http://informahealthcare.com/dre ISSN 0963-8288 print/ISSN 1464-5165 online Disabil Rehabil, 2015; 37(4): 345–354 ! 2015 Informa UK Ltd. DOI: 10.3109/09638288.2014.919361

RESEARCH PAPER

Psychosocial functioning in children with neurodevelopmental disorders and externalizing behavior problems Rubab G. Arim1,2, Dafna E. Kohen1,3, Rochelle E. Garner1, Lucyna M. Lach4, Jamie C. Brehaut2,3, Michael J. MacKenzie5, and Peter L. Rosenbaum6 1

Health Analysis Division, Statistics Canada, Ottawa, Ontario, Canada, 2Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada, 3Department of Epidemiology and Community Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada, 4School of Social Work, McGill University, Montreal, Quebec, Canada, 5School of Social Work, Columbia University, New York, NY, USA, and 6 Department of Paediatrics, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada Abstract

Keywords

Purpose: This study examines psychosocial functioning in children with neurodevelopmental disorders (NDDs) and/or externalizing behavior problems (EBPs) as compared to children with neither condition. Methods: The longitudinal sample, drawn from the Canadian National Longitudinal Survey of Children and Youth, included children who were 6 to 9 years old in Cycle 1 who were followed-up biennially in Cycles 2 and 3 (N ¼ 3476). The associations between NDDs and/or EBPs, child and family socio-demographic characteristics and parenting behaviors (consistency and ineffective parenting), were examined across several measures of child psychosocial functioning: peer relationships, general self-esteem, prosocial behavior and anxiety-emotional problems. Results: Children with NDDs, EBPs, and both NDDs and EBPs selfreported lower scores on general self-esteem. Children with NDDs and both NDDs and EBPs reported lower scores on peer relationships and prosocial behavior. Lastly, children with both NDDs and EBPs self-reported higher scores on anxiety-emotional behaviors. After considering family socio-demographic characteristics and parenting behaviors, these differences remained statistically significant only for children with both NDDs and EBPs. Child age and gender, household income and parenting behaviors were important in explaining these associations. Conclusions: Psychosocial functioning differs for children with NDDs and/or EBPs. Children with both NDDs and EBPs appear to report poorer psychosocial functioning compared to their peers with neither condition. However, it is important to consider the context of socio-demographic characteristics, parenting behaviors and their interactions to understand differences in children’s psychosocial functioning.

Behavior problems, Canada, child disabilities, neurodevelopmental disorders, psychosocial aspects History Received 15 August 2013 Revised 19 February 2014 Accepted 25 April 2014 Published online 19 May 2014

ä Implication for Rehabilitation: 





Practitioners may wish to consider complexity in child health by examining a comprehensive set of determinants of psychosocial outcomes as well as comorbid conditions, such as neurodevelopmental disorders (NDDs) and externalizing behavior problems (EBPs). Other health care professionals working with children with NDDs and/or EBPs may wish to consider several child characteristics together, not just the child’s health conditions but also child sex and age. Developing specific intervention programs that improve the psychosocial functioning of children with complex health problems appears to be warranted.

Introduction Children’s psychological development and their interaction with the social environment comprise their psychosocial functioning, an area that has received much attention in the literature [1–3]. Researchers have focused on different aspects of psychosocial

Address for correspondence: Rubab G. Arim, PhD, Health Analysis Division, Statistics Canada, R.H. Coats Building, 100 Tunney’s Pasture Driveway, Ottawa, ON K1A 0T6, Canada. Tel: (613) 951-0194. Fax: (613) 951-3959. E-mail: [email protected]

functioning, including emotional health, self-esteem, social competence, peer relationships and externalizing behavior problems [4–7]. While psychosocial functioning encompasses a wide range of behaviors, poor psychosocial functioning has adverse consequences for children’s development in various areas, including cognition, motor, language development and mental health [8–10]. Arguably, positive psychosocial functioning is more challenging for children with disabilities than for their healthy peers, given that the former group has special needs in various developmental areas [11]. In this regard, children with

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neurodevelopmental disorders (NDDs) are a particularly interesting group because of the likely impact of their health condition on developmental areas important for psychosocial functioning [12,13], including ambulation, information-processing, self-regulation and communication [14]. In addition, children with NDDs are at a greater risk of having emotional and behavioral problems [15]. Thus, it is important to consider not only children’s NDDs alone but also the complexity of their health, and whether or not they have comorbid health problems. Unfortunately, relatively little is known about psychosocial functioning in children with NDDs and/or behavior problems over time, in particular, after considering the influence of their family environment. Compared to healthy peers, children with disabilities have been shown to have poorer psychosocial functioning. For example, in an epidemiological sample from Australia, approximately 41% of children between 4 and 18 years with a cognitive disability were found to have severe emotional and behavioral disorders [16]. Other studies have found that children with a disability (e.g. autism spectrum disorders (ASDs), intellectual disability) are vulnerable to anxiety and depression [17–21]. Psychosocial problems related to interaction with peers and feelings of loneliness have also been described for children with a disability as compared to their typically developing peers. For example, youth with ASD and with elevated levels of anxiety reported greater feelings of social loneliness [22] than those with low levels of anxiety. Bauminger and colleagues [23] found that children with ASD report greater loneliness than their peers and a lack of understanding of the relationship between social interaction and loneliness. Similarly, Mazurek and Kanne [20] found that children with severe ASD reported poor number and quality of peer relationships than those without severe ASD. In line with these results, Kasari and colleagues [24] also showed that children with a disability reported poor quality friendships than typically developing children in the same classroom, and Solish and colleagues [25] found that children in the latter group had more friends and participated in social activities significantly more than children with disabilities. Another aspect of psychosocial functioning that has been studied in children with disabilities is self-concept. For example, several researchers found that the presence of a child disability (e.g. spina bifida, physical disability, ASD) was associated with a lower sense of worth [26,27] and poorer self-concept (perception of characteristics of oneself) [28]. However, other researchers have not found a difference in self-concept, for example, in comparing children with visual impairment and those without [29]. In fact, these researchers found that children with visual impairment reported higher scores on physical maturity, selfesteem and school adaptiveness than children with normal sight. Children with disabilities are vulnerable not only to concurrent psychosocial problems, such as anxiety, depression, loneliness and poor peer interactions, but also to downstream psychosocial problems over time. For example, Bagwell and colleagues [30] showed that children with attention deficit and hyperactivity disorder (ADHD) who had other behavior or social problems were more likely to have anxiety and depressive disorders in adolescence than children without ADHD. Bagwell and colleagues [31] also found that children with ADHD faced peer rejection that often continued into adolescence. From a life course perspective, it is well-established that psychosocial functioning in childhood is related to outcomes throughout the life span, including adult mental health, general physical health and social relationships. Findings from several longitudinal studies indicate that psychosocial and behavioral problems in childhood are associated with a wide range of negative outcomes in adulthood, such as mental health problems, substance abuse, crime and problems in partner relationships,

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even after controlling for the effects of socio-demographic characteristics that are known to be associated with behavioral and mental health problems [2,32,33]. For example, Reef and colleagues [32] found that children’s various behavior problems predicted disruptive disorders, such as antisocial personality disorder and substance abuse, as well as emotional problems, such as anxiety and mood disorders in adulthood. Fewer studies have focused on positive adult outcomes given the presence of positive outcomes in childhood. For example, using a birth cohort in UK, Richards and Huppert [34] found that ‘‘positive children’’ (those who were rated as popular, happy, energetic, make friends easily, and had less conduct and emotional problems) were more likely to report satisfaction with work, have regular contact with friends and family, engage in social activities, and be less likely to have a mental health problem in their adulthood compared to children who were not identified as ‘‘positive children’’. In a review of longitudinal studies, Fryers and Brugha [35] examined childhood determinants of adult mental illness and found support for the longitudinal link between childhood behavior problems, psychological disturbance and parenting with adult mental-ill health. Taken together, these findings suggest that healthy psychosocial functioning in childhood is associated with positive psychosocial functioning in adulthood. Predictors of psychosocial functioning in children have also been widely examined, with a particular focus on the child’s family environment as a primary level of influence [36–39]. For example, children who experienced persistent family economic hardship were more likely to have behavior problems, difficulties in peer relationships and low self-esteem compared to those who did not [40]. Parenting has also been shown to be a key influence in child psychosocial functioning [41]. For example, Kagan [42] indicates that children of parents who display ineffective parenting behaviors (e.g. neglect or intrusiveness) tend to be aggressive with their peers. Parents may affect their children’s psychosocial functioning in many ways [42,43]. Research has shown that perceived parental support predicted higher global self-worth and social competence, and fewer externalizing behavior problems in children [44], whereas harsh parenting was associated with difficulties in emotion regulation skills, and both higher internalizing and externalizing behavior problems. Our previous research has shown that parents of children with both NDDs and externalizing behaviour problems (EBPs) reported less consistency and more ineffective parenting behaviors as compared to parents of children with neither health conditions, even after controlling for child, parent and family socio-demographic characteristics [45], as well as other factors including family and social context [46]. In contrast, although parents of children with NDDs reported less positive interactions with their child compared to parents of children with neither NDDs nor EBPs, this difference disappeared after controlling for socio-demographic characteristics, parental health and social context factors, such as family functioning and social support [46]. A similar pattern was observed for ineffective parenting behaviors such that parents of children with NDDs reported less ineffective parenting behaviors when they received help from community or social service professionals [46]. These findings suggest that parenting behaviors may differ as a function of child health, which, in turn, may have a differential influence in predicting children’s psychosocial functioning. In addition, it is important to consider sociodemographic characteristics and social context variables, such as family functioning and community support to understand how these factors play a major role, given differences in child health. Taken together, results from the literature highlight the importance of considering child and family socio-demographic characteristics, as well as parenting behaviors, in addition to child

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health conditions when examining variations in children’s psychosocial functioning. While the above-reviewed research shows associations between child disability and poorer psychosocial functioning in various domains, most of the studies have not accounted for socio-demographic factors, such as family socio-economic status and child’s age and gender. In one study that did account for these factors [47], the results demonstrated few links between children with chronic conditions and risks for poor psychosocial functioning (i.e. prosocial behavior) as compared to children without chronic conditions, suggesting that differences might be due to socio-demographic conditions rather than child health per se. There is a shortfall in the literature examining the association between psychosocial functioning in childhood and later wellbeing. Even fewer studies have examined this association for children with health problems and disabilities. Little is known about the psychosocial functioning of children with disabilities and the factors that play a major role in their well-being. Given the additional challenges that children with disabilities often face, such as emotional and behavioral problems [20,48] compared with typically developing children, they may be at a greater risk for poorer psychosocial functioning. Thus, the purpose of this study was to fill this gap in the literature by examining the psychosocial functioning of children with disabilities as compared to children who do not have a disability, and examine a host of associated family context factors, including socioeconomic status and parenting behaviors. Two research questions were addressed in this study. First, do children with NDDs and/or EBPs have poorer psychosocial functioning as compared to children with neither health conditions and, if so, in which domains? Second, are family sociodemographic characteristics and parenting behaviors associated with differences in children’s psychosocial functioning two years later? We anticipated that the largest differences in psychosocial functioning, or poorest outcomes, would exist for children with both NDDs and EBPs, followed by those who have NDDs alone and EBPs alone. However, due to differences in sociodemographic characteristics and parenting behaviors reported previously [45,46,48], we expected that some differences would be accounted for by socio-demographic factors and parenting behaviors. Based on previous findings, it is anticipated that low socioeconomic status and in greater ineffective parenting may partially explain the relationship between child health conditions (NDDs and EBPs) and poor psychosocial functioning.

Methods Data source The National Longitudinal Survey of Children and Youth (NLSCY) is a longitudinal study designed to collect information about Canadian children’s development and well-being from birth to early adulthood. The survey, conducted by Statistics Canada and sponsored by Human Resources and Skills Development Canada (HRSDC), began in 1994–1995 (Cycle 1) with follow-up surveys administered biennially up until 2008–2009 (Cycle 8). The target population of the NLSCY in Cycle 1 was children who were newborn to 11 years old, with children sampled from all areas of the country proportionate to the regional population. The sample excluded children living in institutional settings and residents of the Yukon, Nunavut, Northwest Territories and First Nations reserves (approximately 1% of Canadian children). In total, 13 439 households were interviewed in Cycle 1, with a total of 22 831 children participating in the survey [49]. More detailed information about the NLSCY sample design can be found in the user guide [49]. Computer-assisted interviewing (CAI) technology was used for data collection in the household,

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which included information about the person most knowledgeable (PMK) about the child, the spouse/partner of the PMK (if applicable) and the child. The PMK was the biological mother for 90% of participant children. For the purpose of this study, the PMK will be referred to hereafter as the parent. Prior to Cycle 2, budgeting constraints led to a reduction of the sample eligible for longitudinal follow-up (from 22 831 to 16 903 children). For example, of the households retained, up to two children rather than four were surveyed in Cycle 2. Of the sample eligible for follow-up, these children had a response rate of 91.5% in Cycle 2 and 88.7% in Cycle 3 [49]. Sample The sample for this study included children who were 6 to 9 years old in Cycle 1 (n ¼ 4855) and were followed-up biennially in Cycles 2 and 3. Of these children, 107 (2.20%) were missing information in Cycle 1 used to identify the presence of NDDs or EBPs, and were therefore excluded from the sample. Of the remaining 4748 children aged 6 to 9 years in Cycle 1, approximately 73% (n ¼ 3476) were retained in Cycle 3. To assess the impact of sample attrition, comparisons were conducted between children retained in the sample and those lost to follow-up. Children excluded from the sample due to loss of follow-up were more likely to live in low-income households and less likely to experience ineffective parenting as reported by their parents, compared to children included in the study sample. There were no other statistically significant differences between the two groups, including child gender, age, general health, chronic conditions consistent with NDDs, functional limitations and EBPs (results available upon request). Measures: Child health (Cycle 1, 1994–1996) Neurodevelopmental disorders were identified using two indicators: (a) a checklist of chronic conditions diagnosed by a health professional, and (b) information from the Health Utilities Index (HUI) [50], which classifies children’s overall functional health in eight domains. The checklist included four parent-reported health professional-diagnosed chronic conditions consistent with NDDs: epilepsy, cerebral palsy, intellectual disability (i.e. mental handicap item on the survey) and learning disability. Using the checklist, 111 children were identified as having a NDD in Cycle 1. Scores on four HUI domains were used to identify children’s functional impairment that may have been due to a NDD. Based on previous research [48], the following cut-points were used: a score 3 for the speech and mobility domains, a score 2 for the dexterity domain, and a score 4 for the cognition domain. There were 257 children identified with a NDD using the HUI in Cycle 1. It should be noted that 50 children were identified as having a NDD by both indicators. Thus, in total, 318 (9.15%) children were identified with a NDD in Cycle 1 using one of these two methods. Externalizing behaviour problems were identified using a parent-reported child behavior rating scale, with items derived from the Child Behaviour Checklist (CBCL) [51] but modified for Canadian children [52,53]. Specifically, three EBP scales were used: hyperactivity-inattention (eight items, Cronbach’s alpha ¼ 0.85 [54]; e.g. ‘‘How often would you say that [child] can’t sit still, is restless or hyperactive?’’), physical aggression-conduct disorder (six items, Cronbach’s alpha ¼ 0.78; e.g. ‘‘How often would you say that [child] gets into many fights?’’), and indirect aggression (five items, Cronbach’s alpha ¼ 0.79; e.g. ‘‘How often would you say that [child] when mad at someone, tries to get others to dislike that person?’’). Each item was scored on a 3-point scale ranging from 0 (never or not true) to 2 (often or very true) and summed across items, with higher scores indicating the presence of behavior problems. Consistent with our previous work

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[45,46,48], children were considered to exhibit an EBP if their scores on any of these scales were two standard deviations above the mean or greater. Using these criteria, 455 (13.09%) children were identified with EBPs in Cycle 1. The final classification of children’s health included four groups: (a) children who had a NDD only (NDD; n ¼ 206), (b) children who had an EBP only (EBP; n ¼ 343), (c) children with both a NDD and an EBP (BOTH; n ¼ 112), and (d) children who had neither a NDD nor an EBP (NEITHER; n ¼ 2815). The stability of the child health group membership was examined by calculating the proportion of children who were classified under the same category for the NDD (checklist-identified children only since HUI was not available in Cycle 2; n ¼ 111) and EBP groupings (n ¼ 485) from Cycle 1 to Cycle 2. It should be noted that we could not examine stability from Cycle 2 to Cycle 3 because of the lack of information on both HUI and parentreported EBP scales (i.e. parents did not report on EBPs for children who were older than 11). The findings indicated relatively moderate to high stability, with 96.35% of children with a checklist-identified NDD and 84.52% of children with an EBP being classified in the same categories in Cycle 2 as they were in Cycle 1. Based on these findings, the child health groupings appear stable, and analyses should not be significantly affected by changes in child health status between cycles. Measures: Covariate variables (Cycle 1, 1994–1996) Two other child characteristics were included in the analysis: child’s age and sex. In addition, four variables representing the socio-demographic characteristics of the children’s families were examined: (1) parental age, (2) the number of parents in the home (single versus dual parent households), (3) parent’s educational attainment (ranging from less than high school to college or university degree), and (4) household income. The household income measure was based on parents’ estimates of their household income, which was then compared to the low income cut-off (LICO) score established by Statistics Canada. The LICO represents an income level at which a family will likely spend a greater portion of its income on the basic necessities (i.e. food, clothing and shelter) than does an average family of similar size [55]. Living in low income is defined by an income-to-LICO ratio of less than 1. In this study, we defined moderate income as a household income-to-LICO ratio equal to or greater than 1 but less than 2, and high income as an income-to-LICO ratio equal to or greater than 2. Measures: Parenting behaviors (Cycle 2, 1996–1998) Two parenting behavior scales were included in the analysis: (1) consistency (five items, e.g. ‘‘When you give [your child] a command or order to do something, what proportion of the time do you make sure that [your child] does it?’’; Cronbach’s alpha ¼ 0.66), and (2) ineffective parenting (seven items, e.g. ‘‘How often do you feel you are having problems managing [your child] in general?’’; Cronbach’s alpha ¼ 0.70). The items had been adapted from the Parent Practices Scale developed by Strayhorn and Weidman [56]. Each item was scored on a 5-point scale ranging from 0 (never) to 4 (all the time), with higher sum scores indicating the use of more consistency (or more ineffective) parenting behaviors, as reported by the parent. More information about the psychometric properties of these parenting scales can be found in the NLSCY user guide [49]. Measures: Child psychosocial outcome variables (Cycle 3, 1998– 2000) All outcome variables were drawn from Cycle 3 (1998–1999) and were self-reported by the children when they were 10 to 13 years

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old. Information about the psychometric properties of these child psychosocial outcomes can be found in the NLSCY user guide [49]. Peer relationships. Four items (e.g. ‘‘I have a lot of friends’’; Cronbach’s alpha ¼ 0.77) were used to assess how well the child got along with friends. These items were part of the Peer Relations scale of the Self Description Questionnaire (SDQ) developed by Marsh [57]. Each item was scored on a 5-point scale ranging from 0 (false) to 4 (true). Summing across items, the scale ranges from 0 to 16, with higher scores indicating more friends and more positive relations with friends. General self-esteem. Four items (e.g. ‘‘In general, I like the way I am’’; Cronbach’s alpha ¼ 0.79) were used to assess the child’s overall self-esteem. These items were part of the General-Self scale of the SDQ [57]. Each item was scored on a 5-point scale ranging from 0 (false) to 4 (true). Summing across items, the scale ranges from 0 to 16, with higher scores indicating a more positive general self-esteem image. Prosocial behavior. Ten items (e.g. ‘‘I try to help someone who has been hurt’’; Cronbach’s alpha ¼ 0.82) were used to assess the child’s prosocial behavior. These items were derived from the CBCL [51] but modified for Canadian children [52,53]. Each item was scored on a 3-point scale ranging from 0 (never or not true) to 2 (often or very true). Summing across items, the scale ranges from 0 to 20, with higher scores indicating the presence of more prosocial behavior. Anxiety-emotional problems. Eight items (e.g. ‘‘I am unhappy or sad’’; Cronbach’s alpha ¼ 0.78) were used to assess the child’s anxiety and emotional problems. These items were also derived from the CBCL [51] but modified for Canadian children [52,53]. Each item was scored on a 3-point scale ranging from 0 (never or not true) to 2 (often or very true). Summing across items, the scale ranges from 0 to 16, with higher scores indicating the presence of more anxious or emotional symptoms or behaviors. Data analysis First, descriptive statistics for each variable were presented for the overall sample as well as by each child health grouping (NDD, EBP, BOTH, NEITHER). Next, pair-wise comparisons (chisquare or t-tests) were conducted to examine between-group differences, with the reference being the NEITHER group. Finally, multiple regression analyses were conducted to examine the longitudinal associations between child health, parenting behaviors and child psychosocial outcomes after accounting for the effects of other child, parent and family characteristics. Four years of data (Cycles 1–3) were used in these analyses to examine relationships over time. All covariate variables were drawn from Cycle 1 because, as the baseline cycle of the survey, Cycle 1 had the most complete data, including the measures to identify children with NDDs. Parenting behaviors were drawn from Cycle 2, which allowed us to use parent-reported parenting behaviors in our analyses (in Cycle 3, these were reported by the child). Finally, all child psychosocial outcomes were drawn from Cycle 3, which allowed us to use child-reported psychosocial outcomes, and thus limiting shared method variance. Specifically, three models were examined in multiple regression analyses. Model 1 (Covariate Model) included child health groupings and parentreported socio-demographic characteristics to examine solely the associations between the covariate variables and child psychosocial outcomes. Model 2 (Full Model) included parent-reported parenting behaviors in addition to those variables included in

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Model 1. In Model 2, we examined the longitudinal associations between parenting behaviors and child psychosocial outcomes after accounting for the effects of covariate variables. A third model was fit, which examined possible interactions between parenting behaviors and child health groupings or the child’s sex, because in our previous research [45,46] we showed that parenting behaviors may differ as a function of child health and sex. When such interactions were found to be statistically significant, they are reported as Model 3 (Interactions Model). In such cases, the main effects are not discussed in the presence of statistically significant interaction effects [58]. All analyses were weighted and bootstrapped to account for complex survey design [59], and were conducted using SAS and SAS-callable SUDAAN.

Results Descriptive statistics Table 1 describes the univariate analyses of the sociodemographic covariates (Cycle 1; when children were aged 6 to 9), parenting behaviors (Cycle 2; when children were aged 8 to 11), and children’s psychosocial outcome variables (Cycle 3; when children were aged 10 to 13) for the overall sample and by child health grouping. Regarding socio-demographic covariates, as we have shown previously [45,46], children in the NDD group were statistically significantly older and less likely to live in high-income households relative to children in the NEITHER group. Children in the EBP group were more likely to live in a single-parent household, have a parent who was younger and who had lower educational attainment relative to those in the NEITHER group. Finally, children in the BOTH group were more likely to be boys, were more likely to live in single-parent households, were less likely to live in high income households and had younger than average parents, compared to those in the NEITHER group. Regarding parenting behaviors when children were aged 8–11, parents of children in the EBP and BOTH groups reported significantly less consistency compared to parents of children in the NEITHER group. In addition, parents of children with NDDs

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and/or EBPs reported more ineffective parenting than parents of children in the NEITHER group. Regarding children’s outcomes when children were aged 10–13, children in the NDD and BOTH groups (but not in the EBP group) reported significantly lower scores on peer relationships and prosocial behavior than children in the NEITHER group. In addition, children with NDDs and/or EBPs reported significantly lower scores on general self-esteem than children in the NEITHER group. Finally, only children in the BOTH group reported significantly higher scores on anxiety-emotional problems compared to children in the NEITHER group. The associations between the two parenting behaviors and children’s psychosocial outcomes were examined using Pearson’s correlation coefficients. The results indicated that consistency was not statistically significantly associated with any of the children’s psychosocial outcomes (r50.05 for all children’s psychosocial outcomes), whereas ineffective parenting had a small but significant association with all children’s psychosocial outcomes in the expected direction; namely, lower scores on psychosocial functioning outcomes were associated with higher ineffective parenting behavior scores (r50.15 for all children’s psychosocial outcomes). Regression analyses A summary of results from the multiple regression analyses examining children’s psychosocial outcomes is presented in Table 2. Peer relationships According to Model 1, having a NDD alone or with an EBP (i.e. BOTH) was associated with lower scores on peer relationships. In addition, being older, female or living in a high income household (compared to moderate income) were associated with higher scores on peer relationships. The inclusion of parenting behaviors in the model (Model 2) showed that higher ineffective parenting scores were associated with lower scores on peer relationships, but that consistent parenting had no significant

Table 1. Descriptive statistics of covariates, parenting behaviors and child psychosocial outcome variables.

Variables Parent-reported covariates (Cycle 1) Child age, M (SE) Child is female, % Parent age, M (SE) Single-parent household, % Parent’s highest educational attainment Less than high school, % High school graduated, % Some post-secondary education, % College or university degree, % Household income Low income, % Moderate income, % High income, % Parent-reported parenting behaviours (Cycle 2) Consistency, M (SE), range ¼ 0–20 Ineffective parenting, M (SE), range ¼ 0–25 Child-reported child psychosocial outcomes (Cycle 3) Peer relationships score, M (SE), range ¼ 0–16 General self-esteem score, M (SE), range ¼ 0–16 Prosocial behavior, M (SE), range ¼ 0–20 Anxiety-emotional problems, M (SE), range ¼ 0–16 a

OVERALL n ¼ 3476

NEITHER n ¼ 2815

NDD n ¼ 206

EBP n ¼ 343

BOTH n ¼ 112

7.57 (0.01) 48.5 36.06 (0.15) 14.7

7.55 (0.02) 50.4 36.23 (0.17) 12.8

7.86 (0.10)a 44.1 35.89 (0.48) 14.7b

7.48 (0.08) 43.1 35.25 (0.41)a 23.4a

7.77 (0.13) 29.1a,b 34.87 (0.62)a 31.1a,b

15.2 20.2 29.9 34.7

14.3 20.4 29.3 36.1

13.8b 20.0b 35.6 30.7

21.8a 17.3 31.4 29.4

19.9b 23.4b 29.8b 26.9b

20.3 40.0 39.7

19.3 39.2 41.5

18.4b 50.2a 31.4a

25.9 38.5 35.6

29.6E 45.2 25.2a,b

15.12 (0.09) 9.01 (0.11)

15.24 (0.11) 8.46 (0.12)

15.45 (0.28) 9.31 (0.39)a

14.31 (0.27)a 11.90 (0.39)a

14.18 (0.41)a 12.33 (0.46)a

13.02 13.14 13.41 3.87

13.15 13.26 13.57 3.74

12.54 12.67 12.52 4.12

12.71 12.76 13.18 4.18

11.68 12.39 11.61 5.68

(0.07) (0.08) (0.10) (0.08)

(0.08) (0.09) (0.11) (0.08)

(0.28)a (0.27)a (0.47)a (0.28)

(0.23) (0.24)a (0.33) (0.28)

(0.41)a (0.37)a (0.51)a (0.33)a

Indicates a statistically significant difference (p50.05) from the NEITHER group. Indicates high coefficients of variation in the range of 16.6 to 33.3% for the estimates, which suggests marginal quality for the estimates because of potentially high levels of error associated with the estimates.

b

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Table 2. Summary of results from the multiple regression analyses predicting child psychosocial outcome variables.

Variables

Peer relationships (n ¼ 3320)

General self-esteem (n ¼ 3345)

Model 1 Model 2

Model 1

a

Intercept 12.63 Child health grouping NEITHER ref. NDD 0.60a EBP 0.37 BOTH 1.27a Parent-reported covariates (Cycle 1) Child age (centered at 7.5) 0.19a Child is girl 0.69a Parent age (centered at 36) 0.01 Parent is single parent 0.22 Parent’s educational attainment Less than high school 0.36 High school graduated ref. Some post-secondary education 0.25 College or university degree 0.01 Household income Low income 0.47 Moderate income ref. High income 0.41a Parent-reported parenting behaviours (Cycle 2) Consistency (centered at 15) Ineffective parenting (centered at 9) Interaction terms Consistency  NDD Consistency  EBP Consistency  BOTH Consistency  GIRL R2 for the model 0.05

a

Model 2

12.61

a

13.02

12.98

ref. 0.54 0.18 1.05a

ref. 0.41 0.51a 0.68

0.20a 0.67a 0.02 0.22

a

Prosocial behavior (n ¼ 3002)

Anxiety-emotional problems (n ¼ 2996)

Model 1 Model 2 Model 3 Model 1 a

a

a

a

Model 2

Model 3

a

3.50a

12.72

12.69

12.66

3.49

3.52

ref. 0.37 0.27 0.41

ref. 0.66 0.30 1.39a

ref. 0.63 0.08 1.14a

ref. 0.52 0.15 1.37a

ref. 0.44 0.38 1.83a

ref. 0.39 0.16 1.60a

ref. 0.37 0.19 1.61a

0.42a 0.03 0.01 0.36

0.42a 0.03 0.01 0.37

0.60a 1.92a 0.00 0.35

0.59a 1.93a 0.00 0.37

0.60a 1.93a 0.00 0.35

0.07 0.52a 0.01 0.55a

0.08 0.54a 0.01 0.55a

0.09 0.55a 0.01 0.55a

0.33 ref. 0.26 0.03

0.38 ref. 0.13 0.08

0.38 ref. 0.11 0.09

0.49 ref. 0.07 0.13

0.48 ref. 0.10 0.14

0.49 ref. 0.07 0.11

0.10 ref. 0.10 0.19

0.16 ref. 0.12 0.15

0.19 ref. 0.11 0.16

0.50 ref. 0.41a

0.05 ref. 0.54a

0.04 ref. 0.53a

0.00 ref. 0.03

0.03 ref. 0.03

0.01 ref. 0.03

0.14 ref. 0.36a

0.17 ref. 0.36a

0.15 ref. 0.37a

0.04 0.05

0.09a 0.05

0.05a 0.07a

0.11a 0.07a

0.02 0.06a

0.03 0.06a

0.29a 0.14 0.35a 0.06

0.05

0.06

0.10

0.11

0.11

0.04

0.05

0.11a 0.05

a

Statistical significance of the coefficient; p50.05.

association with the peer relationships. Furthermore, children in the NDD group were no longer significantly different from children in the NEITHER group in terms of peer relationships. All other factors that were significantly associated with peer relationships in Model 1 remained significant after controlling for the effects of parenting behaviors. None of the interaction terms was found to be statistically significant. General self-esteem After controlling for the socio-demographic covariates (Model 1), children in the NDD and BOTH groups no longer differed from children in the NEITHER group in terms of their general selfesteem scores, which were seen descriptively in Table 1. Children with an EBP only continued to have significantly lower scores on general self-esteem than children in the NEITHER group. In addition, younger children and those living in high income households (compared to moderate income) had higher scores on self-esteem than others. Model 2 indicated that higher ineffective parenting behaviors were associated with lower scores on general self-esteem: consistent parenting was not associated with children’s general self-esteem. After taking into account parenting behaviors, children in the EBP group no longer differed in their general self-esteem scores from children in the NEITHER group. None of the interaction terms was found to be statistically significant for general self-esteem. Prosocial behavior Model 1 findings indicate that having BOTH conditions was associated with lower scores on prosocial behavior than other children. In addition, being older and male were associated with lower scores on prosocial behavior. The inclusion of the

parent-reported covariates in Model 1 eliminated the difference in prosocial behavior scores between children in the NDD and NEITHER groups, which were seen descriptively in Table 1. In Model 2, neither parenting behavior scale was significantly associated with prosocial behavior; all other significant associations from Model 1 remained significant in Model 2. There was, however, a significant interaction between parental consistency and child health grouping (Model 3). As shown in Figure 1, while higher consistency scores were associated with higher prosocial behavior scores for children in the EBP and NEITHER groups, higher consistency scores were related to lower prosocial behavior scores for children in the NDD and BOTH groups. Further examination of this interaction effect indicated that, in all child health groups, the majority of consistency scores were between 10 and 17; few reported below 10 (less than 3% of sample). Therefore, predicted values and associations at low consistency levels are primarily extrapolations, and not based on a large sample size. However, when we examined the predicted marginals from the regression model (as depicted in Figure 1), the findings confirmed that the prosocial scores were indistinguishable from one another at the lower end of consistency scores. Only at higher consistency scores, the prosocial behavior scores were significantly lower for children in the BOTH and NDD groups, as compared to children in the NEITHER group. Children in the EBP group had prosocial behavior scores similar to those of children in the NEITHER group at all levels of parental consistency. Anxiety-emotional problems Model 1 indicates that having BOTH conditions was associated with higher scores on anxiety-emotional problems. In addition,

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351

17

Figure 1. Interaction between consistency and child health group in model of prosocial behavior.

BOTH

EBP

NDD

NEITHER

Predicted Marginals of Prosocial Behaviour

16

15

14

13 *

*

12

*

*

*

*

*

* *

11

* *

10 0

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

17

18

19

20

Consistency

4.5

Figure 2. Interaction between consistency and child’s sex in model of anxiety-emotional problems. Predicted Marginals of Anxiety-Emotional Problems

4

3.5

3

2.5

2 *

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

1.5 boys

girls

1 0

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

Consistency

being a girl and living with a single parent were also associated with higher scores on anxiety-emotional problems, whereas living in a high income household (compared to moderate income) was associated with lower anxiety-emotional problem scores. These differences remained significant after adding the parenting behaviors to the model (Model 2). In addition, higher scores on both consistency and ineffective parenting were found to predict higher anxiety-emotional scores. There was one significant interaction term (Model 3) between parental consistency and the child’s sex. Although girls scored higher on anxiety-emotional problems than boys, parental consistency behaviors had no significant association with anxiety-emotional problems among girls (Figure 2). Conversely, higher consistency scores were related to higher anxiety-emotional scores for boys. In other words, at low levels of parental consistency, boys

had significantly lower anxiety-emotional problems scores than girls. But as consistent parenting scores increase, boys’ reports of anxiety-emotional problems become more like those of girls. At consistency scores of 17 or higher, boys and girls have statistically similar anxiety-emotional problem scores (Figure 2). Two things should be noted here, however. First, as with the model for prosocial behavior, only a small proportion of the sample reported parental consistency scores below 10 (less than 3% of sample). Therefore, the lines in Figure 2 for boys and girls at low consistency levels are primarily extrapolations, and not based on a large sample size. Second, the average anxiety-emotional problems scores are low on the scale (possible range of 0 to 16). Therefore, while differences may be statistically significant, their practical and clinical importance may be low.

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Discussion This study examined differences in the psychosocial functioning of children with NDDs and/or EBPs compared to children with neither health condition, and if so, whether family sociodemographic characteristics and parenting behaviors were associated with these differences. Before controlling for family socio-demographic characteristics and parenting behaviors, children in the NDD, EBP and BOTH groups reported poorer psychosocial functioning as compared to children in the NEITHER group. As anticipated, children in the BOTH group reported the poorest psychosocial outcomes, followed by children in the NDD (for all but anxiety-emotional problems), and EBP (only general self-esteem) groups. These findings are consistent with the literature that suggests that children with health problems tend to have poorer psychosocial functioning as compared to their healthy peers. However, an important consideration in this study was the child’s family environment. We examined whether differences in psychosocial functioning remained after controlling for family socio-demographic characteristics and parenting behaviors. The results indicated that psychosocial functioning of children in the NDD as well as in the EBP group was no longer significantly different than psychosocial functioning of children in the NEITHER group for peer relationships, general self-esteem and prosocial behavior outcomes. The effects of child age and gender, household income, and consistency and ineffective parenting behaviors were important in accounting for these differences. However, for children in the BOTH group, differences in poorer psychosocial functioning compared to children in the NEITHER group remained even after considering the effects of family sociodemographic characteristics and parenting behaviors, except for general self-esteem. These findings highlight that, for children with a NDD or with an EBP alone, differences in psychosocial outcomes were largely attributable to socio-demographic characteristics and parenting behaviors. But for children with both conditions, differences persisted even after accounting for these factors, suggesting that different mechanisms of influence play a major role for children in the BOTH group or perhaps observed differences are very large and therefore could not be fully accounted for even after considering various socio-demographic characteristics and parenting behaviors. Two interaction effects emerged for parental consistency behaviors. The first interaction effect suggests that higher consistency is associated with higher prosocial behavior for children in the EBP and NEITHER group, a pattern we would expect based on research by others [60–62]. However, this interaction also showed that higher consistency was associated with less prosocial behavior for children in the NDD and BOTH group suggesting that parental consistency behaviors as assessed in the present study were exerting a different influence on children with NDDs (both with and without EBPs) or that these children were eliciting different patterns of parenting from their parents. The second interaction effect suggested that parental consistency behaviors had a differential impact on anxiety-emotional problems for boys and girls. Parental consistency did not seem to matter for anxiety-emotional problems for girls but higher consistency was associated with higher anxiety-emotional problems for boys. These results are in line with previous research that suggests that parental consistency behaviors had a greater impact for boys’ than for girls [63]. On the other hand, the directionality of these findings might be the opposite, and parenting behaviors might be different as a consequence of the children’s behavioral styles in previous cycles. However, we should note that the measure of parenting behaviors in this study preceded the

Disabil Rehabil, 2015; 37(4): 345–354

measures of children’s outcomes. Research has also shown that lack of parental consistency may lead to continuing anxietyemotional problems in children [64]. One possible explanation for our contradictory finding is that boys perceived their parents’ consistency behaviors differently, for example, as more inhibiting and not as more structured, and thus continued to report higher anxiety-emotional problems. In fact, previous research with the NLSCY indicated a low-to-moderate correlation between children’s and their parents’ reports on parenting behaviors [65]. Contemporary models in developmental psychopathology emphasize the need to focus on two concepts, namely, multifinality and equifinality to understand the effects of contributors to adaptive or maladaptive outcomes [66]. Wood and colleagues [67] discuss the importance of focusing on these concepts to better understand the effects of particular parenting behaviors on childhood behavioral outcomes. Thus, in the context of the present study, multifinality suggests that higher parental consistency may be associated with a variety of positive and negative outcomes, including prosocial behavior and anxiety-emotional problems, depending on the context and child characteristics. Equifinality suggests that there are multiple pathways to child outcomes, such as prosocial behavior and anxiety-emotional problems – pathways not considered here – and therefore higher parental consistency in the absence of the inclusion of these factors important for the process cannot alone account for these outcomes. For example, in the presence of high parenting stress or parental depression, parental consistency may involve high negative discipline (e.g. consistent angry responses to child inappropriate behaviors), which may lead to potentially negative outcomes in children. However, in the absence of poor parental mental health, consistent parenting may lead to positive outcomes. It may also be possible that the interaction effects for the association between high consistency and low prosocial behavior are due to the differences in parenting children with or without EBPs as we have shown in our previous research [45,46]. Another possibility is that children with NDDs with or without EBPs interpret parental consistency differently as compared to children with only EBPs or with neither health conditions, leading to differences in behavioral outcomes. In a similar vein, for the positive association between consistency and anxiety-emotional problems for boys, it is possible that the findings reflect potential differences in parental consistency behaviors for girls versus boys [68]. Although we did not find differences in parental consistency between boys and girls, our analyses do not rule out the possibility that there are differences in how girls and boys interpret and respond to parental consistency. It is also possible that parental consistency is motivated differently for parents of boys and girls and therefore, taps into slightly different parenting behavioral and cognitive frames. Finally, it is also possible that other factors, such as parental health or family functioning, may play a major role, as previous research with the NLSCY suggested that parents of children with both NDDs and EBPs experienced a greater number of health and psychosocial problems [46,48]. These findings highlight the need for future research to identify additional factors and specify the pathways that may link parental consistency and children’s behavior problems particularly for children with NDDs. Our results showed that the link between consistency and prosocial behaviors differs as a function of child’s health conditions. Similarly, the link between consistency and anxietyemotional problems may differ as a function of child’s sex. Overall, these findings highlight the importance of considering complexity in child health (i.e. whether children with NDD have comorbid EBP) and also children’s family socio-demographic characteristics and parenting behaviors, as all these contribute to poor psychosocial functioning. Clinical implications of these

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findings may include developing intervention programs that improve the psychosocial functioning of children with complex health problems. In particular, focusing on peer relationships, prosocial behavior, general self-esteem and anxiety-emotional problems as a basis for positive psychosocial functioning may be especially beneficial for children with health problems (see a review of psychosocial interventions for children with chronic health problems by Bauman and colleagues [69]). Several limitations of this study should be acknowledged. The classification of child health was limited to the health conditions and behaviors that were reported by the parents. In particular, the identification of children’s EBPs was based on a parent-reported non-clinical scale of behavior problems. In addition, we were not able fully to assess the stability of child’s health grouping over time because of the lack of data on child health in subsequent cycles. Children’s psychosocial outcome measures were selfreported and were also based on non-clinical assessments. Finally, there was no additional information to enable a further understanding of parent–child relationships. To do so, measures such as Parent–Child Relationship Inventory (PCRI) [70], DomainSpecific Parental Behavioural Control Scale (DSBCS) [71] or qualitative data based on parent–child interactions would be useful. It should also be acknowledged that the study used data collected over 10 years ago. However, we would not expect the reported associations to change over time even though we acknowledge the potential changes in services, diagnoses and other family socio-demographic characteristics, including an increase in the prevalence of behavior problems. Despite these limitations, this study has major strengths. First, using data from a large-scale population-based study we examined longitudinal relationships among child health, family socio-demographic characteristics, parenting and child psychosocial functioning at three time points before and after considering various child and family factors. Second, we used a non-categorical approach to define children with health problems and we were able to have a comparison group (children in the NEITHER group) that places the findings in context. Third, we were able to address shared method variance issue because we used both parent-reported predictors and childreported outcome measures. Fourth, we were also able to examine a wide range of psychosocial outcomes and a wide range of covariates. In summary, this study showed that psychosocial functioning differs for children with NDDs and/or EBPs. In particular, children with both NDDs and EBPs appear to report poorer psychosocial functioning compared to their peers with neither condition. However, it is important to consider the context of socio-demographic characteristics as well as parenting behaviors to understand these differences. Our findings highlight that while children with NDDs only and EBPs only may be at risk for poor psychosocial functioning, these children can have positive psychosocial functioning in ideal social contexts. These findings offer important implications for practice and research and point to the importance of considering various contexts of influence, as well as their interactions, in understanding differences in children’s psychosocial functioning.

Declaration of interest Funding for this study was provided by a Canadian Institutes of Health Research (CIHR) Emerging Team Grant: Children with Disabilities (TWC-94790). The CIHR does not impose any restrictions on free access to or publication of the research data. There was no conflict of interest. The views expressed in this document are those of the authors and do not represent the position of Statistics Canada.

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