In what ways do parents' interactions with their child affect the development of children with ADHD? How can parents help promote the healthy development of their ADHD child? These are critically important questions for parents and clinicians, and research is beginning to provide us with information that helps answer them.

Currently, there is strong evidence that genetic factors are critically important in the development of ADHD and few scientists believe that "poor parenting" causes ADHD. Some scientists, however, have hypothesized that problems in parent-child interactions are associated with the exacerbation or continuation of ADHD symptoms. In addition, there is evidence that parenting can contribute to the development of behavioral problems such as Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD) in children with ADHD. This is important because the development of these additional problems is generally associated with poorer long-term outcomes.

This does not necessarily mean, however, that parenting directly causes the development of these co-occurring behavioral disorders. Instead, one view is that core ADHD symptoms of inattention and hyperactivity/impulsivity create special challenges in the parent-child relationship, and that ongoing challenges related to these characteristics can promote a pattern of parent-child interaction that contributes to the development of behavior problems. Thus, in this "transactional" view, parenting does not cause the development of ODD or CD. Instead, these behavior disorders emerge from a history of interactions between parent and child that may have their origins in the special challenges created by raising a child with the core symptoms of ADHD.

This begs the question: Which aspects of parenting are related to the development of these behavior problems in children with ADHD?

A study published in an issue of the Journal of Abnormal Child Psychology (Johnston, C. et al. (2002). Responsiveness in interactions of mothers and sons with ADHD: Relations to maternal and child characteristics, 30, 77-88) examined this interesting and important issue.

The authors hypothesized that "responsive parenting" (a parent's ability to appropriately adapt their behavior to their child's abilities, needs, requests, interests, and ongoing behavior) is especially relevant to understanding parent-child interactions among ADHD children. They then suggest "...monitoring and interpreting ongoing child behavior as the basis for adapting one's own behavior is more difficult when interacting with a child, who, by definition, displays impulsive, disorganized, and poorly-regulated behavior."
In other words, responsive parenting may be more difficult for parents of an ADHD child.

Because responsive parenting is important in helping children develop self-regulation skills (i.e. the ability to direct one's behavior in adaptive and organized ways), the authors argue that diminished parental responsiveness may be associated with increased severity of ADHD and ODD/CD symptoms in children with ADHD. This was the hypothesis they set out to test. They also were interested in whether depression would be related to parents' responsiveness with their child, and predicted that parents who reported more depressive symptoms would be rated as less responsive.

Participants in this study were 136 mothers and their ADHD sons. (Ideally, fathers would also have been included, but the sample was restricted to mothers.) All of the boys met criteria for ADHD, Combined Type. Thirty-eight percent of the boys had co-morbid ODD; 3% had co-morbid CD; 21% were co-morbid for both ODD and CD; and 38% had ADHD alone.

Mothers and sons participated in a series of interactions that were videotaped for subsequent analysis. These interactions lasted 17 minutes and consisted of 4 situations designed to elicit typical child-rearing conditions: 1) free play; 2) a situation in which mothers were required to complete a pencil and paper task while their sons were instructed to sit quietly; 3) a teaching task in which mothers instructed their sons to work on a math or handwriting exercise; and 4) a clean up period in which all toys and materials were supposed to be put away.

Multiple aspects of the mothers' behavior during these tasks were later rated on a 7-point scale. These included:

Authoritative Control - the extent to which the mother encouraged her child to participate in decision-making and offered explanation for commands, as opposed to using control strategies that relied on direct and harsh commands;

Sensitivity of Control - the degree to which the mother exerted control in a manner that was sensitive to the child's needs, as opposed to making demands that were unreasonable for the situation;

Responsiveness - the mother's ability to appropriately adapt her behaviors to the child's abilities, needs, requests, interests, and ongoing behavior;

Positive affect - the degree to which the mother displayed frequent and/or intense positive affect towards the child, as opposed to expressions of negative emotion;

Acceptance of the child - the degree to which the mother expressed approval, praise, and positive affection towards her son, as opposed to appearing cold and rejecting; and

Involvement with the child - the amount of time the mother spent in verbal and non-verbal interactions with her son, as opposed to engaging in solitary activities.

As noted above, each dimension was rated on a 7-point scale based on what was observed during the 17-minute interaction period. For all dimensions, higher scores were associated with more positive maternal behavior as judged by the raters.

In addition to rating mothers' behavior during the interaction with their sons, the researchers obtained several additional measures of maternal and child characteristics. They gathered information on the mothers' self-reported depressive symptoms and ADHD symptoms. They also had the mothers complete a measure that assessed their typical methods of disciplining their child. Finally, the researchers obtained ratings from both mothers and teachers of each child's ADHD symptoms and level of "conduct-disordered" behavior.

RESULTS

Prior to examining the main research questions, the authors examined the relationships among the different aspects of maternal behavior they coded. They found that ratings for authoritative control, sensitivity of control, responsiveness, positive affect, and acceptance of child were all highly correlated. Thus, rather than examining these ratings independently in relation to maternal and child characteristics, they formed a composite score that reflected mothers' ratings on these different dimensions. The label given to this overall composite of maternal behavior was "Responsiveness". Mothers with high responsiveness scores were those who demonstrated an ability to adapt their behavior to the needs, demands, interests, and abilities of their child.

Mothers' scores on this composite measure were negatively related to maternal, self-reported use of harsh parenting strategies and corporal punishment. This indicates that the observations of maternal behavior were significantly related to how mothers described their typical methods of disciplining their child. It also suggests that the behavior recorded during the videotaped interactions is a valid indicator of the mothers' behavior in the home.

As predicted, maternal reports of depression were negatively related to responsive parenting. Thus, mothers who were depressed demonstrated less of the responsive parenting style that the authors believe is important in the development of children's self-regulation skills. In contrast, mothers' reports of their own ADHD symptoms were not related to their responsive parenting score.

In addition, child conduct problems were negatively related to maternal responsiveness, indicating that mothers who displayed less-responsive parenting had children with higher levels of conduct-disordered behavior. This was true even after controlling for a variety of demographic factors (e.g. mother's age, marital status, and education) that might be expected to relate to children's behavior problems, Interestingly, maternal responsiveness was not related to the severity of children's ADHD symptoms.

SUMMARY AND IMPLICATIONS

Results of this study confirmed the authors' predictions that maternal responsiveness would be negatively and uniquely related to children's conduct problems. In seeking to explain this finding, the authors suggest that it reflects an interactive process whereby unresponsive parenting is associated with increased difficulties in a child's self-regulation skills. This deficit in self-regulation leads to increased oppositional behavior and conduct problems. This, in turn, is suggested to make it increasingly difficult for mothers to engage in responsive parenting behavior.

In contrast to the negative association between responsive parenting and conduct-disordered behavior, no association between responsive parenting and the severity of children's ADHD symptoms was found. The authors note this is consistent with the emerging consensus that family and parenting characteristics are more closely related to co-morbid ODD/CD behavior in children with ADHD than to the emergence and severity of core ADHD symptoms themselves. The authors note, however, that because their sample was restricted to boys with an ADHD diagnosis, they cannot be certain whether maternal responsiveness would have differed between boys with and without ADHD. This would require an additional study.

As predicted, a negative relationship between the mothers' depression and responsiveness also was found, such that more depressed mothers were judged to be less responsive to their sons. Although recognizing that conclusions about causality cannot be determined from this study alone, the authors suggest, "...a mother's experience of depressive symptoms may interfere with her ability to respond appropriately and sensitively to her child's behavior and this lack of responsiveness may create or exacerbate problematic child behavior." Thus, it is possible that depressive symptoms in mothers may initiate a cycle in which a reduction in responsive parenting, resulting from a parent's depressed mood, may lead to an initiation of conduct problems in a child with ADHD. Other causal relationships between these variables are certainly possible, however, and additional research would be required to help sort this out. For example, it may be that high levels of Conduct Disorder in children with ADHD lead to an increase in mothers' feelings of depression.

As with any study, it is important to be aware of the limitations in this report. The sample was restricted to boys, and whether these findings would generalize to girls with ADHD is unknown. It also is unclear whether similar results would be found for adolescent boys with ADHD, or whether responsiveness in fathers would be related to children's conduct problems in similar ways. In addition, the design of this study does not enable any firm conclusions to be made about whether low maternal responsiveness causes conduct problems in children with ADHD, or whether these factors are merely correlated.

Nonetheless, this study provides an important initial examination of how a particular aspect of a mother's behavior is related to behavioral problems in children with ADHD. The results suggest that psychosocial interventions in families of children with ADHD may be enhanced by focusing specifically on improving parental responsiveness. This would not be for the purpose of trying to reduce ADHD symptoms directly, but rather to reduce or prevent the development of children's conduct problems.

It is important to emphasize that, in making this suggestion, the authors are in no way "blaming" parents for their child's conduct problems. Certainly, there are multiple factors that can contribute to a parent's difficulties relating to their child in a "responsive" manner.

It is also very important to note that "responsive" parenting is not synonymous with "permissive" parenting, and these findings in no way mitigate the importance of parents providing children with clear, consistent, and appropriate limits on their behavior. In fact, in prior research ineffective discipline strategies have also been linked to the development of children's conduct problems.

The findings do suggest, however, that parents may benefit from a careful appraisal of whether they have entered a negative cycle with their child that has made it more difficult for them to engage in "responsive parenting". If this has occurred, it is important to initiate efforts to make the necessary changes. The pay-off for these efforts may be better parent-child relations and reduced behavioral difficulties in children with ADHD.