Psychiatry Research 242 (2016) 121–129

Contents lists available at ScienceDirect

Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Parenting stress among parents of children with Neurodevelopmental

Disorders
Francesco Craig a, Francesca Felicia Operto a, Andrea De Giacomo a, Lucia Margari a,
Alessandro Frolli c, Massimiliano Conson c, Sara Ivagnes b, Marianna Monaco c,
Francesco Margari b,n
a
Child Neuropsychiatry Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari “Aldo Moro”, Italy
b
Psychiatry Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari “Aldo Moro”, Italy
c
Neuropsychology Laboratory, Department of Psychology, Second University of Naples, Caserta, Italy

art ic l e i nf o a b s t r a c t

Article history: In recent years, studies have shown that parents of children with Neurodevelopmental Disorders (NDDs)
Received 25 January 2016 experience more parenting stress than parents of typically developing children, but the relation between
Received in revised form the type of disorders and parenting stress is far from clear. The purpose of this study was to compare the
6 May 2016
parenting stress experienced by parents of 239 children with Specific Learning Disorders (SpLD), Lan-
Accepted 12 May 2016
guage Disorders (LD), Autism Spectrum Disorder (ASD), Attention Deficit Hyperactivity Disorder (ADHD),
Available online 1 June 2016
and typical development (TD). Parents of children with NDDs experience more parenting stress than
Keywords: those of children who have TD. Although, parents of children with ASD or ADHD report the most high
Parenting stress scores of parenting stress, also the parents of children with SpLD or LD report higher parental stress
Specific learning disorders
compared with parent of children without NDDs. Another interesting finding was that IQ level or
Language disorders
emotional and behavioral problems are associated with the higher levels of parenting stress. This study
Autism spectrum disorder
Attention deficit hyperactivity disorder suggest that parent, both mothers and fathers, of children with different type of NDDs should be pro-
vided with interventions and resources to empower them with the knowledge and skills to reduce their
stress and to enhance their quality of life.
& 2016 Elsevier Ireland Ltd. All rights reserved.

1. Introduction
Neurodevelopmental Disorders (NDDs) are a group of condi-
tions with onset in the developmental period, often before the
child enters grade school, and are characterized by developmental
deficits that produce impairments of personal, social, academic, or
occupational functioning (American Psychiatric Association, 2013).
Raising a child with a NDDs puts a greater strain on parenting
skills than that of raising typically developing children. In fact, in
parents of children with NDDs, high levels of parenting stress have
been detected clear (Baker et al., 2002; Hauser-Cram et al., 2001;
Johnston et al., 2003; Ricci and Hodapp, 2003), but the relation
between the type of disability and parenting stress is far from.
Parenting stress is defined as the aversive psychological reaction to
the demands of being a parent (Liles et al., 2012), typically when
the demands of being a parent are not matched with the perceived
resources available to the parent. While all parents may experi-
ence a low degree of parenting stress, high levels of parenting
n
Corresponding author.
E-mail address: francesco.margari@uniba.it (F. Margari).
stress may have serious negative effects on the family and the
parent's psychological health and overall well-being. Several the-
ories suggests that parenting stress is multiply determined by
child, parent, family, and ecological characteristics reciprocally
influencing one another and contributing to outcomes (McCubbin
and McCubbin, 1989; Lazarus and Folkman, 1984).
Abidin developed the transactional model of parenting beha-
viors that describes the interplay between psychological, socio-
logical, and environmental factors (Abidin, 1995). The author
proposed three major domains of parental stress: parent char-
acteristics, child characteristics, and situational/life demographics.
These domains are reflected in Abidin's Parenting Stress Index
(PSI), which is designed to measure the various sources and as-
pects of parental stress (Abidin, 1995). The theoretical framework
used for this study was Abidin's Parenting Stress Theory, focusing
mostly on child characteristics.
Recent developments in the field of parenting stress have led to
a renewed interest in the bidirectional relationship between par-
ental stress and NDDs. The presence of maternal stress during
pregnancy may explain 10–15% of childhood disorders of the
neuro-development (Glover, 2014) and similarly stressful parent-
ing patterns are found in families with children with NDDs.

http://dx.doi.org/10.1016/j.psychres.2016.05.016
0165-1781/& 2016 Elsevier Ireland Ltd. All rights reserved.
122 F. Craig et al. / Psychiatry Research 242 (2016) 121–129
Research suggests that offspring of mothers who experience high
levels of stress during pregnancy are more likely to have problems
in neurobehavioral development and intellectual disabilities
(Bergman et al., 2007; Ronald et al., 2010). Ramchandani et al.
(2010) investigated the influence of prenatal maternal stress on
subsequent behavioral problems of children (four years of life) and
found that the transmission of stress to their offspring is mediated
by high levels of maternal hormones secreted by hypothalamic-
pituitary-adrenal (HPA) axis involved in the response to stress,
hormones that can affect fetal brain development (Ramchandani
et al., 2010). According to this study, fetal neural development
would depend essentially on the duration of exposure to stress
rather than by the specific type of stressful event, the timing of the
stress, the time in which the fetus is exposed to prenatal stress, is
an element critic could lead to a dysregulation the sense neuro-
fetal development (Dipietro, 2012). On the other hand, child be-
havior problems consistently have been shown to predict parental
stress (Baker et al., 2005), particularly autism (Abbeduto et al.,
2004; Estes et al., 2009) and Attention Deficit Hyperactivity Dis-
order (ADHD) (Theule et al., 2013) have been reported as im-
portant correlates. Parents of children with autism experience a
condition of elevated stress and are more vulnerable to potential
negative outcomes compared to parents of children who have
other disability forms (Dunn et al., 2001), and the severity of
Autism Spectrum Disorder (ASD) symptoms is an important pre-
dictor of mother’s parenting stress (Mahoney, 2009). In the same
way, parents of children with ADHD very often experience con-
siderable stress in their parenting roles. A review study confirmed
that parents of children with ADHD experience more parenting
stress than parents of nonclinical controls and that severity of
ADHD symptoms was associated with parenting stress (Theule
et al., 2013).
Multiple comorbid conditions such as emotional and beha-
vioral problems are profound contributor to parental stress and
family instability, because these can compounded functional im-
pairments such as life skill, school performances, ability to work,
and ability to independent. Previous studies have reported that
parents of children with ASD experience higher stress levels than
parents of typically developing children (TD) and that children
with ASD show more behavioral and emotional problems than
controls suggesting that behavioral and emotional problems are
strong predictors of parental stress (Davis and Carter, 2008; Gio-
vagnoli et al., 2015; Hastings, 2002; Huang Chien-Yu et al., 2014;
Lounds et al., 2007). In a meta-analyses study, examining the as-
sociation between parenting stress and ADHD, some authors re-
ported that child co-occurring externalizing behaviors, in parti-
cular conduct problems, predicted parenting stress (Theule et al.,
2013). Another potential child characteristic that may contribute to
increased parent stress is cognitive dysfunction. Parents of chil-
dren with lower intelligence quotient (IQ), may face increased
child-rearing responsibilities. For example, children with lower IQ
need greater assistance with a range of basic activities, from
dressing, to bathing, to toileting. These increased demands may
lead to increased parenting stress or psychological distress (Ken-
nedy, 2012). Recently, some authors reported that in children with
ASD, child's verbal and performance IQ were a significant predictor
of parental stress (Pastor-Cerezuela et al., 2015), on the contrary
others authors showed that in children with ADHD, IQ does not
have an impact on parental stress but the severity of ADHD
symptoms is an important predictor of parenting stress (Grizenko
et al., 2015). Studies that have investigated the parental stress in
children with SpLD or LD which also presented emotional and
behavioral problems and/or intellectual disability are lacking.
The elevated parental stress emanates directly from the pre-
sence of NDDs, given the increased caretaking demands that
children with NDDs impose on their parents. Parents of these
children often find themselves involved in resolving various
school, peer, and sibling difficulties. Although, research on par-
enting stress in parents of children diagnosed with ASD or ADHD
has indicated that the characteristics of these two disorders make
child raising especially stressful, study that has compared the
stress experienced by parents of children with other NDDs, such as
Specific Learning Disorders (SpLD), Language Disorders (LD) and
intellectual and developmental disabilities are lacking. Under-
standing what contributes to stress will then lead to more targeted
interventions to support families and facilitate family functioning.
Therefore, the main objective of the present study was to compare
the parenting stress of children and adolescents affected by dif-
ferent NDDs and TD. A strong point of the study is that we con-
ducted a comparison between mothers and fathers. Higher levels
of parenting stress and psychological distress were mainly re-
ported in mothers of children with ASD (Dabrowska and Pisula,
2010; Tehee et al., 2009) or ADHD (Margari et al., 2013; Theule
et al., 2013) or SpLD (Brock and Shute, 2001; Karande et al., 2009)
or LD (Chaffee et al., 1991), moreover fathers of children with
NDDs experience higher levels of parenting stress than fathers of
TD children (Davis and Carter, 2008; Lach et al., 2009; Podolski
and Nigg, 2001). However, very few studies have been conducted
to compare parenting stress in mothers and fathers of children
with different NDDs. An additional purpose of the study was to
examine the association of parental stress with levels of emotional
and behavioral problems and intellectual disability to have a better
understanding of the parental stress. It was hypothesized that the
level of parental stress is linked with emotional and behavioral
problems or intellectual disability in these children.
2. Method
The clinical sample consisted of 186 children/adolescents, aged
from 3 to 12 years old, consecutively referred to Child Neu-
ropsychiatry Unit-University-Hospital of Bari during the period
from December 2014 to December 2015. Participants were divided
into four groups: SpLD group, LD group, ASD group and ADHD
group. The SpLD group comprised 60 children/adolescents, the LD
group comprised 34 children/adolescents, the ASD group com-
prised 45 children/adolescents, the ADHD group comprised 47
children/adolescents. The diagnoses were made by clinical experts
according to DSM-5. The diagnoses were based on the develop-
mental histories of the children, taken from clinical interviews
with the parents, observations and extended neuropsychological
testing of the children themselves. The control group consisted of
53 TD children/adolescents, that was randomly recruited, based on
the availability of parents or subjects to participate in the study,
from schools located in Puglia and Campagnia.
Exclusion criteria were the presence of other medical condition
or mental disorders and medical/psychiatric illness of parents.
Written informed consent was obtained for all participants after
providing all the details of the study procedure.
2.1. Assessment
The assessment included the administration of IQ test and
clinical standardized scales such as the Parenting Stress Index (PSI)
and Child Behavior Checklist (CBCL).
2.2. IQ test
The IQ was assessed according to the age through Wechsler
Intelligence Scale for Children (WISC-III) (Wechsler, 1991),
Wechsler Preschool and Primary, Scale of Intelligence (WPPSI)
(Wechsler, 2002), and Leiter International Performances Scale
 F. Craig et al. / Psychiatry Research 242 (2016) 121–129
Revised (Leiter-R) (Roid and Miller, 1997) alternatively to WISC-III,
in nonverbal subjects. The control group was not assessed for IQ.
2.3. Parenting Stress Index(PSI): short form
The PSI Short Form (PSI/SF) is a direct derivative of the Par-
enting Stress Index (PSI) full-length test (Abidin, 1995). All 36
items on the Short Form are contained on the Long Form with
identical wording and are written at a 5th-grade reading level, for
parents of children 12 years and younger. Each item requires the
parent/caregiver to rate the degree to which s/he agrees with a
statement on a five-point Likert scale (1 ¼Strongly Agree,
2 ¼Agree, 3 ¼Not Sure, 4 ¼Disagree, and 5 ¼Strongly Disagree).
This self-report uses a three factors model to measure parenting
stress, to which correspond the three subscales: parenting distress
(PD) scale, dysfunctional interaction parent-child (P-CDI) scale,
difficult child (DC) scale. The PD scale defines the level of distress
which a parent perceives in his parenting role, linked to personal
factors directly involved in this role. The P-CDI scale values the
parenting perception of a child that doesn’t respond to the family
expectations and of an interaction neither reinforcing nor re-
warding with the child. The DC scale values how much the parent
perceives his child as easy/difficult to manage, considering some of
his behavioral characteristics. The PSI-SF produces subscale raw
scores ranging from 12 to 60 and an overall parenting stress total
score that ranges from 36 to 180; a higher score indicates a greater
level of stress. A score above 85 (at the 90th percentile) indicates
clinically significant parenting stress (Abidin, 1995). The total
stress (TS) scores, obtained by the sum of the scores of the 3 sub-
scales, can be interpreted as a stress index related to the only
parenting role. The test includes also a Defensive Responding (DF)
scale, useful to control the validity of the protocol, which indicates
if the parent tends to give a better self-image, minimizing the
problems and the perceived stress in the relationship with the
child. In this study, the Cronbach's alpha reliability coefficient of
this measure is 0.91 for mothers and 0.88 for fathers.
2.4. Child Behavior Checklist (CBCL)
The CBCL (Achenbach, 2001) is a common tool used to assess
emotional and behavioral problems in children. The first section of
the scale includes 20 items related to the child's social compe-
tency, as rated by parents. These items address the child's parti-
cipation in sports, hobbies, games, activities, organizations, jobs,
chores, friendships, social interactions during play, independent
work, and school functioning. The second section consists of 120
items on behavior or emotional problems during the past
6 months as rated on a three-point scale. The main areas of this
construct are aggression, hyperactivity, bullying, conduct pro-
blems, defiance, and violence. The following behavioral and
emotional problems are also measured: aggressive behavior, an-
xious/depressed, attention problems, delinquent rule-breaking
behavior, social problems, somatic complaints, thought problems,
withdrawal, externalizing, internalizing, and total problems. Re-
sponses are recorded on a Likert scale: 0 ¼Not True, 1 ¼Somewhat
or Sometimes True, 2 ¼Very True or Often True. Lower scores in-
dicate lower functioning on the academic performance and
adaptive functioning scales. Higher scores indicate higher levels of
maladaptive behavior on the syndrome, total problems, ex-
ternalizing and internalizing scales. In order to verify the mean
differences between groups, we took into account only the com-
mon scales between CBCL/6-18 and CBCL/1 ½-5. The instrument
has an internal validity of 0.90–0.91 for the scales of internalizing
disorders and of 0.95–0.96 for externalizing disorders. Cronbach's
coefficient alpha was 0.95 and 0.96, respectively.
123
2.5. Statistical analysis
All demographic and clinical variables were subjected to sta-
tistical analysis. Descriptive analysis was conducted for socio-
demographics featuring of the four samples. Raw scores obtained
from each subscale of the CBCL and PSI were transformed into
t-scores to allow for consideration of how an individual's response
compares with that of the population norms. For CBCL, the bor-
derline (t-score 465) and clinical (t-score 470) scores were put
together. For each group a clinical cutpoint for the domain specific
syndrome scales and broadband scales is determined as the
minimum raw score corresponding with T-score Z65. The Chi-
square tests (χ2) was used to determine the significance of dif-
ferences in frequencies (gender) between diagnostic groups. Due
to the small sample size and nonnormatively distributed data, the
nonparametric Kruskal-Wallis test was used to compare the mean
score of the IQ, age (chidren, mothers and fathers), CBCL and PSI
scores among groups. To evaluate significant differences between
groups, post hoc analysis of Tamhane was conducted. The non-
parametric Wilcoxon Signed Rank test was performed to evaluate
differences in continuous variables (PD, P-CDI, DC, DF, and TS) of
PSI between mothers and fathers of each group. The nonpara-
metric Spearman rank correlation test was used to measure re-
lationships between TS scores (mothers and fathers) and age of
children, IQ, age of mothers, age of fathers, externalizing, inter-
nalizing and total problems. Spearman’r can vary in magnitude
from  1 to 1, with  1 indicating a perfect negative linear relation,
1 indicating a perfect positive linear relation, and 0 indicating no
linear relation between two variables. For non-parametric tests,
the effect size is interpreted as 0.1 ¼ small, 0.3 ¼ medium, and
0.5 ¼ large.
A p-value of less than 0.05 was considered as statistically sig-
nificant. For statistical processing, we used the data processing
program the Statistical Package for Social Science version 20.0.
3. Results
Socio-demographic characteristics of SpLD, LD, ADHD, ASD and
TD groups are summarized in Table 1.
No statistical differences among groups in gender (p ¼0.32)
were found. However, we found a significant difference in the age
between the groups (p ¼0.005). In particular, the LD group showed
a lower chronological age compared with SpLD (p o0.001), ASD
(p o0.001), ADHD (p o0.001) and TD (p o0.001) groups. A sta-
tistically significant difference was found between the groups in IQ
mean score (p o 0.001). The post-hoc analysis showed that ASD
group had lower IQ mean score, compared with SpLD (p o0.001),
LD (p o0.001), and ADHD (p o0.001) groups. No statistical dif-
ference was found in IQ mean score between SpLD, LD, and ADHD
groups. Although the definition of SpLD includes a normal in-
telligence level, we found a mild intellectual disability in the 5% of
SpLD group but the specific learning difficulties markedly over-
come the IQ's reduction.
Two hundred and thirty fourth mothers (60 SLD, 34 LD, 47
ADHD, 42 ASD, 51 TD) and two hundred and third fathers (48
SpLD, 31 LD, 42 ADHD, 39 ASD, 43 TD) were in agreement to
participate in the study. The greater number of mothers in com-
parison to that of the fathers was a result of different circum-
stances: it was either a single parent household or in a two-parent
household one parent refused to participate. The mothers of
children with ASD showed a higher chronological age than the
parents of children with LD (p ¼0.14). The fathers of children with
SpLD showed a higher chronological age than the parents of
children with LD (p ¼0.007).
124 F. Craig et al. / Psychiatry Research 242 (2016) 121–129

Table 1.
Sociodemographic characteristics and IQ of SpLD, LD, ASD, ADHD groups.

SpLD LD ADHD ASD TD Post hoc analysisb

N ¼60 N ¼34 N¼ 47 N¼ 45 N ¼53 Ha P-Value

Gender (child) 0.32c –

male 65% 80% 80% 66% 77% – – –
female 35% 20% 20% 34% 22% – – –
Age (child) 10.3 7 2.1 4.8 7 1.2 9.3 7 2.1 8.3 7 3.6 8.3 7 2.5 66.2 o0.001* LDo *other gropus
IQ Level (child) 87.4 7 10.3 88.9 7 17.1 82.6 7 12.3 61.4 7 13.2 – 74.5 o0.001* ASD o *other gropus
normal 75% 50% 45% 30% – – – –
borderline 20% 40% 28% 27% – – – –
mild intellectual disability 5% 10% 27% 43% – – – –
Mothers N 60 34 47 42 51 – – –
Age (Mothers) 41.5 7 5.8 37.8 75.9 40.7 7 3.4 41.8 7 4.8 40.6 7 6.4 14.5 0.06* ASD 4 *LD
Fathers N 48 31 42 39 43 – – –
Age (Fathers) 43.93 7 6.2 39.8 7 5.2 41.5 7 3.4 43.17 4.2 41.2 7 3.2 10.2 0.04* LDo *SLD

Specific Learning Disorders (SpLD), Language Disorders (LD), Autism Spectrum Disorders (ASD), Attention-Deficit/Hyperactivity Disorder (ADHD), Typically Developing
Children (TD), Intelligence Quotient (IQ), normal (IQ Z85), borderline (IQ 71-84), mild (IQ 50–70).
a
Kruskal–Wallis test (H).
b
Tamhane test.
c
Chi-square test.
*
p o0.05.

3.1. Parenting stress (p ¼0.02), LD (p o0.001) and TD (p o0.001) groups; higher DC

The analysis conducted to evaluate the differences in parenting
stress among the SpLD, LD, ASD, ADHD and TD groups revealed
statistically significant differences in all the PSI variables (Table 2).
The mothers of SpLD and LD children reported higher PD
(p ¼0.001; p¼ 0.002), P-CDI (p o0.001), DC (p o0.001), DF
(p o0.001; p ¼0.001) and TS (p o0.001) scores compared with the
TD group.
3.1.1. Differences in PSI scores between mothers among groups
The mothers of ADHD children reported higher PD scores com-
pared with the SpLD (po0.001), LD (p¼0.002), TD (po0.001)
groups; higher P-CDI scores compared with the LD (p¼0.009) and TD
(po0.001) groups; higher DC scores compared with TD (po0.001)
group; higher DF scores compared with the SpLD (po0.001), LD
(p¼0.001) and TD (po0.001) groups; higher TS compared with the
SpLD (po0.001), LD (p¼0.006), TD (po0.001) groups.
The mothers of ASD children reported higher PD scores com-
pared with the SpLD (p o 0.001), LD (p ¼0.001), TD (p o0.001)
groups; higher P-CDI scores compared with the SpLD (p ¼0.001),
LD (p ¼0.002), TD (p o0.001) groups; higher DC scores compared
with TD (p o0.001) group; higher DF scores compared with the
SpLD (p o0.001), LD (p ¼0.001), TD (p o0.001) groups; higher TD
scores compared with the SpLD (p o0.001), LD (p o0.001), TD
(p o0.001) groups.
3.1.2. Differences in PSI scores between fathers among groups
The fathers of SpLD children reported higher P-CDI scores
compared with the LD (p ¼0.01) and TD (p o0.001) groups; higher
TS scores compared with the LD (p ¼0.04) and TD (p o0.001)
groups. The fathers of LD children reported higher DC (p o0.001)
and TS (p o0.001) scores compared with the TD groups. The fa-
thers of ADHD children reported higher PD scores compared with
the SpLD (p o0.001), LD (p o 0.001), TD (p o0.001) groups; higher
P-CDI scores compared with the SpLD (p ¼ p o0.001), LD
(p o0.001) and TD (p o0.001) groups; higher DC scores compared
with the SpLD (p o0.001), LD (p ¼ 0.021) and TD (p o0.001)
groups; higher DF scores compared with the SpLD (p o 0.001), LD
(p o0.001)and TD (p o 0.001) groups; higher TS scores compared
with the SpLD (p o 0.001), LD (p o0.001) and TD (p o0.001)
groups. The fathers of ASD children reported higher PD scores
compared with the SpLD (p o0.001), LD (p o 0.001) and TD
(p o0.001) groups; higher P-CDI scores compared with the SpLD
scores compared with the SpLD (p ¼0.041) and TD (p o0.001)
groups; higher DF scores compared with the SpLD (p o0.001), LD
(p o0.001) and TD (p o 0.001) groups; higher TS scores compared
with the SpLD (p o0.001), LD (p o0.001)and TD (p o0.001)
groups.
3.2. Parenting Stress of mothers and fathers within groups
Considering the differences between parents (Table 3), the
mothers of SpLD children showed significantly higher rates of PD
(p ¼0.018) and DF (p o 0.001) than fathers. In ADHD children, the
mothers of showed significantly higher rates of DC (p o0.001)
than fathers. However, no significant difference between mothers
and fathers of LD, ASD and TD children were found in all the PSI
variables.
3.3. Emotional and behaviors problems
The analysis of emotional and behaviors problems showed a
statistically significant difference between the groups in all the
CBCL variables (Table 4). The SpLD group showed higher Total
problems scores compared with the TD (p ¼ 0.002) group; the
ADHD group showed higher Total problems scores compared with
the SpLD (p o0.001), LD(p o0.001), ASD(p o0.001), TD(p o0.001)
groups; the ASD group showed higher Total problems scores
compared with the TD (p ¼0.013) groups.
3.3.1. Externalizing problems
The ADHD group showed higher Externalizing problems scores
compared with the SpLD (p o0.001), LD (p o 0.001), ASD
(p o0.001), TD (p o0.001) groups.
The ADHD group showed higher Attention deficit problems
scores compared with the SpLD (p o0.001), LD (p o 0.001), ASD
(p o0.001), TD (p o0.001) groups; while the SpLD (p o0.001), LD
(p ¼0.01) and ASD (p o0.001) groups showed higher Attention
deficit problems scores compared with the TD group.
The ADHD group showed higher ADHD problems scores com-
pared with the SpLD (p o0.001), LD (p o 0.001), ASD (p o 0.001),
TD (p o0.001) groups; while the SpLD (p ¼0.01) and ASD
(p ¼0.02) groups showed higher ADHD problems scores compared
with the TD group.
The ADHD group showed higher Oppositional defiant disorder
(ODD) scores compared with the SpLD (p o0.001), LD (p o 0.001),
 F. Craig et al. / Psychiatry Research 242 (2016) 121–129 125

Specific Learning Disorders (SpLD), Language Disorders (LD), Autism Spectrum Disorders (ASD), Attention-Deficit/Hyperactivity Disorder (ADHD), Typically Developing Children (TD), Parenting Distress (PD), Dysfunctional In-
ASD (p o 0.001), TD (p o0.001) groups, while the SpLD groups

SpLD, LD 4 *TD; ADHD 4 *LD, TD ASD 4 *SpLD, LD,

showed higher ODD scores compared with the TD group (p ¼0.01).

LD4 *TD, ADHD 4 *SpLD, LD, TD; ASD 4 *LD, TD

SpLD, LD 4 *TD; ASD, ADHD4 *SpLD, LD, TD
3.3.2. Internalizing problems
The SpLD group showed higher Internalizing problems scores
compared with the TD (p ¼0.002) group; the ADHD group showed
higher Internalizing problems scores compared with the ASD

ADHD, ASD 4 *SpLD 4 *LD4 *TD

ADHD, ASD 4 *SpLD 4 *LD, TD;
ADHD, ASD 4 *SpLD, LD4 *TD

ADHD, ASD 4 *SpLD, LD4 *TD

(p ¼0.02), LD (p o0.001) and TD (p o0.001) groups; while the ASD
ADHD, ASD, SpLD, LD 4 *TD;

ADHD, ASD 4 *SpLD, LD, TD

ADHD, ASD 4 *SpLD, LD, TD

group showed higher Internalizing problems scores compared
with the LD (p ¼0.031) and TD (p ¼ 0.013) groups.
Post hoc analysisb

The SpLD group showed higher Anxious/Depressed problems

scores compared with the LD (p ¼0.001), ASD (p o0.001), TD
(p ¼0.023) groups; while the ADHD group showed higher An-
xious/Depressed problems scores compared with the SpLD
(p ¼0.001), LD (p o0.001), ASD (p o0.001), TD (p o0.001) groups.
TD

The ASD (p o0.001), SpLD (p ¼0.001), LD (p ¼0.005) and ADHD

(p o0.001) groups showed higher Social Withdraw problems
o 0.001
o 0.001

o 0.001
o 0.001
o 0.001

o 0.001
o 0.001
o 0.001
o 0.001
o 0.001
p value

scores compared with the TD group.

The SpLD (p o0.001), and ADHD (p o0.001) groups showed
higher Somatic Complain problems scores compared with the TD
94.6.9

118.3
119.5
151.6

98.3

30.6 7 1.2 107.2

30.17 1.3 102.3
122.8
113.1

40.2 7 2.7 78.1

group.
Ha

The ADHD group showed higher Depression scores compared

32.2 7 4.5

with the SLD (p ¼0.007), LD (p o0.001), ASD (p o0.001), TD

40.4 7 3.1

30.5 7 1.2

62.8 7 1.9

31.9 7 4.6
30.17 1.3

627 2.3
% 4Cut-off** M7 SD

(p o0.001) groups; while the SLD (p o0.001), and ASD (p ¼ 0.002)

groups showed higher Depression scores compared with the TD
group.
The SpLD group showed higher Anxiety scores compared with
the LD (p o 0.001) and TD (p o0.001) groups; the ADHD group
showed higher Anxiety scores compared with the LD (p o 0.001),
88.5 7 23.2 39%

60%
45%
75%

9%
18%
30%
83.5 7 25.3 15%
45%
49%
TD

ASD (p ¼0.002), TD (p o0.001) groups; the ASD group showed

88.9 7 18.9
88.9 7 17.9

higher Anxiety scores compared with the LD (p ¼0.024) and TD

96.7 7 6.8

96.5 7 5.6
96.1 73.6
807 23.7
907 27.5
907 69
% 4Cut-off** M 7SD

(p ¼0.033) groups.

3.4. Correlational analyses between parental stress with demo-

graphic characteristics, child emotional and behavioral problems and
intelligence quotient
ASD

67%
74%

80%
73%
93%

46%
73%
86%
67%
87%

We found statistically significant correlation between parental

teraction Parent-Child (P-CDI), Difficult Child (DC), Defensive Responding (DF), Total Stress (TS).
88.5 7 25.9
83.6 7 16.3

90.2 7 26.1
89.4 7 18.8
88.2 7 17.3

87.2 7 16.1
87.3 7 17.9

total stress with demographic characteristics, child emotional and

95.5 7 4.1

97.4 7 4.1
957 2.1
% 4 Cut-off** M 7 SD

behavioral problems and intelligence quotient in mothers and fathers

of children with NDDs. These result are summarized in Table 5.
In the mothers of SpLD children, we observed a negative re-
lationship between total stress and IQ (p o0.001). In the fathers of
SpLD children we observed a negative relationship between total
ADHD

stress and IQ (p ¼0.009).

59.4 7 35.2 83%
85%

86.17 29.9 72%

58.6 7 34.3 83%
87.5 710.5 91%

84%
82%
90%
91%
93%

In the mothers of LD children, we observed a positive re-

32.9 7 24.2

lationship between total stress and children's age (p ¼ p o0.001),

27.5 7 23.3
42.5 7 21.7

82.3 7 5.3
97.6 7 4.3
66.17 30

externalizing (p ¼0.004), and internalizing (p ¼0.007); while we

% 4Cut-off** M 7 SD

observed a negative relationship between total stress and IQ

(p ¼.03). In the fathers of LD children we observed a negative re-
lationship between total stress with IQ (p o0.001), age of mothers
Significant differences in PSI scores between groups.

(p o0.001) and age of fathers (p ¼0.02).

In the mothers of ADHD children, we observed a positive re-
53%
52%

85%
52%
70%

30%
15%
50%
21%
26%
LD

lationship between total stress with externalizing (p ¼0.002) and

total problems (p ¼0.01); while we observed a negative relation-
69.44 729.4
507 28.5
71.8 7 25.8

57.5 7 29.7

30.4 7 25.1
93.4 7 11.2

28.5 7 31.1
98.3 7 3.3
89.17 7.3

88.3 7 7.9

ship between total stress and IQ (p ¼ 0.004). In the fathers of ADHD

% 4 Cut-off** M 7 SD

children we observed a positive relationship between total stress

with children's age (p o0.001) internalizing (p ¼0.01) and total
Kruskal–Wallis test (H).

problems (p ¼0.01); while we observed a negative relationship

between total stress and father's age (p ¼ 0.001).
Tamhane test.

Cut-off 460.

In the mothers of ASD children, we observed a positive re-

SpLD

25%
45%

70%
30%
55%

20%
25%
45%
15%
30%

lationship between total stress and mother's age (p ¼0.003) and

p o0.05.

father's age (p ¼0.005). In the fathers of ASD children we observed

Mothers

Fathers

a positive relationship between total stress and externalizing

Table 2.

P-CDI

P-CDI

(p ¼0.005), internalizing (p ¼ 0.006) and total problems

**
b
DC

DC

a
PD

PD

*
DF

DF
TS

TS

(p ¼0.001).
126 F. Craig et al. / Psychiatry Research 242 (2016) 121–129
Table 3.
Significant differences in PSI scores between mothers and fathers.
SpLD LD
Z Effect size Mothers vs Fa- Z Effect size Mothers vs Fa-
thers p-valuea
PD  2.37 0.35 0.018*  0.79 0.98
P-CDI  0.69 0.03 0.48  0.85 0.97
DC  0.96 0.29 0.33  0.69 0.9
DF 0.3.8. 0.87 o 0.001*  1.5 0.98
TS  0.72 0.06 0.45  0.69 0.72
Specific Learning Disorders (SpLD), Language Disorders (LD), Autism Spectrum Disorders (ASD), Attention-Deficit/Hyperactivity Disorder (ADHD), Typically Developing
Children (TD), Parenting Distress (PD), Dysfunctional Interaction Parent-Child (P-CDI), Difficult Child (DC), Defensive Responding (DF), Total Stress (TS), Mothers (MD),
Fathers (FD),
a
Wilcoxon signed-rank test.
*
p o0.05.
4. Discussion
There is considerable understanding that parents of children
with developmental disabilities experience increased levels of
stress, often related to the severity of their child's behavior (Feizi
et al., 2014; Hayes and Watson, 2013; Huang et al., 2014). However,
the experience of stress is dependent on how individuals perceive
their situation and what are the coping strategies (i.e., problem-
focused, emotion focused, and appraisal- or perception-focused
coping) that are used to manage stress. The first question in this
study sought to determine the levels of parenting stress experi-
enced by parents of children with different NDDs and TD children
to define the profile of parenting stress in each group. The most
obvious finding to emerge from the analysis is that the parents of
the children in the clinical groups perceived greater parenting
stress than that of the parents of typically developing children.
This result would respond to the behavioral manifestation that
usually occurs in NDDs, producing greater difficulties in fulfilling
the parental role and greater tension in the parent–child re-
lationship. In addition, we found some significant differences
among the clinical groups in parenting stress. Our finding seem to
be consistent with other research which found that the mothers of
the ADHD and ASD groups reported elevated levels of parenting
stress (Baker et al., 2005; Harrison and Sofronoff, 2002; Walker
et al., 1999). However, our study shows high levels of parental
stress also in mothers of children with SpLD or LD. These findings
are consistent with those of Karande et al. (2009) who showed
that mothers of children with SpLD reported high stress levels by
the time this hidden disability is diagnosed (Karande et al., 2009).
A possible explanation for this might be chronic poor school per-
formance adversely impacts the child’s peer and family relation-
ships and social interactions. Parents, especially the mother, may
lose confidence in the child’s ability to ever achieve academic
competence, get frustrated, and develop aggressive behavior to-
wards the child. In the present study, also mother of children with
LD reported higher levels of parenting stress than TD group. These
results are in agreement with those obtained by Spiliotopoulou
(2009) that suggested that some parents report constant conflict
with their child and noncompliance, which may be a result of the
frustration that the child feels because of his inability to express
himself (Spiliotopoulou, 2009).
Although, it has been widely demonstrated previously that the
mothers of children with NDDs have significantly higher levels of
stress than mothers of children with TD, few authors have in-
vestigated the parental stress of fathers. In the present study, we
detected higher level of parenting stress in the fathers of children
with ASD or ADHD compared to other groups examined. Never-
theless, fathers of children with SpLD or LD reported more par-
ental stress than children with TD. This shows that parents, both
ADHD ASD
Z Effect size Mothers vs Fa- Z Effect size Mothers vs Fa-
thers p-valuea thers p-valuea thers p-valuea
0.42  0.26 0.36  0.79  1.79 0.89 0.07
0.39  1.24 0.61 0.21  0.81 0.11 0.41
0.48  3.18 0.84 0.001*  1.7 0.6 0.07
0.12  0.12 0.19 0.9 0.77 0.35 0.43
0.48  1.6 0.21 0.1  1.08 0.07 0.27
mothers and fathers, of children with NDDs express anxiety, dis-
comfort and an altered sense of parental competence of their role.
Although there are no statistically significant differences between
mothers and fathers in the TS scale, however there are differences
in the way mothers and fathers perceive stress (PD, DC, DF scales)
with regards to their own and child characteristics. This could
probably be because both mothers and fathers face their own in-
dividual types of challenges and stressors when caring for their
child with ND For example, mothers may be overburdened by
looking after the adaptive needs of their child while fathers may
feel stressed owing to the overburden of making more money to
meet the increased financial needs to look after the medical and
rehabilitation expenses of the child with NDDs (Feizi et al., 2014).
In addition, we evaluated the impact of demographic character-
istics (i.e. parent age, child age), emotional and behavioral pro-
blems and intellectual disability on parenting stress of parent of
children with NDDs. The most frequent association was found
between parent stress and IQ, both in mothers and fathers. This
result suggest that cognitive dysfunctions of the child would be
significantly associated with parental stress. This result may be
explained by the fact that cognitive dysfunctions result in im-
pairment of adaptive functioning, such that the individual fails to
meet standards of personal independence and social responsibility
in one or more aspect of daily life, including communication, social
participation, academic functioning and personal independence at
home. Thus, these characteristics of children diagnosed with NDDs
may account for increased parental stress. However, we found that
cognitive functioning was not associated with parental stress in
ASD children. A plausible explanation for our results is that, in
these children, parenting stress is more directly associated with
severity of cardinal symptoms than IQ level (Hastings and Beck,
2004; Hastings and Johnson, 2001; McStay et al., 2014).
Another interesting finding was that emotional and behavioral
problems of the children were significantly associated with the
overall parental stress. As expected, in our clinical population we
found higher levels of internalizing and externalizing behavioral
problems compared with healthy children. In particular, we found
that ADHD children reported more externalizing behavioral pro-
blems than others groups. These results are in accord with pre-
vious studies indicating that ADHD frequently co-occurs with ex-
ternalizing disorders; 30–50% of individuals meeting the criteria
for ADHD also fulfill the criteria for Conduct Disorder (CD) or
Oppositional Defiant Disorder (ODD) (Angold et al., 1999; Bieder-
man et al., 1991; Singh, 2008), and population-based studies
suggest that ADHD-like and externalizing traits show considerable
covariation in the general population (Costello et al., 2003). It is
interesting to note that we observed a positive relationship be-
tween parental total stress and externalizing problems. This result
are consistent with those of Anastopoulos (1992) who showed that
Table 4.
Significant differences in CBCL symptom scores between groups.

SpLD LD ASD ADHD TD

% 4Cut-off** M 7 SD % 4Cut-off** M 7 SD % 4Cut-off** M 7 SD % 4 Cut-off** M 7 SD % 4Cut-off** M7 SD a

H p value b
Post hoc analysis

Internalizing 55% 56.6 7 11.1 12% 55.3 7 13.2 40% 54.4 7 9.6 74% 68.6 7 7.8 13% 52.3 77.9 49.06 o0.001 ADHD4 *ASD, LD, TD; SpLD4 *TD
Externalizing 40% 61.3 7 11.9 23% 53.7 7 10.7 13% 60.7 7 9.2 78% 66.5 7 7.6 9% 53.9 77.6 69.03 o0.001 ADHD4 *SpLD, LD, ASD, TD
Total Problems 50% 60.9 7 12.4 12% 55.6 7 12.2 46% 61.17 9.1 83% 70.9 7 6.9 11% 53.6 77.5 72.07 o0.001 ADHD4 *SpLD, ASD 4 *LD, TD
Anxious/ 20% 62.6 7 8.7 12% 55.6 7 12.2 28% 57.5 7 5.9 55% 69.2 7 7.9 6% 54.5 76.7 83.8 o0.001 ADHD4 *SpLD4 *ASD, LD, TD
Depressed
Social Withdraw 10% 61.25 7 8.2 9% 61.4 7 8 46% 66.6 712.6 9% 62.2 7 10.2 2% 54.3 75.6 40.3 o0.001 SpLD, ADHD, ASD, LD 4 *TD
Somatic Complain 15% 59.65 7 7.2 11% 56 76.5 19% 56.17 5.6 8% 59.6 7 8.9 9% 53.6 75.5 30.08 o0.001 SpLD, ADHD 4 *TD
Attention deficit 20% 64.95 711.2 32% 63.2 7 12.7 36% 65 77.3 55% 74.6 711.6 9% 55.8 77.6 68.06 o0.001 ADHD4 *SpLD, LD, ASD4 *TD
Depression 30% 63 79.3 12% 59.5 7 10.6 20% 617 8.3 34% 68.8 7 8.4 6% 54.3 76.5 62.6 o0.001 ADHD4 *SpLD, LD, ASD, TD;SpLD, ASD4 *TD
Anxiety 20% 62.8 7 7.6 11% 55.4 7 9.1 26% 60 77.3 57% 66.9 7 6.6 9% 56.17 7.9 58.8 o0.001 SpLD, ASD 4 *LD, TD, ADHD4 *LD, ASD, TD
ADHD 35% 62.65 7 8.4 23% 60.2 7 10.7 9% 59.3 7 6.3 53% 70.5 7 8.7 4% 54.4 76.3 74.7 o0.001 ADHD4 *SpLD, ASD 4 * LD, TD
ODD 3% 56.9 7 5.5 12% 55.5 7 8.7 7% 54.93 7 4.9 73% 67.7 7 7.8 3% 53.2 75.8 83.07 o0.001 ADHD4 *SpLD, LD, ASD, TD; SpLD 4 *TD

F. Craig et al. / Psychiatry Research 242 (2016) 121–129

Child Behavior Checklist (CBCL), Specific Learning Disorders (SpLD), Language Disorders (LD), Autism Spectrum Disorders (ASD), Attention-Deficit/Hyperactivity Disorder (ADHD), Typically Developing Children (TD), Oppositional
Defiant Disorder (ODD),
**
Cut-off 465.
*
p o0.05.
a
Kruskal–Wallis test (H).
b
Tamhane test.

Table 5.
a
Correlational analyses of parental total stress with demographic characteristics, child emotional and behavioral problems and intelligence quotient.

Total Stress

SpLD LD ADHD ASD

Mothers (N ¼60) Fathers (N¼ 48) Mothers (N¼ 34) Fathers (N ¼31) Mothers (N¼ 47) Fathers (N¼ 42) Mothers (N ¼42) Fathers (N¼ 39)

r p r p r p r p r p r p r p r p

Age (child) 0.31 0.051  0.31 0.11 0.75** o 0.001  0.2 0.91  0.05 0.72 0.64** o 0.001 0.2 0.21  0.08 0.58
IQ  0.48** 0.001  0.49** 0.009  0.38* 0.03  0.83** o 0.001  0.41** 0.004 0.21 0.15 0.18 0.24  0.07 0.64
Age (Mothers) 0.3 0.51  0.23 0.24  0.032 0.863  0.94** o 0.001  0.04 0.74  0.17 0.25 0.32* 0.03  0.01 0.91
Age (Fathers) 0.77 0.61  0.12 0.24 0.17 0.35  0.54* 0.03  0.05 0.71  0.48** 0.001 0.42** 0.005  0.013 0.93
Externalizing  0.009 0.95 0.06 0.75 0.36* 0.04 0.22 0.39 0.44** 0.002 0.13 0.36 0.04 0.21 0.44** 0.005
Internalizing 0.15 0.28 0.13 0.48 0.47** 0.007 0.42 0.08 0.14 0.31 0.61** 0.001 0.19 0.2 0.42** 0.006
Total Problems 0.18 0.21 0.86 0.67 0.34** 0.057 0.16 0.52 0.35* 0.015 0.37* 0.01 0.2 0.19 0.4** 0.01

Specific Learning Disorders (SpLD), Language Disorders (LD), Autism Spectrum Disorders (ASD), Attention-Deficit/Hyperactivity Disorder (ADHD), Typically Developing Children (TD), intelligence quotient (IQ), Spearman’s rho(r).
*
p o0.053.
**
po 0.01.

127
128 F. Craig et al. / Psychiatry Research 242 (2016) 121–129
secondary behavioral features such as ODD and aggressive beha-
viors were strong associated with parental stress in parent of
ADHD children (Anastopoulos et al., 1992). However, when com-
pared on internalizing disorders, the SpLD, ADHD and ASD groups
reported higher levels of social withdrawal and anxiety/depression
symptoms compared with the LD and TD groups. Although, studies
comparing internalizing disorders in different NDDs are lacking,
some researchers have highlighted the presence of emotional
problems in ADHD, ASD and SpLD (Rizzutti et al., 2015). These
findings suggest that child emotional and behavioral problems are
significant sources of general parental stress. What cannot be as-
certained, however, due to the correlational nature of this in-
vestigation, is whether these same child and parent factors di-
rectly cause parenting stress. Additional research, therefore, must
be conducted.
Certain methodological limitations inherent in this study
should be noted. The first limitation is related to the stress eva-
luation procedure used. Although the PSI has very good psycho-
metric properties and high reliability and validity in the constructs
that it measures, it is a subjective self-report measure that can lead
to possible biases. Nevertheless, self-reports are crucial when as-
sessing internalized states such as stress. Another limit of this
study is that not provide consistent findings about the relation-
ships between parental stress and relevant child characteristics
such as severity of symptoms and developmental level that could
significantly affect the parenting stress associated to each NNDs.
Further, although this study utilized a fairly representative range
of predictors, it did not include certain variables (e.g., marital
dysfunction, socioeconomic status, skill of resilience, parents’
coping styles, outside support for parenting, parent emotional and
behavioral problems) which prior research has shown to be re-
lated to parenting stress (Derguy et al., 2016).
5. Conclusion
Findings of this study suggest that parents of children with
NDDs experience more parenting stress than those of children
who have TD. Although a lot of attention over the years has given
to parents of children with ASD and ADHD, our findings suggest
that also parent of children with SpLD and LD experienced higher
parental stress than parent of children without NDDs. Therefore,
parent of children with different type of NDDss should be provided
with interventions and resources to empower them with the
knowledge and skills to reduce their stress and to enhance their
quality of life. In addition, considering the results of the present
study, both mothers as well as fathers need equal support and
guidance to be equipped with such coping so as to enhance their
physical and psychological well-being. Through intervention ef-
forts, researchers can aim to promote positive or adaptive ap-
praisals and coping with stressors, and increase appropriate per-
sonal resources in the parental role. These efforts to improve
cognitive and behavioral responses to stress may lead to better
parental well-being, which can ultimately impact multiple func-
tional domains in the family. Another interesting finding was that
child characteristics such as cognitive dysfunction or emotional
and behavioral problems are associated with the higher levels of
parenting stress found among SpLD, LD, ADHD and ASD popula-
tions. This finding suggest that the characteristics common to
children with a range of neuro-developmental disabilities, such as
the presence of emotional and behaviors problem and cognitive
dysfunction, may increase levels of stress in parent of children
with NDDs.
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