Study of Level of Stress in the Parents of Children with Attention-Deficit/Hyperactivity Disorder

Abstract

Background: Parents who have children with attention-deficit hyperactivity disorder (ADHD) often experience high level of stress related to caring for their children. But not much research has been conducted in this area in India. This study aimed to assess the stress of parenting children with ADHD. Methods: This is a clinic based comparative study wherein the parents of fifty children with ADHD were compared with parents of 50 healthy children. DSM-IV diagnostic criteria for ADHD and Conner's Parent Rating Scale were administrated to diagnose and assess subtype of ADHD and the severity of ADHD respectively. Parental Stress scale (PSS) was used to examine subjective stress experienced by the parents. Results: Parents in the case group were more stressed than in control group and the difference was statistically significant. Stress was associated with all 3 subtypes of ADHD but it was highest with combined type and least with inattentive type. Also the combined subtype was the most severe form of ADHD.Conclusion: The results of the study highlight that the parents of children with ADHD experience immense stress. Combined subtype (CT) was the most severe form of ADHD while the inattentive subtype was the least severe one. Further CT was associated with the highest levels of stress in parents, probably because of its highest degree of severity.

Full text

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J. Indian Assoc. Child Adolesc. Ment. Health 2012; 8(2):25-37
Original Article
Study of Level of Stress in the Parents of
Children with Attention-Deficit/ Hyperactivity Disorder
Sujata Sethi*, Raghu Gandhi**, Vidhu Anand***
Department of Psychiatry, PGIMS, Rohtak.
*Senior Professor
**Junior Resident
***Internist
Corresponding Author: Dr. Sujata Sethi, 122/8, Shivaji Colony, Rohtak-124001,
Haryana, Email: reachsujatasethi@gmail.com
ABSTRACT
Background: Parents who have children with attention-deficit hyperactivity disorder
(ADHD) often experience high level of stress related to caring for their children. But not
much research has been conducted in this area in India. This study aimed to assess the
stress of parenting children with ADHD.
Methods: This is a clinic based comparative study wherein the parents of fifty children
with ADHD were compared with parents of 50 healthy children. DSM-IV diagnostic
criteria for ADHD and Conner’s Parent Rating Scale were administrated to diagnose and
assess subtype of ADHD and the severity of ADHD respectively. Parental Stress scale
(PSS) was used to examine subjective stress experienced by the parents.
Results: Parents in the case group were more stressed than in control group and the
difference was statistically significant. Stress was associated with all 3 subtypes of
ADHD but it was highest with combined type and least with inattentive type. Also the
combined subtype was the most severe form of ADHD.

26
Conclusion: The results of the study highlight that the parents of children with ADHD
experience immense stress. Combined subtype (CT) was the most severe form of ADHD
while the inattentive subtype was the least severe one. Further CT was associated with
the highest levels of stress in parents, probably because of its highest degree of severity.
Key words: attention-deficit/ hyperactivity disorder, parents, stress.
INTRODUCTION
Attention- deficit/hyperactivity disorder (ADHD) is one of the most common childhood
onset psychiatric disorders with a prevalence rates ranging from 10-20% [1]. ADHD is a
neurodevelopmental disorder characterised by hyperactivity, inattention and impulsivity.
Children with ADHD are defiant, more demanding of others and less able to play and
work independent of their parents and these difficulties are much more when ADHD is
combined with other comorbid conditions such as conduct disorder [3-4]. All these
differences add to stress of parenting. Parents of children with ADHD not only
experience more parenting stress and decreased sense of parenting competence but also
increased alcohol consumption, increased marital conflict, divorce and maternal
depression have been reported in them [2-4]. Studies done in this area have focused only
on parenting the children with ADHD and compared with children suffering from other
disorders. Further to the best of our knowledge there is no work from India in this area.
The index study was planned to measure the stress in parents of ADHD children and to
compare it with that in the parents of normal children.

27
MATERIAL AND METHODS
This was a clinic based comparative study conducted in the Department of Psychiatry, Pt.
B. D. Sharma University of Health Sciences, Rohtak from August, 2010 to September,
2011. The study was designed to test the hypothesis that the parents of children with
ADHD experience higher levels of stress than those of normal children.
Study sample:
50 consecutive children attending the psychiatry outpatient services, and their parents,
who met inclusion and exclusion criteria of the study were selected as cases. All selected
children were evaluated by the clinical psychologist for their intellectual functioning
(IQ). For the control group, 50 healthy children, of the same gender and age along with
their parents, were selected from purposively selected schools of Rohtak through
systematic random sampling using the attendance registers of students. The control group
was screened for ADHD with a clinical interview, and Child Behaviour Checklist
(CBCL) was used to rule out any other behavioural/emotional problems. The inclusion
criteria for children with ADHD group were i) age 4-16 years ii) current diagnosis of
ADHD according to DSM-IV, iii) drug naïve and that for normal children group were i)
age between 4-16 years ii) either gender. Only those parents who were staying with the
child for more than 2 years and provided written informed consent were included in the
study. Exclusion criteria for both groups included i) associated mental retardation, severe
sensory loss, language disorder, cerebral palsy and pervasive development disorder ii)
history of chronic medical illness or physical disabilities (ruled out with detailed history
and physical examination done by the investigators).

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Tools
A special performa designed for this study was used to gather socio-demographic
information about the children and their parents (both groups). DSM-IV [5] criteria for
ADHD were used to diagnose as well as to subtype the disorder. The behavior of children
with ADHD was assessed using Conners Parent’s 10 item abbreviated index [6] which is
an abbreviated version of the Conners Parent Rating Scale (CPRS) which originally has
93 items. It contains 10 items with rating from zero to three (0=not at all present, 1=just a
little present, 2=pretty much present, 3=very much present), with a range of possible total
scores between 0 and 30. The scale was completed by the investigators with the parents
rating their child’s symptoms from zero to 3.
Parents of children of both groups were assessed using Parental Stress Scale (PSS) [7] is
a self-report scale that contains 18 items representing pleasure or positive themes of
parenthood (emotional benefits, self-enrichment, personal development) and negative
components (demands on resources, opportunity costs and restrictions). Respondents are
asked to agree or disagree with items in terms of their typical relationship with their child
or children and to rate each item on a five-point scale: strongly disagree (1), disagree (2),
undecided (3), agree (4), and strongly agree (5). The 8 positive items are reverse scored
so that possible scores on the scale can range from 18 to 90. Higher scores on the scale
indicate greater stress. The scale is intended to be used for the assessment of parental
stress for both mothers and fathers and for parents of children with and without clinical
problems. This tool is a self-reported scale in English language. Hindi being the first
language of this part of India necessitated the translation of this scale into Hindi

29
vernacular, following the appropriate method of translation. (To check the translation
problems, it was then translated back to English by an independent translator who had no
knowledge of the tool.)
Normality of data was checked by Shapiro – Wilk test and the detailed statistical analysis
was done using appropriate parametric or nonparametric tests such as Chi Square test,
unpaired t test and one-way ANOVA.
RESULTS
Table 1 presents demographic description of the children and parents that constituted the
study sample. Participants in the two groups were demographically well matched. The
only significant difference between the two groups was found in literacy level of father (p
value = 0.019) reflecting higher literacy level of fathers in the control group. However, it
was not likely to affect our results much. Two groups did not show any statistically
significant difference in terms of profession and socioeconomic status.
The mean duration of illness was 2.5 years.

30
Table 1: Sociodemographic characteristics of study population
Variable Cases N=50 Controls
N=50
t/X2 P VALUE
Age ( Mean ±SD 8.64 ±2.126 9.24 ± 2.832 1.198* 0.234*
Gender
Male
Female
37
13
35
15
0.198†0.656†
School grade
1-5
6-10
45
5
34
16
11.28†0.257†
Birth order
1
2
3
5
32
16
1
1
31
15
4
0
2.85†0.416†
Locality
Rural
Urban
13
37
12
38
0.817†0.053†
Age of parents
Father (in years)
Mean ± SD
Mother (in years)
Mean ± SD
37.46 ± 3.20
34.62± 3.989
37.04 ± 5.49
34.3±6.021
0.467*
0.313*
0.642*
0.755*
Literacy level of father
Illiterate
Upto 5th
Upto 8th
Upto 10th
Upto 12th
Graduate
Post graduate
0
6
1
5
10
20
8
2
2
3
2
4
16
21
15.13†0.019†

Literacy level of
mother
Illiterate
Upto 5th
Upto 8th
Upto 10th
Upto 12th
Graduate
Post graduate
3
2
1
3
16
15
10
3
2
0
2
12
15
16
3.16†0.789†
Paternal occupation
Shopkeeper
Businessman
Doctor
Labourer
Teacher
Farmer
Lawyer
Engineer
Govt job
Unemployed
6
8
3
3
6
10
2
1
10
1
7
8
4
0
11
7
3
2
8
0
6.97†0.64†
Maternal occupation
Housewife
Unskilled worker
Self employed
Professional
31
1
0
18
24
1
1
24
2.75†0.43†
*unpaired t test
†Chi square test
Table 2 shows that the scores on the Parental Stress Scale were higher in the case group
than in the control group and the difference was statistically significant. [P value =
<0.001].
31

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Table 2: Comparison of level of stress in parents of ADHD and healthy children
Cases
[Mean ±
SD]
Controls
[Mean ±
SD]
t*
statisti
c
Sig.
(2-
tailed
)
Mean
Differenc
e
SE
Differen
ce
95%
Confidence
Interval of
the
Difference
Lowe
r
boun
d
Uppe
r
boun
d
PSS 52.98±10.3
38
36.68 ±
6.222
9.522 0.001 16.300 1.706 12.91
4
19.68
6
*Unpaired t test
39 out of 50 parents in the case group experienced significant stress whereas in the
control group only 5 parents were stressed [P value = <0.001] (Table 3).
Table 3: Association of stress in parents and ADHD in children
PSS Case (n=50) Control
(n=50)
X 2 * P
Stressed
(ie, scores 45 and above) 39 (78%) 5 (10%)
46.916* <0.001*
Not stressed
(ie, scores less than 45) 11 (22%) 45 (90%)
•Chi square test was applied
Table 4 shows that the stress was associated with all the 3 subtypes of ADHD but it was
the highest with combined type and the least with inattentive type. Also the combined
subtype seems to be the most severe form of ADHD.

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Table 4: PSS and Conner’s scores among various subtypes of ADHD
Type of
Scale Subtype of
ADHD N
Mean
score
Std.
Deviati
on
95% Confidence
Interval for Mean
F
statisti
c* P value
Lower
Boun
d Upper Bound
PSS Combined 34 56.24 9.692 52.85 59.62
6.473 0.003
Inattentive 8 45.5 9.725 37.37 53.63
Hyperactive
-impulsive 8 46.62 7.009 40.77 52.48
Total 50 52.98 10.338 50.04 55.92
Conner’
s
Combined 34 23.79 4.169 22.34 25.25 1
6.
0
2
5
<
0.
0
0
1
Inattentive 8 15.88 3.523 12.93 18.82
Hyperactive
-impulsive 8 18.38 3.503 15.45 21.3
Total 50 21.66 5.061 20.22 23.1
*one way ANOVA was applied
DISCUSSION
This study compared the level of stress in the parents of normal children and children
with ADHD. Results indicated that the parents of children with ADHD report
significantly higher levels of stress as compared to the parents of normal children as has
been reported by other researchers [2, 8-12].
Further, combined subtype (CT) was the most severe form of ADHD while the
inattentive subtype was the least severe one. When the level of parenting stress was
compared among various subtypes of ADHD, CT was associated with the highest levels
of stress in parents, probably because of its highest degree of severity. These findings are
in keeping with the previous studies by Ross et al [13] and West et al [14]. Yang et al
explored the cross-cultural variations of the nosological distribution in ADHD subtypes
and their relation to parental stress [15]. The results were in concordance with our study
that the parents of children with combined subtype of ADHD experience higher parenting

34
stress. But these findings are in conflict with other studies wherein the caregiver stress
was associated with inattentive subtype [11, 16-17].
Though the parents (in the case group) from joint families reported more stress
than those from the nuclear families, this difference was not statistically significant. Joint
family structure may seem to buffer and share the stress of parenting but the
relationships can be strained if the family members differ in their views regarding the
child’s illness, behavior and methods of coping. Kendall reported that children with
ADHD can isolate the families [18]. Also the behavior of children with ADHD can
adversely affect the relationship with extended family [19].
The index study however, has certain limitations. First, comorbid conditions such as CD,
ODD are quite common with ADHD but have not been taken into account here. Second,
there are other reasons such as shared genetic risk among family members, parenting
practices and child rearing attitudes eg; harsh disciplining, inconsistency, stressful and
conflicted family environments, parental psychiatric history eg; depression and anxiety in
mothers, and general life adversities which could add to parental stress. Third, physical
and/or psychiatric morbidity in siblings can be another source of stress for parents. Also,
though every effort was made to select the two groups quite similar, proper matching
would have been ideal. However, it would be difficult to control a large number of
confounding variables through matching.
The case control design, adequate sample sizes of the groups and similarity of socio-
demographics of two groups are the strengths of this study.

35
CONCLUSION
The results of the study highlight that the parents of children with ADHD experience
immense stress. Combined subtype (CT) was the most severe form of ADHD while the
inattentive subtype was the least severe one. Further CT was associated with the highest
levels of stress in parents, probably because of its highest degree of severity.
IMPLICATIONS
Stress in parents as a result of parenting children with ADHD can adversely affect the
child-parent relationship leading to psychopathology in both. There is a need to identify
the disorder at the earliest and to employ appropriate interventions so as to protect both
children with ADHD and their parents from its adverse consequences.
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