Received: 18 February 2020 Revised: 30 July 2020 Accepted: 31 July 2020

DOI: 10.1002/icd.2199

RESEARCH ARTICLE

Developmental delay and parenting: The role

of behaviour problems in toddlers

Maire Claire Diemer | Emily D. Gerstein

University of Missouri-St. Louis, St. Louis,

Missouri
Abstract
Developmental delays (DD) are missed early childhood
Correspondence
developmental milestones in cognitive, motoric or linguistic
Emily D. Gerstein, University of
Missouri-St. Louis, St. Louis, MO. domains. DD associated with behaviour problems may com-
Email: gersteine@umsl.edu pound to impact parenting. This study investigated whether
DD would moderate the relation between behaviour prob-
lems and parenting in families of toddlers. Data were drawn
from an Early Head Start (n = 564) sample. The Ages and
Stages Questionnaire-Third Edition measured developmen-
tal status at age 2 (typically developing, in a monitoring
zone, or having a DD), behaviour problems were assessed
at age 2, and supportive and negative parenting at age
3. Developmental delay moderated the relationship
between behaviour problems and supportive parenting such
that greater behaviour problems were unrelated to parental
supportiveness for children with DD, while greater behav-
iour problems led to less parental supportiveness for typi-
cally developing children. These findings suggest distinct
developmental processes, with parental supportiveness act-
ing as potentially protective for children with DD.

KEYWORDS

behaviour problems, developmental delay, diversity, parent–child

interaction, parenting, toddler

1 | I N T RO DU CT I O N

Toddlers with early developmental compromise are at risk for later developmental-behavioural diagnoses, missed
cognitive and language milestones and delayed motor advancement (Shevell, 2008). A well-established body of
research has demonstrated that behaviour problems may be critical in understanding parenting in families of children
with developmental disabilities, beyond particular diagnoses of the child (Baker, Blacher, Crnic, & Edelbrook, 2002;

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https://doi.org/10.1002/icd.2199
2 of 15 DIEMER AND GERSTEIN

Chang, Olson, Sameroff, & Sexton, 2011; Glascoe, 2000). These findings suggest a cumulative risk process, wherein
the risk factors of behaviour problems and early developmental compromise show a multiplicative negative effect
compared with either on its own (Gerard & Buehler, 2004). However, existing research mostly examines families
when children are older, rather than when children are first flagged as falling behind. By looking at these patterns
before a diagnosis is conferred (which can be school-age and after), clinicians may have some opportunity to
intervene and improve parenting and behavioural problems at an earlier stage.

1.1 | Developmental delay

A developmental delay (DD) is a condition of being behind the normal progression of growth compared with peers
of the same age in any of several cognitive, language or motor skills (Squires, Twombly, Bricker, & Potter, 2009). The
term global developmental delay is typically associated with younger children (ages 0–36 months), where they may
be compared across a range of developmental milestones, whereas later children may be classified as having an intel-
lectual disability based on intelligence testing and adaptive functioning (Shevell et al., 2010). About 1–3% of children
out of the total population get diagnosed with a global delay by 2 years old (Shevell et al., 2010). Children are often
identified as having delays through developmental behavioural screeners, which are norm-referenced, standardized
tools used to monitor development in young children. These may be administered to parents at well-child doctors'
visits, family clinics and community health centres. Typically, if a child's development is reported to be two standard
deviations below the average scores on this screener, this will lead to a recommendation for the child to be referred
for evaluation (Squires et al., 2009). Many screeners also have a delineated 'monitoring zone' (MZ) for children who
are between 1 and 2 standard deviations below the mean (Squires et al., 2009), indicating below average but not
clinically significant delay. The most commonly used screeners have anywhere from a 32 to 64% positive predictive
value for intellectual and developmental disabilities as the child ages (Squires et al., 2009). This wide range of predic-
tive value can be explained by the age at which the screener is administered, the severity of the delay or the socio-
economic status (SES) of the family (Squires et al., 2009). However, 80% of parents whose children go on to have a
developmental-behavioural diagnoses report problems by 2 years old (Shevell et al., 2010), suggesting that parents
have good insight into their child's functioning, even when they are very young.

1.2 | Parenting

DD is an early risk factor that can shape parent attitudes, parent–child relationships and parenting strategies.
Supportive, high quality parenting is considered to be sensitive to the child's abilities and development (Pluess &
Belsky, 2010). High quality parenting is associated with higher IQ, greater school completion and achievement, better
effortful control and fewer externalizing problems, with benefits extending to children with disabilities as well as typi-
cally developing (TD) children (Combs-Ronto, Olson, Lunkenheimer, & Sameroff, 2009; Eisenberg et al., 2005; Fenning,
Baker, Baker, & Crnic, 2007; Glascoe & Leew, 2010). High-quality supportive parenting may consist of positivity,
responsiveness and cognitive stimulation. Positive parenting is associated with better functioning and more positive
behavioural, cognitive and psychological outcomes in both children who are typically and nontypically developing
(Algood, Harris, & Hong, 2013; Dyches, Smith, Korth, Roper, & Mandleco, 2012; Smith, Landry, & Swank, 2000). Parent-
ing focused on developing a relationship through empathy and respect is associated with more stable temperament,
fewer externalizing behaviours and a secure attachment relationship in children who are TD (Boeldt et al., 2012; Van
den Akker, Dekovic, Prinzie, & Asscher, 2010). Highly responsive mothers of children with DD, who engage with their
child and attend sensitively to the child's needs, see many benefits for that child later in life, including better positive
cognitive, behavioural, language and motor development (Warren & Brady, 2007). Encouraging cognitive growth can
include reading to children, providing stimulating play activities, engaging with the child to expand on thought-
DIEMER AND GERSTEIN 3 of 15

processes and problem-solving (Cabrera, Fagan, Wight, & Schadler, 2011; Merz et al., 2015). However, providing a cog-
nitively stimulating environment has been inextricably linked to higher income populations in the literature; parent edu-
cation and socioeconomic status are almost always positively correlated with having time to read and participate in
cognitively stimulating play (Lugo-Gil & Tamis-LeMonda, 2008; Welsh, Nix, Blair, Bierman, & Nelson, 2010).
By contrast, negative regard in parenting involves the parent providing harsh, reactive responses and expressing
overall negative emotionality toward the child (Burchinal, Vernon-Feagans, & Cox, 2008). Poor-quality parenting
during infancy, low in positive regard and sensitivity but high in negative regard, has also been linked to externalizing
behaviours in early childhood (Lorber & Egeland, 2009). Negative regard in parenting is strongly associated with child
DD and parental stress (Brown, McIntyre, Crnic, Baker, & Blacher, 2011; McFadden & Tamis-Lemonda, 2013). Less
positive parenting and more negative parenting were contemporaneously linked to children scoring two standard
deviations below the mean on developmental screeners (Glascoe & Leew, 2010).
Transactional relationships, in which parent and child both impact and prompt behaviours in the other, have been
found in TD children as well as those with DD (Sameroff & Mackenzie, 2003; Woodman, Mawdsley, &
Hauser-Cram, 2015). Toddlers can reduce parent responsivity and sensitivity by having less eye contact, shyness, unin-
telligible speech or stereotypies (Barnett, Gustafsson, Deng, Mills-Koonce, & Cox, 2012; Sameroff & Mackenzie, 2003).
Ciciolla, Gerstein, and Crnic (2014) found that child externalizing behaviours increased maternal distress in both children
with and without DDs. While the literature has focused on how developmental risk and behaviour problems affect
parental stress, effects on specific parenting behaviours at an early developmental age are less known.

1.3 | Behavioural problems

DD is a risk factor that rarely appears in isolation; other child characteristics can also impact parenting. In fact, 30–50%
of children with diagnosed DDs have comorbid behaviour problems (Hinshaw, 1992; Neece, Green, & Baker, 2012).
Child behaviour problems are described as a child acting out in ways that are disruptive, antisocial, lacking control or
inappropriate for the situation and impair family functioning (Hinshaw, 1992; Scott et al., 2012). These behaviours tend
to be stable over the course of development (Baker et al., 2003; Bornstein, Hahn, & Haynes, 2010). In the literature
focusing on young children with diagnoses, research has revealed that it is in fact behaviour problems that have the
most impact on parenting stress, negative parenting and lack of positive parenting, more so than the particular diagno-
ses of the child (Estes et al., 2009; Fenning et al., 2007). Baker et al. (2002) also found that parents of children aged
3 years old with DDs reported significantly higher behaviour problems compared with parents of TD children. Still, the
question of how these behaviour problems are demonstrated in children who may be prediagnostic is important to
understanding the relations among developmental risk, behaviour problems and parenting quality.

1.4 | Social risk

Cumulative risk theory attests that individual risk factors can interact in a compounding way. Thus, more risk factors
are correlated with exponentially higher likelihood for negative health effects, lower cognitive ability, negative
effects on executive functioning and other problems (Evans, Li, & Whipple, 2013; Gerard & Buehler, 2004). Impor-
tant risk factors to consider are sociodemographic risk factors, including poverty, single-parent families, lack of
maternal education and low SES (Engle & Black, 2008; Lima, Caugy, Nettles, & O'Campo, 2010). These social risk fac-
tors may increase stress and subsequently negatively impact parenting (Burchinal, Roberts, Hooper, & Zeisel, 2000;
Trentacosta et al., 2008). Low SES is also correlated with higher rates of DDs and lower cognitive scores (Becker &
Luthar, 2002; Denham & Brown, 2010). Families of children with intellectual disabilities are more likely to be eco-
nomically disadvantaged than those of TD children (Ayoub et al., 2009). In addition, social and emotional difficulties
(such as behavioural problems) are found at higher rates within populations who are socioeconomically disadvan-
taged (Whittaker, Harden, See, Meisch, & Westbrook, 2011).
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1.5 | Current study

The current study examined how early developmental delay and behaviour problems at age 2 may be related to
supportive parenting and negative regard in parenting at age 3. This study used a nationally representative Early
Head Start (EHS) population, where families are typically experiencing significant socioeconomic risk. The focus on
early DD, rather than developmental-behavioural disability, in a diverse population addressed an important gap in
the literature. It was hypothesized that developmental risk, of either delay or in the monitoring zone, would moder-
ate the relation between behaviour problems and parenting, such that the relations between behaviour problems
and parenting would be stronger in the presence of developmental risk.

2 | METHODS

2.1 | Participants

The participants were enrolled in the EHS Family and Child Experiences Study (Baby FACES; Cannon, Murphy,
Bloomenthal, & Vogel, 2014) and recruited from a representative sample of 89 Head Start Programs across the
country from birth or age 1 and followed through age 3. EHS is available to promote the developmental needs of chil-
dren in families who are categorized as low income by the federal poverty guidelines, in foster care, receiving public
assistance, or are homeless (Vogel & Boller, 2014). The attrition rate of the total study sample was 35% by age 3, the
most common reason for dropout was cited as moving (reviewed in Vogel & Boller, 2014). This study used all partici-
pants with age 2 data (n = 564). Sample demographics are listed in Table 1. Families were recruited from selected sites
by on-site coordinators within centres; families consented to participate in the study at a rate of 88.5%.

2.2 | Procedure

This study was part of a larger, longitudinal multisite study. At age 2, researchers came into the home, and primary care-
givers filled out questionnaires about child ability and behaviour. At age 3, researchers returned to the home and
videotaped caregivers and children interacting together in the Two Bag Assessment. In this assessment, a caregiver and
child were presented with two bags, one with a book inside and one with age-appropriate toys (plastic food and plates).
The caregivers were instructed to play with one bag and move on to the second when they were ready. They played
freely and were filmed by the examiner for 8 min. The study was approved by the University of Missouri-St. Louis Insti-
tutional Review Board.

2.3 | Measures

2.3.1 | Developmental status

The Ages and Stages Questionnaire-3 (ASQ-3) is a parent report screener utilized to assess developmental risk, and in
this study was used at age 2 (Limbos & Joyce, 2011). This screener covers five different developmental spheres: com-
munication, gross motor, fine motor, personal-social and problem-solving. The tool has Cronbach's alphas ranging from
.51 to .87 (Vogel & Boller, 2014) and an aggregated sensitivity or specificity of 86% across age intervals. The ASQ-3 also
has an established 'monitoring zone', of between one and two standard deviations below the mean for a particular age.
Any child who was developmentally delayed (below two standard deviations from the mean; in the 'referral zone') in
any of the spheres, was labelled as developmentally delayed (DD), and a child who was not developmentally delayed,
DIEMER AND GERSTEIN 5 of 15

TABLE 1 Weighted descriptive statistics of study variables

Developmentally
Typically developing Monitoring zone delayed

% or Range % or Range % or Range ANOVA

Variables n mean or SD mean or SD mean or SD F-statistic
ASQ total score 564 267.33a 17.47 230.29b 21.46 187.37c 46.25 2,644.79*
a b c
Parental supportiveness 414 4.58 0.75 4.33 0.77 4.19 0.77 58.09*
Parent negative regard 414 2.21a 1.03 2.30a 1.12 2.83b 1.06 63.86*
a b c
BP 648 10.93 6.80 11.76 6.72 14.68 9.23 70.75*
Maternal risk 509 2.36 1.15 2.28 1.44 2.34 1.10 1.61
Gender (male) 629 47.4% 0–1 54.8 0–1 62.8% 0–1
Race 629
White 208 40.5% 0–1 31.2% 0–1 37.3% 0–1
African American 129 17.4% 0–1 13.8% 0–1 20.7% 0–1
Hispanic/Latino 237 32.7% 0–1 39.2% 0–1 36.0% 0–1
Mixed/other 55 9.1% 0–1 13.9% 0–1 6.1% 0–1
Maternal risk elements
On welfare 504 60.2% 0–1 65.4% 0–1 68.0% 0–1
Teen mother 613 48.8% 0–1 52.6% 0–1 45.2% 0–1
Single mother 523 37.1% 0–1 32.7% 0–1 34.9% 0–1
Unemployed 511 31.9% 0–1 25.9% 0–1 37.6% 0–1
Less than high school 508 28.7% 0–1 30.6% 0–1 25.8% 0–1

Note: Values are weighted. The n is unweighted. F values with a '*' are significant at p < .001 among the three groups. Means
in the same row with different superscripts are significantly different from one another.
Abbreviations: ASQ, The Ages and Stages Questionnaire; ANOVA, analysis of variance; BP, behavioural problems.

but in the monitoring zone (MZ) in any sphere was labelled as in the MZ. Those who were not in MZ or DD zone any-
where were considered typically developing (TD). Full diagnostic evaluations were not completed on participants.

2.3.2 | Behavioural problems

The Brief Infant Toddler Social Emotional Assessment (BITSEA) is a 42-item scale used to detect behavioural and
social emotional problems in children, where higher scores indicate worse functioning, and was collected at age
2. Parents rated child characteristics as 'not true/rarely', 'somewhat true/sometimes', or 'very true/often', on sub-
scales of aggression, overactivity, negative emotionality and withdrawal. This study used the BITSEA Problem
Domain Scale (11 items; α = .80; Vogel et al., 2015).

2.3.3 | Parenting

The Parent-Child Interaction Scales were used to rate parent behaviour during the Two-Bag Assessment-Parent
scales (Vogel & Boller, 2014). This measure includes 12 total scales; four were included in the study (Vogel &
Boller, 2014). Sensitivity, stimulation of cognitive development and positive regard were combined to create the sup-
portive parenting index, which has a Cronbach's alpha of .82 to .83 (Vogel et al., 2015). The fourth scale used as an
6 of 15 DIEMER AND GERSTEIN

individual item was negative regard, defined as showing anger or rejection to the child. A 7-point scale was coded
observationally, with one being the lowest evidence of the behaviour and, seven being highest frequency of a certain
behaviour. Supervised teams of trained video coders achieved 92% agreement with the trainer, subsequently inter-
rater reliability was maintained at 80% (Vogel & Boller, 2014).

2.3.4 | Sociodemographics

Sociodemographics were collected at age 2. Baby FACES has a previously established maternal risk factor index
(defined as receiving public assistance, unemployed, less than high school education, teenager motherhood and sin-
gle motherhood) that was used in this study (Vogel & Boller, 2014). In addition, gender of child (0 = female or 1 = male)
and reported race of child were included. Baby FACES categorized race into four groups: White, African American,
Latino and multiple or mixed races/not otherwise mentioned.

2.4 | Data analytic plan

Analyses were completed using multiple regression, with simple slopes analysed according to Preacher, Curran, and
Bauer (2006). For developmental status, two dichotomous variables were used. The DD variable examined those
with DD versus those TD (0 = Typically Developing, 1 = Developmental Delay); the second variable assessed children
in the MZ versus those TD (0 = Typically Developing, 1 = Monitoring Zone).
Weighting was used on all analyses to provide an accurate representation of the EHS population. This method
values different participants more or less heavily in analyses in order to better match a representative sample and
can also help adjust for any differential attrition. This is a requirement of using the Baby FACES data set, and the pre-
sent study used a longitudinal weight constructed by Baby FACES. Weighting impacts sample size and degrees of
freedom so that they appear higher than the number of subjects in the study. Multiple imputation was used to
address missing data on age 3 parenting variables; 40 data sets were generated randomly, and pooled data were
reported. When missing data were analysed for the larger study, moving was the most significant reason for dropout
(Caronongan, Moiduddin, West, & Vogel, 2014). In our study, greater maternal risk (a socioeconomic indicator), was
related to greater attrition, and thus was used in the multiple imputation. No other study variables or covariates were
related to missingness. Multiple imputation expectations were met, and data were considered missing at random
(Enders, 2010).
A power analysis was run with eight predictor variables (three independent, two interactions, five covariates).
The sample size provided sufficient power, given a medium effect size at F2 = 0.15, with an alpha error probability
.05 and .95 power.

3 | RESULTS

3.1 | Descriptives and preliminary analyses

Table 1 presents weighted descriptives for the variables of interest; all variables were normally distributed and there
were no outliers. The proportion of children in the monitoring zone for developmental delay as measured by their
ASQ-3 score was 38.0%, while the percentage of those below threshold for developmental delay was 16.7%.
Table 1 shows descriptive statistics for the sample. The sample was fairly evenly divided by child gender. Boys
were more likely to screen for a DD, χ 2(1) = 38.65, p < .001, and MZ, χ 2(1) = 9.67, p = .002. Boys also had more
behaviour problems, t(4567) = −6.10, p < .001. The large degrees of freedom is due to the weighting procedure used
DIEMER AND GERSTEIN 7 of 15

in all analyses with Baby FACES data. Averages for parent supportiveness and parental negative regard differed
based on race. For parental supportiveness, an analysis of variance results indicated significant differences,
F(3) = 18.52, p < .001. Within this finding, White families were rated significantly more supportive than Hispanic/
Latino and African American families (p < .001). Mixed/other and Hispanic Latino families were rated as higher on
parental supportiveness than African American families (p < .001, p = .034). For parental negative regard, the analysis
of variance results indicated significant differences, F(3) = 79.28, p < .001. Within this finding, African American par-
ents displayed significantly more negative regard than mixed/other parents, (p < .001), who were more negative than
white parents (p = .009). Latino/Hispanic parents showed the least negative regard (p < .001). Because White fami-
lies appeared to have different patterns than African American, Hispanic/Latino or Mixed/other families, the decision
was made to use dummy coding for race in the model, with White as the reference group.
The mean number of maternal risk factors was 2.34 (SD = 1.14), indicating on average, mothers reported
between two and three risk factors (out of five). Of those risk factors, 61.3% of the mothers were on welfare, 49.5%
had their first child before the age of 20, 35.2% were single mothers, 29.0% were employed less than full time, and
28.2% had less than a high school education. Higher maternal risk was weakly negatively correlated with supportive
parenting r = −.14, p < .001, but not quite significantly associated with parental negative regard, r = .04, p = .050.

3.2 | Parental supportiveness

Developmental risk, either delay or MZ, was examined as a moderator in the relation between behaviour problem
and parental supportiveness. Behaviour problems, children with DD, children in the MZ, their interactions and
covariates (race, gender, and maternal risk composite), were entered in a regression analysis with parental support-
iveness as the outcome. The overall model was significant (Table 2) and explained 9.0% of the variance (R2 = .090), a
small effect size. There was an interaction between DD and behaviour problems (Figure 1). Simple slopes indicated
that behaviour problems did not affect parental supportiveness for children who were DD,(b(SE) = .00(.004),
p = .710, while behaviour problems led to less parental supportiveness for TD children, b(SE) = −.02(.003), p < .001.
There was no interaction between MZ and behaviour problems. Compared with TD children, both children in the

TABLE 2 Multiple regression for parental supportiveness

Unstandardized beta SE Significance 95% CI

Male −.011 0.053 .836 [−.116, .094]
Race
African American −.174 0.076 .026 [−.326, −.021]
Hispanic −.108 0.057 .063 [−.223, .006]
Mixed/other −.217 0.098 .031 [−.413, −.021]
Maternal risk −.060 0.021 .006 [−.103, −.017]
BP −.020 0.004 .000 [−.029, −.012]
DD −.189 0.052 .000 [−.292, −.086]
MZ −.156 0.044 .001 [−.243, −.069]
DD × BP interaction .022 0.010 .029 [.002, .041]
MZ × BP interaction .002 0.007 .733 [−.011, .016]

Note: For the race/ethnicity variables, White is used as the comparison group. For the DD and MZ variables, typically devel-
oping is used as the comparison group. Multiply imputed weighted N = 3,280, weighted n = 2,256. Bolded lines indicate sig-
nificant results.
Abbreviations: BP, behavioural problems; CI, confidence interval; DD, developmental delay; MZ, monitoring zone.
8 of 15 DIEMER AND GERSTEIN

F I G U R E 1 Interaction between
developmental delay and monitoring zone
and behaviour problems. Note:
Developmental delay means The Ages
and Stages Questionnaire-third edition
scores were two standard deviations
below the mean, while monitoring zone
means one standard deviation below the
mean. All others are typically developing.
Multiply imputed weighted N = 3,280,
weighted n = 2,256

TABLE 3 Multiple regression for parental negative regard

Unstandardized beta SE Significance 95% CI

Male .129 0.065 .052 [−.001, .259]
Race
African American .515 0.099 .000 [.317, .712]
Hispanic −.222 0.067 .001 [3.540, −.090]
Mixed/other .281 0.105 .009 [.072, .490]
Maternal risk .025 0.032 .441 [−.039, .088]
BP −.005 0.005 .351 [−.015, .006]
DD .471 0.080 .000 [.313, .630]
MZ .091 0.068 .182 [−.044, .226]
DD × BP interaction −.011 0.010 .257 [−.031, .009]
MZ × BP interaction .009 0.008 .265 [−.007, .026]

Note: For the race/ethnicity variables, White is used as the comparison group. For the DD and MZ variables, typically devel-
oping is used as the comparison group. Multiply imputed weighted N = 3,280, weighted n = 2,256. Bolded lines indicate sig-
nificant results.
Abbreviations: BP, behavioural problems; CI, confidence interval; DD, developmental delay; MZ, monitoring zone.

MZ and those with DD had less parental supportiveness by age 3. Greater behaviour problems, more maternal risk
factors, and being nonwhite were also associated with less parental supportiveness.

3.3 | Negative regard

The same analysis was conducted with parental negative regard as the outcome. The overall model was signifi-
cant (Table 3) and explained 11.6% of the variance. There was not a significant interaction between DD or chil-
dren in the MZ and behaviour problems. Having a developmental delay was associated with more parental
negative regard at age 3 in comparison to TD children. There were no differences in negative regard with chil-
dren in the MZ and those who were TD. Behaviour problems and maternal risk were not associated with parental
negative regard. Compared with White children, African American and Mixed/other children were more likely to
have experienced higher parental negative regard, where Hispanic/Latino children experienced less parental nega-
tive regard.
DIEMER AND GERSTEIN 9 of 15

4 | DISCUSSION

The goal of this study was to examine ways in which developmental delay and behavioural problems may jointly
impact parenting for toddlers with socioeconomic risk. Previous research on older children has indicated that devel-
opmental diagnosis alone may be less influential on parenting than in combination with behavioural problems (Baker
et al., 2003). This article addresses a critical gap in the literature, by examining early developmental risk and how it
impacts parenting during toddlerhood. Our analyses came out notably different, finding unique relations among
developmental delay, behaviour problems and parenting. The investigation found support for an interaction; how-
ever, the interaction was opposite to that hypothesized. While behaviour problems were associated with less sup-
portiveness for TD children and children in a MZ, behaviour problems were unrelated to supportiveness in children
with DD. Furthermore, differences were found between which qualities affected parental supportiveness and paren-
tal negative regard, perhaps indicating distinct developmental processes.
Early detection is one of the best means for successful intervention in child development and family dynamics
(Bruder, 2010; Walker et al., 2011) and is in large part facilitated by developmental questionnaires given at well-child
paediatric visits (Glascoe, 2000). Early DD does not unequivocally mean a disability diagnosis will follow, but inter-
vention may be effective in preventing or mitigating potential negative family and child outcomes. Although these
children were 2 years old at the time of the ASQ, some of them may already have had developmental-behavioural
diagnoses, particularly in more severe cases of delay. Furthermore, this study also examined children who were in a
monitoring zone, meaning that some of them were not so far delayed as to receive referrals from paediatricians
(Squires et al., 2009). This study discovered an interaction between developmental delay and behaviour problems,
opposite to what was predicted. Children with DD experienced less supportive parenting than TD children overall,
but supportiveness did not drop off further as behaviour problems increased. By contrast, children in the MZ and TD
children had greater parental supportiveness overall, but supportiveness decreased as behaviour problems increased.
This unexpected finding suggests possible early indications of resilience in parenting very young, at-risk children.
It is possible that parents who have significantly delayed and behaviourally difficult children work to reframe this
behaviour and delay in a way that increases empathy with the child and does not lead to less supportive parenting,
despite challenges (Walker & Cheng, 2007). Research has long supported positive parenting as a protective factor
for children with developmental disabilities (Dyches et al., 2012), even in specifically reducing behaviour problems
(Eisenberg et al., 2005), and the field of developmental disability has begun to explore positive impacts on families of
children with disabilities (Blacher & Baker, 2007; Green, 2007; Myers, Mackintosh, & Goin-Kochel, 2009). However,
in contrast to the findings of this study, Blacher and Baker, (2007) found an inverse relation between behaviour
problems and the child with disability's positive impact. The findings from our study first need replication, but this
research may support early signs of protective and resilient patterns in these families in early toddlerhood.
Despite some potentially positive aspects noted above, we found that being developmentally at-risk, either in
the DD or MZ, in 2-year-old children, was associated with less supportive parenting in comparison to TD children.
This parenting change may be due to increased risks of mental health disorders in children with delays and increased
rates of maternal depression (Baker et al., 2003; Estes et al., 2009). In addition to having less supportive parenting
than TD children, children in the MZ also experienced a decrease in supportive parenting with increased behaviour
problems. Thus, even when development is considered in a monitoring zone, parents may benefit from more educa-
tion regarding development and parenting tools to make parent–child interactions more effective and positive.
In partial support of our initial hypotheses, more severe behaviour problems were associated with less support-
ive parenting for TD children and children in the MZ. This result is in line with research in TD children showing that
child behaviour problems result in less supportive parenting over time (Verhoeven, Junger, van Aken, Dekovic, & van
Aken, 2010). Understanding which factors may de-escalate behavioural problems is critical because disruptive
behaviours contribute to academic underachievement, increased family stress and other negative child and family
factors as a child ages regardless of developmental risk (Ciciolla et al., 2014; Combs-Ronto et al., 2009;
Hinshaw, 1992).
10 of 15 DIEMER AND GERSTEIN

There was no moderation between developmental status and behavioural problems with respect to parental
negative regard. Furthermore, contrary to hypotheses, behaviour problems were not significantly associated with
negative parenting. Only DD, and not children in the MZ, predicted more negative parenting when the child reached
age 3. This could be considered a promising finding, as children in the MZ appeared more like TD children in the
parental response elicited. While these associations were not expected, the behaviour problem findings may be
encouraging, given that negative parenting can cause lasting, undesirable effects in children, both TD and develop-
mentally at risk (Blacher, Baker, & Kaladjian, 2013). There may be multiple reasons for the lack of associations with
parental negativity. First, the task used to measure parenting did not particularly pull for negative behaviours, as it is
a pleasant, cooperative activity. In fact, on the 1–7 scale of negative parenting, 96% of parents were on the lower
2/3 of the scale, rated as 1–4, with 65% of parents in the sample rated as either a 1 or a 2. This reduced variability in
negative regard ratings may obscure the impact of behaviour problems or the interaction. Additionally, it could be
that although parenting supportiveness changes based on factors related to the child, parent negative regard might
be predicted more by parent factors which were not included in this study, such as parent depression (Lovejoy,
Graczyk, O'Hare, & Neuman, 2000), recent job loss (Lim & Sng, 2006) or religious beliefs (Mahoney, Pargament,
Tarakeshwar, & Swank, 2008).
Race was a significant determinant of parental supportiveness and negative regard, particularly with regard to
African American children experiencing less supportive and more negative parenting compared with the white racial
group. These findings are congruent with the literature, which has shown that White families have more supportive
and less negative parenting styles than African American families (Burchinal, Skinner, & Reznick, 2010; Morrison
Gutman, McLoyd, & Tokoyawa, 2005; Skinner, MacKenzie, Haggerty, Hill, & Roberson, 2011). However, more
recently this finding has been re-examined, and may in fact be the result of biases in coding protocols (Longest, Tay-
lor, Barnett, & Raver, 2007). Newer theories posit that emotion is expressed differently in diverse cultural contexts,
and coding regimens created by those from the majority White scientific community may not accurately account for
these variances (Bocknek, Brophy-Herb, & Banerjee, 2009; McNeely & Barber, 2010).
Finally, more maternal risk was associated with less parental supportiveness, but not higher parental negative
regard. This finding was relatively weak, and it is possible that the large sample size impacted the findings. It is
unclear why this critical socioeconomic measure would have less effect on the negative domain of parenting and
more effect of reducing positivity toward children. It may be that, similar to the relation with child behaviour prob-
lems, negative regard in parenting is more affected by other indicators; for example, parent temperament or mental
health (Lovejoy et al., 2000). Our unique sample may contribute to this discrepancy as well. The EHS population is
considered an at-risk population financially. Thus, maternal risk may operate differently among those who are primar-
ily low SES from those who are more affluent, which is the comparison typically made. Although 50.3% of the
mothers who participated in the study were on welfare, a much higher proportion is likely having difficulty making
ends meet.

4.1 | Limitations

There are a few limitations in this study. There was significant attrition, with moving as the cause of the majority of
families dropping out. While the use of weighting and multiple imputation helps to account for this attrition, the
results should be applied with caution given that missing data can affect outcomes. Additionally, these data were col-
lected from EHS programs across the United States, which provide intervention and services to families over the first
3 years of life. For this reason, the results might not be directly generalizable to wealthier families or families not
receiving intervention services. Unfortunately, the study involved limited direct testing of children, and researcher-
administered assessments of children's developmental milestones (i.e., Bayley) were not completed (Bayley, 1993).
The goal of this study was to examine the impact of child factors on parenting. However, other parent or family
factors, such as maternal depression, are also linked to parenting (Chronis et al., 2007; Hoffman, Crnic, &
DIEMER AND GERSTEIN 11 of 15

Baker, 2006; Kiernan & Huerta, 2008). Additionally, DD and behaviour problems were measured by parent report
instead of through third-party observation or diagnosis. Finally, while interesting findings came to light, some were
surprisingly weak in their robustness when considered in light of the sample size. While this may suggest early trends
or weak patterns, the risk and influence of Type I error due to sample size must be considered as well, and replication
is needed.

4.2 | Clinical implications

This study indicates that over time, being developmentally delayed may be associated with less supportive parenting
and increased negative regard in parenting. However, experiencing both significant delay and behaviour problems
may end up reframing a child's experience to parents, allowing for behaviour problems not to influence a parent's
caregiving approach. Dual interventions may be useful to intervene with the child to promote progress toward devel-
opmental milestone goals and also intervene with the parent to reduce stress and improve parental supportiveness.
Given our findings of decreased supportive parenting for children in the MZ, paediatricians may consider conversa-
tions and referrals for parenting groups and parenting skills training even when children do not have severe delays.
Maternal risk also lowered parental supportiveness, which reiterates the need for at-risk families to receive services
that reduce parental stress and support healthy family functioning (Burchinal et al., 2008).

4.3 | Future directions

By parsing out differences between how children who have a developmentally delay, are at-risk for developmental
delay (MZ), and children with severe behaviour problems impact supportive and negative parenting, this investigation
addressed specific interactions in a sensitive developmental period. Future inquiries may examine this more closely
by looking at samples not limited to those in EHS and investigating where specific delays might be intersecting with
behaviour problems most (cognitive, linguistic or motoric). Certain children, such as those in rural areas, children of
colour or low-income families are likely to have later diagnosis than other children (Daniels & Mandell, 2014;
Fountain, King, & Bearman, 2011; Mazurek et al., 2014), and research into how to reduce discrepancies in age of
diagnosis will help improve equity in the field. Further research into protective factors of supportive parenting in
these at-risk children is required.

ACKNOWLEDGEMEN TS
The authors would like to thank the families and staff that participated in the study. They would also like to thank
Ann Steffen for her advice on an earlier draft of this manuscript.

CONF LICT OF IN TE RE ST
The authors whose names are listed above certify that they have no affiliations with or involvement in any organiza-
tion or entity with any financial interest, or nonfinancial interest in the subject matter discussed in this manuscript.

DATA AVAI LAB ILITY S TATEMENT

The data that support the findings of this study are available from the Child and Family Data Archive. Restrictions
apply to the availability of these data, which were used under license for this study. Data are available https://doi.
org/10.3886/ICPSR36074.v1 with the permission of the Child and Family Data Archive.

ORCID
Maire Claire Diemer https://orcid.org/0000-0003-2553-9064
12 of 15 DIEMER AND GERSTEIN

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How to cite this article: Diemer MC, Gerstein ED. Developmental delay and parenting: The role of behaviour
problems in toddlers. Inf Child Dev. 2020;e2199. https://doi.org/10.1002/icd.2199