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R E S E A R C H A R T I C L E Open Access
Parenting stress during infancy is a risk
factor for mental health problems in 3-
year-old children
Nayantara Hattangadi
1
, Katherine T. Cost
1
, Catherine S. Birken
2,3,4,5,6
, Cornelia M. Borkhoff
2,3,5,7
,
Jonathon L. Maguire
4,5,6,8,9
, Peter Szatmari
1,10,11
and Alice Charach
1,10*
Abstract
Background: Although research on the relationship between parent and child mental health is growing, the impact
of early parenting stress on preschool-aged children’s mental health remains unclear. The objective was to evaluate the
association between parenting stress during infancy and mental health problems in 3-year-old children.
Methods: A prospective cohort study of healthy preschool-aged children recruited from 9 primary care practices in
Toronto, Canada was conducted through the TARGet Kids! primary care practice-based research network. Parenting
stress was measured when children were between 0 to 16 months of age, using the Parent Stress Index Short Form,
PSI-SF. Parent-reported child mental health problems were measured at 36 to 47 months using the preschool
Strengths and Difficulties Questionnaire, total difficulties score (TDS). Hierarchical linear regression analysis was used to
investigate the association between standardized PSI-SF and TDS, adjusted for child age, sex, temperament, sleep
duration and household income. To strengthen clinical interpretation, analysis was repeated using adjusted
multivariable logistic regression (TDS dichotomized at top 20%).
Results: A total of 148 children (mean ± SD age, 37.2 ± 1.7 months, 49% male) were included in the analysis. Parenting
stress during infancy (11.4 ± 3.1 months of age) was significantly associated with mental health problems in 3-year-old
children (β= 0.35; 95% CI = 0.20–0.49, p< 0.001). Higher parenting stress was also associated with increased odds of
higher TDS (OR = 2.26, 95% CI = 1.69–2.83, p<0.01).
Conclusion: Healthy preschool-aged children with parents reporting parenting stress during infancy had a 2 times
higher odds of mental health problems at 3 years.
Keywords: Parenting stress, Child mental health, Prospective cohort, Mental health, Parent-child relationship
Background
The etiology of mental health problems in young children
has garnered growing research and clinical interest (1).
Earlychildhoodisaperiodmarkedbycriticalemotional,
social and behavioral development; in the early years, men-
tal health problems can manifest as internalizing behaviors
such as fearfulness and social withdrawal, and externalizing
behaviors such as irritability, temper outbursts and oppos-
itional, non-compliant behavior (2,3). Young children with
such concerns continue to have difficulties as they grow
older; over time, these difficulties are associated with poor
academic, employment and health trajectories (4,5).
Our understanding of early modifiable risk factors for
mental health problems in preschool-aged children is in-
complete. In older children, parenting stress has been re-
ported as a risk factor for parent and child psychopathology
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data made available in this article, unless otherwise stated in a credit line to the data.
* Correspondence: alice.charach@sickkids.ca
1
Department of Psychiatry, Hospital for Sick Children, Toronto, ON, Canada
10
Department of Psychiatry, University of Toronto, Toronto, ON, Canada
Full list of author information is available at the end of the article
Hattangadi et al. BMC Public Health (2020) 20:1726
https://doi.org/10.1186/s12889-020-09861-5
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(6,7).Althoughtheliteratureislimited,somestudieshave
explored the impact of parenting stress in children under
10 years of age and have found links with child behavior
problems (8,9). However, previous studies focused on par-
enting stress in the context of children with neurodevelop-
mental difficulties, chronic illnesses, or developmental
delays (10,11). Thus, the impact of early parenting stress
on typically developing preschool-aged children is unclear.
There are confounding factors that impact the relation-
ship between parenting stress and mental health problems
in preschool-aged children that should be considered.
Namely, temperament or biologically-based differences in
child behavior patterns, have been identified as early risk
factors of mental health problems in children (12,13). In
particular, high negative affect, evidenced as irritability,
and low effortful control or poor impulse self-control, have
been linked to subsequent diagnoses of Attention Deficit
Hyperactivity Disorder (ADHD), Oppositional Defiant Dis-
order (ODD), anxiety disorders and depression (14,15).
As well, children who have high scores on inhibition are at
a greater risk of anxiety disorders than those with lower
scores on this temperamental domain (14). Moreover,
there is increasing interest in the relationship between
sleep and mental health in this age group (16,17). Some
studies link child sleep problems, bedtime resistance, and
parental perceptions of child’s sleep as problematic, with
higher parenting stress (18).
The relationship between parenting stress in infancy
and development of mental health problems in preschool-
aged children is understudied. Parenting stress is a poten-
tially modifiable factor that may contribute to mental
health problems in young children. Findings could lead to
including regular assessments of parenting stress as part
of developmental assessments for children, thereby
informing practitioners to assist parents with managing
and alleviating parenting stress, and to identify and sup-
port children at higher risk for mental health problems.
The objective of our study was to evaluate the associ-
ation between early parenting stress and mental health
problems in preschool-aged children.
Methods
Participants
We conducted a prospective study of healthy urban chil-
dren recruited during health supervision visits from pri-
mary care practices participating in The Applied Research
Group for Kids! (TARGetKids!), a community-based re-
search network in Toronto, Canada (www.targetkids.ca)
(19). Trained research assistants administer parents/care-
givers standardized questionnaires to collect information
on child and parental health (19). In 2016, the preschool
Strengths and Difficulties Questionnaire (P-SDQ), a brief
parent-report screening measure identifying internalizing
and externalizing behaviors in young children was added
to the TARGet Kids! study protocol (20).
Children were included in this study if their parent/care-
giver completed the measure of parenting stress (Parent
Stress Index Short Form; PSI-SF) during infancy (baseline,
between 0 to 16 months of age), as well as the P-SDQ dur-
ing the 3 year health supervision visit (outcome, between 36
to 47 months of age). In addition, parent report of 24-h
sleep duration and temperament (Child Behavior Question-
naire, Very Short Form; CBQ-VSF), collected during the 3
year health supervision visit, were also required for inclu-
sion in this study. TARGet Kids! exclusion criteria are: < 32
weeks gestational age; health conditions affecting growth
(e.g. cystic fibrosis); chronic conditions (other than asthma
and high functioning autism); severe developmental delay;
unscheduled visit because of acute illness; and families who
are unable to complete the measures in English (19). A total
of 149 children met the inclusion criteria for this study
(Fig. 1). One participant had > 20% of missing responses
and was excluded, leaving n= 148 for analysis.
Informed written consent was obtained by parents, and
ethical approval was granted from the Research Ethics
Boards at The Hospital for Sick Children and St. Michael’s
Hospital, Toronto, Canada. The cohort study is registered
at www.clinicaltrials.gov (identifier NCT01869530).
Exposure variable: parenting stress
PSI-SF is a valid and reliable parent-report measure for
early identification of parent–child systems under exces-
sive stress (21). It has 36-items, representing three do-
mains: parent distress, parent-child dysfunctional
interaction, and difficult child. Parenting stress scores,
based upon all three domains, range from 36 to 180.
Parenting stress percentile scores that fall between 15
and 80 are considered typical; over 80th percentile is
high. The parenting stress score has excellent internal
consistency in our sample (Cronbach’s alpha: 0.95).
Outcome variables: mental health problems
The P-SDQ is a 25-item parent-report measure used to
identify young children at high risk for mental health
disorders. The P-SDQ has good psychometric properties
and is valid for use with children age 2–4 years (22). It is
divided into five subscales (emotional problems, conduct
problems, hyperactivity/inattention, peer problems and
prosocial behavior), each comprising of five items rated
on a 3-point Likert scale (0–2), with scores ranging from
0 to 10. The total difficulties score (TDS) includes all
subscale scores except the prosocial behavior subscale,
and ranges from 0 to 40. In our sample, the total diffi-
culties score has acceptable internal consistency (Cron-
bach’s alpha: 0.70). The total difficulties score can be
dichotomized as being at risk of clinical problems (TDS
> 12) or not at risk (< 12). Cutoff was determined based
Hattangadi et al. BMC Public Health (2020) 20:1726 Page 2 of 7
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on published norms and measures for borderline and
definite clinical risk, as well as identifying scores for the
top 20% (characterized as being at risk of clinical prob-
lems) in our total sample of 3-year-old children (23,24).
Covariates
An a priori literature search was conducted to identify po-
tential confounds in the relationship between early parent-
ing stress and mental health problems in preschool-aged
children. Covariates identified included age at baseline,
sex, temperament, sleep duration, and household income.
Parent-reported temperament was measured using the
CBQ-VSF (25). CBQ-VSF is a valid and reliable scale that
identifies three domains: negative affect (negative emo-
tional reactions), effortful control (self-control) and sur-
gency/extraversion (motor activity and seeking closeness
with others). We included the negative affect and effortful
control temperament domains as confounders, as there is
substantial literature in support of their impact on emo-
tional and behavioral problems in young children (13–15).
In our sample, negative affect and effortful control have
acceptable internal consistency (Cronbach’salpha:0.75
and 0.69, respectively). Twenty-four hour sleep duration
was reported by parents in response to the question “How
many hours does your child usually spend sleeping in a
24-hour period”? Sleep duration was parameterized as a
continuous variable denoting the number of hours slept in
a 24-h period. Child age and sex, and self-report annual
household income, were collected during enrollment.
Sample size
The sample size calculation for this study was based on a
review of the existing literature on parenting stress and
mental health problems in young children. A study with a
small effect size (r= 0.1) and a power of 80% would re-
quire a minimum sample of 128, to detect an association
at an alpha level of 5% (26). Thus, our sample of 148 was
deemed appropriate.
Statistical analysis
Descriptive statistics were calculated for the exposure, out-
comes, and covariates and presented as mean values
(standard deviations) for continuous data, and percentages
for categorical data. A correlation matrix was conducted to
assess the Pearson correlations between key variables in
this study. Hierarchical linear regression analysis was con-
ducted to examine the association between early parenting
stress and mental health problems, using a three step-
approach: 1) with covariates (model 1); 2) including key
temperament variables (model 2); and 3), adding parenting
stress (model 3). In addition, we used adjusted multivari-
able logistic regression analysis to strengthen clinical inter-
pretation of the relationship between our exposure and
outcome variable (total difficulties score dichotomized at
top 20%). All variables were standardized to interpret logis-
tic regressions as 1 standard deviation change. Covariates
specified a priori (age at baseline, sex, negative affect, ef-
fortful control, sleep duration, and household income) were
included in the adjusted multivariable models. Statistical
Fig. 1 Participant flowchart 1
Hattangadi et al. BMC Public Health (2020) 20:1726 Page 3 of 7
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analysis was performed using R version 3.6.1 (27). Signifi-
cance level was set at p<0.05.
Twelve of 148 participants had some responses miss-
ing on their PSI-SF (< 9%). Missing responses were im-
puted using multiple imputation. We created and
analyzed 10 imputed datasets (28,29). Missing values on
household income (1%) were also imputed.
Results
Table 1outlines descriptive characteristics. The mean (±
SD) age of children was 11.4 (±3.1) months at baseline,
and 37.2 (±1.7) months at outcome; 49% of children in-
cluded in this study were male. Parents scored an average
of 60.0 ± 15.5 on parenting stress, well below scores con-
sidered high. Approximately 2% of parenting stress per-
centile scores fell within the high or clinically significant
range. Parents were relatively well educated and financially
secure as 96% of mothers had a college/university degree,
and 94% reported an annual household income >$60,000.
A statistically significant correlation was identified be-
tween parenting stress and mental health problems
(Pearson correlation coefficient = 0.44, 95% CI = 0.29–
0.56, p= 0.001). Significant correlations between parent-
ing stress and negative affect, as well as between both
temperament traits and mental health problems, were
also found. See Table 2.
After accounting for child age at baseline, sex, house-
hold income, and sleep duration (model 1), negative
affect and effortful control (model 2), parenting stress
during infancy (model 3) was associated with total men-
tal health problems in children at 3 years (β= 0.35; 95%
CI = 0.20–0.49, p< 0.001). Model 3 explained significant
variance in the outcome (adjusted R-squared = 0.39, F (7,
140) = 14.35, p< 0.001) and significantly more variance
than Model 1 (adjusted R-squared = 0.06, F (4,143) =
3.67, p= < 0.01) and Model 2 (adjusted R-squared = 0.29,
F (6,141) = 11.46, p< 0.001). See Table 3.
In addition, a one standard deviation increase in par-
enting stress during infancy was associated with twice
the odds of the child being at high risk of total mental
health difficulties at 3 years (OR = 2.26, 95% CI = 1.69–
2.83, p< 0.01). See Table 4.
Discussion
We found that stress in the parent-child system during
infancy was associated with subsequent mental health
problems in preschool-aged children. Indeed, while par-
enting stress during infancy is associated with negative
affect, its contribution to preschool mental health prob-
lems is beyond that of temperament factors known to be
linked. This finding expands our understanding of modi-
fiable predictors during infancy and toddlerhood, and
suggests that parenting stress is an important potential
target for intervention (30).
Conceptually, the observed relationship between parent-
child systems under stress and emotional and behavioral
problems in children is well described. Parents under stress
arelesslikelytobeengaged,moreirritableanddistantwith
their young children (31). Particularly in the early years,
positive bonding experiences and interactions between par-
ent and child are fundamental for building competencies
that support growth and development. A lack of early par-
ental nurturance, parental negativity or over-reactivity can
impact emotional and behavioral development in children,
and have deleterious long-term consequences including,
but not limited to, negative adjustment outcomes (e.g.
social-emotional and peer difficulties), and increased risk
for mental health and substance use problems as they grow
older (32,33).
In addition, it is important to highlight the bidirectional
associations between parenting stress and child behavior.
Stress can negatively affect parents’interpretations of child
behaviors, shaping subsequent parent-child interactions,
potentially reducing parental responsiveness and sensitiv-
ity towards children, thus, impacting child behavior (34,
35). While the associations are difficult to disentangle, it is
also well established that excessive stress that hinders par-
ents’abilities to appropriately manage their own moods
and reactions can perpetuate ongoing difficulties for par-
ents and their children (36). Finally, this relationship could
Table 1 Descriptive Characteristics
Characteristics All participants
(n= 148)
Age, mo, mean ± SD (min-max)
Baseline 11.4 ±3.1 (0–16.0)
Outcome 37.2 ±1.7 (36.0–47.0)
Male, n (%) 73 (49.3)
Mental Health Problems
a
,
mean ± SD (min-max)
8.8 ±4.4 (1.0–26.0)
Parenting stress
b
, mean ±
SD (min-max)
60.0 ±15.5 (36.0–105.0)
Temperament
c
, mean ± SD
(min-max)
Negative affect 3.7 ±0.9 (1.8–6.1)
Effortful control 5.4 ±0.7 (3.5–6.7)
Sleep duration
d
, mean ±
SD (min-max)
11.6 ±1.1 (8.0–14.0)
Maternal education high
school or less, n (%)
5 (3.4)
Household income
e
< $60,000, n (%) 7 (4.7)
SD standard deviation
a
Total difficulties score - preschool Strengths and Difficulties
Questionnaire (P-SDQ)
b
Total stress score –Parent Stress Index Short Form (PSI-SF)
c
Child Behavior Questionnaire –Very Short Form (CBQ-VSF)
d
Number of hours slept in a 24-h period
e
Annual household income (dichotomized at 60,000 CAD)
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be reflective of genetic variants that affect both a vulner-
ability to experience stress in parents, and emotional and
behavioral problems in their children (37).
To our knowledge, much of the existing research has
been completed in clinical settings (e.g. parents have
post-partum psychosis or children are experiencing psy-
chiatric disorders); this study is novel as it is document-
ing the association between parenting stress during
infancy and mental health problems in a typically devel-
oping population. The impact of early parenting stress
reinforces that mental health interventions for children
must regularly assess parental well-being and include
programs to assist parents in managing parenting-
related stress in order to effectively benefit young chil-
dren. In addition, regular assessment of parenting stress
can support clinicians in identifying preschool children
at higher risk of clinical mental health problems. Mental
health interventions with parenting programs (aimed at
improving parent-child interactions, managing parenting
stress, and promoting mindful parenting) can be valu-
able contributions to early mental health management
in families (38,39). Some of these early interventions
have identified improvements in child internalizing and
externalizing behaviors, as well as reductions in parent-
ing stress (40).
Strengths and limitations
A strength of this study was the prospective analysis of
parenting stress during infancy, and subsequent assess-
ment of mental health problems in typically developing 3-
year-old children. An additional strength of this study was
controlling for several important covariates, such as tem-
perament traits, sleep duration and sociodemographic
characteristics. Due to our primary care setting, our study
was limited by reliance on parent-report measures, which
could have common method bias. Parenting stress can
affect parents’perceptions of child behavior, and it is pos-
sible that parents who experience early parenting stress
are more likely to perceive their preschool child’sbehavior
as problematic. Future research could include measures
completed by additional caregivers, as well as more inten-
sive observational data collection such as clinical assess-
ments. In addition, few families that participated in our
study experience high levels of socioeconomic risk and are
Table 2 Correlation Matrix
Variable 1 2 3 4
1. Mental health problems 1.0 0.41* −0.37* 0.44*
2. Negative affect 0.41* 1.0 −0.10 0.38*
3. Effortful control −0.37* −0.10 1.0 −0.01
4. Parenting stress 0.44* 0.38* −0.01 1.0
*p< 0.05
Table 3 Hierarchical linear regression for association between parenting stress and mental health problems in 3-year-old children
Variable Model 1 Model 2 Model 3
β(log) 95% CI β(log) 95% CI β(log) 95% CI
Age
a
−0.01 −0.06, 0.04 −0.01 −0.06, 0.03 −0.03 −0.07, 0.01
Sex, female −0.28 −0.60, 0.03 −0.16 −0.45, 0.12 −0.25 −0.52, 0.02
Household income,
b
low 1.19* 0.45, 1.94 0.89* 0.24, 1.55 0.50 −0.13, 1.14
Sleep duration 0.01 −0.15, 0.17 −0.01 −0.15, 0.13 −0.00 −0.13, 0.13
Negative affect 0.34* 0.21, 0.49 0.23* 0.09, 0.37
Effortful control −0.31* −0.46, −0.17 −0.31* −0.45, −0.18
Parenting Stress 0.35* 0.20, 0.49
Adjusted R
b
0.06* 0.29* 0.39*
Model F-statistic (df) 3.67 (4, 143) 11.46 (6, 141) 14.35 (7, 140)
Change in F-statistic (p-value) 0.007 < 0.001 < 0.001
CI indicates Confidence interval
a
Age at baseline
b
Annual household income dichotomized at 60,000 CAD (> 60,000 = high)
*p< 0.05.
Table 4 Adjusted logistic regression for association between
parenting stress and mental health problems in 3-year-old
children
a
Variable Adjusted OR 95% CI
Age
b
0.91 0.77, 1.04
Sex, female 0.96 0.02, 1.94
Household income
c
, low 3.17 1.23, 5.10
Sleep duration 0.99 0.45, 1.52
Negative affect 1.67* 1.15, 2.18
Effortful Control 0.44* 0.08, 0.94
Parenting stress 2.26* 1.69, 2.83
a
adjusted for all other variables in Table
b
Age at baseline
c
Annual househ old income dichotomized at 60,000 CAD (> 60,000 = high)
OR indicates Odds ratio, CI indicates Confidence interval
*p< 0.05.
Hattangadi et al. BMC Public Health (2020) 20:1726 Page 5 of 7
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largely of middle-higher socio-economic status. Therefore,
the results may not be generalizable to less-advantaged
populations. Similarly, most of the reports of parenting
stress measured in our study are considered typical. Yet,
the relative lack of financial stressors and clinically signifi-
cant parenting stress strengthens the importance of our
findings –even in relatively affluent families, and among
parents experiencing typical parenting stress, early parent-
ing stress is associated with child mental health outcomes
in preschool years.
Conclusion
Mental health problems in children emerge early and can
have adverse and long-lasting impact on social, emotional
and behavioral outcomes. This study highlights the role of
early parenting stress as a risk factor for mental health
problems in preschool-aged children. Our initial findings
support further exploration of the relationship among
parenting stress, child temperament and the emergence of
mental health problems in early childhood. Study findings
also underline the importance of identifying parents ex-
periencing stress to help ameliorate mental health prob-
lems in preschool-aged children.
Abbreviations
P-SDQ: Preschool Strengths and Difficulties Questionnaire; PSI-SF: Parent
Stress Index Short Form; CBQ-VSF: Child Behavior Questionnaire –Very Short
Form
Acknowledgements
The authors thank all participating families for their time and involvement in
TARGet Kids! and are grateful to all practitioners who are currently involved
in the research network.
Ethics and consent to participate
The TARGet Kids! research platform has been approved by the Research
Ethics Boards at the Hospital for Sick Children and St. Michael’s Hospital,
Toronto, Ontario, Canada. Informed written consent was obtained from all
study participants. Written consent was obtained by parents of all
participating children.
Authors’contributions
NH conceptualized and designed the study, conducted the analysis and
interpretation of data, and drafted the manuscript. KTC and AC
conceptualized and designed the study, assisted in interpretation of data,
and revised the manuscript. CSB and JLM designed the study, assisted in
acquisition and interpretation of data, and revised the manuscript. CMB and
PZ designed the study, assisted in interpretation of data, and revised the
manuscript. CSB and JLM lead the TARGet Kids! research program. All
authors read and approved the final manuscript, and agree to be
accountable for all aspects of the work.
Funding
The authors acknowledge the support of the Margaret and Wallace McCain
Centre for Child, Youth and Family Mental Health at the Centre for Addiction
and Mental Health (CAMH). The funding agency had no role in the design,
collection, analysis or interpretation of the results of this study or in the
preparation, review, or approval of the manuscript.
Availability of data and materials
The datasets used and/or analyzed during the current study are available
upon reasonable request by contacting www.targetkids.ca/contact-us/.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Author details
1
Department of Psychiatry, Hospital for Sick Children, Toronto, ON, Canada.
2
Division of Pediatric Medicine and the Paediatric Outcomes Research Team
(PORT), Hospital for Sick Children, Toronto, ON, Canada.
3
Child Health
Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada.
4
Department of Pediatrics, Faculty of Medicine, University of Toronto,
Toronto, ON, Canada.
5
Institute of Health Policy Management and Evaluation,
University of Toronto, Toronto, ON, Canada.
6
Joannah & Brian Lawson Centre
for Child Nutrition, Department of Nutritional Sciences, University of Toronto,
Toronto, ON, Canada.
7
Women’s College Research Institute, Women’s College
Hospital, Toronto, ON, Canada.
8
The Centre for Urban Health Solutions, Li Ka
Shing Knowledge Institute of St. Michael’s Hospital, Toronto, ON, Canada.
9
Department of Pediatrics, St. Michael’s Hospital, Toronto, ON, Canada.
10
Department of Psychiatry, University of Toronto, Toronto, ON, Canada.
11
Centre for Addiction and Mental Health, Toronto, ON, Canada.
Received: 15 April 2020 Accepted: 9 November 2020
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