Focus on Autism and Other Developmental Disabilities

http://foa.sagepub.com Parenting Stress and Closeness: Mothers of Typically Developing Children and Mothers of Children With Autism
Charles D. Hoffman, Dwight P. Sweeney, Danelle Hodge, Muriel C. Lopez-Wagner and Lisa Looney Focus Autism Other Dev Disabl 2009; 24; 178 originally published online Jun 19, 2009; DOI: 10.1177/1088357609338715 The online version of this article can be found at: http://foa.sagepub.com/cgi/content/abstract/24/3/178

Published by: Hammill Institute on Disabilities

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Parenting Stress and Closeness

Mothers of Typically Developing Children and Mothers of Children With Autism
Charles D. Hoffman Dwight P. Sweeney Danelle Hodge
California State University

Focus on Autism and Other Developmental Disabilities Volume 24 Number 3 September 2009 178-187 2009 Hammill Institute on Disabilities 10.1177/1088357609338715 http://focus.sagepub.com hosted at http://online.sagepub.com

Muriel C. Lopez-Wagner
Pitzer College

Lisa Looney
California State University
Mothers of children diagnosed with autism (N = 104) reported higher levels of stress than mothers of typically developing children (N = 342) on 13 of 14 subscales of the Parenting Stress Index. The only scores that did not differ were from the Attachment subscale, which indicates lack of emotional closeness and rather cold patterns of parent-child interaction. Mean Child Domain subscale scores for mothers in the autism group were at the 99th percentile; mean scores on the Attachment subscale were at about the 50th percentile for both groups. Despite substantial stress, mothers of children with autism report close relationships with their children. Results substantiate the need to develop interventions to help these mothers reduce their stress. Keywords: autism; maternal stress; parenting; attachment

he unique challenges associated with parenting a child with a developmental disability have been found to be particularly stressful for parents, with these parents reporting greater levels of stress than parents of typically developing children (Abbeduto et al., 2004; Baker, Blacher, Crnic, & Edelbrook, 2002; Higgins, Bailey, & Pearce, 2005; Innocenti, Huh, & Boyce, 1992; Perry, 2005). The characteristics of autism have been found to be especially challenging (Hastings, 2002; Koegel et al., 1992; Perry, Harris, & Minnes, 2005), with parents of children with autism reporting higher levels of stress than parents of children with Down syndrome, developmental disabilities, or other psychiatric difficulties (Bouma & Schweitzer, 1990; Duarte, Bordin, Yazigi, & Mooney, 2005; Eisenhower, Baker, & Blacher, 2005; Fisman, Wolf, & Noh, 1989; Kasari & Sigman, 1997; Konstantareas, 1991; Norton & Drew, 1994). A number of studies have suggested a relationship between the behavior of children with autism and parents stress (e.g., Dunn, Burbine, Bowers, & Tantleff-Dunn, 2001; Tomanik, Harris, & Hawkins, 2004). Furthermore, symptoms associated with the disorder, such as the childrens language

and communication difficulties, cognitive impairments, reactivity to frustration, and repetitive, self-stimulatory behavior (American Psychiatric Association [APA], 2000), also have been found to be related to parents stress (Bebko, Konstantareas, & Springer, 1987; Donenberg & Baker, 1993; Gabriels, Cuccaro, Hill, Ivers, & Goldson, 2005; Norton & Drew, 1994). There is evidence of an association between the severity of behavior problems and level of parental distress for parents of children with developmental disabilities (Abbeduto et al., 2004; Baker et al., 2002; Hastings, 2002; Minnes et al., 1989; Perry et al., 2005). Three studies found limited evidence of a relationship between the severity of childrens autism and parental stress (Bebko et al., 1987; Freeman, Perry, & Factor, 1991; Konstantareas & Homatidis, 1989). Tobing and Glenwick (2002) attempted to address methodological restrictions of these earlier studies and used the Childhood Autism Rating
Authors Note: Address correspondence to Charles D. Hoffman, PhD, Department of Psychology, 5500 University Parkway, San Bernardino, CA 92407 (choffman@csusb.edu).

178

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Hoffman et al. / Parenting Stress and Closeness 179

ScaleParent Version (CARS-P; Bebko et al., 1987) to examine severity of childrens symptomology. They used the Parenting Stress Index (PSI; Abidin, 1995) as an inclusive and widely used instrument to measure parents stress. They found that the severity of childrens impairment was related to mothers stress for their pervasive developmental disordersnot otherwise specified group (N = 19) but not for their autism group (N = 22), although they reported a trend in this direction for the latter group. The limitations of the study included the small sample examined; furthermore, the sample was obtained from a subset of 30% of surveys returned by mothers from parent organizations providing support services for children with pervasive developmental disorders. These mothers reported their childrens diagnosis for the study. Notably, the CARS-P is not norm-referenced and had not been updated to reflect the APA (2000) revisions at the time Tobing and Glenwick conducted their study. The present investigation addresses methodological limitations in the literature. It is the first to compare the stress levels reported by mothers of children with autism by using a larger number of participants for both groups than used in earlier studies of stress in mothers of children with developmental disabilities. Furthermore, the sample consisted of children independently diagnosed with autism as a criterion for mothers inclusion in the autism group. It was anticipated that mothers of children with autism would report more stress on the Child Domain subscales of the PSI than mothers of typically developing children. No prediction was made for the Parent Domain of the PSI, which assesses stress related to parent functioning. Prior research has indicated higher levels of stress than norms reported by Abidin (1995) for parents of children with disabilities on Child Domain scores but not on Parent Domain scores (see Innocenti et al., 1992; Keller & Honig, 2004). Predictions related to mothers stress also were limited to the Child Domain of the PSI as it provides an estimate of stress resulting from the specific needs of the child, with mothers reports of their childs problematic behavioral characteristics seen as serving as the major factors contributing to the overall stress in the parent-child system (Abidin, 1995; see also Tobing & Glenwick, 2002). In this regard, for the autism group, the relationship between the severity of childrens autistic symptoms and mothers stress levels was examined with the expectancy that severity would be related to PSI Child Domain stress scores. Other methodological concerns were addressed in the design of this investigation. For inclusion in the autism group, in addition to mothers having a child with an independent diagnosis of autism, their children were also required to have a Gilliam Autism Rating Scale, Second

Edition (GARS-2) Autism Index (AI) score 85, indicating a high likelihood of the disorder (Gilliam, 2005). The AI is a total score assessing the probability of autism, with higher scores indicating a greater degree of severity. This newly revised, norm-referenced measure of autism was used to assess the severity of childrens symptoms in this study. As in the Tobing and Glenwick (2002) study, the PSI was used here to measure mothers stress. Mothers were the focus of the present study as they tend to have primary responsibility for child care in families with children with developmental disabilities (e.g., Milgrim & Atzil, 1988) and they are the most adversely affected by the negative impact associated with their childs disability (Abbeduto et al., 2004; Fisman et al., 1989; Freeman et al., 1991).

Method
Participants and Procedures
Autism group. Participants in the autism group were 104 mothers (and their children) drawn from a larger, ongoing program of research and evaluation based on the model suggested by Sweeney and Hoffman (2004). The research program is integrated with an established centerbased, supplemental behavioral intervention and parent education program located on a university campus in inland southern California. Parents and consumer children attend weekly 2-hr sessions during which children receive one-to-one behavioral treatment while parents attend a support group. Families typically attend the program for 2 years. The local California State Regional Center refers and provides funding for qualified consumer children and/or adolescents with developmental disabilities and their families who receive treatment services at the center (California Department of Developmental Services, 2002). Fully 161 of the 165 mothers attending the treatment program at the time of data collection volunteered to participate in the research and evaluation program. Of these volunteers, data were analyzed for those with children who met the indicated selection criteria, had completed the data collection process at the time of the study, and had met the established criteria for nonmissing data (N = 104; 65%). All mothers of children selected for participation in the autism group had children referred to the center with an independent Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; APA, 2000) diagnosis of autism (provided by the referring state agency and/or local school district). As indicated previously, each of these children also had GARS-2 AI scores 85, with the scores ranging from 85 to 139 (M = 102.13, SD = 12.7).

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180 Focus on Autism and Other Developmental Disabilities

For GARS-2 subscale standard scores, Stereotyped Behavior ranged from 5 to 18 (M = 10.18, SD = 2.8) and Social Interaction ranged from 5 to 16 (M = 9.89, SD = 2.4); Communication subscale scores (available for 70 children in this sample) ranged from 5 to 18 (M = 11.36, SD = 2.8). Diagnostic information, provided by the referring agency for the autism group, indicated that 48 children had a diagnosis of autism only, 40 had a diagnosis of autism with mental retardation, and 16 had autism with at least one other coexisting condition. Initial behavioral and diagnostic information regarding children in the autism group was collected from the state agency during the referral process. Additional child and family information was obtained from parents and existing agency records. Parents and children were assessed in a three-phase process, with specially trained research assistants or center staff completing the first phase of the assessment (including the GARS-2) at the parents home. During this home visit, parents were given an intake packet containing an overview of the programs of treatment, evaluation, and research. Informed consent was obtained from parents at this time. The second phase of the intake process took place at the treatment center. During the second phase, the child was observed by the clinical staff with the childs parent(s) present to answer any questions that arose from the in-home or in-center observations. For the third phase of the assessment process, mothers met individually with research assistants (unassociated with the treatment program at the Center) to complete demographic indices as well as the PSI and other measures that were part of the ongoing research and evaluation program. These other assessment materials (presented in one of two different random orders) included measures assessing mothers reports of their childrens sleep and their own sleep problems, their wellbeing, and family processes. These assessment sessions typically lasted 1 hrs, with the trained researcher presenting all assessment materials orally to individual mothers. To protect participant anonymity at the Center, answer sheets were sealed in a plain envelope, identified with a predetermined code number, and secured in locked files. Community group. Mothers (N = 342) were solicited by trained research assistants from classes at two local universities, a community college, community organizations (day care centers and churches), and a variety of businesses, all of which were located in the same geographic area as that for the autism sample. Mothers drawn from classes at the university and community colleges (39% of those in the final community group) were provided with extra class credit for their participation.

All mothers were asked to participate in a study addressing sleep problems in children and their parents, parent stress, family processes, and parent well-being. In the cover letter for the questionnaire packet, potential volunteers who were mothers of boys were especially encouraged to participate. Participants also were told that the information they provided would be anonymous and no names were obtained for mothers completing the survey instrument. A total of 425 questionnaire packets, 84% of the total distributed, were returned; 312 (73%) of those returned met the studys established criteria for nonmissing data; reports on children identified by their parents as having an exceptionality were excluded. Mothers completed the questionnaires on their own (taking approximately 45 minutes to do so) and returned them to the researchers. All mothers in the community group completed the same assessment instruments (presented in one of two different random orders) as mothers in the autism group. To determine if method of administration affected results, an additional 32 mothers, who volunteered to do so, were tested in one-on-one hour-long sessions similar to those used for the autism sample. Data from 30 interviews were used in analysis (one mother was excluded because her child had a diagnosed disability and another mother left prior to completing the task). Statistical examination of the obtained scores for these two community groups (self-report and interview format) were compared for both demographic indicators and on each of the scales utilized. Mean scores for these two groups did not differ for any of the demographics or for any of the scales completed by the mothers. Furthermore, examination of subscale scores on both Child and Parent Domains of the PSI indicated no differences between the means for these two groups. Thus, the data for the groups were combined, yielding a total community group N of 342 mothers. The methods and procedures for this investigation were reviewed and approved for human participant protections by the campuss Institutional Review Board. Characteristics of groups. There were 20 female (19.2%) and 84 (80.8%) male children in the autism group; the community group was comprised of 136 (39.8%) female and 205 (59.9%) male children (gender was not indicated for one child in this latter group). Children in both groups ranged from 3 to 16 years of age. The mean age for children in the autism group (M = 8.61, SD = 2.77) did not differ from the mean age of children in the community group (M = 8.03, SD = 3.61). The age of mothers in the groups ranged from 18 to 57 for the autism group (M = 37.52, SD = 7.63) and from 18 to 63 in the community group (M = 34.85, SD = 8.15). These

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Hoffman et al. / Parenting Stress and Closeness 181

means were found to differ significantly from one another, independent samples t(424) = 2.89, p < .01. Additional demographics reported for the autism and the community groups (by percentage for each) are presented in Table 1. The obtained distributions for the four demographic categories indicated did not differ between the two groups.

Table 1 Demographic Information for Autism and Community Groups (%)

Demographic Autism (N = 104) Community (N = 342) 9.60 2.90 34.50 38.00 14.10 1.00 12.30 70.50 8.50 2.60 1.20 4.70 0.30 5.00 10.50 27.50 19.60 17.00 11.00 9.40 11.70 16.40 15.50 12.90 14.90 27.50 1.00

Measures
Parenting Stress Index (Abidin, 1995). The PSI is a standardized measure designed to evaluate stress in parent-child systems. The PSI consists of 101 items that parents respond to on Likert-type scales ranging from strongly agree (1) to strongly disagree (5). The PSI assesses two domains of stress derived from factor analysis: a Child Domain, with high scores indicating that parenting stress originates from child characteristics or behavior problems that make caregiving difficult for the parent, and a Parent Domain, with high scores indicating that the source of stress emanates from some parental functioning, including parent and family context factors that affect a parents ability to function as a competent caregiver. A total Child Domain score is calculated as the sum of the following six subscales: Distractibility/ Hyperactivity (9 items; e.g., My child is so active that it exhausts me), Adaptability (11 items; e.g., It takes a long time and it is very hard for my child to get used to new things), Reinforces Parent (6 items; e.g., My child rarely does things for me that make me feel good), Demandingness (9 items; e.g., My child turned out to be more of a problem than I had expected), Mood (5 items; e.g., Mychild seems to cry or fuss more often than most children), and Acceptability (7 items; e.g., My child is not able to do as much as I expected). The Parent Domain is calculated as the sum of the following seven subscales: Competence (33 items; e.g., Being a parent is harder than I thought it would be), Isolation (7 items; e.g., I feel alone and without friends), Attachment (7 items; e.g., It takes a long time for parents to develop close, warm feelings for their children), Health (5 items; e.g., During the past six months I have been sicker than usual or have had more aches and pains than I normally do), Role Restriction (7 items; e.g., Most of my life is spent doing things for my child), Depression (9 items; e.g., When I think about the kind of parent I am, I often feelguilty or bad about myself), and Spouse Related Stress (7 items; e.g., Having a child has caused more problems than I expected in my relationship with my spouse). The PSI alsoyields a Total Stress Score that is the sum of Child and Parent Domain scores. Abidin (1995)

Child ethnicity African American/Black 12.50 Asian/Pacific Islander 5.80 Hispanic/Latino 26.00 White/Caucasian 40.40 Mixed/Other 14.20 Information missing 1.00 Mothers marital status Single 10.60 Married 69.20 Divorced 9.60 Separated 3.80 Widowed 1.00 Cohabiting 0.00 5.80 Information missing Mothers education Not high school graduate 11.60 High school graduate 14.40 Some college 28.80 AA degree 12.50 BA degree 14.40 Advanced degree 11.50 Information missing 6.70 Annual family income Less than $24,000 17.30 9.60 $24,000 to $35,999 $36,000 to $47,999 15.40 4.80 $48,000 to $59,999 $60,000 to $71,999 8.70 Greater than $72,000 25.00 Information missing 19.20

reported a .90 internal consistency for both domains and the Total Stress score. Test-retest reliability ranged from .63 to .82 in Child Domain scores, .69 to .91 in Parent Domain scores, and .65 to .88 in Total Stress scores. For the present study, internal consistencies were .91 and .93 for the Child Domain scores for the autism and community groups, respectively, and .93 on the Parent Domain scores for both groups. The PSI has been used in numerous studies to examine the effect of a child with a disability on parent stress (e.g., Boyce, Behl, Mortensen, & Akers, 1991; Dumas, Wolf, Fisman, & Culligan, 1991; Innocenti et al., 1992; Keller & Honig, 2004; Margalit, Raviv, & Ankonina, 1992; Noh, Dumas, Wolf, & Fisman, 1989; Tobing & Glenwick, 2002). Gilliam Autism Rating Scale, Second Edition (Gilliam, 2005). The GARS-2, derived from the diagnostic criteria

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182 Focus on Autism and Other Developmental Disabilities

in the DSM-IV-TR (APA, 2000) and from the Autism Society of Americas (2003) definition, is a professional and parent report instrument to evaluate autism symptoms. It is used to assess children on each of three domains associated with the disorder (Stereotyped Behavior, Communication, and Social Interaction; M = 10 and SD = 3 for each). The combined scores on these subscales yield an Autism Index score (M = 100 and SD = 15), which provides a total score assessing the probability of autism, with higher scores indicating a greater degree of severity. Where Communication subscale scores are not available (N in this sample = 34 children), or when a child is nonverbal or does not communicate in any other way, a reliable and valid AI is obtained by computing the sum of the standard scores of the other two subscales available in the manual for the test. Gilliam (2005) reported that standard scores were obtained from a normative sample of children and young adults diagnosed with autism (N = 1,107) and that 90% obtained AI scores 85. Adequate validity and reliability were reported for each of the test domains and the AI. The GARS (Gilliam, 1995) was recommended for use in the diagnosis of autism (Filipek et al., 2000; National Research Council, 2001). The GARS-2, used here, was revised to reflect the most current definition of autism (APA, 2000), and the author addressed psychometric concerns raised for the original GARS (e.g., Lecavalier, 2005; South et al., 2002).

Results
Group differences in mothers stress. An independent samples t test indicated that mothers of children with autism reported higher levels of stress on the Child Domain of the PSI (M = 147.9, SD = 25.7) than did mothers of typically developing children (M = 94.79, SD = 21.7), t(420) = 20.87, p < .001. According to values reported by Abidin (1995), these means were at the 99th percentile for mothers in the autism group and (approximately) at the 40th percentile for mothers in the community group. An independent samples t test conducted to compare mean scores on the Parent Domain of the PSI indicated that mothers in the autism group reported higher levels of stress (M = 137.41, SD = 31.4) than did mothers of typically developing children in the community group (M = 118.7, SD = 29.3), t(420) = 5.62, p < .001. Percentiles associated with these respective values, again as compared to the norms reported by Abidin, were (approximately) at the 75th percentile for mothers in the autism group and the 45th percentile for mothers in the community group.

Two 2 2 between-subjects, Group (autism vs. community) Child Gender multivariate analyses of variance (MANOVAs) were carried out to examine differences in mean scores on the six PSI Child Domain subscales and, in the second MANOVA, on the seven Parent Domain subscales; these subscales were treated as the dependent measures in the respective analyses. Furthermore, two 2 2 (Group Child Gender) multivariate analyses of covariance (MANCOVAs), with adjustment made for both mothers age (which was significantly different for the two groups) and childrens age (a factor found to influence PSI scores; Abidin, 1995), were conducted for the Child and Parent Domain subscales, respectively. The mean scores for each of the Child and Parent Domain subscales of the PSI for both autism and community groups are indicated in Table 2, along with associated F values (and significance levels) obtained for the differences between the means on univariate tests. The table also indicates (approximate) percentiles associated with the means for each subscale, which were derived from the norms reported by Abidin (1995). The results of the MANOVA for the six Child Domain subscales indicated significant differences between the autism and community groups, Wilkss Lambda = .46, F(6, 436) = 85.27, p < .001. There was no effect for child gender and no interactive effect. Univariate betweensubjects effects revealed that the means for the autism group were significantly higher than those obtained for the community group for each of the six Child Domain subscales (ps < .001; see Table 2). The 2 2 MANCOVA carried out on these data, with adjustments made for both mothers and childrens age, obtained the same results: Only the group effect was significant, Wilkss Lambda = .47, F(6, 410) = 78.05, p < .001, with F values for the obtained differences between the groups on the subscales each significant, as in the between effects indicated for the MANOVA, beyond the .001 level. The results of the MANOVA for the seven Parent Domain subscales indicated significant differences between the autism and community groups, Wilkss Lambda = .91, F(7, 435) = 6.42, p < .001. No child gender or interactive effect was obtained. Univariate betweensubjects effects revealed that the means for the autism group were significantly higher than those obtained for the community group for six of the seven Parent Domain subscales (see Table 2). Only the means obtained for the respective groups on the Attachment subscale of the Parent Domain were not significantly different from one another. The 2 2 MANCOVA of the Parent Domain subscale data, with adjustments made for mothers and childrens age, obtained the same results as the MANOVA:

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Hoffman et al. / Parenting Stress and Closeness 183

Table 2 Means and Standard Deviations for Parenting Stress Index (PSI) Child and Parent Domain Subscales for Autism and Community Groups
PSI M Autism (N = 104) SD Percentilea M Community (N = 341) SD Percentilea F 77.43*** 135.32*** 21.14*** 105.59*** 40.13*** 154.67*** 4.52** 10.84*** ns 9.70** 13.85*** 4.53** 7.37***

Child Domain Distractibility/Hyperactivity 32.48 6.10 95 23.30 5.17 45 Adaptability 37.65 7.85 99 22.74 6.38 40 Reinforces Parent 13.43 4.97 87 10.10 3.57 65 Demandingness 28.48 6.58 97 17.30 5.28 50 Mood 13.48 4.12 95 9.49 3.12 55 Acceptability 21.74 4.94 99 11.76 4.02 50 Parent Domain Competence 30.02 7.04 60 27.39 6.68 42 Isolation 16.06 5.39 77 12.92 4.84 58 Attachment 12.56 3.61 53 12.03 3.74 51 Health 14.33 4.08 77 12.15 3.78 60 Role Restriction 22.31 6.65 55 17.96 5.71 52 Depression 21.65 7.17 64 18.99 6.45 45 Spouse 20.36 6.95 74 17.27 5.96 57
a

Percentiles obtained from norms reported by Abidin (1995) are approximate. **p < .01. ***p < .001.

Only the group effect was significant, Wilkss Lambda = .89, F(7, 409) = 7.27, p < .001. F values for the obtained differences for groups in the univariate between-subjects analyses on all but the Attachment subscale were significant at the same levels as those obtained in the MANOVA. Again, the means for the autism and community groups were not significantly different for the Attachment subscale. Autism and mothers stress. Pearson correlations examining the relationship between the level of childrens autism and mothers reports of their stress indicated that GARS AI scores were related to both PSI Child Domain (r = .33, p < .001) and Parent Domain Stress (r = .27, p < .01). Childrens Stereotyped Behavior scores were related to both Child and Parent Domain Stress (r = .30, p < .01 and r = .21, p < .05, respectively), as were childrens Social Interaction scores (r = .30, p < .01 and r = .25, p < .05). Communication scores (based on a smaller N of 70) were not significantly related to these PSI domain scores. Separate regression analyses indicated that GARS AI contributed to the variance in the prediction of both mothers Child Domain, R2 = .11, F(1, 102) = 10.21, p < .001, and Parent Domain stress scores, R2 = .07, F(1, 102) = 8.10, p < .01. Mothers stress and Attachment subscale scores. As mothers in the autism group report significantly higher

levels of Child Domain and Parent Domain stress than mothers in the community group, the finding of no difference between these groups on the Attachment subscale, with mean scores for both groups at about the 50 percentile compared to the norms reported by Abidin (1995), was unexpected. Abidin reported intercorrelations between the subscales on the PSI and one might expect higher Attachment subscale scores, indicating less closeness, particularly for mothers reporting such very high levels of Child Domain stress. To explore this finding further, Pearson correlations between mothers PSI Child Domain and Parent Attachment subscale scores for the community and autism groups were carried out. Overall Child Domain scores were highly correlated with Attachment subscale scores for both the community (r = .60, p < .001) and the autism groups (r = .60, p < .001). Correlations between Child Domain subscales and Attachment subscale scores are indicated in Table 3, along with correlations reported by Abidin (1995), which are included for comparison purposes. These results indicate that mothers reports of higher levels of stress related to the specific domains of their childrens difficult behavior were indeed related to higher Parent Domain Attachment subscale scores (i.e., mothers reports of lower levels of closeness to their children). Separate regression analyses, carried out to further explore the relationship between Child Domain scores and Attachment subscale scores (as the criterion measure),

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184 Focus on Autism and Other Developmental Disabilities

Table 3 Correlations Between Parenting Stress Index (PSI) Attachment and Child Domain Subscale Scores Reported by Abidin (1995) and for Community and Autism Groups in the Present Study
PSI Child Domain Subscales Distractibility/ Hyperactivity Adaptability Reinforces Parent Demandingness Mood Acceptability
a

Community (N = 342) .42** .45** .60** .49** .43** .51**

Autism (N = 104) .24* .19b .55** .44** .24* .52**

Abidina (N = 447) .26 .35 .52 .37 .40 .51

Although significance levels were not reported by Abidin, for the N examined each correlation is significant beyond the .01 level. b p = .056. *p < .05. **p < .01.

indicated significant relationships for both the community, R2 = .36, F(1, 340) = 193.35, p < .001, and autism groups, R2 = .23, F(1, 102) = 31.18, p < .001. Finally, for the autism group, childrens AI scores were significantly correlated with mothers Attachment subscale scores ( r = .21, p < .05). A hierarchical regression analysis was conducted to explore the relationship between childrens AI scores (entered on Step 1) and Child Domain subscale scores (entered on Step 2) and mothers Attachment subscale scores. This analysis revealed that AI scores predicted Attachment scores on Step 1, R2 = .05, F(1, 102) = 7.69, p < .01. Child Domain stress scores contributed significantly to the variance on Step 2, R2 = .21, F(1, 102) = 38.67, p < .001, with AI no longer significant once Child Domain scores were entered.

Discussion
Mothers of children with autism reported significantly higher levels of stress than did mothers of typically developing children. This difference, obtained for each of the PSI Child subscales, was anticipated and in line with prior related research. The levels of stress reported by mothers in the autism group on these subscales were extremely high, at the 99th percentile for overall Child Domain stress based on the norms reported by Abidin (1995). Previous studies indicated higher levels of stress for parents of children with disabilities than the norms reported by Abidin on the Child Domain but not on the Parent Domain of the PSI (e.g., Keller & Honig, 2004). Here, mothers in the autism group reported higher levels of stress than mothers in the community group on 6 of

the 7 Parent Domain subscales. Across the 13 subscales of the PSI, only mean scores for the Attachment subscale of the Parent domain did not differ for these two groups. For the autism group, the relationship obtained between the severity of childrens autistic symptoms and mothers Child Domain stress also was expected (e.g., Tobing & Glenwick, 2002) and supports other literature indicating that greater levels of childrens disabilities are associated with more parental distress (e.g., Baker et al., 2002; Minnes et al., 1989). Here, severity of childrens autistic symptoms was related to mothers Parent Domain stress as well. Mothers reports of their childrens increased problematic behavior on Child Domain subscales were related to mothers reports of their closeness to their child on the PSI Parent Domain Attachment subscale. For mothers in both groups, the more stressful and problematic they reported their childs behavior to be, the less closeness they reported. For the autism group, the severity of childrens autism was related to mothers reports of less closeness on the Attachment subscale. Hierarchical regression analysis suggested that it was childrens higher levels of problematic behavior (indicated by Childrens Domain scores) and not the level of their autism per se that was the major factor contributing to mothers reports of less closeness to their children. This finding may be seen as informing the obtained differences between the groups in mothers reports of their stress. As indicated, parents of children with more maladaptive behaviors report higher levels of distress (Abbeduto et al., 2004), and parents of children with developmental disabilities who evidence significant behavior problems report levels of stress similar to those reported by parents of children without disabilities who evidence significant behavior disorders (Donenberg & Baker, 1993; Dumas et al., 1991; Floyd & Gallagher, 1997). Other work has indicated that the specific type or severity of a childs disability is not related to parents reports of their stress (e.g., Keller & Honig, 2004). A relationship between level of childrens autism and mothers reports of their stress on the PSI was obtained here. The design of the present study does not support further examination of the relative contributions of childrens autism and their problematic behavior to mothers stress, and it is suggested that future research attempt to disentangle these relationships. As indicated, mothers of children with autism reported greater stress across all of the Child Domains of the PSI and on six of the seven Parent Domain subscales of the PSI. Furthermore, mothers reports of higher levels of Child Domain stress were related to their Attachment subscale scoresthat is, to their reports of less closeness to

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Hoffman et al. / Parenting Stress and Closeness 185

their children. Although the mean Child Domain score obtained for mothers in the autism group was at the 99th percentile, mean scores for mothers in both groups were at about the 50 percentile and did not differ from one another on the Attachment subscale. According to Abidin (1995), high scores on the Attachment subscale suggest that a parent does not feel a sense of emotional closeness to his or her child and indicates a parents inability to observe and understand the childs feeling or needs accurately. Abidin indicated that this lack of emotional closeness may reflect an absence of emotional bonding and a rather cold pattern of parent-child interaction (p. 11). The finding of no difference between the groups on the Attachment subscale was unanticipated, and particular attention to this finding seems warranted from a historical perspective as mothers of children with autism were once characterized as refrigerator mothers and blamed for causing their childs disability because of their apparently cold manner of relating to their child (Bettelheim, 1967; Kanner, 1949). Despite the significantly higher levels of Child Domain stress reported by mothers of children with autism and the concomitant correlation between mothers reports of stress and less closeness to their children, mothers of children with autism did not differ from mothers of typically developing children with regard to their reports of their closeness to their children. Perhaps mothers of children with the uniquely challenging characteristics of autism and the behavioral problems associated with this disorder, despite high levels of stress, adapt to their childrens needs with the closeness required to enable them to respond effectively to their children. Possibly, viewing a child with autism as less responsible for his or her problematic behavior may serve to support a mothers understanding of her childs feelings or needs accurately and provide a sense of closeness. In this regard, mothers of children with autism may not view their childrens behavior as bad but rather as attributable to their childrens affliction (e.g., Chavira, Lopez, Blacher, & Shapiro, 2000). Similarly, they may feel partially responsible for contributing to their childrens disorder (e.g., Affleck, McGrade, Allen, & McQueeney, 1985; Rodrigue, Morgan, & Geffken, 1990). Contrariwise, this latter sense of responsibility may contribute to mothers feelings of guilt and thereby lead them to report experiencing levels of closeness that are incommensurate with the stress they report on the other subscales. This guilt or perhaps the sensitivity of mothers of children with autism to the refrigerator mother myth may have affected them, with social desirability differentially influencing their responses to parenting items (e.g., Morsbach & Prinz, 2006) on the Attachment subscale of the PSI (e.g., I expected to have closer and warmer feelings for my

child than I do and this bothers me). These speculations are offered to suggest future research avenues as the present findings with respect to closeness are limited, the result of exploratory analyses of a subscale of the PSI, an instrument designed to assess mothers stress. Other measures may be used to assess mothers self-reports of closeness to their child in relation to indices of their childs difficult behavior in future studies. Nevertheless, these results may be contrasted with earlier notions that blamed a mothers supposed coldness or emotional distance for her childs autism. The Child Domain subscales of the PSI provide indicators of childrens problematic behaviors that are stressful for parents, with higher levels of these behaviors defining increased parental stress. In addition to the role childrens autism may have in contributing to mothers reporting greater stress than mothers of typically developing children may be seen as reflecting the nature of this instrument. Several of the subscales of the PSI provide for parents reports of childrens problem behaviors specifically associated with autism (e.g., Abbeduto et al., 2004) or perhaps the coexisting disorders associated with this disorder. By way of example, as Abidin (1995) indicated, high scores on the Distractibility/Hyperactivity subscale are associated with children who display many of the behaviors characteristic of attention-deficit/ hyperactivity disorder, and high scores on the Adaptability subscale are associated with a childs inability to adjust to changes in his or her environment. Comorbid conditions may contribute independently to mothers stress, and previous research has not addressed this concern or included the diagnostic specificity required to examine these relationships and to advance the field in this regard (see Sweeney & Hoffman, 2004). Furthermore, although the PSI is a widely used measure of parental stress, the present findings are limited in that they are based on mothers self-reports of their childrens behavior. Although the present findings benefit from the methodological approach utilized, it is suggested that future research use other methods of assessing childrens problematic behavior and mothers stress and closeness, including direct observations of childrens behavior, parent-child interactions, and parent interviews. The results of the present study can be interpreted to suggest that mothers of children with autism maintain close relationships with their children despite the stress of the parenting challenges they face. The very high levels of stress reported by these mothers on the Child Domain subscales indicate the importance of effective interventions to help them to cope successfully with the demands of parenting a child with autism. Reducing parental stress should contribute to improving the family

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186 Focus on Autism and Other Developmental Disabilities

climate, to parents ability to manage their childrens behavior, and in turn, to improved outcomes for children with autism and their families.

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Charles D. Hoffman, PhD, is professor emeritus in psychology at California State University, San Bernardino. He serves as the director of research at the on-campus University Center for Developmental Disabilities. His current interests include sleep problems in children with autism, intervention efficacy, and parent, family, and child functioning in families of children with autism. Dwight P. Sweeney, PhD, is a professor in educational psychology and counseling at California State University, San Bernardino. He serves as the director of the on-campus University Center for Developmental Disabilities. His current interests include assessment and sleep problems in children with autism. He also is interested in intervention efficacy and parent, family, and child functioning in families of children with autism. Danelle Hodge, PhD, is a lecturer in psychology at California State University, San Bernardino. She serves as the associate director of research at the on-campus University Center for Developmental Disabilities. Her current interests include sleep problems in children with autism and parent, family, and child functioning in families of children with autism. Muriel C. Lopez-Wagner, MA, is director of institutional research and assessment at Pitzer College. Her current interests include her dissertation research related to intervention efficacy and parent, family, and child functioning in families of children with autism. Lisa Looney, PhD, is a lecturer in psychology at California State University, San Bernardino. Her current interests include parent, family, and child functioning in families of children with autism and other developmental disabilities.

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