The Association Between Emotional and Behavioral Problems in Children with Autism Spectrum Disorder and Psychological Distress in Their Parents: A Systematic Review and Meta-analysis.

Most studies relied on parent self-reports for both their own distress and their child's behavior, which can inflate associations due to shared method bias. When alternative raters were used, the effect size was smaller. The review is largely cross-sectional, so it cannot definitively establish causality or the direction of the relationship between child problems and parent distress. There was significant heterogeneity between studies, particularly in the parenting stress analyses, which may be partly due to differences in how parenting stress was measured (e.g., some scales included items about child behavior). The review did not include studies using biomarkers for stress, such as cortisol, which might have provided different insights into physiological distress.

The authors declare no conflicts of interest. The study was funded by Autistica, the Dr. Mortimer and Theresa Sackler Foundation, the National Institute for Health Research, South London and Maudsley NHS Foundation Trust, the European Union Innovative Medicines Initiative, the Medical Research Foundation, the Economic and Social Research Council, and Guy’s and St Thomas’ Charity.

Do not assume that child behavioral problems are the sole cause of parental distress or vice versa. The association is bidirectional and influenced by other factors like ASD severity and parental coping styles. Furthermore, the strength of the link is partly dependent on who rates the child's behavior, with parent-reported associations being stronger than those rated by others, suggesting a potential bias in perception.