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3 129 02060 4595

This is to certify that the

thesis entitled

Parental Stress and Coping with
a Child's Attention—Deficit and

Hyperactivity
presented by

Cheryl-Lynn Podolski

has been accepted towards fulfillment
of the requirements for

M.A. _degree in Psychology

Joel T. Nigg, Ph.D.

Major professor

Date W99

0-7639 MS U is an Affirmative Action/Equal Opportunity Institution

 

 

PLACE IN RETURN Box to remove this checkout from your record.
TO AVOID FINES return on or before date due.
MAY BE RECALLED with earlier due date if requested.

 

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11/00 cICIRCJDateDuopss—ml

 

 

PARENTAL STRESS AND COPING
WITH A CHILD’S ATTENTION-DEFICIT AND HYPERACTIVITY
By

Cheryl-Lynn Podolski

A THESIS
Submitted to
Michigan State University

in partial firlfillment 0f the requirements
for the degree of

MASTERS OF ARTS

Department of Psychology

1 999

ABSTRACT

PARENTAL STRESS AND COPING
WITH A CHILD’S ATTENTION-DEFICIT AND HYPERACTIVITY

By
Cheryl-Lynn Podolski

Although studies link child Attention-Deficit Hyperactivity Disorder (ADI-ID) with
parent distress (e. g., Johnston, 1996), few controlled child aggression or examined possible
independent effects of inattention and hyperactivity. Also, few studies have examined
parent coping strategies in relation to distress in parents of externalizing children. Child
inattention, hyperactivity, and aggression were examined in relation to parent role distress.
Also, family related ceping strategies were examined as possible mediators of the child
aggression-parent distress relation. Mothers and fathers of elementary school children with
ADHD inattentive type (ADD), children with ADHD (combined type), and non-disordered
comparison children rated child behaviors and self-reported role stress, role dissatisfaction,
ceping style, and social support. Teachers also rated child behaviors.

Parents of children with ADHD but not ADD expressed higher levels of role
dissatisfaction than parents of comparison children. Child inattention and hyperactivity
were also related to parent distress when examined from a dimensional perspective.
However, child ADD and ADHD diagnosis as well as dimensional inattention and
hyperactivity were each not associated with parent dissatisfaction independent of child
aggression. Child aggression was associated independently with parent dissatisfaction.
Parent coping by positive refraining mediated the relation between child aggression and
role dissatisfaction. Ceping factors did not interact with child behavior problems. Social

support was not a significant predictor of parental dissatisfaction.

DEDICATION

To my father, George S. Podolski

iii

 

ACKNOWLEDGMENTS

The guidance of my mentor, Joel T. Nigg, Ph.D., was invaluable in completing this
thesis. Dr. Nigg endorsed my interest in studying family adjustment and encouraged me to
move forward even while supporting my attention to detail. His comments and editing
along with feedback fiom my committee members, Anne G. Bogat, Ph.D. and Robert
Caldwell, PhD, increased the precision of my ideas, methodology, and presentation. The
assistance of each committee member is greatly appreciated.

I would like to acknowledge each of the families who participated in the study,
making this thesis possible. I hope that the information gained may serve to encourage
and assist them. There are many other persons who were a part of seeing me through this
endeavor. The support of many friends, colleagues, family members, and my significant

other was cherished along the way and remains greatly valued.

iv

   

TABLE OF CONTENTS

LIST OF TABLES ...................................................................................................... x
INTRODUCTION ...................................................................................................... l
Attention-Deficit Hyperactivity Disorder ......................................................... l
ADHD and parental stress .............................................................................. 4
Controlling for aggression .............................................................................. 10
Summary ....................................................................................................... 13
Parent coping ................................................................................................. 13
Lazarus and Folkman’s model ............................................................. 15
Interpersonal and Kazak’s family systems model ................................. 16
Ecological models of coping ............................................................... 16
McCubbin and Patterson’s combined model ....................................... 17
McCubbin and Patterson’s model of family adaptation ................................... 18
Origins of the model ........................................................................... 18
Reforrnulation .................................................................................... 19
The five strategies in the model ........................................................... 19
Double ABC-X Model in relation to other coping theories ............................. 21

Application of McCubbin’s model to families whose child has a

chronic illness ..................................................................................... 24

Application of McCubbin’s model to ADHD ................................................. 25

Prior research on parent coping with child’s ADI-II) ....................................... 26

Parent training programs .................................................................... 26
Social support .................................................................................... 27
Rationale for the current study ...................................................................... 28
Overview ...................................................................................................... 29
Hypothesis 1 ................................................................................................. 3O
Rationale 1 ........................................................................................ 30
Prediction 1 ...................................................................................... 31
Hypothesis 2 ................................................................................................ 31
Rationale 2 ................................................................................................. 31
Prediction 2 ...................................................................................... 32
Hypothesis 3 ................................................................................................ 33
Rationale 3 ....................................................................................... 32
Prediction 3 ....................................................................................... 32
Hypothesis 4 ................................................................................................. 33
Rationale 4 .......................................................................................... 33
Prediction 4 ......................................................................................... 33
METHOD ................................................................................................................. 34
Participants .................................................................................................. 34
Procedure .................................................................................................... 3S
Predictors: Measures of inattention, hyperactivity, and aggression ............... 35

Child Behavior Checklist (CBCL) and Teacher Report Form (TRF) . . 36

Swanson, Nolan, and Pelham DSM-IV rating scale ......................... 36

Diagnostic Interview Schedule for Children - IV ............................. 37
Mediating/Moderating variables: Coping measures ..................................... 37

The Family Crisis Oriented Personal Evaluation Scales (F -COPES) .. 37

Social Support Questionnaire Revised (SSQR) ................................ 38

Outcome variables: Parent adjustment ......................................................... 39

Parent Distress Subscale of the Parenting Stress Index .................... 39

Parenting Satisfaction Survey ......................................................... 39

RESULTS ............................................................................................................. 40
Data reduction/formation of composite variables ........................................ 43

Predictor variables: hyperactivity, attention problems, and
aggressive behavior ................................................................. 43

Mediating variable: Family Crisis Oriented Evaluation Scales

(F ~COPES) ............................................................................ 44
Outcome variable: Parenting distress .................................................. 44
Test of hypotheses ........................................................................................ 45
Hypothesis la mothers ....................................................................... 45
Hypothesis 1a fathers .......................................................................... 46
Hypothesis 1b and 1c ......................................................................... 47
Hypothesis 1d ................................................................................... S4
Hypothesis 2: mediation ................................................................... 57
Hypothesis 3 mothers ...................................................................... 60
Hypothesis 3 fathers ......................................................................... 61
Hypothesis 4 .................................................................................... 61

DISCUSSION ......................................................................................................... 63

Child ADHD behaviors in relation to parent role distress ............................. 64
Child inattention versus hyperactivity .......................................................... 69
Child aggression .......................................................................................... 71
Parent coping ............................................................................................. 71
Parent social support .................................................................................. 72
Limitations ................................................................................................ 74
Conclusion ................................................................................................ 7 5
REFERENCES ...................................................................................................... 77
APPENDICES ........................................................................................................ 92
Appendix A: Table of Measures .................................................................... 92
Appendix B: Inter-correlations of measures of inattention by rater .................. 94
Appendix C: Inter-correlations of measures of hyperactivity by rater ............. 95
Appendix D: Inter-correlations of measures of aggression ............................. 96
Appendix E: Inter-correlations of F-COPES subscales .................................. 97
Appendix F: Inter-correlations between measures of parent role distress ....... 98

Appendix G: Using alternative outcome measures to examine the relation

between parent distress and child behaviors ........................................ 99
Hypothesis 1a mothers ....................................................................... 99
Hypothesis 1a fathers ........................................................................ 99
Hypothesis lb and 1c ........................................................................ 100
Hypothesis 1d ................................................................................... 103
Summary regarding alternative outcome measures ............................ 104

viii

Appendix H: Controlling for marital adjustment and stressfirl life events ...... 105

Control Variables: Non-child related stressors ................................. 105
Dyadic Adjustment Scale .................................................... 105
PSI Life Events ................................................................... 106

Examining the relation between parent role distress and child behaviors

with marital adjustment and life stress controlled ................... 106
Hypothesis 1a mothers ......................................................... 106
Hypothesis 1a fathers ............................................................ 107
Hypothesis lb & 1c ............................................................. 109
Hypothesis 1d .................................................................... 117

LIST OF TABLES
Table 1 - Examples of Coping within Three Levels ..................................................... 15
Table 2 - McCubbin’s strategies in relation to emotion and problem focused ceping 23

Table 3 ~McCubbin’s Strategies in Relation to Individual, Familial, and

Ecological levels ............................................................................................. 23
Table 4a - Sample characteristics by group ................................................................. 41
Table 4b - Mothers’ dissatisfaction and use of coping strategies by group ................... 42
Table 4c - Fathers’ dissatisfaction and use of coping strategies by group ................... 42
Table 5 - Correlations between predictor variables ..................................................... 44
Table 6 - Means of parental dissatisfaction with parenting performance ....................... 46

Table 7 - Hypothesis 1b & lc: Correlations: Dissatisfaction with Parenting Performance,
child inattention, and hyperactivity ................................................................... 48
Table 8 - Hypothesis lb: Regression models on mothers’ dissatisfaction by child
inattention with aggression controlled ............................................................ 50
Table 9 - Hypothesis 1b: Regression models on mothers’ dissatisfaction by child
hyperactivity with aggression controlled ........................................................ 50
Table 10 - Hypothesis 1b: Regression models on fathers’ dissatisfaction by child
inattention with aggression controlled ............................................................. 51
Table 11 - Hypothesis 1b: Regression models on fathers’ dissatisfaction by child

hyperactivity with aggression controlled ........................................................ 51

Table 12 - Hypothesis lb & 1c: Regression models on mothers’ dissatisfaction by child
inattention and hyperactivity with aggression controlled ................................ 52
Table 13 - Hypothesis lb & lc: Regression models on fathers’ dissatisfaction by child
inattention and hyperactivity with aggression controlled ................................. 53
Table 14 - Hypothesis 1d: Regression models on mothers’ dissatisfaction by child
aggression with inattention and hyperactivity controlled ................................ 55
Table 15 - Hypothesis 1d: Regression models on fathers’ dissatisfaction by child
aggression with inattention and hyperactivity controlled ................................ 56
Table 16 - Hypothesis 2: Correlations between maternal Dissatisfaction with Parenting
Performance and coping factors .................................................................... 58
Table 17 - Hypothsis 2: Positive refraining as a partial mediator of child behavior and
maternal dissatisfaction ................................................................................. 59
Table 18 - Hypothesis 2: Positive reframing as a partial mediator of child behavior and
paternal dissatisfaction ................................................................................... 60
Table 19 - Hypothesis 4: Correlations between parental dissatisfaction and
social support ................................................................................................ 62
Table 20 - Alternative outcomes hypothesis 1a: Means of parent outcome measures
by group ....................................................................................................... 100
Table 21 - Alternative Outcomes hypothesis 1b & Ic: Correlations: Parent PSI Distress,

PSS Dissatisfaction with Parent-Child Relationship, child inattention, and

hyperactivity ................................................................................................ 101

Table 22 - Alternative outcomes hypothesis 1b: Regression models on mothers’
dissatisfaction with P-C Relationship by child inattention with aggression
controlled ...................................................................................................... 102

Table 23 - Alternative outcomes hypothesis 1d: Correlations between parent
PSI Distress, PSS Dissatisfaction with Parent-Child Relationship, and child
aggression/conduct problems ......................................................................... 103

Table 24 - Controlling for Marital Adjustment and Life Stress Hypothesis lb & 1c:
Regressions: Mother’s Dissatisfaction with Parenting Performance, child
inattention, and hyperactivity ......................................................................... 109

Table 25 - Controlling for Marital Adjustment and Life Stress Hypothesis 1b & 1c:
Regressions: Father’s Dissatisfaction with Parenting Performance, child
inattention, and hyperactivity ......................................................................... 110

Table 26 - Controlling for Marital Adjustment and Life Stress hypothesis 1b & 1c:
Regressions: Mother’s Dissatisfaction with Parenting Performance, child
inattention with aggression/conduct problems controlled ............................... 112

Table 27 - Controlling for Marital Adjustment and Life Stress hypothesis lb & 1c:
Regressions: Mother’s Dissatisfaction with Parenting Performance, child
hyperactivity with aggression/conduct problems controlled ............................ 113

Table 28 - Controlling for Marital Adjustment and Life Stress hypothesis lb & 1c:
Regressions: Father’s Dissatisfaction with Parenting Performance, child inattention

with aggression/conduct problems controlled ................................................. 114

Table 29 - Controlling for Marital Adjustment and Life Stress hypothesis 1b & 1c:
Regressions: Father’s Dissatisfaction with Parenting Performance, child
hyperactivity with aggression/conduct problems controlled ............................ 115

Table 30 - Controlling for Marital Adjustment and Life Stress hypothesis lb & 1c:
Regressions: Mother’s Dissatisfaction with Parenting Performance by child
aggression/conduct problems ......................................................................... 117

Table 31 - Controlling for Marital Adjustment and Life Stress hypothesis 1b & 1c:
Regressions: Father’s Dissatisfaction with Parenting Performance by child

aggression/conduct problems .......................................................................... 118

xiii

INTRODUCTION

! 'Dfi'li "E'l

Attention-Deficit Hyperactivity Disorder (ADHD) is one of the most prevalent
childhood psychiatric disorders. Estimates suggest that 3 to 5% of School aged children
have the disorder (American Psychiatric Association, 1994; Szatmari, Ofi‘ord, & Boyle,
1989). ADI-1]) is a behavioral syndrome characterized by levels of activity, impulsivity,
and/or inattention which are extreme for developmental level and severe enough to
interfere with the child’s adjustment across settings. By definition, children with ADHD
experience difficulties that interfere with their relationships and/or academic functioning.
For example, they ofien fail to pay attention to detail, often avoid organizing things, are
forgetful, and are easily distracted and lose things (American Psychiatric Association,
1994).

Historically, ADHD has been defined according to difi’erent criteria at difi'erent
times. The current Diagnostic and Statistical Manual of Mental Disorders, DSM-IV
(American Psychiatric Association, 1994), specifies three subtypes: ADHD, Predominantly
Inattentive Type (ADD herein); ADHD, Predominantly Hyperactive-Impulsive Type; and
ADHD, Combined Type (ADHD herein). It is notable that much literature reviewed here
used earlier definitions of ADHD.

Although early research on the inattentive and hyperactive subtypes was mixed

(e.g., King & Young, 1982; Maurer & Stewrt, 1980; Rubinstein & Brown, 1984; Shywitz
& Shaywitz, 1985), recent field studies have demonstrated difi’erences. Before

the publication of the DSM-IV, comprehensive field studies were conducted (e.g., Lahey,
Applegate, McBumett, et al., 1994). These filed trials indicated that ADHD -
Predominantly Inattentive type (ADD) and ADHD - Predominantly Hyperactive type are
discrete subtypes (Lahey, et al., 1994). That is, child inattention and hyperactivity
emerged as two factorially distinct dimensions. Relatedly, Lahey and colleagues (1994)
found that child inattention and hyperactivity were associated with different types of
impairment. Hyperactive behaviors were associated with greater global impairment.
Inattention was associated with academic impairment. Other research has indicated that
children who exhibit hyperactive behaviors experience greater conduct problems and peer
relationship difi'lculties (Barkley, DuPaul, & McMurray, 1990; Lahey & Carlson, 1992).
An important distinction between the subtypes may be a relation between the hyperactive
symptomatology and an increased incidence of co-occurring aggression and conduct
problems (Barkley, DuPaul, & McMurray, 1990).

In addition to considering the separate subtypes, developmental
psychopathologists emphasize the need to examine child problems from a continuous,
dimensional perspective as well as from a categorical, diagnostic perspective (Jensen,
Koretz, Locke et al., 1993). In the case of ADI-II), some researchers argue for a clearly
defined syndrome (e. g., Seariglrt, Nahlik, & Campbell, 1995) to assist in treatment
planning and to difi’erentiate children with ADHD from children with other disorders.
Sophisticated studies offer mixed results as to whether ADHD is in fact a categorical or

dimensional phenomena etiologically (see Nigg & Goldsmith, 1998). Additionally, the

diagnostic cut-ofl‘ points, while backed by greater empirical support than the past clinical
dimendons, neglect the significance of sub-threshold problems. Sub-threshold problems
(e. g., periodic inattention or aggression) may be stressful for parents even if a diagnosis is
not warranted. The dynamic interplay of child, parental, and contextual factors is not well
addressed when the sub-threshold problems are ignored. It is therefore important to
investigate these important behavior problems both from categorical and dimensional
perspectives.

Various etiologies for ADHD have been posited. Early research posited that
ADHD was due to genetic factors or brain damage (e.g., Cantwell & Hanna, 1989; Laufer
& Denhofl‘, 1957). Psychoanalytic and family models have also been posed (e. g.,
Bauermeister et al., 1992; Jacobvitz & Sroufe, 1987). Adverse family circumstances are
correlated with ADHD severity and poorer ADHD outcome (Biederman et al., 1995;
Prick, 1994; Frick et al., 1991; Johnston, 1996; Loeber et al., 1995; etc.). Although most
studies have failed to control for aggressive comorbidity or early biological factors, at
least one study suggested that family interactions preceded ADHD behaviors
(Bauermeister et al., 1992). The interactions of contextual factors with ADHD behaviors
and parental distress thus merit fiirther investigation.

Nevertheless, recently there has been a proliferation of positive biogenetic
evidence (Beiderman et al., 1990; Tannock, 1998). Genetic studies reveal a substantial
heritable component to ADHD (e.g., Faraone, Biederman, Krifcher-Lechman et al., 1993;
Faraone, Biederman, Chen et al., 1992). Environmentally influenced biological factors
(e. g., toxins, pre and para-natal development) also may be important in the etiology of

ADHD (e.g., Bennett, Wolin, & Reiss, 1988; Streissguth et al., 1984).

 

Medication studies suggest that the child’s attentional and hyperactivity problems
precede parental adjustment difficulties rather than vice versa (Barkley & Cunningham,
1979; Whalen & Henker, 1991; Whalen, Henker, Buhrmester et al., 1989). Thus, child
problems may serve as a stressor for parents. Subsequent parental distress may negatively
impact parenting, which may result in an increase in problematic child behavior in a kind of
Vicious cycle” (Barkley, Fischer, Edelbrock, & Smallish, 1990). Even if they do not
cause the onset of ADHD, then, negative parent-child interactions may serve to maintain
and exacerbate ADHD symptomatology (Hinshaw, 1994). For instance, two studies
(Anderson et al., 1986; Campbell et al., 1991) found that inefi‘ective parenting practices
predicted greater noncompliance and hyperactivity in children with ADI-ID.

Therefore, rather than studying the effects of parent/family functioning on the child
to examine etiology as many studies already do (e. g., Edwards, Schulz, & Long, 1995;
Schachar & Wachsmuth, 1991), the current study assumes a model wherein child
symtomatology serves as a stressor for parents. Although the bidirectional complexity of
the interaction between child symptomatology and parental distress is acknowledged, the
focus of the current study is the impact of the child’s disorder on parents rather than

parenting efl‘ects on children.

Wares:

Within the literature, stress and stressor are unfortunately often used
interchangeably. For purposes of this discussion, stressors refer to the events that result in
a disruption to an individual’s life. Stress is the consequential emotional feeling state that

results when there is a perceived discrepancy between the demands of a particular

situation and the resources that the individual has or believes him/herself to have. A build
up of stressor events usually leads to a state of stress. Similarly, studies of parent factors
have examined parent role stress, sense of competence, and psychological distress (e. g.,
depression, anxiety). In the current study, parent role distress is used as the most generic
term, referring to role specific stress, dissatisfaction, or lack of esteem. Psychological
distress refers to general anxiety and depression and is not necessarily role specific. A
commonly used instrument, the Parenting Stress Index (PSI; Abidin, 1995) combines role
specific distress and general psychological distress.

Several studies have examined parents’ use of psychiatric services, parenting
stress, and parent role dissatisfaction in relation to a child’s ADHD or hyperactivity.
Mothers of children with ADHD report greater psychological distress (Gillberg,
Carlstrom, & Rasmussen, 1983; Sandberg, Wreselberg, & Shafi‘er, 1980), greater role
specific stress (Mash & Johnston, 1983a), lowered sense of parenting competence (Mash
& Johnston, 1983a) and more health related problems (Breen & Barkley, 1988;
Cunningham, Benness, & Siegel, 1988) than mothers of children without behavioral
disorders. Often these studies focused on the hyperactive component of ADHD, implying
that the hyperactive rather than the inattentive behaviors are the greater stressor for
parents (e.g., Befera & Barkley, 1985; Hechtman, 1996; Mash and Johnson, 1983a;
1983b). Consistently, child hyperactivity was associated with distress in parents (e. g.,
Anastopoulos, Gueverment, Shelton, & DuPaul, 1992; Baker, 1994; Baldwin & McCal,
1995; Breen & Barkley, 1988).

Both an eariy (Gillberg, Carlstrom, & Rasmussen, 1983) and a recent study

(Hechtman, 1996) report that parents of children with ADHD are more likely to utilize

 

mental health services for their (parents’) own needs to a greater degree than parents of
healthy comparison children. In the early community prevalence study, Gillberg and
colleagues identified 141 of 3,448 children who exhibited motor, perceptual, attentional,
and behavioral problems fitting the definition of hyperkinesis, an early name for ADHD.
They compared these 141 children to 59 non-disordered children and found that 56% of
the mothers of the children with high levels of symptomatology sought psychiatric care in
the year prior to the study, whereas only 41% of mothers of children who had low levels
of symptomatology did so. In contrast, only 16% of the mothers of the healthy
comparison children had sought psychiatric care. This study suggests that mothers of
children with hyperactivity and attentional difliculties (combined problematic behaviors)
experience greater psychological distress than mothers of children without such problems
and that distress is associated with severity of symptomatology, not just with diagnosis.
In the more recent lO—year, longitudinal study, Hechtman (1996) also found that
parents of hyperactive children were more likely to have mental health problems and to
utilize psychiatric services for their own needs. Only 17% of the families of the
comparison children sought psychiatric services, whereas 28% of the families of
hyperactive children did so. Although in Hechtman’s study the differences in psychiatric
service seeking behaviors of families of hyperactive children and families of comparison
children were not as different as that found in Gillberg and colleagues’ (1983) earlier
study, Hechtman also looked at psychological distress among those families not seeking
advices for themselves. Of the 83% of families of comparison children and the 72% of
families with hyperactive children who did not seek treatment, 24% of the comparison

families had symptoms of psychological distress whereas 41% of the families with a

hyperactive child experienced symptoms of psychological distress.

In addition to examining parental psychological distress, some early studies
examined variables such as role specific stress and satisfaction. An early study which
compared 40 families with a hyperactive child and 51 families with a non-disordered child
found that not only were mothers of hyperactive children more depressed than mothers of
non—disordered, comparison children, but mothers of hyperactive children also reported
lower levels of parenting esteem and less satisfaction in their roles and parents (Mash &
Johnston, 1983a). Both mothers and fathers of the children with hyperactivity rated
themselves as less skilled and knowledgeable as parents when compared to parents of the
comparison children. Also, both mothers and fathers reported finding less value in and
comfort from their roles as parents than parents of the comparison children. Mash and
Johnston (1983b) also examined self-ratings of parenting esteem/satisfaction and
competence in relation to self and other ratings of the child’s behavior. They found that
mothers’ parenting esteem was more highly correlated with their spouses’ ratings of their
child’s behavior than with their own rating of their child’s behavior. This suggests that the
relation between self-ratings of esteem/ satisfaction and child behavior is not limited to
parent’s own perception of the child’s behavior. Additionally, severity of hyperactivity
and not just ADHD diagnosis was related to parent role distress.

Notably, most researchers have not distinguished between hyperactive versus
inattentive symptoms because these were placed on the same symptom list in DSM-III-R
For instance, Breen and Barkley (1988) found that the number of settings in which ADHD
(inattention and hyperactivity combined) children experienced difiiculties and the mean

severity of the children’s problems were correlated with maternal stress as measured by an

early version of the self-report Parenting Stress Index (PSI). That is, mothers of children
who exhibited more behavioral problems and who exhibited these problems in multiple
settings experienced more stress. Similarly, Mash and Johnston (1983a) found that
greater severity of child problematic characteristics associated with combined
hyperactivity and inattention (i.e., how much the child posed as a source of “bother” to the
parent and “degree of distractibility”) was related to greater maternal distress.

Similarly, in a study of mothers of 104 children who met criteria for an ADI-ID
diagnosis by DSM-III-R criteria, the overall severity of the child’s ADI-1D (combined)
symptomatology was found to be a significant predictor of maternal stress (e.g.,
Anastopoulos, Guevrernont, Shelton, & DuPaul, 1992). Another study of primary care
providers (28 women and 2 men) of 30 children (26 males and 4 females) with ADHD
(Baldwin et al., 1995) found that the fiequency of hyperactivity and inattention behaviors
combined accounted for up to 18% of the variance in overall stress reported by
caregivers.

Of course, it is possible that such parental distress is due to the parent’s own pre-
existing psychopathology. For instance, negative parenting behaviors and parenting stress
decrease significantly when a child is given medication. Rather than this being due to a
simple decrease in child problem behaviors, parents with pre—existing pathology and/or
lower thresholds for tolerating child externalizing behaviors might be more likely to
experience a decrease in parenting distress.

Additionally, some researchers have argued that depressed mothers mispaceive
the severity of their child’s problematic behaviors. That is, the child’s problems may

actually be less severe than mothers perceive. According to this depressiomdistortion

hypothesis, maternal depression may lead to a misperception of elevated child behavioral
problems. Maternal role specific stress and coercive parenting may thus be driven by
mothers’ own psychopathology rather than from child behavior. Contrary to this
hypothesis, a critical review of maternal depression and perception of child behaviors
concluded that rigorous studies using objective raters (as well as mothers) have failed to
support the maternal bias hypothesis (Richters et al., 1992). Richters’ work suggests that
depressed mothers accurately perceive their child’s problems. Taken together, these
findings may support a parent-response model of maternal depression with child
externalizing problems.

Increased stress and decreased satisfaction and parent role related self-esteem may
be a result of specific increased stressors which parents of children with ADHD
symptomatology face in addition to the ADHD behaviors themselves. These other
stressors include increased conflict between the ADI-ID child and siblings (e.g., Mash &
Johnston, 1983b) and peers (Campbell & Paulaskas, 1979; Cunningham & Siegel, 1987),
increased problems in school and community settings (e. g., Barkley, & Edelbrock, 1987;
Whalen, Henker, & Dotemoto, 1981), problems with other parents (e. g., Whalen, Henker,
& Dotemoto, 1981) and strains in the parent child relationship (e. g., Barkley &
Cunningham, 1979; Ross & Ross, 1982). These dificulties may contribute to the parent’s
stress and dissatisfaction.

Among the studies examining parent role distress, few have examined fathers
(Fischer, 1990). According to a review of parenting stress in families of ADHD children,
Fischer (1990) surmised that researchers have focused “almost exclusively on mothers.”

Of those studies which included fathers (Baker, 1994; Johnston, 1996; Lewis, 1992)

different outcomes have been reported corresponding with difi‘erent measures. For
instance, Baker (1994) found no significant difi‘erences between mothers and fathers.
Notably, his dependent measures was comparable to an indicator of parent psychological
rather than role specific distress. Johnston’s (1996) study is one of the few studies to
examine role distress for both mothers and fathers. Findings were similar for mothers and
fathers. Although these initial studies report few differences between mothers and fathers,
additional research is warranted.

Overall, evidence supports that parents of children with ADHD experience
increased levels of role stress and dissatisfaction. Notably, many studies have focused on
the hypmctive symptomatology, finding that hyperactivity is associated with parent role
distress (e.g., Befera & Barkley, 1995; Hechtman, 1996; Mash & Johnston, 1983a,
1983b). Studies which examine the separate contribution of inattention are lacking.
Further, few studies have examined parenting stress in fathers as well as mothers. Lastly,
to date no studies on parent role distress have been published which use DSM-IV criteria

for ADHD.

C ll° E .
Child inattention and hyperactivity appear to be related to parental stress.
However, a key complication is that co-occurring child behaviors also contribute
Significantly to parental stress. Oppositional-Defiant Disorder (ODD) and Conduct
Disorder (CD) are two disruptive behavior disorders characterized by aggression that

often W with ADHD, with estimates of comorbidity rates of at least 30% (e.g.,

10

Anderson et al., 1987; Stewart et al., 1981). Many of the early studies (e. g., Befera &
Barkley, 1983a; Breen & Barkley, 1988; Gillberg, Carlstrom, & Rasmussen, 1983; Mash
& Johnston, 1983a) and even many recent studies (e.g., Baker, 1994; Baldwin, Brown, &
Milan, 1995; Hechtman, 1996; Murphy & Brown, 1996) did not control for child
comorbid aggressive behaviors. Thus, it is possible that comorbid aggressive behavior and
not ADHD symptomatology accounts for parenting stress in those studies.

Consonant with this idea, Anastopoulos, Guevremont, Shelton, and DuPaul’s
(1992) study of 104 ADHD boys found that aggression (measured by CBCL Aggressive
score) accounted for 37% of the variance in predicting parental stress. Hyperactivity and
inattention combined (measured by the Dupaul, 1990, ADI-ID Rating Scale) only
accounting for an additional 4% of the variance (p<.001). Unfortunately, the reverse
model (entering ADHD first in the model) was not tested. In order to gain an
understanding of the separate influences of ADHD and comorbid ADHD/ODD, the
researchers separated the boys into two groups - 59 boys with ADHD only and a 32 boys
with ADHD plus ODD. The parents of the ADHD/ODD boys reported higher levels of
parenting stress than the parents of ADHD only boys. However, the parents of the
ADHD-only boys still reported significantly higher although not severe levels of parenting
stress versus a normative sample, with scores falling at the 80"l percentile. Hence, the
study supported the premise that ADHD contributes to parental stress but suggests that it
does so to a limited degree independent of aggression.

Johnston (1996) compared ADHD children with high (ADHD-HOD) versus low
levels (ADHD-LCD) of Oppositional Defiant Disorder (ODD) to non-disordered

comparison children. She found a significant difference in parents’ sense of competence

ll

depending on the extent to which their ADHD children exhibited ODD. That is, parents
of ADHD children with greater ODD behaviors (ADHD-HOD) expressed a lower sense
of competence than parents ADI-ID children with low levels of ODD behaviors (ADI-ID—
LOD) and than parents of control children who did not exhibit ODD nor ADHD
behaviors. Using a different outcome variable, Johnston found high life stress in parents
of ADHD children compared to parents of non-disordered comparison children but no
significant difl‘erences between stress levels in parents of ADI-1D children with high versus
low levels of ODD behaviors (Johnston, 1996). Unsurprisingly, parents of non-problem
children experienced the lowest levels of distress as measured by the Symptom Checklist
and the life stress measure. These results appear to differ fi'om those of Anastopolous’ et.
al (1992). However, using a similar measure of general distress, Anastopolous’ found that
maternal global psychological distress was a significant predictor of parent role stress. It
thus appears that results may vary depending on the outcome construct under
consideration. Global psychological distress may not be as atfected by child behavior as is
role-specific parenting distress.

In summary, the lower levels of parenting competence found by Johnston (1996) is
similar to Anastopoulos et. al’s (1992) finding of greater parenting stress associated with
hyperactivity, inattention, and particularly aggression. That is, both studies suggest that
child ADHD behaviors (hyperactivity and inattention combined) contribute to parental
role distress in a small but significant manner.

Because so few studies have controlled for aggression, these studies bear
replication. Additionally, the failure to examine hyperactivity and inattention separately

points to the need for additional studies to address the independent contributions of

12

hyperactivity, inattention, and aggression to parenting distress. The extent to which child
ADHD diagnosis, inattention, and hyperactivity predict parental distress independently of
child aggressive behavior and the extent to which child aggression predicts parental
distress when inattention and hyperactivity are controlled were examined in the current
study.

Summary.

Child hyperactivity and/or oppositional/aggressive behavior increases the number
of problems that parents encounter (e.g., Barkley & Edelbrock, 1987; Breen & Barkley,
1988; Cunningham & Siegel, 1987; Mash & Johnston, 1983a, 1983b) resulting in a
decrease in pmenting satisfaction and an increase in parenting role distress (e. g., Breen &
Barkley, 1988; Mash & Johnston, 1983a, 1983b). Few studies have satisfactorily
examined the independent contributions of aggression and inattention versus hyperactivity
to parent role distress. The sources of distress must be clarified, and then coping might be

assessedindetail.

Wiring

Some parents may be buffered from the stress of their child’s ADHD through
efl‘ective coping strategies. Understanding how parents successfirlly cope with their
child’s inattention, hyperactivity, and aggression may elucidate ways in which to counsel
parents. These findings may facilitate the design of appropriate interventions aimed
toward interrupting the cycle between problematic parenting and child problem behaviors.
By impacting parents, interventions might prevent the exacerbation of inattentive,

hyperactive, and development of aggressive behaviors in children. Because few studies of

13

coping in response to child ADHD exist, the literature on parent coping in general is
relevant.

Unsurprisingly, parents who have access to more resources and who use those
resources more efl‘ectively are better able to adapt to family stressors (McCubbin, Olson,
& Larsen, 1987; Monat & Lazarus, 1991; Thompson & Gustafson, 1996). For instance,
social support has been correlated with parental adjustment in families whose children
experience illness, disabilities or stressors (e. g., sickle cell disease, mental retardation, or
immigration; Cmic, Friedrich, & Greenberg, 1983; Hurtig, 1994; N011, Swiecki, Garstein,
& Vannatta, 1994; Sharts-Hopco et al., 1996; Short, 1997). In addition, religiosity and
access to community resources have been associated with adjustment in individuals and in
families (e.g., Commerford, 1996; Maton & Wells, 1995). Resources and the various
ways in which parents make use of them may be conceptualized as coping strategies.

By definition, coping behaviors are used by an individual when s/he is faced with
stressors. The stressors require the individual to utilize her/his resources in order to
protect him/herself fi'om consequential stress or in order to reduce a stress which the
stressors have already induced. Coping is usually portrayed as a transactional process, in
relation to stressors, that operates in multiple domains (McCubbin, Olson, & Larsen,
1987; Thompson & Gustafson, 1996). That is, the stressor event, the individual, his/her
family, specific cOping strategies and the psychological and physical health outcomes of
various family members affect each other in a dynamic manner. Further, these processes
operate on the individual, familial, and comnrunity level. Table 1 (next page) lists

examples of coping at each of these levels.

14

Table 1
E l E; . . ! . 1.! l v !
Level Examples of behaviors

1. Individual appraisal, seeking emotional release, problem
solving or active planning

11. Family working together as a family, use of individual
strategies but together as a family

111. Ecological use of community resources, religious and spiritual
support, social support nawork & satisfaction

 

 

 

 

Most models emphasize one or another level of those represented in Table 1. For
instance, Lazarus and F olkrnan (1984) proposed a coping°model that focused on individual
factors. However, some models have attempted to include multiple levels. Many family
and ecological models retain intra-individual coping factors but also include factors which
account for the inter-relationships among multiple individuals, the stressor, and
environmental factors. Models which emphasize the dynamic exchange among these
factors are often used to understand how parents cope with stressors (e. g., Kazak, 1986;
1996). Ecological models used to understand coping within families include Thompson’s
transactional model (Thompson, Gil, Burbach, Keith, & Kinney, 1993) and Patterson and
McCubbin’s Family Adjustment and Adaptation Response and Double ABC-X models

(McCubbin & Patterson, 1983; Patterson, 1988). These key models are reviewed next.

 

' -‘.. Inna-individual coping
strategies involve how the individual mobilizes his/her own resources to adjust to
challenging circumstances. One of the primary intra-individual models of coping is
Lazarus and Folkrnan’s (1984) dynamic model of problem and emotion-focused coping.
Problem-focused coping is directed at solving the situation at hand. Emotion-focused

coping involves seeking emotional support or minimizing the significance of the problem.

15

 

Specific attributions about the stressor event contribute to the individual’s experience of
the event as stressful. The individual selects problem and/or emotional focused behaviors
to ameliorate the consequential stress. Problem—focused coping has been associated with
better adjustment in families For instance, in a study of 55 families of children with spina
bifida and 55 matched comparison families of healthy children (Hombeck et al., 1997),
active coping and planning and ability to adapt to situations were associated with
parenting satisfaction whereas focusing on venting emotions and behavioral

disengagement were associated with dissatisfaction.

 

Coping also involves
interpersonal factors (e.g., Fiese, 1997; Weiss, Marvin, & Pianta, 1997). For instance,
how each individual family member adapts to the child’s illness is affected by how other
family members cope (e.g., Chaney et al., 1997; Fiese, 1997). According to systems
theory, the change of one family member may disrupt the current homeostatic structural
stability ofthe family (Kazak, 1986; Sheeran, Marvin, & Pianta, 1997). Kazak (1986)
proposed a family systems model which focuses on the way the family adjusts to an illness
as a functioning unit and how the family as a whole uses social support. Although
revolving around systemic factors, Kazak’s measures focus on social support and the
transactional nature of adjustment rather than on the ways in which coping strategies
themselves operate dynamically among members of a family. Her model does not address
inns-individual factors.

Emlggicalmodelsgfmping, Ecological models of coping emphasize
environmental factors (Moos & Tsu, 1977; Wallander, Varni, Babani, Banis, & Wilcox,

1989). These models posit that individuals and families operate within an “ecological

l6

 

system” of professionals, community members, and extended family. An ecological
model of coping, which was designed specifically to understand family coping with a
family member’s illness, is that of Thompson and colleagues (Thompson et al., 1993). In
their transactional model, biomedical, developmental, and psychosocial processes
determine the physical health and psychological outcome of the patient. Thompson
proposes three psychosocial factors related to family adjustment: cognitive appraisals and
expectations, palliative and adaptive coping strategies, and family firnctioning or
environment. The first two factors were borrowed fi'om Lazarus and Folkrnan (1986).
According to Thompson’s conceptualization, family functioning (see Kronenberger &
Thompson, 1990, Moos & Moos, 1981) refers to the overall emotional climate of the
family; that is, how supportive, conflicted, or controlling the family is.

Although Thompson’s model inchides intra-individual and ecological coping
resources, it lacks an emphasis on the familial components relevant to coping. Like
Kazak’s model, Thompson’s focuses on how the well-being of one member impacts the
well-being of another (e.g., maternal adjustment impacts child adjustment and vice versa)
but does not address well the idea that coping may occur at the level of the family and not
just the individual.

WWW McCubbin and Patterson’s Double
ABC-X and Family Adaptation and Functioning (F AAF) combined models includes all
three factors: individual, familial, and ecological (McCubbin, 1981; Patterson, McCubbin,
& Warwick, 1990). The Double ABC-X theory posits that the stressor(s) (A) interacts
with the family’s resources (B) and with the family’s definition of the stressor (C) to

produce the crisis (X). Adjustment depends on the interactions between the stressor, the

17

“a? -....-n sly—I. '

 

way in which the family or parent perceives the stressor, and available resources. While
retaining strategies gleaned from individual coping theories, this model fiames coping in
terms of what the individual does within the family, how coping strategies operate within
the family, and what community resource are used. In essence, it combines the intra-
individual factors, the family systems factors, and the ecological factors posited in the
preceding models. Further, central to McCubbin and Patterson’s theory is the concept
that parental roles and behaviors change as the parent adjusts to the stressful
circumstances. Arguably, McCubbin’s model may be viewed as too “all inclusive” and
therefore not sensitive to the contribution of each factor. Also, coping within this model is
fi‘amed as occuning within the family but, like Kazak’s model, it does not provide an
account of the transactional nature of coping processes themselves. However, as a
comprehensive, family-oriented model, McCubbin’s is arguably best-suited for an initial
examination of how parents cope with their child’s ADHD problems. It was therefore

selected for use in the current study. Further description of this model is therefore

provided in the following section.

 

WW According to the ABC-X model, a stressor event and
related hardships (A) interact with the family’s crisis meeting resources (B), which interact
with the assessment the family makes regarding the event (C), which in turn determines
the experience of stress or “the crisis” (X). The “crisis” would put the family in a state of
disorganization which would require adjustments within the family. Often adjustment

would involve changes in individual roles within the family (see review by McCubbin et

18

 

al., 1980).

Reformnlafign, The model was reformulated for chronic situations (McCubbin &
Patterson, 1983). In chronic situations, there is a built-up of stressors over time (the ‘pile-
up’; “Double”). Initially during adaptation, the family might try to ignore, remove, or
address the stressor with existing resources. Ifthese first efforts failed, there would be a
second adaptation phase. At this time, the family might engage in more direct coping and
make further changes in family structure. Adjustments might involve changes in individual
roles, the family structure as a whole, and the way community resources were used. As
part of the reformulation, five coping strategies were specified commonly used by families
(McCubbin, Olson, & Larsen, 1981).

IhefiyestrategieflnjhemodeL The first factor identified by McCubbin (1980;
McCubbin et al., 1981) as important for family coping is W- A large body of
literature demonstrates that caregivers whose friends and family members provide them
with resources are in better physical and psychological health (e.g., Ptacek, Pierce, Dodge,
& Ptacek, 1997). The Double ABC-X model refers to social support as the family’s or
parent’s ability to actively engage in acquiring support —— emotional, practical, material, or
other -— from relatives, fiiends, neighbors, and extended family.

Research has found that access to social support and satisfaction with social
support may be differentially related to adjustment (e.g., Sarason & Sarson, 1985). For
instance, in a study of coping in 35 mothers of children with neurological and physical
impairments (Hanson & Hanline, 1990), mothers reported being satisfied as parents when
they used a social support network. However, Cunningham, Benness, and Siegel (1988)

found that parents of ADHD children experienced contacts with extended family members

19

as less helpfirl than parents of non-disordered children. In studying parents of ADHD
children, it may be important to examine satisfaction with as well as size of or access to
social support network.

The second coping strategy is the ability of parents to refine family problems in
such a way that they are able to have a feeling of resiliency; that is, the sense that they, as
a family, can handle the problem without feeling too discouraged. Research indicates that
the interpretation one gives stressful events facilitates or impedes adjustment (Lazarus &
Folkrnan, 1984; Seligman, 1990). For instance, research on explanatory style has
demonstrated that individuals who perceive mishaps as due to internal, stable factors
which are consistent across situations are more likely to be depressed (Peterson, 1988).
Peterson and colleagues have termed this “learned helplessness.” In a sense, McCubbin’s
refi'aming concept is opposite of “learned helplessness;” rather than viewing situations in
such a way that the parent is immobilized, positive reframing gives hope for improvement
and subsequently, facilitates healthy adjustment.

The third coping factor is religiosity and mm which parents and
families glean from their faith and from members of their religious community. Literature
indicates that religiosity and spiritual support are associated with better adjustment in the
face of difficulties (e.g., Curbow & Somerfield, 1995; Jenkins & Pargament, 1995; Taylor,
Lichtrnan, & Wood, 1984). Additionally, religiosity or spiritual support has been related
to constructive coping in parents of a child diagnosed with cancer (Spilka, Zwartjes, &
Zwartjes, 1991).

The fourth coping factor in McCubbin’s (McCubbin et al., 1981) model is the

parent’s or family’s ability to W within the community.

20

Utilization of community resources has been found to be important for physical health
(Taylor, Repetti, & Seeman, 1997) and for family adjustment (Bibou-Nako, Dikaiou, &
Bairactaris, 1997; Kazak, 1989; Kazak, Reber, & Carter, 1988; Wallander, Varni, Babani,
Banis, & Wilcox, 1989). Recently, community and school-based programs for children
with ADHD, their families, and their teachers and other school personnel have been
proposed (Cunningham, Bremner, & Secord-Gilbert, 1993; Rostain, Power, & Atkinds,
1993); however, as noted by Rostain, Power, and Atkins (1993), not all parents are
equally likely to pursue treatment for their child’s ADHD. Hence, it is important to assess
parent’s ability to utilize these resources.

The fifth coping factor is the parent’s ability to accept problems, termed by
McCubbin as W- According to McCubbin, passive appraisal demonstrates a
lack of reactivity to problems. Passive appraisal may also indicate, however, an avoidance
or “giving into” problems. For this reason, it is diflicult to speculate how this coping style
may impact families with ADHD children. This lack of reactivity may help families to deal
with the on-going stressor by obtaining an acceptance of the difficulties; however, it may

also indicate an acquiescence.

11 ll EEC-Iillll'fll' Cl {2' Il .

McCubbin’s factors appear to be supported by a recent review of the literature
investigating family adaptation to a child’s illness or disability. Krauss, Warfield, Hauser-
Cram, and Shonkofl‘ (1997) identified three main factors which may be used to understand
how parents adapt to a child’s disability: 1) social support strategies, 2) problem-focused

and emotion-focused parental coping strategies, and 3) the emotional environment of the

21

family —— specifically, factors such as cohesiveness, supportiveness, and
adaptability/flexibility. These factors include the individual strategies proposed by Lazarus
and Folkrnan (1984), family elements as suggested by Kazak (1985), and ecological
elements outlined by Thompson and colleagues (1993). Although not specified by
McCubbin, Patterson (1988) posited their presence. These broad factors are arguably
inherent in McCubbin’s Double ABC-X model. In order to better understand how
McCubbin’s family-oriented model relates to other models, two heuristics are used. First,
McCubbin’s theory is related to Lazarus and Folkman’s emotion-focused and problem-
focused coping. Second, McCubbin’s theory is related to the three broad-based coping
theories. Additionally, it is possible that there may be one global factor captured by
McCubbin’s model.

McCubbin’s ABC-X model incorporates both emotion (i.e., passive-avoidance,
seeking spiritual support) and problem focused strategies (i.e., acquiring social support,
positive reframing of problems, and using community resources). Although McCubbin
does not define coping strategies as emotion or problem focused, they may be grouped
accordingly. Table 2 (next page) lists one way in which MoCubbin’s coping strategies
may related to Lazarus and Folkrnan’s (1984) problem and emotion-focused coping

categories.

22

Table 2

UK .mr , "Est ‘ -.Ir 0 ‘19!” an! 0." 'rr 0 r" 00"

 

Lazarus and Folkman’s groupings
McCubbin’s strategies Emotion focused coping Problem focused coping
Positive refiaming x
Acquiring social support x
Seeking spiritual support x
Using Community resources x
Passive appraisal , x

 

As a comprehensive family-oriented model with individual and ecological coping
strategies, McCubbin’s model provides a means to understand how coping strategies
occur at the individual, familial, and ecological levels. Table 3 lists McCubbin’s strategies

and the levels at which they are likely to operate.

 

. , . . . Ta“? .. .
unior‘ !«."4‘v)-,l'\‘-,!O,| .41... .J.__.___;J.__,.,.o..
Level
McCubbin Strategy Individual Family Ecological
Positive reframing x
Acquiring social support x
Seeking spiritual support x x
Using community x x
resources
Passive appraisal x

 

It is likely that some strategies operate on more than one level. For instance, an
individual seeking spiritual support may increase participation in religious services, taking

advantage of a community resource but also focusing inward for sustaining herself. Also,

23

while using community resources is obviously use of coping which is available at the
ecological level, McCubbin’s operalization of this strategy is that the parent would use
these resources herself but also would mobilize the entire family to engage in these
resources.

In summary, McCubbin’s strategies might be conceptualized as emotional and
problem-focused, coinciding with Lazarus and Folkrnan’s fi'amework. However,
McCubbin’s strategies also appear to measure family-oriented coping in parents who
might use strategies at the individual, familial, and ecological levels. Both
conceptualizations ofi‘er frameworks for providing information about how parents cope
with their child’s ADI-ID. Because models of c0ping with a child’s illness or disability
propose the importance of all of these levels, understanding McCubbin’s model in relation
to the three levels at which coping might occur is expected to be useful for learning about

how parents cope with their child’s ADHD.

O I 9, I. e I o
5'). .3...’. \la ..)"",.'a" . r." ”31.; ,l,,_0l2.‘2 [.3 1'“

McCubbin and Patterson have used the Double ABC-X model in order to
understand how parents and families adjust to a child’s chronic illness (McCubbin &
Patterson, 1983; Patterson & Garwick, 1994; Patterson, McCubbin, & Warwick, 1990)
and how family roles impact adjustment (McCubbin, Thompson, Kretzschamar, Smith,
Snow et al., 1992). For example, using the combined Double ABC-X and FAAF model,
Patterson and colleagues (1990) investigated the effectiveness of parental coping in 72
mothers and fathers of children with cystic fibrosis. They found that engaging in activities

as a family, reframing problems to obtain a sense of optimism, and working as a family to

24

handle demands were all associated with favorable child health.

! 1.. EllCll"l[ll EDIE

“Within the Double ABC-X model, the continued child ADHD behaviors may be
seen as the chronic stressor (A). Although the initial ADHD diagnosis may provide a
stress-relieving framework for parents, the continuance of child behaviors and associated
stressors are likely to build over time, serving as a “pile-up” of stressors. The parent’s
perception of the problem (C) directs resource utilization (B), together comprising the
parent’s coping. The parent’s and/or family’s definition of the problem, the child’s ADHD
behaviors and associated stressors, and the family members immediate responses interact
to determine whether the parent experiences immediate and on-going stress (X). If stress
is ongoing, various coping strategies may be employed to ameliorate the negative effects
of the on-going demands associated with the child’s behaviors.

Given the age of the children in the current study (7-11), it is assumed that the
family is in the adaptation phase of McCubbin’s process; that is, the parents have been
faced with their child’s ADHD behaviors for a number of years but are suffering from the
“pile-up” of stressors over time. Rather than seeking initial definition of the problem,
these parents are presumably using on-going coping strategies. Relating McCubbin’s
model to literature on parenting, it is possible that ineffective coping may provide further
stress to the family. For example, it is possible that the child’s inattention and
hyperactivity will guide the family into a set of negative dynamics, evidenced by parental
criticism and coercive parenting. These patterns of relating may exacerbate child’s ADHD

behaviors and contribute to comorbid aggression.

25

Hence, McCubbin’s model coincides somewhat with the existing ADHD literature
and may be used to describe the processes by which parents cope with their child’s

ADHD.

E' l . 'I I'll’ EEIID

Few studies of parental c0ping with a child’s ADHD have been conducted. Most
studies relevant to ways in which parents might act to ameliorate their own stress focus on
parenting training programs. Also, two studies on parents’ use of social support are
relevant. These literatures are briefly reviewed.

Wm Parent-training programs have been designed to assist
parents with decreasing children’s ADHD and associated problem behaviors (e. g.,
Anastopoulos, Shelton, DuPaul, & Guevremont, 1993; Blakemore, Shindler, & Conte,
1993). Although studies of program effectiveness generally focus on child outcomes
(e.g., Anastopoulos, DuPaul, & Barkley, 1991; Basu & Aniruddha, 1996; Newby, Fischer,
& Roman, 1991; Pisterman, Fireston, McGrath, & Goodman, 1992), some studies
examined parental functioning following involvement in a training program (e.g.,
Anastopoulos et al., 1993; Blakemore et al., 1993; Estrada, 1995; Odom, 1996).

The latter studies have found that parent training programs contributed to an
increase in parents’ sense of competence (Odom, 1996) and to a reduction of parenting
stress (Anastopoulos et al., 1993; Blakemore et al., 1993). In one study, 19 mothers who
completed a nine-session parent training program reported more parenting esteem and less
overall parenting stress compared to 15 mothers who were in a wait-list control condition

(Anastopoulos, Guevremont, Shelton, & DuPaul, 1992). Similarly, Blakemore and

26

colleagues (1993) found that a parenting program targeting child compliance resulted in an
increase child compliance and in sense of parents’ sense of competence. Odom’s (1996)
educational program also impacted parent functioning, specifically affecting sense of
parenting competence and role satisfaction.

Just as parent training programs are associated with reduction in parenting stress
and increase in parenting competence (Anastopoulos et al., 1993), it is likely that parents
may benefit from various coping strategies which do not require involvement in a formal
program. Involvement in a parent training program is one of many resources which
parents may have available to them. Whereas this may be viewed as a community
resource, there are also family, individual, and other community resources which families
may use to cope with their child’s ADHD behaviors.

Manama. Although not using a particular theoretical model of coping, social
support behaviors have been studied in parents whose child has ADHD. For example,
Mash and Johnston (1983a) examined child symptomatology, parent social support, and
parent stress and role satisfaction in 48 parents of children with ADHD (23 ADHD—LCD
and 25 ADHD-HOD) and 33 parents of non-problem children. As reported earlier, they
found that the parents of ADHD children reported more role distress than the parents of
non-symptomatic children Surprisingly, social support was not significantly difi‘erent
across groups; however, it was a significant factor in a model differentiating the groups
according to parental stress outcome.

Cunningham, Benness, and Siegel (1988) also examined social support in parents
of children with ADM). According to a study comparing 58 parents whose child had

ADHD to 58 parents of children without a behavioral or other disorder, parents of

27

 

children with ADHD reported fewer extended family contacts and the contacts which they
had were reportedly less helpful. Although social support is often associated with better
adjustment (Crnic, Friedrich, & Greenberg, 1983; Hanson & Hartline, 1900; Hurtig, 1994;
Noll, Swiecki, Garstein, & Vannatta, 1994; Sharts-Hopco et al., 1996; Short, 1997), it
may be that family contacts may increase rather than decrease stress in families of ADHD
children. While these two studies offer some limited information about how parents use
social support to cope with their child’s ADHD behavior, there is a lack of studies which
examine coping as a comprehensive process.

Parenting a child with ADHD has been associated with increased parental stress
and a decrease in parent role satisfaction. However, surprisingly few studies have focused
on how to assist parents in coping with their child’s symptomatology. It is important to
understand how parents are coping with their child’s ADHD in order to determine what
ameliorates their stress and what does not. Further, parent distress has been found to
impact parenting behaviors which contributes to the development of aggressive behavior
in children. Understanding efi’ective wping in parents may be usefirl in helping parents to

interrupt this cycle.

WW

Child ADHD has been related to parenting stress and role dissatisfaction (Baldwin
& McCal, 1995; Mash & Johnston, 1996). However, the few studies which controlled for
comorbid child aggression yielded inconsistent results (Anastopoulos et al., 1992;
Johnston, 1996). It is possible that child inattention, hyperactivity, and aggression

independently contribute to parental distress.

28

Also, few studies have examined factors which might mediate or moderate the
relation between these child behaviors and parent adjustment. Most studies which have
done so have focused on secondary factors, such as parenting behaviors. The few studies
which have examined social support provide mixed results, which appear to indicate that
certain types of social contact may prove stressfirl for parents (e. g., Cunningham,
Bemness, & Siegel, 1988; Johnston, 1983a). No studies have examined parent coping
strategies m; that is, how parental coping might buffer parents from the stress
associated with a child’s ADHD behaviors and/or aggressive behavior. Because of this
gap in the literature, a study is needed which might provide a preliminary investigation of
how coping mediates the relation between child behavior problems and parent distress in
this child based population. While examining this relation, it is important to note that
parents may use multiple strategies during the early stages of coping which may be

associated positively or negatively with high levels of stress.

Queuim

While it is recognized that the expression of ADHD behavior interacts with a range
of contextual factors (Samerofi', 1995), the current popular view that ADHD is a primarily
biogenetically shaped risk for behavioral disorder is taken to a logical conclusion: in the
current study, ADHD is framed as a stressor for parents. Child ADHD diagnosis and
symptomatology were examined along with aggression in order to understand to what
extent inattention and/or hyperactivity serve as stressors to parents above and beyond
child aggression. The reverse model was also tested; that is, to what extent was

aggression independently related to parent role distress. Parent and teacher reports of

29

 

child behavior were collected for inattention, hyperactivity, and aggression. Because field
studies for DSM-IV supported the evidence of two behavioral dimensions with ADHD-
hyperactivity and inattention - these two domains were treated as distinct predictors in
dimensional analyses. In categorical analyses, parents of children with the combined and
inattentive types were compared to parents of non-disordered children and to each other.
Parent self-reported their own parenting stress and role dissatisfaction.

Further, the effectiveness of parental coping strategies was investigated using
parents’ self-report of McCubbin’s styles of coping (acquiring social support, refraining,
seeking spiritual support, mobilizing to acquire help, and passive appraisal) and Sarason’s
measure of satisfaction with social support. Inter-correlations upheld four of the factors
proposed by McCubbin and did not warrant conducting analyses with two or three factors
as suggested by other conceptualizations of coping. Coping was then examined as a
mediator of the relation between child ADHD and parental role distress.

Wu

W1, Prior studies did not test the independent effects of inattention and
hyperactivity while controlling for aggression. In order to more fully understand the
extent to which these behaviors account for parental role distress, it was important to
assess the reverse model as well. That is, to what extent would child aggression predict
parental role distress independent of hyperactivity and inattention. Based on current
literature, it was unclear to what extent child inattention and hyperactivity would
independently predict parent role distress and to what child aggression independently

would predict parent role distress. Thus, these predictions (lb—c and 1d) were mutually

competitive.

3O

 

W911, ADD and ADHD diagnoses (prediction 1a), severity of inattention
(prediction 1b) and severity of hyperactivity (prediction 1c) would be associated with
higher levels of parent role distress, even with child aggressive and oppositional behavior
controlled. For the diagnostic question, parents whose children have ADD, parents whose
children have ADHD (combined type), and parents of non-problem children were
compared. In competition with the preceding, it was also predicted that severity of child i
aggression (prediction 1d) would be associated with parental distress, even with level of

child inattention and hyperactivity controlled. These predictions were tested with

 

correlations, analysis of variance, and analysis of covariance. Power analyses for the
mothers is reported herein. Power for father analyses was slightly lower in all cases.
Given the current sample size, for the three group Analysis of Variance, a large effect
(f=.40; Cohen, 1992) could be detected at power == .80. For regression analysis with two
predictors, a medium efi‘ect (beta = .15; Cohen, 1992) could be detected at power = .80
(Cohen, 1988).
W12

Rationale; The factor structure of MoCubbin’s F-COPES was analyzed before
testing whether coping mediated the relation between child ADI-{D behaviors and parental
distress. Inter-correlations indicated that analyses should be conducted with four of
McCubbin’s factors. Use of these four coping strategies has been found to be associated
with better outcome in parents (McCubbin, 1979; McCubbin et al., 1980). Hence, it was
predicted that parents who use these strategies to a greater extent would exhibit better
adjustment. As a result, use of coping was expected to mediate the relation between child

behaviors and parent role distress. Because parents may initially utilize multiple strategies

31

regardless of their effectiveness, it was possible that an increase in coping behaviors would
be associated with poorer adjustment or with better adjustment.

mm Greater usage of each of the four coping styles would mediate the
relation between child behaviors and parent role dissatisfaction. Baron and Kenny’s model
for testing mediation effect was used to examine this hypothesis. In regression analyses
with two predictors (the child behavior and the parent coping strategy for detecting
whether one coping factor at a time accounted for variance previously attributed to child
behavior in regression) and given the current sample size, a medium effect (beta = .15;

Cohen, 1992) could be detected at power = .80 (Cohen, 1992).

Hmtheaial

Rationale}, Certain coping factors may prove to be more significant than other
mediators of symptomatology and adjustment (e.g., McCubbin, Kapp, & Thompson,
1993). In order to best understand the role of coping in parental adjustment, specific
coping strategies were investigated as related to adjustment. It was hypothesized that
while certain strategies (e.g., problem-focused coping) might have been associated with
better adjustment, other strategies (e.g., emotion-focused coping) might have been
associated with poor adjustment.

Prediction}, It was initially proposed that if more than one coping factor was
significant, then the significant factors would be compared in terms of direction and
magnitude. Specifically, it was hypothesized that problem-focused coping would be more
strongly associated with better adjustment compared to emotion-focused coping (Aldwin

& Revenson, 1987) and that individual and family coping would be more strongly related

32

to adjustment than ecological coping (Weiss, Marvin, & Pianta, 1997). The problem-
emotion distinction did not hold up in that the styles did not cluster as two factors.
Therefore, this aspect of the hypothesis as originally proposed was not tested. However,
positive refi’aming as a measure of individual c0ping was compared to social support and
community resources as ecological c0ping styles. In order to test this hypothesis, these F
three styles were entered into a single regression equation. Then the point values (mean
score for mothers or fathers) of the ecological factors (i.e., social support and community

resources) were examined in relation the 95% confidence interval for positive reframing.

 

Significant differences would be indicated if the point values fell outside the 95%
confidence interval for positive reframing. Given the current sample size, a large (R2 =

.34; Cohen, 1992) effect could be detected at power == .80 (Cohen, 1992; Cohen, 1988).

W

W As explained by Sarason and Sarason (1985), satisfaction with social
support rather than size of network predicts better adjustment. It was expected that this
would also pertain to parental adjustment when coping with a child’s ADHD (e.g.,
Curmingham, Benness, & Siegel, 1988).

WA. Greater parent satisfaction with social support would be associated
with better parent adjustment. Correlation analyses were used in order to examine a
possible relation between parent dissatisfaction and these two social support variables.
Given the current sample size, a large effect (r=.50; Cohen, 1992) could be detected at
power = .80 (Cohen, 1992). Power was .70 (Cohen, 1992; Cohen, 1988) to detect a

medium effect (tr-.30, Cohen, 1992).

33

METHOD

Enlistments

A total of 66 mothers and 57 fathers of children with ADHD (combined or
inattentive subtypes) and normal control children participated in the study. Out of 74
families contacted, 18.9 percent (N=14) of the children had ADHD inattentive subtype
(ADD), 36.5 percent (N=27) of the children had ADHD combined subtype (ADHD), and
33.8 percent (N=25) served as non-ADHD comparison children. Six families were
screened out based on the child’s IQ not meeting the cut-off; and the data for two families
were unusable due to records being incomplete. The ADD and ADHD samples came
fi'om families recruited through the East Lansing and Lansing school districts and from
pediatric clinics specializing in ADHD (excluding children with uncorrected neurological
or communication deficits; e.g., vision or hearing impairments). Matched comparison
families were recruited from children in the East Lansing and Lansing school districts and
a non-ADHD pediatric clinic. All children were screened for learning disabilities or other
psychopathology. The Child Behavior Checklist (CBCL) and the SNAP-IV DSM-IV
symptoms checklist were used to initially screen for psychopathology. The Wechsler
Intelligence Scales for Chfldren—IH—R (WISC-III-R) short form and Wechsler Individual
Achievement Test (WIAT) screener were used to identify children with learning
disabilities as defined later. The sample was 76.2% Caucasian, 9.5% Hispanic, and 7.9%

Asian American.

34

 

pre

in:
N01
will
end
Tear
scret
Elba
Subsc

okra

Rmeerlute

Parents completed a battery of self-report, spouse-report, and child-rating
questionnaires (see Appendix A, pages 92-93). In most cases, the child’s teacher also
completed ratings of child behavior. However, because many children were treated with
stimulants during school, these ratings did not always reflect the level of behavior parents
were dealing with at home. Families came to campus in order to complete the battery of

questionnaires and tests. The battery of questionnaires included multiple measures of

predictors, mediators, and outcomes.

 

 

In order to obtain dimensional measures of problem behaviors, parents of children
with ADHD completed two measures: (a) the W (CBCL)
aggression subscale (Achenbach, 1991) and (b) the WW
inattention and hyperactivity indices, ODD and CD rating scales (SNAP-IV; Swanson,
Nolan, & Pelham, 1982). Both aggressive behaviors and conduct problems behaviors
were controlled in the current study. However, due to the age of the children,
endorsement of the ODD and CD subscales did not reflect serious delinquent behaviors.
Teacher SNAP-IV inattention and hyperactivity indices were also used as measures of
screening in and dimensionality of ADHD symptomatology. Teacher TRF aggression
subscales also was used for measuring child aggression. SNAP-IV ODD and CD
subscales also were used for measuring child conduct problems. Child report was not
obtained due to lack of resources but also due to the young age of the children which is
associated with invalid and unreliable reporting (Sattler, 1992). In order to obtain a final

diagnosis, the Diagnostic Interview Schedule for Children - Revised (DISC-R) ADHD,

35

 

 

 

tem

Ach

10;;
chec;
of [hi
to in
and It
little 1:
alpha
Cane,

(alpha

Foy the
Whig

ODD, and CD modules (Shaffer, Schawab—Stone, Fisher et al., 1993) were administered
(by trained graduate students in clinical psychology). Each of these measures is next
briefly described.

1' . :-1-: 10 n, .71 : :1. .r. tam out It. ' a Mini
122D. Aggression was measured by the CBCL and TRF aggression subscale. The parent
(CBCL) and teacher (TRF) aggressive behavior subscales both consist of items to be rated
on a 3-point scale (O=not true, l=somewhat or sometimes true, 2=very true or often true).
Parents are asked 20 items whereas teachers complete 25 items. Example items include:

”‘6

“argues a lot, cruelty, bullying, meanness to others,” and “temper tantrums or hot
temper.” Both forms have good reliability (coefficient alphas .85 and .84 respectively;
Achenbach, 1991).

.21 .u u :r :1. " r-..tt D u-h ...1° ..2' a; ’-h' .21‘.n a:
1218). The SNAP-IV consists of 80 items; 69 items which provide a DSM-IV-based
checklist of items for inattention, hyperactivity, CD, and ODD were retained for purposes
of the current study. The teacher form has 90 items, although only the 27 items pertaining
to inattention (9 items), hyperactivity (9 items), and ODD (9 items) were used. Parents
and teachers rated how well each item describes the child on 4-point scale (not at all, just a
little bit, quite a bit, very much). Reliability in prior studies has been high (coefficient
alphas .94, .90, and .80 for ADHD, ODD, and CD subscales respectively; Nigg, Hinshaw,

Carte, & Treuting, 1998). In the current study, reliabilities were good for inattention

(alpha = .97), hyperactivity (alpha == .97), and ODD and CD combined‘ subscales (alpha =

 

1'
For the current study, the ODD and CD symptoms were combined because the two subscales were highly
correlated (mothers: (=74, n<.01; fathers F83, p<.01).

36

.95) for combined parent reports. Teacher report reliablities were also good (inattention,
alpha = .96; hyperactivity, alpha = .92; ODD/CD combined, alpha = .91).

The DISC-IV is a structured interview developed by the National Institute for Mental
Health that was administered to the child’s mother. A series of diagnostic questions are
asked in order to determine whether the child meets criteria for ADHD, CD, ODD or
other disorders. It has adequte validity and reliability for the diagnoses used in this study
(Shafi’er et al., 1993). It is widely used and was designed for use with community samples
such as the current one. The interview includes examination of age of onset and degree of

impairment to assess whether DSM-IV criteria are met.

 

I1' 211'” Cum e.- "-1 .11-: z. .111 .z is. 0' 'u 111
W. The F-COPES was used to identify coping behaviors of parents.
The F-COPES consists of 30 items which are rated on a 5-point scale (l=strongly
disagree, 2=moderately disagree, 3==neither agree nor disagree, 4=moderately agree, and
5=strongly agree).

The F -COPES was designed to capture aspects of the Double ABC-X Model of
family coping. The Double ABC-X Model integrates the ways in which the family utilizes
individual, family, and community resources (McCubbin, Olson, & Larsen, 1987). In the
current study, only four factors were retained due to the low reliability of the passive
appraisal scale. These subscales and their reliabilities as found in current dataset are: (1)
Wm - measures the families ability to actively acquire social support
from relatives, friends, neighbors, and extended family (alpha = .79); (2) mm; - the

37

family’s capability to redefine stressful events in order to make them more manageable
(e. g., “accepting stressful events as a fact of life” and “defining the family problem in a
more positive way so that we do not become too discouraged” (alpha = .78); (3) W
W -— acquire support through religious organizations or personal faith (alpha
== .88); and (4) mohifizingfamimsgum - seeking community resources and assistance
(alpha = .88). Reliability for the scale total score was below an acceptable level
(alpha=.33). Therefore only the subscale scores were used. (McCubbin, Olson, & Larsen
(1987) report original reliabilities for all five subscales).
WM Because measures of social
support network and satisfaction with social support are difi'erentially related to
adjustment, Sarason, Sarason, Shearin, and Pierce (1983) developed a l2-item instrument
that measures both social network and satisfaction with social support. Subjects are asked
to 1) list up to 9 people to whom they can turn and on whom they can rely in given sets of
circumstances and 2 ) indicate how satisfied they are with this support on a 6 point scale
(l=very dissatisfied to 6=very satisfied). Hence, the two subscale scores are: (l) the
number score (N) which is the average number of support persons listed (range, 0-9) and
(2) the satisfaction score (S) which is the average rating given for satisfaction of each

support question. Sarason, Sarason, Shearin, and Peirce (1987) report alphas of .90 for

size of network and .93 for satisfaction.

 

The Parenting Distress
Subscale of the PSI (Abidin, 1983) was used as an outcome variable. Although included

in the PSI, this subscale indicates depression, strain, sickness which the parent is

38

experiencing at time of completion or since having a child. As explicated by Abidin (1983,
p.55), “the Parental Distress subscale determines the distress a parent is experiencing in his
or her role as a parent as a firnction of personal factors that are directly related to
parenting.” Parents were asked to rate the 12 subscale items on a 5-point scale

( l=strongly disagree, 2= disagree, 3= not sure, 4=agree, 5=strongly agree). Example
items include: “I often have the feeling that I cannot handle things well,” “I find myself
giving up more of my life to meet my children’s needs than I ever expected,” and “I feel
that I am not very good at being a parent.” Reliability found in current sample was
satisfactory (study alpha = .82). Guidubaldi and Cleminshaw’s (1994) published alpha
was slightly higher (alpha = .87).

WW Two of the PSS (Guidubaldi & Cleminshaw, 1994)
subscales were used to measure the possible strain experienced by parents of children with
ADHD: satisfaction with the parent-child relationship (alpha = .85) and satisfaction with
parenting performance (alpha = .83). The Satisfaction with the Parent-child Relationship
Subscale consists of 15 items which the parent rates on a 4-point scale (l=Strongly Agree,
2=Agree, 3=Disagree, 4=Strongly Disagree). Items include: “I am delighted with the
relationship I have with my child” and “I think my child obeys me and this pleases me.”
The Satisfaction with parenting performance subscale consists of 15 items (rated on the
same 4-point scale). Items include: “I wish I did not become impatient so quickly with my
child” and “I wish I were a better parent and could do a better job of parenting.” (Note:
for the purposes of the current study, this measure was reverse coded so that a high score

indicated lack of satisfaction).

39

RESULTS
Demographic and child behavior ratings are summarized in Table 4a (next page).
Groups did not differ by percent boys, intelligence scores, age, or ethnicity. Every effort
to recruit both mothers and fathers was made. As expected, father participation was

slightly less than mother participation. Analyses were conducted separately for mothers

and fathers.

[continued next page]

40

Table 4a

W

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADD ADI-1]) Control Sig difl’

N Children 25 27 14 --

N Moms 22 22 14 --

N Dads ,_ 13 16 18 -

Percent boys 64.3 70.4 56.0 n.s’
Full Scale IQ 6 110.8 (16) 103.4 “0'0! 114.6 (15.0) n.s.

Age in years 10.6 (1.2) 9.2 (2.2) 10.2 (1.7) ns.

Percent White 85.7 88.0 75.0 n.s.

SNAP Attn Score - mom rating 1.38 (.68) 2.16 (.47) .57 (.39) .000
SNAP Attn Score - dad rating 1.11 (.73) 1.67 (.85) .56 (.44) .000
SNAP Attn Score - teacher rating 1.41 (.73) 2.16 (.51) .24 (30) .000
SNAP Hyp Score - mom rating .59 (.51) 1.98 (.62) .38 (.42) .000
SNAP Hyp Score - dad rating .56 (.48) 1.53 (1.03) .37 (.52) .000
SNAP Hyp Score - teacher rating .32 (.45) 1.05 (.47) .33 (.68) .000
SNAP ODD/CD Score - mom rating .26 (.19) 1.07 (.39) .28 (.26) .000
SNAP ODD/CD Score - dad rating .28 (.25) .86 (.59) .34 (.30) g .000
SNAP ODD/CD Score - tmcher rating .17 (.22) .57 (.25) .20 (.51) .020
CBCL“ Aggression - mom rating 5.63 (4.53) 20.43 (10.03) 5.50 (5.68) .000
CBCL“ Aggression - dad rating 5.88 (4.49) 14.00 (9.50) 6.17 (7.00) .000
TR? Aggression - teacher rating 55.88 (4.94) 59.43 (9.18) 51.92 (5.26) .015

 

Notes: * Chi-square test, ‘ T-scores; SNAP refers the Swanson. Nolan, and Pelham DSM-IV rating seale.
CBCL refers to Child Behavior Checklist; TRF refers to Teacher Report Form. SNAP scores are reported
asrawscorea CBCLandTRFsooresarereportedasT-soores. ODD referstoOppositionalDefiant
Disorder. Items from the SNAP ODD subscale were averaged to obtain each respondents raw score. CD
referstoConductDisorder. Itemsfromthe SNAP CD subsealewereaveragedtoobtaineach respondents
raw score.

41

 

Mothers’ and fathers’ self-report of Dissatisfaction with Parenting Performance

and use of coping strategies are reported in Tables 4b and 4c.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13121231!

111191 1:11. _:11111:.-11 :1 11‘°______9_u ‘11, 1.11 I

A1212 ADHD 99.111191

Parent Dissatisfaction with parenting 2.41 (.30) 2.56 (.43) 2.18 (.41)

performance
SIR 01.506181 Support Network 4.02 (1.27) 3.34 (1.20) 3.60 (1.49)
Satisfaction with Social Support 4.44 (1.73) 4.71 (.92) 4.92 (.60)
USC ofSocial Support (F-COPES) 3.38 .72) 3.19 (.60) 3.36 (.60)
USC 0f positive refiaming (F-COPES) 3.88 (.65) 3.59 (.59) 4.07 (.52)
Use of spiritual support (F-COPES) 3.23 (1.35) 3.39 (.95) 3.93 (.87)
Use of community resources (F-COPES) 3.82 (.88) 4.08 (.49) 3.70 (.62)
m
1191; 1. .- 4:1111 1.11 ‘1 .111°_3_3=__;°___°1__g__1__11;.= 1.11 I
ADD ADHD 991111221
Parent Dissatisfaction With parenting 2.32 (.30) 2.50 (.42) 2.35 (.34)
performance

Size ofSocial Support Network 2.54 (1.58) 2.93 (1.34) 2.27 (1.23)
Satisfaction with Social Support 4.34 (1.20) 4.57 (.55) 4.42 (.62)
Use ofSocial Support (F-COPES) 2.66 (.60) 2.71 (.63) 2.56 (.65)
Use ofpositive reframing (F-COPES) 3.70 (.38) 3.75 (.60) 3.96 (.48)
Use ofspiritual support (F-COPES) 2.31 (1.12) 2.68 (1.00) 3.44 (1.07)

Use ofoommunity resources (F-COPES) 2.85 (.66) 3.25 (.95) 2.88 (.78)

 

42

D l . CE . E . . l l
:. -.,..,. ._.';. .,.- . ..-.,. 'M' =.~.... . .. -.. ._.. :314‘ ’-.,--.; ..
Hyperactivity and inattention were measured through parent and teacher ratings. Inter-
correlations indicated that mother and father but not teacher scores could be combined to
create composite variables (see Appendices B, C, & D, pages 96 - 98). Further, inter-
correlations demonstrated that CBCL and SNAP-IV scores should not be combined.
Composite measures were: (1) parent rated attention problems (mother and father SNAP-
IV attention items; alpha=.97), (2) hyperactivity (mother and father SNAP-IV ratings;
alpha=.97), (3) teacher rated attention problems (SNAP-IV items; alpha=.96), (4) teacher
rated hyperactivity (SNAP-IV items, alpha-=92), (5) parent rated conduct problems (an
average of mother and father ratings on the SNAP-IV ODD and CD subscales;
alpha=.95), (6) teacher rated conduct problems (SNAP-IV ODD and CD subscales,
alpha=.9l). Additionally, two separate measures of aggression were obtained, using (7) a
parent composite fiom the CBCL aggression scale ratings (alpha=.81) and a teacher rating

from the TRF (alpha=.84). Correlations between predictor variables are reported in Table

5 (next page).

43

 

Table 5

 

 

 

 

 

 

 

 

 

 

 

 

rr i w

Child Child Child Child ODD/CD - ODD/C Child Child
Attn - Hyp - Attn - Hyp - - parent Agg Agg
parent parent teacher teacher - teacher parent teacher

Child Attn - 1.0

parent rating

Child Hyp - .80" 1.0

parent rating

Child Attn .58” .43" 1.0

- teacher rating

Child Hyp .48" .52” .58" 1.0

- teacher rating

ODD/CD - .71 ” .77“ .26 .42” 1.0

parent rating

ODD/CD - .35' .35‘ .41 “ .67” .35‘ 1.0

teacher rating

Child Agg - .68“ .81‘ .34' .46” .88” .34“ 1.0

parent rating

Child Agg - .41" .33‘ .54“ .69” .27 .79“ .29‘ 1.0

teacher rating

Notes: " p<.05, "p<.01
u ‘v.1.1:1_1.' -11_\ I ' 011111 6.1 :111 C- 0 ' AS

detailed in Appendix B (see page 97), inter-correlations did not support the creation of a

one, two, or three factor solution but indicated that McCubbin’s five coping strategies

should be maintained as discrete strategies. The largest bivariate correlation was F28

(p<.05). This was the only correlation which reached statistical significance (p<.05).

Further, a measure of internal consistency revealed that the Passive Appraisal subscale was

unreliable (Cronbach’s alpha = .18 and -.23 for mother and father data respectively). This

subscale was not used in analyses. Thus, four coping variables were retained.

W The correlation between the Parenting Stress

Index parent distress subscale and the Parenting Satisfaction Scale’s measure of

44

dissatisfaction with parenting performance subscale was moderate (r=.48, p<.01; see also
Appendix F, page 98), indicating that creation of a composite variable might be justifiable.
Preliminary analyses, however, revealed that a composite of PSS and PSI subscales
obscured results. Hence, analyses were conducted with each of the three subscales (PSI
parental distress, PSS dissatisfaction with parenting performance, and PSS dissatisfaction
with parent-child relationship). Internal reliabilities for these scales were satisfactory (PSS
Dissatisfaction with Parenting Performance, alpha= .84; PSS Dissatisfaction with parent-
child relationship, alpha= .88; PSI Parenting Distress, alpha=.83).

Similar results were found for all three measures of parent role distress except
where otherwise noted. The most consistent results were found with the PSS
Dissatisfaction with Parenting Performance. For the sake of clarity and ease of readability,
only the results for PSS Dissatisfaction with Parenting Performance are reported here.
Results which differed by outcome measure are noted in footnotes in the text and are
detailed in Appendix G, pages 99-104).

Results were unchanged when child learning disability (LD) was controlled.
W

Hmhcslfla Mothers, For between group comparisons, child diagnostic group
served as the independent variable and parent Dissatisfaction with Parenting score served
as the dependent variable. One-way analysis of variance was computed separately for
mothers and fathers with the independent variable having thee levels (ADD, ADHD, and

no diagnosis). Mothers’ dissatisfaction with parenting performance (E[2, 56]= 5.07,

45

;2<.01)2 differed significantly across the three groups. Using Tukey’s test in post hoc
analyses, mothers of ADHD children were more dissatisfied with their parenting
performance than mothers of non-disordered comparison children; this efi’ect did not hold
when child conduct problems were controlled. Mothers of ADD children were no more
dissatisfied than mothers of non—disordered comparison children. Mothers of ADD and
ADHD children did not differ in their reported levels of parenting dissatisfaction. Means

are reported in Table 6.

Table 6

[51.1 in: ‘ U‘U 1 131111111 .- 11.1) 1-1 .1 111.611 Mgr-111411.11.”

ADD ADHD Control (p)

Man’s PSS 2.40 (.31) 2.55 (.41) 2.41 (.30) <.Ol
dissatisfiction

w/parenting

perforrmnce

Dad’s PSS 2.32 (.30) 2.50 (.42) 2.18 (.34) (.05
dissatisfaction

w/parenting

performance

 

mm Fathers’ dissatisfaction with parenting performance (H2, 47]=3.33,
p<.05) differed significantly across the three child diagnostic groups. Using Tukey’s test
in post hoc analyses, fathers of ADHD children were more dissatisfied with their parenting

performance than fathers of non-disordered comparison children; this efi‘ect did not hold

 

2

Resultsweremn-significantforPSlParentDisUess. Thismeasureislessspecifictoparentroledistres

and capmres more general depressed affect non-specific to role as parent (see Appendix 0, pages 99-104).
Results for PSS Dissatisfaction with parent-child relationship were similar to those reported here
pertaining to Dissatisfaction with Parenting Performance).

46

when child conduct problems were controlled. Fathers of ADD children were no more
dissatisfied tlmn fathers of non—disordered comparison children. Fathers of ADD and
ADHD children did not differ in their reported levels of parenting dissatisfaction. Means
are reported in Table 6 (page 46).3

The prediction that ADHD would be associated with increased parental distress
was supported but only for the combined subtype. However, support was not found for
the independent effect of ADHD (that is, separate fiom comorbid aggression and/or child
conduct problems). Parents of children with ADHD inattentive subtype (ADD) did not
experience significantly greater degrees of parenting dissatisfaction than parents of
comparison children. Parents of ADD and ADHD children did not differ in their reported
levels of parenting dissatisfaction.

W119. Zero order correlations were used to test whether child
dimensional behaviors were related to parent dissatisfaction. Child inattention and
hyperactivity as dimensions were associated with maternal and paternal dissatisfaction
with parenting performance‘. As shown in Table 7 (next page), mothers’ dissatisfaction
was correlated with child inattention (F55, p<.01) and hyperactivity (F38, p<.05).

Fathers’ dissatisfaction was also correlated with child inattention (F34, p<.05) and

 

3
Note: When using father’s satisfaction with parent-child relationship (F[1,23]=9.55, p<.01) and father’s
parent distress (F[l,24]=5.96, p<.05) as outcomes, the significant differences between fathers of ADHD
and fathers of comparison children remained even when child aggression was controlled. Results were
non-significant for PSI Parent Distress. This measure is less specific to parent role distress and captures
moregeneral depressed afl‘ect non-specifictoroleasparent(seeAppendixG, pages 99-104). Resultsfor
PSS Dissatimction with parentchild relationship were similar to those reported here pertaining to
Dissatisfaction with Parenting Performance).

1

Results were similar when looking at dissatisfaction with parent-child relationship but not when looking
at parental distress (see Appendix G, page 99-104).

47

hyperactivity (F32, p<.05). Notably, the significance and magnitude of these
correlations held across rater within the home environment. Neither mothers’ nor fathers’

dissatisfaction scores were significantly correlated with teacher ratings of child behaviors.

 

 

 

 

 

 

 

 

Table 7
1111.19» 11'. ‘ 11‘1111015. -1r11.11'z.‘-1111-"vrl1111:,r..‘ 11
Mom Dissatisfaction Dad Dissatisfaction
SNAP Attn Smre - mom rating .55” .32‘
SNAP Attn Scone - dad rating .45” .34“
SNAP Attn Score - teacher rating .13 ' .26
SNAP Hyp Score - mom rating .38" .42“I
SNAP Hyp Score - dad rating .47” .32*
SNAP Hyp Score - teacher rating .29 .42"

 

1' p<.os; 1* p<.01

Although inattention and hyperactivity are considered separate dimensions of
ADHD (Lahey, et al., 1994), the two dimensions are highly correlated. In the current
sample, mothers’ ([=.75, p<.01) and fathers’ (F82, p<.01) ratings of inattention and
hyperactivity were highly correlated. Due to the high correlation between ratings of
inattention and hyperactivity, these dimensions have shared variance. In an attempt to
understand the separate efl‘ects of each dimensions, regression analyses were conducted in
two ways. As reported above in Table 7, each ADHD dimension was correlated with
parent outcome without controlling for the effect of the other ADHD dimension.
Secondly, the two dimensions were entered simultaneously into one regression equation.
This allowed examination of the relation between inattention and hyperactivity

independently of each other. When controlling for the other dimension, inattention

48

(beta=.62, p<.01) but not hyperactivity was significant for mothers. Neither were
independently related to fathers’ dissatisfaction.

Similarly, child aggression and/or conduct problems were controlled first by
entering each ADHD factor into a regression equation without the other and secondly by
entering both ADHD dimensions into the same regression equation. When using type III
Sums of Squares, each variable entered in a single step is controlled so that what remains
is the independent contribution of each variable. Although only one step is required for
such analyses, two steps are shown so that examination of change in R2 is possible.

When child aggression and/or child conduct problems were controlled, child
inattention and hyperactivity were not significant in predicting maternal (Table 8 and 9,
page 50) or paternal distress (Table 10 and 11, page 51). When child learning disabilities
and child aggression were controlled, child inattention became a significant predictor of
maternal (beta=.34, p<.05) but not paternal dissatisfaction (n.s.). Tables 8 through 11
show results when inattention and hyperactivity were entered into separate regression

models.

49

Table 8

 

 

 

 

 

 

 

 

 

 

oust-m 1Laura:111111'.‘11111.1__° ’1' .1. 1 111 111:1'1.1_1.111
Child beta step 1 beta step 1?.2 Change R2 Change
predictor 2 step 1 step 2
Model 1 composite .55‘” .33“ 31*"
(parent ratings) aggression
inattention .32+ .05+
Model 2 aggression .42“ .45‘I .18"
(teacher ratings)
inattention -.06 .00
Model 3 conduct 54"“ .31+ 29""
(parent ratings) problemsA
inattention .31+ .04+
Model 4 conduct .33* .33‘ .ll‘
(teacher ratings) problemsA
inattention .01 .00

 

+p<. I, ‘p<.05, **p.<01, "*p<.001; " conduct problems refers to child ODD/CD combined score.

 

 

 

 

 

 

 

 

 

 

Table 9
C "J lt'vn“ ' :"J‘ ‘01 "h" .1 Hi9 .1‘, , l .11. .i‘i'l '1'. ' 11401107.”!!! .11.!
Child beta step 1 beta step R2 Change R2 Change
predictor 2 step 1 step 2
Model 1 composite .55‘" .65" 30*“
(parem ratings) aggression
hyperactivity -.12 .00
Model 2 compofie .42" .46‘ .18“
(teacher ratings) aggressio
hyperactivity -.05 .00
Model 3 conduct 52*" .52" 27*"
(parent ratings) problemsA
hyperactivity .01 .00
Model 4 conduct .33" .24 .12“
(teacher ratings) problemsA
hyperactivity .12 .01

 

+p<. l, ’n<.05, "p.<01, "*p<.001; " conduct problems refers to child ODD/CD combined score.

50

Table 10

 

 

 

 

 

 

 

 

 

 

HUM ' {'3' 11111.1.1' 11 . .1‘ ’1111111111l'1r_..-r‘r11.1,1
Child beta step 1 beta step a2 Change R1 Change
predictor 2 step 1 step 2
Model 1 composite 57*" .5311 .331"
(parent ratings) 388195510“
inattention ‘02 _00
Model 2 composite 33+ .30 .12+
(WM ratings) aggression
inattention .06 .00
Model 3 conduct 318*“ .62" .3311"
(parent 1311085) problemsA
inattention -.06 .00
Model 4 conduct .34+ ,291- .124.
(teacher ratings) problemsA
inattention .14 .02

 

+p<. l, ‘p<.05, “p.<01, *”p<.001; A conduct problems refers to child ODD/CD combined score.

 

 

 

 

 

 

 

 

 

 

Table 11
u 11.111t°“ “1"11"‘.1111.1r1‘ 11 t: 15‘ 1m'.:.‘1:_1rt111 11 1111;113:111 .11
Child beta step 1 beta step 1?.2 Change R2 Change
predictor 2 step 1 step 2
Model 1 composite 58*" .72M 33*"
(parent ratings) aggression
hyperactivity -.17 .01
Model 2 composite .33+ -.04 .11+
(teacher ratings) aggression
hyperactivity .44 .06
Model 3 conduct 58"“ .70" 33*"
(parent ratings) problemsA
hyperactivity -.16 .01
Model 4 conduct .34+ .00 .12+
(teacher ratings) problemsA
hyperactivity .40 .05

 

+12<. 1, ‘n<.05, ”n.<01, "*p<.001; A conduct problems refers to child ODD/CD combined score.

51

In order to understand the independent effects of inattention and hyperactivity,
these dimensions were entered into the same regression model at the same step. That is,
when each was examined controlling for the effect of the other. Tables 12 (below) and 13
(next page) show that when controlling for aggression and variance shared by the ADHD
dimensions, neither inattention nor hyperactivity was related to parent role distress.
Sometimes relations were negative suggestions that an decrease in child behavior

problems was associated with lower parent distress. These results indicate that although

inattention and hyperactivity may be considered separately, their effects are highly related.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Table 12
111.11.11.‘ 11': 'i‘ur' 11111.11 111111' ’12:. :.1r111 1112111111
Child beta step 1 beta step 2 1?.2 Change R2 Change
4 predictor step 1 step 2
Model 1 composite 55*" .57" 30*"
(parent ratings) aggression
inattention .55" .12"
hyperactivity -.49"'
Model 2 composite .36* .16 , .13“
(teacher ratings) aggression
inattention 76*" .32‘“
hyperactivity -.24
Model 3 conduct 51*“ .40‘ 26*”
(parent ratings) problemsA
inattention .53“ .11""I
hyperactivity -.32
Model 4 conduct 51*“ .40“ .11‘
(teacher ratings) problemsA
inattention .53" .01
hyperactivity -.32

 

+n<. l, 'p<.05, *‘p.<01, “*p<.001; A conduct problems refers to child ODD/CD combined score.

52

Table 13

 

 

 

 

 

 

 

 

 

 

 

 

 

 

111111 11': {hut-s 11 11.11‘ 11. :1' ’1i 11'111111 1-11,1.1'-1111:_11
Child beta step 1 beta step 2 R2 Change R’ Change
predictor step 1 step 2
Model 1 composite 59*" 38*" .351"
(parent ratings) aggression
inattention .33 .06
hyperactivity -.62+
Model 2 aggression .35+ .30 .13+
(teacher ratings)
inattention -.18 .03
hyperactivity .32
Model 3 conduct 59*" .76*“ .351"
(parent ratings) problems"
inatteng'on .13 .03
hyperactivity -.35
Model 4 conduct .34+ -.01 .12+
(teacher ratings) problemsA
inattention .09 .06
hyperactivity .38

 

+p<. 1, ‘n<.05, "p.<01, "‘p<.001; " conduct problems refers to child ODD/CD combined score.

53

Wild. Child aggression was related to maternal and paternal
dissatisfaction with parenting performance in all models (see Tables 8 and 9, page 50).
These relations remained significant when child inattention and hyperactivity were
controlled. As shown in Table 14 (next page), maternal dissatisfaction was consistently
related to child aggression when child inattention and hyperactivity were both controlled
even when teacher ratings were used. Maternal dissatisfaction was also related to child

conduct problems when child inattention and hyperactivity were both controlled but only

when parent ratings were used.

54

Table 14

111111‘1'1‘31' 1.11111"111._111"1... -. 111 r__1-.994‘-.11..11

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child beta step beta step R2 Change R2 Change
predictor 1 2 step 1 step 2
Model 1 inattention .65" .59“ .30‘”
(parent ratings)
hyperactivity -. 12 -.56"
composite .59” .11“
aggression
Model 2 inattention .07 -.05 .07
(teacher ratings)
hyperactivity .21 -.04
composite .47 " . l 1‘
aggression
Model 3 inattention .65" .55“ 30*”
(parent ratings)

hyperactivity -. 13 -.36
conduct .40’ .06’
problemsA

Model 4 inattention -.04 -.05 .09

(teacher ratings)
hyperactivity .31 .16
conduct .25 .04
problemsA

 

+nr<. l, *p<.05, ”p.<01, *"p<.001; A conduct problems refers to child ODD/CD combined score.

Fathers’ dissatisfaction was consistently related to child aggression and conduct
problems (see Tables 10 and 11, page 51). When controlling for child inattention and
hyperactivity, these relations remained significant but only when using parent ratings of

child behaviors (see Table 15, next page).

55

0 AM 11‘ 0'

s
\

 

Table 15

'91' 11.1 111.11 1.1__:

. . l! .. II!

I.

'. .-°. 1.

-1rl111 1,1

:fu‘

0 .1. 'al.

 

 

 

 

 

 

 

 

 

 

 

 

Child beta step 1 beta step 2 R2 Change Rz Change
predictor step 1 step 2
Model] inattention .04 .15 .19*
(parent ratings)
hyperactivity .40 -.32
composite .74“ .16"
aggression
Model 2 inattention .04 .05 .17
(teacher ratings)
A hyperactivity 39+ .44
composite -.06 .00
aggression
Model 3 inattention .12 .03 .17‘
(parent ratings)
hyperactivity .32 -. 18
conduct .70" .17"
problems“
Model 4 inattention .09 .09 . 18+
(teacher ratings)
hyperactivity .37+ .38
conduct -.Ol .00
problems"

 

+p<. 1, ‘p<.05, ”p.<01, *”p<.001; A conduct problems refers to child ODD/CD combined score.

56

In summary, although child inattention and hyperactivity were associated with
mothers’ and fathers’ role dissatisfaction, these relations did not remain significant when
child conduct problems were statistically controlled. (Note: in one model, the p-value for
the relation between child inattention and mothers’ dissatisfaction was .50 when using
parent ratings of aggression and inattention). Overall, the results do not offer support to
the hypothesis of independent contribution of ADHD behaviors to parent role

dissatisfaction (Hypotheses la, b, c). Child aggression and conduct problems (Hypothesis

1d), however, were consistently associated with both mothers’ and fathers’ dissatisfaction.
Warm The mediation model was tested in relation to child
aggression (teacher rating) and parental distress. According to Baron and Kenny (1986),

the first step is examining the extent to which child aggression accounts for the variance in

parent dissatisfaction. As tested and reported for Hypothesis 1d, aggression was
consistently related to parent role dissatisfaction. The second step is to test whether the

coping factors predict parent dissatisfaction. Univariate correlations revealed significant
relations between two coping factors (positive refraining and community resources) and

parent outcome (see Table 16, next page).

57

Table 16

 

 

 

 

 

 

 

111i1.1r ' ' 112-.11 11111. '1.‘1 111. '11:- in. .1. ' 1111.1 .11 '1 '1.1° "411111-11. .'
Parent Social Positive Spiritual Community

Dissatisfaction Support Reframing Support Resources

Parent 1.0

Dissatisfaction

Social Support .09 1.0

Positive -.52” .22 1.0

Reframing #

Spiritual Support -.19 .23 .30" 1.0

Community .34" .13 -.14 .15 1.0

Resources

 

*p<.05, "n.<01

Therefore, only these two coping factors were examined in the last step of testing
for mediation. The final step in testing a mediation model is to examine whether the
variable hypothesized to be the mediator (in this case, coping factor) explains the relation
between the other variables (i.e., child aggression and parent role dissatisfaction). When
the coping factor is entered into the model (and controlled for), the relation between the
first two variables (child aggression and parent role dissatisfaction) is expected to become
non-significant. This would demonstrate that the relation between child aggression and
parent role distress is due to parent coping. A “partial mediation” is sometimes referred to
if the relation decreases in magnitude. When Positive refraining and child aggression
were entered into the model simultaneously, the relation between child aggression and
parent role distress became non-significant (Table 17, next page). Positive reframing,
thus, mediated the relation between child aggression and maternal role dissatisfaction.

Notably, the mediation efl‘ect was only found when teacher ratings were used, providing

58

very limited support for this effect.

 

 

 

 

 

 

Table 17
- r1i11' ' ’1i' ' “1.1.11.1' : :14... 111.1: 1 1_ . 1 1.‘1.-. r1 11111:.11111
Ii . ll .
Predictor beta step 1 beta step 2 1?.2 Change R2 Change
stepl step2
Modell child aggression .42" .24 .18"
(teacher rating)
positive refraining -.43** .15"
Model 2 child aggression 59"" 47*" 35*”
(parent rating)
positive reframing -.31* .08‘I

 

‘p<.05, ”p<.01, "*p<.001; Type III sums of squares were used, meaning that variables were controlled
within a step.

For fathers, positive renaming also appeared to serve as a possible mediator of the
relation between child aggression (as rated by teacher but not parents) and dissatisfaction

with parenting performance (see Table 18, next page).

59

 

1‘.)

Table 18

01's. 0‘, ' .1 ' ‘ 1111' 1 305."?!1‘1' 1. 0 0 I Q killil. 1.0. 05. ’11..

 

 

 

 

 

 

 

Predictor beta step 1 beta step 2 R’ Change It2 Change
step 1 step 2

Model 1 child aggression .34+ .25 .12+

(teacher rating)

positive refraining -.58” .33"
Model 2 child aggression 60*" .48" 36*"

(parent)

positive reframing -.34" .10"

 

mn<.oor, 11n<.or, 1“<05, +p<.l

However, Community resources did not mediate the child aggression-parent
distress relation for mothers or fathers.

Hypothesis; Because inter-correlations among McCubbin’s four factors did not
support the problem versus emotion-focused distinction, it was not possrble to compare
the coping styles along these lines. In order to examine whether individual factors were
more strongly associated with better adjustment compared to ecological factors, positive
refraining was compared to social support and community resources. None of
McCubbin’s factors could be conceptualized as occurring at the level of the family distinct
from the ecological/conrrmmity level (e.g., spiritual support might have been
conceptualized as family or ecological style).

Mothers. Regression analyses revealed that only positive refraining (beta = -.52,
p<.001) and community resources (beta = .24, p<.05) were significantly associated with

mother’s role dissatisfaction. The relations between community resources and social

60

support (beta = .17, us.) were both positive, indicating that these strategies were
associated with higher rather than lower levels of parent dissatisfaction. The direction of
these relations indicated than individual coping buffered mothers whereas the community
coping styles were associated with an increase in parent role distress. The magnitude of
the betas for community resources and social support were both outside the 95%
confidence intervals around the magnitude of the beta for positive refraining. Thus, not
only were individual and community factors differentially related to parent outcome but
that the beta magnitude between individual coping (i.e., positive refraining) and
community cOping (i.e., social support and community resources) was statistically
significant. In summary, these findings indicate that, as predicted, individual styles were
more helpfiil than community styles.

mm. For fathers, only positive refraining (beta = -.46, p<.01) was significantly
associated with better adjustment. The direction of the non-significant relations between
paternal dissatisfaction and community resources (beta = -.02, as.) and social support
(beta = -.87, as.) were negative, indicating that for fathers these styles were associated
with better rather than worse adjustment. Once again the beta magnitude for cotrrmunity
resources and social support fell outside the 95% confidence interval of positive
reframing, suggesting that the strength of association of each of these factors with parent
outcome differed significantly.

Hmhesisfi, Correlation analyses revealed that neither satisfaction with social
support of size of social support network were significant in predicting parental

dissatisfaction with parenting performance (see Table 19, next page).

6]

Table 19

I I C O O I
01”." ‘. .OI’o. 9.! 3'. skid! 12-51! ‘1... 11.. 1.10.519n. i-u.00.l
mmeW~

 

Size of social Satisfaction with
support network social support network
Maternal dissatisfaction -. l9 -.08

 

Paternal dissatisfaction -.16 -.32

 

WW5, In addition to testing the mediation hypothesis,
reviewers suggested the testing of the moderator hypothesis of ceping. That is, is there a
significant interaction between level of coping and child aggression? Regression analyses
were conducted by entering the product (child aggression‘coping factor) into a
regression equation at step 2 afier controlling for main efi‘ects at step 1. The interaction
term was non-significant for mothers and fathers. The interaction between child
aggression and community resources was also non-significant for mothers and fathers.
Therefore, no support was found for the moderator hypothesis.

However, the interactions of Sarason’s social support variable and child aggression
was on the margin of significance for size of network for fathers (beta=.67, p=.05). All
other interaction terms were non-significant for mothers and fathers. No support was

found for the moderating effect of coping or social support.

62

DISCUSSION

The current study attempted to clarify four issues: (1) whether child inattention and
hyperactivity are related to parent role dissatisfaction independent of aggression or conduct
problems, (2) whether child aggression is associated with parent dissatisfaction, (3)
whether child hyperactivity rather than inattention drives the relation between ADHD and
parent role dissatisfaction, and (4) whether parent coping and satisfaction with social
support mediate the relation between child behaviors and parent role dissatisfaction. Few
studies have examined the effects of child inattention and hyperactivity on parent role
stress or dissatisfaction independently of child aggression. The current studied aimed to
replicate the findings that child ADHD behaviors independently contribute to parental role
distress in a small but significant way (Anastopoulos et al., 1992). No previous study
investigated the effects of inattention and hyperactivity separately on parent adjustment.
However, the DSM-IV field trials indicated that ADD (ADHD- Predominately Inattentive
type) and ADHD (ADHD - Predominately Hyperactive type) are discrete subtypes
(Iahey, et al., 1994). Because these are two factorially distinct dimensions, examining
inattention and hyperactivity separately in both dimensional and categorical analyses aimed
to clarify the different effects of inattention and hyperactivity. In order to best design
interventions for parents and firmilies with ADHD children, the most distressing factors

need to be identified. Further, due to the dynamic interplay of child behavioral problems

63

and parent distress, understanding the specific factors which contribute to each is vital for
interrupting the “vicious cycle” of problem exacerbation and development. That is, if

parents experience increased distress due to specific child behaviors, knowing that allows
for targeted interventions. The findings are discussed in relation to the two major foci of

the study: pment role distress and coping in relation to child behaviors.

El'llmlflill‘ . I' ll'

Child ADHD behaviors were associated with parent role dissatisfaction However,
these relations were largely explained by child aggression and conduct problems (ODD or
CD). Prior to covarying aggression and conduct problems, dimensional ratings indicated
that both inattention and hyperactivity were related to parental role dissatisfaction When
child aggression and/or conduct problems were controlled, the relations between
dimensional ADHD behaviors and parent role dissatisfaction did not remain significant.
When looking at diagnosis, ADHD combined (ADHD) but not inattentive type (ADD)
was associated with greater parental role dissatisfaction for both mothers and fathers
compared to parents of non-ADHD children. This relation did not remain significant
when child aggression/conduct problems were controlled. When parents of ADHD
children were compared to parents of ADD children, groups of parents did not differ in
reported parenting dissatisfaction.

The results regarding the respective contributions to parental outcome of child
aggression, oppositional/conduct problems, and ADHD (combined inattention and

hyperactivity) coincide with Johnston (1996). Johnston (1996) found that parent sense of

64

competence was differentially associated with varying levels of comorbid oppositional-
defiant (ODD) behavior in ADHD children. Parents of ADHD children with low levels of
ODD reported higher levels of parenting competence compared to parents of ADHD
children with high levels of ODD. It is important to note that all of the ADHD children in
Johnston’s study exhibited co-occurring ODD behaviors The parents of these children
were compared to each other and to parents of non-disordered children. Parents of
ADHD children regardless of level of ODD (that is, both parents of children with ADHD-
low ODD and ADHD-high ODD) reported lower levels of parenting competence
compared to the parents of non-disordered children. The current study also found that
child ODD/CD was related to parent role distress. Specifically, in the current study
dimensional analyses revealed that as child aggression and conduct problems increased,
parent role dissatisfaction increased. Although Johnston (1996) found that parents of non-
disordered control children reported higher levels of parenting competence than parents of
ADHD children, she did not examine parents of ADHD children without co-occurring
oppositional or conduct problems. The children in both Johnston’s ADHD groups
exhibited ODD behaviors suficient to warrant a second diagnosis. Hence, Johnston’s
study did not address whether child ADHD was associated with parent role distress
We: of child oppositional defiant behaviors.

In the current study, child ADHD combined subtype was associated with greater
parental role dissatisfaction when parents of ADHD children were compared to parents of
non-disordered children. Child diagnosis of ADD was not associated with greater parental

distress. When child aggression/conduct problems were controlled, neither diagnosis was

65

associated with parent role dissatisfaction. Dimensional inattention and hyperactivity were
also not associated with parent role dissatisfaction independent of child aggression.

In summary, the current study differed fi'om Johnston’s (1996) in four key ways.
First, Johnston did not include an ADHD without ODD behaviors group so did not look at
the effect of ADHD independent of ODD. In the current study, group data showed no
significant difi‘erences when child ODD was controlled in ANCOVA Additionally,
Johnston did not conduct dimensional analyses nor examine child inattention and
hyperactivity separately. The current study found that neither dimensional child
inattention nor hyperactivity were associated with parent distress when child
aggression/conduct problems were controlled. Lastly, Johnston did not examine the
subtypes of ADHD. These were examined in the current study. However, group
difi‘erences were not found when comparing parents of ADHD versus ADD children
(whether or not ODD/CD were controlled). Thus, putting the present study together with
Johnston’s, it can be concluded that child ADHD behaviors are related to parent role
distress; however, this relation may be accounted for by co-occurring child aggression
and/or conduct problems such as Oppositional Defiant behaviors.

Unlike Anastopoulos and colleagues (1992) but using a difi‘erent outcome
measure, the current findings did not support a significant independent contribution of
ADHD to parent role dissatisfaction. Anastopoulos et al. (1992) found that ADHD (using
DSM-III-R criteria, which combined inattention and hyperactivity) explained an additional
four percent of variance (p<.001) in Parenting Stress Index Total Score after child

aggression was accounted for in the model. Inattention and hyperactivity were not

66

examined separately by Anastopoulos et al. In the present study, when inattention and
hyperactivity were entered into the same regression model to enable comparison to
Anastopoulos et al.’s findings, the overall change in R2 was significant even with child
aggression/conduct problems controlled. This result replicated that of Anastopoulos et al.
(1992). However, when examining inattention and hyperactivity separately, these ADHD
behaviors were not significantly associated with parent distress when child
aggression/conduct problems were controlled. Specifically, with child aggression/conduct
problems controlled, the relation between child inattention and parent role distress
approached significance (p=.05) whereas hyperactivity was clearly not independently
associated with parent role distress. Hence, Anastopoulos et al’s. finding that combined
inattention and hyperactivity predict parent role distress even with child aggression
controlled was replicated but taken a step further. That is, child inattention may account
for the independent relation between child dimensional ADHD belmviors and parent role
distress. However, this finding requires replication as in the current study this relation did
not reach significance. If a larger sample size were obtained, this relation may have been
significant. However, the current findings are inconclusive.

Notably, a difi‘erent outcome measure was used in the current study. The current
study used the Parenting Satisfaction Survey (Guidubaldi & Cleminslmw, 1994) score
measuring dissatisfaction with parenting performance. Anastopoulos et al. (1992) used

the Parenting Stress Index’. Therefore, no straight-forward comparison between my and

 

5

NoczthewnemnwymedmePamnfingSmIMexmmahmnwmummemsuuSeeAmendix
G, pages99-104). However, the short formwasusedinthecurrent study, preventing direct comparison

67

Anastopolous’ study could be made.

Anastopoulos et al. (1992) also conducted categorical analyses. At the diagnostic
level, Anastopoulos et al. (1992) found that parents of children with the dual ADHD/ODD
diagnoses reported significantly higher levels of parent stress (PSI Total Score) than
parents of ADI-II) children without the comorbid diagnosis. Additionally, although a
statistical comparison was not made, Anastopoulos et al. (1992) found that parents in both
groups experienced elevated stress scores. In their study, the total stress scores for
parents of ADHD children fell at the 80"I percentile compared to normative sample. Stress
scores for puems of ADHD/ODD children fell at the 90“I percentile‘.

Unlike Anastopoulos and colleagues, the current study did not separate groups
based on a comorbid ODD diagnosis. Rather child aggression/conduct problems were
controlled dimensionally. In contrast to Anastopoulos et al. (1992), the current study did
not find child ADHD or ADD mm to be associated with parent role distress when
child conduct problems were controlled. The contrasting results on this particular point
may be due to difi‘erent methodologies. It is possible that comorbid dimensional
aggression or conduct problems impact children and parents difi‘erently than such

behaviors which meet diagnostic, clinical levels of severity.

 

6

NormativedataisnotavailableforthePSI-SFthatwasusedinthecunentsmdy. Becausecomparative
percentiles are not available, such data could not be calculated so that percentiles might be calculated and

compared to Anastopoulos et al.’s report. Nevertheless, when comparing pments of ADHD to parents of
non-disordered comparison children, no significant differences were found when using the PSI-SF parent
distress score. It is important to note, however, that Anastopoulos et al. (1992) used a study specific score
tocontrol forcverlapbetween stressorsasapredictorvariableandparem stressasanoutcome measure.
Therefore, thePSI-SF parent distress score remains non-equivalent to Anastopouloset al.’s outcome
measure.

68

In addition to employing a different study design, AnastOpoulos et al. used a
difi'erent outcome measure. As discussed in Appendix G (pages 99-104), the PSI Parent
Distress subscale as an alternative outcome in the current study. When using the PSI-SF,
no significant differences were found between parents of ADHD to parents of non-
disordered comparison children. However, even this comparison is incomplete.
Anastopoulos et al. (1992) adjusted the PSI score in order to control for overlap with
predictor variables. It was not possible to replicate this score adjustment. In investigating
the relation between child behaviors and parent distress, it is important to consider the
outcome constructs used. Results vary depending on the outcome construct under
consideration.

In summary, based on the current study, it appears that child ADD or ADHD
diagnosis is not associated with parent role distress when child conduct problems were
controlled. However, as suggested by Anastopoulos et al. (1992), once child behaviors
reach a critical level of severity warranting a comorbid diagnosis of ODD, parent role
distress may increase significantly. These complicated findings underscore the importance

of investigating child problems from both a dimensional and categorical perspective.

Cl .1 l . . l . .
As implied in the preceding, a key way in which the present study departed fiom

prior studies pertains to the separate analyses of inattention and hyperactivity. Most

studies of parent distress have failed to examine these child behavioral domains separately.

When examined in the current study, slightly difierent results were found for categorical

69

and dimensional analyses. When looking at child problems dimensionally in the current
study, both child hyperactive and inattentive symptoms were associated with parental role
dissatisfaction. When child aggression/conduct problems were controlled in dimensional
regression or Analyses of Covariance, neither child inattention or child hyperactivity
contributed significantly to maternal role dissatisfaction. When controlling for child
aggression, the relation between child inattention and maternal role dissatisfaction
approached significance (p=.05). Power was limited due to a small sample size. It is
possible that with a larger sample size, this relation would be significant. Similarly,
categorical analyses revealed that ADHD combined type but not inattentive type was
associated with greater parent role distress. Once again, the small sample size resulted in
low power, especially for ADHD inattentive type (IF-=14).

Categorical analyses partially support the specificity of child hyperactivity as a
stressor for parents at the diagnostic level. That is, once child behaviors meet a critical
cut-ofi‘ in terms of severity, hyperactivity rather than inattentive behaviors appears to
account for parental role dissatisfaction. However, child hyperactivity did not remain
significantly associated with parent role dissatisfaction when aggression/conduct problems
were controlled (in categorical or dimensional analyses). Hyperactivity may serve as a
stressor only in as far as it is linked with child aggression and/or conduct problems. Both
dimensional and categorical analyses supported this premise.

As noted earlier, different results for the two subtypes and the two dimensions
would be consistent with other findings in the literature. However, in the present study,

parent dissatisfaction due to child inattention and hyperactivity both appeared to be driven

70

by comorbid child aggression. Correlations revealed that aggression and conduct
problems are more closely related to child hyperactivity than inattention, suggesting that
children who exhibit hyperactivity may be more at risk for exhibiting co-occurring
aggressive behaviors. The aggression that co-occurs with inattention and hyperactivity

appears to serve as the most compelling stressor for these parents.

Cl .1 l .

The relation between child aggression and parent role dissatisfaction is consistent
with studies of children with aggressive behavioral disorders (e. g., Frick, 1994).
Unsurprisingly, comorbid aggressive behavior (including CD/ODD) is most distressing to
parents. While child ADHD behaviors contribute to parent role distress even when
controlling for child’s age and co-occurring learning disabilities, this contribution appears
small or non-existent in comparison to the impact of child aggression and conduct

problems.

Manning

Regarding coping factors, positive refi'aming appeared to serve as a partial
mediator of the relation between child aggression and both maternal and paterml maternal
role dissatisfaction. However, this relation was found only when using teacher but not
parent ratings of child behavior, ofi‘ering only weak support for this hypothesis. This
finding suggests that parents were helped by adjusting the perspective which they took in

cuping with their child’s behavioral problems and that this strategy may be important as a

71

bufi‘er from stressfirl child behaviors.

Although positive reframing was associated with better parent role adjustment, for
mothers, the relation between community resources and parent dissatisfaction was
positive. This could indicate that this coping style is ineffective in protecting parent role
satisfaction Alternatively, mothers who are more distressed may turn to ecological
coping strategies such as using community resources rather than utilizing individual caping
strategies. Either interpretation would fit the observed pattern of scores. For fathers,
community resources was negatively related to role dissatisfaction, indicating that this was
an effective strategy for fathers. In the present study, social support and spiritual support
were not significantly related to parent role dissatisfaction The interactions between
coping factors and child aggression were also examined in relation to parent role
disatisfaction; however, no interactions emerged as significant, suggesting that coping

does not act as a moderator of parent role dissatisfaction.

Wanna

Similarly, using Sarason’s measure, satisfaction with social support was not found
to be significant in predicting parental dissatisfaction with parenting performance. This
finding indicates that Sarason and Sarason’s (1985) model may not hold for parents of
ADHD children. The interaction between child aggression and parent satisfaction with
social support was not found to be significant, indicating that satisfaction with social
support did not serve as a buffer for parents in the current study. However, given the

small sample size in the current study, non-significant findings may be due to low power.

72

The pattern of results are to be interpreted with caution given the lack of power in the
current study.

In the current study, satisfaction with social support did not emerge as a factor
which buffered parents from ill-effects of stress. Prior research with parents of ADHD
children has been mixed. Mash and Johnston (1983a) found social support to be a
significant factor in a model differentiating the groups according to parental stress
outcome. However, in a separate study, parents of children with ADHD reported fewer
extended family contacts and the contacts which they had were reported as less helpful
(Cunningham, Benness, & Siegel, 1988). Although social support has been associated
with better adjustment in parents and families (Crnic, Friedrich, & Greenberg, 1983;
Hanson & Hanline, 1900; Hurtig, 1994; N011, Swiecki, Garstein, & Vannatta, 1994;
Sharts-Hopco et al., 1996; Short, 1997), it may be that family contacts may increase rather
than decrease stress in families of ADHD children. This would be consistent with clinical
impression, in which many parents report reducing social contacts due to the criticism they
receive about their children fi'om other adults.

In the current study, findings suggest that rather than finding social support as
helpful, parents were best served by focusing on the understanding how they might meet
challenges rather than be discouraged by dimculties. Parents appeared to benefit most
from attending to the ways in which they define problems associated with their child’s

behavioral problems.

73

I...

The current study was cross-sectional in nature. To parse directional effects, a
longitudinal or an experimental intervention design would be usefirl. Another limitation
associated with the cross-sectional nature of the current study is that the developmental
aspect of the McCubbin model could not be tested. McCubbin’s Double ABC-X model of
family coping states that it is important to examine stress and coping over time. Over time
stressors may “pile-up” resulting in an increase in stress and an increased need for
adjustment. While it was assumed that parents would have been at a stage where the
stressors had already accumulated, it was not possible to verify this in the current study.
Many parents coming to the study already knew that their child had ADHD. Other
parents were seeking diagnostic information for the first time although even they were
dealing with the problems for a period of time. Assessing parents at difi‘erent times, may
obscure the efi'ects associated with the varying durations of stressors. Additionally, there
are likely difi'erent coping strategies which might be employed at different stages of facing
a stressor. Inthecrurent study, itwasassmnedthatparentswereinthesecond
adjustment phase and that they would have given up the most inefi‘ective coping strategies
or discontinued indiscriminate use of coping strategies. It was impossible to validate this
assumption. In the current study, community resources was positively correlated with
maternal distress, indicating that parents may have continued using this strategy despite
possrhle ineffectiveness or been in the first phase of adjustment. However, other strategies
were not significamly associated with parent role distress. Further, the only strategy

which significantly mediated relation between child behavior and parent role distress was

74

significant as a buffer.

Marital adjustment and life stress may also have served as confounds in the current
study. That is, parent role distress might be driven by factors other than child behaviors.
Analyses were run controlling for these factors and are included in Appendix H (pages 105
- 118). Results are interpreted with caution due to since a small sample size may have
limited power to detect significant difference. For instance, failure to find significant
difi‘erences between parents of ADD versus ADHD children in categorical analyses may be

due to reduced power for the smaller ADD group.

mama

The current study adds to existing literature on parent stress and child ADHD.
First, when controlling for comorbid aggressive symptomatology, neither ADHD nor
ADD as categorical diagnoses independently contributed to parent role dissatisfaction.
Neither dimensional inattention nor hyperactivity remained significantly related to parent
dissatisfaction with child aggression/conduct problems controlled. Child
aggression/conduct problems were related to poorer parent and child outcomes. As
described by Patterson (1996), a dynamic cycle develops between parental distress and
child aggression with each problem exacerbating the other. That is, greater child
aggression is associated with greater parental distress. Further, parental distress is
associated with coercive parenting which leads to an increase in child aggression.
Interrupting this cycle at all junctures is likely to be beneficial to both parent and child.

In the current study, size of social support network and satisfaction with social

75

 

support did not predict parent role dissatisfaction. However, parent coping - specifically,
positive refiaming - partially mediated the relation between child aggression and maternal
and paternal role dissatisfaction. Surprisingly, the interaction between coping strategy and
child aggression was not significant. Cognitive/behavioral interventions with parents with
an emphasis on framing problems in such a way that promotes mastery may prove
important. For instance, if parents are able to obtain a sense of control even in the face of
their child’s disruptive behavior, they may experience greater parenting satisfaction. A
new fiamework may promote productive parenting behaviors. Parent individual coping
strategies rather than community or ecological coping resources appeared to be most
important in mediating parent adjustment. Further research is needed to investigate

specific parent attitudes which may foster parent satisfaction and promote effective

parenting.

76

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91

APPENDIX A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tables of Measures
Predictor Variables
Measures of Attention-Deficit Hyperactivity Disorder
Variable Measure Mother Father Teacher
SNAP-IV ADHD subscale x x x
DISC-IV ADHD module x
Measures of Parent-Child Conflict
Variable Measure Mother Father
Parent-Child Conflict Parenting Stress x
Index Parent—Child
Dysfunction Subscale
Aggressive Behavior
Variable Measure Mother Father Teacher
Child dimensional CBCL/TRF Aggression x x x
aggression subscales
Child dimensional SNAP-IV Oppositional Defiant x x x
OD/CD and Conduct Disorder subscales
Categorical DISC-IV Oppositional-Defiant x
OD/CD and Conduct Disorder modules

 

 

 

 

 

 

92

 

 

Mediating Variables

Measures of Coping

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Variable Measure Mother Father
Family Oriented F-COPES x x
Coping Strategies
Social Support - SSQR x x
network and
satisfaction
Outcome Variables
Parental Distress
Variable Measure Mother Father
Distress in role as Parenting Stress x x
parent Index Parent Distress
Subscale
Satisfaction in role as Parenting Satisfaction x x
parent Survey
Control Variables
Variable Measure Mother Father Child
Marital Distress Dyadic Adjustment x x
Scale
Stressful life events Parenting Stress x x
Index Life Events
Subscale
Child Intelligence Weschler Intelligence 1:
/Learning Disability Scale for Children -
Short form

 

 

93

 

 

APPENDIX B

Inter-correlations of measures of inattention by rater

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MCBCL DCBCL Teach TRF M SNAP D SNAP Teach
inattention inattention inattention inattention inattention SNAP
inattention

MCBCL 1.0

inattention

DCBCL .77M 1.0

. 'on

TeachTRF .57“I .53" 1.0

inattention

M SNAP .78“ .70" .60" 1.0

inattention

D SNAP .53“ .77" .36“ .68" 1.0

. 'on

Teach .55” .63" .85" .56" .52M 1.0

SNAP

inattention

" p<.01

94

APPENDIX C

Inter-correlations of measures of hyperactivity by rater

 

 

 

 

 

 

 

 

 

 

 

Mom SNAP Dad SNAP Teacher SNAP
child child hyperactivity child
hyperactivity hyperactivity

Mom SNAP 1.0

child hyperactivity

Dad SNAP .77" 1.0

child hyperactivity

Teacher SNAP .49" .60" 1.0

child hyperactivity

** p<.01

95

WT. -

APPENDD( D

Inter-correlations of measures of aggression

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mabel chcl TRF Mabel chel TRF Maw Dam Tap Mun: my Tap
delirn delinq del’mq agg egg agg ODD ODD ODD CD CD CD

Mcbcl 1-0

delinq

chd .74" 1.0

delinq

TRF .26 .32 1.0

delinq

Mcbcl .83“ .23" .26 1.0

'88

chcl .65” .79” .19 .67” 1.0

‘88

TRF .17 .45” .59” .14 .40‘ LG

3889

Mglp .77“ .61” . l 5 .88" .68” .17 1.0

ODD

Dsnp .65” .76” .12 .60“ .85“ .36“ .68” 1.0

ODD

Tsnp .30' .53" .53“ .24 .39- .74' .34' .46” 1.0

ODD

Mmp an" .60” .28 .76” .51" .17 .76” .50“ sec 1.0

CD

Dsnp .69“ .78“ .20 .51“ .76“ .33 .55” .83" .43“ .57” 1.0

CD

Tsnp .40“ .50” .77” .26 .45“ .73” .20 .37‘ .75“ .35‘ .53“ 1.0

CD

* p<.05, ”p<.01

 

 

APPENDIX E

Inter-correlations of F -COPES subscales

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social support Positive Spiritual Passive Community
Reframing Support Appraisal Resources
Social Support 1.0
Positive .22 1.0
Retraining
Spiritual .23 .28“ 1.0
Support
Passive -.O8 .03 -.08 1.0
Appraisal
Community .l3 -.l4 .15 -.15 1.0
Resources
l"p<.01

97

 

I"

km... .

APPENDIX F

Inter-correlations between measures of parent role distress

 

 

 

 

 

 

 

 

 

PSI PSS dissatisfaction PSS
parenting distress w/parenting dissatisfaction
performance with parent-child
relationship
PSI parenting distress 1.0
PSS dissatisfaction .48“ 1.0
w/parcnting performance
PSS dissatisfaction w/p-c .48" .73" ‘ 1.0
relationship
“p<.01

98

 

 

APPENDIX G

Using alternative outcome measures (PSI parent distress and PSS dissatisfaction with

parent child relationship) to examine the relation of parent distress and child behaviors

(Hypotheses la—ld) I

 

In contrast to findings when using parenting role dissatisfaction, no significant group

 

differences were found when examining mother’s general distress as measured by the PSI
Parent Distress score (F [2,58] = .80, ns.). Means are reported in Table 20 (next page).
This measure is less specific to parent role distress and captures more general depressed
afi‘ect non-specific to role as parent. Results for PSS Dissatisfaction with parent-child
relationship were similar to those pertaining to Dissatisfaction with Parenting
Performance.

W13 WWW Results were similar
to earlier findings. When using father’s PSI Parent Distress score (H2, 45] = 4.63, p<.05)
and when using the PSS Satisfaction with Parent-child Relationship score (H2, 47] =
9.77, p<.001), significant group differences were found. As found earlier, a significant
difference was found between fathers of ADHD and fathers of non-disordered children but
not when comparing fathers of ADD children to fathers of non—disordered children.

Means are reported in Table 20 (next page). Contrary to earlier findings, the significant

differences between fathers of ADHD and fathers of comparison children remained even

99

when child aggression was controlled. This was when using father’s satisfaction with

parent-child relationship (E[1,23]=9.55, p<.01) and father’s parent distress (E[l,24]=5.96,

p<.05) as outcomes.

 

 

 

 

 

Table 20
615100.«970.101I‘-1~1_4H-l‘ ' ._ u 1 a 0 an a 1101.17 117.“ gig;-
ADD ADHD Control (9)
Mom’s PSI Parent 2.08 (.46) 2.30 (.65) 2.11 (.62) ns.
Distress Score
Dad’s PSI Parent 1.99 (.56) 2.47 (.55) 1.90 (.54) n<.os
Distress Score
Mom’s PSS 1.71 (.24) 1.84 (.37) 1.54 (.39) ns.
Dissatisfaction with P-C
relationship
Dad’s PSS 1.59 (.28) 2.10 (.27) 1.57 (.36) p<.001
Dissatisfaction with P-C
relationship
0 am If ' 1:“. ,- r. c. a..." 0:15“ 011' .1; .11:

Consistent with earlier findings, child inattention and hyperactivity as dimensions were

associated with maternal and paternal dissatisfaction with parent-child relationship.

However, when using the PSI Parent Distress score, significant relations were found for

fathers but not mothers. Correlations are shown in Table 21 (next page).

100

Table 21

 

 

 

 

 

 

s1‘11..:.1‘01 111‘ 111101: _1~. H‘:11'..‘1 ‘ .‘t' ’
______' «31191. .411 '=-'-1_1 _________________1_ 1. 11.1____1__=_._1_1~___1_11.‘ 1.11m}
Morn PSI Dad PSI Morn PSS Dad PSS
Distress Distress P-C Rel P-C Rel
SNAP Attn Score - mom rating .21 .29 .52“' .49"
SNAP Attn Score - dad rating .19 .18 .44" .28“
SNAPAttn Score-teacherrating -.11 .28 .13 +27
SNAP Hyp Score - mom rating .18 .43“ .41" .55"
SNAP Hyp Score - dad rating .25 37* .43” .46“
SNAP Hyp Score - teacher rating -.09 .46" .23 .48“

 

*n<.os, ”p<.01 '

When child nmsr'QnZggndnct problems commfled. Unlike earlier findtn' gs, child

inattention was not significantly associated with mother’s distress when child

aggression/conduct problems were controlled (see Table 22, next page). All other

findings were similar (Tables 21-24 may be compared to Tables 8-11).

101

Table 22

stem: \‘1 .111'11111' 11.511'111111‘ 111111"1' 1.11.11 .11

 
 
    

    

_1-1 -1’-11.111.1:9_°4‘

Child beta step 1 beta step 2 R2 Change R2 Change

 

 

 

 

 

 

 

 

 

 

 

 

 

predictor step 1 step 2
Model 1 composite .37" .42* .14"
(parent aggression
miner»)
inattention -.07 .00 ‘-
Model 2 aggression .02 .08 .00
(teacher
ratings)
inattention -.10 .01
Model 3 conduct .34" .37* .12" 1.-
(parent problemsA 5
111111138)
inattention -.04 .00
Model 4 conduct .09 .23 .01
(tacher problemsA
ratings)
inattention .ll .02
‘p<.05, ”p<.01

=. 1 311: Consistent with

 

earlier findings, child aggression was consistently related to both mother and father’s PSI
Distress and PSS Dissatisfaction with Parent-Child Relationship. Correlations are shown
in Table 23 (next page). As detailed in the following paragraphs results varied when child

inattention and hyperactivity were controlled.

102

Table 23

 

 

 

 

 

.11111121'1 1111' 11111.13 1'11’11111'11-1'111-‘1'. .J‘tl‘vb
'1'.=.'=1111.11,'o..1111- 11'11111111 1111-1111:. 11__1_11.11 111‘11
Mom PSI Dad PSI Mom PSS Dad PSS
Distress Distress P—C Rel P—C Rel
CBCL Aggression - parent rating .38” .53" .56" .58"
TRF Aggression - teacher rating .06 .30 .36“ .36“
SNAP ODD/CD Score - parent rating .34" .50" .52" .58"
SNAP ODD/CD Score - teacher .09 .28 33* .34
rating
’p<.05, "p<.01
11 11.1111. 1 -1.1=.'°1 1.,. 11.11;. '1" 11'1.:11‘ .111 1 c.1‘ 111 111 «1.1

W Results using the PSI Parent Distress score and the PSS
Dissatisfaction with Parent-child Relationship score were similar for mothers as those
reported earlier as found with the PSS Dissatisfaction with Parenting Performance. For
example, using the PSI Parent Distress measure, child aggression (beta = .62, p<.01) and
conduct problems (beta = .45, p<.05) were significantly related to mothers distress even
when child inattention and hyperactivity were controlled. Using the PSS Dissatisfaction
with Parent-child Relationship, child aggression (beta = .64, p<.01) and conduct problems
(beta = .44, p<.05) were also significantly related to mothers distress even when child
inattention and hyperactivity were controlled (parent ratings; results with teacher ratings
were similar to those reported earlier with PSS Dissatisfaction with Parenting
Performance).

1 1111" 1 -1,1:.°°1' 111111. .0" 1.‘1« 11 .111 1 c.11=.1‘-: (“1.1-
W53. Using the PSI Parent Distress score, parent rating of

child aggression was only marginally significant (beta = .47, p<. 1) when child inattention

103

and hyperactivity were controlled. Parent rating of child conduct problems was not
related to father’s PSI Parent Distress when child ADHD behaviors were controlled.

Using the PSS Dissatisfaction with Parent-Child Relationship score, parent ratings of child
aggression (beta = .66, p<.01) and conduct problems (beta = .59, p<.01) were significantly
related to fathers role distress even with child inattention and hyperactivity controlled. As
with earlier findings, no significant relations were found when using teacher ratings of

child behaviors.

S l' l .
Results were consistent when using the PSS Dissatisfaction with Parent-Child
Relationship scale as an alternative outcome measure. Results varied somewhat when
using the PSI Parent Distress measure. However, because this measure is less specific to
parent role distress and captures more general depressed afi‘ect non-specific to role as
parent, difi‘erent results are not inconsistent with findings in the current study or in the

literature.

104

 

APPENDIX H
Controlling martial adjustment and stressful life events

It is possible that parents may experience stress and distress from other areas of
their lives. For instance, marital difficulties may be associated with parenting stress in
ADHD children (e.g., Befera & Barkley, 1985; Cunningham et al., 1988). Likewise, other
stressful life events may increase parents’ overall stress, inflating parenting stress and
increasing their dissatisfaction in their role as parents. Additionally, age of child has been
found to be related to parent stress (e. g., Mash & Johnston, 1983) with a decrease in
stress as the child grows older. In order to determine whether parenting distress is due to
the child’s ADHD symptomatology, it is important to control for such possrble alternative
stressors. Analyses were run controlling for marital adjustment and recent stressful life
events. Results were largely similar when controlling for marital adjustment and life
stress.

[2 lM ’1] '11 -l'll l l

Dyadic Adjustment Scale (DAS). The DAS (Spanier, 1976) is a 32-item measure
for married or unmarried cohabitating couples. Items are rated on one of two six point
scales, indicating amount of time or fiequency of occurrence (e.g., 0=a1ways disagree,
1=almost always disagree, 2=frequently disagree, 3=occasionally disagree, 4=almost
always agree, 5=always agree; 0=never, l=rare1y, 2=occasionally, 3=more often than not,

4=most of the time, 5==all the time). Example items include: “How often do you discuss

105

 

or have you considered divorce, separation, or terminating your relationship?” “Do you
kiss your mate?” and “Have a stimulating exchange of ideas?” A total measure of
Marital Adjustment was obtained through a weighted sum. A high score indicates good
marital or dyadic adjustment. Reliability found in the current sample was good (alpha =
.91). Published reliability is also good (Cronbach’s coefiicient alpha = .96; Spanier,
1976)

W The Life Events Scale of the PSI consists of a checklist of 19 life
events (e. g., marriage, pregnancy, promotion at work); parents simply answer Wes” or
“no” depending on whether the event has occurred in their immediate family in the past 12

months. Events are weighted by severity and summed to yield a weighted total score.

. 3 "111' l' ‘ RIOI 0.311. 9110.: 'l 0 ‘ "1 31H l. 1 01‘1110 F “1.1 1113001.?
Wrens!
Medals.

WWW Results comparing mothers of
ADHD (combined type) to mothers of non-disordered comparison children were
unchanged when marital adjustment and life events were controlled. Mothers of ADHD
(combined) children were still significantly more dissatisfied with parenting performance
than mothers of non-disordered comparison children. Contrary to earlier analyses, this
difference remained significant when child aggression or conduct problems were
controlled (F(4, 24)=l .92, p<.05). Contrary to earlier results, when controlling for

marital distress and life events, mothers of ADD children were also significantly more

106

 

dissatisfied than mothers of controls (F(4,21)=7.29, p<.05). Findings were consistently
significant when using teacher ratings of child behavior. The change in results appeared
to be driven by marital adjustment. Although neither marital adjustment nor life stress was
significantly correlated with parenting dissatisfaction, when both factors were entered
simultaneously into a regression equation, marital adjustment but not life stress predicted
dissatisfaction with parenting performance. On the other hand, marital adjustment and
life stress were not significantly different across the three groups (F [2, 41] = 2.29, ns.).
Findings were similar when using Dissatisfaction with Parent-Child Relationship as
outcome measure.

Eatherijdramostmwmsmfl‘emd. Contrary to earlier analyses, when
controlling for marital adjustment and life stress, father’s dissatisfaction with parenting
performance did not difi‘er significantly across the three groups (F(4,34)=2. 12, us).
When examining father’s dissatisfaction with parent-child relationship as an outcome, the
three groups difl’ered even when controlling for marital adjustment and life stress. Fathers
of ADHD but not ADD children were found to be significantly more dissatisfied than
fathers of comparison children when marital adjustment, life stress, and teacher rating of
child conduct problems were controlled (F (4,18)=7 .Ol, p<.05). However, this relation
held only when teacher ratings were used.

WW2.
Results for dimensional analyses were basically unchanged when controlling for
marital adjustment and life stress. Child inattention and hyperactivity remained

significantly associated with mother’s and father’s parent role dissatisfaction when marital

107

 

adjustment and life stress were controlled. When also controlling for child
aggression/conduct problems, neither child inattention nor hyperactivity remained
significant. This was similar to earlier results (when marital adjustment and life stress
were not controlled) except that child inattention had remained marginally significant
(mothers only). Findings are detailed in the following paragraphs.

When controlling

 

for marital adjustment and life stress, child inattention and hyperactivity were significantly
associated with mother’s dissatisfaction with parenting performance. Using teacher
ratings of child behaviors, inattention was marginally significant (beta = .30, p<. 1). Using
parent ratings, inattention was highly significant (beta = .50, p<.01). Child hyperactivity
was significantly related to mother’s dissatisfaction when teacher (beta = .41, p<.05) and
parent (beta = .38, p<.05) ratings of child behaviors were used. Table 23 (next page)
summarizes these findings and may be used for comparison to Table 7 (page 48). (Table 7

provides results without marital adjustment and life stress controlled).

108

Table 24
Controlling for Marital Adjustment and Life Stress

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1111113 11'. \‘u“1'11111r‘ . .-. -1r11'.11'.'-111"'-111r11:1;
beta beta R2 Change R2 Change
step I step 2 5161’ 1 Step 2

Model 1 Mom Marital -.21 -.12 .13+

adjust

Mom Life stress .25 .20

inattention .50” .24”

(parent)
Model 2 Mom Marital -. ll -.08 .ll

adjust

Mom Life stress .29 .27

inattn (teacher) .30+ .09+
Model 3 Mom Marital -.21 -.20 .13+

adjust

Mom Life stress .25 .18

hyp (parent) .41" .13“
Model4 MomMarital -.ll -.10 .Il

adjust

Mom Life stress .29 .26

hyp (teacher) .41" .17"

 

"115.001, “p<.01, *n<.05, +p<.1

 

controlling for marital adjustment and life stress, child inattention was marginally related
to father’s dissatisfaction with parenting performance when using parent ratings (beta =
.30, p<.1) but not teacher ratings (beta = .08, ns.). Child hyperactivity was significantly
related to father’s dissatisfaction when using parent ratings (beta = .41, p<.01) and
marginally significant when using teacher ratings (beta = .31, p<.1). Table 25 (next page)

summarizes these findings and may be used for comparison to Table 7 (page 48), which

109

provides results without marital adjustment and life stress controlled.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Table 25
Controlling for Marital Adjustment and Life Stress
111.11‘ 11'. 'l‘ur‘ 11 -1‘ D. .-..-1r11.11’=.f11"'11.111=.1.‘
beta step I beta step 2 R2 Change R2 Change
step I step 2

Model 1 Dad Marital adjust ..5111 -.5111 .2911

Dad Life stress .17 .09

inattention (parent) 30+ .08+
Model 2 Dad Marital adjust -.54" ~40" .27“

Dad Life stress .18 .03

inattn (teacher) .08 .01
Model 3 Dad Marital adjust -5111 -.491'1 .291"1

Dad Life stress .17 .07

hyp (parent) .41" .15"
Model 4 Dad Marital adjust -.43“ -.40"‘ .27*

Dad Life stress . 18 .15

hyp (teacher) .31+ .10+

"111mm, ”'p<.01, *p<.05, +n<.l

 

Ccntrcllinafonchildmcssicnandtctccnductmhlems. Results were similar

when child aggression and/or child conduct problems were also controlled. As noted
above, neither child inattention nor hyperactivity remained significant when marital
adjustment, life stress, and child aggression/conduct problems were controlled. This result
was the same for mothers and fathers.

1111.111» 1. 11.11 .111 1 11 1 ° 1 1 111- w, ~1.. 111,111 When

controlling for child aggression and/or conduct problems as well as marital adjustment and

life stress, neither child inattention (Table 26, page 110) nor hyperactivity (Table 27, page

110

115) remained significantly related to mother’s parent role dissatisfaction. These results
difi‘ered slightly from those found when martial adjustment and life stress were not

controlled. In those earlier analyses, child inattention had remained marginally significant

even when controlling for child aggression (see Table 8, page 50).

[continued next page]

111

O
O “J. it"s“ ‘

 

Controlling for

0 1.‘ x-r"

Table 26
Marital Adjustment and Life Stress

o .’, ..,
woo-r '1‘.

‘.Ln{11 .i 1

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v." .)IH1H..

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

R?Cmnnge
mwa
Model 1
egg (parent .55“ .31 .23"
mango
hnumnfion .30 .04
Gnumfi)
Model 2 Mom Marital -.05 -.06 -.05 .07
adjust
Mom Life .25 .33+ .30
anus
agg(uxmher .43‘ .34 .18‘
unhmo
inattn (teacher) .15 .53
Model 3 Mom Marital -.21 .01 -.02 .13+
ufiufl:
Mom Life .25 .14 .15
Muss
conductpdb .57"‘ .36 .25“‘
(PNNHO
huumnfion .27 .03
Claim)
Model 4 Mom Marital -.ll -.08 -.07 .1 l
mfiufl:
Mom Life .29 .30+ .28
muss
cnnmmupda 30+ .21 .09+
«awhuj
child inattn .20 .03
dammed
"*n<.001. “n<.01, ’n<.05, +n<.l

112

 

 

 

.
I 1’s. 1..

 

Table 27

Controlling for Marital Adjustment and Life Stress

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

113

11': 't 91 tr‘uor'vr’ .1... 1111.11'a-m111'mnuu
beta 1 beta beta R2 Change R2 Change R2 Change
stepl step2 step3 step] step2 step3
Model 1 Mom Marital adjust -.21 -.O3 -.03 .13+
Mom Life stress .25 .08 .08
agg (parent rating) .55” .62" .23”
child hyp (parent) -.O7 .00
Model 2 Mom Marital adjust -.05 -.06 -.07 .07
Mom Life stress .25 .33+ .32+ .18‘
agg (teacher rating) I .43’ .38
child hyp (teacher) .08 A .00
Model 3 Mom Marital adjust -.21 .Ol .01 .13+
Mom Life stress .25 .14 .15
conduct prb (parent) .57‘” .62‘ .25‘“
child hyp (parent) -.06 .00
Model 4 Mom Marital adjust -. ll -.08 -. 10 .11
Mom Life stress .29 .30+ .27
conduct prb 30+ .09 .09+
(teacher)
child hyp (teacher) 35+ .08+
"‘n<.001, “p<.01, ‘p<.05, +p<.l

 

 

Table 28 (child inattention) and Table 29 (child hyperactivity; next page), results were

similarforfathers.
Table 28
Controlling for Marital Adjustment and Life Stress
11 11.11 .,-.,.-,- 1 1'3 '1 ’ “ ‘. an.“ .1 1 "1 9.11.111' ' 1:1 ”Him;

”16:91: :..1‘-1 '
C .

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

beta beta beta R2 Change R2 Change R2 Change
step 1 step 2 step 3 step 1 step 2 step 3

Model 1 Dad Marital adjust ~50” -.36"' -.35‘ .28“

Dad Life stress .18 .05 .05

agg (parent rating) .45" .46‘ .17“

inattention (parent) -.Ol .00
Model 2 Dad Marital adjust -.36 -.30 -.28 .20

Dad Life stress .19 .24 . .37

agg (teacher .27 .40 .07

rating) .

inattn (teacher) -.24 .03
Model 3 Dad Marital adjust -.51” -.38‘ -.36‘ .29”

Dad Life stress .17 .03 .03

conduct prb .49” .54‘ .20”

(parent)

inattention (parent) -.07 .71
Model 4 Dad Marital adjust -.43+ -.40+ -.40+ .27‘

Dad Life stress - .18 .16 .16

conduct prb .23 .23 .05

(teacher)

child inattn .04 .00

(teacher)

“"*n<001, ”p<.01, ‘p<.05, +n<.l

114

 

Table 29

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Controlling for Marital Adjustment and Life Stress
1111.1' 11'? (”4‘ .H' «1". ' 1'1HWP"-3.001”:
beta beta beta R2 Change R2 Change R2 Change
step 1 step 2 step 3 step 1 step 2 step 3

Model 1 Dad Marital -.50” -.36‘ -.39‘ .28“I
adjust
Dad Life stress .18 .05 .04
agg (parent .45” .33 .17"
rating)
child hyp .14 .00
(parent)

Model 2 Dad Marital -.36 -.30 -.38 .20
adjust
Dad Life stress .19 .24 .16
agg (teacher .27 -. 12 .07
rating)
child hyp .46 .07
(teacher)

Model 3 Dad Marital -.5 l ” -.38‘ -.39" .29”
adjust
Dad Life stress .17 .03 .03
conduct prb .49 .41 .20”
(parent)
child hyp .09 .00
(parent)

Model 4 Dad Marital —.43 -.40" -.4 l ‘ .27‘
adjust
DadLife stress .18 .16 .16
conduct prb .23 -.07 .05
(teacher)
child hyp .37 .05
(teacher)

"‘n<.001. ”IF-01, ‘n<.05. +2<-1

115

 

 

H l . l l _ l 'l l .
WM Results were unchanged when marital
adjustment and life stress were controlled. That is, mother’s dissatisfaction with parenting
performance was related to child aggression (beta = .55, p<.05) and child conduct
problems (beta = .50, p<.05) even when child inattention and hyperactivity were
controlled. As found earlier, these results were found only when using parent ratings of
child behaviors. Details are shown in Table 30 (next page).
Emhetshusaressimzresultsdiflered. Unlike earlier findings. when marital
adjustment and life stress were controlled, child aggression (beta = .29, as.) was not
independently related to fathers’ dissatisfaction with parenting performance. Child
conduct problems was marginally related to fathers’ dissatisfaction (beta=.43, p<. 1) but

only when parent ratings were used. Details are shown in Table 31 (page 118).

[continued next page]

116

 

“2.11.

Table 30
Controlling for Marital Adjustment and Life Stress

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

141.11"r 11'.‘ 't‘u‘ 1'11119’ 3.1.5. 1r1r.rr'= 1'1113111111=1..‘u
beta beta beta R2 R2 R2
step 1 step 2 step 3 Change Change Change
step 1 step 2 step 3

Model 1 Mom Marital adjust -.21 -.17 -.10 .13+

Mom Life stress .25 .23 .15

child inattn (parent) .77" .71" .26”

child hyp (parent) -.32 -.68‘

agg (parent rating) .55‘ .08‘
Model 2 Mom Marital adjust -.05 -.04 -.05 .07

Mom Life stress .25 .23 .30

child inattn .24 .14 .14

(teacher)

child hyp (teacher) 4 .17 .02

agg (teacher rating) .33 .05
Model 3 Mom Marital adjust -.21 -. 17 -.07 .13+

Mom Life stress .25 .23 .19

child inattn (parent) .77 " .62‘ .26“

child hyp (parent) -.32 -.55+

conduct prb (parent) .SO‘ .08‘
Model 4 Mom Marital adjust -.l l -.10 -.O9 .1 1

Mom Life stress .29 .26 .26

child inattn .20 .08 .17-I-

(teacher)

child hyp (teacher) .36 .32

conduct prb .07 .00

(teacher)

I""“"p<.001, I"“‘p<.01, *p<.05, +n<.l

117

 

 

 

II A” ,9“

Table 31

Controlling for Marital Adjustment and Life Stress

 

I. I .

. .
,.. A‘.

.‘. an“ 'moma .‘ u

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

! C. \f’I‘ j: 0‘, DJ .-. -.
beta beta beta R2 R2 R2
step 1 step 2 step 3 Change Change Change
step 1 step 2 step 3

Model 1 Dad Marital adjust -.50” -.49“I -.40“ .28”

Dad Life stress .18 .06 .05

child inattn (parent) -. l7 -. l2 .16‘

child hyp (parent) 55+ .27

agg (parent rating) .29 .01
Model 2 Dad Marital adjust -.36 -.36+ -.36 .20

Dad Life stress .19 .27 .27

child inattn (teacher) -. 19 -.25 .16

child hyp (teacher) .43+ .37

agg (teacher rating) .10 .00
Model 3 Dad Marital adjust -.51” -.48“ -.38’ .29“'

Dad Life stress .17 .07 .04

child inattn (parent) -. 14 -.20 :16‘

child hyp (parent) 52+ .24

conduct prb (parent) .43+ .05-*-
Model 4 Dad Marital adjust -.43"' -.40‘ -.40’ .27’

DadLife stress .18 .17 .17

child inattn (teacher) -.04 -.04 .10

child hyp (teacher) .33+ .38

conduct prb (teacher) -.06 .00

"'"n<.001, "p<.01, ‘p<.05, +n<.l

118

 

 

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