562587

research-article2015

JADXXX10.1177/1087054714562587Journal of Attention DisordersLowry et al.

Article

Exploring Parent Beliefs and Behavior: The Contribution of ADHD Symptomology Within Mothers and Fathers

Journal of Attention Disorders 1­–11 © 2015 SAGE Publications Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1087054714562587 jad.sagepub.com

Lynda S. Lowry1, Nicole K. Schatz1, and Gregory A. Fabiano1

Abstract Objective: To use a multi-method approach to examine the association of parental ADHD and gender with observed and self-reported parenting beliefs and behaviors. Method: Seventy-nine mother–father dyads completed measures of child behavior and impairment, parenting beliefs and behaviors, and self- and partner ratings of ADHD symptoms and functional impairment. Forty-five parents also completed structured parent–child interactions. Results: A hierarchical linear model suggests impairment in functional domains may be associated with negative emotions about parenting and less effective parenting strategies. For fathers, greater severity of partner-reported symptoms of ADHD may be associated with greater frequency of negative talk during parent–child interactions. Conclusion: Findings suggest that higher levels of parental ADHD symptoms and functional impairment may be associated with reported beliefs and behaviors related to parenting. Differences emerged among mothers’ and fathers’ use of parenting strategies when self- and other-report of ADHD symptoms and impairment were assessed. (J. of Att. Dis. XXXX; XX(X) XX-XX) Keywords parent–child relationships, parenting, families, adult ADHD For many individuals with ADHD, symptoms persist into adulthood and are associated with comparable impairments in adult functional domains (Faraone et al., 2000; Mannuzza, Klein, Bessler, Malloy, & LaPadula, 1993). Previous research has suggested that ADHD may impact many adult roles and tasks, such as driving (Murphy & Barkley, 1996; Richards, Deffenbacher, Rosen, Barkley, & Rodricks, 2006), school outcomes and employment (Kent et al., 2011; Mannuzza et al., 1993; Moss, Nair, Vallarino, & Wang, 2007; Murphy & Barkley, 1996), and social and romantic functioning (Eakin et al., 2004; Minde et al., 2003). An additional role that may be impacted is that of being a parent. Being a parent involves a balancing act of both providing enough guidance for a child to become autonomous and clearly delineating expectations for a child’s behavior (Collins, Madsen, & Susman-Stillman, 2002). Adults in their role as parents may encounter frustration or confusion, especially during middle childhood, when determining whether to engage in parenting behaviors that promote child self-management or those that are more adult-mediated (Collins et al., 2002). Parents may face additional challenges in their role when a child demonstrates behavioral difficulties. A child diagnosed with ADHD may increase stress for parents and negatively impact their ability to parent effectively (see Deault, 2010, for a review).

Parenting a Child With ADHD Negative parent cognitions may be more common among parents caring for a child with an externalizing behavior disorder, including ADHD (Deault, 2010; Johnston & Mash, 1989; Williamson & Johnston, 2013). For example, among mothers, child inattention difficulties were associated with lower satisfaction in engaging in the role as a parent (Podolski & Nigg, 2001). Child externalizing behavior problems associated with ADHD have also been shown to be predictive of parents’ reported feelings of social difficulties and family conflict (Evans, Sibley, & Serpell, 2009). In a metaanalysis of studies exploring the associations between parenting stress and parenting children with ADHD, Theule, Wiener, Tannock, and Jenkins (2013) found that parents of children with ADHD experience more parenting-related stress than parents of children without ADHD. These negative attitudes and beliefs regarding parenting may also adversely impact parent–child interactions. Mothers of children diagnosed with ADHD have been 1

University at Buffalo, NY, USA

Corresponding Author: Lynda S. Lowry, University at Buffalo, 409 Baldy Hall, Buffalo, NY 142601000, USA. Email: [email protected]

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observed engaging in more negative parenting than mothers of children without ADHD (Buhrmester, Camparo, Christensen, Gonzalez, & Hinshaw, 1992). Mothers of sons experiencing ADHD have also been found to be less responsive and more controlling of child behavior (Seipp & Johnston, 2005). Furthermore, parents of children with ADHD may be less engaging and may use more harsh criticism with their children (DuPaul, McGoey, Eckert, & Vanbrakle, 2001; Peris & Hinshaw, 2003).

Parental ADHD and Parenting Behavior Given the high heritability rate of ADHD (Faraone et al., 2005), many parents of children with ADHD may also find themselves experiencing symptoms and impairment related to ADHD. Subsequently, the challenges associated with parenting a child with ADHD may further become exacerbated when one or more parents also exhibit behaviors characteristic of ADHD (Johnston, Mash, Miller, & Ninowski, 2012). In a review of the current literature on the parenting behaviors of adults with ADHD, Johnston and colleagues (2012) suggested that the core deficits related to ADHD (i.e., inattention and impulsivity) may be associated with engagement in more negative parent–child interactions such as using more lax parenting strategies, arguing more frequently with a child, and using fewer positive and supportive responses for coping with children’s negative emotional states in comparison with parents not experiencing ADHD (Johnston et al., 2012). Indeed, previous research exploring the associations between parental ADHD and parenting behavior has demonstrated that parents with ADHD may engage in lower levels of monitoring child behavior, less consistent discipline practices, and reduced parenting-related problem solving (Murray & Johnston, 2006). Mothers with high levels of ADHD have been found to be less involved with their children and use fewer positive parenting techniques (e.g., praise; Chronis-Tuscano et al., 2008). Perhaps due to these areas of difficulty within parenting, parents with ADHD-related behaviors also have negative beliefs and attitudes regarding their role as a parent. For example, mothers with ADHD have been found to have lower satisfaction and feelings of competence in their role as a parent (Banks, Ninowski, Mash, & Semple, 2008; Sonuga-Barke, Daley, & Thompson, 2002). Babinski and colleagues (2012) also found that in comparison with mothers without ADHD, maternal ADHD was associated with having reduced parental knowledge about their children. Williamson and Johnston (2013) reported fathers’ negative affect resulted in more negative attributions of mothers’ behavior. Thus, parental ADHD can have a negative impact on parenting and family interactions. Examining the differences in parenting behaviors between mothers and fathers with self-reported ADHD

symptomatology has previously suggested that inattention and impulsivity impacts the parenting of mothers and fathers differently (Harvey, Danforth, Eberhardt, Ulaszek, & Friedman, 2003). To our knowledge, only one study has explored the parenting differences of mothers and fathers experiencing ADHD symptoms using both direct observation and rating scales. Using a sample of both mothers and fathers with self-reported ADHD symptoms and impairment, Harvey and colleagues (2003) examined changes in reported and audiotaped parenting behaviors following parent training. Inattention was associated with engagement in self-reported lax parenting style among both mothers and fathers. For mothers, experiencing difficulties with inattention was associated with observed negative parent–child interactions. Impulsivity among fathers was associated with engagement in more negative parenting behaviors including self-reported over-reactivity as well as more observed arguments with children during audiotaped interactions. Most recently, Wymbs, Wymbs, and Dawson (2014) examined the parenting behavior of mother–father dyads interacting with a confederate child displaying ADHD-like symptoms. Parent ADHD symptoms were associated with observed negative parenting during the triadic (father– mother–child) interactions. The child’s behavior was associated with more negative parenting behaviors as reported by both the partner and observers. Differences among mothers’ and fathers’ self-report of parenting behaviors were not assessed. Thus, additional work is needed to explore how parental ADHD symptomatology may uniquely impact the parent–child relationship for each parent. Relatedly, given that knowledge of the relationship between ADHD symptoms and mothers’ and fathers’ parenting beliefs and behavior is limited to examining each parent independent of the other, there is need for the literature to address the issue of nested (dependent) data. Thus, the present study utilizes collateral ratings to assess partner parenting behavior and the extent to which a partner is experiencing ADHD symptoms within a multi-level model to take into account the relationship between mother and father parenting occurring within the context of a parenting dyad.

The Current Study Much of the current research on the associations between parental ADHD symptoms and parenting behaviors has explored difficulties among parents dichotomized as those with and without ADHD (e.g., Chronis-Tuscano et al., 2008). Given the concerns with applying and meeting ADHD diagnostic criteria with adults (Barkley, Murphy, & Fisher, 2010), the present study used a dimensional approach to examining parental ADHD, which included examining symptom elevations for parents who experience daily symptoms and functional impairment but do not meet formal criteria for ADHD. Furthermore, as many individuals

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Lowry et al. Table 1.  Demographic Information for Parents.

Age in years (M, SD) Caucasian Education   Some HS   HS diploma   Some college   Associate degree   Bachelor’s degree   Graduate degree

Fathers

Mothers

41.9 (7.0) 95.2%

40.2 (7.2) 94.9%

18.1% 19.4% 18.1% 19.4% 20.8% 4.2%

7.7% 17.9% 16.7% 32.1% 23.1% 2.6%

Note. N = 79. HS = high school. There were no significant differences between groups on any variables using chi-square tests for percentages or t tests for mean scores (p > .05).

with ADHD lack the appropriate insight to provide valid self-report (Prevatt et al., 2012) and previous work has suggested parents with ADHD may provide self-reports of parenting behavior that do not align with observed behavior (Lui, Johnston, Lee, & Lee-Flynn, 2013), collateral ratings of behavior were also obtained. There has been considerable use of collateral ratings to identify adults experiencing ADHD symptomatology (Chronis-Tuscano et al., 2011; Chronis-Tuscano et al., 2010). The major aim of the current study was to use a multimethod approach (self-report and collateral ratings) to examine the association of parental ADHD symptoms and parenting behaviors among caregiver dyads (e.g., mothers and fathers simultaneously). Our primary hypothesis was that higher levels of parental ADHD symptoms and ADHD functional impairment (according to self- and other-report) would be associated with greater levels of maladaptive parenting behaviors and beliefs as well as more observed difficulty in parenting behaviors. We also sought to explore the association between parental gender and parenting beliefs and behaviors.

Method Participants Seventy-nine families (comprised of 79 mother–father dyads and their 6- to 12-year-old children) participated in the current study. Characteristics of parents included in the investigation are presented in Table 1. Families were recruited through radio advertisements, mailings, and school/pediatrician referrals. To be included in the study, parents had to be cohabitating and both parents had to have complete data on measures of ADHD symptoms and impairment (self- and collateral ratings) as well as self-report measures of parenting behavior. Exclusion criteria included families in which parents were divorced, separated, not cohabitating, or otherwise unable to provide collateral ratings on ADHD symptoms.

The average age for the children was 8.54 years (SD = 1.9), 71.1% were boys, and 90.3% were Caucasian. The children were all diagnosed using criteria from the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000) through mother, father, and teacher ratings scales of ADHD (Fabiano et al., 2006; Pelham, Gnagy, Greenslade, & Milich, 1992), and a semi-structured Disruptive Behavior Disorder (DBD) Interview with the child’s parents (Hartung, McCarthy, Milich, & Martin, 2005). Two PhD-level psychologists reviewed results of the diagnostic assessment and discrepancies were resolved by a third independent review. Overall, 88% of children were identified as ADHD combined type, 7% were identified as ADHD inattentive type, and 5% were identified as ADHD hyperactive–impulsive type.

Procedures Parents and their children attended a clinical visit to consent to larger studies aiming to investigate effective parent training programs for mothers and fathers of children with ADHD (i.e., Fabiano et al., 2012). Parents who participated signed an informed consent and children signed an informed assent, and all procedures were approved by the university’s Institutional Review Board. Then, mothers and fathers independently completed a battery of rating scales. These ratings included measures of child behavior and impairment related to ADHD, parenting behaviors, self-report of ADHD symptoms, and ratings of their partner’s ADHD symptoms. Forty-five families also participated in a structured parent– child interaction that included 10 min of child-led play, 10 min of parent-led play, and 5 min of cleanup. Due to changes in study protocol, the remaining 34 families participated in a different type of parent–child interaction task and data from this task could not be included in analyses as procedures were not comparable. Parents also completed a semistructured clinical interview of ADHD symptoms with a clinician. The results in the present study represent parent and child behaviors at baseline, before any intervention was administered.

Assessment of Parent ADHD Symptoms Parental ADHD symptomatology was assessed using selfreport measures as well as collateral ratings. As the primary purpose of the larger study (i.e., Fabiano et al., 2012) was to focus on child behavior and increasing adaptive parenting strategies among parents of children with a diagnosis of ADHD, parental ADHD status was not part of participant exclusion/inclusion criteria. Thus, the rates of parental ADHD symptoms represent the natural occurrence of these behaviors in the participant sample at baseline. Furthermore, general parent mental health history was not assessed given the child-focused nature of the larger study.

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Table 2.  Correlations for All Relevant Independent and Dependent Variables. DPICS   DBD Interview ASRS Self IRS Self ASRS Other IRS Other P C NT PSOC CP ID MS PP I

ASRS Self IRS Self ASRS Other IRS Other .09 — — — — — — — — — — — — —

.25*** .51*** — — — — — — — — — — — —

.15 .44*** .15 — — — — — — — — — — —

.21*** .09 .41*** .35*** — — — — — — — — — —

P

C

APQ NT

PSOC

CP

ID

MS

.01 .13 .00 .17* .05 .14 .01 .13 .05 .10 .27*** .22*** .22*** .07 .03 .10 .08 .41*** .06 .25*** .15 −.01 −.05 −.10 .13 .04 .04 .13 .01 −.03 −.12 .12 −.05 .14 .09 — .40*** .11 −.15 −.08 −.14 −.18 — — .47*** −.09 .01 −.14 −.04 — — — .06 .18 .04 .16 — — — — .17* .38*** .04 — — — — — .28*** .07 — — — — — — .22*** — — — — — — — — — — — — — — — — — — — — —

PP −.03 .05 −.14 −.11 −.10 .10 .22* −.09 −.31*** −.13 −.14 −.17* — —

I −.14 .00 −.22*** −.16 −.21*** .04 .22* .03 −.37*** −.07 −.11 −.16* .73*** —

CGSQ .34*** .22*** .44*** .00 .13 −.25* −.20* −.05 .56*** .13 .33*** .09 −.04 −.18*

Note. N = 79 for PSOC, and APQ and CGSQ subscales. n = 45 for DPICS-II subscales. ASRS = Adult ADHD Self-Report Scale; IRS = Impairment Rating Scale; DPICS = Dyadic Parent–Child Interaction Coding System; P = Praise; C = Commands; NT = Negative Talk; PSOC = Parenting Sense of Competence; APQ = Alabama Parenting Questionnaire; CP = Corporal Punishment; ID = Inconsistent Discipline; MS = Monitor/Supervision; PP = Positive Parenting; I = Involvement; CGSQ = Caregiver Strain Questionnaire; DBD = Disruptive Behavior Disorder. DPICS Negative Talk, DPICS Commands, and DPICS Praise were transformed due to skewed distributions. An average for each item was calculated for all measures and measures were grand mean centered resulting in total scores ranging from 0 to 4. *p < .05. ***p < .001.

Adult ADHD Self-Report Scale (ASRS).  Mothers and fathers completed the ASRS (Adler et al., 2006). Parents completed the measure about themselves and also about their partner. The ASRS consists of 18 items on a 5-point scale (0 = never to 4 = very often), based on DSM-IV-TR criteria of ADHD; the scale is used to assess symptoms of ADHD. Part A of the ASRS includes the six questions from the ASRS that have been found to be the most predictive of symptoms consistent with ADHD, and thus are considered to be most predictive of an ADHD diagnosis. For the purposes of this study, the self- and partner-report Part A summary scores were used as a measure of parental ADHD symptoms. The summary score is computed as the mean item score for Part A items. Higher scores on the ASRS Part A suggest more severe symptoms of ADHD experienced by parents. The ASRS has demonstrated adequate internal consistency and test–retest reliability (Adler et al., 2006; Kessler et al., 2007). Internal consistency for the six items on Part A for parent self- and partner-report ratings were found to be acceptable (α = .79 and .80, respectively). Functional impairment. A modified version of the six-item Impairment Rating Scale (IRS; Fabiano et al., 2006) was used to assess impairment in important functional domains for adults (e.g., how behavior affects relationships with spouse or partner). Parents placed an “x” on a 7-point visual analogue scale to indicate functioning along a continuum of impairment that ranges from 0 (Not a problem at all. Definitely does not need treatment or special services) to 6 (Extreme problem. Definitely needs treatment and special services). Parents completed this measure about themselves

and also about their partner. On the original six-item IRS (Fabiano et al., 2006), higher scores suggest experiencing more impairment related to ADHD. Higher scores on the modified version of the scale also indicate more impairment and need for treatment. The child IRS exhibits adequate psychometric characteristics (Fabiano et al., 2006). Internal consistency for the composite score for self-report and partner ratings on the IRS in the current sample was adequate (α = .84 and .92, respectively). Correlations examining construct overlap between the ASRS, assessing ADHD symptoms, and the IRS, assessing functional impairment, suggest low to moderate overlap, suggesting that these scales were measuring distinct constructs (see Table 2).

Measures of Parenting Alabama Parenting Questionnaire (APQ).  The APQ consists of 42 items rated on a 5-point scale (1 = never to 5 = always) that assess the five parenting constructs (i.e., Parental Involvement, Positive Parenting, Inconsistent Discipline, Monitoring and Supervision, and Corporal Punishment) related to conduct problems and delinquency in children. For the APQ subscales of Involvement, Positive Parenting, and Inconsistent Discipline, higher scores suggest greater use of each skill. In contrast, for the APQ subscale Monitoring and Supervision, higher scores suggest less use of the skills. For the five subscales related to the constructs of parenting, adequate internal consistency and test–retest validity have been demonstrated (Shelton, Frick, & Wootton, 1996). Analysis of internal consistency using the current sample was found to be low to high (range of α = .56 for Corporal

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Lowry et al. Punishment to .88 for Positive Parenting). The alpha level for the Corporal Punishment subscale was below .70, an acceptable alpha level for research, so it was not included in the analyses. Furthermore, the Monitoring and Supervision subscale was not included in the analyses due to the low variability in scores among parents. Thus, in the present study, only the parental Involvement, Positive Parenting, and Inconsistent Discipline subscales were analyzed. Caregiver Strain Questionnaire (CGSQ).  A 20-item version of the CGSQ was used for the current study. One item (“your child getting trouble in school”) was omitted. The measure is rated on a 5-point scale (0 = not at all to 4 = very much) that has caregivers assess the impact of caring for a child with severe emotional or behavioral issues. Items on the CGSQ tap into caregiver’s perceptions of problems such as financial strain, feelings of isolation, anger, and guilt across three subscales: Objective, Internalized, and Externalized Strain. The CGSQ has previously demonstrated high internal consistency for the entire measure, and adequate to high consistency for the three subscales (Brannan, Heflinger, & Bickman, 1997). Higher total scores on the CGSQ suggest greater caregiver strain. In this study, the overall score from the CGSQ was used as a measure of overall caregiver strain. For the current sample, the internal consistency was found to be high for the CGSQ overall score (α = .91).

Table 3.  Means and Standard Deviations for Self-Report, Other-Report, and Observation Measures. Mothers Scale CGSQ Total PSOC Total APQ Positive Parenting APQ Involvement APQ Inconsistent Discipline ASRS Self ASRS Other IRS Self IRS Other   DPICS Negative Talk DPICS Commands DPICS Praise

M

SD

(N = 79) 2.48 0.78 3.06 0.62 3.23 0.57 3.83 0.49 2.36 0.61 1.54 0.79 1.28 0.66 1.70 1.38 1.60 1.73 (n = 45) 0.53 0.43 1.40 0.27 0.56 0.48

Fathers M

SD

(N = 79) 2.31 0.61 3.10 0.62 3.90 0.66 3.44 0.56 2.40 0.58 1.61 0.76 1.82 0.93 1.73 1.45 1.98 1.70 (n = 45) 0.57 0.49 1.29 0.28 0.51 0.45

Note. CGSQ = Caregiver Strain Questionnaire; PSOC = Parenting Sense of Competence Scale; APQ = Alabama Parenting Questionnaire; ASRS = Adult ADHD Self-Report Scale; IRS = Impairment Rating Scale; DPICS = Dyadic Parent–Child Interaction Coding System. DPICS Negative Talk, DPICS Commands, and DPICS Praise were transformed due to skewed distributions. An average for each item was calculated for all measures and measures were grand mean centered resulting in total scores ranging from 0 to 4.

Parent Sense of Competency (PSOC).  The PSOC is a 16-item measure rated on a 6-point scale (1 = strongly disagree to 6 = strongly agree) used to assess parents’ satisfaction (e.g., positive feelings about parenting) and efficacy (e.g., ability and competence in parenting; Johnston & Mash, 1989). Parents are asked to respond to statements such as “Being a parent makes me tense and anxious” and “My talents and interests are in other areas, not in being a parent.” On the PSOC, higher self-reported scores suggest lower parent satisfaction and efficacy. Previous research has demonstrated adequate validity and internal consistency for use with community samples of mothers and fathers (Ohan, Leung, & Johnston, 2000). Using the current sample, internal consistency was adequate (α = .79).

and developmentally appropriate toys that were used to facilitate parent–child interactions (e.g., train set, marble race construction kit). For the present study, observer codes of frequency counts of Total Commands, Total Praise, and Total Negative Talk across the child-directed, parent-directed, and cleanup segments were used. Following the guidelines of McGraw and Wong (1996), interclass correlations (ICCs) were calculated using a one-way random effects model. Using criteria recommended by Cicchetti (1994), ICCs for Total Commands (ICC = .91) and Total Praise (ICC = .84) were excellent and the ICC for Total Negative Talk (ICC = .71) was good.

Behavioral observations.  For 45 of the families, behavioral observations on the Dyadic Parent–Child Interaction Coding System–II (DPICS-II; Eyberg, Bessmer, Newcomb, Edwards, & Robinson, 1994) were collected (for the remainder of families, an experimental observation procedure was used as part of a measure development process and these outcomes are not reported herein). The DPICS-II measures behavior in child-directed, parent-directed, and cleanup interactions. The DPICS-II has demonstrated sensitivity to measuring outcomes for fathers (Schuhmann, Foote, Eyberg, Boggs, & Algina, 1998). Observations were collected in a laboratory room outfitted with a table, chairs,

Data Analysis

Results Prior to statistical analyses, all variables were assessed for non-normal distributions (Tabachnick & Fidell, 1996). Variables that displayed a departure from normality (i.e., DPICS variables) were log-10 transformed prior to analyses. The majority of variables had skewness and kurtosis statistics within acceptable limits (range = −1 to +1). Table 3 displays the means and standard deviations for all relevant variables. Given the hierarchical structure of the data (mothers and fathers nested within families), and that parental ADHD

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Table 4.  Multi-Level Model Coefficients and Standard Errors for Parent-Reported Stress and Satisfaction. CGSQ total Source Intercept DBD Parent Gender ASRS Self IRS Self ASRS Other IRS Other Parent Gender × ASRS Self Parent Gender × IRS Self Parent Gender × ASRS Other Parent Gender × IRS Other

Coefficient 2.41*** 0.43** 0.07 −0.01 0.26*** −0.00 −0.04 0.05 0.09 −0.01 −0.05

PSOC total SE 0.06 0.14 0.04 0.07 0.05 0.07 0.05 0.08 0.06 0.07 0.05

Coefficient 3.07*** 0.11 −0.12 0.05 0.23*** 0.03 −0.05 −0.06 −0.03 −0.02 0.04

SE 0.05 0.11 0.05 0.08 0.06 0.08 0.05 0.08 0.06 0.08 0.05

Note. N = 79. Coefficients may be interpreted as unstandardized regression coefficients (Campbell, Simpson, Boldry, & Kashy, 2005). With the exception of Parent Gender, which was effect coded (male = −1, female = 1), all predictor variables were grand mean centered. CGSQ = Caregiver Strain Questionnaire; PSOC = Parenting Sense of Competence Scale; DBD = Disruptive Behavior Disorder; ASRS = Adult ADHD Self-Report Scale; IRS = Impairment Rating Scale. **p < .01. ***p < .001.

may interact with other aspects of family functioning (Williamson & Johnston, 2013), the relationship between parental ADHD and parenting was measured using a multilevel model, or hierarchical linear model (HLM; Raudenbush, Bryk, & Congdon, 2002). All models were estimated in SPSS using MIXED with restricted maximumlikelihood estimates and a heterogeneous compound symmetry covariance structure as recommended by Kenny, Kashy, and Cook (2006) to allow heterogeneity of variance across mothers and fathers. Because the Level 2 units (i.e., families) include only two cases (i.e., mothers and fathers), only the intercept was allowed to vary freely. All other effects were constrained to be equal across families. With the exception of parent gender, which was effect coded (male = −1, female = 1), all predictor variables at Levels 1 and 2 were grand mean centered. The primary purpose of this study was to measure the extent to which parenting is related to parental ADHD symptoms and parental functional impairment associated with ADHD. Given that parents with ADHD, particularly fathers, may over endorse how well they are parenting (Hoza, Waschbush, Pelham, Molina, & Milich, 2000; Lui et al., 2013), an additional goal of this study was to investigate the effect of parent gender on observed outcomes. Therefore, the Level 1 model included main effects for parent gender as well as self- and otherreport for the ASRS and functional impairment (i.e., the IRS). The Level 1 model also included two-way interactions between parent gender and each of the self- and other-report measures (i.e., ASRS and IRS). At Level 2, the average score of child ADHD symptoms on the DBD was entered as a predictor of the Level 1 intercept to control for the main effect of the severity of child behavior on parenting variables. This model was used to test the relationship of parental ADHD symptoms and ADHD-related impairment in functional

impairment with the following measures of parenting and parenting perceptions: PSOC Total Score, CGSQ Total Score, APQ (Inconsistent Discipline, Positive Parenting, and Involvement subscales), and DPICS-coded observations of parenting (Total Commands, Total Praise, and Negative Talk composites). CGSQ.  Coefficient estimates and standard errors for CGSQ are reported in Table 4. Parents’ self-ratings on the IRS emerged as a significant main effect of caregiver strain (b = 0.26, t = 4.76, p < .001). Parents reporting more impairment in functional impairment also reported experiencing more negative events and emotions impacting their life as a result of parenting a child with behavioral issues. A significant main effect of the child DBD average score was also found indicating that higher ADHD symptom scores for the child were associated with higher scores on the CGSQ (b = 0.43, t = 3.04, p < .01). Furthermore, there was a significant parent gender main effect on the CGSQ. Being a mother was associated with report of experiencing more caregiver strain (b = 0.081, t = 2.069, p < .05). PSOC.  Table 4 displays coefficient estimates with standard errors and two-tailed significance for outcome variables related to parenting satisfaction. We predicted that parents experiencing more ADHD symptoms and higher levels of functional impairment would endorse lower levels of overall parenting competence. This prediction was partially supported. As reported in Table 3, the main effect for self-ratings of impairment in functioning was a significant predictor for parenting sense of competence (b = 0.23, t = 3.92, p < .001). Levels of functional impairment among parents were negatively related to PSOC. No other predictors were significant for the PSOC overall score.

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Lowry et al. Table 5.  Multi-Level Model Coefficients and Standard Errors for Parent-Reported Parenting Practices. APQ Involvement Source Intercept DBD Parent Gender ASRS Self IRS Self ASRS Other IRS Other Parent Gender × ASRS Self Parent Gender × IRS Self Parent Gender × ASRS Other Parent Gender × IRS Other

Coefficient 3.66*** −0.11 0.20*** 0.13* −0.12* −0.03 −0.05 −0.06 0.04 0.05 −0.05

SE 0.05 0.11 0.03 0.07 0.05 0.06 0.04 0.07 0.05 0.06 0.04

APQ Positive Parenting

APQ Inconsistent Discipline

Coefficient

Coefficient

4.08*** 0.06 0.17*** 0.18* −0.16** −0.06 0.00 −0.03 0.08 0.04 −0.08

SE 0.06 0.13 0.05 0.08 0.06 0.08 0.05 0.09 0.06 0.08 0.05

2.38*** 0.09 −0.06 0.16* 0.05 −0.13 0.05 −0.13 −0.04 −0.01 0.03

SE 0.06 0.12 0.04 0.08 0.05 0.08 0.05 0.08 0.06 0.07 0.05

Note. N = 79. Coefficients may be interpreted as unstandardized regression coefficients (Campbell, Simpson, Boldry, & Kashy, 2005). With the exception of Parent Gender, which was effect coded (male = −1, female = 1), all predictor variables were grand mean centered. APQ = Alabama Parenting Questionnaire; DBD = Disruptive Behavior Disorder; ASRS = Adult ADHD Self-Report Scale; IRS = Impairment Rating Scale. *p < .05. **p < .01. ***p < .001.

APQ.  Coefficient estimates and standard errors for models involving APQ subscales are reported in Table 5. Being a mother was associated with reporting more parental involvement (b = 0.20, t = 5.73, p < .001). Interestingly, parent report of more severe symptoms of ADHD was associated with more involvement in parenting (b = 0.13, t = 2.04, p < .05). On the contrary, more severe functional impairment was associated with less involvement in parenting (b = −0.12, t = −2.59, p < .01). Being a father was related to report of less engagement in positive parenting behaviors (b = 0.17, t = 3.69, p < .01). Furthermore, parents who reported more symptoms of ADHD also reported engaging in more positive parenting (b = 0.18, t = 2.19, p < .05), whereas parents who reported greater functional impairment reported engaging in fewer positive parenting behaviors than did parents who reported lower levels of impairment (b = −0.16, t = −2.77, p < .01). With regard to APQ inconsistent discipline, parents who reported more impairment also reported engaging in more inconsistent discipline than did parents who reported less impairment (b = 0.16, t = 2.16, p < .05). Observations of parenting behavior.  Coefficient estimates and standard errors for models involving observed parent behaviors are reported in Table 6. No other significant main effects or interactions were found for parents’ total praise scores. Mothers were observed to issue more commands during the observations than fathers (b = 0.049, t = 2.28, p < .05). A significant interaction emerged for parent gender and ASRS other report (b = −0.10, t = −3.02, p < .01) as well as parent gender and IRS self-report (b = −0.09, t = −2.05, p < .05). For Total Negative Talk, a significant interaction was observed for parent gender and partner ratings of

ADHD symptoms (b = −0.21, t = −2.92, p < .01). The negative coefficient indicates that for fathers, greater reports of other reported ADHD symptoms reported by the mother were associated with more observed negative talk. In contrast, for mothers, greater reports of other reported ADHD symptoms reported by the father were associated with lower negative talk. A main effect for other report of ADHD was also a significant predictor (b = −0.15, t = −2.15, p < .05); however, due to the significant interaction, the main effect is not interpreted.

Discussion Parents with elevated ADHD symptoms may have more difficulty engaging in positive parent–child interactions (Harvey et al., 2003; Mokrova, O’Brien, Calkins, & Keane, 2010; Murray & Johnston, 2006). However, what is currently known about parents with ADHD has been limited primarily to mothers using a categorical ADHD diagnosis (Chronis-Tuscano et al., 2011; Chronis-Tuscano et al., 2008; Chronis-Tuscano et al., 2010). The present study explored the extent to which parent dimensional ADHD symptomatology and functional impairment were associated with parenting beliefs and behaviors among mother– father dyads using a multi-method, multi-level assessment approach. First, our findings suggest that parent self-report of functional impairment was associated with experiencing more difficulties related to one’s role as a caregiver (i.e., scores on the CGSQ). Child impairment ratings, based on the DBD Interview, were also found to be associated with increased negative feelings on the CGSQ. Second, our prediction that parental ADHD symptoms and functional impairment

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Table 6.  Multi-Level Model Coefficients and Standard Errors for Observed Parenting Behaviors. DPICS Negative Talk Source Intercept DBD Parent Gender ASRS Self IRS Self ASRS Other IRS Other Parent Gender × ASRS Self Parent Gender × IRS Self Parent Gender × ASRS Other Parent Gender × IRS Other

Coefficient 0.52*** −0.05 −0.05 0.09 0.04 −0.15* −0.04 0.16 −0.10 −0.21** 0.03*

SE 0.06 0.14 0.04 0.08 0.05 0.07 0.04 0.08 0.06 0.07 0.05

DPICS Total Commands Coefficient 1.34*** 0.03 0.05* 0.02 0.04 −0.02 0.00 0.08 −0.10** −0.09* 0.04

SE 0.04 0.09 0.02 0.04 0.03 0.04 0.03 0.05 0.03 0.04 0.03

DPICS Total Praise Coefficient 0.55*** 0.03 0.04 0.11 −0.03 −0.01 0.02 0.02 −0.07 0.02 −0.02

SE 0.06 0.15 0.04 0.08 0.06 0.08 0.05 0.09 0.06 0.08 0.05

Note. n = 45. Coefficients may be interpreted as unstandardized regression coefficients (Campbell, Simpson, Boldry, & Kashy, 2005). Parent Gender was effect coded (male = −1, female = 1), other predictor variables were grand mean centered. DPICS = Dyadic Parent–Child Interaction Coding System; DBD = Disruptive Behavior Disorder; ASRS = Adult ADHD Self-Report Scale; IRS = Impairment Rating Scale. *p < .05. **p < .01. ***p < .001.

would be associated with lower levels of parenting competence was partially supported. Third, we found that experiencing more ADHD-related symptoms was associated with engaging in more positive parenting practices. Parents reporting more difficulty related to impairment reported the lowest levels of parent involvement and positive parenting, and reported less consistency in parenting. Fourth, we found differences among mother and father report of parenting behavior. When examining direct observations of parenting behaviors, significant associations with parent gender and parental ADHD symptoms based on partner ratings were found. Each of these findings will be discussed in turn. When examining parents’ beliefs connected with their role as a caregiver, we found that functional impairment was associated with increased feelings of caregiver strain. Experiencing elevated levels of caregiver strain, or increased stress (financial, health, etc.) due to caring for a child with emotional/behavioral difficulties (Brannan et al., 1997), seems plausible when an individual has difficulty managing his or her own mental health concerns. Furthermore, work by Mokrova and colleagues (2010) indicated that report of home chaos was higher among parents with ADHD symptomatology. A parent with ADHD who is caring for a child with ADHD may perceive his or her household as disorganized and disruptive. Thus, it seems likely that a parent specifically reporting functional impairment would also report feeling increased stress as a result of the impairment. In addition, mothers may report experiencing more negative emotions related to caregiving than fathers, given that women often assume the role of primary caregivers in a family (Family Caregiver Alliance, 2001). Exploring parents’ report of feeling confident and knowledgeable in their role as a parent, we found that parents

experiencing more functional impairment also reported less competent behaviors in their parental role. Previous work has identified mothers reporting high levels of ADHD symptomatology as experiencing less satisfaction and selfefficacy in comparison with mothers reporting lower levels of ADHD symptoms (Sonuga-Barke et al., 2002). In addition, these mothers also rated their children as having more behavioral difficulties. Similar findings were reported by Banks and colleagues (2008). In regard to parent report of specific parent practices, those experiencing elevated levels of ADHD symptoms reported the use of more positive parenting strategies and involvement with their children. In contrast, functional impairment was associated with less positive parenting, less involvement, and the use of more inconsistent discipline techniques. Previous research has highlighted that maternal ADHD is associated with less involvement, lower levels of positive parenting, and use of more inconsistent discipline (Chronis-Tuscano et al., 2008). Our findings provide a unique perspective on issues related to the experiences of an individual reporting general ADHD symptomatology versus the ways in which symptoms may manifest. Assessing impairment related to specific functional domains may provide a more adequate picture of a family’s current level of functioning. Differences between the parenting behaviors of mothers and fathers experiencing ADHD resulted in inconsistent findings. In regard to overall gender differences, mothers reported being more involved with their children and fathers reported use of less positive parenting strategies. When examining the role of parental ADHD, our findings were somewhat consistent with Harvey and colleagues (2003). Similar to Harvey and colleagues (2003), we found that fathers experiencing greater levels of ADHD symptoms

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Lowry et al. reported engagement in fewer, positive parent–child interactions. For mothers, greater levels of ADHD symptoms were associated with more negative parent–child interactions (Harvey et al., 2003). In our sample, mothers with more severe ADHD symptoms self-reported more consistency in discipline practices. Interestingly, our findings were specific to partner ratings of ADHD symptoms. Therefore, fathers’ report of mothers’ increased ADHD symptoms were associated with less maternal negative talk. For fathers, mothers’ report of increased ADHD symptoms was related to fathers’ use of more negative talk. These findings are in line with Williamson and Johnston (2013) but in contrast to Wymbs et al. (2014). More research is needed to further explore how partners view their significant other and whether ADHD symptomatology may be predictive of the difficulties related to parenting or whether there is an alternative explanation for these findings (e.g., relationship quality, child oppositional defiant disorder [ODD] behaviors). Overall, findings are in line with previous work such that parental ADHD was again shown to be positively associated with engagement in observed maladaptive parenting strategies (Chronis-Tuscano et al., 2008; Zisser & Eyberg, 2012). Parents who experience higher levels of ADHD symptoms and impairment had lower levels of satisfaction with parenting, reported less involvement, used more inconsistent discipline, and engaged in more negative talk with a child. Importantly, we observed differences among mothers’ and fathers’ reports of using various parenting strategies when we assessed for self- and other-report of ADHD symptoms and impairment. It is worth noting that much of the previous work on parental ADHD has used a comprehensive assessment of ADHD using both self- and collateral ratings as well as clinical interviews and measures for differential diagnosis that may better account for inattention or hyperactivity among parents (e.g., Chronis-Tuscano et al., 2008). In the current study, we used a dimensional approach to examining parental ADHD. Thus, we cannot diagnose parent psychopathology (i.e., ADHD), as our study did not include structured interviews and retrospective accounts of childhood ADHD symptoms, and we cannot rule out the presence of potential comorbid disorders that may include similar symptoms to those of ADHD (e.g., anxiety, mood disorders). Nevertheless, we attempted to follow current approaches to the conceptualization of ADHD status in adults through the use of self- and informant ratings (Chronis-Tuscano et al., 2008), and our approach is consistent with one that might be feasible for clinical settings where the main focus of assessment is on the child referred for treatment. Furthermore, due to the modest sample size and demographics of our parents, findings may not generalize to other populations of ethnically diverse parents. In addition, observational data were available for only half of the sample and

these findings need to be replicated with larger samples to ensure results were not due to low power to detect differences. An additional limitation of this study is that all parents had a child with ADHD, and these results may not generalize to families with children without ADHD. Last, our study is limited in that we were unable to include data on child IQ, child medication status, the presence of child or parent comorbid disorders, and family involvement in previous forms of treatment. Despite these limitations, this study contributes to the literature as it explored both mother and father ADHD status using collateral reports, and the impact of ADHD on self-reported beliefs as well as observed behavior. We highlight the need for future studies to continue to explore the impact of both mother and father ADHD status, with an emphasis on the need to include a systematic assessment of ADHD symptoms and impairment. In terms of clinical implications, findings suggest that parental psychopathology, specifically ADHD, may be an important factor to address during child treatment. As negative parent cognitions were associated with maternal ADHD symptoms, it may be important for child-related treatment to continue to address parent attributions for child misbehavior. It has been suggested that a combination of parent training and pharmacological intervention may be helpful in achieving positive outcomes for mothers with ADHD; however, it is important to address with mothers how parental ADHD symptoms may impede treatment to maximize outcomes (Chronis-Tuscano et al., 2010; Sonuga-Barke et al., 2002). Furthermore, an increase in father involvement in treatment may positively impact fathers’ parenting behaviors (Fabiano et al., 2012); by including both mothers and fathers in treatment, discussions surrounding issues such as co-parenting and family interactions can be facilitated, which may result in greater alignment between parents, an area of need (Williamson & Johnston, 2013). Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was funded by a grant from the National Institute of Mental Health 1R34MH078051.

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Author Biographies Lynda S. Lowry, MA, is a fourth-year doctoral student of Counseling, School, and Education Psychology at the University at Buffalo. Nicole K. Schatz, PhD, is a Postdoctoral Research Associate at Florida International University. Gregory A. Fabiano, PhD, is an associate professor of Counseling, School, and Educational Psychology at the University at Buffalo. His research interests are in the area of evidence-based assessments and treatments for children with ADHD. He is the author on over 50 peer-reviewed publications and book chapters, and his work has been funded by multiple federal agencies.

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