Introduction
Attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) are two of the most common neurodevelopmental disorders (NDD), prevalence rates during childhood are estimated at about 5–7% for ADHD (Salari et al., 2023) and 1 - 1,5% for ASD (Atladottir et al., 2015; Zeidan et al., 2022), and are associated with vast personal, social, and academic consequences. The two conditions, although conceptually distinctive, share in several aspects the same characteristics. They have been suggested to share underlying etiologies, particularly genetic predisposition (Cross-Disorder Group of the Psychiatric Genomics Consortium, 2019; Ma et al., 2021). Twin studies have reported that both ASD and ADHD are highly heritable and that the two conditions co-aggregate in the same families (Ghirardi et al., 2018; Miller et al., 2019). This indicates the increased likelihood of children with NDD having a parent/parents that also have NDD or NDD traits (Faraone et al., 2024; Constantino & Todd, 2005). There is also a high co-occurrence of autism and ADHD (Rong et al., 2021), as well as of other mental health conditions (Lai et al., 2019; Suen et al., 2023).
A large part of the literature related to parenting children with NDD has been focused on parenting stress, that is the stress experienced by parents that results from demands of the parenting role and challenges associated with the relationship with their child, as opposed to other kinds of stress experienced by parents, such as economic, work or academic stress (Abidin, 1992).
Abidin’s theory of parenting stress (Abidin, 1990b), although dated, continues to dominate the literature. This model categorizes factors contributing to parenting stress into three domains: parent, child and situational. The parent domain involves aspects of parental functioning and personality components, such as the sense of competence. The child domain includes the child’s temperamental and behavioral factors of the child, such as adaptability. The situational domain refers to social support and isolation. Abidin developed the Parenting Stress Index (PSI) (Abidin, 1990a), which conceptualizes parenting stress as consisting of two dimensions: the parent and the child. This study specifically focuses on parenting stress within the parent domain.
There is agreement that parents of children with NDD experience higher levels of parenting stress compared to parents of children with no NDD (Valicenti-McDermott et al., 2015; Wiener et al., 2016). A qualitative study (Leitch et al., 2019) reported that parents of children with ADHD commit their entire lives to caring for their children, often suffer from social stigma and request support to cope. Parents of children with ASD have also been found to report more frequent psychological distress and lower social support compared to parents of children with other medical conditions such as Down syndrome and Type 1 diabetes mellitus (Picardi et al., 2018). ADHD and ASD are also associated with higher parental stress and with more parental mental health conditions when compared to parents of children with other mental health conditions, and it has been suggested that parental factors should be given more consideration in support for children with ADHD/ASD (Telman et al., 2017). The elevated levels of parenting stress can be hypothesized to derive from increased caretaking demands, as parents of children with NDD need to manage difficulties related to school, peers and siblings. A qualitative study of parents to children displaying problematic behaviors revealed themes of loneliness and isolation, and many families described several stressors in their lives: relating to the child, to the preschool or school, or to the other parent (Ljungström et al., 2020). Furthermore, children and adolescents with NDD often present emotions or behaviors that are associated with high levels of parenting stress (Craig et al., 2016). Perceived parenting stress can affect the parents’ ability to manage the child’s behaviors, maintaining family relationships, and staying confident about their own abilities (Leitch et al., 2019), and has been linked to hopelessness in caregivers (Liu et al., 2023).
Research on the etiology of parenting stress has explored numerous parent, child and situational factors and found mixed associations. Parent factors involve aspects of parental functioning and personality, and child factors refer to a child’s temperament and behavior, such as externalizing or internalizing behavior. Situational factors include, among others, social support and isolation. Associations have been found between higher amounts of social support, higher educational level and lower levels of parenting stress, and there has been inconsistent evidence on the association between parenting stress and income. Factors associated with parenting stress might however differ among parents parenting children with different care-taking needs. (Fang et al., 2024) To our knowledge, no previous study has investigated the association of parenting stress and psychosocial functioning, which refers to a range of aspects of psychological and social functioning and reflects the child’s capacities to meet demands in everyday situations (Shaffer et al., 1983).
So far, very few studies have compared levels of stress between families with different NDD diagnoses, although it could be hypothesized that, given the core feature differences in ADHD and ASD, the caretaking needs might differ and result in different levels of parenting stress. In addition, recent data on the issue of stress in families of children with NDD have reported mainly about stress perceived by mothers (Miranda et al., 2019; Perez Algorta et al., 2018), and studies that have involved fathers have shown that mothers of children with ASD experience increased levels of stress compared with fathers (Little, 2002; Wiener et al., 2016). However, results are ambiguous, and in a Canadian study (Rivard et al., 2014), fathers of children on the autism spectrum reported higher levels of stress than mothers.
Similarly, studies investigating how NDD affect family life have primarily focused on child factors. Considering that the heritability of NDD is high, with genetic factors accounting for about 80% of the variation in liability for ADHD and ASD (Brikell et al., 2015; Lichtenstein et al., 2010), it is to be expected that the parents themselves experience traits of NDD, which might add even more complexity to the family situation. Many parental activities require cognitive skills such as inhibition of impulses and sustained attention, which might be reduced in parents with ADHD traits even at subthreshold levels (Mokrova et al., 2010), and parents who themselves have ADHD face many concurring practical, psychosocial and parental challenges (Johnston et al., 2012). This suggests that in families where both child and parent have ADHD traits, it is important to consider the interplay between child and parental factors.
The Present Study
Despite earlier research on parenting stress in families of children with NDD, several gaps remain in the literature. Few studies have directly compared parenting stress across families with different NDD diagnoses, despite the distinct support needs of children with ADHD versus ASD. Additionally, much of the existing research have focused primarily on mothers, with conflicting results regarding gender differences in stress levels. There is also limited exploration of the association between parenting stress and the psychosocial functioning of children with NDDs, a crucial aspect of family dynamics.
Furthermore, while previous studies often have focused on child factors, less attention has been given to the impact of parental NDD traits, even though parents with their own NDD traits may experience additional challenges.
In the present study, we aimed to study subdomains of parent domain parenting stress of parents of children with ADHD and/or ASD. Our specific research questions are i) if there is a difference between mother’s and father’s experiences of parenting stress; ii) if there are any differences in parenting stress in groups of parents of children with ADHD, ASD or ADHD + ASD; iii) if there are any associations between parenting stress and the child’s psychosocial function, and; iv) if parents’ own traits of NDD affect levels of parenting stress.
Method
Procedure
Families were recruited from the Child and Adolescent Psychiatry clinic in Region Jönköping County (with one site in Jönkoping and one in Värnamo) and from the Child Neuropsychiatric Clinic in Gothenburg, Sweden (inclusion period: April 2018 – March 2021). Parents of children aged 8–18 years who had recently been diagnosed with ADHD or ASD were consecutively targeted for inclusion. Another inclusion criteria were that the parent had to have sufficient Swedish language skills to take part in the study. Newly diagnosed children and their parents were contacted and invited shortly (less than two months) after completing the assessment. All participants were informed about the study by the interviewer. Written consent was obtained from all parents and children 15 years of age or older. For children younger than 15 years, verbal consent was obtained according to ethics approval. Participation in the study, that lasted about one hour, included an interview performed by a licensed psychologist and completing self-rating questionnaires. After the interview, information from the diagnostic assessment of the child was collected (diagnosis and full-scale intelligence quotient (FSIQ)) from the medical charts. The NDD diagnoses given at the clinics were based on DSM-5 criteria and the assessment was carried out in experienced multi-disciplinary teams, including in all cases a medical doctor and a psychologist. Rating scales, e.g. Five to Fifteen (Kadesjö et al., 2004), Swanson, Nolan, and Pelham Scale, version IV (Hall et al., 2020) and Autism Spectrum Screening Questionnaire (Ehlers et al., 1999), were used to document the child’s NDD characteristics. Descriptions of traits related to the diagnoses was obtained from school staff in all cases. Other possible conditions that may cause similar traits were ruled out.
Each participant received a movie ticket after participation. The study was approved by the Regional Ethics Committee of Gothenburg, Sweden (2017-08-16; ref. no 046-17).
Participants
A total of 147 families fulfilled inclusion criteria during this period and were invited to participate in the study. Of these, 30 (20%) families declined due to lack of interest, 12 (8%) did not have time or energy to participate, 6 (4%) agreed to do the interview but could not be reached on phone to schedule an appointment, 1 (0.7%) had moved from the area and 1 (0.7%) did not show up for their scheduled appointment. The final sample consisted of 97 families. No significant differences were found between the participating and non-participating groups regarding child age, child gender or reason for referral.
In total, 86 mothers and 37 fathers of 97 children participated in the present study. The number of mothers who participated was higher than the number of fathers, due to the participation of mothers with sole custody or the father declining to participate. Sample characteristics of the study group are summarized in Table 1. The mothers were younger than the fathers (Z = 3.573, p < 0.001). There were no other significant differences between mothers and fathers regarding sample characteristics. No significant differences were found in children to participating mothers or fathers in relation to C-GAS, age, gender, or diagnostic category.
Table 1
Sample Characteristics
Mothers n = 86 | Fathers n = 37 | |
|---|---|---|
Child diagnosis n = 97 | N (%) | N (%) |
ASD | 25 (29) | 12 (32) |
ADHD | 36 (42) | 13 (35) |
ASD + ADHD | 25 (29) | 12 (32) |
Child psychosocial function | ||
C-GAS (Mean, range) | 50 (30–62) | 50 (30–61) |
Parent age (Mean, SD) | 42.5 (6.70) | 47.3 (7.07) |
NDD traits | ||
ASSERT, % screen positive ( ≥ 8) | 19.8 | 8.1 |
ADHD-RS, mean met critera (SD) | 5.1 (4.93) | 3.3 (2.52) |
Number of children living with parent | ||
0 | 0 | 1 (3) |
1–2 | 50 (58) | 24 (65) |
3 or more | 36 (42) | 12 (32) |
Parental education | ||
Compulsory school | 4 (5) | 0 |
Upper secondary school | 25 (29) | 16 (43) |
Vocational program | 9 (11) | 4 (11) |
College/University | 48 (55) | 17 (46) |
Weighted household income per month | ||
<1399 euro | 36 (42) | 10 (27) |
>1400 euro | 50 (58) | 27 (73) |
Marital status | ||
Married/common-law partnership | 18 (21) | 33 (89) |
Single | 68 (79) | 4 (11) |
Working status | ||
Full time employment | 36 (42) | 31 (84) |
Part time employment | 30 (35) | 2 (5) |
Full time studying | 7 (8) | 0 |
Unemployed | 1 (1) | 2 (5) |
Long-term sick leave | 12 (14) | 2 (5) |
Support from social services | 30 (35) | 12 (32) |
At the time of the study, the children (n = 97) were 8 to 18 years old (M = 12.2, SD = 2.80) and the majority (59.8%) were boys. The majority of the children (56%) had an FSIQ, measured with a Weschler Intelligence Scale (Wechsler, 2010; Wechsler, 2016), between 85–115. Furthermore, 7% had an IQ between 115–130, 30% between 70–85, and 7% had an IQ-score of 69 or below. The children had a mean C-GAS score of 50 (range 30–62 for the mother’s children, range 30–61 for the father’s children).
Measures
Participation in the study contained a structured interview with the Swedish Parenthood Stress Questionnaire (SPSQ). Background variables, including educational level, marital status, working status, social support, and monthly income, were also collected during the interview. Weighted household income was calculated using the Statistics Sweden guidelines (Statistics Sweden, 2016). After the interview, the parents independently completed the self-report questionnaires Autism Symptom Self-Report for Adolescents and Adults (ASSERT) (Posserud et al., 2013) and ADHD – Rating Scale (ADHD-RS) (DuPaul et al., 1998), both measuring NDD characteristics in adults. The results of these questionnaires were then merged to an aggregated parental NDD-score. The Children’s Global Assessment Scale (C-GAS) (Shaffer et al., 1983) was used to assess the child’s global functioning. The researcher rated the C-GAS score, using all accessible information, including the child’s results from the Strengths and Difficulties Questionnaire (Goodman, 1997), the Autism-Tics, ADHD and other Comorbidities inventory (Hansson et al., 2005) and the Relationship Problem Questionnaire (Minnis et al., 2002). The specific results from these instruments are not reported in this publication. See below for further description of the study instruments.
SPSQ is based on the Parent Domain of Abindin’s Parenting Stress Index (Abidin, 1990a) and measures parenting stress on 34 items divided into five subareas: Incompetence, Role Restriction, Social Isolation, Spouse Relationship Problems and Health Problems. The subarea Incompetence focuses on feelings of incompetence in the parental role and difficulties of parenthood (e.g., “I find it more difficult than expected to be parent”). Role Restriction is about restriction by parental responsibilities (e.g., “My life is controlled by my child’s needs”). Social Isolation includes social contacts outside of the family (e.g., “I feel alone”). Spouse Relationship Problems deals with social experiences within the family (e.g., “I receive less support than expected from my spouse”). Health Problems describes the parents’ health such as physical fitness, infections, and fatigue (e.g., “I am more tired than before”). The SPSQ yields a total score (mean value of all items). We accepted 80% answer rate on each subscale. Due to an administrative error, two items were missed. The response options range from “strongly disagree” to “strongly agree” on a Likert scale scoring from 1 to 5 (Ostberg et al., 1997). No cut-off scores have been established for the SPSQ, but mean scores higher than 3.0 have been considered as indicative of problems (Johansson et al., 2017). The psychometric properties of SPSQ are good according to previous studies (Ostberg & Hagekull, 2000; Ostberg et al., 1997). Cronbach’s alpha was 0.89 for mothers, as well as for both mothers and fathers.
ASSERT is a self-report screening tool for autistic characteristics and consists of seven items on a three-point scale, with response options 0 = “not true”, 1 = “somewhat true” and 2 = “certainly true”. A modified scoring that has been found to improve the diagnostic odds ratio was used (Posserud et al., 2013), where the four social items were scored as 0-2-4, leading to a total score of maximum 22. ASSERT has been found to have good validity as a screening instrument (Posserud et al., 2013). Cronbach’s alpha was 0.75 for mothers, and 0.70 for both mothers and fathers. The total score on the ASSERT was used as an indication of autistic-like experiences. About 20% of mothers (M = 4.00, SD = 4.06, min-max = 0–14) and 8% of fathers (M = 3.24, SD = 2.54, min-max = 0–11) screened positive in this study.
ADHD-RS (DuPaul et al., 1998) was used as a self-report scale of 18 items reflecting the DSM-5 criteria for ADHD. It consists of 9 items on inattention and 9 items on hyperactivity/impulsiveness. The participant answered the items based on current experiences. The response options are “yes”, “no” and “don’t know”. Cronbach’s alpha was 0.89 for mothers, and 0.83 for both mothers and fathers. The total score of the ADHD-RS was used as a trait count. The mothers met on average 5.1 criteria (min-max = 0–20) and fathers met on average 3.3 criteria (min-max 0–14).
The aggregated parental NDD-score was obtained by combining the total trait count of the ASSERT and the ADHD-RS. This variable was created due to multicollinearity. The correlation between ASSERT and ADHD-RS was r = 0.548 for mothers, and r = 0.620 for fathers. No cut-off has been established, but in previous research, variables with a medium correlation has been investigated for multicollinearity (Donath et al, 2012).
The components were standardized prior to combing the scales. The ASSERT was scored as 0 = “not true” and 1 = “somewhat true” and “certainly true”. The ADHD-RS was scored as 0 = “no” or 1 = “yes”.
C-GAS was used to assess the child’s global functioning. Scores over 90 indicate superior functioning, whereas scores under 70 indicates impaired functioning (Shaffer et al., 1983).
Statistics
All analyses were conducted using IBM SPSS version 26. Chi square analyses were run for categorical variables. Due to small sample size and to reduce the impact of outliers, non-parametric tests were used (Mann-Whitney U Test for independent samples, Wilcoxon Signed Rank Test for related samples, Kruskal-Wallis one-way analysis of variance and the Spearman rank correlation). To examine whether parenting stress was associated with C-GAS and parental NDD traits, multiple linear regressions were conducted separately for mothers. The fathers were not entered in the regression models, since no associations were found between paternal parenting stress, paternal NDD traits, and C-GAS. Since the results from ADHD-RS and ASSERT correlated, and since characteristics of ADHD and ASD often covariates, a new variable was generated which aggregated the results of these scales and was used in the regression analysis. Analyses were repeated in two adjusted models that accounted for the impact contextual family variables: weighted income, help from social services, parental work status, and child variables: age and IQ. The unstandardized residuals were approximately normally distributed and the assumptions for linear regression were met.
Results
Domains of Parenting Stress and Differences Between Mothers and Fathers
When comparing mothers and fathers participating alone, we found that both mothers and fathers had a mean score above 3.0, which indicates high levels of parenting stress, in the area Incompetence, Role Restriction and Total scale. Mothers had, in addition, a mean score above 3.0 in the areas Spouse Relationship Problems and Health Problems. Highest levels of parenting stress were reported for both mothers and fathers regarding Role Restriction. Mothers had their lowest levels of parenting stress in the area Social Isolation, and fathers in the area Health Problems. We found no significant differences in any area when comparing mothers and fathers participating alone (Table 2a).
Table 2
a) Swedish Parental Stress Questionnaire (SPSQ) Mean, Standard Deviation and 95% Confidence Interval for Mothers and Fathers Participating Alone b) Swedish Parental Stress Questionnaire (SPSQ) Mean, Standard Deviation and 95% Confidence Interval for Mothers (n = 26) and Fathers (n = 26) Participating Together
a | |||||
|---|---|---|---|---|---|
SPSQ | na | M | SD | CI | p-value |
Incompetence | |||||
Mothers | 60 | 3.14 | 0.93 | 2.98–3.38 | 0.899 |
Fathers | 11 | 3.11 | 1.10 | 2.38–3.86 | |
Role Restriction | |||||
Mothers | 60 | 3.92 | 0.91 | 3.69–4.16 | 0.911 |
Fathers | 11 | 3.77 | 1.29 | 2.90–4.63 | |
Social Isolation | |||||
Mothers | 60 | 2.69 | 0.92 | 2.45–2.93 | 0.667 |
Fathers | 11 | 2.81 | 0.73 | 2.31–3.30 | |
Spouse relationship problems | |||||
Mothers | 59 | 3.15 | 1.14 | 2.85–3.44 | 0.427 |
Fathers | 10 | 2.86 | 0.94 | 2.19–3.53 | |
Health Problems | |||||
Mothers | 60 | 3.23 | 1.21 | 2.92–3.54 | 0.288 |
Fathers | 11 | 2.78 | 1.32 | 1.91–3.68 | |
Total scale | |||||
Mothers | 59 | 3.22 | 0.80 | 3.01–3.43 | 0.912 |
Fathers | 10 | 3.23 | 0.83 | 2.63–3.82 | |
b | ||||
|---|---|---|---|---|
SPSQ | M | SD | CI | p-value |
Incompetence | ||||
Mothers | 3.10 | 0.80 | 2.78–3.42 | 0.053 |
Fathers | 2.94 | 0.78 | 2.62–3.25 | |
Role Restriction | ||||
Mothers | 3.90 | 0.82 | 3.57–4.23 | 0.014** |
Fathers | 3.68 | 0.95 | 3.29–4.06 | |
Social Isolation | ||||
Mothers | 2.65 | 0.67 | 2.38–2.92 | 0.270 |
Fathers | 2.52 | 0.60 | 2.28–2.76 | |
Spouse relationship problems | ||||
Mothers | 2.43 | 0.74 | 2.13–2.74 | 0.239 |
Fathers | 2.32 | 0.80 | 2.00–2.64 | |
Health Problems | ||||
Mothers | 3.32 | 1.05 | 2.89–3.74 | 0.009** |
Fathers | 2.76 | 1.12 | 2.30–3.21 | |
Total scale | ||||
Mothers | 3.08 | 0.57 | 2.85–3.31 | 0.002** |
Fathers | 2.85 | 0.64 | 2.59–3.11 | |
We compared, in a small subgroup (n = 26, 26 mothers and 26 fathers), SPSQ scores of parents of the same child. Here, mothers reported a mean score above 3.0 in the following areas: Incompetence, Role Restriction, Health Problems and Total scale. The fathers reported a mean score above 3.0 in the area Role Restriction. Both mothers and fathers in this group reported their highest levels of parenting stress in the area Role Restriction, and their lowest in the area Spouse relationship problems. Compared to the fathers, mothers reported significantly higher levels of parenting stress in the areas of Role Restriction (Z = −2.456, p = 0.014), Health Problems (Z = −2.604, p = 0.009), as well as in the Total scale (Z = −3.137, p = 0.002) (Table 2b).
In the subgroup of parents of the same child, maternal and paternal levels of parenting stress were significantly and positively correlated in all subareas (Table 3).
Table 3
Correlations between Swedish Parental Stress Questionnaire (SPSQ) Score of Mothers and Fathers Participating Together (n = 26 couples)
Paternal parenting stress | ||||||
|---|---|---|---|---|---|---|
1. | 2. | 3. | 4. | 5. | 6. | |
Maternal parenting stress | ||||||
1. Incompetence | 0.887** | 0.682** | 0.411** | 0.196 | 0.548** | 0.786** |
2. Role Restriction | 0.674** | 0.866** | 0.448* | 0.198 | 0.570** | 0.758** |
3. Social Isolation | 0.207 | 0.202 | 0.676** | 0.244 | 0.412* | 0.459* |
4. Spouse relationship problems | 0.051 | −0.029 | 0.438* | 0.840** | 0.312 | 0.365 |
5. Health Problems | 0.478* | 0.356 | 0.522** | 0.079 | 0.644** | 0.574** |
6. Total scale | 0.760** | 0.671** | 0.659* | 0.376 | 0.722** | 0.886** |
Relationship Between Parental Stress and Characteristics of the Child
No significant differences in parenting stress were found between parents of girls or boys. We did not either find a difference in parental stress when we compared the diagnostic subgroups of the children (ADHD, ASD, and ADHD + ASD), by using Kruskal-Wallis one-way analysis of variance. However, we found a significant positive correlation between stress subarea Social Isolation and the child’s age (r = 0.228, p = 0.035) in mothers. This association was not found in the other subscales (for mothers r range between −0.004–0.125, for fathers r range between −0.152–0.188). Parental age did not correlate with any of the parenting stress subareas, nor with the total scale (for mothers r range between −0.149–0.065, for fathers r range between −0.037–0.168). Mothers with more than three children living with them experienced higher Social Isolation (mean difference = 0.41, Z = 2.175, p = 0.030). No other differences were found between number of children in either the group of mothers or the group of fathers.
The child’s psychosocial function measured with C-GAS was significantly negatively correlated with maternal parenting stress in all the SPSQ subareas except for Spouse relationship problems. No significant associations were found between child psychosocial function, although the association between child psychosocial function and paternal parenting stress subarea Social Isolation was close to significant (p = 0.05) (Table 4).
Table 4
Correlations between Swedish Parental Stress Questionnaire (SPSQ), Children’s Global Assessment Scale (C-GAS) and Parental NDD Traits
Incompetence | Role Restriction | Social Isolation | Spouse relationship problemsa | Health Problems | Total scalea | |
|---|---|---|---|---|---|---|
Mothers (n = 86) | ||||||
C-GAS | −0.272* | −0.283** | −0.271* | −0.010 | −0.356** | −0.323** |
ADHD-RS | 0.175 | 0.142 | 0.183 | 0.121 | 0.174 | 0.221* |
ASSERT | 0.076 | 0.152 | 0.175 | 0.269* | 0.169 | 0.211 |
Aggregated parental NDD-score | 0.152 | 0.169 | 0.218 | 0.184 | 0.188 | 0.241* |
Fathers (n = 37) | ||||||
C-GAS | −0.160 | −0.168 | −0.324+ | −0.020 | −0.089 | −0.143 |
ADHD-RS | −0.014 | 0.147 | −0.002 | −0.013 | 0.227 | 0.056 |
ASSERT | −0.048 | 0.143 | 0.055 | −0.110 | 0.070 | 0.028 |
Aggregated parental NDD-score | −0.072 | 0.131 | 0.028 | −0.016 | 0.214 | 0.062 |
Associations of Parenting Stress and Parental Traits of NDD
Maternal traits of ADHD were significantly associated with SPSQ total scale, and maternal ASD traits was significantly associated with the subarea Relationship problems. No significant associations were found between parental parenting stress and paternal traits of ADHD or ASD.
Regression Analysis of Parenting Stress, Child Psychosocial Functioning and Parental Traits
Regression analysis was performed to further analyze the relationship between parental stress, parental NDD traits and child psychosocial functioning (C-GAS score). Table 5 shows the unadjusted and adjusted analyses of the relationships between the total SPSQ scale, clinican-rated C-GAS and aggregated parental NDD traits in mothers. To control for possible confounding, contextual-family variables were included in the first adjusted model: weighted income, parental work status and contact with social services. In the second adjusted model, the child’s age and IQ score were also included.
Table 5
Regression Analysis of Maternal Parenting Stress, Child Psychosocial Functioning and Parental NDD Traits
Unadjusted model | Adjusted model 1a | Adjusted model 2b | |||||||
|---|---|---|---|---|---|---|---|---|---|
ß | 95% CI | p | ß | 95% CI | p | ß | 95% CI | p | |
C-GAS | −0.036 | −0.059–−0.013 | 0.003* | −0.033 | −0.056–−0.010 | 0.005* | −0.031 | −0.054–−0.008 | 0.009* |
Aggregated parental NDD-score | 0.034 | 0.007–0.061 | 0.013* | 0.032 | 0.003–0.060 | 0.030* | 0.032 | 0.003–0.062 | 0.033* |
In the unadjusted model maternal parenting stress was associated with both parental NDD traits and clinican-rated psychosocial functioning. The association remained robust after adjustment for confounders. No potential confounding variables was associated with parenting stress. In the second adjusted model, including both the contextual-family and the child covariates, the adjusted R2 was 0.18.
Discussion
In this study of stress related to parent characteristics in parents of children with NDD we found i) that both mothers and fathers reported their highest levels of parenting stress in the area Role Restriction, while their lowest levels were found in the areas of Spouse Relationship Problems (mothers and fathers participating together), Social Isolation (mothers participating alone) and Health Problems (fathers participating alone); ii) that when comparing within the same family mothers reported higher total stress than did fathers in the areas Role Restriction, Health Problems and Total scale; iii) no statistical differences in parenting stress between groups of parents of children with ADHD, ASD or ADHD + ASD and iv) that both parental NDD traits and child psychosocial functioning were associated with levels of maternal parenting stress, an association that remained significant in the adjusted model accounting for both family context factors and child factors.
The gender differences in experiences of parenting stress found in the group of parents participating together indicates that mothers and fathers face their own individual experiences when caring for their child. A possible explanation for our results may relate to the proportion of time that each parent spends caring for the child or at work. In this group, more fathers than mothers worked full-time, and it is possible that mother’s greater involvement in childcare leads to greater exposure to situations where challenging behavior occurs. Previous studies have also shown that mothers seem to be more sensitive to their children’s behavior than fathers (Calzada et al., 2004) and that mothers tend to be more engaged in the child’s health care (Renhorn et al., 2019). Mothers of children with ADHD have also been found to have lower parenting efficacy, lower self-esteem, and a greater tendency to attribute noncompliance on their child’s bad mood compared to fathers (Hoza et al., 2000). However, it is not clear that these role differences explain the findings in the current study. It is also important to note that maternal and paternal parenting stress was significantly and positively correlated. This pattern is also found in previous research about stress in parents of children with ASD (Rivard et al., 2014).
We found that mothers with older children experience more Social Isolation. The potential challenges of raising children may become more prominent as the child ages, affecting the parent’s experience of being isolated within the family. This finding might also indicate that time to diagnosis influence parental stress, as children who get their diagnosis later in life have spent more of their childhood without correct support. However, we found no other age-related effects on parenting stress, which is consistent with previous studies (Lecavalier et al., 2006; McStay et al., 2014).
No significant differences were found regarding parenting stress and whether the child had ADHD, ASD, or both diagnoses. This is consistent with Craig et al (Craig et al., 2016) that detected higher levels of parenting stress in both mothers and fathers of children with ADHD or ASD, compared to other groups of NDD, but not compared to each other. This result could demonstrate that it is not only the characteristics of NDD that induce child-rearing stressors, but also accompanying behaviors and the child’s functioning, and is in line with results from other researchers (Modesto-Lowe et al., 2008). However, it is important to also note that the result could be due to power.
We found significant associations between parenting stress and C-GAS in the group of mothers, and a close to significant association between C-GAS and experiences of Social Isolation in the group of fathers. These findings agree with most of the literature, as previous studies have found that child’s adaptive behavior and skills (Hall & Graff, 2011; Rivard et al., 2014) and intensity of NDD traits (Faden et al., 2023) are associated with both parental stress and psychosocial distress. This relationship between parenting stress and child’s functioning is likely bidirectional and the variables have been found to have a mutually escalating effect on each other over time. For both mothers and fathers, high parenting stress seems to contribute to an increase of child internalizing and externalizing behaviors, and simultaneously, an increase in child distressed behavior contribute to a worsening in parenting stress (Neece et al., 2012; Rodriguez et al., 2019). It seems that parents may be stressed by their child’s NDD traits and distressed behavior, which in turn, alters their parenting behavior in ways that increase the child’s level of support needs.
One of the most interesting findings from the present study was that not only child C-GAS was associated with parenting stress, but also maternal traits of NDD, even when controlled for contextual factors and child factors. This is similar to results of previous studies (Theule et al., 2011; Wiener et al., 2016), where maternal traits of ADHD were associated with higher levels of parenting stress. In families where both parents and children experience traits of NDD, significant parenting challenges have been documented. Parents with ADHD have been found to report difficulties in planning and carrying out organizational demands, difficulty in maintaining attention during supervision and procrastination in parenting tasks (Weiss et al., 2000). Comparably, mothers on the autism spectrum have reported more difficulties compared to nonautistic mothers with multi-tasking demands of parenting and domestic responsibilities, and are more likely to find parenthood isolating, to worry about others judging their parenting skills and feel unable to ask for support (Pohl et al., 2020). Parents with traits of NDD may also experience greater stress outside of the family, which might increase the negative effect on their parenting. Given that family, twin and adoption studies show that ADHD and ASD run in families (Faraone & Larsson, 2019; Lichtenstein et al., 2010), it is possible that these findings illustrate an underlying association, resulting in the appearance of an effect for child functioning, instead of parental traits, in explanation of parenting stress.
The fathers were not entered in the regression models, since no associations were found between paternal parenting stress, paternal NDD traits, and C-GAS. One explanation for this might be that because of too few fathers in the sample we did not have enough power to find an association.
Study Implications
These results of this study may have considerable implications for support of children with NDD. Mental health professions need to be alert on the links between parenting stress and parental NDD traits, as parents play a major role in most support for children with NDD, often serving as coaches or co-therapists, and parenting stress has been associated with reduced positive outcomes for behavioral interventions (Osborne et al., 2008). Parents who experience significant stress may believe that they do not have time to comply with necessary components of support: e.g., homework assignments or self-monitoring. Neither pharmacological or psychological support strategies will be fully effective if parenting stress limit attendance or compliance. The parents in this study reported relatively low levels of NDD traits and few met clinical cut-off, which indicates that parental NDD traits affect the experience of parenting even at subclinical levels. Therefore, support strategies may need to be modified or presented in ways that increase the likelihood of compliance and implementation, for example, offering health care visits outside of standard business hours or delivering the support in a customized way. This might optimize the efficacy of support and in turn, have a positive effect on parenting stress. Clinicians should also consider adding specific measures of parenting stress and parental NDD traits prior to implementing any support strategy and to address these issues as a part of a comprehensive support plan for children with NDD.
Strengths and Limitations
The cross-sectional design of this study limits any causal interpretation and prevents conclusions about the directionality of relationships. Although efforts were made to reduce informant effects by using clinician-rated C-GAS, parents reported both their own NDD traits and parenting stress, leading to the possibility that the associations may have been inflated. The aggregated NDD score has not been previously used or validated but was used because of multicollinearity and because ADHD and ASD often covariates (Gillberg, 2010). The sample was particularly small for the fathers, which may have resulted in inadequate power. The children’s wide age-range might also be a limitation given the developmental differences in the role of parents.
The strength in the study was the holistic approach combining different aspects of parenthood with NDD in both parents and children.
Conclusions
Parents of children with NDD carry a large caregiving load and the child’s psychosocial function is of greater importance for the parents’ levels of stress, compared to the child’s specific diagnosis. In mothers, parenting stress is also associated with parental NDD traits, and it is evident that the presence of NDD traits in parents, even at subclinical levels, influences the experience of parenting.
Supplementary information
The online version contains supplementary material available at https://doi.org/10.1007/s10826-025-03042-x.
Acknowledgements
The authors are grateful to all families for participating in the study, and to Ying Li for statistical advice.
Author Contributions
All authors contributed to study design and data interpretation. Data collection was performed by MD, MO, and EB. Data analysis were performed by MD, who wrote the first draft of the manuscript. All authors commented on the previous versions of the manuscript. All authors read and approved the final manuscript.
Compliance with Ethical Standards
Conflict of Interest
The authors declare no competing interests.
Ethical Approval
The study was approved by the Regional Ethical Review Board in Gothenburg and has been performed in accordance with the ethical standards of the 1964 Helsinki declaration and its later amendments.
Informed Consent
All participating parents gave written informed consent prior to participation, for themselves and for their child.
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