Caregiver stress and cultural identity in families of preschoolers with developmental delay and behavioral problems

Abstract

Introduction:

Research on families of young children with developmental delay and disruptive behavior problems has failed to examine caregiver stress in the context of cultural factors.

Methods:

Families of 3-year-old children with developmental delay and behavior problems were recruited from Early Intervention sites. All caregivers in the current analysis (n = 147) were from immigrant and/or cultural minority backgrounds. Regarding income-to-needs, most families (57.8%) fell into the extreme poverty, poor, or low-income categories. Caregivers reported on their own experiences of acculturation and enculturation as well as their child’s problems.

Results:

Path analyses revealed that higher caregiver acculturation was associated with less parenting-specific stress, and higher caregiver enculturation was associated with less caregiver general stress. Severity of child problems was associated with more parenting-specific stress and general stress. Exploratory analysis yielded significant differences in associations between acculturation, enculturation, and caregiver stress in Black/African American caregivers versus Hispanic White caregivers.

Conclusion:

Findings suggest that among cultural minority caregivers of young children with developmental and behavioral problems, acculturation and enculturation may influence caregiver stress. While the cross-sectional nature of the study precludes causal conclusions, clinicians should consider how cultural factors can be harnessed to strengthen caregiver resiliency and improve engagement in parenting interventions.

Caregivers of young children with developmental delay (DD) and behavior problems, relative to caregivers of typically developing youth, have been identified as at increased risk for elevated stress (Barroso et al., 2017; Hayes & Watson, 2013). Increased demands inherent in raising a child with DD and disruptive behavior, and the associated interference in family functioning, can produce stress in caregivers that reduces overall wellness and quality of life. High levels of caregiver stress, in turn, are associated with long-term negative sequelae for the caregiver (Kersh et al., 2006; Olsson & Hwang, 2001), as well as further child emotional and behavioral health problems (Baker et al., 2003; Donenberg & Baker, 1993). Given these links, gaining an improved understanding of risk and protective factors that influence caregiver stress in families with children with DD and behavior problems is vital to enhancing clinicians’ ability to strengthen family members’ resiliency and wellbeing.

Importantly, research to date examining the stress of caregivers of youth with co-occurring DD and behavior problems has focused on predominately White, non-Hispanic samples and has failed to sufficiently consider key cultural factors that may be relevant to the parenting experience. The lack of research with racial/ethnic minority families is particularly concerning given that across families of children with DD, wellbeing has been found to be significantly lower among caregivers from racial/ethnic minority backgrounds (Eisenhower & Blachard, 2006). Several findings further underscore the need to better understanding how cultural factors may influence caregiver stress in this particularly vulnerable population. First, DD and behavior problems are disproportionately observed in youth from racial and ethnic minority backgrounds (Briggs-Gowan et al., 2001; Nguyen et al., 2007), calling into question the generalizability of prior research on predominantly White non-Hispanic samples. Second, families of racial and ethnic minority backgrounds show poorer engagement with mental health services and have greater rates of unmet needs (Alegria et al., 2010; Garland et al., 2005), highlighting gaps in the extent to which existing mental health care models adequately respond to the unique needs and strengths of minority families. Third, caregiver stress has been one of the most commonly examined predictors of treatment engagement, with studies demonstrating that higher caregiver stress is associated with reduced capacity to engage in treatment (e.g., session attendance, motivation; Gopalan et al., 2010). Given the importance of caregiver engagement in treatment response, understanding how cultural factors may relate to caregiver stress is necessary to inform clinician strategies for better engaging families (Sanchez et al., 2021; So et al., 2020).

Acculturation, referring to the psychological process by which a member of a minority group adopts, acquires, or adapts to a majority culture (Birman & Simon, 2013), may be particularly relevant to caregiver functioning in cultural minority families. In the United States, increasing research highlights how varying levels of adaptation to mainstream American culture (e.g., facility with the English language, familiarity, and identification with mainstream American culture) may help explain some of the within-group heterogeneity in parenting and adjustment in various cultural minority groups (e.g., Obasi & Leong, 2010; Williams et al., 2017). Research also indicates that acculturation should not be examined without its counterpart, enculturation, which refers to the psychological process by which a member of a minority group maintains their identification with their familial culture of origin. Acculturation and enculturation are thought to be interactive, yet bilinear processes (Yoon et al., 2011). Previous work conducted in a diverse urban community found that aspects of both parental enculturation and parental acculturation predicted more adaptive behavior in preschoolers (Calzada et al., 2009). One potential reason for such link is acculturation and enculturation’s influence on caregiver mental health.

Research examining the link between acculturation and stress has painted a nuanced picture. Some work suggests that becoming more acculturated to the dominant United States culture puts individuals at risk for internalizing stereotypes and encountering psychological challenges associated with common American perceptions of “success” (Buriel, 2012; Burnett-Zeigler et al., 2013), whereas other studies suggest that acculturation to the dominant/mainstream culture may be protective for stress and other mental health problems (Yoon et al., 2013). In the context of parenting, identifying with and developing familiarity and facility with the predominant culture may be particularly helpful for families in navigating healthcare, education, and other available services (Berdahl & Torres Stone, 2009; Costigan & Koryzma, 2011; Ho et al., 2007). However, this association may vary depending on multiple, intersecting factors. For one, acculturation to the United States for individuals from more oppressed racial minority backgrounds (e.g., Black/African American caregivers) may be harmful in that it involves assimilating a culture plagued with discrimination and racism (Obasi & Leong, 2009). Further, although understudied, caregivers’ nativity or generational status may impact individuals’ experiences with acculturation (e.g., Rodriguez et al., 2002). For example, foreign-born individuals may have added stress around acquiring English language proficiency later in life, whereas first- or second-generation immigrants may have added stress around identity development (Birman & Simon, 2013). As such, considering acculturation in samples with high proportions of foreign-born individuals in addition to individuals that transcend generational statuses may be beneficial.

In regard to enculturation, studies have shown that having a close tie to one’s cultural background or racial/ethnic group protects against mental health problems (e.g., Burnett-Zeigler et al., 2013; Yoon et al., 2013). For example, maintaining identification with one’s culture of origin may yield benefits to caregivers around connecting with family members, neighborhoods, or other social support networks with shared cultural backgrounds (Birman & Simon, 2013). Further, researchers have hypothesized that promoting a strong cultural identity can buffer or enhance self-esteem in the face of discrimination. Previous research indicates that this protective association may be even more pronounced for Black/African American caregivers (Yoon et al., 2011; Yoon et al., 2013). Indeed, similar constructs (e.g., racial identity, racial socialization) have been conceptualized as worthwhile treatment factors and targets for Black/African American families coping with the deleterious effects of racism (Anderson et al., 2018; Hughes et al., 2006; Jones et al., 2020; Lee & Ahn, 2013).

While extant studies on stress in caregivers of children with co-occurring DD and behavior problems have largely ignored cultural factors, they have gleaned important information about how child problems contribute to caregiver stress. Most work has found that behavior problems show larger effect sizes than DD in predicting caregiver stress (e.g., Baker et al., 2003; Barroso et al., 2018), however, other studies have found that cognitive deficits, child social functioning, speech problems, and tantrums contribute to caregiver stress (Davis & Neece, 2017; Spratt et al., 2007), underscoring the need to consider the cumulative impact of child problems when examining caregiver burdens. Further, most studies have exclusively examined parenting-specific stress (i.e., stress that arises from the caregiver role; e.g., Neece et al., 2012), with few studies examining parents’ general stress (i.e., overall level of experienced stress, regardless of source; e.g., Firth & Dryer, 2013). Although research shows that the extent of child difficulties and associated demands considerably predict caregiver stress (e.g., everyday tasks of caring for a child with disabilities; Baker et al., 2003; Crnic & Low, 2002), other contextual and/or cultural factors may add to, or moderate, these associations (e.g., financial hardship, English language competence; Conger & Donnellan, 2007; Perreira et al., 2006). Thus, considering a more comprehensive portrait of caregiver well-being may afford clinicians with a better understanding of how to support caregivers in their parenting roles.

The current study examined how culture-related psychological processes in caregivers (i.e., acculturation and enculturation) differentially contribute to their general stress levels, as well as to their parenting-specific stress in a sample of families with young children with DD and behavior problems. In light of previous findings on the effects of child behavior problems and DD on caregiver well-being (e.g., Eisenhower et al., 2009), a cumulative index of child problem severity (e.g., affective problems, pervasive developmental problems) was also included in the analyses. Families were recruited from the Part C of Individuals with Disabilities Education Act Early Intervention (EI) system of care in South Florida, and caregivers were diverse in myriad and intersecting ways (e.g., race, ethnicity, nativity, generational status, and region of origin). Recruiting such diversity in this sample afforded the unique opportunity to examine these constructs in a sample that reflects the cultural diversity of the South Florida community (i.e., where the majority of residents identify as racial and/or ethnic minorities) as well as the growing racial/ethnic distribution across urban mental health service systems in the United States. In addition to assessing how these factors cut across the diverse backgrounds seen in the full sample, we ran subgroup analyses to examine into how such factors may differ within and across caregivers from specific racial/ethnic backgrounds.

We hypothesized that within this population more severe scores of total child problems would be associated with higher levels of general stress and parenting-specific stress. Consistent with findings on the adaptiveness of high acculturation and enculturation, we hypothesized that higher acculturation and higher enculturation would be associated with lower parenting-specific stress and general stress. Exploratory analyses further examined (a) whether acculturation/enculturation might moderate links between child problems and caregiver stress, and (b) whether patterns between acculturation/enculturation and caregiver stress would vary across specific racial/ethnic groups.

Methods

Participants and Procedures

All study procedures were approved by the Florida International University Institutional Review Board. All families provided informed consent prior to participation. Data for the present analysis were drawn from the baseline assessments of a clinical trial evaluating methods for extending access to parenting interventions for preschoolers with DD and behavior problems. All data were collected prior to the onset of the COVID-19 pandemic. Families were recruited from three urban EI clinic sites located in the Southeastern region of the U.S., around the time of the child’s third birthday. All participating families had been receiving EI services for their child’s DD and demonstrated elevated levels of behavior problems. Specifically, families were included in the study if the child’s score on the Externalizing Problems scale of the Child Behavior Checklist 1.5–5 (CBCL 1.5–5; Achenbach & Rescorla, 2000) was in the clinically significant range (i.e., T-Score ≥ 60), and if the primary caregiver spoke English or Spanish fluently. Although children with a range of delays and communication deficits were included, youth with severe social communication deficits associated with autism-spectrum disorder were excluded (i.e., Social Responsiveness Scale, Second Edition > 75) from participation. This criterion was implemented due to requirements in the larger clinical trial that youth participate and engage in a parenting intervention. For the same reason, families in which the caregiver received a scaled score lower than 4 on the vocabulary subtest of either the Weschler Abbreviated Scale of Intelligence (WASI; Wechsler, 1999) or La Escala de Inteligencia Wechsler Para Adultos – Third Edition (EIWA-III; Pons et al., 2008) were also excluded.

Whereas the larger clinical trial included 150 families meeting the above criteria, the present analysis focused on the subset of primary caregivers from immigrant and/or cultural minority backgrounds (n = 147; 98% of the clinical trial sample), so that all participants in the study identified an ethnic/racial minority identity or a culture of origin outside of the United States. Roughly half of the subset sample identified as foreign-born and 92% identified as a member of a racial and/or ethnic minority group. Most primary caregivers (92.5%) identified as female, and on average, were in their mid-thirties (M = 34.4 years; SD = 6.3). Income-to-needs ratios (INRs; see Measures) indicated that the majority of families (57.8%) fell into the extreme poverty, poor, or low-income ranges. Approximately 29% of the subset sample reported that they were married. Full sociodemographic details are presented in Table 1.

Table 1.

Sociodemographic characteristics

	Full sample (N=147)		Sample Subgroup
			Hispanic caregivers (n=99)		Black/African American caregivers (n=35)
	n	%	n	%	n	%
Caregiver Gender
Female	136	92.5	92	92.9	33	94.3
Male	11	7.5	7	7.1	2	5.7
Caregiver Ethnicity a
Hispanic	99	68.8	99	100.0	5	15.2
Non-Hispanic	45	31.3	0	0.0	28	84.8
Caregiver Race b
White	102	69.9	90	90.9	0	0.0
Black/African American	35	24.0	5	5.1	35	100.0
Asian	5	3.4	0	0.0	0	0.0
A different race (e.g., biracial)	4	2.7	4	4.0	0	0.0
Caregiver Region of Origin
Caribbean Countries	59	40.1	44	44.4	15	42.9
South American Countries	28	19.0	27	27.3	0	0.0
Central American Countries	12	8.2	12	12.1	1	2.9
European Countries	6	4.1	0	0.0	0	0.0
Asian Countries	5	3.4	0	0.0	0	0.0
Other (includes North American)	37	25.2	16	16.2	19	54.3
Caregiver Nativity a
Foreign-born	76	52.8	58	59.8	9	25.7
United States-born	68	47.2	39	40.2	26	74.3
Caregiver Generational Status c
First Generation American	23	33.8	18	46.2	4	15.4
Second Generation American	12	17.6	6	15.4	5	19.2
Third Generation American	6	8.8	2	5.1	3	11.5
Fourth Generation American	2	2.9	0	0.0	2	7.7
Not applicable	25	36.8	13	33.3	12	46.2
Caregiver Education a
Did not complete high school	14	9.7	14	14.4	0	0.0
Completed high school/GED	59	41.0	38	39.2	20	57.1
Completed college	71	49.3	45	46.4	15	42.9
Income to Needs Ratio d
Extreme poverty	10	7.4	8	8.7	4	12.5
Poor	32	23.7	19	20.7	13	40.6
Low-income	36	26.7	29	31.5	5	15.6
Adequate-income	31	23.0	20	21.7	8	25.0
Affluent	26	19.3	16	17.4	2	6.3
Child Gender
Female	39	26.5	24	24.2	11	31.4
Male	108	73.5	75	75.8	24	68.6
Child Ethnicity e
Hispanic	104	71.7	97	98.0	7	20.6
Non-Hispanic	41	28.3	2	2.0	27	77.1
Child Race b
White	101	69.2	90	90.9	0	0.0
Black/African American	35	24.0	5	5.1	34	97.1
Asian	4	2.7	0	0.0	0	0
A different race (e.g., biracial)	6	4.1	4	4.0	1	2.9

^abased on n = 144 who provided such data;

^bbased on n = 146 who provided such data;

^cbased on n = 68 who were United States-born individuals;

^dbased on n = 135 who reported income;

^ebased on n=145 who provided such data

Participating caregivers completed study questionnaires as part of a baseline assessment and were compensated with a $100 gift card. Measures were completed online via the Research Electronic Data Capture platform.

Measures

Child Problem Severity.

Child Problem Severity was assessed using the child’s T-score on the CBCL 1.5–5. (Achenbach & Rescorla, 2000) Total Problems scale. The CBCL is a 99-item caregiver-report questionnaire regarding the behavioral, emotional, and social problems in children between the ages of 18 months and 5 years. T-scores are normatively scaled, based on a mean of 50 and a standard deviation of 10. A score of 60 is the cutoff for the borderline clinical range and a score of 64 is the cutoff for the clinical range. The scale has been shown to reliably capture specific clusters of symptoms (e.g., emotionally reactive, attention problems; Ivanova et al., 2010), as well as a cumulative index of total problems. It has displayed strong psychometric properties in samples of young children with DD (Dekker et al., 2002); internal consistency in the current sample was high (α= .95).

Acculturation and Enculturation.

The 43-item Abbreviated Multidimensional Acculturation Scale (AMAS-ZABB; Zea et al., 2003) was used to assess dimensions of acculturation and enculturation. This questionnaire has shown strong convergent, discriminant, and construct validity as well as strong internal consistency in Latinx populations (Zea et al., 2003). Internal consistency in the current study was very good (α_{Acculturation} =.96, α_{Enculturation} = .94). The AMAS-ZABB provides an open-response box for participants to self-report their “culture of origin,” which is used to guide responses on the enculturation domain. Items assessing “identity” asks how strongly participants identify as a United States American (acculturation domain) and with their culture of origin (enculturation) on a Likert-style scale from 1 (Strongly disagree) to 4 (Strongly agree). The language competence portion of the scale asks caregivers to indicate how well they speak and understand English, and how well they speak and understand their native language, on a scale of 1 (Not at all) to 4 (Extremely well). The cultural competence items assess how well the participants know American history, television shows, actors, and political leaders, and how well they know those from their culture of origin, on a scale of 1 (Not at all) to 4 (Extremely well).

General Stress in Caregivers.

General stress was assessed via the Stress subscale of the Depression, Anxiety, & Stress Scale (DASS-21; Lovibond & Lovibond, 1995). The DASS-21 a 21-item, well-supported measure of negative affect, with reliable subscales assessing depression, anxiety, and stress. The 7-item stress subscale used in the present study measures experiences of general stress (e.g., “I found it hard to wind down,” “I tended to over-react to situations,” “I found it difficult to relax.”). Respondents rate how much a statement applied to them over the past week, on a scale of 0 (Did not apply to me at all) to 3 (Applied to me very much, or most of the time). Internal consistency in the current study was high (α = .87). All item scores are multiplied by two to generate a total score. On the stress subscale, total scores from 0 to 14 are thought to be in the normative range, whereas scores of 15 or above are thought to be in the clinical range. In the current sample, 21% of caregivers provided responses that fell in the clinical range.

Parenting-Specific Stress.

The Family Impact Questionnaire (FIQ; Donenberg & Baker, 1993) was used to measure parenting-specific stress (i.e., stress specifically tied to the roles, responsibilities, and experiences of parenting). The FIQ has six subscales assessing caregiver perceptions of their child’s impact on their family. For the present study, we used the 9-item subscale that measures caregivers’ negative feelings toward parenting. Items on this subscale ask caregivers to identify their feelings and attitudes about their children by comparing them with other children of the same age (e.g., “My child is more stressful,” “My child brings out feelings of frustration and anger more,” “When I am with my child, I feel less effective and competent as a parent”) on a scale of 0 (Not at all) to 3 (Very much). The FIQ has been used with caregivers of young children with externalizing problems and DD, and it has exhibited strong psychometric properties (Donenberg & Baker, 1993). To speak to how the FIQ negative feelings towards parenting subscale compares to a normative sample, the original psychometric paper reported means on the subscale for families of youth without significant behavior problems (m=8.4) and families of youth with significant behavior problems (m=12.5; Donenberg & Baker, 1993). The mean in the current study was 12.22. Internal consistency in the current study was adequate (α = .69).

Income to Needs Ratio (INR).

INR was included as a covariate in all models to ensure any culture-related findings were not simply due to economic factors. INR was calculated by dividing total household income by the Federal Poverty Threshold (FPT) for a given year and family size (United States Department of Health & Human Services, 2018). The INR can be categorized: “extreme poverty” (INR ≤ .5), “poor” (.5 < INR ≤ 1), “low-income” (1 < INR ≤ 2), “adequate-income” (2 < INR ≤ 4), and “affluent” (INR > 4).

Cultural Background.

To capture the most common patterns of racial and ethnic intersectionality in the sample, race and ethnicity data were used. Caregiver participants self-identified as: Hispanic White (61.6%), Black/African American [non-Hispanic] (19.2%), Foreign-born, non-Hispanic White (4.8%), and other (e.g., Black/African American Hispanic, Asian non-Hispanic; 14.4%).

Data analysis

Analyses were conducted using MPlus version 7 (Muthen & Muthen, 1998–2012) with Robust Maximum Likelihood estimation. Missing value analysis indicated that data were consistent with missing at random, and therefore, Full Information Maximum Likelihood was used to handle missing data. Analyses included two path models, the base model (see Figure 1), and then a secondary multi-group model examining differences in the model between the two largest groups, caregivers who identified as Hispanic White (n = 90) and caregivers who identified as Black/African American (n = 35), given the low sample size of the other groups. Both the base model and the multi-group model were overidentified with df = 27 and df = 50, respectively.

Figure 1.

Path coefficients for the base model. n = 147. *p<0.05, **p<0.01. Covariate (i.e., INR) was omitted from this figure for ease of interpretation.

To examine the incremental utility of adding cultural factors as predictors of caregiver stress, a likelihood ratio test (LRT) was computed to compare a series of nested models (Satorra, 2000). First, an LRT comparing a model with child problem severity and INR was compared to a model adding acculturation as an exogenous variable. Second, an LRT comparing a model with child problem severity and INR was compared to a model adding enculturation as an exogenous variable. Third, an LRT comparing a model with child problem severity and INR was compared to a model adding both cultural factors (i.e., acculturation and enculturation).

The base and multi-group models examined the paths from (a) child problem severity acculturation, (b) acculturation, (c) enculturation to two endogenous variables (i.e., general stress and parenting-specific stress). A path from INR to general stress and parenting-specific was included to control for the influence of financial hardship on stress. Further, given the related constructs of general stress and parenting-specific stress, the error terms between the endogenous variables were allowed to covary. Likewise, given possible links between acculturation, enculturation, and child problem severity (e.g., Calzada et al., 2009), the error terms between the exogenous variables were allowed to covary.

Results

Preliminary Findings

Zero-order correlations and basic descriptive statistics for study variables are provided in Table 2. DASS-21 scores indicated that, on average, caregivers across the sample reported “normal” levels of general stress, although 21% reported experiencing mild, moderate, or severe levels of general stress. Consistent with prior literature suggesting bilinear measurement of acculturation and enculturation (Birman & Simon, 2013), acculturation and enculturation were relatively orthogonal in nature (r = .03, p = .72). All LRTs examining whether acculturation and/or enculturation significantly added to the prediction of caregiver stress (beyond the variance accounted for by child problem severity and INR) yielded significant outcomes. This pattern of findings provided justification to proceed with the more complex models containing cultural factors, child problem severity, and INR as exogenous variables.

Table 2.

Descriptive Statistics and Bivariate Correlations Between Study Variables

Variable	M(SD)	1	2	3	4
1. General Stress	9.07 (8.94)	-
2. Parenting-specific Stress	12.22 (4.17)	.37**	-
3. Acculturation	3.14 (0.71)	.22**	−.08	-
4. Enculturation	3.20 (0.62)	−.24**	−.13	.03	-
5. CBCL Problems	61.52 (10.67)	.33**	.37**	.21*	−.14

n = 147.

^*p<0.05

^**p<0.01

Base Model

Path analyses examined the extent to which caregivers’ general stress and their parenting-specific stress were each uniquely predicted by acculturation, enculturation, and child problem severity (after controlling for INR and the association between caregivers’ general stress and parenting-specific stress; see Figure 1).

Regarding the prediction of general stress in caregivers, child problem severity and parental enculturation were each significant predictors. For every unit increase in child problem severity, caregivers’ general stress increased by .27 units on average (p < .001). At the same time, caregiver enculturation showed an inverse relationship with general stress in caregivers. For every unit increase in caregiver enculturation, general stress in caregivers decreased 2.70 units on average (p = .01). Caregiver acculturation was not significantly associated with general stress.

Regarding the prediction of parenting-specific stress, child problem severity and caregiver acculturation were significant predictors. For every unit increase in child problem severity, parenting-specific stress increased .16 units on average (p < .001). At the same time, caregiver acculturation showed an inverse relationship with parenting-specific stress. For every 1-unit increase in caregiver acculturation, parenting-specific stress decreased 1.04 units on average (p = .01). Caregiver enculturation was not significantly associated with parenting-specific stress.

Additional exploratory models added two-way interaction terms as predictors to consider whether caregiver acculturation and/or caregiver enculturation moderated links between child problems and caregiver stress. Specifically, we added the Child Problems * Acculturation interaction term and the Child Problems * Enculturation interaction term in the prediction of general stress in caregivers and parenting-specific stress. These interaction tests did not yield any significant effects (all ps > .05).

Multi-group Model

An additional exploratory model was run to examine whether cultural background moderated the associations between acculturation/enculturation and caregiver stress. A likelihood ratio test revealed that the two models were statistically different from one another, indicating that the Hispanic White caregivers and Black/African American caregivers in the sample showed a significantly different pattern of associations among variables. The parameter estimates for both groups are displayed in Table 3. Specifically, among Black/African American caregivers, the paths from child problem severity and acculturation to parenting-specific stress, as well as from enculturation to general parental stress, remained significant but showed an even stronger association than the base model. Additionally, higher levels of acculturation were associated with significantly higher general stress in Black/African American caregivers, and child problem severity was not a significant predictor of general stress. By contrast, the associations between acculturation and enculturation and the stress outcome variables were not significant in the Hispanic White group.

Table 3.

Multi-Group Results

Dependent Variable	Parameter	Hispanic White (n=90)			Black/African American (n=35)
General stress		Est.	SE	p	Est.	SE	p
	Child problems	0.31**	0.09	0.00	0.01	0.10	.89
	Acculturation	1.41	0.91	0.12	8.52**	2.94	0.00
	Enculturation	−2.37	1.36	0.08	−6.96*	2.69	0.01
	INR	0.39	0.25	0.13	−0.54	1.44	0.71
Parenting-specific stress		Est	SE	p	Est	SE	p
	Child problems	0.12*	0.05	0.02	0.24**	0.05	0.00
	Acculturation	−0.32	0.47	0.49	−2.82*	1.25	0.02
	Enculturation	−0.17	0.73	0.81	0.17	1.23	0.89
	INR	−0.21	0.15	0.16	0.52	0.50	0.30

Note: Above models account for association between general stress in caregivers and parenting-specific stress. Covariance estimate in Hispanic White caregivers = 8.24 (SE = 4.50), p = 0.07; covariance estimate in Black/African American caregivers = 11.25 (SE = 4.84), p = 0.02.

n = 125.

^*p<0.05

^**p<0.01

Discussion

The current study offers novel insights into the growing body of literature that emphasizes the need to better understand caregiver wellbeing to optimize gains in EI programs and parenting interventions among underrepresented groups (Caley, 2012; Crnic et al., 2017). Consistent with previous work conducted in majority White, non-Hispanic middle class samples, the present cross-sectional findings suggest that severity of child problems is associated with higher levels of parenting-specific stress and general stress in caregivers from diverse cultural and socioeconomic backgrounds even when controlling for cultural factors and income-to-needs ratios. This robust tie between child problem severity and caregiver stress underscores the need to comprehensively address the broader wellness of the family when implementing parenting interventions for children with problems and DD.

Caregiver stress was also predicted by two key cultural factors—caregiver acculturation and caregiver enculturation. In the full sample, higher caregiver acculturation was associated with less parenting-specific stress, and higher caregiver enculturation was associated with less general stress. The finding that enculturation served as a protective factor against general stress is consistent with prior theories suggesting that closer orientation to culture of origin might better position immigrants and/or other racial/ethnic minorities to thrive in a close-knit family and/or ethnic community (Lara et al., 2005). However, previous studies on the effects of acculturation are more equivocal, which may reflect the divergent findings in the current study (i.e., acculturation predicted lower levels of parenting stress in the full sample, but higher levels of parenting stress in Black/African American caregivers).

These outcomes support the contextual view of acculturation and enculturation, such that acculturation to the majority culture (mainstream U.S. culture, in this case) may be more helpful for some caregivers in certain, child-related contexts (e.g., EI system of care; Berdahl & Torres Stone, 2009; Ho et al., 2007; Pham et al., 2017), whereas enculturation to one’s culture of origin may be more helpful in other contexts (e.g., connecting with family with shared cultural backgrounds; Birman & Simon, 2013). Further, much of the literature on early childhood has focused exclusively on caregiver acculturation (e.g., Hurwich-Reiss & Watamura, 2019), with the current findings suggesting that future work would do well to include both acculturation and enculturation as two independent, yet interactive, processes contributing to the wellbeing of caregivers (Berry et al., 2006).

Even though the cultural diversity of the current sample reflects the diversity seen in large urban pediatric clinics and within the broader South Florida community, thoughtful inspection of how acculturation and enculturation differ across specific cultural groups is needed. Therefore, secondary exploratory analyses suggest group differences in Hispanic White caregivers from Black/African American caregivers. The protective associations of acculturation and enculturation were no longer significant in the Hispanic White group, but were strengthened for Black/African American participants. The lack of significance in the Hispanic White group may speak to the importance of evaluating the ethnic density of the urban community in which this sample was examined. Indeed, previous research suggests that the ethnic density of an individual’s neighborhood plays a key role in ethnic minorities’ mental health (e.g., Bécares et al., 2018; Bosqui et al., 2014). Based on state data, over two thirds of the residents in the broader community identify as Hispanic/Latinx. Therefore, Hispanic/Latinx caregivers in the present sample may perceive the dominant culture of their community to be relatively consistent with their culture of origin (Birman & Simon, 2013), and acculturation and enculturation processes may function differently and/or may not have the same impact on their experiences of stress.

Regarding the Black/African American group, the negative effects of acculturation has been documented previously (e.g., Burnett-Zeigler et al., 2013) and may be explained by the theory of internalized racism (Mouzon & McLean, 2016; Williams & Mohammed, 2013), or the process by which identifying with an American identity may also consist of internalizing racism that permeates American society. In essence, for Black/African American individuals, becoming more acculturated to the United States may lead to adopting negative stereotypes and prejudice against themselves. Instead, the inverse association between enculturation and general stress is consistent with research showing that stronger racial identity or stronger identification with being Black/African American has been shown to protect against race-related stressors (Sellers et al., 2003; Yoon et al., 2013).

Several study limitations merit mention. First, due to the heterogeneity of cultural groups in the sample, the current study did not have sufficient power to examine specific group differences in cultural origin and generational status. Future research would do well to look at specific regions of origin as well as specific immigrant generations as moderators of the association between cultural factors and caregiver stress. Second, the present study relied on cross-sectional data and therefore cannot speak to causal effects of cultural identification factors on stress, nor can it speak to the bidirectional effects between child problems and caregiver stress. It may be that caregivers who have a higher degree of general stress are more likely to report their children as having higher problem scores, due to poorer stress tolerance or heritable mental health problems. Third, the current analysis did not include a range of other family level factors that can also contribute to caregiver stress (e.g., single caregiver household, family size). Previous work suggests that such family characteristics may present unique risk and protective factors that may influence caregiver stress, childhood psychopathology, and engagement with services (Bagner & Graziano, 2013; Copeland et al., 2009). Future work in this area would do well to account for such variables. Fourth, although psychometric evaluations of the AMAS have been reported previously, this prior work has been conducted with samples from different demographic background (e.g., samples of entirely Latinx/Hispanic participants), and thus the AMAS may have performed somewhat differently in this more heterogenous sample. Fifth, given the unique cultural composition of the broader community, research would benefit from further examination of associations between cultural identification and caregiver stress across several geographic parts of the United States. Last, given differences in how cultural factors varied across racial/ethnic groups, future research should integrate qualitative and quantitative data to better understand caregivers’ perspective of their cultural identity, subjective experiences with acculturation and enculturation, and how they perceive such factors may relate to stress and wellness. Utilizing a community-based participatory research framework (Bogart & Uyeda, 2009; Thompson & Hood, 2017) would offer the opportunity to collaboratively work with caregivers to co-develop possible solutions that lead to more person-centered clinical care.

Despite these limitations, the current findings lend themselves to several clinical implications. First, assessing cultural factors in addition to child problems may help providers better assess and address caregiver stress. We recommend implementing surveys (e.g., AMAS; Zea et al., 2003) and/or interviews (e.g., Cultural Formulation Interview; APA, 2013; Lewis-Fernandez et al., 2020; Sanchez et al., 2021) that qualitatively inquire about families’ cultural backgrounds as well as their individualized needs and expectations at the outset of treatment (La Roche et al., 2020; Zigarelli et al., 2016). Importantly, such tools may help inform person-centered practice and lead to better engagement throughout intervention (Sanchez et al., 2021). Of note, consistent with the divergent findings among Hispanic White and African American/Black caregivers, the results of qualitative cultural assessments are likely to vary based on the specific experiences and intersecting identities of families. Thus, remaining reflective and responsive to families’ unique profiles of strengths and needs is critical (Sandeen, Moore, & Swanda, 2018). Lastly, the current findings on the link between enculturation and general stress point to the promising utility of reaffirming cultural identity as a means of empowering caregivers from cultural minority backgrounds (Anderson et al., 2018; Lee & Ahn, 2013).

Taken together, the information gained from the current study extends our understanding of caregiver stress in families from diverse cultural backgrounds raising children with DD and behavior problems. Structural barriers have left racial and ethnic minority families in the United States with greater rates of unmet needs (Garland et al., 2005; de Haan et al., 2018). When identifying ways to optimize parenting interventions, considering caregivers’ cultural factors, such as their process of acculturating to the United States and maintaining their culture of origin, may augment caregiver resiliency, mitigate caregiver stress, enhance engagement in services, and improve overall family wellness.

Practitioner Points:

• In families of young children with comorbid developmental and behavioral problems, caregiver stress has been associated with reduced child and family functioning. As such, clinicians and treatment programs should monitor and address caregiver well-being.

• The current study suggests that caregiver acculturation and enculturation may play a protective role against stress. Thus, clinicians working with cultural minority families may do well to assess and incorporate cultural identity factors in order to strengthen caregiver resiliency and family wellness and improve successful engagement in parenting interventions.

• The current study suggests that severity of child problems is associated with higher levels of caregiver stress. Therefore, clinicians may do well to monitor severity of child problems as a risk factor for heightened caregiver stress.