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

Sleep and internalizing problems in primary school children with attention-deficit hyperactivity disorder

BACKGROUND

Internalizing and externalizing problems have received great attention, and children with ADHD exhibit high rates of comorbid internalizing and externalizing disorders. This study aimed to explore the relationship between sleep and internalizing problems in children with attention-deficit hyperactivity disorder (ADHD) and the probable mediating role of externalizing problems.

METHODS

A total of 203 primary school children diagnosed with ADHD for the first time were recruited for this study. Children with ADHD were evaluated by Children's Sleep Habits Questionnaire (CSHQ), Strengths and Difficulties Questionnaire (SDQ). Internalizing problems were represented by emotional symptoms and peer problems of SDQ, and externalizing problems were represented by conduct problems and hyperactivity-inattention problems of SDQ. Multi-step linear regression analysis was used to investigate the mediating effect of externalizing problems on the relationship between sleep and internalizing problems.

RESULTS

Sleep in children with ADHD was associated with emotional problems in internalizing problems, and conduct problems in externalizing problems mediated the association between sleep and emotional problems.

CONCLUSION

For children with ADHD, when it is difficult to identify internalizing problems, especially emotional problems, we can take sleep and externalizing problems as clues to improve our clinical ability to recognize and deal with emotional problems.

IMPACT

1. We first explored the possible mediating role of conduct problems between sleep and emotional problems in primary school children with ADHD. 2. When it is difficult to identify internalizing problems, especially emotional problems, we can take sleep and externalizing problems as clues to improve our clinical ability to recognize emotional problems for children with ADHD. 3. For children with ADHD with potential internalizing problems, especially emotional problems, interventions for their sleep and externalizing problems may be the possible methods to deal with.

Children's Daily Living Routine Mediates the Relations Between Parent-Child Relationships and Child Adjustment Problems During School Suspension in Hong Kong

Young children's adjustment problems were found to be prevalent during the COVID-19 pandemic. Such adjustment problems may be dependent on children's relationships with their parents and children's daily living routine in the family during the pandemic-related school suspension period. This study examines how children's routine mediated the associations between parent-child relationships and child adjustment problems during the fifth wave of the COVID-19 pandemic in Hong Kong, when schools were suspended. The study collected data from 937 parents (87.8% mothers) of children aged 5-12 (M = 7.35 years, SD = 2.09; 50.5% girls). Parents reported on parent-child relationships, children's daily living routine, and child adjustment problems in an online survey. Our findings from structural equation modeling indicate that parent-child closeness was negatively related to child adjustment problems, whereas conflict was positively related to child adjustment problems. Children's routine mediated the associations between parent-child relationships (i.e., closeness and conflict) and child externalizing problems. However, children's routine did not mediate the associations between parent-child relationships (i.e., closeness and conflict) and child internalizing problems. The findings show that parents should be helped to establish routine, especially in difficult times when young children experience turbulence in their daily life, so as to reduce their adjustment problems, in particular of an externalizing nature.

Meta-Analyses of the Relationships between Family Systems Practices, Parents' Psychological Health, and Parenting Quality

(1) Background: Family systems theories include assertations that both personal and environmental factors are determinants of parents' psychological health, well-being, and parenting quality. Applied family systems theories focus on determinants that can be operationalized as intervention practices. The analyses described in this paper focused on the direct and indirect effects of four family systems practices (family needs, resources, supports, and strengths), parents' psychological health (depression, well-being, etc.), and parenting quality (parenting beliefs, involvement, and practices) in families of children with identified disabilities, medical conditions, or at-risk conditions for poor outcomes; (2) Methods: Data from previously completed meta-analyses of the relationships between family systems practices and parents' psychological health outcomes and parenting quality outcomes were reanalyzed. Next, a meta-analysis of the relationships between parents' psychological health and parenting quality was completed to identify which predictors were related to which parenting quality outcomes. Both main effects and mediated effects were examined; (3) Results: The four family systems practices were each related to six different psychological health measures and three parenting quality measures. The six different parental psychological health measures were also related to the three parenting quality measures. The relationships between family systems practices and parenting quality were partially mediated by parents' psychological health; (4) Conclusions: The effects of family systems practices and parents' psychological health on parenting quality were primarily direct and independent. The relationships between family systems practices and parenting quality were partially mediated by parents' psychological health. Future research should focus on the identification of other mediator variables found to be important for explaining the indirect effects of family systems practices measures on parenting beliefs, behavior, and practices.

School-Age Child Routines: Adaptation and Validation Studies of the Portuguese Version of the Child Routines Questionnaire

Child routines have been recognized as positive contributors to children's development. However, in Portugal there is still a lack of instruments available to assess school-age child routines. The purpose of this study was to present the translation, adaptation, and validation studies of the Portuguese version of the Child Routines Questionnaire (CRQ), a parent self-report measure developed to assess school-age child routines. A total of 460 parents of children aged between 6 and 12 years-old participated in the study. Two studies were conducted to define the CRQ-PT factor structure. In Study 1 (n = 204 children from 6 to 12 years-old), findings from the exploratory factor analysis provided evidence for a four-factor structure (for 32 items), which explained 43.53% of the total variance. In Study 2 (n = 256 children from 6 to 9 years-old), results from confirmatory factor analysis showed good model fit indices (CFI = 0.84, RMSEA = 0.06). The total scale of the CRQ-PT (α = 0.89) and its subscales showed good internal consistency. Further evidence of construct validity was shown by weak to moderate correlations with measures of parental sense of competence and family mealtime routines. Relevant contributions of the study are underscored, namely the availability and usefulness of a reliable and valid assessment tool to evaluate the routines of Portuguese school-age children for clinical practice and research purposes.

The Impact of Internalizing Symptoms on Impairment for Children With ADHD: A Strength-Based Perspective

BACKGROUND/PURPOSE

This study aims to investigate the influence of internalizing symptoms on functional impairment for children with ADHD, and whether child strengths and parenting strengths have moderating effects on this relationship.

METHODS

Participants included 209 children with ADHD and their caregivers seeking mental health services between the ages of 5 and 11 years. To examine the moderating effects of parenting and child strengths, ordinary least squares regression models were tested using the PROCESS macro for SPSS (v3.5).

RESULTS

Results suggest that levels of internalizing symptoms influence functional impairment in children with ADHD. Child strengths moderate the relationship between internalizing symptoms and functional impairment when internalizing symptoms are medium to high.

CONCLUSION

Findings from this study demonstrate that facilitating child strengths can help moderate functional impairment for children who experience ADHD and internalizing symptoms.

The impact of the COVID-19 pandemic on the mental health of families dealing with attention-deficit hyperactivity disorder

BACKGROUND

The COVID-19 pandemic uprooted regular routines forcing many children to learn from home, requiring many adults to work from home, and cutting families off from support outside the home. Public health restrictions associated with the pandemic caused widespread psychological distress including depression and anxiety, increased fear, panic, and stress. These trends are particularly concerning for families raising neuroatypical children such as those with Attention-Deficit Hyperactivity Disorder (ADHD), as these children are already more likely than their typically developing peers to experience comorbid mental health issues, and to experience greater distress when required to stay indoors. Families with children who have ADHD are also at greater risk for experiencing heightened familial stress due to the challenges associated with managing ADHD behavioural symptoms, greater parental discord and divorce, and greater financial difficulties compared to other families. The current study engaged families comprised of at least one child diagnosed with ADHD to elucidate 1) the unique ways that the COVID-19 pandemic affected their mental health and 2) the specific barriers these families faced to maintaining optimal mental wellbeing.

METHODS AND FINDINGS

A total of 33 participants (15 parent-child dyads) engaged in virtual interviews. Content analysis revealed that the most frequently identified mental health effects for families were increased child anxiety and disconnectedness, as well as deteriorating parental mental health. The most frequently identified barriers to maintaining optimal mental wellbeing were lack of routine, lack of social interaction and social supports, and uncertainty and fear.

CONCLUSIONS

Findings underscore areas of need during times of large-scale social isolation, specifically for families with children who have ADHD. This work contributes to a growing body of research aimed at creating safeguards to support mental wellbeing for vulnerable families during times of crisis.

Young Adult Routines Inventory (YARI): Development and Initial Validation

Young adulthood is characterized by important life transitions (e.g., college, employment, relocation, marriage), where time management skills and routines help promote positive adjustment. Routines are observable, repetitive behavior that are context specific and automate aspects of daily life (e.g., personal hygiene, health, occupational, academic). Although measures of routines exist for children, adolescents, and older adults, similar measures assessing young adult routines are lacking. The purpose of this study was to develop and initially validate The Young Adult Routines Inventory (YARI). Analyses revealed a four-factor measure reflecting daily routines, social routines, time management, and procrastination. The YARI demonstrates good internal consistency, construct, and convergent validity, and was positively correlated with measures of emotional well-being and perceived life satisfaction. The YARI was negatively correlated with self-reported symptoms of Attention-Deficit/Hyperactivity Disorder (ADHD) and successfully distinguished individuals with and without ADHD symptomatology. Preliminary evidence suggests the YARI is a promising measure of young adult routines.

Parental Factors That Confer Risk and Resilience for Remote Learning Outcomes During the COVID-19 Pandemic Among Children With and Without Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

To test whether parental factors including internalizing symptoms, parenting style, and confidence in assisting with remote learning conferred risk/resilience for children with/without ADHD's learning and emotional outcomes during the COVID-19 pandemic.

METHOD

291 parents of children (ages 6-13; n = 180 males) with (n = 148) and without ADHD completed questionnaires online (April-July 2020).

RESULTS

Structural equation modeling identified parental risk/resilience factors. Across groups, risk predicted greater difficulties with learning, internalizing and externalizing symptoms, while parent confidence in educating their child predicted better outcomes. A positive association was observed between parental involvement and child difficulties, which was stronger in families of children with ADHD. Children with/without ADHD did not differ in remote learning difficulties.

CONCLUSION

Parent factors impacted child emotional and learning outcomes during the pandemic. With increases in remote learning practices, there is a need for improved understanding of how parent factors impact outcomes of children with/without ADHD.

Externalizing and Internalizing Behaviors in Children with ADHD during Lockdown for COVID-19: The Role of Parental Emotions, Parenting Strategies, and Breaking Lockdown Rules

Lockdown experience for COVID-19 pandemic significantly affected children and adolescents with Attention-Deficit/Hyperactivity Disorder (ADHD) exacerbating or promoting the onset of externalizing and internalizing symptoms. However, few studies have considered how externalizing and internalizing behaviors changed in relation to parental emotions and parenting strategies. In the present study, 992 caregivers of children and adolescents with ADHD from 5 to 18 years were presented with an online survey evaluating youths’ externalizing and internalizing behaviors, their non-compliance with lockdown rules, and parental factors related to parental emotions and parenting strategies. Two hierarchical linear regression models were performed to examine the contribution of children’s non-compliance with lockdown rules, parental emotions, and parenting strategies on children’s externalizing and internalizing behaviors. Results revealed that externalizing behaviors were higher in children and adolescents with ADHD non-compliant with lockdown rules. Moreover, positive parenting strategies moderated the relationship between non-compliance with lockdown rules and externalizing behaviors. Differently, higher internalizing behaviors were observed in children with ADHD who had parents reporting more negative emotions and positive parenting strategies. In this case, parents’ negative emotions had a moderator effect in the association between internalizing behaviors and non-compliance to lockdown measures. The clinical implications of these two different patterns of relations are discussed.

Impact of COVID-19-related Stress on Preschool Children's Internalizing and Externalizing Problem Behaviors: The Indirect Effect of Mother's Depression and Parenting Behavior

The COVID-19 pandemic is affecting families and children worldwide. Experiencing the pandemic leads to stress in families resulting from fear of infection and social isolation derived from social distancing. For families raising preschoolers, the prolonged closure of childcare centers puts additional childcare burden on family members, especially mothers. Due to the limited research exploring the impact of COVID-19 on preschool children's problem behaviors, this study examines the association between stress due to COVID-19 and preschool children's internalizing and externalizing problem behaviors related to mother's depression and parenting behavior. The study sample included data collected from 316 South Korean mothers raising preschool-aged children aged 3 to 5. The study findings suggest that mother's COVID-19 stress was indirectly associated with preschool children's internalizing and externalizing problem behaviors resulting from the mother's depression and parenting behaviors, although the direct effect of COVID-19 stress on preschool children's outcomes was not statistically significant. Increase in mother's COVID-19 stress was associated with increase in depression, and sequentially decreased positive parenting behaviors, which in turn resulted in preschool children's internalizing and externalizing problem behaviors. The study findings highlight the need to focus on enhancing mental health of mothers and preschool children's adjustment by implementing supportive interventions to reduce the adverse impacts of the prolonged COVID-19 pandemic.

It took a pandemic: Perspectives on impact, stress, and telehealth from caregivers of people with autism

Shelter in place mandates due to the COVID-19 pandemic left caregivers to determine how to best meet the therapeutic requirements of their children with autism spectrum disorder (ASD). Understanding the challenges faced by families, and their experiences using telehealth for the first time, may help make services sustainable in future public health emergencies. A sample of 70 caregivers of people with ASD from across the US completed an anonymous online survey. Results indicate that impaired emotion regulation was a primary contributor of parent-reported stress for persons with ASD during the pandemic, while loss of established structure and routine contributed to parental stress. Nearly half the sample reported using telehealth for the first time. Many caregivers were appreciative that telehealth permitted continuation of services, but expressed concerns about limited effectiveness due in part to their children's social communication problems.