Association between emotional and behavioral problems and perceived parenting in attention deficit hyperactivity disorder: An exploratory study.

BACKGROUND: Parent-child relationship difficulties are seen in families of children and adolescents diagnosed with attention deficit hyperactivity disorder (ADHD), and they may contribute to long-term negative outcomes. AIM: Our aim was to examine perceived parenting and its correlation with emotional and behavioral problems in children and adolescents with a diagnosis of ADHD.
MATERIALS AND METHODS: This was a cross-sectional study involving 38 children and adolescents, between 8 and 16 years of age, diagnosed to have ADHD. Parents rated the children and adolescents on the Strengths and Difficulties Questionnaire (SDQ), whereas children/adolescents rated parents on the Alabama Parenting Questionnaire (APQ).
RESULTS: The study population primarily consisted of males (86.8%), between 8 and 12 years (68%), and belonged to urban families (82%). Warm, attentive, and engaged parenting behaviors which were subsumed under the domain of parental involvement in the APQ were associated with fewer total problem behaviors as well as specifically lower conduct and peer problems on the SDQ. Similarly, parents who used positive disciplining strategies as per the APQ had fewer total behavioral problems as well as specifically lower emotional problems on the SDQ. Children with comorbid oppositional defiant disorder reported lesser mean scores in all domains of parenting and significantly in the domains of parental involvement and positive parenting as per the APQ.
CONCLUSIONS: Parental involvement and positive parenting were significantly associated with fewer emotional and behavioral problems in children and adolescents diagnosed with ADHD. This has direct implications for clinical practice. Further studies are needed to adapt parenting strategies to the Indian context. Copyright:

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder with both genetic and environmental underpinnings as well as with considerable functional impairment.[12] Emotional and behavioral problems, especially those pertaining to deficits in rule-governed and social behavior, are often seen in children with ADHD.[3456] Especially in clinically referred children who are diagnosed with ADHD, neurodevelopmental and psychiatric comorbidities are quite common and may occur throughout their lifespan.[78910] Often times, the emotional and behavioral problems associated with ADHD are the context of the referral.[3] With respect to treatment of this condition, clinical practice guidelines include parent management training as an essential component of the combined treatment approach to manage ADHD.[1112]

In order for parent management training to be effective, understanding parenting behaviors is important. Given the high degree of heritability of ADHD in families, as well as the presence of other psychopathology in parents of children with ADHD, parenting behaviors are influenced by a number of factors including genetic and are fairly complex.[131415] On the other hand, parenting when understood from a psychosocial and cultural perspective is quite multifaceted and its influence on psychopathology is in no means deterministic.[161718] However, in India, largely when parenting styles are specifically studied, most point to an authoritarian style of parenting with demanding behavior, use of harsh punishment, and overall less acceptance.[18]

Parent–child relationship difficulties have been reported widely in children and adolescents diagnosed with ADHD.[1920] In general, mothers of children with ADHD are seen to be more directive and negative and less socially interactive and children are seen to be less compliant and more negative.[31521] In an effort to control their children's problem behaviors, parents may develop counterproductive strategies which may exacerbate or maintain emotional and behavioral problems.[22] Thus, effectively modifying poor parenting practices and behaviors are of paramount importance as poor parenting is one of the more robust predictors of negative long-term outcomes in children with behavior problems.[23]

Parenting behaviors are contemporaneous and culture specific; therefore, the need for ongoing research into into present-day parenting practices given its direct clinical applicability. Given that co-occurring emotional and behavioral problems and disorders are common in ADHD, this study was an attempt to examine the role of perceived parenting and its association with emotional and behavioral problems in an at-risk population, namely children diagnosed with ADHD.

MATERIALS AND METHODS

Design and setting

This was a cross-sectional study conducted between April 2018 and March 2019 at the Department of Child and Adolescent Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India. These preliminary findings are part of a larger study whose primary aim was to evaluate the social and adaptive functioning in children and adolescents diagnosed with ADHD.

Sample

The sample comprised children and adolescents who attended the outpatient and inpatient services of the Department of Child and Adolescent Psychiatry, NIMHANS, who were diagnosed to have ADHD, as per the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition criteria, by a consultant child and adolescent psychiatrist. The parents in our sample had not gone through any formal parent behavioral management training and the children were treatment naïve. Subjects were excluded if they had coexisting progressive neurological disorder or any sensory impairment, if they had comorbid intellectual developmental disorder or autism spectrum disorder, and/or if they were diagnosed to have a current episode of bipolar affective disorder, major depressive disorder, or childhood-onset schizophrenia.

Materials

Attention Deficit Hyperactivity Disorder Rating Scale-IV

It is a clinician-rated 18-item checklist rated on a four-point Likert scale. It has two subscales – the inattentive and the hyperactive/impulsive subscales. The total score is a sum of all the item ratings. It can be administered to 5–18-year-old individuals. It has good internal consistency and test–retest reliability. Higher scores indicate greater severity of ADHD symptoms. The ADHD-Rating Scale-IV (ADHD-RS-IV) has high utility in clinical situations as it is quick, is easy to administer and score, and is sensitive to treatment. In this study, it was used to assess the severity of ADHD symptoms.[2425]

Strengths and Difficulties Questionnaire

The parental report form of the Strengths and Difficulties Questionnaire (SDQ) was used to assess the emotional and behavioral problems in children and adolescents diagnosed to have ADHD in the study. The four domains evaluated on the SDQ for the purpose of this study included emotional, conduct, hyperactivity, and peer problems which added up to a total problem score.[26] Higher scores indicate greater severity of problem behavior of children and adolescents. This questionnaire was used recently in a large developmental cohort study from India,[27] which reaffirms its applicability in the Indian sociocultural setting. In the present study, SDQ was completed in 38 participants

Alabama Parenting Questionnaire

This scale was developed in 1991, and was intended for use in parents who had children in the age range 6–18 years. The Alabama Parenting Questionnaire (APQ) measures five dimensions of parenting that are relevant to the etiology and treatment of child externalizing problems: (1) positive involvement with children, (2) supervision and monitoring, (3) use of positive discipline techniques, (4) consistency in the use of such discipline, and (5) use of corporal punishment. The APQ has been adapted and validated in a number of languages and cultures and has good psychometric properties.[28293031] In this study, the APQ was used as a measure to understand the parenting dimensions which may be relevant to the co-occurring behavior problems seen in children who already have a diagnosis of ADHD. The children rated the parents on the APQ. This was done in order to prevent or minimize an overestimation of parenting competence, especially positive parenting by parents, when they rated their own parenting behaviors.[32] This scale was also used in a large developmental cohort study from India.[27] In the present study, APQ was completed in 38 subjects.

Procedure

The study was approved by the Institutional Ethics Committee. Children and adolescents and their parents were invited to participate in the study after being diagnosed to have ADHD by a consultant child and adolescent psychiatrist and were recruited after obtaining written informed consent from the parents and assent from the child or adolescent. Sociodemographic and clinical details were obtained by the 2nd author. The following scales were applied by the 2nd author to all the participants of the study – ADHD-RS-IV, SDQ, and the APQ. Children rated their parents on the APQ, and the parents gave information necessary for the other scales mentioned.

Statistical analysis was carried out by the Statistical Package for the Social Sciences version 25. Shapiro–Wilk test was used to test the normality of study variables, and it was observed that SDQ scores were not normally distributed; hence, a correlation between SDQ and APQ was assessed using Spearman's correlation test. Independent sample groups were compared using the Mann–Whitney tests due to the smaller number of subjects in each group. All tests, wherever relevant, were two-tailed. The level of significance was fixed at 0.05.

RESULTS

Thirty-eight children and adolescents, between the ages of 8 and 16 years, were included in the study. They were all diagnosed to have ADHD. The sample characteristics are presented in Table 1.

Table 1

Sociodemographic and clinical variables

Variable	n (%)
Gender
Male	33 (86.8)
Female	5 (13.2)
Age range (years)
8-12	26 (68.4)
13-16	12 (31.6)
Urban/rural
Urban	31 (81.6)
Rural	7 (18.4)
Comorbid diagnoses (multiple comorbidities may be present in a single child)*
ODD	20 (52.6)
SLD	19 (50)
Others (dissociative disorder and obsessive compulsive disorder)	2 (5.3)
None	6 (15.8)

ODD – Oppositional defiant disorder; SLD – Specific learning disability

ADHD-RS-IV was used to rate the severity of ADHD, and total scores were taken as the measure to correlate with other variables of interest. The mean scores on ADHD-RS-IV were 33.42 (standard deviation [SD]: 8.05) for the entire sample. 82.5% of the sample had either a neurodevelopmental comorbidity such as specific learning disorder or psychiatric comorbidity such as oppositional defiant disorder (ODD). Other less common comorbidities were dissociative disorder (1) and obsessive–compulsive disorder (1).

As evident in Table 2, parental involvement was significantly negatively correlated with the total problem scores on SDQ as well as individual scores with respect to peer and conduct problems. Positive parenting significantly correlated with both the total problem scores on SDQ as well as the individual scores on emotional problems. The other domains of poor supervision, inconsistent disciplining as well as corporal punishment did not correlate significantly with the problem scores on the SDQ.

Table 2

Correlation of parent-reported Strengths and Difficulties Questionnaire scores and child-reported Alabama Parenting Questionnaire scores

Strengths and Difficulties Questionnaire domains	Alabama Parenting Questionnaire domains, Spearman correlation coefficient (P)
	Involvement (mother)	Involvement (father)	Involvement- avg	Positive parenting	Poor supervision	Inconsistent discipline	Corporal punishment
Emotional problems
ρ	−0.231	−0.026	−0.206	−0.393*	0.026	0.170	0.226
P	0.163	0.878	0.214	0.015	0.875	0.309	0.172
Conduct
ρ	−0.371*	−0.471*	−0.504*	−0.286	0.875	0.309	0.172
P	0.022	0.004	0.001	0.081	0.165	0.029	0.185
Hyperactivity
ρ	−0.184	−0.188	−0.199	−0.274	0.220	0.080	0.158
P	0.268	0.230	0.230	0.096	0.084	0.633	0.345
Peer problems
ρ	−0.345*	−0.220	−0.345*	−0.219	−0.113	−0.114	0.034
P	0.034	0.198	0.034	0.186	0.501	0.496	0.839
Total problem score
ρ	−0.420*	−0.394*	−0.489*	−0.459*	0.147	0.083	0.256
P	0.009	0.018	0.002	0.004	0.379	0.620	0.120

Avg – Average between the mother’s and father’s score per child with respect to involvement

Subgroup analysis of children with attention deficit hyperactivity disorder and oppositional defiant disorder

ODD was present in 52.6% in our sample population. The mean score of ADHD RS IV in subjects with comorbid ODD was higher (mean: SD = 36.05: 8.45) compared to those without (mean: SD = 30.50: 6.95), and this was statistically significant (P < 0.05). It was observed that children and adolescents with comorbid ODD scored significantly higher in overall problem score than others (P < 0.05). They tend to have more social difficulties, for example, in peer relations and friendships, and they also display more aggression, hostility, and rule breaking behaviors. This group also reported lesser mean scores in all domains of parenting; especially in the domains of parental involvement and positive parenting (P < 0.05).

DISCUSSION

In this study, our aim was to examine the association of perceived parenting by children with their presenting emotional and behavioral problems, given the understanding that they are already an at-risk population due to the diagnosis of ADHD. One of the most significant findings as reported by the children and adolescents was in the domains of parental involvement and positive parenting. Attentive, engaged, and interested parenting behaviors were included under the domain of parental involvement, and an acknowledgment by the parents of positive child behavior was subsumed under the domain of positive discipline. The above two positive parenting domains were seen to have had a significant influence on the total problem domain scores as well as conduct, peer, and emotional problems ascertained by SDQ in the sample. Poor parental involvement and decreased positive parenting were especially robust in those children who had comorbid ODD and behavioral problems. These findings have been reported in a number of studies done in the West, and our study adds to this literature coming from a different context, thereby attesting to the universality of certain parenting domains.[1521] Positive parenting domains are the cornerstone of parenting programs and thus have been recommended in the treatment of ADHD as well.[33]

However, other aspects of parenting including poor supervision, inconsistent disciplining, and corporal punishment which are very important domains of parenting, especially in the Indian context, were not statistically significant in our sample.[34] There may be a number of reasons for this finding including the changing milieu in urban India where corporal punishment is not used any longer as a predominant pattern of punishment.[1718] Other reasons may also be due to a response bias in children who may have given socially desirable answers or may have been worried about their parents' response if they suggested that their parents' disciplining patterns were not ideal. The design of the study was to minimize an overestimation of parental competence and a social desirability bias on the part of the parents, but this may have also contributed to a degree of self-censorship in the child responses.

A big strength of the study was that it assessed the perception of parenting from the child's perspective which is not usually done. It also examined parenting and problem behaviors, both emotional and behavioral, specifically in population that already had a primary disorder, namely ADHD, and was therefore an at-risk population. The limitations of the study include lack of a control group as only children and adolescents with ADHD were included in the study. The child's temperament was not assessed. Parental psychopathology including ADHD, mood disorders, and substance use disorders was not assessed independently. In addition, this being a cross-sectional study, there are limitations to the extent to which these findings can be generalized to assume a degree of causation in any direction. However, despite the above limitations, these findings have implications for everyday clinical practice. Enhancing parental involvement and positive parenting can have tremendous impact on children and adolescents who already have ADHD and achieve maximum clinical efficacy, especially by limiting co-occurring emotional and behavioral problems.

CONCLUSIONS

Perceived parenting behaviors such as involvement and positive parenting are seen to be associated with fewer emotional and behavior problems in children and adolescents with a diagnosis of ADHD. This is especially true for children with a comorbid diagnosis of ODD. These findings have important implications for everyday clinical practice. Parenting-related psychological and psychosocial inputs are necessary elements in the comprehensive services that must be offered to children, adolescents, and families, especially to reduce the burden of comorbidities. Further research is needed to adapt parenting strategies to the unique needs of children and families with ADHD in the Indian context, keeping in mind the cultural and social diversity of India.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.