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ADHD: An Introduction

ADHD: An Introduction. ADHD is a neurodevelopmental disorder of childhood characterized by developmentally inappropriate levels of hyperactivity and impulsivity and/or attention problems.

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ADHD: An Introduction

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  1. ADHD: An Introduction • ADHD is a neurodevelopmental disorder of childhood characterized by developmentally inappropriate levels of hyperactivity and impulsivity and/or attention problems. • With a prevalence of 3 - 5% in the general population (APA, 1994), this disorder is a common reason for referral to pediatricians, child psychiatrists and psychologists.

  2. ADHD: An Introduction • Clinical experience with this disorder suggests that the behavior of children with ADHD, can be highly disruptive and contribute to increased levels of parental/family stress. • Additional stress may result from the demands and family disruptions experienced by parents as a result of problem behaviors displayed in various settings. • For example, parents must often deal with repeated phone calls from teachers because of their child’s misbehavior.

  3. ADHD: An Introduction • They often have to “explain” their child’s behavior to other parents. • They are often restricted socially due to their inability to find someone to care for their child. • They often must miss work to attend clinic appointments. • And, many worry incessantly (with some justification) about the possibility of accidental injury to their child as a result of his/her behavior. • These represent only a few of the stressors experienced by parents of children with ADHD (Bussing & Gary, 2001).

  4. Parenting and Caretaker Stress • Relevant to the disruptive behaviors displayed by children with ADHD, researchers have begun to emphasize the role of everyday parenting events as sources of caretaker stress. • For example, Crnic and Acevedo highlight "daily parenting hassles," as routine childrearing responsibilities that parents may, in the form of chronic demands, find irritating, frustrating, annoying, and distressing. • High levels of daily parenting hassles have been shown to relate to lower life satisfaction, more negative mood and affect, and increased maternal distress (Crnic & Acevedo, 1995; Crnic & Greenberg, 1990)

  5. ADHD and Family Stress • Crnic and Greenberg (1990) have found these daily parenting hassles to be even more stressful to parents than major life events. • That daily parenting hassles can also have significant implications for parent-child interactions is suggested by research indicating that mothers who report more daily parenting hassles tend to display more negative affect towards children and respond in ways that increase children's negativity. • Dumas (1986) and Patterson (1983) also found that mothers engaged in significantly more aversive or irritable/coercive interactions with children on days when they experienced high rates of minor stressors.

  6. ADHD and Family Stress • This concept of daily parenting stress is important in understanding the functioning of families of children with ADHD. • Parents of children with this disorder often have to deal with problematic behaviors at much higher rates and at higher levels of intensity than is usually found in normal families. • For parents of children with ADHD, parenting stressors may be of special significance as regards their potential impact on parent, child, and familyfunctioning. • These outcomes may include the development of parenting styles that increase negative child behavior, parental psychopathology, and strained marital relationships, as well as other negative outcomes.

  7. ADHD and Parent Adjustment • Regarding the potential impact of ADHD-related stress on the family, studies have shown that mothers of children with ADHD have higher rates of psychological difficulties (Fischer, 1990) • They seek treatment for psychological difficulties significantly more often than mothers of normal children (Gillberg, Carlstrom, and Rasmussen, 1983). • In the latter study, treatment-seeking behavior was also found to be correlated with the severity or pervasiveness of the child's hyperactivity (Gillberg, et al., 1983).

  8. ADHD and Parent Adjustment • Several studies have shown that mothers of children with ADHD show higher rates of depressive symptoms than mothers of normal children (Befera & Barkley, 1985; Brown & Pacini 1989; Cunningham). • Alcohol consumption has been found to be elevated in parents of children with ADHD (Cunningham et al., 1988; Pelham & Lang, 1999). • Other studies have found increased marital discord and strained interpersonal relationships in ADHD families (Johnston, 1996). • These findings suggest that having a disruptive child within the home is often associated with a range of psychological, interpersonal and family difficulties.

  9. ADHD and “Parenting Stress” • A number of studies have focused on the degree of stress experienced by parents of children with ADHD. • Most of these studies have used the Parenting Stress Index (PSI; Abidin, 1995) in comparing parents of children with and without ADHD. • Briefly, the PSI is a parent-report measure which assesses characteristics of the child, the parent, and situation/demographic factors that can place a strain on the parent-child system. • Several studies have found parents of children with ADHD to show significantly elevated levels of “parenting stress” as indexed by this measure.

  10. ADHD and “Parenting Stress” • Mash and Johnston (1983), for example, found mothers of hyperactive children to report higher levels of overall parenting stress than parents of normal children. • They found that child characteristics including “distractibility” and “perceived degree of bother” accounted for the most variance in parenting stress scores. • Mothers of hyperactive children also reported more feelings of social isolation and role restriction compared to parents of normal children.

  11. ADHD and “Parenting Stress” • Breen and Barkley (1988) found mothers of hyperactive clinic-referred girls to display higher PSI stress levels that did mothers of normal girls. • They also found the severity of child aggression, conduct problems, and hyperactivity to be significantly related to parent stress levels. • These findings suggest that stress levels, not only increase as the severity of ADHD symptoms increase, but also as a function of comorbid features that often accompany ADHD.

  12. ADHD and “Parenting Stress” • The view that parenting stress can be increased by comorbid conditions that accompany ADHD is also supported by findings from Anastopoulos, et al (1992). • In addition to finding increased levels of stress among parents of children with ADHD, they also found the severity of ADHD symptoms and aggressive and oppositional-defiant behavior to account for some 43% of the variance in parenting stress scores. • Studies such as these provide general support for the view that ADHD-related behavior is associated with significant levels of parental stress.

  13. On The Measurement of “Parenting Stress” • Despite findings of a link between ADHD and “parenting stress”, it should be noted that these studies provide relatively little information regarding the specific types of stressors experienced by parents of children with ADHD. • Indeed a careful look at the nature of the PSI suggests that scores on this measure provide only an indirect reflection of the stress resulting from having a child with ADHD.

  14. A Quick Look at the PSI Stress • The PSI is designed to assess sources of stress resulting from the Child, the Parent, and the Environment that place strain on the parent-child system. This measure includes: • Child Domain measures. • Parent Domain measures. • Measures of Life Stress (optional).

  15. PSI Child Domain Measures Adaptability Acceptability Demandingness Mood Distractibility/Hyperactivity Child Reinforces Parent Critique Scales reflect the presence of difficult child temperament and overlap considerably with features displayed by many children with ADHD. Measures would be expected to correlate significantly with ADHD symptom measures Characteristics assessed may contribute to stress but do not seem to represent measures of stress per se.

  16. PSI Parent Domain Measures • Depression • Attachment • Parental Role Restriction • Sense of Competence • Social Isolation • Relationship with Spouse • Parent Health Critique Measures do not appear to assess parenting stress per se, but more likely stress related outcomes.

  17. So What Does All This Suggest? • That children with ADHD display disruptive behaviors that can result in family stress. • Research provides general support for the view that parents of children with ADHD often display negative outcomes related to adjustment and family functioning. • Measures designed to assess specific stressors, resulting from ADHD related behavior, are needed.

  18. ADHD and Family Burden • The need for additional research related to ADHD family stress has been highlighted by the proceedings of a Centers for Disease Control conference, convened in 1999, to develop a research agenda for studying the public health costs of this disorder. • The conclusions and recommendations resulting from this conference include the following:

  19. ADHD and Family Burden • It is reasonable to assume - • That family members of a child with ADHD are impacted by this condition. • That the magnitude of the social and economic burden of ADHD on the family has not been systematically documented. • That families of children with ADHD may be more likely to experience conflict and increased family stress. • That the impact of a child with ADHD may reduce the ability of parents to participate in activities outside the home such as work and social activities.

  20. ADHD and Family Burden • That to understand the nature of ADHD, it is imperative to understand its effects on families. • That considerable research is needed to clarify those aspects of the family it impacts and in what ways. • Finally, it was suggested, • That since the development of effective interventions for ADHD is dependent on having reliable and valid measures to assess the impact of the disorder, the development of standardized burden measures are central to this process.

  21. Assessing ADHD-Related Stress • In line with CDC recommendations much of the work in our lab, during the past couple of years, has dealt with an attempt to develop a reasonably reliable and valid measure of ADHD-related stress. • Our goal has been to develop a measure that provides information regarding both the occurrence and stressfulness of specific family changes, family disruptions, and other circumstances resulting from having a child with ADHD in the family. • Our focus has been on assessing specific ADHD behavior-related family stressors, rather than obtaining more global indices of family stress, or measures of stress-related outcomes experienced by family members..

  22. Assessing ADHD-Related Stress • Our belief has been that a measure of this type, should serve as a useful treatment outcome measure. • Should be of value in providing important family assessment data for comprehensive ADHD clinical evaluations. • Should be useful as a research tool in studying the impact of ADHD related stress on the family. • Indeed, the development of measures of this type appears to be a prerequisite for conducting meaningful research on the nature and impact of ADHD on families.

  23. Assessing ADHD Related Stress:Development of the DBSI • The initial work on the the Disruptive Behavior Stress Inventory (DBSI) conducted by Steve Reader and myself, began with developing an initial item pool. • Here, preliminary items were obtaining from parents of children with ADHD who were asked to complete an open-ended survey requiring them to list the five most significant stressors or family disruptions they experienced as a result of their child's behavior.

  24. Assessing ADHD Related Stress:Development of the DBSI • Of the 134 items described as highly stressful by parents, 40 were retained for inclusion in the final measure. • The preliminary asked parents to indicate whether they have experienced a particular stressor within the past six months and to rate the degree of stress associated with that stressor on a 4-point scale (0 = Not at all Stressful; 3 = Very Stressful).

  25. Assessing ADHD Related Stress:Development of the DBSI DBSI Instructions Listed below are a range of potential stressors that are sometimes experienced as a result of having a child who displays behavioral difficulties. Read each of the following items carefully and indicate those situations you have experienced as a result of your child’s behavior during the past six months. Circle "Yes" if you have experienced what is described in the item. Circle "No" if you have not. For each item where you circled "Yes", indicate on the following 4 point scale the extent to which it was/is stressful to you: 0 (Not at all Stressful); 1 (Somewhat Stressful); 2 (Moderately Stressful); 3 (Very Stressful). Please be sure to respond to each item.

  26. Assessing ADHD Related Stress:Sample items from the DBSI • Complaints from teachers about your child’s behavior. • Problems paying for services your child needs. • Complaints from other parents regarding child’s behavior. • Not being able to go out to eat because of child’s behavior. • Disagreement with spouse about managing child’s behavior. • Having your child embarrass you in front of others. • Not having enough time for yourself due to child’s behavior. • Having to miss work because of your child’s behavior • Not being able to work outside of home due to child’s behavior. • Having to miss or leave church because of child’s behavior. When scored, the DBSI yields a Stress Experience score (number of stressors experienced) and a Stress Degree score (sum of the ratings for each reported stressor).

  27. Assessing ADHD Related Stress:Development of the DBSI • Preliminary validity and reliability data for the DBSI (were obtained from two groups of parents; a group of 55 parents of children, age 4 - 15, with a primary diagnosis of ADHD and a comparison group of 38 parents of similarly aged children without ADHD or other diagnosed disorder. • Twenty-two parents of children with ADHD completed the measure a second time (1-2 week interval) to provide test-retest reliability data. Here, findings suggested both good internal consistency (alphas .93 & .96) and adequate test-retest reliability (r = .76 & .65). • Group comparisons suggested that both DBSI stress measures differentiated between groups, with stress measures provided by parents of children with ADHD being significantly higher.

  28. Assessing ADHD Related Stress:Development of the DBSI • Further, stress measures of parents of children with Combined type ADHD were found to be significantly higher than those of parents of children with ADHD Predominately Inattentive type. • Stress measures of the Predominately Inattentative type did not differ from the non-ADHD comparison group. • The initial results were viewed as providing preliminary support for the adequacy of the DBSI in assessing stressors experienced by parents of children with ADHD.

  29. Assessing ADHD Related Stress:Additional Findings with the DBSI • In a recently completed study, Reader, McAlister, and Johnson (2005) have replicated the initial DBSI study with a sample of 126 children with and 119 children without ADHD. • As in the initial study, both the DBSI Stress Experience and Stress Degree scores differentiated the two groups. • In both cases, significantly higher scores were found in the ADHD sample. • When ratings on the DBSI “Stress Degree” scale were considered, each of the 40 DBSI items individually differentiated parents of children with and without ADHD.

  30. Frequencies of Specific ADHD Family Stressors • Since items included in the DBSI were derived from reports of family stressors, experienced by parents of children with ADHD, it was of interest to look at the frequency with which specific stressors were reported by parents of children with and without ADHD. • This data is provided in following slides.

  31. Frequencies of Specific ADHD Family Stressors • (N = 126) • Age Range (Patient): 4 – 15; Mean Age = 8.86 • Age Range (respondent): 24 – 72; Mean Age = 36.79 • 76.4% Male; 23.6% Female • Medication: 73.2% Yes; 25.2% No • Ethnicity: Caucasian 35.4 %; African American 11.8%; Latino-American 4.7%; Mixed/Other 3.1% • Family Income Range: $5,772 - $170,000; Mean Income = $38,699 • ADHD Subtype: Combined 35.4%; Hyperactive-Impulsive 6.3%; Inattentive 8.6%; Unknown 48.8%

  32. Frequencies of Specific ADHD Family Stressors • Item # % Reporting • Conflicts with your child over homework 81.1 • Dealing with teachers’ complaints about your child. 80.3 • Dealing with your child’s academic difficulties. 78.0 • Having to explain your child's behavior to others. 78.0 • Spending an excessive helping child with homework 74.0 • Not knowing how to deal with your child’s behavior 74.0 • Having to watch child so he/she doesn’t get into trouble 68.5 • Having your child embarrass you in front of others 67.7 • Being concerned about your child being injured 63.0 • Being interrupted when taking care of other children. 62.2 • Not able to take your child shopping because of behavior 60.6 • Disagreements with spouse about child’s behavior 59.8 • Calls from school regarding your child's behavior 59.1 • Dealing with your child’s conflicts with other children 59.1 • Other people telling you how to parent your child 58.3

  33. Frequencies of Specific ADHD Family Stressors • Item # % Reporting • Not having enough time for self due to child’s behavior 57.5 • Calls from school regarding child's academic problems 57.5 • Not getting work done at home due to child’s behavior 53.5 • Difficulties getting school-based services for your child 48.7 • Not knowing how to explain child’s behavior to others 46.5 • Not being able to go out to eat because of child’s behavior 46.5 • Difficulties finding professional services for your child 44.1 • Not getting support from others for child’s problems 42.5 • Not able to spend enough time with your other children 40.9 • Having less time with partner because of child’s behavior 40.9 • Not being able to leave your child with a baby sitter 40.2 • Not able to get to bed at decent hour due to behavior 39.4 • Having to miss work because of your child’s problems 38.6 • Problems paying for services your child needs 38.6 • Problems related to medication side effects38.6

  34. Frequencies of Specific ADHD Family Stressors • Item # % Reporting • Being unable to take your child to public places 37.8 • Difficulties getting your child to appointments 35.4 • Dealing with complaints from other parents about child 34.6 • Having to miss important social events due to 29.1 • Having to miss/leave church because of child’s behavior 25.2 • Getting complaints from school bus driver 24.4 • Difficulties finding adequate after school placement 22.8 • Difficulties dealing with your child’s doctors 20.5 • Dealing with complaints from neighbors about behavior 18.1 • Not able to work outside home due to child’s behavior 17.3

  35. Frequencies of Specific ADHD Family Stressors • As can be seen, very high frequencies of many specific stressors are found in this group of children with ADHD. • Indeed, 18 of the 40 DBSI items were reported as experienced by at least 50% of the sample.

  36. Frequency of Specific Family Stressors in Non-ADHD Families • The ADHD frequency data just presented can be contrasted with the frequency of experiencing these same family stressors by parents of children without ADHD (N = 119). • These data are presented in the following slides.

  37. Frequencies of Specific Family Stressors in Non-ADHD Families • Item # % Reporting • Conflicts with your child over homework 46.8 • Being interrupted when taking care of other children. 46.8 • Disagreements with spouse about child’s behavior 46.8 • Not knowing how to deal with your child’s behavior 43.5 • Dealing with teachers’ complaints about your child 39.5 • Other people telling you how to parent your child 37.9 • Dealing with your child’s conflicts with other children 37.1 • Being concerned about your child being injured 34.7 • Having your child embarrass you in front of others 33.9 • Dealing with your child’s academic difficulties. 31.5 • Spending excessive time helping with homework 29.8 • Having to explain your child's behavior to others 25.8 • Not being able to take your child shopping 24.2 • Not being able to leave your child with a baby sitter 23.4 • Calls from school regarding your child's behavior 21.8

  38. Frequencies of Specific Family Stressors in Non-ADHD Families • Item # % Reporting • Not able to spend enough time with your other children 21.0 • Not having enough time for self because of behavior 20.2 • Having less time with partner because of child’s behavior 20.2 • Having to watch your child so doesn’t get into trouble 19.4 • Not being able to go out to eat because of behavior 18.5 • Not able to get to bed at decent hour because of behavior 18.5 • Not getting work done at home because of behavior 16.9 • Calls from school regarding child's academic problems 13.7 • Having to miss work because of your child’s problems 12.9 • Problems paying for services your child needs 12.1 • Having to miss or leave church because of your behavior 12.1 • Difficulties finding adequate after school placement 9.7 • Not knowing how to explain child’s behavior to others 8.9 • Difficulties getting your child to appointments 8.9 • Difficulties finding professional services for your child 8.9

  39. Frequencies of Specific Family Stressors in Non-ADHD Families • Item # % Reporting • Not getting support from others with child’s problems 8.9 • Being unable to take your child to public places 8.1 • Difficulties dealing with your child’s doctors 6.5 • Getting complaints from school bus driver 5.6 • Difficulties getting school-based services for your child 4.8 • Dealing with complaints from other parents about child 4.8 • Problems related to medication side effects 4.0 • Having to miss social events due to your child’s behavior 4.0 • Dealing with complaints from neighbors about behavior 3.2 • Not able to work outside home because of child’s behavior .8

  40. Frequencies of Specific Family Stressors in ADHD and Non-ADHD Families • Note that fairly high frequencies of behavior-related stressors are also found in families of children without ADHD • Also note that, when the frequency of stressors experienced by parents of children with and without ADHD were compared, significant differences in frequencies between the ADHD and Non-ADHD group were found on all items.

  41. Family Correlates of ADHD-Related Stress: Some Preliminary Findings • Given preliminary findings from two studies supporting the validity of the DBSI as a measure of ADHD-related stress, we have begun to focus our efforts on collecting data to study the relationship between DBSI scores and measures of family functioning. • To date, we have obtained preliminary data on a small sample of children with Combined type ADHD and have begun to look at the associations between DBSI stress indices and • 1) ADHD symptom severity measures, • 2) PSI Parent Domain Measures, and • 3) Indices of marital satisfaction

  42. Family Correlates of ADHD-Related Stress: Some Preliminary Findings Participants in this study (N = 31, thus far) were recruited through the UF interdisciplinary ADHD Program via mail or phone contact. Participants consisted of parents of children seen for psychological evaluation and/or treatment through the ADHD program and who had received a DSM-IV diagnosis of ADHD (combined type) as a result of a comprehensive psychological evaluation.

  43. Family Correlates of ADHD-Related Stress: Some Preliminary Findings • N = 31; 2 fathers, 27 mothers, 1 Grandmother, 1 Other Guardian) • Medication: 87% on medication for ADHD • Ethnicity: 77.4% Caucasian, 16.1% African American, 6.5% Latino American • Caregiver Age:M = 38.19, SD = 9.86 • Child Gender: 55% males, 45% females • Child Age:M = 8.48, SD = 2.47

  44. Correlations between Measures of ADHD Symptom Severity and DBSI Stress Scores CPRS-R:L Subscale Stress Experience Stress Degree ADHD Index .383* .505** DSM-IV Inattentive .381* .531** DSM-IV Hyperactive/ Impulsive .450* .588** *p<.05, **p<.01 Note. Here it was predicted that there would be a positive and significant relationship between level of ADHD symptom severity and level of stress.

  45. Relationships between DBSI Stress and Indices of Parent and Marital Functioning PSI SubscaleStress Experience Stress Degree Scale CHILD MEASURES Adaptability .501** .581** Demandingness .470** .679*** --------------------------------------------------------------------------------- PARENT MEASURES Social Isolation .338 .396* Role Restriction .353 .437* Relation/Spouse .429* .503** --------------------------------------------------------------------------------- *p<.05, **p<.01, ***p<.001 The DBSI Stress Degree Scale also significantly correlated with the Dyadic Consensus (r=-4.1, p<.05) and Affectional Expression (r=-5.05, p<.05) Subscales from the DAS.

  46. Dimensions of ADHD Related Stress: Factor Structure of the DBSI Although we have found reasonable preliminary support for the validity and reliability of the DBSI, these studies did not attempt to determine the factor structure of this measure. This issue was of interest as the DBSI includes a range of items, that presumably reflect different types of stressors, experienced by families of children with ADHD. Given this interest, we undertook a study designed to define a factor structure representing meaningful dimensions of ADHD family stress in a child and adolescent population.

  47. Dimensions of ADHD Related Stress: Factor Structure of the DBSI Participants were parents of 246 children aged 4 to 15 years-old. Of these, 127 were parents of children with ADHD. Children in this group had all received a DSM-IV diagnosis of ADHD based on a thorough psychological evaluation. The sample also included parents of 119 children drawn from the general population. Children in the non-ADHD group did not have a diagnosis of ADHD or other psychological disorder, based on parent report.

  48. Dimensions of ADHD Related Stress: Factor Structure of the DBSI • Demographic Characteristics of both groups of parents are presented below: • ADHDNon-ADHD • N = 127 (115 mothers, 12 fathers) N = 119 (104 mothers, 15 fathers) • Child Age: M = 8.77, SD = 2.69 Child Age: M= 8.17, SD= 2.57 • Child Gender: 76% males, 24% female Child Gender: 50% male, 50% female

  49. Dimensions of ADHD Related Stress: Factor Structure of the DBSI Analyses involved principal axis factoring with Promax (oblique) rotation. An oblique rotation was selected, as it was believed that factors would be reasonably correlated as they all tap the related dimension of ADHD family stress. Data provided by participants on the DBSI Stress Experience scale was not considered in these analyses as this data involves dichotomous reports of whether specific stressors have or have not occurred. Present findings are based on analyses derived from the DBSI Stress Degree scale, which provides parental ratings (on a four-point scale) of the stressfulness of experienced events.

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