Research in Developmental Disabilities 34 (2013) 3449–3459

Contents lists available at ScienceDirect

Research in Developmental Disabilities

Mothers of children with developmental disabilities:

Stress in early and middle childhood
Gazi Azad, Jan Blacher *, George A. Marcoulides
University of California, Riverside, United States

A R T I C L E I N F O A B S T R A C T

Article history: Using a sample of 219 families of children with (n = 94) and without (n = 125)
Received 22 April 2013 developmental disabilities, this study examined the longitudinal perspectives of maternal
Received in revised form 3 July 2013 stress in early (ages 3–5) and middle childhood (ages 6–13) and its relationship to
Accepted 9 July 2013 mothers’ and children’s characteristics. Multivariate latent curve models indicated that
Available online 3 August 2013 maternal stress remained high and stable with minimal individual variation in early
childhood, but declined with significant individual variation in middle childhood.
Keywords: Maternal stress at the beginning of middle childhood was associated with earlier maternal
Developmental disabilities
stress, as well as children’s behavioral problems and social skills. The trajectory of
Intellectual disabilities
maternal stress across middle childhood was related to children’s behavioral problems.
Maternal stress
Parenting stress
Implications for interventions are discussed.
ß 2013 Published by Elsevier Ltd.

1. Introduction

Over half a century of research suggests that mothers of individuals with developmental disabilities (DD) report more
stress than mothers of individuals with typical development (TD) (Blacher & Baker, 2002; Griffith, Hastings, Nash, & Hill,
2010; Yoong & Koritsas, 2012). However, a majority of this research ignores middle childhood, uses one point in time, and is
linked to children’s behavioral problems. There are no studies to our knowledge that investigate the longitudinal
perspectives of maternal stress in differential developmental periods, and the relationship between maternal stress and the
characteristics of mothers and children. The objective of the present study was to examine maternal stress in early and
middle childhood in relation to the demographic characteristics of mothers and the functioning levels in their children.

1.1. The trajectory of maternal stress

Research on maternal stress and DD is primarily conducted without consideration of developmental stage (Murphy,
Christian, Caplin, & Young, 2007), often with a singular focus on families of young children (Estes, Munson, Koehler, Zhou, &
Abbot, 2009), adolescents (Embregts, Grimbel de Bois, & Graef, 2010), or young adults with intellectual disabilities (Yoong &
Koritsas, 2012). Nearly all of these studies were conducted using data from one point in time. As the field of DD evolved,
studies moved to examine pre- and post-measures of maternal stress. For example, in 123 families of young children with
DD, stress was stable from the initial assessment to the 12-month post assessment (Herring et al., 2006).
With the advent of more sophisticated statistical techniques, studies emerged which examined the longitudinal
perspectives of maternal stress. For example, Crnic, Gaze, and Hoffman (2005) examined stress in 125 mothers with children

* Corresponding author at: Graduate School of Education, University of California, Riverside, 900 University Avenue, Riverside, CA 92521, United States.
Tel.: +1 951 827 3875; fax: +1 951 827 3942.
E-mail address: jan.blacher@ucr.edu (J. Blacher).

0891-4222/$ – see front matter ß 2013 Published by Elsevier Ltd.

http://dx.doi.org/10.1016/j.ridd.2013.07.009
3450 G. Azad et al. / Research in Developmental Disabilities 34 (2013) 3449–3459

with TD and reported that daily hassles and major life stress were relatively stable across the preschool period. More
recently, Neece, Green, and Baker (2012) examined the developmental trajectory of maternal stress and reported that after
accounting for behavioral problems, there was an increase in stress over time (ages 3–9) for mothers of children with DD. The
present study overlaps to some extent with Neece et al. (2012) because both studies examined maternal stress over time in
families of children with and without DD. However, the present study used additional time points separated into early and
middle childhood periods, other child and mother characteristics, a more complex model and analytic technique, and a
specific ethnic composition.
It is important to examine maternal stress in early and middle childhood because these stages represent particular
benefits and challenges for parents. For example in early childhood, mothers are spending a lot more time with their young
children, many of whom are newly identified as having developmental delays (Battaglia & Carey, 2003). Therefore, it is likely
that maternal stress would be high in early childhood (Baker, Blacher, Crnic, & Edelbrock, 2002; Baker et al., 2003; Tervo,
2012). However in middle childhood, children are faced with a longer and more structured school environment. This may
result in decreases in parenting stress because parents are spending less time with their children, while at the same time
children are receiving school-based services (Blacher, Baker, & Eisenhower, 2009). On the other hand, this may give parents
an opportunity to make more peer comparisons and realize how far behind their child is, leading to more maternal stress in
the elementary years (Neece et al., 2012; Webster, Majnemer, Platt, & Shevell, 2008).

1.2. Predictors of maternal stress

The theoretical literature on stress suggests that there are four components to the stress process: (1) an external causal
event or agent, (2) a cognitive appraisal of the event of agent, (3) coping mechanisms to reduce the impact of the event or
agent, and (4) the stress reactions (Lazarus, 1993). Children’s characteristics may be causal agents of maternal stress (Neece
et al., 2012). The majority of research on maternal stress and DD has been linked to children’s behavioral problems. Several
studies indicated that children’s behavior problems, much more than their cognitive delay or disability type, accounted for
maternal stress (Baker et al., 2002, 2003; Blacher & McIntyre, 2006; Griffith et al., 2010; Herring et al., 2006; Neece et al.,
2012).
Relative to behavioral problems, there is limited research examining the relation between maternal stress and children’s
social skills. For example, Peters-Scheffer, Didden, and Korzilis (2012) reported that when behavior problems were entered
into the regression analyses, social skills (e.g., initiating social interactions) no longer predicted maternal stress. However,
other studies have suggested that children’s social skills and behavior problems both predict maternal stress. Specifically,
there could be a multiplicative effect, such that high levels of behavior problems and low levels of social skills put mothers of
children with DD at the most risk for high stress levels (Neece & Baker, 2008).
There are several maternal characteristics that also may be covariates of stress. When faced with an external agent of
stress (i.e., child characteristics), there may be individual differences in mothers’ cognitive appraisal of the event (Deater-
Deckard, 1998). For example, when children’s misbehaviors were attributed to an internal locus of control, there was an
enhanced stress reaction. However, in Latino families, mothers’ attributions often focused on an external locus of control
(Chavira, Lopez, Blacher, & Shapiro, 2000). Several studies have shown that Latino families may be less connected to
disability service systems and less able to access services such as respite care because of financial, linguistics, and/or cultural
barriers (Eisenhower & Blacher, 2006; Shapiro, Monzo, Rueda, Gomez, & Blacher, 2004). Despite these difficult
circumstances, Blacher and McIntyre (2006) reported no differences in maternal stress for Latino mothers, relative to
Anglo mothers of low-functioning young adults with intellectual disabilities.
Along with mothers’ ethnic background, socio-economic characteristics may be related to maternal stress, specifically
with regard to the coping mechanisms used in the stress process. Unfortunately, some families of children with disabilities
face financial demands that result in economic hardship (Murphy et al., 2007). This is a robust finding supported by studies
conducted by Emerson and his colleagues (Emerson et al., 2009, 2011).
A closer examination of the literature elucidates how child and maternal characteristics may fit together. First, there is a
well-established link between socio-economic status (SES) and the prevalence of ID/DD. According to Emerson et al. (2011),
exposure to socio-economic disadvantage may account for most or all of the risk of poorer mental health among mothers of
children with ID. SES is often manifested in the neighborhoods in which families reside. Some immigrant Latino families live
in low-income neighborhoods that are viewed as relatively dangerous by its inhabitants (Reese, 2002). For many Latino
parents, the family is the primary mechanism for teaching ethnic values, since la calk (literally meaning the street, but
referring more generally to outside of the home) may be a source of danger to children (Halgunseth, Ispa, & Rudy, 2006;
Reese, 2002). For Latino parents, important childrearing goals are to raise a child who will become a ‘‘good person’’ (persona
de bien) and follow the ‘‘good path’’ (i.e., el buen camino) (Goldenberg & Gallimore, 1995). Therefore in Latino families,
especially those living in low SES neighborhoods, social skills and behavioral competency are highly valued in children, and
as such, may be related to maternal stress in middle childhood above and beyond maternal stress in early childhood.

1.3. Limitations of previous research and contributions of present study

To date, there are no studies that examined maternal stress in both early and middle childhood, especially within Anglo or
Latino families. There is limited research examining the relationship between disability status (i.e., having a child with DD vs.
 G. Azad et al. / Research in Developmental Disabilities 34 (2013) 3449–3459 3451

TD) and maternal stress in middle childhood (Webster et al., 2008). Given the well-established link between behavior
problems and maternal stress (Griffith et al., 2010; Neece & Baker, 2008; Neece et al., 2012), it is reasonable to hypothesize
that behavior problems will influence maternal stress in middle childhood. However, what still remains unclear is the role of
social skills. Currently, researchers focusing on maternal stress and DD might report the impact of socio-economic variables
as independent contributors to maternal stress or control for their impact (Dekker, Koot, Van Der Ende, & Verhulst, 2002;
Quittner et al., 2010). However, failing to consider socio-economic characteristics may mask or elevate findings, possibly
leading to faulty conclusions (Stoneman, 2007).
The objective of the present study was twofold: (1) to examine the longitudinal perspectives of maternal stress in early
and middle childhood and (2) to examine the relations between maternal stress in middle childhood and previous maternal
stress, mother characteristics, and child characteristics. We examined three research questions: (1) Do mothers’ perceptions
of stress change across early childhood and middle childhood?; (2) Can maternal stress during middle childhood be
predicted by maternal stress during early childhood?; and (3) Can maternal stress during middle childhood be predicted by
mothers’ (ethnicity, socio-economic variables) and/or children’s (disability status, behavioral problems, and social skills)
characteristics?

2. Method

2.1. Participants

Participants were 219 families that participated in a larger longitudinal study of families of children with and without DD.
The study took place over a span of 11 years, with data collected at child ages 3, 4, 5, 6, 7, 8, 9, and 13. There was no data
collected at child ages 10–12. The current sample constituted 84% of the original sample and there were no statistically
significant differences between participants included and those excluded on child and mother/family characteristics of
interest in this study. Selection criteria were that children had to be between 30 and 40 months of age. Children in the TD
group were recruited at age 3 from preschools and day care programs. Children were excluded if they had any type of
disability or were born prematurely. Children in the DD group were recruited at age 3 through community agencies that
provided services for individuals with DD. Children who could not walk or had profound delays were excluded from the DD
group at initial assessment.
Children categorized as having DD had Stanford-Binet and Vineland scores of 84 or lower, indicating deficits consistent
with borderline, mild, or moderate functioning (DSM-IV-TR, APA, 2000). The average Stanford-Binet score was 61.17 (15.31)
and the average Vineland score was 65.86 (13.96). There were nine children with IQ scores less than 84, but Vineland scores
of 85 or greater. These children were categorized in the DD group because there was no statistically significant difference
between this group of nine participants and the other participants in the DD group on child and mother/family
characteristics. They were also retained because these children were considered delayed since the beginning of the study and
were receiving appropriate educational treatment for DD. The etiology of the DD group included children with Down
syndrome, autism spectrum, and cerebral palsy. Children categorized as TD had Stanford-Binet scores of 85 or higher, with
an average score of 103.33 (11.21).
Table 1 shows the demographic characteristics for the entire sample and by disability status. In the entire sample, over
half of the families (58.7%) had an annual income of over $50,000. By parent report, 77% of the mothers were Anglo and 23% of
the mothers were Latino. Slightly less than half of the mothers (43.7%) had a BS/BA or higher. A majority of mothers reported
being married (83.3%) and having good to excellent health (81.6%). Approximately 59.2% of the mothers reported working
outside of the home. There were 125 children with TD and 94 children with DD, with 60% male. Most of the children (94.2%)
were reported to be in good or excellent health.

2.2. Procedures

The Institutional Review Boards approved all procedures. Prior to the initial assessment, parents completed a telephone
interview with staff and received an informed consent. At the first assessment, consent procedures were explained again,
and parents were given the opportunity to ask questions. The Stanford-Binet and Vineland were administered to determine
disability status and eligibility for the study. In addition, parents received a questionnaire packet at each assessment session.
Ethnic status, mothers’ education, and family income were determined using information provided on the demographic
questionnaire.

2.3. Measures

2.3.1. Stanford-Binet Intelligence Scale-Fourth Edition (Thorndike, Hagan, & Sattler, 1986)
The Stanford-Binet is a widely used cognitive assessment useful for the evaluation of children with delays because the
examiner adapts starting points according to the child’s developmental level. It has been shown to be a psychometrically
sound measure of cognitive functioning among children (Glutting, 1989). Stanford-Binet scores at age 5 were used to
establish children’s disability status.
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Table 1
Demographic characteristics for the entire sample and by disability status.

Variable Entire sample (N = 219) TD (n = 125) DD (n = 94)

Annual family income

Less than $50,000 40.8% 32.6% 52.2%
$50,000 or more 58.7% 67.4% 47.8%
Mothers’ ethnicity
Anglo 168 103 65
Latino 51 22 29
Mothers’ education
Less than BS/BA 56.3% 38.4% 74.7%
BS/BA or higher 43.7% 61.6% 25.3%
Marital status
Married 83.3% 86.4% 78.9%
Not married 16.7% 13.6% 21.1%
Mothers’ health
Poor to fair 18.4% 14.5% 23.9%
Good to excellent 81.6% 85.5% 76.1%
Mothers’ employment
Works outside the home 59.2% 67.0% 47.9%
Does not work outside the home 40.8% 33.0% 52.1%
Gender
Females 88 50 37
Males 131 75 57
Children’s health
Poor to fair 5.8% 2% 53.6%
Good to excellent 94.2% 98% 46.4%
Social skills (SSRS) 93.08 (19.80) 99.47 (17.09) 83.81 (17.15)
Behavioral problems (CBCL) 54.20 (9.80) 51.79 (9.13) 57.55 (9.80)

Note. SSRS, Social Skills Rating System; CBCL, Child Behavior Checklist.

2.3.2. Vineland Adaptive Behavior Scales (Sparrow, Balla, & Cicchetti, 2005)
Children’s adaptive behavior was assessed with the Vineland Adaptive Behavior Scales (VABS) in the DD group only. The
VABS is a semi-structured interview that assesses the day-to-day activities that are necessary for children to take care of
themselves. Mothers were used as informants in the present study. Three subscales (communication, daily living skills, and
socialization) were combined to form an Adaptive Behavior Composite. VABS scores at age 5 were used to establish children’s
disability status. Cronbach’s alpha was .92.

2.3.3. Family Impact Questionnaire (Donenberg & Baker, 1993)

The FIQ is a 50-item measure that focuses on parents’ perception of the child’s impact on the family compared to the
impact of other children. Respondents (in this case, mothers) were asked to compare her child to other children his or her
age. This measure is equally suitable for children without any disabilities as none of the items are disability-laden. Sample
items are: ‘‘My child’s behavior embarrasses me in public more; I feel like I could be a better parent with my child; My child
interferes more with my opportunity to spend time with friends; It is more difficult to find a babysitter to stay with him/her.’’
Each question is answered on a 4-point scale ranging from not at all to very much. There are five scales including impact on
parenting (9 items), social relationships (11 items), finances (7 items), and if applicable, siblings (9 items), and marriage (9
items). However, we only used two subscales (i.e., impact on social relationships and parenting), which together provided a
negative impact composite. The negative impact composite is essentially a measure of maternal stress. The higher the
composite, the more stress endorsed by mothers. The FIQ has been found to relate highly to the Parenting Stress Index
(r = .84). In the present study, we utilized the FIQ at child age 3, 4, 5, 6, 7, 8, 9, and 13. Cronbach’s alpha for age 3 was .78; for
age 4 was .77; for age 5 was .80; for age 6 was .78; for age 7 was .80; for age 8 was .81; for age 9 was .81; and for age 13 was
.79.

2.3.4. Child Behavior Checklist (CBCL, Achenbach & Rescorla, 2001)

Mothers completed the CBCL for ages 6–18, a 113-item questionnaire used to identify patterns of behavior problems.
Each item was rated on a 3-point scale from 0 (not true) to 2 (very true or often true). The CBCL parent form divides behavioral
concerns into eight categories. A total score that sums all eight categories is provided as a comprehensive index of a child’s
behavior problems. The total behavior problems t-score at age 6 was used for the present study. Cronbach’s alpha was .91.

2.3.5. Social Skills Rating System (SSRS, Gresham & Elliot, 1990)
Mothers completed the elementary-level form of the SSRS, a 38-item measure about social skills and problem behaviors.
Each social skill and problem behavior item was rated from 0 (never) to 2 (very often) for ‘‘how often’’ they occur. Each social
skill item was also rated from 0 (not important) to 2 (critical) for ‘‘how important’’ the social skill is. The total score for social
skills at age 6 was used in the present study. Cronbach’s alpha for the current sample was .89.
 G. Azad et al. / Research in Developmental Disabilities 34 (2013) 3449–3459 3453

Table 2
Descriptive statistics for maternal stress.

Variable Mean Standard deviation

Maternal stress during early childhood

Y1 = Maternal stress at age 3 14.68 11.16
Y2 = Maternal stress at age 4 14.80 10.69
Y3 = Maternal stress at age 5 14.36 10.58
Maternal stress during middle childhood
Y1 = Maternal stress at age 6 14.13 10.61
Y2 = Maternal stress at age 7 13.87 10.23
Y3 = Maternal stress at age 8 13.51 10.78
Y4 = Maternal stress at age 9 13.13 10.49
Y5 = Maternal stress at age 13 12.24 9.60

3. Results

Multivariate models were used to simultaneously consider maternal stress in early childhood vs. middle childhood and
the potential predictors of maternal stress in middle childhood (Bollen & Curran, 2006). The proposed models were fit using
Mplus with full information maximum likelihood (FIML) parameter estimation to handle the presence of missing data
(Arbuckle, 1996; Muthen & Muthen, 2006). The sample descriptive statistics are presented in Table 2.

3.1. Do mothers’ perceptions of stress change across early childhood and middle childhood?

An unconditional model for maternal stress is depicted in Fig. 1. It is labeled ‘‘unconditional’’ because there are no mother
or child predictors included. The upper portion is for early childhood using three repeated measurements of maternal stress,

Fig. 1. Multivariate unconditional model for maternal stress (MS) during early childhood and middle childhood.
3454 G. Azad et al. / Research in Developmental Disabilities 34 (2013) 3449–3459

Table 3
Factor loading and mean value parameter estimates, standard errors, and critical t ratios for multivariate unconditional model.

Variable Estimate Standard error Critical ratio

Maternal stress during early childhood

Y1 = Maternal stress at age 3 0=
Y2 = Maternal stress at age 4 .85*** .26 3.21
Y3 = Maternal stress at age 5 1=
Mean value on L1 14.61*** .78 18.79
Mean value on S1 .08 .55 .15
Maternal stress during middle childhood
Y1 = Maternal stress at age 6 0=
Y2 = Maternal stress at age 7 .44* .20 2.18
Y3 = Maternal stress at age 8 .76*** .20 3.80
Y4 = Maternal stress at age 9 1.05*** .33 3.22
Y5 = Maternal stress at age 13 1=
Mean value on L2 14.24*** .66 21.58
Mean value on S2 1.06** .33 3.26

Note. L1, level factor during early childhood; S1, shape factor during early childhood; L2, level factor during middle childhood; S2, shape factor during
middle childhood.
* p < .05.
** p < .01.
*** p < .001.

with each loading onto the Level factor (L1) and the Shape factor (S1). The lower portion is for middle childhood using five
repeated measurements of maternal stress, with each loading onto the second Level factor (L2) and Shape factor (S2) (Raykov
& Marcoulides, 2006, 2008). We used the Level and Shape (LS) modeling strategy because of the unequal measurement
interval present in middle childhood. Specifically, the LS approach is only concerned with examining the proportional
magnitude of change in the measured process from one time point to the next and not the magnitude of the time points
themselves (Biesanz, Deeb-Sossa, Papadakis, Bollen, & Curran, 2004).
To evaluate model fit, three indices are commonly expected: (1) non-significant x2 goodness-of-fit value; (2) CFI > .90;
(3) RMSEA below .05, with the left endpoint of its 90% confidence interval markedly smaller than .05. Since the chi-square
test is sensitive to sample size, emphasis was placed on the other reported fit criteria (Raykov & Marcoulides, 2006, 2008).
The multivariate unconditional LS model provided the following fit criteria x2 = (18, N = 219) = 29.30, p < .05; CFI = .99; and
RMSEA = .05 (.01; .09). Based upon these criteria, the model was determined to fit the data well.
Table 3 presents the factor loadings obtained for early and middle childhood. The loadings on the Shape factor (S1)
represent the proportion of change relative to the total change occurring over the three time points for early childhood (i.e., 0,
.85, and 1). Specifically, there was evidence of minor change in maternal stress from age 3 to age 4 (.85, p < .001). The mean
value on the Shape factor (S1) was negative and not significantly different from zero 0 (mby = .08, t = .154, p = .88),
indicating that overall there was no significant change in maternal stress during early childhood (i.e., no significant change
from the initial mean value on the Level factor (L1) (may = 14.61, t = 18.79, p < .001)). There was also no significant variance in
the first Level Factor (L1) (s2 = 154.118, t = 1.13, p = .26) or the Shape Factor (S1) (s2 = 75.07, t = .55, p = .59), suggesting no
significant individual differences in starting position or in the amount of change in maternal stress over the three years. The
non-significant covariance between the first Level and Shape factors (cov = 67.34, t = .49, p = .63) indicated that initial
levels of maternal stress at age 3 were not related to the trajectory of maternal stress in early childhood and vice versa.
The estimated factor loadings on the second Shape factor (S2) (0, .44, .77. 1.05, and 1), reflect a decline in maternal stress
during middle childhood. Specifically, there was evidence of significant decline in maternal stress from age 6 to age 7 (.44,
p < .05), from age 6 to age 8 (.76, p < .001), and from age 6 to age 9 (1.05, p < .001). The mean value on the Shape factor (S2)
was negative and significantly different from zero 0 (mby = 1.06, t = 3.26, p < .05), indicating that overall there was
significant average decline in maternal stress during middle childhood (i.e., from the initial mean value on the Level factor –
may = 14.24, t = 21.54, p < .001). No significant variance was observed in the Level Factor (L2) (s2 = 95.65, t = .98, p = .33).
However, there was significant variance in the Shape Factor (S2) (s2 = 23.12, t = 2.12, p < .05), reflecting individual differences
in the amount of change in maternal stress over the five years. The non-significant covariance between the Level (L2) and
Shape (S2) factors (cov = 1.58, t = .23, p = .82) suggested that initial levels of maternal stress at age 6 were not related to
the trajectory of maternal stress in middle childhood and vice versa.

3.2. Can maternal stress during middle childhood be predicted by maternal stress during early childhood?

Table 4 shows that initial levels of maternal stress at age 3 (L1) predicted initial maternal stress at age 6 (L2) (g = .96,
p < .001); specifically, mothers who reported higher values of maternal stress at age 3 had significantly higher values of
stress at age 6. The trajectory of maternal stress from age 3 to age 5 (S1) also predicted initial levels of maternal stress at age 6
(L2) (g = 1.06, p < .001). However, maternal stress at age 3 (L1) (g = .12, p = .15) and its trajectory from age 3 to age 5 (S1)
 G. Azad et al. / Research in Developmental Disabilities 34 (2013) 3449–3459 3455

Table 4
Level and shape factors from middle childhood regressed on level and shape factors from early childhood.

Unstandardized estimate Standard error Critical ratio

Model to explain level (L2) of middle childhood

Level (L1) of early childhood .96*** .06 16.86
Shape (S1) of early childhood 1.06*** .21 4.99
Model to explain shape (S2) of middle childhood
Level (L1) of early childhood .12 .08 1.43
Shape (S1) of early childhood .07 .14 .48
*** p < .001.

Fig. 2. Multivariate conditional model for maternal stress (MS) during early childhood and middle childhood.

(g = .07, p = .63) did not significantly predict the trajectory of maternal stress from age 6 to age 13 (S2). Therefore, the
results suggested that the starting position for maternal stress during middle childhood was predicted from previous stress
levels. However, the trajectory of maternal stress during middle childhood was not predicted from previous stress levels, and
therefore, may be due to other variables.

3.3. Can maternal stress during middle childhood be predicted by mothers’ and/or children’s characteristics?

The multivariate conditional model is depicted in Fig. 2. The model is now labeled ‘‘conditional’’ because it includes three
predictors that corresponded to mothers’ characteristics and three to children’s characteristics. These included (i) mothers’
education (number of grades completed), (ii) family income (low, medium, or high), (iii) ethnic status (1 = Anglo mothers and
2 = Latina mothers), and (i) disability status at age 5 (0 = TD and 1 = DD), (ii) social skills (total social skills score on the SSRS),
and (iii) behavioral problems (total behavioral problems score on the CBCL), respectively. Although disability status was
determined at the beginning of the study (age 3), the entire sample was again re-tested when children were 5 years old, using
both a measure of cognitive development and adaptive behavior. No statistically significant difference was found between
age 3 and age 5 (x2(1) = 2.01, p > 05), and therefore, disability status at age 5 was chosen as the predictor. Child
characteristics at age 6 were used as predictors (rather than child characteristics measured earlier in development) because
this was the first year in the longitudinal study that both measures of behavior and social skills were collected.
To examine the fit of the multivariate conditional model, we used the same criteria described above. The following fit
criteria were obtained: x2 = (42, N = 219) = 70.64, p = .01; CFI = .98; and RMSEA = .06 (.03; .08), indicating that the conditional
model also fit the data well. Table 5 shows that children’s social skills significantly predicted the Level (L2) factor of middle
childhood (g = .07, p < .05), indicating that the more social skills mothers’ reported for children at age 6, the significantly
3456 G. Azad et al. / Research in Developmental Disabilities 34 (2013) 3449–3459

Table 5
Multivariate conditional coefficient estimates for level and shape factors from middle childhood regressed on mother and child characteristics.

Unstandardized estimate Standard error Critical ratio

Model to explain level (L2) of middle childhood

Mothers’ education .01 .25 .04
Family income .06 .70 .09
Ethnic status .41 1.08 .38
Disability status .002 .06 .03
Children’s social skills .07* .03 2.32
Children’s behavioral problems .27*** .07 3.77
Model to explain shape (S2) of middle childhood
Mothers’ education .43 .33 1.33
Family income .25 .87 .28
Ethnic status 1.83 1.40 1.31
Disability status .04 .07 .47
Children’s social skills .02 .04 .41
Children’s behavioral problems .18* .09 1.97
* p < .05.
*** p < .001

lower initial values on maternal stress at age 6. Children’s behavioral problems also significantly predicted the Level (L2)
factor of middle childhood (g = .27, p < .001), indicating that the more behavioral problems that mothers’ reported for
children at age 6, the significantly higher initial values on maternal stress at age 6. Next, we note that children’s behavioral
problems significantly predicted the Shape (S2) factor of middle childhood (g = .18, p < .05), indicating that the more
behavioral problems that mothers’ reported for children at age 6, the less decline in maternal stress from age 6 to age 13. The
results suggested that the starting position for maternal stress during middle childhood was predicted by children’s
characteristics, specifically their social skills and behavioral problems. However, the trajectory of maternal stress during
middle childhood was only predicted by behavioral problems.

4. Discussion

The purpose of the present study was to examine the longitudinal perspectives of maternal stress in early vs. middle
childhood and the predictors of maternal stress in middle childhood. Our findings suggested that maternal stress was
different (with regard to starting position and change over time) depending on the children’s developmental stage. In
families of children with and without DD, maternal stress remained high and stable in early childhood, but declined with
significant individual variation in middle childhood. Further, maternal stress in early childhood predicted maternal stress at
the beginning of middle childhood (age six). Children’s characteristics, particularly their behavioral problems and social
skills, predicted maternal stress in middle childhood.
In early childhood, maternal stress appeared to remain high and stable, which is consistent with earlier work (Crnic et al.,
2005). The fact that there was no significant individual variation in maternal stress at child age three, suggests commonality
in mother reports of stress when their children were young. There was also no significant individual variation in the
trajectory of maternal stress from child ages three to five, indicating that mothers stress during early childhood was
somewhat stable. One probable explanation for these results is offered by Crnic et al. (2005) who suggested that although
types of parenting challenges may change or fluctuate, one type is no more or less stressful to parents.
In middle childhood, we found that there was a significant decline in maternal stress over time. For children with and
without DD, entry into elementary school (i.e., marking the beginning of middle childhood) represents a qualitatively
different experience for both children and parents. By first grade, children are spending a majority of their time in school. The
demands of a more structured school environment, coupled with better cognitive and emotion-regulation skills may
attenuate behavior problems (Neece et al., 2012). Although we did not include children’s behavior problems as a time-
varying covariate, other studies have shown a decrease in behavior problems across childhood for children with and without
DD (de Ruiter, Dekker, Douma, Verhulst, & Koot, 2007; Neece et al., 2012). This may be one probable explanation as to why
there were decreases in maternal stress during middle childhood. In an earlier study using this sample of families, Blacher
et al. (2009) noted that the number of children with DD who were mainstreamed decreased from 40.5% at child age six to
25.7% at child age 8. It is possible that as children with DD progress from the very early grades, IEP teams recommend more
specialized placements that can target behavior problems, and subsequently reduce maternal stress at home.
Our findings also suggested that there was no significant individual variation in maternal stress at child age six. Therefore,
mothers did not differ much in their reported stress when their children entered middle childhood. However, there was
significant individual variation in the trajectory of maternal stress from child ages six to thirteen, suggesting that some
mothers did differ in how they changed in maternal stress across middle childhood. This is consistent with findings reported
by Glidden and Schoolcraft (2003), who reported significant individual variation in the trajectory of distress over the life
course for mothers of children with intellectual disabilities. One probable reason for this finding may be that as children
 G. Azad et al. / Research in Developmental Disabilities 34 (2013) 3449–3459 3457

progress through middle childhood, factors such as peer comparisons from school may be associated with increased stress
for some parents and decreased stress for other parents. For example, if parents are comparing their mild, moderate, or
borderline children with those who have severe or profound intellectual or physical disabilities, they may experience
decreased stress (Ricci & Hodapp, 2003). On the contrary, if they are comparing them to typically developing children, they
may experience increased stress (Neece et al., 2012). Finally, similar to early childhood, mothers’ reported levels of stress at
child age six were not related to changes in stress across middle childhood. In other words, for both early and middle
childhood, where mothers started off in their stress levels did not determine how they changed in their stress over time.
Overall, our findings indicated that maternal stress remained high and stable with minimal individual variation in early
childhood, but declined with significant individual variation in middle childhood.
Another major question addressed in the present study pertained to predicting later stress from earlier stress. Our
findings suggested that maternal stress at the beginning of middle childhood (child age six) was associated with maternal
stress in early childhood. This represents a fairly nuanced relation between maternal stress in early and middle childhood.
Moreover, this finding suggests that mothers of children with and without DD may benefit from interventions in early
childhood to reduce later maternal stress. For example, in other studies, some parents reported that their own coping
strategies were insufficient for dealing with stress (Hall & Graff, 2011). According to Douma, Dekker, and Koot (2006), 88.2%
of the parents in their sample needed support, particularly a friendly ear, respite care, and child mental health services. It is
likely that mothers who received support and advice when their children were young entered the middle childhood stage of
childrearing with decreased maternal stress.
The final question of interest was to examine whether mother and/or child characteristics contributed to maternal stress
in middle childhood. We found that mother’s characteristics, including ethnicity, education, and income did not predict
maternal stress at child age six, nor change in maternal stress from child ages six to thirteen. This is consistent with findings
reported by Blacher and McIntyre (2006) pertaining to young adults with intellectual disabilities, where Anglo or Latina
mothers did not differ in their reports of stress. The present findings suggest that regardless of ethnic background, all
mothers experienced the stressors associated with raising a child with DD (Blacher & McIntyre, 2006; Leyser, 1994)
We were surprised to find that socio-economic variables (i.e., education and income) were not related to maternal stress.
This is contrary to the studies conducted by Emerson and his colleagues (Emerson et al., 2009, 2011), which largely
supported the role of economic adversity in putting families at risk, even more so, than aspects of child disability or ethnicity.
One probable reason for these inconsistent findings is the level of adversity experienced by the mothers in the present
sample vs. the mothers in Emerson’s studies. For example, in the present study a little over half of the sample was employed
and over three-quarters were partnered or married. However, in the Emerson et al. (2009) study, a majority of the families
faced far more adversity with regard to income and social support. Under such drastic financial circumstances, it was not
surprising that socio-economic variables were more prominent predictors of well-being, perhaps more so than
developmental disability per se.
With regard to children’s characteristics, disability status (TD or DD) did not predict maternal stress at child age six or the
change in maternal stress from child ages six to thirteen. However, children’s behavior problems and social skills
significantly predicted maternal stress at child age six. Thus, it appeared that children’s characteristics were related to
mothers’ initial stress levels at the beginning of middle childhood. This is consistent with previous research showing that
children’s behavior problems and social skills both contributed to stress for mothers of children with and without DD
(Anthony et al., 2005; Neece & Baker, 2008).
Furthermore, children’s behavior problems significantly predicted the trajectory of maternal stress from child ages six to
thirteen. Therefore, behavior problems related to how mothers changed in their stress across middle childhood. In families of
children with DD, the types of behavioral challenges that are particularly stressful for parents include children’s emotional
reactivity and withdrawn behavior (Tervo, 2012), adaptation, mood, and distractibility (Embregts et al., 2010), and attention
problems and aggressive behavior (Dekker et al., 2002). The present study indicated that behavior problems predicted not
only where mothers started off in stress, but also how mothers changed in stress across middle childhood.
As with any study, there are some limitations to note. First, due to the complexity of the analyses and the level of detail
required to explain the results, only total scores for behavior problems and social skills were used. Second, the focus of the
present study and the analytic approach emphasized a uni-directional influence (e.g., from behavioral problems to maternal
stress); however, several studies provided evidence for the reverse influence (e.g., from maternal stress to behavioral
problems) (Baker, Heller, & Henker, 2000; Crnic et al., 2005) as well as a transactional relationship between behavioral
problems and maternal stress (Baker et al., 2003; Neece et al., 2012). Third, we are aware that future studies may consider
moderators, not examined here, such as parental coping strategies or personality attributes (Baker, Blacher, & Olsson, 2005;
Crnic et al., 2005).

4.1. Implications for practice

The results from the present study provided some insight for designing developmentally appropriate, resource efficient
interventions. Our findings suggested that in early childhood, interventions targeting stress may be imperative for mothers
of children with and without DD, especially for those who may be at an increased risk for chronic stress. A comprehensive
review of stress interventions conducted by Hastings and Beck (2004) suggested that standard service models (e.g., respite
care) reduce stress in mothers of children with intellectual disabilities. However, the evidence base was strongest for group
3458 G. Azad et al. / Research in Developmental Disabilities 34 (2013) 3449–3459

interventions using cognitive behavioral techniques (CBT). The authors indicated that the key to designing effective group
interventions was placing parents with similar needs/experiences together. Since maternal stress is high and stable in early
childhood, mothers may need standard service models and CBT with other mothers going through similar experiences. These
CBT interventions should not only target parenting strategies, but also assess the emotional context in which these strategies
are implemented (Williford, Calkins, & Keane, 2007). Since maternal stress in early childhood was a predictor of maternal
stress in middle childhood, it may also be helpful for agencies that serve young children to work collaboratively with school
social workers/counselors (Keller & Honig, 2004). Hastings and Beck (2004) recommended a model in which one mediator
works closely with the family and selected service providers in order to enhance positive outcomes.
With regard to resource efficient interventions, our results suggested that interventions targeting sources of maternal
stress are critical in middle childhood. In families of children just entering middle childhood, interventions should target an
important risk group – families of children with low social skills and high behavior problems (Neece & Baker, 2008). A
comprehensive program with both family and school components (e.g., pairing children with compatible peers, creating
circumstances to minimize conflict, providing support from teachers or mothers) has been shown to prevent increases in
children’s negativity and unusual play patterns (Guralnick, Connor, Neville, & Hammond, 2006). School based interventions
may also be implemented in collaboration with parents to facilitate child competencies and self-management (Keller &
Honig, 2004). Effective components may include targeting replacement behaviors; including activity schedules;
communicating effectively with peers; setting rules and giving time-outs (Hudson et al., 2003; Roberts, Mazzucchelli,
Studman, & Sanders, 2006).
Parents, especially mothers, are often the glue that hold together a complex network of relationships. When mothers are
stressed, there are negative consequences for other relationships within and outside the family (Dolev, Oppenheim, Koren-
Karie, & Yirmiya, 2009), which in turn, can lead to adverse outcomes for children (Baker, Neece, Fenning, Crnic, & Blacher,
2010). Therefore, interventions targeting maternal stress in accordance with developmental stage and with consideration of
particular child characteristics may not only improve the well being of mothers, but also improve the outcomes for children.

Acknowledgements

This paper was based on the activities of the Collaborative Family Study, supported by the Eunice Kennedy Shriver
National Institute of Child Health and Human Development, grant number: 34879-1459 (Drs. Bruce L. Baker, and Jan Blacher,
PIs). We are indebted to our staff, to the doctoral students who worked on this study, and to the families who participated in
this longitudinal research.

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