The Associations Between Internalizing and Externalizing Behaviors in Children with Autism and Parenting Stress: A Systematic Review

Children with autism often exhibit behavioral problems, which can significantly affect family’s well-being by increasing parenting stress. A thorough understanding of the interactions between child behavioral problems and parenting stress is critical for developing effective support strategies. This systematic review synthesized findings from 88 studies investigating the associations between internalizing and externalizing behaviors and parenting stress in families of children with autism. The review specifically examined age-related changes in children’s behavioral patterns, identified behavioral subtypes most strongly linked to parenting stress, compared mothers’ and fathers’ experiences, and explored the evolution of these relationships over time. Studies assessing interventions designed to reduce behavioral problems and/or alleviate parenting stress were also included to evaluate their effectiveness. Across studies, higher levels of child behavioral problems were consistently linked to increased parenting stress. However, findings regarding the influence of the child’s age on the severity of behavioral problems, as well as the differences between mothers’ and fathers’ parenting stress levels, remained inconsistent. Longitudinal evidence supports transactional and bidirectional interactions that may intensify over time. Intervention programs demonstrated beneficial effects on both child behaviors and parenting stress, with effect sizes varying according to intervention type (parent-focused, child-focused, or parent–child interaction-centered). This review underscores the bidirectional relationship between child behavioral problems and parenting stress, highlighting the importance of interventions tailored to children’s developmental stage and family context.