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ADHD AND MOTHERS' PSYCHOLOGICAL DISTRESS: THE IMPORTANCE OF CHILD BEHAVIOR AND MOTHERS'

David Rabiner, Ph.D.
Senior Research Scientist
Duke University

Researchers studying the impact on parents of raising a child with ADHD have emphasized that increased caretaking demands exist for parents throughout childhood and adolescence.  These increased demands can have an adverse impact on parents and increase the parenting related stress that they experience.  In fact, several studies have documented that, on average, parents of children with ADHD experience more parenting stress than parents of other children, including parents of children with disorders other than ADHD.  These findings have encouraged additional research on how children with ADHD affect parents so that interventions to alleviate distress in parents can be developed.

What factors are associated with the psychological stress experienced by parents of ADHD children?  The severity of a child's symptoms would be one important factor, with more severe symptoms linked to greater parental distress.  Several researchers have suggested, however, that how parents' interpret their child's behavior, and whether they believe they have control over their child's behavior, are also important factors to consider.

How people explain the behavior they observe in themselves or others are referred to as "attributions".  In regards to parenting, it has been demonstrated that parents' attributions for their child's behavior (i.e. why they think their child did what he/she did) play an important role in determining parents' behavioral and emotional response.

A simple example will help illustrate this.  If a parent sees their knock over a favorite vase they are more likely to become punitive and angry if they believe it was done intentionally rather than by accident.  Similarly, if a child is behaving inappropriately in a public setting - something that is not uncommon for children with ADHD - parents will become more upset if they believe their child's behavior reflects willful disobedience rather than difficulty their child has managing his/her behavior when overstimulated.  The latter attribution could promote a non-punitive effort to help the child regain control over his/her behavior, while the former would be more likely to promote a punitive response.

Researchers have suggested that parents who consistently regard the behavior problems of their ADHD child as under their child's control, as opposed to recognizing how ADHD often contributes to non-compliance, are prone to feelings of anger and discouragement.  Some researchers have speculated that when this occurs, parents can withdraw from their child in an attempt to avoid further failure experiences that they view as reflecting their own incompetence as parents.

What about parents' perceptions of their own ability to control their child's behavior?  Parents vary substantially in the degree of control they believe they have over their child's behavior.   Parents who believe they can control the behavior of their ADHD child may feel less distressed because, despite any behavior problems their child displays, they retain the sense of being in command and able to direct their child's actions.  Alternatively, a strong belief that one can control the behavior of a child who consistently shows behavior difficulties could lead to feelings of discouragement and distress.  This is because such a belief would be increasingly difficult to reconcile with the child's behavior.

The relationships between parents' attributions and beliefs about the controllability of children's behavior, and parents' psychological distress is an important and developing research area in the field of ADHD.  These relationships were examined more closely in a recently published study (Harrison, C., & Sofrofoff, K. (2002). ADHD and parent psychological distress: Role of demographics, child behavioral characteristics, and parental cognitions. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 703-711.)  These researchers hypothesized that parents distress would be predicted by: 1) the severity of children's behavioral disturbance; 2) parents' knowledge of ADHD; 3) parents' tendency to believe the child's misbehavior was under the child's control, and, 4) the degree to which parents believed they could control their child's behavior.

Participants in this study were 100 mothers of 4-12 year-old children who had a confirmed diagnosis of ADHD.  As noted above, the researchers were interested in: 1) how much control mothers believed they had had over their child's ADHD related behaviors; 2) how much control they believed their child had over these same behaviors; 3) mothers' opinions about what causes these behaviors in their child (i.e. their attributions); and, 4) the severity of the child's symptoms.

Beliefs about controllability were measured by having mothers rate each symptom of ADHD (for a list of specific ADHD symptoms click here), as well as 8 symptoms of oppositional defiant disorder (ODD) on a 1 "not all controllable" to 6 "completely controllable" scale.  These ratings were completed two times for each of the 22 symptoms: once to reflect the control mothers believed they had over their child's symptoms and a second time to assess mothers' perceptions of their child's control over the symptoms.

Mothers' attributions for their child's behavior were measured by asking mothers why their child displayed each of the symptoms they had just rated.  Responses such as "to get attention", "laziness", "to get his way", "its just his nature" were coded as reflecting "internal" attributions (i.e. the behavior was understood as occurring because of something about the child).  Responses such as "the medication makes him act this way", "the teacher doesn't know how to manage him", "we don't provide him with sufficient structure" were coded as "external" (i.e. the causes of behavior were seen as outside the child).  A single attribution score was then calculated by subtracting the number of external attributions from the number of internal attributions.  Higher scores thus reflected a stronger belief that the cause of the behavior resided within the child and was intentional.

In addition to assessing mothers' beliefs about the controllability and reasons for their child's behavior, they were asked to rate the severity of their child's behavioral disturbance using standardized behavior rating scales.  This included ratings of behaviors specific to ADHD as well as ratings of other behavioral and emotional problems.  Mothers' knowledge of ADHD along with demographic information on mothers (e.g. years of education) was also obtained.

Finally, mothers' rated the amount of parenting stress they were experiencing as well as their current level of depressive symptoms.
 

RESULTS

What predicts the level of parenting stress and depression in mothers of children with ADHD?

For parenting stress, children's behavior problems and the severity of their ADHD symptoms predicted greater stress.  It was noteworthy, however, that total behavior problems were a stronger predictor of mothers' stress than ADHD symptom severity.

Even after taking the severity of children's behavior problems into account, however, mothers' beliefs about their ability to control their child's behavior predicted their stress.  Specifically, the more mothers believed they were in control, the less stress they experienced.

Parenting stress was not related to mothers' attributions for children's behavior, whether mothers believed children could control their behavior, or mothers' knowledge of ADHD.  In addition, neither children's gender, age, nor medication status (i.e. taking medication vs. not) predicted mothers' stress.

For maternal depression, similar results were obtained.  Once again, higher maternal depression was predicted by higher child behavior problem scores.  In contrast, mothers who believed they could control their child's behavior reported fewer depressive symptoms.

Interestingly, maternal depression was not related to the severity of children's ADHD symptoms.  Maternal depression was also not related to mothers' attributions for their child's behavior, whether mothers believed children could control their behavior, or mothers' knowledge of ADHD.  As before, child age, gender, and medication status were also not significant predictors.
 

SUMMARY AND IMPLICATIONS

Results from this study suggest that children's behavior problems, and mothers' beliefs about being able to control their child's behavior, contribute to parenting stress and depression in mothers of children with ADHD.

Not surprisingly, mothers whose child displayed greater behavior problems reported higher levels of stress and depression.  What is noteworthy, however, is that maternal distress was more strongly predicted by overall child behavior problems than by the severity of ADHD symptoms specifically, that predicted maternal distress.

This suggests that when other behavioral and emotional problems do not accompany children's ADHD symptoms, the impact on mothers' psychological well-being will be diminished.  Thus, preventing emotional and behavioral problems from developing in children with ADHD may not only result in better outcomes for children, but for their mothers as well.

As previously noted, maternal distress was predicted not only by the severity of children's behavior problems, but also by mothers' beliefs about being able to control their child's behavior.  Essentially, this means that for children displaying comparable behavior difficulty, mothers who felt less able to control their child's behavior experienced more stress and depression.

As with any study, there are limitations to this report that should be considered.  First, all of the data - including information about children's behavior - was provided by mothers' themselves.  Collecting independent information about the severity of children's behavior problems would enable one to have greater confidence in these results.

Second, it is important to note that outcome measures (i.e. maternal stress and depression) were collected at the same time as the predictor variables (e.g. controllability beliefs, attributions for children's behavior).  Ideally, these findings would be re-examined in the context of a longitudinal study in which maternal beliefs about being able to control their child's behavior at one point in time were used to predict mothers' stress and depression in the future.  Finding this predictive relationship would provide stronger evidence that mothers' beliefs have a direct impact on their distress level.

Finally, it would be interesting to replicate this study with fathers.  Based on the current work, in which fathers were excluded, the applicability of these results to fathers of children with ADHD remains unknown.

In summary, this study suggests that children's behavior problems, and mothers' beliefs about being able to control their child's behavior, contribute independently to stress and depression in mothers of ADHD children.  This is an interesting finding but the meaning remains a bit unclear.

On the one hand, it certainly makes sense that mothers who believe they cannot control their child's behavior would feel stressed and discouraged.

On the other hand, it is not clear why mothers who believe they can control her child's behavior, but whose children display significant behavior problems, would feel better.  In this instance, the mothers' belief and the reality of their child's behavior seem inconsistent, and how such inconsistency would result in less maternal distress is hard to understand.

Perhaps, however, the belief of being in control, even when this is not the case, results in more hopefulness and less discouragement.  This would be an interesting issue to consider in subsequent research.  In the meantime, working with mothers to provide them with the skills and knowledge to maintain better control over their child's behavior, in addition to simply focusing on their beliefs, would seem be an important component of comprehensive treatment for ADHD.

I hope you enjoyed the above review.  The next issue of Attention Research Update will be sent to you in approximately 2-3 weeks.  Take care.

Sincerely,

David Rabiner, Ph.D.
Senior Research Scientist
Duke University


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