Parenting Behavior in Moms with ADHD

This article is from Attention Research Update, a free newsletter written by Dr. David Rabiner of Duke University that helps parents, professionals, and educators keep informed about new research on
AD/HD.  You can learn more about Attention Research Update, and sign up for a free subscription, at http://www.helpforadd.com

As awareness that ADHD frequently persists into adulthood has grown - as recently as the late 1980s, ADHD was still regarded as almost exclusively a disorder of childhood - increasing attention has been given to how ADHD impacts the lives of adults. Surprisingly, however, research on how ADHD may impact parenting behavior has been extremely limited.

In the extensive literature on how parenting behavior influences children's development, 3 aspects of parenting - parental monitoring, inconsistent discipline, and parental problem solving - have emerged as particularly important.

Parental monitoring involves tracking where a child is, what he or she is doing, and whom he or she is with. Poor parental monitoring has consistently been found to be strongly associated with poor child outcomes, particularly antisocial outcomes. It is also clear that monitoring becomes increasingly important as children make the transition to adolescence.

Inconsistent discipline refers to variability in parents' responses to child noncompliance - with parents sometimes punishing and sometimes reinforcing noncompliance by "giving in" to the child's demands. This inconsistent responding to negative child behavior has been shown to predict increases in oppositional and defiant behavior in children.

Finally, parental problem solving reflects the ability to generate multiple solutions for addressing child behavior problems, to accurately evaluate the likely effectiveness of different solutions, and to skillfully implement the chosen strategy. Less effective parental problem solving has been linked to negative child outcomes in a number of studies.

Although there are many other dimensions of parenting are important influences on children's development - a parent's warmth and affection towards the child is certainly one - the parenting dimensions described above have been widely studied and are frequent targets for change in parenting interventions. In fact, when parents improve their skills in these areas children's behavior problems decrease.

There is good reason to expect that parents with ADHD would have difficulty in these 3 aspects of parenting. Parents who have difficulty listening and attending may miss out on information that is important for carefully monitoring their child's activities and whereabouts.

Enforcing household rules consistently may be a struggle for a parent who acts impulsively or who becomes so absorbed in an activity that he or she does not notice a child's failure to comply.

Finally, effective problem solving requires the ability to refrain from acting impulsively with the first idea that pops into one's mind, and to instead systematically generate and evaluate different possibilities.

A recently published study in the Journal of Abnormal Psychology provides the first data on how parents with ADHD perform on these key parenting tasks (Murray & Johnston, 2006. Parenting in mothers with and without Attention-Deficit/Hyperactivity Disorder. JAP, 115, 52-61).

Participants were 60 mothers between the ages of 31 and 50. These mothers were recruited via notices in community centers, schools, libraries, newspapers, and local support groups for ADHD. Thirty of these mothers were diagnosed with ADHD based on a comprehensive and rigorous evaluation. The remaining mothers did not have ADHD and served as the comparison group. All of the mothers had at least one child between the ages of 8 and 14 who had been diagnosed with ADHD. This is important because it helps guard against the possibility that any group differences in parenting that were found could be attributed to the fact that moms with ADHD were more likely to be dealing with the challenges of parenting a child with ADHD.


- Measures -

Participants completed a variety of measures to assess their own functioning as well as their parenting. First, a structured clinical interview was administered to assess for psychiatric difficulties. Next, children's level of oppositional and antisocial behavior was assessed by having the moms complete a standardized behavior rating scale.

Well-established measures were administered to assess the key aspects of parenting - monitoring, consistency, and problem solving - noted above.

Monitoring - The Poor Monitoring Scale is a 10-item measure designed to assess a parents' knowledge of their child's friends, knowing where the child is after school, and the variety of activities that a child engages in. Sample items include:


"You ask your child about his or her day in school."

"You ask your child what his/her plans are for the coming day."

"Your child is out with friends you don't know."


Moms rated how often they engaged in these kinds of behaviors on a 1 "never" to 5 "always" scales so that high scores on this scale are indicative of a parent who is well informed about their child's whereabouts, activities and companions.

In addition to this measure of monitoring, each mother and child were asked a series of identical and specific questions about the child's social, academic, and leisure activities during the prior 24 hours. Moms and children were interviewed separately to insure that their answers were independent, and the number of nonmatching responses were used to compute an index of poor monitoring.


Inconsistency - Several validated parenting scales were used to assess moms' consistency in disciplining their child. Examples of items include:

"You threaten to punish your child and then do not actually punish him/her."

"Your child talks you out of being punished after he/she has done something wrong."


Moms rated how often they engaged in these kinds of behaviors on the same 1 to 5 scale noted above. High scores thus reflect more inconsistent discipline.


Problem solving - Parental problem solving was assessed by presenting mothers with 3 common child management problems, e.g., getting the child to comply with a request that he/she did not want to follow such as cleaning their room. Mothers were asked to discuss how they would solve the problem and their response was coded for the number of solutions they offered, the likely effectiveness of these solutions, and the level of planning indicated by the solutions. Response coding was done by research assistants who were blind to the study hypotheses as well as to mothers' diagnostic status.


Positive parenting - The final parenting measure administered was included to evaluate whether moms with and without ADHD differed in their positive parenting behaviors, e.g., affection, praise, etc. Sample items from this scale include:


"You compliment your child when he/she is doing something well."

"You hug or kiss your child when he/she has done something well."


Parents rated how often they engaged in each positive behavior on a 1 to 5 scale with high scores reflecting more positive parenting.


- Results -

Demographics, Psychiatric Problems, and Child Problems

Mothers with ADHD were more likely to be single parents and had lower levels of formal education. In addition, 70% of moms with ADHD had a mood or anxiety disorder compared to only 23% of the comparison moms. Interestingly, of the 16 moms with ADHD taking psychiatric medication, 15 were on antidepressant or antianxiety medication and only 1 was taking stimulant medication for ADHD. This is important in that it suggests that adults with ADHD may often fail to receive medication that specifically targets ADHD symptoms.

Mothers with ADHD also reported greater impairment in multiple domains of functioning and that their children had higher rates of oppositional and antisocial behavior.


- Parenting Behavior -

Monitoring - As predicted, moms with ADHD reported monitoring their children less carefully than moms without ADHD and the magnitude of the difference on the Poor Monitoring Scale would be considered to reflect a large effect. In addition, on the interview of children's activities during the prior 24 hours, moms with ADHD provided substantilly more answers that did not match their child, indicating less awareness of their child's activities.

Inconsistency - As predicted, moms with ADHD reported that they were significantly less consistent in their discipline behavior and the group difference was again large. Interestingly, the children of moms with and without ADHD did not report any differences in their mother's consistency.

Problem Solving - Although mothers with ADHD did not provide fewer solutions to the problem solving scenarios than other mothers, their solutions were judged to be lower in quality and to reflect lower levels of planning. Group differences were again large.

Positive Parenting - Based on both mother report and child report, there were no statistically significant differences between groups for the number of positive parenting techniques used.


- Secondary Analyses -

As noted above, moms with ADHD were more likely to have a mood or anxiety disorder, and also reported that their children displayed higher rates of antisocial behavior. Thus, it is possible that the differences found in parenting behavior reflect these differences rather than the presence or absence of ADHD. In other words, perhaps the poorer monitoring in moms with ADHD was not related to ADHD per se, but to anxiety and depression that interfered with their ability to monitor their child.

To rule out this explanation, supplementary analyses were conducted controlling for group differences in other psychiatric problems, in single parent status, and in child behavior problems. Even with these controls in place, parenting differences between mothers with and without ADHD remained evident.

The authors also examined whether parenting behavior in moms with ADHD varied as a function of ADHD subtype, i.e., inattentive ADHD vs. combined ADHD. Interestingly, mothers with the inattentive subtype of ADHD monitored their children less well than mothers with the combined type, and also reported that they were less consistent in their discipline practices.


- SUMMARY AND IMPLICATIONS -

Results from this study document the parenting difficulties experienced by mothers with ADHD. Compared to other mothers, moms with ADHD were less knowledgeable about their child's whereabouts, friends, and activities, were less consistent in their discipline strategies, and generated less effective solutions to child management problems. In most cases, the parenting differences between mothers with and without ADHD were large in addition to being statistically significant, with most effect sizes greater than 1. Despite these difficulties, however, they were no less positive than other moms in how they related to their child, and provided their child with similar levels of positive feedback and support.

The parenting differences found cannot be explained by the fact that moms with ADHD were more likely to be have mood and/or anxiety disorders, to be single parents, to have less formal education, and to have children with higher rates of disruptive behavior. This is because even when these factors were controlled for, parenting differences between the groups remained evident. Thus, while this study does not prove that ADHD "causes" the parenting difficulties reported, the results suggest that ADHD plays a central role in these difficulties.

It is interesting to note that mothers with the inattentive type of ADHD, i.e., those with inattentive symptoms but not hyperactive-impulsive symptoms, appeared to have greater difficulty with monitoring and consistency than moms with ADHD, Combined Type. Although these results are preliminary, the authors suggest that in mothers with inattentive and hyperactive symptoms, high levels of activity and energy may partially compensate for their attention difficulties and allow them to be more involved in their child's life, and thus better at monitoring their child.

The authors note several limitations to their study that are important to recognize. First, as already discussed, the design of this study does not allow clear conclusions to be made about whether ADHD is the specific cause of the parenting difficulties that were reported.

Second, parenting was assessed primarily by mothers' self-report and future studies should incorporate other ways to assess parenting behavior. For example, observations of mother-child interactions could allow a more objective assessment of maternal consistency. In cases of two-parent families, having spouses report on their partner's monitoring behavior would also be an enhancement.

Finally, it would be very helpful to conduct a similar study in fathers with ADHD. One cannot assume that the results obtained with mothers would also be found with fathers, and an understanding of how paternal ADHD may impact parenting and children's development is thus an important topic for future research.

Despite these limitations, this study extends our knowledge of ADHD in adults by clearly indicating that it is associated with difficulties in key parenting tasks for mothers. Because it has been estimated that between 40-60% of children with ADHD have at least one parent with ADHD, these results highlight the importance of taking this into consideration when implementing treatment for children with ADHD. Moms with ADHD, because they are less likely to supervise their child's activities or to have regular routines, may have difficulty administering medication consistently. They may also face particular challenges in traditional parent training programs, that emphasize the important of consistency, monitoring, and effective problem solving. Thus, effectively treating children for ADHD may frequently necessitate treatment of ADHD symptoms in parents as well.

While the results of this study represent an initial step in understanding how ADHD can impact parenting behavior, it is important to recognize that not all parents with ADHD struggle in the ways suggested here. It is also important to recognize that even in this sample, moms with ADHD were as positive and supportive as other moms. Thus, it is very important that one does not conclude from this study that moms with ADHD cannot be warm, supportive, and effective parents to their child.

Instead, an important contribution of this study is that by increasing awareness of the parenting difficulties that ADHD contributes to, it may facilitate more parents with ADHD obtaining effective treatment for the disorder. Such treatment would be expected to help address the parenting difficulties reported here, and thus contribute to more positive outcomes for children as well as parents. That would certainly be a wonderful outcome for this type of research.

David Rabiner, Ph.D.  Senior Research Scientist, Duke University