Disabilities | Free Full-Text | Behavior Problems among Children of Mothers with Mild Intellectual Disability: The Role of Maternal Sensitivity, Trauma History, and Intelligence

Parenting in the context of ID has long been discouraged, and persons with ID, particularly women, were long subjected to societally organized sterilization practices [5]. Parental rights have now been established in the UN Convention on the right of Persons with Disabilities (UNCRPD; 2006). Yet, skepticism prevails, with negative attitudes centered on concerns regarding the quality of care provided by parents with ID [6]. More specifically, there are widespread beliefs that parental ID in and of itself results in an inability to provide sufficient childcare [7]. Accordingly, parental ID increases the likelihood of child out-of-home placements, even when controlling for case-specific factors [1].

Parents with ID and their children do constitute high-risk families in need of support. The parents are at risk of caregiving difficulties, including insufficient childcare skills and limited knowledge about child development [2,8]. The children are also at risk of developmental delays and behavior problems [3]. Moreover, the families are at elevated risk for care assessments and, as noted, for child out-of-home placements, most commonly due to concerns about neglect and the parents’ interactional skills [9]. In fact, it has been estimated that 30–50 percent of children to a parent with ID are placed in out-of-home care, and that approximately 20 percent of all children who are removed by child protection services have parents with intellectual or cognitive impairments [1,10]. This pattern of findings, together with insufficient access to evidence-based interventions, has likely contributed to the current pessimism regarding these parents’ and children’s prospects.

Nonetheless, we reiterate that families headed by parents with ID are heterogeneous. A substantial proportion of the parents provide good-enough care, and a good-enough home-environment, for their children [11]. Many of these parents are also receptive to caregiving interventions, when adapted to their cognitive needs [2,12,13]. Further, the children exhibit significant variation in developmental outcomes [3]. The critical question is thus not whether the parents can be competent caregivers who support their children’s development; it is about discerning which parents and children need additional support, and with which aspects of caregiving and child development. A key question, therefore, concerns distinct aspects of caregiving that may be challenging and predictive of child development [14]. Another important question concerns contextual factors that influence caregiving behavior and child development [4,15].

Research on the development of children to parents with ID, and potential contributions of caregiving, can be divided into direct and indirect studies [16]. Systematic direct studies, including observations of caregiving behavior, are scarce. This is not surprising given the well-attested difficulties to do such research with these vulnerable families, particularly quantitative research. Reasons include, but are not limited to, the low percentage of people diagnosed with ID, of whom mainly those with mild ID become parents; the high proportion of families separated due to child out-of-home placements; that families must often be recruited through professionals, who may act as gate keepers; and that the parents may decline participation for a number of reasons (for a discussion, see [3]).

Not surprisingly, then, early observational research of caregiving had various limitations, including very small sample sizes, brief and unrepresentative observations of parent-child interactions, and absent or insufficient comparison groups [8,15,16]. Yet, this pioneering research indicated that parents with ID may interact less with their children, be less sensitive, use less praise and reinforcement, and issue more commands. While the designs often precluded examination of associations with child development, links were found between the quality of the home environment (including parental involvement and responsivity) and children’s cognitive development [17].

Subsequent observational research has largely been done in the context of caregiving interventions and, while paramount for evidence-based support, have rarely examined effects on the children [2,12,13]. Indeed, Collings and Llewellyn [3] have argued that there has been a preoccupation with caregiving interventions, and that child outcomes have been a secondary interest. Exceptions include studies by Feldman et al. [18,19,20], who found that training of parents’ interactional skills, such as imitating child vocalizations, had a positive impact on children’s use of language.

Direct research on caregiving in relation to children’s socioemotional development has been particularly scarce. Feldman and Walton-Allen [21] found that child behavior problems were common, more so than among similarly impoverished comparison children, and predicted by the quality of the home environment. Yet, later research has failed to replicate this association [14]. There is thus a need for direct research examining caregiving in relation to child development, particularly socioemotional development.

Most research on the development of children to parents with ID, and the potential influence of caregiving, has been indirect, based on associations between parental ID and children’s developmental outcomes. Collings and Llewellyn [3] only found 26 studies concerning child development, 11 of which had a primary focus on child outcomes, and the vast majority were indirect. Many of these studies found that the children are at elevated risk for developmental delays and disabilities [20,22,23,24]. However, the child outcomes studied often pertained to highly genetically heritable phenomena (e.g., autism, intellectual disability). While informative concerning developmental prospects, it is invalid to infer effects of caregiving from indirect designs, particularly when such child outcomes are studied. Indeed, controlling for genetically based vulnerabilities has been found to erase most deviations from age-norms [14].

Collings and Llewellyn [3] also highlighted that a notable portion of the studies were based on case files from child protection or service agencies; only six studies used community samples. Such sampling strategies may skew the results toward families who experience difficulties and need support, which in turn may be due to factors beyond the parents’ ID. Indeed, scholars have long observed that families headed by parents with ID tend to be disadvantaged, and have called for research on contextual risk-factors [8,15,16]. Such factors include, but are not limited to: socioeconomic adversity [25]; teenage parenthood, single parenthood and partners with behavioral or emotional problems [26]; and social isolation and limited social support [27]. Not surprisingly, parenting stress is very common [28], sometimes even at clinical levels [29].

A recent approach to addressing the importance of contextual risk-factors for the children’s development is population-based studies, enabling large samples and control for contextual factors. Prior to controlling for contextual factors, such studies have tended to find that children of parents with ID are at elevated risk for suboptimal development (e.g., injuries, hyperactivity, externalizing problems, mental illness, developmental delays, peer problems). Yet, findings have been inconsistent following control for socioeconomic factors; while some have found elevated risk for adverse outcomes even after such controls [30,31], other studies have found that pertinent controls erase group differences [32,33]. Importantly, these studies have used preexisting, notably heterogenous samples and operationalizations, making it difficult to synthesize findings. Nonetheless, Schuengel et al. [34] concluded that contextual factors account for a substantial proportion of the risks for the children. While obviously important, the population-based studies have not included observational measures of caregiving and are thus, still, indirect.

Feldman [35] has developed a contextual model of caregiving for parents with ID, the components of which have been supported in many studies [4]. A key component is parental experiences of abuse, trauma and maltreatment (ATM), which are robustly linked to suboptimal caregiving and child development in the general population [36,37]. Regarding parents with ID and their children, McGaw et al. [26,38] found that the parents were at elevated risk of ATM, and that such experiences were better than the parents’ intelligence in predicting whether social services had registered concern. Similarly, Feldman et al. [39] found that childhood experiences of ATM among parents with ID predicted child leaning and developmental difficulties. Recently, a systematic review found that a majority of parents with ID had experienced ATM, and that such experiences were linked to caregiving-related variables [40]. However, very few studies had examined links to child development, and those which had yielded inconsistent results, indicating a need for additional research.

The current study is part of a larger project. Motivated by the knowledge gaps described above, the project aims to further knowledge on caregiving behavior among mothers with ID, their children’s development, and influential factors. To this end, the project includes direct observations of maternal sensitivity—the ability to notice, interpret and respond to child signals timely and appropriately—a key caregiving behavior linked to many aspects of child development among other populations [41]. Moreover, the project includes examination of a contextually based influential factor in the form of maternal experiences of abuse, trauma and maltreatment (ATM). Finally, since previous direct research has been critiqued for insufficient comparison groups, the project includes a socioeconomically matched comparison group. Previous studies from the project have examined maternal sensitivity in relation to maternal experiences of ATM [42,43]. Mothers with ID showed notable within-group variation in sensitivity, but were significantly lower than the comparison mothers. However, the mothers with ID had also experienced markedly more ATM; in fact, a majority had experienced physical and sexual abuse, and a large minority emotional abuse and neglect. Crucially, maternal experiences of ATM predicted low maternal sensitivity. Yet, children’s psychosocial adaptation, and factors influencing adaptation, remains to be examined.

The aim of the present study was to further knowledge on the development of children to mothers with mild ID and influential factors. The study was, as reviewed above, motivated by a scarcity of direct research on caregiving behavior in relation to child developmental outcomes [3], and a need for further research on contributions from contextual factors [4]. To this end, the study examined contributions from maternal sensitivity and maternal experiences of ATM. The roles of maternal and child intelligence were also examined. We asked the following, specific research questions:

• Do children to mothers with mild ID show higher levels of behavior problems than socioeconomically matched comparison children?

• Are behavior problems among children to mothers with mild ID predicted by maternal sensitivity, maternal ATM, and maternal and child intelligence?

Concerning the first research question, we hypothesized that children of mothers with ID would be rated higher in behavior problems. This hypothesis was based on previous direct and indirect research, which has indicated elevated risks for these children [3,21]. As regards the second research question, we hypothesized that caregiver sensitivity would be associated with child behavior problems. This hypothesis was based on consistent links between maternal sensitivity and various aspects of child development among other populations [41]. Moreover, we hypothesized that maternal experiences of ATM would be linked to child behavior problems. This hypothesis was based on links between maternal ATM, caregiving behavior and child development among parents and children from the general population [36,37], and links between maternal ATM and caregiving-related factors among parents with ID [40]. Finally, we treated it is as an open question whether maternal and child intelligence would be linked to child behavior problems, since previous research has been inconsistent [3,26,38].