Parents perception of ADHD
Attention deficit hyperactivity disorder (ADHD) involves the display of developmentally inappropriate levels of inattention, impulsivity, and over activity resulting in functional impairment across two or more settings (APA, 1994). Attention deficit/hyperactivity disorder (ADHD) affects about three percent to seven percent of the school-age population (APA, 2000). This represents about two million children of the United States school systems (Snead, 2005, p. 2). The disorder is diagnosed much more often in boys than in girls. Females are traditionally thought to be at lower risk of ADHD than males; however, recent studies have indicated that girls also may be at increased risk of remaining undetected and untreated (Bussing et al., 1998). One commonly offered explanation for this is that attention-deficit disorder (ADD), which is presumed to be more common among girls (Lahey et al., 1994), may be less obvious to parents and therefore less likely to prompt help-seeking.
Children with this disorder are at higher risk than average children, conduct problems, and social relationship difficulties, as a function of the core symptoms of ADHD (Barkley, 1990). The disorder is chronic for most individuals and requires long-term treatment (Weiss & Hechtman, 1993). According to the Diagnostic and Statistical Manual of Mental Disorders (2000), in ADHD “the essential feature is a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than is typically observed in individuals at a comparable level of development” (p.78).
The rile of parents who raise children with ADHD is very significant as their perception and views on ADHD significantly impact how they raise and educate their children. The more perplexing question for parents over the years has been to find suitable strategies that could help them in handling their children with ADHD. The effectiveness of parent training program for modifying parenting perception by educating parents in parenting skills and communication to brig about positive behavioral changes in the child are well documented in the literature to parenting and childbearing (Anastopoulos & Shelton, 2001). The focus of PTP is to teach the parent how to apply social learning strategies (clear instruction, differential attention praise, time out) when interacting with their child and avoid coercive interchanges (Spitzer, Webster-Stratton, & Hollingsworth, 1991). Facilitators within the parent training program encourage parents to utilize learned strategies in naturally occurring opportunities to teach the child social skills and self-evaluation techniques to use when interacting with others in a social setting (Barkley, 1995). Evidence of the positive effect of parent training on parental interventions with children’s difficult behaviors has been a catalyst in PTP being suggested for parents of children with ADHD (Barkely, 1997; Hoza et al., 2000).
Father Role in the Family
Traditionally consideration of parental influences on children’s psychopathology within the literature has focused primarily on the role of the mother, many times neglecting to gather data on the effect of paternal involvement. In an examination of the literature on developmental psychopathology from 1984-1991, Phares and Compas (1992) found a continued underrepresentation of fathers in the literature of developmental psychopathology when compared with mothers even though fathers were found to play a significant role. Evidence suggests that fathers have significant influence on child’s learning behavior as compared to mothers.
Without consideration for the research most individuals today would say that mothers still spend the majority of the time with their children over fathers and bear the bulk of the responsibilities for care. There is some basis for this perception, Phares (1999) points out that when both parents are employed fathers spent about 33% of the time in direct interactions, 65% being available, and 10% being responsible for child well-being when mother time involvement was considered at 100% for comparison. However, Lamb (1986) points out that fathers are actually more involved when considered proportionately during times mothers are employed.
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Phares (1996) points out that when both parents are employed fathers showed greater responsibility in only one area in comparison with mothers and that was playing, however, activities such as bathing, transportation, teaching and night-time care showed similar levels of responsibility amongst parents although fathers have a tendency to incorporate play into these activities as well. When caretaking is considered fathers show that they are just as competent during the newborn period, it is the decrease in time spent in this caretaking role that serves to diminish the father’s sense of confidence in his parenting abilities which carries over as the child ages so that mothers are deferred to as the caretakers (Cath, Gurwitt, & Gunsberg, 1989; Lamb, 1986). In Marsiglio’s (1991) study of paternal engagement activities with minor children he found that: a) fathers with sons ages-5-18 spent time mostly in activities which were leisurely involving play or projects, b) were more active with their biological children and c) more education increased the likelihood that fathers read to and helped their children with homework. Findings from Russell and Russell’s (1987) study of mother and father-child relationships with children 6 to 7-years of age found: a) little evidence of father-son preference, b) a different relationship was indicated for boys and girls with their parents, c) mothers were found to be more directive as well as dominant and assertive than fathers, d) observational data contradicted self-report data that mothers engaged in more caretaking than fathers and e) the idea that fathers engage children more in play was supported. Wood and Repetti (2004) found that father involvement in care giving over a 3-year period was linked with and increased by the number of male children and the experience of life events (i.e., change in employment, financial changes).
Children with ADHD provide different challenges to parents as opposed children without psychopathology. In a discussion of the research, Phares (1999) points to the fact that both men and women experience feeling worse, greater distress and changed mood after interacting with a hyperactive and difficult child. Similarly, Crnic and Booth (1991) note that evidence suggests that stress is an important determinant of parenting. For example, fathers who had preschool children exhibiting behavior problems are shown to have a greater amount of role strain, depression and physical symptoms (Phares, 1996). Phares indicated that fathers of children with ADHD compared with non-ADHD children had shorter attention spans themselves, had feelings of hopelessness when it came to their child’s behavior problems and felt worse about themselves and their parenting abilities.
In a study looking at stress in married couples with an ADHD child, Baker (1994) found that mothers considered their children to be more stressful than fathers, while fathers felt significantly less attached to their children. In this same study, findings indicated that the stress which was related to child characteristics and the variance was influenced by total problem behaviors, fewer years of marriage, increased SES and a small percentage was affected by parent gender (Baker, 1994).
Longitudinal studies of the parent-child relationship provide a unique perspective in the literature. One of the findings from Gadeyne, Ghesquière and Onghena’s (2004) study investigating the relationship between parenting and child adjustment in a longitudinal analysis from kindergarten to second grade was that teacher rating of externalizing and attention problems were predictive of higher reported levels of mother control and lower levels of paternal support. The results of this study indicate the importance of considering parental control and support. A more recent study by Lifford, Harold andThapar (2008) conducted a 3-year longitudinal analysis of parent-child relationships. Specifically, they investigated displays of rejection and ADHD symptoms in school-aged children. Findings suggested that rejection in the father-child relationship exerts an effect on ADHD symptoms across and within time while ADHD symptoms appear to exert effects on the parent-child relationship for mothers. This study is critical in understanding not only the effects of ADHD symptoms and rejection in the parent-child relationship but also illustrates the differences which exist for both mothers and fathers in their relationships with children over time.
Fathers have different interactions, parenting, and attributions of their ADHD children when compared to mothers, some of which has already been discussed. Mother presence in the parent-child interaction is another factor which influences fathers parenting in the triadic situation. For example, Buhrmester, Camparo, Christensen, Gonzalez and Hinshaw (1992) found that fathers were not as demanding of their ADHD sons without their mother present but increased the level of demands when they were present, father involvement in the presence of the mother also increased when it came to child management allowing mothers to take a less controlling role.
In a study evaluating a parent education program for fathers of school-aged children, Levant and Doyle (1983) found an improvement in father’s communication skills over the control group with a decrease in undesirable but not desirable responses, an increase in general sensitivity, a change in father perception of family relationships as well as positive changes in child perceptions of their relationship with their father. This study was limited by its small sample size but did highlight that fathers are able to take away skills from parent training which they try to implement in their family in such a manner which serves to change relational perceptions. A larger study with 46 families of two-year olds perceived as behaviorally difficult aimed at increasing positive parent-child relationships and found that mothers showed benefits of participation while fathers did not show any significant effects of training which may have been influenced by the fact that 40% attended fewer than half the sessions (Gross, Fogg, & Tucker, 1995). Pre- and post-treatment affects of receiving parent training in connection with parent coping style, discipline and child behavior were investigated by McKee, Harvey, Danforth, Ulaszek and Friedman (2004). These authors found that for fathers their coping styles which were maladaptive and less adaptive in nature led to a disciplinary approach which was self reported as lenient before and after treatment but when fathers came into treatment as self reportedly less adaptive and less seeking of support a greater response to training was found (McKee et al., 2004).
In Danforth, Harvey, Ulaszek and McKee’s (2006) pre- and post-treatment study they discussed the effects of group parent training for mothers as well as fathers and changes inADHD children’s behavior. Fathers in this study were found to attend fewer sessions than mothers; however, they shared similar effects of participation such as a decrease in the number of behavior problems reported, less over reactive parenting, laxness and stress but change in praise and repeated directions was not found for either parent (Danforth et al., 2006). A similarity in the trend for treatment effect was suggested by these findings indicated that both parents have the potential to benefit equally from parent training. Two pre- and post-treatment studies were conducted by Webster-Stratton (1990, 1992) utilizing videotape modeling treatment for parent training and indicated different effects for fathers. In the Webster-Stratton (1990) study a small sample size of fathers impaired the ability to make significant findings. However, the second study conducted by Webster-Stratton (1992) found that compared to the wait-list control fathers receiving videotape treatment showed a significant reduction in the number of criticisms and no-opportunity commands used, children had fewer noncompliant and deviant behaviors in interactions with fathers and in a one-year follow-up fathers reported fewer child behavior problems. Parent-child interaction therapy (PCIT) is an evidence-based behavior parent training program often used in the treatment of preschool children who exhibit disruptive behaviors (Bagner & Eyberg, 2003). Three studies utilizing PCIT that explored father involvement and effects will be presented. In the first study conducted by Schumann, Foote, Eyberg, Boggs and Algina (1998), fathers were not only included but their results were analyzed separate from mothers which is a strength when the limited number of studies examining fathers in this way are considered. Findings within this study indicated that both parents felt more confident in controlling their child’s behavior causing them less distress, child compliance increased for fathers as well as mothers and parents interacted more positively with their children (i.e., more praise, less criticisms; Schumann et al., 1998). The second PCIT study to be discussed took a different approach with more of a focus on the impact of father involvement although father results were not discussed separately from mothers.
Bagner and Eyberg (2003) found that when father involvement was considered those families where the father was involved instead of absent had mothers who reported that they were able to maintain treatment gains at a 4 month follow-up which may indicate that when fathers are involved effect of involvement is seen soon after treatment. Another unexpected but suggestive finding from this study was the fact that when only mothers received treatment compared to father involved families the absent father families showed more improvements in child behaviors (Bagner & Eyberg, 2003). In the final PCIT study to be explored, Nixon, Sweeney, Erickson and Touyz (2003) looked at different levels of PCIT treatment for parents with oppositional preschoolers which included a standard and abbreviated format along with a waitlist control group and reported some effects for fathers. The finding for fathers indicated in this study was father reported decrease in child oppositional behavior post-treatment when receiving the PCIT abbreviated treatment compared to the waitlist control but not the standard treatment group, although other factors were explored in the results for mothers, this was the only effect discussed regarding fathers (Nixon et al., 2003).
Similar findings to Bagner and Eyberg’s (2003) study were found in other studies examining father inclusion. Martin’s (1977) study using brief family intervention which found that mother-child problems improved the same regardless of father inclusion. Support for this idea was also found in a study of the necessity of fathers in parent training groups conducted byFirestone, Kelly and Fike (1980). This study looked at parents of children 3 to 11-years old with conduct problems who were assigned to mother and father behavioral management training, a mother only treatment group and a wait-list group and found that father attendance in treatment was not necessary for behavior change to occur in the home (Firestone et al., 1980). Adesso and Lipson’s (1981) study conducting mother training, father training, couple training or no treatment each treatment group was effective in improving targeted behaviors and maintaining gains at a 3-month follow-up. Although, results in these studies may seem to imply that father attendance is not critical it is important to consider the alternative explanations which include that parents differing perceptions of behavior problems may lead to contradictory implementation of behavior strategies at home when they both receive training, fathers may not see behaviors as a problem to begin with leaving no room for improvement and it may be that in families were fathers were not involved in treatment mothers carried over and taught the management techniques to fathers successfully negating the fact that there was no explicit participation for these fathers in parent training. Also, the Adesso and Lipson (1981) study also indicated that fathers are as effective as mothers in learning behavior modification techniques as evidenced by the fact that the father training group was as successful as the mother training and couple training group.
A disruptive behavior disorder can affect not only the world of a child, but also the lives of his or her family. The stress of raising a child with a disruptive behavior disorder can impact parent-child relationships and create a difficult home environment. Therefore, when treating a child with a disruptive behavior disorder, it is important that clinicians can be assured that their treatment is not only alleviating a child’s symptoms, but is also working to decrease parent stress and improve familial functioning. One particular way to investigate this is by examining whether or not a child with Attention-Deficit/Hyperactivity Disorder’s (ADHD) participation in a Summer Treatment Program (STP) can affect decreases in their parents’ reports of stress. To unravel this question, an understanding of what parent stress is will be developed, the unique contributions of ADHD to parent stress will be investigated, other ADHD treatments that have been shown to reduce parent stress will be reviewed, the Summer Treatment Program will be outlined, and finally hypotheses regarding parents’ stress reports and a child’s participation in a STP will be presented.
Ask any parent if raising a child is stressful and they will immediately answer yes. Furthermore, parenting stress is ubiquitous. All parents, despite their own or their children’s characteristics, their economic status, or any other possible explanatory variable experience parenting stress to some degree (Deater-Deckard, 1998). What exactly it is that makes parenting stressful and how to define parenting stress, however, is an answer that is much more difficult to produce. Over the past several decades a number of researchers have attempted to define parenting stress, develop instruments to measure the amount of stress that a parent is experiencing, and develop models that explain the complex processes involved in parenting stress. These attempts have lead to great strides in the conceptualization of parenting stress and have informed both assessment and treatment for parents under stress. Deater-Decker (2004) defines parenting stress as, “a set of processes that lead to aversive psychological and physiological reactions arising from attempts to adapt to the demands of parenthood. This is often experienced as negative feelings and beliefs toward and about the self and the child. By definition, these negative feelings arise directly from the parenting role,” (p.6). This definition states that parenting stress must be directly associated with the demands of parenting. It also states that parenting stress involves not only negative feelings toward one’s own ability to function as a parent but also involves negative feelings toward the child. This definition points to the idea that parenting stress must involve parent factors and child factors. It also implies that the parent-child relationship can be affected by parenting stress. It is further the tension between the vast array of demands of parenting and the available resources to deal with these demands that determines the degree to which parents experience stress. The demands of parenting are many and include things such as meeting children’s typical survival needs, such as providing food, water, clothing, and shelter. It also includes more abstract demands such as providing children with love, support, affection, and attention (Deater-Deckard, 2004). Resources to cope with these demands are also varied and may be more difficult to access for some parents than others. They “include a host of mental and physical factors such as adequate protection.