakness 28.4 (3.0) 27.9 (4.5) 0.439 .51 /
Visual/Auditory Sensitivity 21.4 (3.2) 20.4 (3.4) 1.849 .18 /
ASDBI Contact/Isolation Sensory Perceptual Approach
Behaviours
39.5 (5.6) 45.6 (7.9) 10.510 .01 .17
Ritualisms/Resistence to Change 44.1 (8.7) 49.7 (11.1) 5.087 .05* .06
Social Pragmatic Problems 36.1 (4.5) 41.7 (7.7) 10.960 .01** .18
Semantic Pragmatic Problems 43.6 (5.2) 48.9 (8.7) 7.535 .01** .13
Arousal Problems 33.1 (7.6) 40.4 (12.3) 6.730 .05* .12
Pragmatic Communication 44.1 (7.6) 47.9 (9.4) 1.089 .30 /
Specific Fears 44.1 (7.6) 48.0 (9.3) 2.664 .11 /
Aggressiveness 41.9 (7.9) 45.8 (10.8) 2.227 .14 /
Legend. ABAS-II ¼Adaptive behavior assessment system; BRIEF-P ¼Behavior Rating; Inventory of Executive Function; ASDBI ¼ASD Behavior
Inventory.
*P<.05; **P<.01.
6Autism & Developmental Language Impairments
presence of severe difficulties. As can be seen in
Table 2, the symptoms of the children of the ASD
group are described as significantly more problematic
than those manifested by the children of the control
group in some areas: in fact, they show more symptoms
in the area of sensory/perceptual approach behaviours
(F
(1,85)
¼10.510; P <.01), such as, for example, staring
at objects, pica, repetitive toy play. The children of the
ASD group also show greater difficulties in reacting to
environmental changes and in the manifestation of rit-
ualism (F
(1,85)
¼5.087; P <.05). They also show greater
pragmatic and social problems (F
(1,85)
¼10.960;
P<.01), for example in the way of approaching other
people, of social self-awareness, of inappropriate reac-
tions to the other.
Correlations between autistic symptoms and
behavioural characteristics of ASD children
The relationships between the severity of the symptoms
assessed at the time of diagnosis (measured through the
three ADOS-2 scores: total, SA and RRBs) and the dif-
ferent areas of cognitive, adaptive and behavioural devel-
opment the child shows at moment of research, were
calculated. As shown in Table 3, low cognitive profile
scores (IQ) correspond to high and severe ADOS-2
scores. Also compared to adaptive skills (ABAS-II),
high and severe scores of ADOS-2 correspond to lower
scores in the area of community use (CU), of functional
academics (FA), of home living (HL), health and safety
(HS), self-care (SF) and socialization (Soc).
From the questionnaires that evaluate sensory
behaviours of the child (SSP) it emerges that severe
ADOS-2 scores correspond to weaker attention skills
in contexts where there is background noise (auditory
filtering) and excessive general auditory reactivity
(visual/auditory sensitivity).
Finally, from the questionnaire on symptomatic
contact and isolation behaviours that the child shows
at home (ASDBI) it emerges that the high scores of the
Social Affects subscale of ADOS-2 correspond to
greater alterations in the sensory perceptual approach,
of pragmatic communication and aggressiveness.
Perceived parental stress
The scale assesses the stress perceived by parents; the
higher the score, the greater the presence of stress
reported in the last month. From the data analysis,
no significant correlations emerge between the
Table 3. Correlation between ADOS-2 scores (Total, SA and RRBs) and Intellective Quotient, Adaptive Behaviour (ABAS-II),
Sensory Profile and Behavioural characteristics (ASDBI) of the child with ASD (N ¼53).
Total ADOS-2 SA ADOS-2 RRBs ADOS-2
IQ .618
**
.545
**
.477
**
ABAS-II Community Use .356* .330* .245
Functional Academics .376
**
.298* .376
**
Home Living .282* .238 .248
Health and Safety .317* .303* .195
Leisure .270 .259 .151
Self-Care .287* .214 .322*
Self-Direction .161 .135 .134
Social .483
**
.458
**
.281*
Short Sensory Profile Tactile Sensitivity .022 .023 .013
Taste/Smell Sensitivity .016 .045 .059
Movement Sensitivity .031 .055 .216
Under responsivity/Seeking Sensation .246 .269 .059
Auditory Filtering .281* .313* .054
Low Energy/Weak .029 .004 .100
Visual/Auditory Sensitivity .298* .288* .165
ASDBI Contact/Isolation Sensory Perceptual Approach Behaviours .253 .184 .334*
Ritualisms/Resistance to Change .043 .121 .187
Social Pragmatic Problems .228 .171 .272
Semantic/Pragmatic Problems .197 .286 .119
Arousal Problems .116 .102 .111
Pragmatic Communication .104 .014 .310*
Specific Fears .002 .052 .152
Aggressiveness .253 .184 .334*
Legend. SA ¼Social Affect; RRB ¼Restrictive and Repetitive Behaviour; ABAS-II ¼Adaptive behavior assessment system; ASDBI ¼ASD Behavior
Inventory.
*
P<.05; **P <.001.
Di Renzo et al. 7
ADOS-2 scores of the children of the ASD group and
the level of Stress Perceived by their parents (r ¼.10).
The parents of the ASD group generally obtained sig-
nificantly higher and clinical scores of perceived stress
than the parents of the control group (control group ¼
12.9 5.4 vs ASD ¼16.1 7.1; F ¼4.64; p <.05); the
covariates ‘age of the child’ (P ¼.29) and ‘months of
therapy’ (P ¼.98) were not significant. From the qual-
itative analysis of the answers given to each item it
emerges that there are three questions to which parents
of ASD children answered with higher scores, thus
indicating greater stress: No. 1 (how often did you
feel out of your mind since something unexpected
happen?) (F
(1,51)
¼6.43; p <.05); No. 2 (how often
did you feel you were not able to control important
things in your life?) (F
(1,51)
¼6.18; p <.05) and No.
10 (how often did you feel that difficulties were accu-
mulating to such a point that you could not overcome
them?) (F
(1,51)
¼11.64; p <.05).
The relationships between the profile of parents’ per-
ceived stress and the adaptive, executive, sensory and
behavioural characteristics of the child were then ana-
lyzed in the two study groups. Significant correlations
are shown in Table 4. As for autonomies (ABAS-II), a
higher level of perceived stress is related to greater
adaptive difficulties of self-control in the child only in
the control group. All other areas of ABAS-II do not
show significant correlations with the scores at the
Perceived Stress Scale. As for executive functioning
(BRIEF-P: inhibit, shift, emotional regulation), in
both groups the child’s greatest difficulties correlate
with greater parental stress. Compared to the Sensory
Profile (SSP: Tactile Sensitivity, Under-Responsivity/
Seeking Sensation and Visual/Auditory Sensitivity),
more alterations of the child correlate with greater
stress of the parent only in the control group. Finally,
in both groups, greater behavioural symptoms
(ASDBI: Sensory/Perceptual Approach Behaviours,
Arousal Problems, Specific fears, Aggressiveness), cor-
relate with higher stress levels.
Discussion
From the data analysis retrospectively collected with
the parents, it appears that the children of the ASD
and Control groups do not differ in terms of the
achievement of the very first stages of development of
postural control, the first autonomous walking and the
appearance of the first single words. The combination
of words and the appearance of the first sentences,
however, seems to be later in the children of the ASD
group, in line with other studies that have investigated
the understanding and phrasal expression in autism
(Luyster et al., 2005).
Significant differences also emerged in the descrip-
tions that parents of the ASD and control groups make
of their children in relation to adaptive skills. As found
also by other authors (Joseph et al., 2002; Kanne et al.,
2011), the children of the ASD group are described as
having less ability in the conceptual, social and practi-
cal domains. The difficulties in the latter domain are
manifested in the domestic context, in the use of the
external environment, in self-care and in the regulation
of safety behaviours, and were related to the duration
of the therapy of the child; a longer period of treatment
corresponds to fewer difficulties in the practical
domain. In the literature, the association between
adaptive behaviour and symptoms of autism seems to
be confirmed, particularly in younger children (Golya
& McIntyre, 2018; Kanne et al., 2011), although some
research highlights that behavioural, social and linguis-
tic difficulties associated with ASD in preschool can
Table 4. Correlations between Perceived Stress Scale scores and Adaptive Behaviour (ABAS-II), Sensory Profile (SSP), Executive
Functions (BRIEF-P) and Behavioural characteristics (ASDBI).
Test Subtest Control Group (N ¼34) ASD group (N ¼53)
ABAS-II Self-Direction .356* .112
BRIEF-P Inhibit .439** .334*
Shift .198 .334*
Emotional Regulation .346* .412*
Short Sensory Profile Tactile Sensitivity .395* .234
Under responsivity/Seeking Sensation .449** .167
Visual/Auditory Sensitivity .378** .225
ASDBI Sensory Perceptual Approach Behaviours .487** .239
Arousal Problems .502** .223*
Specific Fears .450** .288*
Aggressiveness .439** .349**
Legend. ABAS-II ¼Adaptive behavior assessment system; BRIEF-P ¼Behavior Rating Inventory of Executive Function; ASDBI ¼ASD Behavior
Inventory.
*
P<.05; **P <.001.
8Autism & Developmental Language Impairments
make the measurement of adaptive skills particularly
unstable and subject to changes over time (Joseph
et al., 2002; Rapin, 2003).
Similarly, more significant impairments emerged in
the children of the ASD group compared to the exec-
utive functions assessed in the family context, in par-
ticular in the inhibition, shift, working memory and
planning skills. However, no differences emerged in
the area of emotional regulation. These results are in
line with the data present in the literature, but as also
emerges from a recent meta-analysis (Demetriou et al.,
2018), contrary to what one might expect, the individ-
ual subdomains of executive functions are compro-
mised to a different extent and not homogeneous in
the autistic population.
With respect to the sensory profile, the research
results demonstrate significantly greater difficulties in
children of the ASD group compared to the control
group. Hyper-and hypo-reactivity to sensory input
are currently included as key features of autism in the
DSM-5 (APA_American Psychiatric Association,
2013). The children of the ASD group showed severe
difficulties in the areas of Tactile Sensitivity, so they
express greater discomfort during moments of personal
care or react excessively to physical contact; in the
Under-Responsivity/Seeking Sensation for which they
seek sensory stimulation, manipulate objects and things
in a more stereotyped way and in the area of Auditory
Filtering, so, for example they are more bothered by
background noises, caused by fans, refrigerators, etc.,
or by sudden noises, which can lead them to show
bizarre reactions.
As might be expected, from the results obtained
through the rating scale on problematic Contact/
Isolation behaviours, detected in the daily context by
parents, it emerges that in the children of the ASD
group more symptoms are described in the Sensory
Perceptual Approach Behaviours, such as example,
gaze fixation, use of the mouth for the exploration of
inedible objects, repetitive handling behaviours.
Furthermore, the children of the ASD group also
show greater difficulties in reacting to environmental
changes and in the manifestation of Ritualism, greater
Social-Pragmatic difficulties, for example in the way of
approaching other people, of inappropriate reactions
to the others and greater symptoms of impaired excit-
ability and aggression, for example motor restlessness,
sleep regulation and aggressive attitudes towards self or
others. When the level of stress perceived by parents
was investigated through the Perceived Stress Scale, it
emerged that the parents of ASD children, compared
to the control group, showed significantly higher levels
of stress, mainly due to the difficulty of managing unex-
pected events, the feeling of loss of control over one’s
life and the fear of not being able to cope with the
adversities they were experiencing. This is consistent
with previous studies showing that parents of ASD
children report higher stress levels than both parents
of children with typical development and those of chil-
dren with other disabilities (Baker-Ericz
en et al., 2005;
Blacher & McIntyre, 2006; Rivard et al., 2014).
However, the stress level of the parents was not
related to the severity level of the autistic symptomatol-
ogy, assessed through the ADOS-2 score, nor to the
adaptive skills of the child with ASD; this data differs
from what is usually reported in some studies, which
identify among the factors associated with parental
stress, the severity of autistic symptoms and the level
of functioning of children (Hall & Graff, 2011;
Ingersoll & Hambrick, 2011, Miranda et al., 2019). In
this research, stress detection tools are used aimed at
detecting the stress experienced by the parent with
respect to his or her parental role. In the present
study, on the other hand, was used the Perceived
Stress Scale, which instead aims to measure the percep-
tion of stress that an adult experiences, with respect to
the changes that have occurred in his or her life, with-
out focusing exclusively on the parental role. The
results of this research are in fact in line with the
research that shows that parents of children with
ASD report stress levels more correlated to personal
aspects rather than to the symptomatic characteristics
of the child or to the parent-child relationship (Rivard
et al., 2014). The severity of autistic symptoms repre-
sented, according to these authors, a predictor of pater-
nal, but not maternal, stress.
The analysis of the data instead shows that the stress
perceived by the parents is related to the executive
functioning of the child, so the parents of children
with greater dysfunctions in the areas of inhibition,
shift and emotional regulation were more stressed. In
the literature, the research is quite consistent in consid-
ering the impairment of executive functions as one of
the central aspects of the autism spectrum disorder
(Craig et al., 2016; Demetriou et al., 2018). It is inter-
esting to note that in the present research the areas that
were most critical, both for children with autism and
for those with speech disorders, concern the so-called
‘hot’ executive functions, which are usually activated to
regulate emotional reactions and motivation, during
stressful situations or in emotionally significant con-
texts. This also seems to be confirmed by the significant
correlations between the stress perceived by the parent
and the behavioural symptomatology (assessed
through the ASDBI) concerning the methods of
Sensory/Perceptual Approach Behaviours, problems
of excitability of children.
The multiple relationships between the child’s emo-
tional and behavioural characteristics and the stress
perceived by the parent were also investigated in a
Di Renzo et al. 9
recent study (Miranda et al., 2019), in which the
authors analyzed a sample of school-aged children
(from seven to 11 years). They conclude that mothers’
support, as well as active coping strategies and emo-
tional support are all elements that mothers need to
deal with stress, and represent valid mediators capable
of significantly reduce parental stress in managing the
behavioural difficulties of ASD children.
Therefore, supporting the ways in which caregivers
adapt to the signals of children is an important strate-
gy, which has now become a key element of treatments
for autism mediated by parents. Some authors (Shire
et al., 2016) observed that during parent-child play
interactions, parental responsiveness and joint atten-
tion increased after a cycle of intervention mediated
by parents compared to standard psycho-educational
interventions.
The results of this study must be interpreted in the
light of its methodological limitations. For example,
the tool used to measure stress assesses parental per-
ception and should be accompanied by measures that
can highlight other stress and resilience factors that
could modulate parental well-being. Furthermore, the
correlational design does not allow the determination
of the causal relationships between perceived stress and
characteristics of children. It should be further investi-
gated how these relationships can influence each other,
in order to adapt and personalize therapeutic interven-
tions more, shifting the focus of treatment from the
pathological symptom of the child to what some
authors describe as family maladaptation, understood
as the continuous discrepancy between needs of the
child and the family’s ability to deal with them
(Miranda et al., 2019).
Conclusions
The study just described therefore highlighted how
much the difficulties that children with ASD manifest
in adaptive skills, sensory profile and executive func-
tioning are often more evident and clinically more sig-
nificant than in children with SLI. The level of stress
perceived by the parents is also less related to the spe-
cific clinical symptomatology, and more connected to
the difficulties that children show at a behavioural level
(problems of excitability, specific fears, aggressive
behaviour), in emotional regulation and generally in
the emotional component of the executive operation.
Hence the reflection on how much this relationship can
create a vicious circle, in which the child’s behavioural
and affective regulation difficulties can favour the
increase of stress in the parents, and consequently
how high stress levels reduce the parenting coping
skills in management, but also in understanding the
child’s problem behaviours. This suggests the
importance of including parents in children’s therapeu-
tic paths, not so much as ‘educators’ or ‘therapists’ of
their children, but as fundamental parts of a meaning-
ful relationship, in which they can work to transform
the vicious circle into a virtuous one. In this way, the
parent is supported in understanding the meanings of
the symptom and how it manifests in the child, is
helped to understand how to manage it. This should
consequently increase the self-efficacy experiences in
the parent, and consequently reduce the perception of
stress due to the loss of control over one’s life. Future
studies will provide crucial information on possible
support programs that could be implemented for
families.
Acknowledgements
This article is based on the activities of the Institute of
Ortofonologia (IdO) of Rome. We are grateful to the psy-
chologist, child psychiatrist, speech therapist, parents, and
children whose participation made this work possible.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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