Attention Research Update

November 2011

"Helping parents, professionals and educators stay informed about new research on ADHD"

David Rabiner, Ph.D.  Associate Research Professor, Duke University

Daily Distress in Moms of Children with ADHD

Parents of children with ADHD have been found to experience elevated levels of parenting stress and distress in multiple studies.  This is not surprising given the greater challenges associated with raising a child who consistently exhibits high levels of ADHD symptoms. 

Studies of child ADHD and parenting stress have typically relied on global and static measures of both children's behavioral problems, e.g., having parents complete rating scales and parents' reports of stress/distress.  Correlating these reports provides useful information on how children's ADHD symptoms relate to parents' average distress level, but say little about the moment-to-moment fluctuations in parents' stress that may occur in response to fluctuations in their child's behavior. This dynamic aspect of the parent child relationship can only be captured by relating parents' stress to children's behavior as it occurs in real time.

Examining the ebb and flow of parents' distress in relation to children's behavior was the focus of an interesting study published recently in the Journal of Family Psychology [Whalen et al., (2011). Dissecting daily distress in mothers of children with ADHD: An electronic diary study. Journal of Family Psychology, 25, 402-411.  Participants were 51 8- to 12-year old children with ADHD and their mothers (about 70% boys) and 58 comparison dyads where the child did not have ADHD.  The authors had intended to include fathers but were unable to recruit a sufficient number.  All children with ADHD were being treated with a long acting medication during the study and were reported by their mothers to be doing well on medication.

Over a 7-day period during nonschool hours, mothers and children rated their moods and behavior using Personal Digital Assistants, i.e., PDAs, roughly every thirty minutes when prompted by a beep from the device.  Each time the beep occurred, mothers rated the child's level of attention/concentration, hyperactive-impulsive behavior, and oppositional behavior. They also rated how stressed, worried, worried about their child, and sad they were feeling in the moment. These ratings were averaged to obtain a measure of moms' overall distress at each recording point.

Children used their eDiary device to rate their mood and behavior by indicating how angry, restless, impatient, and focused they were feeling each time they were prompted. 

Moms and children were instructed to completed their diaries independently and privately without consulting each other so as not to influence one another's ratings. Compliance was excellent with mothers and children in the ADHD and comparison group completing ratings at over 90% of the prompts.  Thus, researchers were able to obtain data that provided an especially fine-grained look at how mothers' distress varied directly in relation to children's behavior over the course of a typical week.

Additional Measures

The researchers also obtained measure of 'maternal risk' at baseline using a composite of mothers' self-reported ADHD symptoms, depression, and the intensity of child-related stressors that she experienced during the prior 6 months.  Obtaining an estimate of maternal risk at baseline enabled the researchers to test whether mothers at higher risk were more negatively reactive to their child's behavior in the moment.


Baseline characteristics of mothers

Not surprisingly, baseline risk scores were substantially higher in mothers of children with ADHD compared to other mothers.  These mothers were more depressed, reported more ADHD behaviors in themselves, and were experiencing significantly greater stress related to their children.

Question 1: Do ongoing child behaviors and maternal distress fluctuate together?

As expected, the answer to this question was clearly yes.  In both groups of mothers, elevated levels of distress were reported during times when the mother perceived her child to be hyperactive, oppositional, or lacking in concentration.  Similarly, maternal distress was higher when the child reported him or herself to be angry, impatient, or restless.

Question 2:  Are mothers of children with ADHD more reactive to their child's negative behaviors?

Again, the answer was yes.  The increase in maternal distress reported by moms whose child had ADHD was significantly greater when the child displayed negative behaviors/moods compared to the other mothers.  Thus, even though distress increased during these times for all mothers, distress levels in moms in the ADHD group were negatively affected to a greater degree.

Question 3: Is the link between negative child behavior and maternal distress stronger in moms at higher risk?

The answer to this question was also clearly yes.  Moms with higher baseline scores on the risk index reported greater increases in distress when their child displayed negative behaviors than did moms with lower risk scores.  This was true for both groups of moms but recall that moms of children with ADHD had substantially higher risk scores to begin with.  Thus, this was especially problematic for these mothers.

Summary and Implications

Results from this study go beyond prior research demonstrating that mothers of children with ADHD have higher parenting stress by documenting how this association operates during the ebb and flow of daily life.  When children display negative behaviors or mood states, e.g. oppositional behavior, hyperactivity, anger, mothers' distress level increases significantly.  And, these increases are greater in moms whose child has ADHD and who report higher rates of ADHD symptoms, depression and child-related stress to begin with.  These moms appear to be especially sensitive to negative behaviors in their child and are prone to respond by experiencing increasing distress.

Results from this study have several important implications.  First, the higher baseline risk scores in mothers from the ADHD group, and the greater reactivity of these moms to their child's behavior, highlights the importance of recognizing the impact that ADHD can have on parents and of providing parents with necessary treatment and support.  Too often, children themselves are the sole focus of ADHD treatment and important issues that parents are struggling with do not receive sufficient attention. 

Second, these findings highlight the particular struggles that mothers experience dealing effectively with the negative behaviors that occur more frequently in children with ADHD.  Because such behavior triggers significant increases in what may already be high levels of distress, responding consistently in the ways that are often discussed in behavioral parent training programs may be especially difficult.  This suggests that there would be important value in helping mothers develop skills to manage their distress in the moment, and to learn to recognize particular triggers of increased distress.  This could decrease the ":..cumulative emotional toll of raising a child with a chronic disorder."  And, reducing negative emotional reactions to challenging child behavior could make it easier for mothers to follow through consistently with behavioral strategies they are trying to implement.

In future work it would be important to include fathers so that the processes studied here can be investigated in dads as well.  It would also be valuable to include larger number of females so that potential differences in mothers' reactions to sons and daughters could be investigated.  Using these findings to develop ways to help mothers manage their distress in the moment would also be valuable to pursue.

In sum, results from this study highlight the links between mothers' distress and children's negative behavior and the fact that these links are stronger in families where a child has ADHD.  As the authors conclude "This type of information can help guide not only interventions targeted on improving quality of life in families of children with ADHD, but also programs to help all parents recognize and manage the daily stressors of child rearing."

Information presented in Attention Research Update is for informational purposes only, and is not a substitute for professional medical advice.  Although newsletter sponsors offer products and services that I believe will be of interest to subscribers, sponsorship of Attention Research Update does not constitute a specific endorsement or guarantee of any company's product or services.

(c) 2011 David Rabiner, Ph.D.