Breaking this down further, the effect size for the relationship between inattention and total parenting stress as well as parent domain stress was medium, while the association between inattention and child domain stress was not significant (Table 2). Finally, the effect between hyperactivityimpulsivity and parenting stress was large for total stress and child domain stress, but medium for parent domain stress (
Introduction
Parenting is one of the most demanding responsibilities of adult life Parenting stress is the affective response to the, at times, overwhelming, demands of parenting It is dynamic and results when the balance between parents’ perceptions of the demands of parenting outweigh their perceptions of their resources for meeting those demands (Deater-Deckard, 2004) Current theory holds that parenting stress is a normative part of the parenting role (Crnic & Greenberg,
1990), becoming clinically important when elevated to such an extent that it negatively impacts parenting practices and the parent-child relationship (Abidin, 1992; Belsky, 1984; Morgan, Robinson, & Aldridge, 2002; Rodgers, 1998; Webster-Stratton, 1990) Parents who experience extreme levels of parenting stress may be less able to implement interventions to help their children (Kazdin, 1995), which is especially relevant for children with a clinical diagnosis such as Attention-Deficit/Hyperactivity Disorder (ADHD) Further, effective interventions for parenting stress have been linked to increases in the efficacy of parent management training (Kazdin & Whitley, 2003), a very commonly used intervention with children with ADHD and other disruptive behaviour disorders Moreover, studies have shown that parenting stress is inversely related to response to behavioural treatment (e.g., Kazdin, 1995; Kazdin, Holland, Crowley, & Breton, 1997; Kazdin & Wassell, 1999; Osborne, McHugh, Saunders, & Reed,
2008), may affect parental psychological well-being (Abidin, 1992; Crnic & Greenberg, 1990; Kwok & Wong, 2000; Wolf, Noh, Fisman, & Speechley, 1989), and may affect child development and behaviour (e.g., Anthony et al., 2005; Crnic, Gaze, & Hoffman, 2005)
ADHD is a chronic, pervasive condition characterized by inattention, impulsivity, and hyperactivity (American Psychiatric Association, DSM-IV-TR, 2000) It is also one of the most common childhood disorders, affecting about 5% of school-aged children world-wide
(Polanczyk & Jensen, 2008) Recent research indicates that in most cases, ADHD is a lifelong disorder, existing in at least a partial remission form into adulthood (Barkley, Fischer, Smallish,
& Fletcher, 2002; Faraone, Biederman, & Mick, 2006) Up to two-thirds of children with ADHD have a parent with a history of ADHD (Mulsow, O’Neal, & McBride Murry, 2001; Schachar & Wachsmuth, 1990) and current research points to strong genetic influences (Levy, Hay, &
Bennett, 2006; Willcutt, in press) There is considerable research to indicate that parents of children with ADHD experience elevated rates of parenting stress (e.g., Breen & Barkley, 1988; Johnson & Reader, 2002; Joyner, Silver, Stavinoha, 2009; Kadesjử, Stenlund, Wels, Gillberg, & Họgglửf, 2002; Reader, Stewart, & Johnson, 2009; van der Oord, Prins, Oosterlaan, &
Emmelkamp, 2006; Whalen et al., 2006; Yang, Jong, Hsu, & Tsai, 2007)
The overarching objective of this dissertation was to clarify the predictors of parenting stress in parents of children with ADHD and to investigate the role of parent and contextual predictors In this dissertation, I explored the following two main questions: what is the magnitude of the association between child ADHD and parenting stress, and what are the parent and contextual predictors of parenting stress as a function of child ADHD symptoms? These questions will be addressed in two studies included in this dissertation, which will be referred to as Study 1 and Study 2 These two studies were written in manuscript format in order to be submitted for publication Chapter 2 is devoted to Study 1, and Chapter 3 to Study 2 It is important to note that as a result of the manuscript structure of this dissertation, there is some overlap in the background sections of both studies Chapter 4 discusses the findings from both studies and considers implications for future research, policy, schools, and clinical practice
Parenting is influenced by, and influences several parent, child, and contextual factors Belsky (1984) offers a process model of the determinants of parenting that suggests that parenting is impacted by the parent’s own developmental history, the parent’s personality, marital relations, parental work, the parent’s social network, and the child’s characteristics In turn, parenting is proposed to affect child development Belsky’s model focuses on parenting behaviour, as opposed to internal cognitive or affective aspects of parenting The determinants of parenting in his model include both external constructs, such as work, and internal constructs, such as personality In Belsky’s examples he links cognitive constructs (e.g., mother’s esteem for their husbands) to their behavioural outcomes in parenting (praise for children) The outcome of Belsky’s model of parenting is child development, mainly defined in terms of child competence Belsky’s description of child characteristics is less developed than his detailing of parent characteristics, but one major child characteristic he addresses is temperament (Belsky, 1984), suggesting that difficult child temperaments negatively impact parenting He is careful to note, however, that child characteristics are not sufficient for poor outcomes In terms of contextual factors, Belsky lists social and spousal support and parental work as determinants of parenting
Belsky’s definition of parenting subsumes such concepts as parental sensitivity, parental negativity, and parental role performance These terms differ in their positive/negative valence, but also in the degree to which they refer to internal cognitive or affective constructs, or external behavioural constructs Parental sensitivity refers both to a parents’ attunement to their children’s needs, and to their contingent, consistent, responses (Belsky, 1984; Farrell Erickson & Kurz- Reimer, 1999) Parental negativity refers to the negative perceptions parents have of their children and to the ensuing negative, hostile behaviours parents engages in (Anderson, Hinshaw,
& Simmel, 1994; Johnston & Mash, 2001) Although the previous two terms combined internal and external manifestations of the constructs, parental role performance refers solely to the external, behavioural manifestation of a parents’ behaviours in their role as parents (McCleary,
Belsky (1984) does not specifically address parenting stress, but his model would seem to subsume parenting stress under general parental psychological well-being The assumption underlying the current research is that parenting stress is an internal construct that impacts the external (behavioural) outcome of “parenting.” This assumption leads to the question of how parenting stress and parenting are linked
Four major theories of parenting stress in families of children with ADHD have been proposed (McCleary, 2002) Three of these theories feature a strong focus on the mechanism through which parenting stress becomes elevated in parents of children with ADHD and other disruptive behaviour disorders These three theories all identify cognitive factors in the parent as at least one of the mechanisms through which child factors influence parenting stress These theories feature transactional effects, such that parenting stress is the result of the other factors suggested, and also contributes to the system over time
The first theory, the Parent-Child Interactive Stress Model, proposed by Mash and
Johnston (1990), holds that child characteristics are the primary contributors to parent-child stress, but that environmental factors also have direct influences on stress This theory also suggests that parent-child stress affects child, parent, and environmental characteristics (see Figure 1) Unlike the other theories of parenting stress that will be discussed, this theory addresses “parent-child interactive stress” rather than parenting stress more generally The authors describe parent-child interactive stress as one aspect of parenting stress; it is defined as the stress which manifests itself in parent-child conflict (Mash & Johnston, 1990) In this model, the effects of child and environmental stressors are mediated by parental characteristics, which notably include parental cognitions, and more specifically, attributions for child behaviour Other parent characteristics that Mash and Johnston suggest mediate child and environmental characteristics include affective states, personality, behavioural repertoires, and health
Cognitions are characterized in this theory by their affect-generating and motivational properties
As such, they are presumed to be able to exacerbate, reduce, or prevent parent-child stress In addition to attributions for child behaviour, perceptions of the severity of child behaviour and parenting efficacy (one’s sense of one’s ability to manage the demands of parenting) are highlighted as parenting cognitions mediating parent-child stress Other parent cognitive factors such as intellectual ability, values, and behavioural intentions are also posited as affecting parent- child stress
The second theory, proposed by Webster-Stratton (1990), suggests that extrafamilial stressors, interpersonal stressors, and child stressors affect parenting Extrafamilial stressors in this theory include unemployment and low socioeconomic status, and interpersonal stressors include marital distress and divorce Child stressors refer most significantly to behaviour problems Negative parent-child interactions also increase parenting stress, such that children’s behaviour problems are both a contributor to and a product of increased parenting stress These negative interactions are posited to explain the cycle of parenting stress and child behaviour problems in families of children with ADHD and other conduct problems Webster-Stratton further proposes that the impact of extrafamilal, interpersonal, and child stressors on parenting stress are mediated by a variety of parental characteristics, including cognitive factors, such as appraisal of the stressor Other parent factors that mediate the effect of stressors on parenting stress include parents’ psychological well-being, quality of social support, gender, and drug use
McCleary (2002) proposed a third theory to conceptualize parenting stress in families of adolescents with ADHD This theory uses Lazarus and Folkman’s (1984) theory of stress, appraisal, and coping as its starting point; as such cognitive factors are at the centre of this theory McCleary proposes that stress results from the parent’s cognitive appraisal of the child’s needs or behaviours as taxing or exceeding the parent’s resources What each parent appraises as stressful differs based on the parent’s own resources and characteristics, including their values, beliefs, and commitments, and situational characteristics including outside stressors such as finances When child behaviours are appraised as stressful, coping, which refers to the parent’s efforts to manage the stressors, occurs In addition, social support, and cognitive variables such as self-efficacy and attributions for the child’s behaviour affect a parent’s appraisals Adaptation, which can be negative or positive, occurs as a result of coping In the case of parenting stress, adaptation refers to parent’s role performance Parental role performance refers to the behaviours a parent engages in Parental role performance is then posited to impact the child’s behaviour, thus forming a loop similar to Webster-Stratton’s (1990) theory
The fourth theory of parenting stress was proposed by Abidin in 1976 (as cited in Abidin,
Parenting Stress in Families of Children with ADHD: A Meta-Analysis
Parenting Stress in Families of Children with ADHD: A Meta-Analysis
This study represents the first meta-analysis of parenting stress and ADHD Analyses were conducted to examine findings on the association between parenting stress and ADHD
Predictors comprising child, parent, and contextual factors, and methodological and demographic moderators of the relationship between parenting stress and ADHD were examined Findings from 22 published and 22 unpublished studies prepared through October 2007 were included Results confirmed that parents of children with ADHD experience more parenting stress than parents of nonclinical controls and that severity of ADHD symptoms was associated with parenting stress Child co-occurring conduct problems and parental depressive symptomatology predicted parenting stress Little difference in parenting stress was found between mothers and fathers, but child gender was a significant moderator of parenting stress, with lower stress levels in samples with higher proportions of girls None of the methodological moderators examined (i.e., publication type, publication year, parenting stress measure, diagnostic criteria) were significant
This meta-analysis investigates the relationship between Attention-Deficit/Hyperactivity Disorder (ADHD) and parenting stress ADHD is a chronic, pervasive condition characterized by inattention, impulsivity, and hyperactivity (American Psychiatric Association, 2000) Current research points to strong genetic influences (Levy et al., 2006; Willcutt, in press), including elevated rates of ADHD symptomatology (Epstein et al., 2000) in the parents of children with ADHD Conduct problems (e.g., Barkley, DuPaul, & McMurray, 1990; Biederman, Faraone, & Lapey, 1992; Wilens et al., 2002) and other disorders, such as anxiety (e.g., Biederman,
Newcorn, & Sprich, 1991; March et al., 2000; Newcorn et al., 2001) and learning disabilities (e.g., Barkley et al., 1990; Mayes, Calhoun, & Crowell, 2000) commonly co-occur in children with ADHD In addition to these co-occurring disorders, child ADHD is also associated with elevated levels of parenting stress (e.g., Breen & Barkley, 1988; Johnson & Reader, 2002;
Parenting stress is a distinct type of stress that arises when a parent’s perceptions of the demands of parenting outstrip his or her resources for dealing with them (Deater-Deckard, 2004) The dominant model of parenting stress delineates two major components: a child domain, arising directly from child characteristics, and a parent domain that is more affected by parental functioning (Abidin, 1995) Total stress is the result of combining parent- and child-based stress (Abidin, 1995) Studies of families with children with ADHD show elevations in both domains of parenting stress (e.g., Breen & Barkley, 1988; Dupaul et al., 2001) More so than other types of stress, parenting stress is associated with parenting practices and child development (Deater-Deckard, 2004) Although experiencing some parenting stress is considered normal (Crnic & Greenberg, 1990), elevated levels of parenting stress may affect the parent-child relationship and negatively impact parenting practices (Abidin, 1992; Belsky, 1984; Morgan et al., 2002;
Rodgers, 1998; Webster-Stratton, 1990) Parents who experience extreme levels of this type of stress may be less able to implement interventions to help their children (Kazdin, 1995) By contrast, reductions in parenting stress are linked to increases in the efficacy of parent management training (PMT; Kazdin & Whitley, 2003) PMT is a very commonly used intervention with children with ADHD (Kazdin, 1997)
Six qualitative reviews of the literature on parenting stress and ADHD have been conducted (Deault, 2010; Fischer, 1990; Johnston & Mash, 2001; Mash & Johnston, 1990; McCleary, 2002; Morgan et al., 2002) The reviews concluded that parents of children with ADHD experience more stress than parents of normal controls (Deault, 2010; Fischer, 1990; Johnston & Mash, 2001; Mash & Johnston, 1990; Morgan et al., 2002) and that the relationship between severity of ADHD and parenting stress was clearly established (McCleary, 2002;
Morgan et al., 2002) The co-occurrence of ADHD with conduct problems was a common point of discussion Some reviews concluded that parents of younger children with ADHD experience higher levels of stress than parents of older children (McCleary, 2002; Morgan et al., 2002), while another concluded there was no significant effect of child age (Johnston & Mash, 2001), and a third concluded that stress remains high through adolescence (Deault, 2010) Typically, child gender was not found to be predictive of parenting stress (Johnston & Mash, 2001;
The reviews reported that parents of children with ADHD experience increased levels of psychopathology, which is assumed to be caused by the same factors that lead to the children’s ADHD (in some of the reviews parental psychopathology was used as a proxy for parenting stress; i.e., Fischer, 1990) One review concluded that fathers of children with ADHD experience less parenting stress (McCleary, 2002), while another concluded there were no significant differences between mothers and fathers (Johnston & Mash, 2001) ADHD is also associated with decreased marital quality (Deault, 2010; Fischer, 1990; McCleary, 2002) One review noted that social support is a protective factor against parenting stress in this population (McCleary,
2002) Based on the prevailing theories, the reviews generally assumed a child to adult direction of effect, with some making this directionality explicit (i.e., Fischer, 1990; Mash & Johnston,
1990) The contributions of and moderating role of maternal cognitions (e.g., parenting sense of competence) in relation to parenting stress was also often part of the conceptual framework used in the reviews (Mash & Johnston, 1990; McCleary, 2002; Morgan et al., 2002)
These reviews reveal several unanswered questions, including the associations between SES and parenting stress in this population (Johnston & Mash, 2001) and the nature of the relationship between conduct problems and parenting stress (Johnston & Mash, 2001)
Inconsistencies between studies on various aspects and/or predictors of parenting stress was a common theme in all of these reviews, but each review was unable to deal with these inconsistencies, except to note them and provide possible explanations This is one of the major problems with narrative reviews (Johnson & Eagly, 2000) Furthermore, recent research has been conducted that has not been included in any of the currently available reviews, necessitating this literature be revisited In addition, many of the reviews equated parent-child conflict and parenting stress or grouped life stress and parenting stress together, whereas greater conceptual clarity can be achieved by considering parenting stress separately This meta-analysis was conducted to clarify these predictors and also to establish the magnitude of the effect between parenting stress and ADHD
A meta-analysis provides a systematic manner of reviewing studies that integrates disparate findings and attempts to identify reasons (moderators) for the contradictions The inclusion of unpublished studies in meta-analyses is a strength of this methodology, as the exclusion of these studies may lead to a positive bias in the findings (Lipsey & Wilson, 2001; Rothstein, Sutton, & Borenstein, 2005) The purpose of the current study was to use meta- analytic methodology to analyze findings on the relationship between parenting stress and
ADHD Predictors comprising child, parent, and contextual factors, as well as methodological and demographic moderators of the relationship between parenting stress and ADHD were examined
A primary area of inquiry in the domain of methodological moderators was the effect of different measures used to evaluate parenting stress The dominant measure of parenting stress (Johnston & Mash, 2001) is the Parenting Stress Index (PSI; Abidin, 1983, 1990, 1995) The PSI provides scores in two domains: child and parent domain stress, as well as a total stress score and a life stress score The total stress score is the sum of the parent and child domain scores Child domain stress refers to stress arising directly from factors within the child Sample items include
“My child does a few things which bother me a great deal” and “My child turned out to be more of a problem than I had expected.” Parent domain stress refers to stress related more to factors arising from within the parent Sample items on this scale include “I find myself giving up more of my life to meet my children’s needs than I ever expected.” Moderators were examined here in relation to the effect between total stress and ADHD symptoms overall (rather than on each effect; results from studies not using the PSI were included in all analyses using “total stress”) This was done in order to reduce the probability of Type II error Data from group comparison studies (i.e., studies using t-tests and ANOVAs to evaluate their effects) and dimensional studies
(i.e., studies using correlation) were analyzed separately Each predictor was also evaluated as to its relationship with each of total, parent domain, and child domain stress
The following research questions were derived from the reviews of ADHD and parenting stress and by investigations into parenting stress in the developmental literature
1 How is having a child with ADHD associated with parenting stress? (a) Do parents of children with ADHD experience more parenting stress than parents of children without ADHD?; and (b) Do parents of children with ADHD experience more stress than parents of other clinically-referred children?
2 What is the magnitude of the association (correlation) between ADHD symptoms (ADHD symptoms overall, inattentive symptoms, and hyperactive-impulsive symptoms) and parenting stress?
Predicting Parenting Stress in Families of Children with ADHD: Consideration
Predicting Parenting Stress in Families of Children with ADHD:
Consideration of Informants, and The Role of Parental ADHD Symptoms, and Other
This study examined parent (parental ADHD symptoms) and contextual (parental education, social support, and marital status) predictors of parent domain parenting stress (parental distress) as a function of parent- and teacher-reported child ADHD symptoms in a sample of 95 parents of
8 to 12 year-old children with and without ADHD Parents’ perceptions of parental distress and social support were inversely related Parental ADHD symptomatology was the strongest predictor of parental distress considered Models using teacher reports of child ADHD symptomatology and oppositionality differed from ones using parent reports in that child oppositionality was only predictive of parental distress in the parent-report model A post-hoc analysis showed that child factors did not predict parental distress over and above parent and contextual factors
ADHD is a chronic, pervasive condition characterized by inattention, impulsivity, and overactivity It is also one of the most common childhood disorders, affecting 5% of school-aged children (Polanczyk & Jensen, 2008) This disorder has been shown to be highly familial The genetic factors involved in ADHD have been studied using both behavioural genetic and molecular genetic approaches (Levy et al., 2006; Willcutt, in press) Family studies have consistently established elevated rates of ADHD in the biological relatives of children with ADHD (e.g., Faraone, Biederman, & Friedman, 2000) and higher rates of ADHD concordance have been found in monozygotic than dizygotic twins (Levy, Hay, McStephen, Wood, &
Waldman, 1997; Willcutt, Pennington, & DeFries, 2000) Further, ADHD has a very high heritability, of approximately 73 (Levy et al., 2006; Willcutt, in press) Research is also pointing to the stability of ADHD, with more than 50% of children diagnosed with ADHD continuing to experience the disorder into adulthood (Barkley et al., 2002), although a recent meta-analysis shows that in adulthood the disorder is not necessarily present at the level necessary for diagnosis (Faraone et al., 2006) Therefore, elevated rates and symptoms of ADHD in parents of children with ADHD would be expected and studies have shown that up to two-thirds of children with ADHD have a parent with a history of ADHD (Schachar & Wachsmuth, 1990)
One well-accepted sequela of ADHD in a child is increased parenting stress (Johnston & Mash, 2001) Parenting stress has been defined as “the aversive psychological reaction to the demands of being a parent” (Deater-Deckard, 1998, p 315) and is determined by the presence of stressors, an individual’s appraisal of the stressor, and his or her resources for coping with the stressor Although having some parenting stress is considered normal (Crnic & Greenberg,
1990), parents who experience extreme levels of this stress may suffer psychologically and may be less able to implement interventions to help their children (Kazdin, 1995) Increased parenting stress may also affect the parent-child relationship and negatively impact parenting practices (Abidin, 1992; Rodgers, 1998; Webster-Stratton, 1990)
Numerous studies (Anastopoulos et al., 1992; Baldwin, Brown, & Milan, 1995; Breen & Barkley, 1988; Harrison & Sofronoff, 2002; Lin & Chung, 2002; Mash & Johnston, 1983;
Podolski & Nigg, 2001; Riley, Lyman et al., 2006; van der Oord et al., 2006; Vitanza &
Guarnaccia, 1999) including the meta-analysis presented here in Study 1, have reported elevated and clinical rates of parenting stress as a function of child ADHD symptoms These studies have also identified child-level predictors of increased parenting stress in families of children with ADHD, most notably internalizing (Beck, Young, & Tarnowski, 1990; Breen & Barkley, 1988; Mash & Johnston, 1983) and externalizing behaviours (Anastopoulos et al., 1992; Beck et al., 1990; Harvey, 1998; Mash & Johnston, 1983; Podolski & Nigg, 2001; van der Oord et al., 2006) However, few parent or contextual level predictors have been extensively studied with regards to parenting stress in families of children with ADHD, with the exception of parental depressive symptomatology, which has been found to predict parenting stress (Breen & Barkley, 1988; Harrison & Sofronoff, 2002; van der Oord et al., 2006; Vitanza & Guarnaccia, 1999)
The purpose of the current study was to examine how parent and contextual factors predict parenting stress after controlling for the effects of child factors that have been found to be associated with parenting stress in parents of children with ADHD (child ADHD symptomatology, oppositionality, and child gender) Taking the meta-analysis presented in Study
1 as a starting point, this study examined potential parent and contextual predictors of parenting stress (parental ADHD symptoms, parental education, social support, and marital status) as a function of teacher-reported child ADHD symptoms in a sample of children with and without clinical levels of ADHD symptomatology Furthermore, a comparison of models predicting parenting stress using teacher versus parent reports of child ADHD symptomatology and oppositionality was undertaken Finally, a model examining the moderating role of parental ADHD symptomatology on the association between child ADHD symptomatology and parental distress was evaluated Exploratory analyses into other potential moderating models of parenting stress were also conducted
In spite of studies showing elevated rates of ADHD in the parents of children with
ADHD, adult ADHD has yet to be considered as a possible contributing factor to parenting stress in these families Parental ADHD, however, has significant effects on family functioning
Mothers with ADHD have been shown to be poorer at monitoring the behaviour of their children with ADHD and provide less consistent discipline than mothers without ADHD (Murray & Johnson, 2006) Furthermore, both maternal inattention and impulsivity have been linked to poorer parenting practices (Chen & Johnston, 2007) Mothers with ADHD have also been shown to have less affect control than mothers without ADHD (Weinstein, Apfel, & Weinstein, 1998), and current clinical opinion holds that parents with ADHD may be exceptionally sensitive to the difficult behaviours shown by their children (Weiss, Hechtman, & Weiss, 2000) In sum, it seems that parental ADHD symptoms may reduce parents’ resources for coping with the child’s ADHD and associated behavioural difficulties, leading to increased levels of parenting stress Indeed, in a literature review of parenting stress and ADHD, Fischer reported that “although some parents of hyperactive children do appear to experience stress from their own psychopathology apart from the children’s behavioural disturbance, it is possible that this primary stress may interact with secondary parenting stress in an exponential way” (1990, p
Other factors that may affect parenting stress include coping resources, such as social support and spousal support, and systemic factors, such as socioeconomic status (SES) Studies of other populations have found that social supports are important coping mechanisms (e.g., Hauser-Cram, Warfield, Shonkoff, & Krauss, 2001) Families of children with ADHD, however, have been shown to have lower levels of social support than families of children without ADHD (Lange et al., 2005) Community support, such as support from professionals, has been associated with greater distress in mothers of children with ADHD (Podoloski & Nigg, 2001) This may be due to distressed families seeking out more of this type of support (Podoloski & Nigg, 2001) One would expect that spouses would be another source of support, as has been found in families with a child with developmental disabilities, where single parent families experience more parenting stress than two-parent families (Quine & Pahl, 1985) In families of children with ADHD, however, studies have not shown a link between marital status and parenting stress (Anastopoulos et al., 1992; Harrison & Sofronoff, 2002) The association between SES and parenting stress in families of children with ADHD varies by study Some studies have found that maternal education, financial difficulties, and SES are unrelated to parenting stress in the families of children with ADHD (Anastopoulos et al., 1992; Harrison & Sofronoff, 2002; Mash & Johnston, 1983), but other studies have found that family income and financial stressors are significant predictors of parenting stress in these families (Baker, 1994; Baldwin et al., 1995)
Abidin’s theory of parenting stress (1976, as cited in Abidin, 1995) was used as a starting point in the investigation into the predictors of parenting stress This ecological theory proposes that parenting stress is determined by parent factors, child factors, and situational factors and comprehensively lists variables for consideration What this theory lacks, however, is consideration of biological factors in both the child and parent that impact parenting stress Therefore, a bio-ecological layer was added to Abidin’s theory (Bronfenbrenner, 2001) The most notable biological factor influencing this study is the idea of shared genetic influences between parent and child Given the highly heritable nature of ADHD (Levy et al., 2006;
Willcutt, in press), this was seen as particularly relevant Furthermore, Bronfenbrenner and Ceci
(1993) posited that “heritability” is highly influenced by environmental factors, suggesting a genotype by environment interaction, or moderating model
The first objective of this study was to investigate whether parental ADHD symptoms, parental education, social support, and marital status predicted parenting stress over and above child ADHD symptomatology, oppositionality, and child gender This study considered parent- specific parenting stress, known here as parental distress (or parent domain stress), rather than overall parenting stress to ensure independence between measures of child behavioural disturbance and measures of parenting stress, as would occur if total parenting stress was considered (total parenting stress is calculated by adding child and parent domain parenting stress) Given that the meta-analysis in Study 1 showed no significant difference between mothers and fathers in parent domain stress, both mothers and fathers were eligible for inclusion in this study It was hypothesized that parental ADHD symptoms would predict parenting stress given the far-reaching effects of parental ADHD reported above, as well as the significant relationship between parental depressive symptomatology and parenting stress (Breen &
Barkley, 1988; Harrison & Sofronoff, 2002; van der Oord et al., 2006; Vitanza & Guarnaccia,
1999), especially parent domain stress (see Study 1), and the high comorbidity between adult ADHD and depressive disorders (Kessler et al., 2006) Due to the conflicting findings on the other predictors investigated, no hypotheses were made Teacher reports of child symptoms were used in the primary analysis to ensure independence between reports of parenting stress and reports of child ADHD symptomatology and oppositionality In order to determine whether models of parenting stress differed based on whether teacher reports or parent reports of child ADHD symptoms were used, the analyses were repeated using parental report of child ADHD symptomatology and oppositionality This secondary analysis was undertaken as differences between parents and teachers in reporting of ADHD symptomatology have been found (e.g., Wolraich et al., 2004) and no other studies were identified that used teacher reports of ADHD symptomatology in investigations of parenting stress (although van der Oord et al., 2006 did look at the association between discrepancies between parents and teachers in child ADHD symptom reports and parenting stress) Due to the lack of any guiding theory or previous research in this area, no specific prediction was made
The second objective of this study was to explore whether parental ADHD symptomatology moderated the association between teacher-reported child ADHD symptomatology and parental distress This model was proposed as a result of the findings of increased rates of ADHD symptoms in the parents of children with ADHD (Chronis Epstein et al., 2000), and the suggestion from Weiss and colleagues (Weiss et al., 2000) that parents with ADHD may be exceptionally sensitive to the difficult behaviours of children with ADHD Given this, it was hypothesized that parent and child ADHD symptomatology would interact, such that parents with higher rates of ADHD symptomatology would be especially stressed by their child’s ADHD symptoms, whereas parents with lower rates of ADHD symptomatology would find it easier to cope with this source of stress
Conclusions and Implications
Six key conclusions emanate from the research in this dissertation First, the findings confirmed that parents of children with ADHD experience considerably more parenting stress than parents of children without ADHD Second, child ADHD symptomatology is positively related to parenting stress Third, parent-reported internalizing and externalizing symptoms in the child are positively associated with parenting stress Fourth, social support, as perceived by parents, is inversely related to parenting stress Fifth, child oppositionality is only predictive of parenting stress when reported by parents, but not when reported by teachers The final and most central conclusion of this line of research relates to the findings on parental psychopathology and parenting stress The two studies presented here showed that parental psychopathology
(depression and ADHD) accounts for a large proportion of the variance in parenting stress; furthermore, this research showed that once we consider parent and contextual factors (including parental ADHD symptomatology), child factors (including child ADHD symptomatology) are no longer predictive of parent domain parenting stress
This final conclusion raises questions about the association between child ADHD symptomatology and parenting stress as reported in the bulk of the literature, and the meta- analysis presented here, which summarized that literature Before going further, it is necessary to consider the noteworthy caveats that any relationship between parental psychopathology and parenting stress may be an artefact of measurement issues—in Study 2 and in all studies included in the meta-analysis in Study 1, parents reported both on their own psychopathology and on parenting stress One may therefore expect that this alone would result in some non-zero correlation between these two constructs, as a result of the parent’s reporting style In addition, the second study only investigated parent domain parenting stress, so it is not yet clear how these findings relate to parenting stress as a whole (although one would expect some overlap, as parent domain stress constitutes half of the parenting stress score, as operationalized on the PSI)
With these caveats in mind, one wonders whether child factors would predict parenting stress over and above parental depression symptoms, given what we know from the meta- analysis about the association between parental depressive symptomatology and parenting stress, and the high co-occurrence between depression and ADHD in adults (Biederman et al., 2004) Although this could be investigated in new research, much of this data already exists in previously reported studies (as described in the meta-analysis reported in Chapter 2), and could be re-analyzed to provide insight into this question Given the significant effects found here for the role of parental psychopathology in parenting stress, the next logical step would be to study parental ADHD and depression together This would illuminate the extent to which these disorders share variance in predicting parenting stress, as has been suggested throughout this dissertation Alternatively, it may suggest independent and/or interactive effects
The findings on parental psychopathology and parenting stress also suggest that more research is needed on the effects of parental psychopathology on family functioning If, indeed, parental ADHD symptomatology, which might be expected to be elevated commensurate with the severity of child ADHD symptomatology, given the familiality of the disorder (Levy et al., 2006; Schachar & Wachsmuth, 1990) explains elevated levels of parenting stress in families of children with ADHD, more attention needs to be given to addressing and supporting parents in these families This idea is corroborated by the small effects of behavioural interventions for child ADHD on parenting stress (Anastopolous, Shelton, DuPaul, & Guevremont, 1993;
Danforth, 1998; Pisterman, Firestone, McGrath, & Goodman, 1992; van den Hoofdakker et al.,
2007; Weinberg, 1999; Wells et al., 2000); however, child factors likely play a more substantial role in total parenting stress than they do in parent domain stress Taken together, this suggests that multisystemic interventions, addressing both parents and children, may be needed to support these families
The meta-analysis illustrated the necessity of these types of interventions by showing that the effect size for parenting stress in parents of children with ADHD is very high (d = 1.8) The considerable research base in this area, and the magnitude of this effect indicates that further research on parenting stress and ADHD should focus on the mechanisms of this relationship, rather than on establishing again that these parents are more stressed than parents of typically- developing children A major limitation of the literature to date is that the child participants in all of the studies were 12 years of age or younger, possibly because the most commonly used measure of parenting stress (the PSI) is normed for this population Although the manifestations of ADHD in adolescents differs somewhat from those in younger children (i.e., reductions in hyperactivity), adolescents are apt to engage in behaviours such as risky driving and substance use (Barkley, Fischer, Smallish, & Fletcher, 2004) that may indeed be associated with elevated parenting stress Research on parenting stress in parents of adolescents with ADHD is therefore clearly warranted
The current research was also able to show that social support is inversely related to parenting stress However, it is not clear from the work here whether low levels of social support are a contributor to, or an effect of, increased parenting stress Longitudinal studies and intervention research on parenting stress may illuminate this relationship further
Study 2 clarified that child oppositionality is only predictive of parenting stress when reported by parents Although it is possible that high parenting stress causes oppositional behaviour, it is also possible that stressed parents perceive their children’s behaviour as oppositional even when these behaviours are typical of children at that developmental stage It is also possible that these children behave differently at home from in school There is considerable research pointing to problematic parenting and disciplinary practices, including greater negativity and control, in parents of children with ADHD (e.g., Anderson, Hinshaw, & Simmel, 1994; Buhrmester et al., 1992; Cunningham & Barkley, 1979; Winsler, 1998; Woodward,
Taylor, & Dowdney, 1998) In addition, many children with ADHD are on medication only during school hours and take “drug holidays” on weekends (Martins et al., 2004) Further, the structured environment of the classroom may enable these children to better regulate their behaviour than in a less-structured home environment The most likely explanation of the different predictive power of child oppositionality in predicting parenting stress is that there is an interaction between all of these factors listed This suggests that future research needs to consider how child oppositionality and parenting stress are related, rather than simply reporting the association
The finding of different reporting patterns by teachers and parents is consistent with research on quality of life in families of children with ADHD Klassen et al., (2004) found that health-related quality of life in families of children with ADHD was correlated with parent- reported child ADHD symptom severity, but not with teacher-reported symptoms (although this too could be demonstrating an informant effect) Furthermore, quality of life was significantly lower in families with children with comorbid oppositionality or conduct problems than in families with children with ADHD alone or ADHD and a learning disability Although quality of life and parenting stress seem, at first glance, to represent opposite ends of a continuum, it is not clear how these two concepts are related For example, Riley, Spiel et al (2006) found that there is no link between quality of life and parental ADHD, but the current research showed a large effect for parental ADHD on parenting stress Further, quality of life improves more with treatment for the child’s ADHD (Danckaerts et al., 2009) than does parenting stress, where the effects are generally quite modest (Anastopolous, Shelton, DuPaul, & Guevremont, 1993;
Danforth, 1998; Pisterman, Firestone, McGrath, & Goodman, 1992; van den Hoofdakker et al., 2007; Weinberg, 1999; Wells et al., 2000) Simultaneously studying these two concepts might elucidate their relationship better and refine the definitions of the terms themselves
As suggested by Klassen et al (2004), another important area for future research is an investigation into reporting patterns in families of children with ADHD Previous research on parenting stress and child ADHD has confounded raters, leading to potential for informant biases Some research (e.g., Wolraich et al., 2004) has started to address the impact of low interrater reliability on diagnosis of ADHD, but this area of research has not yet been expanded to looking at the impact on larger family constructs, such as parenting stress
Overall, the findings from the research presented in this dissertation support Abidin’s theory of parenting stress (1995), which stipulates that parent (i.e., depression, ADHD symptoms), child (i.e., ADHD symptoms, internalizing and externalizing behaviours), and situational (i.e., social support) factors contribute to parenting stress Abidin’s model, however, is limited in that it suggests factors to examine, but does not provide a framework to explain how these factors are linked The results of the present study support a bio-ecological model
(Bronfenbrenner, 2001) Specifically, the substantial role of parental ADHD symptoms in the prediction of parenting stress, suggests that bio-ecological factors affect parenting stress That is, it seems that perhaps certain genetic factors are associated with parental ADHD symptoms, and that parental ADHD symptoms are associated with increased perceptions of parenting stress