Title: Health Habits in Caregivers of Young Children with ASD
Description: Background. Caregivers of individuals with Autism Spectrum Disorder (ASD) are a highly stressed group and their parenting stress has been linked to increased depression, anxiety, and reduced parenting self-efficacy (Osborne & Reed, 2008; Rezendes & Scarpa, 2011; Weiss & Lunsky, 2011). Given these areas of concern that parents of children with autism experience, there is a need to look more closely at modifiable factors that improve parental well-being. As such, health habit behaviors, including sleep, diet, exercise, and substance use are modifiable factors demonstrated to be causally related to well-being in adults. The present dissertation consists of two studies that explored how parents’ engagement in health habits (sleep, diet, exercise, and substance use) related to their well-being (stress and depression) and explored the possible determinants of health habit engagement. Specifically, how parental characteristics (both psychological and demographic), social support (both relationship-based and resource-related), and child factors (child behavior and demographic variables), relate to parents’ engagement in these habits.

And, in study two, these exploratory analyses went further by examining how parent’s engagement in healthy habits relates to the observed parenting quality. Methods and Results: Study 1. Study one was a needs assessment completed by mothers and fathers (n=68) of children in an Applied Behavior Analysis (ABA) early intervention program in the northeastern United States, all at-risk for a developmental disability, many of whom were at risk for developing ASD. Parents completed questionnaires that included questions about their healthy habit engagement adapted from the Promise Neighborhoods RFA Indicators and the Promise Neighborhoods Research Consortium [PNRC] Measurement System (Promise Neighborhoods Research Consortium: Measures, 2001) as well as those related to parent, social support, and child characteristics. Parental characteristics included demographic characteristics of caregiver age and education level along with questionnaires on the parent’s psychological functioning; a measure of well-being (WHO-5; Topp, Østergaard, Søndergaard, & Bech, 2015), parental stress (PSI-4; Abidin, 2012), and caregiver depressive symptoms (PHQ-9; Kroenke, Spitzer, & Williams, 2001).

Questionnaires covering the second domain of social support included a measure of perceived social support (Interpersonal Support Evaluation List (ISEL-12); Cohen & Hoberman, 1983), marital satisfaction (Kansas Marital Satisfaction Scale; Schumm et al., 1986a), household income, and caregiver nativity. Questionnaires covering the third domain of child factors included a measure of child sleep problems (Children’s Sleep Habits Questionnaire; Owens, Spirito, & McGuinn, 2000), the ratio of children to adults in the home, child age, and child gender. Overall, about half of the caregivers reported an insufficient amount of sleep (less than 7 hours on average). A third of caregivers reported they did not exercise at all. Only a third reported eating breakfast every day, half ate only one serving of fruit most days and one serving of vegetables a day, half ate family meals prepared at home almost every day, a third ate fast food regularly, about half were told to lose weight. Most did not smoke or drink alcohol regularly.

Additionally, about 30% reported elevated levels of depressive symptoms and elevated levels of parental stress. Significant relationships were found between parental characteristics, social support, child factors, and healthy habit engagement. Of note, caregiver stress, depression, and well-being were related adversely to mother’s sleep, diet, and substance use. Perceived social support was positively related to sleep, marital satisfaction negatively to smoking, household income negatively to diet and alcohol consumption, and nativity positively to sleep, diet, and alcohol consumption. No correlations were found with child factors and healthy habits. Examining a regression model of the facilitators and barriers to healthy habit engagement, caregiver well-being positively related (t=4.015, p<.001) while child sleep disruptions negatively related to healthy habit engagement (t=-2.344, p=.026). Additionally, depression was found tomediate the relationship between healthy habit engagement and parental stress using PROCESS (CI= (-1.811, -.324), R2=.274).

Methods and Results: Study 2. Study two aimed to narrow in on a specific population of mothers of preschool-aged children with autism. Participants were 46 mother-child dyads, with children ages 2-6 to 5-6 recruited from a preschool utilizing an Applied Behavior Analysis (ABA) approach to schooling. Children had a classification of ASD, verified by the Autism Diagnostic Observation System – Two (ADOS-2) (Lord, Rutter, DiLavore, Risi, Gotham, & Bishop, 2012). Parenting behaviors, categorized as positive and harsh parenting, were observed across three tasks and coded using the Psychological Multifactor Care Scale — ASD Adapted Preschool Version (Brassard, Donnelly, Hart, & Johnson, 2016). Mothers completed the same questionnaires as study one for measures of healthy habit engagement, parental characteristics (excluding the WHO-5), and social support, There were additional child factor measures; however, including the child sleep problems and child externalizing behavior subscales from the CBCL (Achenbach & Rescorla, 2000), child language functioning (Vineland-III Communication subscale; Sparrow, Cicchetti, & Saulnier, 2016), ASD severity (ADOS-2), along with ratio of children to adults in the home, child age, and child gender.

Overall, more than half of the mothers reported an insufficient amount of sleep (less than 7 hours on average). Almost half of mothers reported they did not exercise at all. Almost half reported eating breakfast every day, a third ate only one serving of fruit most days, and half ate one serving of vegetables a day, a third ate family meals prepared at home almost every day, a third ate fast food regularly, and a third were told to lose weight. Most did not smoke. Additionally, 11% of the sample had elevated depressives symptoms and 20% had elevated levels of parental stress. Similar significant relationships were found between parental characteristics, social support, child factors, and healthy habit engagement in study two. Of note, caregiver stress and depression were related negatively to caregiver’s sleep, diet, exercise, and being overweight. More perceived social support was related to better diet, household income to not being overweight, and nativity to smoking. Correlations were also found with child factors and healthy habits; child sleep with mother’s sleep, externalizing behavior problems withsmoking, and high child to adult ratio with mother’s sleep.

Examining a regression model of the facilitators and barriers to healthy habit engagement, caregiver depressive symptoms related negatively to healthy habit engagement (t=-.380, p=.049). ASD severity (t=-.511, p=.045) and child age (t=-.523, p=.014) came out as negatively related to mother’s diet in a similar model analysis. Additionally, mothers sleep directly related to both positive (R2=.213) and harsh (R2=.165) observed parenting quality. Conclusion. The results from study one and study two suggest that sleep, diet, exercise and substance use are important for parent’s well-being in both parents of children in early intervention and mothers of preschool-aged children with autism. Furthermore, parental wellbeing was the most predictive of engagement in healthy habits when examining possible facilitators and barriers. Child sleep was an important potential barrier in parents of children in early intervention and autism severity and child age were important potential barriers to mother’s diet in mothers of preschool-aged children with ASD.

Furthermore, in study two, mothers sleep was an important factor not only for well-being but also for an objective measure of parentingquality, further strengthening the importance and value of sleep for a highly stressed population.