Topics in Early Childhood

Special Education
Volume 28 Number 3

Family Stress and Children’s Language November 2008 148-157

© 2008 Hammill Institute on
Disabilities

and Behavior Problems 10.1177/0271121408318678

http://tecse.sagepub.com
hosted at http://online.sagepub.com

Results From the National Survey of Children’s Health

Carolyn E. Long
Matthew J. Gurka
James A. Blackman
University of Virginia

The impact of language delays and behavior problems in young children on family function was assessed using data from
the 2003 National Survey of Children’s Health. Over 50% of parents who reported concerns regarding their children’s lan-
guage skills also reported concerns regarding their children’s behavior. Although parents reported increased stress and more
difficulty coping and meeting their children’s needs when they were concerned about their children’s language skills,
children with behavior problems were especially stressful for families. Parental stress increased as children with challeng-
ing behaviors reached preschool age. To address the negative impact on family function, service providers must couple spe-
cific intervention strategies and methods that improve language skills and mitigate behavior problems in young children.

Keywords: language delays; behavior problems; early intervention; preschool; survey of children’s health; family function

T wo key aspects in the early development of

preschool children are language and behavior.
Research has led to increased awareness of the need to
improve language skills and behavior in young children
(Gertner, Rice, & Hadley, 1994; Kaiser, Hancock, Cai,
Foster, & Hester, 2000). In addition, the early identifica-
tion of language delays and behavior problems in
children is essential for effective intervention (Qi &
Kaiser, 2004). The critical role of emotional and social
well-being in school readiness and the negative out-
comes of early problem behavior have led to a national
focus on the importance of providing prevention and
intervention services to young children with challenging
behaviors and their families (Drotar, 2004; Dunlap,
Ester, Langhans, & Fox, 2006; Powell, Dunlap, & Fox,
2006; Shonkoff & Phillips, 2000).
According to the Sameroff transactional model
(Sameroff & Fiese, 2000), developmental outcomes are
seen as a result of a continuous dynamic interaction
among children’s behavior, caregivers’ responses to
children’s behavior, and environmental variables that
may influence both children and caregivers. A child’s
behavior triggers a parent’s interpretation, which pro-
duces the parent’s response. In the case of a child with
language delays, the child’s behavior may be influenced
by an inability to comprehend a request or by frustration
at not being understood. Subsequently, the child may
exhibit a challenging behavior, such as aggression, that
increases parental stress levels and results in ineffective
parenting. The parent may even limit his or her attempts
at interacting with the child. The transactional model
illustrates how multiple risk factors, such as language
delay, behavior problems, and parental stress, may result
in poor outcomes for the child’s development and the
family’s coping.
Speech and language disorders are the most common
disabilities in the United States, with studies reporting a
range of incidence between 3% and 15% in preschool
children (Downey et al., 2002). There is evidence that
language concerns are often a risk factor for problem
behaviors in young children. Preschool children who
exhibit challenging behaviors are more likely to have
language deficits than peers without language concerns
(Kaiser et al., 2000). Preschool children with expressive
language delays are more likely to have social-emotional
problems, and those with receptive delays experience
pervasive developmental problems (Tervo, 2007).
Previous research has shown that children from low-
income families are especially at risk for significant
behavior and language problems (Qi & Kaiser, 2004).
Children from families with lower socioeconomic status
have lower language scores. Qi, Kaiser, Milan, and

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148

Hancock (2006) found that African American preschool
children from low-income families scored 1.5 standard
deviations below the mean on a test of language func-
tioning compared with European American preschool
children. A large percentage of toddlers (41.8%) and
preschoolers (68.1%) referred to child welfare agencies
have developmental and behavioral needs (Stahmer et al.,
2005). In addition, children may have underlying risk
factors, including premature birth or genetic disorders,
for language and behavior problems (Nelson, Stage,
Duppong-Hurley, Synhorst, & Epstein, 2007).
The persistent nature of behavior problems in young
children has been well documented. Approximately half
of preschoolers who demonstrate problem behaviors
continue to have behavior problems when older
(Campbell, 1995). Young children are often referred to
developmental clinics because of problem behaviors,
with disruptive behavior being the single most common
reason for referral to child mental health services.
Younger age of onset is associated with greater severity
(Kazdin, 1987), and disruptive behavior has been shown
to worsen with time (Neary & Eyberg, 2002).
The characteristics and temperament of preschool
children with challenging behaviors have also been stud-
ied. Externalizing behaviors, such as aggression, are most
predictive of future behavior problems. Other characteris-
tics that may lead to problem behaviors include impul-
siveness, distractibility, irritability, inflexibility, and
attention-deficit problems (Brier, 1995). Children classi-
fied as developmentally delayed were more likely to be
reported in the clinical range for externalizing problems
on the Child Behavior Checklist (Baker et al., 2003). The
prevalence of behavior problems in children with or at
risk for developmental delays was found to be 42%,
according to Feldman, Hancock, Rielly, Minnes, and
Cairns (2000). Infants and toddlers who exhibit external-
izing behaviors, such as aggression and destructiveness,
have a high probability of demonstrating problem behav-
iors in school (Gresham, Lane, & Lambros, 2000).
Research has indicated that the families of children
with developmental disabilities may experience height-
ened levels of stress, particularly related to child rearing
(Crnic, Friedrich, & Greenberg, 1983; Hastings, 2002).
Parenting stress is an important predictor of a child’s
behavior problems, regardless of the child’s cognitive
functioning (Crnic & Greenberg, 1990). Parenting stress
is related to behavior problems in both developmentally
delayed and nondelayed samples of young preschool
children (Baker & Heller, 1996). Baker et al. (2003) and
Hastings (2002) noted a similar relationship between
children’s behavior problems, parental stress, and par-
enting behavior.
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Long et al. / Results From the NSCH 149
When parents report concerns regarding their young
children, they often include the areas of language and
behavior problems. In a survey conducted by Tervo
(2005) of 180 parents of children aged 16 to 80 months,
the most common concerns reported by the parents
included language and behavioral characteristics. The
recent National Survey of Early Childhood Health of
parents of children under 3 years of age reported rela-
tively high concerns regarding their children’s behavior
(48%), language (45%), and getting along with others
(41%) (Halfon et al., 2002).
In summary, there appears to be an increased occur-
rence of behavior problems in young children with
developmental and/or language delays. Studies also sug-
gest an increase in family stress when young children
exhibit behavior problems. A gap in research knowledge
remains regarding the strength of the interrelationship
between language delays and behavior problems and
their effect on family function.
To further explore the relationship between language
and behavior problems and their impact on family func-
tion, a recent nationwide survey was used to answer the
following research questions: What is the percentage of
reported language problems only and behavior problems
only, independently, among young children? If parents
are concerned about language problems in their children,
how much more likely are they to be concerned about
behavior problems? Do parents report increased levels of
stress and more problems in coping when they also
report concerns regarding their children’s language
development and/or behavior? Do parents report
increased levels of stress as children become older and
reach preschool age?
Methods
Data
The primary data source for this analysis was the 2003
National Survey of Children’s Health (NSCH). This sur-
vey addressed the physical, emotional, and behavioral
health of children, including the following child and
family demographics: child physical and mental health,
health insurance status, family functioning, and parental
mental health. Questions regarding language and behav-
ior used in this study were taken from the early child-
hood section of the survey and were developed using the
Parent’s Evaluation of Developmental Status (PEDS).
The PEDS is a tool used to identify children at risk for
developmental, behavioral, and social delays (Glascoe,
1997). The PEDS was standardized on a large number of
families from diverse backgrounds and validated against
150 Topics in Early Childhood Special Education
several diagnostic measures. The parental stress ques-
tions constitute the Aggravation in Parenting Scale
derived from the Parenting Stress Index (Abidin, 1990)
and the Parental Attitudes About Childrearing Scale
(Oster et al., 2002). Questions from these instruments
were written at the fourth to fifth grade reading level.
The Parenting Stress Index has been empirically vali-
dated to predict observed parenting behavior and
children’s current and future behavioral and emotional
adjustment in a variety of international populations.
The families were asked the question “Are you cur-
rently concerned about how your child makes speech
sounds and how your child understands you?” to elicit
language concerns. The responses “a lot” and “not at all”
were used for the analyses of parental language con-
cerns. To elicit behavioral concerns, the parents were
asked the question “Are you currently concerned about
how your child behaves?” Again, the responses “a lot”
and “not at all” were used for the analyses of parental
behavioral concerns. The responses “a little,” “don’t
know,” and “refused” were excluded from the data for
simplification purposes.
Sampling
The NSCH data were obtained by the Centers for
Disease Control and Prevention’s National Center for
Health Statistics using the State and Local Area
Integrated Telephone Survey program. Individuals who
conducted the telephone surveys were paid employees of
the National Center for Health Statistics and had exten-
sive training in survey administration. Households with
children aged less than 18 years in all 50 states and the
District of Columbia were identified using the random-
digit dialing sampling framework of the National
Immunization Survey. One child from each household
was randomly selected to be the focus of the survey. The
survey respondent was an adult identified in the house-
hold as being “the parent or guardian who lives in this
household who knows the most about the health and
health care of the child.” Parental interviews were con-
ducted in 12 languages, including English and Spanish,
during 2003 and 2004. The data were gathered on a total
of 102,353 children aged 0 to 17 years. For the purpose
of this study, only children between the ages of 10
months and 5 years 11 months were included. The total
number of children in the study sample was 27,350, with
13,871 boys and 13,466 girls. English-speaking families
totaled 24,524, with 2,809 families speaking other lan-
guages. Nearly 69% of the households contacted for the
NSCH completed the 25-minute telephone interview.
Thirty-two states accomplished response rates of over
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55%, with a range of 49.6% to 64.4%. A total of 6,035
interviews, or 5.9% of the original sample, were con-
ducted in Spanish. Detailed information regarding the
design of the NSCH is available at the survey’s Web site
(http://www.nschdata.org).
Analysis
All analyses of the NSCH data were performed using
SUDAAN, which produces accurate variance estimates
for complex survey designs (Research Triangle Institute,
2004). Population-based estimates were obtained by
assigning sampling weights to each sampled child for
whom an interview was completed (Blumberg et al.,
2005). Estimates of percentages and odds ratios provided
in this article were calculated excluding missing values
for the variables in question. Responses of “refused” or
“I don’t know” were also excluded from the denomina-
tor. Univariate analyses via χ2 tests at the .05 significance
level were performed to determine the extent of the asso-
ciation between language and behavior concerns and the
other variables, such as socioeconomic factors and
parental stress and coping outcomes.
To get a more accurate measure of the association
between language and behavior concerns and parental
stress, logistic regression was used to model the odds of
the stress outcomes of interest, adjusting for the potential
confounding effects of age, gender, race, parental educa-
tion, and household income. Adjustment for potential
confounders was limited by what data were collected in
the NSCH, but the variables selected represent the usual
demographic, environmental, and psychological vari-
ables that are considered the most likely confounders in
outcomes research of this kind. The following levels of
concern were analyzed in these models: parents with no
concern regarding their children’s language or behavior,
parents concerned only with their children’s language,
parents concerned only with their children’s behavior,
and parents concerned with their children’s language and
behavior. Adjusted odds ratios and their corresponding
95% confidence intervals were computed for each of the
three levels of concern, compared with not having lan-
guage and behavior concerns.
Results
Table 1 describes demographic information for
parents who expressed a lot of concern regarding their
children’s language and for those who were concerned
about their children’s behavior. Language was defined in
terms of how a child understood his or her parent or how
a child spoke. Behavior was defined as how a child
 Long et al. / Results From the NSCH 151

Table 1
Language and Behavior Concerns by Demographics, Children Aged 10 Months to 5 Years
% With “a Lot” % With “a Lot”
of Parental of Parental
Concern Concern
Regarding Regarding
Demographic Number of Languagea Behaviora
Variable Children (%) (n = 2,163) pb (n = 1,405) pb

Total 27,350 (100%) 9.9 (0.3) 6.6 (0.3)

Gender <.0001 .0001
Male 13,871 (50.9%) 11.5 (0.5) 7.7 (0.4)
Female 13,466 (49.1%) 8.4 (0.4) 5.4 (0.4)
Ethnicity <.0001 <.0001
White, non-Hispanic 17,895 (58.3%) 7.3 (0.3) 4.6 (0.3)
Hispanic 4,391 (20.6%) 9.4 (0.8) 6.2 (0.7)
Black, non-Hispanic 2,338 (13.4%) 20.2 (1.3) 14.3 (1.2)
Multiracial, 1,192 (3.2%) 9.1 (1.5) 6.3 (1.1)
non-Hispanic
Other, non-Hispanic 1,153 (4.4%) 14.4 (2.8) 11.3 (3.1)
Relation of respondentc .0078 .0003
Maternal 22,183 (83.1%) 9.8 (0.4) 6.2 (0.3)
Paternal 4,144 (13.4%) 9.5 (0.8) 6.8 (0.6)
Other 1,021 (3.5%) 15.3 (1.8) 14.8 (2.1)
Number of adults <.0001 <.0001
in household
One 2,477 (10.5%) 15.1 (1.2) 14.1 (1.4)
Two 20,640 (73.9%) 8.4 (0.4) 5.3 (0.3)
Three or more 4,198 (15.6%) 13.7 (1.0) 8.0 (0.8)
Highest level of <.0001 <.0001
education of anyone
in household
Less than high school 1,448 (8.7%) 10.4 (1.3) 9.3 (1.4)
High school graduate 5,443 (25.5%) 13.2 (0.8) 8.8 (0.7)
More than high school 20,299 (65.8%) 8.5 (0.4) 5.3 (0.3)
Primary household language .7484 .2996
English 24,524 (84.4%) 10.0 (0.4) 6.4 (0.3)
Other 2,809 (15.6%) 9.6 (1.1) 7.6 (1.1)
Health care coverage at <.0001 <.0001
time of survey
No 1,888 (7.6%) 9.3 (1.3) 7.2 (1.1)
Private 17,826 (60.3%) 7.9 (0.4) 4.4 (0.3)
Public 7,313 (32.0%) 14.0 (0.7) 10.5 (0.7)
Household income <.0001 <.0001
classification
Below federal 3,561 (19.7%) 14.7 (1.0) 11.1 (1.0)
poverty leveld
At or above federal 21,238 (80.3%) 8.6 (0.4) 5.3 (0.3)
poverty level

Source: 2003 National Survey of Children’s Health.

a. All variables are listed as percentages (with standard errors in parentheses) of the row attribute. Those participants who were not applicable
(because of age or otherwise) or who had missing values for particular variables were not included in calculations.
b. P value resulting from a χ2 test comparing the distribution of the percentages of “a lot” of concern across the levels of the particular demo-
graphic characteristic.
c. Biological, step, foster, or adoptive.
d. Children living in households with incomes <100% of the federal poverty level.

behaved. A larger percentage of parents expressed con- concern regarding their children’s language and behavior
cern about their children’s language (10%) than about more often than parents of girls, and a larger percentage
their children’s behavior (7%). Parents of boys expressed of Black parents reported concern about their children’s
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152 Topics in Early Childhood Special Education
language (20%) and behavior (14%) than White parents
(7% for language and 5% for behavior) or Hispanic
parents (9% for language and 6% for behavior). The per-
centages of mothers and fathers reporting concern
regarding their children’s language and behavior were
similar. Parents who were the only adults in their house-
holds expressed more concern regarding their children’s
language (15%) and behavior (14%) than those in house-
holds with two or more adults. Parents in households
with adults who had education levels of high school
graduate or less reported more concern about language
and behavior in their children than those in households
with adults who had higher education levels. A larger
percentage of families whose parents reported concern
regarding language and behavior in their children had
public health care coverage.
Table 2 shows the relationship between parental lan-
guage concerns and behavioral concerns in children aged
10 months to 5 years 11 months. As shown in the table,
53.9% of parents of children aged 10 months to 2 years
11 months and 54.3% of parents of children aged 3 years
to 5 years 11 months who reported concerns regarding
their children’s language also reported concerns about
their children’s behavior problems, whereas only 0.9%
of parents of children aged 10 months to 2 years 11
months and 2.1% of parents of children aged 3 years to
5 years 11 months who had no concerns about their
children’s language reported concerns about their
children’s behavior problems.
Table 3 provides the age-specific estimated adjusted
odds of parental stress outcomes of interest, comparing
parents who reported concerns regarding their children’s
language, behavior, or both with parents who reported
neither type of concern. The two age groups were com-
posed of younger children (aged 10 months to 2 years 11
months) and older children (aged 3 years to 5 years 11
months). To demonstrate how to read this table, a parent
who was concerned “a lot” with only language in his or
her younger child was estimated to be 6.85 times more
likely to feel that he or she was not coping well with the
daily demands of parenthood than a parent with no con-
cerns regarding language or behavior (p < .05). When
parents of older children were asked this same question,
they were 2.57 times more likely to feel that they were
not coping well with daily demands.
Parents who reported concern about their children’s
behavior described feeling much more stress than
parents reporting concern about their children’s lan-
guage development. Parents of older children were 18
times more likely to report that their children did things
that bothered them and that they were having difficulty
coping with the day-to-day demands of parenthood
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Table 2
Relationship Between Parental Language
Concerns and Behavioral Concerns: Children
Aged 10 Months to 5 Years
Percentage of Parents/Respondents With
“a Lot” of Concern Regarding How Their
Children Behave (95% confidence interval)
Language 10 Months to 2 Years 3 Years to 5 Years
Concern 11 Months Old 11 Months Old
“A lot” of parental 53.9 (47.8 to 59.8) 54.3 (48.9 to 59.6)
concern regarding
speech or
comprehension
No parental concern 0.9 (0.6 to 1.4) 2.1 (1.6 to 2.8)
regarding speech
or comprehension
Source: 2003 National Survey of Children’s Health.
Note: Participants with missing values for particular variables were
not included in the tabulations provided.
when they also expressed concern regarding their
children’s behavior. Parents of older children reported
increased stress levels compared with parents of
younger children when they also reported concerns
regarding their children’s behavior. Parents who
expressed concern regarding their children’s behavior
were 13 times (younger children) to 22 times (older
children) more likely to report that their children were
much harder to care for than most children, compared
with approximately 2 times more likely for parents who
expressed concern regarding their children’s language.
Parents were 12 times more likely to express feeling
angry with their older children if they also reported
concerns regarding their children’s behavior than
parents who expressed no concern about their children’s
behavior.
Although it was reasoned that parents expressing con-
cern regarding both language and behavior problems in
their children might have the most stress, that was not
found to be true from the results of this study. If parents
reported concerns regarding both language and behavior,
they were 7 times more likely to report that their children
were more difficult to care for than most children if their
children were in the younger age group and 12 times
more likely for older children. However, parents reported
more difficulty coping overall with children having only
behavior problems.
Although the effects of several demographic vari-
ables, including gender, race, low socioeconomic level,
and a high school level of education or less, were taken
into account in the multivariate analysis, there were few
significant associations with parental stress outcomes
 Long et al. / Results From the NSCH 153

Table 3
Estimated Adjusted Odds Ratios (95% confidence intervals) of Parent-Related
Stress Outcomes of Interest: Children Aged 10 Months to 5 Years
“A Lot” of Parental Concern Regarding

10 Months to 2 Years 11 Months Old 3 Years to 5 Years 11 Months Old

Parental Both Both

Stress Outcome Language Behavior Language and Language Behavior Language and
of Interest Onlya Onlya Behaviora Onlya Onlya Behaviora

In general, the parent 6.85 1.01 1.17 2.57 18.67 2.83

feels he or she is coping (1.93 (0.11 (0.28 (0.36 (4.89 (1.24
with the day-to-day to 24.31) to 8.90) to 4.86) to 18.50) to 71.22) to 6.50)
demands of parenthood
not very well or not
well at allb
During the past month, 2.35 12.82 7.04 2.09 22.51 12.53
the parent usually or (1.12 (4.83 (3.92 (1.01 (10.92 (7.78
always felt that the to 4.92) to 34.01) to 12.66) to 4.32) to 46.39) to 20.19)
child was much harder
to care for than most
children his or her agec
During the past month, 1.18 13.75 4.21 1.29 18.66 6.91
the parent usually or (0.43 (5.10 (2.23 (0.57 (9.52 (4.09
always felt that the to 3.21) to 37.06) to 7.95) to 2.94) to 36.59) to 11.68)
child did things that
bothered the parent
a lotc
During the past month, 1.67 3.62 2.69 1.58 4.71 2.38
the parent usually or (0.91 (1.27 (1.75 (0.90 (2.55 (1.58
always felt that he or to 3.08) to 10.32) to 4.12) to 2.76) to 8.73) to 3.59)
she was giving up
more of his or her
life to meet the
child’s needs than
he or she ever
expectedc
During the past month, 1.92 5.67 3.81 2.43 12.58 3.86
the parent usually or (0.57 (1.51 (0.97 (0.73 (5.59 (2.01
always felt angry with to 6.54) to 21.35) to 14.89) to 8.08) to 28.33) to 7.43)
the childc

Source: 2003 National Survey of Children’s Health.

Note: Adjusted odds ratios were estimated using logistic regression, with the models including age, gender, race or ethnicity, income, and edu-
cation. Reported 95% confidence intervals that do not contain 1 indicate significance at the .05 level.
a. Odds ratios of the stress-related outcomes odds ratios were estimated for (a) “a lot” of parental language concern only versus no parental lan-
guage or behavior concern, (b) “a lot” of parental behavior concern only versus no parental language or behavior concern, and (c) “a lot” of
both language and behavior concern versus no such concerns. To demonstrate how to read this table, a parent who is concerned “a lot” with only
language is an estimated 6.85 times more likely to feel that he or she is not coping well with the daily demands of parenthood than parents with
no concerns regarding language or behavior (p < .05).
b. Possible responses include “very well,” “somewhat well,” “not very well,” and “not well at all.”
c. Possible responses include “never,” “sometimes,” “usually,” and “always.”

compared with the associations of stress and language
and behavior concerns. Overall, parents of older children
reported more stress than parents from the younger age
group. For example, parents of older boys reported that
their children did things that bothered them more often
than parents of younger boys. Parents of older children
reported that they had more difficulty coping if they also
reported incomes below the federal poverty line. Parents
with high school degrees or less reported more difficulty
coping and more anger if their children were older.

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154 Topics in Early Childhood Special Education
Discussion
In the current study involving an extensive survey of
parents of young children across the United States, a sig-
nificant number of parents expressed concern regarding
their children’s language development. There is evidence
from previous studies that parents are able to detect
developmental delays, including language delays, in
their young children. Scarborough, Hebbler, and Spiker
(2006) found that speech and communication impair-
ment or delay was the most frequently presenting prob-
lem in children eligible for early intervention services
according to parents (34%) as well as providers (39%).
Glascoe (1999) also reported expressive language as a
common concern of parents.
Another important finding of the present study was that
a large percentage of parents who expressed a lot of con-
cern regarding their children’s language development also
reported concerns about their children’s behavior, indicat-
ing that both language delay and behavioral problems may
be present. The emergence of behavior problems in young
children with developmental delays may be an example of
the transactional nature of factors over time (Crnic et al.,
1983). Children with developmental delays have been
shown to have less interactive play (Guralnick, 1987) and
more negative conflicts with peers, which may lead to
adjustment problems (Guralnick, 1999).
There were socioeconomic differences in the findings,
as seen in the adults’ levels of education, the number of
adults in the household, income levels, and access to
public health care between families who reported lan-
guage and behavioral concerns and those who did not,
with those from lower socioeconomic and educational
levels expressing more concern. Particular efforts should
be made to survey families of lower socioeconomic sta-
tus to identify children who might benefit from assis-
tance for possible language delays and behavior
problems (Nelson et al., 2007). One population to con-
sider for intervention services is children referred to the
child welfare system; yet Stahmer et al. (2005) found
that only 22.7% of children in child welfare who demon-
strated developmental and behavioral needs received
intervention services.
Parents who reported behavioral concerns regarding
their young children were much more likely to express
high levels of stress and difficulty coping. Despite the
evidence that parents can often reliably report concerns
regarding their children’s development (Glascoe, 1999),
professionals have sometimes failed to respond to their
concerns and have taken a “wait and see” approach.
Delays in diagnosis and intervention may be related to
poor outcomes later in the children’s development
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(Rannard, Lyons, & Glenn, 2005). Rannard et al. (2005)
suggested that children who are not referred prior to
school age may develop behavior problems, poor acade-
mic performance, and personal and social difficulties.
Glascoe (1999) found that if parents’ concerns are sys-
tematically elicited, this approach can be used to make
reasonably accurate referral decisions. The level of con-
cern and amount of stress expressed by parents in the
current study are indicators of the importance of the
early identification of language and behavior problems
in children to improve family function, regardless of the
children’s diagnoses.
Parents who expressed concern regarding both lan-
guage and behavior did not report the most stress in the
current study. It was suspected that the group of children
with both language and behavior problems may repre-
sent a unique population that has either changed parental
expectations or is receiving intervention services. For
example, Blanchard, Gurka, and Blackman (2006) found
that families with children diagnosed with autism spec-
trum disorder reported being “very close” to their
children and were able to “cope very well” compared
with parents of children having other chronic develop-
mental problems (48% vs. 39%). In addition, nearly 90%
of families with children diagnosed with autism spec-
trum disorder said that they had emotional support in
raising their children. On the other hand, Schieve,
Blumberg, Rice, Visser, and Boyle (2007) found that
parenting a child with autism who required special ser-
vice needs seemed to be associated with stress.
To determine if families with children diagnosed with
autism spectrum disorder had an effect on the results of the
current study, analyses of the responses of parents from this
group were conducted. There were 45 children in the older
age group who had been diagnosed with autism spectrum
disorder. Of this group, 40 parents reported that their
children had both speech and behavior concerns, 3 had nei-
ther speech or behavior concerns, 1 had speech concerns
only, and 1 had behavior concerns only. Overall, the small
sample size limited the ability to assess the associations of
interest in this study for this subgroup.
Implications for Intervention
The early identification of language and behavior
problems may need to be addressed by a variety of edu-
cation and health care providers, including family doc-
tors and pediatricians, preschool and Head Start
teachers, public health nurses, social workers, and child
and day care providers, among others. The American
Academy of Pediatrics (2006) recommended develop-
mental surveillance for children at the intervals of 9, 18,

24, and 30 months. The families of infants and preschool
children should be asked about their own specific con-
cerns regarding their children’s comprehension, verbal
skills, and behavioral control. Parents should rate their
own levels of stress so that service providers can deter-
mine the urgency and extent of treatment options. There
are tools available for rating parenting stress (Abidin,
1990) and child characteristics (Conners, 2002). Health
care providers and educators will need to be knowledge-
able regarding community resources that may be able to
assist families. These resources include early interven-
tion programs, early childhood special education pro-
grams through local public schools, and child and family
counseling services. Families may especially benefit
from parent support groups, and young children may
benefit from classroom or play groups that encourage
social, behavioral, and language development.
The treatment of language problems in infants and tod-
dlers has included an emphasis on teaching caregivers
strategies in the natural setting of the family (Childress,
2004; Raab & Dunst, 2004). A variety of techniques have
been proposed, such as the development of a functional
communication system (Dunlap et al., 2006; World
Health Organization, 2001) and the use of augmentative
communication systems, including signs or pictures
(Romski & Sevcik, 2005). It is not within the scope of the
current study to determine the most appropriate means of
increasing communication skills and decreasing problem
behaviors in young children. However, the findings do
suggest that any intervention program developed to assist
family function may need to address both the communi-
cation needs of children and the children’s challenging
behaviors (Dunlap et al., 2006). Approaches may need to
be developmental and behavioral in nature and include
alternative forms of communication. The approaches
should also be sensitive to cultural diversity in the popu-
lation served (Stayton, Miller, & Dinnebell, 2003).
Intervention may be most effective when a team
approach is used that pairs the skills of a speech and lan-
guage therapist with those of a behavioral psychologist
or a special educator. All personnel providing interven-
tion services should have a strong knowledge base and
be able to engage in role release (help others learn one
another’s skills) and role acceptance (Smith et al., 2002).
In addition, services should be family based, with
resources and supports matching the family’s concerns
and leading to parent competence.
Limitations of the Study
The NSCH is the largest, most comprehensive survey
of the health of children in the United States to date. This
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Long et al. / Results From the NSCH 155
survey’s limitations should be noted because this analysis
is based on data from the study. Conclusions regarding
causality could not be made, because the data in the sur-
vey are cross-sectional. In addition, the survey excluded
data from institutionalized children and children from
homes without telephones. Although parental observa-
tions from surveys are supported in the literature as a
valid method of data collection, there are inherent biases,
such as cultural differences in reporting development and
functional status. The questions used to elicit parental
stress have been shown to produce possible cultural dif-
ferences between English-speaking and Spanish-speak-
ing families (Oster et al., 2002). The families were not
asked questions regarding their children’s participation in
early intervention or preschool services or treatment pro-
grams involving speech and language therapy, specialized
instruction, or behavior management, so the effectiveness
of intervention programs could not be determined. In
addition, families were not asked to provide specific
examples of family function that may have been
adversely affected by increased levels of stress.
Conclusions
The 2003 NSCH provides us with a large sample of
data on the percentage of families in which parents
express concern regarding their children’s acquisition of
language skills and their perceptions of behavior prob-
lems, with a significant number of parents reporting con-
cern about both. Over 50% of parents expressing
concerns regarding their children’s speech were also
concerned about their children’s behavior. Parents were
especially worried about their own ability to cope with
the stress of raising children with behavior problems.
The early identification of parents’ concerns regarding
their children’s language and behavior will need to take
place in a variety of settings and be conducted by a
number of professionals from the health care and educa-
tion fields. Parents have been shown to be reliable
reporters of concerns regarding language and behavior
problems. Parents should be specifically asked about
their children’s language skills using straightforward
questions, such as those in the survey. Parents should
also be questioned regarding their children’s ability to
behave and to get along with others. Most important,
parents should be asked about their own levels of stress
as an indicator of the need and model for intervention
services. Parents may need to learn specific strategies,
such as communication treatments paired with behavior
management techniques, to improve their children’s
overall level of functioning.
156 Topics in Early Childhood Special Education
Research suggests that the early detection and treat-
ment of language delays and behavior problems in young
children lead to optimal outcomes, and the most impor-
tant identified child outcomes for program accountability
are based on the acquisition of language and social skills
(Early Childhood Outcomes Center, 2005). The ultimate
goal in any intervention program should be increased
family function, which can be rated by reduced parental
stress and improved coping. When evaluating interven-
tion programs, positive outcomes for families are one of
the most important factors of quality (Bailey et al., 2006).
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Carolyn E. Long, MA, MS, is a hospital teacher with the
Charlottesville Hospital Education Program and works at the Kluge
Children’s Rehabilitation Center and Research Institute at the
University of Virginia Children’s Hospital.
Matthew J. Gurka, PhD, is an assistant professor in the Division of
Biostatistics and Epidemiology in the Department of Public Health
Sciences and an assistant professor in the Department of Pediatrics at
the University of Virginia School of Medicine.
James A. Blackman, MD, MPH, is a professor of pediatrics and head
of the Division of Developmental Pediatrics at the Kluge Children’s
Rehabilitation Center and Research Institute, University of Virginia
Children’s Hospital.