PREDICTING PARENTING STRESS IN FAMILIES OF CHILDREN WITH ADHD by Jennifer Theule A thesis submitted in conformity with the requirements for the degree of Doctor of Philosophy Graduate Department of Human Development and Applied Psychology Ontario Institute for Studies in Education University of Toronto © Copyright by Jennifer Theule 2010 PREDICTING PARENTING STRESS IN FAMILIES OF CHILDREN WITH ADHD Doctor of Philosophy, 2010 Jennifer Theule Graduate Department of Human Development and Applied Psychology University of Toronto Abstract This dissertation consists of two studies that investigated predictors of parenting stress as they relate to child ADHD. Two main questions were explored: what is the magnitude of the association between child ADHD and parenting stress, and what are the parent and contextual predictors of parenting stress? In Study 1, meta-analyses were conducted on the association between parenting stress and ADHD. Predictors comprising child, parent, and contextual factors, and methodological and demographic moderators of the relationship between parenting stress and ADHD were examined. Findings from 44 studies were included.
In Study 2, I examined parent and contextual (parental ADHD symptoms, parental education, social support, and marital status) predictors of parent domain parenting stress (parental distress) as a function of teacher-reported child ADHD symptoms. Results confirmed that parents of children with ADHD experience more parenting stress than parents of nonclinical control children, and that severity of child ADHD symptoms are associated with parenting stress. Child oppositionality was only predictive of parental distress when reported by parents (not teachers). A post-hoc analysis in Study 2 showed that child factors did not predict parental distress over and above parent and contextual factors.
In Study 1, children’s co-occurring conduct problems and parental depressive symptomatology predicted ii parenting stress. Little difference in parenting stress was found between mothers and fathers, but lower parenting stress levels were found in samples with higher proportions of girls. Parental ADHD symptomatology was the strongest predictor of parental distress considered in Study 2. Social support was inversely related to parental distress in Study 2, whereas parental age and education were unrelated to parental distress.
In Study 2, marital status was significantly correlated with parental distress, but was not a significant predictor in the regression. Marital quality was not a significant predictor of parenting stress in Study 1. The large effects observed for parent level predictors suggests that parent factors (i., ADHD and depressive symptoms) are critically important in parenting stress and play a primary role in the experience of elevated parenting stress. Future research should give greater consideration to factors outside of the child in increasing parenting stress.
iii Acknowledgements This dissertation would not have been possible without the gracious support, encouragement, and guidance of so many people. Maria Rogers and Imola Marton thoughtfully and generously allowed me to use their extensive and wonderfully constructed and designed database. This gesture was instrumental in helping me zero in on a topic and complete this work on time. They were also great examples in how to complete this, at times, overwhelming process.
My amazing supervisor, Judy Wiener, was an incredible support. She provided much needed encouragement and direction and was always willing to meet and help me sort out my thoughts. Her flexibility and enthusiasm helped me through the moments when I was discouraged and feeling overwhelmed by what could feel like conflicting responsibilities. The other members of my committee, Rosemary Tannock and Jenny Jenkins, were much needed providers of encouragement, direction, and ideas.
My supervisors (Andrea Spooner, Joy Andres-Lemay, Terry Diamond, and Shari Lecker) at my internship placement, ROCK, always so kindly inquired about my progress, without pressuring me, and provided me with all the time and flexibility I needed to complete this dissertation. My friends and family both in Southern Ontario and in Winnipeg were great cheerleaders, never doubting for a moment that I could do this. Finally, my wonderful husband and children are the reason I kept on trudging through. They listened to me talk about this dissertation ad nauseum and sat inside on many a beautiful weekend while I worked.
Lily gave up her mama time to a pile of papers and Cole lived with his mama’s school work for as long as he can remember. To all of these people I would like to extend my heartfelt thanks. iv Table of Contents Abstract.iv Chapter 1: Introduction. 1 Chapter 2: Parenting Stress in Families of Children with ADHD: A Meta-Analysis.
27 Search and retrieval of studies and eligibility criteria. 27 Study Characteristics and Coding. 35 Co-Occurring Disorders. 36 Parent and Contextual Factors.
38 Strengths and Limitations. 40 Directions for Future Research. 42 Clinical Implications and Conclusions. 43 Chapter 3: Predicting Parenting Stress in Families of Children with ADHD: Consideration of Informants, and The Role of Parental ADHD Symptoms, and Other Parent and Contextual Factors.
48 Parenting Stress and ADHD. 51 Objectives of the Study. 55 Parenting Stress Index—Short Form (PSI/SF). 55 Conners’ Rating Scales—Revised: Long Version (CRS).
56 Conners’ Adult ADHD Rating Scales (CAARS). 56 Family Support Scale. 57 Wechsler Abbreviated Scale of Intelligence (WASI) and Wechsler Intelligence Scale for Children, Fourth Edition (WISC-IV). 61 Limitations and Directions for Future Research.
65 Chapter 4: Conclusions and Implications. 80 vi List of Tables Table 1 Meta-Analyses of Studies Comparing Groups on Parenting Stress. 45 Table 2 Meta-Analyses of Dimensional Parenting Stress Studies. 46 Table 3 Intercorrelations between Parenting Stress, and Major Child, Parent, and Contextual Variables.
67 Table 4 Hierarchical Multiple Regression Predicting Parenting Stress from (Teacher-Reported) Child, Parent, and Contextual Variables. 68 Table 5 Hierarchical Multiple Regression Predicting Parenting Stress from (Parent-Reported) Child, Parent, and Contextual Variables. 69 List of Figures Figure 1. Model of Parent-Child Interactive Stress.
Adapted from Mash & Johnson, 1990. Flow Diagram of Studies Included in Meta-Analysis……………………………….47 List of Appendices Appendix A Coding Manual. 107 Appendix B Coding Form. 120 Appendix C Correlations within Subsamples.
129 vii 1 Chapter 1: Introduction Parenting is one of the most demanding responsibilities of adult life. Parenting stress is the affective response to the, at times, overwhelming, demands of parenting. It is dynamic and results when the balance between parents’ perceptions of the demands of parenting outweigh their perceptions of their resources for meeting those demands (Deater-Deckard, 2004). Current theory holds that parenting stress is a normative part of the parenting role (Crnic & Greenberg, 1990), becoming clinically important when elevated to such an extent that it negatively impacts parenting practices and the parent-child relationship (Abidin, 1992; Belsky, 1984; Morgan, Robinson, & Aldridge, 2002; Rodgers, 1998; Webster-Stratton, 1990).
Parents who experience extreme levels of parenting stress may be less able to implement interventions to help their children (Kazdin, 1995), which is especially relevant for children with a clinical diagnosis such as Attention-Deficit/Hyperactivity Disorder (ADHD). Further, effective interventions for parenting stress have been linked to increases in the efficacy of parent management training (Kazdin & Whitley, 2003), a very commonly used intervention with children with ADHD and other disruptive behaviour disorders. Moreover, studies have shown that parenting stress is inversely related to response to behavioural treatment (e., Kazdin, 1995; Kazdin, Holland, Crowley, & Breton, 1997; Kazdin & Wassell, 1999; Osborne, McHugh, Saunders, & Reed, 2008), may affect parental psychological well-being (Abidin, 1992; Crnic & Greenberg, 1990; Kwok & Wong, 2000; Wolf, Noh, Fisman, & Speechley, 1989), and may affect child development and behaviour (e., Anthony et al., 2005; Crnic, Gaze, & Hoffman, 2005). ADHD is a chronic, pervasive condition characterized by inattention, impulsivity, and hyperactivity (American Psychiatric Association, DSM-IV-TR, 2000).
It is also one of the most 1 2 common childhood disorders, affecting about 5% of school-aged children world-wide (Polanczyk & Jensen, 2008). Recent research indicates that in most cases, ADHD is a lifelong disorder, existing in at least a partial remission form into adulthood (Barkley, Fischer, Smallish, & Fletcher, 2002; Faraone, Biederman, & Mick, 2006). Up to two-thirds of children with ADHD have a parent with a history of ADHD (Mulsow, O’Neal, & McBride Murry, 2001; Schachar & Wachsmuth, 1990) and current research points to strong genetic influences (Levy, Hay, & Bennett, 2006; Willcutt, in press). There is considerable research to indicate that parents of children with ADHD experience elevated rates of parenting stress (e., Breen & Barkley, 1988; Johnson & Reader, 2002; Joyner, Silver, Stavinoha, 2009; Kadesjö, Stenlund, Wels, Gillberg, & Hägglöf, 2002; Reader, Stewart, & Johnson, 2009; van der Oord, Prins, Oosterlaan, & Emmelkamp, 2006; Whalen et al., 2006; Yang, Jong, Hsu, & Tsai, 2007).
The overarching objective of this dissertation was to clarify the predictors of parenting stress in parents of children with ADHD and to investigate the role of parent and contextual predictors. In this dissertation, I explored the following two main questions: what is the magnitude of the association between child ADHD and parenting stress, and what are the parent and contextual predictors of parenting stress as a function of child ADHD symptoms? These questions will be addressed in two studies included in this dissertation, which will be referred to as Study 1 and Study 2. These two studies were written in manuscript format in order to be submitted for publication. Chapter 2 is devoted to Study 1, and Chapter 3 to Study 2.
It is important to note that as a result of the manuscript structure of this dissertation, there is some overlap in the background sections of both studies. Chapter 4 discusses the findings from both studies and considers implications for future research, policy, schools, and clinical practice. 3 Parenting Parenting is influenced by, and influences several parent, child, and contextual factors. Belsky (1984) offers a process model of the determinants of parenting that suggests that parenting is impacted by the parent’s own developmental history, the parent’s personality, marital relations, parental work, the parent’s social network, and the child’s characteristics.
In turn, parenting is proposed to affect child development. Belsky’s model focuses on parenting behaviour, as opposed to internal cognitive or affective aspects of parenting. The determinants of parenting in his model include both external constructs, such as work, and internal constructs, such as personality. In Belsky’s examples he links cognitive constructs (e., mother’s esteem for their husbands) to their behavioural outcomes in parenting (praise for children).
The outcome of Belsky’s model of parenting is child development, mainly defined in terms of child competence. Belsky’s description of child characteristics is less developed than his detailing of parent characteristics, but one major child characteristic he addresses is temperament (Belsky, 1984), suggesting that difficult child temperaments negatively impact parenting. He is careful to note, however, that child characteristics are not sufficient for poor outcomes. In terms of contextual factors, Belsky lists social and spousal support and parental work as determinants of parenting.
Belsky’s definition of parenting subsumes such concepts as parental sensitivity, parental negativity, and parental role performance. These terms differ in their positive/negative valence, but also in the degree to which they refer to internal cognitive or affective constructs, or external behavioural constructs. Parental sensitivity refers both to a parents’ attunement to their children’s needs, and to their contingent, consistent, responses (Belsky, 1984; Farrell Erickson & Kurz- Reimer, 1999). Parental negativity refers to the negative perceptions parents have of their children and to the ensuing negative, hostile behaviours parents engages in (Anderson, Hinshaw, 4 & Simmel, 1994; Johnston & Mash, 2001).
Although the previous two terms combined internal and external manifestations of the constructs, parental role performance refers solely to the external, behavioural manifestation of a parents’ behaviours in their role as parents (McCleary, 2002). Belsky (1984) does not specifically address parenting stress, but his model would seem to subsume parenting stress under general parental psychological well-being. The assumption underlying the current research is that parenting stress is an internal construct that impacts the external (behavioural) outcome of “parenting.” This assumption leads to the question of how parenting stress and parenting are linked. Theories of Parenting Stress Four major theories of parenting stress in families of children with ADHD have been proposed (McCleary, 2002).