Raising an ADHD Child: An Examination of Maternal Well-Being in Canada and the United States

by

Patricia Elizabeth Neff April 7, 2008

A dissertation submitted to the Faculty of the Graduate School of

the State University of New York at Buffalo in partial fulfillment of the requirements for the

degree of Doctor of Sociology

Department of Sociology

Copyright by

Patricia Elizabeth Neff 2008

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ACKNOWLEDGEMENTS

The members of my dissertation committee, Sampson Lee Blair, Marilou Blair, and

Robert Wagmiller, have generously given their time and expertise to advance my work. I

thank them all for their contributions and their invaluable advice and guidance. In

particular, I am especially grateful to my dissertation chair, Sampson, for investing his

time and traveling with me to McMasters University in Hamilton, Ontario, Canada to

assist in data analysis. Over the past five years, he has fed my intellectual curiosity as

well as my stomach; teased and tormented me; and pushed me to do things I was afraid of

failing at. I couldn’t have asked for a better mentor. I also owe a special thanks to

Robert for spending many hours commenting and expanding on drafts of this dissertation.

He has helped me to learn new things and develop indispensable skills which I will be

able to use for years to come. Lastly, I would like to thank my editor, my mom, for her

continuous support and encouragement throughout my graduate career.

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TABLE OF CONTENTS

ACKNOWLEDGEMENTS……………………………………. ………………………..iii TABLE OF CONTENTS…………………………………………………………………iv LIST OF TABLES……………………………………………………………………….vii ABSRACT……………………………………………………………………………….vii CHAPTER 1. INTRODUCTION......................................................................................................1 Definitions and Consequences of ADHD……………………………………………..1 Theoretical Framework………………………………………………………………..3 Objective………………………………………………………………………………6 Rational………………………………………………………………………………..7 Data……………………………………………………………………………………8 Contributing Factors of Maternal Well-being…………………………………………8 Expected Findings……………………………………………………………………..9 2. REVIEW OF THE LITERATURE………………………………………………11 The Diagnostic Reach of ADHD…………………………………………………….13 The Treatment and Management of ADHD…………………………………………23 The Mother-Child Relationship……………………………………………………...28 Maternal Stress, Pathology and Marital Discord in Families of ADHD children…...29 Maternal Contributions to ADHD…………………………………………………...31 Evidence of Mother Blame…………………………………………………………..32 The Influence of Social Support on Maternal Well-being…………………………...33 Distinctions between Canadian and American Families of ADHD children………..40

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Summary……………………………………………………………………………..47 3. DATA AND METHODOLOGY………………………………………………….50 National Longitudinal Interview Survey (NHIS)……………………………………50

Dependent Measure: Maternal Well-being…………………………………………..51

Independent Measures……………………………………………………………….51

Social Support………………………………………………………………..52

The Behavior of the Child……………………………………………………52

National Longitudinal Survey of Children and Youth (NLSCY)………...………….54

Dependent Measure: Maternal Well-being…………………………………………..55

Independent Measures……………………………………………………………….55

Social Support………………………………………………………………..56

The Behavior of the Child……………………………………………………57

Sample Population…………………………………………………………………...59

Analytical Plan to Address Study Questions………………………………………...60

4. CANADIAN FINDINGS……………………………………………………...…...62

Means………………………………………………………………………………...62

OLS Regressions……………………………………………………………………..69 5. AMERICAN FINDINGS……………………………………………………...…..81 Means………………………………………………………………………………...81 OLS Regressions……………………………………………………………………..88 6. CONCLUSION AND DISCUSSION...…………………………………………...98 Hypothesis 1………………………………………………………………………...100 Hypothesis 2………………………………………………………………………...101

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Hypothesis 3………………………………………………………………………...102 Limitations and Suggestions for Future Research………………………………….103 Summary……………………………………………………………………………104 REFERENCES…………………………………………………………………………105

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LIST OF TABLES

Table 1 (CA): Mean levels of Maternal Well-Being by the ADHD Status of the Child………………..64 Table 2 (CA): Mean levels of Maternal Social Support by the ADHD Status of the Child……….........66

Table 3 (CA): Mean levels of Family and Child Characteristics by the ADHD Status of the Child……68

Table 4 (CA): OLS Regression Coefficients (unstandardized) for Relationship between Maternal Well-being, Social Support, Family Characteristics and the ADHD Status, Medication Use and Behavior of Child…………………………………………………………………....71 Table 5 (CA): Table 5 (CA): OLS Regression Coefficients (unstandardized) for Relationship between Maternal Well-being, the ADHD Status of Child, Family Characteristics and Selected Interaction Terms…………………………………………………………..76 Table 1 (US): Mean levels of Maternal Well-Being by the ADHD Status of the Child………………..83 Table 2 (US): Mean levels of Maternal Social Support by the ADHD Status of the Child……….........85

Table 3 (US): Mean levels of Family and Child Characteristics by the ADHD Status of the Child……87

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Table 4 (US): OLS Regression Coefficients (unstandardized) for Relationship between Maternal Well-being, Social Support, Family Characteristics and the ADHD Status, Medication Use and Behavior of Child…………………………………………………………………....90 Table 5 (CA): OLS Regression Coefficients (unstandardized) for Relationship between Maternal Well-being, the ADHD Status of Child, Family Characteristics and Selected Interaction Terms…………………………………………………………………….........................94

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ABSTRACT

Previous research indicates that mothers of ADHD children experience more

emotional stress, anxiety and depression than mothers of non-ADHD children. The

purpose of this study is to examine the influence of having an ADHD child on maternal

well-being, and to assess whether there are differences for Canadian and U.S. mothers.

Although, several researchers have investigated the relationship between parenting stress

and the occurrence of ADHD, few studies have examined the importance of social

support as a coping mechanism used to ease the maternal burden associated with raising

an ADHD child. This research is unlike related studies, in that it focuses on social

support as an important contributing factor of maternal well-being. Comparable data

from the 2001 U.S. National Health Interview Survey and the 2002 Canadian National

Longitudinal Survey of Children and Youth is used to examine the manners by which

mothers utilize their informal social support networks as a means of dealing with various

stressors related to childrearing. Given the differences in health care in the two countries,

cross-cultural comparisons between the United States and Canada may produce a greater

understanding of how mothers are impacted by an ADHD child. The central aim of this

research is to document similarities and difference, and to use such findings as evidence

for more effective policies to better assist mothers of ADHD children.

Chapter 1 Introduction

In many regards, the diagnosis and treatment of Attention Deficit Hyperactivity

Disorder in the United States and Canada is quite similar. Over the last several decades,

a growing number of school-aged children in both countries have become officially

diagnosed with the disorder and prescribed medication for its treatment. American and

Canadian children are generally diagnosed using the same clinical criteria, as stipulated

in the American Psychological Association’ s fourth edition of the Diagnostic and

Statistical Manual of Mental Disorders (DSM IV). Beyond similarities in diagnosis,

children in both countries are also often treated with the same brands of medication.

Additionally, mothers in Canada and the U.S. are typically exposed to the same types of

literature and informational materials about the disorder. Yet, apart from these parallels,

there are significant differences between the nations’ respective medical systems which

have a major bearing on the affordability of health care and routine access to social

services to assist ADHD children and their families. Canadian mothers’ access to cost-

free medical services (at point of service) suggests that they may be better situated to

cope with the associated difficulties of raising an ADHD child.

Definitions and Consequences of ADHD

Children with ADHD are distinguished by an excess of several behavioral

characteristics such as inattention, distractibility, restlessness, hyperactivity, and

impulsivity (American Psychiatric Association, 1994). While most children display these

behaviors to some extent, it is the excess of these behaviors which are thought to be

particularly problematic. Researchers have found that the presence of ADHD can

significantly impair the child’s ability to function successfully in a variety of social roles

1

and settings (Barkley, 1997; Quinn, 1997; Hallowell & Ratey, 1994). As the problematic

nature of the disorder suggests, increased caretaking demands exist for parents of

children with ADHD (Anastopoulos, et al., 1992; Barkley & Cunningham, 1980).

The behavioral characteristics of ADHD children have been found to significantly

add to the stress experienced by mothers. For example, children with ADHD have been

found to be generally less compliant with mothers’ requests, more often off-task and

distractible, as well as more demanding of attention and assistance in comparison to non-

ADHD children (Barkley & Cunningham, 1980; Mash & Johnston, 1983; 1982). Several

studies suggest that mothers of children with ADHD are significantly more likely to

experience stress, anxiety, and depression as a result of the increased caretaking

responsibilities associated with their child’s disorder (Fischer, 1990; Cunningham,

Benness & Siegel, 1988; Befera & Barkley, 1985). Lower parenting self-esteem and self-

confidence (Cunningham & Boyle, 2002) and greater family tension and interpersonal

conflict (Brown & Pancini 1989; Johnston 1996) have also been found to be greater

among mothers of ADHD children.

The emotional impact associated with raising an ADHD child is a relevant concern,

since children often display more behavioral problems in reaction to their parent’s

distress. Psychological distress can also impair the mother’s ability to manage the

behavioral manifestations of their child’s disorder, which reduces the child’s receptivity

to intervention and treatment. This in turn creates more stress and strain for mothers

(Fischer, 1990). Given the prevalence of ADHD in both Canada and the US, addressing

the issue of maternal stress is a vital concern for both health and educational

professionals dealing with ADHD children. However, little is known about how mothers

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cope with the heightened experience of psychological stress and family strain associated

with raising an ADHD child (Bussing, Shoenberg & Perwien, 2003).

Theoretical Framework

Social support is most commonly referred to as a coping resource or “fund”, made up

of family members, significant others and friends which people may draw upon in

stressful times of need or crisis (Thoits, 1995). Literature indicates that women are more

actively involved in social networks than men and are more likely to seek the support and

comfort of family and friends to deal with the occurrence of stress (Aneshensel, 1992).

Previous research has also demonstrated significant gender differences in symptoms of

stress and associated coping mechanisms. According to the socialization hypothesis, men

are socialized to use instrumental coping strategies to deal with stress; whereas women

are socialized to use emotion-focused coping strategies. In other words, men are more

likely to handle a problem by planning and executing individual strategies of action,

whereas women are more likely to seek the guidance and support of others to help solve a

problem (Levy-Shiff, 1999). The effects, or rather the symptoms, of stress have been

found to result in lower reported psychological wellbeing in women and greater physical

illness in men (Jick and Mitz, 1985). This indicates that social support may be more

important to the well-being experienced by mothers as compared to fathers.

The structure of an individual’s social support network is usually determined by the

number of social ties, types of relationships, and amount and quality of time shared

(Thoits 1995). Members of an individual’s social support network can offer instrumental,

informational and/or emotional aid (House & Kahn 1985) which is generally thought to

reduce or safeguard the impact of stressful incidents and ongoing strains (Cohen & Wills

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1985). Spousal support is considered to be the greatest coping resource available to a

parent (Nath, et al., 1991). However, other members of a social support network can also

play a significant role in meditating the effects of persistent stresses and daily hassles

commonly faced by mothers (Cooke, et al., 1988).

For parents, supportive aid may vary from problem solving assistance and

sympathetic ears, to household tasks and babysitting services (Marcenko and Meyers

1991). The capacity to cope with everyday family demands and childcare

responsibilities is highly related to sources and functions of a parent’s social support

network (Nath, et. al., 1991). Researchers have found that to some extent, stresses that tax

a parent’s personal resources can be alleviated by their access to social supports (Cooke,

et al., 1988). Theory would suggest that mothers of ADHD children who receive greater

levels of social support are in a better position to manage stresses associated with their

child’s disorder than mothers who receive lower levels of social support.

Several studies have investigated in to the various ways in which social support

influences the family. In particular, the benefits of social support have been associated

with positive family adjustment, greater maternal satisfaction, lower maternal stress

(Kazak and Martin, 1984), and reduced marital and parent-child conflict in families of

children experiencing an illness or handicap (Marcenko and Meyers, 1991). Yet, some

researchers have also suggested that social support can be potentially harmful and cause

even greater distress (Harris, 1992). Supportive attempts can sometimes be perceived as

intrusive and officious (Aneshensel, Pealin & Schuler, 1993). Additionally, increased

levels of stress and marital discord have also been associated with higher rates of family

involvement in personal affairs (Kazak and Martin, 1984).

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For some parents, the birth or presence of a handicapped child may adversely affect

pre-existing relationships with friends or relatives (McAllister, et al., 1973). In one

study, families with a severely handicapped child were found to be significantly less

likely to participate in social activities or visit with friends, relatives and neighbors than

parents without such a child (McAllister, et al., 1973). In another study, neighbors of

families with a handicapped child were reported to be more standoffish and tended to

only interact with, or offer assistance to non-handicapped siblings in the family

(McAndrew, 1976).

Although the significance of social support has been recognized in families with

children experiencing an illness or particular handicap (Kazak and Martin, 1984;

Marcenko and Meyers, 1991), few studies have extended those findings to explore the

use of social support as beneficial or harmful to mothers of ADHD children (Podolski

and Nigg, 2001). Despite a general lack of research on the subject, there is some

indication that mothers with ADHD children are lacking in coping resources, including

social supports. According to an early study, mothers of ADHD children participate in

social activities less often and report significantly higher levels of social isolation than

mothers of non-ADHD children (Mash and Johnston, 1983). Mothers of ADHD children

have also been found to have less contact with extended family (Malacrida, 2003) and

perceive supportive attempts made by family members as less helpful (Cunningham, at

al., 1988).

In her study of Canadian and British mothers with ADHD children, Malacrida finds

that almost all of the mothers she interviewed were met with personal and professional

conflict when searching to find ways to help their children. While professionals were

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often described as scrutinizing and suspicious, family members, friends and other parents

were often described as disapproving and confrontational. According to Malacrida, these

stigmatizing interactions significantly contributed to the mothers’ feelings of stress and

inadequacy as they struggled to come to terms with their children’s difficulties and to

find the appropriate means of help and support. Clearly the disputed status of ADHD has

serious social implications for mothers seeking recognition and understanding of their

child’s disorder, which may negatively impact their ability to secure support through

preexisting social networks. Yet, despite its relative importance, little is known about the

utilization of social support by mothers of ADHD children.

The ecological systems approach has frequently been applied to assess the

interpersonal dynamics of families with a handicapped child. As this theory purports, a

change or difficulty experienced by one family member ultimately impacts the entire

family as a unit and creates the need for family adjustment or adaptation. Research

designs incorporating the ecological systems approach to the study of the family have

highlighted the importance of social resources (Bernier and Siegel, 1994). Aside from

individual aspects of a child’s disorder, inadequate access to social support may

contribute to dysfunction in families of ADHD children.

Objective

The primary goal of this study is to examine the effects of having an ADHD child on

maternal well-being. Mothers of ADHD children are compared to mothers of non-

ADHD children in both the United States and Canada. This research also explores and

analyzes various dimensions of social support which are also important predictors of

maternal well-being. Although several researchers have investigated the relationship

6

between parenting stress and the occurrence of ADHD, few studies have examined the

influence of social support as a coping mechanism used to ease the parental burden

associated with raising an ADHD child.

Since Canadian mothers have access to cost-free medical care (at point of service)

and a greater array of social services available for themselves and their children, higher

levels of emotional well-being are expected to be found among mothers living in Canada.

American mothers of ADHD children are also expected to rely on more on sources of

support, such as friends and family, than Canadian mothers of ADHD children. Since

Canadian mothers of ADHD children are expected to place less strain on informal social

support networks, the support they receive is expected to have more of a positive effect

on their level of well-being.

Rational

The present research attempts to offer a contribution to our knowledge about the

stress experienced by mothers of ADHD children. Analysis for this study is designed in

an effort to understand the significance of social support as beneficial or harmful to the

well-being of mothers of ADHD children by testing for the effects of the child’s behavior

and ADHD status, and predictors of social support. American and Canadian mothers of

ADHD children are compared to their non-ADHD counterparts. This research attempts

to fill the void in cross-cultural comparative research of families with ADHD children.

This research is also unlike related studies, in that it focuses on social support as an

important contributing factor of maternal well-being. The knowledge gained from this

analysis may help to shed light on the situation of mothers and their ADHD children.

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Data

This research utilizes data from the 2001 U.S. National Health Interview Survey and

Cycle 4 of the Canadian National Longitudinal Survey of Children and Youth conducted

between 2000 and 2001. Canadian children and American mothers of children between

the ages of 8 and 12 were selected. Other caregivers such as grandparents were excluded

for the purpose of this analysis. Statistical weights were employed in the sample design

of both datasets. Due to limitations in the sample size of fathers of ADHD and non-

ADHD children, only mothers were included for the purpose of analysis. The net sample

includes 3,919 (97.3%) non-ADHD children and 110 (2.7%) ADHD children, which

equals to a total of 4,029 Canadian children. As for the American sample, there are a

total of 181 (6.0%) mothers of ADHD children and 2,819 (93.9%) mothers of non-

ADHD children, which equals to a total of 3,000 American mothers.

Contributing Factors of Maternal Well-being

It is necessary to conceptualize maternal well-being as a multi-dimensional variable

using a combination of factors. For the purpose of this study, maternal well-being is

defined by six variables of emotional health and measured by the respondent’s

perceptions of their well-being based on these variables. For both the Canadian and

American data, all of these items are measured using a 4 point scale with responses

ranging from ‘rarely or none of the time’ to ‘most or all of the time’. The use of these

variables will aid in making comparisons between the well-being of mothers of ADHD

children and mothers of non-ADHD children.

In the NHIS, the Strengths and Difficulties Questionnaire (SDQ), devised and

copyrighted by Robert Goodman (Goodman, 1997), is employed to obtain information

8

about a variety of behavioral problems displayed by children and its impact on family

functioning. The twenty-five item questionnaire measures emotional symptoms, conduct

problems, hyperactive behavior, peer relationships and pro-social behavior displayed by

the child. For the purpose of this analysis, all of the original items in the SDQ

questionnaire are combined into one multidimensional measure. High scores received on

the SDQ are associated with greater behavioral problems. In concordance with The

Strengths and Difficulties Questionnaire (SDQ) found in the NHIS, a multi-dimensional

measure of child behavior was constructed from 25 of the 39 related variables found in

the NLSCY. We can expect that both American and Canadian children with ADHD will

score higher on this behavioral measure than non-ADHD children. Mothers’ well-being

is expected to be negatively influenced by higher scores received on the SDQ in

comparison to mothers whose children score lower. Canadian children are more likely to

have a mother who is negatively affected by comparably higher behavioral problems.

Social support is measured by seven variables from the NHIS data which determine

the frequency of social contact and access to social support. A multi-dimensional

measure of social support is also constructed from the NLSCY data using 7 variables.

These variables measure respondents’ level of satisfaction with the social support that

they receive.

Expected Findings

After considering the proposed measures, we can hypothesize a number of ways in

which the predictor variables may influence the well-being of mothers of ADHD children

in either a positive or negative way. As previously mentioned, research on parenting an

ADHD child suggests that mothers of ADHD children experience significantly more

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stress, anxiety and depression in comparison to mothers of non-ADHD children. It can

be expected that American mothers of ADHD children will have lower levels of well-

being in comparison to mothers of non-ADHD children. Secondly, mothers of ADHD

children may require more social support to deal with the difficulties of raising an ADHD

child than mothers of non-ADHD children. Consequently, both Canadian and American

mothers of ADHD children are expected to report higher levels of social support than

mothers of non-ADHD children. Furthermore, American mothers are expected to rely

more heavily on social support than Canadian mothers. Lastly, since American mothers

may place more strain on their social support networks, Canadian mothers are expected to

experience the largest gains in well-being from the social support they receive.

Overall, this study seeks to amplify our understanding of the stress associated with

parenting an ADHD child while considering the effects of social support and the behavior

of the child. The findings of this study can also add to our knowledge of the

significance of social support. Mothers will be better equipped to deal with the

difficulties of raising an ADHD child with an enhanced understanding of the effects of

social support.

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Chapter 2 Literature Review

It is important to identify how mothers and fathers are affected by their child’s

Attention Deficit Hyperactivity Disorder (ADHD) for several reasons. According to the

ecological systems approach to studying the family, (sometimes referred to as family

systems theory) a change or difficulty experienced by one family member ultimately

impacts the entire family unit and creates the need for family adjustment or adaptation

(Seligman and Darling, 1989). The ecological systems approach also suggests that

parents have a significant influence on the behavior exhibited by their child and that a

child’s conduct has a mutual or reciprocal influence on parenting behavior (Bernier and

Siegel, 1994; Bubolz and Whiren, 1984; Elgar et al., 2004). Literature concerning

families of ADHD children indicates that the parent-child relationship is highly

susceptible to cyclical patterns of dysfunctional behavior (Bernier and Siegel, 1994). The

stress associated with raising an ADHD child is a relevant concern because children may

react to related parental tensions by displaying greater levels of problematic behavior.

Furthermore, psychological distress may impair a parent’s ability to cope with the

symptomatic behaviors of their child’s disorder, which can reduce the child’s

responsiveness to intervention and adherence to treatment; in turn creating more stress

and strain for the parents (Fischer 1990).

The usefulness of the family systems approach has frequently been illustrated in the

study of families with a handicapped member. Results of such studies indicate that the

presence of a handicapped child places intense stress on the family and its total resources,

including physical, psychological, and financial resources, as well as social supports

(Birenbaum, 1970; Wikler, 1981; Bubolz and Whiren, 1984; Earhart and Sporakowski,

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1984). Other matters, such as poverty, unemployment, defaulting child-support payments

and inadequate schools, administrators or teachers can exacerbate family stress (Bernier

and Siegel, 1994). Researchers speculate that if sufficient resources are not accessible to

families with a handicapped child, family adaptation may not be possible. However, little

research has attempted to incorporate an ecological or family systems approach in the

study of families with ADHD children. Evidence of dysfunction in families of ADHD

children necessitates an ecological systems approach that considers the social context and

other relevant factors, aside from aspects of the individual child’s disorder which may

contribute to this dysfunction (Bernier and Siegel, 1994). ADHD does not occur in a

vacuum; it affects not only the diagnosed child, but the entire family unit and its total

resources.

A critical review of the research related to the stress and burden of parenting a child

with ADHD is presented in this chapter. The discussion begins with an overview of

existing conceptualizations of ADHD and the controversy surrounding the diagnostic

validity of the disorder, as well as the ethics of medicinal treatment. Attention is then

directed back to research concerning the parent-child relationship and mother’s role in

relation to their child’s ADHD with emphasis on evidence of mother blame. Discussion

is then focused on the importance of the availability of social support and the influence of

social support on maternal well-being and family functioning. Lastly, this section also

considers possible differences in the experiences of American parents of ADHD children

compared to their Canadian counterparts.

In terms of research efforts and literature concerning ADHD children and the family,

there does not appear to be a great deal of discrepancy between the two neighboring

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nations. Both Canadian and American parents are exposed to corresponding types of

literature and informational materials about the disorder. Parents in both countries are

also faced with a significant amount of skepticism regarding the existence of the disorder

and its various forms of treatment. Yet, aside from these similarities, there is reason to

suspect that differences between the nations’ respective medical systems have

considerable bearing on the distinctive experiences of ADHD families across the two

cultures. Research has demonstrated the increased health care costs and social services

associated with raising an ADHD child (Harpin, 2005; Swensen et al., 2003). However,

few studies have considered cultural differences in the public services available to

families of ADHD children and what such differences mean in terms of assessment and

intervention. Important gaps in theoretical and empirical research prevent a clear

understanding of the disorder and its influence on those diagnosed and the people and

structures around them. Gaining a greater understanding of the impact of the disorder on

parents can help to identify appropriate means of intervention for all members of the

family.

The Diagnostic Reach of ADHD

ADHD is currently the most frequently diagnosed and medicinally treated disorder

among school-aged children, especially among boys, across Canada and the United States

(Barkley, 1998; Malacrida, 2003; Szatmari, et. al 1989). As previously stated, the core

behavioral symptoms of the disorder include inattention, distractibility, restlessness,

hyperactivity, and impulsivity (American Psychiatric Association, 1994). Low self-

esteem, mood variability, low frustration tolerance, short-term memory impairment, poor

social skills and social immaturity have also been considered defining characteristics of

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ADHD (Johnson, 1988; Harrison and Sofronoff, 2002). The presence of these symptoms

have been found to significantly impair the child’s ability to function successfully in

school, social and home environments, which can lead to serious academic, teacher-

student, peer, and parent-child related conflicts (Barkley, 1997; Quinn, 1997; Hallowell

& Ratey, 1994). As the stressful and demanding nature of the disorder suggests, children

with ADHD can cause considerable disruption to the family environment and the

psychological functioning of parents (Johnston and Mash, 2001). The treatment of

ADHD is meant to improve the educational and social functioning of the child, in

addition to reducing interpersonal tensions within the family (Cunningham, Benness, &

Siegel, 1988).

While it is difficult to estimate the actual incidence of the disorder, there has been a

marked increase in the prescription of ADHD related medications over the last several

decades (Diller, 1996, 1998; Safer, Zito & Fine 1996). The American Psychiatric

Association’s Diagnostic and Statistical Manual of Mental Disorders, fourth edition,

(DSM IV) states that only about 3 to 5% of the student population is afflicted by ADHD

(American Psychiatric Association, 1994). However, data to the contrary suggests that as

many as 15% of U.S. students in some schools take medication for ADHD (Haber 2000).

Serious concerns have also been raised about over-diagnosing and over-medicating

Canadian children with the disorder (Johnson, 2006; Nieman, 2003; Laurence, 1997).

The U.S. Centers for Disease Control and Prevention (CDC) recently released data

from 2005 which suggests that roughly 4 million children between the ages of 3-17 years

old have ever been diagnosed with ADHD, which is approximately 6.5% of the total

population of children 3-17 years old (Bloom, et al., 2006). The data also indicates that

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for every girl diagnosed with ADHD, there are roughly 2.5 times as many boys.

Approximately 9.2% of boys between the ages of 3-17 years of age have ever been

diagnosed with the disorder compared to only about 3.8% of girls within the same age

cohort (Bloom, et al., 2006). However, other estimates suggest as many as 80% of all

ADHD children are male (Pellegrini and Horvat, 1995). Unfortunately, comparable

national statistics for Canadian children with ADHD do not appear to exist or be

available to the public.

To a certain extent, the increased diagnosis of ADHD is due to the enormous

amount of media attention, professional discourse and informational material that has

been made available to inform parents, teachers and the general public about the

disorder. According to Sociologists Peter Conrad and Joseph Schneider (1980), there

is a direct correlation between the growth in diagnosis/treatment and the number of

articles and books published about the subject. From a relatively rare and vague

conceptualization, to a commonplace and well-defined diagnostic category, ADHD has

become a part of our every day language and has seeped into the most fundamental

structures of modern Western society. Lay, professional and media sources have

significantly contributed to the increased recognition of the disorder. However, the rise

in the diagnosis and medicinal treatment has not gone unchallenged by the public or

professionals across disciplines, outside as well as within the medical community. In

recent years, serious questions have been raised about the changing diagnostic criteria,

the broadening spectrum of the disorder, and the possibilities of stimulant abuse and

prescription for profit (Goldman, et al., 1998).

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Some critics claim that the emergence of ADHD transpired, along with a whole host

of childhood disorders, illnesses and syndromes, with an increased professional interest

in better explaining, managing, classifying and predicting child behavior (Conrad and

Schneider, 1980). Shrag and Divoky (1975) argue that “ADHD (then called

‘hyperactivity’) is a ‘myth’ which allows control of the individual in order to create a

‘hygienic state’”. The increased intolerance and scrutiny over common behavioral

problems has been described as the ‘psychiatrization’ of difference (Castel et al., 1982;

Malacrida, 2003). According to Thomas Szasz, modern psychiatry is a form of social

control which defines the limits of ‘normality’ in order to mold society and its’ people in

a desired direction. He claims that over the history of the discipline, a vast number of

behaviors have been reclassified as ‘illnesses’ and that these products of strategic

categorization have become mistaken for ‘naturally occurring’ events (Szasz, 1974).

Another perspective suggests that a broad set of societal forces have encouraged the

‘medicalization’ of a vast array of problems and areas of life that once were considered

deviant or non-medical in nature (Conrad and Potter, 2000; Conrad, 1992). According to

the sociological theory of medicalization, psychiatric disorders are more likely to gain

recognition through cultural and socio-political actions, rather than actual indicators of a

condition (Cooksey and Brown, 1998). Such factors, which have set the stage for

medicalization to take place, include: the diminished role of religion, the growth in

industrialization and bureaucracy, an increased faith in science, rationality and scientific

progress, and a growing reliance on medical experts (Williams and Calnan, 1996; Conrad

and Leiter, 2004). While some have argued that the expanding domain of medicine is

mainly due to the abusive power and dominance of the medical profession, others claim

16

that medical and health professionals are merely bystanders responding to the broader

societal factors which have encouraged ‘the medicalization of society’ (Williams and

Calnan, 1996).

In Deviance and Medicalization: from Badness to Sickness (1980), Conrad and

Schneider use ADHD as a vivid illustration of medicalization in modern society. They

claim “what stands out to a sociologist is that the treatment was available long before the

disorder that was being treated was clearly conceptualized” (Conrad and Schneinder,

1980: 159). In other words, the tangible conceptualization of ADHD as a mental illness

did not occur until after the implicit benefits of the drug were inadvertently discovered.

According to Conrad and Schneider, the discovery of ADHD as a medical condition

occurred in conjunction with an increasing desire to tame deviant child behavior. As

they purport, a medical label was essentially necessary in order to rationalize the use of

medicine to contain a whole class of undesirable behaviors (Conrad and Schneider,

1980).

Yet, as some argue, those outside of the medical arena are not just passive and

accepting actors in the processes of medicalization and the expansion of medical woes.

Patients have become progressively more informed, demanding and reproachful of

available medical care and services (Williams and Canlan, 1996). In many ways,

consumer ‘demands’ for medical solutions facilitate medicalization (Conrad and Leiter,

2004). Without the earnest appeals and demands of sufferers and lay advocates, certain

psychiatric disorders are unlikely to gain recognition. In contrast, active campaigning

and lobbying can help sufferers to achieve significant medical and public acceptance for

their particular disorder (Conrad and Potter, 2000).

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Medicalization is considered to be an ongoing process which occurs at varying levels

within a given culture (Conrad, 1992). As an object of medicalization, ADHD is

influenced by the intersecting interactions of parents, educators, physicians, and mental

health professionals (Malacrida, 2004). The workings of the pharmaceutical industry

have also been implicated in the establishment of ADHD as a medical affliction, as well

as the expanded stimulant treatment of the disorder in pre-school and adult populations

(Safer, Zito and Fine; 1996). In the past, pharmaceutical companies primarily marketed

prescription drugs to health professionals; whereas today marketing efforts have been

increasingly directed towards consumers. Between 1996 and 2000, spending on direct-

to-consumer advertising and promotion increased by 212 % (Rosenthal, et al., 2002).

The rise in pharmaceutical advertising has been associated with the ‘commodification’ of

medical products and services (Conrad and Leiter, 2004). While proponents claim that

direct-to-consumer advertising of prescription drugs results in better-informed consumers

and improved quality of care, others caution that such marketing techniques may lead to

inappropriate treatment requests, greater health care costs and excessive profits for the

pharmaceutical industry (Rosenthal, et al., 2002).

Although dominant perspectives tend to promote biological or psychological

explanations for the occurrence of the disorder, biologists have yet to discover any gene,

sufficient evidence of brain damage or laboratory test worthy of an ADHD diagnosis

(American Psychiatric Association, 2000). The DSM IV is presently the most widely

used tool to assess for the presence of ADHD among school-aged children in both

Canada and the U.S. (Malacrida, 2003). The DSM has been described as a literal

gateway to diagnostic and scientific legitimization (Conrad and Potter, 2000). Its latest

18

edition was compiled in 1994 and was further revised in 2000. The numerous

amendments reflect distinctive approaches taken by psychologists and other mental

health professionals “towards understanding human troubles as psychiatric conditions”

(Conrad and Potter, 2000).

Although some have traced the emergence of ADHD back to social and cultural

events and development during the late 1800’s and early 1900’s (Neff, 2006; Rafalovich,

2001; Lakoff, 2000), it did not begin to resemble a diagnostic category until the 1950’s

(Conrad and Potter, 2000; Conrad, 1975). The definition and classification of ADHD has

been in a constant state of flux since its conceptual inception (Pellegrini and Horvat,

1995). The diagnostic criterion was first delineated by the American Psychological

Association in 1968. The second DSM outlined a set of behaviors defined as

Hyperkinetic Reaction of Childhood, which would later be related to what is now known

as ADHD. Other labels used at the time include: Hyperkinetic Syndrome, Hyperactive

Child Syndrome, Minimal Brain Dysfunction (MBD), Minimal Cerebral Dysfunction,

Minor Cerebral Dysfunction and Attention Deficit Disorder (American Psychiatric

Association, 1980). Most early work referred to the condition as MBD and

Hyperactivity. These terms remained in vogue until the late 1970’s.

The criterion of the disorder underwent many changes during the conversion of DSM

III, which was published in 1980, to the DSM IV in 1994. During most of the 1980’s

and early 1990’s the disorder was commonly referred to as Attention Deficit Disorder or

ADD. The earlier focus on hyperactivity had shifted toward problems associated with

attention and impulsivity. Yet, the DSM IV brought focus back to the centrality of

hyperactivity (Goldman, et. al., 1998). The DSM IV text revision states that the

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prevalence of the disorder according to the latest criterion may be somewhat greater than

the prevalence based on the previous criterion due to the diagnostic inclusion of the

hyperactive/impulsive component (American Psychiatric Association, 2000). In a three

part study, the DSM III and the DSM IV was used separately to assess for ADHD in the

same group of students (1,077), grades 1-4, and in all three samples there was over a 15%

increase in the prevalence of the disorder resulting from the changing criteria (Wolraich

and Baumgaertek, 1996).

The DSM IV provides a rating scale or behavioral checklist which is to be used by

parents, teachers and clinicians during the assessment of a child. Taken together, these

individual evaluations form the basis of an ADHD diagnosis. The entire scale is

comprised of 18 items: 9 items pertaining to inattention, 6 items about hyperactivity, and

3 items concerning impulsivity. The criterion of the disorder is broken down into three

subsets: Attention Deficit/Hyperactivity Disorder, predominately inattentive type,

Attention Deficit/Hyperactivity Disorder, predominately hyperactive-impulsive type and

lastly, Attention Deficit/Hyperactivity Disorder, combined type. Items which make up

the inattention component of the disorder include: ‘careless mistakes’, ‘difficulty

‘sustaining attention’, ‘seems not to listen’, ‘fails to finish tasks’, ‘difficulty organizing’,

‘avoids tasks requiring sustained attention’, ‘loses things’, ‘easily distracted’, and

‘forgetful’. Hyperactivity is measured by the following variables: ‘fidgeting’, ‘unable to

stay seated’, ‘moving excessively (restless)’, ‘difficulty engaging in leisure activities

quietly’, ‘on the go’, and ‘talking excessively’. Lastly, items in the impulsivity component

of the disorder consist of: ‘blurting answers before questions completed’, ‘difficulty

awaiting turn’ and ‘interrupting or intruding upon’ (American Psychiatric Association,

20

2000). There are also two pre-conditions of the disorder: symptoms must be present

before the age of seven in at least two or more settings (e.g. home and school) and these

behaviors must be present to a significantly ‘disruptive’ degree for at least six months or

longer (DSM IV text revision, 2000).

Evidence indicates that most young boys with ADHD have the combined type, while

girls, adolescents and adults afflicted with the disorder are much less likely to exhibit the

hyperactive or impulsive components (Quinn, 1997). Regardless of ADHD, girls are also

less likely to be diagnosed with behavioral or conduct disorders and learning disabilities

(Biederman, et al., 2004). Some researchers speculate that since girls with ADHD may

not be as outwardly rambunctious or as boisterous as their male counterparts, they may

be under-diagnosed and under-treated (Wolraich and Baumgaertel, 1996). On the other

hand, there is the distinct possibility that the disproportionate rate of ADHD and other

psychiatric disorders among boys and girls exists because of gender-based biases in the

referral process (Biederman, et al., 2004). It has been suggested that the over-

representation of female teachers in the primary schools may play a role in the greater

referral of boys. As a result of the increased incidence of ADHD among boys, girls have

been largely excluded from research designs and it is uncertain if the developmental

course of the disorder is different for girls (Pelligrini and Horvat, 1995).

A major problem with the DSM’s definition of ADHD is that the criterion of the

disorder is reliant upon several individual assessments which are largely subjective in

nature. Research shows that parents, teachers and doctors are often in disagreement

about what constitutes negative behavior or symptoms of the disorder (Wolraich, et al.,

2004). It is also questionable whether loosely held notions of behavior, such as

21

“restlessness” or “carelessness”, can be accurately measured. The slightest variation

between “not at all”, “just a little” and “quite a lot” has an extreme impact on

classification and the slightest differences in responses can dramatically affect

concurrence of diagnosis. Yet, the DSM IV does not provide guidelines on how to make

distinctions among these response categories and how to consider the environment or

social context in which the behavior takes place. Some of the symptoms could be

described as school based, while other symptoms are more social and contextual in

nature. Furthermore, there are no suggestions on how to factor the age of the individual

into diagnosis (Barkley, et al., 2002). Most of the diagnostic items on the DSM IV scale

seem to be geared toward, or more specific to, the behaviors and activities of younger

children.

Originally, ADHD was perceived as a childhood illness one simply grew out of over

time. Early definitional understandings of the disorder excluded children under the age

of seven, as well as adults. However, more recently, distinguishing features of the

disorder have been claimed to develop early on in life and persist well beyond

adolescence. The behavioral manifestations of ADHD are now thought to vary in

intensity, frequency and patterning over the course of an individual’s life (Quinn, 1997).

Estimates suggest that anywhere between 5% and 60% of children afflicted with the

disorder will continue to experience difficulties into adulthood (Harpin, 2005;

Biederman, 2005). Efforts to detect the disorder in younger and older populations have

become greater with the advancement of alternative diagnostic tools, which contextually

adjust for the relative age of the individual (Barkley, 1998). Additionally, literature

22

concerning ADHD in younger and older populations has been gradually rising over the

past two decades (Hanford and Snarey, 2001).

The Treatment and Management of ADHD

Within the medical model, ADHD is characterized as an individual affliction and

intervention is primarily directed toward individual modes of treatment (Conrad and

Schneider, 1980). Consequently, medication is often perceived as the optimal strategy of

management for controlling the undesirable symptoms associated with the disorder. A

dramatic improvement in behavior is apparent in as many as 70% to 80% of ADHD

children treated with stimulant medication (Johnson, 1988). To a lesser extent,

behavioral modification and parent training is recommended. Several studies suggest that

medication works better than either behavioral modification or parent training alone

(Johnson, 1988)

Ritalin, which is a powerful stimulant medication, is the most commonly

recommended form of medicinal treatment for ADHD. Every year the number of

individuals taking some form of medication for ADHD rapidly increases (Diller, 1996).

Yet, serious questions about the misdiagnosis and misuse of stimulant medications for

ADHD have been advanced by a growing number of parents and professionals across

disciplines. Some ponder if the use of such medications might somehow change the core

of a person’s ‘authentic sense of self’ or obscure the unfolding path to self realization

(Kramer, 1993). The terms “cosmetic psychopharmacology” (Kramer, 1993) and

“enhancement technologies” have been used to depict modern treatments which improve

mental health, performance, appearance and/or behavior where such intervention is not

medically necessary or financially prudent (Singh, 2005). While some new forms of

23

medical treatment are considered legitimate, necessary and morally justified, other

treatments, specifically enhancement treatments, are considered excessive, artificial and

morally corrupt. Medical treatments frequently raised in debates about enhancement

include depression, anxiety and ADHD. Thus, the use of Ritalin and other stimulant

drugs represent a distinctively common moral dilemma for parents (Singh, 2005).

In reality, Ritalin does not “cure” ADHD; it only reduces or blocks the symptoms of

the disorder temporarily and provisionally. There is often confusion about the effects of

Ritalin. Most people think that drugs like Ritalin and its’ relatives are only effective

if you have ADHD. However, this would mean we would be able to assess ADHD

simply through the effects of the drug, which is far from the case. Studies conducted

by Judith Rapaport of the National Institutes of Mental Health in the mid 1970’s and

early 1980’s demonstrate that most people experience improved performance on tasks

which require mental attention with the use of stimulant drugs (DeGrandpre, 1999).

This means it is impossible to determine if an individual has ADHD just by looking at

the drug reactions. Research also demonstrates that behavior modification is incomplete

and contingent upon continued use of the medication. It must be taken regularly for

continued benefits or the individual will revert back to the previous undesirable behavior

before the introduction of Ritalin (Diller, 1998). Yet, while the benefits of Ritalin are

short-lived, for many parents and adults with ADHD, the effectiveness of the medication

outweighs its transitory duration. According to one study, a parent’s decision to

medicate their ADHD child is significantly influenced by perceptions associated with

the implicit benefits, potential risks and side effects, as well as the possible positive and

24

negative social implications which are involved for their child and family (Dosreis et al.

2003).

It is difficult to find accurate information regarding the number of youths and adults

taking ADHD related medications or the actual number of individuals diagnosed with

ADHD who receive medication. Estimates in the U.S. range between 3.3 million

children and 1.5 million adults, (total population-4.8 million) (Johnson, 2006), to about

23 million youths and 6 million adults (total population-29 million) (Harris, 2005). The

Centers for Disease Control and Prevention approximates that in 2003, as many as 2.5

million children between the ages of 4-17 years old had received medication for the

disorder (Visser and Lesesne, 2005). In Canada, an estimated 2 million prescriptions

were issued for stimulant drugs associated with ADHD (The Canadian Press, 2005).

According to the Central Intelligence Agency, the current population of Canada and U.S.

is 33,390,141 and 301,139,947 respectively (CIA, 2007). If the lower estimate is taken

(4.8 million), about 2% of the total U.S. population is currently taking ADHD

medications. The higher estimate (29 million) would suggest the nearly 10% of the total

U.S. population takes medications for ADHD. If the Canadian estimate is used (2

million), around 6% of the total population takes stimulant medications.

Side-effects exist for users of medication for ADHD, regardless of age. Although

some side effects only have a minimal negative impact, other side-effects may pose a

serious threat to the health and well-being of the user. The scope of side-effects and risks

associated with stimulant drugs is still largely unknown. While no medication is without

a battery of potential side-effects, it often takes more or other medications to

counterbalance the negative side-effects of ADHD medications, which can often be even

25

more dangerous. The medications can last or stay in the system as long as 3-5 hours to

12-24 hours or longer. While some medications work in a matter of an hour, others can

take up to two weeks to take full effect (Quinn, 1997). Interpreting these aspects of the

medications can become somewhat of a juggling act when introducing and combining

other medications.

Children taking medications for ADHD have frequently been found to grow and

develop at a slower rate than children who are not taking similar medications (Johnson,

1988). Parents are instructed to closely monitor their child’s height, weight and appetite

(Kratochvil, et al., 2006). Other frequent side-effects of the most common ADHD

medications (i.e., Ritalin, Methylphenidate, Dextramphetamine, and Dexedrine) include:

loss of appetite, stomachaches, weight loss, insomnia, headaches, social anxiety,

irritability and tics. Ritalin and other stimulant medications, such as Concerta and

Straterra, have also been linked to suicidal thoughts, psychotic and aggressive behaviors

and a greater risk of cancer for children later in life (Harris, 2005). Less common

medications (i.e., Imipramine, Desipramine, and Clonidine) cause side-effects such as

sleepiness or fatigue, dizziness, nausea, dry mouth, constipation, abdominal pain,

headache, hypotension and blurry vision. Users of Imipramine and Desipramine are also

recommended to have baseline electrocardiograms preformed to access for possible heart

conditions, which can make the use of these medications deadly (Quinn, 1997). In

studies with rats, early exposure to stimulant drugs was found to have long-term effects

on the organization of the brain (Kratochvil, 2006).

According to statistics provided by the U.S. Centers for Disease Control and

Prevention, every year millions of children and adults are driven to emergency rooms for

26

accidental overdoses and serious side-effects from ADHD related medications (Schappert

and Burt, 2006). Children with ADHD are also known to be somewhat more accident-

prone than non-ADHD children. For instance, they may engage in impulsive and

potentially risky behavior, such as crossing the street without looking or riding a bike

over dangerous terrain (Johnson, 1988). Such related accidents also contribute to the

elevated hospital and public health care costs associated with ADHD. During the time

period of 2001 to 2002 there was an estimated 5.4 million ambulatory care visits linked to

ADHD (Schappert and Burt, 2006).

The Food and Drug Administration released a report indicating that there have been

at least 25 deaths linked to drugs for ADHD over the 4 year period between 1999 and

2003. Serious heart problems, heart attacks, and strokes were reported in another 54

cases in which many of the patients did not have previous heart problems. Potential

cardiac problems such as chest pain, high blood pressure and elevated heart rate also

existed for a large number of ER patients who had taken medication for ADHD.

Researchers at the Centers for Disease Control and Prevention claim that the majority of

these dangerous incidents could have been prevented by parents locking up the

medication (Johnson, 2006).

Although to a lesser extent than medicinal treatment, psychological intervention is

also considered an important component of ADHD management. Parents of ADHD

children are often encouraged by professionals to participate in parent training and

counseling, either individually or in groups with other parents of ADHD children.

C.H.A.D.D. (Children and Adults with Attention Deficit Disorder), which is the largest

not-for profit advocacy organization in the U.S. and Canada, offers social support groups

27

to parents of ADHD children, as well as ADHD adults. Interestingly, C.H.A.D.D. is also

largely funded by Novartis, a major drug company and the nation’s leading manufacturer

of medications used to treat the disorder (chadd.org).

The Mother-Child Relationship

The mother-child relationship in families of ADHD children has been often

characterized as stressful and problematic. Children with ADHD have been found to be

generally less compliant with mothers’ requests, commands and rules, more often off-

task and distractible, as well as more demanding of attention and assistance in

comparison to their non-ADHD counterparts (Barkley & Cunningham, 1980; Mash &

Johnston, 1983; 1982). In addition to frequent mother-child conflicts, studies also

suggest that ADHD children fight with their siblings and peers more often, disturb

neighbors, and have reoccurring negative interactions with teachers and other school

personnel which further contribute to daily parenting hassles and conflict in the parent-

child relationship (Pelham and Lang, 2000).

Mothers of children with ADHD have been found to display more negative and

disapproving reactions to their child’s disruptive behavior and are typically more

reprimanding and controlling than parents of other children (Barkley, et al., 1985; Befera

& Barkley, 1984; Cunningham & Barkley, 1979; Mash & Johnston, 1982; Tallmadge &

Barkley 1983). Yet, it is difficult to determine whether mothers’ disciplinary actions are

merely a reaction to or a cause of the child’s deviant behavior (Fisher, 1990). The

behaviors displayed by ADHD children and their mothers may also be influenced by the

settings in which the research takes place.

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Maternal Stress, Pathology and Marital Discord in Families of ADHD Children

A great deal of research has investigated the relationship between ADHD and

parenting stress. Stress experienced by mothers has been significantly associated with

increased behavior problems in children (Baker, 1994: Mash and Johnston, 1983).

Researchers speculate that the disruptive behaviors of ADHD may be intensified by

maternal stress and pathology. In a study conducted by Mash and Johnston (1982)

mothers of children with ADHD were found to experience more stress, anxiety,

depression and frustration compared to mother of non-ADHD children. The researchers

attribute the lower parenting self-esteem and self-confidence found among these mothers

to frequent failed attempts to control the behaviors associated with their child’s disorder

(Mash and Johnston, 1982). Mash and Johnston (1983) also found that mothers felt less

skilled and experienced lower satisfaction from parenting an ADHD child. These studies

suggest that the negative attributes of mothers may carry over into parenting conduct and

ultimately aggravate the family environment.

Studies also indicate that mothers of ADHD children often view their family life as

high in interpersonal conflict, less supportive and less cohesive and more demanding than

families of children without ADHD (Brown and Pancini, 1989; Johnston, 1996: Mash

and Johnston 1983). Increased familial demands are also associated with higher numbers

of siblings and negative sibling interactions. Sibling conflict is found to be highly

correlated with increased child-related stress and diminished parenting self-esteem and

confidence (Mash and Johnston, 1983). According to some researchers, increased marital

dysfunction, dissatisfaction, separation and divorce are more frequent among ADHD

parents (Barley, 1981; Befera and Barkley, 1984). Additionally, the stress associated

29

with raising an ADHD child has been linked to greater alcohol consumption and abuse

among parents (Pelham and Lang, 2000).

Other researchers claim that findings of parental depression and pathology are

conflicting, inconsistent and unreliable (Brown and Pancini, 1989). For example, in a

study conducted by Stewart et al., (1980) parents of ADHD children were no more likely

to receive psychiatric diagnoses than other parents. They claim that increased levels of

pathology found among ADHD parents are spurious effects of the target population.

Since most of the ADHD children and parents sampled in such studies are often clinically

referred, there might be an overrepresentation of co-morbid or conduct-disordered

children in ADHD experimental groups.

The direction of causality between ADHD and marital discord has also been

contested. Some researchers have suggested that marital dysfunction is highly correlated

with increased behavior problems in children (O’Leary, et al., 1981); whereas others have

argued that deviant behavior may initiate marital discord (Befera and Barkley, 1985;

Gillberg and Rasmussen, 1983). Still others have claimed that children’s deviant

behavior is independent of marital tension. Hartdagen and colleagues (1987) found there

were no significant differences in martial adjustment or satisfaction in parents of ADHD

children compared to parents of non-ADHD children. Another study’s findings indicate

that marital discord is not as strong a predictor of future behavioral problems as the early

temperament and characteristics of the child (Earls and Jung, 1987). Complimentary

findings conclude that children’s symptomatic behaviors transpire before marital discord,

rather than resulting from pre-divorce conflict (Block, et al., 1986).

30

Other important critiques of the current methodologies in clinical and empirical

observations of the parent-child relationship include: the use of relatively small

homogeneous (mainly white) cross-sectional samples, which are not very representative

of the ADHD population, the over-representation of mothers and sons, as well as a

relative lack of understanding about the influence of social support on parental well-

being. Overall these studies fail to convincingly demonstrate that ADHD mothers and

fathers are more likely to experience greater levels of stress, pathology or marital discord

as a cause or a result of the behaviors displayed by their child (Fischer 1990).

Maternal Contributions to ADHD

Although cultural factors, particularly competition, increased speed and over-

stimulation (DeGrandpre, 1999), institutional and professional structures, such as

schools, medical care providers and pharmaceutical companies (Shrag and Divoky, 1975;

Conrand and Schneider, 1992), and biological and organic circumstances, including

heredity, diet, sugar intake, and artificial food additives (Barkley, 1997; Rafalovich,

2001) have all been suspiciously implicated, mothers are often the most common source

of blame for the diagnosis and medicinal treatment of ADHD. Mothers of children

diagnosed with ADHD are often blamed for the unconventional behaviors of their

children and are primarily viewed as responsible for the cause and cure (Malacrida,

2003). The assumption that mothers are integral part of their child’s problem and the

philosophy of proper parenting are discourses which are rampant in popular literature

about ADHD, childrearing, and motherhood. Ideologies which imply that a ‘bad’ child is

the result of ‘bad’ mothering are difficult to challenge because they often “masquerade as

common sense” (Bennet, 2007).

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Mothers occupy a particularly vulnerable position in the web of blame due to their

social, educational, medical and genetic influence on the emotional and physical health of

their children (Singh, 2004). Although prominent ADHD researchers have established a

biologically oriented definition of the disorder and argue that it is unfair and inaccurate to

link ADHD to poor parenting (Barkley, 1997; Hallowell and Ratey, 1994), the personal

attributes and well-being of mothers are still frequently called into question when

children show significant signs of maladjustment. Framing ADHD as a family problem

reinforces mothers’ feelings of guilt and inadequacy and makes the medicinal treatment

of the disorder appear to be excessive and unwarranted (Johnson, 1988).

Evidence of Mother Blame

The tendency to blame mothers can be seen in their over-representation in public

forums and clinical research. The unruly conduct of children is often seen as a reflection

of the mother’s inability to parent properly (Singh, 2004). Prevailing norms and

stereotypes imply that ‘bad’ children have ‘bad’ mothers. Canadian Sociologist Claudia

Malacrida argues that opponents and advocates of ADHD alike stigmatize mothers for, at

least in part, being to blame for the behaviors and characteristics associated with their

child’s disorder. Opponents of ADHD are more likely to attribute childhood difficulties

to poor mothering, such as improper disciplinary techniques, neglect or pure

incompetence. Furthermore, critics allege that mothers callously push for medication to

control their children and make up for their own short-comings. Conversely, advocates

of the disorder are more likely to point to poor prenatal care and even alcohol and drug

abuse as biological precursors of ADHD. This assessment of a mother’s responsibility is

evident in both popular lay and scholarly discourse. The background, social class,

32

martial status, as well as the character, disciplining abilities and parenting philosophies of

the mother are often directly or indirectly taken into consideration during the assessment

and treatment of a child (Malacrida, 2003). Professional and non-professional scrutiny

over the causes of ADHD has had disabling effects on suffers of the disorder, as well as

their families (Cooper and Bilton, 1999).

According to the qualitative findings of research conducted by British Psychologist

Janette Bennett (2007), mothers of ADHD children often face public accusations of

blame, as well as personal feelings of responsibility for their child’s disorder. Within

social contexts the associated behaviors of ADHD were found to cause mothers a great

deal of embarrassment and stigma. Additionally, feelings of isolation, failure, blame and

negative self-esteem were reoccurring themes throughout the interviews. Yet, many

mothers were able to deflect blame by viewing their child’s negative behavior in terms of

their disorder, rather than the result of their approach to mothering. Bennett suggests

that under some circumstances, ADHD produces a strong mother instead of a

demoralized or disappointed mother.

The Influence of Social Support on Maternal Well-being

A considerable amount of research indicates that social support serves to reduce or

safeguard the harmful impact of undesirable life events, stressful incidents or ongoing

strains (Thoits, 1981; Cohen and Wills, 1985). This is often referred to as the buffering

hypothesis, which suggests that individuals with strong and cohesive social ties have

comparably greater coping success and better psychological well-being than those with

weak and less stable ties to social support networks (Thoits, 1982). Although this theory

33

has been generally supported in empirical research, there are several conceptual and

methodological considerations which need to be addressed.

Most researchers have failed to formulate a clear and precise definition of social

support which can be demonstrated by valid and reliable indicators (Thoits, 1982). The

various dimensions and functions of social support have been uniquely evaluated across

studies (Lin, et al., 1986). Since the concept of social support is often conceptualized and

measured in different ways, it is extremely difficult to make legitimate comparisons

among studies (Mitchell and Moos, 1984). Therefore, the specific attributes or features of

social support which function to reduce the impact of stress cannot be accurately

identified (Thoits, 1982).

Social support literature also tends to focus on women’s participation in social

networks more than the relational experiences of men. Previous research has

demonstrated significant gender differences in perceptions of stress and reactive coping

mechanisms. The socialization hypothesis suggests that men are socialized to use

instrumental coping strategies to deal with the perception of stress such as planning and

executing strategies of action. Women, on the other hand, are socialized to use emotion-

focused coping strategies such as seeking the advice and comfort of others to deal with

the presence of stress (Levy-Shiff, 1999). Conversely, the role constraint hypothesis

contends that gender differences in perceptions of stress and coping techniques result

from diverging role-related demands and available supportive resources and

opportunities, rather than differences in socialization. Under this paradigm, responses to

stress will vary depending upon the situation (Levy-Shiff, 1999).

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Most researchers describe social support as a coping resource or “fund” made up of

family members, significant others, friends or co-workers, which people may draw upon

in stressful times of need (Thoits, 1995). The composition of an individual’s social

support network is usually determined by the actual number of social ties, types of social

relationships, and the amount and quality of time shared (Thoits, 1995). Members of

social support networks can offer instrumental, informational and/or emotional aid

(House and Kahn, 1985). Yet, social supportive attempts are only considered helpful or

beneficial when the receiver actually perceives them as such (Lin, et al., 1986). Overall,

emotional support and perceptions of being loved, respected and cared for have been

found to have a stronger positive impact on psychological well-being than instrumental or

informational assistance (Dunkel-Schetter and Bennet, 1990; Wethington and Kessler,

1986). However, defining and quantifying this intricate type of support is often

methodologically impractical since the dimensions and indicators of emotional support

may not be as apparent as instrumental or informational forms of support. It is still

uncertain exactly how these three types of aid can help to prevent or sustain physical or

psychological health-related transformations (Thoits, 1995).

Although spousal support is often considered to be the greatest coping resource

available to a parent (Nath, et al., 1991), other members of a social support network can

also play a significant role in mediating the effects of persistent stress and daily hassles

commonly encountered by parents (Cooke, et al., 1988). For mothers, supportive aid

may vary from problem solving assistance and sympathetic ears, to household tasks and

babysitting services (Marcenko and Meyers, 1991). The capacity to cope with everyday

family demands and childcare responsibilities is highly related to sources and functions

35

of a parent’s social support network (Nath, et al., 1991). Researchers have found that to

some extent, stresses which tax a parent’s personal resources can be alleviated by their

access to social supports (Cooke, et al., 1988).

As with social support, stressful events and strains have not been accurately or

consistently measured across studies (Eckenrode, 1984; Kessler, et al., 1985).

Interpretations of the physical and emotional health related effects of stress often produce

speculative and provisional results. Stress has been commonly defined as any

environmental, social or internal demand that calls for behavior modification or

emotional readjustment (Holmes and Rahe, 1976). Theory suggests that the perception of

stress or demand typically generates coping endeavors (Lazarus and Folkman, 1984). If

attempts to cope or adjust are unsuccessful, the probability that physical and

psychological sickness, disease or disorder will result is significantly increased (Brown

and Harris, 1987: Dohrenwend and Dohrenwend 1974: Lazarus and Folkman, 1984;

Pearlin, 1989). However, health problems may not necessarily be associated with the

occurrence of stress and there is no way to accurately determine the success of social

coping strategies on health-related consequences.

Dimensions of stress typically fall into three categories: life events, chronic or

ongoing strains and daily aggravations. Research generally focuses more on the stressful

effects of life events, such as family deaths, divorce or unemployment. This is partly due

to the fact that chronic strains or daily hassles are harder to classify and compartmentalize

(Thoits, 1995). Furthermore, life events are more difficult to prevent and/or change

(Thoits, 1987). Yet, despite evidence that stressful life events intensify emotional

problems, especially when the events themselves cause persistent or reoccurring strain

36

(Aneshensel, 1992; Pearlin, et al., 1982), little is known as to how chronic strains are

managed or how they may impact future stress or illness.

Although most literature suggests that social support is positively associated with

psychological well-being, little is known about the specific aspects or dimensions of

social support which serve to reduce stress and strain (Brown, 1979). Research has

primarily focused on how social support can alleviate the impact of stress, disregarding

the potential for social support or social interactions to influence or provoke further

distress. Additionally, this type of research often does not take into account the influence

of social support on the psychological well-being of individuals in the absence of

stressful life events or chronic strain (Thoits, 1982). Clearly, more needs to be known

about what makes social support networks beneficial or harmful to the psychological

well-being of its members (Thoits, 1986).

Many sociologists have hypothesized that an individual’s relative self esteem is a

product of others’ perceptions or view of them and there is a strong association between

social interactions and self-evaluations (Cooley, 1902; Coopersmith, 1967; Mead, 1934).

Research has also indicated that particular perceptions of social support are closely

related to an individual’s self-esteem and self-image (Aseron, et al., 1992; Sarason, et al.,

1991). The assessment and feedback offered by others has been shown to have a

continuous and lasting effect on the psychological well-being of an individual

(Rosenberg, 1965: Lin, et al. 1986). Therefore, even in the absence of stress, social

support is considered key to the successful functioning and even the survival of an

individual (Lin, et al., 1986).

37

Several researchers have suggested that social support is not always perceived as

positive or helpful and can actually be harmful and cause greater distress (Harris, 1992).

Rook (1984) suggests that negative social relationships may have stronger impact on

psychological well-being than positive social relationships. She points out that not all

social ties are necessarily positive, supportive or beneficial to our well-being. For

example, increased levels of stress and marital discord have been associated with higher

rates of family involvement (Kazak & Martin 1984). Additionally, some supportive

attempts have been found to be perceived as intrusive and officious in studies examining

the influence of social support on parenting stress (Aneshensel, Pealin and Schuler,

1993).

A considerable amount of literature associates social support with positive family

adjustment, greater maternal satisfaction, lower maternal stress (Kazak and Martin 1984),

and reduced marital and parent-child conflict in families of children experiencing an

illness or handicap (Marcenko and Meyers 1991). Yet, for some parents the birth or

presence of a handicapped child may adversely affect pre-existing relationships with

friends or relatives (McAllister, Butler and Lei 1973). In one study, families with a

severely handicapped child were found to be significantly less likely to participate in

social activities or visit with friends, relatives and neighbors than parents without such a

child (McAllister, Butler and Lei 1973). In another study, neighbors of families with a

severely handicapped child were reported to be more standoffish and tended to only

interact with, or offer assistance to non-handicapped siblings (McAndrew, 1976).

Despite the growing number of publications regarding parenting stress, few studies

have examined the potential benefits of social support in families of ADHD children

38

(Podolski and Nigg, 2001; Pelham and Lang, 2000). Although the literature on the

subject is sparse, research tends to demonstrate that there is a negative association

between the social support and the well-being mothers with ADHD children. Evidence

suggests that mothers of ADHD children participate in social activities less often

(Margalit and Ben-Arzi, 1986) and report higher levels of social isolation (Mash and

Johnston, 1983) than parents of non-ADHD children. According to one study, mothers

of preschool children with externalizing behavior problems experience more difficulties

in their social life than mothers of older children with similar issues (Donenberg and

Baker, 1993). Mothers of ADHD children have also been found to have less contact with

extended family and perceive supportive attempts made by family members as less

helpful (Cunningham, Bemness and Siegel 1988). However the researchers of these

studies have failed to explain possible reasons for these findings. Generally, flaws in

social support networks are not considered as causes of social isolation or reclusion. It

may be that stress itself has caused tension to social networks or altered the availability of

social support by weakening an individual’s motivation to maintain strong social ties

(Mitchell and Moos, 1984). On the other hand, deficiencies or flaws in preexisting social

networks could also explain the higher rates of social inactivity and social isolation

among mothers of ADHD children.

Network criticism appears to be a major problem faced by mothers of ADHD

children. The influences of social support networks and community resources have been

found to be associated with increased levels of maternal stress and strain (Podolski and

Nigg, 2001). This is poignantly expressed in the qualitative research of sociologist

Claudia Malacrida (2003), which demonstrates that Canadian and British mothers of

39

ADHD children feel additional pressure and responsibility for their children’s troubles

from disapproving family members, friends and other parents. Mothers are the focus of

her research in response to their vulnerable position in ADHD literature and research.

According to Malacrida, these stigmatizing interactions with others significantly

contributed to the mothers’ feelings of responsibility and inadequacy as they struggled to

come to terms with their children’s difficulties and to find the appropriate means of help

and support.

A more recent study found that many American parents are more likely to ‘socially

reject’ children with a mental illness than children with a physical illness, such as asthma,

or ‘normal troubles’. Approximately 30% of the 1,134 parents who participated did not

approve of their child forming a friendship or even socializing outside of school with

other kids identified as having depression and 25% reported similar concerns about peers

with ADHD. The researchers attribute these findings to the stigma associated with

mental health problems compared to physical health problems with known and

standardized solutions (Sinha, 2007). In addition to highlighting the peer and relational

difficulties experienced by ADHD children, this study also demonstrates the stigmatizing

and negative viewpoints that parents frequently encounter from others. Parents of ADHD

children may face significant social isolation, not only as a result of their child’s

problematic behavior, but also because of the stigma attached to ADHD.

Distinctions between Canadian and American Families of ADHD Children

In an era of expansive globalization, cross-cultural comparisons have become

increasingly relevant. Given the close proximity, high degree of economic cooperation,

and the historical, cultural, social, technological and political likenesses of the

40

neighboring countries, Canadians and Americans are frequently compared to one another

on multiple fronts. While the U.S. and Canada share a great deal in common, the two

countries take a very different approach to the way health care services are organized,

managed and distributed to citizens (Sanmartin and Ng, 2003). It is this difference that

receives the most attention in comparative analyses. In response to escalating health care

costs and the growing number of uninsured (approximately 47 million) and dissatisfied

Americans, U.S. policy makers have started to look to other countries for viable solutions

(Gerber, 2007). Naturally, the system of health care in Canada has been considered as an

attractive and potential model for the U.S. (Scanlan, et al., 1996).

Canada is continually acclaimed for having the most successful health care system in

the world. Since January 1, 1971, Canada has been providing all of its residents with

public health insurance which covers all necessary medical services and hospital

expenses (Coyte, 1990). All pregnant women are able to receive prenatal care, Pap

smears are available to every woman and most of the provinces cover routine physical

examinations and immunizations for all residents (Spasoff, 1990). The United Nations

cites Canada as being the most livable country in the world, year after year. The health

care system in the U.S., on the other hand, is consistently ranked near the bottom among

leading industrialized nations (Gerber, 2007). Furthermore, evidence indicates that

Canada outperforms United States health care in terms of life expectancy, infant

mortality (eight deaths per thousand live births vs. six infant deaths per thousand live

births) and maternal mortality as well as general physical health and mental well-being.

Evidence suggests that even the elderly in the U.S., the only segment of the population

with access to Medicare, are worse off than the elderly in other Westernized nations

41

(Evan and Roos, 1999). The excellent quality of care in Canada also comes at a far lower

price compared to the U.S. (Gerber, 2007). In recent years, comparative literature and

research concerning health care in the United States and Canada has become increasingly

abundant. Additionally, recent political agendas have focused a great deal of attention on

expanding health coverage and improving the health of American citizens. Yet, in search

of solutions to America’s medical woes, the strengths as well as the weaknesses of the

universal health care system in Canada must be considered.

What stands out most to the sociologist is the diverging role of the national

governments in achieving social objectives. The Canadian government, “acting as a

single taxpayer for health expenditures”, has succeeded in keeping expenses below that

of private health insurance carriers, where increased expenditures often result in higher

premiums for the consumers, without raising the costs to average Canadian taxpayers

(Coyte, 1990). The Canadian system of health is primarily financed through progressive

taxes-taxes which increase with income, while low income Americans are the most

seriously affected by increased health expenditures (Terris, 1990). Each province and

territory is provided with federal funds for the distribution of health services to all

residents. Hospitals are owned and operated by various voluntary non-for-profit

organizations and agencies which shore up costs that exceed the federal budget (Coyte,

1990). The design of universal health care is built upon the belief that health is a basic

human right which should be upheld by the government, not a privilege based on

financial wealth.

As Robert Evans and Noralou Roos (1999) put it, “the American social environment

is brutal for the less successful”. Although the annual income of Americans surpasses the

42

yearly earnings of Canadians, the income gap among Americans has dramatically

increased over the last thirty years. So while the wealthiest Americans are wealthier than

the top earning Canadians, the poorest Americans are much more impoverished than

lower income Canadians. In contrast to other developed nations, the U.S. government

does little to prevent economic inequality (Evans and Roos, 1999). The rate of poverty

and the gap between those at the higher and lower ends of the social structure is

comparably greater in the U.S. In 2002, the top earning 20% of Americans retained 80%

of the nation’s wealth, while the top 1% owned close to 40% of the wealth. At the same

time, the poverty rate reached 12.1%, which indicates that slightly more than one out of

every ten families in the U.S. is living in extreme poverty. While more poverty exists in

Canada than many European countries, there is still considerably more economic

inequality in the U.S. (Colemen and Kerbo, 2006). As the disparity in the income and

wealth of Americans grows, so does the gap in the health and quality of life between the

rich and the poor. Additionally, a great deal of research has highlighted serious racial

inequalities in the access to health care, as well as the quality of the services received by

American minority groups (Shi, 1999).

According to the findings from a recent CBS news poll (2007), most Americans are

dissatisfied with the current state of healthcare. Only 32% of Americans who responded

to the poll are satisfied with the health care system in the U.S. Moreover, an

overwhelming 81% of the respondents are dissatisfied with health care costs. Public

support concerning the various options for expanding health coverage in the U.S. is often

divided (Gerber, 2007). Many Americans forgo medical services because of high health

care costs. The National Institute of Medicine estimated that some 18,000 Americans die

43

from lack of health coverage each year. It is further speculated that there is an annual

$60 billion to $120 billion loss to the U.S. economy from poor health and premature

death (Gerber, 2007).

Although, almost half of all Americans worry about the expenses of health care

coverage, there is little consensus over what can be done to extinguish those fears

(McNerney, 2007). An online health care survey of 2,402 U.S. citizens, ages 18 and

older, reveals that most Americans are in favor of a variety of plans to expand health

insurance coverage, but there is less support for options that involve higher taxation or

greater reliance on ‘big government’. For example, while almost 75% of the respondents

were in favor of requiring employers to provide health insurance for all of their

employees, only 26% were willing to pay more income taxes to cover more people on

Medicare or Medicaid (McNerney, 2007).

The Canadian healthcare system has its flaws as well. The results of a recent survey

conducted by the Health Quality Council of Alberta indicate that poor access to hospital

care, emergency room services and medical specialists is a serious concern among

Albertans. For instance, 56% of the respondents claimed that overall access to health

care and services was difficult to obtain, 47% found it difficult to acquire a medical

specialist and 45% said that hospital care is not easily accessible. Additionally, close to

15% of the respondents reported a serious complaint concerning the health care services

they have received in the past year and almost as many report that they, or one of their

family members has experienced some form of unintentional harm while receiving

medical attention (Ferguson, 2006).

44

According to the most recent release of the Joint Canada/United States Survey of

Health 2002-2003, most Canadians and Americans appear to enjoy good health.

Approximately 85% of Canadians reported being in good, very good, or excellent health,

compared to 83% of Americans. In addition, Americans report being at the lower end of

the health status spectrum. 15% of Americans report to be in fair or poor health

compared to only about 12% of Canadians. This difference in health status appears to be

greatest among women and Americans in poverty. In both countries, those in the lowest

income bracket rated their health as lower compared to other income groups. Yet, low

income Americans were almost 10% more likely than their Canadian counterparts to rate

their overall health as poor. On either side of the border, such differences in the health

status of individuals did not exist for those at the higher end of the income scale. 11% of

American women reported to be in fair health compared to 8% of Canadian women. The

researchers of the study claim that this finding may be related to the higher rates of

obesity among American women (21%) compared to Canadian women (13%) and other

health-related problems associated with obesity, such as hypertension and diabetes. It

may also be related to the fact that women and the poor living in the U.S. have less access

to health care and a regular medical doctor (85% vs. 80%) (Sanmartin and Ng, 2003).

Overall, the Joint Canada/United States Survey of Health indicates that Americans

were slightly more likely to have unmet health care needs in the past year (13%

compared to 11%). Yet, this difference in unmet health care needs did not exist between

Canadians and insured Americans. Reasons for unmet health care needs also varied

significantly between the two countries with cost being the greatest reason reported by

Americans and waiting time for Canadians. More Canadians also report to have a regular

45

health care provider compared to Americans (85% vs. 80%). Yet again, this difference

was lower among insured Americans (Sanmartin and Ng, 2003).

Lastly, results from the Joint Canada/United States Survey of Health also indicate that

more Americans report experiencing a major depressive episode in the last year. The

overall difference in mental health is slight for Canadians and Americans between the

ages of 18-44. Yet, this difference is particularly greater among respondents between the

ages of 45-64, especially women. In both countries, women were about 3% more likely

than men to report experiencing a major depressive episode in the last year.

Approximately 11% of American women between the ages of 45-64 report experiencing

a major depressive episode in the last year compared to about 9% of Canadian women

within the same age cohort. Virtually no differences appear to exist in the mental health

of Canadian and American males (Sanmartin and Ng, 2003).

Despite the relative growth of research comparing the United States to Canada in

terms of health care, there has been little consideration of how related differences

between the two counties may translate into diverse experiences for Canadian and

American families of ADHD children. While there is ample reason to suspect

similarities in the experiences of American and Canadian families of ADHD children,

this research contends that differences between the two respective health care systems

will have considerable bearing on the well-being of parents of ADHD children, as well as

parents of non-ADHD children, and the social support they receive.

In Europe and other parts of the world, the diagnosis and medicinal treatment of

ADHD is a rare occurrence (Wolraich and Baumgaetel, 1996). In Britain, hyperactivity

is the sole characteristic of diagnosis and symptoms of inattention are largely disregarded

46

in formal diagnosis. Some have suggested that ADHD is under-diagnosed and under-

treated because there is a great deal of skepticism among British professionals regarding

the existence of the disorder (Kewley, 1998). While ADHD is often considered to be an

“American disorder”, Canada experiences a similar wide range of frequency (Biederman,

2005). Varying rates in the prevalence of the disorder is primarily attributed to the way

the disorder is conceptualized and assessed across countries, rather than cultural or

behavioral differences in children (Wolraich and Baumgaetel, 1996; Biederman, 2005).

Regardless of geographic location, controversy surrounding the psychiatric labeling and

medicinal treatment of ADHD continues to significantly complicate the situations of

parents seeking guidance and support for their children.

Summary

As the ecological systems approach to the study of the family theorizes, a change or

difficulty experienced by one family member ultimately impacts the entire family unit

and creates the need for family adjustment or adaptation. Although few studies have

attempted to incorporate an ecological systems approach to the study of mothers of

ADHD children, research indicates that the behavioral characteristics of children with

ADHD cause considerable disruption to the family environment and the psychological

functioning of mothers. Maternal stress and family strain has also been associated with

increased behavioral problems in children. Thus, the mother-child relationship in

families of ADHD children is highly susceptible to cyclical patterns of dysfunctional

behavior. Yet, little is know about how mothers cope with the added stress associated

with raising an ADHD child. An ecological systems approach encourages consideration

of the social context and other relevant factors aside from aspects of the individual child’s

47

disorder which may contribute to this dysfunction. This research considers how mothers

of ADHD children are affected not only by the behavioral problems of their child, but

also by the social support they receive, which may contribute to or relieve levels of stress

and strain. Previous studies concerning the stress associated with parenting an ADHD

child have failed to properly take into account the important influence of social support

on maternal well-being.

Literature on social support demonstrates that social interactions have a significant

consequence on psychological well-being across a number of settings. Social support is

considered to be a valuable resource which serves to buffer the harmful effects of

undesirable life events, stressful incidents and/or ongoing strains. Research also suggests

that social support has a considerable influence on family functioning and maternal well-

being. Although few studies have examined the effects of social support in families of

ADHD children, there is reason to suspect that these mothers may suffer from significant

social isolation as a result of their child’s problematic behavior. This research also

speculates that public and professional scrutiny regarding the psychiatric label and

medicinal treatment of ADHD has bearing on mothers’ interactions with potential

sources of social support. Thus, mothers of ADHD children are not only impacted by the

problematic behavior of their child, but also the stigma attached to their child’s disorder.

In addition to a lack of research concerning social support in families of ADHD

children, few studies have attempted to analyze the impact of ADHD across cultures.

This research expects that significant differences between American and Canadian

mothers of ADHD children exist in terms of the social support they receive, as well as its

impact on maternal levels of well-being. In the following chapter hypotheses related to

48

the unique experiences of American mothers of ADHD children, as compared to their

Canadian counterparts, are discussed in greater detail.

49

Chapter 3 Data and Methodology

The design of this study is based on comparable data from the 2001 U.S. National

Health Interview Survey (NHIS) and wave 4 of the 2000-2001 Canadian National

Longitudinal Survey of Children and Youth (NLSCY). Similar demographic variables

and multi-dimensional measures of parental well-being, child behavior, and social

support found in the Canadian National Longitudinal Survey of Children and Youth were

selected in order to perform cross-cultural comparisons between mothers of ADHD

children and mothers of non-ADHD children living in the U.S and Canada. However,

the unit of analysis is the mother, whereas the unit of analysis is the child in the NLSCY.

Due to limitations in the population size of fathers who responded to the NHIS and the

NLSCY, only American mothers of ADHD children and non-ADHD children and

Canadian children with and without ADHD are included for the purpose of analysis.

National Longitudinal Interview Survey (NHIS)

The NHIS has been collecting data on multiple dimensions of health, behavior and

health care services from non-institutionalized United States citizens and households

every year since its inception in 1957 by the National Center for Health Statistics

(NCHS), Centers for Disease Control and Prevention (CDC). Information for the NHIS

is collected through a stratified multistage probability design, which is recalculated every

ten years using population data from the most current decennial census. For each NHIS

family, one sample adult and one sample child (under the age of 18) from each household

is selected randomly to be interviewed face-to-face by Census interviewers. For the

purpose of this analysis, data on adults is collected from the primary respondents. Adults

provide information regarding the medical conditions, physical development and

50

behaviors of one child in the household. This includes medical or behavioral conditions

such as Attention Deficit Hyperactivity Disorder. Adults also provide information about

their own emotional health and engagement in social networks.

Dependent Measure

Parental Well-being

For the purpose of this research, six different variables are used to assess mental

health or wellbeing: ‘sad’, ‘nervous’, ‘restless’, ‘hopeless’, ‘effort’, and ‘worthless’.

Additionally, these variables are added together to represent a composite measure of

well-being (ranging from 0-30). However, well-being is based a factor analysis score in

the OLS regression models. A five-point scale is used to measure respondent’s

perceptions regarding their emotional well-being. Matrix questions were incorporated to

make it easier for respondents to answer these questions based on the same response

categories. Respondents were asked to indicate how often they experienced these

feelings in the past thirty days. Response categories included: all most all the time, most

of the time, some of the time, a little of the time or none of the time. After considering

the available literature on this subject, we should expect that mothers of ADHD children

will experience lower levels of well-being in comparison to parents of non-ADHD

children.

Independent Measures

The independent variables used in this analysis to determine important indicators of

maternal well-being are: marriage status, race, family household size, age, and education

and most importantly social support and the ADHD status and behavior of the sample

child. Marital status and race are recoded into dummy variables. Multi-dimensional

51

measures are used to assess the respondents’ level of social support, as well as the

behavior of their child.

Social Support

Social support is measured by seven variables: ‘going to worship services’, ‘going to

group events’, ‘going out to eat at a restaurant’, ‘getting together with relatives’, ‘talking

with relatives on telephone’, ‘getting together with friends’, and ‘talking on telephone

with friends’. These measures are used to determine the frequency of social contact.

Respondents are asked to indicate if they participated in each of these social dimensions

within the past two weeks. Scores for each of the social support variables range from 0 to

1. All of these variables add up to 7 when combined into a composite measure of social

support. In the OLS regression analysis, social support is based on a factor score. Since

mothers have been found to experience greater levels of emotional stress and family

tension in relation to the increased care-taking demands of an ADHD child

(Anastopoulos, et. al., 1992; Fischer, 1990; Cunningham, et. al., 1988; Befera & Barkley,

1985), we should expect that mothers of an ADHD child will report greater use of social

support than mothers of non-ADHD children.

The Behavior of the Child

The Strengths and Difficulties Questionnaire (SDQ), devised and copyrighted by

Robert Goodman (Goodman, 1997), is employed to obtain information about a variety of

behavioral strengths and problems displayed by children and its impact on family

functioning. This twenty-five item questionnaire is divided into five subscales to

measure the following psychological and social dimensions: emotional symptoms,

52

conduct problems, hyperactive behavior, peer relationships and pro-social behavior.

Each subscale consists of five items.

Items in the Emotional Symptoms Scale include: “Often complains of headaches,

stomach-aches, or sickness”, “Many worries, often seems worried”, “Often unhappy,

depressed or tearful”, “Nervous or clingy in new situations” and “Many fears, easily

scared”.

The items which make up the Conduct Problems Scale are: “Often has temper

tantrums or a hot temper”, “Generally obedient, usually does what parents want”, “Often

fights with other children or bullies”, “Often lies or cheats” and “Steals from home,

school or elsewhere”.

The Hyperactive Behavior Scale includes: “Restless, overactive, cannot stay still for

long”, “Constantly fidgeting or squirming”, “Easily distracted, concentration wanders”,

“Thinks things out before acting” and “Sees tasks through to the end, good attention

span”.

The Peer Relationships Scale items are: “Rather solitary, tends to play alone”, “Has

at least one good friend”, “Generally liked by other children”, “Picked on or bullied by

other children” and “Gets on better with adults than other children”.

Finally, the Pro-social Behavior Scale is used to measure children’s positive

behaviors. These items include: “Considerate of other people’s feelings”, “Shares

readily with other children”, “Helpful if someone is hurt, upset, or feeling ill”, “Kind to

other children”, and “Often volunteers to help others”.

All of the items in the SDQ are based on 3 response categories including: not true,

somewhat true and definitely true, with scores ranging from 0-2. Items in the subscale

53

can be calculated for an overall score between 0-50. High scores received on the SDQ

are associated with greater behavioral problems. The five subscales which make up the

SDQ can be used to capture specific psychological dimensions of child behavior. For the

purpose of this analysis all of the original items in the SDQ questionnaire will be

combined into one multi-dimensional measure. However, for the OLS regression model,

child behavior is based on a factor analysis score. It is expected that children with

ADHD will score higher on the SDQ than non-ADHD children. Additionally, the level

of well-being experienced by mothers is expected to be negatively influenced by a higher

score received on the SDQ in comparison to parents whose children score lower.

National Longitudinal Survey of Children and Youth

The 2002 NLSCY is a longitudinal study of non-institutionalized children across

Canada’s 10 providences which began in 1994 when the first cohort of children were

between the ages of 0-11. The second cohort consists of children who were selected in

1998 and between the ages of 0-1. The third and last cohort of children was selected in

2000 and was also between the ages of 0-1. Many of the respondents in the NLSCY

were drawn from the Labor Force Survey (LFS) sample of households and some

respondents were selected through provincial birth records. The study was designed to

compile information about children and their social, emotional and behavioral

development over time. Topics including the health (ADHD status), physical

development, learning, behavior and social environment (friends, family, school and

community) of children are covered by the NLSCY. Data from the survey is collected

from parents, youth and teachers. Information is gathered from respondents through

questionnaires administered by interviewers using computer-assisted telephone

54

interviewing (CATI), computer-assisted personal interviews (CAPI) and paper

questionnaires.

Dependent Measure

Maternal Wellbeing

As with the NHIS data, a multi-dimensional measure of maternal well-being is

designed using the NLSCY data in order to test the effects of having an ADHD child.

For the purpose of this analysis, parental well-being is comprised of 6 variables: ‘I felt

that I could not shake the blues even with help of family/friends’, ‘trouble keeping mind

on what I was doing’, ‘I felt depressed,’ ‘I felt that everything I did was an effort’, ‘I felt

hopeless about the future’, and ‘my sleep was restless’. All of these items are measured

using a 4 point scale with responses ranging from ‘rarely or none of the time’ to ‘most or

all of the time’ and can be added together to equal a score between 0 and 24. However,

in the OLS regression analysis, maternal well-being is based on a factor score. Similar to

Americans, Canadian mothers of ADHD children are expected to experience lower levels

of well-being in comparison to mothers of non-ADHD children.

Independent Measures

Several variables may be associated with the level of well-being experienced by

mothers of ADHD children in comparison to mothers of non-ADHD children. The

demographic variables drawn from the NLSCY data include: the ADHD status of the

child, marital status, race, family household size and the age and education of the parents.

Marital status was recoded to include married and unmarried. The race of respondents

was recoded into white and non-white. Families with over 10 members were recoded to

equal 10. The age of mothers between the ages of 16-24 was recoded to equal 24, while

55

the age of mothers between the ages of 55-76 was recoded to equal 55. Response

categories for the education of the mother include: ‘no schooling’, ‘elementary school (8

years if schooling or less)’, ‘some secondary school (9 years of schooling or more with

no degree)’, ‘secondary school graduation’, ‘other school beyond high school’, ‘some

trade school, etcetera’, ‘some community college, etcetera’, ‘some university’,

‘diploma/certificate for trade school, etcetera’, ‘diploma/certification for community

college, etcetera’, ‘bachelor’s degree’, and ‘masters, degree in medicine or doctorate.’

‘Other school beyond high school’ was collapsed to equal ‘some community college’.

Multi-dimensional measures of the sample child’s behavior and the parent’s social

support, which are also considered important indicators of maternal well-being, have also

been devised.

Social Support

A multi-dimensional measure of social support is constructed from the NLSCY data

using 7 variables. These variable include: 1) ‘I lack a feeling of closeness with another

person’, 2) ‘there is no one I feel comfortable talking about problems with’, 3) ‘I have

family and friends who help me feel safe, secure and happy’, 4) ‘there is someone I trust

whom I would turn to for advice if I were having problems’, 5) ‘there are people I can

count on in an emergency’, 6) ‘I feel part of a group of people who share my attitudes

and beliefs’, 7) ‘there is no one who shares my interests or hobbies’. All of these items

are measured by 4 response categories including: ‘strongly disagree’, ‘disagree’, ‘agree’

and ‘strongly agree’. To align the Canadian data more closely with the American data,

the responses were recoded into two categories to indicate agreement or disagreement.

Thus, as with the NHIS data, all of these variables add up to 7 when combined into a

56

composite measure of social support. In the OLS regression analysis, social support is

based on a factor score. American mothers of ADHD children are expected to receive

greater levels of social support than Canadian mothers of non-ADHD children. Yet,

American mothers of ADHD children are expected to rely more heavily on informal

source of social support, such as that offered by friends and family and Canadian mothers

are expected to receive more formal social support, such as that offered by professionals.

Child Behavior

A multi-dimensional measure of child behavior was constructed from 25 of the 39

related variables found in the NLSCY. In concordance with The Strengths and

Difficulties Questionnaire (SDQ) found in the NHIS, the 25 variables that make up this

measure can be divided into five sub-scales which measure the following psychological

and social dimensions: emotional symptoms, conduct problems, hyperactive behavior,

peer relationships, and pro-social behavior.

The emotional symptom scale is made up of 5 variables including: ‘Doesn’t seem as

happy as other children’, ‘Cries a lot’, ‘has trouble enjoying themselves, ‘is worried’, and

‘is nervous or high strung’.

The conduct problem scale consists of the following variables: ‘Gets in to many

fights’, ‘is mean /bully others’, ‘threatens people’, ‘destroys your things’ and ‘kick or hits

others’.

Items in the hyperactive behavior scale include: ‘Can’t sit still/restless’, ‘is easily

distracted’, ‘can’t concentrate/short attention’, ‘has difficulty waiting for turn in

games/groups’, and ‘acts on impulse’.

57

The peer relationships scale is comprised of the following variables: ‘When mad at

someone, tries to get others to dislike that person’, ‘comforts another child’, ‘when mad,

says things behinds others back’, ‘when accidentally hurt, reacts with anger/fighting’, and

‘when mad, tells secrets to third person’.

Lastly, items in the pro-social scale involve: ‘Volunteers to help clear up a mess

someone else has made’, ‘stops quarrels or disputes’, ‘will invite others to join in a

game’, ‘helps others who do not do as well’, and ‘helps other children who are sick’.

In contrast to the SDQ, all the child behavior measures are based on a five-point scale

with responses ranging from ‘almost every time’ to ‘almost never’. These variables were

recoded to reduce the number of response categories from 5 to 3 and to align the NLCSY

data closer to the NHIS data. For the purpose of this analysis all of the items which make

up the five scales will be collapsed into one multi-dimensional measure based on a scale

from 0 to 25. However, for the OLS regression model, child behavior is based on a factor

analysis score. Children who score higher will have greater behavioral problems.

ADHD children are expected to receive higher scores than non-ADHD children.

Unlike the U.S. data, analysis of the Canadian data allows for consideration of the

sample child’s use of Ritalin or similar medications prescribed on a regular basis. This

variable is based on a score from 0 to 1. Since Ritalin is a medication primarily used to

treat ADHD, it is expected that more children with ADHD will take Ritalin or similar

prescription medications on a regular basis than children who have not been diagnosed

with ADHD.

58

Sample population

The sample used in this study consists of mothers of ADHD children and mothers of

non-ADHD children who participated in the NHIS and the NLSCY. However, it is

important to note that the unit of analysis is the child in the NLSCY and the mother in the

NHIS. Interpretations must be made cautiously because respondents of the two surveys

may be influenced in different ways by the focus of the research. Canadian mothers

might be more reluctant to provide accurate data about themselves since their

participation is based on the fact that it is a study concerning their children. Again,

because of the lack of Canadian and American fathers who participated in the NLSCY

and NHIS, only American mothers of ADHD children and non-ADHD children and the

mothers of the sample Canadian children with and without ADHD are included for the

purpose of analysis. Other caregivers, such as grandparents or other family members,

will be excluded for the purpose of this analysis since the unique parent-child

relationship, which is a major focus of this study, significantly differs from these other

types of relationships. Mothers/children were selected if their child was between the ages

of 8 and 11. This age cohort was chosen for the purpose of analysis since children are

often diagnosed with the disorder early on in their educational careers. Research has also

demonstrated that pre-adolescent children with externalizing behavior problems cause

more stress to parents than adolescent children with the same problems, which indicates a

greater need for social support when children are younger (Donenburg & Baker 1993).

In both the NHIS and the NLSCY, the ADHD status of the child will be determined by

maternal conferment of diagnosis by a health care professional.

59

Analytical Plan to Address Study Questions

Study Question I: Do mothers of ADHD children report lower levels of emotional well-

being as compared to mothers of non-ADHD children? Do Canadian and American

mothers differ in terms of their overall emotional well-being, as a consequence of raising

an ADHD child?

Hypothesis: American and Canadian mothers of ADHD children are expected to report

the lower levels of emotional well-being than mothers of non-ADHD children. Canadian

mothers are expected to rate their overall emotional well-being higher than American

parents.

Null Hypothesis: There is no difference in the emotional well-being of mothers ADHD

children and mothers of non-ADHD children. There is no difference in Canadian and

American mother’s assessment of their emotional well-being.

Study Question II: Do mothers of ADHD children differ in social support as compared to

mothers of non-ADHD children? Do Canadian and American mothers receive similar

levels of social support?

Hypothesis: Canadian and American mothers of ADHD children will report higher levels

of social support than mothers of non-ADHD children. American mothers will rely on

social support more than Canadian parents.

Null Hypothesis: There is no difference in the amount of social support received by

mothers of ADHD children in comparison to mothers of non-ADHD children. Canadian

and American mothers do not differ in terms of the amount of social support that they

receive.

60

Study Question III: Does social support have a positive influence on the well-being of

mothers? Does the influence of social support on well-being vary for Canadian and

American mothers?

Hypothesis: Both Canadian and American mothers are expected to benefit from the

social support that they receive. Since American mothers are expected to rely more

heavily on social support than Canadian mothers, American mothers in this study may be

placing greater demands on their informal support networks. Therefore, Canadian

mothers are expected to experience the largest gains in well-being from the social support

they receive.

Null Hypothesis: There will not be a significant influence of social support on maternal

well-being. There will be no difference in the influence of social support on well-being

for Canadian and American mothers.

Analysis of Study Questions: The Statistical Package for the Social Sciences (SPSS) will

be used to manipulate the NHIS and NLSCY data and extract both bivariate and

multivariate analyses. Approval of the research and permission to utilize data from the

NLSCY has been granted by Statistics Canada, the Social Sciences and Humanities

Research Council and the Canadian Institutes of Health Research. Analysis of the

Canadian data will be conducted at the Research Data Centre (RDC) at McMasters

University in Hamilton, CA in accordance with the rules and regulations of Statistics

Canada.

61

Chapter 4 Canadian Findings

The Canadian results are displayed in this chapter. The first several tables present the

mean levels of maternal well-being, social support, child behavior, Ritalin use, and

relevant socio-demographic variables. The following table displays findings from an

OLS regression model in which a multi-indicator measure of maternal well-being based

on factor analysis is regressed on ADHD status, child behavior and Ritalin use, social

support, and the demographic variables. The final table presented in this chapter

illustrates how ADHD status might moderate the effects of other factors related to

maternal well-being, such as the age and education level of the mother.

Means

The mean level of maternal well-being by the ADHD status of the child is presented

in Table 1. Standard errors are presented in the parentheses beneath the mean scores. As

previously discussed, six different emotional well-being-related variables are analyzed: ‘I

felt that I could not shake the blues even with help of family/friends’, ‘trouble keeping

mind on what I was doing’, ‘I felt depressed,’ ‘I felt that everything I did was an effort’,

‘I felt hopeless about the future’, and ‘my sleep was restless’. These components of well-

being are all based on a scale of 1 to 4 with responses ranging from ‘all of the time’ to

‘none of the time’. Higher scores indicate greater well-being. All of the predictors

variables were also combined into a composite measure of well-being, based on a scale of

1 to 24, with a higher mean score indicating greater well-being. A reliability test reveals

that these variables are significantly correlated with one another and when combined,

these variables represent an acceptable indicator of maternal well-being (α = .771).

62

As can be seen in Table 1, there are few differences in the well-being reported by

mothers of ADHD children as compared to mothers of non-ADHD children. Of the six

emotion-related variables, only mothers’ experience of blues significantly differs (p =

.05). It appears that children with ADHD are more likely to have a mother with a higher

level of perceived blues than children without ADHD. Despite minute differences in the

other variables, the composite measure of well-being also suggests that mothers of non-

ADHD children experience greater well-being than mothers of ADHD children (p = .05).

Overall, the small and mostly insignificant mean differences presented in this section fail

to confirm prior research concerning the poor emotional well-being of mothers with

ADHD children.

63

ADHD Mothers

Non-ADHD

Blues Unable to Concentrate Depressed Hopelessness Effort Restlessness

3.63* (0.72) 3.46 (0.80) 3.61 (0.80) 3.32 (0.96) 3.45 (0.83) 3.16

3.76 (0.61) 3.57 (0.75) 3.70 (0.64) 3.47 (0.91) 3.56 (0.81) 3.28

(1.06) (1.02) Well-being

20.65*

21.35

(3.93) (3.24) N 110 3,919

Table 1 (CA): Mean levels of Maternal Well-Being by the ADHD Status of the Child

Note: Stars indicate statistically significant differences between parents of ADHD children and non-ADHD children. ***p<.001 **p<.01 *p<.05

64

Table 2 summarizes the mean levels of maternal social support by the child’s ADHD

status. As previously discussed, social support is measured by seven different variables:

‘I lack a feeling of closeness with another person’, ‘there is no one I feel comfortable

talking about problems with’, ‘I have family and friends who help me feel safe, secure

and happy’, ‘there is someone I trust whom I would turn to for advice if I were having

problems’, ‘there are people I can count on in an emergency’, ‘I feel part of a group of

people who share my attitudes and beliefs’, ‘there is no one who shares my interests or

hobbies’. These measures indicate the respondent’s level of satisfaction with social

support. All of the variables were also combined into a composite measure of social

support, based on a scale of 1 to 7, with a higher score indicating greater satisfaction.

According to a reliability test, these variables are significantly correlated with one

another and when combined, these variables represent an acceptable indicator of social

support (α = .717).

As the data indicates, there are no discernable mean differences in the level of

satisfaction with social support reported by mothers of ADHD children as compared to

mothers of non-ADHD children. The composite measure of social support confirms this

lack of difference. Overall, it appears that both children with ADHD and children

without ADHD have mothers with a satisfying level of social support. For instance,

100% of the children with ADHD in this sample have a mother who reports that there are

people she can count on in an emergency. The results presented here are in contrast to

the findings of previous studies, which suggest that mothers of ADHD children do not

receive adequate social support, as compared to mothers of non-ADHD children.

65

Table 2 (CA): Mean levels of Maternal Social Support by the ADHD Status of the Child

ADHD Mothers

Non-ADHD

Lack of closeness No one to talk to

0.95 (0.22) 0.95 (0.23)

0.93 (0.25) 0.95 (0.22)

Friends, family/Safe, happy Can turn to someone/ Advice Can count on people/ Emergency Group/Share beliefs No one who shares interests

0.99 (0.08) 0.96 (0.20) 1.00 (0.06) 0.95 (0.21) 0.99 (0.12)

0.95 (0.21) 0.96 (0.19) 0.98 (0.15) 0.94 (0.23) 0.96 (0.19)

Ave. Social Support

6.78

6.68

(0.67) (0.90) N 110 3,919

Note: Stars indicate statistically significant differences between parents of ADHD children and non-ADHD children. ***p<.001 **p<.01 *p<.05

Table 3 presents the mean levels of family and child characteristics by the ADHD

status of the child. The marital status, race, family size, age, and education of the mother

are considered, as well as the behavior and Ritalin use of the child. The first section in

66

this table suggests that there is only a significant difference in the marital status of

mothers of ADHD children, as compared to mothers of non-ADHD children. While the

majority of respondents are married, ADHD children are less likely to have a married

mother (61%) compared to children without ADHD (71%).

In contrast, the mean difference in child behavior and use of Ritalin both reached

statistical significance at the .001 level. As discussed in Chapter 3, the behavior of the

child is a multi-dimensional measure constructed from 25 of the 29 variables regarding

child behavior found in the NLSCY. These variables were chosen because of their

similarity to the behavioral variables located in the NHIS. All the child behavior

measures are based on a five-point scale with responses ranging from ‘almost every time’

to ‘almost never’. The reliability test for this scale reveals that all of the variables related

to child behavior are significantly correlated with one another (α = .825). Children who

score higher display greater behavioral problems. As expected, there is a statistically

significant difference in the behavior of ADHD and non-ADHD children. In accordance

with previous research, this data suggests that children with ADHD display almost twice

the amount of behavioral problems, as compared to children without the disorder (18.66

vs. 9.81).

There also appears to be a significant difference in the use of Ritalin by ADHD

children and non-ADHD children. As can be seen, about 54% of the ADHD children

take Ritalin, next to 1% of non-ADHD children. However, if 1% of non-ADHD children

in this sample take Ritalin, this indicates that some Canadian children who have not been

diagnosed with the disorder are being treated with a medication mainly used to treat

ADHD.

67

ADHD Mothers

Non-ADHD

Family Characteristics

Marital Status Race

0.61* (0.49) 0.85 (0.35)

0.71 (0.45) 0.87 (0.32)

Family Size Parent Age Education Child Characteristics Problematic Behavior Use of Medication

4.32 (1.33) 38.02 (5.78) 7.18 (3.13) 18.66 (6.90) .51

4.41 (1.23) 38.49 (5.78) 7.03 (2.98) 9.81*** (5.47) .01***

(0.50) (0.11) N 110 3,919

Table 3 (CA): Mean levels of Family and Child Characteristics by the ADHD Status of the Child

Note: Stars indicate statistically significant differences between parents of ADHD children and non-ADHD children. ***p<.001 **p<.01 *p<.05

68

OLS Regressions

Table 4 presents the results from an OLS regression model for the relationship between

maternal well-being and the ADHD status, behavior and Ritalin use of the child, social

support and the selected socio-demographic variables. Standard errors are displayed in

parentheses directly below the unstandardized coefficients. In place of scale scores,

factor analysis scores for the dependent measure, as well as social support and child

behavior are used for the purpose of this analysis. As previously discussed, the purpose

of using factor analysis was to reduce the amount of measurement error in the values of

the different variables used to measure these multi-dimensional constructs.

The first model in this table displays the effect of ADHD status on maternal well-

being. As can be seen, the ADHD status of the child alone does not have a significant

effect on the dependent measure. Considering the size of the coefficient and the R-

square, the strength of the relationship between maternal well-being and ADHD status is

extremely weak. This indicates that having an ADHD child has little to no impact on the

well-being experienced by mothers.

Model 2 includes ADHD status and problematic behavior as explanatory variables of

maternal well-being. As the data indicates, problematic behavior has a negative influence

on the dependent measure, which is significant at conventional levels (p = .001). This

implies that as problematic behavior increases, maternal well-being declines. The

addition of this variable also results in a slight increase in the size of the R-squared (R2 =

.004). This suggests that only about .4% of the variance in maternal well-being can be

explained by the behavior of the child.

69

As with ADHD status, the Ritalin use of the child does not appear to have an

important influence on maternal well-being. The size of the R-square remains constant

with the introduction of this child related variable in Model 3. Surprisingly, the

introduction of social support in Model 4 also fails to have a significant impact on the

dependent measure. This finding runs contrary to theoretical and applied research

concerning the importance of social support on well-being, especially the well-being of

mothers.

The final model in Table 4 combines all of the independent variables and

demographic characteristics. As can be seen, in addition to the behavior of the child,

several of the family characteristics have an important influence on maternal well-being.

It appears that both marriage and education have a positive effect on the maternal well-

being of the sample children, which is significant at conventional levels (p = .001).

Additionally, with the inclusion of the demographic variables, the R-square becomes

greater (R2 = .026).

Overall, these findings suggest that behavioral problems have a greater negative

impact on the level of well-being reported by the mothers of the children in this sample,

which is significant at conventional levels, as compared to ADHD status alone. So the

question remains, does the effect of having an ADHD child depend on the level of

behavioral problems displayed? This question, as well as others related to the interaction

of ADHD status and the family characteristics, is addressed in the next part of this

analysis.

70

Table 4 (CA): OLS Regression Coefficients (unstandardized) for Relationship between Maternal Well-being, Social Support, Family Characteristics and the ADHD Status, Medication Use and Behavior of Child ___________________________________________________________________

Model 1 Model 2 Model 3 Model 4 Model 5 ADHD Status Problematic Behavior

-.101 (.097)

- .067 (.097) -.061*** (.016)

-.153 (.118) -.062*** (.018)

-.154 (.118) -.062*** (.016)

-.112 (.117) -.055*** (.016)

Ritalin Use Social Support Family Size Marital Status Race Parent Age Education

.149 (.117)

.150 (.117) .005 (.016)

.160 (.116) .008 (.016) .030 (.015) .225*** (.038) .107 (.058) .002 (.003) .023*** (.005)

Intercept R2

.000 (.016) .000

-.002 (.016) .004

-.004 (.016) .004

-.004 (.016) .004

-.636*** (.142) .026

___________________________________________________________________

N = 4,029 Note: Standard errors are displayed in parentheses below the standardized coefficients. Stars indicate statically significant effects on maternal well-being.

***p<.001 **p<.01 *p<.05

71

Table 5 display findings from OLS regression models for the relationship between

maternal well-being and the interaction between ADHD status and characteristics of the

family and child. The purpose of this type of analysis is to determine whether there are

child and family contexts in which the effects of ADHD status on maternal well-being are

moderated. For example, it might be that the effect of having an ADHD child with a

higher level of behavioral problems will have a stronger negative impact on maternal

well-being than the effect of having an ADHD child with a lower level of behavioral

problems.

This table presents nine separate models. In the first model of Table 5, only the

ADHD status of the child is considered as an important explanatory variable of the well-

being experienced by the mothers of the children in this sample. To reiterate, the data

presented in this analysis suggests that the ADHD status of the child does not have an

important influence on maternal well-being. Model 2 includes the ADHD status of the

child and the demographic characteristics. As in the previous model, the addition of both

marital status and education in the model proves to have a positive influence on the

dependent measure, which is significant at conventional levels (p = .001). Additionally,

the size of the R-square is also greater with the introduction of these variables (R2 =.022)

The effects of the various interaction terms on maternal well-being are presented in

Models 3 through 9. The latent factors scores for child behavior and social support were

replaced with dummy variables to represent low and high problematic behavior, and low

and high satisfaction with social support. Low behavioral problems were coded 0 if the

behavior score was between 0 and 7 and high behavioral problems were coded 1 if the

score was between 8 and 25. The cutoff for low behavioral problems was based on the

72

mean behavioral problems score for American children without ADHD. A median split

was computed to divide social support into two categories such that those who scored at

or above the median were recorded as having high social support while those below the

median were recorded as having high social support. Low family size was coded 0 if the

family was between 1 and 2 members and 1 if the family contained between 3 and 12

members. Young mothers were coded 1 if between the ages of 18 and 30 and 0 if

between 31 and 85. Lastly, responses were recoded so that education below grade 11

were recorded as 0 and grade 12 and over was recoded to equal 1.

Model 3 displays the effects of the ADHD status of the child, the demographic

characteristics, comparably high behavioral problems, and the interaction between

ADHD status and high behavioral problems on the well-being reported by mothers of the

children in this sample. While the effect of having a child with greater behavioral

problems appears to have a significantly negative impact on the dependent measure, the

interaction between ADHD status and high behavioral problems is positive, yet fails to

reach significance at conventional levels. This indicates that the influence of having an

ADHD child is not moderated by the level of behavioral problems displayed by the child.

As can be seen in Model 4, having comparably high social support has a positive

impact on the dependent measure and is significant at conventional levels (p = .05). This

is in contrast to the effect of the full measure of social support in the previous table. It

also appears that the interaction between ADHD status and high social support has a

considerably large positive effect on the level of well-being reported by the mothers of

the sample children in this analysis (B = 1.424). This implies that having an ADHD child

73

is positively moderated by the effect of experiencing a high level of satisfaction with

social support.

The effect of having a comparably larger family size on maternal well-being is

displayed in Model 5. Both large family size and the interaction between ADHD status

and family size fail to reach significance. Also, the interaction between ADHD status

and race, as presented in Model 5, as well as the interaction between ADHD status and

marriage, as presented in Model 6, does not appear to be significantly related to the

dependent measure. This suggests that the effect of ADHD status on maternal well-being

is not moderated by family size, race, or marital status.

The results presented in Model 8 indicate that the effect of being a comparably

younger mother is negative and statistically significant (p = .01). In contrast, the

interaction between the ADHD status of the child and being a comparably younger

mother appears to have a significantly positive influence on the well-being reported by

the mothers of children in this sample (p = .01). It seems that younger mothers of ADHD

children may be more able to cope than older mothers of ADHD children. It might be

that younger mothers of the sample ADHD children in this analysis have more energy to

deal with the troubles associated with the disorder.

Lastly, Model 9 in Table 5 illustrates the effect of having higher education and the

interaction between higher education and ADHD status. While having a comparably

higher level of education appears to have a significantly positive influence on the well-

being reported by the mothers of children in this sample, the interaction between ADHD

status and high education fails to reach statistical significance. This indicates that the

influence of ADHD status on maternal well-being is not moderated by the level of

74

education attained by mothers. Compared to the other models in Table 5, it appears that

high behavioral problems and the corresponding interaction with ADHD status in Model

3 has the strongest association with the dependent measure (R2 = .027).

75

Table 5 (CA): OLS Regression Coefficients (unstandardized) for Relationship between Maternal Well-being, the ADHD Status of Child, Family Characteristics and Selected Interaction Terms ____________________________________________________________________

Model 1 Model 2 Model 3 Model 4 Model 5 ADHD Status -.101 -.047 -.148 -.021 -.005 (.097) (.097) (.564) (.097) (.113) Family Size

----

.023

.027

.023

----

(.015) (.015) (.015) Marital Status

----

.236***

.232***

.231***

.247***

(.038) (.038) (.037) (.037)

Race ----

.105

.129*

.111

.103

(.058) (.059) (.058) (.058) Parent Age

----

.003

.003

.003

.003

(.003) (.003) (.003) (.003) Education

----

.022***

.022***

.023***

.022***

(.005) (.005) (.005) (.005) High Behavior ADHD*High Behavior

---- ----

---- ----

-.126*** (.032) .163 (.574)

---- ----

---- ----

High Social

----

----

----

.275* (.051)

----

ADHD*High Social

---- ---- ---- 1.424* (.214)

----

High Family

----

----

----

----

-.038 (.043)

ADHD*High family Size

---- ---- ---- ---- .150 (.212)

Intercept .000 -.653*** -.603*** -.654*** -.575*** (.016) (.142) (.144) (.142) (.128) R2

.000

.022

.027

.025

.022

N = 4,029 Note: Standard errors are displayed in parentheses below the standardized coefficients. Stars indicate statically significant effects on maternal well-being. *** p<.001 ** p<.01 * p<.05

76

Table 5 (CA): OLS Regression Coefficients (unstandardized) for Relationship between Maternal Well-being, the ADHD Status of Child, Family Characteristics and Selected Interaction Term Cont. ________________________________________________________________________

Model 6 Model 7 Model 8 Model 9 ADHD Status

.005

-.081

-.149

.018

(.280) (.148) (.152) (.119) Family Size

.023

.023

.024

.023

(.015) (.015) (.015) (.015) Marital Status

.236***

.234***

.227***

.242***

(.038) (.039)

(.038) (.038)

Race .108 .105 .097 .108 (.059) (.058) (.058) (.058) Parent Age

.003

.003

----

.004

(.003) (.003) (.003) Education

.022***

.022***

.021***

----

(.005) (.005) (.005) ADHD*Race -.059 ---- ---- ---- (.298) ADHD*Marital Status

---- .059 (.194)

----

----

Low Age

----

----

-.167** (.056)

----

ADHD*Low Parent Age

---- ---- .734** (.273)

----

High Education ADHD*High Education

---- ----

---- ----

---- ----

.111*** (.033) .192 (.200)

Intercept -.656*** -.651*** -.496*** -.487*** R2

(.142) .022

(.142) .022

(.092) .025

(.143) .021

N = 4,029 Note: Standard errors are displayed in parentheses below the standardized coefficients. Stars indicate statically significant effects on maternal well-being. *** p<.001 ** p<.01 * p<.05

77

According to this analysis, the mothers of the sample ADHD children are not that

different from the mothers of the sample non-ADHD children. Table 2 reveals that there

are no significant differences in satisfaction with social support. Yet, in terms of well-

being and the socio-demographic variables there was some variation (as seen in Table 1

and Table 3). It appears that significant differences exist in the perception of blues, the

composite measure of well-being, the behavior and Ritalin use of the child, and the

marital status the mother. Thus, children with ADHD are more likely to have a mother

with a higher level of perceived blues than children without ADHD. Despite a lack of

group difference in the other five emotional-related variables, mothers of children with

ADHD also appear to have a lower overall level of well-being as compared to the

mothers of the non-ADHD sample children. The behavioral problems and Ritalin use of

the child is significantly greater for those with ADHD. Lastly, children without ADHD

are more likely to have a married mother than ADHD children.

The OLS regression analysis, in which the multi-indicator measure of maternal well-

being was regressed on ADHD status, child behavior and Ritalin use, social support, and

the demographic variables, reveals that ADHD status has little to no association with the

dependent measure. However, the problematic behavior of the child and the marital

status and education level of the mother do have an important impact on maternal well-

being. Overall, it appears that problematic behavior negatively influences maternal well-

being, while marriage and education have a positive effect (as seen in Table 4).

The purpose of this analysis was also to determine if the impact of ADHD status

becomes more influential under certain contexts. For instance, having an ADHD child

may not negatively influence maternal-well-being, unless the level of problematic

78

behavior displayed by the child is taken into account. As demonstrated in this part of the

analysis, the effect of having a child with comparably high behavioral problems

significantly differs from the effect of having a child with comparably lower behavioral

problems. However, the interaction between ADHD status and high behavioral problems

fails to reach significance at conventional levels. Thus, the influence of having an

ADHD child is not mediated by the level of behavioral problems displayed by the child

(as seen in Model 1 of Table 5).

It also appears that significant differences exist between mothers with a comparably

higher level of satisfaction with social support and those with a lower level of satisfaction

with social support. Additionally, the interaction between ADHD status and high social

support has a considerably large positive effect on the level of well-being reported by the

mothers of the sample children in this analysis. In other words, the effect of having an

ADHD child is positively moderated by the effect of experiencing a high level of

satisfaction with social support. Thus, mothers of ADHD children who experience a

higher level of satisfaction with social support might be in a better position to cope with

the occurrence of stress (as seen in Model 2 of Table 5).

As for the interaction between ADHD status and the socio-demographic

characteristics, the data displayed in Table 5 indicates that there is a negative correlation

between the dependent measure and being a comparably younger mother. Yet, the

interaction between having an ADHD child and being younger appears to have a positive

impact on maternal well-being (Model 8). It might be that younger mothers of the

sample ADHD children in this analysis have more energy or patience to deal with the

troubles associated with the disorder. The data also suggests that the effect of having a

79

comparably higher education level is significantly more positive than the effect of having

a lower education level. However, the interaction between ADHD status and high

education fails to reach significance at conventional levels (Model 9). This indicates that

the influence of ADHD status on maternal well-being is not moderated by the level of

education attained by mothers. Overall, the interaction between ADHD status and high

behavioral problems has the strongest association with the dependent measure in this part

of the analysis.

80

Chapter 5 American Findings

This chapter describes the results derived from the American data. The first several

tables display the mean levels of maternal well-being and social support, child behavior

and use of medication, and relevant socio-demographic variables. This section of the

research also presents findings from an OLS regression model in which a multi-indicator

measure of maternal well-being based on factor analysis is regressed on ADHD status,

behavior and medication use of the child, social support, and the demographic variables .

Additionally, tables are presented that show how ADHD status might moderate the

effects of other factors, such as problematic behavior and social support, on maternal

well-being.

Means

Table 1 presents the mean levels of maternal well-being by the ADHD status of the

child. Standard errors are presented in the parentheses beneath the mean scores. As

previously discussed in Chapter 3, six different emotional well-being-related variables

are analyzed. These six components of well-being are all measured on a scale of 1 to 4

with responses ranging from ‘all of the time’ to ‘none of the time’. Higher scores

indicate greater well-being. For example, higher scores signify lower degrees of sadness,

nervousness, restlessness, hopelessness, effort, and worthlessness. All of the variables

were also combined into a composite measure of well-being, based on a scale of 1 to 24,

with a higher mean score indicating greater well-being. According to a reliability test,

these variables are significantly correlated with one another and taken together, are an

adequate indicator of well-being (α = .852). Although previous research tends to suggest

that parents of ADHD children experience higher levels of stress and strain as a result of

81

parenting an ADHD child, the data analyzed in this section of the study suggests

otherwise.

As can be seen in Table 1, none of the differences in the well-being of mothers in this

sample are significant at conventional levels. Contrary to expectations, levels of well-

being are nearly identical for mothers of ADHD children and mothers of non-ADHD

children. Again, higher mean scores indicate a greater level of well-being. Overall, the

composite measure of well-being suggests that virtually no differences exist between the

well-being of mothers of ADHD children (22.96) and mothers of non-ADHD children

(22.90). These findings fail to support previous research concerning differences in the

emotional status of mothers of ADHD children as compared to mothers of children who

have not been diagnosed with the disorder.

82

ADHD Mothers

Non-ADHD

Sadness Nervousness Restlessness Hopelessness Effort Worthlessness

3.83 (0.52) 3.75 (0.60) 3.73 (0.65) 3.92 (0.39) 3.80 (0.58) 3.93

3.81 (0.52) 3.74 (0.60) 3.74 (0.60) 3.91 (0.39) 3.78 (0.61) 3.92

(0.35) (0.34) Well-being

22.96

22.90

(2.30) (2.46) N 181 2,819

Table 1 (US): Mean levels of Maternal Well-Being by the ADHD Status of the Child

Note: Stars indicate statistically significant differences between parents of ADHD children and non-ADHD children. ***p<.001 **p<.01 *p<.05

Table 2 summarizes the mean levels of maternal social support by the child’s ADHD

status. Social support is measured by seven different variables. These measures indicate

the respondent’s frequency of social contact and more importantly access to social

support. Respondents were asked if they participated in each of the particular social

activities within the past two weeks. Scores were based on a scale of 0 to 1, with scores

83

closer to one indicating more social contact and greater access to social support. All of

the variables were also combined into a composite measure of social support, based on a

scale of 1 to 7 with a higher score indicating greater social contact and potentially greater

access to social support. A reliability test reveals that these variables are significantly

correlated with one another and when combined, these variables represent an acceptable

indicator of social support (α = .622).

As can be seen in Table 2, there are few differences in the social support received by

mothers ADHD children and mothers of non-ADHD children. Only talking to relatives

on the telephone reaches significance at the .05 level. As these variables are based on a

score of 0-1, it can be suggested that 94% of mothers of ADHD children this sample have

spoken to relatives on the telephone in the past two weeks compared to about 90% of

mothers of ADHD children. Overall, the data indicates that there are few discernable

differences in the social support received by mothers of ADHD children as compared to

mothers of non-ADHD children.

84

ADHD Mothers

Non-ADHD

Worship Services Group Events

0.57 (0.50) 0.60 (0.49)

0.51 (0.50) 0.57 (0.50)

Dining Out Relatives/Visit Relatives/Telephone Friends/Visit Friends/Telephone

0.81 (0.39) 0.81 (0.40) 0.94* (0.23) 0.83 (0.37) 0.87

0.81 (0.39) 0.79 (0.41) 0.90 (0.30) 0.85 (0.36) 0.88

(0.34) (0.33)

Ave. Social Support

5.43

5.30

(1.62) (1.54) N 181 2,819

Table 2 (US): Mean levels of Maternal Social Support by the ADHD Status of the Child

Note: Stars indicate statistically significant differences between parents of ADHD children and non-ADHD children. ***p<.001 **p<.01 *p<.05

85

Table 3 presents mean levels of family and child characteristics by the ADHD status

of the child. The first section of the table reveals no significant differences in the family

characteristics of mothers of ADHD children as compared to mothers of non-ADHD

children. In contrast, the mean differences in child characteristics reached statistical

significance at the .001 level. As was previously discussed in Chapter 3, the Strengths

and Difficulties Questionnaire (SDQ) was used to access problematic behavior in

children. Scores for the SDQ range from 0 to 25. High scores are associated with the

display of greater behavioral problems. As the reliability test for this scale reveals, all of

the variables related to child behavior are significantly correlated with one another (α =

.739). As expected, children with ADHD scored significantly higher on the SDQ in

comparison to children without ADHD. ADHD children scored close to 19, while non-

ADHD children scored less than 8. This indicates that the ADHD children in this sample

display more behavioral problems and difficulties than the non-ADHD children. As for

the medical treatment of the child, the data suggests that well over half of the ADHD

children in this sample take some form of prescription medication compared to less than

10% of children without ADHD.

86

ADHD Mothers

Non-ADHD

Family Characteristics

Marital Status Race

0.40 (0.49) 0.59 (0.49)

0.39 (0.49) 0.58 (0.49)

Family Size Parent Age Education Child Characteristics Problematic Behavior Use of Medication

3.51 (1.83) 47.02 (17.48) 11.87 (5.10) 18.39 (8.38) .54

3.41 (1.70) 45.99 (17.74) 11.78 (4.99) 7.90*** (5.86) .09***

(0.50) (0.29) N 181 2,819

Table 3 (US): Mean levels of Family and Child Characteristics by the ADHD Status of the Child

Note: Stars indicate statistically significant differences between parents of ADHD children and non-ADHD children. ***p<.001 **p<.01 *p<.05

87

OLS Regressions

Table 4 presents the results from an OLS regression model for the relationship

between maternal well-being and the ADHD status, behavior and medication use of the

child, social support and the selected socio-demographic variables. Standard errors are

displayed in parentheses directly below the unstandardized coefficients. Factor analysis

scores for the dependent measure, as well as social support and child behavior are used

for the purpose of this analysis. Social support is expected to enhance the well-being of

both mothers ADHD children and mothers of non-ADHD children, while the ADHD

status and problematic behavior displayed by children is anticipated to have a negative

impact on well-being.

In Model 1 the data suggests that the ADHD status of the child does not have a

significant effect on maternal well-being. Considering that the coefficient representing

the effect of the ADHD status of the child (B = .045) is smaller than the standard error

(SE = .070), as well as the negligible size of R-squared (R2 = .000), the strength of the

relationship between maternal well-being and ADHD status alone is extremely weak.

Model 2 includes ADHD status and problematic behavior as explanatory variables of

maternal well-being. As the data indicates, neither ADHD status (B = -.033) nor

problematic behavior (B = .015) has a large impact on the dependent measure or reaches

statistical significance. Additionally, the R-squared remains unchanged from the addition

of problematic behavior in the model (R2 = .000).

In the next model, the medication use of the child is included in the regression. As

with ADHD status and problematic behavior, the medication use of the child does not

88

appear to have an important influence on the dependent measure. However, the addition

of medication use in the model results in a slight increase in the R-squared (R2 = .001).

In Model 4, social support is seen to have a relatively large and positive effect on

maternal well-being (B = .154) and is significant at the .001 level. With the addition of

social support within the model, the R-squared also increases (R2 = .027). Overall,

compared to other explanatory variables utilized in this analysis, the strength of the

relationship between maternal well-being and social support is the strongest.

The final model in Table 4 combines all of the independent variables and

demographic characteristics. However, the addition of the family characteristics in the

model does not have a significant impact on the strength of the overall model. As can be

seen, R-squared remains constant from Model 4 to Model 5. The effects of family size,

marital status, the race, age, and education of the respondent are relatively small in

magnitude and none of these variables have a significant influence on the well-being of

mothers in this sample. The conditional effects of ADHD status in the final model

indicate that controlling for all other factors, having an ADHD child does not have a

deleterious impact on the well-being experienced by mothers. With few exceptions, the

effects of these explanatory variables on maternal well-being are inconsistent with prior

research concerning the impact of raising an ADHD child (Harrison and Sofronoff, 2002;

Anastopoulos, et al., 1992; Barkley, 1998; Cunningham and Boyle, 2002; Johnston and

Mash, 1996).

89

Table 4 (US): OLS Regression Coefficients (unstandardized) for Relationship between Maternal Well-being, Social Support, Family Characteristics and the ADHD Status, Medication Use and Behavior of Child ___________________________________________________________________

Model 1

Model 2

Model 3

Model 4

Model 5

ADHD Status Problematic Behavior

.045 (.070)

- .032 (.074) .015 (.018)

.037 (.077) .015 (.018)

.048 (.076) .015 (.017)

.050 (.077) .015 (.017)

Medication Use Social Support Family Size Marital Status Race Parent Age Education

-.032 (.054)

-.035 (.054) .154*** (.017)

-.034 (.054) .154*** (.017) -.009 (.010) .001 (.037) .016 (.035) -.001 (.001) .002 (.004)

Intercept R2

.028 (.017) .000

.029 (.017) .000

.032 (.018) .000

.030 (.018) .029

-.531 (.098) .030

___________________________________________________________________________________ N = 3,000 Note: Standard errors are displayed in parentheses below the standardized coefficients.

***p<.001 **p<.01 *p<.05

90

Table 5 display findings from OLS regression models for the relationship between

maternal well-being and the interaction between ADHD status and characteristics of the

family and child. The purpose of this type of analysis is to determine whether there are

child and family contexts in which the effects of ADHD status on maternal well-being are

important. For instance, it might be that there will be significant group differences

between mothers of ADHD children with comparably lower behavioral problems,

mothers of ADHD children with high behavioral problems, mothers of non-ADHD

children with low behavioral problems and mothers of non-ADHD children with high

levels of behavioral problems. Additionally, it would seem reasonable to expect that

having an ADHD child with comparably higher levels of social support will have a

stronger impact on maternal well-being than the effects of ADHD status alone.

Nine separate models are presented in Table 5. In the first model, only the ADHD

status of the child is considered as an explanatory variable of maternal well-being, while

the second model includes ADHD status and family characteristics. To reiterate, the data

suggests that the ADHD status of the child does not have an important influence on

maternal well-being. The addition of family characteristics, such as family size, marital

status, and the race, educational level and age of the mother also does not appear to have

a significant impact on the overall strength of Model 2 (R2 =.002). The effect of each of

the variables on the dependent measure is small in magnitude and not statistically

significant. For example, the effect of being married, which has frequently been

associated with greater levels well-being, only appears to increase the well-being of

mothers in this sample by unit increase of .001.

91

The effects of the various interaction terms on maternal well-being are presented in

Models 3 through 9. The latent factors scores for child behavior and social support were

replaced with dummy variables to represent low and high problematic behavior, and low

and high social support. Low behavioral problems were coded 0 if the behavior score

was between 0 and 7 and high behavioral problems were coded 1 if the score was

between 8 and 25. The cutoff for low behavioral problems was based on the mean

behavioral problems score for children without ADHD. A median split was computed to

divide social support into two categories such that those who scored at or above the

median were recorded as having high social support while those below the median were

recorded as having high social support. Low family size was coded 0 if the family was

between 1 and 2 members and 1 if the family contained between 3 and 12 members.

Young mothers were coded 1 if between the ages of 18 and 30 and 0 if between 31 and

85. Lastly, responses were recoded so that education below grade 11 were recorded as 0

and grade 12 and over was recoded to equal 1.

As can been seen in Model 3 of Table 5, having an ADHD child with higher

behavioral problems appears to a positive impact on the dependent variable, while the

opposite is the case for mothers of ADHD children with lower levels of problematic

behavior (B = .350 vs. B = -.350). Although the effect of this interaction fails to reach

significance (p = .08), there does appear to be significant group differences between

mothers of ADHD children with high behavioral problems and mothers of non-ADHD

children with high behavioral problems (.605). Yet, the influence of having an ADHD

child with high behavioral problems does not significantly differ from the effect of

92

having an ADHD child with lower behavioral problems. This suggests that the impact of

having an ADHD child is not significantly influenced by behavioral levels.

Overall, the results presented in this section suggest that only the interaction between

ADHD status and education has a significant impact on maternal well-being. However,

the effect of high education alone is not significant. As the data suggests, being more

educated with an ADHD child appears to have a positive effect on maternal well-being as

compared to the interaction between ADHD status and low education (B = .310 vs. to B

= -.310). Thus, mothers with a higher level of education may have a greater capacity to

cope with the stress associated with raising an ADHD child.

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Table 5 (US): OLS Regression Coefficients (unstandardized) for Relationship between Maternal Well-being, the ADHD Status of Child, Family Characteristics and Selected Interaction Terms _______________________________________________________________________

Model 1 Model 2 Model 3 Model 4 Model 5

N = 3,000

ADHD Status .045 -.047 -.267 .107 .003 (.070) (.070) (.238) (.202) (.079) Family Size

----

-.007

-.009

-.006

----

(.011) (.011) (.010) Marital Status

----

.001

-.004

.011

-.002

(.037) (.038) (.037) (.037)

Race ----

.015

.009

.013

.017

(.035) (.036) (.035) (.035) Parent Age

----

-.002

-.001

-.001

-.001

(.001) (.001) (.001) (.001) Education

----

.002

.002

.002

.002

(.004) (.004) (.004) (.004) High Behavior ADHD*High Behavior

---- ----

---- ----

-.002 (.035) .350 (.252)

---- ----

---- ----

High Social

----

----

----

.482*** (.051)

----

ADHD*High Social

---- ---- ---- -.074 (.214)

----

High Family

----

----

----

----

-.038 (.043)

ADHD*High family Size

---- ---- ---- ---- .195 (.168)

Intercept .028 .089 .102 -.377*** .070 (.017) (.081) (.084) (.094) (.066) R2

.000

.002

.002

.032

.002

Note: Standard errors are displayed in parentheses below the standardized coefficients. Stars indicate statically significant effects on maternal well-being. *** p<.001 ** p<.01 * p<.05

94

Table 5 (US): OLS Regression Coefficients (unstandardized) for Relationship between Maternal Well-being, the ADHD Status of Child, Family Characteristics and Selected Interaction Term Cont. _______________________________________________________________________

Model 6 Model 7 Model 8 Model 9 ADHD Status

-.015

.001

.148

-.131

(.108) (.090) (.152) (.107) Family Size

-.007

.226

-.007

-.008

(.011) (.279) (.011) (.011) Marital Status

.222

-.008

.001

.001

(.105) (.011)

(.037) (.038)

Race .001 .015 .014 .017 (.037) (.035) (.035) (.035) Parent Age

-.002

-.002

----

-.002

(.001) (.001) (.001) Education

.002

.002

.002

----

(.004) (.004) (.004) ADHD*Race -.107 ---- ---- ---- (.142) ADHD*Marital Status

---- -.116 (.143)

----

----

Low Age

----

----

-.040 (.041)

----

ADHD*Low Parent Age

---- ---- -.129 (.171)

----

High Education ADHD*High Education

---- ----

---- ----

---- ----

-.005 (.040) .310* (.141)

Intercept (.092) .093 .052 .120 R2

(.081) .002

(.081) .002

(.075) .001

(.069) .003

N = 3,000 Note: Standard errors are displayed in parentheses below the standardized coefficients. Stars indicate statically significant effects on maternal well-being. *** p<.001 ** p<.01 * p<.05

95

According to this analysis, American mothers of ADHD children are not that

different from American mothers of non-ADHD children. In terms of well-being, social

support, and the socio-demographic variables there were few to no differences between

the two samples. For instance, there were no significant differences in the well-being of

mothers of ADHD children as compared to mothers of non-ADHD children (as seen in

Table 1). Despite significant differences in child behavior and use of medication, these

variables did not prove to have an important influence on the dependent measure.

Additionally, the socio-demographic characteristics do not explain a great deal of

variation in the outcome. Most importantly, it appears that ADHD status has little to no

association with the dependent measure. Overall, social support had the largest impact

on maternal well-being (as seen in Model 4 and 5 of Table 4).

This analysis also attempted to determine if the impact of ADHD status becomes

stronger under certain contexts. For instance, having an ADHD child may not negatively

influence maternal-well-being, unless the level of social support is taken into account.

However, as demonstrated in this part of the analysis, the effect of having an ADHD

child with comparably low social support does not significantly differ from the effect of

having an ADHD child with comparably high social support (as seen in Model 4 of Table

5). As for the interaction between ADHD status and the socio-demographic

characteristics, only the education of the mother appeared to have an important

intervening effect (as seen in Model 9 of Table 5). Mothers of ADHD children with

comparably high education may have greater coping skills than mothers of ADHD

children with low education. In the next chapter, these results will be compared to the

96

results derived from the Canadian data. The limitations of this analysis and suggestions

for further research will also be presented in the next chapter.

97

Chapter 6 Conclusion and Discussion

Understanding the influence of raising an ADHD child on the well-being of Canadian

and American mothers has been the focus of this research. The cardinal symptoms of

ADHD include inattention, distractibility, restlessness, hyperactivity, and impulsivity

(American Psychiatric Association, 1994). As previous research suggests, the presence

of these symptoms can cause considerable disruption to the family environment and the

psychological functioning of mothers (Johnston and Mash, 2001). Instead of

concentrating on the behavior of the child as the sole indicator of maternal well-being,

this research has incorporated various measures of social support. The findings from this

study reveal important similarities between mothers of ADHD children and mothers of

non-ADHD children, as well as significant differences between Canadian and American

mothers of ADHD and non-ADHD children.

Although the United States and Canada are often compared to one another, especially

in terms of health care, there has been little consideration of how differences between the

two counties may translate into diverse experiences for Canadian and American families

of ADHD children. Contemporary research concerning ADHD is often generalized to

children and families across the neighboring countries with little discernment. While

there is reason to suspect similarities in the experiences of American and Canadian

families of ADHD children, this research has been based on the speculation that

differences between the two respective health care systems have considerable bearing on

the well-being and social support received by American mothers of ADHD children and

non-ADHD children as compared to the mothers of the sample Canadian ADHD children

and non-ADHD children.

98

The design of this study was based on data from the 2001 U.S. National Health

Interview Survey and Cycle 4 of the Canadian National Longitudinal Survey of Children

and Youth conducted between 2000 and 2001. The unit of analysis is the child in the

NLSCY and the mother in the NHIS. Interpretations have been made with care since the

subject matter of the research was different for participating American mothers as

compared to Canadian mothers. The sample population included 3,919 (97.3%) non-

ADHD children and 110 (2.7%) ADHD children, which equals to a total of 4,029

Canadian children. As for the American sample, there were a total of 2,819 (93.9%)

mothers of non-ADHD children and 181 (6.0%) mothers of ADHD children, which

equals a total of 3,000 American mothers. This suggests that a smaller proportion of the

children in the Canadian sample have been diagnosed with ADHD as compared to the

American sample. The likelihood of receiving an ADHD diagnosis may be greater for

American children.

In general, the findings revealed in Chapter 4 and Chapter 5 are only somewhat

consistent with the hypotheses presented in Chapter 3. So that each can be discussed and

analyzed, the three hypotheses will be restated. Each hypothesis is then considered more

closely to determine their veracity based on the findings derived from the NLSCY and

the NHIS.

Previous research has suggested that mothers of ADHD children experience

significantly more stress, anxiety and depression in comparison to mothers of non-ADHD

children. Therefore, both Canadian and American mothers of ADHD children were

expected to have lower levels of emotional well-being than mothers of non-ADHD

children. American mothers were expected to rate their overall emotional well-being

99

lower than Canadian mothers. Secondly, mothers of ADHD children may require more

social support to deal with the difficulties of raising an ADHD child than mothers of non-

ADHD children. Consequently, both Canadian and American mothers of ADHD

children were expected to report higher levels of social support than mothers of non-

ADHD children. Furthermore, American mothers were expected to rely more heavily on

social support than Canadian mothers. Lastly, since American mothers may place more

strain on their social support networks, Canadian mothers were expected to experience

the largest gains in well-being from the social support they receive.

Hypothesis 1

While numerous studies have found that mothers of children diagnosed with ADHD

are at a greater risk for stress, anxiety and depression than mothers without an ADHD

child (Anastopoulos, et. al., 1992; Cunningham, et. al., 1988; Befera and Barkley, 1985;

Mash and Johnston, 1982; 1983), this research presents contrary findings. The data

indicates that American mothers of ADHD children have a similar level of well-being as

compared to their non-ADHD counterparts. In contrast, it appears that Canadian children

with ADHD are more likely to have a mother who reportedly experiences a slightly lower

level of well-being than Canadian children without ADHD. Although Canadian mothers

of ADHD children and mothers of non-ADHD children differ in terms of their overall

well-being, of the six emotion-related variables, only the perception of blues experienced

is significantly different across the two samples. As both of the composite measures of

well-being were based on a scale from 0 to 24, it appears that American mothers of

ADHD and non-ADHD children rate their overall emotional well-being higher than

Canadian mothers of both ADHD and non-ADHD children.

100

These comparable findings suggest that mothers of ADHD children may not be as

susceptible to poor emotional well-being as suggested by previous studies. This can

possibly be attributed to the fact that most of these previous studies are based on

clinically referred samples, whereas this study is based on two nationally representative

samples. To date, few studies have attempted to explore the influence of ADHD with

nationally representative data such as the NHIS and the NSLCY. This is the first study to

use a nationally representative sample of American mothers and Canadian children.

Clinically referred mothers and children obviously differ from the mothers and children

sampled in this research.

There is also the possibility that the variables used in this study were poor indicators

of maternal well-being. Although the reliability tests for both measures of maternal well-

being indicated that the chosen variables were significantly correlated with one another,

and taken together were an adequate indicator of well-being, there were some

inconsistencies in the results. For example, marriage, which has frequently been

associated with well-being, does not appear to have a significant influence on the well-

being of American mothers. Additionally, the small size of the R-squared in each of the

OLS regression models indicates that there is a great deal of variance which is not

captured by the independent variables.

Hypothesis 2

The hypothesized sense of stress associated with raising an ADHD child suggests that

mothers of ADHD children are in greater need of social support. While significance of

social support has been recognized in families with children experiencing an illness or

particular handicap (Kazak and Martin, 1984; Marcenko and Meyers, 1991), few studies

101

have extended those findings to explore the use of social support as beneficial or harmful

to mothers of ADHD children (Podolski and Nigg, 2001). Yet, despite a general lack of

research on the subject, there is some indication that mothers with ADHD children are

lacking in coping resources, including social supports. This research suggests that there

are few differences in the level of social support received by American mothers of

ADHD children as compared to mothers of non-ADHD children. Of the seven social

support related variables, it appears that there is only a significant mean difference in the

amount of time spent talking to relatives on the telephone. Approximately 94% of

mothers of ADHD children in this sample have spoken to relatives on the telephone in

the past two weeks compared to about 90% of mothers of non-ADHD children.

The results of this research also indicate that Canadian children with ADHD are no

more or less likely to have a mother with a satisfying level of social support than children

without ADHD. Although the measurement of social support is based on variables

related to access for American mothers and satisfaction for the mothers of the Canadian

sample children, comparisons can still be made since both of the composite measures are

based on a scale from 0 to 7. As scores closer to 7 indicate greater access or satisfaction

with social support, it appears that Canadian children with and without ADHD may be

more likely to have a mother with satisfying levels of social support since the composite

score for social support was closer to 7 than for American mothers.

Hypothesis 3

For American mothers, social support proved to be a more important indicator of

maternal well-being than the ADHD status, behavior or medication use of the child. In

fact, the ADHD status of the child had little to no association with maternal well-being in

102

either the Canadian or American analyses. The American data indicated that the effect of

having comparably higher social support on maternal well-being is significantly positive.

However, the effect of having an ADHD child with comparably low social support does

not significantly differ from the effect of having an ADHD child with comparably high

social support. In contrast, social support did not have a significant influence on the

well-being experienced by the mothers of the Canadian children in this sample. It

appears that Canadian children are likely to have a mother who is negatively affected by

problematic behavior. The effect of having comparably higher behavioral problems was

significantly negative. Yet, the interaction between ADHD status and high behavioral

problems failed to yield a significant effect on maternal well-being. Thus, the effect of

having an ADHD child is not moderated by social support or the problematic behavior of

the child.

Limitations and Suggestions for Future Research

While the design of the NHIS and the NLSCY allowed for a comparative sample of

American mothers of ADHD children and mothers of non-ADHD children, as well as

Canadian children with and without ADHD, this analysis is still limited in its scope.

Due to limitations in the population size of fathers who responded to the NHIS and the

NLSCY, only American mothers of ADHD children and non-ADHD children and

Canadian children with and without ADHD are included for the purpose of analysis.

There may be significant gender differences that need to be addressed. Evidence of

gender differences in perceptions of stress and reactive coping mechanisms suggests that

mothers and fathers may be affected differently by raising an ADHD child. Additionally,

these methods are not the only way to examine the influence of ADHD, social support

103

and the behavior of the child on the well-being of mothers. The context of these intricate

relationships is still largely unknown. Longitudinal analysis was not possible since the

social support related variables found in the NHIS are not available in other waves of the

survey. While there were variables related to health coverage in the NHIS, such

information was not available in the NLSCY. Both the NHIS and the NLSCY did have

information about respondents’ frequency of contact with health care personnel. Future

research should also examine whether contact with health care personnel has an

important influence on mothers’ and fathers’ ability to cope with an ADHD child.

Summary

The results of this study conflict with the findings of previous research which

suggests that mothers of ADHD children experience more stress and emotional strain in

association with the behavioral manifestations of their child’s disorder than parents of

non-ADHD children. As this research has demonstrated, American mothers of ADHD

children are not very different from American mothers of non-ADHD children in terms

of well-being or social support. Additionally, Canadian children with ADHD and

without ADHD have mothers with similar levels of well-being and social support.

Families, especially mothers, with ADHD children have often been demonized in

different ways. Clinically referred samples may contribute to negative characterizations.

However, for the most part, American and Canadian mothers appear to be well equipped

to deal with the difficulties associated with their child’s disorder. In sum, future research

should focus on the resiliency of mothers of ADHD children, rather than the speculated

pathology. The strengths and resources that enable mothers to successfully cope with

persistent challenges need further consideration.

104

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