Journal of Abnormal Child Psychology

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Journal of Abnormal Child Psychology Parenting Stress of Parents of Adolescents with Attention-Deficit/Hyperactivity Disorder --Manuscript Draft-Manuscript Number:

JACP-D-13-00189

Full Title:

Parenting Stress of Parents of Adolescents with Attention-Deficit/Hyperactivity Disorder

Article Type:

Original Research

Keywords:

Attention-Deficit/Hyperactivity Disorder; parenting stress; adolescence; parental ADHD; externalizing behaviour

Corresponding Author:

Daniella Biondic, M.A. Ontario Institute for Studies in Education, University of Toronto Toronto, Ontario CANADA

Corresponding Author Secondary Information: Corresponding Author's Institution:

Ontario Institute for Studies in Education, University of Toronto

Corresponding Author's Secondary Institution: First Author:

Daniella Biondic, M.A.

First Author Secondary Information: Order of Authors:

Daniella Biondic, M.A. Judith Wiener, Ph.D.

Order of Authors Secondary Information: Abstract:

This study examined parenting stress among parents of adolescents with AttentionDeficit/Hyperactivity Disorder (ADHD). The sample comprised 45 adolescents (26 ADHD; 19 Comparison) age 13 to 18 and their parents. Both mothers and fathers of participating youth completed the Stress Index for Parents of Adolescents. Parents of adolescents with ADHD reported more stress than parents of adolescents without ADHD. Mothers of adolescents with ADHD experience higher levels of stress in all areas. Fathers of adolescents with ADHD experience more total stress and more stress in the Adolescent and Adolescent-Parent Relationship domains. Maternal inattention and adolescent externalizing behaviour mediated the relationship between ADHD status and maternal parenting stress, and ADHD status and adolescent externalizing behaviour were found to predict paternal parenting stress. The results of this study provide strong support for the need to provide parents of adolescents with ADHD with interventions designed to reduce or help them cope with parenting stress.

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Parenting Stress of Parents of Adolescents with Attention-Deficit/Hyperactivity Disorder Daniella Biondic, M.A.1 Ontario Institute for Studies in Education, University of Toronto Judith Wiener, Ph.D. Ontario Institute for Studies in Education, University of Toronto

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Address all correspondence Daniella Biondic, Department of Applied Psychology and Human th Development, Ontario Institute for Studies in Education, University of Toronto, 252 Bloor Street West, 9 Floor, Toronto, Ontario, Canada M5S 1V6; e-mail: [email protected]

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Parenting Stress of Parents of Adolescents with Attention-Deficit/Hyperactivity Disorder Parenthood, viewed by many parents as being their most important role (Thoits, 1992), demands a tremendous amount of time, energy, and economic and emotional resources (Furstenberg, 1999). Most parents therefore experience parenting stress (Crnic & Greenberg, 1990), which is defined as an aversive experience where the demands of parenting are perceived to exceeded the physical, economic, and emotional resources available meet these demands (Deater-Deckard, 2004). Although parenting stress is common, when parents experience high levels of parenting stress, they are often less effective in their role as parents (e.g., Kazdin, 1995). In addition, the effort and daily sacrifices put forth by parents increases when children exhibit problem behaviours (Stice, Ragan, & Randall, 2004). Consequently, parents of children with Attention-Deficit/Hyperactivity Disorder (ADHD) report significantly more parenting stress than parents of children without ADHD (Theule, Wiener, Jenkins, & Tannock, 2010). According to a meta-analysis by Theule et al. (2010), parents of children with ADHD, ages 8 to 12, experience more parenting stress (d =1.80) than parents of children without ADHD. Parenting stress was associated with child ADHD symptoms, conduct problems, internalizing symptoms, and parental depression. In addition, Theule and colleagues (2001) found that parental ADHD symptoms and low social support are predictors of parenting stress. Although there is considerable research on parenting stress among parents of children with ADHD, it is unclear whether these findings can be extrapolated to parents of adolescents with ADHD. To our knowledge, there are no previous published studies investigating whether parents of adolescents with ADHD experience more stress than parents of typically developing adolescents and whether mothers and fathers of adolescents with ADHD report comparable levels of parenting stress. Consequently, the overall aim of this study is to investigate the degree to which parents of

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adolescents with ADHD experience parenting stress and to identify factors that contribute to increased stress. This is an important area of investigation because parents of children with ADHD who experience high levels of parenting stress have poorer psychological well being (Crnic & Greenberg, 1990) and are less able to implement parenting interventions (e.g., Kazdin, 1995). Furthermore, parent management training interventions are more effective when the intervention initially focuses on reducing parenting stress (Kazdin & Whitley, 2003). In accordance with Abidin’s (1976; 1990) model of parenting stress, the impact of child factors (e.g., problem behaviours) and parent factors (e.g., psychopathology) on stress in the child, parent, and child-parent relationship domain will be examined. Adolescent externalizing behaviours and parental ADHD symptoms will be investigated as predictors of parenting stress over and above adolescent ADHD status. Adolescent Externalizing Behaviour Child oppositionality and conduct problems have been linked to increased parenting stress (Theule, Wiener, Jenkins, & Tannock, 2010) among parents of children with ADHD. The experience of parenting an adolescent, however, has been reported to be more challenging than parenting a young child (Pasley & Gecas, 1984). Adolescents with ADHD are more likely to exhibit oppositional behaviours, conduct problems, low academic achievement, substance abuse, risk taking behaviours (Barkley, Fischer, Smallish, & Fletcher, 2004; Wilens et al., 2010) and negative affect (Whalen et al., 2010) than other adolescents. Furthermore, youth with ADHD are more likely to be affiliated with a deviant peer group because their difficulties with behaviour and emotion regulation (Whalen & Henker, 1992) cause them to be rejected by prosocial peers (Hinshaw & Melnick, 1995). This deviant peer group affiliation is a risk factor for substance use and abuse (Marshal, Molina, & Pelham, 2003), rule breaking and delinquent behaviour (Duncan,

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Duncan , & Strycker, 2000; Patterson, Dishion & Yoerger, 2000). Although the link between externalizing behaviour and parenting stress among parents of adolescents with ADHD has yet to be examined, Anderson (2008) found that social skills (i.e., cooperation, responsibility, selfcontrol) and problem behaviours (i.e., fighting, arguing, moodiness) explained most of the variability in parenting stress in a high risk sample of youth between the ages of 10 and 18. Consequently, this link warrants investigation among parents of adolescents with ADHD. Parental ADHD Symptomatology Approximately 30 to 50 percent of children with ADHD continue to show symptoms in adulthood (Murphy & Barkley, 1996), and 40 to 60 percent of parents with ADHD also have a child with ADHD (Biederman et al., 1995; Minde et al., 2003). Given the prevalence of ADHD symptomatology in adulthood and among families of children with ADHD, the impact of parental ADHD symptoms on parenting stress among parents of adolescents with and without ADHD warrants investigation. Parental ADHD symptoms are positively associated with inconsistent discipline and nonsupportive responses to the negative emotions and behaviours of children (Mokrova, O’Brien, Calkins, & Keane, 2010). Parents who have ADHD also tend to be inconsistent in enforcing rules and placing limits on their children, which may be due to difficulties with monitoring and following through with consistent consequences (Murray & Johnston, 2006). Furthermore, mothers with ADHD have been found to be relatively unaware of their children’s activities (Weiss, Hechtman & Weiss, 2000). During the transition into adolescence, parents also tend to spend less time with children because of reduced child care needs and increased child autonomy (Phares, Fields, & Kamboukos, 2009). Thus, as parents and adolescents spend more time apart, more effort and diligence may be required for parents to monitor their children.

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Parents of children with ADHD have also reported having a lower sense of competence and low parenting self-efficacy (Breen & Barkley, 1988; Mash & Johnston, 1983). In addition, parents of adolescents with ADHD have expressed feelings of failure and inadequacy in their parenting role (McCleary & Ridley, 1999). These feelings of low self-efficacy, incompetence, and failure may lead these parents to experience more parenting stress. The division of household responsibilities and efficacy with which childcare duties are met may also interact with parental ADHD symptomatology. Since mothers tend to take on more parenting responsibilities (Phares, Fields & Kamboukos, 2009) and spend more time interacting with their children (Scarr, Philips & McCartney, 1990) even within dual-income families (Blanchi & Raley, 2005), the quality of their parenting may be more likely to be impacted by their ADHD symptoms. Fathers with ADHD, however, may be less burdened by childcare demands and with fewer parenting responsibilities, may be less distressed by problem behaviours. Thus, parental ADHD symtomatology may differentially impact maternal and paternal stress levels. Study Objectives This research is guided by two objectives: Objective 1 is to determine whether parents of adolescents with ADHD experience more stress than parents of typically developing adolescents. We will examine whether parents of adolescents with and without ADHD differ in their total parenting stress and specific domains of parenting stress including stress in relation to adolescent characteristics, the impact of parenting on other life roles, and the quality of the adolescentparent relationship. Similar to findings with children with ADHD (Theule, Wiener, Jenkins, & Tannock, 2010), it is expected that parents of adolescents with ADHD will report experiencing more parenting stress than parents of comparison adolescents.

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Objective 2 is to identify whether specific factors associated with parenting stress of parents of children with ADHD are associated with higher levels of parenting stress in parents of adolescents. Abidin’s (1976; 1990) model of parenting stress will be the framework used to identify these predictors. Abidin suggests that child characteristics, parent characteristics, and situational factors are predictive of parenting stress. In this study, we will examine whether parental ADHD symptoms and the severity of adolescent inattentive and hyperactive symptoms, oppositional behaviour and conduct problems are predictors of parenting stress. It is expected that adolescent ADHD symptom severity will continue be associated with increased parenting stress (Theule, Wiener, Rogers, & Marton, 2011). Given that the manifestation of ADHD in adolescents differs somewhat from younger children and because adolescents with ADHD are more likely to exhibit behaviours that elicit parenting stress (i.e., oppositional behaviours, conduct problems, and risk-taking behaviours; Barkley, Fischer, Smallish, & Fletcher, 2004), it is possible that oppositional and aggressive behaviours will be strong predictors of parenting stress among parents of adolescents. Finally, given that parental ADHD symptoms are positively associated with ineffective parenting (i.e., inconsistent discipline, non-supportive responses to behaviours of children; Mokrova, O’Brien, Calkins, & Keane, 2010) and parents of children with ADHD report low parenting self-efficacy and a low sense of competence (Breen & Barkley, 1988; Mash & Johnston, 1983), it is hypothesized that parents of adolescents with ADHD who have high levels of ADHD symptoms themselves will experience more parenting stress. METHOD Participants The sample comprised 45 13 to 18-year old adolescents (26 with ADHD, 19 without ADHD) and their parents. Participants with ADHD were recruited through flyers sent to

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physicians and children’s mental health centres. Adolescents in the comparison sample were recruited through advertisements placed in the community. All adolescent participants had average intellectual ability (IQ ≥ 85). Participants with ADHD received a diagnosis of ADHD at least one year prior to participating in the study. The presence of ongoing ADHD symptoms was confirmed using a standardized diagnostic questionnaire that is in accordance with DSM-IV criteria (Conners-3; Conners, 2008). Participants were classified as having ADHD when at least one rater (i.e., parent or teacher) reported that the adolescents’ inattentive or hyperactiveimpulsive symptoms were within the clinical range (T ≥ 70) and the second rater (i.e., parent or teacher) indicated that inattentive or hyperactive-impulsive symptoms were within the borderline or clinical range (T ≥ 65). Adolescents with certain comorbid diagnoses were excluded (i.e., Rett’s Disorder, Autism Spectrum Disorders, Intellectual Disabilities, Psychotic Disorders, Genetic Disorders, Bipolar Disorder, Tourette’s Disorder). However, due to high comorbity rates, adolescents with ADHD who also had co-occurring learning disabilities, conduct disorder, oppositional defiant disorder, anxiety, or depression were included. Adolescents with and without ADHD did not differ in age (Table 1) or gender (ADHD: 16 boys, 10 girls; comparison: 9 boys, 11 girls; χ² (1, N = 46) = 1.25, p = .264). Parents reported that 69.2% (n = 18) of adolescents with ADHD were taking medication to manage their ADHD symptoms. Sixty-eight percent (n = 17) of adolescents with ADHD had one or more comorbid diagnoses (i.e., learning disability (n = 15), anxiety (n = 4), depression (n = 1), oppositional defiant disorder (n = 2)). Three adolescents without ADHD had a diagnosis of a learning disability. As shown in Table 1, adolescents with ADHD had a lower IQ, as measured by the Wechsler Abbreviated Scale of Intelligence (WASI; Wechsler, 1999), and higher scores on the Conners-3 rating scales (Conners, 2008).

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A total of 42 mothers and 34 fathers participated in the study. Of the 45 adolescent participants, 68.9% (n = 31) had parenting stress and parental ADHD symptom ratings provided from both parents, 24% (n = 11) had only mother ratings, and 6.7% (n = 3) had only father ratings. One parent was recently widowed and others were single, separated, or divorced and were unable to obtain consent for participation from their former partner or spouse. Father data were missing for 6 adolescents with ADHD and 5 comparison adolescents. Mother data were missing for 1 adolescent with ADHD and 2 comparison adolescents. As shown in Table 1, parents of adolescents with and without ADHD did not differ in age. Fathers of adolescents with and without ADHD did not differ in their highest education level attained; however, comparison mothers had a higher level of education than mothers of adolescents with ADHD. The majority of parents were married or in common-law relationships (60% (n = 15) ADHD, 75% (n = 14) comparison) and a similar proportion of parents of adolescents with and without ADHD were single, separated or divorced (40% (n = 10) ADHD, 21.1% (n = 4) comparison). These differences in marital status between groups were not significant (2 (2, N = 44) = 1.44, p = .49). In this sample, 9.4% (n = 4) of families reported speaking a language other than English at home (i.e., Chinese, Persian, or Spanish). Both mothers (2 (1, N = 45) = 4.46, p = .035) and fathers (2 (1, N = 45) = 16.44, p = .000) of adolescents with ADHD were more likely to be diagnosed with or suspect they have ADHD (Mothers: 30.8%, n = 8; Fathers: 57.7%; n = 15) than parents of adolescents without ADHD (Mothers: 5.3%, n = 1; Fathers 0%, n = 0). Parents of adolescents with ADHD reported higher levels of ADHD symptoms than parents of adolescents without ADHD (Table 1).

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Measures Parenting Stress: The Stress Index for Parents of Adolescents (SIPA; Sheras, Abidin, & Konold, 1998) assesses parenting stress across three domains: Adolescent, Parent, and the Adolescent-Parent Relationship. The Adolescent domain measures parenting stress as a function of the characteristics of the adolescent (e.g., mood, delinquency, motivation). Stress in the Parent domain is a measure of the effect of parenting on other life roles. The Adolescent-Parent Relationship domain measures the perceived quality of the relationship parents have with their children (e.g., degree of communication, amount of affection). In addition, there are several subscales within the adolescent (i.e., moodiness/emotional lability, social isolation/withdrawal, delinquency/antisocial, failure to achieve or persevere) and parent domains (i.e., life restrictions, relationship with spouse/partner, social alienation, incompetence/guilt). The SIPA has strong internal consistency (Cronbach alpha for Toal Stress and the 3 domains > .90 and for the subscales range from .80 - .90) and test-retest reliability (coefficients range from .74 - .93). Parental ADHD Symptomatology: The Conners Adult ADHD Self-Report Rating ScaleShort Version (CAARS-S:SV; Conners, Erhardt, Sparrow, 1999) was used to screen parents for the core symptoms of ADHD, including symptoms of all three DSM-IV subtypes of ADHD. The CAARS-S:SV is a 30-item measure that contains subscales that are most directly relevant to ADHD diagnosis: DSM-IV inattentive symptoms, DSM-IV hyperactive-impulsive symptoms, DSM-IV Total ADHD symptoms, and ADHD index. Each symptom of hyperactivity and inattention is rated on a 4-point scale, ranging from 0 (Not at all true/Never) to 3 (Very Much/Very Frequently). All subscales have been reported to have internal consistency of .80 or higher (Conners et al., 1999). In terms of its validity, the CAARS-S: SV produces an overall

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correct classification rate of 85% for adults with ADHD and strongly correlates with other measures of adult ADHD (Erhardt, Epstein, Conners, Parker, & Sitarenios, 1999). Adolescent ADHD Symptomatology and Externalizing Behaviour: The long forms of the Conners-3 rating scales (Conners, 2008; Parent and Teacher Report forms) were used to confirm the presence of ADHD symptomology. Parents and teachers rated the youth on a 4-point scale ranging from 0 (Not at all/Seldom, Never) to 3 (Very Much True/ Very Often, Very Frequent) to evaluate inattention, hyperactivity, oppositional and aggressive behaviour, conduct problems and problems related to peer relations. These ratings were used as indicators of the severity of the adolescents’ ADHD symptoms across two settings (home and school). The two DSM-IV ADHD subscales that were used to confirm the ADHD diagnosis and to measure the severity of ADHD symptomology (DSM-IV Inattentive, DSM-IV Hyperactive- Impulsive) demonstrate high internal consistency (Parent: .93, .92; Teacher: .94, .95) and adequate to high test-retest reliability (Parent: .84, .89; Teacher: .85, .84). Cognitive Functioning: The Vocabulary and Matrix Reasoning subscales of the Wechsler Abbreviated Scale of Intelligence (WASI; Wechsler, 1999), a standardized abbreviated test of intelligence, was administered to obtain an estimate of adolescents’ cognitive functioning. These tests have strong internal consistency (.93) and test-retest reliability (ranging from .88 to .93). Procedure The Research Ethics Board of the University of Toronto approved this study. Trained graduate students in school and clinical child psychology tested the adolescent participants. Prior to the testing session, parental consent and adolescent consent/assent were obtained and parents (primarily mothers) of adolescents completed the Conners-3 parent rating scale (Conners, 2008). If adolescents met criteria for inclusion in the study, parents were mailed a package containing

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the SIPA and CAARS-S: SV questionnaires and the Conners-3 teacher rating scale. Parents were asked to give the Conners-3 to a teacher whom they felt could best comment on their child’s current level of ADHD symptoms. When rating adolescents who took medication to manage ADHD symptoms, parents and teachers were asked to think of the adolescents’ behaviours when they were unmedicated. Parent characteristics (i.e., age, education) and household characteristics (i.e., marital status, number of siblings) were assessed at intake by asking one parent to complete a demographic questionnaire. RESULTS Data Analysis Two-way analyses of variance with adolescent ADHD status and gender as independent factors, were used to compare parents of adolescents with and without ADHD on Total stress and stress in the Adolescent, Parent, and Adolescent-Parent Relationship domains. Multivariate analyses of variance were used to compare parents of adolescents with and without ADHD on the subscales within the Adolescent and Parent domains. T-tests were used to compare the levels of stress of parents of medicated adolescents with ADHD with parents of unmedicated adolescents with ADHD. All of the above analyses were done for mothers and fathers separately. Two-way ANOVAs were used to compare mothers and fathers of adolescents with and without ADHD in terms of their Total stress and stress in the three domains. Correlates of maternal and paternal parenting stress were examined for the whole sample, the ADHD sample, and the comparison sample (Table 4 and 5). To reduce the number of variables included in the regression analyses, a composite of the externalizing symptoms on the Conners-3 parent rating scale was created by adding the T-scores for parent ratings of aggression, conduct problems and oppositionality. The correlations between these variables ranged from .74 to .86.

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Hierarchical multiple regression analyses were conducted to predict parenting stress by entering ADHD status in step 1 and correlated variables in step 2 (i.e., adolescent externalizing behaviour and maternal inattention). Significant predictors of parenting stress were explored through a mediation analysis using the procedures suggested by Baron and Kenny (1986). In addition, the Sobel (1982) procedure was used to investigate the effect of the proposed mediators on the relationship between ADHD status and parenting stress. Prior to conducting these analyses the data was checked for outliers by examining descriptive statistics and creating boxplots of the variables of interest. There were two outliers on the Adolescent-Parent Relationship domain that were not adjusted because they did not significantly affect the variable range. Adolescents with ADHD had lower full-scale IQ scores than adolescents without ADHD and IQ was negatively correlated with parenting stress in the Adolescent domain for mothers (r = -.36, p = .021) and fathers (r = -.52, p = .002). Analysis of covariance comparing parents of adolescents with and without ADHD in Adolescent domain parenting stress revealed that IQ was not a significant covariate (Mothers: F (1, 38) = .306, p = .583, p2 = .008; Fathers: F (1, 30) = .000, p = .983, p2 = .000), therefore, IQ was not controlled for in any of the analyses reported. Levels of Parenting Stress The first objective of this study was to determine whether mothers and fathers of adolescents with ADHD experience more stress than parents of adolescents without ADHD. As shown in Table 2, mothers of adolescents with ADHD reported significantly more Total stress, more stress in the Adolescent domain, the Parent domain, and the Adolescent-Parent Relationship domain than comparison mothers. They also differed from comparison mothers on the amount of stress they reported on the subscales which compose the Adolescent (F (4, 35) =

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20.56, p = .000, p2 = .70) and Parent domains (F (4, 31) = 2.94, p = .036, p2 = .28). Within the Adolescent domain, mothers of adolescents with ADHD reported more stress associated with the youth’s moodiness/emotional lability, social isolation/withdrawal, delinquency/antisocial behaviour, and achievement/failure to persevere. Within the Parent domain, mothers of adolescents with ADHD reported more stress on all of the subscales. There were no adolescent gender or ADHD status by gender interaction effects for any of the parenting stress domains. Furthermore, there were also no significant differences in Total parenting stress (F (1, 21) = .038, p = .847, p2 = .00) or stress in the Adolescent (F (1, 24) = .019, p = .892, p2 = .00), Parent (F (1, 21) = .193, p = .665, p2 = .01), and Adolescent-Parent Relationship domains (F (1, 23) = 1.92, p = .179, p2 = .08), between parents of medicated (n = 15) and unmedicated (n = 7) adolescents with ADHD. As shown in Table 3, fathers of adolescents with ADHD reported significantly more Total stress and more stress in the Adolescent and the Adolescent-Parent Relationship domains than comparison fathers. No differences were found for the Parent domain. Fathers of adolescents with ADHD differed from comparison fathers on the amount of stress they reported on the subscales which compose the Adolescent domain (F (4, 27) = 7.78, p = .000, p2 = .54); however, they did not differ on the amount of stress reported on the subscales within the Parent domain (F (4, 26) = 1.56, p = .214, p2 = .19). Fathers of adolescents with ADHD reported more stress associated with the youth’s moodiness/emotional lability, delinquency/antisocial behaviour and achievement/failure to persevere but did not report more stress associated with the adolescent’s social isolation/withdrawal. There were no gender differences on ADHD status by gender interaction effects. No significant differences were found in Total (F (1, 18) = .026, p = .873, p2 = .00) parenting stress or stress in the Adolescent (F (1, 18) = .034, p = .855, p2 = .00),

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Parent (F (1, 18) = .030, p = .864, p2 = .00), and Adolescent-Parent Relationship (F (1, 18) = .001, p = .970, p2 = .00) domains between fathers of adolescents currently on (n = 15) or off (n = 5) ADHD medication. Finally, there were no significant parent gender effects (Total: F (1, 67) = 1.49, p = .226, p2 = .02; Adolescent domain: F (1, 72) = .150, p = .699, p2 = .00; Parent domain: F (1, 67) = .436, p = .511, p2 = .01; Adolescent-Parent Relationship domain: F (1, 72) = 2.91, p = .092, p2 = .04) or ADHD by parent gender interaction effects (Total: F (1, 67) = .694, p = .408, p2 = .01; Adolescent domain: F (1, 72) = .896, p = .347, p2 = .01; Parent domain: F (1, 67) = 2.25, p = .139, p2 = .03; Adolescent-Parent Relationship domain: F (1, 72) = .035, p = .852, p2 = .00).

Predictors of Parenting Stress The second objective of the study was to determine whether adolescent externalizing behaviours and parental ADHD symptoms, which are associated with parenting stress of parents of children with ADHD (Theule, Wiener, Jenkins, & Tannock, 2010), are also associated with higher levels of parenting stress in parents of adolescents with the disorder. Results of Pearson product-moment correlations (Table 4 and Table 5) indicate that parent ratings of adolescent ADHD symptoms and externalizing problems and parental ADHD symptoms are positively correlated with maternal and paternal stress. Maternal Stress The results of the regression analysis show that ADHD status, externalizing behaviour, and maternal inattention are significant predictors of Total parenting stress (Table 6). ADHD status alone predicted 32.6% of the variance in Total stress (R2 = .326, F (1, 35) = 16.94, p = .000); however, the addition of the externalizing behaviour composite and maternal inattention

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predicted an additional 21.8% of the variance (R2 change = .218, p = .002). Thus, the entire model (ADHD status, externalizing behaviour composite, maternal inattention) predicted 54.4% of the variance in Total stress (R2 = .544, F (3, 33) = 13.11, p = .000). Figure 1a illustrates that the relationship between ADHD status and Total stress is fully mediated by adolescent externalizing behaviour as the standardized regression coefficient between ADHD status and Total stress decreased significantly when controlling for externalizing behaviour. The Sobel test indicated that externalizing behaviour (z = 2.48, p = .01) was a significant mediator. As Figure 1b illustrates, the standardized regression coefficient between ADHD status and Total stress decreased when controlling for maternal inattention, indicating that relationship between ADHD status and Total stress is partially mediated by maternal inattention. However, the Sobel test indicated that maternal inattention (z = 1.59, p = .11) was not a significant mediator of the influence of ADHD status on Total stress. The other conditions of mediation were met in both analyses: ADHD status was a significant predictor of Total stress, maternal inattention and adolescent externalizing behaviour. When controlling for ADHD status, maternal inattention and adolescent externalizing behaviour were significant predictors of Total stress. ADHD status and externalizing behaviour are significant predictors of maternal Adolescent domain stress. Maternal inattention was not a significant predictor of stress in the Adolescent domain. ADHD status alone predicted 58.3% of the variance in Adolescent domain stress (R2 = .583, F (1, 37) = 51.66, p = .000); however, the addition of the externalizing behaviour composite and maternal inattention predicted an additional 14.2% of the variance (R2 change = .142, p = .001). Thus, the entire model (ADHD status, externalizing behaviour composite, maternal inattention) predicted 72.5% of the variance in Adolescent domain stress (R2 = .725, F (3, 35) = 30.73, p = .000). As Figure 1c illustrates, the standardized regression

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coefficient between ADHD status and Adolescent domain stress decreased when controlling for externalizing behaviour, indicating that the relationship between ADHD status and Adolescent domain stress is partially mediated by externalizing behaviour. The other conditions of mediation were also met: ADHD status was a significant predictor of Adolescent domain stress and of externalizing behaviour, and externalizing behaviour was a significant predictor of Adolescent domain stress while controlling for ADHD status. The Sobel test indicated that externalizing behaviour (z = 2.95, p = .003) was a significant mediator of the influence of ADHD status on Adolescent domain stress. ADHD status and maternal inattention are significant predictors of maternal stress in the Parent domain. Externalizing behaviour was not a significant predictor of stress in the Parent domain. ADHD status alone predicted 19.9% of the variance (R2 = .199, F (1, 35) = 8.68, p = .006); however, the addition of maternal inattention and the externalizing behaviour composite predicted an additional 25.4% of the variance (R2 change = .254, p = .002). Thus, the entire model (ADHD status, maternal inattention, externalizing behaviour composite) predicted 45.2% of the variance in Parent domain stress (R2 = .452, F (3, 33) = 9.09, p = .000). As Figure 1d illustrates, the standardized regression coefficient between ADHD status and Parent domain stress significantly decreased when controlling for maternal inattention, indicating that the relationship between ADHD status and Parent domain stress was fully mediated by maternal inattention. The other conditions of mediation were also met: ADHD status was a significant predictor of Parent domain stress and of maternal inattention, and maternal inattention was a significant predictor of Parent domain stress while controlling for ADHD status. The Sobel test indicated that maternal inattention (z = 1.98, p = .05) was a significant mediator of the influence of ADHD status on Parent domain stress.

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Finally, ADHD status and maternal inattention were found to be significant predictors of maternal stress in the Adolescent-Parent Relationship domain. ADHD status alone predicted 10.8% of the variance (R2 = .108, F (1, 37) = 4.48, p = .041); however, the addition of maternal inattention predicted an additional 10.2% of the variance in Adolescent-Parent Relationship domain stress (R2 change = .102, p = .038). Thus, the entire model (ADHD status, maternal inattention) predicted 21.0% of the variance in Adolescent-Parent Relationship domain stress (R2 = .210, F (2, 36) = 4.77, p = .014). As Figure 1e illustrates, the standardized regression coefficient between ADHD status and Adolescent-Parent Relationship domain stress significantly decreased when controlling for maternal inattention, indicating that relationship between ADHD status and Adolescent-Parent Relationship domain stress is fully mediated by maternal inattention. The other conditions of mediation were also met: ADHD status was a significant predictor of Adolescent-Parent Relationship domain stress and of maternal inattention, and maternal inattention was a significant predictor of Adolescent-Parent Relationship domain stress while controlling for ADHD status. The Sobel test indicated that maternal inattention (z = 1.61, p = .110) was not a significant mediator of the influence of ADHD status on Adolescent-Parent Relationship domain stress. Paternal Stress ADHD status was a significant predictor of Total parenting stress, predicting 30.5% of the variance (R2 = .305, F (1, 31) = 13.58, p = .001). Although the addition of the externalizing behaviour composite predicted an additional 4.2% of the variance in Total stress (R2 change = .042, p = .173), the additional variance explained was not significant. Thus, the entire model (ADHD status) predicted 30.5% of the variance in Total stress (Table 7).

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ADHD status and externalizing behaviour are significant predictors of paternal stress in the Adolescent domain. ADHD status alone predicted 51.5% of the variance in Adolescent domain stress (R2 = .515, F (1, 32) = 34.02, p = .000); however, the addition of the externalizing behaviour composite predicted an additional 9.1% of the variance (R2 change = .091, p = .012). Thus, the entire model (ADHD status, externalizing behaviour composite) predicted 60.6% of the variance in Adolescent domain stress (R2 = .606, F (2, 31) = 23.88, p = .000). As Figure 1f illustrates, the standardized regression coefficient between ADHD status and Adolescent domain stress decreased when controlling for externalizing behaviour, indicating that the relationship between ADHD status and Adolescent domain stress is partially mediated by externalizing behaviour. The other conditions of mediation were also met: ADHD status was a significant predictor of Adolescent domain stress and of maternal inattention, and externalizing behaviour was a significant predictor of Adolescent domain stress while controlling for ADHD status. In addition, the Sobel test indicated that externalizing behaviour (z = 2.42, p = .02) was a significant mediator of the influence of ADHD status on Adolescent domain stress. Finally, results indicate that ADHD status was a significant predictor of parenting stress in the Adolescent-Parent Relationship domain while externalizing behaviour was not. ADHD status alone predicted 11.5% of the variance (R2 = .115, F (1, 32) = 4.18, p = .049). Although the addition of the externalizing behaviour composite predicted an additional 5.9% of the variance in Adolescent-Parent Relationship domain stress (R2 change = .059, p = .146), the additional variance explained was not significant. Thus, the entire model (ADHD status) predicted 11.5% of the variance in Adolescent-Parent Relationship domain stress. DISCUSSION

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Mothers and fathers of adolescents with ADHD experience more parenting stress than parents of adolescents without ADHD. Parenting stress was not associated with adolescent gender or medication status. Mothers of adolescents with ADHD reported higher levels of stress than other parents in terms of life restrictions, alienation from friends, and conflict with their spouse. Adolescent externalizing behaviour (i.e., oppositionality, conduct problems, aggression) mediated the influence of ADHD status on maternal Total stress and stress in the Adolescent domain and maternal inattention mediated the relationship between adolescent ADHD status and maternal stress in the Parent and the Adolescent-Parent Relationship domains. Adolescent externalizing behaviour partially mediated the relationship between adolescent ADHD status and paternal stress in the Adolescent domain. The results of this study indicate that although mothers and fathers of adolescents with ADHD report high levels of parenting stress across all stress domains, they differ in the factors that predict their level of parenting stress. Levels of parenting stress The first objective of this study was to determine whether parents of adolescents with ADHD experience more stress than parents of typically developing adolescents. Consistent with the hypotheses and previous studies with children with ADHD (Theule, Wiener, Jenkins & Tannock, 2010), mothers of adolescents with ADHD experience significantly higher levels of stress in all areas. Fathers of adolescents with ADHD experience more Total stress and more stress in the Adolescent and Adolescent-Parent Relationship domains. Both mothers and fathers of adolescents with ADHD report more stress associated with their child’s moodiness and emotional lability, social isolation and withdrawal, delinquent and antisocial behaviour, and their failure to achieve and persevere. The presence of these stressors is consistent with the findings that adolescents with ADHD report more negative affect (i.e., elevated anger, anxiety, sadness),

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spend more time participating in non-productive activities and less time completing homework or developing new skills (Whalen, Jamner, Delfino, & Lozano, 2002). In addition, parents report higher levels of stress in the Adolescent-Parent Relationship domain which is indicative of less expressed affection and poor communication (Sheras, Abidin, & Konold, 1998). This is consistent with previous research showing that adolescents with ADHD and their parents report higher levels of conflict (e.g. Edwards, Barkley, Laneri, Fletcher & Metevia, 2001). There are several possible reasons for the finding that mothers of adolescents with ADHD experience more stress in the Parent domain than mothers of typically developing adolescents whereas this difference was not evident for fathers. First, mothers typically take responsibility for the majority of childcare duties in the household (e.g., discipline, daily needs, recreational activities; Parke, 2000) and provide more direct involvement throughout infancy and early childhood (Hoffereh et al., 2007). This imbalance in childcare duties continues into adolescence (Hosley & Montemayor, 1997) and is evident within dual-income families (Blanchi & Raley, 2005). Fathers tend to spend time participating in leisure activities with their children and adolescents (Hosley & Montemayor, 1997; Lewis & Lamb, 2003). Thus parenting challenges may impact mothers more strongly than fathers. This was evident in this sample as mothers of adolescents with ADHD reported more life restrictions, feelings of incompetence and guilt, and social alienation due to less time spent with friends and relatives than comparison mothers. These feelings of social alienation may be indicative of low levels of social support which would be consistent with previous findings that families of children with ADHD have lower levels of social support than families of children without ADHD (Lange et al., 2005). Furthermore, high levels of paternal stress are associated with lower parental engagement and less support when co-parenting (Bronte-Tinkew, Horowitz, & Carrano, 2009). These difficulties

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with co-parenting and reduced spousal support were reflected in maternal stress ratings as mothers of adolescents with ADHD reported higher levels of stress in their relationship with their spouse or partner. No differences in parenting stress were found between parents of medicated and unmedicated adolescents with ADHD. Although ADHD medication reduces inattentive and hyperactive/impulsive symptoms (McClellan & Werry, 2003), it is possible that parents mainly interact with their adolescent children when the effects of the medication have worn off at the end of the school day. ADHD symptoms and problem behaviours may increase at this point and continue for the duration of the day. Predictors of parenting stress The second objective of this study was to determine whether adolescent externalizing behaviours and parental ADHD symptoms, which are associated with parenting stress of parents of children with ADHD (Theule, Wiener, Jenkins, & Tannock, 2010), are also associated with higher levels of parenting stress in parents of adolescents with the disorder. Child oppositionality, conduct problems and aggression have been shown in previous literature to be highly predictive of parenting stress among parents of children with ADHD (Theule, Wiener, Jenkins, & Tannock, 2010). The current study has shown that externalizing behaviour continues to be predictive of parenting stress among parents of adolescents with ADHD. Externalizing behaviour in the current study was assessed by a composite of the aggression, conduct problems and oppositionality scales of the Conners-3 (Conners, 2008) parent rating scale. These scales rate behaviours that are likely to be stressful for anyone interacting frequently with the individual displaying them (see Morgan, Robinson, & Aldridge, 2002 for review) including bullying, threatening, physically hurting others, arguing, and actively refusing

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to comply with adult requests. Adolescents displaying these types of behaviours typically have low academic achievement, engage in substance abuse and other risk-taking behaviours (Barkley, Fischer, Smallish, & Fletcher, 2004) and associate with deviant peer groups (Whalen & Henker, 1992). It is important to note that adolescent externalizing behaviours fully mediated the influence of ADHD status on maternal Total and Adolescent domain stress and partially mediated the influence of ADHD status on paternal Adolescent domain stress. This mediation may have occurred because ADHD symptoms and externalizing behaviour are highly correlated (Inattention: r = .70, p = .000; Hyperactivity/Impulsivity: r = .65, p = .000). Furthermore, due to the relative independence of adolescents compared to younger children, parents may not be constantly exposed to their sons’ and daughters’ inattention, hyperactivity and impulsivity. Although oppositional behaviours (e.g., swearing at a teacher), conduct problems (e.g., stealing), and aggression are less frequent than inattention, hyperactivity and impulsivity, they may have a larger impact on parent stress levels. Previous research has reported that parents of children with ADHD with higher levels of ADHD symptoms reported more Parent domain stress (Theule, Wiener, Jenkins, Tannock, 2010). The current study showed that maternal inattention fully mediated the relationship between adolescent ADHD status and stress reported in the Parent and Adolescent-Parent Relationship domains, suggesting that mothers with higher levels of inattention experience more stress. Parental ADHD symptoms are positively associated with inconsistent discipline and nonsupportive responses to the negative emotions and behaviours of children (Mokrova, O’Brien, Calkins, & Keane, 2010). In addition, parents with ADHD tend to be inconsistent in enforcing rules and placing limits on their children and this may be due to difficulties with

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monitoring and following through with consistent consequences (Murray & Johnston, 2006). Thus, when parents are unable to effectively manage their children’s behaviour, this may result in increased problem behaviours and in turn, increased parenting stress. Given that mothers are primarily responsible for childcare duties (Blanchi & Raley, 2005; Hosley & Montemayor, 1997; Parke, 2000), parenting may become much more difficult when mothers have difficulty sustaining attention and concentration. Mothers with ADHD, for example, are relatively unaware of their children’s activities and are more sensitive to problem behaviours (Weiss, Hechtman, & Weiss, 2000). Monitoring a child’s behaviour and whereabouts poses a greater challenge when adolescents begin spending more time outside of the home and away from the family. Thus, symptoms of inattention may make it difficult for mothers to parent effectively and contribute to higher levels of Total stress and Parent Domain stress. Lower tolerance for problem behaviours may also result in greater conflict which then leads to a strained adolescent-parent relationship. Although maternal inattention was positively associated with increased parent domain stress for mothers, this was not the case for fathers. It is possible that because mothers tend to take on more parenting responsibilities (Phares, Fields & Kamboukos, 2009), fathers with high levels of inattention may be less overwhelmed by the demands of parenting. Strengths and limitations This study was the first to explore parenting stress in parents of adolescents with ADHD. A strength of this study is that ratings of parenting stress were obtained from both mothers and fathers. Furthermore, the measure of parenting stress used has strong psychometric properties and provides a broad picture of parenting stress by examining stress levels in multiple domains. Despite the important findings, this investigation is not without its limitations. First, items on the SIPA (Sheras, Abidin, & Konold, 1998; e.g. Since my child became a teenager, my

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spouse/partner and I don’t spend as much time together as a couple as I had expected) could not be adequately answered by parents who were divorced, separated, or single; which precluded the calculation of a Parent domain stress score for those parents (n = 12). Second, the relatively small sample size of this study may have affected the exploratory analysis of the effect of ADHD medication status on parenting stress where no differences were found between parenting stress levels for parents of adolescents on or off medication. Although this may have been due to the small number of unmedicated adolescents with ADHD (n =7), the effect sizes were small. Conclusion Parents of adolescents with ADHD experience significantly more stress than parents of adolescents without ADHD. Maternal inattention and adolescent externalizing behaviour emerged as significant mediators of maternal parenting stress and ADHD status and adolescent externalizing behaviour were found to predict paternal parenting stress. This study obtained partial eta squared values for differences in parenting stress levels between parents of adolescents with and without ADHD ranging from .13 to .59 for mothers and .12 to .52 for fathers, suggesting that parenting stress among parents of adolescents with ADHD is a significant issue that warrants continued investigation. Through obtaining an understanding of the causes of parenting stress in this population, clinicians may be better able to identify and target the specific challenges these parents experience and provide strategies to alleviate stress. This is particularly important for parents of adolescents because current behavioural treatments for ADHD are geared to parents of children (Fabiano et al., 2009). The results of this study provide strong support for the need to provide parents of adolescents with ADHD and externalizing behaviour problems and mothers with ADHD and symptoms of inattention with interventions designed to reduce and help them cope with parenting stress.

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Kazdin, A.E. (1995). Child, parent and family dysfunction as predictors of outcomes in cognitive-behavioral treatment of antisocial children. Behaviour Research and Therapy, 33(3), 271-281. doi:10.1016/0005-7967(94)00053-M Kazdin, A. E., & Whitley, M. K. (2003). Treatment of parental stress to enhance therapeutic change among children referred for aggressive and antisocial behavior. Journal of Consulting and Clinical Psychology, 71, 504-515. doi:10.1037/0022-006X.71.3.504 Lange, G., Sheerin, D., Carr, A., Dooley, B., Barton, V., Marshall, D.,... Doyle, M. (2005). Family factors associated with attention deficit hyperactivity disorder and emotional disorders in children. Journal of Family Therapy, 27, 79-96. doi: 10.1111/j.14676427.2005.00300.x Lewis, C., & Lamb, M. E. (2003). Fathers’ influences on children’s development: The evidence from two-parent families. European Journal of Psychology of Education, 18, 211–228. doi:10.1007/BF03173485 Marshal, M.P., Molina, B.S.G. & Pelham, W.E. (2003). Childhood ADHD and adolescent substance use: An examination of deviant peer group affiliation as a risk factor. Psychology of addictive behaviors, 17, 293-302. doi:10.1037/0893-164X.17.4.293 Mash, E.J., & Johnston, C. (1983). Parental perceptions of child behavior problems, parenting self-esteem, and mothers’ reported stress in younger and older hyperactive and normal children. Journal of Consulting and Clinical Psychology, 51, 86-99. doi:10.1037/0022-006X.51.1.86 Mash, E. J., & Johnston, C. (1990). Determinants of parenting stress: Illustrations from families of hyperactive children and families of physically abused children. Journal of Clinical Child Psychology, Special Issue: The Stresses of Parenting, 19, 313-328. doi:10.1207/s15374424jccp1904_3 McCleary, L. & Ridley, T. (1999). Parenting adolescents with ADHD: Evaluation of a psychoeducation group. Patient Education and Counseling, 38, 3-10. doi:10.1016/S07383991(98)00110-4 McClellan, J. M., & Werry, J. S. (2003). Evidence-based treatments in child and adolescent psychiatry: An inventory. Journal of the American Academy of Child and Adolescent Psychiatry, 42, 1388-1400. Minde, K., Eakin, L., Hechtman, L., Ochs, E., Bouffard, R., Greenfield, B., et al. (2003). The psychosocial functioning of children and spouses of adults with ADHD. Journal of Child Psychology and Psychiatry, 44, 637-646. doi:10.1111/1469-7610.00150 Mokrova,I., O’Brien, M., Calkins, S. & Keane, S. (2010). Parental ADHD symptomology and ineffective parenting: The connecting link of home chaos. Parenting, 10 (2), 119135. doi:10.1080/15295190903212844

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Theule, J., Wiener, J., Jenkins, J. & Tannock, R. (2010). Parenting stress in families of children with ADHD: A meta-analysis. Journal of Emotional and Behavioral Disorders. doi:10.1177/1063426610387433 Theule, J., Wiener, J., Rogers, M.A. & Marton, I. (2011). Predicting parenting stress in families of children with ADHD: Parent and contextual factors. Journal of Child and Family Studies, 20 (5), 640-647. doi:10.1007/s10826-010-9439-7 Wechsler, D. (1999). Manual for the Wechsler Abbreviated Scale of Intelligence (WASI). San Antonio, TX: Psychological Corporation. Weiss, M., Hechtman, L., & Weiss, G. (2000). ADHD in parents. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 1059-1061. doi: 10.1097/00004583200008000-00023 Whalen, C.K., Jamner, L.D., Henker, B., Delfino, R.J. & Lozano, J.M. (2002). The ADHD spectrum and everyday life: Experience sampling of adolescent moods, activities, smoking and drinking. Society for Research in Child Development, 73, 209-227. doi:10.1111/14678624.00401 Whalen, C.K. & Henker, B. (1992). The social profile of attention-deficit hyperactivity disorder: Five fundamental facets. Child and Adolescent Psychiatric Clinics of North America, 1, 395410. Wilens, T.E., Martleton, M., Joshi, G., Bateman, C., Fried, R., Petty, C. & Biederman, J. (2010). Does ADHD predict substance-use disorders? A 10-year follow-up study of young adults with ADHD. Journal of the American Academy of Child and Adolescent Psychiatry, 50, 543-553. doi:10.1016/j.jaac.2011.01.021

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Figure

FIGURE Figure 1: Mediation models of Parenting Stress

a. Total Stress – Mother

b. Total Stress - Mother

c. Adolescent Domain - Mother

d. Parent Domain – Mother

e. Adolescent Parent-Relationship - Mother

f. Adolescent Domain - Father

Table

TABLES Table 1: Adolescent and Parent Demographics

Non ADHD M SD df 15.32 1.64 43 109.32 10.64 43

n 26 26

ADHD M 15.15 99.88

SD 1.85 5.8

n 19 19

26 26 26 26 26 26

79.23 83.69 72.15 66.65 71.31 69.58

11.99 6.29 15.66 14.28 10.96 16.13

19 19 19 19 19 19

49.95 51.84 50.95 48.11 50.79 48.37

6.7 7.93 8.02 5.94 6.69 6.72

Hyper/Impulsivity Inattention Aggression Conduct Disorder Oppositional Defiant Peer Relations

23 23 23 23 23 23

66.09 71.26 64 57.96 64.22 64.39

16.47 12 16.4 14.09 17.37 18.41

19 19 19 19 19 19

47.39 46.78 48.17 47.39 48.39 49.11

Mother Age Father Age Mother Education Father Education Mother Inattention Mother H/I Father Inattention Father H/I

25 21 23 21 22 22 16 16

45.56 47.76 8.09 7.24 54.73 45.18 51.00 52.69

6.74 6.88 1.28 2.23 19.18 11.64 17.15 15.53

17 18 18 19 17 17 15 15

49.06 50.78 9.11 8.47 42.24 41.76 36.93 45.07

Variable Adolescent Age Full Scale IQ

t .31 3.50a

p .76 .002**

40 43 39 35 43 43

-10.43a -15.02 -5.92a -5.95a -7.22 -6.03

.000*** .000*** .000*** .000*** .000*** .000***

4.23 6.8 8.9 5.12 9.32 7.78

25 36 35 29 35 31

-5.23a -8.24a -3.34a -3.18 a -3.74a -3.59 a

.000*** .000*** .001** .002** .001** .001**

3.96 4.58 1.41 1.65 10.63 9.27 8.20 8.36

40 37 39 38 34 37 29 23

-1.92 -1.58 -2.44 -1.97 2.58a .99 2.88 1.71a

.06 .12 .02* .06 .01* .33 .007** .10

Conners-3 Parent Hyper/Impulsivity Inattention Aggression Conduct Disorder Oppositional Defiant Peer Relations Conners-3 Teacher

a

Levene’s test of Equality of Variances was significant; equal variances not assumed

*p < .05, **p < .01, ***p