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. Author manuscript; available in PMC: 2024 Oct 11.
Published in final edited form as: Adv Neurodev Disord. 2022 Jun 6;7(1):35–45. doi: 10.1007/s41252-022-00260-y

Routines as a Protective Factor for Emerging Mental Health and Behavioral Problems in Children with Neurodevelopmental Delays

Kathryn Hatherly 1, Shaelyn Stienwandt 2, Marlee R Salisbury 3, Leslie E Roos 2,4, Philip A Fisher 5
PMCID: PMC11469585  NIHMSID: NIHMS2002003  PMID: 39398327

Abstract

Objectives

Children with neurodevelopmental delays show higher levels of externalizing behavioral problems, resulting in increased parental stress. This study aims to determine if the frequency of family routines moderates children’s externalizing problems and associated parental stress based on children’s cognitive ability longitudinally.

Methods

Children with neurodevelopmental delays and caregivers (N = 202) participated in assessments that included the Wechsler Preschool and Primary Scale of Intelligence-Forth Edition, Child Behavior Checklist, Parent Daily Report, and Family Routines Inventory. Child participants were 28 to 72 months old (M = 48.00, SD = 10.652) and predominantly male (69.3%).

Results

Frequency of family routines at baseline (b = − .375, SE = .112, p = .001) was associated with lower child externalizing behaviours at baseline (b = − .104, SE = .047, p = .031). Frequency of family routines moderated parental stress for children with average (i.e., at the mean; b = − .211, SE = .119, p = .08) and above average (i.e., 1SD above mean; b = − .436, SE = .177, p = .02) nonverbal skills. Longitudinally, increased frequency of family routines (b = − .193, SE = .092, p = .04) was associated with less child externalizing behaviors.

Conclusions

Findings demonstrate that routines may reduce parental stress, but the use of routines alone may be less practical for children with lower verbal skills. Additionally, the importance of routines for minimizing behavioral problems in children was significant for children with average or higher nonverbal skills at baseline, suggesting that nonverbal skills are protective for these children.

Keywords: Parenting, Neurodevelopmental delay, Routines, Behavior problems, Family, Developmental psychopathology

Parents of children with neurodevelopmental delays (NDD; e.g., autism spectrum disorder, intellectual disability, attention-deficit hyperactivity disorder, speech difficulty) report significantly higher levels of stress than parents of typically developing children (Neece et al., 2012). High parenting stress is linked to more coercive parent–child interactions that can contribute to children’s behavior problems (Baumrind, 2013). Difficult child behavior can then exacerbate parenting stress and result in a persistent and reciprocal pattern of coercive interactions (Neece et al., 2012; Patterson, 1982; Trivette et al., 2010). Parents of children with NDDs are particularly vulnerable to these patterns of coercive interactions given that (1) parents of children with NDDs tend to have higher levels of stress (Neece et al., 2012) and (2) children with NDDs tend to have higher levels of behavior problems (Neece & Chan, 2017). Longitudinal research has demonstrated that the increased demand for parenting a child with an NDD can increase strain in the parent–child relationship, decrease children’s use of coping mechanisms, and result in less positive, effective parenting (Lee, 2013; Woodman et al., 2015). Preventing these types of interactions is important for family well-being and functioning within the context of NDD. Consistent use of well-integrated routines into daily life may be one effective solution to limit coercive interactions and improve overall family functioning.

Family routines consist of a set of repetitive behaviors in which a family interacts in a predictable way on a consistent daily or weekly schedule (Hale et al., 2011). Routines are associated with the positive development of children’s cognitive skills, executive functioning, school readiness, and social-emotional skills (Kitsaras et al., 2018; Masten & Monn, 2015; Muniz et al., 2014). Moreover, the use of routines has been demonstrated to reduce stress and anxiety for children with suspected or diagnosed NDDs and is linked to improved psychological adjustment, self-care, and social functioning in children (Bridley & Jordan, 2012). The structure provided by routine assists in developing adaptive behaviors that become habitual for both children and parents, which is of particular importance for children with NDDs who have lower levels of adaptive skills than their typically developing peers (Lanza & Drabick, 2011; Paul et al., 2014). Increasing adaptive behaviors in these children, through the use of routines, can result in reduced externalizing problems (Harris et al., 2014). Several studies have demonstrated a robust link between routine use aimed at improving adaptive skills and fewer externalizing behavior problems in children with attention-deficit hyperactivity disorder (ADHD; Wirth et al., 2019). Within a typically developing sample, previous research has also demonstrated that increased use of routines at 14 months is linked to higher social competence at 36 months (Ferretti & Bub, 2014). Conversely, a lack of parenting structure in the home and/or inflexible rule-setting has been associated with increased instances of both internalizing and externalizing behavior problems (Greening et al., 2010; Patock-Peckham & Morgan-Lopez, 2009). Routines can create structure and consistency in a child’s life when implemented in a way that compliments their current developmental stage, which can improve overall family cohesion and well-being (Bridley & Jordan, 2012), including parenting stress (McRae et al., 2018). However, few studies have examined the relative benefit of routine use for children with NDDs despite the increased importance of promoting a structured and predictable environment for these children (Larsen & Jordan, 2020).

Research has demonstrated that parents who report higher stress levels also report lower use of family routines (Bonis, 2016; Hayes & Watson, 2013). Particularly in parents of children with NDDs, parenting stress increases as children’s externalizing problems and emotion dysregulation increase (Stoppelbein et al., 2016; Woodman, 2014). Moreover, parents of children with suspected or diagnosed NDDs report lower levels of routine use and structure in the home which is linked to higher levels of externalizing behavior problems and child emotion dysregulation (Bater & Jordan, 2017; Harris et al., 2014). This suggests that higher parental stress is linked to more child externalizing behavior problems and lower use of household routines. Increased behavior problems in children with NDDs can contribute to exacerbated parenting stress as the demands of parental care may increase (Montirosso et al., 2021). It is theorized that routines, which increase consistency, structure, and predictability in a child’s life, improve children’s overall behavior, therefore reducing parenting stress in the context of NDD (Neece et al., 2012). Given the bidirectional nature of parenting stress and children’s behavior problems, increased use of routines may reduce both stress and child externalizing behaviors simultaneously (Hur et al., 2015). While routines may have benefits for reducing children’s behavior problems and parenting stress, there may be individual differences in how children respond to routines given that NDDs can vary in severity. However, there is limited research on the individual difference factors that may contribute to how children with NDDs respond to various interventions, including routines (Romano et al., 2022). For example, the cognitive ability can vary significantly among children with NDD (Allotey et al., 2018) and may be one individual difference factor influencing the relative benefit of routines. Analyzing the relationship between individual difference factors and routine use will assist in determining how routines are best implemented for children with NDDs to improve overall family functioning.

Children with suspected or diagnosed NDDs have varying cognitive abilities, social skills, and language ability (Papachristou & Flouri, 2020). Differences in cognitive ability may lead to differences in children’s behavior problems and, in turn, parental stress levels (Almogbel et al., 2017). For example, children with NDDs who have lower verbal language skills demonstrate higher levels of externalizing and internalizing behaviors than those with higher verbal language skills (Hentges et al., 2021). Similarly, children with NDDs produce a higher proportion of utterances for the purposes of behavioral regulation, which can be attributed to their higher levels of externalizing and internalizing behavior problems, when compared to their typically developing counterparts (Delehanty et al., 2018; Gillespie-Lynch et al., 2012; Maljaars et al., 2011). Since children with lower cognitive ability tend to have more behavior problems (Pugliese et al., 2015), this is likely linked to greater parenting stress (Goodman et al., 2011). Therefore, understanding how routines play a role in mitigating externalizing behavior problems and parental stress can assist in improving family well-being.

Routine use may be more effective for children with higher cognitive ability, as lower child cognitive ability has been demonstrated to be a hindrance to routine implementation due to difficulties in following multi-step instructions (Becker et al., 2012). However, if implemented in a step-by-step practice that scaffolds the routine, it may be effective in reducing externalizing behaviors in children with lower cognitive ability (Harris et al., 2014). The aforementioned link between routine use and child cognitive ability has not been widely examined in the literature. Rather, the literature has focused on links between routine use and parenting practices (Bater & Jordan, 2017) and routine use and child factors such as self-regulation (Hardaway et al., 2012). Moreover, the links between routine use and child cognitive ability, particularly for children with NDDs, are underrepresented, making it critical to understand how the implementation of routines can alter familial mental health trajectories (Romano et al., 2022). Therefore, identifying how routines are currently used among children with NDDs with varying degrees of cognitive ability is necessary to determine the efficacy of a routine-based intervention.

The bidirectional link between child behavior problems and parenting stress is well-established, which suggests that higher parenting stress is linked to more behavior problems in children over time which is in turn linked to greater parental stress over time (Woodman et al., 2015). For families with children with NDDs, it is imperative to understand the best methods of intervention for improving overall family quality of life, particularly through routine-based interventions. The present study examined links between family routines and externalizing behavior problems in children with suspected or diagnosed NDDs. More specifically, this study examined if child cognitive ability was associated with parent-reported child behavioral problems and related parenting stress. A second aim of this study was to examine whether these associations were moderated by the use of routines in the household. Finally, these relationships were examined longitudinally to determine whether these associations were moderated by change in the frequency of family routines.

Methods

Participants

The current study is a secondary analysis of the KEEP program, in which 202 families were drawn from the pre- and post-assessments of an efficacy trial of school readiness intervention program (Salisbury et al., 2022). Caregivers and their children were recruited from Early Childhood CARES (service provider affiliated with the University of Oregon). Eligibility requirements included children at-risk for NDDs, which included or those who were referred for treatment services for suspected or diagnosed NDD or those socioeconomically at-risk and eligible for a variety of child development services. This is consistent with other samples of younger children (Mahone & Hoffman, 2007), as children typically do not receive formal diagnoses until ages 5–8 years. These children will be referred to as children with NDDs hereafter. Children were aged 2.5 to 6 years, and caregivers were above the age of 18 years and fluent in English. Parent participants ranged in age from 20 to 71 years (M = 35.12, SD = 8 0.715) and were predominantly female (87.1%). Child participants ranged in age from 28 to 72 months (M = 48.00, SD = 10.652) and were predominantly male (69.3%). A total of 77.7% participants reported a Euro-American/Caucasian/White ethnicity. Parent education included some community college or vocational training (26.7%), standard 4-year college or university graduation (14.9%), and community college degree or certification (12.9%). A large proportion of families reported having income less than $25,000 (38.6%) (see Table 1 for further demographic information). This program in its entirety did not have group-level impacts on changes in family routines over time (Salisbury et al., 2022) so we do not include group assignment in the present analyses.

Table 1.

Participant descriptive data

n % Mean (SD)
Child demographics
 Age (months) 202 48.00 (10.65)
Sex
 Female 51 25.2
 Male 140 69.3
Caregiver demographics
 Age (years) 198 35.12 (8.72)
Sex
 Female 176 87.1
 Male 15 7.4
Caregiver ethnicity
 Native American/American Indian 3 1.5
 Asian 4 2.0
 Native Hawaiian or other Pacific Islander 1 0.5
 African American/Black 1 0.5
 Caucasian/White 157 77.7
 Other 2 1.0
 Mixed race/ethnicity 19 9.4
 Latino 15 7.4
Caregiver education
 Partial high school 8 4.0
 GED/high school 31 15.4
 Some college 54 26.7
 Partial 4-year college 16 7.9
 Specialized or vocational training 12 5.9
 Community college degree/certificate 26 12.9
 4-year college or university graduate 30 14.9
 Some graduate courses 11 5.4
 Graduate degree 14 6.9
Caregiver income
 < $4999–9999 21 10.4
 $10–19,999 37 18.3
 $20–29,999 39 19.3
 $30–49,999 39 19.3
 $50–79,999 44 21.8
 $80–100,000 + 21 10.4
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Procedure

During the pre- and post-assessments (approximately 12 weeks after the pre-assessments), families completed a variety of questionnaires. Of relevance for the present study are the Wechsler Preschool and Primary Scale of Intelligence-IV, Child Behavior Checklist, Parent Daily Report, and Family Routines Inventory. Separate assessors facilitated questionnaires and tasks for both the child and parent, who were separated for the duration of the in-lab visit. All questionnaire data were collected at both pre- (baseline) and post-assessments.

Measures

Wechsler Preschool and Primary Scale of Intelligence‑Forth Edition (WPPSI‑IV)

The WPPSI-IV is a widely used tool to measure children’s verbal and performance IQ (Wechsler, 2012). The test is designed to assess a child’s general intellectual ability and cognitive ability based on a combination of their test result and age. A raw score is given which is then scaled with the child’s age to obtain their actual score. The two subtests of the WPPSI-IV used in this assessment were Receptive Vocabulary (M = 8.61, SD = 0.34), which measured verbal comprehension and Block Design (M = 7.28, SD = 0.35), which measured spatial awareness. For the purposes of this study, the Receptive Vocabulary subtest will be referred to as “verbal skills” and the Block Design subtest will be referred to as “nonverbal skills” (Gibbons & Warne, 2019). The WPPSI-IV has good construct and discriminative validity in addition to good test–retest reliability (Weschler, 2012).

Child Behavior Checklist (CBCL)

The CBCL for ages 1.5–5 years is a standardized 100-item parent-report measure of children’s emotional and behavioral problems (Achenbach & Edelbrock, 1983). Children’s behaviors are rated on a 3-point Likert scale of 0 to 2 where (0 indicates “not true” of their child, 1 indicates t “somewhat or sometimes true,” and 2 indicates “very true or often true”), which generate scores on 9 psychopathology subscales (Achenbach & Ruffle, 2000). Scores can be used to provide summaries of the child’s internalizing, externalizing, and total behavior problems (a combination of the internalizing and externalizing summaries). Externalizing behavioral problem scores were used for the current study (M = 60.40, SD = 0.92). The CBCL has been researched extensively, exemplifying psychometric properties of the total behavior problem scale (α = 0.95) (Achenbach & Rescorla, 2000).

Parent Daily Report (PDR)

The PDR is a 31-item problem behavior checklist that is used to assess the frequency of problem behaviors and associated parental stress within a 24-h period (Chamberlain & Reid, 1987). A team member completed the PDR with families on 3 successive days via telephone to create an average of the child’s problem behaviors and the average stress parents felt as a result at both baseline and followup. Example behaviors on this measure include defiance, stealing, and hyperactivity. Parental stress associated with behaviors are rated on a scale from 0 to 2 with 0 indicating the behavior “Did not occur,” 1 indicating “Occurred & Not Stressful,” and 2 indicating “Occurred & Stressful” (M = 7.09, SD = 0.57). The PDR has been demonstrated to have substantial interparent reliability and parent reports significantly correlate with home observation data collected concurrently (Chamberlin and Reid, 1987).

Family Routines Inventory (FRI)

The FRI is used to assess the frequency and importance of everyday events (e.g., children go to bed at the same time almost every night, parent(s) read or tell stories to the children almost every day) on 28 different routines (Jensen et al., 1983). The frequency of events is rated on a scale from 1 to 4, with 1 indicating “Almost never” and 4 indicating “Everyday” (M = 51.71, SD = 0.90). The FRI shows good test–retest reliability (α = 0.74) and was validated against the Moos Family Environment Scale (FES; Moos & Moos, 1981) with well-established reliability and validity (Jensen et al., 1983).

Data Analyses

Data were analyzed in SPSS to investigate the relationship between parental stress, family routines, children’s externalizing behaviors, and child cognitive ability (i.e., verbal and nonverbal skills). First, correlational analyses were completed to determine any covariates to include in subsequent analyses. Next, moderation analyses were conducted using the Hayes PROCESS add-on in SPSS v.22 (Hayes, 2013). The frequency of family routines at baseline was analyzed as a potential moderator of two associations of interest: (1) verbal and nonverbal skills and child problem behaviors at baseline and (2) verbal and nonverbal skills and parental stress at baseline. We further examined the difference between baseline and follow-up values in family routines as a potential moderator of two additional associations of interest: (3) verbal and nonverbal skills and changes in child problem behaviors and (4) verbal and nonverbal skills and changes in parental stress.

Results

Correlations Among Variables

Zero-order correlations were conducted with all variables of interest and covariates of child age, child sex, parent education, and household income (Table 2). Child age was not correlated with any variables of interest and therefore was not included in subsequent analyses (ps > 0.10). Parent education was negatively correlated with parental stress at baseline, such that parents with higher education reported lower stress (r[166] = − 0.238, p = 0.002). However, parent education was not included in subsequent analyses as it was highly correlated with household income (r[173] = 0.479, p < 0.001), and the latter was also correlated with both parental stress (r[168] = − 0.247, p = 0.001) and child externalizing behaviors at baseline (r[168] = − 0.166, p = 0.031). Household income was negatively correlated with parental stress at baseline (r[166] = − 0.247, p = 0.001), and child externalizing behaviors at baseline (r[166] = − 0.166, p = 0.031). Child sex was negatively correlated with change in parental stress, with parents of girls reporting a decrease in stress over time (r[128] = − 0.222, p = 0.011). In summary, child sex and household income were included as covariates, while child age and parent education were not.

Table 2.

Zero-order correlations between all variables

1 2 3 4 5 6 7 8 9 10 11 12
1. Child age -
2. Child sex −.005 -
3. Parent education −.071 −.016 -
4. Annual household income −.076 .023 .479** -
5. CBCL externalizing T score (Tl) .117 .011 −.140 −.166* -
6. Change in CBCL externalizing T Score −.068 −.098 .115 .111 −.392** -
7. PDR mean stressful behaviors (Tl) .077 .111 −.238** −.247** −.132 −.132 -
8. Change in PDR mean stressful behaviors .075 −.222* .068 .045 −.336** .272** −.624** -
9. Frequency of routines (Tl) .092 −.019 .059 .123 −.272** .091 −.201** .074 -
10. Change in frequency of routines −.109 .048 .030 .049 −.015 −.150 .010 −.060 −.421** -
11. Child receptive vocabulary (Tl) .025 .080 .122 .026 −.099 −.099 −.100 .021 −.010 −.006 -
12. Child block design score (Tl) .039 −.009 .026 −.026 −.123 .136 −.127 .176 .000 .000 .488** -
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*

Correlation is significant at the 0.05 level (2-tailed)

**

Correlation is significant at the 0.01 level (2-tailed)

Moderation Analyses

The Hayes and Watson (2013) PROCESS macro was used in SPSS to investigate the relationship between children’s cognitive ability (e.g., verbal and nonverbal skills), externalizing behaviors, and parental stress both at baseline and over time, as moderated by the frequency of family routines and change in frequency of routines. Conditional effects are reported for all marginally significant analyses (e.g., p < 0.10).

Baseline Regression Analyses

Model 1: Verbal Skills, Routines, and Externalizing Behaviors

In examining the effects of children’s verbal skills and frequency of family routines on children’s externalizing behaviors at baseline, linear regression results showed that lower routine use was associated with higher child externalizing behaviors (b = − 0.343, SE = 0.108, CI = − 0.557 to − 0.129, p ≤ 0.01) after controlling for sex and household income. Children’s verbal skill was not associated with externalizing behaviors (b = − 0.430, SE = 0.284, CI = − 0.993–0.132, p = 0.13) and there was no interaction between verbal skills and frequency of family routines (b = − 0.026, SE = 0.028, CI = − 0.030, p = 0.36). Overall, 13.6% of the variance in children’s externalizing behaviors was accounted for by the predictors and covariates (i.e., verbal skills, frequency of family routines, sex, household income), collectively (R2 = 0.14, F[5,130] = 4.10, p ≤ 0.01).

Model 2: Nonverbal Skills, Routines, and Externalizing Behaviors

Regarding the effects of children’s nonverbal skills and frequency of family routines on children’s externalizing behaviors at baseline, results indicated that lower routine use was associated with higher child externalizing behaviors (b = − 0.375, SE = 0.112, CI = − 0.600 to − 0.154, p < 0.01) after controlling for sex and household income. Children’s nonverbal skills was not associated with externalizing behaviors (b = − 360, SE = 0.273, CI = − 0.896–0.184, p = 0.19) and there was no interaction between nonverbal skills and frequency of family routines (b = − 0.046, SE = 0.030, CI = − 0.106–0.014, p = 0.13). Overall, 14.1% of the variance in children’s externalizing behaviors was explained by the predictors and covariates (i.e., nonverbal skills, frequency of family routines, sex, household income), collectively (R2 = 0.14, F[5,129] = 4.26, p < 0.01).

Model 3: Nonverbal Skills, Routines, and Parental Stress

In considering the relationship between children’s nonverbal skills and frequency of routines on parental stress levels at baseline, results showed that lower routine use was associated with higher parental stress (b = − 0.130, SE = 0.048, CI = − 0.225 to − 0.034, p = 0.01) after controlling for sex and household income. Children’s nonverbal skills was not associated with parental stress (b = − 0.196, SE = 0.119, CI = − 0.431–0.039, p = 0.10). There was a marginally significant interaction of nonverbal skills and frequency of family routines on parental stress (b = − 0.024, SE = 0.013, CI = − 0.050 to − 0.003, p = 0.08) When looking at the moderating effects of frequency of family routines on the link between children’s nonverbal skills and parental stress, higher frequency of family routines was marginally associated with less parental stress for children with average nonverbal skills (i.e., at the mean; b = − 0.211, SE = 0.119, CI = − 0.446–0.024, p = 0.08) and higher nonverbal skills (i.e., 1SD above mean; b = − 0.436, SE = 0.177, CI = − 0.787 to − 0.085, p = 0.02). However, there was no relation in children with low nonverbal skills (i.e., 1SD below mean; b = 0.035, SE = 0.178, CI = − 0.317–0.388, p = 0.84). Overall, 16.4% of the variance in parental stress was explained by the predictors and covariates (i.e., nonverbal skills, frequency of family routines, sex, and household income), collectively (R2 = 0.16, F[5,130] = 5.11, p < 0.001).

Model 4: Verbal Skills, Routines, and Parental Stress

In examining the effects between children’s verbal skills and frequency of routines on parental stress levels at baseline, results indicate that lower routine use was associated with higher parental stress (b = − 104, SE = 0.048, CI = − 0.199 to − 0.010, p = 0.03) after controlling for sex and household income. Children’s verbal skills were not associated with parental stress (b = − 0.177, SE = 0.126, CI = − 0.425–0.072, p = 0.16) and there was no interaction between verbal skills and frequency of family routines (b = 0.003, SE = 0.013, CI = − 0.021–0.028, p = 0.79). Overall, 13.6% of the variance in parental stress was accounted for by predictors and covariates (i.e., verbal skills, frequency of family routines, sex, and household income), collectively (R2 = 0.14, F[5,131] = 4.12, p < 0.01).

Longitudinal Follow‑up Regression Analyses

To determine change in family routine use, child externalizing behaviors, and parental stress over time over time, the following longitudinal analyses used the difference between follow-up and baseline scores.

Model 1: Verbal Skills, Change in Routines, and Change in Externalizing Behaviors

When examining the association between family routines and children’s verbal skills on child externalizing behaviors, results showed that lower routine use over time was associated with increased externalizing behaviors (b = − 0.193, SE = 0.092, CI = − 0.377 to − 0.010, p = 0.04) after controlling for sex, household income, and baseline levels of externalizing behaviors. Children’s verbal skills were not associated with externalizing behaviors (b = − 0.315, SE = 0.194, CI = − 0.699 – 0.069, p = 0.11) and there was no interaction between verbal skills and routine use (b = − 0.018, SE = 0.026, CI = − 0.069–0.033, p = 0.49). Overall, 24.8% of the variance was explained by the predictors and covariates (i.e., verbal skills, routine use, sex, household income, and baseline externalizing behaviors), collectively (R2 = 0.25, F[6,97] = 5.34, p < 0.001).

Model 2: Nonverbal Skills, Change in Routines, and Change in Externalizing Behaviors

Examining the association between family routines and children’s nonverbal skills on externalizing behaviors, results showed that lower routine use over time was marginally associated with increased externalizing behaviors (b = − 0.173, SE = 0.098, CI = − 0.367–0.022, p = 0.08) after controlling for sex, household income, and baseline externalizing behaviors. Children’s nonverbal skills at baseline were not associated with externalizing behaviors (b = 0.150, SE = 0.191, CI = − 0.229–0.529, p = 0.43) and there was no interaction between nonverbal skills and routine use (b = 0.002, SE = 0.028, CI = − 0.053–0.057, p = 0.95). Overall, 22.7% of variance in externalizing behavior was accounted for by the predictors and covariates (i.e., nonverbal skills, routine use, sex, household income, and baseline externalizing behaviors), collectively was explained (R2 = 0.23, F[6,96] = 4.70, p < 0.001).

Model 3: Verbal Skills, Change in Routines, and Change in Parental Stress

When examining the association between family routines and children’s verbal skills on parental stress, results showed that there was no association between routine use and parental stress (b = − 0.037, SE = 0.049, CI = − 0.124–0.050, p = 0.40) after controlling for sex, household income, and baseline parental stress. Children’s verbal skills were not associated with parental stress (b = − 0.028, SE = 0.092, CI = − 0.210–0.155, p = 0.76) and there was no interaction between verbal skills and routine use (b = − 008, SE = 0.012, CI = − 0.032–0.016, p = 0.51). Overall, 38.1% of variance in parental stress was explained by the predictors and covariates (i.e., verbal skills, routine use, sex, household income, and baseline parental stress), collectively (R2 = 0.38, F[6,97] = 9.96, p < 0.001).

Model 4: Nonverbal Skills, Change in Routines, and Change in Parental Stress

In examining the effects of children’s nonverbal skills and routine use on parental stress, results showed that there was no association between routine use and parental stress (b = − 0.039, SE = 0.046, CI = − 0.130–0.052, p = 0.40) after controlling for sex, household income, and baseline parental stress. Children’s nonverbal skill was not associated with parental stress (b = 0.076, SE = 0.090, CI = − 0.103–0.255, p = 0.40) and there was no interaction between nonverbal skills and routine use (b = − 0.011, SE = 0.013, CI = − 0.037–0.014, p = 0.39). Overall, 38.7% of the variance in parental stress was accounted for by the predictors and covariates (i.e., nonverbal skills, routine use, sex, household income, and baseline parental stress), collectively (R2 = 0.39, F[6,96] = 10.12, p < 0.001).

Discussion

This study examined links between children’s cognitive ability (e.g., verbal and nonverbal skills), externalizing behaviors, and parental stress among families with a child with a suspected or diagnosed NDD. We further examined the moderating effect of family routine frequency to evaluate whether routine use is associated with children’s externalizing behaviors and parental stress for children with varying cognitive abilities. Broadly, results indicated that lower use of routines is associated with both higher levels of child externalizing behavior and increased parental stress at baseline. Longitudinally, results indicated that higher use of routines was associated with a reduction in child externalizing behavior, but not parental stress. This demonstrates that routines serve as a protective factor for children’s emerging mental health. However, there was no association between the frequency of family routines and verbal skills, but a marginal association with nonverbal skills. Greater routine use was associated with decreased externalizing behaviors, particularly for children with higher nonverbal skills.

Our results examined a sample of families with preschool-aged children seeking early intervention services. Findings broadly align with prior research that suggests family routines are associated with fewer child behavior problems in both normative (Kitsaras et al., 2018) and neurodevelopmentally at-risk (Factor et al., 2016) samples. In particular, the current study demonstrated links between routine use and the frequency of child externalizing behaviors such that children with higher levels of routine use at baseline, also reported lower levels of externalizing behaviors. Previous research has found that routines may have particular benefits for children with NDDs who tend to exhibit higher levels of internalizing and externalizing behavior problems (Petersen & LeBeau, 2021). For example, children with higher levels of behavior problems display lower impulsivity, aggression, and oppositionality when routines are implemented consistently (Lanza & Drabick, 2011).

Results from the baseline analyses align with previous research that describes routine use as a predictor of lower levels of externalizing problem behaviors (Bater & Jordan, 2017; Bridley & Jordan, 2012). At baseline, a higher frequency of family routines was found to be associated with lower child externalizing behaviors. This is consistent with research that posits that a daily routine which is predictable and expected can support positive child behavior (Rice et al., 2020). It is possible that families who are able to implement routines effectively may also engage in more mindful parenting, which may explain the association between a higher frequency of family routines and lower child externalizing behaviors (Bögels et al., 2014). For example, parents who practice mindful parenting may experience higher levels of awareness to their child’s needs and more present-moment attention, contributing to their ability to respond to their child in a positive way (Potharst et al., 2021). Understanding the relationship between the frequency of family routines and child externalizing behaviors is especially important for children with NDDs who exhibit higher levels of externalizing behavior problems, which can persist and lead to more pervasive mental health problems in adolescence and adulthood without early intervention (Lindsey et al., 2020; Mackler et al., 2015). Providing a consistent, stable daily routine from a young age may help to reduce early externalizing behaviors and potentially prevent the development of clinically relevant mental health problems later in life (Bridley & Jordan, 2012; McRae et al., 2018). Furthermore, routines may be particularly beneficial for children with NDDs who demonstrated greater challenges with transitions between tasks, unexpected interruptions, or understanding daily expectations and multi-step routines (Harris et al., 2014).

With respect to parental stress, results demonstrated that greater routine use was linked to lower parental stress at baseline, but not over time. For parents facing burnout, it is possible that implementing routines, if not done consistently, exacerbates household stress and increases the frequency of inconsistent child-rearing practices (Mikolajczak et al., 2018) Therefore, adding routines to their lifestyle may introduce additional difficulties and increase daily caregiving strain and contribute to ongoing stress. Another possible explanation is that routines were increased broadly, but were still not used consistently (e.g., increase from zero times per week to two times per week, but not used consistently 5 to 7 days per week), having minimal impact on externalizing behaviors and parental stress. Routines are best implemented frequently and consistently to reduce child externalizing behaviors (Lanza & Drabick, 2011). Finding ways to reduce parental stress is essential in minimizing intergenerational transmission of mental health diagnoses, including depression and anxiety (Shonkoff & Fisher, 2013). This is of particular importance for children of NDDs who exhibit higher levels of externalizing behavior, as these externalizing behaviors typically continue into adolescence, compounding the risk for continued mental health challenges for both the child and their parents (Keyser et al., 2017).

Results from the moderation analysis support extant literature that routines may have differential relevance for family well-being based on child verbal and nonverbal skills even in a sample broadly at-risk for NDDs. For children with average or above average nonverbal ability, greater routine use was linked to lower parental stress, while no association was found between these variables for children with low nonverbal ability. Of note, children in our study with average or above average nonverbal cognitive abilities relative to the sample had scores within the average range (i.e., scaled scores between 7 and 12) compared to the population norms on the WPPSI (Sattler, 2018). This suggests that, for children with stronger nonverbal skills among a sample with NDDs, greater routine use is associated with lower levels of stress for parents. Alternatively, it may be possible that less stressed parents have more bandwidth or resources for implementing family routines (Bekelman et al., 2019). Regardless, it is notable that routines did not seem to be linked to parental stress for families of children with low nonverbal abilities, suggesting that routines may be best implemented in conjunction with other supports to be an effective intervention for these children.

Limitations and Future Research

Findings may have limited generalizability outside of the primary participant demographics which included a majority of White caregivers of children aged 28–72 months with suspected or diagnosed NDDs. Additionally, data were collected in one region, which may limit generalizability to different cultural and sociodemographic contexts. Nonetheless, the results are consistent with other samples taken from other demographic regions (Mackler et al., 2015). Additionally, a sample at-risk for NDDs is particularly important to understand as these families may benefit most from early interventions utilizing routines and may be most in need of early intervention for improving child and family outcomes. Parent-report measures on child behavior may have introduced self-report bias (Chamberlain and Reid, 1987; Van de Mortel, 2008). However, both the CBCL and PDR have been documented as valid in concurrent home observations (Han et al., 2004). Moreover, the longitudinal study design allowed relationships among variables over time to be evaluated.

It is imperative to explore the effectiveness of routines for children with varying cognitive ability and NDD severity to determine how routines can be best implemented to promote family well-being. More research is needed on routine-based interventions for children with NDDs who have lower verbal ability as our results suggest they may benefit the most. Future research should not only address the frequency of family routines, but also determine the types of routines (e.g., bedtime, mealtime) most likely to reduce overall family dysfunction (e.g., parenting stress and child externalizing behavior problems). By determining the type of routines most effective in reducing parental stress, interventions can improve their specificity (Salisbury et al., 2022, Vismara & Rogers, 2018).

Funding

This study was funded by R01HD075716 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development. Student research was supported through the Children’s Hospital Research Institute of Manitoba, Canadian Institutes of Health Research and Social Sciences and Humanities Research Council.

Footnotes

Conflict of Interest The authors declare no competing interests.

Declarations

Ethics Approval All procedures involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent Informed consent/assent was obtained from all individual participants included in the study.

Data Availability

This study was a secondary analysis of a larger dataset used in conjunction with another research team; therefore, the data is not widely available.

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Data Availability Statement

This study was a secondary analysis of a larger dataset used in conjunction with another research team; therefore, the data is not widely available.

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