predicting parenting stress in families of children …...demographic moderators of the relationship...
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PREDICTING PARENTING STRESS IN FAMILIES OF CHILDREN WITH ADHD
by
Jennifer Theule
A thesis submitted in conformity with the requirements for the degree of Doctor of Philosophy
Graduate Department of Human Development and Applied Psychology Ontario Institute for Studies in Education
University of Toronto
© Copyright by Jennifer Theule 2010
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PREDICTING PARENTING STRESS IN FAMILIES OF CHILDREN WITH ADHD
Doctor of Philosophy, 2010 Jennifer Theule
Graduate Department of Human Development and Applied Psychology University of Toronto
Abstract
This dissertation consists of two studies that investigated predictors of parenting stress as they
relate to child ADHD. Two main questions were explored: what is the magnitude of the
association between child ADHD and parenting stress, and what are the parent and contextual
predictors of parenting stress?
In Study 1, meta-analyses were conducted on the association between parenting stress and
ADHD. Predictors comprising child, parent, and contextual factors, and methodological and
demographic moderators of the relationship between parenting stress and ADHD were examined.
Findings from 44 studies were included. In Study 2, I examined parent and contextual (parental
ADHD symptoms, parental education, social support, and marital status) predictors of parent
domain parenting stress (parental distress) as a function of teacher-reported child ADHD
symptoms.
Results confirmed that parents of children with ADHD experience more parenting stress than
parents of nonclinical control children, and that severity of child ADHD symptoms are
associated with parenting stress. Child oppositionality was only predictive of parental distress
when reported by parents (not teachers). A post-hoc analysis in Study 2 showed that child factors
did not predict parental distress over and above parent and contextual factors. In Study 1,
children’s co-occurring conduct problems and parental depressive symptomatology predicted
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parenting stress. Little difference in parenting stress was found between mothers and fathers, but
lower parenting stress levels were found in samples with higher proportions of girls. Parental
ADHD symptomatology was the strongest predictor of parental distress considered in Study 2.
Social support was inversely related to parental distress in Study 2, whereas parental age and
education were unrelated to parental distress. In Study 2, marital status was significantly
correlated with parental distress, but was not a significant predictor in the regression. Marital
quality was not a significant predictor of parenting stress in Study 1.
The large effects observed for parent level predictors suggests that parent factors (i.e., ADHD
and depressive symptoms) are critically important in parenting stress and play a primary role in
the experience of elevated parenting stress. Future research should give greater consideration to
factors outside of the child in increasing parenting stress.
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Acknowledgements
This dissertation would not have been possible without the gracious support,
encouragement, and guidance of so many people.
Maria Rogers and Imola Marton thoughtfully and generously allowed me to use their
extensive and wonderfully constructed and designed database. This gesture was instrumental in
helping me zero in on a topic and complete this work on time. They were also great examples in
how to complete this, at times, overwhelming process.
My amazing supervisor, Judy Wiener, was an incredible support. She provided much
needed encouragement and direction and was always willing to meet and help me sort out my
thoughts. Her flexibility and enthusiasm helped me through the moments when I was
discouraged and feeling overwhelmed by what could feel like conflicting responsibilities.
The other members of my committee, Rosemary Tannock and Jenny Jenkins, were much
needed providers of encouragement, direction, and ideas. My supervisors (Andrea Spooner, Joy
Andres-Lemay, Terry Diamond, and Shari Lecker) at my internship placement, ROCK, always
so kindly inquired about my progress, without pressuring me, and provided me with all the time
and flexibility I needed to complete this dissertation.
My friends and family both in Southern Ontario and in Winnipeg were great
cheerleaders, never doubting for a moment that I could do this. Finally, my wonderful husband
and children are the reason I kept on trudging through. They listened to me talk about this
dissertation ad nauseum and sat inside on many a beautiful weekend while I worked. Lily gave
up her mama time to a pile of papers and Cole lived with his mama’s school work for as long as
he can remember. To all of these people I would like to extend my heartfelt thanks.
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Table of Contents
Abstract .......................................................................................................................................... ii Acknowledgements……...……………………..………………………………………………..iv Chapter 1: Introduction ............................................................................................................... 1 Chapter 2: Parenting Stress in Families of Children with ADHD: A Meta-Analysis .......... 21
Abstract .................................................................................................................................... 21 Introduction ............................................................................................................................. 22 Research Questions................................................................................................................. 26 Method ..................................................................................................................................... 27
Search and retrieval of studies and eligibility criteria. ...................................................27 Study Characteristics and Coding......................................................................................... 29 Analysis.................................................................................................................................... 31 Results...................................................................................................................................... 34
Study characteristics........................................................................................................... 34 ADHD Diagnosis (Level of Symptoms)................................................................................. 35 Co-Occurring Disorders......................................................................................................... 36 Parent and Contextual Factors.............................................................................................. 37 Moderator Analyses................................................................................................................ 37 Discussion................................................................................................................................. 38 Strengths and Limitations......................................................................................................40 Directions for Future Research............................................................................................. 42 Clinical Implications and Conclusions.................................................................................. 43
Chapter 3: Predicting Parenting Stress in Families of Children with ADHD: Consideration of Informants, and The Role of Parental ADHD Symptoms, and Other Parent and Contextual Factors...................................................................................................................... 48
Abstract .................................................................................................................................... 48 Parenting Stress and ADHD.................................................................................................. 51 Objectives of the Study........................................................................................................... 52 Method ..................................................................................................................................... 55
Participants.......................................................................................................................... 55 Measures.............................................................................................................................. 55
Parenting Stress Index—Short Form (PSI/SF)............................................................ 55 Conners’ Rating Scales—Revised: Long Version (CRS)............................................ 56 Conners’ Adult ADHD Rating Scales (CAARS).......................................................... 56 Family Support Scale...................................................................................................... 57 Wechsler Abbreviated Scale of Intelligence (WASI) and Wechsler Intelligence Scale for Children, Fourth Edition (WISC-IV). .................................................................... 57
Procedure................................................................................................................................. 57 Results...................................................................................................................................... 58 Discussion................................................................................................................................. 61 Limitations and Directions for Future Research................................................................. 64 Clinical Implications ............................................................................................................... 65
Chapter 4: Conclusions and Implications................................................................................ 70 Conclusion........................................................................................................................... 79
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References.................................................................................................................................... 80
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List of Tables Table 1 Meta-Analyses of Studies Comparing Groups on Parenting Stress ................................ 45 Table 2 Meta-Analyses of Dimensional Parenting Stress Studies................................................ 46 Table 3 Intercorrelations between Parenting Stress, and Major Child, Parent, and Contextual Variables ....................................................................................................................................... 67 Table 4 Hierarchical Multiple Regression Predicting Parenting Stress from (Teacher-Reported) Child, Parent, and Contextual Variables....................................................................................... 68 Table 5 Hierarchical Multiple Regression Predicting Parenting Stress from (Parent-Reported) Child, Parent, and Contextual Variables....................................................................................... 69
List of Figures Figure 1. Model of Parent-Child Interactive Stress. Adapted from Mash & Johnson, 1990 ....... 20 Figure 2. Flow Diagram of Studies Included in Meta-Analysis………………………………...47
List of Appendices Appendix A Coding Manual .................................................................................................... 107 Appendix B Coding Form ........................................................................................................ 120 Appendix C Correlations within Subsamples ........................................................................ 129
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Chapter 1:
Introduction
Parenting is one of the most demanding responsibilities of adult life. Parenting stress is
the affective response to the, at times, overwhelming, demands of parenting. It is dynamic and
results when the balance between parents’ perceptions of the demands of parenting outweigh
their perceptions of their resources for meeting those demands (Deater-Deckard, 2004). Current
theory holds that parenting stress is a normative part of the parenting role (Crnic & Greenberg,
1990), becoming clinically important when elevated to such an extent that it negatively impacts
parenting practices and the parent-child relationship (Abidin, 1992; Belsky, 1984; Morgan,
Robinson, & Aldridge, 2002; Rodgers, 1998; Webster-Stratton, 1990). Parents who experience
extreme levels of parenting stress may be less able to implement interventions to help their
children (Kazdin, 1995), which is especially relevant for children with a clinical diagnosis such
as Attention-Deficit/Hyperactivity Disorder (ADHD). Further, effective interventions for
parenting stress have been linked to increases in the efficacy of parent management training
(Kazdin & Whitley, 2003), a very commonly used intervention with children with ADHD and
other disruptive behaviour disorders. Moreover, studies have shown that parenting stress is
inversely related to response to behavioural treatment (e.g., Kazdin, 1995; Kazdin, Holland,
Crowley, & Breton, 1997; Kazdin & Wassell, 1999; Osborne, McHugh, Saunders, & Reed,
2008), may affect parental psychological well-being (Abidin, 1992; Crnic & Greenberg, 1990;
Kwok & Wong, 2000; Wolf, Noh, Fisman, & Speechley, 1989), and may affect child
development and behaviour (e.g., Anthony et al., 2005; Crnic, Gaze, & Hoffman, 2005).
ADHD is a chronic, pervasive condition characterized by inattention, impulsivity, and
hyperactivity (American Psychiatric Association, DSM-IV-TR, 2000). It is also one of the most
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common childhood disorders, affecting about 5% of school-aged children world-wide
(Polanczyk & Jensen, 2008). Recent research indicates that in most cases, ADHD is a lifelong
disorder, existing in at least a partial remission form into adulthood (Barkley, Fischer, Smallish,
& Fletcher, 2002; Faraone, Biederman, & Mick, 2006). Up to two-thirds of children with ADHD
have a parent with a history of ADHD (Mulsow, O’Neal, & McBride Murry, 2001; Schachar &
Wachsmuth, 1990) and current research points to strong genetic influences (Levy, Hay, &
Bennett, 2006; Willcutt, in press). There is considerable research to indicate that parents of
children with ADHD experience elevated rates of parenting stress (e.g., Breen & Barkley, 1988;
Johnson & Reader, 2002; Joyner, Silver, Stavinoha, 2009; Kadesjö, Stenlund, Wels, Gillberg, &
Hägglöf, 2002; Reader, Stewart, & Johnson, 2009; van der Oord, Prins, Oosterlaan, &
Emmelkamp, 2006; Whalen et al., 2006; Yang, Jong, Hsu, & Tsai, 2007).
The overarching objective of this dissertation was to clarify the predictors of parenting
stress in parents of children with ADHD and to investigate the role of parent and contextual
predictors. In this dissertation, I explored the following two main questions: what is the
magnitude of the association between child ADHD and parenting stress, and what are the parent
and contextual predictors of parenting stress as a function of child ADHD symptoms? These
questions will be addressed in two studies included in this dissertation, which will be referred to
as Study 1 and Study 2. These two studies were written in manuscript format in order to be
submitted for publication. Chapter 2 is devoted to Study 1, and Chapter 3 to Study 2. It is
important to note that as a result of the manuscript structure of this dissertation, there is some
overlap in the background sections of both studies. Chapter 4 discusses the findings from both
studies and considers implications for future research, policy, schools, and clinical practice.
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Parenting
Parenting is influenced by, and influences several parent, child, and contextual factors.
Belsky (1984) offers a process model of the determinants of parenting that suggests that
parenting is impacted by the parent’s own developmental history, the parent’s personality,
marital relations, parental work, the parent’s social network, and the child’s characteristics. In
turn, parenting is proposed to affect child development. Belsky’s model focuses on parenting
behaviour, as opposed to internal cognitive or affective aspects of parenting. The determinants of
parenting in his model include both external constructs, such as work, and internal constructs,
such as personality. In Belsky’s examples he links cognitive constructs (e.g., mother’s esteem for
their husbands) to their behavioural outcomes in parenting (praise for children). The outcome of
Belsky’s model of parenting is child development, mainly defined in terms of child competence.
Belsky’s description of child characteristics is less developed than his detailing of parent
characteristics, but one major child characteristic he addresses is temperament (Belsky, 1984),
suggesting that difficult child temperaments negatively impact parenting. He is careful to note,
however, that child characteristics are not sufficient for poor outcomes. In terms of contextual
factors, Belsky lists social and spousal support and parental work as determinants of parenting.
Belsky’s definition of parenting subsumes such concepts as parental sensitivity, parental
negativity, and parental role performance. These terms differ in their positive/negative valence,
but also in the degree to which they refer to internal cognitive or affective constructs, or external
behavioural constructs. Parental sensitivity refers both to a parents’ attunement to their children’s
needs, and to their contingent, consistent, responses (Belsky, 1984; Farrell Erickson & Kurz-
Reimer, 1999). Parental negativity refers to the negative perceptions parents have of their
children and to the ensuing negative, hostile behaviours parents engages in (Anderson, Hinshaw,
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& Simmel, 1994; Johnston & Mash, 2001). Although the previous two terms combined internal
and external manifestations of the constructs, parental role performance refers solely to the
external, behavioural manifestation of a parents’ behaviours in their role as parents (McCleary,
2002).
Belsky (1984) does not specifically address parenting stress, but his model would seem to
subsume parenting stress under general parental psychological well-being. The assumption
underlying the current research is that parenting stress is an internal construct that impacts the
external (behavioural) outcome of “parenting.” This assumption leads to the question of how
parenting stress and parenting are linked.
Theories of Parenting Stress
Four major theories of parenting stress in families of children with ADHD have been
proposed (McCleary, 2002). Three of these theories feature a strong focus on the mechanism
through which parenting stress becomes elevated in parents of children with ADHD and other
disruptive behaviour disorders. These three theories all identify cognitive factors in the parent as
at least one of the mechanisms through which child factors influence parenting stress. These
theories feature transactional effects, such that parenting stress is the result of the other factors
suggested, and also contributes to the system over time.
The first theory, the Parent-Child Interactive Stress Model, proposed by Mash and
Johnston (1990), holds that child characteristics are the primary contributors to parent-child
stress, but that environmental factors also have direct influences on stress. This theory also
suggests that parent-child stress affects child, parent, and environmental characteristics (see
Figure 1). Unlike the other theories of parenting stress that will be discussed, this theory
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addresses “parent-child interactive stress” rather than parenting stress more generally. The
authors describe parent-child interactive stress as one aspect of parenting stress; it is defined as
the stress which manifests itself in parent-child conflict (Mash & Johnston, 1990). In this model,
the effects of child and environmental stressors are mediated by parental characteristics, which
notably include parental cognitions, and more specifically, attributions for child behaviour. Other
parent characteristics that Mash and Johnston suggest mediate child and environmental
characteristics include affective states, personality, behavioural repertoires, and health.
Cognitions are characterized in this theory by their affect-generating and motivational properties.
As such, they are presumed to be able to exacerbate, reduce, or prevent parent-child stress. In
addition to attributions for child behaviour, perceptions of the severity of child behaviour and
parenting efficacy (one’s sense of one’s ability to manage the demands of parenting) are
highlighted as parenting cognitions mediating parent-child stress. Other parent cognitive factors
such as intellectual ability, values, and behavioural intentions are also posited as affecting parent-
child stress.
The second theory, proposed by Webster-Stratton (1990), suggests that extrafamilial
stressors, interpersonal stressors, and child stressors affect parenting. Extrafamilial stressors in
this theory include unemployment and low socioeconomic status, and interpersonal stressors
include marital distress and divorce. Child stressors refer most significantly to behaviour
problems. Negative parent-child interactions also increase parenting stress, such that children’s
behaviour problems are both a contributor to and a product of increased parenting stress. These
negative interactions are posited to explain the cycle of parenting stress and child behaviour
problems in families of children with ADHD and other conduct problems. Webster-Stratton
further proposes that the impact of extrafamilal, interpersonal, and child stressors on parenting
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stress are mediated by a variety of parental characteristics, including cognitive factors, such as
appraisal of the stressor. Other parent factors that mediate the effect of stressors on parenting
stress include parents’ psychological well-being, quality of social support, gender, and drug use.
McCleary (2002) proposed a third theory to conceptualize parenting stress in families of
adolescents with ADHD. This theory uses Lazarus and Folkman’s (1984) theory of stress,
appraisal, and coping as its starting point; as such cognitive factors are at the centre of this
theory. McCleary proposes that stress results from the parent’s cognitive appraisal of the child’s
needs or behaviours as taxing or exceeding the parent’s resources. What each parent appraises as
stressful differs based on the parent’s own resources and characteristics, including their values,
beliefs, and commitments, and situational characteristics including outside stressors such as
finances. When child behaviours are appraised as stressful, coping, which refers to the parent’s
efforts to manage the stressors, occurs. In addition, social support, and cognitive variables such
as self-efficacy and attributions for the child’s behaviour affect a parent’s appraisals. Adaptation,
which can be negative or positive, occurs as a result of coping. In the case of parenting stress,
adaptation refers to parent’s role performance. Parental role performance refers to the behaviours
a parent engages in. Parental role performance is then posited to impact the child’s behaviour,
thus forming a loop similar to Webster-Stratton’s (1990) theory.
The fourth theory of parenting stress was proposed by Abidin in 1976 (as cited in Abidin,
1995). Abidin is also the creator of the leading measure of parenting stress, The Parenting Stress
Index (PSI; 1983/1995). Although this theory is the oldest, it still dominates the literature. Rather
than a theory that explains the mechanism or “how” of parenting stress, this ecological theory
more carefully elucidates potential mediators and moderators of parenting stress. Abidin
proposes that parenting stress is determined by parent factors, child factors, and situational
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factors. In this theory parent factors are defined as parental attachment, sense of competence, and
depression; child factors as adaptability, acceptability, demandingness, mood, hyperactivity, and
being reinforcing to parent; and situational factors as role restriction (the impact of parenthood
on the parent’s other life roles), parental health, social support/isolation, and spousal relationship
(support and relational conflict). Outside life stressors are seen as global factors that can
exacerbate parenting stress without having any direct effects on parenting stress. In this theory,
parenting stress is proposed to negatively affect parenting (behaviours), which then affects child
outcomes.
Abidin’s theory has several commonalities with Belsky’s (1984) process model of
parenting. These include the delineation of factors affecting parenting or parenting stress and the
reciprocal interactions between these factors. There are some differences between these two
models. The first of two substantive differences are that in Belsky’s model, the parent, child, and
situational factors are presumed to determine parenting, while in Abidin’s theory, they are
presumed to determine parenting stress, which then leads to dysfunctional parenting. The second
difference is that Belsky is more clear about the effects of parenting on child outcomes. Abidin
implies that parenting impacts child outcomes in his writings (e.g., Abidin, Jenkins, &
McGaughey, 1992), but does not elaborate on this relationship when discussing his theory
(Abidin, 1995); he does, however, reference the applicability of Belsky’s model to his work
(Abidin et al., 1992). The differences between these models thus amount to the inclusion of the
affective concept through which parent, child, and situational factors affect parenting practices,
and the clarity with which they link parenting to child outcomes. One other minor difference
bears consideration. Belsky (1984) assumes that the same processes are in effect in both
“dysfunctional” and “normal” families, while Abidin’s theory is one solely of dysfunction. The
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current research, in its inclusion of both families of children with ADHD and families of children
without ADHD sits balanced in the middle of the continuum between these two theories.
Given the dominance of Abidin’s theory (1995) and its fit within the larger parenting
literature, it was used as the conceptual framework for this dissertation. In part, the decision to
use this theory as a guiding framework was made because the data available for inclusion in the
meta-analysis were most directly applicable to this theory. Although the other three theories are
well-established and discussed extensively within the literature (especially the Mash & Johnston
theory, 1990), the fact that the Abidin theory maps so clearly on to the PSI, which is still the
dominant measure of parenting stress, makes it easiest for researchers to test and evaluate. In its
favour, this theory more comprehensively lists variables for consideration than do other theories.
This theory is also universally adopted because it is well-considered and empirically-informed
(see Abidin, 1990, 1995). Outside of vague allusions to “temperament”, Abidin’s theory does not
consider of biological factors in both the child and parent that impact parenting stress. The
research presented here, takes Abidin’s theory as a starting point, but takes a more bio-ecological
viewpoint as Bronfenbrenner would define it (Bronfenbrenner, 2001). Bronfenbrenner brings
together the biology of the child and the parent with the environment, to enhance understanding
of the development of the parent, the child, and the family. The biological factor considered in
this dissertation was the shared genetic influences between parent and child, given the highly
familial nature of ADHD (Levy, Hay, & Bennett, 2006; Willcutt, in press). Bronfenbrenner and
Ceci (1993) suggest that “heritability” is highly influenced by environmental factors, suggesting
an interactive model as was investigated in Study 2.
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In the remaining portion of this chapter, I will review the developmental literature on
parenting stress. This literature is relevant to the two studies here, and indeed informed them, but
due to space constraints, was not reviewed in either Chapter 2 or Chapter 3. Research on quality
of life issues and parenting in families of children with ADHD will also be reviewed. A more
detailed review of the literature on parenting stress in families of children with ADHD is located
in Chapter 2. This introductory chapter ends with a discussion of the rationale for the present
research, the primary objectives of the dissertation, and a general outline of the two studies.
Parenting Stress in the Developmental Literature
Predictors of parenting stress in parents of typically-developing children with no past or
present identified health, medical, sensory, or perinatal issues fall into three main categories
(Abidin, 1995; Bendell, Stone, Field, & Goldstein, 1989; McIntire, 1991; Ostberg & Hagekull,
2000): child factors, parent factors, and contextual factors. Child factors are by the far the most
extensively studied. Parent factors, on the other hand, have received relatively little attention.
There is a great deal of variability among contextual factors, with variables such as social and
marital support, socioeconomic status (SES), and culture receiving a great deal of attention,
while other variables such as work stress, family composition, and negative life events receiving
comparatively little.
Child factors studied in typically-developing children include internalizing (Gutermuth
Anthony et al., 2005) and externalizing behaviours (Bendell et al., 1989; Deater-Deckard,
Pinkerton, & Scarr, 1996; Guternuth Anthony et al., 2005), which have both been found to be
positively associated with parenting stress. Children’s social competence or sociability and self-
esteem (Deater-Deckard et al., 1996; Gutermuth Anthony et al., 2005; McBride, Schoppe, &
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Rane, 2002; Bendell et al., 1989) have also been investigated as predictors of parenting stress
and been found to be inversely related. Because many studies of parenting stress in the
developmental literature focus on very young children, the relationship between child
temperament and parenting stress has been studied extensively, showing that parents of children
categorized as “difficult” or “fussy” are more likely to experience increased levels of parenting
stress (Gelfand, Teti, & Fox, 1992; McBride et al., 2002; Mulsow, Caldera, Pursley, Reifman, &
Huston, 2002; Ostberg & Hagekull, 2000). Finally, other child characteristics that increase
parents’ “daily hassles”, such as poorly established sleep patterns, have also been associated with
increased rates of parenting stress (Sepa, Frodi, & Ludvigsson, 2004). One issue that should be
considered when interpreting this literature is that, in general, parents reported on both the “child
factors” (e.g., internalizing behaviours) and on parenting stress. This presents potential informant
issues.
In terms of parent-level predictors of parenting stress, most studies have restricted
themselves to examining measures of psychological well-being and simple personal factors, most
notably parental age. Further, the majority of the research is limited to mothers (e.g., Bendell et
al., 1989; Crnic & Greenberg, 1990; Deater-Deckard et al., 1996; Gelfand et al., 1992; Mulsow
et al., 2002; Ostberg & Hagekull, 2000; Reitman, Currier, & Stickle, 2002). Both severity of
maternal psychological symptoms (as reported on a general screening questionnaire e.g.,
Reitman et al., 2002) and maternal depression have been associated with increased rates of
parenting stress (e.g., Gelfand et al., 1992; Webster-Stratton & Hammond, 1988). Further,
maternal self-esteem has been identified as relating inversely to parenting stress (Bendell et al.,
1989). Maternal personality traits have also been associated with parenting stress, such that
mothers who are more extraverted and agreeable and less neurotic, have been found to have
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lower parenting stress (Mulsow et al., 2002). No systematic relationship between parenting stress
and parental age has been identified (Deater-Deckard, 2004), although the totality of research
seems to be demonstrative of a bimodal relationship; becoming a parent at either extreme of the
typical age range leads to increased rates of stress. Ostberg and Hagekull (2000) showed that
advanced maternal age is associated with elevated levels of parenting stress, while Richardson
and colleagues showed that teenage parenthood is also associated with more stress (Richardson,
Barbour, & Bubenzer, 1995). Bhavnagri (1999) found an inverse relationship between parenting
stress and maternal age in a low income sample (which included a number of very young
parents). Deater-Deckard and Scarr (1996), on the other hand, found no relationship between
parental age and parenting stress in an upper middle class sample. Finally, there is some
literature to suggest that parents’ own parenting history (i.e., how they perceived the degree to
which they were cared for and protected as a child) predicts parenting stress (Cain & Combs-
Orme, 2005).
Contextual predictors of parenting stress studied extensively include daily hassles,
defined as the “irritating, frustrating, annoying, and distressing demands” of parenthood (Crnic &
Greenberg, 1990, p. 1629); social support, including instrumental and emotional support from
friends, family, the community, and professionals; and marital support, including emotional and
instrumental support from one’s spouse. Increases in daily hassles are associated with increased
parenting stress (Crnic & Greenberg, 1990). The relationship between social support and
parenting stress, however, is less clear. A large Swedish study found that low levels of social
support were associated with increased parenting stress, but that higher levels did not act as a
buffer against stress (Ostberg & Hagekull, 2000). On the other hand, Crnic and Greenberg (1990)
found that social support moderated the effects of parenting stress. Others have found social
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support generally positive, but dependent on the child’s developmental stage (Mulsow et al.,
2002), while some studies have found no effect of social support at all (Sepa et al., 2004).
Collectively, the findings suggest that in typically-developing populations, where parenting
stress is generally lower, social support shows a small inverse relationship with parenting stress.
The size of this relationship likely constrains power to detect this effect, although it is also
possible that a moderating or interactional relationship exists. Marital support has a more
straightforward relationship with parenting stress. Partner intimacy (Mulsow et al., 2002) and
spousal support (McIntire, 1991) have both been shown to be associated with lower levels of
parenting stress, while marital disruption (Deater-Deckard & Scarr, 1996; Webster-Stratton,
1989) and marital discord (in depressed mothers; Gelfand et al., 1992) have been associated with
increased levels of parenting stress. One study of African-American mothers, however, failed to
find any effect of marital status (Cain & Combs-Orme, 2005).
Other contextual factors of parenting stress include family size, work, negative life
events, socioeconomic status, and culture. Parenting stress has been found to increase with the
number of children in the home (Ostberg & Hagekull, 2000). High household workload has also
been associated with increased levels parenting stress (Ostberg & Hagekull, 2000). Whether a
mother works outside the home or not, however, is unrelated to parenting stress (McCarten,
2003), as is whether she engages in part-time or full-time work (Bhavnagri, 1999). Another
significant predictor of parenting stress is negative life events, such as a death or loss of
employment (Ostberg & Hagekull, 2000).
Socioeconomic status (SES) provides another example of the complexity of predicting
parenting stress. For instance, in a longitudinal study, SES was a significant predictor of
parenting stress at one of the time points, but not at others (Mulsow et al., 2002). Some studies
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have found maternal education to be unrelated to parenting stress (Bhavnagri, 1999; Ostberg &
Hagekull, 2000), while others have found it to be inversely predictive of parenting stress
(Gelfand et al., 1992). Bhavnagri (1999) found no effect of occupation. Both Reitman and
colleagues (Reitman et al., 2002) and Deater-Deckard and Scarr (1996) found that both maternal
education and family income are predictive of parenting stress, but both groups of researchers
suggested that SES is only influential in low income samples and thus to obtain sufficient power,
very economically diverse samples are needed. Consistent with these conclusions, Cain and
Combs-Orme (2005) found that poverty is positively associated with parenting stress.
Culture has also been identified as a potential predictor of parenting stress. Cain and
Combs-Orme (2005), for instance, contend that various contextual factors affect African-
American families differently from European-American families resulting in differences in the
experience of parenting stress. Based on comparisons to published norms, most other studies of
African-American families, however, have found that the nature of parenting stress is essentially
the same in African-American and European-American families. Some studies have reported that
African-American families experience similar levels of parenting stress to other families
(Reitman et al., 2002) and others have found that African-American families experience more
stress than majority group families in some areas, but that the size of this effect is quite small
(Bendell et al., 1989; Bhavnagri, 1999; Hutcheson & Black, 1996). Analogous findings have
been reported for American Hispanic families (Solis & Abidin, 1991) and Chinese families
living in Hong Kong (Tam, Chan, & C. Wong, 1994). On the other hand, other researchers
studying parenting stress in Hong Kong Chinese families have suggested that cultural and social
factors result in different sources of stress for Chinese and European-American families, such as
cultural beliefs emphasizing parental responsibility for training children to be obedient and a
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greater sense of social obligation in Chinese families (Kwok & D. Wong, 2000). In one of the
few studies employing direct comparisons between European-American and African-American
families (most other studies compared the group of interest to reported norms on the Parenting
Stress Index questionnaire), no differences were found between the groups in the largely middle
class sample (Deater-Deckard & Scarr, 1996). Acculturation and immigration have also been
investigated as possible contributors to parenting stress. One significant contributor to increased
parenting stress is differential acculturation between parent and child (Martinez, 2006).
One variable that does not fit nicely into the three-factor model of parenting stress
identified earlier is attachment security. Attachment has been studied extensively in relation to
parenting stress. Studies have consistently shown that insecure attachment between parent and
child is associated with increased levels of parenting stress (e.g., Jarvis & Creasy, 1991; Scher &
Mayseless, 2000; Sepa et al., 2004). Indeed, the PSI includes a scale addressing attachment
(Abidin, 1995). Current theory holds that parenting stress disrupts parental sensitivity and
responsiveness, resulting in the development of an insecure attachment relationship (Deater-
Deckard, 2004). Interestingly, ADHD is associated with less secure attachment (Clarke et al.,
2002; Erdman, 1998; Stiefel, 1997), although research has not yet addressed ADHD, attachment
security, and parenting stress simultaneously.
Parenting and Quality of Life in Families of Children with ADHD
Recent research has investigated quality of life issues in families of children with ADHD.
This research shows that children with ADHD have a significant negative impact on parents’
emotional well-being, parents’ time to meet their own needs, and on family functioning (family
activities and cohesion; Klassen, Miller, & Fine, 2004; Hakkaart-van Roijen et al., 2007). ADHD
15
also affects the psychosocial quality of life for the child (Hakkaart-van Roijen et al., 2007;
Danckaerts et al., 2009), although less so than it does for the parents of the child (Danckaerts et
al., 2009). Interestingly, the large European ADORE study showed that having a parent with a
mental health problem is associated with poorer quality of life in children with ADHD, although
parental ADHD was not associated with quality of life reports (Riley, Spiel et al., 2006).
More generally, there is a significant literature on parenting in families of children with
ADHD. The parent-child relationship is often disrupted and parents have a reduced sense of self-
efficacy and role-specific competence (Johnston & Mash, 2001). Families of children with
ADHD engage in more conflict (Danforth, Barkley, & Stokes, 1991; Smith, Brown, Bunke,
Blount, & Christophersen, 2002) and parents are less responsive and rewarding of children with
ADHD (Danforth et al., 1991; DuPaul, McGoey, Eckert, & VanBrakle., 2001). Comorbid
oppositionality and/or conduct problems are often implicated in the higher rates of conflict in
families of children with ADHD (Barkley, Anastopoulos, Guevremont, & Fletcher, 1992;
Barkley, Fischer, Edelbrock, & Smallish, 1991). When interacting with their children with
ADHD, parents tend to be more negative, controlling, intrusive, and harsh (Buhrmester,
Camparo, Christensen, Gonzalez & Hinshaw, 1992; Johnston & Jassy, 2007; Winsler, 1998).
Inconsistency is also common (Johnston & Jassy, 2007). Parents of children with ADHD tend to
attribute their children’s negative behaviour to internal causes and their prosocial behaviour to
external causes (Johnston & Freeman, 1997). Finally, parents of children with ADHD perceive
their relationships with their children more negatively than parents of children without ADHD
(Gerdes, Hoza, & Pelham, 2003) and children with ADHD more often show an insecure
attachment pattern (Clarke, Ungerer, Chahoud, Johnson, & Stiefel, 2002). It is therefore not
surprising that parents of children with ADHD experience high levels of parenting stress (Breen
16
& Barkley, 1988; Johnson & Reader, 2002; Kadesjö et al., 2002). Significant child-level
predictors of parenting stress in this population include: severity of child ADHD symptoms
generally (Anastopoulous, Guevremont, Shelton, & DuPaul, 1992; Baker & McCall, 1995;
Vitanza & Guarnaccia, 1999), hyperactivity (Breen & Barkley, 1988), and
inattention/distractibility (Podoloski & Nigg, 2001). Oppositional defiant, aggressive, and
externalizing behaviour has often been found to be an even more potent predictor of parenting
stress (Anastopoulos et al., 1992; Baker, 1994; Breen & Barkley, 1988; Costa, Weems, Pellerin,
& Dalton, 2006; Goldstein, Harvey, & Friedman-Weieneth, 2007; Podoloski & Nigg, 2001) in
the parents of children with ADHD or other disruptive behaviour disorders than ADHD
symptoms per se. Furthermore, parent-child interactions improve when a child is placed on
stimulant medication (Barkley, 1989; Schachar, Taylor, Wieselberg, Thorley, & Rutter, 1987).
However, medication status is unrelated to parenting stress (Harrison & Sofronoff, 2002;
Anastopoulos et al., 1992).
Parental psychopathology, most notably maternal depression, has also been shown to be
associated with parenting stress in this population (Anastopoulos et al., 1992; Breen & Barkley,
1988; van der Oord, Prins, Oosterlaan, & Emmelkamp, 2006). The early studies on parenting
stress and ADHD (Gillberg, Carlstrom, & Rasmussen, 1983; Sandberg, Wieselberg, & Shaffer,
1980) equated parental psychopathology and parenting stress. Later studies utilized more direct
measures of parenting stress, such as the Parenting Stress Index, and have shown that the parent-
child dysfunctional interaction domain of parenting stress shows specificity to internalizing
symptoms in the child when parental psychopathology is controlled for (Costa et al., 2006).
Attributions for child behaviour have also been found to predict both parenting stress and
maternal depression in samples of families of children with ADHD (Harrison & Sofronoff,
17
2002). To date, all studies on parenting stress and depression in families of children with ADHD
were based on cross-sectional studies, rather than treatment or longitudinal studies.
Rationale for the Current Research and Outline of Studies
The above literature review highlights several important findings that led to the decision
to study parenting stress as it relates to child ADHD. First, there are several negative
consequences from the elevated parenting stress characteristic of families of children with
ADHD. It is associated with poorer treatment outcomes (Kazdin, 1995; Kazdin et al., 1997;
Kazdin & Wassell, 1999; Osborne et al., 2008), affects child development (Anthony et al., 2005;
Crnic et al., 2005), and affects parent well-being (Abidin, 1992; Crnic & Greenberg, 1990; Kwok
& Wong, 2000; Wolf et al., 1989). Second, although the literature on parenting stress and ADHD
is substantial, it is at times contradictory and unclear, as will be discussed in detail in Chapter 2.
The research does consistently show that severity of child ADHD symptoms and parental
depression are positively associated with parenting stress (Anastopoulos et al., 1992; Baker &
McCall, 1995; Breen & Barkley, 1988; Podoloski & Nigg, 2001; van der Oord et al., 2006;
Vitanza & Guarnaccia, 1999). There is also research to suggest that marital quality and social
support are related to parenting stress (see Fischer, 1990; McCleary, 2002). Questions remain
about the association between child conduct problems, child age, child gender, parent gender,
and parenting stress (see Chapter 2).
The third reason that parenting stress was studied as it relates to child ADHD was that
little attention has been given to the parent and contextual factors that impact parenting stress as
a function of child ADHD symptomatology, although Abidin’s (1995) theory of parenting stress
(and the other theories as well) posited that these classes of factors have predictive power. We
18
also know from the developmental literature that these factors have significant effects. To this
end, Study 1 is a meta-analysis of the literature on parenting stress in parents of children with
ADHD and Study 2 examines parent and contextual predictors of parenting stress in this
population.
Study 1 is entitled “Parenting Stress in Families of Children with ADHD: A Meta-
Analysis.” The primary objective of this study was to clarify the literature on parenting stress and
ADHD, and to indicate areas requiring further inquiry, both for future research, and for
investigation as part of Study 2. A secondary objective was to establish the magnitude of the
effect between parenting stress and ADHD. The specific questions addressed in Study 1 were:
how are child ADHD, the presence of co-occurring disorders in children with ADHD, parent
gender, parental depressive symptomatology, and marital quality associated with parenting stress
in parents of children with ADHD. Both demographic (child gender, child age) and
methodological (publication type, publication year, parenting stress measure, diagnostic criteria
used in designating sample) moderators of the findings were also investigated.
Study 2 is entitled “Predicting Parenting Stress in Families of Children with ADHD:
Consideration of Informants, and The Role of Parental ADHD Symptoms, and Other Parent and
Contextual Factors.” It addressed the second major objective of this study, investigating parent
and contextual predictors of parenting stress as a function of child ADHD symptomatology.
Many of the questions addressed in this study were informed by the meta-analysis conducted in
Study 1. Parental ADHD symptoms, parental education, social support, and marital status were
investigated as a function of teacher-reported child ADHD symptoms in a sample of children
with and without clinical levels of ADHD symptomatology. It was hypothesized that parental
ADHD symptoms would predict parenting stress, given the previously reported effects of
19
parental depressive symptomatology on parenting stress (e.g., Anastopolous et al., 1992; Breen
& Barkley, 1988; van der Oord et al., 2006), and the high comorbidity between ADHD and
depression in adults (Kessler et al., 2006). To prevent confounding measures of parenting stress
and measures of child behaviour, parent-specific parenting stress, “parental distress”, was used in
Study 2 as the dependent variable. Furthermore, a comparison of models predicting parenting
stress using teacher versus parent reports of child ADHD and oppositionality was undertaken.
Finally, a model examining the moderating role of parental ADHD symptomatology on the
association between child ADHD symptomatology and parental distress was evaluated.
Exploratory analyses into other potential moderating models of parenting stress were conducted.
20
Figure 1. Model of Parent-Child Interactive Stress. Adapted from Mash & Johnson, 1990
21
21
Chapter 2:
Parenting Stress in Families of Children with ADHD: A Meta-Analysis
Abstract
This study represents the first meta-analysis of parenting stress and ADHD. Analyses were
conducted to examine findings on the association between parenting stress and ADHD.
Predictors comprising child, parent, and contextual factors, and methodological and demographic
moderators of the relationship between parenting stress and ADHD were examined. Findings
from 22 published and 22 unpublished studies prepared through October 2007 were included.
Results confirmed that parents of children with ADHD experience more parenting stress than
parents of nonclinical controls and that severity of ADHD symptoms was associated with
parenting stress. Child co-occurring conduct problems and parental depressive symptomatology
predicted parenting stress. Little difference in parenting stress was found between mothers and
fathers, but child gender was a significant moderator of parenting stress, with lower stress levels
in samples with higher proportions of girls. None of the methodological moderators examined
(i.e., publication type, publication year, parenting stress measure, diagnostic criteria) were
significant.
22
Introduction
This meta-analysis investigates the relationship between Attention-Deficit/Hyperactivity
Disorder (ADHD) and parenting stress. ADHD is a chronic, pervasive condition characterized by
inattention, impulsivity, and hyperactivity (American Psychiatric Association, 2000). Current
research points to strong genetic influences (Levy et al., 2006; Willcutt, in press), including
elevated rates of ADHD symptomatology (Epstein et al., 2000) in the parents of children with
ADHD. Conduct problems (e.g., Barkley, DuPaul, & McMurray, 1990; Biederman, Faraone, &
Lapey, 1992; Wilens et al., 2002) and other disorders, such as anxiety (e.g., Biederman,
Newcorn, & Sprich, 1991; March et al., 2000; Newcorn et al., 2001) and learning disabilities
(e.g., Barkley et al., 1990; Mayes, Calhoun, & Crowell, 2000) commonly co-occur in children
with ADHD. In addition to these co-occurring disorders, child ADHD is also associated with
elevated levels of parenting stress (e.g., Breen & Barkley, 1988; Johnson & Reader, 2002;
Kadesjö et al., 2002).
Parenting stress is a distinct type of stress that arises when a parent’s perceptions of the
demands of parenting outstrip his or her resources for dealing with them (Deater-Deckard, 2004).
The dominant model of parenting stress delineates two major components: a child domain,
arising directly from child characteristics, and a parent domain that is more affected by parental
functioning (Abidin, 1995). Total stress is the result of combining parent- and child-based stress
(Abidin, 1995). Studies of families with children with ADHD show elevations in both domains
of parenting stress (e.g., Breen & Barkley, 1988; Dupaul et al., 2001). More so than other types
of stress, parenting stress is associated with parenting practices and child development (Deater-
Deckard, 2004). Although experiencing some parenting stress is considered normal (Crnic &
Greenberg, 1990), elevated levels of parenting stress may affect the parent-child relationship and
23
negatively impact parenting practices (Abidin, 1992; Belsky, 1984; Morgan et al., 2002;
Rodgers, 1998; Webster-Stratton, 1990). Parents who experience extreme levels of this type of
stress may be less able to implement interventions to help their children (Kazdin, 1995). By
contrast, reductions in parenting stress are linked to increases in the efficacy of parent
management training (PMT; Kazdin & Whitley, 2003). PMT is a very commonly used
intervention with children with ADHD (Kazdin, 1997).
Six qualitative reviews of the literature on parenting stress and ADHD have been
conducted (Deault, 2010; Fischer, 1990; Johnston & Mash, 2001; Mash & Johnston, 1990;
McCleary, 2002; Morgan et al., 2002). The reviews concluded that parents of children with
ADHD experience more stress than parents of normal controls (Deault, 2010; Fischer, 1990;
Johnston & Mash, 2001; Mash & Johnston, 1990; Morgan et al., 2002) and that the relationship
between severity of ADHD and parenting stress was clearly established (McCleary, 2002;
Morgan et al., 2002). The co-occurrence of ADHD with conduct problems was a common point
of discussion. Some reviews concluded that parents of younger children with ADHD experience
higher levels of stress than parents of older children (McCleary, 2002; Morgan et al., 2002),
while another concluded there was no significant effect of child age (Johnston & Mash, 2001),
and a third concluded that stress remains high through adolescence (Deault, 2010). Typically,
child gender was not found to be predictive of parenting stress (Johnston & Mash, 2001;
McCleary, 2002).
The reviews reported that parents of children with ADHD experience increased levels of
psychopathology, which is assumed to be caused by the same factors that lead to the children’s
ADHD (in some of the reviews parental psychopathology was used as a proxy for parenting
stress; i.e., Fischer, 1990). One review concluded that fathers of children with ADHD experience
24
less parenting stress (McCleary, 2002), while another concluded there were no significant
differences between mothers and fathers (Johnston & Mash, 2001). ADHD is also associated
with decreased marital quality (Deault, 2010; Fischer, 1990; McCleary, 2002). One review noted
that social support is a protective factor against parenting stress in this population (McCleary,
2002). Based on the prevailing theories, the reviews generally assumed a child to adult direction
of effect, with some making this directionality explicit (i.e., Fischer, 1990; Mash & Johnston,
1990). The contributions of and moderating role of maternal cognitions (e.g., parenting sense of
competence) in relation to parenting stress was also often part of the conceptual framework used
in the reviews (Mash & Johnston, 1990; McCleary, 2002; Morgan et al., 2002).
These reviews reveal several unanswered questions, including the associations between
SES and parenting stress in this population (Johnston & Mash, 2001) and the nature of the
relationship between conduct problems and parenting stress (Johnston & Mash, 2001).
Inconsistencies between studies on various aspects and/or predictors of parenting stress was a
common theme in all of these reviews, but each review was unable to deal with these
inconsistencies, except to note them and provide possible explanations. This is one of the major
problems with narrative reviews (Johnson & Eagly, 2000). Furthermore, recent research has been
conducted that has not been included in any of the currently available reviews, necessitating this
literature be revisited. In addition, many of the reviews equated parent-child conflict and
parenting stress or grouped life stress and parenting stress together, whereas greater conceptual
clarity can be achieved by considering parenting stress separately. This meta-analysis was
conducted to clarify these predictors and also to establish the magnitude of the effect between
parenting stress and ADHD.
25
A meta-analysis provides a systematic manner of reviewing studies that integrates
disparate findings and attempts to identify reasons (moderators) for the contradictions. The
inclusion of unpublished studies in meta-analyses is a strength of this methodology, as the
exclusion of these studies may lead to a positive bias in the findings (Lipsey & Wilson, 2001;
Rothstein, Sutton, & Borenstein, 2005). The purpose of the current study was to use meta-
analytic methodology to analyze findings on the relationship between parenting stress and
ADHD. Predictors comprising child, parent, and contextual factors, as well as methodological
and demographic moderators of the relationship between parenting stress and ADHD were
examined.
A primary area of inquiry in the domain of methodological moderators was the effect of
different measures used to evaluate parenting stress. The dominant measure of parenting stress
(Johnston & Mash, 2001) is the Parenting Stress Index (PSI; Abidin, 1983, 1990, 1995). The PSI
provides scores in two domains: child and parent domain stress, as well as a total stress score and
a life stress score. The total stress score is the sum of the parent and child domain scores. Child
domain stress refers to stress arising directly from factors within the child. Sample items include
“My child does a few things which bother me a great deal” and “My child turned out to be more
of a problem than I had expected.” Parent domain stress refers to stress related more to factors
arising from within the parent. Sample items on this scale include “I find myself giving up more
of my life to meet my children’s needs than I ever expected.” Moderators were examined here in
relation to the effect between total stress and ADHD symptoms overall (rather than on each
effect; results from studies not using the PSI were included in all analyses using “total stress”).
This was done in order to reduce the probability of Type II error. Data from group comparison
studies (i.e., studies using t-tests and ANOVAs to evaluate their effects) and dimensional studies
26
(i.e., studies using correlation) were analyzed separately. Each predictor was also evaluated as to
its relationship with each of total, parent domain, and child domain stress.
Research Questions
The following research questions were derived from the reviews of ADHD and parenting
stress and by investigations into parenting stress in the developmental literature.
1. How is having a child with ADHD associated with parenting stress? (a) Do parents of
children with ADHD experience more parenting stress than parents of children
without ADHD?; and (b) Do parents of children with ADHD experience more stress
than parents of other clinically-referred children?
2. What is the magnitude of the association (correlation) between ADHD symptoms
(ADHD symptoms overall, inattentive symptoms, and hyperactive-impulsive
symptoms) and parenting stress?
3. How are the presence of co-occurring disorders in children with ADHD associated
with parenting stress? (a) What is the association between child conduct problems and
parenting stress?; (b) Do parents of children with ADHD alone experience more or
less stress than parents of children with ADHD and co-occurring conduct problems?;
and (c) What is the association between child internalizing symptoms and parenting
stress?
4. How are parental factors associated with parenting stress in parents of children with
ADHD? (a) What is the relationship between parental depressive symptoms and
parenting stress?; and (b) Do fathers and mothers differ in their experience of
parenting stress?
27
5. How is the contextual factor of marital quality associated with parenting stress in
parents of children with ADHD?
6. How do the following moderators affect the effect between ADHD severity and
parenting stress? (a) Methodological moderators: publication type (published vs.
unpublished), publication year, parenting stress measure used, and diagnostic criteria
used in designating sample; and (b) Sample moderators: child gender (percent girls in
sample) and mean child age of sample.
A number of other research questions were proposed, but were abandoned due to
insufficient data (2 or fewer studies providing relevant data). These questions related to the
relationships between parenting stress and child ADHD subtype, child medication usage, child
co-occurring disorders other than conduct problems, parenting sense of competence, parent
education, parental ADHD, parent age, social support, marital status, family size, culture, and
language. Family SES was also abandoned as a potential moderator due to insufficient data.
Method
Search and retrieval of studies and eligibility criteria.
A computerized search was conducted to locate relevant studies using PSYCInfo, ERIC,
Medline, Dissertation Abstracts International, and Google Scholar. Search terms were composed
of combining descriptors addressing ADHD (Attention Deficit Disorder with Hyperactivity,
Attention Deficit Disorder, Hyperactivity, Hyperkinesis, Minimal Brain Dysfunction, behaviour
problems) with descriptors addressing parenting stress1 (stress and caregiver burden). The
citation indices of PSYCInfo, ERIC, and Medline were also searched for reports citing those
1 “Parenting stress” was not available as a descriptor in any of the databases consulted. The terms used (stress and caregiver burden) were selected based on a backward search locating the keywords used to describe/search clearly relevant articles.
28
reports already identified. The reference lists of relevant identified articles were reviewed for
appropriate studies not identified elsewhere. In addition, review articles (e.g., Fischer, 1990;
Johnston & Mash, 2001), books (Deater-Deckard, 2004), and a listing of relevant articles
produced by the developer of the dominant parenting stress measurement tool (Abidin, 2003)
were consulted. Using the title and abstracts of the reports, this body of work was narrowed
down to 117 studies for possible inclusion in the meta-analysis.
Studies were included in the meta-analysis based on the following criteria:
1. The study was reported in English and prepared up to October 2007. It involved
quantitative consideration of the relationship between ADHD and parenting stress,
either within a sample of children with ADHD (i.e., correlational/dimensional
studies), between ADHD samples (e.g., studies comparing mothers and fathers of
children with ADHD), or between an ADHD sample and a comparison sample
(typically-developing or clinical). Studies that compared an ADHD sample to
published norms were not eligible (to ensure independence between effects). Both
published and unpublished reports were eligible.
2. The study examined one or more variables or relationships of interest and provided
and/or conducted (in which case the author provided) statistical analyses amenable to
current meta-analytic technique. Furthermore, the study’s methodology and statistical
analyses met basic standards of practice, such as independence between samples and
subjects.
3. The study included some measure of ADHD symptomatology (including
hyperactivity, inattention, or ADHD symptoms overall) or previous diagnosis of
ADHD, ADD (attention-deficit disorder), or hyperactivity by a qualified health
29
professional. Studies that considered children “at risk of ADHD”, but that did not
measure ADHD symptoms (e.g., through a standardized questionnaire), studies where
symptoms of ADHD were attributed to an identified toxin exposure, and studies that
evaluated ADHD symptoms, but whose primary concern was with children with other
clinical diagnoses (e.g., developmental delays or autism) were not included.
Similarly, studies primarily of children with oppositional or conduct problems were
omitted unless they designated a separate ADHD group. Studies where children with
ADHD were compared to children with other diagnoses (including developmental
delays, autism, oppositional defiant disorder, conduct disorder, learning disabilities,
depression, or anxiety) were included.
4. The study included a direct measure of stress relating to the parenting role, such as
the Parenting Stress Index (Abidin, 1995). Studies that only included measures of life
stress, parental psychopathology, parenting sense of competence, and/or parental self-
esteem were not included. Furthermore, the measure of parenting stress must have
been shown to have adequate psychometric properties, such as internal consistency,
validation with previously established measures and/or other predictors, or test-retest
reliability, as appropriate; studies where this was established within the confines of
the study were eligible.
Study Characteristics and Coding
A total of 44 written reports (22 journal articles and 22 dissertations) met the criteria for
inclusion. In some cases, two or more written reports were available on the same data, often
including a conference report. The following hierarchy was used in selecting amongst the
reports: articles from peer-reviewed journals were preferred, dissertations and theses were used if
30
no formally published reports were available, and conference papers were used if they were the
only report available (in all cases dissertations were located to replace conference papers). This
hierarchy was established to ensure the highest quality reports were included in the meta-analysis
and to ensure that the most comprehensive data were available. These 44 studies generated 208
effect sizes on a total sample of 4991 families. Figure 2 illustrates the identification, screening,
eligibility, and inclusion of studies in the meta-analysis in a flow diagram format.
A coding manual (Appendix A) was developed for the coding of study reports. This
coding scheme was based on the research questions formulated above and on an examination of
common data points present within this body of literature. Primary coding was completed by the
author using pencil and paper forms (Appendix B) and entered into Comprehensive Meta-
Analysis Version 2.2 (CMA; Borenstein, Hedges, Higgins, & Rothstein, 2007) for analysis. The
coding scheme required little interpretation. Study descriptors coded were: bibliographic
information (citation, publication year, publication type), methodological information (ADHD
definition, ADHD diagnostic procedures, measure used), and sample information (percent
female children in sample, percent mothers in sample, mean child age in sample, mean SES of
sample). Effects were coded for their relationship with each of total, parent domain, and child
domain stress on the PSI (and the PSI-Short Form [PSI/SF], where parental distress was equated
with parent domain stress from the PSI, and difficult child was equated with child domain stress
from the PSI), the most common measure of parenting stress. Results from measures other than
the PSI were coded as total stress, and measures which included evaluations of both intensity and
frequency were coded for their measure of intensity if both were available.
In order to ensure independence between comparable effects, only one measure of
parenting stress was used from each study (e.g., PSI or Family Strain Index, not both; however,
31
total, parent, and child domain stress scores from the PSI were all used where applicable as each
was entered into a separate analysis). This decision was made systematically using the order of
preference laid out in the coding manual (with results from the PSI being the most preferred—in
all cases where more than one measure was available this was the one used). This hierarchy was
developed based on the prevalence of the measures in the literature, such that more prevalent
measures were always given preference so that niche measures with little empirical support
would not dominate the analysis. Furthermore, when results were present from more than one
parent on each child, the results from the mothers were used as father data were often only
obtained on a subsample of participating children in any given study. In only one journal article
was insufficient data available for statistical analysis. The primary author of this study was
contacted, but did not provide the necessary data.
Analysis
The methodology recommended by Lipsey and Wilson (2001) was used for this meta-
analysis. Separate meta-analyses were conducted to answer each of the research questions as
described above. Cohen’s d, representing the standardized mean difference, was used for the
analyses that involved group comparisons (except for the mother-father comparison, where the
standardized paired difference was used). The pooled correlation coefficient, r, was used for
dimensional (correlational) analyses. Effect sizes were interpreted as suggested by Cohen (1977,
1988): for d: ≤ .20, small; .50, medium; and ≥ .80, large and for r: ≤ .10, small; .25, medium; and
≥ .40, large. Given the large number of analyses conducted, an alpha level of .01 was used in
inspecting the weighted effect sizes and moderator analyses to reduce the probability of Type I
error. Mean effect sizes were considered interpretable if composed of 3 or more effect sizes.
32
For each analysis a Forrest plot was created using CMA and inspected visually for
outliers (Borenstein, Hedges, Higgins et al., 2007; Johnson & Eagly, 2000; Lipsey & Wilson,
2001; Sterne & Harbord, 2004. An examination of all outliers was also undertaken using the
often employed criterion of individual study effect sizes exceeding three standard deviations
from the composite effect size (Lipsey & Wilson, 2001). Using these criteria, outliers were
common in this meta-analysis, though in few cases could obvious reasons for the variation be
found. Given the relatively small number of effect sizes in each analysis and the ubiquity of
outliers in this study, each was retained at its current value. In the majority of cases, however, the
outlier effects were in the same direction as the mean effect (and other component effects),
suggesting little question about the presence of a given effect.
Homogeneity analyses were conducted on each analysis using the Q statistic (Lipsey &
Wilson, 2001). Given that the majority of the analyses reflected heterogeneous effect sizes, a
random effects model was consistently used in conducting the meta-analyses (Lipsey & Wilson,
2001). In a few analyses (e.g., the correlation between parent domain stress and parental
depressive symptoms) the null hypothesis of homogeneity was not rejected. As analyses tended
to involve a very small number of effect sizes (2 to 3), Q may not have had sufficient power to
detect an effect of heterogeneity, leading to a high chance of Type II error. Therefore,
heterogeneity was assumed for all analyses and a random effects model was employed.
Furthermore, a random effects model was the logical choice for analysis given the criteria laid
out by Borenstein, Hedges, and Rothstein (2007) of using a random effects model for studies
where there is little reason to believe that the component studies are virtually identical. A random
effects model, as opposed to a fixed effects model, assumes variation among effect sizes above
sampling level error alone, suggesting the presence of moderators. In a random effects model,
33
each study included in a meta-analysis is assumed to be a random sample of the distribution of
effects. Thus the combined effect is the mean of the distribution of effects. In a fixed effects
model, conversely, there is assumed to be one true effect which is shared by all the studies
included in the meta-analysis. These models weight individual studies differently. In a fixed
effects model, each study is weighted by its sampling error, such that larger studies are weighted
more heavily. In a random effects model, each study is assumed to be estimating a different
effect size and thus the weights given to each study are more balanced and less influenced by
sample size (sampling error).
Separate metaregressions were used to examine the effects of the following continuous
moderator variables: child gender (percent of child sample female), child age, and publication
year. Analog ANOVAs were used to evaluate the categorical moderators (ADHD diagnostic
criteria, publication type, measure of parenting stress). Mixed effects models were used for both
the metaregressions (method of moments) and analog ANOVAs. Due to the small K (number of
effects) in each meta-analysis, results were not broken down by significant moderators for each
analysis, nor were moderator analyses conducted on each analysis; instead the correlation
between ADHD symptoms overall and total stress was evaluated as a representative illustration
of the effect of various moderators on the relationship between child ADHD and parenting stress.
Reliability coding was completed by a Master’s level graduate student trained by the
author in meta-analytic procedure. Training consisted of four sessions where the principles of
meta-analysis, the purpose of the present analysis, and the nature of the coding scheme were
discussed. The second coder coded sample studies (not included in the reliability analysis) with
discussion and feedback until acceptable agreement was reached on all constructs. The second
coder then independently coded a randomly-selected sample of 12 studies used in the meta-
34
analysis. Interrater reliability was calculated for each variable in the coding system using
Cohen’s kappa for categorical variables and the intraclass correlation coefficient for continuous
variables. The agreement for all constructs was high with kappas ranging from .8 (measure used
in correlational analysis) to 1 (publication type, ADHD criteria used, parenting stress outcome
measure, group matching) and intraclass correlation coefficients ranging from .91 (percent
children female) to 1 (all effect size variables).
Results
Study characteristics.
Forty-four studies met criteria for inclusion in this meta-analysis. The year of publication
ranged from 1983 to 2007. Thirty-eight of the studies were conducted in North America, 4 in
Western Europe, and 2 in Asia. Most studies utilized the Parenting Stress Index (PSI; Abidin,
1983, 1990, 1995) or a variant of it to measure parenting stress (PSI: n = 20; Parenting Stress
Index-Short Form: n = 12; translations of the full or short form: n = 3). The remaining studies
used adaptations of the PSI (n = 2; i.e., creating a new stress variable based upon a principal
components analysis of the PSI and other stress or parenting competence measures), the Family
Strain Index (n = 1; Riley, Lyman et al., 2006), the Circle of Stress Index (n = 1; Circle, 1998),
the Disruptive Behavior Stress Inventory (n = 2; Johnson & Reader, 2002), the Parenting Daily
Hassles Scale (n = 1; Crnic & Greenberg, 1990), the Nijmegen Child-Rearing Situation
Questionnaire (n = 1; Wels & Robbroeckx, 1996, as cited in Kadesjö et al., 2002), the Pearlin
Parental Stress Scale (n = 1; Pearlin & Schooler, 1978), and the Questionnaire on Resources and
Stress-Short Form Adapted (n = 2; Salisbury, 1986).
The studies used different diagnostic criteria to confirm or establish ADHD in the child
participants. Nineteen studies used the DSM-IV criteria for ADHD, 10 used the DSM-IIIR
35
criteria, and 1 used the DSM-III criteria. One study used a combination of ICD-10 criteria and
DSM-IV criteria, and 1 study of preschool-aged children specifically opted not to use organized
criteria as the authors felt they were not applicable to that age group (Goldstein et al., 2007). The
remaining 12 studies did not specify the diagnostic criteria they used, although all studies
included in the meta-analysis employed some measure of ADHD symptoms or a formal
diagnosis of ADHD as a condition of eligibility.
The majority of the studies examined parenting stress solely in mothers (n = 24), while 9
studies did not report on the parent sample makeup. The remainder of the parent samples were
composed primarily of mothers (85% or more of the sample), unless mother-father comparisons
were being undertaken. The age range of children in the samples varied from 3 to 12 years, with
an unweighted mean age from those studies reporting applicable data of 8.48 years. The
percentage of girls in the samples in each study ranged from 0 to 100%, with a mean of 19.25%.
The number of effects comprising each weighted mean effect (i.e., answering each
research question) ranged from 2 to 10. Each study provided between 1 and 18 effect sizes (M =
4.73). Results will only be discussed when K ≥ 3. The results of the group comparison studies are
presented in Table 1, and results of the dimensional studies in Table 2, in the order of the
research questions listed above.
ADHD Diagnosis (Level of Symptoms)
As shown in Table 1, parents of children with ADHD experienced significantly more
parenting stress than parents of nonclinical controls in terms of total, parent domain, and child
domain stress. These effects were large. As shown in Table 2, the relationship between overall
ADHD symptoms and total parenting stress was large and the relationship between overall
ADHD symptoms and parent domain stress was medium. The effect was not significant for child
36
domain stress. Breaking this down further, the effect size for the relationship between inattention
and total parenting stress as well as parent domain stress was medium, while the association
between inattention and child domain stress was not significant (Table 2). Finally, the effect
between hyperactivity/impulsivity and parenting stress was large for total stress and child
domain stress, but medium for parent domain stress (Table 2).
Parents of children with ADHD were also compared to parents of children with learning
disabilities (k = 1), autism (k = 1), developmental delays (k = 1), internalizing disorders (k = 1),
and unspecified clinical disorders (k = 2; e.g., consecutive non-ADHD referrals to a children’s
mental health agency). As shown in Table 1, these comparisons were only significant in the area
of child domain stress, where the effect was medium.
Co-Occurring Disorders
As shown in Table 1, parents of children with ADHD and clinical levels of co-occurring
conduct problems (defined as ratings of conduct problems, oppositionality, externalizing
behaviour problems, and aggression and/or clinical diagnoses of conduct disorder or oppositional
defiant disorder) experienced significantly more parenting stress than parents of children with
ADHD who did not have conduct problems. The effect size was medium for total stress, small
for parent domain stress, and large for child domain stress. Furthermore, as shown in Table 2, the
size of the relationship between total and child domain stress and conduct problems was large,
while the size of the relationship between parent domain stress and conduct problems was
medium. The association between internalizing symptoms and parenting stress in children with
ADHD was large for total, parent domain, and child domain stress.
37
Parent and Contextual Factors
As shown in Table 2, a large effect was found for the association between parental
depressive symptoms and total stress (insufficient data were available for interpretation on the
relationship between parental depressive symptoms and child and parent domain stress). The
effect size for fathers versus mothers for total and child domain stress was small, but negative,
indicating that mothers experience more stress than fathers, as shown in Table 1. However, the
results did not achieve significance in the parent domain, indicating that mothers and fathers of
children with ADHD do not differ significantly in their reports of parenting stress in this area.
The variable “marital quality” was composed of both measures of marital satisfaction and
marital discord, which was reverse-scored. The marital discord effect, once reversed was similar
in size to the marital satisfaction effects, supporting its inclusion here. The association between
marital quality and parenting stress was not significant.
Moderator Analyses
As stated earlier, all moderator analyses were conducted on the effect for the association
between ADHD symptoms and total stress (Fisher’s Z, a transformation of r, was used in these
analyses rather than r, as the sampling distribution of r is not normally distributed). Child gender
(percent child sample female) was a significant moderator, QR(1) = 9.77, p = .002, with less
parenting stress in samples with higher proportions of girls. Mean child age, however, was not a
significant moderator, QR(1) = 0.54, p = .463.
There were no significant methodological moderators. Although the effects for
publication type (journal vs. thesis/dissertation) showed a trend toward larger effects in the
published works (r = .55) than the unpublished works (r = .42), the difference was non-
significant (QB(1) = 2.21, p = .14). A weighted regression analysis showed that publication year
38
was not a significant moderator (QR(1) = 2.59, p = .11). The ANOVA analog for parenting stress
measure was not significant (QB(4)= 2.43, p = .66). Finally, diagnostic criteria used in
designating the sample (e.g., DSM-III, DSM-IV, other) was not a significant moderator (QB(2)=
2.52, p = .28).
Discussion
This meta-analysis provided a quantitative update to Fischer’s (1990), Mash and
Johnston’s (1990), Johnston and Mash’s (2001), McCleary’s (2002), and Morgan et al.’s (2002)
reviews on parenting stress in parents of children with ADHD. One of the most important
elements of this meta-analysis was its inclusivity. The majority of studies included in this
quantitative review were not included in any of the previous qualitative reviews. In part, this is a
result of the inclusion of unpublished studies in the meta-analysis. A number of studies included
here were also conducted subsequent to the previous reviews, which clearly resulted in their not
being previously considered.
Overall, this meta-analysis showed that parents of children with ADHD experience
significantly more parenting stress than parents of children without ADHD. Except in child
domain stress, ADHD was not associated with more parenting stress than other clinical
disorders, indicating that parent domain stress may result from factors common to having a child
identified with any clinical disorder (e.g., genetic factors that contributed to the child’s disorder,
hassles associated with having a child with a clinical disorder such as financial obligations and
time commitments related to appointments). Furthermore, both hyperactive-impulsive and
inattentive symptoms were predictive of parenting stress (although inattentive symptoms were
not predictive of child domain stress), indicating that both types of symptoms play a role in
parenting stress, but that inattentive symptoms are associated with less family disruption.
39
Externalizing and internalizing symptoms in this population were also linked to parenting stress.
Co-occurring conduct problems in children with ADHD increased parenting stress. This is
consistent with Sameroff’s model (1995; Sameroff, Bartko, Baldwin, Baldwin, & Seifer, 1998)
of developmental continuity and multiple risks; that is, the risk posed by each of ADHD and
conduct problems increased the probability that the family experienced negative outcomes in
terms of increased parenting stress. It is unfortunate that insufficient data were available on other
co-occurring disorders to evaluate whether they too increased a family’s total risk.
In terms of parent and contextual predictors of parenting stress, mothers and fathers of
children with ADHD reported the same amount of parent domain stress, but mothers experienced
a small amount more child domain (and total) stress. Parental depressive symptoms were a
significant predictor of parenting stress, especially in terms of parent domain stress. Furthermore,
parental depressive symptoms were the strongest predictor examined of parent domain stress.
There are a number of possible explanations for this effect, including overlap in the content of
the PSI parent domain items and commonly used measures of parental depression (e.g., the Beck
Depression Inventory) and informant effects, as parents typically reported on both their own
depressive symptoms and their parenting stress (as well as child ADHD symptomatology).
Another possibility, however, is that parental depression in this population may be related to an
underlying genetic predisposition with ADHD (Biederman et al., 1992). This is consistent with
both the Fischer (1990) and Johnston and Mash (2001) reviews, which suggested that parental
psychopathology was an important factor in increased parenting stress in this population and
resulted from common factors with the child’s ADHD. This finding points to the importance of
considering more parent-level factors in the experience of parenting stress in parents of children
with ADHD and in other populations, and in considering the effects of familiality, which might
40
otherwise result in the identification of child-level factors, but which may be more
parsimoniously tied to parent factors. In families of children with ADHD, consideration of
parental ADHD is indicated given the highly familial nature of ADHD (Levy et al., 2006;
Mulsow et al., 2001; Schachar & Wachsmuth, 1990;Willcutt, in press).
The only significant moderator that emerged from this literature was child gender, with
female gender being associated with less stress. This is in contrast to the findings of Breen and
Barkley (1988) who found no difference between the parents of boys and girls with ADHD and
Podoloski and Nigg (2001) who found that parents of girls with ADHD experienced more stress
than parents of boys with ADHD. By combining results from many studies, the current research
obtained the power necessary to detect this effect that was not clear in individual studies.
Mean child age was not a significant moderator in this meta-analysis. Furthermore, no
methodological moderators (publication type, publication year, parenting stress measure,
diagnostic criteria) were significant, indicating that although there was a great deal of
heterogeneity in the effect sizes, the results were not affected by any obvious methodological
issues, which may increase our confidence in the results.
Strengths and Limitations
One element of this meta-analysis that could be considered both a strength and a
limitation is the inclusion of unpublished studies. The strength of this approach is that it avoided
the “file-drawer” problem common to studies with null effects. It also greatly increased the
sample size considered. Furthermore, the inclusion of unpublished studies confirms that the
effects studied were powerful enough to be detected even in less methodologically rigorous
studies. On the other hand, unpublished studies cause greater concern in terms of
methodological quality as they have not passed peer review. The eligibility criteria set out for
41
this meta-analysis, however, excluded those studies with truly questionable methodology or
analysis. Given the constraints of current meta-analytic technique, however, the relative
statistical simplicity of these studies was not detrimental as the results of t-tests and correlations
are easily meta-analyzed, whereas results from sophisticated published studies, which included
structural equation models and regressions, are not (Lipsey & Wilson, 2001). Indeed, the
inability to include all the results from some of the more sophisticated studies on parenting stress
and ADHD (e.g., Bussing et al., 2003; Harrison & Sofronoff, 2002; Peris & Hinshaw, 2003) was
a limitation of this meta-analysis.
Another limitation to this meta-analysis was the lack of a searchable keyword or
“descriptor” for parenting stress in any of the relevant article databases. The absence of
“parenting stress” as a descriptor is surprising given the sizable research on this topic; however,
without it one can never be entirely confident that all relevant studies were uncovered during the
retrieval phase.
The limited number of component effect sizes (k) in some analyses is also a limitation of
this study. A number of the analyses only included 3-4 studies. Although meta-analysis is still
statistically appropriate in these cases, one study may sway results. A random effects model was
used, however, to mitigate this possibility. The results of analyses with limited number of effects
may be fruitful areas for further inquiry in order to confirm the findings.
Other limitations included the research questions that could not be addressed due to
insufficient available data (i.e., studies on these topics). These included the associations of social
support, marital status, parental ADHD, and child ADHD subtype with parenting stress. The
preponderance of mothers in the parent samples included in the meta-analysis is another
limitation. The findings from this meta-analysis are therefore more readily applicable to mothers
42
than fathers, although given the generally small differences between mothers and fathers found
in this study, it is likely that the results apply to fathers as well.
Directions for Future Research
Although the literature on parenting stress and ADHD is reasonably well-developed, this
meta-analysis highlighted several areas for future inquiry. First, future research needs to explore
parental and contextual predictors of parenting stress in families of children with ADHD further.
The few parental and contextual variables in this meta-analysis with sufficient data showed
significant effects. One variable in particular that warrants further attention is parental ADHD,
especially given the relationship between adult ADHD and depression (e.g., Biederman et al.,
1992) and the findings here of a positive relationship between parental depressive
symptomatology and parenting stress. Parental cognitive factors, such as parenting sense of
competence, have also received very little attention in spite of Mash and Johnston’s (1990)
model giving maternal cognitions a substantial role in parent-child interactive stress. Parental
education and age are other variables requiring further exploration. Similarly, non-nuclear family
arrangements require consideration, along with consideration of family size. Cultural and
language differences also bear exploration. Buffers such as social support and marital status also
need further investigation, as these may be important factors to consider in interventions for
elevated parenting stress.
Although the literature on child-level factors and parenting stress in families of children
with ADHD is generally larger than that on parent and contextual-level factors, the effects of
ADHD subtype require more attention, as do the effects of co-occurring internalizing and
learning disorders. Furthermore, studies on parenting stress and ADHD have typically used
samples of children 12 years of age and under (this may be related to measurement issues; i.e.,
43
the PSI is only valid in younger children). Given the problems with academic achievement and
risk taking behaviours of adolescents with ADHD, studies examining parenting stress in families
of adolescents are needed.
Clinical Implications and Conclusions
This study clearly illustrated that it is important for clinicians to consider parenting stress
in families of children with ADHD. In light of Kazdin and Whitley’s (2003) findings of
increased response to treatment in children whose parents received intervention for their
parenting stress, this is clearly an issue not just for assessment, but also for intervention for
clinicians working with families with children with ADHD.
Moreover, from the perspective of Sameroff’s model of multiple risks (1995; Sameroff et
al., 1998), this study elucidated multiple potential risk factors in these families for increased
parenting stress (e.g., parental depression, child internalizing and externalizing
symptomatology), along with other presumed risk factors such as poverty and life stress that
clinicians should assess when considering a family’s stress levels and needs. On the other hand,
there are few differences between mothers and fathers in parenting stress; thus both parents
should be targeted for interventions for parenting stress. The pervasiveness of the PSI, which was
designed as a clinical tool (Abidin, 1995), in conducting research into this topic also showed how
simply and practically this construct can be assessed by clinicians.
In summary, this meta-analysis, the first quantitative review of parenting stress and
ADHD, confirmed findings of higher parenting stress in parents of children with ADHD than
parents of children without ADHD. Severity of ADHD symptoms were linked to severity of
parenting stress and co-occurring conduct problems and internalizing symptoms significantly
increased parenting stress. Parent and contextual factors also played a role in parenting stress,
44
with parental depressive symptomatology showing the largest effect. Child gender was a
significant moderator of the relationship between total parenting stress and ADHD symptoms.
By systematically collating the data on this topic this meta-analysis was able to clarify findings,
indicate the magnitude of the effect between ADHD and parenting stress, consider moderators,
identify areas requiring further research, and suggest new areas of inquiry.
45
Table 1
Meta-Analyses of Studies Comparing Groups on Parenting Stress
95% CI
Comparison
Stress
domain
K
d
p Lower limit Upper limit
Q
Total 9 1.80 <.001 1.24 2.37 88.04* ADHD vs. nonclinical
control Parent 10 0.90 <.001 0.50 1.30 44.03*
Child 9 2.12 <.001 1.45 2.79 68.62*
Total 3 0.30 .385 -0.38 0.98 8.48* ADHD vs. other clinical
Parent 6 0.17 .313 -0.16 0.51 10.59
Child 6 0.56 .009 0.14 0.97 15.34*
Total 5 -0.66 <.001 -0.89 -0.44 4.94 ADHD vs. ADHD +
conduct problems Parent 5 -0.42 .001 -0.67 -0.18 5.73
Child 5 -0.83 <.001 -1.21 -0.45 12.80*
Fathers vs. mothers Total 7 -0.33 <.001 -0.46 -0.19 6.45
Parent 7 -0.06 .608 -0.27 0.16 5.88
Child 5 -0.35 .004 -0.58 -0.11 0.74
Note. Data are coded so that a positive effect indicates that the first group listed reports higher parenting
stress than the second group. K = Number of effect sizes; d = standardized mean difference, except for
fathers vs. mothers comparison, which used the standardized paired difference; CI = confidence interval;
Q = test of homogeneity; ADHD + conduct problems = ADHD plus co-occurring ODD and/or clinical
levels of aggression.
*p < .05 (for Q).
46
Table 2
Meta-Analyses of Dimensional Parenting Stress Studies
95% CI
Variable correlated with
stress
Stress
domain
K
r
p Lower
limit
Upper
limit
Q
Overall ADHD
symptoms
Total 7 .51 <.001 .42 .58 14.64*
Parent 4 .28 .005 .09 .45 6.29
Child 4 .50 .047 .01 .79 45.14*
Inattention Total 8 .37 <.001 .25 .49 24.22*
Parent 4 .28 .001 .11 .43 4.45
Child 3 .43 .081 -.06 .76 18.38*
Hyperactivity/impulsivity Total 9 .49 <.001 .41 .56 17.23*
Parent 4 .38 .001 .16 .56 8.48*
Child 3 .63 <.001 .35 .80 9.90*
Conduct problems Total 10 .56 <.001 .41 .68 49.88*
Parent 5 .39 <.001 .27 .50 3.18
Child 4 .66 .005 .24 .88 24.29*
Internalizing Total 4 .57 <.001 .29 .76 10.23*
Parent 3 .47 <.001 .32 .60 1.38
Child 3 .63 .001 .30 .82 5.39
Total 5 .48 <.001 .26 .66 21.04* Parental depressive
symptoms Parent 2 .67 <.001 .49 .79 2.57
Child 2 .28 <.001 .13 .42 0.40
Marital quality Total 4 -.20 .075 -.40 .02 6.62
Parent Insufficient data
Child Insufficient data
Note. K = Number of effect sizes; r = pooled correlation coefficient; CI = confidence interval; Q = test of
homogeneity.
*p < .05 (for Q).
47
47
177 records identified through PSYCInfo
125 records identified through Medline
Other records identified from reference lists, DAI, ERIC, GoogleScholar,
reviews, lists
100s of records screened
117 full-text articles assessed for eligibility
44 studies included in meta-analysis
73 full-text articles excluded Reasons:
• No measure of parenting stress: 20 (including studies that only measured life stress)
• Measure of parenting stress not validated: 2
• ADHD related to toxin exposure: 1
• Study not in English: 4 • No measure/diagnosis of
ADHD: 8 • Review/qualitative study: 11 • No separate ADHD group
(behavioural difficulties): 8
• Primarily developmental delay sample: 1
• Treatment study/did not evaluate relationships of interest: 16
• Use of published norms: 2
Figure 2. Flow Diagram of Studies Included in Meta-Analysis.
48
Chapter 3:
Predicting Parenting Stress in Families of Children with ADHD:
Consideration of Informants, and The Role of Parental ADHD Symptoms, and Other
Parent and Contextual Factors
Abstract
This study examined parent (parental ADHD symptoms) and contextual (parental education,
social support, and marital status) predictors of parent domain parenting stress (parental distress)
as a function of parent- and teacher-reported child ADHD symptoms in a sample of 95 parents of
8 to 12 year-old children with and without ADHD. Parents’ perceptions of parental distress and
social support were inversely related. Parental ADHD symptomatology was the strongest
predictor of parental distress considered. Models using teacher reports of child ADHD
symptomatology and oppositionality differed from ones using parent reports in that child
oppositionality was only predictive of parental distress in the parent-report model. A post-hoc
analysis showed that child factors did not predict parental distress over and above parent and
contextual factors.
49
ADHD is a chronic, pervasive condition characterized by inattention, impulsivity, and
overactivity. It is also one of the most common childhood disorders, affecting 5% of school-aged
children (Polanczyk & Jensen, 2008). This disorder has been shown to be highly familial. The
genetic factors involved in ADHD have been studied using both behavioural genetic and
molecular genetic approaches (Levy et al., 2006; Willcutt, in press). Family studies have
consistently established elevated rates of ADHD in the biological relatives of children with
ADHD (e.g., Faraone, Biederman, & Friedman, 2000) and higher rates of ADHD concordance
have been found in monozygotic than dizygotic twins (Levy, Hay, McStephen, Wood, &
Waldman, 1997; Willcutt, Pennington, & DeFries, 2000). Further, ADHD has a very high
heritability, of approximately .73 (Levy et al., 2006; Willcutt, in press). Research is also pointing
to the stability of ADHD, with more than 50% of children diagnosed with ADHD continuing to
experience the disorder into adulthood (Barkley et al., 2002), although a recent meta-analysis
shows that in adulthood the disorder is not necessarily present at the level necessary for
diagnosis (Faraone et al., 2006). Therefore, elevated rates and symptoms of ADHD in parents of
children with ADHD would be expected and studies have shown that up to two-thirds of children
with ADHD have a parent with a history of ADHD (Schachar & Wachsmuth, 1990).
One well-accepted sequela of ADHD in a child is increased parenting stress (Johnston &
Mash, 2001). Parenting stress has been defined as “the aversive psychological reaction to the
demands of being a parent” (Deater-Deckard, 1998, p. 315) and is determined by the presence of
stressors, an individual’s appraisal of the stressor, and his or her resources for coping with the
stressor. Although having some parenting stress is considered normal (Crnic & Greenberg,
1990), parents who experience extreme levels of this stress may suffer psychologically and may
be less able to implement interventions to help their children (Kazdin, 1995). Increased parenting
50
stress may also affect the parent-child relationship and negatively impact parenting practices
(Abidin, 1992; Rodgers, 1998; Webster-Stratton, 1990).
Numerous studies (Anastopoulos et al., 1992; Baldwin, Brown, & Milan, 1995; Breen &
Barkley, 1988; Harrison & Sofronoff, 2002; Lin & Chung, 2002; Mash & Johnston, 1983;
Podolski & Nigg, 2001; Riley, Lyman et al., 2006; van der Oord et al., 2006; Vitanza &
Guarnaccia, 1999) including the meta-analysis presented here in Study 1, have reported elevated
and clinical rates of parenting stress as a function of child ADHD symptoms. These studies have
also identified child-level predictors of increased parenting stress in families of children with
ADHD, most notably internalizing (Beck, Young, & Tarnowski, 1990; Breen & Barkley, 1988;
Mash & Johnston, 1983) and externalizing behaviours (Anastopoulos et al., 1992; Beck et al.,
1990; Harvey, 1998; Mash & Johnston, 1983; Podolski & Nigg, 2001; van der Oord et al., 2006).
However, few parent or contextual level predictors have been extensively studied with regards to
parenting stress in families of children with ADHD, with the exception of parental depressive
symptomatology, which has been found to predict parenting stress (Breen & Barkley, 1988;
Harrison & Sofronoff, 2002; van der Oord et al., 2006; Vitanza & Guarnaccia, 1999).
The purpose of the current study was to examine how parent and contextual factors
predict parenting stress after controlling for the effects of child factors that have been found to be
associated with parenting stress in parents of children with ADHD (child ADHD
symptomatology, oppositionality, and child gender). Taking the meta-analysis presented in Study
1 as a starting point, this study examined potential parent and contextual predictors of parenting
stress (parental ADHD symptoms, parental education, social support, and marital status) as a
function of teacher-reported child ADHD symptoms in a sample of children with and without
clinical levels of ADHD symptomatology. Furthermore, a comparison of models predicting
51
parenting stress using teacher versus parent reports of child ADHD symptomatology and
oppositionality was undertaken. Finally, a model examining the moderating role of parental
ADHD symptomatology on the association between child ADHD symptomatology and parental
distress was evaluated. Exploratory analyses into other potential moderating models of parenting
stress were also conducted.
Parenting Stress and ADHD
In spite of studies showing elevated rates of ADHD in the parents of children with
ADHD, adult ADHD has yet to be considered as a possible contributing factor to parenting stress
in these families. Parental ADHD, however, has significant effects on family functioning.
Mothers with ADHD have been shown to be poorer at monitoring the behaviour of their children
with ADHD and provide less consistent discipline than mothers without ADHD (Murray &
Johnson, 2006). Furthermore, both maternal inattention and impulsivity have been linked to
poorer parenting practices (Chen & Johnston, 2007). Mothers with ADHD have also been shown
to have less affect control than mothers without ADHD (Weinstein, Apfel, & Weinstein, 1998),
and current clinical opinion holds that parents with ADHD may be exceptionally sensitive to the
difficult behaviours shown by their children (Weiss, Hechtman, & Weiss, 2000). In sum, it
seems that parental ADHD symptoms may reduce parents’ resources for coping with the child’s
ADHD and associated behavioural difficulties, leading to increased levels of parenting stress.
Indeed, in a literature review of parenting stress and ADHD, Fischer reported that “although
some parents of hyperactive children do appear to experience stress from their own
psychopathology apart from the children’s behavioural disturbance, it is possible that this
primary stress may interact with secondary parenting stress in an exponential way” (1990, p.
343).
52
Other factors that may affect parenting stress include coping resources, such as social
support and spousal support, and systemic factors, such as socioeconomic status (SES). Studies
of other populations have found that social supports are important coping mechanisms (e.g.,
Hauser-Cram, Warfield, Shonkoff, & Krauss, 2001). Families of children with ADHD, however,
have been shown to have lower levels of social support than families of children without ADHD
(Lange et al., 2005). Community support, such as support from professionals, has been
associated with greater distress in mothers of children with ADHD (Podoloski & Nigg, 2001).
This may be due to distressed families seeking out more of this type of support (Podoloski &
Nigg, 2001). One would expect that spouses would be another source of support, as has been
found in families with a child with developmental disabilities, where single parent families
experience more parenting stress than two-parent families (Quine & Pahl, 1985). In families of
children with ADHD, however, studies have not shown a link between marital status and
parenting stress (Anastopoulos et al., 1992; Harrison & Sofronoff, 2002). The association
between SES and parenting stress in families of children with ADHD varies by study. Some
studies have found that maternal education, financial difficulties, and SES are unrelated to
parenting stress in the families of children with ADHD (Anastopoulos et al., 1992; Harrison &
Sofronoff, 2002; Mash & Johnston, 1983), but other studies have found that family income and
financial stressors are significant predictors of parenting stress in these families (Baker, 1994;
Baldwin et al., 1995).
Objectives of the Study
Abidin’s theory of parenting stress (1976, as cited in Abidin, 1995) was used as a starting
point in the investigation into the predictors of parenting stress. This ecological theory proposes
that parenting stress is determined by parent factors, child factors, and situational factors and
53
comprehensively lists variables for consideration. What this theory lacks, however, is
consideration of biological factors in both the child and parent that impact parenting stress.
Therefore, a bio-ecological layer was added to Abidin’s theory (Bronfenbrenner, 2001). The
most notable biological factor influencing this study is the idea of shared genetic influences
between parent and child. Given the highly heritable nature of ADHD (Levy et al., 2006;
Willcutt, in press), this was seen as particularly relevant. Furthermore, Bronfenbrenner and Ceci
(1993) posited that “heritability” is highly influenced by environmental factors, suggesting a
genotype by environment interaction, or moderating model.
The first objective of this study was to investigate whether parental ADHD symptoms,
parental education, social support, and marital status predicted parenting stress over and above
child ADHD symptomatology, oppositionality, and child gender. This study considered parent-
specific parenting stress, known here as parental distress (or parent domain stress), rather than
overall parenting stress to ensure independence between measures of child behavioural
disturbance and measures of parenting stress, as would occur if total parenting stress was
considered (total parenting stress is calculated by adding child and parent domain parenting
stress). Given that the meta-analysis in Study 1 showed no significant difference between
mothers and fathers in parent domain stress, both mothers and fathers were eligible for inclusion
in this study. It was hypothesized that parental ADHD symptoms would predict parenting stress
given the far-reaching effects of parental ADHD reported above, as well as the significant
relationship between parental depressive symptomatology and parenting stress (Breen &
Barkley, 1988; Harrison & Sofronoff, 2002; van der Oord et al., 2006; Vitanza & Guarnaccia,
1999), especially parent domain stress (see Study 1), and the high comorbidity between adult
ADHD and depressive disorders (Kessler et al., 2006). Due to the conflicting findings on the
54
other predictors investigated, no hypotheses were made. Teacher reports of child symptoms were
used in the primary analysis to ensure independence between reports of parenting stress and
reports of child ADHD symptomatology and oppositionality. In order to determine whether
models of parenting stress differed based on whether teacher reports or parent reports of child
ADHD symptoms were used, the analyses were repeated using parental report of child ADHD
symptomatology and oppositionality. This secondary analysis was undertaken as differences
between parents and teachers in reporting of ADHD symptomatology have been found (e.g.,
Wolraich et al., 2004) and no other studies were identified that used teacher reports of ADHD
symptomatology in investigations of parenting stress (although van der Oord et al., 2006 did look
at the association between discrepancies between parents and teachers in child ADHD symptom
reports and parenting stress). Due to the lack of any guiding theory or previous research in this
area, no specific prediction was made.
The second objective of this study was to explore whether parental ADHD
symptomatology moderated the association between teacher-reported child ADHD
symptomatology and parental distress. This model was proposed as a result of the findings of
increased rates of ADHD symptoms in the parents of children with ADHD (Chronis Epstein et
al., 2000), and the suggestion from Weiss and colleagues (Weiss et al., 2000) that parents with
ADHD may be exceptionally sensitive to the difficult behaviours of children with ADHD. Given
this, it was hypothesized that parent and child ADHD symptomatology would interact, such that
parents with higher rates of ADHD symptomatology would be especially stressed by their child’s
ADHD symptoms, whereas parents with lower rates of ADHD symptomatology would find it
easier to cope with this source of stress.
55
Method
Participants.
The sample was comprised of 95 families. From each participating family, one child and
one biological parent participated in the study. Families were excluded from participation if the
parents or children were not proficient in speaking or reading in English or if the child had a full
scale IQ score below 80 or a diagnosis of a pervasive developmental disorder, Tourette’s
disorder, a psychotic disorder, or bipolar disorder. A second language was spoken in the home in
34.74% of families (n = 33). The majority of participating parents were mothers (n = 82, 86.3%),
and the majority of participating children were boys (n = 70, 73.7%). Roughly half of the
participating children (n = 50, 52.6%) had been previously diagnosed with ADHD. Of the
children with ADHD, 24 (48%) were currently taking psychostimulant medication. The ages of
participating children ranged from 8 to 12 years (M = 10.10, SD = 1.41), and the ages of the
parents ranged from 27 to 54 years (M = 41.64, SD = 5.88). The majority of participating parents
were in partnered relationships (married or living with an adult partner; n = 75, 78.9%). Families
of typically-developing children were recruited using community postings (local newspaper
advertisements, school notices, brochures and flyers at community centres and physician
offices); families of children with ADHD were recruited though both community postings and
clinic referrals.
Measures.
Parenting Stress Index—Short Form (PSI/SF).
The PSI/SF (Abidin, 1995) is a 36-item self-report measure evaluating parenting stress in
parents of children under 13 years. This commonly used measure has a 5-point Likert scale,
ranging from Strongly Agree to Strongly Disagree for most items. The PSI/SF produces scores
56
on three subscales (Parental Distress, Parent-Child Dysfunctional Interaction, and Difficult
Child) in addition to a Defensive Responding Scale and a Total Score. Similar to Anastopoulos
et al. (1992) and Harrison and Sofronoff (2002), the Parental Distress subscale was used at the
dependent variable in this study to minimize content overlap with measures of child behaviour.
Sample items on this subscale include “I feel trapped by my responsibilities as a parent” and
“Having a child has caused more problems than I expected in my relationship with my spouse.”
The PSI/SF is based on the full-length PSI, and possesses similarly strong psychometric
properties, with test-retest reliability over 3 months for the Parental Distress subscale of .85 and
internal reliability of .87 (Abidin, 1995).
Conners’ Rating Scales—Revised: Long Version (CRS).
Conners’ Rating Scales (1997) are norm-referenced questionnaires designed to assess
ADHD symptoms in children and adolescents. The Conners’ Rating Scales include subscales
assessing symptoms of related disorders, including oppositional behaviour, anxiety, and social
problems. Parent (CPRS), teacher (CTRS), and youth self-report versions are available. The
Conners’ scales are widely-used measures of ADHD symptom severity and have been shown to
have good validity and reliability with Cronbach’s alpha for the relevant scales on the CPRS
ranging from .90 to .94 and on the CTRS ranging from .91 to .95 (Conners, 1997).
Conners’ Adult ADHD Rating Scales (CAARS).
The CAARS (Conners, Erhardt, & Sparrow, 1999) is based on the childhood Conners’
Rating Scales described above. The self-report screening version of this questionnaire was used
to assess parental ADHD symptoms. The ADHD Index was used here to measure ADHD
symptomatology in the parent. Internal consistency for the ADHD Index ranges from .81
(women) to .83 (men) and the test-retest coefficient at 1 month is .90 (Conners et al., 1999). The
57
CAARS has an overall diagnostic efficiency rate of 85% when compared with the
Semistructured Interview for Adult ADHD (Erhardt, Epstein, Conners, Parker, & Sitarenios,
1999).
Family Support Scale.
The Family Support Scale (Dunst, Trivette, & Jenkins, 1986) is a 20-item questionnaire
asking about the sources and helpfulness of social supports for parents in raising their children.
Ratings are made on a 6-point Likert scale ranging from 0 (Not available) to 5 (Extremely
Helpful). The Family Support Scale total score has acceptable internal consistency (.85) and test-
retest reliability (.73; Hanley, Tasse, Aman, & Pace, 1998).
Wechsler Abbreviated Scale of Intelligence (WASI) and Wechsler Intelligence Scale
for Children, Fourth Edition (WISC-IV).
The WASI (Wechsler, 1999) is a standardized abbreviated measure of intelligence. The
Vocabulary and Matrix Reasoning subtests were administered to each child to obtain an estimate
of cognitive functioning. In a subset of the sample comprising children with ADHD, the WISC-
IV (Wechsler, 2003) was administered in lieu of the WASI as these children were seen for
clinical diagnosis in a hospital setting. In this study these data were used only for screening
purposes (children with full-scale IQs less than 80 were not eligible for participation). Both the
WISC-IV and the WASI are commonly used measures of intelligence in children. Both tests
possess well-documented reliability and validity (Sattler, 2008).
Procedure
Ethics approval was obtained from the Research Ethics Boards of the University of
Toronto, the Hospital for Sick Children, and the Centre for Addiction and Mental Health. Data
on typically-developing children were collected solely at the University of Toronto site (n = 45).
58
Data on children diagnosed with ADHD were collected at all three sites (University of Toronto,
n = 29; Hospital for Sick Children, n = 14; Centre for Addiction and Mental Health, n = 7).
Families were initially interviewed over the phone and screened for the exclusionary disorders
listed above. Families meeting these selection criteria were then scheduled for an in-person
individual assessment session. The vast majority of families contacted regarding the study agreed
to participate (families who did not participate generally failed to follow-up with scheduling
calls; none declined participation based on stated concerns with the study protocols) and all but
one family who agreed to participate completed the study2. Assessment sessions lasted
approximately 4 hours. The assessors were doctoral psychology students with extensive
assessment experience. Teachers of the participating children were mailed-out a series of
questionnaires. All parents were provided with an educational and social-emotional report
outlining their children’s current functioning as indicated by the administered test battery.
Results
Ample research (e.g., Levy et al., 1997; Lifford, Harold, & Thapar, 2008) shows that it is
valid to consider the behaviour associated with ADHD as a dimensional trait, with children with
diagnosable ADHD at the uppermost extreme of this dimension (Barkley, 2006). In order to
maximize statistical power, ADHD symptoms were analyzed continuously in both children and
adults with and without this diagnosis. This data analysis approach has been used in several
previous studies (e.g., Semiz et al., 2008; Thapar et al., 2003). Furthermore, Deater-Deckard has
posited that severity of symptoms, not the presence or absence of a diagnosis, predicts parenting
stress (2004). The meta-analysis in Study 1 also verified that severity of ADHD symptoms is
predictive of parenting stress.
2 This family was made up of a mother and daughter, who had not been previously diagnosed with ADHD. The child evidenced significant behavioural difficulties which made the completion of testing impossible.
59
Preliminary Analyses.
Table 3 shows the intercorrelations among all major variables in this study. Parent and
child ADHD symptoms, as rated by both parents and teachers, were correlated with parental
distress. Child gender, parent age, and parent education were not significantly correlated with
parental distress. Parent-rated child oppositionality was correlated with parental distress, and
teacher-rated child oppositionality was not. Both contextual variables studied, marital status and
social support, showed significant associations with parenting stress. Furthermore, there were
high intercorrelations between both parent and teacher-reported child ADHD and oppositionality
symptoms and parent-level variables (parent ADHD symptoms, parent age, and parent
education).
Scatterplots were created for all possible correlations and inspected visually to check for
outliers or the presence of multi-modal distributions. None were identified. Given the variety of
sampling sources (community, hospital, and clinic) correlational analyses were conducted on
each subsample separately. There were some interesting differences between the two off-campus
subsamples (Centre of Addiction and Mental Health and Hospital for Sick Children) and the
University-collected subsamples. The correlations for these subsamples were often at odds with
the University-collected subsamples, and also at times with one another. This is likely due to
increased sampling error in these small subsamples and restriction of range in ADHD
symptomatology and parenting stress. These tables are available in Appendix C.
Regressions.
Two hierarchical multiple regressions were conducted to predict parental distress as
shown in Tables 4 and 5. This approach enabled consideration of the additive effects of each
class of predictors. Teacher-rated child ADHD symptoms, oppositionality, and child gender were
60
entered into the first regression as the first step to control for these previously-established child-
level predictors of parenting stress. Parent and contextual variables were entered in the second
step. Child factors accounted for a significant amount of the parental distress variability, R2 =
.10, F(3, 91) = 3.26, p = .03, indicating that parents of children with higher levels of ADHD
symptoms tended to have higher levels of parental distress. The second step of this regression
indicated that parent and contextual factors significantly predicted parental distress over and
above child factors, R2∆ = .25, F(5, 86), p < .001. In this analysis parental ADHD symptoms and
social support were uniquely significant, indicating that parents with higher levels of ADHD
symptoms and lower levels of social support tended to report more parental distress. This model
accounted for 34% of the total variance. Similar results were obtained using parent reports of
child ADHD symptoms and oppositionality as shown in Table 5 (Step 1: R2 = .19, F(3, 91) =
7.03, p < .001; Step 2: R2∆ = .20, F(5, 86), p < .001). The total variance explained was 39%. The
difference between the two models resulted mainly from a much larger effect of oppositionality
in the parent-report model than in the teacher-report model.
The analysis exploring the moderating role of parental ADHD symptomatology on the
association between teacher-reported child ADHD symptomatology and parental distress was
conducted using the procedures suggested by Baron and Kenny (1986). It was not significant,
R2∆ = .01, F(1, 85), p = .18., indicating no significant interaction between teacher-reported child
ADHD symptoms and parent ADHD symptoms3.
3 Moderating models testing the interaction between child ADHD symptomatology and parent gender, child gender, social support, parent age, and parent education were also tested post-hoc. These models were tested using each of parent and teacher reports of child ADHD symptomatology and oppositionality. None of the models reached statistical significance. Moderating models looking at the role of parental ADHD symptomatology on the association between parent-reported child ADHD symptomatology, teacher-reported child oppositionality, or parent-reported oppositionality, and parental distress were also not significant.
61
A post-hoc analysis was conducted where the hierarchical multiple regression discussed
above was re-run with the steps reversed, so that parent and contextual factors were entered as
the first step and teacher-reported child factors as the second step. This model indicated that
child factors did not predict parental distress over and above parent and contextual factors, R2∆ =
.03, F(3, 86), p = .22.
Discussion
Although not hypothesized, the central finding of this study was that child factors did not
predict parental distress (parent domain parenting stress) over and above parent and contextual
factors. Furthermore, parental ADHD symptomatology was the strongest predictor of parental
distress considered. The large effect for parental ADHD symptomatology in the prediction of
parental distress is consistent with the meta-analysis in Study 1, which showed large effects for
parental depressive symptoms in the prediction of parent domain parenting stress. Given the
familial link between ADHD and depression (Biederman, Faraone, Keenan et al., 1992; Faraone
& Biederman, 1997; Mick, Biederman, Santangelo, & Wypij, 2003), and the co-occurrence of
these two disorders (Biederman, Faraone, Monuteaux, Bober, & Cadogen, 2004), there is a
possibility that these findings are both illustrating the same underlying relationship. Furthermore,
research on typically-developing infants has shown that depressed mothers experience more
parenting stress (Gelfand et al., 1992). A similar relationship may occur in families of children
with ADHD, whereby parental psychopathology (ADHD or a depressive disorder) results from
the same genetic factors responsible for child ADHD (Biederman et al., 1995; Grigoroiu-
Serbanescu, Christodorescu, Magureanu, & Jipescu, 1991; Hammen, Burge, Burney, & Adrian,
1990; Minde et al., 2003; Pilowsky et al., 2006), resulting in the appearance of an effect for child
62
ADHD symptomatology in the prediction of parenting stress, when in fact the third variable,
parental psychopathology, is causal.
Parental ADHD symptomatology did not emerge as a moderator of the association
between teacher-reported child ADHD symptomatology and parental distress in this study. This
may be a result of the substantial amount of variance taken up by parental ADHD
symptomatology. With this variable in the regression, little variance was left to be explained by
the interaction between parent and child ADHD symptomatology. In part, this may be due to the
strength of the parent informant effect as parents reported both on their own ADHD symptoms
and on parental distress.
The second major finding of this study relates to its use of teacher reports of child ADHD
symptoms and oppositionality. Using teachers as independent reporters clarified the relationships
studied by eliminating the potential of reporter bias, whereby parents would report both on the
child’s ADHD symptomatology and oppositionality and their perceived parenting stress. One
interesting difference was found between the model using teacher reports of child ADHD
symptomatology and oppositionality and one using parent reports. Child oppositionality was a
significant predictor of parental distress only in the parent-report model. All other predictors
retained similar levels of significance. This teacher report model also stands in contrast to many
other published studies, as these other studies, which used parent reports, have shown that
oppositionality is predictive of parenting stress in families of children with ADHD (e.g.,
Anastopoulos et al., 1992; Podoloski & Nigg, 2001; see also the meta-analysis presented in
Study 1).
The difference between the teacher-report and parent-report models suggests that child
oppositionality and parental distress may be linked in ways other than those previously
63
elucidated (e.g., Eyberg, Boggs, & Rodriguez, 1992; Ross, Blanc, McNeil, Eyberg, & Hembree-
Kigin, 1998). Specifically, it seems that rather than child oppositionality increasing parental
distress, parental distress may heighten parents’ sensitivity to child oppositionality, resulting in a
reporting bias. Another possibility is that children with ADHD may behave differently in school
for a variety of reasons (e.g., peer pressure, more structured environment). A third possibility is
that child oppositionality in the home may be associated with inconsistent parenting resulting
from parental ADHD symptomatology (Chen & Johnston, 2007; Harvey, Danforth, Eberhardt
McGee, Ulasek, & Friedman, 2003; Murray & Johnston, 2006).
This study also clarified the relationship between various contextual factors and parenting
stress. It showed that social support is inversely-related to parenting stress whereas parental age
and education are unrelated to parenting stress. Marital status was significantly correlated with
parenting stress such that single parents experienced more stress, but did not emerge as a
significant predictor in the regression. Inspecting the correlation matrix, however, there is a
significant intercorrelation between marital status and parental ADHD symptomatology
indicating that they may share variance (parents with greater levels of ADHD symptoms are less
likely to be partnered), explaining why this variable did not significantly predict parenting stress
in this analysis.
In terms of child-level variables investigated here, child ADHD symptoms, as reported by
parents or teachers, were correlated with parenting stress. Child ADHD symptoms were,
however, non-significant predictors of parenting stress when parental ADHD was added to the
analyses. Child gender did not show significant predictive power with respect to parental
distress. Both of these findings stand in contrast to the results of Study 1, where child gender was
examined as a moderator. The lack of effect for child ADHD symptomatology may be explained
64
by different reporting patterns in parents and teachers, similar to the difference observed in
reporting patterns for child oppositionality. However, child ADHD symptomatology did not
retain significance in the second step of the parent-report model either, once parental ADHD
symptomatology was considered. This may suggest that previous findings indicating that child
ADHD symptomatology predicts parenting stress were limited in that they did not investigate
parental ADHD symptomatology. The non-significant relationship between parenting stress and
child gender in this study may be explained by measurement differences (moderator analyses for
Study 1 were conducted using total stress, rather than parental distress/parent domain stress as
was used in this study) or greater power in the meta-analysis.
Limitations and Directions for Future Research
One limitation of this study was that a relatively brief measure of parenting stress (the
PSI/SF) was used, which may have limited the specificity of the findings. Nevertheless, this
measure is well-validated and highly correlated with the full length Parenting Stress Index.
Second, this study combined subsamples from a variety of sources, including self-referred
community samples, community mental health samples, and hospital-based samples. This may
have affected the results obtained, especially as evidenced by the different pattern of correlations
found within each subsample. Third, efforts were made to reduce informant effects by using
teacher ratings of child ADHD symptomatology and oppositionality in the primary analyses;
however, parents still reported both on their own ADHD symptoms and parental distress, as
discussed above. Therefore, caution should be exercised in our confidence in these results, as the
strengths of the associations reported may have inflated by an informant effect (i.e., we would
expect higher correlations between parent ADHD symptoms and parental distress as these were
reported by the same person). Fourth, future research should give further consideration to
65
reporting discrepancies between parents and teachers. More study in this area would clarify the
interpretation of these findings further. That is, intervention studies or other studies which allow
consideration of the mechanism through which reporting differences in child oppositionality and
parenting stress are related may elucidate these relationships more clearly. Another area for
future research is replication of these findings in a larger sample. A larger sample may enable a
more sophisticated statistical approach, such as path analysis, which may clarify the studied
relationships further. Future studies should also give greater attention to parental
psychopathology. Simultaneously investigating parental depression and ADHD may illuminate
the independent and interactive effects of these disorders. Furthermore, though ADHD was
posited here to exist dimensionally, studies should investigate whether a shift is present at
clinical levels, or any other thresholds, of adult ADHD. This study investigated parental distress,
rather than parenting stress more generally to ensure independence between measures of child
behavioural disturbance and measures of parenting stress. Although this may have clarified these
relationships from a measurement standpoint, it may be interesting to learn how parent and
contextual factors are associated with parenting stress more generally, as a function of child
ADHD symptomatology. Finally, although not an area of investigation here, it was interesting to
note the associations between child ADHD symptoms and oppositionality and parent-level
factors, such as parental age and education. This may be a fruitful area for further inquiry.
Clinical Implications
As has been suggested by numerous researchers, treatment of parental ADHD
symptomatology may have large effects on child functioning, as it might reduce parenting stress
and improve a parent’s ability to implement interventions directed toward children, such as
parent management training (Evans, Vallano, & Pelham, 1994; Sonuga-Barke, Daley, &
66
Thompson, 2002). Parenting stress is an important predictor of response to cognitive-behavioural
treatments in children with conduct problems (Kazdin, 1995) and interventions to reduce
parenting stress improve response to parent management training (Kazdin & Whitley, 2003). In
addition, this study’s findings of a significant effect for social support in predicting parenting
stress indicates that interventions aimed at reducing parenting stress should also include sessions
on connecting with community resources, developing a personal support network, and lists of
parent support groups. Group interventions that include a parent support component may be
especially helpful (e.g., COPE; Cunningham, 2006). Physicians and teachers should also be
mindful of the likelihood that parents of children with ADHD may have ADHD themselves and
may find the professional’s demands for involvement in their children’s homework to be
stressful. Clinicians should consider a discrepancy between teacher and parent reports of
oppositionality as a potential indicator of heightened parenting stress and intervene accordingly.
Furthermore, this type of discrepancy may be suggestive of increased parental sensitivity to child
oppositionality, suggesting diminished coping resources, or inconsistent parenting resulting from
parental ADHD, consistent with the Harvey et al.’s (2003) finding that parental ADHD and
parental depression are both positively associated with negative parent-child interactions.
In conclusion, the majority of the literature on parenting stress and ADHD has focused on
the contributions of parent-reported child-level predictors to increased parenting stress in the
families of children with ADHD. This study has expanded the literature on parenting stress as a
function of child ADHD symptoms by highlighting the role of parental and contextual factors in
the prediction of parent domain parenting stress and by clarifying established relationships by
using independent reporters. In this study, parent and contextual factors were stronger predictors
of parent domain parenting stress than child-level factors.
67
67
Table 3
Intercorrelations between Parenting Stress, and Major Child, Parent, and Contextual Variables (N = 95)
Variable 1 2 3 4 5 6 7 8 9 10
1. Parenting stress --
2. Teacher-rated C. ADHD .29** --
3. Teacher-rated child opp. .12 .50*** --
4. Child gendera .14 .12 .11 --
5. P. ADHD symptoms .48*** .30** -.06 .09 --
6. Parent age -.09 -.32** -.29** -.15 -.20* --
7. Parent education -.15 -.34*** -.25** -.13 -.36*** .37*** --
8. Marital statusb -.35*** -.17 -.10 -.04 -.41*** .18* .14 --
9. Social support -.30* -.15 .02 -.12 -.13 .03 .09 .16 --
10. Parent-rated C. ADHD .35*** .69*** .35*** .13 .37*** -.35*** -.46*** -.2 8** -.13 --
11. Parent-rated child opp. .42*** .62*** .44*** .06 .33*** -.30** -.38*** -.25 ** -.10 .78***
Note. C. ADHD = child ADHD symptoms; Child opp. = child oppositionality; P. ADHD symptoms = parent ADHD symptoms.
aChild gender was coded “0” for boys, “1” for girls. bMarital status was coded “0” for single and “1” for partnered parents.
*p < .05. **p < .01. ***p < .001.
66
68
Table 4
Hierarchical Multiple Regression Predicting Parenting Stress from (Teacher-Reported) Child,
Parent, and Contextual Variables
Variables R2 R2∆ B SE B β
Step 1 .10* .10*
Child ADHD symptoms 0.17 .07 .30*
Child oppositionality -0.02 .07 -.04
Child gendera 2.04 1.87 .11
Step 2 .34*** .25***
Child ADHD symptoms 0.05 0.07 .09
Child oppositionality 0.07 0.06 .12
Child gendera 1.25 1.67 .07
Parent ADHD symptoms 0.31 0.08 .41***
Parent age 0.10 0.14 .07
Parent education 0.34 0.47 .07
Marital statusb -2.81 1.97 -.14
Social support -0.14 0.06 -.22*
aChild gender was coded “0” for boys, “1” for girls. bMarital status was coded “0” for single and “1” for
partnered parents.
*p < .05. ***p < .001.
69
Table 5
Hierarchical Multiple Regression Predicting Parenting Stress from (Parent-Reported) Child,
Parent, and Contextual Variables
Variables R2 R2∆ B SE B β
Step 1 .19*** .19***
Child ADHD symptoms 0.02 .08 .03
Child oppositionality 0.22 .09 .39*
Child gendera 2.12 1.78 .11
Step 2 .39*** .20***
Child ADHD symptoms -0.03 0.07 -.06
Child oppositionality 0.20 0.08 .35*
Child gendera 1.63 1.61 .09
Parent ADHD symptoms 0.26 0.08 .34**
Parent age 0.10 0.13 .07
Parent education 0.44 0.46 .10
Marital statusb -2.51 1.90 -.13
Social support -0.14 0.06 -.22*
aChild gender was coded “0” for boys, “1” for girls. bMarital status was coded “0” for single and “1” for
partnered parents.
*p < .05. **p < .01. ***p < .001.
70
Chapter 4:
Conclusions and Implications
Six key conclusions emanate from the research in this dissertation. First, the findings
confirmed that parents of children with ADHD experience considerably more parenting stress
than parents of children without ADHD. Second, child ADHD symptomatology is positively
related to parenting stress. Third, parent-reported internalizing and externalizing symptoms in the
child are positively associated with parenting stress. Fourth, social support, as perceived by
parents, is inversely related to parenting stress. Fifth, child oppositionality is only predictive of
parenting stress when reported by parents, but not when reported by teachers. The final and most
central conclusion of this line of research relates to the findings on parental psychopathology and
parenting stress. The two studies presented here showed that parental psychopathology
(depression and ADHD) accounts for a large proportion of the variance in parenting stress;
furthermore, this research showed that once we consider parent and contextual factors (including
parental ADHD symptomatology), child factors (including child ADHD symptomatology) are no
longer predictive of parent domain parenting stress.
This final conclusion raises questions about the association between child ADHD
symptomatology and parenting stress as reported in the bulk of the literature, and the meta-
analysis presented here, which summarized that literature. Before going further, it is necessary to
consider the noteworthy caveats that any relationship between parental psychopathology and
parenting stress may be an artefact of measurement issues—in Study 2 and in all studies included
in the meta-analysis in Study 1, parents reported both on their own psychopathology and on
parenting stress. One may therefore expect that this alone would result in some non-zero
correlation between these two constructs, as a result of the parent’s reporting style. In addition,
71
the second study only investigated parent domain parenting stress, so it is not yet clear how these
findings relate to parenting stress as a whole (although one would expect some overlap, as parent
domain stress constitutes half of the parenting stress score, as operationalized on the PSI).
With these caveats in mind, one wonders whether child factors would predict parenting
stress over and above parental depression symptoms, given what we know from the meta-
analysis about the association between parental depressive symptomatology and parenting stress,
and the high co-occurrence between depression and ADHD in adults (Biederman et al., 2004).
Although this could be investigated in new research, much of this data already exists in
previously reported studies (as described in the meta-analysis reported in Chapter 2), and could
be re-analyzed to provide insight into this question. Given the significant effects found here for
the role of parental psychopathology in parenting stress, the next logical step would be to study
parental ADHD and depression together. This would illuminate the extent to which these
disorders share variance in predicting parenting stress, as has been suggested throughout this
dissertation. Alternatively, it may suggest independent and/or interactive effects.
The findings on parental psychopathology and parenting stress also suggest that more
research is needed on the effects of parental psychopathology on family functioning. If, indeed,
parental ADHD symptomatology, which might be expected to be elevated commensurate with
the severity of child ADHD symptomatology, given the familiality of the disorder (Levy et al.,
2006; Schachar & Wachsmuth, 1990) explains elevated levels of parenting stress in families of
children with ADHD, more attention needs to be given to addressing and supporting parents in
these families. This idea is corroborated by the small effects of behavioural interventions for
child ADHD on parenting stress (Anastopolous, Shelton, DuPaul, & Guevremont, 1993;
Danforth, 1998; Pisterman, Firestone, McGrath, & Goodman, 1992; van den Hoofdakker et al.,
72
2007; Weinberg, 1999; Wells et al., 2000); however, child factors likely play a more substantial
role in total parenting stress than they do in parent domain stress. Taken together, this suggests
that multisystemic interventions, addressing both parents and children, may be needed to support
these families.
The meta-analysis illustrated the necessity of these types of interventions by showing that
the effect size for parenting stress in parents of children with ADHD is very high (d = 1.8). The
considerable research base in this area, and the magnitude of this effect indicates that further
research on parenting stress and ADHD should focus on the mechanisms of this relationship,
rather than on establishing again that these parents are more stressed than parents of typically-
developing children. A major limitation of the literature to date is that the child participants in all
of the studies were 12 years of age or younger, possibly because the most commonly used
measure of parenting stress (the PSI) is normed for this population. Although the manifestations
of ADHD in adolescents differs somewhat from those in younger children (i.e., reductions in
hyperactivity), adolescents are apt to engage in behaviours such as risky driving and substance
use (Barkley, Fischer, Smallish, & Fletcher, 2004) that may indeed be associated with elevated
parenting stress. Research on parenting stress in parents of adolescents with ADHD is therefore
clearly warranted.
The current research was also able to show that social support is inversely related to
parenting stress. However, it is not clear from the work here whether low levels of social support
are a contributor to, or an effect of, increased parenting stress. Longitudinal studies and
intervention research on parenting stress may illuminate this relationship further.
Study 2 clarified that child oppositionality is only predictive of parenting stress when
reported by parents. Although it is possible that high parenting stress causes oppositional
73
behaviour, it is also possible that stressed parents perceive their children’s behaviour as
oppositional even when these behaviours are typical of children at that developmental stage. It is
also possible that these children behave differently at home from in school. There is considerable
research pointing to problematic parenting and disciplinary practices, including greater
negativity and control, in parents of children with ADHD (e.g., Anderson, Hinshaw, & Simmel,
1994; Buhrmester et al., 1992; Cunningham & Barkley, 1979; Winsler, 1998; Woodward,
Taylor, & Dowdney, 1998). In addition, many children with ADHD are on medication only
during school hours and take “drug holidays” on weekends (Martins et al., 2004). Further, the
structured environment of the classroom may enable these children to better regulate their
behaviour than in a less-structured home environment. The most likely explanation of the
different predictive power of child oppositionality in predicting parenting stress is that there is an
interaction between all of these factors listed. This suggests that future research needs to consider
how child oppositionality and parenting stress are related, rather than simply reporting the
association.
The finding of different reporting patterns by teachers and parents is consistent with
research on quality of life in families of children with ADHD. Klassen et al., (2004) found that
health-related quality of life in families of children with ADHD was correlated with parent-
reported child ADHD symptom severity, but not with teacher-reported symptoms (although this
too could be demonstrating an informant effect). Furthermore, quality of life was significantly
lower in families with children with comorbid oppositionality or conduct problems than in
families with children with ADHD alone or ADHD and a learning disability. Although quality of
life and parenting stress seem, at first glance, to represent opposite ends of a continuum, it is not
clear how these two concepts are related. For example, Riley, Spiel et al. (2006) found that there
74
is no link between quality of life and parental ADHD, but the current research showed a large
effect for parental ADHD on parenting stress. Further, quality of life improves more with
treatment for the child’s ADHD (Danckaerts et al., 2009) than does parenting stress, where the
effects are generally quite modest (Anastopolous, Shelton, DuPaul, & Guevremont, 1993;
Danforth, 1998; Pisterman, Firestone, McGrath, & Goodman, 1992; van den Hoofdakker et al.,
2007; Weinberg, 1999; Wells et al., 2000). Simultaneously studying these two concepts might
elucidate their relationship better and refine the definitions of the terms themselves.
As suggested by Klassen et al. (2004), another important area for future research is an
investigation into reporting patterns in families of children with ADHD. Previous research on
parenting stress and child ADHD has confounded raters, leading to potential for informant
biases. Some research (e.g., Wolraich et al., 2004) has started to address the impact of low
interrater reliability on diagnosis of ADHD, but this area of research has not yet been expanded
to looking at the impact on larger family constructs, such as parenting stress.
Overall, the findings from the research presented in this dissertation support Abidin’s
theory of parenting stress (1995), which stipulates that parent (i.e., depression, ADHD
symptoms), child (i.e., ADHD symptoms, internalizing and externalizing behaviours), and
situational (i.e., social support) factors contribute to parenting stress. Abidin’s model, however,
is limited in that it suggests factors to examine, but does not provide a framework to explain how
these factors are linked. The results of the present study support a bio-ecological model
(Bronfenbrenner, 2001). Specifically, the substantial role of parental ADHD symptoms in the
prediction of parenting stress, suggests that bio-ecological factors affect parenting stress. That is,
it seems that perhaps certain genetic factors are associated with parental ADHD symptoms, and
that parental ADHD symptoms are associated with increased perceptions of parenting stress.
75
These same genetic factors that resulted in parental ADHD symptoms may be passed from parent
to child, resulting in increased rates of child ADHD symptomatology in children of parents with
ADHD, with potentially no direct effect from child ADHD on parent domain parenting stress.
Given the significant correlations between parent and child ADHD symptomatology (as reported
in Chapter 3) we know that children with more severe ADHD symptomatology have parents with
more severe ADHD symptomatology. The findings from this research, especially the central
finding on the associations between parental psychopathology and parenting stress, also fit in
with the general parenting literature. Belsky (1984) holds that parental personality and
psychological well-being are the most influential determinants of parenting, consistent with these
findings of the substantial effects of parental psychopathology on parenting stress.
Although the findings from the current research are not inconsistent with the Mash and
Johnston (1990) and Webster-Stratton (1990) theories of parenting stress, the parental cognitive
factors central to these theories were not examined in this research. McCleary’s (2002) theory of
parenting stress, which addressed the role of appraisals and coping in parenting stress, was not
supported given that McCleary states that interventions for parenting stress should address
problem behaviours in the child. The finding that teacher-reported oppositionality was not
predictive of parenting stress suggests that changing child behaviour alone would not reduce
parenting stress. Furthermore, as will be discussed below, parents’ capacity to implement
interventions effectively is reduced when they are stressed (Kazdin, 1995).
Although addressing problem behaviours in the child is unlikely on its own to have
significant effects on parenting stress, parenting stress and problem behaviours in the child do
seem linked. The Webster-Stratton (1990) and Abidin (1995) theories suggest that parenting
stress leads to increased oppositional child behaviour, consistent with the findings of the current
76
research. Future studies may wish to directly investigate parenting behaviour and parent-child
interaction, as Webster-Stratton suggested that negative parent-child interaction leads to
parenting stress, which then leads to child behaviour problems, and Abidin suggested that
parenting stress affects parenting behaviour, which affects child behaviour. Consideration of
parenting behaviour, combined with the use of more sophisticated statistical analyses, such as
path analysis, may clarify the implications of these theories further.
Given the primary role of parental cognitions in the Webster-Stratton (1990) and Mash
and Johnston (1990) theories of parenting stress, and the paucity of literature on these topics,
further research on parental cognitions as predictors of parenting stress in parents of children
with ADHD is also needed. These cognitive factors may include parenting sense of competence,
attributions for child behaviour, self-efficacy and parenting efficacy, and appraisal of stressors.
Implications for Clinicians, Schools, and Policy
Reducing parenting stress is important for parents and for children. Although moderate
stress is adaptive, high stress has negative implications for both physical and mental health.
Parents experiencing high levels of parenting stress are also less likely to be capable of
implementing interventions that change children’s behaviour (Kazdin, 1995). Consequently,
clinicians, school personnel, and policy makers need to be aware of the high parenting stress of
parents of children with ADHD and take necessary steps to reduce this stress. The identification
of child, parent, and contextual factors that predict parenting stress in the present research
suggests possible directions that should be implemented and evaluated.
Given the modest effects of treatment for child ADHD symptoms on parenting stress
(Anastopolous et al., 1993; Danforth, 1998; Pisterman et al., 1992; van den Hoofdakker et al.,
77
2007; Weinberg, 1999; Wells et al., 2000), a comprehensive family approach, such as the
interventions for parenting stress designed by Kazdin and Whitley (2003) and Treacy, Tripp, and
Baird (2005), is suggested by the research presented in this dissertation. Both of these
interventions for parenting stress focus on the role of the parent, including instruction in
problem-solving skills, self-care, and support in managing a variety of stressors in the parent’s
life. The research presented here, however, suggests refinements to these previously developed
interventions, including addressing parent depression and ADHD. Clinicians who work with
parents with ADHD may also need to ensure that their interventions consider the executive
functioning deficits that may impair the functioning of these parents in many aspects of daily
living, including parenting (Murphy, 2006). Extending existing effective coaching programs for
adults with ADHD to specifically address parenting problems may also be helpful. Furthermore,
parent training programs, such as COPE (Cunningham, 2006) may wish to address parenting
stress more directly, although this program does already have positive impacts on parenting
stress (Thorell, 2009). Finally, due to the inverse relationship between parenting stress and social
supports, interventions for parenting stress should address social supports, including helping
families reconnect with informal supports, such as friends and family, and access more formal
supports, such as parent groups. It is therefore possible that group parenting stress interventions
such as that proposed by Treacy et al. (2005) may be more efficacious than individual treatment.
Program evaluation research is needed to assess the efficacy of the interventions suggested by
the findings from the current research.
The differences between the models predicting parenting stress when child ADHD
symptoms are rated by parents versus when they are rated by teachers have implications for
clinical practice in the area of diagnosis. Psychologists and psychiatrists should be cognizant that
78
parent ratings of child externalizing and internalizing behaviours may be affected by elevated
parenting stress. Therefore, with parental consent, it may be prudent to contact outside
informants, such as teachers, to clarify the nature of the child’s behaviours and the settings in
which they occur.
The research presented in this dissertation has implications for the school system. Parents
of children with ADHD are frequently asked to support their children’s learning (Rogers,
Wiener, Marton, & Tannock, 2009a) because of the academic underachievement associated with
this disorder (Loe & Feldman, 2007). The findings from the current research indicate that due to
elevated rates of parenting stress, these parents may not be able to adequately support their
children in this way. Moreover, parents with high levels of parenting stress are likely to
experience higher levels of ADHD symptoms themselves, which may further impede their
abilities to be helpful. In addition, Rogers, Wiener, Marton, & Tannock (2009b) have shown that
elevated levels of parenting stress are associated with less supportive styles of parental academic
involvement. Finally, schools and teachers should be mindful of discrepancies between their
observations of oppositionality in the child and the parents’ as a potential marker for both
elevated parenting stress and impaired academic involvement.
From the perspective of policy, this research has implications for community-wide
resources and funding. The severity of parenting stress in families of children with ADHD is so
substantial that it suggests that these parents require greater support in coping and managing than
is currently provided. Most jurisdictions in Canada provide free or reduced-cost respite care to
parents of children with autism and other developmental disabilities. Although their stress is
considerable, parents of children with autism do not experience higher levels of parenting stress
than parents of children with ADHD (Markham, 2001). It is likely that parents of children with
79
ADHD would benefit from similarly funded services. To the extent that parenting stress impacts
parenting practices, as suggested by Abidin (1990), McCleary (2002), and Webster-Stratton
(1990), intervening in parenting stress has the potential to achieve far-reaching benefits within
families and communities.
Conclusion
Overall, the two studies in this dissertation pointed to the significant effects of child,
parent, and contextual factors on parenting stress. The meta-analysis contributed to the literature
by summarizing and clarifying findings on parenting stress in families of children with ADHD
and also indicated areas requiring further study. In Study 2 I was able to focus on relevant and
under-investigated predictors of parenting stress as suggested by the meta-analysis. The results
suggested that parent factors are critically important in parenting stress. Earlier research, in its
focus on the behaviours associated with child ADHD, to some extent lost sight of the nature of
the construct of parenting stress and the familiality of ADHD. Future research should be directed
at exploring parent factors further and evaluating interventions directed at reducing parenting
stress in parents of children with ADHD. Given the numerous negative outcomes associated with
elevated parenting stress (reduced response to intervention, decreased parental psychological
well-being, constrained child development) this will be critically important for the well-being of
families of children with ADHD, and potentially also, families of parents with ADHD.
80
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Appendix A
Coding Manual
Coding Manual for Meta-Analysis of Parenting Stress and ADHD
General coding notes. Complete only one Study Level Descriptors (Section I) form for each written report. Then attach as many data forms (sections II and/or III—Group Comparison Studies and Correlational Studies) as necessary to code all the effects for a given report. Some reports may use both section II and section III forms, while others may use only one or the other. Record the Study ID number at the top of every page used to code a given study. In both sections II and III the data is broken down into “Total Stress”, “Parent Domain”, and “Child Domain”. These distinctions are based on the PSI (Parenting Stress Inventory), the most commonly employed measure of parenting stress. If a study doesn’t specify parent domain or child domain stress, of if you are unfamiliar with the measure, assume it is measuring total stress. On any measure other than the PSI use only the “Total” score (for the PDH use “severity”). Measures of life stress and parent-child interaction dysfunction are not coded anywhere. Note also that measure of parenting sense of competence and parenting self-esteem are not coded as measures of parenting stress (but parenting sense of competence is coded as a predictor of parenting stress in section III). In the case of longitudinal studies only record data from the first timepoint. I. Study Level Descriptors 1. Bibliographic reference: _____________________________________________
________________________________________________________________ ________________________________________________________________
Write out the study reference in APA format. If two or more written reports were prepared on the same data, use the most comprehensive one. 2. Study ID number: ___________ The Study ID number can be found in the “meta-analysis tracking file.” 3. Type of publication:
1. Journal article 2. Book chapter
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3. Conference paper 4. Thesis or doctoral dissertation 5. Unpublished data 6. Other: ____________________
Please circle the number corresponding to the type of publication of the most comprehensive report consulted for this study.
4. Publication year: _____________ Please enter the year of publication of the study.
5. Study type:
1. Group comparison 2. Correlational/regression 3. Both 4. Other: _______________________
Circle the study type. “Group comparison” refers to studies where parenting stress was evaluated solely by comparing two or more groups. “Correlational/regression” refers to studies where the relationship between parenting stress and some other variable(s) was evaluated using correlations, regression, and/or structural equation modelling.
6a. ADHD definition based on:
1. DSM-III criteria 2. DSM-IIIR criteria 3. DSM-IV criteria 4. Doesn’t specify 5. Other (e.g., ICD-10 criteria): _______________
Circle the criteria used to define/diagnose ADHD in the study. Only circle one of the DSM categories if this is specifically mentioned in the written report. Do not use publication date as a proxy for DSM criteria. If another criteria set for ADHD definition/diagnosis is used, please specify and circle “Other”. If two or more DSM criteria sets were used, code the older one (e.g., if a study specifies that participants were diagnosed using DSM-III and DSM-IIIR criteria, circle, DSM-III).
6b. ADHD diagnosed/confirmed by (circle all that apply):
1. Previous diagnosis by a qualified health professional (e.g., psychologist, family physician, paediatrician, psychiatrist) a condition of participation
2. K-SADS (this is a diagnostic interview) 3. DISC (this is a diagnostic interview)
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4. Study Clinician interview (any activity undertaken by a qualified professional involved in the study to establish or confirm a diagnosis of ADHD, other than the K-SADS or DISC)
5. Questionnaire (e.g., Conner’s, BASC, CBCL, ADHD Rating Scale) 6. Other: ___________________ 7. None 8. Doesn’t specify
The listing of questionnaires in #4 is not exhaustive. Other questionnaires may also be used and would be appropriately included in #4. For the CBCL and BASC, only scales indicating attention problems or similar would be appropriate. If a procedure other than those listed here is indicated, please circle 6, and indicate the procedure.
7. Outcome measure:
1. PSI (Parenting Stress Index) 2. PSI-SF (Parenting Stress Index-Short Form) 3. PDH (Parenting Daily Hassles Scale) 4. DSBI (Disruptive Behavior Stress Inventory) 5. FSI (Family Stress Inventory) 6. Other: _________________
If more than one outcome measure is used in a given study choose the most comprehensive measure. They are listed here in approximate descending order of comprehensiveness. When completing the rest of the coding, use the measure you indicated here. For example if the study used both the PDH and the PSI, here you would choose PSI and you would code the study using only the results from the PSI. This is to ensure that in any given meta level analysis each study only contributes one effect size. That is, to ensure each effect size is independent of the others, we cannot combine the results of two measures used on one sample of families in any given analysis. To prevent this from occurring we code only one result from each sample for a given analysis.
8. Gender of identified children:
1. All boys (100% of identified children) 2. All girls 3. Both: % female ADHD group: _____________ 4. Study compared girls and boys 5. Doesn’t specify
Indicate whether the sample was restricted to parents of boys, parents of girls, or if both boys and girls were included. If both boys and girls were included. Indicate the percentage of the children who were female (if a comparison group study, indicate the percentage of the ADHD group that was female). If the study compared boys and girls, choose #4.
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9. Parents 1. All mothers 2. All fathers 3. Both: % mothers: ____________ 4. Study compared mothers and fathers 5. Doesn’t specify
Indicate whether the sample was restricted to mothers, fathers, or if both mothers and fathers were included. If both mothers and fathers were included. Indicate the percentage of the parents who were mothers. If the study included data from both mothers and fathers on any given child, choose #4. For the purposes of this question, “mother” refers to any custodial female caregiver, while “father” refers to any custodial male caregiver.
10. Child age
Mean SD n Total Sample ADHD group Comparison group: ___________ Girls Boys Other Comparison group: ________
Indicate the mean age of the sample and any subsamples as appropriate. Also indicate the standard deviation (SD) and sample size (n) where this information is available. Note that most studies will not provide information in all the categories. Record as much information as is available. At times you may need to calculate the mean age from other available data. If no age information is provided please write “Doesn’t specify” beside child age. 11. SES--Hollingshead
Mean SD n Total Sample ADHD group Comparison group: ___________ Girls Boys Other Comparison group: ________
Indicate the mean SES of the sample and any subsamples as appropriate. Also indicate the standard deviation (SD) and sample size (n) where this information is available. Note that most studies will not provide information in all the categories. Record as much information as is available. ONLY RECORD SES INFORMATION IF IT WAS CALCULATED USING THE HOLLINGSHEAD METHOD. If this
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information is not available or was calculated using another method, please write “doesn’t specify”. 12. Medication usage in the ADHD group: ___________%
Record the percent of children in the ADHD group (or total sample if a correlational study) that were taking stimulants or other psychoactive drugs to treat their ADHD at the time of the study. If this information is not available, write “doesn’t specify”.
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II. Group Comparison Studies Omit data from any clinical comparison group that includes children with ADD or ADHD (i.e., if the study compares children with “ADHD” to a mixed clinical group that includes “ADD”, do not code this comparison). 1. Group matching:
1. SES 2. IQ 3. Child gender 4. Child age 5. Combination: ___________________ 6. Other: __________________ 7. None 8. Not applicable (e.g., mother-father comparisons)
Indicate whether the groups were matched on SES (using any appropriate SES indicator, including family income, parental education, parental job status), child cognitive abilities (IQ), child gender, child age, or some combination of these criteria. For #5, indicate the characteristics the groups were matched on. If they were matched on any other criteria, please indicate so in #6. If no purposeful matching was undertaken, choose #7. 2. Total N (both/all groups): ____________ Indicate the total number of families on which data is presented in all relevant groups. 3. Compared to/between:
1. Non-clinical, typically-developing 2. ADHD + ODD (comorbid ADHD and oppositional defiant disorder) 3. ODD/CD (oppositional defiant disorder and/or conduct disorder) 4. Autism 5. LD (learning disabilities) 6. DD (developmental disabilities) 7. Depression 8. Other clinical 9. Girls vs. boys 10. Mothers vs. fathers 11. ADHD subtype 12. Medication status 13. Parental marital status
Indicate what the identification of the group that the ADHD group was compared to and/or what comparisons were made within the ADHD group (categories 9 through 13). If more than one comparison was made (e.g., the study compared parents of children
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with ADHD to parents of children with autism and also compared mothers and fathers of children with ADHD) please do a separate form on each comparison. 4. Type of data effect size based on:
1. Means and SD 2. t-test 3. One-way ANOVA
Indicate what type of data the effect size will be based on. They are ordered here in order of preference, with means and standard deviations being the most preferred format. Only choose one. 5. Raw difference shows parenting stress more severe in: ____________________ Indicate which group has the most severe parenting stress for the current comparison. Base this judgement purely on means where they are available. If means are not available, consult the text for indications. Do not evaluate the statistical significance or the size of the difference. 6. Parenting stress values (only fill-in where necessary) Separate tables are presented for “Total Stress”, “Parent Domain”, and “Child Domain”. For any given study you may use all three tables or only one or two. If means, standard deviations (SD) and sample size (n) are available, the other columns (t, F, df, p) do not need to be filled-in. Please note, for ANOVAs, only oneway ANOVAs are eligible for effect size calculation. Also, for both t-tests and ANOVAs, record the most specific p value you can locate. If a specific p value is not indicated you may record the alpha level (e.g., p < .05) or n.s. for nonsignificant, if appropriate. If more than one parent comparison is made (i.e., both ADHD and comparison group parents are broken out by gender/role) compare ADHD group mothers to comparison group mothers. Similarly, if child gender is broken out in addition to other groupings, compare ADHD group boys to comparison group boys and/or ADHD group girls to comparison group girls, as applicable. Note 1: In these cases, parent and child gender comparisons should also be recorded on a separate form. Note 2: If an overall group (genders combined) score/comparison is also provided this should be used in place of a single gender comparison between ADHD and comparison groups. For the purposes of this meta-analysis, please include “aggressive”, “oppositional”, and “conduct disorder” comparison groups all in the ODD/CD row. The “ADHD + ODD” row is to be used for studies that compared a group consisting solely of children diagnosed with both ADHD and ODD (oppositional defiant disorder) to a pure ADHD group or other clinical group. Please note that most ADHD groups will have some children with ODD. Unless the entire group has ODD in addition to ADHD, use the “ADHD” row. Also
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studies which compared children with ADHD with and without aggression, could also be compared using the ADHD + ODD designation. The “LD” row is to be used for comparison groups consisting of children diagnosed with learning disabilities (excluding ADHD), while the “DD” row is to be used for comparison groups consisting of children diagnosed with developmental disabilities (mental retardation). The “depression” row is to be used for comparison groups consisting of children diagnosed with depression. The “Other clinical” row is to be used for any other clinically-referred comparison group. Oftentimes these studies used a group of consecutive referrals to a children’s mental health agency. These groups usually consist of children with both externalizing and internalizing difficulties, only some of whom may actually ever receive a diagnosis. The “Inattentive subtype”, “H-I subtype”, and “Combined” rows are for comparisons between subtypes of ADHD. Inattentive subtype referring to the Predominantly Inattentive Subtype, H-I subtype referring to the Predominantly Hyperactive-Impulsive subtype, and “Combined” to the Combined subtype of ADHD. These rows should only be used if subtype comparison was explicitly examined as part of the study. They should not be used based upon a characterization of the sample as consisting mostly of children with, for example, the combined subtype of ADHD. The “ADHD medicated” and unmedicated rows are only for studies which explicitly examined the role of medication status (i.e., whether the child takes stimulants or other psychoactive medications to treat his/her ADHD). The final rows on marital status are for studies which compared parenting stress in parents of children with ADHD on the basis of whether the parents were married or partnered or not. Total Stress: Comparison Mean SD n t F df p ADHD Nonclinical ADHD + ODD
ODD/CD Autism LD DD depression Other clinical Girls (ADHD) Boys (ADHD)
Mothers (ADHD)
Fathers
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(ADHD) Inattentive subtype
H-I subtype Combined ADHD medicated
ADHD unmedicated
Younger Older Parent married
Single parent
Parent Domain: Comparison Mean SD n t F df p ADHD Nonclinical ADHD + ODD
ODD/CD Autism LD DD depression Other clinical Girls (ADHD) Boys (ADHD)
Mothers (ADHD)
Fathers (ADHD)
Inattentive subtype
H-I subtype Combined ADHD medicated
ADHD unmedicated
Younger
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Older Parent married
Single parent
Child Domain: Comparison Mean SD n t F df p ADHD Nonclinical ADHD + ODD
ODD/CD Autism LD DD depression Other clinical Girls (ADHD) Boys (ADHD)
Mothers (ADHD)
Fathers (ADHD)
Inattentive subtype
H-I subtype Combined ADHD medicated
ADHD unmedicated
Younger Older Parent married
Single parent
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III. Correlational Studies If correlations are presented separately for mothers and fathers, do not record both sets. Use only the mother data. 1. Sample
1. ADHD only 2. ADHD and non-ADHD 3. Other: ____________________
Indicate whether the study investigated parenting stress solely in an ADHD group, in a combined ADHD and non-ADHD group (where ADHD symptoms were then included as a correlation), or in a differently-composed group (in which case, please specify). Note: Do NOT code the correlations between parenting stress and any ADHD symptoms in a purely non-ADHD sample (including nonclinical comparison groups and other non-ADHD clinical groups). 2. N: ____________ Indicate the study’s total sample size. 3. Correlations with parenting stress (if n differs from N above, please note appropriate n) It is very unlikely that any one study will have investigated all of these constructs. Please only indicate those that are relevant. Under “Measure” indicate the instrument used to measure the construct at hand (e.g., for conduct problems, the measure may be the CBCL, for parental depression the measure may be the BDI). A legend of abbreviations for commonly used measures is listed separately following this document. a. Child psychopathology: Correlation (r ) with: Construct Total
stress Child
domain Parent domain
n Measure
ADHD symptoms overall
Inattentive Hyperactive-impulsive
Externalizing Oppositional Aggressive
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Conduct problems
Internalizing Anxiety Mood/depression
“ADHD symptoms overall” is to be used when ADHD symptoms are linked to parenting stress without specifying whether it is the inattentive or the hyperactive-impulsive symptoms being measured. b. Other child factors: Correlation (r ) with: Construct Total
stress Child
domain Parent domain
n Measure
Child age Range: _______
N/A
Medication usage
N/A
Child academic achievement
Child IQ Child gender N/A
Under child age, indicate the range of ages investigated in the study in years. For child IQ, include any measure or proxy of cognitive development (e.g., WISC, Stanford-Binet, PPVT). c. Parental psychopathology Correlation (r ) with: Construct Total
stress Child
domain Parent domain
n Measure
Depression ADHD Other/overall psychopathology
“Other/overall psychopathology” includes measures of overall functioning, such as the Brief Symptom Inventory (BSI). d. Other parent factors Correlation (r ) with: Construct Total
stress Child
domain Parent domain
n Measure
Parent age N/A Parenting sense of competence
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Parent education N/A Parent role/gender
N/A
e. Contextual factors Correlation (r ) with: Construct Total
stress Child
domain Parent domain
n Measure
Martial discord Marital satisfaction
# Children in home
N/A
Social support SES (by income or occupation)
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Appendix B
Coding Form
Coding Form for Meta-Analysis of Parenting Stress and ADHD I. Study Level Descriptors 2. Bibliographic reference: _____________________________________________
________________________________________________________________ ________________________________________________________________
2. Study ID number: ___________ 3. Type of publication:
1. Journal article 2. Book chapter 3. Conference paper 4. Thesis or doctoral dissertation 5. Unpublished data 6. Other
4. Publication year: _____________ 5. Study type:
1. Group comparison 2. Correlational/regression 3. Both 4. Other: _______________________
6a. ADHD definition based on:
1. DSM-III criteria 2. DSM-IIIR criteria 3. DSM-IV criteria 4. Doesn’t specify 5. Other (e.g., ICD-10 criteria): _______________
6b. ADHD diagnosed/confirmed by (circle all that apply):
1. Previous diagnosis by a qualified health professional (e.g., psychologist, family physician, paediatrician, psychiatrist) a condition of participation
2. K-SADS (this is a diagnostic interview) 3. DISC (this is a diagnostic interview) 4. Study Clinician interview (any activity undertaken by a qualified
professional involved in the study to establish or confirm a diagnosis of ADHD, other than the K-SADS or DISC)
5. Questionnaire (e.g., Conner’s, BASC, CBCL, ADHD Rating Scale
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6. Other: ___________________ 7. None
7. Outcome measure:
1. PSI (Parenting Stress Index) 2. PSI-SF (Parenting Stress Index-Short Form) 3. PDH (Parenting Daily Hassles Scale) 4. DSBI (Disruptive Behavior Stress Inventory) 5. FSI (Family Stress Inventory) 6. Other: _________________
8. Gender of identified children:
1. All boys (100% of identified children) 2. All girls 3. Both: % female ADHD group: _____________ 4. Study compared girls and boys 5. Doesn’t specify
9. Parents
1. All mothers 2. All fathers 3. Both: % mothers: ____________ 4. Study compared mothers and fathers 5. Doesn’t specify
10. Child age
Mean SD n Total Sample ADHD group Comparison group: ___________ Girls Boys Other Comparison group: ________
11. SES--Hollingshead
Mean SD n Total Sample ADHD group Comparison group: ___________ Girls Boys Other Comparison group: ________
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12. Medication usage in the ADHD group: ___________%
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II. Group Comparison Studies 2. Group matching:
1. SES 2. IQ 3. Child gender 4. Child age 5. Combination: ___________________ 6. Other: __________________ 7. None 8. Not applicable (e.g., mother-father comparisons)
2. Total N (both/all groups): ____________ 3. Compared to/between:
1. Non-clinical, typically-developing 2. ADHD + ODD 3. ODD/CD 4. Autism 5. LD 6. DD 7. Depression 8. Other clinical 9. Girls vs. boys 10. Mothers vs. fathers 11. ADHD subtype 12. Medication status 13. Parental marital status
4. Type of data effect size based on:
1. Means and SD 2. t-test 3. One-way ANOVA
5. Raw difference shows parenting stress more severe in: ____________________ 6. Parenting stress values (only fill-in where necessary)
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Total Stress: Comparison Mean SD n t F df p ADHD Nonclinical ADHD + ODD
ODD/CD Autism LD DD depression Other clinical Girls (ADHD) Boys (ADHD)
Mothers (ADHD)
Fathers (ADHD)
Inattentive subtype
H-I subtype Combined ADHD medicated
ADHD unmedicated
Younger Older Parent married
Single parent
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Parent Domain: Comparison Mean SD n t F df p ADHD Nonclinical ADHD + ODD
ODD/CD Autism LD DD depression Other clinical Girls (ADHD) Boys (ADHD)
Mothers (ADHD)
Fathers (ADHD)
Inattentive subtype
H-I subtype Combined ADHD medicated
ADHD unmedicated
Younger Older Parent married
Single parent
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Child Domain: Comparison Mean SD n t F df p ADHD Nonclinical ADHD + ODD
ODD/CD Autism LD DD depression Other clinical Girls (ADHD) Boys (ADHD)
Mothers (ADHD)
Fathers (ADHD)
Inattentive subtype
H-I subtype Combined ADHD medicated
ADHD unmedicated
Younger Older Parent married
Single parent
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III. Correlational Studies 1. Sample
1. ADHD only 2. ADHD and non-ADHD 3. Other: ____________________
2. N: ____________ 3. Correlations with parenting stress (if n differs from N above, please note appropriate n) a. Child psychopathology: Correlation (r ) with: Construct Total
stress Child
domain Parent domain
n Measure
ADHD symptoms overall
Inattentive Hyperactive-impulsive
Externalizing Oppositional Aggressive Conduct problems
Internalizing Anxiety Mood/depression
b. Other child factors: Correlation (r ) with: Construct Total
stress Child
domain Parent domain
n Measure
Child age Range: _______
N/A
Medication usage
N/A
Child academic achievement
Child IQ Child gender N/A
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c. Parental psychopathology Correlation (r ) with: Construct Total
stress Child
domain Parent domain
n Measure
Depression ADHD Other/overall psychopathology
d. Other parent factors Correlation (r ) with: Construct Total
stress Child
domain Parent domain
n Measure
Parent age N/A Parenting sense of competence
Parent education N/A Parent role/gender
N/A
e. Contextual factors Correlation (r ) with: Construct Total
stress Child
domain Parent domain
n Measure
Martial discord Marital satisfaction
# Children in home
N/A
Social support SES (by income or occupation)
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Appendix C
Correlations within Subsamples
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Intercorrelations between Parenting Stress, and Major Child, Parent, and Contextual Variables (University non-ADHD Sample; n = 45)
Variable 1 2 3 4 5 6 7 8 9 10
1. Parenting stress --
2. Teacher-rated C. ADHD .08 --
3. Teacher-rated child opp. .12 .40** --
4. Child gendera .18 -.20 -.13 --
5. P. ADHD symptoms .53*** .01 -.14 .09 --
6. Parent age .06 -.10 -.05 -.11 -.10 --
7. Parent education -.01 .07 .31 -.06 -.10 .10 --
8. Marital statusb -.42** -.13 .15 .11 -.55*** .07 -.02 --
9. Social support -.36* -.03 -.15 -.06 -.03 .21 .04 .13 --
10. Parent-rated C. ADHD .30 .23 .10 .02 .45** -.02 .23 -.33* -.15 --
11. Parent-rated child opp. .13 .09 .32* .01 .34* -.15 .07 -.16 -.05 .53***
Note. C. ADHD = child ADHD symptoms; Child opp. = child oppositionality; P. ADHD symptoms = parent ADHD symptoms.
aChild gender was coded “0” for boys, “1” for girls. bMarital status was coded “0” for single and “1” for partnered parents.
*p < .05. **p < .01. ***p < .001.
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131
Intercorrelations between Parenting Stress, and Major Child, Parent, and Contextual Variables (University ADHD Sample; n = 29)
Variable 1 2 3 4 5 6 7 8 9 10
1. Parenting stress --
2. Teacher-rated C. ADHD .31 --
3. Teacher-rated child opp. -.09 .35 --
4. Child gendera .18 .36 .26 --
5. P. ADHD symptoms .49** .24 -.32 .27 --
6. Parent age -.17 -.21 -.33 -.36 -.26 --
7. Parent education -.06 -.04 -.23 -.31 -.26 .43* --
8. Marital statusb -.33 .20 .09 -.11 -.34 .12 .02 --
9. Social support -.09 -.16 .14 -.04 -.06 -.21 .17 .08 --
10. Parent-rated C. ADHD .01 .03 -.07 .56** .26 -.34 -.40* -.13 .00 --
11. Parent-rated child opp. .32 .19 .11 .14 -.13 -.26 -.15 .12 .13 .33
Note. C. ADHD = child ADHD symptoms; Child opp. = child oppositionality; P. ADHD symptoms = parent ADHD symptoms.
aChild gender was coded “0” for boys, “1” for girls. bMarital status was coded “0” for single and “1” for partnered parents.
*p < .05. **p < .01. ***p < .001.
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132
Intercorrelations between Parenting Stress, and Major Child, Parent, and Contextual Variables (Hospital for Sick Children Sample; n = 14)
Variable 1 2 3 4 5 6 7 8 9 10
1. Parenting stress --
2. Teacher-rated C. ADHD -.22 --
3. Teacher-rated child opp. -.20 .31 --
4. Child gendera -.24 .58* .52 --
5. P. ADHD symptoms -.01 .21 .12 .15 --
6. Parent age -.09 -.35 -.33 -.27 .44 --
7. Parent education .31 -.30 -.44 -.43 -.14 .26 --
8. Marital statusb .00 -.41 -.68** -.30 -.18 .37 .54* --
9. Social support .08 -.32 .37 -.25 .36 .25 -.09 .02 --
10. Parent-rated C. ADHD -.15 .67** .23 .71** .09 -.50 -.52 -.38** -.57* --
11. Parent-rated child opp. .22 .47 .51 .22 .38 .07 -.09 -.55* -.35 .05
Note. C. ADHD = child ADHD symptoms; Child opp. = child oppositionality; P. ADHD symptoms = parent ADHD symptoms.
aChild gender was coded “0” for boys, “1” for girls. bMarital status was coded “0” for single and “1” for partnered parents.
*p < .05. **p < .01. ***p < .001.
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133
Intercorrelations between Parenting Stress, and Major Child, Parent, and Contextual Variables (Centre for Addiction and Mental
Health Sample; n = 7)
Variable 1 2 3 4 5 6 7 8 9 10
1. Parenting stress --
2. Teacher-rated C. ADHD -.11 --
3. Teacher-rated child opp. -.14 .60 --
4. Child gendera .31 .75 .25 --
5. P. ADHD symptoms .40 -.14 -.27 -.27 --
6. Parent age -.24 -.54 -.58 -.27 -.41 --
7. Parent education .15 -.26 -.66 .33 -.40 .64 --
8. Marital statusb -.59 .35 .24 -.09 -.38 .19 -.24 --
9. Social support -.66 .39 .50 .13 -.82* .27 -.06 .76*
10. Parent-rated C. ADHD .69 .58 .11 .88* .15 -.45 .21 -.35 -.31 --
11. Parent-rated child opp. .83* .41 .23 .61 .23 -.53 -.5 -.22 -.33 .86*
Note. C. ADHD = child ADHD symptoms; Child opp. = child oppositionality; P. ADHD symptoms = parent ADHD symptoms.
aChild gender was coded “0” for boys, “1” for girls. bMarital status was coded “0” for single and “1” for partnered parents.
*p < .05. **p < .01. ***p < .001.
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