A cross-sectional study to assess the prevalence of DSM-5 specific learning disorders in representative school samples from the second to sixth grade in Brazil.

Little is known about specific learning disorder (SLD) in low- and middle-income countries (LMICs), and even less from representative school samples in small size cities outside huge urban centers. Few studies addressed the new DSM-5 criteria for SLDs. We investigated the prevalence of DSM-5 SLDs, their comorbidities and correlates in school samples of students from the second to sixth grades living in median cities from four different geographic regions in Brazil. A national test for academic performance covering reading, writing and mathematical abilities was applied. Psychiatric diagnoses were assessed by the K-SADS-PL applied to the primary caregiver. A total of 1618 children and adolescents were included in the study. The following prevalence rates of SLDs were found: 7.6% for global impairment, 5.4% for writing, 6.0% for arithmetic, and 7.5% for reading impairment. Attention-deficit/hyperactivity disorder (ADHD) was the only comorbidity significantly associated with SLD with global impairment (p = 0.031). Anxiety disorders and ADHD were associated with SLD with arithmetic impairment. Significant differences were detected in prevalence rates among cities, and several socio-demographic correlates (age, gender, IQ, and socioeconomic status) were significantly associated with SLD with global impairment in our sample. Careful validation and normatization of instruments to assess academic performance is a major problem in LMICs. As expected, we found a significant heterogeneity in prevalence rates of SLD according to geographic regions considering that Brazil is a country with a robust diversity. SLD with global and arithmetic impairment was significantly associated with psychiatric comorbidities.

Evaluating the effectiveness of a training program that builds teachers' capability to identify and appropriately refer middle and high school students with mental health problems in Brazil: an exploratory study.

BACKGROUND: In Brazil, like many countries, there has been a failure to identify mental health problems (MHP) in young people and refer them to appropriate care and support. The school environment provides an ideal setting to do this. Therefore, effective programs need to be developed to train teachers to identify and appropriately refer children with possible MHP. We aimed to evaluate teachers' ability to identify and appropriately refer students with possible MHP, and the effectiveness of a psychoeducational strategy to build teachers' capability in this area. METHODS: To meet the first objective, we conducted a case-control study using a student sample. To meet the second, we employed longitudinal design with repeated measures before and after introducing the psychoeducational strategy using a teacher sample. In the case control study, the Youth Self-Report was used to investigate internalizing and externalizing problems. Before training, teachers selected 26 students who they thought were likely to have MHP. Twenty-six non-selected students acted as controls and were matched by gender, age and grade. The underlying principle was that if teachers could identify abnormal behaviors among their actual students, those with some MHP would likely be among the case group and those without among the control group. In the longitudinal study, 32 teachers were asked to evaluate six vignettes that highlighted behaviors indicating a high risk for psychosis, depression, conduct disorder, hyperactivity, mania, and normal adolescent behavior. We calculated the rates of correct answers for identifying the existence of some MHP and the need for referral before and after training; teachers were not asked to identify the individual conditions. RESULTS: Teachers were already able to identify the most symptomatic students, who had both internalizing and externalizing problems, as possibly having MHP, but teachers had difficulty in identifying students with internalizing problems alone. At least 50.0% of teachers learned to identify hypothetical cases as problematic and to make the appropriate referral, and 60.0% of teachers who before training could not identify normal adolescence learned to do so. CONCLUSIONS: The strategy was partially effective but could be improved mainly by extending its duration, and including discussion of actual cases.

Influence of psychosocial risk factors on the trajectory of mental health problems from childhood to adolescence: a longitudinal study.

BACKGROUND: Longitudinal epidemiological studies involving child/adolescent mental health problems are scarce in developing countries, particularly in regions characterized by adverse living conditions. We examined the influence of psychosocial factors on the trajectory of child/adolescent mental health problems (CAMHP) over time. METHODS: A population-based sample of 6- to 13-year-olds with CAMHP was followed-up from 2002-2003 (Time 1/T1) to 2007-2008 (Time 2/T2), with 86 out of 124 eligible children/adolescents at T1 being reassessed at T2 (sample loss: 30.6%). OUTCOME: CAMHP at T2 according to the Child Behavior Checklist/CBCL's total problem scale. Psychosocial factors: T1 variables (child/adolescent's age, family socioeconomic status); trajectory of variables from T1 to T2 (child/adolescent exposure to severe physical punishment, mother exposure to severe physical marital violence, maternal anxiety/depression); and T2 variables (maternal education, child/adolescent's social support and pro-social activities). RESULTS: Multivariate analysis identified two risk factors for child/adolescent MHP at T2: aggravation of child/adolescent physical punishment and aggravation of maternal anxiety/depression. CONCLUSIONS: The current study shows the importance of considering child/adolescent physical punishment and maternal anxiety/depression in intervention models and mental health care policies.

Temperament and character traits in children and adolescents with major depressive disorder: a case-control study.

OBJECTIVES: To evaluate temperament and character traits using the Junior Temperament and Character Inventory (JTCI) in children and adolescents with major depressive disorder (MDD) in comparison with healthy control subjects (HC), and to verify if comorbidity with disruptive behavioral disorders and being currently depressed influence JTCI scores. METHODS: A case-control study comprising 41 MDD children/adolescents matched to 40 HC by gender and age (8-17years). All participants were assessed diagnostically with the Kiddie Schedule for Affective Disorders and Schizophrenia - Present and Lifetime (K-SADS-PL). Temperament and character traits were measured with the parent and child versions of JTCI, and depression was evaluated with the Children's Depression Rating Scale (CDRS). RESULTS: According to child and parent data, MDD subjects had significantly higher scores on harm avoidance and novelty seeking, and lower scores on reward dependence, persistence, self-directedness and cooperativeness compared with HC. According to parent data only, MDD subjects significantly differed from HC on self-transcendence (lower spirituality scores and higher fantasy scores). Comorbidity with disruptive behavioral disorders exerted influence on almost all dimensions, in general increasing the mean differences between MDD and HC subjects. Also, being currently depressed did not influence the results, except for reward dependence according to parent data. LIMITATIONS: The cross-sectional nature of the study and its limited sample size. CONCLUSIONS: MDD children/adolescents have a different temperament and character profile compared to HC subjects. This study supports previous findings of trait-like characteristics of harm avoidance and self-directedness.

Epidemiology of childhood conduct problems in Brazil: systematic review and meta-analysis.

PURPOSE: This study aimed to review evidence on the prevalence of and risk factors for conduct problems in Brazil. METHODS: We searched electronic databases and contacted Brazilian researchers up to 05/2012. Studies were included in the review if they reported the prevalence of or risk factors for conduct problems, conduct disorder, or oppositional defiant disorder for 100 + Brazilian children aged ≤18 years, systematically sampled in schools or the community. Prevalence rates and sex differences were meta-analysed. Risk factor studies were reviewed one by one. RESULTS: The average prevalence of conduct problems in screening questionnaires was 20.8%, and the average prevalence of conduct disorder/oppositional defiant disorder was 4.1%. There was systematic variation in the results of screening studies according to methodology: recruitment location, informants, instruments, impairment criterion for case definition, and response rates. Risk factors previously identified in high-income countries were mainly replicated in Brazil, including comorbid mental health problems, educational failure, low religiosity, harsh physical punishment and abuse, parental mental health problems, single parent family, and low socioeconomic status. However, boys did not always have higher risk for conduct problems than girls. CONCLUSIONS: Studies using screening questionnaires suggest that Brazilian children have higher rates of conduct problems than children in other countries, but diagnostic studies do not show this difference. Risk factors in Brazil were similar to those in high-income countries, apart from child sex. Future research should investigate developmental patterns of antisocial behaviour, employ a variety of research designs to identify causal risk mechanisms, and examine a broader range of risk factors.

Lifetime paid work and mental health problems among poor urban 9-to-13-year-old children in Brazil.

OBJECTIVE: To verify if emotional/behavioral problems are associated with lifetime paid work in poor urban children, when taking into account other potential correlates. METHODS: Cross-sectional study focused on 9-to-13-year-old children (n = 212). In a probabilistic sample of clusters of eligible households (women 15-49 years and son/daughter <18 years), one mother-child pair was randomly selected per household (n = 813; response rate = 82.4%). CBCL/6-18 identified child emotional/behavioral problems. Potential correlates include child gender and age, socioeconomic status/SES, maternal education, parental working status, and family social isolation, among others. Multivariate analysis examined the relationship between emotional/behavioral problems and lifetime paid work in the presence of significant correlates. FINDINGS: All work activities were non-harmful (e.g., selling fruits, helping parents at their small business, and baby sitting). Children with lower SES and socially isolated were more involved in paid work than less disadvantaged peers. Children ever exposed to paid work were four times more likely to present anxiety/depression symptoms at a clinical level compared to non-exposed children. Multivariate modeling identified three independent correlates: child pure internalizing problems, social isolation, and low SES. CONCLUSION: There is an association between lifetime exposure to exclusively non-harmful paid work activities and pure internalizing problems even when considering SES variability and family social isolation.

The Child Mental Health Treatment Gap in an Urban Low-Income Setting: Multisectoral Service Use and Correlates.

OBJECTIVE: To efficiently target capacity-building efforts for child mental health services in low- and middle-income countries (LMICs), it is critical to define how care is structured across sectors and individual-level factors. METHODS: In a community-based sample of 1,408 children and adolescents (ages 6-15 years) from Itaboraí, Brazil, the authors assessed need and service use across four care systems (mental health specialty, health, welfare, and informal). Individual-level factors included child gender and age, maternal perception of child mental health need, paternal absence, maternal education, and maternal anxiety and depression. RESULTS: The mental health treatment gap was 88%, with only 12% of children with psychiatric problems using mental health services. Children with mental health problems were more likely than those without these problems to use health and other sectors of care and to use services in more than one sector of care. Overall, 46% of the children with any clinical mental health problems and 31% of those with only internalizing problems were identified by their mothers as having a mental health need. Among those with clinical mental health problems, factors associated with mental health service use were being a boy and paternal absence but not mental health problem type or maternal awareness. CONCLUSIONS: Closing the child mental health treatment gap in urban settings in LMICs where resources are scarce will likely require system-level changes, such as engagement of diverse service sectors of care. Interventions need to target increased maternal awareness about mental health problems and encourage provision of mental health services to girls.

Do adolescents exposed to peer aggression at school consider themselves to be victims of bullying? The influence of sex and age.

INTRODUCTION: Exposure to peer aggression (PA) and bullying victimization (BV) are both expressions of peer victimization. OBJECTIVES: In four age-sex groups, (1) Can exposure to PA and BV be considered distinct experiences? (2) To what extent do adolescents exposed to PA consider themselves bullying victims? and (3) What is the effect on BV of the number of PA events experienced? METHODS: This cross-sectional study evaluated a probabilistic community-based sample of 669 adolescents (11-15 years, 51.7% girls). A three-stage probabilistic sampling plan involved random selection of census units, eligible households, and one target child per household selected. A 15-item scale investigated exposure to PA events (physical aggression, verbal harassment, social manipulation) occurring more than once in the past six months. BV occurring more than once a week or most days in the past six months was investigated after presenting respondents with a BV definition that required them to feel harmed by their victimization experiences. RESULTS: Adolescents exposed to PA and/or BV reported PA only (76.2%), BV only (4.7%), and both (19.1%). Rates of BV among those exposed to PA were as follows: 11-to-12-year-old boys (22.7%), 13-to-15-year-old boys (9.7%), 11-to-12-year-old girls (46.5%), and 13-to-15-year-old girls (13.2%). Multiple logistic regression analysis (outcome = BV) found a significant interaction between PA, age, and sex. PA events had a significant effect on BV for all except older girls. CONCLUSION: Exposure to PA and BV are different constructs; few older boys exposed to PA consider themselves bullying victims; and older girls are less affected by PA when it comes to BV.

Environmental factors associated with adolescent antisocial behavior in a poor urban community in Brazil.

BACKGROUND: Investigating risk factors for anti-social behavior (ASB) is particularly relevant in a poor urban and violent community of a developing country where homicide is the primary cause of death among 15-24-year olds. OBJECTIVES: To identify individual and environmental factors associated with ASB in adolescents from an urban poor community in the outskirts of São Paulo City, Brazil. METHOD: This cross-sectional study was based on a probabilistic sample of clusters that included all eligible households (women aged 15-49 years with a son or daughter <18 years of age). One mother-child pair was randomly selected per household (n = 813; response rate: 82.4%). This study is focused on the age group 11-17 years (n = 248). ASB was identified by externalizing scores in the clinical range on the Child Behavior Checklist and/or the Youth Self Report. Potential correlates included individual, maternal, paternal, and familial characteristics. Backward logistic regression analysis identified independent correlates and significant interactions. FINDINGS: Youths with high ASB scores were more likely to be victims of severe physical punishment and have an absent father/substitute. Maternal anxiety/depression was a risk factor only among older adolescents (15-17 years), while the presence of internalizing problems was a risk factor only among younger adolescents (11-14 years). Having a non-working mother increased the risk for ASB only among low-income adolescents. CONCLUSION: The recognition that certain environmental factors may have harmful effects on adolescents' mental health, and the identification of more vulnerable groups can contribute to the development of effective strategies for prevention and treatment of ASB.

Convergent validity of K-SADS-PL by comparison with CBCL in a Portuguese speaking outpatient population.

BACKGROUND: Different diagnostic interviews in child and adolescent psychiatry have been developed in English but valid translations of instruments to other languages are still scarce especially in developing countries, limiting the comparison of child mental health data across different cultures. The present study aims to examine the convergent validity of the Brazilian version of the Schedule for Affective Disorders and Schizophrenia for School-Age Children/Present and Lifetime Version (K-SADS-PL) by comparison with the Child Behavior Checklist (CBCL), a parental screening measure for child/adolescent emotional/behavior problems. METHODS: An experienced child psychiatrist blind to CBCL results applied the K-SADS-PL to a consecutive sample of 78 children (6-14 years) referred to a public child mental health outpatient clinic (response rate = 75%). Three K-SADS-PL parameters were considered regarding current disorders: parent screen interview rates, clinician summary screen interview rates, and final DSM-IV diagnoses. Subjects were classified according to the presence/absence of any affective/anxiety disorder, any disruptive disorder, and any psychiatric disorder based on K-SADS-PL results. All subjects obtained T-scores on CBCL scales (internalizing, externalizing, total problems). RESULTS: Significant differences in CBCL mean T-scores were observed between disordered and non-disordered children. Compared to children who screened negative, children positive for any affective/anxiety disorder, any disruptive disorder, and any psychiatric disorder had a higher internalizing, externalizing and total problem T-score mean, respectively. Highly significant differences in T-score means were also found when examining final diagnoses, except for any affective/anxiety disorder. CONCLUSIONS: Evidence of convergent validity was found when comparing K-SADS-PL results with CBCL data.

Severe physical punishment: risk of mental health problems for poor urban children in Brazil.

OBJECTIVE: To examine the relationship between specific types of child mental health problems and severe physical punishment, in combination with other important known risk factors. METHODS: We conducted a cross-sectional study in Embu, São Paulo, Brazil, as the Brazilian component of a multicountry survey on abuse in the family environment. From a probabilistic sample of clusters that included all eligible households (women aged 15-49 years with a son or daughter < 18 years of age), we randomly selected one mother-child pair per household (n = 813; attrition rate: 17.6%). This study focused on children aged 6-17 years (n = 480). Child Behaviour Checklist CBCL/6-18 was used to identify children with internalizing problems only, externalizing problems only, and both internalizing and externalizing problems (comorbidity). Severe physical punishment was defined as being hit with an object, being kicked, choked, smothered, burnt, scalded, branded, beaten or threatened with a weapon. We examined other potential correlates from four domains: child (gender, age, ever witnessing marital violence); mother (education, unemployment, anxiety or depression, marital violence); father (absence, drunkenness); and family (socioeconomic status). The WHO Self-Reporting Questionnaire (SRQ-20) was used to identify maternal anxiety or depression (score > 7). Backward logistic regression analysis identified independent correlates and significant interactions. FINDINGS: Multivariate modelling showed that severe punishment was an independent correlate of comorbid internalizing and externalizing problems but was not associated with internalizing problems only. It increased the risk of externalizing problems alone only for children and adolescents not exposed to maternal anxiety or depression. Maternal anxiety or depression increased the risk only for children or adolescents not exposed to severe punishment. CONCLUSION: Severe punishment may be related to child mental health problems, with the mechanism depending on the type of problem. Its influence persists in the presence of family stressors such as the father's absence and maternal anxiety or depression.

Does cyberbullying occur simultaneously with other types of violence exposure?

OBJECTIVE: Our study aimed to verify whether cyberbullying victimization among adolescents occurs concomitantly with other forms of violence exposure (at home, at school and in the community). METHODS: A collaborative longitudinal study by Norwegian and Brazilian researchers was conducted in Itaboraí, a low-income city in southeast Brazil. At baseline, trained interviewers applied a semi-structured questionnaire to a population-based sample of 669 in-school adolescents (11-15 years old). The investigated types of violence exposure included cyberbullying, traditional bullying, severe physical punishment by parents and community violence (victimization and eye-witnessed violent events outside the home and school). RESULTS: In the previous six months, 1.9% of the adolescents had been victims of cyberbullying, and 21.9% had been victims of physical aggression, verbal harassment and/or social manipulation by peers. However, only 5.5% of the adolescents considered themselves bullying victims. In the previous 12 months, 12.4% of adolescents had suffered severe physical punishment, 14.0% had been victims of community violence, and 20.9% eye-witnessed community violence. Multivariable regression analysis showed that victimization by multiple types of traditional bullying and self-perceived bullying victimization were correlates of cyberbullying victimization, while suffering violence at home and in the community were not. CONCLUSION: This study provides evidence of an association between cyberbullying, traditional bullying and self-perceived bullying among low-income Brazilian adolescents.

[Mental health and violence among sixth grade students from a city in the state of São Paulo]. / Saúde mental e violência entre estudantes da sexta série de um município paulista.

OBJECTIVE: To analyze risk and protective factors for mental health problems among adolescents. METHODS: Cross-sectional study with a random sample (N=327; attrition rate=6.9%) of sixth grade students from all public and private schools in the city of Barretos, Southeastern Brazil, conducted in 2004. The factors studied were: exposure to intrafamilial and urban violence, family socioeconomic level, sex, motherless household, participation in social activities (protective factor). All the independent risk and protective factors were included in the initial logistic regression model. Only the variable with a significance level of p<0.05 remained in the model. RESULTS: It was observed that exposure to violence was the only factor associated with mental health problems in the final logistic regression model (p=0.02, 95% CI: 1.12;4.22). In addition, adolescents exposed to intrafamilial violence were three times more likely to have problems than those exposed to urban violence (p=0.04; 95% CI: 1.03;7.55). CONCLUSIONS: Intrafamilial violence was associated with mental heath problems among adolescents studied and it could be more important than urban violence in medium-sized cities.

Gender differences in aggressiveness in children and adolescents at risk for schizophrenia.

OBJECTIVE: This study aimed to investigate whether differences in aggression-related behavioral problems occur between boys and girls at high risk for schizophrenia living in the city of São Paulo, Brazil. METHOD: Using the Child Behavior Checklist, we compared the prevalence of behavioral problems between genders for the offspring (6-18 years) of mothers with diagnosis of schizophrenia and a comparison group of children born to women with no severe mental disorders recruited at the gynecology outpatient clinic of the same hospital. The Structured Clinical Interview for DSM-IV Axis I Disorders, Patient Edition was applied for the evaluation of diagnostic status of mothers. RESULTS: Male children of women with schizophrenia had a lower prevalence of aggressive behavior compared to females (4% vs. 36%; p = 0.005), whereas no gender differences regarding aggression were detected in the comparison group (24% vs. 32%; p = 0.53). Logistic regression analyses showed that male gender and being a child of women with schizophrenia interacted so as to favor lower prevalence of aggressive behavior (p = 0.03). CONCLUSION: These findings reinforce the notion that behavioral gender differences related to schizophrenia are already detectable in childhood.

Maternal recognition of child mental health problems in two Brazilian cities.

OBJECTIVE: To identify child behaviors and types of impairment that increase the likelihood of maternal recognition of emotional/behavioral problems (EBP) in children and adolescents. METHODS: Maternal-reported data were obtained from two subsamples of 11-to-16-year-olds derived from cross-sectional studies conducted in two Brazilian municipalities: Itaboraí, state of Rio de Janeiro (n=480), and Embu, state of São Paulo (n=217). The Itaboraí study involved a representative sample of 6-to-16-year-olds (n=1,248; response rate = 86.0%) selected from the Family Health Program registry, which covered 85.5% of the municipal population. The Embu study was based on a probabilistic sample of clusters of eligible households (women aged 15-49 years, child < 18 years), with one mother-child pair selected randomly per household (n=813; response rate = 82.4%). The outcome variable was mother's opinion of whether her child had EBP. Potential correlates included types of child behaviors (hyperactivity/conduct/emotional problems as isolated or combined conditions) and impairment, assessed using the Strengths and Difficulties Questionnaire (SDQ); child's age and gender; maternal education and anxiety/depression (assessed using the Self-Reporting Questionnaire [SRQ]). RESULTS: Multivariate regression models identified the following correlates of maternal perception of child EBP: comorbidity (co-occurring hyperactivity/conduct/emotional problems), emotional problems alone, and interference of problems with classroom learning and friendships. CONCLUSION: Comorbidity of different problem types, emotional problems alone, and interference with classroom learning and friendships increase the likelihood of maternal recognition of EBP in children.

Prevalence of mental health problems in children and adolescents from the outskirts of Sao Paulo City: treatment needs and service capacity evaluation.

OBJECTIVE: To estimate the prevalence of mental health problems in children and adolescents, with or without considering global impairment, within a low-income urban community; to estimate the public service delivery capacity in terms of mental healthcare; and to determine the relationship between delivery capacity and treatment demand. METHOD: Cross-sectional study. Probabilistic sample of clusters including all eligible households (low-income community - Embu, Southeastern Brazil). PARTICIPANTS: 479 children and adolescents (aged 6-17 years; attrition rate: 18.8%). MEASUREMENT: 1) Clinical mental health problems in children and adolescents using the Child Behavior Checklist and/or Youth Self-Report total problem scales; 2) Global impairment: positive score in the Brief Impairment Scale (total score > 15.5); 3) Care service capacity: total number of cases annually seen by psychologists/psychiatrists in the health, education, juvenile justice, and child welfare sectors. RESULTS: Prevalence of mental health problems in children and adolescents: 24.6% (20.7-28.5) without considering global impairment; 7.3% (5.0-9.6) with global impairment (cases in need of treatment). Current annual service capacity can only provide care for 14.0% of impaired cases; approximately seven years would be necessary for all to be treated. CONCLUSIONS: Mental health problems in children and adolescents are frequent in the studied community, and the current structure of the community's public service system is not prepared to treat impaired cases in an adequate timeframe.

Do adolescents exposed to peer aggression at school consider themselves to be victims of bullying? The influence of sex and age

Abstract Introduction Exposure to peer aggression (PA) and bullying victimization (BV) are both expressions of peer victimization. Objectives In four age-sex groups, (1) Can exposure to PA and BV be considered distinct experiences? (2) To what extent do adolescents exposed to PA consider themselves bullying victims? and (3) What is the effect on BV of the number of PA events experienced? Methods This cross-sectional study evaluated a probabilistic community-based sample of 669 adolescents (11-15 years, 51.7% girls). A three-stage probabilistic sampling plan involved random selection of census units, eligible households, and one target child per household selected. A 15-item scale investigated exposure to PA events (physical aggression, verbal harassment, social manipulation) occurring more than once in the past six months. BV occurring more than once a week or most days in the past six months was investigated after presenting respondents with a BV definition that required them to feel harmed by their victimization experiences. Results Adolescents exposed to PA and/or BV reported PA only (76.2%), BV only (4.7%), and both (19.1%). Rates of BV among those exposed to PA were as follows: 11-to-12-year-old boys (22.7%), 13-to-15-year-old boys (9.7%), 11-to-12-year-old girls (46.5%), and 13-to-15-year-old girls (13.2%). Multiple logistic regression analysis (outcome = BV) found a significant interaction between PA, age, and sex. PA events had a significant effect on BV for all except older girls. Conclusion Exposure to PA and BV are different constructs; few older boys exposed to PA consider themselves bullying victims; and older girls are less affected by PA when it comes to BV.

Factors associated with stress in mothers of children with autism.

The objective of this case-control study was to investigate the determinants of maternal stress in mothers of children with autism. Mothers of 31 children with autism from mental health clinics were matched by child age/gender and mother age to 31 mothers of children without mental health problems, drawn from public schools and a primary care unit. Logistic regression models showed that the presence of stress in mothers was primarily associated with having a child with autism. However, poor expression of affect, little interest in people, being an older mother, and having a younger child also contributed to increased stress levels. Although having a child with autism was the main factor responsible for stress, the presence of the other factors further increased maternal stress. The implication is that a subgroup of mothers of children with autism is more prone to experience stress, thus requiring special attention from mental health professionals.