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A Population-Based Investigation of Behavioural and Emotional Problems and Maternal Mental Health: Associations with Autism Spectrum Disorder and Intellectual Disability

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Title: A Population-Based Investigation of Behavioural and Emotional Problems and Maternal Mental Health: Associations with Autism Spectrum Disorder and Intellectual Disability
Language: English
Authors: Totsika, Vasiliki, Hastings, Richard P., Emerson, Eric, Lancaster, Gillian A., Berridge, Damon M.
Source: Journal of Child Psychology and Psychiatry. Jan 2011 52(1):91-99.
Availability: Wiley-Blackwell. 350 Main Street, Malden, MA 02148. Tel: 800-835-6770; Tel: 781-388-8598; Fax: 781-388-8232; e-mail: cs-journals@wiley.com; Web site: http://www.wiley.com/WileyCDA/
Peer Reviewed: Y
Page Count: 9
Publication Date: 2011
Document Type: Journal Articles
Reports - Research
Education Level: Elementary Education
Elementary Secondary Education
Middle Schools
Descriptors: Emotional Problems, Mothers, Mental Retardation, Autism, Emotional Disturbances, Hyperactivity, Mental Health, Risk, Behavior Problems, Comparative Analysis, Age, Sex, Investigations, Foreign Countries, Children, Adolescents
Geographic Terms: United Kingdom
DOI: 10.1111/j.1469-7610.2010.02295.x
ISSN: 0021-9630
Abstract: Background: While research indicates elevated behavioural and emotional problems in children with autism spectrum disorders (ASD) and decreased well-being in their parents, studies do not typically separate out the contribution of ASD from that of associated intellectual disabilities (ID). We investigated child behavioural and emotional problems, and maternal mental health, among cases with and without ASD and ID in a large population-representative sample. Methods: Cross-sectional comparison of child behavioural and emotional problems and maternal mental health measures among 18,415 children (5 to 16 years old), of whom 47 had an ASD, 51 combined ASD with ID, 590 had only ID, and the remainder were the comparison group with no ASD or ID. Results: The prevalence of likely clinical levels of behavioural and emotional problems was highest among children with ASD (with and without ID). After controlling for age, gender, adversity, and maternal mental health, the presence of ASD and ID significantly and independently increased the odds for hyperactivity symptoms, conduct, and emotional problems. Emotional disorder was more prevalent in mothers of children with ASD (with or without ID). The presence of ASD, but not ID, significantly increased the odds for maternal emotional disorder. As has been found in previous research, positive maternal mental health was not affected by the presence of ASD or ID. Conclusions: ASD and ID are independent risk factors for behavioural and emotional problems. ASD (but not ID) is positively associated with maternal emotional disorder. Approaches to diagnosing hyperactivity and conduct problems in children with ASD may need to be reconsidered. (Contains 4 tables.)
Abstractor: As Provided
Number of References: 47
Entry Date: 2012
Accession Number: EJ973507
Database: ERIC
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  Value: <anid>AN0055677461;jyy01jan.11;2024Jun04.07:35;v2.2.500</anid> <title id="AN0055677461-1">A population-based investigation of behavioural and emotional problems and maternal mental health: associations with autism spectrum disorder and intellectual disability. </title> <p>Background:  While research indicates elevated behavioural and emotional problems in children with autism spectrum disorders (ASD) and decreased well‐being in their parents, studies do not typically separate out the contribution of ASD from that of associated intellectual disabilities (ID). We investigated child behavioural and emotional problems, and maternal mental health, among cases with and without ASD and ID in a large population‐representative sample. Methods:  Cross‐sectional comparison of child behavioural and emotional problems and maternal mental health measures among 18,415 children (5 to 16 years old), of whom 47 had an ASD, 51 combined ASD with ID, 590 had only ID, and the remainder were the comparison group with no ASD or ID. Results:  The prevalence of likely clinical levels of behavioural and emotional problems was highest among children with ASD (with and without ID). After controlling for age, gender, adversity, and maternal mental health, the presence of ASD and ID significantly and independently increased the odds for hyperactivity symptoms, conduct, and emotional problems. Emotional disorder was more prevalent in mothers of children with ASD (with or without ID). The presence of ASD, but not ID, significantly increased the odds for maternal emotional disorder. As has been found in previous research, positive maternal mental health was not affected by the presence of ASD or ID. Conclusions:  ASD and ID are independent risk factors for behavioural and emotional problems. ASD (but not ID) is positively associated with maternal emotional disorder. Approaches to diagnosing hyperactivity and conduct problems in children with ASD may need to be reconsidered.</p> <p>Keywords: intellectual disability; hyperactivity; conduct disorder; emotional disorder; Autism spectrum disorders</p> <p></p> <ulist> <item> Abbreviations:</item> <p></p> <item> ASD autism spectrum disorder</item> <p></p> <item> ID intellectual disability</item> </ulist> <p>Autism spectrum disorders (ASDs) are characterised by abnormalities in social interaction, patterns of communication, and a repetitive repertoire of interests and behaviours. ASDs are present in about 1% of the general population ([<reflink idref="bib3" id="ref1">3</reflink>]; [<reflink idref="bib23" id="ref2">23</reflink>]), and between 50% and 70% of children with ASD are reported to also have an intellectual disability (ID) ([<reflink idref="bib9" id="ref3">9</reflink>]; [<reflink idref="bib46" id="ref4">46</reflink>]). Children with an ASD present increased levels of behaviour problems and emotional difficulties, while their parents appear to be at risk for decreased psychological well‐being ([<reflink idref="bib25" id="ref5">25</reflink>]). The mechanisms for these putative broader effects of ASD are poorly understood because existing research studies typically have two significant limitations: samples that are unlikely to be representative, and the confounding impact of associated ID. We will begin by discussing how these methodological difficulties may have affected the findings in this area, and we will then describe how the present study will attempt to address these issues.</p> <p>To explore behaviour problems in children with ASD, case–control designs have typically been used: children with ASD are compared to children without ASD (e.g., children with Down syndrome, fragile X, psychiatric disorders, intellectual or developmental disabilities, and typical development; [<reflink idref="bib6" id="ref6">6</reflink>]; [<reflink idref="bib8" id="ref7">8</reflink>]; [<reflink idref="bib11" id="ref8">11</reflink>]; Fombonne, Simmons, Ford, Meltzer, & [<reflink idref="bib20" id="ref9">20</reflink>]; [<reflink idref="bib18" id="ref10">18</reflink>]; [<reflink idref="bib29" id="ref11">29</reflink>]). Children with ASD are typically found to have more behavioural and emotional problems than other groups, and to some extent even more severe difficulties than typically developing children with other psychiatric diagnoses ([<reflink idref="bib17" id="ref12">17</reflink>]; [<reflink idref="bib18" id="ref13">18</reflink>]).</p> <p>Following similar case–control research designs, parents of children with ASD have been compared to parents of typically developing children, parents of children with ID or developmental delay, parents of children with specific developmental conditions (Down syndrome, fragile X, cerebral palsy), and parents of children with physical or mental health problems. Parents of children with ASD are typically found to be at a significant disadvantage on a number of outcomes: increased stress ([<reflink idref="bib10" id="ref14">10</reflink>]; [<reflink idref="bib33" id="ref15">33</reflink>]; [<reflink idref="bib45" id="ref16">45</reflink>]), more psychological distress ([<reflink idref="bib17" id="ref17">17</reflink>]; [<reflink idref="bib45" id="ref18">45</reflink>]), more symptoms of depression ([<reflink idref="bib1" id="ref19">1</reflink>]; [<reflink idref="bib5" id="ref20">5</reflink>]; [<reflink idref="bib33" id="ref21">33</reflink>]; [<reflink idref="bib43" id="ref22">43</reflink>]), decreased quality of life, and increased levels of physical and mental health problems ([<reflink idref="bib38" id="ref23">38</reflink>]; [<reflink idref="bib47" id="ref24">47</reflink>]).</p> <p>Behaviour problems in children with ASD have also been consistently associated with their parents' psychological well‐being ([<reflink idref="bib11" id="ref25">11</reflink>]; [<reflink idref="bib39" id="ref26">39</reflink>]), even after controlling for autism symptoms and the level of the child's adaptive functioning ([<reflink idref="bib26" id="ref27">26</reflink>]). In some studies, the effect of ASD on maternal outcomes is still present after accounting for the impact of the child's behaviour problems (e.g., [<reflink idref="bib11" id="ref28">11</reflink>]; [<reflink idref="bib24" id="ref29">24</reflink>]), while in others ASD ceases to be associated with maternal outcomes once behaviour problems are controlled ([<reflink idref="bib6" id="ref30">6</reflink>]; [<reflink idref="bib29" id="ref31">29</reflink>]). Findings from the latter studies suggest that if one controls for the behaviour problems of children with ASD, their parents' well‐being is no longer different from that of other parents ([<reflink idref="bib6" id="ref32">6</reflink>]; [<reflink idref="bib25" id="ref33">25</reflink>]; [<reflink idref="bib29" id="ref34">29</reflink>]; [<reflink idref="bib34" id="ref35">34</reflink>]), indicating that it may not be the presence of ASD that drives these differences, but the associated behaviour problems.</p> <p>This latter conclusion is tempered by the fact that the frequent overlap of ASD with ID may exacerbate behavioural and emotional problems. Owing to the heterogeneity of symptoms in ASD, it is very difficult to distinguish the effects of the core symptoms of autism from those of ID, and this is more pronounced at the lowest end of the intellectual functioning spectrum ([<reflink idref="bib35" id="ref36">35</reflink>]). As an example, one of the diagnostic criteria for autism is the presence of stereotyped and repetitive behaviours and these are also a common behaviour problem among individuals with severe ID ([<reflink idref="bib36" id="ref37">36</reflink>]).Very few studies examine the contribution of each condition (ID and ASD) to children's behaviour separately. Case‐cohort studies do not usually discriminate the IQ levels of children within the ASD group, which does not allow for the separate effects of ID to be demonstrated, or they compare children with an ASD of a particular ID level to other diagnostic categories of similar ID level, which makes any findings of elevated behaviour problems relevant only to children with ASD and ID, and not all children with ASD.</p> <p>Evidence for different behavioural profiles is emerging from studies that examine behaviour problems within ASD groups of different levels of intellectual functioning. [<reflink idref="bib8" id="ref38">8</reflink>] found differences in the pattern of behaviour problems among children with an ASD: those with moderate–severe ID presented with more self‐absorbed and social relating problems compared to those with borderline ID or IQ within the normal range. [<reflink idref="bib16" id="ref39">16</reflink>] also demonstrated that different IQ levels in children with an ASD are associated with a different behavioural profile longitudinally, where lower‐functioning children (as indicated by standardised scores being below 70) presented higher levels of hyperactivity, irritability, and stereotyped problems three years later, whereas higher‐functioning children were more anxious and depressed over time. Although the level of intellectual functioning in children with an ASD may not always be associated with behaviour problems overall (e.g., [<reflink idref="bib8" id="ref40">8</reflink>]; [<reflink idref="bib42" id="ref41">42</reflink>]), certain areas of behavioural functioning may be more affected than others. These findings suggest that when comparing the behavioural profile of children with an ASD to that of children with developmental disabilities or who are typically developing, we need to control for the presence of any associated intellectual disability.</p> <p>An additional methodological complication is that the vast majority of existing studies recruit their participants from clinical referrals to ID or psychiatric services, or parent associations. It is very likely that the prevalence of behaviour problems or parental mental health problems is higher in referred or self‐referred groups than in the general population. The use of clinically referred samples tends to overestimate the prevalence of psychiatric problems ([<reflink idref="bib40" id="ref42">40</reflink>]), which poses a threat to interval validity: findings of elevated problems may be present as a result of the group's referral status rather than effects or correlates of the presence of an ASD. The issue of unrepresentative sampling is further accentuated by findings suggesting that the relationship between parental well‐being and children's problem behaviours is moderated by the family's socioeconomic position ([<reflink idref="bib12" id="ref43">12</reflink>]; [<reflink idref="bib28" id="ref44">28</reflink>]). In samples that are not population representative, certain socioeconomic strata among ASD participants are more prevalent than others (e.g., higher SES; [<reflink idref="bib18" id="ref45">18</reflink>]; [<reflink idref="bib11" id="ref46">11</reflink>]). Again, this is a threat to internal validity in that any findings of the presence or absence of a relationship between parental mental health and child behaviour problems might be affected by the particular socioeconomic group represented in the sample. Given this validity threat, it is important to use a population‐representative sample and to examine possible moderating effects of the family's socioeconomic position.</p> <p>In the few studies with non‐referred samples, researchers have not controlled for the presence of ID in ASD groups. [<reflink idref="bib17" id="ref47">17</reflink>] reported on groups representative of the whole UK population (using the Office of National Statistics [ONS] 1999 mental health survey of children and adolescents). Children with ASD presented with significantly more behaviour problems compared to children with other psychiatric diagnoses, or typically developing children, but ID was not accounted for in any of the analyses. Other studies of non‐referred samples have focused on ID rather than ASD. [<reflink idref="bib14" id="ref48">14</reflink>] reported on psychiatric disorder in an ID group drawn from a UK representative sample of 18,415 children (ONS 1999 and 2004 mental health surveys). Children with ASD were included in the ID group, but their levels of behavioural and emotional problems were not examined separately. [<reflink idref="bib7" id="ref49">7</reflink>] identified 12 ASD children with ID from an epidemiological study representative of one geographical area in Canada, and matched these to 12 ID only children. The ASD‐ID group presented with more behaviour problems and psychiatric disorders. In the single published study to examine maternal well‐being in a population‐representative sample (USA), researchers did not control for ID levels as ASD children were only matched on prosocial skills to non‐ASD children ([<reflink idref="bib38" id="ref50">38</reflink>]). Therefore, no study to date has investigated the levels of behaviour problems and maternal well‐being in a population‐representative sample of children with ASD <emph>with</emph> and <emph>without</emph> ID. The goal of the present study is to examine independently the association of ASD and ID with child behavioural and emotional problems, and maternal mental health, using the population‐representative sample of 18,415 children of the 1999 and 2004 ONS surveys from the UK.</p> <p>In the present study, our aims were to: (a) investigate the levels of behavioural and emotional problems among children with ASD, ID, ASD and ID, and those without ASD or ID (comparison group) in a population‐representative sample, (b) investigate maternal mental health in these four sub‐groups, (c) examine the independent association of ASD and ID with the presence of behavioural and emotional problems, controlling for any associations with maternal mental health and socioeconomic position, and (d) examine the association of ASD and ID with maternal mental health, over and above any associations with socioeconomic position and increased child behaviour problems. Specific hypotheses about the direction of group differences and relationships were not made as the review of existing information was not sufficient to support robust hypotheses.</p> <hd id="AN0055677461-2">Method</hd> <p>The study is a secondary analysis of data from two UK national surveys on psychiatric morbidity of 5–16‐year‐olds (Office of National Statistics, ONS 1999 and 2004; [<reflink idref="bib23" id="ref51">23</reflink>]). Participants were identified from the Child Benefit Records (a non‐means‐tested welfare benefit payable to all families with children in the UK) held by the Department of Work and Pensions, representing 475 randomly selected postal sectors across the country. In 1999, 10,438 children were surveyed, representing 83% of the eligible sample. In 2004, 7,977 were included, representing 76% of the eligible sample. Owing to the absence of differences in the data ([<reflink idref="bib23" id="ref52">23</reflink>]), the 1999 and 2004 data have subsequently been combined into a single database.</p> <hd id="AN0055677461-3">Sample</hd> <p>A total of 18,415 children and adolescents participated in the current study. Children were on average 10 years old (SD 3 yrs), and 50.6% were boys. All lived in private households. Data were obtained via face‐to‐face interviews with the children's primary caregiver, which in 94.3% of cases was the mother. The majority of mothers (> 70%) were aged between 30 and 44 years old, and were married or cohabiting (78.5%).</p> <p>Among the sample, 641 children were identified as having ID (3.5% of the total sample; [<reflink idref="bib14" id="ref53">14</reflink>]), using a combination of information provided by the child's mother and teacher. Maternal reports of the presence of an ID were examined in conjunction with teacher reports of marked difficulties in three areas of scholastic achievement (reading, maths, and spelling) and estimates of the children's developmental quotients ([<reflink idref="bib12" id="ref54">12</reflink>]; [<reflink idref="bib14" id="ref55">14</reflink>]). This definition of ID resulted in a sample‐based prevalence consistent with other epidemiological studies ([<reflink idref="bib12" id="ref56">12</reflink>]; [<reflink idref="bib14" id="ref57">14</reflink>]).</p> <p>Ninety‐eight children were diagnosed with ASD (0.53% of the total sample), established by a clinical diagnosis. Fifty‐one of the 98 children with ASD also had an associated ID. Thus, the prevalence of ID among ASD cases in this UK‐representative sample is 52% (95% CI: 42% to 62%). Table 1 summarises the four groups of participants.</p> <p>1  The characteristics of the children and their families in each group</p> <p> <ephtml> <table><thead valign="bottom"><tr><th /><th>Comparison
<italic>N </italic>=<italic> </italic>17727</th><th>ASD only
<italic>N </italic>=<italic> </italic>47</th><th>ID only
<italic>N </italic>=<italic> </italic>590</th><th>ASD/ID
<italic>N </italic>=<italic> </italic>51</th><th>Test statistic<sup>1</sup> (<italic>p</italic>)</th></tr></thead><tbody valign="top"><tr><td>Average child age in years (sd)</td><td>10.20 (3.27)</td><td>9.70 (3.05)</td><td>10.01 (3.03)</td><td>10.22 (3.07)</td><td>2.15 (.540)</td></tr><tr><td>Child male</td><td>50%</td><td>87%</td><td>65.0%</td><td>76.5%</td><td>88.92 (<.001)</td></tr><tr><td>Poor family</td><td>29.4%</td><td>14%</td><td>48.9%</td><td>26.3%</td><td>97.76 (<.001)</td></tr><tr><td>Mother left school ≤ 16 yrs without qualifications </td><td>28.2%</td><td>35.6%</td><td>51.6%</td><td>26.8%</td><td>147.49 (<.001)</td></tr><tr><td>Neither parent in paid employment</td><td>13.8%</td><td>17.4%</td><td>28.4%</td><td>42.6%</td><td>125.96 (<.001)</td></tr><tr><td>1 + negative life events </td><td>46.8%</td><td>45.7%</td><td>57.1%</td><td>63.6%</td><td>28.03 (<.001)</td></tr><tr><td>2 + high adversity indices<sup>2</sup></td><td>31.9%</td><td>27.9%</td><td>57.4%</td><td>44.7%</td><td>154.51 (<.001)</td></tr></tbody></table> </ephtml> </p> <p>1 <sups>1</sups>Comparisons were performed using a chi‐square test, except for age (Kruskal–Wallis test).</p> <p>2 <sups>2</sups>Adversity is a composite of poverty, educational qualifications, economic activity and negative life events.</p> <hd id="AN0055677461-4">Measures</hd> <p>The presence of an ASD was evaluated by clinicians using the Development and Well‐Being Assessment (DAWBA; [<reflink idref="bib22" id="ref58">22</reflink>]), which is designed to identify psychiatric problems in children and adolescents. The DAWBA was administered to all participants in the study, and information was provided by the primary caregiver on a range of structured and open‐ended questions. This information was subsequently assessed by clinicians on the basis of ICD‐10 and DSM‐IV diagnostic criteria to decide on the presence of specific clinical diagnoses. The assessment tool can reliably discriminate clinical cases among community samples ([<reflink idref="bib22" id="ref59">22</reflink>]). The clinical diagnosis of ASD used in our study was based on ICD‐10 criteria, as equivalent DSM‐IV diagnoses were available for a proportion of the sample only (only for the 1999 survey) whereas ICD‐10 diagnoses were available for the whole sample.</p> <p>Children's behavioural and emotional problems were measured with the Strengths and Difficulties Questionnaire (SDQ; [<reflink idref="bib21" id="ref60">21</reflink>]). This measure assesses emotional symptoms, conduct problems, hyperactivity, peer relationship problems, and prosocial behaviour. Analyses of the SDQ data from the first ONS survey indicated satisfactory reliability (inter‐rater, test–retest, and internal consistency), and acceptable sensitivity/specificity for use as a community screen ([<reflink idref="bib20" id="ref61">20</reflink>]). Cut‐off scores are available to indicate borderline and abnormal levels of problem behaviours. The SDQ also has validity for use with individuals with an ID, and this has been established in samples of children also including those with autism ([<reflink idref="bib13" id="ref62">13</reflink>]; [<reflink idref="bib31" id="ref63">31</reflink>]). While the SDQ has not yet been separately validated for use in ASD, it is extensively used in ASD research (e.g., [<reflink idref="bib41" id="ref64">41</reflink>]). In the present study, we focused on conduct problems, emotional symptoms, and hyperactivity. Peer relationships and prosocial behaviour were not examined as they represent areas of functioning affected by ASD also represented in diagnostic criteria for ASD. Scores indicating borderline and abnormal levels of problems were combined to identify children with elevated hyperactivity, emotional symptoms and conduct problems.</p> <p>Maternal mental health was assessed with the General Health Questionnaire (GHQ‐12; [<reflink idref="bib19" id="ref65">19</reflink>]), which has been designed to screen community populations for non‐psychotic psychiatric problems. It is normally scored to provide a unidimensional assessment of psychological health and the ONS surveys have used a cut‐off score (<reflink idref="bib3" id="ref66">3</reflink>) to indicate the presence of possible emotional disorder ([<reflink idref="bib23" id="ref67">23</reflink>]; [<reflink idref="bib37" id="ref68">37</reflink>]). While the same approach was adopted in this study, the GHQ‐12 was also used to provide information on positive mental health. [<reflink idref="bib30" id="ref69">30</reflink>] demonstrated how the GHQ‐12 can reliably discriminate between positive and negative mental health. A positive mental health score was estimated by summing the six positive GHQ items (<reflink idref="bib1" id="ref70">1</reflink>, 3, 4, 7, 8, 12; [30]). Positive mental health includes items such as: 'Have you recently felt capable of making decisions about things?', and 'Have you recently been feeling reasonably happy, all things considered?'. Scores range from 0 to 18 for this positive mental health index. Internal consistency for this score in our study was found to be adequate (Cronbach's α:.76). A median split across the whole sample was used to establish a binary measure of high vs. low positive mental health.</p> <p>The family's socioeconomic position (SEP) was estimated from four indices: relative poverty (a dichotomy of income above or below 60% of the national median equivalised income), maternal education (a dichotomy of low educational qualifications [left school at 16 or earlier] vs. higher), the family's economic activity (neither parent in paid employment vs. at least one parent in paid employment), family negative life events (none vs. one or more negative life events). While life events are not typically part of socioeconomic status indices, they are closely related. In this study, they were combined to capture the adversity experienced by the family, and thus account for that part of the variance in children's behaviour problems and maternal mental health associated with these circumstances. The resulting adversity composite had adequate internal consistency (Kuder Richardson 20 = .60). For the purposes of analysis, the index was converted to a dichotomous variable: none or one low SEP factors (low adversity) vs. two or more low SEP factors (high adversity).</p> <hd id="AN0055677461-5">Procedure and data analysis</hd> <p>The ONS anonymised survey data were obtained from the UK Data Archive (http://www.data‐archive.ac.uk/). The ethical responsibilities of the present authors included the protection of participants' anonymity and confidentiality.</p> <p>The four sub‐groups of children were identified: ASD only (<emph>n </emph>=<emph> </emph>47), ASD and ID (<emph>n </emph>=<emph> </emph>51), ID only (<emph>n </emph>=<emph> </emph>590), and comparison group with no ASD or ID (<emph>n </emph>=<emph> </emph>17,277). An a priori power analysis was conducted to determine the power of the existing sample to detect group differences. Appropriate effect sizes calculated from studies with relevant data suggested that for α = .05, the power to detect differences in children's problem behaviours was at least.95,.85 for maternal emotional disorder, and.95 for predicting maternal mental health after controlling for child problem behaviours. Full details are available from the first author on request.</p> <p>For the purposes of research question (a), group differences in elevated hyperactivity, emotional symptoms and conduct problems were examined using chi‐square tests. Similarly, maternal mental health differences (emotional disorder and positive mental health) were compared using chi‐square tests (research question b). Appropriate effect sizes (Cramer's V) were used to indicate the strength of the association between group status and the presence of elevated behavioural and emotional problems. Cramer's V ranges from 0 (no association) to 1 (perfect association), with values of.50 +  indicating large effects.</p> <p>Logistic regression models were used to investigate research questions (c) and (d). As the research objective was to investigate the association of ASD and ID with child behaviour problems or maternal mental health <emph>over and above</emph> associations with other important variables, we conducted logistic regression and adopted a stepped approach for variable entry. There were three child outcomes (elevated hyperactivity, emotional symptoms, conduct problems) and two maternal outcomes (presence of emotional disorder, positive mental health). The predictors in each model for the child outcomes were (by order of entry): child's age, gender, adversity (step 1), maternal mental health (step 2), interaction of maternal mental health with adversity (step 3), ASD status, ID status (final step). The purpose of including step 3 was to control for the potential moderation of adversity in the relationship between maternal mental health and child behaviour problems ([<reflink idref="bib12" id="ref71">12</reflink>]; [<reflink idref="bib28" id="ref72">28</reflink>]). For each child outcome, two separate maternal mental health variables were controlled: maternal emotional disorder, and positive mental health. The predictors in each model of maternal mental health were: child's age, gender, adversity (step 1), elevated child behaviour problems (step 2), interaction of adversity and child behaviour problems (step 3), ASD status, ID status (final step). In step 2, the presence of elevated child problem behaviours was defined as borderline or abnormal range levels on one or more of the three domains of child behaviour (hyperactivity, emotional symptoms, or conduct problems).</p> <hd id="AN0055677461-6">Results</hd> <p></p> <hd id="AN0055677461-7">Group differences in child and maternal outcomes</hd> <p>Table 2 presents the proportion of children with elevated behavioural and emotional problems in each group. There were significant group differences yielding small to moderate effect sizes (Cramer's V ranged from.126 to.222), which suggested small yet significant associations between group status and child behaviour. The comparison group had the lowest levels of behaviour problems. On the basis of normative data, it would be expected that about 20% of children would have SDQ scores in the borderline and abnormal range ([<reflink idref="bib21" id="ref73">21</reflink>]), and whereas this is the case for children in the comparison group, there was a two‐ to three‐fold increase in children with ID (41.6 to 63.2%), and a three‐ to four‐fold increase for children with ASD (63.8 to 87.5%). Children who had only an ASD presented with the highest levels of hyperactivity, emotional symptoms and conduct problems, followed by children who had both an ASD and ID. The final two rows in Table 2 present the maternal outcomes. Maternal emotional disorder was significantly different among groups (a small V of.047). Mothers of children with an ASD (with and without ID) presented the highest levels of emotional disorder (43.6% and 43.5%, respectively). In contrast, there were no significant group differences in positive mental health.</p> <p>2  Levels of behavioural and emotional problems in each group</p> <p> <ephtml> <table><thead valign="bottom"><tr><th /><th>Comparison</th><th>ASD only</th><th>ID only</th><th>ASD/ID </th><th>Chi‐square statistic (<italic>p</italic>)</th><th>Effect size (Cramer's V)</th></tr></thead><tbody valign="top"><tr><td>Child hyperactivity</td><td>19.1%</td><td>84.8%</td><td>63.2%</td><td>87.5%</td><td>892.05 (<.001)</td><td>.222</td></tr><tr><td>Child emotional symptoms</td><td>17.8%</td><td>73.9%</td><td>41.6%</td><td>70.5%</td><td>373.76 (<.001)</td><td>.143</td></tr><tr><td>Child conduct problems</td><td>21.8%</td><td>63.8%</td><td>46.3%</td><td>65.3%</td><td>286.67 (<.001)</td><td>.126</td></tr><tr><td>Maternal emotional disorder</td><td>23.7%</td><td>43.5%</td><td>32.4%</td><td>43.6%</td><td>40.12 (<.001)</td><td>.047</td></tr><tr><td>Positive maternal mental health (% high)</td><td>28.5%</td><td>17.4%</td><td>27.0%</td><td>22.5%</td><td>4.15 (.246)</td><td>.015</td></tr></tbody></table> </ephtml> </p> <hd id="AN0055677461-8">The association of ASD and ID with elevated behavioural and emotional problems in children</hd> <p>Logistic regression models were performed for each of the three child outcomes. In all models, the predictors added in the final step were always associated with a significant prediction, over and above the effect of previous steps. Table 3 presents the results of the final step for the models predicting child problem behaviours (Odd Ratios, and 95% CIs). The upper part of the table presents the results of the models that controlled for positive maternal mental health while the lower part presents the models that controlled for maternal emotional disorder.</p> <p>3  The contribution of ASD and ID to elevated behavioural and emotional problems controlling for maternal mental health</p> <p> <ephtml> <table><thead valign="bottom"><tr><th valign="bottom"> </th><th>Hyperactivity</th><th>Emotional symptoms</th><th>Conduct problems</th></tr><tr><th>OR (<italic>p</italic>)<sup>1</sup></th><th>95% CI<sup>2</sup></th><th>OR (<italic>p</italic>)</th><th>95% CI</th><th>OR (<italic>p</italic>)</th><th>95% CI</th></tr></thead><tbody valign="top"><tr><td>Control for positive mental health</td></tr><tr><td> Child's age</td><td>.95 (<.001)</td><td>.93–.96</td><td>1.01 (.274)</td><td>.99–1.02</td><td>.95 (<.001)</td><td>.94–.96</td></tr><tr><td> Child gender (male)</td><td>2.15 (<.001)</td><td>1.98–2.33</td><td>.81 (<.001)</td><td>.75–.88</td><td>1.35 (<.001)</td><td>1.25–1.45</td></tr><tr><td> Adversity (high)</td><td>1.54 (<.001)</td><td>1.32–1.80</td><td>1.64 (<.001)</td><td>1.40–1.93</td><td>2.04 (<.001)</td><td>1.76–2.37</td></tr><tr><td> Positive mental health (high)</td><td>.95 (.321)</td><td>.85–1.06</td><td>.81 (<.001)</td><td>.72–.91</td><td>.87 (.012)</td><td>.78–.97</td></tr><tr><td> Adversity by positive mental health (adverse)</td><td>1.37 (.001)</td><td>1.14–1.64</td><td>1.08 (.407)</td><td>.90–1.31</td><td>1.32 (.002)</td><td>1.11–1.56</td></tr><tr><td> ASD presence</td><td>10.31 (<.001)</td><td>5.52–19.25</td><td>8.32 (<.001)</td><td>4.94–14.01</td><td>4.08 (<.001)</td><td>2.52–6.61</td></tr><tr><td> ID presence</td><td>5.85 (<.001)</td><td>4.85–7.05</td><td>2.75 (<.001)</td><td>2.29–3.30</td><td>2.40 (<.001)</td><td>2.01–2.88</td></tr><tr><td>Control for maternal emotional disorder</td></tr><tr><td> Child's age</td><td>.94 (<.001)</td><td>.93–.96</td><td>1.00 (.556)</td><td>.99–1.02</td><td>.95 (.001)</td><td>.94–.96</td></tr><tr><td> Child gender (male)</td><td>2.16 (<.001)</td><td>2.00–2.35</td><td>.81 (<.001)</td><td>.75–.88</td><td>1.35 (<.001)</td><td>1.26–1.46</td></tr><tr><td> Adversity (high)</td><td>1.75 (<.001)</td><td>1.59–1.93</td><td>1.47 (<.001)</td><td>1.33–1.64</td><td>2.24 (<.001)</td><td>2.04–2.45</td></tr><tr><td>Emotional disorder (presence)</td><td>1.54 (<.001)</td><td>1.37–1.74</td><td>1.96 (<.001)</td><td>1.74–2.20</td><td>1.70 (<.001)</td><td>1.51–1.90</td></tr><tr><td> Adversity by emotional disorder (adverse)</td><td>1.13 (.182)</td><td>.95–1.34</td><td>1.20 (.040)</td><td>1.01–1.43</td><td>1.13 (.148)</td><td>.96–1.33</td></tr><tr><td> ASD presence</td><td>9.60 (<.001)</td><td>5.14–17.94</td><td>7.81 (<.001)</td><td>4.63–13.18</td><td>3.77 (<.001)</td><td>2.32–6.11</td></tr><tr><td> ID presence</td><td>5.80 (<.001)</td><td>4.81–7.00</td><td>2.73 (<.001)</td><td>2.26–3.29</td><td>2.36 (<.001)</td><td>1.97–2.83</td></tr></tbody></table> </ephtml> </p> <p>3 <sups>1</sups>OR: Odds ratio; <sups>2</sups> 95% CI: 95% confidence intervals.</p> <p>Controlling for child age, gender, adversity, maternal mental health, and any moderating effects of adversity, the presence of ASD and ID always significantly increased the odds for behaviour problems (adjusted ORs for ASD and ID were statistically significant). Comparing the size of the adjusted ORs between ASD and ID, Table 3 suggests that ASD increased the odds for every type of problem behaviour more than the presence of ID did, although they were both significant predictors.</p> <p>The presence of maternal emotional disorder was a significant independent risk factor for elevated hyperactivity and conduct problems in the child (ORs 1.54 and 1.70 respectively), but its association with the child's emotional symptoms was moderated by adversity (OR<subs>interaction</subs> = 1.20): maternal emotional disorder significantly increased the odds for elevated emotional symptoms in the child and this was more pronounced in families experiencing high adversity. Positive maternal mental health was an independent predictor of reduced child emotional symptoms (OR = .81) such that high levels of positive mental health decreased the odds for emotional symptoms irrespective of adversity level. However, the effect of maternal positive mental health on hyperactivity and conduct problems was moderated by adversity (OR<subs>interaction</subs> = 1.37 and 1.32, respectively). In families experiencing high adversity, the presence of low positive mental health in the mother was likely to increase the odds for hyperactivity and conduct problems in the child.</p> <hd id="AN0055677461-9">The association of ASD and ID with maternal mental health</hd> <p>Table 4 presents the ORs and 95% CI for each predictor of maternal mental health resulting from the final step of the logistic regression. Controlling for child's age and gender, adversity, and the presence of any elevated child problem behaviours, ASD significantly increased the odds for maternal emotional disorder (OR: 1.82), while ID did not have such an effect (OR: 1.02). Positive mental health was not predicted by the presence of ASD or ID (both adjusted ORs were non‐significant). High adversity and the presence of any child problem behaviours were significant independent predictors of maternal emotional disorder (ORs: 1.79, and 1.78, respectively). The presence of any child behaviour problems decreased the odds for positive mental health in families with higher socioeconomic status (i.e., low adversity; OR<subs>interaction</subs> = .84).</p> <p>4  The contribution of ASD and ID to maternal mental health controlling for elevated child behaviour problems</p> <p> <ephtml> <table><thead valign="bottom"><tr><th valign="bottom"> </th><th>Maternal emotional disorder</th><th>Positive mental health</th></tr><tr><th>OR (<italic>p</italic>)<sup>1</sup></th><th>95% CI<sup>2</sup></th><th>OR(<italic>p</italic>)</th><th>95% CI</th></tr></thead><tbody valign="top"><tr><td>Child's age</td><td>1.04 (<.001)</td><td>1.02–1.05</td><td>.98 (.001)</td><td>.97–.99</td></tr><tr><td>Child gender (male)</td><td>.94 (.100)</td><td>.87–1.01</td><td>1.03 (.469)</td><td>.96–1.10</td></tr><tr><td>Adversity (high)</td><td>1.79 (<.001)</td><td>1.61–2.00</td><td>1.02 (.633)</td><td>.93–1.13</td></tr><tr><td>Any elevated child behaviour problems</td><td>1.78 (<.001)</td><td>1.62–1.96</td><td>.87 (.002)</td><td>.80–.95</td></tr><tr><td>Adversity by child behaviour problems (adverse)</td><td>1.12 (.141)</td><td>.96–1.30</td><td>.84 (.017)</td><td>.72–.97</td></tr><tr><td>ASD presence</td><td>1.82 (.012)</td><td>1.14–2.89</td><td>.67 (.165)</td><td>.39–1.18</td></tr><tr><td>ID presence</td><td>1.02 (.833)</td><td>.84–1.24</td><td>1.05 (.661)</td><td>.86–1.27</td></tr></tbody></table> </ephtml> </p> <p>4 <sups>1</sups>OR: Odds ratio; <sups>2</sups> 95% CI: 95% confidence intervals.</p> <hd id="AN0055677461-10">Discussion</hd> <p>In the present study, we examined the levels of behavioural and emotional difficulties, along with maternal well‐being, in a UK representative sample of children who had an ASD, ASD combined with ID, ID only, or neither of these conditions (comparison group). Elevated hyperactivity, emotional symptoms and conduct problems were more likely among children with an ASD (with or without ID). Regression analyses suggested that both ASD and ID significantly increased the odds for hyperactivity, emotional symptoms and conduct problems, after accounting for any effects of gender, age, socioeconomic position and maternal mental health. The contribution of ASD to behavioural and emotional problems was larger than that of ID. While our findings support previous studies of elevated behaviour problems among children with an ASD ([<reflink idref="bib6" id="ref74">6</reflink>]; [<reflink idref="bib8" id="ref75">8</reflink>]; [<reflink idref="bib11" id="ref76">11</reflink>]; Fombonne et al., 2005; [<reflink idref="bib18" id="ref77">18</reflink>]; [<reflink idref="bib29" id="ref78">29</reflink>]), they also highlight the potential independent association with ASD and ID.</p> <p>The prevalence of maternal emotional disorder was highest amongst mothers of children with an ASD (with or without ID). Maternal positive mental health, however, was not associated with disability status. In fact, levels of maternal positive mental health were very similar between mothers of children with ID and mothers of children without ID or an ASD.</p> <p>Previous research findings suggested that the pattern of behaviour problems may also be affected by the severity of ID both concurrently ([<reflink idref="bib8" id="ref79">8</reflink>]) and over time ([<reflink idref="bib16" id="ref80">16</reflink>]). A drawback of the present study was the lack of differentiation of ID levels that prevented us from examining such an effect. Furthermore, as the definition of ID was developed by researchers on the basis of information available in the survey, it does not meet the international standards for ID diagnosis which combine standardised IQ and adaptive behaviour assessments. However, using an ID definition developed independently of the ASD diagnosis lends validity to the identified co‐morbidity (52% here). [<reflink idref="bib44" id="ref81">44</reflink>] questioned the high co‐morbidity levels reported (e.g., up to 70%), suggesting that they simply reflect an increased probability of identifying children with autism and moderate/severe ID during research or clinical assessments (resulting in ascertainment bias). In our study, where ASD diagnosis was provided by clinicians independently of the development of the ID definition by researchers, the potential for such methodological problems was minimal.</p> <p>While both ASD and ID were associated with elevated child behaviour problems, this was not the case for maternal mental health. Maternal emotional disorder was significantly more likely when ASD was present (but not ID). High levels of positive mental health were unrelated to both ASD and ID. The fact that these two maternal outcomes were associated with different correlates suggests that mental ill‐health (emotional disorder) is not simply the conceptual opposite of well‐being (positive mental health). Mothers of children with disabilities can be experiencing both negative and positive well‐being simultaneously ([<reflink idref="bib27" id="ref82">27</reflink>]).</p> <p>The absence of group differences in positive mental health supports earlier findings ([<reflink idref="bib6" id="ref83">6</reflink>]; [<reflink idref="bib11" id="ref84">11</reflink>]), indicating that the presence of a significant disability in the child does not necessarily compromise maternal well‐being. The presence of ASD (but not ID) was associated with an increase in the odds of maternal emotional disorder, suggesting that maternal emotional disorder may be associated more strongly with symptoms characteristic of autism than the child's decreased cognitive or adaptive skills. This finding is in line with a recent meta‐analysis ([<reflink idref="bib47" id="ref85">47</reflink>]) reporting increased rates of psychiatric disorder among parents of children with an ASD when compared to parents of children with no disorder (typically developing) or with a disorder not associated with a genetic liability (e.g., unknown aetiology ID). While the design of our study cannot indicate whether the high rates of emotional disorder in mothers of children with ASD are part of the broad autism phenotype in ASD relatives, or a consequence of the 'greater burden' of raising a child with ASD ([<reflink idref="bib2" id="ref86">2</reflink>]) (or a combination of the two), it does highlight the significant association between ASD and maternal emotional disorder. The methodological implication of this is that earlier findings of increased negative outcomes in parents of children with intellectual or developmental disabilities (e.g., [<reflink idref="bib4" id="ref87">4</reflink>]; [<reflink idref="bib12" id="ref88">12</reflink>]) could be driven by the inclusion of ASD cases among participants with ID.</p> <p>The present findings support previous findings of an association between problem behaviours with maternal stress and emotional problems ([<reflink idref="bib26" id="ref89">26</reflink>]; [<reflink idref="bib29" id="ref90">29</reflink>]), and contradict the findings of no association with ASD symptoms ([<reflink idref="bib6" id="ref91">6</reflink>]; [<reflink idref="bib11" id="ref92">11</reflink>]; [<reflink idref="bib26" id="ref93">26</reflink>]) by suggesting that, in a population‐representative sample, the presence of an ASD appears to have a significant independent association with maternal emotional disorder, even after controlling for child behaviour problems. The relationship between child behaviour problems and maternal mental health is also still present even after controlling for the presence of ASD and ID. In this cross‐sectional analysis, maternal emotional disorder was significantly associated with child behaviour problems. Positive mental health was negatively associated with child emotional symptoms, as suggested by the significant odds ratio, after accounting for the effect of disability. If such results are confirmed in subsequent longitudinal studies, efforts to increase maternal well‐being may directly improve the child's emotional symptoms, or, by targeting specifically families of low SEP/high adversity, increase resilience with its positive impact on children's conduct and hyperactivity problems. Adversity was associated with an increased likelihood of maternal emotional disorder, even after controlling for elevated levels of behaviour problems. This suggests another route to increasing resilience in families by directly addressing socioeconomic disadvantage/family adversity ([<reflink idref="bib15" id="ref94">15</reflink>]).</p> <p>The clinical implications of the present findings are primarily for ID or mental health services, and diagnostic practice. The presence of ASD or ID should alert clinicians to the possibility of elevated behaviour problems in children, and the need for assessment of psychiatric disorders. In the hierarchical classification system of ICD‐10 and DSM‐IV ASD takes diagnostic precedence over hyperkinesis or ADHD, and in the case of ICD‐10, also over conduct disorders. Our findings confirm the presence of elevated hyperactivity and conduct problems in children with an ASD ([<reflink idref="bib32" id="ref95">32</reflink>]; [<reflink idref="bib42" id="ref96">42</reflink>]), suggesting that diagnostic practices should be reconsidered. In terms of treatment practice, the present findings suggest that efforts to reduce the levels of children's behaviour problems should also target maternal emotional disorders. Our findings suggest that improvements in maternal emotional disorder might have a direct impact on children's conduct and hyperactivity problems and, in families of low SEP/high adversity, also on children's emotional problems.</p> <hd id="AN0055677461-11">Key points</hd> <p></p> <p>• •</p> <p></p> <ulist> <item> Previous research studies have typically failed to estimate the independent associations of ASD and ID with child behavioural and emotional problems and maternal psychological adjustment.</item> <p></p> </ulist> <p>• •</p> <p></p> <ulist> <item> In this population‐representative sample, ASD and ID are independent predictors of hyperactivity, conduct problems and emotional symptoms in children.</item> <p></p> </ulist> <p>• •</p> <p></p> <ulist> <item> ASD (but not ID) is a significant predictor of maternal emotional disorder. Positive maternal mental health was not associated with ASD or ID. Child behaviour problems and maternal mental health are still significantly associated, even after accounting for any ASD or ID effects.</item> <p></p> </ulist> <p>• •</p> <p></p> <ulist> <item> Resilience in families of children with developmental disabilities may be increased by fostering maternal positive mental health (especially in low socioeconomic levels) or by targeting maternal emotional disorder.</item> </ulist> <hd id="AN0055677461-12">Acknowledgements</hd> <p>The study was supported by a research grant from the Economic and Social Research Council, UK (ESRC; RES‐000‐22‐3216).</p> <hd id="AN0055677461-13">Correspondence to</hd> <p>Vasiliki Totsika, School of Psychology, Bangor University, Brigantia Building, Penrallt Road, Bangor, Gwynedd, LL57 2AS, Wales, UK; Tel: +44 (0) 1248 388706; Email: v.totsika@bangor.ac.uk</p> <ref id="AN0055677461-14"> <title> Footnotes </title> <blist> <bibl id="bib1" idref="ref19" type="bt">1</bibl> <bibtext> Conflict of interest statement: No conflicts declared.</bibtext> </blist> </ref> <ref id="AN0055677461-15"> <title> References </title> <blist> <bibtext> Abbeduto, L., Seltzer, M.M., Shattuck, P., Krauss, M.W., Orsmond, G., & Murphy, M.M. 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Berridge</p> <p>Reported by Author; Author; Author; Author; Author</p> </aug> <nolink nlid="nl1" bibid="bib23" firstref="ref2"></nolink> <nolink nlid="nl2" bibid="bib46" firstref="ref4"></nolink> <nolink nlid="nl3" bibid="bib25" firstref="ref5"></nolink> <nolink nlid="nl4" bibid="bib11" firstref="ref8"></nolink> <nolink nlid="nl5" bibid="bib20" firstref="ref9"></nolink> <nolink nlid="nl6" bibid="bib18" firstref="ref10"></nolink> <nolink nlid="nl7" bibid="bib29" firstref="ref11"></nolink> <nolink nlid="nl8" bibid="bib17" firstref="ref12"></nolink> <nolink nlid="nl9" bibid="bib10" firstref="ref14"></nolink> <nolink nlid="nl10" bibid="bib33" firstref="ref15"></nolink> <nolink nlid="nl11" bibid="bib45" firstref="ref16"></nolink> <nolink nlid="nl12" bibid="bib43" firstref="ref22"></nolink> <nolink nlid="nl13" bibid="bib38" firstref="ref23"></nolink> <nolink nlid="nl14" bibid="bib47" firstref="ref24"></nolink> <nolink nlid="nl15" bibid="bib39" firstref="ref26"></nolink> <nolink nlid="nl16" bibid="bib26" firstref="ref27"></nolink> <nolink nlid="nl17" bibid="bib24" firstref="ref29"></nolink> <nolink nlid="nl18" bibid="bib34" firstref="ref35"></nolink> <nolink nlid="nl19" bibid="bib35" firstref="ref36"></nolink> <nolink nlid="nl20" bibid="bib36" firstref="ref37"></nolink> <nolink nlid="nl21" bibid="bib16" firstref="ref39"></nolink> <nolink nlid="nl22" bibid="bib42" firstref="ref41"></nolink> <nolink nlid="nl23" bibid="bib40" firstref="ref42"></nolink> <nolink nlid="nl24" bibid="bib12" firstref="ref43"></nolink> <nolink nlid="nl25" bibid="bib28" firstref="ref44"></nolink> <nolink nlid="nl26" bibid="bib14" firstref="ref48"></nolink> <nolink nlid="nl27" bibid="bib22" firstref="ref58"></nolink> <nolink nlid="nl28" bibid="bib21" firstref="ref60"></nolink> <nolink nlid="nl29" bibid="bib13" firstref="ref62"></nolink> <nolink nlid="nl30" bibid="bib31" firstref="ref63"></nolink> <nolink nlid="nl31" bibid="bib41" firstref="ref64"></nolink> <nolink nlid="nl32" bibid="bib19" firstref="ref65"></nolink> <nolink nlid="nl33" bibid="bib37" firstref="ref68"></nolink> <nolink nlid="nl34" bibid="bib30" firstref="ref69"></nolink> <nolink nlid="nl35" bibid="bib44" firstref="ref81"></nolink> <nolink nlid="nl36" bibid="bib27" firstref="ref82"></nolink> <nolink nlid="nl37" bibid="bib15" firstref="ref94"></nolink> <nolink nlid="nl38" bibid="bib32" firstref="ref95"></nolink>
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Items – Name: Title
  Label: Title
  Group: Ti
  Data: A Population-Based Investigation of Behavioural and Emotional Problems and Maternal Mental Health: Associations with Autism Spectrum Disorder and Intellectual Disability
– Name: Language
  Label: Language
  Group: Lang
  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Totsika%2C+Vasiliki%22">Totsika, Vasiliki</searchLink><br /><searchLink fieldCode="AR" term="%22Hastings%2C+Richard+P%2E%22">Hastings, Richard P.</searchLink><br /><searchLink fieldCode="AR" term="%22Emerson%2C+Eric%22">Emerson, Eric</searchLink><br /><searchLink fieldCode="AR" term="%22Lancaster%2C+Gillian+A%2E%22">Lancaster, Gillian A.</searchLink><br /><searchLink fieldCode="AR" term="%22Berridge%2C+Damon+M%2E%22">Berridge, Damon M.</searchLink>
– Name: TitleSource
  Label: Source
  Group: Src
  Data: <searchLink fieldCode="SO" term="%22Journal+of+Child+Psychology+and+Psychiatry%22"><i>Journal of Child Psychology and Psychiatry</i></searchLink>. Jan 2011 52(1):91-99.
– Name: Avail
  Label: Availability
  Group: Avail
  Data: Wiley-Blackwell. 350 Main Street, Malden, MA 02148. Tel: 800-835-6770; Tel: 781-388-8598; Fax: 781-388-8232; e-mail: cs-journals@wiley.com; Web site: http://www.wiley.com/WileyCDA/
– Name: PeerReviewed
  Label: Peer Reviewed
  Group: SrcInfo
  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 9
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2011
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Research
– Name: Audience
  Label: Education Level
  Group: Audnce
  Data: <searchLink fieldCode="EL" term="%22Elementary+Education%22">Elementary Education</searchLink><br /><searchLink fieldCode="EL" term="%22Elementary+Secondary+Education%22">Elementary Secondary Education</searchLink><br /><searchLink fieldCode="EL" term="%22Middle+Schools%22">Middle Schools</searchLink>
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Emotional+Problems%22">Emotional Problems</searchLink><br /><searchLink fieldCode="DE" term="%22Mothers%22">Mothers</searchLink><br /><searchLink fieldCode="DE" term="%22Mental+Retardation%22">Mental Retardation</searchLink><br /><searchLink fieldCode="DE" term="%22Autism%22">Autism</searchLink><br /><searchLink fieldCode="DE" term="%22Emotional+Disturbances%22">Emotional Disturbances</searchLink><br /><searchLink fieldCode="DE" term="%22Hyperactivity%22">Hyperactivity</searchLink><br /><searchLink fieldCode="DE" term="%22Mental+Health%22">Mental Health</searchLink><br /><searchLink fieldCode="DE" term="%22Risk%22">Risk</searchLink><br /><searchLink fieldCode="DE" term="%22Behavior+Problems%22">Behavior Problems</searchLink><br /><searchLink fieldCode="DE" term="%22Comparative+Analysis%22">Comparative Analysis</searchLink><br /><searchLink fieldCode="DE" term="%22Age%22">Age</searchLink><br /><searchLink fieldCode="DE" term="%22Sex%22">Sex</searchLink><br /><searchLink fieldCode="DE" term="%22Investigations%22">Investigations</searchLink><br /><searchLink fieldCode="DE" term="%22Foreign+Countries%22">Foreign Countries</searchLink><br /><searchLink fieldCode="DE" term="%22Children%22">Children</searchLink><br /><searchLink fieldCode="DE" term="%22Adolescents%22">Adolescents</searchLink>
– Name: Subject
  Label: Geographic Terms
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22United+Kingdom%22">United Kingdom</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1111/j.1469-7610.2010.02295.x
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 0021-9630
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Background: While research indicates elevated behavioural and emotional problems in children with autism spectrum disorders (ASD) and decreased well-being in their parents, studies do not typically separate out the contribution of ASD from that of associated intellectual disabilities (ID). We investigated child behavioural and emotional problems, and maternal mental health, among cases with and without ASD and ID in a large population-representative sample. Methods: Cross-sectional comparison of child behavioural and emotional problems and maternal mental health measures among 18,415 children (5 to 16 years old), of whom 47 had an ASD, 51 combined ASD with ID, 590 had only ID, and the remainder were the comparison group with no ASD or ID. Results: The prevalence of likely clinical levels of behavioural and emotional problems was highest among children with ASD (with and without ID). After controlling for age, gender, adversity, and maternal mental health, the presence of ASD and ID significantly and independently increased the odds for hyperactivity symptoms, conduct, and emotional problems. Emotional disorder was more prevalent in mothers of children with ASD (with or without ID). The presence of ASD, but not ID, significantly increased the odds for maternal emotional disorder. As has been found in previous research, positive maternal mental health was not affected by the presence of ASD or ID. Conclusions: ASD and ID are independent risk factors for behavioural and emotional problems. ASD (but not ID) is positively associated with maternal emotional disorder. Approaches to diagnosing hyperactivity and conduct problems in children with ASD may need to be reconsidered. (Contains 4 tables.)
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: Ref
  Label: Number of References
  Group: RefInfo
  Data: 47
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2012
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ973507
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ973507
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      – Type: doi
        Value: 10.1111/j.1469-7610.2010.02295.x
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      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 9
        StartPage: 91
    Subjects:
      – SubjectFull: Emotional Problems
        Type: general
      – SubjectFull: Mothers
        Type: general
      – SubjectFull: Mental Retardation
        Type: general
      – SubjectFull: Autism
        Type: general
      – SubjectFull: Emotional Disturbances
        Type: general
      – SubjectFull: Hyperactivity
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      – SubjectFull: Mental Health
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      – SubjectFull: Risk
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      – SubjectFull: Behavior Problems
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      – SubjectFull: Comparative Analysis
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      – SubjectFull: Adolescents
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      – SubjectFull: United Kingdom
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      – TitleFull: A Population-Based Investigation of Behavioural and Emotional Problems and Maternal Mental Health: Associations with Autism Spectrum Disorder and Intellectual Disability
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            NameFull: Hastings, Richard P.
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            NameFull: Emerson, Eric
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            NameFull: Lancaster, Gillian A.
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            NameFull: Berridge, Damon M.
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