The severity of disruptive behaviors is significantly more predictive of maternal stress, child outcomes, and overall family quality of life than the primary diagnosis. Although sensory-based behaviors co-occur with autism spectrum disorders (ASDs), the dichotomy between sensory dysfunction behaviors related to ASD and their effect on the mother-child relationship remains poorly articulated and underexplored in the literature (Ben-Sasson, Soto, Martinez-Pedraza, & Carter, 2013). Understanding the influence of sensory processing and integration disorders for individuals with and without autism is underexplored in the literature. Consequently, research outcomes cannot validly be applied to clinical populations (Nieto, López, & Gandía, 2017; Pfeiffer, May-Benson, & Bodison, 2018).
High levels of maternal stress strain the mother-child relationship, whereas strong maternal-child cohesion serves as a protective factor, even predicting enhanced benefit from clinical interventions (Osburne, McHugh, Saunders, & Reed, 2008). Parenting stress reduces the effectiveness of early teaching interventions for ASDs.
Understanding how sensory processing and integration disorders relate to maternal stress and mother-child interactions has important implications for effective child interventions that can reduce maternal stress (Ausderau, Sideris, Little, Furlong, Bulluck, & Baranek, 2016; DeGrace, 2004). Caring for children with sensory features of ASD and related disorders has consistently been shown to contribute to increased levels of parental stress (Allen & Knott, 2016; Dellapiazza, Vernhet, Blanc, Miot, Schmidt, & Baghdadli, 2018; Gourley, Wind, Henninger, & Chinitz, 2013; Kirby, White, & Baranek, 2015; Nieto et al., 2017). Parents of children with ASD report higher levels of parental stress and the need for extensive adaptive parenting strategies compared with parents of children with developmental disabilities (Harrop, Tu, Landa, Kasier, & Kasari, 2018). Although these studies included covariate contributions of the child's cognition and the mother's education, the contribution of sensory features independent of any other primary diagnosis remains unknown. Although sensory-based difficulties are identified in more than 95% of children with ASD (Tomchek & Dunn, 2007) and disruptive behaviors associated with ASD predict maternal stress (Whitney & Smith, 2015; Williams, Kirby, Watson, Sideris, Bulluck, & Baranek, 2018), consideration of sensory processing disorder (SPD) independent of ASD is underexplored in the literature.
The goal of this study was to analyze the correlation between maternal stress and mother-child relationships for mothers raising a child with SPD (without ASD) compared with ASD. The Parenting Stress Index Short Form (PSI/SF) was used to operationalize the outcome variables of total maternal stress (TS), quality of the mother-child relationship (P-CDI), and difficult child (DC). Although SPD is not a recognized diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, parents reported this term as the diagnosis given to their child by a professional.
Subjects were recruited through the Interactive Autism Network and Sensory Street as part of a larger study (Whitney & Smith, 2015). This study compared two groups of mothers, those who reported that their child had been diagnosed by a professional as having autism (ASD group; n = 52) as their only diagnosis and those whose child had the single diagnosis of SPD (SPD group; n = 18). Children who were reported to have more than one diagnosis (i.e., ASD and SPD or ASD and attention deficit hyperactivity disorder) were excluded from the study population. For each group, three dependent variables of interest were examined with the PSI: total maternal stress (TS), quality of the mother-child relationship (P-CDI), and difficult child (DC) (Abidin, 1995) (Table 1).
Mothers were asked to indicate any diagnosis that their child had received from a health care professional through a short demographic survey. Outcome variables of maternal stress level and mother-child relationship were measured with the PSI/SF, which is a clinical and research self-report instrument that has high reliability and validity (Cronbach's α ≥ 0.90) for identifying parent-child relationships under stress (Abidin, 1995). The PSI is one of the most commonly used tools to identify parental stress levels. The PSI/SF is one of the few assessments to provide a quantified representation of the difficult child (DC) domain score. The combined total maternal stress (TS) score measures the personal experience of stress associated with a child's behavioral characteristics as well as the stress associated with the role of mother. The parental distress (PD) and parent-child dysfunctional interaction scores operationalize stress that is uniquely and specifically identified to occur within the occupational role of parent. Participants respond to the 36 questions with a 5-point Likert scale, with higher reported scores indicating greater levels of stress (Abidin, 1995). Scores at or above the 85th percentile on the PSI/SF are considered clinically significant (Table 2).
Parenting Stress Index
Bivariate relationships between the child's diagnosis and maternal stress or the mother-child relationship were analyzed by conducting one-tailed t tests, two-tailed t tests, and simple regressions (analysis of variance). Correlation coefficients were computed for five maternal demographic characteristics (age, income, partnership status, education, and ethnicity).
Mean age of the mothers in this study was 31 to 50 years, and annual household income was $60,000 or greater. The sample was primarily White (86.5%). Most children in this sample were boys (71.6%) and 3 to 12 years (83.8%).
Total maternal stress for this population was within the clinically significant range (N = 69, M = 96.17, SD = 20.27). Quality of mother-child interactions (P-CDI) was low (N = 69, M = 32.93, SD = 8.32). Consistent with previous literature, there was a strong correlation between level of disruptive child behaviors (M = 26.05, SD = 8.37) and mother-child interaction (M = 37.26, SD = 8.74, Pearson's r = 0.596; p < .001).
Analysis of variance was conducted to evaluate the relationship between diagnosis (ASD, SPD) and maternal stress and quality of mother-child interactions. Although mothers who reported having a child with the diagnosis of SPD had slightly lower levels of maternal stress (TS), quality of mother-child interactions (P-CDI), and disruptive behaviors (DC) than parents who reported a diagnosis of ASD, importantly, the difference was not statistically significant (F[2,72] = 0.867, p = .425).
Consistent with previous literature, this study found clinically significant total maternal stress (M ≥ 85) for mothers of children with ASD. Importantly, the findings showed that mothers who reported that their child had a diagnosis of SPD without ASD experienced stress similar to that of mothers of children with ASD. The finding of high levels of maternal stress for mothers raising children with ASD is well documented, suggesting ongoing maternal needs across the child's developmental trajectory (McStay, Trembath, & Dissanayake, 2014). The findings of this study suggest that the effect on maternal stress that has been attributed to disruptive behaviors may be viewed more accurately as challenges of sensory processing and integration. These results suggest that challenges with sensory integration and processing can be disruptive to day-to-day family routines, even when deficits of communication and social interactions (primary characteristics of children with ASD) are not part of the child's diagnostic constellation.
Understanding the effect that sensory-based behaviors have on maternal stress and mother-child relationships is important when creating client-centered interventions. Overlooking this effect limits the ability to accurately measure the effect of challenges with sensory integration and processing and the potential for evidence-based interventions guided by the theoretical postulates of Ayre's sensory integration approach (Pfeiffer et al., 2018). Occupational therapy practitioners use their knowledge of how individuals interact with and are influenced by the environment as they engage with meaningful and purposeful occupations (American Occupational Therapy Association [AOTA], 2014). Maternal stress, the mother-child relationship, and the child's own sensory system can create a self-referential system that promotes or impedes occupational engagement. Analysis of a child's occupation includes assessment of the child's developmental assets and challenges. Performance patterns are viewed in context, acknowledging the barriers and supports available to the child, and “performance skills, performance patterns, context or environment, client factors and activity demands are all considered” (AOTA, 2014, p. S10). Recognizing the effect of sensory-based disruptive behaviors is critical to targeting meaningful outcomes for the child, the parent, and the family system.
Although the mothers included in this study reported that the diagnosis of SPD was given by a health care practitioner, SPD is not an established diagnosis, and for this reason, the results should be viewed with caution. Future studies are needed to confirm the diagnoses of ASD and SPD and further document the nature of the disruptive behaviors displayed by children to provide a better understanding of the factors that influence maternal and family health. Still, the findings of this study suggest that understanding the effect of maladaptive sensory processing on disruptive behaviors, maternal stress, and mother-child interaction is important in the overall treatment of disruptive behaviors in children.
Recognizing that sensory features (in both children with ASD and children who are otherwise typically developing) may be driving high maternal stress has important implications for occupational therapists. These results suggest a covariance between sensory processing difficulties, disruptive behaviors, and maternal well-being, with important implications for clinical practice. Although there is strong evidence that the Ayres Sensory Integration intervention results in positive outcomes for children with ASD (Schaaf, Dumont, Arbesman, & May-Benson, 2018; Schoen et al., 2019), these treatment strategies are not always made available to children who do not have autism but do have challenges with sensory integration and processing. This study adds to the growing body of literature suggesting that children can have challenges of sensory integration and processing without ASD and that, when present, a child's attempt to self-regulate can be maladaptive, add stress to the mother-child relationship, and affect overall occupational participation. This study suggests that disruptive behaviors may be viewed as a maladaptive attempt to self-regulate challenges of sensory processing and integration. Recognizing the interdependent nature of sensory processing, sensory integration, and disruptive behaviors is critical to achieving optimal treatment goals and predictable outcomes.
Maternal stress and the relationship between mother and child are related to a child's difficulty with sensory processing and integration. The level of stress on the mother is comparable to her maternal stress and reduced quality of life resulting from having a child with autism. This research has important implications for intervention in pediatric populations. Providing ways to reduce sensory-based behaviors can improve maternal health and promote better health trajectories for children with challenges of sensory processing and integration.
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|Maternal stress||Indicates overall parental distress irrespective of other occupational roles or life events. Parents who obtain a total stress score of the 90th percentile are experiencing stress at clinically significant levels. Operationalized by total maternal stress (PSI/SF; P-TS).|
|Quality of mother-child interactions||Relates to the perception that the child does not meet the parent's expectations and the interactions between the mother and child do not positively reinforce maternal-child attachment. This score was used operationally to measure the quality of the mother-child relationship in this study. Operationalized by parent-child dysfunctional interaction (PSI/SF; P-CDI).|
|Disruptive behaviors||Spotlights the behavioral characteristics that make the child hard to parent and difficult to manage. Defiance, noncompliance, and demandingness are factors within this subscale. Poor self-regulation, poor social relating skills, temperament or mood instability, and impulsivity can all result in difficult child behavioral characteristics. High scores activate urgency to discern whether the parent is coping well but compensatory strategies are taxed by a child who has exceptionally nonengaging behaviors. This score was used operationally to measure the level of socially disruptive behaviors in this study. Operationalized by difficult child (PSI/SF; P-DC).|
Parenting Stress Index
|Subscales from the Parenting Stress Index||Total stress||N||M||SD||SE||%|
|Total maternal stress (TS)||Total||69||96.17||20.27||1.89||93a|
|Parent-child dysfunctional interaction (P-CDI)||Total||69||37.26||8.74||0.81||99+a|
|Difficult child (DC)||Total||69||26.05||8.37||0.79||55|