Does Maternal Responsiveness Predict Sons' Conduct Disordered Behavior?

In what ways do parents' interactions with their child affect the development of children with ADHD? How can parents help promote the healthy development of their ADHD child?  These are critically important questions for parents and clinicians, and research is beginning to provide us with information that helps answer them.
 
Currently, there is strong evidence that genetic factors are critically important in the development of ADHD and few scientists believe that "poor parenting" causes ADHD.  Some scientists, however, have hypothesized that problems in parent-child interactions are associated with the exacerbation or continuation of ADHD symptoms.  In addition, there is evidence that parenting can contribute to the development of behavioral problems such as Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD) in children with ADHD.  This is important because the development of these additional problems is generally associated with poorer long-term outcomes. Click here for more information on the co-occurrence of ODD and CD with ADHD:

This does not necessarily mean, however, that parenting directly causes the development of these co-occurring behavioral disorders.  Instead, one view is that core ADHD symptoms of inattention and hyperactivity/impulsivity create special challenges in the parent-child relationship, and that ongoing challenges related to these characteristics can promote a pattern of parent-child interaction that contributes to the development of behavior problems.  Thus, in this "transactional" view, parenting does not cause the development of ODD or CD.  Instead, these behavior disorders emerge from a history of interactions between parent and child that may have their origins in the special challenges created by raising a child with the core symptoms of ADHD.
 
This begs the question: Which aspects of parenting are related to the development of these behavior problems in children with ADHD?
 
A study published in a recent issue of the Journal of Abnormal Child Psychology (Johnston, C. et al. (2002). Responsiveness in interactions of mothers and sons with ADHD: Relations to maternal and child characteristics, 30, 77-88) examined this interesting and important issue.
 
The authors hypothesized that "responsive parenting" (a parent's ability to appropriately adapt their behavior to their child's abilities, needs, requests, interests, and ongoing behavior) is especially relevant to understanding parent-child interactions among ADHD children.  They then suggest "...monitoring and interpreting ongoing child behavior as the basis for adapting one's own behavior is more difficult when interacting with a child, who, by definition, displays impulsive, disorganized, and poorly-regulated behavior."
 
In other words, responsive parenting may be more difficult for parents of an ADHD child.
 
Because responsive parenting is important in helping children develop self-regulation skills (i.e. the ability to direct one's behavior in adaptive and organized ways), the authors argue that diminished parental responsiveness may be associated with increased severity of ADHD and ODD/CD symptoms in children with ADHD.  This was the hypothesis they set out to test.  They also were interested in whether depression would be related to parents' responsiveness with their child, and predicted that parents who reported more depressive symptoms would be rated as less responsive.
 
Participants in this study were 136 mothers and their ADHD sons.  (Ideally, fathers would also have been included, but the sample was restricted to mothers.)  Participants were part of the larger MTA Study, the largest treatment study of ADHD ever conducted. This was an extension of the MTA study, and conducted at two of the MTA study sites.  All of the boys met criteria for ADHD, Combined Type.  Thirty-eight percent of the boys had co-morbid ODD; 3% had co-morbid CD; 21% were co-morbid for both ODD and CD; and 38% had ADHD alone.
 
As part of the baseline assessment battery in the MTA study, mothers and sons participated in a series of interactions that were videotaped for subsequent analysis.  These interactions lasted 17 minutes and consisted of 4 situations designed to elicit typical child-rearing conditions: 1) free play; 2) a situation in which mothers were required to complete a pencil and paper task while their sons were instructed to sit quietly; 3) a teaching task in which mothers instructed their sons to work on a math or handwriting exercise; and 4) a clean up period in which all toys and materials were supposed to be put away.
 
Multiple aspects of the mothers' behavior during these tasks were later rated on a 7-point scale. These included:
 
Authoritative Control - the extent to which the mother encouraged her child to participate in decision-making and offered explanation for commands, as opposed to using control strategies that relied on direct and harsh commands;
 
Sensitivity of Control - the degree to which the mother exerted control in a manner that was sensitive to the child's needs, as opposed to making demands that were unreasonable for the situation;
 
Responsiveness - the mother's ability to appropriately adapt her behaviors to the child's abilities, needs, requests, interests, and ongoing behavior;
 
Positive affect - the degree to which the mother displayed frequent and/or intense positive affect towards the child, as opposed to expressions of negative emotion;
 
Acceptance of the child - the degree to which the mother expressed approval, praise, and positive affection towards her son, as opposed to appearing cold and rejecting; and
 
Involvement with the child - the amount of time the mother spent in verbal and non-verbal interactions with her son, as opposed to engaging in solitary activities.
 
As noted above, each dimension was rated on a 7-point scale based on what was observed during the 17-minute interaction period.  For all dimensions, higher scores were associated with more positive maternal behavior as judged by the raters.
 
In addition to rating mothers' behavior during the interaction with their sons, the researchers obtained several additional measures of maternal and child characteristics.  They gathered information on the mothers' self-reported depressive symptoms and ADHD symptoms.  They also had the mothers complete a measure that assessed their typical methods of disciplining their child.  Finally, the researchers obtained ratings from both mothers and teachers of each child's ADHD symptoms and level of "conduct-disordered" behavior.
 

RESULTS
 
Prior to examining the main research questions, the authors examined the relationships among the different aspects of maternal behavior they coded.  They found that ratings for authoritative control, sensitivity of control, responsiveness, positive affect, and acceptance of child were all highly correlated.  Thus, rather than examining these ratings independently in relation to maternal and child characteristics, they formed a composite score that reflected mothers' ratings on these different dimensions.  The label given to this overall composite of maternal behavior was "Responsiveness". Mothers with high responsiveness scores were those who demonstrated an ability to adapt their behavior to the needs, demands, interests, and abilities of their child.
 
Mothers' scores on this composite measure were negatively related to maternal, self-reported use of harsh parenting strategies and corporal punishment.  This indicates that the observations of maternal behavior were significantly related to how mothers described their typical methods of disciplining their child.  It also suggests that the behavior recorded during the videotaped interactions is a valid indicator of the mothers' behavior in the home.
 
As predicted, maternal reports of depression were negatively related to responsive parenting.  Thus, mothers who were depressed demonstrated less of the responsive parenting style that the authors believe is important in the development of children's self-regulation skills.  In contrast, mothers' reports of their own ADHD symptoms were not related to their responsive parenting score.
 
In addition, child conduct problems were negatively related to maternal responsiveness, indicating that mothers who displayed less-responsive parenting had children with higher levels of conduct-disordered behavior.  This was true even after controlling for a variety of demographic factors (e.g. mother's age, marital status, and education) that might be expected to relate to children's behavior problems, Interestingly, maternal responsiveness was not related to the severity of children's ADHD symptoms.
 

SUMMARY AND IMPLICATIONS
 
Results of this study confirmed the authors' predictions that maternal responsiveness would be negatively and uniquely related to children's conduct problems.  In seeking to explain this finding, the authors suggest that it reflects an interactive process whereby unresponsive parenting is associated with increased difficulties in a child's self-regulation skills. This deficit in self-regulation leads to increased oppositional behavior and conduct problems.  This, in turn, is suggested to make it increasingly difficult for mothers to engage in responsive parenting behavior.
 
In contrast to the negative association between responsive parenting and conduct-disordered behavior, no association between responsive parenting and the severity of children's ADHD symptoms was found.  The authors note this is consistent with the emerging consensus that family and parenting characteristics are more closely related to co-morbid ODD/CD behavior in children with ADHD than to the emergence and severity of core ADHD symptoms themselves.  The authors note, however, that because their sample was restricted to boys with an ADHD diagnosis, they cannot be certain whether maternal responsiveness would have differed between boys with and without ADHD.  This would require an additional study.
 
As predicted, a negative relationship between the mothers' depression and responsiveness also was found, such that more depressed mothers were judged to be less responsive to their sons.  Although recognizing that conclusions about causality cannot be determined from this study alone, the authors suggest, "...a mother's experience of depressive symptoms may interfere with her ability to respond appropriately and sensitively to her child's behavior and this lack of responsiveness may create or exacerbate problematic child behavior."  Thus, it is possible that depressive symptoms in mothers may initiate a cycle in which a reduction in responsive parenting, resulting from a parent's depressed mood, may lead to an initiation of conduct problems in a child with ADHD.  Other causal relationships between these variables are certainly possible, however, and additional research would be required to help sort this out.  For example, it may be that high levels of Conduct Disorder in children with ADHD lead to an increase in mothers' feelings of depression.
 
As with any study, it is important to be aware of the limitations in this report.  The sample was restricted to boys, and whether these findings would generalize to girls with ADHD is unknown.  It also is unclear whether similar results would be found for adolescent boys with ADHD, or whether responsiveness in fathers would be related to children's conduct problems in similar ways.  In addition, the design of this study does not enable any firm conclusions to be made about whether low maternal responsiveness causes conduct problems in children with ADHD, or whether these factors are merely correlated.
 
Nonetheless, this study provides an important initial examination of how a particular aspect of a mother's behavior is related to behavioral problems in children with ADHD.  The results suggest that psychosocial interventions in families of children with ADHD may be enhanced by focusing specifically on improving parental responsiveness.  This would not be for the purpose of trying to reduce ADHD symptoms directly, but rather to reduce or prevent the development of children's conduct problems.
 
It is important to emphasize that, in making this suggestion, the authors are in no way "blaming" parents for their child's conduct problems.  Certainly, there are multiple factors that can contribute to a parent's difficulties relating to their child in a "responsive" manner.
 
It is also very important to note that "responsive" parenting is not synonymous with "permissive" parenting, and these findings in no way mitigate the importance of parents providing children with clear, consistent, and appropriate limits on their behavior.  In fact, in prior research ineffective discipline strategies have also been linked to the development of children's conduct problems.
 
The findings do suggest, however, that parents may benefit from a careful appraisal of whether they have entered a negative cycle with their child that has made it more difficult for them to engage in "responsive parenting".  If this has occurred, it is important to initiate efforts to make the necessary changes. The pay-off for these efforts may be better parent-child relations and reduced behavioral difficulties in children with ADHD.

 
Although it was once commonly believed that ADHD generally ended with the transition to adolescence, there is no longer any doubt that many children diagnosed with ADHD continue to have difficulties throughout adolescence.  For some adolescents with ADHD, these difficulties are pervasive, and evident in academic, social, and occupational domains. They also may be apparent in substance use or abuse and other forms of illicit activity.
 
Despite this knowledge of the difficulties that many adolescents with ADHD experience, there is virtually no information currently available on the day-to-day experience of adolescents with ADHD.  How, and with whom, do these youth spend their time?  What are their typical mood states and do these differ from adolescents without ADHD?  How frequently do they experience urges to engage in health-threatening behaviors like smoking and drinking?
 
Answers to such questions would provide us with a better appreciation for how adolescents with ADHD experience the world and could also assist in the development of more effective interventions to prevent the development of secondary emotional and behavioral difficulties that often accompany ADHD in teens.  For these reasons, learning more about the daily experience of teens with ADHD is an important research task.
 
Recently, a fascinating study was published in Child Development in which the daily experience of adolescents with high levels of ADHD symptoms was explored (Whalen, C. et al., (2002). The ADHD spectrum and everyday life: Experience sampling of adolescent moods, activities, smoking, and drinking. 73, 209-227).
 
Participants in this study were 153 adolescents (average age 14.5) from predominantly middle-income, well-educated families.  Approximately 60% of the sample was female.  These participants were selected based on the results of a health behavior survey administered to all freshmen in three southern-California high schools.  Efforts were made to include as many self-reported smokers as possible (the current investigation is part of a larger project on teen smoking) and to recruit non-smokers matched for gender and ethnicity.  67 of the participants were smokers, representing 43% of the self-reported smokers who had been invited to participate.
 
All participants completed a Teen Health Screening Survey that inquired about a variety of health-related behaviors including smoking, diet, sleep patterns, and seatbelt usage.   Each adolescent and his or her parent(s) also completed an ADHD-symptom rating scale.  This was used to identify adolescents with low, medium, and high levels of ADHD symptoms, based on their own report and those of their parents.  Thus, no participant was formally diagnosed with ADHD and the data reported below was examined in relation to self- and parent-reported ADHD symptom levels.
 
The procedure used to gather information about the daily experience of participants is called Experience Sampling (ES), and is a clever and innovative method.  Each adolescent was provided with a Palm III handheld computer on which a customized personal diary program was installed.  For two four-day periods, an auditory signal was emitted every 30 minutes during the students' waking hours.  When they heard the signal, students were instructed to stop what they were doing and take approximately one minute to complete a diary record for that 30-minute period.  (They were of course instructed to ignore any signal that occurred during an incompatible activity such as bike riding, taking a test, etc.)  The four-day ES periods were spaced six months apart.
 
The diary record that students completed contained 24 items to tap contexts, activities, and emotional reactions that are relevant to the daily lives of adolescents.  For example, when the signal went off, they were asked to indicate where they were, what they were doing, and whether they had smoked cigarettes or consumed alcohol since the prior entry. They also were asked to rate the current intensity of various emotions, and to indicate whether they were experiencing an urge to smoke or eat.  Answers to these items were keyed directly into the Palm Pilot and became part of the experience record for the adolescents.
 
Over the course of each Experience Sampling period, each participant completed multiple diary reports.  In fact, the mean number of reports per student across the two periods was just over 171, with reports being made on about 80% of possible occasions.  Thus, this is an enormously rich data set that provides a unique window into the lives of these students, and a terrific opportunity to learn how the daily experience of adolescents may vary in relation to their level of ADHD symptoms.
 

RESULTS
 
Adolescents with ADHD symptoms ratings that fell in the lower third, middle third, and upper third of the distribution were placed into low-, middle-, and high-symptom groups, respectively.  As noted above, this classification was based on both self and parent ratings. The correlation between these ratings -- although statistically significant -- was relatively modest.  Thus, whether participants were assigned to the low-, middle-, or high-symptom group depended on which source was used to make the classifications, and the data was analyzed using both methods of classification.
 
Question 1: How do the daily moods of adolescents vary in relation to their levels of ADHD symptoms?
 
When ADHD classification was based on adolescents' self-ratings, both the middle- and high-ADHD groups were between 1.5 and 2 times more likely than the low-symptom group to report feeling anxious, sad, angry, and stressed, and about half as likely to report feelings of happiness and well-being.  They also were half as likely to report feeling alert.
 
When parent ratings were the basis of the classification, in contrast, there were no associations between ADHD-symptom levels and any of the mood items.
 
Question 2: How do the typical social contexts of adolescents vary in relation to their level of ADHD symptoms?
 
In examining social contexts, the researchers were interested in learning about the kinds of individuals with whom the adolescents were most likely to spend time (i.e. how frequently did they report being alone, with friends, with a boyfriend/girlfriend, by themselves, or in class or other organized activity.)
 
When teen ratings were used, the researchers found that those in the high-ADHD group were more likely than those in the low-symptom group to report spending time with friends or a boyfriend/girlfriend.  They also were less likely to report spending time with their families.  Results based on parent ratings were highly similar, although the researchers found no association between ADHD group and the likelihood of being with a boyfriend/girlfriend.
 
Question 3: How do the typical activities of adolescents vary in relation to their level of ADHD symptoms?
 
For self-rated classifications, high-ADHD adolescents were about one-third more likely than their low-ADHD counterparts to be talking or engaged in other types of entertaining activities.  Parent-rated, high-ADHD adolescents were only about one-third as likely as the low group to be reading or writing and were almost 1.5 times more likely to be engaged in entertaining activities.
 
Question 4: How do adolescents' smoking and drinking behaviors, and the "urges" they experience to smoke and drink, vary in relation to their level of ADHD symptoms?
 
When self-ratings were used for classification, robust group differences emerged in relation to these variables.  Compared to those in the low group, adolescents in the high-ADHD group were 10 times more likely to have smoked, 8 times more likely to report an urge to smoke, and almost 4 times more likely to have consumed alcohol.  Results based on parent classifications were essentially identical, as were results obtained for those in the "agreement" sample.
 
To place these results in the appropriate context, it is important to note that even among the high-ADHD group, the absolute level of smoking and drinking behavior reported was relatively low -- 2.3% of the time for drinking and 5.8% of the time for smoking.  Of course, since these are illegal activities for adolescents, they are problematic at any level.  Among adolescents in the low-ADHD group, these behaviors were reported for less than 1% of the diary entries.
 
Question 5: To what extent is the association between ADHD symptom levels and daily experience modified by gender?
 
In general, there was little consistent evidence that gender played a significant role in moderating the relationship between ADHD symptom levels and daily experience, although several noteworthy differences between males and females were reported.  The association between anxiety and symptom level was only found among males, while the association between alertness and symptom level was restricted to females.  Interestingly, although findings for smoking and alcohol consumption, as well as the urge to smoke, were significantly associated with symptom levels for both genders, the results were even more pronounced among girls.
 

SUMMARY AND IMPLICATIONS
 
These results provide an interesting window into the lives of teenagers with varying levels of ADHD symptoms.  Among adolescents reporting high levels of ADHD symptoms, daily life was characterized by significantly more negative emotional experiences. They also experienced feelings of happiness and well being less often than their peers. Smoking and drinking were more frequent occurrences, as was the urge to smoke.
 
These findings are especially interesting in light of the fact that adolescents reporting high levels of ADHD symptoms also were spending more time with friends and engaged in entertaining activities with greater frequency.  One would expect this would be associated with more frequent positive emotional states, but this was not the case.  The fact that these teens also were spending less time with their families raises concerns about whether parents were able to monitor their whereabouts and activities as carefully as they would like to.  This is an important concern because close monitoring and supervision is especially important for teenagers beginning to engage in antisocial activities. Additionally, a reduced level of parental monitoring is known to predict escalation in such behavior.
 
Findings for the relationship between ADHD-symptom level and mood were not evident when symptom level was based on parent ratings, and the reasons for this discrepancy are not clear.  Because the more overt indicators of ADHD (e.g. excessive activity level) are less pronounced among adolescents -- an age range at which problems with inattention and feelings of restlessness are typically more prominent -- it is possible that parents are less aware of a child's ADHD symptoms at this age.  If so, then parent ratings of ADHD symptoms among adolescents may underestimate the difficulties the youth are experiencing. This would partially explain why associations between parent-rated ADHD symptoms and negative-mood states were not found.   It is also possible that adolescents who reported high levels of ADHD symptoms are youngsters who are simply more troubled in a variety of areas, and this explains why the associations between teen-reported ADHD symptoms and more frequent negative emotional states were found.
 
Regardless of the reason for the different pattern of associations between ADHD symptoms and emotional states for parent and teen ratings, there seems to be a subgroup of emotionally reactive adolescents who see themselves as having problems with attention, impulsivity, and hyperactivity, but who are not viewed by their parents as having these difficulties.  This points to the importance of attending to the emotional well-being of adolescents who experience problems related to ADHD, and the need for a thorough assessment of emotional functioning to be part of ADHD evaluations.
 
This study represents a first step towards understanding the differences in everyday feelings and activities between adolescents with ADHD characteristics and their peers.  A follow-up study that compared adolescents with and without the formal diagnosis of ADHD -- rather than simply comparing adolescents with different symptom levels as was done in the current study -- would be an important next step.  Such a study could shed additional light on how the daily experiences of teens with ADHD contribute to many of the negative outcomes these youth experience, and how such outcomes could be prevented.
 
The important message from the current study, however, is that many adolescents with high levels of ADHD symptoms are moving along a non-optimal developmental trajectory, even though they might not qualify for a formal diagnosis.  Helping these teens move to a healthier developmental path may require efforts in multiple domains, including enhancing emotion regulation, improving family relations, and helping them refrain from smoking and drinking.  Information obtained in studies such as this can be critically important to those efforts, and one hopes the authors will continue this important line of work.