Parenting An Autism Child

O R I G I N A L P A P E R

Impacts of Autistic Behaviors, Emotional and Behavioral Problems on Parenting Stress in Caregivers of Children with Autism

Chien-Yu Huang • Hsui-Chen Yen •

Mei-Hui Tseng • Li-Chen Tung • Ying-Dar Chen •

Kuan-Lin Chen

Published online: 28 November 2013

� Springer Science+Business Media New York 2013

Abstract This study examined the effects of autistic

behaviors and individual emotional and behavioral prob-

lems on parenting stress in caregivers of children with

autism. Caregivers were interviewed with the Childhood

Autism Rating Scale and completed the Strength and Dif-

ficulties Questionnaire and the Parenting Stress Index Short

Form. Results revealed that caregivers of children with

mild/moderate autistic behavior problems perceived lower

parenting stress than did those of children with no or severe

problems. In addition, prosocial behaviors and conduct

problems respectively predicted stress in the parent–child

relationship and child-related stress. The findings can

provide guidance in evaluations and interventions with a

focus on mitigating parenting stress in caregivers of chil-

dren with autism.

Keywords Autistic behaviors � Emotional and behavioral problems � Parenting stress � Autism

Introduction

The challenges of raising a child with autism adversely

affect caregivers, who face restrictions in social activities

and elevated parenting stress (Lecavalier et al. 2005).

Caregivers of children with autism have more parenting

stress than those raising typically developing children,

children with Down syndrome, or children with behavior

disorders (Dumas et al. 1991). Elevated parenting stress

can degrade the caregiver’s functioning, causing depres-

sion and poor well-being (Phetrasuwan and Shandor Miles

2009), which in turn hampers a child’s development and

the effectiveness of early intervention (Osborne et al.

2008). It is therefore important to investigate parenting

stress and its correlates that are amenable targets for

intervention and prevention efforts.

Autistic behaviors, along with emotional and behavioral

problems, have been widely discussed in terms of their

associations with parenting stress (Hastings 2003; Lecav-

alier et al. 2005; Davis and Carter 2008). Children with

autism often present a range of unusual behavior patterns in

object use, relating to people, and verbal and nonverbal

communication. Those unusual behaviors, called autistic

behaviors, make children with autism appear different from

other children, and they are often linked to difficulties in

child development and education (Lecavalier et al. 2006;

Windle and Windle 1996). In addition to autistic behaviors,

children with autism also present emotional and behavioral

problems such as emotional symptoms, hyperactivity, and

peer problems, which are common in a wide range of

C.-Y. Huang � M.-H. Tseng School of Occupational Therapy, College of Medicine, National

Taiwan University, No. 17, Xu-Zhou Rd., Taipei 100, Taiwan,

ROC

H.-C. Yen � L.-C. Tung Department of Physical Medicine and Rehabilitation, Chi Mei

Medical Center, No. 901, Zhonghua Rd., Tainan 710, Taiwan,

ROC

M.-H. Tseng � K.-L. Chen Department of Physical Medicine and Rehabilitation, National

Taiwan University Hospital, Taipei, Taiwan, ROC

Y.-D. Chen

Department of Physical Medicine and Rehabilitation, Country

Hospital, No. 61, Sec. 4, Renai Rd., Taipei 106, Taiwan, ROC

K.-L. Chen (&) School of Occupational Therapy, College of Medicine, National

Cheng Kung University, No. 1, University Rd., Tainan 701,

Taiwan, ROC

e-mail: [email protected]

123

J Autism Dev Disord (2014) 44:1383–1390

DOI 10.1007/s10803-013-2000-y

children with disabilities (Dumas et al. 1991; Hastings and

Brown 2002). Generally, studies have suggested that the

more autistic behaviors the child presents, the higher par-

enting stress the caregivers perceive (Wang et al. 2012;

Phetrasuwan and Shandor Miles 2009; Konstantareas and

Homatidis 2006), and the same is true for emotional and

behavioral problems (Hastings 2003; Lecavalier et al.

2005; Davis and Carter 2008; Estes et al. 2009; Estes et al.

2013; Walsh et al. 2013).

However, two critical issues still need to be addressed in

studies examining the relationships of parenting stress with

autistic behaviors and emotional and behavioral problems.

First, results on the relationship between autistic behavior

and parenting stress in joint considerations of emotional

and behavioral problems have been contradictory (Davis

and Carter 2008; Hastings et al. 2005). Hastings et al.

(2005) reported that parenting stress could not be predicted

by autistic behaviors, but Davis and Carter (2008) showed

that delays in children’s social relatedness, a trait of autistic

behaviors, were associated with parenting stress. Since the

results were inconclusive, it is unclear whether autistic

behaviors are indeed associated with parenting stress, or

the impact of autistic behaviors on parenting stress can be

explained by their co-existing emotional and behavioral

problems. More studies are warranted to clarify the rela-

tionship between autistic behaviors and parenting stress.

Identifying parenting stress related to autistic behaviors

could provide empirical evidence for clinicians to use in

providing suggestions to caregivers.

Second, little is known about how each aspect of emo-

tional and behavioral problems, such as emotional symp-

toms and conduct problems, individually contributes to

parenting stress. Understanding the impacts of different

aspects of emotional and behavioral problems on parenting

stress may help clinicians target specific problems and plan

corresponding interventions. However, the summary score

has often been used to assess overall emotional and

behavioral problems in children with autism (Phetrasuwan

and Shandor Miles 2009; Hastings 2003; Lecavalier et al.

2005), except in the study of Davis and Carter (2008). The

participants in Davis and Carter’s study were caregivers of

toddlers with autism. It is warranted to investigate the

individual effects of emotional and behavioral problems on

parenting stress in caregivers of older children with autism,

such as preschool and school-aged children.

To fill the above gaps, the present study examined the

effects of autistic behaviors and those of individual emo-

tional and behavioral problems on parenting stress simul-

taneously. We hypothesized that autistic behaviors and

each aspect of emotional and behavioral problems would

be associated with high parenting stress. That is, if children

present more autistic behaviors, emotional problems, and

behavioral problems, the caregivers should perceive higher

parenting stress. Clarifying the effects of autistic behaviors

and individual emotional and behavioral problems on

parenting stress will be of use in developing and refining

interventions for preventing and decreasing high parenting

stress.

Methods

Participants

A cross-sectional survey was conducted from July to

September 2012. Children with autism and their caregivers

were recruited from five hospitals and pediatric clinics in

Taipei and Tainan, two cities in Taiwan. Inclusion criteria

were: (1) age of 3–12 years old; (2) diagnosis of Autistic

Disorder based on the diagnostic criteria of the Diagnostic

and Statistical Manual of Mental Disorders–Fourth edition,

Text Revision (DSM-IV-TR) (American Psychiatric

Association 2000) or the International Statistical Classifi-

cation of Diseases and Related Health Problems 10th

Revision (ICD-10) (World Health Organization 1992) by a

pediatric psychiatrist, and pediatric psychiatrists made the

diagnosis by using multiple information sources, including

interviews of the parents, observation of the child, and

multi-disciplinary assessments; also, these children had the

Catastrophic Illness Card with the diagnosis of autism

issued by the Bureau of National Health Insurance,

Department of Health, Taiwan; and (3) caregivers could

communicate in Mandarin.

Measures

Four measures were included in the present study. A brief

demographic questionnaire was used to collect a child’s

age and gender, caregivers’ ages, monthly household

income, and number of children in the family. The

remaining measures are described below.

Childhood Autism Rating Scale (CARS)

The CARS (Schopler et al. 1980), a 15-item scale, has been

widely used to assess autistic behaviors in children aged

2 years and older. Items in the CARS target autism’s

characteristics, such as relatedness to others, body use,

object use, and verbal and nonverbal communication. Each

item is rated on a scale from 1 (normal) to 4 (severely

abnormal), with a total score ranging from 15 to 60. A

higher total score represents more autistic behavior prob-

lems. Two cut-off scores are used to categorize autistic

behavior problems into three severity levels: no problems,

mild to moderate problems, and severe problems. A total

score below 30 indicates that a child does not meet the

1384 J Autism Dev Disord (2014) 44:1383–1390

123

clinical threshold considered autistic problems, one of

30–36 suggests mild to moderate problems, and one of 37

or higher represents severe problems (Schopler et al. 1980).

The CARS has sound psychometric properties (Eaves and

Milner 1993; DiLalla and Rogers 1994; Schopler et al.

1988).

Strengths and Difficulties Questionnaire-Chinese

version (SDQ-C)

The Strengths and Difficulties Questionnaire-Chinese ver-

sion (SDQ-C), a measure for children aged 4–16 years, was

used to assess the emotional problems, behavioral prob-

lems and a strength in the children with autism. The SDQ-

C covers five subscales with four assessing difficulties

(emotional symptoms, hyperactivity/inattention, conduct

problems, peer problems) and one assessing the strength

(prosocial behaviors). Each subscale contains 5 items rated

from 1 (not true) to 3 (certainly true), and generates a

subscale score. Two cut-off points are used in each sub-

scale to categorize children into three severity levels: close

to average, at risk, and at high risk of having problems.

Except the subscale of prosocial behavior, a higher score

represents a higher number of emotional or behavioral

problems. The reliability and validity of the SDQ-C have

been well established (Du et al. 2008).

Parenting Stress Index Short Form-Chinese version

(PSI/SF-C)

The Parenting Stress Index/Short Form-Chinese version

(PSI/SF-C) was used to assess parenting stress. The PSI/

SF-C is a 36-item scale measuring parent-related stress,

child-related stress, and stress from caregiver-child rela-

tionships, which correspond to its three domains: parenting

distress (PD), difficult child (DC), and parent–child dys-

functional interaction (PCDI). Parents rated their agree-

ment with each item on a 5-point scale from 1 (strongly

agree) to 5 (strongly disagree). Each domain generates a

stress score. A higher score on a domain represents a

greater level of stress perceived by the caregiver. In addi-

tion, each domain has a cut-off point, above which a sig-

nificant level of parenting stress is indicated. The PSI/SF-C

has sound reliability and validity (Yeh et al. 2001; Wen

2003).

Procedures

The present study was approved by the Institute Review

Board of a teaching Hospital. Clinicians in five hospitals

and pediatric clinics were contacted for their help in

recruiting participants. Cover letters and consent forms

were distributed to caregivers referred by clinicians.

Caregivers who agreed to participate would (1) be inter-

viewed with the CARS by trained researchers, and (2) fill

out three questionnaires, including a brief demographic

questionnaire, the SDQ-C and the PSI/SF-C. Completed

questionnaires were returned and then researchers checked

for any missing information.

Data Analysis

Descriptive analysis was conducted to characterize the

demographic data, autistic behaviors, the emotional and

behavioral problems, and parenting stress of participants.

Analysis of variance (ANOVA) with post hoc Fisher’s

Least Significant Difference (LSD) tests was conducted to

examine if group differences existed in parenting stress

between different severity levels of autistic behavior

problems as well as the emotional and behavioral prob-

lems. Pearson’s correlations coefficients were used to

investigate the correlations of total scores of autistic

behaviors and of individual emotional and behavioral

problems with parenting stress.

Three multiple regression models were conducted to

examine the impacts of autistic behaviors, individual

emotional and behavioral problems on the three domains of

parenting stress (PD, DC, and PCDI). The stress scores of

the three PSI/SF-C domains were used as dependent vari-

ables respectively for three regression models. The CARS

and the five subscales of the SDQ-C were examined as

independent variables. Based on univariate analysis, the

CARS and SDQ-C subscale scores or the severity level

were used for regression analysis, depending on their linear

or nonlinear relationships with parenting stress. In addition,

significant demographic variables were also included for

further analysis as covariates. The goodness-of-fit (GOF)

measure, adjusted R 2 , was used to assess the adequacy of

the fitted model. Statistical analyses were performed using

SAS 9.1.3 software. Two-sided p B 0.05 was considered

statistically significant.

Results

Demographic Characteristics of the Children

and Caregivers

A total of 52 caregivers enrolled in the study. Table 1

shows the demographic characteristics of children with

autism and their caregivers. The mean ages of the chil-

dren and their caregivers were 6.33 and 39.24 years old

(SD = 2.3 and 5.9), respectively. Most respondents

(86.5 %) were mothers. Approximately 94 % of the

J Autism Dev Disord (2014) 44:1383–1390 1385

123

children were boys (n = 49), and most children (65.4 %)

had at least one sibling. Among caregivers, 67.8 %

reported their monthly household income was above

50,000 Taiwan dollars (about 1,682 US dollars), which

was about the average monthly income in Tainan and

greater Taipei.

Autistic Behaviors, Emotional and Behavioral

Problems in Children with Autism

As for the severity levels of autistic behavior problems,

44.2 % (n = 23) of children presented mild to moderate

autistic behavior problems, and 17.3 % (n = 9) presented

severe autistic behavior problems. Comparison of the mean

scores among four subscales assessing difficulties in the

SDQ revealed higher mean scores in the domains of

hyperactivity/inattention and peer problems (Table 1).

Furthermore, most children were characterized as at high

risk of having problems for hyperactivity/inattention, peer

problems, and prosocial behavior (Fig. 1).

Parenting Stress in Caregivers of Children with Autism

Table 2 shows the mean scores and proportions of care-

givers perceiving high parenting stress in three domains of

the PSI/SF-C. Among the three domains, mean scores were

higher in DC and PD. In addition, the highest rate of high

parenting stress was in DC; 40.4 % caregivers scored

above the cut-off point. That result indicated that DC was

the most stressful area for caregivers of children with

autism.

Table 1 Sample characteristics of the children and caregivers (N = 52)

Child Mean (SD)/percentage

Age (years) 6.33 (2.3)

Gender (% male) 94 %

Childhood Autism Rating Scale 21 (5.00)

Strengths and Difficulties Questionnaire

Emotional symptoms 2.90 (1.83)

Conduct problems 2.08 (1.69)

Hyperactivity/inattention 6.85 (2.20)

Peer problems 5.67 (1.75)

Prosocial behaviors 3.50 (2.36)

Caregiver/family

Caregiver’s age (years) 39.24 (5.9)

Responders (mothers) 86.5 %

Number of children in the family

1 32.7 %

2 65.4 %

3 1.9 %

Monthly household income (NTD)

\ 50,000 32.7 % 50,000–100,000 36.5 %

100,000–150,000 25 %

[ 150,000 5.8 %

Fig. 1 Group distributions of the five subscales of the

Strengths and Difficulties

Questionnaire, including

emotional symptoms, conduct

problems, hyperactivity/

inattention, peer problems, and

prosocial behavior (N = 52)

Table 2 Descriptive statistics of three domains of the PSI/SF-C (N = 52)

Domains Mean (SD) Above cut-off points

(n, %)

Parental distress 35.81 (8.65) 15 (28.8)

Parent–child dysfunctional

interaction

31.34 (5.76) 11 (21.2)

Difficult child 35.50 (7.43) 21 (40.4)

1386 J Autism Dev Disord (2014) 44:1383–1390

123

Impacts of Autistic Behaviors and Emotional

and Behavioral Problems on Parenting Stress

A significant difference was found in mean PCDI stress

scores compared to the mean stress score in three domains

of the PSI/SF-C across three severity levels of autistic

behavior problems [F (2,49) = 8.10, p \ .01]. Post-hoc LSD tests revealed that caregivers of children with mild/

moderate autistic behavior problems had higher mean

stress scores than those of children with no or severe

autistic behavior problems (Table 3). In addition, signifi-

cant differences were found in mean DC stress scores

respectively across severity levels of conduct problems

[F (2, 49) = 11.66, p \ .01] and hyperactivity/inattention [F (2, 49) = 6.21, p \ .01]. Post-hoc LSD tests revealed that the stress scores of the levels of mild/moderate and

severe problems were significantly higher than that of the

level of no problems in the DC domain (Table 3).

There were no significant correlations between the

autistic behaviors and any domain of the PSI/SF-C

(p [ .05). Small to moderate correlations were found between three SDQ domains and the DC domain of the

PSI/SF-C. These were emotional symptoms (r = 0.30),

conduct problems (r = 0.61), and hyperactivity/inattention

(r = 0.36).

Three regression analyses were conducted to examine if

autistic behaviors, emotional and behavioral problems were

related to parenting stress. Among demographic variables,

only the variable of child’s age was significantly associated

with DC stress score (p \ .05). Therefore, the child’s age was included in the DC regression model as the covariate.

In addition, since a nonlinear relationship was found

between autistic behaviors and parenting stress based on

univariate analysis, the severity level of autistic behavior

problems was used as the ordinal variable in the regression

analysis. As for the DC model, the score of conduct

problems contributed significantly to the stress score,

accounting for 32.9 % of the total variance. The result

Table 3 Significant group differences on parenting stress by severity levels of autistic behavior problems as well as emotional and behavioral problems

Domains of parenting stress Autistic behavior problems Conduct problems Hyperactivity/Inattention

No Mild to

moderate

Severe Close to

average

At risk High

risk

Close to

average

At risk High

risk

Parent–child dysfunction

interaction: Mean (SD)

28.25

(5.01)

34.43 (5.32) 30.33

(4.61)

F(2, 49) = 8.10**

Post-hoc test: 2 [ 3=1a

Difficult child: mean (SD) 33.35

(6.26)

35.67

(4.23)

45.67

(7.80)

30.6 (4.81) 37.43

(5.06)

37.76

(7.91)

F (2,49) = 11.66**

Post-hoc test: 2 = 3[1a F (2, 49) = 6.21**

Post-hoc test: 2 = 3[1a

a Results of post hoc test: 1 = No problems/Close to average, 2 = Mild to Moderate problems/At risk, and 3 = Severe/High risk

** p \ .01

Table 4 Multiple regressions for parenting stress in the DC domain

Estimate T value p-

Value

(Constant) 30.35 6.20 .00**

Child age (month) .01 .38 .70

Emotional symptoms .61 1.19 .24

Conduct problem 2.37 3.96 .00**

Hyperactivity/inattention .45 .96 .34

Peer problems -.78 -1.46 .15

Prosocial behaviors -.57 -1.31 .20

Mild/Moderate autistic behavior

problems

2.07 1.10 .28

Severe autistic behavior problems -.21 -.08 .94

** p \ .01

Table 5 Multiple regressions for parenting stress in the PCDI domain

Estimate T value p-

Value

(Constant) 30.51 7.63 .00**

Child age (month) .00 -.09 .93

Emotional symptoms .63 1.51 .14

Conduct problem .62 1.27 .21

Hyperactivity/inattention .07 .18 .86

Peer problems -.48 -1.09 .28

Prosocial behaviors -.77 -2.15 .04**

Mild/Moderate autistic behavior

problems

6.18 4.01 .00**

Severe autistic behavior problems .46 .22 .83

** p \ .01

J Autism Dev Disord (2014) 44:1383–1390 1387

123

revealed that caregivers who had a child with more conduct

problems perceived higher child-related parenting stress

(Table 4). As for the PCDI model, mild to moderate

autistic behavior problems and prosocial behaviors made

significant contributions to the PCDI stress score,

accounting for 40.0 % of the total variance (Table 5). The

results showed that a caregiver who had a child with mild

to moderate autistic behavior problems and a lack of pro-

social behaviors perceived higher stress in the parent–child

relationship. Regarding parenting stress on PD, no signif-

icant variables were found in multiple linear regression

models.

Discussion

Our study investigated the impacts of autistic behaviors

and those of individual emotional and behavioral problems

simultaneously on parenting stress in caregivers of children

with autism. The results revealed that caregivers of chil-

dren with mild to moderate autistic behavior problems

perceived higher stress in the parent–child relationship than

did those of children with no or severe problems. Associ-

ated with child-related parenting stress were three domains

of emotional and behavioral problems: emotional symp-

toms, conduct problems, and hyperactivity/inattention.

When considering autistic behaviors, behavioral problems,

and emotional problems jointly, mild to moderate autistic

behavior problems and prosocial behaviors respectively

predicted stress in the parent–child relationship, and con-

duct problems predicted child-related parenting stress.

It was noteworthy that caregivers of children with mild

to moderate autistic behavior problems perceived higher

stress in the parent–child relationship. This finding could

explain Hasting et al.’ finding (2005) that significant

associations were not found between autistic behaviors and

parenting stress, for linear relationships were considered

between autistic behaviors and parenting stress in their

study. The explanation for these nonlinear relationships

may be that children having mild to moderate autistic

behavior problems have more potential to improve their

problems. Caregivers may invest more time and effort,

demand more of their children, and ask their children to

meet their expectations, thereby causing tension between

the caregivers and their children and further increasing

their parenting stress. On the other hand, for children

within the group of no autistic behavior problems, autistic

behaviors were not predominant characteristics, and their

behavior patterns may be similar to those of typically

developing children. Caregivers therefore may not pay

much attention to their autistic behaviors and thus do not

perceive them as a source of stress. In the same vein,

caregivers of children with severe autistic behavior

problems may have lowered expectations of their children

and therefore do not perceive much stress when taking care

of their children. This result provides an important clinical

message: Caregivers of children having mild to moderate

autistic behaviors are at risk of perceiving high parenting

stress. As a result, clinicians should pay more attention to

this group when dealing with parenting stress in caregivers

of children with autism.

Furthermore, it is intriguing to note that caregivers of

children with more prosocial behaviors perceived lower

stress in the parent–child relationship. It could be that the

children’s prosocial behavior, reflecting the degree of

children helping, supporting, and empathizing others (King

et al. 2005), promotes positive interactions with their

caregivers. Caregivers might be satisfied with these inter-

actions, which were assessed in items of the PCDI domain

of the PSI/SF-C. This result suggests that intervention

programs focused on facilitating prosocial behaviors may

mitigate the stress in the parent–child relationship.

One finding of note was that conduct problems predicted

child-related parenting stress when autistic behaviors,

behavioral problems, and emotional problems were con-

sidered together. This association implies that conduct

problems are critical for parenting stress in caregivers of

children with autism, though only a quarter of the children

in this study were at risk of having conduct problems.

Lecavalier et al. (2005) also reported associations between

conduct problems and parenting stress. Conduct problems

are disruptive and rule-breaking behaviors (McMahon et al.

1998). Compared to emotional symptoms and hyper-

activity/inattention, conduct problems more obviously

contradict the caregiver’s expectations and social norms.

For example, stealing and cheating are often viewed as

serious problems by the public. Therefore, caregivers may

perceive great stress and challenges if their children have

conduct problems. The results of this study highlight the

importance of assessing conduct problems in children with

autism and intervening. Clinicians, caregivers and children

should work collaboratively to solve conduct problems to

decrease parenting stress.

In contrast to the above, peer problems were not asso-

ciated with parenting stress, though large portions of

children were at high risk of having difficulties in these two

domains (92 and 75 %, respectively). Although peer

problems are relevant to the core symptoms of autism (poor

social interaction), such problems may not directly influ-

ence caregivers when taking care of their children in daily

life. Peer problems are often observed in the school or the

community, where these children meet their friends. As a

result, peer problems likely had a secondhand impact on

these caregivers because caregivers may be informed about

peer problems by children’s teachers and peers rather than

by their own experience of caregiving. The passive

1388 J Autism Dev Disord (2014) 44:1383–1390

123

perceptions may reduce the effects of peer problems on

parenting stress.

A notable issue was that the percentage agreement of the

diagnosis of autism between the DSM-IV-TR/ICD-10 and

the CARS was only 61.5 % in our study. However, pre-

vious studies have reported that some children with autism

or high functioning autism (HFA) are indeed less likely to

achieve the clinical threshold of the CARS based on the

caregiver’s report. Mayes et al. (2009) reported that only

45 % of children with HFA scored in the clinical range on

caregivers’ reports. Moreover, two studies suggested that a

cut-off score of 25.5 was most accurate in screening chil-

dren with autism from those without it (Chlebowski et al.

2010; Mayes et al. 2012). Our study also found that 98 %

of children scored above the suggested cut-off score 25.5 in

interviews with caregivers. Alternatively, 86.5 % of the

children in our study had been receiving long-term reha-

bilitation services. Therefore, their autistic behavior prob-

lems might have decreased, and they might have behaved

more similarly to typically developing children.

It is noted that we adopted the caregiver’s perspective to

measure all variables of autistic behaviors and emotional

and behavioral problems, as well as parenting stress.

Children’s behaviors can be assessed from the perspectives

of caregivers, therapists, and teachers. However, since

parenting stress is the caregiver’s subjective perception

when they take care of their children, consistent subjective

observations from caregivers on children’s behaviors could

directly reflect whether those behaviors were sources of

caregiver’s parenting stress.

A limitation in this study is that the small sample size

influences the generalization of the results. Nevertheless,

consistent results from both univariate and multivariate

analysis provide solid evidence for interpreting these

results. Finally, the present study has made two contribu-

tions. First, the results of the study help clarify the con-

flicting results of previous studies concerning autistic

behaviors contributing to parenting stress. Second, the

present study specifies the effects of individual emotional

and behavioral problems on parenting stress. These find-

ings provide references for clinicians to make appropriate

evaluations and develop interventions targeting specified

emotional and behavioral problems, and it focuses attention

on caregivers of children with mild to moderate behavior

problems to help mitigate high parenting stress.

Conclusion

Our study found that caregivers of children having mild to

moderate autistic behavior problems perceived higher

stress in the parent–child relationship than did those of

children with no or severe problems. In addition, prosocial

behaviors and conduct problems respectively predicted the

stress of the parent–child relationship and child-related

stress. The findings of this study could encourage clinicians

to pay additional attention to caregivers perceiving high

parenting stress. It could also help clinicians to target

specified evaluations and interventions for emotional and

behavioral problems in order to mitigate high parenting

stress.

Acknowledgments We especially appreciate the occupational therapists of Country Hospital, Department of Physical Medicine and

Rehabilitation, and De Shang Clinic, the social worker and the

director of the St. Raphael Opportunity Center, and Yong Cheng

Rehabilitation Clinic for their assistance with recruiting participants.

We also thank all the caregivers and children for participating in the

study. This study was supported by a grant awarded to the corre-

sponding author from the National Science Council of Taiwan (100-

2410-H-006-103-MY3).

Conflict of interest None.

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