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. Author manuscript; available in PMC: 2026 Aug 25.
Published in final edited form as: Child Abuse Negl. 2026 Jun 25;179:108188. doi: 10.1016/j.chiabu.2026.108188

Risk and protective factors for consistent family routines among caregivers with preschool-age children

Eileen M Condon a,b,*, Sangchoon Jeon c, Lois S Sadler c, Nancy S Redeker a,c
PMCID: PMC13501488  NIHMSID: NIHMS2191469  PMID: 42348994

Abstract

Background:

Consistent family routines (e.g. bed/wake times, shared meals) are associated with improved child health and behavior, but caregiver risk and protective factors for these routines are poorly understood.

Objective:

To examine the extent to which caregiver risk (childhood maltreatment history, mental health symptoms) and protective (positive childhood experiences, social support) factors are associated with consistent family routines. We also examine whether caregivers' protective factors mitigate relationships between risk factors and family routine consistency.

Participants and setting:

Caregivers (n = 107 mothers, n = 23 fathers) with children age 3–5 years recruited from community settings.

Methods:

In this cross-sectional study, caregivers self-reported routines, risk factors, and protective factors using validated measures. We used multivariate linear regression to examine associations between caregiver factors and family routines. We tested moderation using interaction terms.

Results:

Caregivers' childhood maltreatment history (β = −0.34(0.06), p = .002, f2 = 0.14) and mental health symptoms (f2 = 0.08–0.18) were associated with less consistent family routines. Positive childhood experiences (β = 0.25(0.63), p = .03, f2 = 0.09) and social support (f2 = 0.14–0.25) were associated with more consistent routines. Childhood maltreatment history remained associated with less consistent routines in models adjusted for mental health symptoms. Social support, but not positive childhood experiences, moderated relationships between caregivers' childhood maltreatment history and less consistent routines (p = .03–0.04), such that this relationship was only present among caregivers reporting low emotional and instrumental support.

Conclusions:

Caregivers with a history of childhood maltreatment or current mental health symptoms may benefit from interventions to help promote consistent family routines. Future longitudinal research may elucidate the role of family routines in the intergenerational transmission of childhood maltreatment and other stressors.

Keywords: Adverse childhood experiences, Parent-child relations, Family relations, Parenting

1. Background

Consistent routines provide a stable and supportive environment that can help children acquire the cognitive, social, emotional, behavioral, and developmental skills needed to thrive (Doan & Evans, 2020; Yang et al., 2025). These routines may include regular bed and wake times, shared family meals, and regular engagement with family members through activities like reading and playing (Ponti, 2023; Selman & Dilworth-Bart, 2024). Among toddlers and preschool-age children, consistent family routines are associated with a myriad of positive outcomes including fewer behavior problems (Bater & Jordan, 2017; Larsen & Jordan, 2020), better social emotional health (Bocknek et al., 2018; Ferretti & Bub, 2014; Muñiz et al., 2014), better physical health and sleep (Ferretti & Bub, 2017; Koopman-Verhoeff et al., 2019), and increased literacy, mathematics skills, and school readiness (Dove et al., 2015; Ferretti & Bub, 2017; So et al., 2023; Turnbull et al., 2022). Among older children and adolescents, consistent family routines are associated with less obesity (Anderson, 2012; Bates et al., 2018; White et al., 2024), better oral health (Pardi et al., 2024), fewer behavior problems (Hosokawa et al., 2023), less substance use (Abar et al., 2020), fewer depressive symptoms (Manczak et al., 2017), better parent–adolescent relationships (Boat et al., 2025), and higher rates of university enrollment (Barton et al., 2019). Given the importance of consistent family routines, family-based interventions that promote these routines may be critical for supporting children's long-term health and development. However, to develop effective interventions, family factors that may support or impede routine consistency must first be understood.

Caregivers are largely responsible for implementing and maintaining consistent family routines (Spagnola & Fiese, 2007). However, providing this consistency may be challenging for caregivers experiencing stress, poor mental health, or for those who did not have consistent and nurturing routines modeled for them during their own childhood. Caregivers with a history of childhood maltreatment may find it particularly challenging to implement consistent family routines with their own children. Consequences of childhood maltreatment and other adverse childhood experiences (ACEs) include poor emotion regulation (Rudenstine et al., 2019), impaired executive functioning skills (Lund et al., 2020), poor sleep (Kajeepeta et al., 2015), and increased risk for mental health disorders (Daníelsdóttir et al., 2024), each of which may hinder a caregiver's ability to promote consistent routines within the family system. Caregiver ACEs are widely associated with poor health and behavioral outcomes for children, and several parenting mechanisms have been implicated as potentially underlying this relationship (Zhang et al., 2023). However, despite known links between family routines and child outcomes, associations between caregivers' childhood maltreatment history and current family routines have not yet been studied.

Caregivers' childhood maltreatment history may influence current family routines through several pathways, including effects on caregivers' mental health (Racine et al., 2021). Mental health symptoms may also influence family routines independently from caregivers' history. Maternal depression has harmful effects on parenting sensitivity, affection, involvement, responsiveness, and stimulation, each of which are necessary for maintaining consistent and supportive routines for children (Lages et al., 2025). Anxiety and post-traumatic stress disorder (PTSD) symptoms are also common among caregivers of young children (Cross et al., 2018; Leach et al., 2017; Leiferman et al., 2021) and associated with several maladaptive behaviors that may influence family routines such as hypervigilance and overprotection (Jones et al., 2021), less sensitive responsivity (Nicol-Harper et al., 2007), hostility and controlling behaviors (Teetsel et al., 2014), and increased parenting stress (Christie et al., 2019). Maternal depression has been associated with less consistent family routines in a few studies (Churchill & Stoneman, 2004; Ettinger et al., 2018), but the relationship between other mental health symptoms and family routines remains otherwise largely unstudied. Improved understanding of the relationship between caregivers' mental health and family routines, both independent of and within the context of caregivers' childhood maltreatment history, will critically inform targets for family routine-promoting interventions.

To effectively support family routines through intervention, positive family factors that promote consistent routines must also be understood. Positive childhood experiences (PCEs) describe experiences related to closeness, support, love, protection, and responsiveness to health and material needs, both within the family and from other positive relationships, like teachers and peers (Bethell et al., 2019). A robust body of recent literature demonstrates that PCEs are associated with better mental health and reduced stress in adulthood (Cunha et al., 2025; Han et al., 2023), and emerging studies also suggest positive effects on parenting, such as increased maternal self-efficacy (Chasson & Taubman–Ben-Ari, 2023; Håkansson et al., 2018). The stability and support provided by PCEs, which may have included a supportive home environment with structured routines, may enhance a caregiver's ability to provide such an environment for their own children. However, the relationship between caregivers' history of PCEs and current family routines in adulthood has not yet been studied. Further, family theories suggest that while PCEs may help protect against the harmful effects of childhood maltreatment (Lieberman et al., 2005), the protective effects of PCEs on physical and mental health have been largely unsupported in empirical studies (Han et al., 2023). Additional research is needed to uncover whether PCEs protect against the harmful intergenerational effects of caregivers' risk factors on outcomes related to parenting and family functioning, including family routines (Cunha et al., 2025).

Finally, social support is a key protective factor for family health and functioning (Black & Lobo, 2008), but associations with family routines are poorly understood. Social support includes emotional support, which describes relationships that promote encouragement and understanding, and instrumental support, which refers to tangible or practical help, such as help with childcare or transportation (Morelli et al., 2015). Emotional support may help caregivers maintain routines by reducing stress and supporting emotional regulation, while instrumental support may help caregivers overcome logistical challenges, like irregular work schedules that often disrupt routines. Recent studies suggest that social support may also help to mitigate the harmful effects of childhood maltreatment and other ACEs on an individual's physical and mental health (Crouch et al., 2019). For example, in a large cohort study of adults, perceived social support mitigated the effects of ACE history on depressive symptoms (Von Cheong et al., 2017). Among pregnant women, social support buffered the association between ACE history and antenatal health risks (Racine et al., 2018). Improved understanding of the protective effects of social support on family routines may inform tailored strategies for family intervention, especially in the context of caregiver risk factors.

The purpose of this study is to examine the extent to which caregiver risk (childhood maltreatment history, mental health symptoms) and protective factors (PCEs, emotional support, instrumental support) are associated with consistent routines among families with preschool-age children. We also examine whether protective factors moderate relationships between caregivers' risk factors and current family routines. We focus on the children at preschool-age because this developmental stage is characterized by increasing child autonomy, evolving behavioral expectations, and transitions in daily structure (e.g., preschool entry), all of which may uniquely influence the consistency of family routines (Halle & Darling-Churchill, 2016). While family routines emerge earlier in childhood, the preschool period represents a particularly important window for intervention as caregivers must actively adapt and re-establish routines in response to these developmental and contextual changes. This period therefore offers a prime opportunity to support families in maintaining consistent routines during a time when they are at heightened risk for disruption (Borges Rodrigues et al., 2022; Ling et al., 2017). Given this developmental context, by focusing on both risk and protective factors, insights gained from the families in this study may help identify targets for interventions aiming to support consistent routines among families with young children.

2. Methods

2.1. Design

We used data from the CARING Study (Childhood Adversity and Resilience in the Next Generation), a cross-sectional study of caregivers with children age 3 to 5 years (Condon et al., 2024). The full CARING Study protocol is reported in (Condon et al., 2024). Families were recruited through social media and in collaboration with community organizations across the state of Connecticut. Caregivers provided informed consent for their own participation and parental permission for their child's participation. The study was approved by the University of Connecticut institutional review board. Families were included if the child was age 3 to 5 years, the caregiver lived in the same household as the child, and the caregiver spoke English or Spanish. We defined caregivers as any adult with parenting responsibilities for the enrolled child. Dyads were excluded if the caregiver was pregnant or the child had a health or behavioral condition that prohibited data collection for other aspects of the larger study (e.g. wrist actigraphy). In the present analysis, we used caregiver-report questionnaires that were collected and managed using the REDCap electronic data capture tool hosted by UConn Health (Harris et al., 2009).

2.2. Variables and measures

2.2.1. Demographic characteristics

Caregivers provided information on demographic characteristics for the dyad and family including race, ethnicity, gender, education level, employment, marital status, household size, and enrollment in income-based social services (e.g., Special Supplemental Nutrition Program for Women, Infants and Children [WIC], Supplemental Nutrition Assistance Program [SNAP]).

2.2.2. Current family routines

Caregivers reported on strength-promoting family routines using the Family Routines Inventory (FRI), a reliable and valid 28-item instrument that that evaluates the frequency of engagement in family routines such as mealtimes, morning and bedtime routines, and leisure activities (Jensen et al., 1983). Reliability of the FRI was high (Cronbach's α =0.85) among caregivers in our study.

2.2.3. Caregivers' childhood maltreatment history

Caregivers completed the short form version of Childhood Trauma Questionnaire (CTQ), a valid retrospective measure of childhood maltreatment history up to age 18 years (Bernstein et al., 2003). The CTQ short form includes 28 items that are calculated to create a total score and five subscales: physical abuse, emotional abuse, sexual abuse, physical neglect, and emotional neglect. Internal consistency of the CTQ was high among caregivers in our sample (Cronbach's α =0.84–0.94).

2.2.4. Caregivers' mental health symptoms

We evaluated caregivers' depression and anxiety symptoms using the NIH PROMIS® measures for depression (8 item version; Cronbach's α = 0.92) and anxiety (7 item version; Cronbach's α = 0.92) (Pilkonis et al., 2011). PROMIS® measures were developed using item-response theory and generate standardized t-scores to evaluate symptom severity relative to population norms (Cella et al., 2007). We evaluated caregivers' PTSD symptoms using the PTSD Checklist-Civilian, a reliable (Cronbach's α = 0.93) and widely used measure of trauma symptoms (Weathers et al., 1993).

2.2.5. Caregivers' positive childhood experiences

We evaluated PCEs using the Benevolent Childhood Experiences Scale, a retrospective measure of positive experiences in the first 18 years of life. The BCE includes 10 dichotomous items (yes/no) such as “Did you have at least one caregiver with whom you felt safe?” The BCE has been validated in diverse populations and internal consistency was acceptable (Cronbach's α = 0.77) in our current sample (Merrick et al., 2019; Narayan et al., 2018).

2.2.6. Caregivers' current social support

Caregivers indicated current social support using two NIH PROMIS® measures: PROMIS Emotional Support (8 items), which evaluates the extent to which individuals feel valued and cared for, and Instrumental Support (8 items), which evaluates tangible supports like help with daily tasks or financial resources (Kent et al., 2020). PROMIS measures are standardized (t-scores) and validated in diverse populations (Rung Wu et al., 2024; Shensa et al., 2016).

2.3. Data analysis

Data analyses were performed using SAS Version 9.4 (Inc., 2023) and the PROCESS Macro for SPSS (Hayes, 2023). We first calculated descriptive statistics to describe participant demographic characteristics and all study variables. We described clinically-meaningful childhood maltreatment and mental health symptom levels using established cutoff scores (Gore et al., 2013; Kroenke et al., 2021; MacDonald et al., 2016).We reviewed variables for normality of distributions, missing data, and outliers. We used two-sample t-tests and one-way ANOVA tests to compare family routines by family demographic characteristics. We used Pearson and Spearman correlations to examine bivariate relationships between study variables.

We used multivariable linear regression to examine relationships between caregivers' risk factors (CTQ total score, maltreatment subscales, mental health symptoms) and current family routines. We also used linear regression to examine associations between caregivers' protective factors (PCEs, emotional support, instrumental support) and current family routines. All models were adjusted for caregiver gender, age, and household size based on their theoretical relevance to family routines. We also conducted sensitivity analyses by including caregivers' education, level, race and ethnicity, and employment status as covariates in the models. We used Cohen's guidelines to interpret effect sizes (f 2), with values of 0.02, 0.15, and 0.35 representing small, medium, and large effects, respectively (Cohen, 2013).

Next, as childhood maltreatment history and mental health symptoms are often co-occurring, we included them together as independent variables in regression models to compare their relative associations with family routines. We used the CTQ total score and examined each mental health symptom in a separate model to explore individual effects and to avoid multicollinearity. We did not repeat these analyses for the individual CTQ maltreatment subscales to reduce the number of statistical tests and minimize the risk of Type I error. We again adjusted for caregiver gender, age, and household size, and conducted sensitivity analyses adjusting for caregiver education level, race and ethnicity, and employment, as described above.

Finally, we examined whether protective factors moderated the relationship between caregivers' risk factors and current family routines. To aid interpretation of our findings, we dichotomized the PROMIS Emotional and Instrumental Support scales to indicate lower (t-score < 50) or higher (t-score ≥ 50) levels of support compared to the general population. PCEs were dichotomized at the median (8), as a recommended cutoff score is not available. We conducted independent samples t-tests to first compare caregivers' risk factors (CTQ total score, depression symptoms, anxiety symptoms, PTSD symptoms) by high and low levels of protective factors (PCEs, emotional support, instrumental support). We then conducted multivariable linear regression as described above and added an interaction term between each risk and protective factor. Each interaction was tested in a separate model to examine independent effects.

3. Results

One hundred thirty dyads were included. Caregivers were an average of 36.9 (SD 5.2) years of age and 84% were women (Table 1). Most were employed full-time and over 50% reported a graduate or professional degree. Descriptive statistics for the study variables are presented in Table 2. Based on recommended instrument cutoff scores, 20% of caregivers reported mild to moderate levels of childhood maltreatment history, 10% reported moderate to severe levels, and 7% reported severe to extreme levels (MacDonald et al., 2016). Thirty two percent of caregivers had at least mild depression symptoms (t-score > 55), 46% had at least mild anxiety symptoms (t-score > 55), and 33% had probable PTSD symptoms (score > 31) (Gore et al., 2013; Kroenke et al., 2021). Family routines differed by caregiver race and ethnicity (p = .005), with higher routines reported among non-Hispanic White caregivers compared to other groups (Supplemental Table 1). Family routines did not differ by caregiver or child gender, country of origin, education level, employment, or enrollment in social services.

Table 1.

Sample demographics.

Variable M (SD)
Caregiver age (years) 36.9 (5.2)
Child age (years) 3.7 (0.7)
Household size 4.1 (1.2)
N (%)
Caregiver Gender
 Woman 104 (84)
 Man 19 (15)
 Genderfluid 1 (1)
Child Gender
 Girl 58 (47)
 Boy 66 (53)
Caregiver Race and Ethnicity
 Non-Hispanic White 83 (66)
 Hispanic/Latino/Latina 17 (14)
 Asian 11 (9)
 Non-Hispanic Black 10 (8)
 Multiple/Other Races or Ethnicities 4 (3)
Caregiver Birth Country
 United States 96 (76)
 Outside of the United States 30 (24)
Caregiver Education Level
 Graduate or Professional Degree 66 (53)
 Bachelor's or Associate's Degree 35 (28)
 Some college for vocational training 14 (11)
 High School Diploma or equivalent 5 (4)
 Less than high school 5 (4)
Caregiver Employment
 Full time 80 (67)
 Part time 21 (18)
 Not working/On leave 19 (16)
Enrollment in Social Services 35 (27)
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Note. Social services include self-reported enrollment the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), the Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), the Section 8 Housing Choice Voucher program, Medicaid, and/or Care 4 Kids (Childcare Assistance).

Table 2.

Descriptive statistics for study variables.

Variable M (SD)
Family Routines Inventory 55.0 (10.1)
Childhood Trauma Questionnaire
 Total Score 40.1 (16.4)
 Physical Abuse 6.45 (3.02)
 Physical Neglect 6.70 (2.86)
 Emotional Abuse 9.03(4.94)
 Emotional Neglect 10.2 (4.90)
 Sexual Abuse 7.15 (4.51)
PROMIS Depression (t-score) 50.4 (8.58)
PROMIS Anxiety (t-score) 53.0 (9.27)
PTSD Checklist-Civilian 28.5 (11.7)
Positive Childhood Experiences 8.7 (1.8)
PROMIS Emotional Support (t-score) 53.4 (8.51)
PROMIS Instrumental Support (t-score) 55.0 (9.28)
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In adjusted regression models (Table 3), CTQ total score was associated with less consistent family routines (β = −0.34(0.06), f2 = 0.14), and similar patterns were identified across maltreatment subscales. Caregivers' depression symptoms (β = −0.36(0.11), f2 = 0.18), anxiety symptoms (β = −0.21(0.11), f2 = 0.08), and PTSD symptoms (β = −0.28(0.08), f2 = 0.11) were also associated with less consistent family routines. Caregivers' protective factors, including PCEs (β = 0.25(0.63), f2 = 0.09), emotional support (β = 0.43 (0.09), f2 = 0.25), and instrumental support (β = 0.32(0.11), f2 = 0.14) were associated with more consistent family routines. In sensitivity analyses, inclusion of caregiver education level, race and ethnicity, and employment status as covariates did not meaningfully change model fit (ΔR2 ≈ 0.01–0.05), and associations between caregiver risk and protective factors and family routines remained substantively unchanged.

Table 3.

Associations between caregivers' characteristics and current family routines.

β(SE) p Cohen's f2
Risk Factors
 CTQ Total Score −0.34(0.06) 0.002 0.14
 Childhood Physical Abuse −0.26(0.32) 0.02 0.09
 Childhood Physical Neglect −0.20(0.33) 0.053 0.06
 Childhood Emotional Abuse −0.26(0.19) 0.01 0.10
 Childhood Emotional Neglect −0.35(0.19) 0.001 0.15
 Childhood Sexual Abuse −0.26(0.21) 0.01 0.10
 Depression Symptoms −0.36 (0.11) <0.001 0.18
 Anxiety Symptoms −0.21 (0.11) 0.04 0.08
 PTSD Symptoms −0.28 (0.08) 0.007 0.11
Protective Factors
 Positive Childhood Experiences 0.25(0.63) 0.03 0.09
 Emotional Support 0.43(0.09) <0.0001 0.25
 Instrumental Support 0.32(0.11) 0.002 0.14
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Note. Models adjusted for caregiver age, gender, and household size. CTQ, Childhood Trauma Questionnaire; PTSD, Post-Traumatic Stress Disorder.

According to Cohen's guidelines, f 2 values of 0.02, 0.15, and 0.35 represent small, medium, and large effect sizes, respectively (Cohen, 2013; Selya et al., 2012).

In models including both CTQ total score and mental health symptoms, caregivers' childhood maltreatment history continued to be associated with less consistent family routines, although the size of the effect decreased (Table 4). Notably, both CTQ total scores and depression symptoms remained significantly associated with less consistent family routines, showing medium-sized overall model effects (f2 = 0.20). In contrast, after adjusting for childhood maltreatment history, anxiety and PTSD symptoms showed weak associations with current family routine, with an overall model effect size of f2 = 0.14.

Table 4.

Associations between caregivers' childhood maltreatment history and current family routines, adjusted for caregivers' mental health symptoms.

β(SE) p Cohen's f2
Model 1
 CTQ Total Score −0.22 (0.07) 0.07 0.20
 Depression Symptoms −0.26 (0.12) 0.03
Model 2
 CTQ Total Score −0.29 (0.06) 0.01 0.16
 Anxiety Symptoms −0.14 (0.11) 0.22
Model 3
 CTQ Total Score −0.26 (0.07) 0.06 0.16
 PTSD Symptoms −0.14 (0.10) 0.30
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Note. Models adjusted for caregiver age, gender, and household size. CTQ, Childhood Trauma Questionnaire; PTSD, Post-Traumatic Stress Disorder.

When comparing CTQ total scores by caregivers' level of protective factors, we found that childhood maltreatment history was higher among caregivers with low instrumental support compared to high support (p = .001), and among caregivers with low PCEs compared to high PCEs (p < .001). However, CTQ total scores did not differ by caregivers' emotional support level (p = .21; Supplemental Table 2). For mental health symptoms, depression, anxiety, and PTSD symptoms were higher among caregivers with low emotional and instrumental support compared to those with high support (Supplemental Tables 2-3). PTSD symptoms were higher among caregivers with low PCEs compared to high PCEs (p = .02), but depression and anxiety symptoms did not significantly differ by PCE history (Supplemental Table 4).

Results of our moderation analyses are presented in Table 5. Caregivers' emotional support moderated the relationship between CTQ total score and less consistent family routines (p = .04), such that this association was present among caregivers reporting low emotional support (β = −0.30(0.09), p = .0007) but not among those reporting high emotional support (β = −0.06 (0.08), p = .44). Similarly, instrumental support moderated the relationship between CTQ total score and less consistent family routines (p = .027), such that this relationship was observed among caregivers reporting low instrumental support (β = −0.28 (0.08), p = .0009) but not high support (β = −0.03 (0.08), p = .73). Caregivers' PCEs did not moderate the relationship between CTQ total score and current family routines.

Table 5.

Moderating effects of protective factors on the association between caregivers' risk factors childhood maltreatment history and current family routines.

Moderator 1: Emotional Support Moderator 2: Instrumental Support Moderator 3: PCEs
β(SE) p β(SE) p β(SE) p
Model 1
 CTQ Total Score −0.30(0.10) 0.0007 −0.28(0.08) 0.0009 −0.30(0.12) 0.02
 Moderator −6.18(5.1) 0.22 −5.73(5.1) 0.27 −8.55(8.3) 0.31
 CTQ Total Score x Moderator 0.24(0.11) 0.036 0.25(0.11) 0.027 0.16(0.15) 0.29
Model 2
 Depression Symptoms −0.56(0.17) 0.002 −0.46(0.19) 0.02 −0.31(0.27) 0.26
 Moderator −15.4(11.7) 0.19 −7.98(12.8) 0.53 6.86(16.3) 0.68
 Depression Symptoms x Moderator 0.35(0.22) 0.11 0.23(0.24) 0.32 −0.07(0.30) 0.82
Model 3
 Anxiety Symptoms −0.36(0.16) 0.03 −0.03(0.16) 0.86 −0.28(0.35) 0.43
 Moderator −13.8(11.8) 0.25 16.9(11.9) 0.16 0.05(20.8) 0.99
 Anxiety Symptoms x Moderator 0.32(0.21) 0.14 −0.20(0.21) 0.35 0.08(0.38) 0.84
Model 4
 PTSD Symptoms −0.43(0.12) 0.001 −0.30(0.13) 0.02 −0.04(0.19) 0.84
 Moderator −9.81(5.20) 0.06 −2.78(5.50) 0.61 10.6(8.14) 0.20
 PTSD Symptoms x Moderator 0.43(0.16) 0.008 0.27(0.18) 0.10 −0.18(0.22) 0.42
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Note. Statistically significant interaction terms are indicated in bold text. Models adjusted for caregiver age, gender, and household size; CTQ, Childhood Trauma Questionnaire; PCEs, Positive Childhood Experiences; PTSD, Post-traumatic Stress Disorder.

For mental health symptoms, emotional support moderated the relationship between PTSD symptoms and family routines (p = .008), such that PTSD symptoms were associated with fewer family routines when emotional support was low (β = −0.43 (0.12), p = .001), but not when emotional support was high (β = −0.01(0.10), p = .96). Protective factors did not otherwise moderate the relationships between mental health symptoms and family routines (Table 5).

4. Discussion

We identified several risk and protective factors for consistent family routines among caregivers with preschool-age children. As hypothesized, caregivers' childhood maltreatment history and current mental health symptoms were associated with less consistent family routines, while PCEs and current social support were associated with more consistent family routines. Childhood maltreatment history was associated with less consistent family routines even when adjusting for caregivers' current mental health symptoms, indicating that this is an independent risk factor with critical implications for family functioning. Moderation analyses suggested that caregivers' current social support may buffer the effects of childhood maltreatment history and PTSD symptoms on family routine consistency, but PCEs did not emerge as a significant moderator of these relationships. Together, these findings indicate critical directions for future research and interventions to promote consistent routines, especially among families with a history of childhood maltreatment.

The magnitude of the associations observed in this study were generally in the small to medium range (Cohen, 2013; Selya et al., 2012), suggesting that caregiver risk and protective factors contribute modestly to family routine consistency. This is consistent with theoretical frameworks suggesting that family routines are shaped by a complex interplay of individual, relational, and structural factors (Selman & Dilworth-Bart, 2024), and highlight the importance of multi-component interventions that address both caregiver well-being and the broader social context, rather than focusing on any single risk or protective factor in isolation. We also observed differences in family routines by caregiver race and ethnicity; however, these findings should be interpreted with caution due to small sample sizes within some groups. These differences may reflect unmeasured structural or contextual factors, and future research in larger and more diverse samples is needed to better understand potential disparities in family routines across populations.

To our knowledge, this is the first empirical study to demonstrate the intergenerational transmission of caregivers' childhood history on current family routines. Caregivers' history of childhood maltreatment and other ACEs are associated with a wide range of poor outcomes for children, including physical health problems, physiologic disruption, developmental delay, behavioral problems, and poor mental health (Racine et al., 2023; Zhang et al., 2023). Several behavioral mechanisms have been implicated in the intergenerational transmission of caregiver ACEs to child health, including caregiver depression, stress, hostility, insecure attachment, and low sensitivity (Zhang et al., 2023). Results of this study provide novel evidence to suggest that inconsistent family routines may also link caregivers' childhood maltreatment history with child health. Although longitudinal research is needed to fully uncover these mechanistic pathways, known relationships between family routines and child outcomes suggest that this may be a key modifiable target for intervention to disrupt the harmful intergenerational effects of caregivers' childhood maltreatment.

Caregivers' current depression, anxiety, and PTSD symptoms were each associated with fewer regular routines among caregivers in our sample. This is consistent with other known consequences of caregiver mental health symptoms on family functioning, including decreased family cohesion and household control (Foster et al., 2008; Pérez et al., 2018). Caregiver anxiety and PTSD symptoms had small but statistically significant effects on family routines, while caregiver depression had medium-sized effects on family routines. This aligns with a wealth of prior research suggesting that caregiver depression is a particularly potent stressor on the family system (Morales et al., 2023; Sutherland et al., 2022). These findings may also reflect hypothesized mechanisms through which caregivers' mental health symptoms may influence family routines; anxiety and PTSD symptoms may disrupt routines due to hypervigilance and controlling behavior, while the fatigue, emotional withdrawal, and executive dysfunction associated with depression may have different and stronger influences on a caregiver's ability to maintain consistent routines for their family (Nuño et al., 2021). While additional research is needed to fully characterize the effects of caregiver mental health on family routines, results of this study suggest mental health symptoms may be important modifiable targets to help promote routines through family intervention.

When caregivers' childhood maltreatment history and mental health symptoms were included the same models, childhood maltreatment history and depression symptoms continued to be associated with less consistent family routines, although the size of the effects reduced. This suggests that childhood maltreatment history and depression symptoms are each independently associated with family routines, but share some variance, as caregivers with a history of childhood maltreatment may be more likely to have depression symptoms. Conversely, caregivers' anxiety and PTSD symptoms were no longer associated with family routines in these models, although associations between caregivers' childhood maltreatment history and less consistent routines remained consistent. This suggests that associations between caregivers' anxiety and PTSD symptoms and less consistent family routines may be partially explained by caregivers' maltreatment history. This is supported by prior analyses conducted with this cohort, in which we found that caregivers' childhood maltreatment was strongly associated with mental health symptoms [Blinded, under review]. Together, these results underscore the important role of childhood maltreatment history in influencing both mental health symptoms and family routines.

Results of this study provide new and important insights into protective factors for family routine consistency. First, we found that caregiver's PCEs are associated with more consistent family routines. This supports our hypothesis that caregivers with PCEs may have experienced more structured, supportive environments that are conducive to family routines, and in turn they may be better able to provide these environments and promote consistent routines for their own children. However, PCEs did not mitigate relationships between caregivers' childhood maltreatment history and less consistent family routines. This is consistent with the findings of a recent systematic review which suggest that PCEs do not protect against the harmful effects of ACEs on a wide range of outcomes, including depression, anxiety, stress, and harsh parenting (Han et al., 2023). Together, these findings suggest that while caregivers' PCEs may contribute to better family functioning, they may be insufficient to buffer the harmful effects of childhood maltreatment history.

Social support also emerged as an important protective factor among families in this study. First, both emotional and instrumental support were associated with more consistent family routines, as hypothesized. Second, results of our moderation analyses indicate social support may buffer associations between caregivers' childhood maltreatment history and less consistent family routines. These findings add to a large body of research on the protective effects of social support for caregivers (Bedaso et al., 2021; Dunst, 2022), and the potential for social support to buffer the harmful effects of ACEs among adults (Aldomini et al., 2025; Brown et al., 2025). These results should be interpreted with caution, as risk factors differed between caregivers with high and low levels of support. For example, CTQ total scores were higher among caregivers reporting low instrumental support compared to those reporting high instrumental support, and thus the protective effects of instrumental support may be confounded with caregivers' maltreatment history levels. However, there was no significant difference in CTQ total scores by emotional support level, suggesting that the buffering effect of emotional support is less likely to be influenced by group differences in maltreatment history. Additional research on the distinct influences of emotional and instrumental support is needed to clarify these protective effects.

Emotional and instrumental support did not moderate associations between caregivers' mental health symptoms and family routines, except for a significant interaction between emotional support and PTSD symptoms. Depression, anxiety, and mental health symptoms were lower among caregivers reporting high support compared to those with low support, suggesting that social support was linked with better mental health among caregivers in our sample. However, perceived social support may also be influenced by mood disorder symptoms, thus inflating observed relationships and masking potential moderating effects. An in-depth examination of social support among these caregivers is needed to better understand the directionality of these relationships and identify social protective factors for mental health symptoms among families with young children.

4.1. Strengths and limitations

Strengths of this study include our use of reliable, well validated measures and our focus on a specific stage of child development during which family routines are at heightened risk for disruption but also present an important opportunity for intervention. While most prior research has focused specifically on mothers, our study is also strengthened by defining caregivers more broadly, including 19 participants who identified as fathers.

The study is limited by the cross-sectional design, which prohibits causal inferences or examination of mediating pathways. Our sample was also relatively homogeneous, with most caregivers identifying as non-Hispanic White, highly educated, and female. Some participants were also recruited through social media, which may have introduced selection bias by disproportionately reaching caregivers who are more digitally connected and socioeconomically advantaged. As such, findings of this study may not be generalizable to more diverse populations, including caregivers from racially and ethnically minoritized groups, those with lower levels of educational attainment, or those experiencing socioeconomic disadvantage.

We were unable to include a reliable measure of household income in our analyses due to inconsistencies and missingness in participant responses. This is an important limitation, as socioeconomic disadvantage is a well-established risk factor for childhood maltreatment and may influence family routines through structural factors such as housing instability, work demands, and access to resources. To partially account for socioeconomic context, we included caregiver education level and enrollment in social services as indicators of socioeconomic status; however, these measures may not fully capture the complexity of financial strain. Given that consistent family routines are particularly beneficial for families with few financial resources (Budescu & Taylor, 2013; Liu & Merritt, 2021; Roche & Ghazarian, 2012); additional research that is specific to families living with poverty is needed to inform the tailoring of routine-promoting interventions.

Notably, childhood maltreatment history was prevalent and associated with family routines even within this relatively advantaged sample, suggesting that the harmful effects of childhood maltreatment history may extend beyond populations traditionally considered at higher risk. However, we were unable to examine other aspects of the family environment that may influence family routines, such as caregiver work schedules, distractions in the home environment (e.g. television, phones), or access to supportive resources (e.g., childcare assistance) (Ettinger et al., 2018; Jones, 2018). We were also unable to examine other aspects of childhood maltreatment with important influences on long-term outcomes, such as the timing and duration of maltreatment (McCutchen et al., 2022), or other caregiver ACEs related to household dysfunction (e.g. parental mental illness, substance misuse). We used the original version of the Benevolent Childhood Experiences scale (Narayan et al., 2018), but an expanded scale is now available, including an item to evaluate exposure to predictable home routines (Narayan et al., 2023). Future research that incorporates more comprehensive assessments of family context and caregiver experiences will provide additional insights into the intergenerational transmission of caregiver ACEs and PCEs on family routines.

4.2. Implications for clinical practice and public health

Results of this study indicate that caregivers with a history of childhood maltreatment may be a critical population to target for family interventions aiming to promote routines and related health behaviors, such as sleep and physical activity. Prior research demonstrates that family routines can be modified through intervention; however most routine-promoting interventions have been designed to address specific child conditions, such as autism spectrum disorder (Marsh et al., 2019; Romano et al., 2022). To address routines in the context of caregivers' childhood maltreatment history, family interventions should include a trauma-informed approach that includes building trust, ensuring emotional safety, and supporting family strengths (Champine et al., 2018). Interventionists could take a dual approach that addresses both the logistical aspects of routines (e.g. promoting regular bedtimes) and the emotional support needed to effectively maintain these routines (e.g. addressing mental health symptoms, promoting parental responsivity and sensitivity). Our findings related to instrumental support suggest that caregivers with a history of childhood maltreatment may benefit from individualized assistance with addressing instrumental needs and locating potential resources to promote regular routines, such as transportation and childcare. Results of our study also suggest that promoting social support through group intervention or providing access to resources may also be a critical strategy to support consistent routines among these families.

5. Conclusion

Childhood maltreatment history and other ACEs are highly prevalent, with 60% of the global population estimated to have at least one ACE (Madigan et al., 2023). While a caregiver's history of childhood maltreatment cannot be erased, addressing modifiable behaviors like family routines may help to prevent harmful intergenerational consequences of ACEs and promote health among children in these families. Additional research on risk and protective factors for consistent family routines, including both structural (e.g. financial resources, transportation access) and interpersonal (parenting, family relationships) factors, will inform more precise strategies for trauma-informed intervention.

Supplementary Material

MMC1

Funding/support

This work was supported by the National Institute of Nursing Research of the National Institutes of Health (K99NR018876, R00NR018876).

Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi.org/10.1016/j.chiabu.2026.108188.

Footnotes

CRediT authorship contribution statement

Eileen M. Condon: Writing – original draft, Methodology, Investigation, Formal analysis, Conceptualization. Sangchoon Jeon: Writing – review & editing, Methodology, Formal analysis. Lois S. Sadler: Writing – review & editing, Methodology, Conceptualization. Nancy S. Redeker: Writing – review & editing, Methodology, Conceptualization.

Declaration of competing interest

The other authors have no conflicts of interest to disclose.

Data availability

Data will be made available on request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

MMC1
NIHMS2191469-supplement-MMC1.docx (22.2KB, docx)

Data Availability Statement

Data will be made available on request.

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