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1 RELATIONS AMONG ADULT ADHD SYMPTO MS AND CHILD ADHD, ODD, AND PARENT-CHILD INTERACTIONS By ALISON REBECCA ZISSER A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2008
2 2008 Alison Rebecca Zisser
3 ACKNOWLEDGMENTS I would lik e to thank Sheila Eyberg, Ph.D., my chair and research advisor, for her mentorship and support as I conducted this project. I would also like to thank Bill Perlstein, Ph.D., Michael Perri, Ph.D., and Brenda Wien s, Ph.D., members of my masters thesis committee, for the time and energy they have de voted to providing thoughtful feedback, and to the Child Study Laboratory for thei r guidance and encouragement as I worked on this thesis. I would also like to thank my pa rents, Carolyn and Elliot Zisser, for their love and support. Finally, I would like to acknowle dge the National Institute of Mental Health (R01-MH-072780) for funding the project from which these data were collected.
4 TABLE OF CONTENTS page ACKNOWLEDGMENTS...............................................................................................................3 LIST OF TABLES................................................................................................................. ..........5 LIST OF FIGURES.........................................................................................................................6 ABSTRACT.....................................................................................................................................7 CHAP TER 1 INTRODUCTION....................................................................................................................8 ADHD in Adulthood.................................................................................................................8 Adult ADHD and Parenting...................................................................................................... 9 Specific Aims..........................................................................................................................11 2 METHODS.............................................................................................................................14 Participants.............................................................................................................................14 Screening Measures............................................................................................................. ...15 Study Measures.......................................................................................................................17 Assessment Procedure........................................................................................................... .20 3 RESULTS...............................................................................................................................24 Descriptive Data for Mothers................................................................................................. 24 Analysis of Normality.......................................................................................................... ...25 Consistency among Adult Self-Report and Child Measures of ADH D Symptom atology..... 25 Pearson Correlational Analyses of Adult ADHD and Child ADHD and ODD ..................... 26 Analysis of Maternal ADHD Behavior s during Parent-Ch ild Interactions ............................ 27 4 DISCUSSION.........................................................................................................................35 Adult ADHD and Child Disruptive Behavior........................................................................ 35 Adult ADHD and Parent Behavior in Parent-Child Interactions ............................................ 38 Limitations, Strengths, a nd Future Directions ........................................................................40 REFERENCES..............................................................................................................................44 BIOGRAPHICAL SKETCH.........................................................................................................49
5 LIST OF TABLES Table page 2-1 Dyadic Parent Child Interaction Coding System composite categories............................ 23 3-1 Pearson correlations between m easures of adult ADHD................................................... 30 3-2 Pearson correlations between m other and child ADHD measures....................................31 3-3 Pearson correlations between adult ADH D and m aternal behaviors during parentchild interactions............................................................................................................. ...32
6 LIST OF FIGURES Figure page 3-1 Association between maternal inattenti on (on CAARS) and child attention problem s (on CBCL).........................................................................................................................33 3-2 Association between maternal atte ntion problem s (on ASR) and child ODD symptom level (on SNAP-IV)........................................................................................... 34
7 Abstract of Thesis Presen ted to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science RELATIONS AMONG ADULT ADHD SYMPTO MS AND CHILD ADHD, CHILD ODD, AND PARENT-CHILD INTERACTIONS By Alison Rebecca Zisser May, 2008 Chair: Sheila Eyberg Major: Psychology -Clinical and Health Psychology This study quantified the relationship be tween adult ADHD symptomatology and child ADHD and ODD symptomatology in mother-child dyads and investigated how adult ADHD symptomatology is related to parent behavior during parent-child interactions. Data from 26 mother-child dyads participating in a family-b ased, behavioral treatment program for child ADHD were used in the analyses. Findings revealed significant relations between adult inattention and child attention problems as well as between adult inattention and child ODD symptomatology. The results also in dicated that across three standa rdized play situations, adult inattention was related to le ss direction of the childs play, and greater maternal ADHD symptomatology as a child was related to more ne gativity towards the chil d. Maternal inattention was also associated with greater maternal impatie nce during a play situati on in which the mother was instructed to follow the childs lead. Resu lts highlight the relationship between maternal ADHD symptomatology and child symptomatology and demonstrat e how parents may present differently during parent-child interac tions based on their ADHD symptom level.
8 CHAPTER 1 INTRODUCTION ADHD in Adulthood Attention Deficit Hyperactivity Disorder (ADHD), a childhood-onset condition m arked by symptoms of inattention, hyperactivity, and impul sivity, was once thought to be a disorder of childhood, outgrown in the adolescent and early a dulthood years. Research over the past fifteen years, however, has demonstrated that ADHD symp toms do not simply dissipate with age, but often persist throughout adulthood and affect th e individuals psychosocial functioning in personal and professional domains (Borland & Heckman, 1976; Murphy & Barkley, 1996). In fact, family studies of children with ADHD and normal controls have shown that 15 to 20% of mothers of children with ADHD have ADHD themse lves (Biederman, et al., 1992). As research on childhood ADHD treatment turns to more behavior al, family-based models as an alternative to medication, it is critical to understand how ADHD symptoms a ffect not only the child, but also the parent involved in the childs treatment. The prevalence of adult ADHD is estimated between 3% and 6%, with 49% to 66% of childhood cases later meeting diagnostic crit eria for ADHD in adulthood or expressing significant symptoms of the disorder (Barkle y, Fischer, Smallish, & Fletcher, 2006; Murphy & Barkley, 1996). Family and twin studies have de monstrated the heritability of ADHD at 60 to 90%, suggesting that researchers and clinic ians must attend not only to a childs ADHD symptoms, but also to the potential for ADHD symptoms in the childs parents (Levy, Hay, McStephen, Wood, & Waldman, 1997; Smalley et al., 2000). Both children and adults with ADHD experience impairment in cognitive, scholastic/vocational, and in terpersonal domains (Dinn, Robbins, & Harris, 2001; Murphy & Barkley, 1996; Schweitzer et al ., 2000). Although the overt hypera ctive and impulsive symptoms
9 seen in childhood ADHD decline with age, inatte ntive symptoms tend to remain stable through adulthood (Hart, Lahey, Loeber, Applegate, & Frick, 1995) and lead to functional impairments in many facets of adult life. Adults with ADHD report more difficulties in work, more job changes, and lower socioeconomic status than their non-ADHD siblings (Borla nd & Heckman, 1976) as well as more psychological maladjustment than other adults (Morrison, 1980; Murphy & Barkley, 1996). Adult ADHD has also been associated with higher rates of family conflict and divorce (Biederman, Fara one, & Monuteaux, 2002). Adult ADHD and Parenting Clinical and em pirical evidence suggests that persistent and pervasive symptoms of inattention, hyperactivity, and impulsivity may hinde r the ability of adults with ADHD to parent effectively (Murray & Johnston, 2006). Parenting is among the most important and perhaps the most demanding responsibility many individual s will face in adulthood. Until recently, however, this domain of adult functioning was la rgely overlooked by research on adult ADHD. Deficiencies in executive functioning in adults wi th ADHD, such as an inability to redirect attention or effectively apply problem-solving stra tegies, may contribute to a parents difficulties in organizing normal activities of daily living (Sonuga-Barke, Daley, & Thompson, 2002). Murray and Johnston (2006) found highly signifi cant deficiencies in parental monitoring, consistent discipline, and effective problem solvi ng in adults with ADHD, re lated to the parents deficits in attention. Research has shown that parent behavior s such as parental monitoring, consistency, and problem solving have a sign ificant impact on child development and that deficiencies in these domains contribute to ch ild problem behavior (Co llins, Maccoby, Steinberg, Hetherington, & Bornstein, 2000; Dishion & McMahon, 1998). In fact, early interactions between parents and children are considered to have the most significant impact on a childs behavioral development (Campbell, 1997), and pare nting practices contin ue to influence the
10 maintenance of externalizing behavior, such as oppositional defiant behavior, during childhood and adolescence (McMahon & Estes, 1997). Analysis of parental monitoring, defined as attending to where a child is and what the child is doing, have revealed that parents with ADHD establis h fewer routines and possess less awareness of their childrens activities than pare nts without ADHD (Murray & Johnston, 2006). In the Murray and Johnston study, mothers with ADHD reported significantly more inconsistency on scales measuri ng discipline and parental laxn ess than parents without ADHD. Lack of parental monitoring has also been asso ciated with disruptive be havior in early childhood and the development of antisocial behavior in middle childhood and adolescence (Dishion & McMahon, 1998; Patterson & Stouthamer-Loeber, 1984). Parenting by adults with ADH D may be further complicated if the child also has ADHD. Between 40% and 60% of parents with ADHD have children with ADHD (Biederman et al., 1995; Minde et al., 2003). These parents must not only cope with the effects of their own symptoms, but also must manage the challenges of their childrens inattentive and impulsive behaviors. Effective management of chil dhood ADHD symptoms requires consistency and structure in the childs daily environment (Pisterman, McGrath, Firestone, & Goodman, 1989), which is particularly difficult for parents with ADHD, who struggle to establish consistency and structure in their own tasks and responsibilities. Parent-child dyads in which both parent and child have ADHD symptoms have been associat ed with poorer psychological and social functioning of the child than dyads in which only the parent or ne ither the parent nor the child have ADHD (Minde et al., 2003). The effect of parent ADHD on the treatment of childhood ADHD is an especially critical question for family-based, behavioral treatment programs. Parent training programs that teach
11 parents how to interact more effectively with their children and manage their childrens ADHD symptoms provide an alternative to medicati on for treating childrens problematic behaviors (Chronis, Chacko, Fabiano, Wymbs, & Pelham, 2004). Success in family-based behavioral treatment programs requires the commitment of pa rticipating parents to attend weekly sessions, integrate new communication and disciplinary skills, and practice skills daily with their children. ADHD symptoms in parents can interfere with the organization and consistency necessary to assist actively in their childrens tr eatment (Weiss, Hechtman, & Weiss, 2000). Investigating the impact of maternal ADHD on a parent training program for preschool children with ADHD, Sonuga-Barke, Daley, and Thompson (2002) found that parent training had no effect on the childrens ADHD symptom leve l when mothers also displayed significant levels of ADHD symptoms. In contrast, ch ildren with ADHD whose mothers reported few ADHD symptoms greatly benefited from the parent training program. The authors suggested that differences in motivational style, difficultie s in interpersonal relationships, and cognitive impairment of parents with ADHD might account fo r the discrepancy in tr eatment effectiveness (Sonuga-Barke et al., 2002). Specific Aims The purpose of this study was to investigat e how parent ADHD sy mptoms are manifest at the start of parent-child therapy for children s ADHD behaviors. The first question was whether there is an association between the level of ADHD symptomatology in the mother and level of ADHD symptomatology and oppositional behavior in the child. Although past research has shown that the prevalence of adult ADHD is highe r in parents of children with ADHD than in parents of children without ADHD (Alberts-Cor ush, Firestone, & Goodman, 1986), no published study to date has investigated the relation betwee n parent and child ADHD symptom severity levels or between parent ADHD and child extern alized disruptive behavior, as measured through
12 symptom level of Oppositional Defiant Disorder (ODD; American Psychiatric Association [APA], 2000), among children with diagnosed ADHD. We hypothesized a positive relation between mother ADHD symptom levels and child symptom levels of both ADHD and ODD in these parentchild dyads. Our second research question was whether th ere are observable diffe rences in parentchild interactions based on the parents level of ADHD symptomatology. Observational research on parent-child interact ions has suggested that the rate of certain hyperactive behaviors in children is influenced by parent behaviors such as more reprim anding, less rewarding, and more direction (Danforth, Barkley, & Stokes, 1991). Determining which parent behaviors during parent-child interactions are a ssociated with adult ADHD would en able future therapists both to recognize these behaviors more easily and to assi st parents with ADHD in coping with their own ADHD symptomatology as they learn new communication and pa renting strate gies. Based on research suggesting that mothers with ADHD are more reactive and negative with their children (Harvey, Danforth, McKee, Ulaszek, & Friedma n, 2003), we hypothesized th at during structured parent-child interactions, ADHD symptom levels in mothers of children with diagnosed ADHD would be positively associated with the frequency of their verbalizations, with the proportion of negative verbalizations, and with an indicator of their impatience in the parent-child interactions. We further hypothesized that the mothers ADHD symptom levels would be positively related to the proportion of commands and negatively rela ted to the proportion of praise in their verbalizations to their child. A third exploratory aim was to determine if relationships between study constructs vary based on the specific assessment measure used. Pa st research has shown discrepancy in child symptom severity amongst different informants (i.e., parent versus teacher) (Antrop, Roeyers,
13 Oosterlaan, & Van Oost, 2003) as well as different methods of measurement (i.e., parent report versus direct observation) (Querido, Eyberg, & Boggs, 2001). Measures used to assist in diagnosis of mental health diso rders also differ substantially in the derivation of test items, although differences based on test constructi on methodology have received little research attention. Symptom report measures in this study fell in to two distinct categor ies of item derivation items based on factor analysis and items based on the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV; APA, 2000). The DSM -IV-based measures use items copied closely from the DSM-IV (APA, 2000) symptom criteria a nd provide a direct comparison to the diagnostic symptom criteria commonly implemented in clinical decision making. However, these rationally derive d symptom measures do not account for differences in symptom manifestation at different ages, as the DSM-IV does not tailor symp tom criteria to age. Factor analytically derived symptom scales result in a statistical grouping of be havioral items that are related to a common construct or factor for a defined sample (Achenbach & Rescorla, 2000, 2001). Thus, behavioral items for the factor of oppositional behavior may differ for preschool aged children and for school aged children, and both scales may differ from a DSM-IV based scale measuring oppositional behavior. However, it is unknown whether scale derivation of the commonly used ADHD scales affects the pattern of relationships betw een diagnostic rating scales.
14 CHAPTER 2 METHODS Participants Twenty-six mother-child dyads participated in this investigation. Pa rticipants were drawn from a larger study of treatment for young child ren with ADHD. Participating families met the following inclusion and exclusion cr iteria: (a) the child was between 4 and 6 years of age; (b) the child met diagnostic criteria for Attention Deficit Hyperac tivity Disorder (ADHD) according to both parent and teacher report; (c) the primary maternal caregiver was the childs biological mother; the mother was willing to participate in the childs treatment; (d) the child was not taking medication for ADHD; (e) the child was enro lled in a structured daycare, preschool, or school; (f) the mother achieved a standard score of 75 on a cognitive screening measure; (g) the child achieved a standard score of 70 on a cogni tive screening measure; and (h) the child had no history of major sensory impairment (e.g., deaf), or pervasive developmental disorder. Families that did not meet study criteria were referred for alternative treatment. Participant children were 73% ( n = 19) male, with a mean age of 5.42 years ( SD = .72). Their parent-reported ethnic/ racial background was 85% (n = 22) Caucasian, 4% ( n = 1) African American, 8% (n = 2) Hispanic, and 4% ( n = 1) bi-racial. Of the 25 participating children for whom comorbid diagnostic info rmation was available, 92% ( n = 23) met diagnostic criteria for ODD, 24% ( n = 6) for Conduct Disorder (CD), 8% (n = 2) for Separation Anxiety Disorder (SAD), and 4% ( n = 1) for Major Depressive Disord er (MDD) in addition to ADHD. Eight percent (n = 4) of the childr en received a diagnosis of AD HD without a comorbid diagnosis. Children achieved a mean standard score of 108 ( SD = 14.05) on the Peabody Picture Vocabulary Test (PPVT-III).
15 Participant mothers had a mean age of 33.44 ( SD = 5.97), and their self-identified ethnic/racial background was 77% (n = 20) Caucasian, 8% ( n = 2) Hispanic, 4% ( n = 1) African American, and 11% ( n = 3) Biracial. Si xty-one percent ( n = 16) of mothers were married, 12% ( n = 3) were separated, 8% ( n = 2) were divorced, and 19% ( n = 5) were never married. For highest level of educational attainment, 8% (n = 2) of mothers had a gra duate or professional degree, 46% ( n = 12) had completed college, 39% ( n = 10) had completed some college, and 8% (n = 2) had received a high school diploma. Mother s achieved a mean standard score of 106 ( SD = 11.00) on the Wonderlic Personnel Test. Screening Measures Child Behavior Checklist (CBCL; Achenbach & Rescorla, 2000). The CBCL has different versions for adm inistra tion to children in the age range s of 1.5 to 5 years and 6 to 18 years. Because children in this study were 4 to 6 years of age, both versions were used. A T score > 61 was required on the statistically derived Attention Proble m Syndrome scale of both versions of the CBCL for study inclusion. Cronbachs alphas for the Attention Problem Scale were .68 and .86, respectively, and test-retest reliabilities were r = .78 and r = .92, respectively. Standard scores from the Attention Problem Syndrome scal e were also used in study analyses as a measure of child ADHD symptomatology. Conners Teacher Rating Scale-Revised: Long Version (CTRS-R: L; Conners, Sitarenios, Parker, & Epstein, 1998). This 59-item teacher rating scale assesses ADHD and common comorbid disorders in ch ildren ages 3 to 17 years. A T score > 65 on either the DSM-IV Hyperactive/Impulsive subscale or the DSM-IV Total Problems subscale of the CTRS-R:L was required for study inclusion. The DSM-IV Hyper active-Impulsive subscale was used in study analyses as a teacher-reported, rationally derive d scale that corresponds with DSM-IV criteria for
16 hyperactive behavior. Internal reliability coeffi cients for the DSM-IV Hyperactive-Impulsive subscale range from .82 to .95 across male and female 3 to 8 year olds. Diagnostic Interview Schedule for Young Children (YC-DISC; Strong, Lucas, & Lucas, 2006). The YC-DISC, a computer-assisted diagnostic interview for preschool-aged children, is a downward extension of the DISC-IV-P (Shaffer, Fisher, Lucas, Dulcan, & SchwabStone, 2000). The psychometric properties of the YC-DISC have not yet b een established, but its high similarity to the DISC-IV-P suggests that these properties ma y be similar. One-week testretest reliabilities of the DI SC-IV-P with parents of 9to 17-year-old children for the 5 diagnostic categories used in this study have been reported at .79 for ADHD, .54 for ODD, .54 for CD, .58 for SAD, and .66 for MDD (Shaff er, Fisher, & Lucas, 1998). The YC-DISC was used in this study because symptom items ar e worded more appropriately for young children than its parent measure. Children were requ ired to meet diagnostic criteria for ADHDHyperactive type or ADHD-Combined t ype for inclusion in this study. Peabody Picture Vocabulary Test-Third Edition (PPVT-III; Dunn & Dunn, 1997). The PPVT-III is a well-standardized measure of receptive language in individuals age 2.6 years and older. Split-half reliability coefficients for children have ranged from .86 to .97, with a median of .94, and test-retest reliabilities have ranged from .91 to .94. A PPVT-III standard score at or above 70 was required for in clusion of children in this study. Wonderlic Personnel Test (WPT; Dodrill, 1998). The WPT is a 50-item screening scale of adults' intellectual abilitie s. In a sample of 120 normal adults, the WPT score was highly correlated (r = .93) with the WAIS Full Scale IQ score and was with in 10 points of the WAIS IQ score for 90% of the sample. A WPT standard scor e of 75 or higher was required for inclusion of parents in this study.
17 Study Measures Clinical In terview An unstructured clinical interview was constructed for use with the mothers in this study. The interview addressed the childs developmenta l, medical, and school history, as well as problem beha viors and discipline techniques implemented in the home. The clinical interview also included several questi ons related to whether the biological mother, biological father, or other family members livin g in the home had been diagnosed with ADHD or had experienced symptoms of ADHD. If the moth er or a family member had been diagnosed with ADHD, the mother was asked to indicate wh ether she or the family member had received treatment for the ADHD symptoms. Adult Self Report for Ages 18-59 (ASR; Achenbach & Rescorla, 2003). The ASR is a 123-item self-report measure of adult emotional and behavioral problems. The ASR Attention Problems Syndrome scale was used as a statis tically derived measur e of parent problem behaviors associated with attention difficulties. The Attention Problems Syndrome scale has oneweek test-retest reliability of .91 and internal consistency (alpha coefficient) of .87. Conners Adult ADHD Rating Scale Self-Report: Short Version (CAARS-S:S; Conners, Erhardt, & Sparrow, 1999). The CAARS-S: S is a 26-item, statistically-derived, selfreport scale of current adult ADHD symptoms that was administered to the mothers. The 26 items are grouped into factor-analy tically-derived subscales that include an Inattention/Memory Problems scale and a Hyperactivity/Restlessness scale. An ADHD index sc ore is also provided as a summary measure of adult ADHD symptomatol ogy. Internal reliability coefficients varying from .80 to .82 for the ADHD index, .80 to .81 for the Inattention/Memory Problems scale, and .80 to .83 for the Hyperactivity/ Rest lessness scale have been reported.
18 Wender Utah Rating Scale Short Version (WURS; Wender & Reimherr, 1993). The WURS is a 25-item retrospective measure of adults ADHD symptoms during childhood. The items fall into two sections: (a) As a child, I wa s consisting of 22 genera l traits and (b) As a child in school, I was consisting of three schoo l-related traits. Each ite m is scored on a fivepoint scale, from (0) Not at all or Very Slightly to (4) Very Much indicating the extent to which the trait describes the parent duri ng childhood. High internal consistency ( = .91) and test-retest reliability (.88) have been reported. Child Behavior Checklist (CBCL; Achenbach & Rescorla, 2000). In addition to the Attention Problems syndrome scale, describe d under screening meas ures, the Aggressive Behavior syndrome scale was included in study analyses. A statistically derived measure of oppositional and conduct-disordered behavior, th e Aggressive Behavior syndrome scale has shown good reliability, with Cronbachs alpha on the 1.5 to 5 year-old version of .92 and on the 6 to 18 year-old version of .94, and one-week te st-retest reliabilities of .87 and .90, respectively. Conners Teacher Rating Scale-Revised: Long Version (CTRS-R: L; Conners et al., 1998). In addition to the Conners DSM-IV Hype ractive-Impulsive scale detailed above, the Conners DSM-IV Inattentive scal e was used as a rationally de rived DSM-based teacher-report measure of inattentive behavior in children. The Conners DSM-IV Ina ttentive subscale has internal reliability coefficients that range from .87 to .95 for male and female 3to 8-year-olds, respectively. Swanson-Nolan-and-Pelham-IV Rating Scale (SNAP-IV; Swanson, 1992). The SNAPIV is a rating scale, designed fo r completion by parents or teachers, that consists of the DSM-IV symptoms for ADHD and ODD. Only the parent comp leted SNAP-IV scores were used in this study, because not enough teacher forms had been completed at the time of this study. Recent
19 analysis of the psychometric properties of the SNAP-IV sh ows acceptable to good internal consistency with an overall coefficient alpha of .94 and coefficient al phas of .90, .79, and .89 for the subdomains of inattention, hyperactivity/impulsivity, and ODD, respectively (Bussing et al., in press). The SNAP-IV Inattent ion, Hyperactivity/Impulsivity, a nd ODD subscales were used in this study. Dyadic Parent-Child Interaction Coding System (DPICS; Eyberg, Nelson, Duke, & Boggs, 2005). The DPICS is a behavioral observation system that assesses the quality of parentchild interactions. The DPICS was designed to ca pture important parent and child behaviors and interaction patterns indicative of maladaptive pare nting styles and disruptive child behavior. The DPICS categories include parent ve rbalizations as well as sequences of dyadic behavior, such as child compliance to parent commands, reco rded during 15 minutes of observation on two occasions, one week apart. Categories are coded during three standard 5-minute parent-child interaction situations [child-led play (CLP), pare nt-led play (PLP), and clean-up (CU)] that vary in the degree of parental control required. Fo r the CLP and PLP interactions, a 5-minute warmup period precedes the 5-minute coding period. Thus, the DPICS observations require approximately 25 minutes of observation per pare nt on each of two occasions, and result in a total of 30 minutes of coded mother-child data. Reliability and validity of the DPICS meas ures are summarized in the DPICS manual (Eyberg et al., 2005). Post-baccalaureate and gradua te student research as sistants served as coders. They were trained in the DPICS system and met 80% accuracy in coding criterion tapes before coding parent-child interactions in this study. Verbal and sequence categories from the DPICS were used to measure maternal behavior during parent-child interactions. Five DPICS categories were analyzed: (a) Total Verbalizations;
20 (b) Parent Praise; (c) Parent Negative Talk; (d) Parent Commands; a nd (e) Parent Patience. Category definitions are shown in Table 2-1. Frequency counts of each verbalization or sequence behavior were summed across play situations and averaged across the two observation days. With the exception of Total Verb alizations, the averaged freque ncy counts were divided by the averaged total verbalizations to represent the perc entage of total maternal verbalization that was positive or negative. This procedure controls for the talkativeness of the mother. Parent Patience was defined as the number of maternal commands given to the child that could not be obeyed because the mother issued another command too quickly or completed the task herself before giving her child adequate time to comply. Commands that referred to future behavior (i.e., Show me when we get home) or that called for unobs ervable behavior (i.e., Listen to me) were also included in this category. Kappa statistics for the DPICS categories used in this study were: Commands .80, Praise .85, Parent Negative Talk .73, and Patience .71. Kappa values between.61 and .80 indicate Substan tial agreement, and kappa values above .81 indicate Almost Perfect agreement (Landis & Koch, 1977). Assessment Procedure Fa milies attended two 3-hour assessment sessions, scheduled one week apart. The first assessment visit was devoted to completing the informed consent process, determining the families eligibility for the study, and if elig ible, completing measures addressing the ADHD symptoms of both parent and child. This visit included the clinical interview, the YC-DISC diagnostic interview, and DPICS behavioral obser vations. Families returned one week later to repeat the behavioral observations to increase the stability of the observational scores. On both occasions, the 25-minute mother-child interaction observations were conducted in the same way. The dyad was observed in the three standard DP ICS situations: CLP, PLP, and Clean Up. The parent-child interactions were recorded onto DVD for later scoring.
21 Study measures were selected from those avai lable in the larger study of treatment for young children with ADHD. Based on DSM-IV (A PA, 2000) diagnostic criteria for ADHD, which requires documented impairment in two or more settings, both parent-report and teacherreport measures of child ADHD symptomatology were included. Two different parent-report measures (i.e., CBCL Attention Problems s yndrome scale and SNAP-IV Inattention and Hyperactivity scales) were examined to explore the effects of using ratio nally-derived measures, based on the DSM-IV (APA, 2000), versus statisti cally-derived measures of child ADHD in the investigation of relations betw een parent and child symptoma tology. Two measures of child oppositional behavior (i.e., the DSM-based SNAP -IV Oppositional Defiant Disorder scale and the statistically-based CBCL Aggression Problem s syndrome scale) were also included to explore effects of the differ ent types of diagnostic measur es on the study questions. Three different instruments were used to measure adult ADHD symptomatology. The CAARS and ASR contain statistically-de rived measures of current adult ADHD symptomatology. Both instruments were incl uded because the CAARS provides separate measurement of inattention and memory problem s versus hyperactivity and restlessness. The ASR Attention Problems Syndrome scale was included in addition to the CAARS scales to measure symptoms of adult inattentiveness as well as problems associated with adult inattentiveness. The items on the ASR Attentio n Problems Syndrome scale are similar to the inattentive parent behaviors associated with disruptive child beha vior (Dishion & McMahon, 1998; Murray & Johnston, 2006). Finally, the WURS was included in the second study question as a retrospective measure of ADHD symptoms the mothers experienced as a child. Because DSM-IV (APA, 2000) ADHD diagnostic criteria re quires the presence of inattentive and/or hyperactive symptoms prior to age 7, the WU RS was selected to determine how the ADHD
22 symptomatology experienced by the mothers as children related to maternal behavior during parent-child interactions.
23 Table 2-1: Dyadic Parent Child Interac tion Coding System composite categories Category Equation Total Parent Verbalizations pNegative Talk + pCommand + pPraise + pQuestions + pReflections + pDescrip tions + pNeutral Talk Percent Praise pPraises / To tal Parent Verbalizations Percent Commands pCommands / To tal Parent Verbalizations Percent Negative Talk pNegative Talk / Total Parent Verbalizations Parent Patience cNo Opportunity to Comply / (cComply + cNonComply + cNo Opportunity to Comply) Note. The subscript p indicates the parent categor y, and the subscript c indicates the child category.
24 CHAPTER 3 RESULTS Descriptive Data for Mothers Based on their self-report during the clinical interview, 15% (n = 4) of the mothers in this study reported having received a diagnosis of ADHD, and 15% (n = 4) reported having experienced symptoms of ADHD but not having received a diagnosis Of the mothers who either had received an ADHD diagnosis or experien ced symptoms of ADHD, only 8% reported currently receiving treatment for their ADHD symp toms. In contrast to mothers who reported neither a diagnosis nor symptoms of ADHD, the mothers who reported either a diagnosis or symptoms scored significantly higher on three of the four adult ADHD measures, including the CAARS adult ADHD index, t (24) = -3.02, p < .01, the CAARS adult H yperactivity/ Restlessness scale, t (24) = -3.01, p < .01, and the WURS retrospective measure of ADHD symptoms as a child, t (24) = -3.17, p < .01. Mothers who reported a di agnosis of ADHD did not differ significantly from mothers who reported symptoms but no diagnosis on these same measures [CAARS ADHD index, t (6) = -1.19, p = .28, CAARS Hyperactivity /Restlessness scale, t (6) = -1.44, p =.20, and WURS, t (6) = -2.14, p = .08] as well as on the ASR Attention Problems Syndrome scale, t (6) = -1.47, p = .19. Scores ranged from 0 to 27 on the CAARS ADHD index. Using criteria established by Conners, Erhardt, and Sparrow (1999), 4% (n = 1) of mothers scored in the Much Above Average range (CAARS T score > 66) for Adult ADHD, 23% (n = 6) were in the Above Average range (CAARS T score 56 65) for Adu lt ADHD, 27 % (n = 7) were in the Average range (CAARS T-score 45 55) for Adult ADHD, 38% (n = 10) of mothers were in the Below Average range (CAARS T-score 35 44) for Adult ADHD, and 8% (n = 2) of mothers scored in the Much Below Average Range (CAARS T-score 30 34) for Adult ADHD.
25 Scores ranged from 0 to 23 on the ASR Attention Problems syndrome scale. Using criteria set forth by Achenbach and Rescorla (2003), 4% (n = 1) of mothers scored in the Borderline Clinical range (ASR T-score 65 69 ) for Adult ADHD, and 12% (n = 3) of mothers scored in the Clinical range (T > 69) for Adult ADHD. Analysis of Normality Due to small sample size and consequent limited power, normality was determined by examining the absolute value of skewness and kurtosis. Variables with skewness or kurtosis greater than the absolute value of 1.5 were considered non-normal Measures of adult and child ADHD and child ODD fell within the normal range. Among the measures of observed behavior, Parent Negative Talk and Parent Commands during the Child-Led Play (CLP) situation were transformed using the natural log. Before tr ansformation, the skewness values for Parent Negative Talk and Commands were 2.06 and 2.67, respectively. Before transformation, the kurtosis values for Parent Negative Talk and Commands were 4.40 and 10.41, respectively. Consistency among Adult Self-Report and Child Measures of ADHD Symptomatology As depicted in table 3-1, th e self-report measures of a dult ADHD were highly correlated with each other, suggesting consistent reporting of adult ADHD symptomatology by mothers and valid measurement of adult ADHD. Parent measur es of child oppositional behavior were also significantly correlated with each other, r (n = 23) = .41, p = .05. The parent and teacher measures of child ADHD were less consistently correlated with each other, with statis tically significant correlations only between the DSM-based SNAP-IV inattention scale and the statis tically derived CBCL measure of child attention problems, r (n = 23) = .70, p < .01, and between the inattention and hypera ctive subscales of the teacher report measures, r (n = 23) = .43, p < .05. These findings may suggest th at teachers discriminate less
26 well between inattentive and hyperactive sympto ms than parents, who may also be more consistent in their reporting of the childs inattentive symp toms than hyperactive symptoms. Pearson Correlational Analyses of Adult ADHD and Child ADHD and ODD Pearson correlations were conducted to measure the association between adult ADHD symptomatology and child ADHD symptomatology. With the exception of the CBCL Attention Problems syndrome scale, raw scale scores were first converted to z-scores in order to compare different measures. Normed T scores were used for the CBCL Attention Problems syndrome scale to account for the different scoring of th e two CBCL versions implemented in this study. Adjusted r and adjusted r values were also calculated thro ugh simple regression to control for the small sample size. Adjusted r values are reported for statistically significant relationships. The SNAP-IV was missing for three families and the CTRS was missing for one family. Thus, analyses involving the SNAP-IV were conducted with 23 instead of 26 families, and analyses involving the CTRS and the SNAP-IV were conducted with 22 instead of 26 families. Table 3-2 displays correlations among th e three measures of current adult ADHD symptomatology (as a retrospectiv e measure, the WURS was not in cluded in this analysis) and the five measures of child ADHD symptomatology. Adult ADHD symptomatology was measured by the CAARS Inattention/Me mory Problems scale, the CAARS Hyperactivity/Restlessness scale, and the ASR Attention Problems syndrome scale. Child Inattention was measured by the CBCL Attention Problems scale, the SNAP-IV Inattention scale, and the CTRS DSM-IV In attentive scale. Child Hyperactivity was measured by the SNAPIV Hyperactivity scale and the CTRS DSM-IV Hyperactive-Impulsive scale. The only significant correlation between an adult ADHD measure and a child ADHD measure was the correlation between the CAARS Inattention/Memory Problems scale and the CBCL Attention
27 Problems syndrome scale, r (n = 23) = .48, p < .05, adjusted r = .44 This relationship is depicted in figure 3-1. Adult inattention, as measured by the AS R Attention Problems syndrome scale, was significantly correlated with child oppositiona l behavior, as measured by the SNAP-IV, r (n = 23) = .43, p < .05, adjusted r = .38. The association between a dult inattention and child oppositional behavior is also depicted in figure 3-2. It is important to note that the CBCL measure of aggressive behavior was not rela ted to any measure of adult ADHD symptomatology. Thus, only one of the measures of child oppositional behavior was related to adult ADHD symptoms. This inconsistency in results will be addressed furthe r in the discussion. Analysis of Maternal ADHD Behaviors during Pa rent-Child Interactions The hypothesized relations between matern al ADHD symptomatology and mother-child interaction style were examined using Pearson correlations. After natura l log transformation of the observational variables that were not normally distributed, the interacti on data were analyzed within each standard DPICS play situation (i.e., Child Led Play [CLP], Parent Led Play [PLP], and Clean-Up [CU]) and across the combined se t of observational data. Adjusted r values, controlling for small sample size, are reported fo r statistically significan t correlation values only. Data from all 26 mother-child dyads were used in the analyses examining relations between adult ADHD and maternal behavior. The intercorre lation matrix is shown in table 3-3. Maternal self-report of ADHD symptomatology as a child, as measured by the WURS, was positively associated with mothers negative talk during interactions with their children, r (n = 26) = .49, p = .012, adjusted r = .45 This particular associa tion was the most pronounced during the PLP situation. In cont rast to our hypothesis, maternal inattention, as measured by the ASR Attention Problems syndrome scale, was ne gatively related to mothers observed command frequency, r (n = 26) = 0.41, p < .05, adjusted r = -0 .37. Across play situations, no significant
28 associations were found between self-ratings of Adult ADHD and observed frequency of total verbalizations, praise of the child, or parent impatience. During the 5-min Child-Led Play situation [o r CLP], parents were instructed to allow their child to lead the play. In this situation, maternal inat tention, as measured by the ASR Attention Problems Scale, was positively related to both maternal total verbalization frequency, r (n = 26) = .40, p < .05, adjusted r = .35 and maternal impatience, r (n = 26) = .50, p < .01, adjusted r = .47 No significant associations were f ound between measures of maternal ADHD and negative parent verbalizations or parent praise of the child during the CLP situation. During the Parent Led Play situation [or PLP], parents were instructed to lead the play. Similar to the finding across situations, a n ear significant negative association was found between ASR maternal inatten tion and command frequency, r (n = 26) = -0.38, p = .053, adjusted r = -0.33. Contrary to our hypothesis, a near significant positive association was found between ASR maternal inatten tion and praise of the child, r (n = 26) = .39, p = .052, adjusted r = .34. As mentioned above, the WURS retr ospective measure of maternal ADHD symptomatology was positively related to negative talk towards the child, r (n = 26) = .48, p = .014, adjusted r = .44 No statistically significant associations were found during PLP between maternal ADHD and frequency of pa rent verbalizations or parent impatience. During the Clean Up situation, maternal ADHD symptomatology was not related to any of the hypothesized maternal behaviors. In exploring the associations betwee n mothers ADHD symptomatology and their behavior during parent-child in teractions, other factors poten tially affecting the mothers behavior, such as child ADHD and ODD symptomato logy, were explored as potential covariates in predicting maternal behavior. Before c ontrolling for child ADHD and oppositional behavior,
29 we first conducted correlational analyses to determine whether child inattention, hyperactivity, or oppositional behavior was related to maternal behavior during the play situations. Full consideration of these anal yses is beyond the scope of this pape r. However, associations in which both maternal attention problems and child ADHD or ODD were found to be significantly related to maternal behavior were reanalyzed using multiple regression to control for the influence of child behavior on parent beha vior during parent-child interactions. Multiple regression, which controlled for ch ild ADHD symptomatology across situations, revealed that maternal inattention remained a significant predictor of parent command frequency during the parent-child interaction ( = -.43, t (20) = -2.28, p < .05). However, after controlling for child hyperactivity during CLP, maternal attention problems was no longer a significant predictor of frequency of parent verbalizations ( = .33, t (20) = 1.72, p = .10).
30 Table 3-1. Pearson correlations between measures of adult ADHD Variable 1 2 3 4 1. CAARS Inattention/Memory Problems 0.62** 0.71** 0.39* 2. CAARS Hyperactivity/Restlessness 0.35 0.52** 3. ASR Attention Problems Syndrome Scale 0.35 4. WURS Retrospective Measure Note. CAARS = Conners Adult ADHD Rating Scale; ASR A ttention Problems = Adult Self Report, Attention Problems Syndrome Scale; WURS = Wender Utah Rating Scale; Sample included 26 families. *p < 0.05. ** p < 0.01.
31 Table 3-2. Pearson correlations between mother a nd child ADHD measures Measure CAARS Inattention/ Memory Problems CAARS Hyperactivity/ Restlessness ASR Attention Problems SNAP-IV: Inattention 0.13 -0.07 0.12 SNAP-IV: Hyperactivity -0.06 0.01 -0.20 CBCL: Attention Problems 0.48* 0.23 0.19 CTRS: DSM-IV Inattentive -0.22 -0.13 0.02 CTRS: DSM-IV Hyperactive/ Impulsive -0.21 -0.04 -0.14 Note. CAARS = Conners Adult ADHD Rating Scale; ASR A ttention Problems = Adult Self Report, Attention Problems Syndrome Scale; SNAP-IV = Swanson, Nolan and Pelham Questionnaire; CBCL Attention Problems = Child Behavior Checklist Attention Problems Syndrome Scale; CTRS = Conners Teacher Rating Scale; Sample included 23 families, with missing data resulting in differences in the total number of participants for some analyses. *p < 0.05.
32 Table 3-3. Pearson correlations between adult ADHD and maternal behaviors during parent-child interactions Situation and Measure Total Verbalizations Commands Negative Talk Praise Impatience Across Situations CAARS Inattention/Memory Problems -0.10 -0.10 0.02 0.06 0.01 CAARS Hyperactivity Restlessness -0.10 -0.10 0.32 -0.13 -0.12 ASR Attention Problems 0.26 -0.41 -0.09 0.23 0.21 WURS Retrospective 0.06 0.14 0.49 0.02 0.08 Child Led Play CAARS Inattention/Memory Problems -0.15 -0.24 -0.12 0.10 0.22 CAARS Hyperactivity Restlessness -0.16 -0.14 0.18 -0.13 0.24 ASR Attention Problems 0.40 -0.36 -0.14 0.10 0.50 ** WURS Retrospective 0.18 0.20 0.37 0.09 0.22 Parent Led Play CAARS Inattention/Memory Problems -0.06 -0.17 0.10 0.16 -0.18 CAARS Hyperactivity Restlessness -0.18 -0.13 0.28 -0.02 -0.33 ASR Attention Problems 0.14 -0.38 0.01 0.14 0.02 WURS Retrospective -0.24 -0.05 0.48 -0.24 0.02 Clean Up CAARS Inattention/Memory Problems -0.03 -0.01 0.06 -0.06 0.00 CAARS Hyperactivity Restlessness 0.14 -0.13 0.30 -0.2 -0.03 ASR Attention Problems 0.10 -0.14 -0.09 0.00 0.06 WURS Retrospective 0.25 0.31 0.31 -0.06 0.07 Note. CAARS = Conners Adult ADHD Rating Scale; ASR A ttention Problems = Adult Self Report, Attention Problems Syndrome Scale; WURS = Wender Utah Rating Scale; Sample included 26 families. *p < 0.05. **p< 0.01.
33 60 65 70 75 80 85 -2 -1 0 1 2 3 Maternal Inattention (Z score)Child Attention Problems (T score) Figure 3-1. Association between maternal inatte ntion (on CAARS) and ch ild attention problems (on CBCL).
34 -2.5 -2 -1.5 -1 -0.5 0 0.5 1 1.5 2 2.5 -2.5-2-1.5-1-0.500.511.522.5Mother Attention Problems (Z score)Child ODD Symptom Level (Z score) Figure 3-2. Association between maternal atte ntion problems (on ASR) and child ODD symptom level (on SNAP-IV).
35 CHAPTER 4 DISCUSSION Adult ADHD and Child Di sruptive Behavior Significant relations were found between m aternal inattention and child symptoms of ADHD and ODD, as hypothesized. Th ese findings have not previously been reported, likely due to the recent recognition in the literature that adult ADHD symptomatology significantly impacts parenting behaviors. Studies have begun to demonstrate relations between maternal ADHD symptomatology and deficiencies in parental monitoring, inc onsistent discipline, and poor problem solving (Murray & Johnston, 2006; Sonuga-Barke et al., 2002). It is probable that this relation between maternal ADHD symptomatology a nd ineffective parenting behavior accounts for the relations found between maternal inattention and both child ADHD and ODD symptomatology in our sample of clinic-referred preschoolers. Although significant relations were found betw een only certain measures of adult ADHD and certain measures of child ADHD and ODD, th e findings are consistent with research suggesting that parenting contributes to the e xpression of child ADHD symptoms as well as the development of problems comorbid with ADHD (Barkley, 1990). In fact, these results are consistent with previous work suggesting that in attention in parenting ta sks contributes to the development and maintenance of disruptiv e child behavior (D ishion & McMahon, 1998; Dishion, Patterson, Stoolmiller, & Skinner, 1991). Whereas a significant association was found between maternal inattention and child ADHD and ODD symptoms, no significant asso ciation was found between maternal hyperactivity and child ADHD symptomatology or oppositional behavior. The complete absence of evidence relating adult hyperac tivity to child behavior proble ms as manifest in either ADHD or ODD is not surprising, because the negative parenting behavior s such as deficient parental
36 monitoring and poor problem solving have been at tributed to parental inattention but not to parental hyperactivity. In fact, Murray and Johnston (2006) found that parenting practices are more impaired among the inattentive subtype of mothers with ADHD than the combined subtype. They suggested that the higher activit y and energy levels of hyperactive mothers may compensate for attention deficits by providing more opportunities to spend time with their children (and thus monitor) their childr ens activities (Murray & Johnston, 2006). Recent findings presented by Chronis et al. (2007) have demonstrated a relationship between maternal inattention and child oppositional behavior but not between adult inattention or hyperactivity and child ADHD symptomatology. It is possible that the rela tionship between adult inattention and child ADHD symptom expression is more pronounced among younger children than older children (the Chronis study included children between the ages of 6 and 10 years). Differences in findings may also be due to the use of a different measure of child ADHD symptomatology. As is evident in our study, the statistical relationships between constructs differed greatly depending on the specific sc ale used to measure the construct. It is important to consider the consistency of the findings. Several measures of adult and child symptomatology were used in this study. Although a significant association was found between the adult CAARS Inattention/Memory Problems scale and the CBCL measure of attention problems in children, no signifi cant association was f ound between the CAARS measure of adult inattention and the SNAP-IV measure of child inattention or hyperactivity. Similarly, although a significant association was found between th e ASR adult syndrome scale of attention problems and the SNAP-IV measur e of child ODD symptomatology, no significant association was found between the ASR Attention Problems syndrome scale and the CBCL Aggressive Problems syndrome scale.
37 Inconsistent findings between measures do not render a particular finding less significant, but they do stimulate questions as to why these differences in relationships among measures emerged. One explanation for the inconsistency in results could be method variance, which is an overlap in variance between two variables due to the type of measurement tool implemented or type of measurement approach used (i.e., sc ale construction). Method variance may cause observed relationships between cons tructs to differ from true relationships (Campbell & Fiske, 1959; Doty & Glick, 1998). Method variance may in flate a relationship between two constructs if the methodological components of the individual measures are more positively related than the true relationship between the constructs. Conversely, method variance may deflate the relationship between two constructs if systematic error compon ents of two measures are less positively related than the true relationship (Doty & Glick, 1998). Thus, as an example, combining the two versions of the CBCL Attent ion Problems syndrome scale into one measure may have introduced systematic error which mini mized the potential true association between this measure of child inattention and the ASR Attention Problems syndr ome scale for adults. Results not only varied between measures with differing item derivati on (i.e., Statistical versus DSM/Rational approach), but also varied between measures using the same method of item derivation. Without a consistent pattern to the results ba sed on item derivation, we cannot conclude that item-derivation is a factor in the inconsistent relations found between measures. However, it is evident that measure selection sign ificantly affects research findings and that scale construction introduces systematic variance that should be controlled in statistical analyses. Doty and Glick (1998) proposed confirmatory factor analysis (CFA) as a method for reducing systematic error in studies containing multiple measures of one construct. Sample size in this study did not permit the use of CFA. However, futu re investigation of th e study questions with a
38 larger sample size will make it possible to impl ement CFA to determine more effectively the nature of associations between adult ADHD a nd child hyperactive and di sruptive behavior. Another explanation for the inconsistency in resu lts is that a particular significant finding was a statistical anomaly (an expl anation made more plausible by a small sample size). However, past research linking parental inattention to the expressi on of child ADHD and disruptive behaviors (Barkley, 1990; Minde et al., 2003; Murray & Johnston, 2006) reinforces the validity of these findings. It is more li kely that although different measur es of the same construct may both be valid, they tap into different aspects of the construct and result in different statistical relationships. Adult ADHD and Parent Behavior in Parent-Child Interactions In addition to investigating rela tions of maternal ADHD a nd child behavior, this study examined relations of maternal ADHD and mother s behaviors during inte ractions with their hyperactive young children. Consistent with our hypothesis that moth ers with higher levels of ADHD would show more negative behavior towards their chil d, a particularly intriguing relationship was found between the WURS retrospective measure of maternal ADHD symptomatology and maternal negative talk acr oss the three standard situations. Although maternal Negative Talk was not significan tly associated with any measures of current adult ADHD symptomatology, mothers who experienced mo re ADHD symptoms as children tended to be more critical or sarcastic towards their childre n. This relationship was especially strong during the PLP situation, in which the parent was inst ructed to lead the ch ilds activity. A potential explanation for the relations hip between a mothers ADHD symptom level as a child and negative reactivity towards her child is that mothers with higher symptom levels as children may have developed a need for calm and order to cope with their own symptoms. Interruption by their children could make these mothers especially r eactive to their childrens hyperactive behavior
39 (Weiss et al., 2000). Periods in which the child is expected to comply with parent direction may become particularly stressful for the ADHD mo ther, which may result in greater negativity towards the child duri ng the PLP situation. Across the three structured parent-child situations, maternal inattention was also associated with less maternal direction of the childs activities, as measured by command frequency. This finding was contrary to our hyp othesis, based on research by Harvey et al. (2003), that hyperactivity and impulsivity in mothers with higher levels of ADHD symptomatology would be manifested through more active direction of the childs play. The negative relation between ADHD symptomatology a nd parent commands in the mother-child interaction may be due to the more signifi cant role of inattentive than hyperactive symptomatology during the play situation. This finding would be consistent with research showing that mothers with ADHD monitor th eir childrens activiti es poorly (Dishion & McMahon, 1998; Murray & Johnston, 2006; Weiss et al ., 2000). An inability to attend to and track the childs play may have created a situat ion in which the mothers hyperactivity could not be directly observed in relation to the child. It is important to note that during the Child Led Play situation [CLP], when mothers are instructed to allow the child to lead the pla y, inattentive mothers did not give more commands, but showed more impatience in the commands that they gave to the child. During CLP, inattentive mothers were more likely to repe at their commands without allowing the child adequate time to comply, to use quick phrases (e .g., Listen to me) to serve as restatements of their commands, or to complete the task for th e child. Research by Harvey et al. (2003) found a similar result that mothers with greater inattention used more repetition when attempting to get their children to comply.
40 This research has important implications for understanding not only how mothers with ADHD symptomatology interact with their childr en but also how maternal ADHD symptoms are manifested in the treatment setting. Inattentive mothers who present with their children for family-based treatment of child ADHD may experi ence more difficulty allowing their child to lead parent-child interactions evidenced through increased impa tience. Allowing the child some control in play contributes to a positive, recipr ocal interaction between parent and child. This research suggests that during treatment, parents with ADHD may require more focused coaching in following their childs lead during play. When a parent shows evidence of ADHD symptomatology, the therapist may also discuss research findings on mothers with ADHD and direct ly address and problem solve aspects of the parent-child interaction that ar e particularly difficult for the pa rent. Explaining how the mothers condition is affecting her interact ion with her child may relieve some personal attributions of failure if the mother is struggling in skill ac quisition. Directly addressing the mothers ADHD symptoms may also help the mother gain more understanding and contro l of her own symptoms as well as her childs symptoms. Limitations, Strengths, and Future Directions All children who particip ated in this study m et di agnostic criteria for ADHD Hyperactive-type or Combined-type and surpassed a pre-designated cutoff for ADHD symptom expression on both a mother-report and teacher-re port rating scale. Thus, all children, regardless of the parents ADHD symptom level, entered the study with an elevated level of ADHD symptomatology as compared to a normal sample of 4to 6-year-old children. Although the childrens scores on the ADHD measures were norm ally distributed, the re striction in range of child ADHD symptoms likely affected and may have reduced the magnitude of the correlations between adult and child ADHD symptom expression.
41 Restricting the sample to clinic-referred, 4to 6-year-old children and their mothers also limited the generalizability of findings to mothers of young children with clinical levels of ADHD. These results cannot be generalized to fath ers or to older childr en with ADHD. Further, most of the children in this sample met criteri a for a comorbid diagnosis of ODD. Thus, these results may not generalize to mother-child dyads in which the child has ADHD without a comorbid diagnosis. The dimensional measurement of maternal ADHD symptomatology should also be noted. Because we did not use a DSM measure of th e mothers ADHD symptoms, we are unable to determine which mothers met full diagnostic cr iteria for ADHD. However, two of the adult ADHD scales provided cutoffs i ndicating ADHD in the clinical ra nge for 12% and in the above average or higher range for 27%. These numbers ar e fairly consistent with research suggesting that 15 to 20% of mothers of children with ADHD have ADHD themselves (Biederman, et al., 1992). Further, it is important to acknowledge that adult ADHD frequently co-occurs with other psychological conditions such as antisocial personality, anxiety, depression, or substance use disorders (Borland & Heckman, 1976). Thus, future research must tease apart the role of inattention versus comorbid conditions in contributing to the expression of child symptomatology and maternal behaviors during parent-child interactions. Although this study did not directly measure parenting practices, several items on the ASR Attention Problems scale (i.e I have trouble making decisi ons) relate to problematic parenting behaviors cited in the research as related both to adult ADHD and to the development of disruptive behavior in childre n (Harvey et al., 2003). Still, the inclusion of a measure of parenting practices in future research would permit confirmati on of the meditational role of
42 ineffective parenting practices assumed to be operating among inattentive mothers in the development of disruptive child behavior. Despite the limitations of this study, there are several important strengths. To our knowledge, this is the first study to investigat e the relationship betw een symptom level of maternal ADHD and symptom level of child ADHD and ODD in preschool-aged children. This study also contributes to the growing body of research on how adult ADHD manifests in the parenting domain and treatment setting by expl oring how adult ADHD is related to parent interaction style, a major focus of parent tr aining interventions for child ADHD and disruptive behavior. Finally, a methodological strength of this paper is the inclusion of multiple psychometrically sound rating scale measures to explore how results vary based on the measure used. The inconsistency in results found in this pa per suggests that researchers must consider the measure that was used when comparing findings in different studies. The preliminary results in this study are promising, and it wi ll be important to continue to collect data to reexamine the study questions with a larger sample. Based on these results, we predict that upon reanalysis with CFA, factor s related to adult ina ttention but not adult hyperactivity will be related to child ADHD expre ssion and ODD behaviors. We also predict that factors related to inattention will remain consiste ntly related to aspects of mother behavior such as maternal impatience during CLP. The inclus ion of non-clinic referred children and their mothers will also contribute more range in th e measurement of child ADHD, which may reduce some of the inconsistency in results and will allo w for greater generalizability of the findings. In conclusion, this study offers important imp lications for family-based treatment of child ADHD. The childs mother is a critical member of the family unit, and better understanding of her potential ADHD symptomatology will allow for mo re effective treatment. By exploring how
43 adult ADHD is related to child disruptive behavior and affects the parent -child interaction, the therapist may tailor treatment to focus support on behaviors specific to parents with adult ADHD, leading to more effective treatment of fa milies in which both the parent and the child are experiencing ADHD symptomatology.
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49 BIOGRAPHICAL SKETCH Alison Rebecca Zisser was born in Jacks onville, Florida, on February 17, 1983. The younger of two children, she was raised in Jackso nville and graduated from the Bolles School in 2001. She earned her B.A. in psychology and history and graduated magna cum laude from Washington University in St. Louis in 2005. Upon graduating, Alison spent five months in Durban, South Africa, working with HIV positive children and conducting research on AIDS prevention. After returning to the United States, Alison worked for six months as an ea rly intervention therapist with developmentally delayed children. In August of 2006, she enrolled in a dual Master of Science and Doctor of Philosophy program at the University of Floridas Department of Clinical and Health Psychology. Alison currently has a research assi stantship in the Child Study Laboratory under the mentorship of Sheila Eyberg, Ph.D. Upon comp letion of her Master of Science, Alison will continue her Doctor of Philosophy work in the Department of Clinical and Health Psychology.