Journal of Intellectual Disability Research

874

doi: 10.1111/j.1365-2788.2006.00904.x

pp
Blackwell Publishing LtdOxford, UKJIRJournal of Intellectual Disability Research- The Authors. Journal compilation Blackwell Publishing Ltd12874882Original ArticleBehaviour

and emotional problemsS. Herring

et al.

Behaviour and emotional problems in toddlers with

pervasive developmental disorders and developmental
delay: associations with parental mental health and
family functioning
S. Herring,1 K. Gray,1 J. Taffe,1 B. Tonge,1 D. Sweeney1 & S. Einfeld2
1 Monash University, Centre for Developmental Psychiatry & Psychology, School of Psychology, Psychiatry & Psychological

Medicine, Clayton, Vic., Australia

2 University of New South Wales, Sydney, NSW, Australia

Abstract
Background Behavioural and emotional problems
occur at a high rate in children and adolescents with
intellectual disability, often from a young age. Some
studies have indicated that children and adolescents
with autism present with even higher rates. Less is
known about the presentation, development and
family impact of these difficulties in young children
with autism. This study aimed to explore these issues
in toddlers with pervasive developmental disorders
(PDDs), those with delay without a PDD, and their
families.
Methods Participants were children aged
months, referred to a developmental assessment
clinic. Parents completed a checklist on child behavioural and emotional problems, and individual questionnaires on family functioning, their own mental
health, and stress in relation to parenting their child.
The childs language and cognitive skills, adaptive
functioning and behaviour were assessed by stan-

Correspondence: Dr Kylie M. Gray, Centre for Developmental

Psychiatry & Psychology, Dept. of Child & Adolescent Psychiatry,
Monash Medical Centre, Clayton, Vic. , Australia (e-mail:
kylie.gray@med.monash.edu.au).

dardized measures. Measures were repeated year

postdiagnosis. Behavioural and emotional problems
in young children with a PDD were compared with
those in children with developmental delay without a
PDD, and their impact on parental outcomes
explored over time.
Results Initial and follow-up measures of child
behaviour and emotional problems, parent mental
health problems, parent stress and family functioning
were significantly correlated, providing some evidence of stability over time. Child emotional and
behavioural problems contributed significantly more
to mother stress, parent mental health problems, and
perceived family dysfunction than child diagnosis
(PDD/non-PDD), delay or gender. Compared with
mothers, all fathers reported significantly less stress
in relation to parenting their child.
Conclusion Results highlighted the importance of
addressing emotional and behavioural problems in
very young children with autism and/or developmental delay. The need for early support and intervention
for mothers, fathers and families in this context was
also evidenced. As research has shown that behavioural and emotional problems persist into adolescence and young adulthood, understanding of these
issues in very young children and their parents has

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S. Herring et al. Behaviour and emotional problems

important implications for intervention and longterm outcomes.

Keywords behaviour and emotional problems,
children, developmental delay, family, pervasive
developmental disorders

Introduction
Autism is a neurodevelopmental disorder characterized by severe qualitative impairments in reciprocal
social interaction, communication, and restricted,
repetitive behaviour, interests and activities (American Psychiatric Association ). Having a child
with autism has a significant impact upon parents,
particularly in terms of stress (Bristol & Schopler
; Sanders & Morgan ; Dunn et al. ),
mental health (DeMeyer ; Olsson & Hwang
; Yirmiya & Shaked ) and family functioning (Choutka ; Johnson & Hastings ).
Greater levels of distress are present in families of
children with autism than those of typical children
(Koegal et al. ; Fombonne et al. ; Mruzek
et al. ) or children with other disabilities (Holroyd & McArthur ; Sanders & Morgan ;
Fombonne et al. ). Mothers of children with
autism generally report greater distress than fathers
(Milgram & Atzil ; Wolf et al. ; Konstantareas et al. ; Gray ; Hastings ; Hastings
et al. ), although this finding is not universal
(Bebko et al. ; Konstantareas & Homatidis ;
Hastings et al. ). Child behaviour and parent
mental health are variables proposed to impact differentially on the stress of mothers and fathers of
children with autism (Hastings ; Hastings et al.
).
Research indicates that compared with children
and adolescents with intellectual disability (ID),
behaviour and emotional problems occur at particularly high rates in children and adolescents with
autism (Tonge & Einfeld ) and in preschool children with a pervasive developmental disorder (PDD)
(Gadow et al. ). It has been suggested that the
presence of behaviour and emotional problems contributes significantly to the stress of mothers of children with ID (Hastings ; Beck et al. ), and
to stress in parents of older children and adolescents
with autism (Donenberg & Baker ; Bromley et al.
; Tomanik et al. ; Lecavalier et al. ).

However, behaviour problems of young children with

autism have been found to predict maternal but not
paternal stress (Hastings et al. ).
In infants and toddlers with developmental delay
(excluding autism), behaviour and emotional problems have been shown to be present at early age
(Baker et al. ), persist over a -month period,
and contribute more to parent stress than the developmental delay itself (Baker et al. ). It has been
suggested that child behaviour problems and parenting stress are mutually escalating (Baker et al. ),
exacerbating each other over time (Lecavalier et al.
; Mruzek et al. ). Models that suggest a
reciprocal relationship between child behaviour
problems, parental stress and parenting behaviour,
mediated by parental negative emotional reactions
and moderated by their psychological resources
(Hastings ), are increasingly proposed. The central relationship between child behaviour problems
and stress has been supported by research in children
with developmental delay (Hastings ) and in
children with autism spectrum disorders (Lecavalier
et al. ), but has not been investigated in
toddlers.
Parental variables are also important in investigating the impact of autism (Wood Rivers & Stoneman
; Hastings et al. ). Current findings suggest
systemic variables such as partner mental health may
also play a role in parental distress, with partner
depression predicting parent stress in one study
(Hastings et al. ). Other findings suggest a differential impact, with partner mental health predictive of mother, but not father stress (Hastings ).
Appropriately controlled, larger sample studies are
required to clarify these findings and their application
to autism.

Contribution of the current study

Preliminary research highlights the important role of
child behaviour and emotional problems in contributing to parental distress in children and adolescents
with autism and ID. It also indicates significant differences in presentation and parental impact between
the diagnostic groups. However, less is known about
these phenomena in toddlers with autism and developmental delay. Differential impact of many of these
factors across development has also been suggested
(Bebko et al. ; Dumas et al. ), but little lon-

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S. Herring et al. Behaviour and emotional problems

gitudinal research has been conducted. Knowledge

regarding factors contributing to parental distress in
the families of very young children with autism is also
in the early stages. As few appropriately controlled
studies have yet to be conducted in this area, the
specificity of existing findings to families of children
with autism is uncertain.
To advance previous research and extend existing
findings, this study therefore aimed to examine
behaviour and emotional problems in toddlers with
developmental delay and/or autism, along with
parental mental health, stress and family functioning
for both mothers and fathers. Utilizing a prospective,
longitudinal design, progression of these factors over
the months postdiagnosis was examined.

Method
Participants
A total of children aged months were
referred to an assessment clinic with suspected developmental difficulties. Children and their parents were
allocated to a PDD [(Autistic Disorder, Pervasive
Developmental Disorder Not Otherwise Specified
(PDD-NOS)] or non-PDD group based on the
childs diagnosis at Time .

Measures
Diagnosis was made according to Diagnostic and
Statistical Manual of Mental Disorder (DSM)-IV
(American Psychiatric Association ) criteria,
based upon information gathered through administration of the Autism Diagnostic Interview Revised
(ADI-R; Lord et al. ) and the Autism Diagnostic
Observation Schedule (Lord et al. ). The clinicians (K.G. and D.S.) arrived at a consensus diagnosis, taking into account all information obtained
during the assessment. Developmental age was
assessed using the Psychoeducational Profile
Revised (Schopler et al. ). Adaptive behaviour
was assessed with the Vineland Adaptive Behaviour
Scales parent interview (Sparrow et al. ); adaptive behaviour level indicated with the derived Adaptive Behaviour Composite (ABC) standard score.
Language ability was assessed with the Reynell
Developmental Language Scales (Edwards et al.
).

Where possible, the Wechsler Preschool and Primary Scale of Intelligence (WPPSI-III; Wechsler
) was administered as a measure of general intellectual ability. Of the non-PDD group, one child
completed a WPPSI at Time ; at Time , full scale
IQs ranged from to . Of the PDD group,
children completed a WPPSI at Time , full scale IQs
ranging from to . Children were classified as
developmentally delayed if their developmental age
was or more months below their chronological age
or their WPPSI-III full scale IQ less than . Children
were classified as having delayed language if their
Reynell age-equivalent scores were or more months
below their chronological age. Child behavioural and
emotional problems were assessed using the Developmental Behaviour Checklist Primary Carer Version (DBC-P; Einfeld & Tonge ); level of
disturbance indicated by the mean total behaviour
problem score.
Parental mental health was evaluated with the item version of the General Health Questionnaire
(GHQ-; Goldberg & Williams ). The GHQ
total score provides an overall screening measure of
mental health problems. Family functioning was evaluated with the Family Assessment Device General
Functioning Scale (FAD; Epstein et al. ; Byles
et al. ). Parenting stress was measured with a
stress thermometer visual analogue scale. Parents
rated how stressed they felt in relation to parenting
their child on a -point Likert scale, ranging from
no stress to very very very stressed. All parent
questionnaires were self-report; increasing scores
indicated increasing distress.

Procedure
Data were collected as part of a larger prospective
community screening study for autism, involving
assessment at three time points: diagnosis, -month
postdiagnosis review and -month review. The current study utilized data from Times and . All
children were referred to the clinic by participating
paediatricians or the Department of Human Services
Specialist Childrens Services with suspected
autism and/or developmental delay. Families of children meeting selection criteria of less than years of
age with suspected developmental or language delay
were invited for a comprehensive assessment. The
first assessment session involved administration of the

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ADI-R parent/caregiver interview schedule. Parent

questionnaires were explained and provided to parents for completion. Parents were asked to complete
the DBC-P together, and their individual FAD,
GHQ and stress thermometer measures separately.
The second session comprised a comprehensive
assessment of the childs language and developmental
skills, adaptive functioning and behaviour and autistic symptomatology. Final diagnosis was made on the
basis of clinical judgement. The third session provided diagnostic feedback to the childs parents/caregivers, and discussion of appropriate intervention
options.
This procedure was repeated in a review assessment months postdiagnosis. All initial measures
were repeated without a review of the childs file or
initial report. Review questionnaires were posted to
parents/caregivers weeks prior to the review assessment for completion. Review assessments involved a
simultaneous parent interview and child assessment,
with diagnostic feedback and discussion of any interventions occurring immediately following or soon
after the assessment session.

Data analysis
Preliminary group comparisons were conducted in
Version .. for Windows (SPSS Inc. ),
comprising independent and paired samples t-test
and chi-square. Correlational and regression analyses
were conducted in Stata (StataCorp ). Pearsonss correlations were calculated for Time and
Time parent outcome variables and for Time and
Time child behaviour and emotional problems.
Longitudinal regression was used to model parental
outcomes as linear functions of the childs gender,
age, relative delay, behaviour problem score and diagnostic group (PDD, non-PDD). For the parental
stress outcomes, partner mental health was added to
the model. The ratio of developmental to chronological age was used to represent developmental age in
the regression analyses. Adaptive behaviour level was
not included in regressions due to a high correlation
with this ratio (r = .). The childs age was decomposed into average age across Times and (reflecting age at entry to the study) and deviation from this
average at Times and (reflecting ageing during the
study). In light of multiple comparisons, a P-value of
<. was considered significant.

Results
Seventy-nine mothers and fathers in the PDD
group, and mothers and fathers in the nonPDD group completed parent questionnaires at Time
. At Time , six families declined or were unable to
continue to participate in the study; children
(.%) remained, with mothers and fathers
participating. Time parental response rate was
therefore .% of original sample. Seventy-one of
the children had a diagnosis of autistic disorder and
of PDD-NOS. Other descriptive data for the sample at Times and are presented in Table .
Independent sample t-tests revealed the PDD
group had significantly lower developmental ages,
t() = ., P < ., and recorded significantly
lower adaptive behaviour levels, t() = .,
P < ., than the non-PDD group at Time . Chisquare analyses with Yates correction for continuity
indicated a significantly larger proportion of the PDD
group were developmentally delayed, 2(,
n = ) = ., P < .. There were no significant
differences between the two groups in terms of chronological age, gender distribution or language delay
at Time .
In terms of behaviour and emotional problems,
there were no differences between the PDD and nonPDD groups at Time , nor was there any significant
change over time for either group. However, at Time
, the PDD group had higher mean total behaviour
problem score than the non-PDD group,
t() = ., P < ..
Group differences on parental measures were
investigated with independent sample t-tests. Mean
scores on parent measures are presented in Table .
There were no significant differences between PDD
and non-PDD groups on parent variables of stress,
mental health or reported family dysfunction at Time
. At Time , fathers in the PDD group reported
significantly more stress than those in the non-PDD
group, t() = ., P < .. At Time , mothers
reported significantly more stress than fathers in both
the PDD and non-PDD groups, t() = ., P < .;
t() = ., P < .. At Time , mothers again
reported more stress than fathers for both groups,
t() = ., P < .; t() = ., P < ..
The relationship between the Time and Time
outcome variables was also explored with Pearsons
correlations. Results are presented in Table . All

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S. Herring et al. Behaviour and emotional problems

Table 1 Descriptive data means, standard deviations, frequencies for PDD and non-PDD samples at Time and Time

Sample
PDD (n = 84)

Chronological age (months)

Developmental age (months)
Vineland Adaptive Behaviour Composite
Mean DBC-P total behaviour problem score

Non-PDD (n = 39)

Time 1

Time 2

Time 1

Time 2

37.75 (7.07)
21.42* (8.27)
61.78* (13.13)
0.55 (0.27)

50.19 (6.96)
26.34 (11.41)
58.68 (12.80)
0.58* (0.27)

38.25 (7.73)
29.29* (9.17)
73.95* (12.06)
0.50 (0.32)

49.66 (7.50)
35.25 (9.65)
72.64 (14.71)
0.43* (0.28)

PDD

Male
Developmental delay
Language delay

Non-PDD

Frequency

Percentage

Frequency

Percentage

75
75
81

89.3
89.3*
96.4

29
25
36

74.4
64.1*
92.3

Mean (SD).
*P < ..
DBC-P, Developmental Behaviour Checklist Primary Carer Version; PDD, pervasive developmental disorder.

Table 2 Means and standard deviations for parent outcome variables at Times and for PDD and non-PDD samples

Time 1
Parent outcome variable

PDD

Mother stress thermometer

Mother GHQ total
Mother FAD total
Father stress thermometer
Father GHQ total
Father FAD total

2.22
53.00
1.93
1.58
47.25
1.84

(0.99)
(11.22)
(0.46)
(0.95)
(10.25)
(0.35)

Time 2
Non-PDD

PDD

Non-PDD

2.13
49.61
1.88
1.33
46.15
1.77

2.13 (0.96)
51.10 (12.39)
1.99 (0.54)
1.71* (0.98)
48.84 (11.73)
1.95 (0.47)

1.74 (0.96)
47.94 (11.55)
1.86 (0.47)
1.06* (0.93)
44.28 (8.20)
1.77 (0.42)

(0.93)
(10.47)
(0.50)
(0.85)
(9.67)
(0.48)

Mean (SD).
*P < ..
FAD, Family Assessment Device General Functioning Scale; GHQ, General Health Questionnaire; PDD, pervasive developmental disorder.

Time and Time parent outcome variables were

significantly positively correlated, as were Time
and Time child behaviour and emotional
problems.
Relationships between parental outcomes, partner
mental health and child variables were explored with
longitudinal regression analyses. Regression results

are summarized in Table . Paternal stress was the

only parental outcome not significantly positively
associated with child emotional and behavioural
problems. Partner mental health did not contribute
significantly to either maternal or paternal stress.
None of the outcomes was associated with child age
at entry to the study, ageing during the study, diag-

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S. Herring et al. Behaviour and emotional problems

nostic group (PDD, non-PDD), gender, nor relative

developmental delay.

Discussion
The results of this study indicated that behaviour
and emotional problems have a significant impact on
parent outcome, with the exception of father stress.
Overall, fathers consistently reported less stress than
mothers, regardless of whether their child had a
PDD or not. However, fathers of children with a
PDD were significantly more stressed than other

Table 3 Correlations between Time (T) and Time (T) parent

outcome variables and child behaviour and emotional problems

Outcome variable

T1T2
correlation

Mother stress thermometer

Mother GHQ total
Mother FAD total
Father stress thermometer
Father GHQ total
Father FAD total
Child DBC-P mean total problem behaviours

0.41***
0.58***
0.53***
0.52***
0.59***
0.39**
0.75***

*P < ., **P < ., ***P < ..

DBC-P, Developmental Behaviour Checklist Primary Carer
Version; FAD, Family Assessment Device General Functioning
Scale; GHQ, General Health Questionnaire.

fathers at Time . Measures over time of child

behaviour and emotional problems, parent and family distress were significantly positively correlated.
Moderate to strong correlations suggested a tendency for those who scored high on these measures
at Time to continue to do so at Time . Despite
non-significant changes over time in behaviour problems for both groups, at Time , the PDD group
had significantly more behaviour and emotional
problems than those with developmental delay without a PDD. No parental outcome was associated
with the childs diagnosis, nor with degree of developmental delay.
The significant contribution of emotional and
behavioural problems to maternal stress and parental
mental health problems is consistent with current
findings with older children with PDDs (Tonge &
Einfeld ; Hastings ; Lecavalier et al. )
and young children with developmental delay without autism (Baker et al. ). The greater degree of
emotional and behavioural problems experienced by
children with a PDD at Time is also consistent with
research with older children and adolescents (Tonge
& Einfeld ). Longitudinal studies of individuals
with a PDD have indicated stability in these problems during middle to late childhood (Lecavalier
et al. ), with some decrease in emotional and
behavioural disturbance as they move to adolescence
(Tonge & Einfeld ). The current findings
expand what we know to an earlier developmental
period. The fact that group differences in behaviour

Table 4 Unstandardized coefficients for regressions of maternal and paternal outcome variables on child variables

Stress

GHQ

FAD

Child variables

Mother

Father

Mother

Father

Mother

Father

Female gender
Age at entry
Ageing during study
Developmental to chronological age ratio
DBC-P mean TBPS
PDD
Partner GHQ
(Constant)

0.26
0.02
0.02
0.05
1.27*
0.08
0.01
1.94*

0.34
0.02
0.01
0.37
0.28
0.16
0.01
0.09

1.02
0.29
0.21
2.79
10.11*
1.96
_
58.39*

3.62
0.03
0.02
6.20
8.46*
0.58
_
45.61*

0.07
0.00
0.00
0.05
0.48*
0.08
_
1.70*

0.08
0.01
0.01
0.13
0.36*
0.09
_
1.35*

*P < ..
DBC-P, Developmental Behaviour Checklist Primary Carer Version; FAD, Family Assessment Device General Functioning Scale; GHQ,
General Health Questionnaire; PDD, pervasive developmental disorder; TBPS, total behaviour problem score.

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S. Herring et al. Behaviour and emotional problems

and emotional problems were significant only at

Time suggests that consistently reported differences in older children become more apparent over
time.
Partner mental health problems were not a significant contributor to mother or father stress. This contrasts with previous findings with smaller, autismspecific samples (Hastings et al. ). Across a
larger sample of children with broader developmental
difficulties, child behaviour and emotional problems
appear to be a more important factor.

Study strengths and limitations

Methodological strengths of the current study
included the sample age range of months,
extending current knowledge in this area to younger
children. The prospective, longitudinal design incorporated reassessments at months post diagnosis,
providing needed insight into the progression of
behaviour and emotional problems, parent distress,
and their relationship over time. Finally, children
with developmental delay without autism were
included as controls, allowing PDD-specific conclusions and clarification of previous findings. In terms
of limitations, the collapse of separate PDD types
(autism and PDD-NOS) into a single group may
reduce the diagnostic specificity of the findings
(Lecavalier et al. ). However, there were only
children in the PDD group with a diagnosis of PDDNOS rather than Autistic Disorder, and little difference in psychiatric comorbidity across PDD types in
young children has been found (Gadow et al. ).
A further limitation was the size of the non-PDD
sample; despite the fact that consecutive referrals
were included, the final sample comprised more children with a PDD than without. Finally, parental
emotional states may have influenced their perceptions of their childs emotional and behavioural problems, although such an effect is probably modified by
the fact of the parents completing this measure
together. Parental distress measures were completed
in conjunction with measures of their childs problems. This potential confound could have been
avoided through the use of an independent report,
such as a teacher or child worker; however, young
children are often not in educational or intervention
programmes when first assessed, making this
difficult.

Conclusion
Results from this study highlight the importance of
addressing emotional and behavioural problems in
very young children with autism and/or developmental delay. Such behaviours should be a target for early
intervention, and existing evidence supports intervention for behaviour problems (e.g. Gavidia-Payne
& Hudson ; Hudson et al. ). Reduction of
child behaviour problems has the potential to ameliorate parental stress, mental health problems and
family dysfunction. As studies have shown that
behavioural and emotional problems in autism and
persist into adolescence and young adulthood (Tonge
& Einfeld ), understanding of these issues in
very young children and their parents has important
implications for intervention and long-term outcomes. An emphasis on providing early intervention
for behaviour and emotional problems, along with
additional support, education and skills training for
parents, is justified.

Acknowledgements
This research was funded by the National Health and
Medical Research Council and the Australian
Research Council, Australia. The authors would like
to thank Erin Mooney for her assistance in data collection, and participating children and their families
for their support.

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Accepted July

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