The Relation Between Parental Expressed Emotion and Externalizing Behaviors in Children and Adolescents With an Autism Spectrum Disorder

Abstract

The current study examined the relation between parental expressed emotion, a construct of the quality and amount of emotion expressed within the family environment that is a well-established predictor of symptom relapse in various psychological disorders, with externalizing behaviors in children and adolescents with an autism spectrum disorder (ASD). Participants were 111 parents of 6- to 18-year-old children and adolescents with an ASD who completed questionnaires measuring family environment variables (including parental expressed emotion, parental distress, and parenting practices), as well as assessing their child’s autism symptoms and emotional and behavioral functioning. Results of regression analyses indicated that parental expressed emotion, specifically criticism/hostility, accounted for 18.7% of the variance in child externalizing behaviors beyond that accounted for by demographic control variables, overinvolvement, parental distress, and parenting practices. Findings highlight a possible point of intervention for parents of children and adolescents with an ASD with concomitant externalizing behaviors.

Keywords

autism spectrum disorder expressed emotion criticism overinvolvement externalizing behaviors parenting

Along with the core symptoms of an autism spectrum disorder (ASD)—namely impairments in social skills, communication skills, and stereotyped behaviors (American Psychiatric Association [APA], 2000)—children with an ASD often present with externalizing behavior problems, including aggressive acts, tantrums, screaming, hyperactivity, and active non-compliance (Ming, Brimacombe, Chaaban, Zimmerman-Bier, & Wagner, 2008). Parenting a child with these ASD-associated behavior problems is linked to significant parental stress and distress (Karst & Van Hecke, 2012), even when controlling for the core symptoms of ASD (e.g., Davis & Carter, 2008; Herring et al., 2006). Such parental stress can leave parents of children with an ASD with a low sense of parenting efficacy and competence (Ekas, Lickenbrock, & Whitman, 2010) and may interrupt healthy parenting practices. For example, stressed and distressed parents, in general, are more likely to use negative parenting practices and less likely to use positive ones (e.g., Goodman et al., 2011). Thus, parental distress and parenting practices appear to be important parenting factors within the family environment that relate to child externalizing behaviors. Another parenting factor—parental expressed emotion (i.e., criticism/hostility or emotional overinvolvement; Brown & Rutter, 1966)—may be one manifestation of the stress parents experience from their child’s behavioral problems and may, in turn, actually perpetuate those problems. Thus, it is important to consider parental expressed emotion when exploring family environment predictors of externalizing behaviors among children with an ASD.

Fortunately, although the preponderance of research on associated behavior problems among children with an ASD has focused on child-specific predictors, researchers have more recently begun to examine family environment predictors, including the role of parental expressed emotion in predicting child externalizing behaviors. Initial studies of families with a child with an ASD indicate a relation between parental expressed emotion and child externalizing behaviors (Greenberg, Seltzer, Hong, & Orsmond, 2006; Hastings, Daley, Burns, & Beck, 2006) that holds over time (i.e., J. K. Baker, Smith, Greenberg, Seltzer, & Taylor, 2011). Thus, it appears that parental expressed emotion may be an important family environment factor to consider in clinical assessment and treatment of ASD. The overall goal of the current study was to determine whether a relation between expressed emotion and externalizing behaviors among children and adolescents with an ASD is found within a model considering other robust family environment predictors of externalizing behaviors as well.

Expressed Emotion

Originally conceptualized by Brown and Rutter (1966), expressed emotion involves making critical comments, showing signs of marked hostility (e.g., resentment, annoyance), or showing marked evidence of emotional overinvolvement (e.g., over-protectiveness of the individual that is extreme for that individual’s developmental capabilities; Butzlaff & Hooley, 1998). Correlates of expressed emotion that are well established within the schizophrenic population, such as symptom relapse (e.g., Barrowclough & Hooley, 2003), have been extended to other medical and clinical populations, including those with depression, anxiety, bipolar disorder, posttraumatic stress disorder, asthma, epilepsy, eating disorders, alcohol and drug abuse, attention deficit hyperactivity disorder (ADHD) symptoms, and behavior disorders (B. L. Baker, Heller, & Henker, 2000; Peris & Baker, 2000; Peris & Hinshaw, 2003; Stubbe, Zahner, Goldstein, & Leckman, 1993; Wearden, Tarrier, Barrowclough, Zastowny, & Rahill, 2000). Results of such studies have consistently provided evidence that expressed emotion is linked to poorer outcomes in treatment, increased problem behaviors, and relapse following release from an inpatient facility. Furthermore, when interventions have been implemented with families with high expressed emotion, particularly to reduce criticism and hostility, relapse rates were greatly decreased (Pharoah, Mari, & Streiner, 1999; Pitschel-Walz, Leucht, Bauml, Kissling, & Engel, 2001). Thus, it appears that expressed emotion is a relevant construct among families of individuals with medical or psychiatric disorders that include symptoms that may impact the interaction between the patient and family member or the functioning among the family unit. Whereas a reaction to the patient’s symptoms would be expected, the manifestation of expressed emotion, specifically, among family members appears to actually exacerbate the patient’s symptoms.

ASD and the Family

Parental Distress, Parenting Practices, and Child Behavior

Parental distress and parenting practices are family environment variables that may impact associated behaviors in children with an ASD. For example, Herring and colleagues (2006) found that the emotional and behavioral problems of a child with an ASD contributed significantly more to maternal stress, parent mental health problems, and perceived family dysfunction than did child diagnosis (ASD or non-ASD) or cognitive delay. Other studies have shown that mothers of children with an ASD exhibited more stress than mothers of children with a developmental delay without an ASD (B. L. Baker et al., 2003; Estes et al., 2009) or that, among children with an ASD, delays in the child’s ability to socially relate to others were associated with parental distress (Davis & Carter, 2008).

Whereas there has been limited research on how such stress possibly influences parenting practices among parents of children with an ASD, it is widely known that parenting stress and distress often relate to use of more negative parenting practices and less positive parenting practices and that such a pattern is associated with higher levels of child behavior problems in other clinical populations (e.g., aggressive children; Barry, Dunlap, Lochman, & Wells, 2009; ADHD; Gerdes et al., 2007). Indeed, initial studies indicate that the same types of parenting practices linked to behavior problems among these other clinical populations may also be associated with behavior problems among children with an ASD (Osborne, McHugh, Saunders, & Reed, 2008).

Thus, parental distress and parenting practices are two family environment variables that may impact associated behavior problems among children with an ASD. Another important family environment factor to consider is parental expressed emotion. Given its relation to symptomatology and relapse within other psychological disorders and its particular relevance to the problems associated with an ASD (J. K. Baker et al., 2011), parental expressed emotion should be considered further among families with a child with an ASD. Certainly, given that parental distress and the use of negative parenting practices have also been linked to child externalizing behavior, it is imperative to consider these other family environment factors in any model examining the relation between parental expressed emotion and child behavior.

Expressed Emotion and Child Behavior Among Children With Developmental Delays or an ASD

Hastings and Lloyd (2007) reviewed 11 studies examining either the base rate of expressed emotion or the relation between expressed emotion and other variables in families of children and adults with intellectual/developmental disabilities. Various measures of expressed emotion were used across the studies and included the Camberwell Family Interview (CFI; Vaughn & Leff, 1976; a common tool for assessing expressed emotion among family members of chronically disabled patients), Five-Minute Speech Sample (Magaña et al., 1986), and the patient version of the Level of Expressed Emotion scale (Cole & Kazarian, 1988). Overall, it was found that parents of children with an intellectual or developmental disability exhibit higher levels of expressed emotion, typically emotional overinvolvement, and that these measures of expressed emotion reliably and validly assessed the parents’ levels of expressed emotion (Hastings & Lloyd, 2007).

There have been very few studies specifically examining parental expressed emotion and externalizing behaviors among individuals with an ASD (e.g., Wasserman, de Mamani, & Mundy, 2010). Nevertheless, the research available suggests a relation among these constructs. For example, in examining the broad autism phenotype (BAP), Petalas et al. (2012) found that siblings demonstrated more conflict when they had mothers who demonstrated high levels of criticism toward the child with an ASD, toward the typically developing sibling of the child with an ASD, or toward both children. Likewise, Hastings and colleagues (2006) found that only the criticism/hostility component of expressed emotion, not the emotional overinvolvement component, was cross-sectionally related to externalizing behaviors in a heterogeneous sample of children with intellectual disabilities, including those with an ASD. However, neither component of expressed emotion was longitudinally related to externalizing behaviors.

In another longitudinal study on the effects of parents’ expressed emotion on their adolescent or adult children with an ASD, high levels of maternal expressed emotion (particularly levels of criticism/hostility) were related to an increase in severity and intensity of externalizing, internalizing, and socially maladaptive behaviors among individuals with autism 18 months later, even after controlling for initial levels of behavior problems (Greenberg et al., 2006). However, high levels of problem behaviors were not related to an increase in maternal criticism/hostility 18 months later (Greenberg et al., 2006). These findings suggest that, rather than a bidirectional effect, there may be a unidirectional effect of parental expressed emotion on problem behaviors in adolescent and adult children with an ASD. In fact, in a follow-up study with the original sample, these researchers examined linked trajectories of criticism and behavior problems for 7 years and found that the individual changes in these two constructs were positively correlated over time and that changes in criticism significantly predicted the final measurement of behavior problems, whereas the reverse was not true (J. K. Baker et al., 2011). These latter findings support the theory that criticism from parents precipitates—or at least perpetuates—externalizing behavior problems among children.

Rationale for Current Study and Hypothesis

The results of J. K. Baker et al. (2011), Hastings et al. (2006), and Greenberg et al. (2006) underscore the importance of the criticism/hostility component, rather than the emotional overinvolvement component, of expressed emotion in predicting externalizing behaviors among children with an ASD. Yet, none of these studies controlled for a variety of other family environment factors to consider the unique relation of parental expressed emotion. Likewise, none considered overinvolvement and criticism/hostility in the same model to determine whether criticism/hostility predicted child externalizing behaviors above and beyond the variance attributable to overinvolvement. Finally, consideration of child externalizing behaviors above and beyond the symptoms of autism (i.e., by controlling for those symptoms) has also not been universally applied. Because each of these other child- and parent-specific variables also may exacerbate child behavior problems, additional research using models with more robust controls is clearly needed to understand the potential unique role of parental expressed emotion in predicting behavior problems among children with an ASD.

Accordingly, the current study aimed to build on the existing literature by examining the unique relation of parental expressed emotion to child externalizing behaviors within a sample of children and adolescents with an ASD—after controlling for the variance that parental expressed emotion shared with parental distress, positive and negative parenting practices, and autism symptom severity. For the current study, it was hypothesized that parental criticism/hostility would uniquely positively relate to externalizing behaviors in children and adolescents with an ASD (even after controlling for any shared variance with emotional overinvolvement, ASD symptom severity, parental distress, parenting practices, and any demographic variables significantly related to externalizing behaviors), whereas a unique relation was not expected for emotional overinvolvement.

Method

Participants

Participants were 111 parents of a child with an ASD. Only one parent per household participated, and each reported data for only one child with an ASD. Parents ranged in age from 25 to 58 years (M = 42, SD = 6.75) and were predominantly mothers (97%). Children ranged in age from 6 to 18 years (M = 11, SD = 3.53). Of the 111 children, 86% were male and 14% were female; 91% were White, 4% were Black, 3% were Latino, and 2% were Mixed or Other ethnicity. The participants were sampled from 20 different states, with the majority coming from New York, Mississippi, and Missouri. When asked about the total family annual income, 34% of parents reported US$100,000 or above, 18% reported US$75,000 to US$99,999, 23% reported US$50,000 to US$74,999, 11% reported US$35,000 to US$49,999, 6% reported US$25,000 to US$34,999, 4% reported US$15,000 to US$24,999, 3% reported US$10,000 to US$14,999, and 1% reported US$4,999 or less. The range of children in the household (including the child with an ASD) was from one to five children, with a mean of 2.09.

Each child included in the sample was independently diagnosed with a Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; APA, 2000) Pervasive Developmental Disorder (i.e., ASD; APA, 2000). Specifically, 34% were diagnosed with Asperger, 44% with Autism, and 22% with Pervasive Developmental Disorder–Not Otherwise Specified (PDD-NOS). The age at which children had been first diagnosed with an ASD ranged from 1 to 17 years, with a mean age of diagnosis of 5 years old (SD = 3.45). More than 60% of the sample were diagnosed before the age of 5 years, with 77% of the sample being diagnosed by the age of 8 years. The modal age of diagnosis was from 2 to 4 years. All diagnoses were made by professionals independent of the current study: 42% were made by a psychologist, 27% by a neurologist, 16% by a psychiatrist, 13% by a pediatrician, and 2% by another professional.

Measures

Demographic and Diagnostic Questionnaire

This extensive questionnaire was used to obtain socioeconomic, sociocultural, diagnostic, and assessment information about the child and family. The questionnaire included confirmation of a diagnosis of an ASD. Parents reported on diagnostic classification, age of diagnosis, professional and affiliation making diagnosis (i.e., to rule out parents merely self-reporting that they think the child has the diagnosis), medication history, current medication type/dosage, family history of ASD diagnoses, and history and details of diagnoses of other psychological/behavioral disorders for the child (if applicable).

Child Behavior Checklist for ages 6–18 (CBCL/6–18)

The CBCL is a broadband measure of child psychopathology that consists of 113 items pertaining to behavior and emotional problems (Achenbach & Rescorla, 2001). All items are scored on a 3-point Likert-type scale ranging from 0 to 2, with 0 being Not True (as far as you know), 1 being Somewhat or Sometimes True, and 2 being Very True or Often True. The CBCL/6–18 yields age-adjusted norm-based T scores, with a mean of 50 and a standard deviation of 10. A T score of up to 65 is considered in the normal range, from 65 to 70 in the borderline clinical range, and of 70 or higher in the clinical range (Achenbach & Rescorla, 2001). The full CBCL was administered; however, only the Externalizing Problems score—a composite of the Rule-Breaking Behavior and Aggressive Behavior scales (Achenbach & Rescorla, 2001)—was of interest for the current study as the measure of externalizing behaviors in children and adolescents with an ASD. Examples of items on this composite score include “argues a lot,” “disobedient at home,” “disobedient at school,” “doesn’t seem to feel guilty after misbehaving,” and “threatens people” (Achenbach & Rescorla, 2001). The Externalizing Problems composite score has demonstrated strong test–retest reliability and internal consistency, r = .92 and α = .94, respectively, as well as construct validity when correlated with other measures of externalizing behaviors (Achenbach & Rescorla, 2001). The CBCL has been used widely in other studies to measure behavioral functioning among children with an ASD (e.g., Ozonoff, Goodlin-Jones, & Solomon, 2005; Sikora, Hall, Hartley, Gerrard-Morris, & Cagle, 2008). Internal consistency (α = .90) was also excellent for the current sample.

The Family Questionnaire (FQ)

The FQ is a brief scale assessing expressed emotion (Wiedemann, Rayki, Feinstein, & Hahlweg, 2002). The family member rates how each of 20 statements relates to their feelings about their child on a 4-point Likert-type scale (Never/Very Rarely, Rarely, Often, Very Often). Ten items pertain to criticism/hostility (e.g., “He/she irritates me”; “I have to try not to criticize him/her”; Wiedemann et al., 2002). The other 10 items pertain to emotional overinvolvement (e.g., “I often think about what is to become of him/her”; “I have given up important things in order to be able to help him/her”; Wiedemann et al., 2002). To minimize inaccurate responses, the questions in the FQ were worded intentionally, so that the negative responses would not be conceptualized as the fault of the relative, but rather as being an understandable outcome of excessive stress (Wiedemann et al., 2002).

In a validation study with the CFI, there was a high degree of agreement between the full scale of the FQ and the CFI among patients diagnosed with schizophrenia (Wiedemann et al., 2002). When using one informant, 73 of 95, or 76.8% of the participants, were correctly classified. Of these 95 participants, 55 were rated with high expressed emotion by the CFI and 44 by the FQ, whereas 40 were rated with low expressed emotion by the CFI and 29 by the FQ (Wiedemann et al., 2002). These findings show that, in comparison with the CFI, the FQ is 80% accurate in identifying high expressed emotion and 72.5% accurate in identifying low expressed emotion (Wiedemann et al., 2002). Thus, it appears to be a time-efficient alternative to the standard interview for tapping the construct of expressed emotion. For the current sample, internal consistency of both scales was good (criticism/hostility, α = .86; overinvolvement, α = .80).

Children’s Social Behavior Questionnaire (CSBQ)

The CSBQ is a measure of ASD symptom severity for children and adolescents, ages 3 to 18 (Hartman, Luteijn, Serra, & Minderaa, 2006; Luteijn, Luteijn, Jackson, Volkmar, & Minderaa, 2000). Parents rate their children, on each of the 49 items from 0 to 2, with 0 being “it does not describe the child,” 1 being “infrequently describes the child,” and 2 being “clearly applies to the child” (Luteijn et al., 2000). The CSBQ contains five scales as well as an overall severity scale. Scales include Acting-out Behaviors (e.g., “over-reacts to everything and everyone,” “quickly gets angry”), Social Contact Problems (e.g., “has little or no need for contact with others,” “lives in a world of his/her own”), Social Insight Problems (e.g., “does not fully understand what is being said to him/her,” “does not understand jokes”), Stereotypical Behaviors (e.g., “is fascinated by certain colors, forms, or moving objects,” “is extremely pleased by certain movements and keeps doing them”), and Anxious/Rigid Behaviors (e.g., “panics in new situations or if change occurs,” “opposes change”; Luteijn et al., 2000). Reliability and validity properties of the scales have been well established (Hartman et al., 2006).

For the current study, a revised CSBQ Total score was created that excluded five items (Items 30, 31, 32, 37, and 44) due to overlap in content with the outcome variable (CBCL Externalizing Problems), given that the CSBQ Total score would be used as a control variable in analyses with this outcome variable. The items removed focused on changes in mood, anger, disobedience, and stubbornness, all of which were reflected in the CBCL Externalizing Problems composite. Internal consistency within the current sample was very good with α = .92 for the original total scale and α = .92 for the revised total scale.

For descriptive purposes—and to compare the current sample with previous samples—the original CSBQ Total score was also calculated (only the revised score was used in analyses described in the Results section). Although no known studies have evaluated a cut-off total score as a measure of diagnostically categorizing children, descriptive statistics for various ASD groups are available (Hartman et al., 2006). Specifically, children in a mental retardation (MR) + PDD group had an average total score of 33.64 (SD = 15.71), children in a PDD-NOS group had an average total score of 37.84 (SD = 15.94), and children in a high functioning autism group had an average total score of 47.22 (SD = 15.37; Hartman et al., 2006). Thus, any score of 18 points or higher is within a standard deviation of the average score of at least one of the ASD groups (i.e., given that 17.93 is one standard deviation below the mean for the MR + PDD group) and can serve as a proxy for a significant score. A more conservative score of 20 has previously been used as a target score for inclusion in an ASD group for research purposes (i.e., in comparison with a control group; Henderson, Barry, Bader, & Jordan, 2011). Individual scores from the current sample ranged from 14 to 82 (median = 46, mode = 42), with only 6 of 111 participants with a score below the more conservative score of 20. On average, the current sample demonstrated high levels of ASD symptom severity (M = 46.52, SD = 16.48) based on the original CSBQ Total score.

Parenting Stress Index–Short Form (PSI/SF)

The PSI/SF is a 36-item measure designed to assess stable patterns of parental distress that are commonly linked to dysfunctional parenting (Abidin, 1995). Parents rate their perceptions on a 5-point Likert-type scale, with 1 being “Strongly Agree” and 5 being “Strongly Disagree,” on items such as “My child is not able to do as much as I expected” and “I feel alone and without friends.” Scores on the PSI/SF are reversed scored, so that higher scores represent higher levels of stress/distress. Items load onto three scales, Parental Distress, Parent–Child Dysfunctional Interaction, and Difficult Child, as well as an overall Total Stress score. For the current study, only the Parental Distress scale was used as a control variable in the analyses examining the relation between parental expressed emotion and child externalizing behavior. The Total Stress score was not used due to the overlap between the Parent–Child Dysfunctional Interaction scale and the construct of parental expressed emotion as well as between the Difficult Child scale and the construct of child externalizing behaviors. The PSI/SF scales, including the Parental Distress score, have shown strong test–retest reliability and internal consistency, and its correlation with the full-length PSI indicates that it shares the same strong validity as the full-length PSI (Abidin, 1995). The PSI/SF has been used in other studies with samples of parents of children with an ASD (e.g., Dumas, Wolf, Fisman, & Culligan, 1991; Hoffman, Sweeney, Hodge, Lopez-Wagner, & Looney, 2009; Tomanik, Harris, & Hawkins, 2004). Internal consistency for the current sample was also good, α = .89.

Alabama Parenting Questionnaire (APQ)

On the APQ, parents rate how well each of 42 items describes their parenting practices on a 5-point Likert-type scale (Frick, 1991; Shelton, Frick, & Wootton, 1996). Examples of items include “You have a friendly talk with your child” and “You feel that getting your child to obey you is more trouble than it’s worth” (Shelton et al., 1996). Although the APQ is not normed to use as a clinical measure of parenting practices, it has a strong empirical base supporting its use in research (e.g., De Los Reyes et al., 2013; Shaffer, Lindheim, Kolko, & Trentacosta, 2013) and has fairly recently updated psychometric information (including with translated versions of the measure) that reconfirms its factor structure (e.g., Essau, Sasagawa, & Frick, 2006). Scales from the APQ have also been used previously in research with ASD samples (e.g., Brookman-Frazee, Taylor, & Garland, 2010).

In the current study, Positive and Negative Parenting Composite scores were created by summing the z scores of the respective scales. The Parental Involvement and Positive Parenting scales (which were significantly correlated, r = .43, p < .001) loaded on the Positive Parenting Composite. The Poor Monitoring/Supervision, Inconsistent Discipline, and Corporal Punishment scales loaded on the Negative Parenting Composite. Poor Monitoring/Supervision and Inconsistent Discipline were significantly correlated, r = .22, p = .02, and Inconsistent Discipline and Corporal Punishment were significantly correlated, r = .27, p = .004. However, Poor Monitoring/Supervision and Corporal Punishment were not significantly correlated, r = −.06, p = .57. The two composite scores demonstrated good to excellent internal consistency in the current sample with α = .83 and α = .97 for the Positive Parenting Composite and the Negative Parent Composite, respectively. For the current study, the Positive Parenting Composite and Negative Parenting Composite were used as control variables in the analyses examining the relation between parental expressed emotion and child externalizing behavior.

Procedure

All procedures were approved by the Institutional Review Board, and copyright permission was obtained and appropriate fees were paid to use the copyrighted measures online. Participants were recruited using various methods such as an email sent on autism support group listservs and postings on websites related to autism throughout the country. Interested parents were either emailed their own unique link to the survey site to complete the questionnaires online or mailed a paper version of the questionnaires (when requested). Following informed consent, participants completed the Demographic and Diagnostic Questionnaire, CBCL, FQ, CSBQ, PSI/SF, and APQ—as well as some additional questionnaires (e.g., of sleep hygiene and sleep quality) that were used in another study with these participants. The total battery (including the additional measures) took parents approximately 1 hr to complete. A total of 116 participants were recruited and began the study, but 5 participants did not complete the entire set of questionnaires and, subsequently, were not included in the analyses. For every participant who completed the set of questionnaires, US$5 was donated to a national autism research foundation that was independent of the research team.

Results

Descriptive statistics for the variables of interest are displayed in Table 1. As noted earlier, the current sample demonstrated high levels of ASD symptom severity (M = 46.52, SD = 16.48) based on the original CSBQ, which is consistent with a clinically significant score on the CSBQ. The overall level of externalizing behaviors based on the CBCL Externalizing Problems T score was within one standard deviation of the normative range albeit slightly elevated relative to norms (M = 57.31, SD = 10.63). Thus, the sample did not exhibit a clinically significant level of externalizing behaviors (on average), and the average level of behavior problems in the current sample was lower than the mean for a referred subgroup within the standardization sample for the measure, the latter of which had average T scores ranging from 64.6 (girls, ages 12–18) to 68.5 (boys, ages 6–11; Achenbach & Rescorla, 2001). Nevertheless, with a sample standard deviation of 10.63 and a range from 30 to 81, a subset of children in the current sample (31 out of 111; 27.93% of the sample) experienced clinically significant levels (T scores ≥ 65) of externalizing behaviors, highlighting the need to determine which variables related to higher levels of these behavior problems.

Table 1.

Descriptive Statistics for Variables of Interest.

			Range
	M	SD	Minimum	Maximum	Skewness	Kurtosis
CBCL Externalizing Problems	57.31	10.63	30	81	−.14	−.44
FQ Criticism/Hostility	22.41	5.54	12	34	.15	−.77
FQ Emotional Overinvolvement	27.66	5.03	16	39	−.02	−.64
CSBQ Total ASD Symptom Severity^a	46.52	16.48	14	82	.07	−.71
CSBQ Total ASD Symptom Severity–Revised^b	41.41	14.72	13	75	.13	−.65
PSI Parental Distress	31.20	9.98	12	57	.15	−.44
APQ Positive Parenting Composite^c	0.00	0.84	−1.84	1.65	−.09	−.41
APQ Negative Parenting Composite^c	0.00	0.65	−1.17	1.65	.19	−.47

Note. CBCL = Child Behavior Checklist; FQ = Family Questionnaire; CSBQ = Children’s Social Behavior Questionnaire; ASD = autism spectrum disorder; PSI = Parenting Stress Index; APQ = Alabama Parenting Questionnaire.

The CSBQ Total score is reported descriptively for comparison with previous samples. ^bFor the current study’s analyses, a revised CSBQ Total score that excluded five items (Items 30, 31, 32, 37, and 44) due to overlap in content with the outcome variable (CBCL Externalizing Problems) was used as a control variable in analyses. ^cBased on a composite of scales which were converted to z scores and summed.

Parents in the current study demonstrated borderline to high levels of expressed emotion, although it is important to note that the FQ was established with parents of an individual with schizophrenia, not an ASD. On the FQ Criticism/Hostility scale, the average parent score for the current sample was 22.41 (SD = 5.54), with 51 of 111 parents (45.95%) meeting the cut-off score of 23 for high expressed emotion on this scale (Wiedemann et al., 2002). On the FQ Emotional Overinvolvement scale, the average parent score for the current sample was 27.66 (SD = 5.03), with 64 of 111 parents (57.66%) meeting the cut-off sore of 27 for high expressed emotion on this scale (Wiedemann et al., 2002). Thus, the FQ scales did appear to assess elevated levels of expressed emotion within this sample of parents of a child with an ASD.

Zero-order correlations were performed among the variables of interest to determine how they were interrelated prior to conducting the regression analyses (see Table 2). As expected, with the exception of the APQ Positive Parenting Composite, all of the variables significantly related to the CBCL Externalizing Problems composite. It is important to note that the main predictor variables of interest, FQ Criticism/Hostility and FQ Emotional Overinvolvement, were significantly positively correlated with the CBCL Externalizing Problems composite score, r = .65, p < .001 and r = .32, p = .001, respectively. Also, both scales from the FQ, Criticism/Hostility and Overinvolvement, were significantly correlated, r = .54, p < .001. Although significantly correlated with one another, the FQ scales were examined as separate constructs (entered simultaneously) in their relation to child externalizing behaviors to determine the unique contribution of each domain. This decision was further supported when applying Steiger’s (1980) method for comparing two dependent correlations (i.e., those sharing one common variable—the associated feature), which indicated that the magnitude of the correlation between criticism/hostility and child externalizing behaviors was significantly higher than the magnitude of the correlation between overinvolvement and child externalizing behaviors, t(108) = −2.57, p = .012.

Table 2.

Correlations Among Variables of Interest.

	1	2	3	4	5	6	7
1. CBCL Externalizing Problems	—	.65***	.32**	.53***	.27**	−.01	.34***
2. FQ Criticism/Hostility		—	.54***	.38***	.38***	−.18^†	.44***
3. FQ Emotional Overinvolvement			—	.33***	.51***	.06	.14
4. CSBQ Total ASD Symptom Severity–Revised^a				—	.24*	.01	.14
5. PSI Parental Distress					—	−.12	.17^†
6. APQ Positive Parenting Composite						—	−.26**
7. APQ Negative Parenting Composite							—

Note. CBCL = Child Behavior Checklist; FQ = Family Questionnaire; CSBQ = Children’s Social Behavior Questionnaire; ASD = autism symptom severity; PSI = Parenting Stress Index; APQ = Alabama Parenting Questionnaire.

The CSBQ Total score was revised to remove five items that overlapped in content with the CBCL Externalizing Problems score.

†

p < .10 (trend). *p < .05. **p < .01. ***p < .001.

Zero-order correlations were also performed with demographic variables to determine if any were significantly related to externalizing behaviors. Categorical variables were dichotomized (e.g., race was coded as White or non-White) before calculating correlation coefficients. Child’s age, r = −.21, p = .03, parent’s age, r = −.26, p = .01, and total family income, r = −.28, p = .003, significantly related to the CBCL Externalizing Problems composite. Thus, these three demographic variables were controlled for in further analyses. In addition, based on an a priori decision, ASD symptom severity (revised score), parental distress, positive parenting practices, and negative parenting practices were used as control variables. The number of children in the home did not correlate with the CBCL Externalizing Problems composite (nor any of the parental distress or expressed emotion variables) and, therefore, it was not used as a control variable.

A hierarchical multiple regression analysis (Baron & Kenny, 1986) was conducted to examine the two components of expressed emotion (criticism/hostility and emotional overinvolvement) as predictors of child externalizing behaviors. Step 1 included the control variables—the correlated demographic variables (child’s age, parent’s age, total family income) and the a priori control variables (ASD symptom severity—revised score, parental distress, positive parenting practices, and negative parenting practices). Step 2 included the two components of expressed emotion (criticism/hostility and emotional overinvolvement). Both components of expressed emotion were entered simultaneously, so that the amount of variance in child externalizing behaviors accounted for by parental expressed emotion could be evaluated (i.e., through an examination of R²Δ at Step 2) and so that the unique relation of each component of parental expressed emotion and child externalizing behaviors could be evaluated (i.e., through an examination of the β-weights).

Results revealed that the full model significantly predicted the CBCL Externalizing Problems composite, F(9, 101) = 16.68, p < .001; R² = .60. Table 3 displays R² for Step 1 and R²Δ for Step 2 as well as the standardized regression coefficients for each variable. After controlling for the demographics and other parenting variables, parental expressed emotion still accounted for 18.7% of the variance in child externalizing behaviors, which was a significant increase, F(2, 101) = 23.49, p < .001. An examination of the β-weights indicated that FQ Criticism/Hostility significantly predicted the CBCL Externalizing Problems composite, β = .60, p < .001, even when controlling for all other variables (including the other component of expressed emotion), whereas the unique contribution of FQ Emotional Overinvolvement in predicting the CBCL Externalizing Problems composite did not, β = −.15, p = .08. Notably, although the zero-order correlation between FQ Emotional Overinvolvement and the CBCL Externalizing Problems composite was significant and positive, r = .32, p = .001, the direction of the relation between these two variables was negative once the other variables were entered into the regression analysis, suggesting a suppressor effect from the other variables. This finding was not interpreted, however, given that the relation was non-significant.

Table 3.

Expressed Emotion Predicting Externalizing Behaviors in Children With an ASD.

	CBCL Externalizing Problems
Model 1 (control) R²	.41***
Child’s age	−.17^†
Parent’s age	.01
Total family income	−.13
CSBQ Total ASD Symptom Severity–Revised^a	.45***
PSI Parental Distress	.06
APQ Positive Parenting Composite	.03
APQ Negative Parenting Composite	.25**
Model 2 (main effects) R²Δ	.19***
FQ Criticism/Hostility	.60***
FQ Emotional Overinvolvement	−.15^†

Note. Beta-weights reported for each predictor. R² and R²Δ for models are shown in bold. CBCL = Child Behavior Checklist; CSBQ = Children’s Social Behavior Questionnaire; ASD = autism symptom severity; PSI = Parenting Stress Index; APQ = Alabama Parenting Questionnaire; FQ = Family Questionnaire. Overall Model 2, F(9, 101) = 16.68, R² = .60, p < .001.

The CSBQ Total score was revised to remove five items that overlapped in content with the CBCL Externalizing Problems score.

†

p < .10 (trend). **p < .01. ***p < .001.

Discussion

The findings of the current study supported the hypothesis that high levels of parental criticism/hostility, a component of expressed emotion, uniquely related to high levels of externalizing behaviors in children and adolescents with an ASD, even after controlling for emotional overinvolvement (i.e., another component of expressed emotion), ASD symptom severity, parental distress, parenting practices, and demographic variables related to child externalizing behaviors. As hypothesized, criticism/hostility accounted for the overall relation between parental expressed emotion and externalizing behaviors in children and adolescents with an ASD. In fact, this is the first known study to demonstrate the relation between parental expressed emotion and externalizing behavior among children and adolescents with an ASD using such a robust set of control variables, particularly considering other aspects of the family environment.

Parental emotional overinvolvement was not expected to uniquely contribute to the prediction of externalizing behaviors in children and adolescents with an ASD. However, it did positively relate to child externalizing behaviors at the zero-order level, and there was an unexpected trend (i.e., a marginal negative relation between emotional overinvolvement and child externalizing behaviors after controlling for all other variables). This unanticipated finding underscores the potential importance of parental expressed emotion, in general, in predicting behavior problems in children and adolescents with an ASD. It also suggests that multiple elements of parental expressed emotion—not only criticism/hostility but also emotional overinvolvement—may be important considerations for the ASD child and adolescent population and that the pattern of relation may be complex when considering other variables. This pattern of findings differs from the conclusions of Greenberg et al. (2006), who studied this issue among adolescents and adults with an ASD, and Hastings et al. (2006), who studied this issue among a heterogeneous sample of children with intellectual disabilities that included non-ASD children as well as children with ASD. Such a variation may suggest that emotional overinvolvement exhibits a stronger effect size among the ASD population (rather than a general intellectual disabilities population) and among younger children and adolescents (rather than adolescents/adults) with an ASD.

Still, criticism/hostility is the only unique predictor among the elements of parental expressed emotion. The finding for criticism/hostility was robust and held even when controlling for other parenting variables. That is, the relation between parental expressed emotion and child externalizing behaviors does not appear attributable to overall distress or use of specific parenting practices. This robust finding further highlights the potential benefits of exploring parental criticism/hostility as a significant family environment variable.

Theoretical and Clinical Implications of the Findings

The current study adds to the expressed emotion literature by broadening support for the overall utility of considering parental expressed emotion as a significant family environment variable and showing that its relation to child externalizing behaviors generalizes to children and adolescents with an ASD. Specifically, it expands Greenberg and colleagues’ (2006) and J. K. Baker and colleagues’ (2011) findings to a younger child and adolescent population and Hastings and colleagues’ (2006) findings to a more diagnostically homogeneous sample of children and adolescents with an ASD. The current study also included more controls than the previous studies, highlighting the robust relationship between parental expressed emotion and externalizing behaviors.

It is widely accepted that decreasing expressed emotion in family members is an integral component of some treatments for other disorders, specifically schizophrenia (Pharoah et al., 1999; Pitschel-Walz et al., 2001), as well as depression, anxiety, health disorders, and behavior disorders (Butzlaff & Hooley, 1998; Stubbe et al., 1993; Wearden et al., 2000). The current study suggests that addressing family environment variables by adding a component to decrease parental expressed emotion for parents of children and adolescents with an ASD may also be beneficial. Further studies examining the benefits of adding such a component to the overall treatment package for children and adolescents with an ASD are warranted.

Furthermore, the findings of the current study provide some initial support for the theory that the behavior of children and adolescents with an ASD may be explained by the manner in which parents respond. Parents who exhibit higher levels of criticism/hostility likely react to their children’s externalizing behaviors in a more emotional manner than those with lower expressed emotion. This emotional reaction, with its reinforcing property of attention, could then serve to exacerbate both the frequency and intensity of the children’s externalizing behaviors. Thus, it follows that a training protocol aimed at addressing family environment variables by reducing expressed emotion may aid parents in not reacting in emotional or overinvolved ways, but rather in ways that may be more beneficial at minimizing child externalizing behaviors.

Indeed, a training protocol aimed at reducing expressed emotion has resulted in improved child behaviors, although the exact mechanism of change is still unclear (Kuipers, 2006). In this protocol, the therapist helps families (a) understand specifically what is happening, what it means, and how the symptoms relate to the difficult behaviors; (b) address issues through constructive problem-solving techniques and reappraise problems and solutions; and (c) identify ways to manage and contain their emotions (Patterson, Birchwood, & Cochrane, 2005). In fact, this protocol has some similarities with parental mindfulness training, which also has been shown to lower maladaptive behaviors in children with an ASD in a pre–post study (Singh et al., 2007). When a parent is mindful (i.e., fully in the present moment), the parent can respond to his or her child’s maladaptive behavior in alternative, non-judgmental, and more effective ways (Kabat-Zinn, 1994). Thus, mindfulness training addresses many similar issues that are implicated for parents experiencing high levels of expressed emotion, given that it trains parents to not react in critical, emotional, or overinvolved ways—but, rather, in more efficient and beneficial ways.

As illustrated above, treatment packages to address externalizing behaviors in children with an ASD have been exploring (and addressing) what family environment variables may be affecting the child’s behaviors as well. With parental expressed emotion having such a robust relationship with externalizing behaviors in children with an ASD, it appears only fitting that this begin to be included as a family environment variable to be addressed.

Limitations and Directions for Future Research

Several limitations of the current study should be mentioned. First, use of a monoinformant design could result in a rater response set such that parents may have answered similarly (negatively or positively) across measures, which can inflate relations among constructs. However, the nature of the parent constructs lends itself to self-report and, for this population, parent ratings of child behavior are widely used. Furthermore, the results do provide preliminary evidence of a relation among the constructs of interest within a child and adolescent ASD sample. Future studies should attempt to replicate these finding with other methods and other informants. For example, teachers could rate classroom behavior of children and adolescents with an ASD; teachers could also provide ratings of their own expressed emotion, given their high level of involvement with children and adolescents with an ASD.

Second, the child’s diagnosis was not corroborated with assessment measures beyond the CSBQ, which could draw into question the validity of their diagnosis. However, notably, the Demographic and Diagnostic Questionnaire provided extensive information to ascertain that a diagnosis had been made by an independent practitioner. Likewise, the current sample’s mean fell within a clinical range for ASDs on the CSBQ. Nevertheless, more detailed diagnostic information, including structured clinical interviews or standardized observation schedules, would be helpful to determine whether diagnostic classification (e.g., Autistic Disorder, Asperger Disorder, PDD-NOS) moderates the relation between parental expressed emotion and child externalizing behavior.

Third, the study was designed to include a broad age range to examine the issue of predictors of externalizing behaviors among both children and adolescents with an ASD. Still, the broad age range could be a limitation in that the meaning—and the resulting relation—of parenting behaviors and attitudes (including the expressed emotion constructs) could vary across developmental periods. Notably, however, age was used as a covariate in the models to control for any confound with age. Likewise, post hoc analyses were conducted to ensure that age did not moderate the relation between parental expressed emotion (criticism/hostility or emotional overinvolvement) and child externalizing behaviors for the current sample, and the interactions were non-significant, F(1, 107) = 1.16, p = .28; R²Δ = .01 and F(1, 107) = .14, p = .71; R²Δ = .00 for age by criticism/hostility and age by emotional overinvolvement, respectively. Thus, age was not a moderator in the relation between parental expressed emotion and child externalizing behaviors.

Fourth, although support groups, listservs, and websites were used to sample throughout the country (in both rural and urban settings), the majority of the sample included White, married parents with higher socioeconomic standing, who are also active in autism support groups. Furthermore, given the solicitation method, participants were a non-random, self-selected sample. Given that this sample of parents was already involved in autism support groups, they may have had even more support than other parents of children with an ASD. Thus, the findings may not generalize to all parents of children and adolescents with an ASD. In fact, it could be that the sampling method attenuated the relation between parental expressed emotion and externalizing behaviors in children with an ASD (i.e., to the extent that parental social support may serve as a moderator in that relation). Future studies should include more diverse samples in regard to race, socioeconomic status, marital status, and involvement in supportive activities. In addition, future research should assess parental support to determine whether it reduces parental expressed emotion as well as whether it serves as a protective factor in the relation between parental expressed emotion and child externalizing behaviors among children with an ASD.

Finally, the conclusions that can be drawn are further limited by the correlational design of the study, and no causal effects can be determined. It is possible, as we theorize, that parental expressed emotion further exacerbates externalizing behaviors among children and adolescents with an ASD. However, it is also possible that higher externalizing behaviors in children and adolescents lead to higher parental expressed emotion. The former conclusion is best supported by previous research with an adolescent and adult ASD sample (e.g., J. K. Baker et al., 2011; Greenberg et al., 2006). Thus, it is likely that the same pattern exists within this sample of younger children and adolescents with an ASD. If that same pattern does exist, it would highlight an important point of intervention in the treatment of children and adolescents with an ASD. However, to fully address this issue and formulate less tentative causal conclusions, a longitudinal study that allows a comparison of changes from Times 1 to 2 in both the parental and child variables is needed.

Conclusion

In conclusion, whereas there are various limitations listed above (monoinformant design; self-selected, non-representative sample; broad age range; child’s diagnosis was not corroborated with assessment measures; and correlational design), the current study adds to both the autism and expressed emotion literature, as it is the first known study looking at the relation between parental expressed emotion and externalizing behaviors in a homogeneous sample of children and adolescents with an ASD. The current study provides a basis to now further explore this relation, possibly examining theoretically relevant moderators, testing causal relationships, and assessing benefits of focusing on reducing the family environment variable of parental expressed emotion for children and adolescents with an ASD. Such research can foster a deeper understanding of assessment, diagnostic, and treatment issues for children and adolescents with an ASD in an effort to minimize the impairments associated with this set of disorders. Ultimately, if a causal relationship between parental expressed emotion and externalizing behaviors in children and adolescents with an ASD is found, then lowering parental expressed emotion could become an important point of intervention as a component of a larger treatment package aimed at decreasing externalizing behaviors in children and adolescents with an ASD.

Footnotes

Authors’ Note

Stephanie H. Bader was affiliated with Kennedy Krieger Institute, Baltimore, MD, USA, during the writing of the article.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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