Mother-child interactions in ADHD and comparison boys: relationships with overt and covert externalizing behavior

Socio-demographic and clinical correlates of parenting style among parents having ADHD children: a cross-section study

Background

ADHD affects 7.8% of the school-aged population, making it one of the most common childhood brain illnesses. It is characterized by abnormally high levels of inattention, activity, and impulsivity at a young age. Being a parent of a child with ADHD is a real challenge, as the parents tend to be more disapproving, critical, and provide more impulse control directions; such parenting style can have an impact on the illnesses course, accentuate its signs and symptoms, and lead to secondary development of co-morbid psychiatric and behavioral problems. This makes the parent-child effect a matter of clinical importance that needs to be carefully assessed and managed. We aimed to estimate the sociodemographic and clinical correlates of parenting attitudes among parents having ADHD children. This cross-sectional study included 48 ADHD children from both sexes, aged from 6 to 12 years old, and their parents. In our study, we applied the Stanford-Binet Intelligence Scale 5th edition, the Conner’s Parent Rating Scale-revised, the parenting style as perceived by children questionnaire, and the Fahmy and El-Sherbini questionnaire for the measurement of socioeconomic status.

Results

Mothers of ADHD children had significantly lower scores of over-protections parenting style than the fathers; the current study showed a significant increase in total parenting scores and warmth/support in mild ADHD cases than in moderate and severe ones, and there is a significant increase in the mother’s positive parenting style toward ADHD children with lower levels of social problems, mild cases, and older age. There is a significant increase of positive parenting style toward ADHD children exerted by post graduated, professionally working, and high social class fathers and by working mothers among rural residents and high social class mothers. There is a positive correlation between IQ and a mother’s warmth/support.

Conclusion

ADHD children with mild symptoms, higher social functioning of the child, high socioeconomic level of the family, better education, and professional occupations of parents were associated with positive parenting style.

Comorbid Internalizing and Externalizing Symptoms Among Children with ADHD: The Influence of Parental Distress, Parenting Practices, and Child Routines

Emotional/behavioral concerns are common among children with ADHD. Familial factors (e.g., parental adjustment, parenting behaviors) are linked to the presence of comorbid internalizing/externalizing symptoms among children with ADHD. The purpose of the present study was to evaluate a model that includes multiple familial variables and their direct and indirect effects on child emotional and behavioral problems among children with ADHD. Participants included parents of children (6-12 years of age; M = 8.87, SD = 1.92) with a diagnosis of ADHD (N = 300). Participants completed measures of child emotional/behavioral concerns, parental distress, routines, and parenting behaviors. Path analyses revealed direct effects for parental distress, parent behavior and routines on child adjustment, after controlling for the other variables. A significant indirect relation between parental distress, routines, and externalizing behavior was observed. These findings highlight one specific path through which parental distress appears to influence specific behavioral concerns that are commonly observed in children with ADHD.

A Review of the Clinical Utility of Systematic Behavioral Observations in Attention Deficit Hyperactivity Disorder (ADHD)

This review evaluates the clinical utility of tools for systematic behavioral observation in different settings for children and adolescents with ADHD. A comprehensive search yielded 135 relevant results since 1990. Observations from naturalistic settings were grouped into observations of classroom behavior (n = 58) and of social interactions (n = 25). Laboratory observations were subdivided into four contexts: independent play (n = 9), test session (n = 27), parent interaction (n = 11), and peer interaction (n = 5). Clinically relevant aspects of reliability and validity of employed instruments are reviewed. The results confirm the usefulness of systematic observations. However, no procedure can be recommended as a stand-alone diagnostic method. Psychometric properties are often unsatisfactory, which reduces the validity of observational methods, particularly for measuring treatment outcome. Further efforts are needed to improve the specificity of observational methods with regard to the discrimination of comorbidities and other disorders.

Parenting Stress and Youth Symptoms among Girls with and without ADHD

OBJECTIVE

To examine the aspects of parenting stress-parental distress [PD] and parental stress due to dysfunctional interactions [PSDI]-reported by mothers of girls with attention-deficit/hyperactivity disorder (ADHD) in both childhood and adolescence and to understand their associations with internalizing and externalizing symptoms in adolescence.

DESIGN

The diverse sample comprised 120 girls with ADHD and 81 age- and ethnicity-matched comparison girls, evaluated at ages 6-12 years and followed prospectively for 5 years. Basic demographics, oppositionality, childhood behavioral outcomes and symptoms, and key parenting practice were covaried in the analyses.

RESULTS

Longitudinally, PD during the participants' childhood was positively associated with adolescent externalizing and internalizing behaviors, even when statistically controlling for parallel childhood behaviors. PSDI during adolescence was associated with contemporaneous adolescent depressive symptoms and externalizing behaviors, but PD was associated with only internalizing behaviors. With respect to moderation by diagnostic group, PSDI (in childhood) was associated with adolescent internalizing symptoms only in girls with ADHD. However, associations between PD in childhood and internalizing behaviors were stronger in the comparison than the ADHD sample.

CONCLUSIONS

Minimizing early dysfunctional interactions might reduce internalizing behaviors in girls with ADHD. Interventions targeting parental distress may be beneficial for girls, regardless of ADHD status.

Self-regulated compliance in preschoolers with autism spectrum disorder: The role of temperament and parental disciplinary style

Regulatory difficulties are common in children with autism spectrum disorder. This study focused on an important aspect of self-regulation—the ability to willingly comply with frustrating demands of socialization agents, termed “self-regulated compliance.” We studied compliance to parental demands in 40 preschoolers with autism spectrum disorder and 40 matched typically developing preschoolers, during separate interactions with mother and father, while engaging in two paradigms: toy pick-up and delayed gratification, which tap the “do” and “don’t” aspects of self-regulated socialization at this age. Parents’ disciplinary style was micro-coded from the two paradigms and child temperament was parent reported. Compared to their typically developing peers, children with autism spectrum disorder showed more noncompliance and less self-regulated compliance to parental demands and prohibitions and greater temperamental difficulties across several domains. No group differences were found in parental disciplinary style. Child self-regulated compliance was associated with parental supportive disciplinary style and with child attention focusing. Findings highlight the importance of parental supportive presence in structuring the development of socialization in children with autism spectrum disorder. Implications for parent–child emotion regulation interventions are discussed.

The North American Perspective On Attention Deficit Hyperactivity Disorder

The purpose of the present paper is to (1) provide an overview of the nature of attention-deficit hyperactivity disorder (ADHD) as it seems to be viewed by North American clinicians and clinical scientists; (2) describe its diagnostic criteria as they are applied in that region; (3) discuss the prevalence of ADHD in the region; and (4) briefly present a new theoretical model of the authors emerging from that North American perspective. Some of the critical issues related to these matters will be raised along the way. Given the thousands of scientific papers on this topic, however, an overview of these various topics is all that space here can afford. Readers wishing a more thorough treatment of these topics as well as those pertaining to history, developmental courses, associated risks, assessment, and treatments for ADHD are directed to other writings by the author (Barkley, 1990).

Störungstypische Erziehungsfaktoren bei Aufmerksamkeits- und Angststörungen im Kindes- und Jugendalter

Zusammenfassung. Theoretischer Hintergrund: Die Erziehungsfaktoren Negativität und Kontrolle werden sowohl im Zusammenhang mit der Aufmerksamkeits-Defizit-Hyperaktivitäts-Störung (ADHS) als auch mit Angststörungen (AS) diskutiert. Fragestellung: Unklar ist bislang, ob ADHS und AS gleichermaßen mit negativer Erziehung zusammenhängen oder ob verschiedene Erziehungsfaktoren bei den jeweiligen Störungsbildern eine störungstypische Rolle spielen. Methode: Einschlägige Studien aus dem Zeitraum von 1994 bis 2014 wurden systematisch analysiert. Neben generellen Zusammenhängen wurden moderierende Faktoren ermittelt. Ergebnisse: Während kindliche ADHS verstärkt mit elterlicher Negativität, zum Teil aber auch mit Kontrolle, assoziiert ist, zeigt sich bei kindlichen AS insbesondere ein Zusammenhang mit elterlicher Kontrolle. Die Ergebnisse werden von verschiedenen Faktoren wie Erhebungsmethode (Fragebogen vs. Beobachtung) und Medikation moderiert. Schlussfolgerungen: Störungstypische Zusammenhänge zwischen kindlicher Psychopathologie und Erziehungsfaktoren betonen die Relevanz gegenüberstellender Forschung von ADHS und AS und können Implikationen für eine störungsorientierte Psychotherapie haben.

Parenting Stress as a Mediator Between Childhood ADHD and Early Adult Female Outcomes

The purpose of this study is to examine the mediating role of parenting stress (both parental distress and stress due to dysfunctional interactions in the mother-daughter relationship [PSDI]) in the link between childhood attention-deficit/hyperactivity disorder (ADHD) status and several important young adult outcomes. The diverse sample comprised 140 girls with ADHD and 88 age- and ethnicity-matched comparisons, evaluated at ages 6-12 years and followed prospectively for five years (M age = 14.2) and 10 years (M age = 19.6). The PSDI experienced by a mother during her daughter's adolescence mediated the link between her daughter's childhood ADHD status and adult externalizing and internalizing symptoms. PSDI also mediated the link between ADHD status and young adult nonsuicidal self-injury and had an indirect effect in the relation between childhood ADHD and young adult depressive symptoms. The mediating role of PSDI with respect to internalizing symptoms and depressive symptoms remained in place even when covarying adolescent internalizing/depressive symptoms. Parenting stress, particularly related to maternal perceptions of dysfunctional interactions with adolescent daughters, serves as a key mediator in the association between childhood ADHD status and important domains of young adult functioning. Minimizing parenting stress and dysfunctional mother-daughter interactions during adolescence might reduce the risk of adverse adult outcomes for girls with ADHD.

Impairment in children with and without ADHD: contributions from oppositional defiant disorder and callous-unemotional traits

OBJECTIVE

To ascertain the association of childhood ADHD and oppositional defiant disorder (ODD) on functional impairment and to test the moderating influence of callous-unemotional (CU) traits.

METHOD

Ethnically diverse 6- to 9-year-old children with (n = 59) and without (n = 47) ADHD were ascertained using multiple methods (i.e., rating scales and structured interview) and informants (i.e., parent, teacher, and interviewer).

RESULTS

Using ratings of impairment that were independent of the diagnostic assessment of ADHD and ODD, the association between ADHD and impairment was significantly moderated by CU traits, such that CU traits positively predicted impairment at low and moderate levels of ADHD but not at high levels of ADHD. CU traits did not moderate the association of ODD and impairment.

CONCLUSION

The authors discuss findings within the context of multiple pathways to and from negative outcomes and the utility of evaluating CU traits in studies of ADHD and conduct problems.

Gender differences in consequences of ADHD symptoms in a community-based organization for youth

Attention-Deficit/Hyperactivity Disorder (ADHD) has been linked to disruptive behavior and disciplinary consequences; however, the variables involved in this process are largely unknown. The current study examined rule-breaking behavior as a mediator of the relation between ADHD symptoms and disciplinary actions 1 year later during after-school care at a community-based organization in a sample of 147 school-age children ( M = 8.22 years; 54.4% male). Additionally, gender was examined as a moderator of these relations. Total ADHD symptoms positively predicted rule-breaking behavior at 1-year follow-up, which in turn was positively associated with disciplinary actions also at 1-year follow-up. Gender moderated these relations, such that the mediated effect of rule-breaking behavior on the association between total ADHD symptoms and disciplinary actions was significant for boys but not for girls. Further, when ADHD symptom dimensions were simultaneously included in the model, only hyperactive/impulsive symptoms were a positive predictor of rule-breaking behavior, and rule-breaking behavior mediated this link between hyperactive/impulsive symptoms and disciplinary actions. However, when examining ADHD symptom dimensions, no gender differences emerged. Implications for findings and future directions are discussed.

A video ethnography approach for linking naturalistic behaviors to research constructs of neurocognition in schizophrenia

Few methods are available to explore the impact of neurocognition in schizophrenia on behaviors performed in usual contexts. The authors developed a video ethnography approach to examine the relationship between naturalistic behaviors and research constructs of neurocognition. Video ethnographers accompanied subjects through usual routines gathering continuous video data. Researchers developed codes to measure four behavioral domains observed on video. This paper describes the psychometric characteristics to be considered in the development of observational approaches. It also highlights differences between behaviors performed in usual environments and neuropsychological constructs. The authors demonstrate that everyday behaviors that have been shown to correspond to neurocognitive skills in a pilot feasibility study can be identified and rated. They further suggest that observational methods could provide novel strategies for linking research findings and clinical concerns.

Ethnicity as a moderator of treatment effects on parent--child interaction for children with ADHD

OBJECTIVE

To examine ethnic differences in observed parenting and child behavior and the moderating effects of ethnicity on the relationship between treatment and parent and child behavior.

METHOD

Observations of 508 children with ADHD (ages 7-9) and their caregivers, collected during the Multimodal Treatment Study of ADHD, were analyzed using univariate and mixed-model ANOVAs.

RESULTS

Although baseline parenting practices differed by ethnic group, ethnicity did not moderate the relationship between treatment and either parenting or child behavior.

CONCLUSION

Consistent with data from normative samples, parents of children with ADHD differed by ethnicity in their utilization of certain parenting strategies. However, different ethnic groups did not differ on benefit received from treatments for ADHD, measured by parent and child behavior. Although ethnicity did not emerge as a moderator, ethnic minority family engagement in treatment may be increased by recognizing different parenting strategies and modifying interventions accordingly.

Contextual risk, maternal parenting and adolescent externalizing behaviour problems: the role of emotion regulation

BACKGROUND

The objective of this study was to test if emotion regulation mediates the association between mothers' parenting and adolescents' externalizing behaviour problems (conduct problems and hyperactivity). The parenting dimensions were warmth, psychological control and behavioural control (measured with knowledge, monitoring and discipline). Adjustment was made for contextual risk (measured with the number of proximal adverse life events experienced), gender, age and English as an additional language.

METHOD

Data were from a UK community sample of adolescents aged 11-18 from a comprehensive school in a disadvantaged area.

RESULTS

At the multivariate level, none of the parenting variables predicted hyperactivity, which was associated only with difficulties in emotion regulation, contextual risk and English as a first language. The parenting variables predicting conduct problems at the multivariate level were warmth and knowledge. Knowledge did not predict emotion regulation. However, warmth predicted emotion regulation, which was negatively associated with conduct problems. Contextual risk was a significant predictor of both difficulties in emotion regulation and externalizing behaviour problems. Its effect on conduct problems was independent of parenting and was not via its association with difficulties in emotion regulation.

CONCLUSIONS

The findings add to the evidence for the importance of maternal warmth and contextual risk for both regulated emotion and regulated behaviour. The small maternal control effects on both emotion regulation and externalizing behaviour could suggest the importance of paternal control for adolescent outcomes.

Parenting of 7-month-old infants at familial risk for attention deficit/hyperactivity disorder

Patterns of interaction between parents and 7-month-old boys at familial risk for attention deficit/hyperactivity disorder (ADHD) and a comparison group were studied during a warm-up and two play episodes. The sample included 78 (47 at-risk, 31 comparison) mother-child and 45 (27 at-risk, 18 comparison) father-child dyads. A coding system developed by G. Kochanska (1997, 1998) was used. Infants in the risk group did not differ from the comparison group in the rate of emission of infant-related events. However, they received less adequate responsivity from both their fathers and their mothers to these events, and specifically to negative emotions or distress, than did the comparison group. Maternal psychopathology did not account for these findings. Mothers were more adequately responsive than were fathers, especially for physiological needs. The association between nonoptimal interaction in infancy and the development of ADHD is discussed.

Patterns of parenting in Korean mothers of children with ADHD: A Q-methodology study

The purpose of this study was to investigate patterns of parenting in Korean mothers of children with attention-deficit/hyperactivity disorder (ADHD) and identify major threads that structured various patterns of parenting. Q-methodology, a technique for extracting subjective attitudes, was used for data collection and analysis. Participants were asked to sort statements on issues associated with parenting. Factor analysis was applied to identify patterns in the ranking of statements. Participants were 45 Korean mothers of children with ADHD. As a result, three patterns of parenting emerged: Praise-Fairness, Strict-Control, and Sensitive Response-Balanced. These patterns differed on two axes: external and internal control and positive and negative reinforcement. This study provides an opportunity to enhance our understanding of the parenting patterns of mothers of children with ADHD in Korea. The findings can function as a cornerstone for developing future models of parenting children with ADHD and parent-child interactions.

Peer relationships in boys with attention-deficit hyperactivity disorder with and without comorbid aggression

Peer relationship difficulties and peer rejection are common in youngsters with attention-deficit hyperactivity disorder (ADHD), mandating focus on assessment issues, underlying reasons for peer approval and disapproval, links with comorbid aggression, and the mediating role of sociocognitive mechanisms as well as emotion regulation strategies. With previously unfamiliar ADHD and comparison boys who attended naturalistic summer research programs, we found the following: (a) parent and teacher estimates (but not self-reports) showed moderate correspondence with peer-nominated social preference; (b) ADHD boys were more likely than their comparison peers to accept other ADHD agemates; (c) aggression and noncompliance Predominated as self-reported reasons for rejecting agemates in both ADHD and comparison groups, with Perceived similarity the chief mediator of peer acceptance; (d) the high-aggressive subgroup of ADHD boys showed markedly worse peer sociometric status than did ADHD boys without aggression, for whom social isolation was also a predictor of peer reputation; and (e) self-reported social goals of a sensation-seeking nature and observed emotional reactivity characterized high-aggressive boys with ADHD and predicted end-of-program peer disapproval. We discuss implications for normal developmental processes and for intervention efforts.

Predictors of adolescent functioning in girls with attention deficit hyperactivity disorder (ADHD): the role of childhood ADHD, conduct problems, and peer status

Predictors of adolescent functioning were studied in an ethnically diverse sample of girls with attention deficit hyperactivity disorder (ADHD; n = 140) and age- and ethnicity-matched comparison girls (n = 88) who participated in naturalistic summer programs during childhood. Over a 5-year follow-up (sample retention = 92%; age range = 11.3-18.2 years), conduct problems were predicted by hyperactivity-impulsivity (HI) symptoms and noncompliance (NC). Academic achievement was predicted only by inattention symptoms, whereas school suspensions and expulsions were predicted by inattention symptoms (ADHD sample only), NC, and negative peer status. Substance use was predicted by NC and HI symptoms. Internalizing problems were predicted by HI symptoms, NC, and covert antisocial behavior. Finally, initial peer status was the only significant predictor of later negative social preference.

Do maternal attention-deficit/hyperactivity disorder symptoms exacerbate or ameliorate the negative effect of child attention-deficit/hyperactivity disorder symptoms on parenting?

The impact of similarity in parent and child characteristics on the quality of parenting is underresearched. The current study examined the interaction between mother and child attention-deficit/hyperactivity disorder (ADHD) symptoms on parenting. Two hypotheses were tested: the similarity-fit hypothesis, which predicted that parent and child similarity will improve parenting, and the similarity-misfit hypothesis, which predicted the opposite. Study 1 examined the associations between maternal and child ADHD symptoms and child-specific rearing attitudes of 95 mothers with school-aged children. In Study 2 this analysis was extended to more objective observer-rated mother–child interaction and maternal expressed emotion in 192 mothers of preschool children. Child ADHD symptoms were associated with negative maternal comments and maternal ADHD symptoms with negative expressed emotion. In both studies maternal ADHD symptoms appeared to ameliorate the effects of child ADHD symptoms on negative parenting. Parental response to children with high ADHD symptoms was more positive and affectionate when the mother also had high ADHD symptoms. The results support the similarity-fit hypothesis and highlight the importance of considering both child and maternal ADHD symptoms in studies of parenting.

Attention-deficit/hyperactivity disorder: a neuropsychological perspective towards DSM-V

Neuropsychological methods and techniques have much to offer in the evaluation of the individual suspected as having Attention-Deficit/Hyperactivity Disorder (ADHD). After a review of the historical evolution of the ADHD concept, incidence and prevalence, and DSM-IV criteria for diagnosis, especially as regards omission related to gender differences, and other associated cultural, familial, socioenvironmental, and subject influences, this paper describes a number of dilemmas and obstacles encountered in clinical practice. Included are the confounds associated with the wide range of possible comorbidities, the insufficiency of current DSM-IV criteria, the emergence of subtype differentiation and its impact on diagnosis and treatment. The complex relationship between neuropsychological constructs and ADHD, and obstacles to valid assessment are also addressed. The complexities associated with a thorough ADHD evaluation are viewed within an impressive and expansive existing scientific framework and recommendations are made for future directions.

Parental and family factors for attention-deficit hyperactivity disorder in Taiwanese children

OBJECTIVE

The present study aimed to examine the association between attention-deficit-hyperactivity disorder (ADHD) and maternal psychological distress, parenting style and perceived family support, and the child's interaction with parents and behavioural problems at home in Taiwan.

METHODS

The sample included 375 medicated pediatric patients with DSM-IV ADHD, and 750 school controls selected based on the age and gender structures of the ADHD group. Mothers reported on the Chinese Health Questionnaire, the Chinese versions of the Parental Bonding Instrument, the Family Adaptation, Partnership, Growth, Affection, and Resolve, and the Home Behaviours of the Social Adjustment Inventory for Children and Adolescents.

RESULTS

Mothers of children with ADHD reported greater psychological distress and perceived less support from their families than did mothers of controls. Moreover, mothers of children with ADHD were less affectionate and more overprotective and controlling toward their children than were mothers of controls. This difference was more apparent in boys than in girls. Children with ADHD were less likely to interact with their parents, yet demonstrated more severe behavioural problems at home.

CONCLUSIONS

Although the Taiwanese children with ADHD were under treatment with methylphenidate, they and their families still encountered a variety of difficulties in interaction, support, and communication with each other. Therefore, the parental approach should be integrated into the medication treatment for ADHD in Taiwan.

Parenting, Family Loneliness, and Peer Functioning in Boys with Attention-Deficit/Hyperactivity Disorder

The goal of the present study was to consider the associations between family functioning (parenting and family loneliness) and peer functioning in a sample of boys with ADHD (N = 110) and their mothers (N = 108) and fathers (N = 53). Results indicated that higher paternal warmth was associated with more peer acceptance, less peer rejection, and less problematic social behavior, but only for boys who reported low levels of family loneliness. In addition, more paternal power assertion was related to less peer acceptance, but only for boys who reported low levels of family loneliness. Maternal warmth and power assertion were not significantly related to boys' peer functioning. We discuss these findings in the context of the processes by which parenting may affect the peer relationships of these children.

Linkages between child abuse and attention-deficit/hyperactivity disorder in girls: behavioral and social correlates

OBJECTIVE

The objectives of this study were to examine whether girls with attention-deficit/hyperactivity disorder (ADHD) are at increased risk of having histories of abuse and to assess whether the presence of an abuse history may constitute a distinct subgroup of youth with ADHD.

METHOD

We examined rates and correlates of child abuse in an ethnically and socioeconomically diverse sample of girls with attention-deficit/hyperactivity disorder (ADHD; n=140) and a matched comparison sample of girls without ADHD (n=88), all aged 6-12 years. A thorough chart review reliably established documented rates of physical and sexual abuse in both samples.

RESULTS

There were significantly higher rates of abuse for girls with ADHD (14.3%) than for the comparison sample (4.5%), with most of the abuse found in girls with the Combined as opposed to the Inattentive type. Higher rates of externalizing behaviors (including objective observations in a research summer camp) and peer rejection (indexed through peer sociometric nominations) characterized the subgroup of girls with ADHD with abuse histories compared to the subgroup without such histories, with moderate to large effect sizes. Subgroup differences regarding internalizing problems and cognitive deficits did not emerge. Findings regarding peer rejection were explained, in part, by higher rates of observed aggressive behavior in the abused subgroup.

CONCLUSIONS

The findings raise important questions about the possible etiologic and/or exacerbating role of abusive trauma in a subgroup of children with ADHD.

Treatment-related changes in objectively measured parenting behaviors in the multimodal treatment study of children with attention-deficit/hyperactivity disorder

The present study examined treatment outcomes for objectively measured parenting behavior in the Multimodal Treatment Study of Children with Attention-Deficit/Hyperactivity Disorder (ADHD). Five hundred seventy-nine ethnically and socioeconomically diverse children with ADHD-combined type (ages 7.0-9.9 years) and their parent(s) were recruited at 6 sites in the United States and Canada and randomly assigned to 1 of 4 treatment groups for 14 months of active intervention: medication management (MedMgt), intensive behavior therapy, combination of the 2 (Comb), or a community-treated comparison (CC). Baseline and posttreatment laboratory observations of parent-child interactions were coded by observers blind to treatment condition. Comb produced significantly greater improvements in constructive parenting than did MedMgt or CC, with effect sizes approaching medium for these contrasts. Treatment effects on child behaviors were not significant. The authors discuss the importance of changes in parenting behavior for families of children with ADHD and the need for reliable and objective measures in evaluating treatment outcome.

Toward Mapping Daily Challenges of Living with ADHD: Maternal and Child Perspectives Using Electronic Diaries

Attention-deficit/hyperactivity disorder (ADHD) has an impact on the family as well as the affected child. This study developed and tested an electronic diary for mapping the challenges of everyday family life in a sample of children with ADHD being treated with pharmacotherapy. Across 7 days, mothers and children (27 ADHD; 25 non-ADHD) independently reported their moods, behaviors, and social contexts every 30 min during nonschool hours. Symptomatic behaviors and negative moods were elevated in the ADHD group, combined with maternal perceptions of lower parenting effectiveness and quality of life. Differences in the contexts of maternal anger were salient, with mothers in the ADHD group more often angry when with their children and comparison mothers more often angry when not. Although mothers' diaries were more informative, children's diaries also distinguished the two groups, especially during mornings and weekends. The need for family-wide interventions, the utility of child self-reports, and the promise of electronic diaries are discussed.

Family Correlates of Oppositional and Conduct Disorders in Children With Attention Deficit/Hyperactivity Disorder

Comorbidities among children with ADHD are key determinants of treatment response, course, and outcome. This study sought to separate family factors (parental psychopathology and parenting practices) associated with comorbid Oppositional Defiant Disorder (ODD) from those associated with Conduct Disorder (CD) among children with Attention Deficit/Hyperactivity Disorder. Clinic-referred families (n = 149) were diagnosed using DSM-IV criteria. Parents completed measures of parenting practices. Comorbid ODD and CD were significantly associated with maternal negative/ineffective discipline. Comorbid CD, but not ODD, was significantly associated with lack of maternal warmth and involvement, paternal negative/ineffective discipline, and with paternal Antisocial Personality Disorder (APD). However, the risk of CD posed by parenting appeared concentrated among children without a father having APD. While consistent discipline appears important for addressing comorbid ODD and CD, paternal psychopathology and the quality of the relationship between mother and child may pose risk specifically for comorbid CD. Efforts to prevent and/or treat CD should consider not only provision of structure and prudent discipline, but also the affective qualities of the relationship between the primary caretaker and child.

Objective Assessment of Covert Antisocial Behavior: Predictive Validity and Ethical Considerations

Although less observable than the overt actions of fighting and assault, covert antisocial behaviors such as stealing and property destruction comprise an important subclass of externalizing behavior patterns, displaying considerable predictive power toward delinquency in adolescence. I discuss a laboratory paradigm for objective observation of such behaviors in children that has shown impressive concurrent and predictive validity among samples of boys with and without attention deficit hyperactivity disorder. Addressed herein are crucial questions regarding the ethics of tempting children to steal objects and small amounts of money and to deface property as well as the types of informed consent and debriefing procedures utilized in research with this paradigm. Weighing ethical considerations alongside the ability to predict delinquent behavior presents provocative issues for those interested in understanding the development of antisocial behavior.

Mother?Son Interactions in Families of Boys With Attention-Deficit/Hyperactivity Disorder With and Without Oppositional Behavior

Parenting responsiveness and over-reactivity were assessed among 25 mothers of 7-9-year-old sons with Attention-Deficit/Hyperactivity Disorder (ADHD) and oppositional behavior (Oppositional Defiant, OD), 24 mothers of sons with ADHD only, and 38 mothers of nonproblem sons. Responsiveness was observed during mother-son play and clean-up interactions and over-reactivity was assessed using self-reports of parenting in discipline situations. Mothers of sons with ADHD/OD were less responsive and more over-reactive than mothers of nonproblem sons, and mothers of sons with ADHD only did not differ from the other groups. Mothers of sons with ADHD/OD reported more hostility than mothers of nonproblem sons, and controlling for maternal hostility eliminated the significant group differences in responsiveness during clean-up and in over-reactivity. Controlling for the child's ADHD subtype did not alter the pattern of results. The implications for addressing responsiveness and over-reactivity as components of parent-mediated behavioral treatments for ADHD are considered.

Parenting and Children's Externalizing Problems in Substance-Abusing Families

This study tested associations in path models among positive and negative parenting and children's rule-breaking behavior, aggressive and oppositional behavior, and attention problems for families with a drug-dependent parent. A structural model tested relations between parenting and children's externalizing problems for 251 families with 399 children between the ages of 6 and 18, controlling for nonindependence of ratings at the family level. The model also tested potential moderators, including child age, gender, and ethnicity (White vs. other), and caregiver gender (families with a female substance-abusing caregiver vs. families with a male substance-abusing caregiver). Results indicated that caregiver ratings of monitoring predicted rule-breaking behavior and use of inconsistent discipline predicted ratings of all 3 externalizing syndromes, after controlling parenting and externalizing problems for the effects of the moderators and after controlling significant relations among types of parenting and types of externalizing problems.

Design and rationale of controlled study of long-term methylphenidate and multimodal psychosocial treatment in children with ADHD

OBJECTIVE

To describe the rationale, methodology, and sample characteristics of a dual-site treatment study (New York and Montreal) of children with attention-deficit/hyperactivity disorder (ADHD) conducted between 1990 and 1995. The hypotheses were that (1) methylphenidate combined with comprehensive multimodal psychosocial treatment was superior to methylphenidate alone in improving multiple functions and (2) the efficacy of the psychosocial intervention resulted from its specific components and not from nonspecific treatment effects.

METHOD

One hundred three children with ADHD (ages 7-9), free of conduct and learning disorders, who responded to methylphenidate, were randomized for 2 years to (1) methylphenidate treatment alone; (2) methylphenidate combined with multimodal psychosocial treatment that included parent training and counseling, academic assistance, psychotherapy, and social skills training; or (3) methylphenidate plus attention control treatment that excluded specific aspects of the psychosocial intervention. Children were switched to single-blind placebo after 12 months; methylphenidate was reinstituted when clinically indicated. Assessments included ratings by parents, teachers, children, and psychiatrists; school observations in academic and gym classes; and academic performance tests. Almost 80% of families completed the 2-year study. Companion papers present treatment effects.

CONCLUSIONS

A comprehensive 2-year psychosocial treatment was delivered successfully to children with ADHD and their families.

Does Maternal Warmth Moderate the Effects of Birth Weight on Twins' Attention-Deficit/Hyperactivity Disorder (ADHD) Symptoms and Low IQ?

The moderating effect of maternal warmth on the association between low birth weight and children's attention-deficit/hyperactivity disorder (ADHD) symptoms and low IQ was studied in 2,232 twins. Half of 5-year-old children had low birth weights, below 2,500 g. Maternal warmth, a component of expressed emotion, was coded from mothers' audiotaped descriptions of each child. Both parents and teachers rated children's ADHD symptoms, and the children were administered an IQ test. Results showed a significant interaction between children's birth weight and maternal warmth in predicting mothers' and teachers' ratings of ADHD. The interaction was not significant for IQ. The findings suggest that the effect of children's birth weight on their ADHD symptoms can be moderated by maternal warmth and that enhancing maternal warmth may prevent behavior problems among the increasing population of low-birth- weight children.

Family dynamics and preadolescent girls with ADHD: the relationship between expressed emotion, ADHD symptomatology, and comorbid disruptive behavior

BACKGROUND

Despite the strong biological underpinnings of attention-deficit/hyperactivity disorder (ADHD), family factors remain salient influences on the course of the disorder. However, relatively little is known about how family-level variables relate to ADHD in girls and whether these variables are linked primarily to core ADHD symptomatology or to comorbid aggressive conditions.

METHODS

We investigated the relationship between parental expressed emotion (EE), measured via the five-minute speech sample (FMSS), and ADHD as well as comorbid disruptive behavior disorders, in a diverse sample of 131 girls aged 6-12 years.

RESULTS

High parental EE was associated with both ADHD and aggression, whether these constructs were measured categorically or continuously. The EE component of criticism, as opposed to emotional overinvolvement (EOI), showed the stronger associations with both constructs. ADHD subtypes (Inattentive vs. Combined) were equivalent with respect to prediction from high EE status. Whereas linkages with EE were stronger for ADHD than for aggression and withstood control of comorbid aggression, the converse was not true--i.e., the link between EE and aggression did not hold with control of ADHD. Multiple regression analyses revealed that the associations were independent of parenting stress and maternal depression; exploratory analyses revealed interactions between EE and (a) maternal depression and (b) Child Verbal IQ with respect to predictions of disruptive behavior.

CONCLUSIONS

These findings add to a growing body of literature on ADHD in girls and highlight a pivotal link between family dynamics and the spectrum of ADHD-related behaviors. They also indicate that inattentive symptoms may be equally challenging to parents as hyperactive/impulsive symptoms.

Process, mechanism, and explanation related to externalizing behavior in developmental psychopathology

Advances in conceptualization and statistical modeling, on the one hand, and enhanced appreciation of transactional pathways, gene-environment correlations and interactions, and moderator and mediator variables, on the other, have heightened awareness of the need to consider factors and processes that explain the development and maintenance of psychopathology. With a focus on attentional problems, impulsivity, and disruptive behavior patterns, I address the kinds of conceptual approaches most likely to lead to advances regarding explanatory models in the field. Findings from my own research program on processes and mechanisms reveal both promise and limitations. Progress will emanate from use of genetically informative designs, blends of variable and person-centered research, explicit testing of developmental processes, systematic approaches to moderation and mediation, exploitation of "natural experiments," and the conduct of prevention and intervention trials designed to accentuate explanation as well as outcome. In all, breakthroughs will occur only with advances in translational research-linking basic and applied science-and with the further development of transactional, systemic approaches to explanation.

Responsiveness in interactions of mothers and sons with ADHD: relations to maternal and child characteristics

We observed mother-child interactions, at baseline, in 136 families of 7-10-year-old boys with attention-deficit/hyperactivity disorder (ADHD) who were part of a large clinical trial, the Multimodal Treatment Study of Children with ADHD. Independent coders rated stylistic aspects of maternal behavior and factor analyses revealed a responsiveness factor that included overall responsiveness and sensitivity to the child, warmth and acceptance, and appropriate control. We examined relations between maternal responsiveness and (a) maternal depressive symptoms and maternal childhood ADHD symptoms, and (b) boys' ADHD and conduct problem symptoms. Controlling for all other variables, maternal responsiveness displayed a unique negative association with mother-reported child conduct problems, but not with child ADHD symptoms, and also was negatively related to maternal depressive symptoms. We discuss the unique association between mother-reported child conduct problems and parenting, and note the utility of studying parenting style in families of children with ADHD. We describe the results within the framework of a transactional model.

Attention and conduct problems in children exposed to family violence

This study examines the impact of family violence on the development of attention and conduct problems in girls and boys. Mothers (n = 287) were interviewed and given diagnostic assessment instruments to measure attention deficit/hyperactivity disorder and conduct disorder in 1 of their children. Six years later, youths were interviewed about their delinquent behavior. Family violence related to attention and conduct problems in girls only. Girls who displayed these problems in childhood were not necessarily at risk for later delinquency. Family violence in childhood had a direct effect on delinquency in girls. Boys who developed attention problems were more likely to show conduct problems that eventually led to adolescent delinquency. Family violence failed to account for problems or delinquency in boys.

Mutter-Kind-Interaktion und externalisierende Störungen bei Kindern im Grundschulalter

Zusammenfassung: Fragestellung: Das Verhalten von achtjährigen Kindern mit externalisierenden Störungen (hyperkinetische Störung und Störung des Sozialverhaltens) in der Interaktion mit ihren Müttern wurde untersucht. Methodik/Ergebnisse: Im univariaten Vergleich waren Mütter in der Interaktion mit ihren hyperkinetischen Kindern restriktiver, abwertender und weniger angemessen als Mütter unauffälliger Kinder, während sich die Kinder unaufmerksamer und impulsiver sowie weniger assertiv und hilflos verhielten. Kinder mit einer Störung des Sozialverhaltens waren in der Interaktion mit ihren Müttern abwertender, aggressiver und provokativer als unauffällige Kinder, während die Mütter mehr Ungeduld zeigten. Schlussfolgerung: Eine Interaktion zwischen aggressivem Kindverhalten und Restriktivität der Mutter trug zu vermehrten dissozialen Symptomen bei. Eine höhere Zahl hyperkinetischer Symptome wurde durch die Interaktion zwischen impulsivem Kindverhalten und mütterlicher Aversivität begünstigt.

Families of children with attention-deficit/hyperactivity disorder: review and recommendations for future research

This review integrates and critically evaluates what is known about family characteristics associated with childhood Attention-Deficit/Hyperactivity Disorder (ADHD). Evidence suggests that the presence of ADHD in children is associated to varying degrees with disturbances in family and marital functioning, disrupted parent-child relationships, specific patterns of parental cognitions about child behavior and reduced parenting self-efficacy, and increased levels of parenting stress and parental psychopathology, particularly when ADHD is comorbid with conduct problems. However, the review reveals that little is known about the developmental mechanisms that underlie these associations, or the pathways through which child and family characteristics transact to exert their influences over time. In addition, the influence of factors such as gender, culture, and ADHD subtype on the association between ADHD and family factors remains largely unknown. We conclude with recommendations regarding the necessity for research that will inform a developmental psychopathology perspective of ADHD.

Overt and covert dimensions of antisocial behavior in early childhood

The present study was designed to assess both the prevalence and structure of antisocial behavior in a normative sample of preschoolers. Prevalence estimates suggested that 40% of preschoolers exhibit at least one antisocial behavior each day. Furthermore, 10% of preschoolers exhibit six or more antisocial behaviors each day. Consistent with research based on older children, factor analyses provided support for conceptualizing antisocial behavior in early childhood as consisting of both overt and covert dimensions. While both overt and covert behaviors had acceptable test-retest reliability, only overt behaviors had acceptable interrater reliability. Finally both overt and covert dimensions of antisocial behavior were uniquely related to general measures of conduct problems, hyperactivity, and adult and peer conflict in the classroom setting. Findings are discussed with regard to early assessment and the developmental course of antisocial behavior.

Parenting and family stress treatment outcomes in attention deficit hyperactivity disorder (ADHD): an empirical analysis in the MTA study

Parenting and family stress treatment outcomes in the MTA study were examined. Male and female (579), 7-9-year-old children with combined type Attention Deficit Hyperactivity Disorder (ADHD), were recruited at six sites around the United States and Canada, and randomly assigned to one of four groups: intensive, multi-faceted behavior therapy program alone (Beh); carefully titrated and monitored medication management strategy alone (MedMgt); a well-integrated combination of the two (Comb); or a community comparison group (CC). Treatment occurred over 14 months, and assessments were taken at baseline, 3, 9, and 14 months. Parenting behavior and family stress were assessed using parent-report and child-report inventories. Results showed that Beh alone, MedMgt alone, and Comb produced significantly greater decreases in a parent-rated measure of negative parenting, Negative/Ineffective Discipline, than did standard community treatment. The three MTA treatments did not differ significantly from each other on this domain. No differences were noted among the four groups on positive parenting or on family stress variables. Results are discussed in terms of the theoretical and empirically documented importance of negative parenting in the symptoms, comorbidities and long-term outcomes of ADHD.

Psychosocial treatment strategies in the MTA study: rationale, methods, and critical issues in design and implementation

The Collaborative Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder (ADHD), the MTA, is the first multisite, cooperative agreement treatment study of children, and the largest psychiatric/psychological treatment trial ever conducted by the National Institute of Mental Health. It examines the effectiveness of Medication vs. Psychosocial treatment vs. their combination for treatment of ADHD and compares these experimental arms to each other and to routine community care. In a parallel group design, 579 (male and female) ADHD children, aged 7-9 years, 11 months, were randomly assigned to one of the four experimental arms, and then received 14 months of prescribed treatment (or community care) with periodic reassessments. After delineating the theoretical and empirical rationales for Psychosocial treatment of ADHD, we describe the MTA's Psychosocial Treatment strategy applied to all children in two of the four experimental arms (Psychosocial treatment alone; Combined treatment). Psychosocial treatment consisted of three major components: a Parent Training component, a two-part School Intervention component, and a child treatment component anchored in an intensive Summer Treatment Program. Components were selected based on evidence of treatment efficacy and because they address comprehensive symptom targets, settings, comorbidities, and functional domains. We delineate key conceptual and logistical issues faced by clinical researchers in design and implementation of Psychosocial research with examples of how these issues were addressed in the MTA study.

Emotion regulation and parenting in AD/HD and comparison boys: linkages with social behaviors and peer preference

Children's emotion regulation strategies and parenting responses in a family task that elicited frustration are investigated by comparing core attention-deficit/hyperactivity disorder (AD/HD) symptomatology, emotional reactivity, and emotional regulation in the prediction of social behaviors and peer social preference. Participants were boys, ages 6-12 years, either with AD/HD (n = 45) or without problem behaviors (comparison; n = 34). A high-aggressive subgroup of AD/HD boys showed a significantly less constructive pattern of emotional coping than did both a low-aggressive AD/HD subgroup of boys and nondiagnosed comparison boys, who did not differ. With statistical control of core AD/HD symptomatology, noncompliance in a naturalistic summer camp was predicted by boys' overall emotion regulation and three specific strategies (emotional accommodation, problem solving, negative responses) during the parent-child interaction. Emotional accommodation and negative responses to the frustration task also marginally predicted social preference at the camp. These emotion regulation variables outperformed emotional reactivity in predicting such outcomes. Some emotion-related parenting behaviors were associated with child coping in the task. We discuss the relationship of emotion regulation to core AD/HD symptomatology and emotional reactivity, and the role of parents' behaviors in influencing children's emotional responses.

Hormonal and behavioral homeostasis in boys at risk for substance abuse

This study modeled the influences of cortisol reactivity, androgens, age-corrected pubertal status, parental personality, family and peer dysfunction on behavioral self-regulation (BSR), in boys at high (HAR) and low average risk (LAR) for substance abuse. Differences between risk groups in cortisol and androgen concentrations, and cortisol reactivity were also examined. Subjects were 10- through 12-year-old sons of substance abusing fathers (HAR; n = 150) and normal controls (LAR; n = 147). A multidimensional construct of BSR was developed which utilized multiple measures and multiple informants. Boys reported on family dysfunction and deviant behavior among their peers. Parents reported on their propensity to physically abuse their sons, and their own number of DSM-III-R Antisocial Personality Disorder symptoms. Endocrine measures included plasma testosterone, dihydrotestosterone, and salivary cortisol. HAR boys, compared to LAR boys, had lower mean concentrations for testosterone, dihydrotestosterone, salivary cortisol prior to evoked related potential testing, and lower cortisol reactivity. The number of maternal Antisocial Personality Disorder symptoms, parental potential for physical abuse, degree of family dysfunction, and peer delinquency were significantly associated with BSR. Parental aggression antisocial personality symptoms and parental physical abuse potential are likely to influence sons' behavioral dysregulation and homeostatic stress reactivity. These key components of liability are posited to increase the likelihood of developing suprathreshold Psychoactive Substance Use Disorder (PSUD).

Family and peer correlates of behavioral self-regulation in boys at risk for substance abuse

Behavioral self-regulation (BSR), defined herein as the degree to which one can control one's own activity and reactivity to environmental stimuli, has been posited to be salient to the onset of adolescent substance abuse. The goal of this study was to clarify particular family and peer correlates of BSR in at-risk sons. Subjects were 10-through 12-year-old sons of substance-abusing fathers (high-average risk [HAR]; n = 176) and normal controls (low-average risk [LAR]; n = 199). A BSR latent trait was developed using multiple measures and multiple informants. Analyses included separate hierarchical linear regressions for HAR and LAR groups. In the hierarchical linear model for HAR sons, family dysfunction and deviant peer affiliation were significantly associated with BSR, whereas for LAR sons, only peer affiliation was significantly associated with BSR. The above family and peer correlates differed in proportions of variance explained for BSR in HAR and LAR sons. These findings extend previous studies by showing that, in a hierarchical linear model, BSR in HAR sons is associated with specific interpersonal, family, and peer factors. These findings suggest that empirical, theory-guided interventions to prevent worsening of BSR in HAR boys should address specific interpersonal, family, and peer factors.

Outlasting disruption: the process of reinvestment in families with ADHD children

The goal of the research described in this article was to generate a grounded theory of how parents of children with attention deficit hyperactivity disorder (ADHD) coped with this chronic behavioral disorder. Interview data from 15 families with ADHD children (N = 59) were analyzed using the grounded theory method. Data analysis revealed that parents outlasted the disruption of ADHD through three subprocesses of "reinvesting": making sense, recasting biography, and relinquishing the "good ending." Findings suggest that there is a developmental trajectory of how parents adjust to the disorder over time and that there is a need for increased social and mental health services for all members of the family over the course of the disorder.

Peer Status in Boys With and Without Attention-Deficit Hyperactivity Disorder: Predictions from Overt and Covert Antisocial Behavior, Social Isolation, and Authoritative Parenting Beliefs

Because of the centrality of peer relationship difficulties for children with attentiondeficit hyperactivity disorder (ADHD), we investigated behavioral (overt and covert antisocial activity), internalizing (self-reports and observed social isolation), and familial (authoritative, authoritarian, and permissive parenting beliefs) predictors of peer sociometric nominations among previously unfamiliar, ethnically diverse ADHD (N=73) and comparison (N=60) boys, aged 6-12 years. Authoritative maternal parenting beliefs and negatively weighted social isolation explained significant variance in positive peer regard; aggression, covert behavior, and authoritative parenting beliefs were the independent predictors of both negative peer status and peer social preference. We extended such predictions with statistical control of (1) child cognitive variables, (2) maternal psychopathology, and (3) ADHD boys, but authoritative parenting beliefs were stronger predictors in ADHD than in comparison youth. We discuss family-peer linkages regarding peer competence.

Covert visual spatial attention in boys with attention deficit hyperactivity disorder: lateral effects, methylphenidate response and results for parents

We report three related studies of covert visual spatial orienting in child attention deficit hyperactivity disorder (ADHD). In Study 1, we examined covert visual spatial orienting in ADHD and comparison boys, Study 2 comprised a dose-response study of methylphenidate for the ADHD group, and Study 3 was an investigation of biological and adoptive parents. In contrast with comparison subjects (n = 17). ADHD boys aged 6-12 (n = 27) showed both slower reaction times overall and within-condition (lateral) asymmetries in reaction times. Specifically, boys with ADHD reacted more slowly to uncued targets in the left visual field than in the right visual field. Responses to stimuli in the two visual fields were differentially affected by methylphenidate for the ADHD group. Medication equalized visual field responses to the uncued targets, resulting in a significant cue x dose x visual field interaction. Further, medication altered the relative cue responsivity in the two visual fields, resulting in a significant dose x visual field interaction for the Validity Effect. Biological parents of ADHD boys (n = 16) also showed slower reaction times to uncued left visual field targets than to right visual field targets; in addition they showed slower response to invalidity cued targets in the right visual field. These literal effects were not observed in adoptive parents of ADHD boys (n = 12) or biological parents of comparison boys (n = 14). Possible abnormal hemispheric asymmetry of attention functions in boys with ADHD and their biological parents is discussed.