The Interrelation between Autistic Children’s Socio-Emotional Skills, Parent Mental Health, and the Parent-Child Relationship

doi:10.21203/rs.3.rs-4983529/v1

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The Interrelation between Autistic Children’s Socio-Emotional Skills, Parent Mental Health, and the Parent-Child Relationship

https://doi.org/10.21203/rs.3.rs-4983529/v1

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Autistic people often struggle with socio-emotional skills and have idiosyncratic behavior and sensory preferences, which can lead to several adverse outcomes, including challenging behaviors. This can create parenting stress and mental health issues in parents, which, in turn, might challenge the parent-child relationship and subsequently affect their parenting socio-emotional skills. Thus, autistic children’s reduced socio-emotional skills and increased behavioral problems, parent’s mental health, and the parent-child relationship might underlie a spiraling interrelation that can cause detrimental effects for both children and their parents.

To examine the relationship between these four constructs, data were collected in person from 39 children (21 autistic; 18 neurotypical), one of their parents, and the class teacher. Measures included the WNV, SRS-2, ASEBA, ERSSQ, CPRS, WHO-5, and MDI.

Results indicated that although parents of autistic children reported worse psychological well-being and autistic children had reduced socio-emotional skills and more problem behavior, the parent-child relationship did not differ between autism and neurotypical families. Multiple regression analyses showed that parent-child closeness was positively related to parent psychological well-being and that children’s socio-emotional skills difficulties related to more parent-child conflict. However, partial-correlations revealed that children’s socio-emotional skills, parent mental health, and parent-child relationships might interrelate differently in autism families than in neurotypical families, which might have a valuable influence on interventions targeting mental health issues and socio-emotional skills difficulties in autism.

Psychology

autism

socio-emotional skills

parent-child relationship

parent mental health

multi-rater

in-person data collection

Autistic people often struggle with social communication and interaction and tend to prefer routines or repetitive, idiosyncratic patterns of behavior and activities (American Psychiatric Association [APA], 2022). Their struggles with social interactions can lead to problems in their social integration (Howlin & Goode, 1998) and increase the risk for mental health difficulties (Bauminger & Kasari, 2000). Subsequently, that can create adverse outcomes for their parents, who might struggle with their children’s challenging behavior and worry about their future (Bonis & Sawin, 2016). At the same time, parents’ mental health was found to interfere with the parent-child relationship (Hickey et al., 2020) and possibly affect children’s socio-emotional skills and autism characteristics (Greenberg et al., 2006). Thus, autistic children’s reduced socio-emotional skills and increased behavioral problems, parent’s mental health, and the parent-child relationship might underlie a spiraling interrelation that can cause detrimental effects for both children and their parents.

Parent mental health in autism

In addition to the general challenges and pleasures of parenthood, parents[i] of autistic children tend to face additional demands, often experiencing significantly more adverse psychological and physiological outcomes compared to parents of neurotypical children (Allik et al., 2006; Baker-Ericzén et al., 2005; Hayes & Watson, 2013; Montes & Halterman, 2007) or to parents of children with other developmental conditions, such as cognitive developmental delay (Mugno et al., 2007; Weiss, 2002), down syndrome (Dabrowska & Pisula, 2010; Rodrigue et al., 1990), cerebral palsy (Mugno et al., 2007), or general long-term health condition or disability (Seymour et al., 2017).

An integrative literature review has identified numerous factors contributing to parental distress in the context of autism (Bonis & Sawin, 2016). Highlighted factors included child-related aspects, such as hypersensitivity or hyposensitivity to sensory stimuli and related reactive behaviors, disrupted sleep patterns, restrictive eating preferences, and aggressive, destructive, or self-harming behaviors. Furthermore, context-related aspects were emphasized, including limited access to healthcare, social stigmatization, financial strain, parental fatigue, social isolation, and a lack of capacity for self-care among parents. Worry over the child’s life trajectory, social inclusion, and future safety and care were also highlighted.

In contrast, prosocial behavior in children, higher educational levels of parents, psychological acceptance and positive perceptions, and parenting beliefs were found to be protective factors. Adaptive coping, self-efficacy, and social support by family members, friends, and a wider community constitute additional protective factors for parental adaptation and consequent psychological well-being (Allik et al., 2006; Bonis & Sawin, 2016; Costa et al., 2017; Higgins et al., 2023; Porter et al., 2022; Schiltz et al., 2018; Weiss et al., 2012).

Nonetheless, risks outweighed protective factors for stress management in parents (Bonis & Sawin, 2016). Consequently, parents of autistic children present repeatedly increased prevalence of stress, depression, anxiety, somatic complaints, and burnout (Lecavalier et al., 2005; Stewart et al., 2017; Weiss, 2002). In addition, autism is for some part linked to genetics (Gaugler et al. 2014) and some parents of autistic children present social tendencies that are similar to autism, called broader autism phenotype [BAP] (Bolton et al. 1994). BAP has been linked to increased depression, anxiety, obsessive-compulsive disorder, and reduced cognitive and executive functioning (Gerdts and Bernier 2011; Sucksmith et al. 2011). Consequently, parents of autistic children, especially fathers (Rubenstein & Chawla, 2018), might experience additional mental health challenges linked to their own autistic tendencies.

Parent mental health and the parent-child relationship

The scientific literature on the mental health of parents and parent-child relationships in families with autistic children is scarce and ambiguous. For instance, a study by Hickey et al. (2020) found that parenting stress and depressive symptoms in mothers of autistic children predicted reduced warmth and increased criticism a year later. Fathers’ parenting stress also predicted higher levels of criticism toward their children over time. Similarly, mindful parenting practices, such as maintaining a calm, present-focused mindset, enhanced maternal parenting satisfaction and improved overall interactions with their children (Singh et al., 2006). However, Baker et al. (2011) found contradictory results. In their study, the quality of the mother-child relationship was not significantly affected by variations in the mothers’ depressive symptoms or the children’s behavior problems. It was suggested that considering factors like self-efficacy or parenting stress might have led to different conclusions.

When comparing mothers of autistic children to those of neurotypical children, the results are equally mixed. Mothers of autistic children were found to report more closeness with their children despite increased stress and lower quality of communication (Montes & Haltermann, 2007). Conversely, Hoffman et al. (2009) found no significant difference between the two groups of mothers in terms of emotional closeness. They proposed that a child’s autism diagnosis might serve as a protective factor in the parent-child relationship, as parents may attribute less responsibility to the child for problematic behavior. In support of this hypothesis, Montes and Haltermann (2007) found that parents of autistic children were less likely to express anger toward their children, even though they reported being bothered by their children’s behavior. However, this protective factor may come at a cost, as parents may internalize blame for their children’s misbehavior, potentially leading to reduced parenting efficacy and overall well-being (Hoffman et al., 2009).

Research involving neurotypical families is also somewhat ambiguous. In a longitudinal study covering the early years of childhood, fathers who reported increased depressive symptomatology indicated a poorer father-infant relationship, lower romantic relationship satisfaction, and poorer child development outcomes (Nicolaus et al., 2021). However, in a study including 545 mothers, prenatal anxiety was linked to more perceived bonding difficulties but not to a poorer researcher-observed mother-infant interaction quality (Nath et al., 2019). Interestingly, two large-scale longitudinal studies found a significant association between prenatal maternal mental health problems and prenatal family adversity. These latter two related significantly to overall mental health problems in children to a later time, which, in turn, were significantly related to an unstable family structure and family dysfunction (Lereya et al., 2015).

In summary, the findings on the relationship between parent psychological well-being and parent-child relationships in families are relatively ambiguous, and findings seem to greatly depend on the etymology and methodology of studies.

Parent-child relationship and children’s socio-emotional skills

While social skills are contingent on genetic predispositions and developmental change, they are malleable and can be taught, as they are context- and situation-specific. Thus, it is not surprising that parents’ interaction with their children can play a decisive role in children’s development of socio-emotional skills. The scientific literature on this topic in the context of autism is scarce. However, some findings propose interesting results that align with research on neurotypical people. For instance, emotional support from parents and parent-child cohesiveness have been positively associated with enhanced social abilities in autistic children (Haven et al., 2014). Furthermore, parent-child cohesiveness has been found to mediate the relationship between children’s autism diagnosis and their social skills, effectively mitigating some of the associated challenges. Consistent with these findings, stronger synchronization and attunement between parents and children have been linked to better joint attention over time, with these effects repeatedly observed up to 16 years later (Siller & Sigman, 2002).

More intimate mother-child relationships have also been associated with superior peer friendships, regardless of the developmental level of autistic children (Bauminger et al., 2010). Additionally, maternal warmth and high-quality relationships between mothers and their children have been linked to reduced subsequent internalizing and externalizing behavior, improved abilities for social reciprocity, and reduced repetitive behaviors (Smith et al., 2008). Conversely, high levels of maternal criticism and or emotional overinvolvement were found to lead to increased maladaptive behaviors and more salient autism characteristics over time (Greenberg et al., 2006). The found effects were particularly strong for externalizing, internalizing, impaired reciprocal social interactions, and asocial behaviors, with criticism being a key driver.

Interestingly, nonverbal communication, including body language, gestures, and headshaking, did not yield a significant relationship with either criticism or overinvolvement. Additionally, mothers exhibited lower levels of criticism and overinvolvement with sons compared to daughters or in the presence of co-occurring cognitive developmental delay. Mothers also expressed less criticism or overinvolvement when their children displayed higher levels of internalizing maladaptive behavior, such as inattention, emotional disengagement, or self-injury. It was hypothesized that this might indicate reciprocal emotional disengagement. In contrast, parenting practices emphasizing mindfulness, such as maintaining a calm and present-focused mindset, have been associated with improved behavioral outcomes in autistic children (Singh et al., 2006). These practices may help reduce non-cooperation, aggressive behavior, and self-injury, highlighting the importance of parental approaches in supporting children to develop appropriate socio-emotional skills.

Socio-emotional skills and autism

Diagnostic criteria for autism include social communication difficulties and repetitive, idiosyncratic behavior patterns across contexts, so that autistic and neurotypical people tend to differ in their overall way of communication, interaction, and behavior (APA, 2022). Socialization difficulties can create significant detriments for autistic people in their academic and professional careers (Howlin & Goode, 1998), as well as psychological well-being (Myles, 2003; Tantam, 2003), irrespective of their cognitive and language skills (Carter et al., 2005). In general, autistic children are at greater risk for social exclusion than their neurotypical (Chamberlain et al., 2007; Humphrey & Lewis, 2008; Maïano et al., 2016; Schroeder et al., 2014) and otherwise neurodiverse peers (Humphrey & Hebron, 2015; Sreckovic et al., 2014). Thus, it is not surprising that, compared to neurotypicals, autistic adolescents report experiencing more loneliness and less social support and express a greater desire for peer social interaction (Bauminger & Kasari, 2000). As they grow up, autistic people may experience significant distress as social relationships and interactions tend to become more complex, and they might gain greater awareness of their challenges (Tantam, 2003). Accordingly, autistic adults have very limited relationships (Howlin et al., 2004). In a study by Howlin et al. (2013), 66% of the autistic participants stated that they never had any peer relationships for activities outside the home. Furthermore, 77% of the autistic participants reported that they had never had a reciprocal, close, and intimate friendship or relationship lasting more than a month or any such friendship or relationship at all.

The present study

Parents of autistic children are at an increased risk for mental health issues in comparison to parents of neurotypical or other neurodiverse children (e.g., Bonis & Sawin, 2016). Their mental health issues put them at additional risk for parenting stress, which might decrease parenting self-efficacy. In turn, reduced parenting self-efficacy was found to account for increased anxiety and depression symptoms in mothers, further increasing their risk for psychopathology (Rezendes & Scarpa, 2011). So far, autism research has not come to a consensus on whether parents’ weaker mental health relates to differences in their relationship with their children. Some found that parenting stress and parents’ depressive symptoms predicted reduced warmth and increased criticism over time (Hickey et al., 2020). Others found that the quality of the mother-child relationship was not related to mothers’ depressive symptoms (Baker et al., 2011). In addition, their results also showed no significant relationship between parent-child relationships and children’s behavior problems (Baker et al., 2011). However, these results are in contradiction with findings with neurotypical people (e.g., Eisenberg et al., 1998) and with autistic people (e.g., Greenberg et al., 2006; Haven et al., 2014), which repeatedly emphasize the importance of parent-child interactions for the development of social skills. These findings are of specific significance when considering that autistic people have persistent difficulties in social communication and social interaction (APA, 2022), which are associated with significant adverse outcomes for autistic people (e.g., Howlin et al., 2013; Van Heijst & Geurts, 2014). Then again, children’s difficulties with socio-emotional abilities and related problem behaviors have been associated with reduced parent mental health. In turn, prosocial behavior was found to constitute a protective factor for mental health outcomes in parents (Bonis & Sawin, 2019; Higgins et al., 2023). Overall, findings on the relations between parent mental health, parent-child relationships, and socio-emotional skills of autistic children are limited and tend to be inconclusive, if not even contradictory.

Consequently, we aim to extend the understanding of the complex interplay between autistic children’s socio-emotional skills, the parent-child relationship, and parent mental health. In line with previous literature, we hypothesize that (1) parents of autistic children have increased mental health difficulties than parents of neurotypical children. Similarly, we expect that (2) autistic children have reduced socio-emotional abilities and more behavioral problems than neurotypical children. Based on findings from neurotypical research and little research with autistic people, we further hypothesize that (3.₁) children’s reduced socio-emotional skills, poor parent mental health, and more conflictual parent-child relationships interrelate with each other and that (3.₂) these interrelations are more salient for families with an autistic child. Furthermore, we hypothesize that (4) better parent mental health and children’s superior socio-emotional skills are associated with closer parent-child relationships.

[i] The terminologies parent and parents are used in this study to refer to children’s biological parents, but also non-biological parents, caregivers, guardians, and other people responsible for the upbringing of the child in daily life.

Participants

The data for this study was gathered as part of a larger research project, with information collected from children, one of their parents, and their class teacher. The autism group counts 21 participant triads, and the neurotypical control group consists of 18 triads. Data collection for 5 children of the autism group was prematurely stopped as they did not react to test instructions. Data from one teacher could not be collected as the child dropped out of school prematurely. Altogether, 39 parents (36 mothers, 3 fathers), 38 teachers (27 women and 11 men), and 27 boys and 12 girls (~31%) participated in the study. The mean age for both parents was M_ageP = 43.28 (32 – 53; SD_ageP = 4.68), and the children were aged between 6 and 14 years old (M_ageC = 9.85; SD_ageC = 2.01). Participants represented 24 nationalities in total, while 10 parents (25.64%) and 6 children (15.38%) had more than one. Groups did not differ significantly on responding parent’s gender, household income, and age and educational level of both parents, as well as children’s age, gender, and IQ (see Table 1). Autistic children had significantly more difficulties with social responsiveness and repetitive patterns of behavior relevant to an autism spectrum disorder (ASD) diagnosis than neurotypical children. Their mean score indicated moderate to significant deficiencies in reciprocal social behavior. Further details on both samples can be consulted in Supplementary Table 1.

According to the parents, autistic children were diagnosed by either a psychiatrist or a multidisciplinary team, including a psychiatrist. Of the 21 children in the autism group, 9 had an ASD diagnosis, 9 had an Asperger Syndrome diagnosis, 1 had a Pervasive developmental disorder, and 2 were still in the diagnostic process. The latter two were included in the autism group due to parents’ reports of the child’s characteristics and their significantly high scores in the SRS-2 (i.e., a screening tool for autism).

Table 1

Frequency and within-group percentage or mean and standard deviation values for demographic data of children and parents for both groups. Pearson’s chi-square (X²) or Two-sample Kolmogorov–Smirnov Z Test (Z) values for group differences and significance levels (p). Phi (φ) or Cliff’s Delta (δ) effect size measurements.

Measure

Neurotypical group

n = 18

Autism group

n = 21

Statistics

n ; M

% ; SD

n ; M

% ; SD

Child

Gender – Male

Age in years

Intelligence

Social responsiveness

8.97

107.22

51.00

55.06%

1.77

13.91

7.02

10.72

93.42

75.71

81.00%

1.89

24.74

9.69

X²(1,39) = 2.935, p = .163, φ = .274

Z(39) = 1.087, p = .188, δ = -.082

Z(36) = 1.167, p = .131, δ = .505

Z(39) = 2.668, p < .001, δ = -.963

Parent

Gender – Female

Age in years

Household income

Education level

CPRS Closeness

CPRS Conflict

42.00

5.22

5.31

31.28

16.61

94.40%

4.62

9.43

0.79

4.13

6.98

44.56

4.88

4.82

29.29

19.35

90.50%

4.50

1.32

1.29

4.10

6.28

X²(1,39) = 0.215, p = 1.000, φ = .074

Z(39) = 0.618, p = .840, δ = -.407

Z(39) = 0.988, p = .283, δ = .217

Z(39) = 0.717, p = .684, δ = .130

Z(39) = 1.062, p = .209, δ = .421

Z(39) = 0.865, p = .443, δ = -.315

Note. Intelligence = IQ standardized value, Social responsiveness = SRS-2 standardized t-value, Gender = parent respondent, Age in years = age of both parents, Household income = 6-point Likert scale ranging from 0-1899€ to +8500€, educational level = 6-point Likert scale ranging from fundamental/primary to Master’s degree, for both parents, CPRS = Child-Parent-Relationship Scale.

Instruments and measures

Questionnaire on socio-demographic data

Socio-demographic data for the parents included their age, gender, nationality, relation to the child, level of education, economic status, and number of people included in the household. Socio-demographic data for the children included their age, gender, nationality, diagnosis, intellectual development, and co-occurring diagnoses.

Level of cognitive development

To assess their cognitive development, children completed two subscales of the Wechsler Nonverbal Scale of Ability [WNV] (Wechsler & Naglieri, 2006). Children under 8 years completed the “matrices” and “recognition” subtasks, and children of 8 years and more completed the subtasks “matrices” and “spatial span”. Raw scores are summed and converted to standardized T-scores and a total IQ score. The mean from the French and German normative values were used for all participants, as norms for Luxembourg do not exist. Scores below 70 indicate below-average cognitive abilities, and scores of 130 and higher indicate above-average cognitive abilities. The WNV has been evaluated against several other (non- and verbal) measures for ability and provided correlations ranging from r = .73 – .84 (Naglieri & Brunnert, 2009).

Social responsiveness, as an index for autistic traits

Parents were asked to complete the Social Responsiveness Scale – 2 [SRS–2] (Constantino & Gruber, 2012) to identify the presence and extent of autism-related behavior. The questionnaire targets persistent challenges in social communication and interaction (across contexts and time) and focalized, repetitive patterns of behavior, interests, or activities relevant to an ASD diagnosis. The questionnaire includes 65 items on a 4-point Likert scale and is available as a self-, relative, or third-party report form. Answer possibilities range from not true to almost always true. At the time of data processing, only the English normative values were available and were used with this sample. Total t-scores range from 30 to 90+, where t-scores of 60 – 65 indicate mild social skills impairment, scores between 66 – 75 indicate moderate impairment, and t-scores of 76 and higher indicate significant deficiencies in reciprocal social behavior. In addition to the total score, the test provides scores for five subscales, i.e., “social awareness”, “social cognition”, “social communication”, “social motivation”, and “restricted interests and repetitive behavior”. Internal consistency ranges between Cronbach’s α = .94 – .96 across standardization and clinical subgroups for the three age forms (Bruni, 2014). Interrater reliability ranges from .61 – .92 across all report forms. Discriminant validity is outstanding between autistic people and neurotypical controls ROC-AUC = 1.0 (95 % CI .99 – 1.0) and good between autistic people and people with oppositional defiant (ODD) or conduct disorder (CD) ROC-AUC = .82 (95 % CI .74 – .90) (Cholemkery et al., 2014).

Behavioral problems

The Child Behavior Checklist for Ages 6-18 [CBCL] and the Teacher’s Report Form [TRF] of the Achenbach System of Empirically Based Assessment (Achenbach & Rescorla, 2001) were completed by parents and teachers, respectively, to assess children’s challenging behaviors. The empirically based problem scales have a total of 113 items, which are answered on a 3-point Likert scale ranging from not true (as far as you know) to somewhat or sometimes true and very true or often true. In addition to a total scale, the questionnaires provide nine subscales, i.e., “anxious/depressed”, “withdrawn/depressed”, “somatic complaints”, “social problems”, “thought problems”, “attention problems”, “rule-breaking behavior”, “aggressive behavior”, and “other problems”. At the time of data processing, only the English normative values were available and were used to transform total raw scores into standardized T-scores. Scores of 65 and lower are in a normal range, scores between 65 and 70 lie within a borderline clinical range, and scores of 70 and above fall into a clinical range. Cronbach’s alphas for the subscales range from α = .72 – .97.

Children’s Socio-Emotional Skills

Parents and teachers completed the Emotion Regulation and Social Skills Questionnaire [ERSSQ] (Beaumont & Sofronoff, 2008) to assess children’s emotion regulation and social skills. The questionnaire contains 25 (teacher report) or 27 (parent report) items. However, exploratory item factor analysis indicated that a three-factor structure with 21 items for the parent report provides a better fit (Black et al., 2023). Consequently, we calculated the total overall socio-emotional skills scores with all items included, but the subscales were calculated according to the three-factor model. Statements of the frequency of children’s socio-emotional skill behaviors are rated on a 5-point Likert scale ranging from never to always. The subscales “coping” for emotion regulation and “initiating” and “interacting” for social communication skills are computed, in which higher scores indicate superior socio-emotional skills. Internal consistency for the “coping” subscale is very good with α = .84 and α = .87 for “initiating” and good with α = .75 for the “interacting” subscale. Spearman’s correlations indicated that the latent constructs are distinctive. The “coping” subscale correlated strongly with emotion-regulation measures, and both other subscales correlated as expected with social skills measures (Black et al., 2023).

Parent-Child Relationship

The Child-Parent Relationship Scale – Short Form [CPRS–SF] (Driscoll & Pianta, 2011) was used to evaluate parents’ perceptions of their relationship with their child. The questionnaire consists of 15 statements on a 5-point Likert scale, ranging from definitively does not apply to definitively applies. The test measures “closeness” and “conflicts” with positively scaled scores, where higher scores indicate greater closeness (max = 35) and more conflicts (max = 40), respectively. Internal consistency ranges between Cronbach’s α = .64 – .74 for closeness and between Cronbach’s α = .78 – .84 for conflict among both parent report forms (Driscoll & Pianta, 2011). Closeness and conflict scales correlate significantly but very lightly (r = -.18 – .16), indicating two distinct domains of parent-child relationships (Driscoll & Pianta, 2011; Dyer et al., 2017). Convergent validity between the CPRS and The Child Behavior Checklist [CBCL] (Achenbach & Rescorla, 2001), the Social Skills Rating System [SSRS] (Gresham & Elliot, 1990), and structured parent-child interactions yielded significant correlations of lower associations though.

Parent mental health

Parents were asked to complete the WHO (Five) Well-being Index [WHO-5] (World Health Organization, 1998) to screen for their mental well-being. In addition, parents completed the Major Depression Inventory [MDI] (Bech et al., 2001). Both questionnaires list statements for which respondents indicate how much they have experienced them over the last two weeks. Responses on a 6-point Likert scale range from at no time to all of the time.

For the WHO-5, total raw scores range from 0 to 25 and are quadrupled for a total score range between 0 and 100, where higher scores represent better well-being. Scores below 52, or any response using the two lowest frequencies, are an indication of poor well-being, and further testing for depression is recommended. Internal consistency for the WHO-5 is high, with Cronbach’s α = .91 (Löwe et al., 2004). Across 18 studies, the WHO-5 has an average sensitivity of .86 and an average specificity of .81 for detecting depressive symptoms (Topp et al., 2015).

For the MDI, a cut-off score of 21 represents mild depression, 26 denotes moderate depression severity, and 31 indicates severe depressive symptoms (Bech et al., 2015). Internal consistency for the MDI is very high, with Cronbach’s α = .94 (Bech et al., 2001). A score of 26 represents the best cut-off point, with a sensitivity of 1.00 and a specificity of .82.

Procedure

The data used in this study was collected within a more extensive research project. Participants were recruited firstly via the Ministry of Education, Childhood and Youth, the Centre pour Enfants et Jeunes présentant un Trouble du Spectre de l’Autisme, local primary schools, and the Fondation Autisme Luxembourg, who supported the research project. In addition, we contacted numerous local professionals, institutions, and associations for autism (e.g., (e.g., Unité Autisme du CHL, Eis Schoul, Schola Europaea Luxembourg, ZEFI), parent groups (e.g., APPAAL, 3AL, Passage), and organizers of leisure activities (e.g., Sport pour tous). Furthermore, the research project was broadcast on several local media channels (e.g., RTL, Tageblatt, L’Essentiel) and was advertised via paid social media posts.

Data collection was administered in person, and participants were invited to appointments for approximately two hours at either one of two campuses of the University of Luxembourg. Appointments were held in one of Luxembourg’s three official languages or English. The child and at least one parent were welcomed, and parents and children signed informed consent forms. Questions about socio-demographic data were answered orally by parents and children conjointly. Afterward, the researcher and the child moved to an adjacent room to complete the selected tests. Breaks were offered according to the needs of the child.

In the meantime, parents stayed in the first room and completed a selection of paper questionnaires. We collected first parent-report data on the child’s diagnosis and general health for the present research. Subsequently, parents completed the SRS-2 (Constantino & Gruber, 2012), selected items from the CBCL (Achenbach & Rescorla, 2001), the ERSSQ (Beaumont & Sofronoff, 2008), the CPRS (Driscoll & Pianta, 2011), the WHO-5 (World Health Organization, 1998), and finally the MDI (Bech et al., 2001). Meanwhile, the researcher completed several psychological tests with the child, among which only the WNV (Wechsler & Naglieri, 2006) is used for this study. With consent from the parents, the children’s class teachers were contacted to report on children’s socio-emotional abilities (ERSSQ; Beaumont & Sofronoff, 2008) and behavior (CBCL; Achenbach & Rescorla, 2001) in the school context.

The collected data was subject to legal regulations of the EU General Data Protection Regulation. Data was pseudonymized and stored at a secure location at the University of Luxembourg, along with encrypted data servers. The study was approved by the Ethics Review Panel of the University of Luxembourg (ERP 20-072-A ASA).

Differences in parent mental health, children’s socio-emotional abilities, and behavioral problems

Hypotheses 1 and 2 were analyzed using Two-samples Kolmogorov-Smirnov Z tests. Parents of autistic children reported significantly less psychological well-being (WHO-5; Z(39) = 1.705, p < .01, δ = .730) than parents of neurotypical children. More importantly, autistic parents’ mean score lied below 52, indicating significantly poor well-being. However, parent groups did not differ significantly regarding depressive symptoms (MDI; Z(39) = 1.260, p = .084, δ = -.450). One parent of a neurotypical child scored for mild depression, 1 autism parent of an autistic child scored for mild depression, 1 for moderate depression severity, and 1 for severe depressive symptoms. Nevertheless, mean scores for both groups fell below clinical thresholds. As hypothesized, autistic children had significantly weaker socio-emotional skills (ERSSQ; Z(39) = 2.619, p < .001, δ = .868) and more behavioral problems (ASEBA; Z(39) = 2.150, p < .001, δ = -.725) than neurotypical children. Furthermore, children differed significantly on all subscales, except for somatic problems (Z(39) = .840, p = .481, δ = -.302) and rule-breaking behavior, which was only marginally significant (Z(39) = 1.334, p = .057, δ = -.360). All computations can be retrieved from Table 2.

Relationships among children’s socio-emotional skills, parent mental health, and parent-child relationships

Hypotheses 3.₁ and 3.₂ were tested using non-parametric partial correlations between children’s socio-emotional skills, parent mental health, and parent-child relationships while controlling for autism diagnosis. Visualizations of shared variances between the constructs can be retrieved from Figure 1, and Figure 2 summarizes the significance of results among the constructs.

Does parents’ mental health relate to the parent-child relationship?

In the zero-order correlations, better overall psychological well-being in parents (WHO-5) correlated significantly with closer parent-child relationships (CPRS Closeness; r_S= .546, p < .001; see B and D in Figure 1.1), but only marginally with less conflict in the parent-child relationship (CPRS conflict; r_S= -.305, p = .059; see B and D in Figure 1.1). In addition, superior well-being correlated significantly with less depressive symptoms (MDI; r_S= -.669, p < .001; green circle in Figure 1.1) and the absence of autism diagnosis (r_S= -.634, p < .001; A and D in Figure 1.1). Increased parents’ depressive symptomatology correlated significantly with reduced closeness (r_S= -.391, p < .05; B and D in Figure 1.1) but not with more conflicts in the parent-child relationship (r_S= .546, p < .001; B and D in Figure 1.1). However, parents’ depressive symptoms related

Table 2

Two-sample Kolmogorov–Smirnov Z Test (Z) values and Cliff’s Delta (δ) effect size measurements for group differences in parent mental health, children’s socio-emotional abilities and behavioral problems.

Measure

Neurotypical group

n = 18

Autism group

n = 21

Statistics

Parent

WHO-5

MDI

70.22

8.78

12.36

5.25

46.67

13.95

17.13

7.66

Z(39) = 1.705, p < .01, δ = .730

Z(39) = 1.260, p = .084, δ = -.450

Child – ERSSQ

Coping

Initiating

Interacting

24.28

8.97

23.25

5.85

2.08

4.20

16.02

5.05

11.40

5.30

2.06

3.87

Z(39) = 2.100, p < .001, δ = .680

Z(39) = 2.199, p < .001, δ = .693

Z(39) = 2.767, p < .001, δ = .844

Total

73.58

13.40

44.45

11.44

Z(39) = 2.619, p < .001, δ = .868

Child – ASEBA

anxious/depressed

withdrawn/depressed

somatic complaints

social problems

thought problems

attention problems

rule-breaking behavior

aggressive behavior

Do autistic children’s socio-emotional skills relate to the parent-child relationship?

Zero-order correlations between children’s socio-emotional skills (ERSSQ total score), the parent-child relationship (CPRS closeness; CPRS conflict), and the autism diagnosis were all significant, except for the correlation between conflict and autism diagnosis (r_S = .430, p = .093; C and G in Figure 1.2). Increased socio-emotional skills in children were associated with more closeness (r_S = .450, p < .01; E and G in Figure 1.2) and less conflict (r_S = -.501, p < .01; E and G in Figure 1.2) in parent-child relationships. Closeness correlated negatively with conflict (r_S = -.400, p < .05; red circle in Figure 1.2), and children’s socio-emotional skills were significantly reduced in autism (r_S = -.750, p < .001; F and G in Figure 1.2).

When removing autism diagnosis from the correlations, increased socio-emotional skills in children continued to relate to less conflict in the parent-child relationship (r_xy.z(36)= -.466, p < .01; see E in Figure 1.2). In addition, closeness still correlated negatively with conflict (r_xy.z(36)= -.344, p < .05; red circle in Figure 1.2). However, the relationship between children’s socio-emotional skills and parent-child closeness was no longer significant (r_xy.z(36)= .287, p = .080; see E and G in Figure 1.2).

Consequently, children’s socio-emotional skills significantly relate to fewer conflicts in the parent-child relationship, independent of an autism diagnosis. However, superior socio-emotional only significantly relates to a closer parent-child relationship in autism families, but not so much in families with a neurotypical child. In addition, an autism diagnosis significantly relates to reduced socio-emotional skills in children and less closeness in the parent-child relationship, but not more conflict.

Do autistic children’s socio-emotional skills relate to the parents’ mental health?

Zero-order correlations between children’s socio-emotional skills (ERSSQ total score), parental mental health (WHO-5; MDI), and the autism diagnosis were all significant (i.e., A, F, H, and I in Figure 1.3). Children’s superior socio-emotional skills related to increased overall psychological well-being (r_S= .597, p < .001; H and I in Figure 1.3) and reduced depression symptoms (r_S= -.489, p < .01; H and I in Figure 1.3) in parents. Parents’ superior general psychological well-being related to reduced depressive symptoms (r_S= -.669, p < .001; green circle in Figure 1.3). In addition, children’s diagnosis correlated with reduced socio-emotional skills (r_S= -.750, p < .001; F and I in Figure 1.3), reduced psychological well-being (r_S= -.634, p < .001; A and I in Figure 1.3), and more depressive symptoms (r_S= .389, p < .05; A and I in Figure 1.3) in parents.

However, when removing autism diagnosis from the correlations, children’s superior socio-emotional skills no longer correlated significantly to the overall psychological well-being of parents (r_xy.z(36)= .239, p = .148; H in Figure 1.3). The association between children’s superior socio-emotional skills and reduced depression symptoms remained significant (r_xy.z(36)= -.323, p < .05; H in Figure 1.3). In addition, parents’ superior general psychological well-being continued to relate to reduced depressive symptoms (r_S= -.593, p < .001; green circle in Figure 1.3).

These results indicate that children’s socio-emotional skills, parent mental health, and children’s autism diagnosis are interrelated significantly with each other. Furthermore, children’s superior socio-emotional skills relate to reduced depression symptoms in parents, disregarding whether the child is autistic or neurotypical. However, the positive relationship between children’s socio-emotional skills and parents’ overall psychological well-being seems to be more significant in autism families than in families with neurotypical children.

Factors affecting parent-child relationships

Two bootstrapped multiple regression analyses were conducted to examine parents’ psychological well-being, children’s autism, IQ, socio-emotional skills, and behavior problems as possible predicting factors for

Table 3

Linear model of predictors of closeness in the parent-child relationship. Standard errors and 95% bias-corrected and accelerated confidence intervals are based on 1000 bootstrap samples.

			95 % CI
	Estimate	SE	LL	UL	β	p
(Constant)	18.40	14.73	-10.53	88.309		p = .197
WHO-5	0.11	0.05	0.00	0.22	.448	p < .05
Child IQ	-0.03	0.04	-0.10	0.04	-.157	p = .319
ERSSQ Total	0.11	0.12	-0.07	0.38	.433	p = .346
ASEBA Total	0.02	0.17	-0.37	0.33	.046	p = .914
Autism diagnosis	1.98	3.26	-3.36	10.40	.228	p = .548

Note.R² = .301, p < .05.

Table 4

Linear model of predictors of conflict in the parent-child relationship. Standard errors and 95% bias-corrected and accelerated confidence intervals are based on 1000 bootstrap samples.

			95 % CI
	Estimate	SE	LL	UL	β	p
(Constant)	33.18	19.58	-3.91	57.78		p = .078
WHO-5	-0.06	0.07	-0.19	0.09	-.15	p = .420
Child IQ	0.07	0.06	-0.07	0.17	.21	p = .246
ERSSQ Total	-0.29	0.14	-0.56	0.25	-.74	p < .05
ASEBA Total	0.03	0.22	-0.43	0.70	.05	p = .877
Autism diagnosis	-5.10	3.36	-11.14	2.69	-.37	p = .128

Note.R² = .350 p < .05.

closeness or conflict in the parent-child relationship (Hypothesis 4). Table 3 summarizes the analysis results on closeness with forced-entry predictive factors. The Durbin-Watson statistic of 1.66 suggests no autocorrelation and sufficiently independent errors, and multicollinearity was satisfactory, with variance inflation factors (VIFs) ranging from 1.26 – 5.54. The overall model was significant (F(5,30) = 2.581, p < .05), in which parents’ superior general psychological well-being (WHO-5) predicted more closeness in the parent-child relationship (CPRS closeness; t(30) = 2.282, p < .05). While the model is significant, it explains relatively slight variance of closeness in the parent-child relationship (Adjusted R² = .18). Thus, substantial variance in close parent-child relationships is significantly related to external factors not included in this model.

Table 4 summarizes the analysis results on conflict with the same forced-entry predictive factors. The Durbin-Watson statistic of 2.68 suggests no autocorrelation and sufficiently independent errors. Multicollinearity was satisfactory, with VIFs ranging from 1.26 – 5.54. The overall model was significant (F(5,30) = 3.227, p < .05), in which children’s superior socio-emotional skills predicted less conflict in the parent-child relationship (t(30) = -2.122, p < .05). The model explains about 24% of the variance in parent-child conflict (Adjusted R² = .24), which indicates that this model does not cover a significant amount of variance.

Group differences in parent mental health and child characteristics

Our main aim in this study was to expand the understanding of the complex interplay between autistic children’s socio-emotional skills, the parent-child relationship, and parent mental health. As expected, autistic children were reported to have clinically significant difficulties with social responsiveness and to prefer focalized, somewhat repetitive patterns of behavior, interests, or activities (SRS-2). In addition, they were also reported to have weaker socio-emotional skills (ERSSQ) and more behavioral problems (ASEBA) than neurotypical children. Our findings were also congruent with previous literature on parents’ mental health. Parents of autistic children reported significantly worse general mental health than neurotypical parents. More importantly, though, their mean score was below the threshold of 52, indicating poor well-being with a recommendation to analyze for depression. Although one parent of a neurotypical child and 3 autism parents scored above clinical cut-off scores, mean scores for both groups fell below clinical thresholds.

However, an extensive body of previous literature reports that parents of autistic children present a higher incidence of psychological problems, such as depression, anxiety, or emotional distress, than parents of neurotypical children (see Hayes & Watson, 2013 and Bonis & Sawin, 2016 for reviews). They reasoned that children’s challenging behavior (e.g., emotional outbursts, aggression, self-harming, and/or destructive behaviors) might significantly strain parents. For instance, mothers of autistic children reported feeling distressed when they did not know how to help their child during episodes of repetitive or self-harming behavior, resulting in helplessness and reduced parenting confidence. In addition, parents of autistic children might also face difficulties in the diagnostic process of their children, children’s school enrolment, and child-care support (Papadopoulos, 2021). Children’s impaired social skills might lead to social (Mugno et al., 2007) and academic exclusion (Manti et al., 2011), possibly causing stigmatization. Consequently, parents might worry about their child’s social and academic/professional future and the development of co-occurring diagnoses (Papadopoulos, 2021).

The children participating in our study presented some variety in their problematic behavior. On the individual level, 5 autistic children achieved a score in the clinical and 9 in the borderline clinical range. In comparison, only 1 neurotypical child crossed into the clinical range and 2 into the borderline clinical range. However, on the group level, autistic children had significantly more behavioral problems than their neurotypical peers, but none of the ASEBA mean scales reached the clinical range. Children included in our study also presented some variance in care dependency and age-appropriate independence. Thus, data collection with 5 children was prematurely stopped, of which also one teacher could not report data due to school exclusion. In addition, through spontaneous, anecdotal data, some parents of autistic children expressed a demand for parenting advice specific to the child’s diagnosis and reported challenges in communication with diagnostic services. They also expressed spontaneously similar concerns regarding education and professional care, as found in previous research.

Alternatively, the positive aspects of parenting might outweigh these challenges. Some studies highlight the positive effects of raising a child with special needs. For instance, aspects such as an enhanced sense of personal strength and confidence, appreciation of the child’s achievements, a greater appreciation of life and a more meaningful arrangement of priorities, and deeper and more meaningful relationships might help reduce parental distress (Beighton & Wills, 2017). Similarly, a solid and secure child-parent relationship might help alleviate the increased demands of parenting a child needing support (Beighton & Wills, 2017). In our study, parents of autistic children reported no significant differences in the parent-child relationship to parents of neurotypical children and achieved quite positive scores (29.29 / 35 Closeness, 19.35 / 40 Conflict). Thus, we assume that their relationship might stand above the negative aspects related to their children’s diagnosis and that their relationship might even constitute a resource for them, alleviating adverse mental health issues.

Relations between parent mental health, parent-child relationship, and socio-emotional skills

In addition to group differences, non-parametric partial correlation results indicated that better general parental mental health related to a closer parent-child relationship and increased socio-emotional skills in children related to less conflictual parent-child relationships and less depressive symptoms in parents, independently of an autism diagnosis. When variance shared by an autism diagnosis was included, additional significant relations emerged among the constructs. Depressive symptoms now correlated significantly with less closeness, and reduced general mental health marginally correlated with more conflict. Reduced socio-emotional skills correlated with less close parent-child relationships and reduced general mental health in parents. Furthermore, autism diagnosis in children was significantly correlated with reduced socio-emotional skills in children, less closeness in the parent-child relationship, reduced general mental health, and more depressive symptoms in parents. In subsequent multiple regression analyses, we found that superior general mental health in parents was associated with more closeness and that reduced socio-emotional skills in children were associated with more conflict in parent-child relationships.

Our findings are in line with previous research indicating that parent mental health can influence the parent-child relationship. For example, parenting stress and depressive symptomatology in parents of autistic children predicted increased criticism toward their children over time a year later. In mothers, parenting stress and depressive symptomatology are also related to reduced warmth (Hickey et al., 2020). Correspondingly, a calmer, more present-focused mindset was found to relate to superior overall interactions with children (Singh et al., 2006). The other way around, depressive symptoms in children were linked to less communicative, critical, less supportive, and less empathic parenting styles (Berg-Nielsen et al., 2002).

Our significant findings between general mental health in parents and a closer parent-child relationship are only partly in line with previous research. In a study by Schiltz et al. (2018), parental stress due to adolescents’ challenging behavior was associated with more depressive symptoms in parents, leading to decreased parental involvement. Consequently, they hypothesized a potential indirect relation between adolescents’ challenging behavior and reduced parental involvement via increased parenting stress and parental depressive symptoms. However, parenting stress was directly related to reduced parental involvement beyond challenging adolescent behaviors (Schiltz et al., 2018). Consequently, better socio-emotional skills in children might favor parental mental health (e.g., Allik et al., 2006), subsequently affecting the parent-child relationship (Schiltz et al., 2018). Others found that autism characteristics, such as reduced socio-emotional skills and behavior problems, were related to less qualitative parent-child interaction patterns but not to the parent-child relationship quality (Beurkens et al., 2013).

Similarly, Baker et al. (2011) proposed that parents’ mental health and children’s behavior problems might not so much relate to the parent-child relationship but rather parents’ self-efficacy or, specifically, their parenting stress. Their findings suggest that the definition and etymology of constructs might play a crucial role in disentangling the complex interrelations between children’s socio-emotional skills and behavior, parent mental health, and the parent-child relationship. In addition, in our findings, the factors that predicted closeness and conflict in the parent-child relationship were different. Thus, we hypothesize that the relationship between parent mental health, children’s socio-emotional skills, and the parent-child relationship might not be entirely linear, and we recommend that future research considers using non-linear statistical models, such as logistical or logarithmic models.

Limitations

While our results offer additional understanding and interesting results, several limitations should be noted. First, we want to highlight that most of our data was collected via parent- and teacher reports. While parent and teacher reports allow us to assess children’s abilities that they might not have yet gained self-awareness over, parents and teachers might not necessarily know the true extent of children’s abilities. For example, some parents reported being unsure about answering a few questions about children’s emotional abilities or social cognition. We recommend that future research corroborates data with autistic people’s reports.

In addition, we collected only data on parents’ general mental health and depressive symptomatology, but we did not ask whether they ever received any psychological or psychiatric diagnosis. We recommend that in future research, parents are screened for any mental health conditions, especially autism as well. Concerning children’s socio-emotional skills, it could be very interesting to assess whether autistic parents might experience their children differently than neurotypical parents might do. According to the theory of the double empathy problem (Milton, 2012), socio-emotional difficulties in autism might result from a mutual, bidirectional misunderstanding amongst autistic and neurotypical people. It is argued that socialization difficulties may depend on bidirectional differences in communication style, social cognition, and social experiences instead of inherent social skills impairment.

Most importantly, we want to identify that we did not collect longitudinal data due to limited project time allocation. The understanding of the complex interrelation of the constructs used in this study could be substantially improved by using multiple data assessments. It would allow for tracking the development of children’s social abilities, parents’ mental health, and the development of parent-child relationships over time. With additional power (i.e., more participants), longitudinal data would allow the use of more complex statistical models, such as multilevel modeling or structural equation models, and allow for hypotheses of direction of relations and causality. Unfortunately, we did reach only a relatively humble participant number. While we did our best to account for the limited power by choosing statistical calculations specific to small participant numbers, the generalizability of our results should be interpreted with caution and within the respective limits.

Implications and Conclusion

Despite the limitations in the generalizability of our findings, our results highlight the importance of precision when researching socio-emotional skills, parent mental health, and parent-child relationships. Although parents’ general mental health and children’s socio-emotional skills were found to be generally related to closeness and conflict in parent-child relationships, and autism families report difficulties with both constructs, they did not report any significant differences in the relationships to their children than parents of neurotypical children. It can be hypothesized that interrelations between children’s characteristics, parent mental health, and parent-child relationships might differ between autism and neurotypical families, which is supported by the findings of our partial correlations. Consequently, parents of autistic children might have unique resources for their parent-child relationship, or the other way around, the parent-child relationship acts as a resource for parents’ mental health and children’s socio-emotional skills. This could especially be helpful in interventions targeting reduced socio-emotional skills and parent mental health issues, which are frequently found in autism families.

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The authors declare no competing interests.

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The Interrelation between Autistic Children’s Socio-Emotional Skills, Parent Mental Health, and the Parent-Child Relationship

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Abstract

Figures

Introduction

Parent mental health in autism

Parent mental health and the parent-child relationship

Parent-child relationship and children’s socio-emotional skills

Socio-emotional skills and autism

The present study

Methods

Participants

Instruments and measures

Questionnaire on socio-demographic data

Level of cognitive development

Social responsiveness, as an index for autistic traits

Behavioral problems

Children’s Socio-Emotional Skills

Parent-Child Relationship

Parent mental health

Procedure

Results

Differences in parent mental health, children’s socio-emotional abilities, and behavioral problems

Relationships among children’s socio-emotional skills, parent mental health, and parent-child relationships

Does parents’ mental health relate to the parent-child relationship?

Do autistic children’s socio-emotional skills relate to the parent-child relationship?

Do autistic children’s socio-emotional skills relate to the parents’ mental health?

Factors affecting parent-child relationships

Discussion

Group differences in parent mental health and child characteristics

Relations between parent mental health, parent-child relationship, and socio-emotional skills

Limitations

Implications and Conclusion

References

Additional Declarations

Supplementary Files

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