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Infant and Child DevelopmentInf. Child. Dev. 20: 148161 (2011)

Published online 12 April 2010 in Wiley Online Library

(wileyonlinelibrary.com). DOI: 10.1002/icd.682

Maternal Positive Parenting Style isAssociated with Better Functioningin Hyperactive/InattentivePreschool Children

Dione M. Healeya,, Janine D. Floryb,c, Carlin J. Millerd

and Jeffrey M. Halperinb,caDepartment of Psychology, University of Otago, Dunedin, New ZealandbDepartment of Psychology, Queens College of the City University of New York,Flushing, NY, USAcDepartment of Psychiatry, Mount Sinai School of Medicine, New York, NY, USAdDepartment of Psychology, University of Windsor, Windsor, Ont., Canada

Many preschoolers are highly inattentive, impulsive, and hyper-active; but only some are impaired in their functioning. Yet factorsleading to functional impairment, above and beyond the severityof inattentive and hyperactive symptoms, have not been system-atically examined. This study examined a model suggesting thatafter controlling for attention-deficit/hyperactivity disorder(ADHD) symptom severity, child temperament is uniquelyassociated with parenting stress; that parenting stress affectsparenting style, above and beyond child characteristics; thatparenting style is related to the level of child impairment, aboveand beyond the effects of child symptoms, temperament, andparenting stress; and finally that parenting style moderates the

relationship between ADHD symptom severity and child func-tioning. Child measures included parent- and teacher-ratedADHD symptom severity, teacher-rated temperament, and clin-ician-rated functioning in a sample of 138 inattentive/hyperactivepreschoolers. Maternal self-ratings of parenting style and parent-ing stress were obtained. Analyses indicated that, after controllingfor symptom severity, child temperament was related to maternalparenting stress, which was additionally related to both maternalparenting style and child functioning. Maternal positive parent-ing style moderated the relationship between ADHD symptomseverity and child impairment, indicating that a positive

parenting style plays a protective role in the functioning of


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hyperactive/inattentive preschoolers. Copyright r 2010 JohnWiley & Sons, Ltd.

Key words: ADHD; child temperament; maternal factors; childfunctioning

MATERNAL POSITIVE PARENTING STYLE IS ASSOCIATED WITHBETTER FUNCTIONING IN HYPERACTIVE/INATTENTIVEPRESCHOOL CHILDREN

Attention-deficit/hyperactivity disorder (ADHD) is a common and oftentimesdebilitating life-long psychiatric disorder associated with high levels of activity,impulsivity, and difficulties with sustained mental effort. According to the

DSM-IV, a diagnosis of ADHD requires symptoms to: (1) be present before 7years of age; (2) occur across two or more settings; and (3) cause significantimpairment in the individuals functioning (American Psychiatric Association,2000). It is important to note that without significant functional impairment (e.g.difficulties in making and keeping friends, disruptive at home and school,academic under achievement) as a result of the symptoms, a diagnosis cannot bemade. Moreover, the degree to which symptomatic individuals are impaired intheir functioning varies greatly; for instance Healey, Miller, Castelli, Marks, andHalperin (2008) examined the proportion of symptomatic preschoolers who metimpairment criteria using various cut-offs and found that only 2354% met bothsymptom and impairment criteria, depending on cut-off levels applied. Similarly,

in older children, Gordon et al. (2006) found that when imposing impairmentcriteria on a group who met the symptom criteria for ADHD, only 33% met thefull diagnostic criteria (i.e. symptoms and functional impairment). They alsoreported that correlations between symptoms and impairment were modest, at

best, and that symptom severity rarely accounted for more than 25% of thevariance in impairment. In line with this discrepancy between symptoms andimpairment, several studies have shown that treatment-induced reductions inADHD symptoms oftentimes do not ameliorate functional impairment inchildren with the diagnosis. For example, despite improved attention or reducedactivity levels following the use of medications, many children with ADHD

continue to have trouble making and keeping friends, have poor social skills, ordo poorly in school (Frankel, Myatt, Cantwell, & Feinberg, 1997; Pelham,Schnedler, Bologna, & Contreras, 1980). Thus, it is clear that symptom severityand impaired functioning are not completely overlapping. Yet little attention hasfocused on why some symptomatic children function quite poorly, while othersdo relatively well. As such, the field could profit considerably from a betterunderstanding of additional factors that are associated with impairment infunctioning so as to better assess and treat the wide array of deficits in everydayfunctioning that are experienced by children with ADHD.

A number of factors are known to be involved in child functioning. One im-portant contributor, particularly in young children, is temperament. An extensive

body of literature has demonstrated the link between temperament and psy-chopathology. Children with difficult temperaments have repeatedly been shownto develop more psychopathology than those with more easy going tempera-

Maternal Positive Parenting Style 149


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Parental characteristics have also frequently been linked to child functioning.Observational studies of parentchild interactions have shown that mothers ofchildren with ADHD are more controlling, more negative, and less socially in-teractive than mothers of children without ADHD (Barkley, Karlsson, & Pollard,

1985; Campbell, 1995; Johnston & Mash, 2001; Keown & Woodward, 2002;Winsler, 1998). Campbell, Shaw, and Gilliom (2000) found that those preschoolerswho continued to have externalizing problems in middle childhood were oneswhose mothers used high levels of negative control. Using a genetically sensitive,longitudinal design to investigate the direction of the relationship between par-ental hostility and ADHD symptom severity, Lifford, Harold, and Thapar (inpress) found that symptom severity in boys with ADHD impacted upon mo-therson hostility, both within and across time, but there was no significant re-lation in the opposite direction (i.e. motherson hostility leading to ADHDsymptom severity). This finding suggests that difficult child behaviour drivesparental hostility rather than the other way around.

Parents of children with ADHD have also, not surprisingly, been reported toexperience considerable stress (Fisher, 1990; Johnston & Mash, 2001). Wolfsonand Grant (2006) found that, among mothers of children with developmentaldifficulties, high parenting stress was associated with a more authoritarian par-enting style, suggesting that high stress as a result of their childs difficult be-haviour, may impact upon the level of negative control used by parents ofdifficult children. Therefore, because difficult children elicit more stress andnegative control, and negative parental control has been associated with adversetrajectories in disruptive preschool children (Campbell et al., 2000) it is likely thata childs ADHD symptom severity, as well as their temperament, will influence

how parents interact with their child (e.g. difficult children eliciting more stressleading to a more hostile parenting style), which in combination impacts uponchild outcome.

We propose a model where both ADHD symptom severity and difficult childtemperament will account for unique variance in maternal parenting stress, withparents of children displaying more severe symptomatology and more difficulttemperament exhibiting higher levels of parenting stress. It is further predictedthat, above and beyond individual child characteristics, high parenting stress will

be associated with a more punitive and less positive parenting style. Finally it ispredicted that this type of parenting style will be associated with poorer childfunctioning, above the effects of individual child characteristics and parenting

stress; and that parenting style will moderate the relationship between ADHDsymptom severity and child functioning (Figure 1).

Child ADHD

symptom severity &

temperament

Child

FunctioningMaternal

Parenting Stress

ADHD Symptom

Severity

Maternal

Parenting Style

D.M. Healey et al.150


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METHOD

Participants

The participants were 138 (105 male, 33 female) 3- and 4-year-old (M54.36,

S.D.50.47), children who were recruited through preschools (n5 68) and clinicalreferrals (n570) from an urban area. The children were all classified ashyperactive/inattentive as determined by the endorsement of at least sixsymptoms of hyperactivityimpulsivity and/or inattention across parent andteacher ratings on the Attention Deficit/Hyperactivity Disorder Rating Scale-IV(ADHD-RS-IV; DuPaul, Power, Anastopoulos, & Reid, 1998). For example, aparent may have endorsed four symptoms of hyperactivity/impulsivity and theteacher five symptoms of hyperactivity/impulsivity, with two of them beingdifferent from those endorsed by the parent, resulting in six individualsymptoms of hyperactivity/impulsivity being endorsed across settings (i.e. four

by parent and an additional two by teacher). By design, this requirement resultedin a sample with a wide range in severity of symptoms, with some (21.7%) notmeeting full DSM-IV diagnostic criteria for any of the three subtypes of ADHDdiagnosis (i.e. predominantly hyperactive/impulsive, predominantly inattentive,or combined), but all being characterized as symptomatic in at least one setting.Within the sample 18.8% were rated as meeting ADHD symptom criteria (i.e. sixor more symptoms of hyperactivity and/or inattention) by parent only, 30.4% byteacher only, and 50.7% by both. With regard to ADHD subtypes 13.8% wererated as predominantly inattentive, 36.2% as predominantly hyperactive, and50% as combined type.

The ethnicity of the sample was diverse; 40.6% of the children were White,

Non-Hispanic; 19.6% were White, Hispanic; 13.0% were Black, Non-Hispanic;2.2% were Black, Hispanic; 5.8% were Asian; and 18.8% reported mixed or otherethnicity/race. Socio-economic status (SES) was measured using the Nakao-TreasSocioeconomic Prestige Index (Nakao & Treas, 1994) where high scores are in-dicative of higher SES. The SES of this sample was variable (range: 2089), butmost of the children were living in homes with moderate SES (M553.12,S.D.515.52).

Measures

ADHD-RS-IV (DuPaul et al., 1998): ADHD symptom severity was assessed usingthe ADHD-RS-IV, a rating scale based on the 18 DSM-IV-specific ADHDsymptoms for which a score on a 4-point scale is assigned by the rater (i.e. Neveror rarely50, Sometimes51, Often5 2, Very often53) and the maximumpossible score is 54. The psychometric properties of this scale, which can becompleted by parents and teachers, have been well-established for childrenabove the age of 5 years (DuPaul et al., 1998). More recent data similarly indicatethat the scales are highly reliable and valid when used with preschool children(McGoey, DuPaul, Haley, & Shelton, 2007). Consistent with this, in our sample of3- and 4-year-old children, reliability, as assessed by coefficient a, was found to bequite strong for both parent (a5 0.92) and teacher (a50.94) ratings. For the

analyses in this study, a composite score representative of combined parent andteacher ratings was created using a variant of the or-rule which is a commonmethod for combining information from two informants (Costello et al 1988;



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observed or to occur in particular settings (Hartman et al., 2007), for each item onthe ADHD-RS-IV the higher of the two ratings (i.e. parent and teacher) was theitem score used in developing the composite, which served as the index forsymptom severity in this study (maximum score554; sample range: 1754;

M5

38.48, S.D.5

7.82). This approach for combining parent and teacher ratingshas the advantage over averaging the two ratings of maximally capturing theimpact of symptoms that are generally manifest in only one setting (e.g. the childwho has severe difficulty sustaining attention in school, but no such demands aremade at home, or loses things at home but this is not apparent to the teacher).

Childrens Global Assessment Scale (CGAS; Shaffer et al., 1983). This scale assessesglobal functioning across settings, and ratings take into consideration the childslevel of functioning at home and in school, as well as the nature and quality ofpeer relations. Scores on this measure range from 0 to 100 with lower scoresindicating more impairment. Information regarding (1) developmental history/demographics; (2) psychosocial functioning (as reported by the parent via direct

interview; and both parents and teachers on the Behavioural Assessment Scalefor Children (BASC-2; Reynolds & Kamphaus, 2004), a measure of general psy-chosocial functioning, and the Childrens Problems Checklist (CPC; Healey et al.,2008) a brief measure of child impairment); (3) behavioural observations acrosstwo 3-h cognitive testing sessions, rated by the evaluator on the BehaviouralRating Inventory for Clinicians (Gopin, Healey, Castelli, Marks, & Halperin, inpress), a brief 4-item measure of hyperactivity, inattention, mood, and sociability;(4) as well as neuropsychological functioning were presented to a group of410 trained clinicians who each independently rated the level of impairmentexperienced by the child on the CGAS. Clinician raters were blind to all child

temperament and maternal parenting stress and parenting style scores. Themedian of all ratings was assigned to each child, and served as the primarymeasure of impairment for this study. Ratings across clinicians showed con-siderable consistency; the mean within-subject standard deviation, which isanalogous to the standard error of measurement, was 4.88 points. Median CGASscores for this sample ranged from 32.5 to 84.0, with a mean of 49.25 (S.D.59.94).

Temperament Assessment Battery for ChildrenRevised (TABC-R; Martin &Bridger, 1998). Teachers rated each childs temperament on this 29-item ques-tionnaire. Each item was rated on a scale from 1 (hardly ever) to 7 (almostalways). This measure generates four subscales: Inhibition, Negative Emotion-ality, Activity Level, and Lack of Task Persistence. Three of these subscales (i.e.

Negative Emotionality, Activity Level, and Lack of Task Persistence) can becombined to form a single dimension named Impulsivity (Martin & Bridger,1998). The three measures loading onto the Impulsivity dimension were sig-nificantly inter-correlated in our sample (all po0.001). Thus, for this study thetwo broad dimensions of Inhibition (i.e. shyness) and Impulsivity (i.e. dysregu-lation) were used in the analyses. Scores are converted into T-scores. The Mean(S.D.) of scores in this sample were 45.7 (11.23) for Inhibition and 59.1 (9.56) forImpulsivity. As reported in the TABC-R manual, the internal consistency (asrange from 0.860.95), inter-rater reliability (rs range from 0.34 to 0.66), andtemporal stability (rs range from 0.47 to 0.71) for this teacher-rated temperamentscale has been found to be adequate (Martin & Bridger, 1998). Within our sample,

internal consistency was only slightly lower with as ranging from 0.81 to 0.89.Alabama Parenting QuestionnairePreschool Revision (APQ-PR; Clerkin, Marks,

P li & H l i 2007) M th l t d thi lf t f



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items rated on a 5-point scale ranging from 1 (never) to 5 (always). This measuregenerates three parenting dimensions: Positive, Inconsistent, and Punitive Par-enting. Possible scores for the Positive Parenting dimension range from 0 to 60with high scores indicating more praise and positive engagement. The Mean

(S.D.) for our sample was 52.97 (4.34). The Inconsistent Parenting dimension hasa possible range from 0 to 35, with higher scores indicating more ambivalent andinconsistent engagement and discipline. The Mean (S.D.) for our sample was15.40 (3.96). The Punitive Parenting dimension has a range of possible scoresfrom 0 to 25, with higher scores indicating more yelling and use of physicalpunishment. The Mean (S.D.) for this sample was 9.61 (2.30). All threefactors have been shown to have adequate internal consistency (as range from0.63 to 0.82) and temporal stability (rs range from 0.52 to 0.80) in preschool agedchildren (Clerkin et al., 2007). In our sample, coefficient a for the InconsistentParenting subscale was somewhat low (a50.57), but internal consistency indicesfor the Positive and Punitive parenting factors were good (as50.70 and 0.77,

respectively).Parenting Stress IndexShort Form (PSI-SF; Abidin, 1995). This 36-item rating

scale is a measure of stress related to parenting. Three individual indices aregenerated: Parenting Distress, Difficult Child, and ParentChild DysfunctionalInteraction. These are combined to form a composite Total Stress, which is themeasure used for the analyses in this study. Higher Total Stress scores indicatemore stress experienced in relation to parenting the target child. All PSI data usedin this study was based on maternal self-report on this measure. Scores for thismeasure were converted into T-scores and the Mean (S.D.) for this samples Totalstress score were 81.23 (19.22). The internal consistency (as range from 0.80 to

0.91) and testretest reliability (rs range from 0.68 to 0.85) have been found to beadequate (Abidin, 1995). Within our sample, internal consistency for the Totalstress score was excellent (a5 0.91).

Procedures

In screening children for suitability to participate in the study, parents andteachers completed the ADHD-RS-IV. These questionnaires were first distributedto parents in local preschools, along with consent forms, and returned in postage-paid addressed envelopes. After receiving the parent rating and consent, theADHD-RS-IV was sent to the childs teacher. Once being deemed eligible andagreeing to participate, parents were sent out a package containing additionalquestionnaires. They completed the Demographics Questionnaire, BASC-2, CPC,APQ-PR, and PSI either just before attending their first laboratory session, orwhile waiting for their child to complete the laboratory session. Consent was alsogiven for teachers to complete the TABC-R and return it in a postage-paidaddressed envelope. During the initial laboratory session parents providedsigned informed consent and participants were reimbursed $20/h for their timespent attending laboratory sessions. This study was approved by the relevantlocal Institutional Review Board.

Data Analysis

Hierarchical Linear Regression analyses were conducted to examine the



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child ADHD symptom severity and impairment by including interaction terms inthe hierarchical regression equation. In this case, the predictor variables (i.e.ADHD symptom severity and maternal parenting style) were centered, bysubtracting the sample mean from the individual score, prior to calculating

interaction terms between these variables. The plotted moderation modelthen indicated under which conditions the main effects occur (Jose &Huntsinger, 2005).

RESULTS

Relationship between Child Temperament and Maternal Parenting Stress (AfterControlling for Childs ADHD Symptom Severity)

The first step of the proposed model suggests that ADHD symptom severity and

child temperament will each account for unique variance in the level of maternalparenting stress, with higher symptom severity and a more difficult tempera-ment relating to higher maternal parenting stress. Hierarchical Linear Regressionanalysis indicated that both ADHD symptom severity and the child temperamentdimension Impulsivity (indicating the level of behavioural, emotional andcognitive dysregulation) accounted for significant unique variance in maternalparenting stress (Table 1). As expected, higher ADHD symptom severity andImpulsivity were associated with higher maternal parenting stress.

Relationship between Maternal Parenting Stress and Parenting Style (After

Controlling for Childs ADHD Symptom Severity and Impulsivity)The second step in the proposed model suggests that maternal parenting stress isassociated with maternal parenting style, above and beyond individual childfactors. Three Hierarchical Linear Regression analyses were conducted toexamine whether maternal parenting stress accounted for unique variance ineach of the three maternal parenting styles (punitive, inconsistent, andpositive). Results indicated that the level of maternal parenting stress wassignificantly related to all three parenting styles, with higher stress associatedwith more punitive and inconsistent, and less positive parenting styles(Table 2).

Table 1. Hierarchical Linear Regression examining whether ADHD symptom severity andchild temperament account for unique variance in maternal parenting stress

Variables Ba S.E. b t p Adjusted R2 DR2 DF

Model 1 0.021 0.028 3.962ADHD symptom severity 0.413 0.208 0.168 1.990 0.049

Model 2 0.046 0.039 2.773

ADHD symptom severity 0.688 0.237 0.280 2.910 0.004Inhibition 0.068 0.148 0.040 0.460 0.646Impulsivity 0.473 0.201 0.233 2.354 0.020



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Relations between Maternal Parenting Style and Child Functioning (AfterControlling for Childs ADHD Symptom Severity and Impulsivity, and MaternalParenting Stress)

The third step in the model suggests that above and beyond the effects of childsymptom severity and temperament, as well as maternal parenting stress,maternal parenting style will be additionally associated with child functioning.A Hierarchical Linear Regression analysis revealed that while ADHD symptomseverity, impulsivity, and maternal parenting stress all accounted for significantunique variance in child functioning, none of the parenting styles reachedsignificance, although maternal positive parenting style approached significance(p5 0.051; Table 3).

Does Parenting Style Moderate the Relationship between a childs ADHDSymptom Severity and Their Level of Impairment?

The final aspect of the model suggests that the relationship between ADHDsymptom severity and the childs level of functioning will be moderated bymaternal parenting style For moderation analyses the independent (ADHD

Table 2. Hierarchical Linear Regression examining whether ADHD symptom severity,Impulsivity and maternal parenting stress account for unique variance in maternalparenting styles (i.e. punitive, inconsistent, and positive)

Variables Ba

S.E. b t p Adjusted R2

DR2

DF

Predictors of punitive parentingBlock 1 0.008 0.009 0.520ADHD symptom severity 0.003 0.033 0.009 0.081 0.935Impulsivity 0.022 0.027 0.090 0.817 0.416Block 2 0.045 0.061 7.344ADHD symptom severity 0.026 0.033 0.089 0.800 0.426Impulsivity 0.006 0.027 0.025 0.224 0.823Maternal parenting stress 0.031 0.011 0.257 2.710 0.008Predictors of inconsistentparenting

0.018 0.000 0.000

Block 1

0.001 0.056

0.003

0.024 0.981ADHD symptom severityImpulsivity 0.000 0.046 0.000 0.003 0.998Block 2 0.027 0.053 6.237ADHD symptom severity 0.039 0.057 0.077 0.686 0.494Impulsivity 0.025 0.046 0.061 0.545 0.587Maternal parenting stress 0.049 0.020 0.239 2.497 0.014Predictors of positive parentingBlock 1 0.122 0.061 0.219 2.008 0.047 0.018 0.035 2.033ADHD symptom severityImpulsivity 0.045 0.050 0.100 0.913 0.363Block 2 0.057 0.047 5.744ADHD symptom severity 0.083 0.062 0.149 1.340 0.183

Impulsivity 0.019 0.050 0.042 0.384 0.702Maternal parenting stress 0.051 0.021 0.226 2.397 0.018

Note: The bolded values are the p-values which indicate level of significance.aUnstandardized coefficients.



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variables and the independent variable. These variables were then subjected to ahierarchical regression analysis predicting the level of child impairment. Block 1included the centered ADHD symptom severity composite, followed by the

centered moderator variables (punitive, inconsistent, and positive parentingstyles) in Block 2, and the interaction terms (ADHD symptom severitypunitiveparenting style, ADHD symptom severity inconsistent parenting style, andADHD symptom severitypositive parenting style) in Block 3. Results showedthat symptom severity and positive parenting style were both associated with thelevel of child impairment, as was the interaction between these two (Table 4 forstandardized regression coefficients). Figure 2 depicts that among children whomeet symptom criteria for ADHD, positive parenting style was protective amongthose with a less severe symptom presentation (i.e. X1 S.D. below the mean;ADHD-RS mean score for this group530.66). However, when symptom severitywas extreme (i.e. X1 S.D. above the mean; ADHD-RS mean score for this

group546.30), the beneficial effect of positive parenting is negligible.

Additional Control Variables

To ensure that the above findings were not accounted for by the childs age,gender, and SES, the regression analyses were rerun entering these variables ascontrols in the first block. None of these variables accounted for a significantamount of variance and none appreciably altered the findings.

Revised ModelBased on the results of the analyses in this study, Figure 3 depicts the revised

t ti f th d d l h ADHD t it d hi h

Table 3. Hierarchical Linear Regression examining whether ADHD symptom severity,impulsivity, maternal parenting stress, and maternal parenting styles account for uniquevariance in child functioning

Variables Ba

S.E. b t p Adjusted R2

DR2

DF

Predictors of child functioning 0.348 0.357 37.556Block 1ADHD symptom severity 0.440 0.104 0.338 4.248 o0.001Impulsivity 0.380 0.086 0.353 4.429 o0.001Block 2 0.394 0.049 11.146ADHD symptom severity 0.357 0.103 0.274 3.462 0.001Impulsivity 0.435 0.084 0.404 5.156 o0.001Maternal parenting stress 0.122 0.036 0.230 3.339 0.001Block 3 0.405 0.024 1.872ADHD symptom severity 0.330 0.103 0.253 3.187 0.002

Impulsivity

0.434 0.084

0.403

5.183o0.001

Maternal parenting stress 0.107 0.038 0.203 2.814 0.006Punitive parenting style 0.325 0.308 0.075 1.054 0.249Inconsistent parenting style 0.177 0.178 0.071 0.999 0.320Positive parenting style 0.316 0.160 1.38 1.973 0.051




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punitive and inconsistent, and less positive parenting style, and to lower childfunctioning (i.e. more impairment). When a positive parenting style was present,it moderated the relationship between child symptom severity and impairment,playing a protective role.

DISCUSSION

Th i f thi t d t i f t b d b d t

Table 4. Hierarchical Linear Regression examining whether parenting styles moderate therelationship between ADHD symptom severity and child functioning

Variables Ba S.E. b t p Adjusted R2 DR2 DF

Block 1 0.277 0.283 47.726ADHD symptom severity 0.672 0.097 0.532 6.908 o0.001Block 2 0.297 0.038 2.172ADHD symptom severity 0.633 0.098 0.501 6.480 o0.001Punitive parenting style 0.352 0.358 0.079 0.984 0.327Inconsistent parenting style 0.298 0.201 0.118 1.483 0.141Positive parenting style 0.350 0.183 0.150 1.912 0.058Block 3 0.320 0.039 2.321ADHD symptom severity 0.661 0.098 0.523 6.734 o0.001Punitive parenting style 0.386 0.353 0.086 1.095 0.276Inconsistent parenting style 0.278 0.021 0.110 1.384 0.169Positive parenting style 0.450 0.185 0.193 2.427 0.017ADHDpunitive 0.049 0.056 0.080 0.882 0.380ADHD inconsistent 0.013 0.029 0.039 0.434 0.665ADHDpositive 0.058 0.024 0.200 2.481 0.015


Figure 2. Moderating effect of maternal positive parenting style on the relationshipbetween ADHD symptom severity and child functioning.



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existent literature, it was hypothesized that difficult child temperament would beadditionally associated with high parenting stress, and that high parenting stresswould be associated with a parenting style high in negative control and low inpositive interactions, which in turn would be associated with the level of childimpairment. The data indicated that after controlling for symptom severity, highlevels of temperamental impulsivity (i.e. negative emotionality, attentionproblems, and lack of task persistence) in the child were associated with highlevels of maternal parenting stress (i.e. how stressful the mother finds parentingher child), which in turn was additionally associated with higher levels ofpunitive and inconsistent parenting, and lower levels of positive parenting.While ADHD symptom severity, impulsivity, and maternal parenting stress wereall uniquely associated with child functioning, parenting style did not account forany additional variance in functioning. However, maternal positive parentingstyle was found to moderate the relationship between ADHD symptom severityand functioning such that in children with a less severe (albeit above threshold)level of symptoms, positive parenting was protective as high levels of positiveparenting were associated better child functioning. These data indicate thatmaternal parenting style plays a substantial role in influencing how impaired

their childs psychosocial functioning is, and may influence the likelihood of thechild receiving a diagnosis of ADHD. No studies to date have examined theimpact of parent factors on the functioning of hyperactive/inattentive childrendespite existing literature suggesting that more negative and controllingparenting styles are common reactions among parents of children with ADHD(Barkley et al., 1985; Campbell, 1995; Johnston & Mash, 2001; Keown &Woodward, 2002; Winsler, 1998).

In addition the results of this study reiterate the role that maternal parentingstress plays in parenting styles and that high maternal stress is related to moreinconsistent and punitive, and less positive parenting styles (Wolfson & Grant,2006). Finally, these data suggest that a childs temperamental style (in particular

their self regulatory skills) uniquely impacts upon their level of impairment bothdirectly, and indirectly through increasing parenting stress.

It h t i i th t iti d i i t t ti t l

Child ADHD

Symptom Severity &

DysregulationChild

Functioning

Maternal

Parenting Stress

ADHD Symptom

Severity

Maternal Punitive

Parenting

Maternal Inconsistent

Parenting

Maternal Positive

Parenting

Figure 3. Refined model of the relation between child and maternal characteristics and

level of functioning in hyperactive/inattentive preschoolers.



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1985; Campbell, 1995; Johnston & Mash, 2001; Keown & Woodward, 2002;Winsler, 1998). This may be explained by the fact that parenting style was as-sessed through maternal self-report and the Mean (S.D.) for inconsistent andpunitive parenting were both low in this sample. The low incidence of punitive

and inconsistent parenting styles in this sample could be due to a number offactors such as a positive skew in their reporting (many of the past studies haveused observational measures of parentchild interactions), a reduced likelihoodof these parenting styles being used in a sample of moderate SES, or may beparents of young preschoolers have not yet developed the more hostile parenting

behaviours exhibited by parents of older children whom they have struggled tomanage for longer. Finally, past studies have all examined the relations betweenparenting style and ADHD symptom severity (Barkley et al., 1985; Campbell,1995; Johnston & Mash, 2001; Keown & Woodward, 2002; Winsler, 1998) and notlooked at its unique effect on child functioning, nor did they control for symptomseverity and parenting stress when examining the relation between parenting

style and child behaviour. Given that this past work has also mostly been con-ducted cross-sectionally, it may be that in the case of ADHD difficult child

behaviours drive negative parent behaviours more than the opposite way round,as indicated in Lifford et al.s (in press) study.

Identification of additional factors associated with the functioning of childrenwith ADHD, as well as the relations among predictors, has important implica-tions for understanding and treating this disorder. While the use of medication isfrequently successful in reducing symptoms it oftentimes does not amelioratefunctional impairment for children with ADHD (Frankel et al., 1997; Pelham et al.,1980). Additionally, the use of parent management training, while often suc-

cessful in the short term, is seldom successful in reducing long-term impairmentin these children (Eyberg, Edwards, Boggs, & Foote, 1998; Webster-Stratton,1990). Given the results of this study, targeting child self-regulation, as well asparental stress and coping, within the treatment of ADHD may compliment ourcurrent treatment regimens, assist in significantly improving the functioning ofthese children, and have more long-lasting effects; as once the parent and childlearn these skills they may become both internalized and generalized.

As with all studies, this one is not without limitations. First, this study wastesting a novel model that integrated evidence from several previous studies andit is therefore essential that these findings be replicated in further samples.Second, the maternal variables (i.e. parenting stress and parenting style) in this

study were self ratings, thus introducing the possibility of rater bias; althoughimportantly, a teacher report was used to assess the childs temperament. Third,the use of cross-sectional data in this study makes causal inferences difficult, andthus longitudinal studies of these relationships are needed. Fourth, this studyused a preschool sample only and thus generalization of these results to olderchildren is difficult. Finally, although controlling for gender did not change thepattern of results, the sample was too small to examine whether these relations

between child and parent factors are similar or different for boys and girls. It ispossible that sex differences exist.

Implications for Research Policy and Practice

Th li i fi di t th t hil t d t f



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higher maternal parenting stress, which in turn is related to less positive andmore punitive and inconsistent parenting styles. However, those hyperactive/inattentive preschoolers whose mothers displayed a positive parenting style werefunctioning much better. Thus by improving coping skills and reducing

parenting stress, mothers may be better able to manage their childs dysregula-tion, help their children to learn to self-regulate and thus improve theirfunctioning (Calkins & Fox, 2002). Additionally, aiding children in their ownself regulation may reduce parenting stress. Thus, these data suggest thattreatments for children with ADHD should focus on symptom reduction, as wellas improving behavioural, cognitive, and emotional regulation skills in the childand coping skills in the parent, in order to best attempt to alleviate impairment inthe childs functioning.

ACKNOWLEDGEMENTS

This research was supported by NIMH grant R01 MH68286.

REFERENCES

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