The role of maternal and child ADHD symptoms in shaping interpersonal relationships

Functional Impairments Associated With ADHD in Adulthood and the Impact of Pharmacological Treatment

OBJECTIVE

Among untreated adults, functional impairments associated with ADHD are widespread and cumulative, and can include social, educational, and professional impairments, increased risk of accidents and mortality, and reduced quality of life. Here, we review the most prominent functional impairments in adults with ADHD and summarize evidence describing the potential role of medication in improving outcomes.

METHOD

Articles related to the search terms "ADHD," "adult," and functional impairments were identified through Google Scholar and PubMed and selected for inclusion based on four criteria: strength of evidence, relevance to current challenges in adult ADHD, impact on the field, and recency of the results.

RESULTS

We identified 179 papers to support the conclusions on the relationship between ADHD and functional impairments, and the impact of pharmacological therapy on functional impairments.

CONCLUSION

This narrative review provides evidence that pharmacological treatment can be effective in minimizing not only the symptoms of ADHD, but its functional consequences as well.

The impact of preschool child and maternal attention-deficit/hyperactivity disorder (ADHD) symptoms on mothers' perceived chronic stress and hair cortisol

Providing care for a child with attention-deficit/hyperactivity disorder (ADHD) is associated with parenting stress. Moreover, adults with elevated ADHD symptoms report increased perceived stress. Despite this, it has rarely been examined whether and how child and maternal ADHD symptoms may affect maternal perceived stress and the stress-sensitive hypothalamic–pituitary–adrenal axis. This study therefore investigated the possible impact of child and maternal ADHD symptoms on mothers' perceived chronic stress and hair cortisol concentration (HCC), while simultaneously considering the effects of child oppositional defiant/conduct disorder (ODD/CD) and maternal depressive symptomatology. In total, 124 mothers (35.96 ± 5.21 years) of preschool children were included. Maternal perceived stress, ADHD and depressive symptoms were assessed using self-report measures. Child ADHD symptoms were assessed using an interview and questionnaires completed by mothers and teachers. Additionally, mothers provided information about their children’s ODD/CD symptoms. Hair samples were taken from mothers to assess HCC. Child and maternal ADHD, child ODD/CD, and maternal depressive symptoms accounted for 50% of the variance in perceived chronic stress (F(4, 119) = 30.24; p < 0.01), with only maternal ADHD (β = 0.52, p < 0.01) and depressive symptoms (β = 0.49, p < 0.01) being uniquely significant. Maternal ADHD symptoms did not moderate the relationship between child ADHD symptoms and maternal perceived chronic stress (b = − 0.01; SE b = 0.17; t(5, 118) = − 0.05; p = 0.96). Mother’s age became the only significant predictor of maternal HCC (β = 0.29; p < 0.01). Based on these findings, practitioners are advised to be aware of and take into account possible maternal ADHD and depressive symptomatology and perceived chronic stress when treating children diagnosed with ADHD.

Does helping mothers in multigenerational ADHD also help children in the long run? 2-year follow-up from baseline of the AIMAC randomized controlled multicentre trial

ADHD often affects multiple generations in a family. Previous studies suggested that children with ADHD benefit less from therapy if parents are also affected, since ADHD symptoms interfere with treatment implementation. This two-group randomised controlled trial examined whether targeting maternal ADHD boosts the efficacy of parent-child training (PCT) for the child's ADHD. Here, we report follow-up results 2 years from baseline. Mothers of 144 mother-child dyads (ADHD according to DSM-IV) were examined for eligibility (T1) and randomised to 12 weeks of intensive multimodal treatment comprising pharmacotherapy and DBT-based cognitive behavioural group psychotherapy (TG, n = 77) or clinical management comprising non-specific counselling (CG, n = 67) for Step 1 (concluded by T2). Subsequently, all dyads participated in 12 weekly PCT sessions for Step 2 (concluded by T3). In Step 3, participants received maintenance treatments for 6 months (concluded by T4). At 24 months after baseline (T5), we performed follow-up assessments. The primary endpoint was child ADHD/ODD score (observer blind rating). Outcomes at T5 were evaluated using ANCOVA. Assessments from 101 children and 95 mothers were available at T5. Adjusted means (m) of ADHD/ODD symptoms (range 0-26) in children did not differ between TG and CG (mean difference = 1.0; 95% CI 1.2-3.1). The maternal advantage of TG over CG on the CAARS-O:L ADHD index (range 0-36) disappeared at T5 (mean difference = 0.2; 95% CI - 2.3 to 2.6). Sensitivity analyses controlling for medication and significant predictors of follow-up participation showed unchanged outcomes. Within-group outcomes remained improved from baseline. At the 24-month follow-up, TG and CG converged. The superiority of intensive treatment regarding maternal symptoms disappeared. In general, cross-generational treatment seems to be effective in the long term. (BMBF grant 01GV0605; registration ISRCTN73911400).

Do Parents' ADHD Symptoms Affect Treatment for their Children? The Impact of Parental ADHD on Adherence to Behavioral Parent Training for Childhood ADHD

Nearly half of all youth with Attention-Deficit Hyperactivity Disorder (ADHD) have at least one parent who also meets criteria for the disorder, and intergenerational ADHD is a significant risk factor for poor outcomes following evidence-based behavioral parent training (BPT) programs. Given that BPT is predicated on consistent parental involvement, symptoms of ADHD in parents may be a significant barrier to effective engagement with BPT treatment. In the present investigation, we examine the effect of parental ADHD symptoms on BPT treatment engagement for children with ADHD-predominantly inattentive presentation (N = 148, ages 7-11). We examine the following parent- and clinician-rated treatment engagement domains: between-session skill adherence, in-session participation, perceived skill understanding, treatment-engagement attitudes, and session attendance. Parent- and clinician-rated between-session adherence was the only treatment engagement domain related significantly to parental ADHD symptoms. This finding was robust and remained even after accounting for symptoms of parental anxiety and depression, child ADHD symptom severity, and various sociodemographic factors (parental education level, household income, employment status, and being a single parent). These findings suggest that targeting parental ADHD symptoms in the context of parenting interventions may be a promising approach for improving adherence and treatment outcomes for BPT interventions.

Testing the Similarity Fit/Misfit Hypothesis in Adolescents and Parents With ADHD

OBJECTIVE

Higher rates of conflict are observed between adolescents with ADHD and their parents due to cognitive, academic, social, and behavioral difficulties. Conflict should be even more pronounced when parents have ADHD themselves; however, some research suggests that parents with ADHD may have increased tolerance toward children who share similar challenges (i.e., similarity-fit hypothesis).

METHOD

We tested the similarity-fit model and its converse, the similarity-misfit model, in a sample of 93 ADHD adolescents, 63 comparison adolescents, and their parents with varying levels of ADHD. Quantity and intensity of conflict were examined in mothers and fathers separately.

RESULTS

We found evidence for the similarity-fit process in fathers, and similarity misfit in mothers, particularly regarding quantity of conflict between parent and adolescent.

CONCLUSION

Results indicate the importance of differential parental roles in mothers and fathers, and have implications for involving parents in treatment for ADHD in adolescents.

Factors Associated with Healthy and Impaired Social Functioning in Young Adolescents with ADHD

There is variability in the extent to which adolescents with attention-deficit/hyperactivity disorder (ADHD) exhibit social impairment, as the same diagnosis does not necessarily entail impairment in the same area(s) of functioning. The current study entailed a cross-sectional examination of enhancers to healthy social functioning and risk factors to parent- and self-rated social impairment in 324 middle school youth (ages 10-14 years) with ADHD. A series of binary logistic regression analyses were conducted to evaluate a risk-resilience model for social functioning, including testing compensatory (i.e., main; buffering) and protective (i.e., interaction) effects of enhancers in the presence of identified risk factors. Youth conduct problems, youth depression, and negative parenting emerged as risk factors. Self-rated social acceptance, activity participation (breadth and intensity), and parent involvement were enhancers of healthy social functioning. Of these enhancers, activity participation (breadth and intensity) and parent involvement showed buffering effects against the negative impact of the risk factors on social functioning. None of the enhancers displayed protective effects. The findings of this study enhance our understanding of the social functioning of young adolescents with ADHD, who comprise an understudied population relative to younger children with similar problems.

Parental ADHD symptoms and parenting behaviors: A meta-analytic review

Attention-deficit/hyperactivity disorder (ADHD) persists throughout the lifespan, and there are known impairments associated with adult ADHD. Understanding ADHD-related impairments in the parenting domain is particularly important given that the children of adults with ADHD also are likely to have ADHD, and there is potential for parenting to alter the developmental outcomes of these children. The present study quantitatively synthesizes evidence regarding the associations between parental ADHD symptoms and parenting behaviors. Across 32 studies, this meta-analysis found that parental ADHD symptoms accounted for 2.9%, 3.2%, and 0.5% of the variance of harsh, lax, and positive parenting, respectively. Greater parental ADHD symptoms were associated with less positive and more harsh and lax parenting behaviors. Variables, such as the proportion of children in the sample diagnosed with ADHD, child gender, and method/rater variance, moderated the strength of these relations. Results also suggest more similarities than differences in the associations between parenting behaviors and the two dimensions of inattention and hyperactivity/impulsivity symptoms. Overall, parental ADHD symptoms are significantly associated with parenting behaviors with effect sizes similar to the associations found between other parental psychopathologies and parenting, although the associations remain relatively small. The paper concludes with comments regarding remaining gaps in the literature that warrant further research and the clinical implications of the associations between parental ADHD symptoms and parenting.

Parent ADHD and Evidence-Based Treatment for Their Children: Review and Directions for Future Research

One fourth to one half of parents of children with attention-deficit/hyperactivity disorder (ADHD) have ADHD themselves, complicating delivery of evidence-based child behavioral and pharmacological treatments. In this article, we review the literature examining the relation between parent ADHD and outcomes following behavioral and pharmacological treatments for children with ADHD. We also review research that has incorporated treatment of parent ADHD (either alone or in combination with child treatment) with the goal of improving parenting and child outcomes. Finally, we offer recommendations for future research on the relation between parent ADHD and evidence-based treatment outcomes for their children, with the purpose of advancing the science and informing clinical care of these families.

Social Functioning in Children With or At Risk for Attention Deficit/Hyperactivity Disorder: A Meta-Analytic Review

Considerable work has demonstrated significant impairment in social functioning for children with attention deficit/hyperactivity disorder (ADHD). The social functioning profiles of children with ADHD are marked by impairments across diverse domains as they tend to experience greater rates of peer rejection, have lower levels of social skills, and have impaired social cognitions. The purpose of this study was to (a) quantitatively examine the association between ADHD and deficits across several domains of social functioning (peer functioning, social skills, social information processing), (b) examine differences in the magnitude of such associations, and (c) examine the effect of potential moderators. A meta-analysis of 109 studies (n = 104,813) revealed that children with ADHD have the most impairment within the peer functioning domain (weighted effect size [ES] r = .33) followed by significantly smaller effects within the social skills (weighted ES r = .27) and social information-processing domains (weighted ES r = .27). When examining potential moderators, results revealed that the association between ADHD and deficits within the social skills domain was weaker among studies that controlled for co-occurring conduct problems (CP). Studies that utilized sociometric and teacher reports of peer status reported the largest effects within the peer functioning domain. In addition, studies that utilized the "gold standard" approach to diagnosing ADHD documented the largest effects within both the social skills and peer functioning domains. Last, studies utilizing younger samples revealed the largest effects for deficits within the peer functioning domain. Theoretical and clinical implications are discussed.

Neurodevelopmental disorders are highly over-represented in children with obesity: A cross-sectional study

OBJECTIVE

To investigate prevalence of neurodevelopmental disorders in children with obesity and to compare body mass index (BMI) and metabolic profile in the children.

METHODS

Seventy-six children (37 girls, 39 boys) were consecutively recruited from a university outpatient clinic specialized in severe obesity. Neurodevelopmental disorders including attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), and developmental coordination disorder (DCD) were assessed using interviews and questionnaires. Neurodevelopmental diagnoses were collected retrospectively in medical records.

RESULTS

BMI ranged between 1.9 and 5.9 SDS and age between 5.1 and 16.5 years. In 13.2% and 18.4% ASD and ADHD was assigned, respectively. In addition, 25% screened positive for DCD, 31.6% had at least one neurodevelopmental disorder, and 18.4% had a parent who screened positive for adult ADHD. Girls with ASD/ADHD had higher BMI SDS than girls without neurodevelopmental disorder (P = 0.006).

CONCLUSIONS

One third of children with obesity referred to specialist centers have a neurodevelopmental disorder including deviant motor skills, and these problems may deteriorate weight status. One fifth of the parents exhibit ADHD symptomatology which could partly explain the poor adherence by some families in obesity units. Future obesity therapy could benefit from incorporating a neurodevelopmental treatment approach.

Mother-Child Communication: The Influence of ADHD Symptomatology and Executive Functioning on Paralinguistic Style

Paralinguistic style, involving features of speech such as pitch and volume, is an important aspect of one's communicative competence. However, little is known about the behavioral traits and cognitive skills that relate to these aspects of speech. This study examined the extent to which ADHD traits and executive functioning (EF) related to the paralinguistic styles of 8- to 12-year-old children and their mothers. Data was collected via parent report (ADHD traits), independent laboratory tasks of EF (working memory, inhibitory control, and cognitive flexibility), and an interactive problem-solving task (completed by mothers and children jointly) which was coded for paralinguistic speech elements (i.e., pitch level/variability; volume level/variability). Dyadic data analyses revealed that elevated ADHD traits in children were associated with a more exaggerated paralinguistic style (i.e., elevated and more variable pitch/volume) for both mothers and children. Mothers' paralinguistic style was additionally predicted by an interaction of mothers' and children's ADHD traits, such that mothers with elevated ADHD traits showed exaggerated paralinguistic styles particularly when their children also had elevated ADHD traits. Highlighting a cognitive mechanism, children with weaker inhibitory control showed more exaggerated paralinguistic styles.

Developmental trajectories of aggression, prosocial behavior, and social-cognitive problem solving in emerging adolescents with clinically elevated attention-deficit/hyperactivity disorder symptoms

Middle school is a critical yet understudied period of social behavioral risks and opportunities that may be particularly difficult for emerging adolescents with attention-deficit/hyperactivity disorder (ADHD) given their childhood social difficulties. Relatively few ADHD studies have examined social behavior and social-cognitive problem solving beyond the elementary years, or examined aspects of positive (prosocial) behavior. The current study examined how middle school students with clinically elevated ADHD symptoms differ from their non-ADHD peers on baseline (6th grade) and age-related changes in prosocial and aggressive behavior, and the extent to which social-cognitive problem solving strategies mediate these relations. Emerging adolescents with (n = 178) and without (n = 3,806) clinically elevated, teacher-reported ADHD-combined symptoms were compared longitudinally across 6th through 8th grades using parallel process latent growth curve modeling, accounting for student demographic characteristics, oppositional-defiant disorder (ODD) symptoms, deviant peer association, school climate, and parental monitoring. Sixth graders with elevated ADHD symptoms engaged in somewhat fewer prosocial behaviors (d = -0.44) and more aggressive behavior (d = 0.20) relative to their peers. These small social behavioral deficits decreased but were not normalized across the middle school years. Contrary to hypotheses, social-cognitive problem solving was not impaired in the ADHD group after accounting for co-occurring ODD symptoms and did not mediate the association between ADHD and social behavior during the middle school years. ADHD and social-cognitive problem solving contributed independently to social behavior, both in 6th grade and across the middle school years; the influence of social-cognitive problem solving on social behavior was highly similar for the ADHD and non-ADHD groups.

Child ADHD and ODD behavior interacts with parent ADHD symptoms to worsen parenting and interparental communication

Attention-deficit hyperactivity disorder (ADHD) in children and adults increases risk of parenting difficulties and interparental discord. However, little is known about whether disruptive child behavior and adult ADHD operate additively or synergistically to predict parenting and interparental relationship quality. As part of a larger study, 90 parent couples were randomly assigned to interact with a 9-12 year-old confederate child exhibiting either ADHD/ODD-like behavior or typical behavior. Before these interactions, parents reported their own ADHD symptoms. Afterwards, parents reported on their partner's parenting and interparental communication behavior. Observers coded the parenting and communication behavior of both partners during the tasks. Child ADHD/ODD-like behavior was found to predict less positive and more negative parenting and communication reported by partners and observers beyond adult ADHD symptoms and other covariates. Elevated adult ADHD symptoms only uniquely increased risk of observer-coded negative parenting. Child and adult ADHD behavior interacted synergistically to predict partner-reported negative parenting and interparental communication, such that parents reporting greater ADHD symptoms-especially inattentiveness-were rated by their partners as parenting and communicating more negatively when managing child ADHD/ODD-like behavior than parents with fewer ADHD symptoms or those managing typical child behavior. Child and adult ADHD behavior did not interact to predict observer-coded parenting or interparental communication, and patterns did not differ for mothers or fathers. Our results underscore the potential risk of parents with elevated ADHD symptoms parenting and communicating negatively, at least as perceived by their partners, during interactions with children exhibiting ADHD/ODD behavior.

Parenting in adults with attention-deficit/hyperactivity disorder (ADHD)

Although the validity of adult ADHD is well established and research has identified a variety of impairments associated with the condition in adults, study of how ADHD impacts an adult's ability to parent has been relatively neglected. Parenting is a particularly important domain of functioning given the familial nature of the disorder and emerging evidence that parenting behaviors play a role in the development or maintenance of child ADHD symptoms, comorbid psychopathologies, and other associated difficulties. In this paper, we focus on three broad categories of cognitive dysfunction proposed across models of ADHD - cognitive processes (e.g., working memory, planning, and inhibitory control), self-regulation deficits (e.g., self-monitoring of performance to detect errors or the need for regulation of behavior and/or emotions), and motivational or arousal difficulties (e.g., response to incentives, delay aversion). We consider how these deficits may lead to impairments in the parenting behaviors of effective behavioral control and emotional responsiveness, and review the available evidence regarding parenting in adults with ADHD symptoms. We conclude by noting the limitations in existing studies, and argue for further research that is theoretically grounded in how core deficits of ADHD may be related to dimensions of parenting. The implications of an improved understanding of how ADHD impacts parenting for the development of early intervention or prevention programs are outlined.

Parental attention-deficit/hyperactivity disorder predicts child and parent outcomes of parental friendship coaching treatment

OBJECTIVE

This study investigated the impact of parental attention-deficit/hyperactivity disorder (ADHD) symptoms on the peer relationships and parent-child interaction outcomes of children with ADHD among families completing a randomized controlled trial of parental friendship coaching (PFC) relative to control families.

METHOD

Participants were 62 children with ADHD (42 boys and 20 girls, 6 through 10 years old) and their parents. Approximately half of the families received PFC (a 3-month parent training intervention targeting the peer relationships of children with ADHD), and the remainder represented a no-treatment control group.

RESULTS

Parental inattention predicted equivalent declines in children's peer acceptance in both treatment and control families. However, treatment amplified differences between parents with high versus low ADHD symptoms for some outcomes: Control families declined in functioning regardless of parents' symptom levels. However, high parental inattention predicted increased child peer rejection and high parental inattention and impulsivity predicted decreased parental facilitation among treated families (indicating reduced treatment response). Low parental symptoms among treated families were associated with improved functioning in these areas. For other outcomes, treatment attenuated differences between parents with high versus low ADHD symptoms: Among control parents, high parental impulsivity was associated with increasing criticism over time, whereas all treated parents showed reduced criticism regardless of symptom levels. Follow-up analyses indicated that the parents experiencing poor treatment response are likely those with clinical levels of ADHD symptoms.

CONCLUSIONS

Results underscore the need to consider parental ADHD in parent training treatments for children with ADHD.