Parent Stress and Coping in Relation to Child ADHD Severity andAssociated Child Disruptive Behavior Problems

Cheryl-Lynn Podolski and Joel T. NiggDepartment of Psychology, Michigan State University

Examined parent role distress and coping in relation to childhood attention deficit hy-peractivity disorder (ADHD) in mothers and fathers of 66 children age 7 to 11 (42boys, 24 girls; mean age = 10.2). Parents of children with ADHD combined and inat-tentive subtypes expressed more role dissatisfaction than parents of control children.Parents of ADHD combined and inattentive type children did not differ significantly inlevels of distress. For mothers, child inattention and oppositional–conduct problemsbut not hyperactivity contributed uniquely to role distress (dissatisfaction related toparenting or parenting performance). For fathers, parenting role distress was associ-ated uniquely with child oppositional or aggressive behaviors but not with ADHDsymptom severity. Parent coping by more use of positive reframing (thinking aboutproblems as challenges that might be overcome) was associated with higher role satis-faction for both mothers and fathers. Community supports were associated withhigher distress for mothers only.

Attention deficit hyperactivity disorder (ADHD) af-fects 3% to 5% of school-age children (American Psy-chological Association, 1994; Szatmari, Offord, &Boyle, 1989). These children’s difficult to manage be-haviors contribute to frequent parent-initiated clinicalreferrals. The influence of parents and children on oneanother is bidirectional, and a sizable literature showsthat family context may exacerbate both ADHD(Biederman et al., 1995) and associated disruptive be-haviors (for a review, see Whalen & Henker, 1999).

Conversely, the stressful impact of these child be-haviors on parents is only beginning to be explored(Whalen & Henker, 1999). Yet the level of burdenplaced on parents as caregivers of children with ADHD,as well as how parents cope with this burden, is of keeninterest to parent support groups, clinicians, and theore-ticians. Child behaviors clearly impact parents(Barkley & Cunningham, 1979), and difficult child be-haviors likely increase parental distress (Whalen &Henker, 1999; Whalen et al., 1989). Ongoing negativeparent–child interactions may exacerbate child misbe-havior in a recursive fashion. Thus, the burden on par-ents of coping with child disruptive behaviors informsmodels of family process as well as potential family in-

terventions. In this study we examined parental distressand coping in response to multiple domains of disrup-tive behavior in children with and without ADHD.

The Disruptive Behavior Domain

Two major models are used to describe and measurechild disruptive behaviors. First, the Diagnostic andStatistical Manual of Mental Disorders (4th ed. [DSM–IV]; American Psychiatric Association, 1994) is basedon a categorical taxonomy that identifies discrete syn-dromes of child psychiatric difficulty. It specifies twodimensions of ADHD behaviors: inattention–disorga-nization and hyperactivity–impulsivity (Lahey et al.,1994). In addition, children can exhibit symptoms ofconduct disorder, its frequent precursor, oppositionaldefiant disorder (ODD), or both (Loeber, Keenan,Lahey, Green, & Thomas, 1993). Second, seminal fac-tor analyses of child behavior problem lists have led to afactorial model in child psychopathology that empha-sizes problem domains rather than diagnostic catego-ries (see Achenbach, Howell, Quay, & Conners, 1991).It is operationalized by several major rating scales, in-cluding Achenbach’s (1991) Child Behavior Checklist(CBCL). The latter provides for a single AttentionProblems scale, but that scale includes items tappingboth hyperactivity–impulsivity and inattention. Ittherefore reflects both of the behavioral dimensions inthe DSM–IV model of ADHD, similar to the Diagnosticand Statistical Manual of Mental Disorders (3rd ed.,rev. [DSM–III–R]; American Psychiatric Association,1987). In the disruptive domain, the CBCL also has an

503

Journal of Clinical Child Psychology Copyright © 2001 by2001, Vol. 30, No. 4, 503–513 Lawrence Erlbaum Associates, Inc.

This work was supported by National Institute of Mental HealthGrant R01–MH59105.

We thank Benjamin Addleson, Lisa Blaskey, Cynthia Huang-Pollock, and Margaret Sheridan for their help with data collection.We also thank the children and families for their participation.

Requests for reprints should be sent to Cheryl-Lynn Podolski,Michigan State University, Department of Psychology, 135 SnyderHall, East Lansing, MI 48824–1117.

aggression factor (overt antisocial behaviors; e.g.,fighting, arguing) and a delinquency factor (covert be-haviors; e.g., lying, stealing).

Because both the DSM–IV and the factorial (CBCL)models are in wide use, we sought to replicate and ex-tend prior findings by using both approaches. The twoADHD factors in DSM–IV have substantially distinctexternal correlates (Gaub & Carlson, 1997); hence, it ispossible they may affect parents to different degrees.Thus, we considered relations of child ADHD andexternalizing problems with parent distress from a di-mensional perspective in addition to considering diag-nostic group comparisons.

ADHD and Parental Distress

For clarity, we consider parent role-specific distressasdissatisfaction, stress,or lackofself-esteemrelated tothe parenting role or identity (Johnson, 1996). We con-siderglobalpsychologicaldistressasageneralizedstatethat is not confined to the parenting role (Johnston,1996). From this perspective, the existing literature in-dicates that parents of children with ADHD experienceboth role-specific (Johnson, 1996; Mash & Johnston,1983a) and global (Befera & Barkley, 1985) distress.Althoughtheseconceptsoftenarenotdistinguished, it isparticularly important to improve understanding ofrole-specific distress in relation to ADHD; it may be themost related to disruption of family relations and ame-nable to intervention (Anastopoulos, Shelton, DuPaul,& Guevremont, 1993).

Thus, although mothers of children with ADHD re-port greater global psychological distress (Befera &Barkley, 1985), they also report greater role-specificstress (Mash & Johnston, 1983a) and lower sense ofparenting competence (Mash & Johnston, 1983a) ver-sus mothers of children without ADHD. The latter is-sue is especially relevant to families with ADHDchildren. Severity of child DSM–III–R ADHD symp-toms has been linked to maternal parenting stress(Anastopoulos, Guevremont, Shelton, & DuPaul,1992). Furthermore, the number of settings in whichthe child with ADHD has difficulty and the severity ofother comorbid difficulties were positively correlatedwith maternal role-specific distress (Breen & Barkley,1988; Mash & Johnston, 1983a).

However, limitations remain in this literature. First,many studies either treated ADHD as a single con-struct, following DSM–III–R, or focused on child hy-peractivity (Befera & Barkley, 1985; Hechtman, 1996;Mash & Johnston, 1983a, 1983b) without examiningseparate effects of child inattention–disorganization. Infact, as far as we are aware, no study has examined par-ent role distress in relation to the two-factor DSM–IVmodel of ADHD. Also, most studies focused exclu-sively on mothers, with relative neglect of the impact on

fathers. Finally and crucially, comorbid disruptive be-haviors may have accounted for many of these findings;these were not controlled in most ADHD studies.

Two exceptions to the latter issue suggest thatADHD might contribute to parent role distress inde-pendently, although modestly. Anastopoulos et al.(1992) found that child CBCL (Achenbach, 1991) Ag-gression accounted for 37% of the variance in parentalstress; CBCL Attention Problems accounted for a fur-ther 4% of variance (p < .001). Johnston (1996), usingDSM–III–R, found that parents of ADHD children withsevere ODD felt less competent as parents than did par-ents of ADHD children with less severe ODD or con-trols but did not experience greater global distress.

Parent Coping and Child ADHD

Parent coping, such as social support (Crnic,Friedrich, & Greenberg, 1983), religiosity, access tocommunity resources, and attributions or perceptions(McCubbin, Olson, & Larsen, 1987), have been relatedto parent adjustment in families whose children experi-ence illness or disabilities. Yet surprisingly few studieshave examined parent coping with child ADHD per se.

Johnston (1996) examined child symptoms, parentsocial support, and parent stress and role satisfaction in48 parents of children with ADHD plus low and highseverity of ODD. Social support played a significantrole in a model that differentiated the groups accordingto parental stress. However, Cunningham, Bemness,and Siegel (1988) found that parents of ADHD childrenhad fewer extended family contacts, and the contactsthey had were perceived as less helpful. Coping strate-gies other than social or community support have notbeen studied, to our knowledge.

Current Study Rationale and GuidingQuestions

Although the expression of ADHD behavior doubt-less interacts with contextual factors, in this studyADHD and associated disruptive behaviors wereframed as a stressor for parents. Two overarching ques-tions were examined: Would severity of inattention, hy-peractivity, or associated disruptive behaviors beuniquely and positively correlated with parent role-spe-cific distress? In addition, would particular parent cop-ing strategies be most related to lower parent distress?

Method

Procedure

Overview. Parents completed current self-re-ports, and parents and teachers completed child ratings.

504

PODOLSKI AND NIGG

However, teacher ratings often reflected current childbehavior while on medication. Therefore, parent rat-ings were viewed as the best index of severity of childbehavior with which parents were coping, but teacherratings were included for completeness.

Parents provided written informed consent and chil-dren provided verbal assent to all procedures. Socio-economic status (SES) was assessed by the RevisedDuncan Socioeconomic Index (Stevens & Featherman,1981). Child full-scale IQ was estimated through a reli-able and valid short method (Block Design and Vocabu-lary subtests of the Wechsler Intelligence Scale forChildren [3rd ed.; WISC–III]; Wechsler, 1991b), whichcorrelates r = .86 with the full WISC–III (Sattler, 1992).

Participants. Both mothers (n = 66) and fathers(n = 57) participated in a study of family and cognitivecorrelates of child ADHD. All parents rated child be-haviors, but 15% of self-distress ratings were missingdue to time constraints during data collection (Ns arenoted for each analysis in the Results). Their children (n= 66) were boys and girls age 7 to 11 and included com-parison children who did not have ADHD (n = 22),ADHD inattentive subtype (ADD, n = 15), ADHDcombined subtype (ADHD–C, n = 22), ADHD hyper-

active subtype (n = 3), subclinical ADHD problems orADHD not otherwise specified (NOS; n = 3), and ADDwith borderline IQ (n = 1). Data for children who didnot fit into the ADHD–C, ADD, or control group wereincluded in dimensional analyses but not in between-group comparisons. Families were recruited throughinvitations mailed to all parents in local school districtsor from local support groups (n = 49) or through invita-tions to parents of children who were in treatment forADHD at a specialty pediatric clinic (n = 12), with con-trols for the latter sought via fliers distributed at a gen-eral pediatric clinic (n = 5). Children recruited from theADHD clinic had been diagnosed before entry in thestudy, and those families were recontacted and invitedto participate in the study. The sample was 76.2% Cau-casian, 9.5% Hispanic, and 7.9% Asian American andranged from lower to upper class, with more details inthe Results (Table 1).

Diagnostic assignment. Children were consid-ered as possible ADHD–C or ADD if they exceededscreening cutoffs on at least one current parent andteacher rating scale: CBCL or Teacher Report Form(TRF) Attention Problems T > 60 (Chen, Faraone,Biederman, & Tsuang, 1994); Parent or Teacher Behav-

505

PARENT DISTRESS AND CHILD ADHD

Table 1. Sample Characteristics by Group

ADD ADHD–C Control p

N Children (%boys) 15(56%) 22(70%) 22(67%) nsN Moms/Dads 15/13 22/16 22/18 nsChild full-scale IQ 110.8(16) 103.4(10) 114.6(15) nsChild age (years) 10.6(1.2) 9.2(2.2) 10.2(1.7) nsChild percentage White 85.7 88.0 75.0 nsFamily SES 49.3 (20.7) 34.0 (13.1) 43.0 (19.4) nsCommunity recruited 11(73%) 14(64%) 18(82%) nsDSM–IV inattention (M) 1.38(0.7)ac 2.16(0.5)bc 0.57(0.4) <.001DSM–IV inattention (P) 1.11(0.7)a 1.67(0.9)b 0.56(0.4) <.001DSM–IV inattention (T) 1.41(0.7)a 2.16(0.5)b 0.24(0.3) <.001DSM–IV hyperactivity (M) 0.59(0.5)ac 1.98(0.6)bc 0.38(0.4) <.001DSM–IV hyperactivity (P) 0.56(0.5)ac 1.53(1.0)bc 0.37(0.5) <.001DSM–IV hyperactivity (T) 0.32(0.5)c 1.05(0.5)bc 0.33(0.7) <.001DSM–IV ODD/CD (M) 0.26(0.2)c 1.07(0.4)bc 0.28(0.3) <.001DSM–IV ODD/CD (P) 0.28(0.3)c 0.86(0.6)bc 0.34(0.3) <.001DSM–IV ODD/CD (T) 0.17(0.2) 0.57(0.3)b 0.20(0.5) .020ODD (count/% of group) 3 (20%)ac 13 (59%)bc 0 (0%) <.001CD (count/% of group) 0 (0%) 5 (22%) 0 (0%) .010ODD or CD 3 (20%)ac 16 (73%)bc 0 (0%) <.001CBCL attention problem (M) 59.9(8.6)ac 72.9(10.1)bc 52.5(3.9) <.001CBCL attention problem (P) 61.3(6.5)ac 70.0(9.9)bc 52.2(5.9) <.001TRF attention problem (T) 64.8(9.1)a 67.1(11.3)b 51.7(2.2) <.001CBCL aggression (M) 55.1(6.4)c 71.4(13.9)bc 52.2(4.6) <.001CBCL aggression (P) 53.8(5.7)c 67.2(13.6)bc 52.1(5.8) <.001TRF aggression (T) 58.5(6.2)a 59.4(7.8)b 53.1(5.5) .032

Notes: Values are mean (standard deviation) unless otherwise noted. Scores for the Diagnostic and Statistical Manual of Mental Disorders (4th ed.;DSM–IV) are mean ratings from the Swanson, Nolan, and Pelham rating scale (4th ed.). Child Behavior Checklist (CBCL) and Teacher ReportForm (TRF) ratings are T scores. M = maternal ratings; P = paternal ratings; T = teacher ratings of the child. P values were computed using one-wayanalysis of variance or chi-square as appropriate to variable type. SES = socioeconomic status. ODD = oppositional defiant disorder; CD = conductdisorder; ADHD = attention deficit hyperactivity disorder; ADD = ADHD inattentive subtype; ADHD–C = ADHD combined subtype. Super-scripts indicate significant post-hoc pair-wise differences, as follows: acontrol vs. ADD; bcontrol vs. ADHD; cADHD vs. ADD.

ior Assessment Scale for Children (Reynolds &Kamphaus, 1992) Hyperactivity or Inattention scale T >60; parent or teacher Conners (1997) Rating Scale hy-peractivity index T > 60; or at least four symptoms of in-attention or hyperactivity endorsed (with a rating of 2 or3) on the parent or teacher DSM–IV revision of theSwanson, Nolan, and Pelham rating scale (Swanson,1992; Swanson, Lerner, March, & Gresham, 1999), re-ferred to subsequently as the DSM–IV Checklist. In ad-dition, for the clinic participants, children wereconsidered as possible ADHD–C or ADD if they werepreviously diagnosed as ADHD by a physician or psy-chologistwhoused teacherandparent ratings toarriveatthe diagnosis. Due to the age of the sample, for manycases the child’s original diagnosis occurred before thestudy. Children were considered possible controls ifthey were below cutoffs on all parent and teacher scalesand were never diagnosed with ADHD in thecommunity.

ADHD diagnostic assignment and subtype then wasconfirmedbyusingan“or”algorithm.Thealgorithmre-lied on the parent Diagnostic Interview Schedule forDSM–IV (DISC–IV; Shaffer, Fisher, & Lucas, 1997)supplemented by teacher ratings. The DISC–IV is astructured diagnostic interview developed by the Na-tional Institute for Mental Health. It implements a strin-gent diagnostic algorithm requiring onset before age 7,persistence of symptoms greater than 6 months, andsymptom-specific impairment in at least two settings(all children with any type of ADHD were impairedacross settings, except 1 child with ADHD NOS). Priorversions of the DISC have exhibited acceptable reliabil-ity and validity (Shaffer et al., 1996). The computer-as-sisted interview was administered to the primarycaregiver of every child in the study (ADHD and non-ADHD)by trained interviewers. Interviewswerevideo-taped. Quality control involved viewing of a randomlyselected 20% of tapes by Joel Nigg for fidelity to themanual and correcting of procedure as needed.

Following the validity data from the DSM–IV fieldtrials (Lahey et al., 1994), we used a modified “or” al-gorithm for final diagnostic assignment for the commu-nity cases: If children were one or two symptoms shy onthe parent DISC, additional symptoms reported byteachers could be used to reach the diagnosis (requiredfor 5 children, all with ADD). Based on the DISC–IV,30% (19 children) of the current sample met criteria forODD and 8% (5 children) met criteria for conduct dis-order (CD). Due to the small number of children withCD (typical in this age group), oppositional and con-duct problems were combined for covariance analyses.To reduce the confounding effect of other potentiallydistressing child disorders, children were excludedfrom the study if they had learning disability (LD), evi-dence or history of neurological disorder, or major de-pression. LD was defined as a word recognition <85(standard score) on the Wechsler Individual Achieve-

ment Test (Wechsler, 1991a) and significantly belowestimated IQ. Children in the control group did notmeet criteria for any subtype of ADHD on the DISC–IV, had T < 60 on all of the ADHD symptom scales citedearlier, had four or fewer DSM–IV symptoms of bothinattention and hyperactivity, and did not have ODD orCD (by the DISC–IV) or LD.

Among the ADHD–C group, short-acting stimu-lants (Ritalin or Adderol, n = 13) and longer actingmedications (Welbutrin, n = 4; Cylert, n = 1; Tofranil, n= 1) had been prescribed. ADD children had been pre-scribed Ritalin (n = 5), Tegretol (n = 1), or Klonidine (n= 1). No control children were on medication.

Data Reduction and Variables Used inAnalyses

Dimensional predictor variables. The inde-pendent or predictor variables were parent-rated child(a) DSM–IV symptoms and (b) CBCL factor scores. Forthe DSM–IV approach, the variables were as follows:inattention–disorganization from the DSM–IV Check-list items (Swanson et al., 1999; α = .97), hyperactiv-ity–impulsivity from the DSM–IV items (α = .92), andoppositional–conduct problems from the DSM–IVitems, which was a combination of the ODD and CDitems due to their tight intercorrelation (α = .95). Forthe CBCL approach, the variables were CBCL Atten-tion Problems (α = .84) and CBCL Aggressive Prob-lems (α = .85). Unless otherwise indicated, mother andfather ratings for child behavior were averaged; for ex-ample, mother and father CBCL ratings of child aggres-sion were combined into a single parent CBCLaggression variable. All parent-rating composites hadα > .80. The correlation between composite parent-rat-ing score and teacher ratings was small for CBCL Ag-gression (r = .29) and DSM–IV ODD/CD (r = .37) andwas moderate for DSM–IV Inattention (r = .56), DSM–IV Hyperactivity (r = .53), and CBCL Attention Prob-lems (r = .55). Mother–father ratings correlated from r= .66 (DSM–IV ODD/CD; CBCL Aggression) to r = .77(DSM–IV Hyperactivity).

Parent outcome variables I: Role-specific dis-tress. Two major measures of parent distress wereobtained. The Satisfaction With Parenting Performancesubscale of the Parenting Satisfaction Scale (PSS;Guidubaldi & Cleminshaw, 1994) was the first and pri-mary measure of parent role-specific distress (α = .83).Examples of the 15 items, rated on a 4-point scale, in-cluded, “I wish I did not become impatient so quicklywith my child,” and “I wish I were a better parent andcould do a better job of parenting.” The score was re-versed so that high scores reflected dissatisfaction. Thesecond measure was the Parenting Stress Index–ShortForm (PSI–SF; Abidin, 1995) Parent Distress subscale

506

PODOLSKI AND NIGG

(α = .82). Example items include, “I often have the feel-ing that I cannot handle things well,” and “I find myselfgiving up more of my life to meet my children’s needsthan I ever expected.” The PSI–SF Parent Distress scoreserved as a second, replication measure of parent dis-tress. We expected somewhat weaker associations withchild behavior (than expected with the more role-spe-cific PSS measure) due to its link to global distress inthe literature (Thoits, 1982). We used subscale scoresrather than total scores to minimize overlap of child be-havior and parent distress scores.

PSS and PSI distress scales correlated at r = .47 formothers and r = .63 for fathers, suggesting that theytapped partially overlapping distress constructs. Mater-nal and paternal distress was correlated r = .35 on thePSS and r = .20 on the PSI, suggesting that parent dis-tress was not always shared.

Parent outcome variables II: Parent coping. Par-ents completed the 30-item Family Crisis Oriented Per-sonal Evaluation Scales (F–COPES; McCubbin et al.,1987), designed to capture McCubbin’s transactionalcoping model. The model posits that coping operatesacross multiple domains (individual, family, commu-nity) and strategies, which interact over time dynami-cally (McCubbin et al., 1987). Parents rated the extentto which they tended to use several kinds of copingstrategies. One issue with a scale of this nature is thatcoping strategies may differ depending on what prob-lem a parent has in mind when she answers the ques-tions. For this project, the packet included, with theusual F–COPES instructions, instructions to respondwith reference to the child in the study. Thus, it was in-tended that parents would think of coping with prob-lematic child behaviors. The F–COPES yields fivefactor scores and a total score. One factor (passive ap-praisal) and the total were deemed too unreliable (lowalphas in the current data) for analysis. The four re-maining scales were as follows: (a) acquiring socialsupport (α = .79), parent’s ability to actively acquire so-cial support from relatives, friends, and neighbors; (b)reframing (α = .78), which reflects the parent’s abilityto redefine stressful events to make them more manage-able, for example, “accepting stressful events as a factof life”; (c) seeking spiritual support (α = .88), whichreflects acquiring support through religious organiza-tions or personal faith; and (d) seeking community re-sources (α = .88), which reflects accessing communityresources outside of religion.

Results

Preliminary Description of Sample

A sample description is provided in Table 1. Childgroups were similar in SES, age, sex, IQ, and propor-

tion of children recruited from the community versusmedical clinics (all p > .05). Group means on parent andteacher rating scales of child behaviors are reported inTable 1. The ADHD–C children had the highest levelsof inattentive and hyperactive symptoms, leading aswell to higher scores on the composite CBCL AttentionProblems subscale (which includes impulsivity–hyper-activity). The ADD group had high levels of inattentivebut not hyperactive symptoms. Comorbid disruptivebehaviors were most marked in the ADHD–C group.The children who were not in any group (see Method),who are not shown in Table 1, had teacher-rated rawDSM–IV Hyperactivity = .32 and Inattention = .71, andTRF Attention Problems T = 55.

Between-group analyses were conducted on thethree largest groups (ADD, ADHD–C, control);correlational analyses included all cases. For the for-mer we ran an omnibus, one-way, three-group analysisof variance (ANOVA; ADD, ADHD–C, control); iffindings were significant, we conducted post hocpairwise comparisons, using the overall mean squareerror to maximize power. Results were checked bycovarying child comorbid disruptive behaviors. We ex-amined child sex effects in the regression models but,due to low power, not in the ANOVAs. Mother and fa-ther outcomes were analyzed separately.

Child Behavior and Parent Distress

Means on parent distress ratings are displayed in Ta-ble 2. In relation to norms, the PSS Dissatisfaction WithParenting Performance subscale (satisfaction score re-versed) for maternal dissatisfaction was as follows:ADD = 60th percentile (T = 52), ADHD–C = 76th per-centile (T = 56), and control = 30th percentile (T = 45).Paternal PSS dissatisfaction was ADD = 44th percen-tile (T = 49), ADHD–C = 70th percentile (T = 54), andcontrol = 37th percentile (T = 47). With regard to thePSI, we analyzed only the subscale score, as explainedearlier. However, to enable normative comparisons, weestimated the PSI total score. That estimated long-formtotal (correlated r = .94 with short-form total; Abidin,1995) for mothers of ADD children was at the 76th per-centile (T = 55), ADHD–C = 82nd percentile (T = 58),and control = 33rd percentile (T = 47). Paternal PSI To-tal Stress was ADD = 60th percentile (T = 52), ADDH–C = 91st percentile (T = 64), and control = 31st percen-tile (T = 47). Samples exhibited moderate distress, sim-ilar to that seen in other studies.

We first compared groups by using ANOVA. Mater-nal PSS role-specific distress differed across the threegroups, F(2, 50) = 6.06, p = .004. Mothers of ADHD–Cchildren reported more distress than mothers of con-trols, F(1, 50) = 11.73, p < .01. Mothers of ADD chil-dren also reported more distress than controls, F(1, 50)= 4.69, p < .05. Mothers of ADHD–C children had

507

PARENT DISTRESS AND CHILD ADHD

qualitatively higher distress levels than mothers ofADD children, but the effect was nonsignificant, F(1,50) = 1.11, ns. The omnibus three-group comparisonwas nonsignificant with DSM–IV ODD/CD ratingscovaried, F(2, 50) = 1.69, p = .194. Maternal PSI Dis-tress did not differ by child group (p = .76). Fathers’dis-satisfaction with parenting performance was shy of asignificant omnibus three-group effect for both thePSS, F(2, 41) = 3.09, p = .056, and the PSI, F(2, 39) =2.64, p = .08, so post hoc comparisons were notconducted.

We next examined dimensions of child behaviorwith correlations, which were expected to be more sen-sitive than the between-group analysis, to enable acloser look at competing behavioral dimensions. Asnoted earlier, parent ratings were viewed as the best in-dex of problems parents were responding to in thechild. However, zero-order results for the teacher rat-ings also are displayed for completeness in Table 3.

Table 3 shows that maternal role-specific distress asoperationalized on the PSS was associated with childADHD symptoms when we used both the DSM–IV andthe CBCL measures. This effect replicated with fathers’ratings of child behaviors and with teachers’ ratings onthe CBCL/TRF but not the DSM–IV. The effect did notreach significance on the PSI, perhaps reflecting itsgreater loading on global distress. DSM–IVOppositional/Conduct or CBCL Aggression also con-tributed to maternal distress (as found by Johnston,1996), replicating across raters and instruments.

Paternal PSS role-specific distress was associatedwith both child inattention and hyperactivity–impulsivity, although this was a weaker finding with the

CBCL model than the DSM–IV model. The effectreplicated across all child behavior raters for DSM–IVHyperactivity but failed to replicate for teacher ratingsof child DSM–IV Inattention or CBCL/TRF Attentionproblems. Paternal PSI distress also was clearly associ-ated with child DSM–IV Hyperactivity across all raters.Paternal PSS and PSI distress also were associated withchild oppositional–conduct or aggression problems (asin Johnston, 1996) as rated by both mothers and fathers(by using either the DSM–IV Checklist or the CBCL)but not as rated by teachers, perhaps reflecting the set-ting-specific nature of problematic oppositionalbehaviors.

To examine the specificity of effects to child ADHDsymptoms versus other disruptive problems, regressionmodels were used. We report semi-partial correlationsof each behavior domain with parent distress, withother child behaviors controlled. Models were com-puted separately for the DSM–IV checklist and CBCLand for mothers and fathers. Composite parent ratingsof child behaviors served as predictors to limit the num-ber of models tested.

For mothers (n = 56 for all models), whenoppositional–conduct problems were controlled, PSSrole-specific distress was uniquely associated withDSM–IV Inattention (sr = .36, p = .01) but not Hyperac-tivity (sr=.04,p=702).Conversely, afterchildDSM–IVInattention and Hyperactivity were partialled, childDSM–IV Oppositional–Conduct Problems still contrib-uted significantly to maternal PSS role distress (sr = .30,p = .008). CBCL Attention Problems and Aggressionmade roughly equivalent contributions in a significantregression model (R2 = .35, p < .001). However, these

508

PODOLSKI AND NIGG

Table 2. Parent Stress by Diagnostic Group and Child Sex

ADD ADHD–C Control

M SD M SD M SD

PSS role dissatisfactionMothers

Boys and girls combined 36.52 4.70 38.68 6.69 32.09 5.96Boys 36.50 5.04 38.46 4.93 29.42 4.70Girls 36.55 4.69 39.50 12.40 36.68 5.22

FathersBoys and girls combined 34.34 4.62 37.80 6.43 33.03 5.07Boys 32.31 3.13 36.85 6.47 33.56 5.17Girls 37.60 5.03 43.50 6.71 32.43 5.23

PSI–SF distressMothers

Boys and girls combined 26.55 6.01 26.18 8.29 24.83 6.95Boys 24.14 6.51 23.84 6.68 23.55 6.07Girls 29.31 4.28 34.36 9.02 27.02 8.27

FathersBoys and girls combined 24.75 7.85 29.00 6.09 23.17 6.46Boys 21.95 6.69 27.71 5.71 24.36 6.79Girls 29.24 8.11 35.45 3.86 21.82 6.23

Note: Note that, in the table, as in the text, PSS scores were reversed to reflect dissatisfaction. ADHD = attention deficit hyperactivity disorder;ADD = ADHD inattentive subtype; ADHD–C = ADHD combined subtype; PSS = Parenting Satisfaction Scale dissatisfaction with parenting per-formance; PSI = Parenting Stress Index–Short Form.

two variables were highly correlated (r = .83, p < .001),and neither made a significant unique contribution tomaternal PSS distress (Attention Problems, sr = .15, p =.18; Aggression, sr = .20, p = .13). Mothers’PSI distressfailed to show unique relations with any of the DSM–IVsymptom scales in regression models (DSM–IV ODD/CD, sr = .24, p = .078; DSM–IV Inattention, sr = .02, p =.913; DSM–IV Hyperactivity, sr = –.04, p = .769). It wasuniquely related to CBCL Aggression (sr = .31, p =.019) but not CBCL Attention Problems (sr = –.13, p =.31). The same result held for the estimated PSI TotalScore (per Anastopolous et al., 1992). Overall, maternaldistresswasuniquelyassociatedwithchildoppositionalor aggressive behaviors and inattention but nothyperactivity.

For fathers (n = 45 for all analyses), PSS role-specificdistress was linked uniquely to DSM–IV OppositionalDefiant behaviors (sr = .31, p = .03) and not to childDSM–IV Inattention (sr = .04, p = .79) or DSM–IV Hy-peractivity–Impulsivity (sr = .02, p = .91). The same re-sult held when using the CBCL, with Aggression (sr =.53, p = .000) but not Attention Problems (sr = –.24, p =.054) contributing uniquely. This pattern was replicatedwith the paternal PSI score: Distress was related to child

DSM–IVODD/CD(sr=.31,p=.02)butnotDSM–IV In-attention (sr = –.07, p = .58) or DSM–IV Hyperactivity(sr = .06, p = .62); and it was related to CBCL Aggres-sion (sr = .38, p = .007) but not CBCL Attention Prob-lems (sr = –.08, p = .54).

All main effects of child behavior on parent distresswere independent of child sex. However, child sex wasalso uniquely related to parent distress, with girls tend-ing to elicit more distress than boys. To examine possi-ble moderator effects of child sex on parent distress, weexamined sex by behavior problem interactions (aftercontrolling for main effects). For mothers, these inter-action effects were nonsignificant for PSS distress, butinteractions contributed to PSI distress for sex byCBCL Attention Problems (β = –.54, p = .04) and sexby Aggression (β = –.54, p = .02). Results were similarfor the DSM–IV Checklist in relation to the maternalPSI. Similar results held for fathers, in that no interac-tion effects emerged for PSS distress. Child sex was un-related to paternal PSI distress, but there was aninteraction with child sex of DSM–IV Inattention (inter-action β = –.94, p = .01), Hyperactivity (interaction β =–.61, p = .04), and ODD/CD (interaction β = –.47, p =.05) in relation to paternal PSI distress. These results

509

PARENT DISTRESS AND CHILD ADHD

Table 3. Correlation of Parent Stress and Child Behaviors

PSS Role Distress PSI Distress

Mothers Fathers Mothers Fathers

DSM–IV inattentionMother rating .57*** .32* .17 .29Father rating .45** .34* .19 .18Combined parents .57*** .38** .23+ .28+Teacher rating .15 .26 –.11 .27

DSM–IV hyperactivityMother rating .41** .42** .10 .43**Father rating .47** .32* .23 .37*Combined parents .44** .41** .21 .44**Teacher rating .30+ .41* –.10 .46**

DSM–IV oppositional–conductMother rating .56*** .49** .32* .53***Father rating .48** .58*** .45** .39*Combined parents .55*** .58*** .35** .50**Teacher rating .33* .33+ .10 .30

CBCL attention problemsMother rating .54*** .33* .23 .42**Father rating .56*** .31+ .30+ .24Combined parents .56*** .32* .24+ .37*Teacher rating .40** .26 .11 .13

CBCL aggression problemsMother rating .55*** .56*** .35** .56***Father rating .56*** .56*** .48** .43**Combined parents .57*** .58*** .37** .52***Teacher rating .36* .36* .06 .30

Note: Note that, in the table, as in the text, PSS scores were reversed to reflect dissatisfaction. PSS = Parenting Satisfaction Scale; PSI = ParentingStress Index–Short Form. Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM–IV) refers to Swanson, Nolan, and Pelham ratingscale (4th ed.). CBCL = Child Behavior Checklist. Sample size for mother distress with parent CBCL ratings, n = 56, with parent DSM–IV ratings,n = 56, teacher ratings and mom distress, n = 41; father distress with parent CBCL ratings, n = 44, with parent DSM–IV ratings, n = 45, with teacherratings, n = 31.+p < .1. *p < .05. **p < .01. ***p < .001.

suggest that the association of child misbehavior to pa-rental distress was stronger for girls than for boys, butthis effect emerged only on the PSI.

Parental Coping

The second goal of the study was to examine copingstrategies in relation to parent role distress. Univariatecorrelations with coping scores are shown in Table 4.Lower maternal distress was associated with greateruse of positive reframing. However, greater use of com-munity resources was associated with higher maternaldistress. For fathers, positive reframing was also themost notable coping strategy.

To examine whether reframing was associated morestrongly with better adjustment than other copingstyles, we compared related correlations with Wil-liams’s (1959) modification of T (Steiger, 1980). Theseanalyses confirmed the qualitative impression given byTable 4. Lower maternal PSS dissatisfaction was asso-ciated more strongly with more use of positivereframing than with more use of community resources,T(49) = –5.34, p < .001, or social support, T(49) = –4.57, p << .001, but not spiritual support, T(49) = –0.57,ns. It was notable that community resources were asso-ciated with more, rather than less, dissatisfaction. Forfathers, the magnitude of the relation between positivereframing and distress (r = –.52) was significantlygreater than that between spiritual support and distress(r = –.16), T(37) = –2.25, p < .05, but did not signifi-cantly exceed the other associations.

Discussion

This was the first study to examine stress and copingin parents by using the DSM–IV model of ADHD, and itincluded replication with the factorial (CBCL) model.We examined specificity of effect of inattention and hy-peractivity on parent role distress and also examinedparent coping strategies. Unlike most prior studies, weincluded fathers as well as mothers.

The first study question was whether severity of in-attention, hyperactivity, or associated disruptive behav-

iors were uniquely and positively correlated with par-ent role-specific distress. In general, both mothers andfathers were distressed by child DSM–IV Oppositional/Conduct or CBCL Aggressive Behavior, and these ef-fects were over and above the contribution to distress ofchild ADHD symptom severity. Mothers, but not fa-thers, were also distressed by child DSM–IV ADHD In-attention symptoms, over and above the effects of childDSM–IV Oppositional/Conduct problems. The latterwas not true of child hyperactivity, which did not im-pact parental distress after other disruptive behaviorswere controlled. Zero-order effects replicated acrossboth parents’ ratings of child behaviors and, in mostcases, with teachers’ ratings, suggesting that effectswere not explained by shared rater source variance.

The results regarding the contribution to parent dis-tress of child aggression or oppositional–conduct prob-lems in children with ADHD replicate and extend thetwo prior studies to examine this question. BothJohnston (1996) and Anastopoulos et al. (1992) alsofound that the distress of parents who had children withADHD (diagnosed by using DSM–III–R) was related tochild aggressive or oppositional behaviors. The chil-dren in both of Johnston’s (1996) ADHD groups exhib-ited ODD behaviors sufficient to warrant a seconddiagnosis. Johnston found that both mothers and fa-thers of children with higher levels of ODD reportedmore role distress. We confirmed the importance to ma-ternal distress of child oppositional behavior in a groupof ADHD children diagnosed by DSM–IV, of whomsome had ODD and some did not. Extending that work,we showed that fathers were also distressed by associ-ated disruptive child behaviors, whereas mothers expe-rienced added distress related to child inattention.

Anastopoulos et al. (1992) found a small but sig-nificant independent contribution of CBCL AttentionProblems to maternal role dissatisfaction when CBCLAggression was controlled. We found similar resultswhen using the DSM–IV Checklist symptom scales,in that child inattention maintained a unique associa-tion with maternal distress apart from childoppositional–conduct problems. Our attempt to repli-cate the results of Anastopoulos et al. (1992) by usingthe CBCL scales was not successful, perhaps due tolower power in our study.

510

PODOLSKI AND NIGG

Table 4. Correlation of Parent Stress and Parent Coping Styles for Each Parent

PSS Role Distress PSI Parent Stress

Mothers Fathers Mothers Fathers

Positive reframing –.52*** –.52** –.34* –.33*Seeking social support .11 –.25 –.00 .01Community resources .37** –.15 .30* –.14Spiritual support –.16 –.16 –.03 –.23

Note: Note that, in the table, as in the text, PSS scores were reversed to reflect dissatisfaction. PSS = Parenting Satisfaction Scale; PSI = ParentingStress Index.*p < .05. **p < .01. ***p < .001.

Although sex effects were not a primary focus of ourstudy, we noted that both parents were more distressedin relation to girls’ than boys’ externalizing behaviorproblems. That preliminary finding underscores theimportance of further consideration of gender roles, so-cialization, and parent expectation effects in responseto the challenge of the child with ADHD. Most priorstudies have focused on boys, and the particular stress-ors associated with parenting externalizing girls areunderstudied.

The second overarching research question pertainedto effects of parent coping strategies. Inferences aboutthe coping data must be made in the context of a samplethat was recruited after families were well along in theircoping efforts. Due to the age of the child sample, fami-lies had been contending with ADHD and related be-havior problems for up to several years before ourstudy. Direction of causal effects was therefore indeter-minate. Nevertheless, coping results were intriguing.Positive reframing was associated with lower levels ofparent distress but also with lower levels of child misbe-havior. In contrast, use of community resources and so-cial support was associated with more maternaldistress, leading to a significant difference in the mag-nitude of apparent impact on parental adjustment ofthese coping strategies.

Alternate interpretations of these data are importantto consider. First, mothers of more severely impairedexternalizing ADHD children experience greater roledistress and also may tend to activate more extensivecoping efforts as a result, including seeking supportfrom the community. For fathers, on the other hand, so-cial support and accessing community resources werenot significantly associated with role distress. Furtherstudy is warranted with larger sample sizes to testwhether mothers and fathers may exhibit different cop-ing strategies in relation to parenting distress. Overall,reaching out to community resources may be a standardcoping approach as child problems escalate. Indeed, asseverity of child problems increases, community mem-bers (e.g., teachers) are more likely to become involved.Such interventions may be helpful to the child or theparent. Yet, because mothers are in more distress at thepoint that they seek community support, those supportsare associated with more rather than less distress.

However, a second interpretation must also be con-sidered. It is possible that community-oriented copingstyles were ineffective or even counterproductive formothers. Parent subjective isolation may increase aspersistent and severe child behavior taxes communitymembers (teachers, babysitters, neighbors, club lead-ers) as well as parents. Some community resources maywithdraw from parents of these difficult children, lead-ing to more isolation for parents. The resultant socialinsularity may result in a downward spiral. Becauseparents lack support, their distress may increase andlead to greater difficulty with parenting, elevated risk

for negative parent–child interactions, and even an in-creased risk for child abuse (Bishop & Leadbeater,1999).

Several other clinical implications may be drawnfrom these results. First, given the distressing impact ofchild oppositional–aggressive behaviors, even whenthe presenting problem is ADHD the focus may need tobe on parent training to reduce these comorbid child be-haviors, especially for children with ADHD combinedtype. At the same time, the potential benefit to parentsof strategies to enhance child attention and organiza-tion may be underappreciated, particularly when work-ing with mothers. With fathers, it may be important toplace even greater emphasis on addressing manage-ment of child oppositional behaviors. Second, cogni-tive approaches may be valuable for some parents toaddress attributions about child behavior. Third, sensi-tivity to possible parent demoralization with prior at-tempts to seek community involvement may beimportant, along with efforts to facilitate communitysupports.

Limitations

This study was cross-sectional, yet different copingstrategies may be attempted at different stages of facinga stressor. Parental coping closer to the time of childADHD diagnosis may appear differently than it did inthis study. Likewise, longitudinal work might clarifythe dynamic relation of coping strategies to higher orlower distress levels over time. Second,nonsignificance of ADHD symptom effects reported insome models must be viewed with caution in view ofthe relatively modest sample size, especially for fa-thers. Power was limited to detect smaller but poten-tially important effects, some of which were close tosignificant. Third, although the majority of families ineach group were recruited from the community and di-agnostic groups were similar in recruitment source, it isimportant to recognize that clinic and community sam-ples may not yield the same patterns of results (Good-man et al., 1997).

Conclusion

Severity of ADHD behavior is distressing to parentsin their parenting role. We confirmed that this effectwas notable for fathers as well as for mothers. However,whereas maternal role-specific distress was related toboth oppositional child behaviors and child inatten-tion–disorganization, paternal distress was accountedfor by child oppositional or aggressive behaviors.These co-occurring behaviors played a major role incontributing to the parenting distress of both mothersand fathers, over and above the severity of ADHD prob-

511

PARENT DISTRESS AND CHILD ADHD

lems. Lower levels of parenting role distress were asso-ciated with cognitive coping strategies (reframing).Patterson (1996) described a dynamic cycle betweenparental distress and child aggression, with each prob-lem exacerbating the other. Parents of children withADHD may be particularly vulnerable to such a cycle(Nigg & Hinshaw, 1998). Future work should pursuethe role of specific parent attributions as well as com-munity experiences that may be associated with betteror worse adjustment in parents of children with ADHD.

References

Abidin, R. R. (1995). Parenting Stress Index (3rd ed.). Odessa, FL:Psychological Assessment Resources.

Achenbach, T. M. (1991). Manual for the Child Behavior Checklist/4-18 and 1991 Profile. Burlington: University of Vermont, De-partment of Psychiatry.

Achenbach, T. M., Howell, C. T., Quay, H. C., & Conners, C. K.(1991). National survey of problems and competencies amongfour- to-sixteen-year-olds. Monographs of the Society for Re-search in Child Development, 56, 1–119.

American Psychiatric Association. (1987). Diagnostic and Statisti-cal Manual of Mental Disorders (3rd ed., rev.). Washington,DC: American Psychiatric Association.

American Psychiatric Association. (1994). Diagnostic and Statisti-cal Manual of Mental Disorders (4th ed.). Washington, DC:American Psychiatric Association.

Anastopoulos, A. D., Guevremont, D. C., Shelton, T. L., & DuPaul,G. J. (1992). Parenting stress among families of children with at-tention deficit hyperactivity disorder. Journal of AbnormalChild Psychology, 20, 503–519.

Anastopoulos, A. D., Shelton, T. L., DuPaul, G. J., & Guevremont, D.C. (1993). Parent training for attention-deficit hyperactivity dis-order: Its impact on parent functioning. Journal of AbnormalChild Psychology, 21, 581–596.

Barkley, R. A., & Cunningham, C. E. (1979). The effects ofmethylphenidate on the mother–child interactions of hyperac-tive children. Archives of General Psychiatry, 36, 201–208.

Befera, M. S., & Barkley, R. A. (1985). Hyperactive and normal girlsand boys: Mother–child interactions, parent psychiatric statusand child psychopathology. Journal of Child Psychology andPsychiatry, 26, 439–452.

Biederman, J., Milberger, S., Faraone, S. V., Kiely, K., Guite, J.,Mick, E., Ablon, J. S., Warburton, R., Reed, E., & Davis, S. G.(1995). Impact of adversity on functioning and comorbidity inchildren with attention-deficit hyperactivity disorder. Journal ofAmerican Academic Child and Adolescent Psychiatry, 34,1495–1503.

Bishop, S. J., & Leadbeater, B. J. (1999). Maternal social support pat-terns and child maltreatment: Comparison of maltreating andnonmaltreating mothers. American Journal of Orthopsychiatry,69, 172–181.

Breen, M. J., & Barkley, R. A. (1988). Child psychopathology andparenting stress in girls and boys having attention deficit disor-der with hyperactivity. Journal of Pediatric Psychology, 13,265–280.

Chen, W. J., Faraone, S. V., Biederman, J., & Tsuang, M. T. (1994).Diagnostic accuracy of the child behavior checklist scales for at-tention-deficit hyperactivity disorder: A receiver-operatingcharacteristics analysis. Journal of Consulting and Clinical Psy-chology, 62, 1017–1025.

Conners, C. K. (1997). Conners Rating Scales–Revised. Toronto,ON: Multi-Health Systems.

Crnic, K. A., Friedrich, W. N., & Greenberg, M. T. (1983). Adapta-tion of families with mentally retarded children: A model ofstress, coping, and family ecology. American Journal of MentalDeficiency, 88, 125–138.

Cunningham, C. E., Bemness, B. B., & Siegel, L. S. (1988). Familyfunctioning, time allocation, and parental depression in the fam-ilies of normal and ADHD children. Journal of Clinical ChildPsychology, 17, 169–177.

Gaub, M., & Carlson, C. L. (1997). Behavioral characteristics ofDSM–IV ADHD subtypes in a school-based population. Jour-nal of Abnormal Child Psychology, 25, 103–111.

Guidubaldi, J., & Cleminshaw, H. K. (1994). Parenting SatisfactionScale. San Antonio, TX: Psychological Corporation.

Goodman, S. H., Lahey, B. B., Fielding, B., Dulcan, M., Narrow, W.,& Regier, D. (1997). Representativeness of clinical samples ofyouths with mental disorders: A preliminary population-basedstudy. Journal of Abnormal Psychology, 106, 3–14.

Hechtman, L. (1996). Families of children with Attention Deficit Hy-peractivity Disorder: A Review. Canadian Journal of Psychia-try, 41, 350–360.

Johnston, C. (1996). Parent characteristics and parent–child interac-tions in families of nonproblem children and ADHD childrenwith higher and lower levels of oppositional–defiant behavior.Journal of Abnormal Child Psychology, 24, 85–104.

Lahey, B. B., Applegate, B., McBurnett, K., Biederman, J., Grenhill,L., Hynd, G. W., Barkley, R. A., Newcorn, J., Jensen, P.,Richters, J., Garfinkel, B., Kerdyk, L., Frick, P. J., Ollendick, T.,Perez, D., Hart, E. L., Waldman, I., & Shaffer, D. (1994). DSM–IV field trials for attention deficit hyperactivity disorder in chil-dren and adolescents. American Journal of Psychiatry, 151,1673–1685.

Loeber, R., Keenan, K., Lahey, B. B., Green, S. M., & Thomas, C.(1993). Evidence for developmentally based diagnoses ofoppositional defiant disorder and conduct disorder. Journal ofAbnormal Child Psychology, 21, 337–410.

Mash, E. J., & Johnston, C. (1983a). Parental perceptions of child be-havior problems, parenting self-esteem, and mothers’ reportedstress in younger and older hyperactive and normal children.Journal of Consulting and Clinical Psychology, 51, 86–99.

Mash, E. J., & Johnston, C. (1983b). Sibling interactions of hyperac-tive and normal children and their relationship to reports of ma-ternal stress and self-esteem. Journal of Clinical ChildPsychology, 12, 91–99.

McCubbin, H. I., Olson, D. H., & Larsen, A. S. (1987). F–COPES:Family Crisis Oriented Personal Evaluation Scales. In H. I.McCubbin & A. I. Thompson (Eds.), Family assessment inven-tories for research and practice (pp. 192–205). Madison: Uni-versity of Wisconsin–Madison Press.

Nigg, J. T., & Hinshaw, S. P. (1998). Parent personality and psychiat-ric history in relation to child antisocial behaviors in childhoodADHD. Journal of Child Psychology and Psychiatry, 39, 145–160.

Patterson, G. R. (1996). Some characteristics of a developmental the-ory for early-onset delinquency. In M. F. Lenzenweger & J. J.Haugaard (Eds.), Frontiers of developmental psychopathology(pp. 81–124). New York: Oxford University Press.

Reynolds, C. R., & Kamphaus, R. W. (1992). Behavioral assessmentsystem for children manual. Circle Pines, MN: American Guid-ance Service.

Sattler, J. M. (1992). Assessment of children—Revised and updatedthird edition. San Diego, CA: Sattler.

Shaffer, D., Fisher, P., Dulcan, M., Davies, M., Piacentini, J.,Schwab-Stone, M., Lahey, B., Bourdon, K., Jensen, P., Bird, H.,Canino, G., & Regier, D. (1996). The NIMH DiagnosticInterveiw Schedule for Children (DISC 2): Description, accept-ability, prevalence rates, and performance in the MECA study.Journal of the American Academy of Child and Adolescent Psy-chiatry, 35, 865–877.

512

PODOLSKI AND NIGG

513

PARENT DISTRESS AND CHILD ADHD

Shaffer, D., Schwab-Stone, M., Fisher, P., et al. (1993). The Diagnos-tic Interview Schedule for Children–Revised Version (DISC–R): I: Preparation, field testing, interrater reliability, and accept-ability. Journal of the American Academy of Child and Adoles-cent Psychiatry, 32, 643–650.

Steiger, J. H. (1980). Tests for comparing elements of a correlationmatrix. Psychological Bulletin, 87, 245–251.

Stevens, G., & Featherman, D. L. (1981). A revised socio-economicindex of occupational tasks. Social Science Research, 10, 364–395.

Swanson, J. M. (1992). School based assessments and interventionsfor ADD students. Irvine, CA: K.C. Publications.

Swanson, J. M., Lerner, M. A., March, J., & Gresham, F. M. (1999).Assessment and intervention for attention-deficit/hyperactivitydisorder in the schools: Lessons from the MTA study. PediatricClinics of North American, 46, 993–1009.

Szatmari, P., Offord, D. R., & Boyle, M. H. (1989). Ontario ChildHealth Study: Prevalence of attention deficit disorder with hy-peractivity. Journal of Child Psychology & Psychiatry & AlliedDisciplines, 30, 219–230.

Thoits, P. A. (1982). Conceptual, methodological, and theoreticalproblems in studying social support as a buffer against lifestress. Journal of Health and Social Behavior, 23, 145–159.

Wechsler, D. (1991a). Manual for the Wechsler Individual Achieve-ment Test Screener. San Antonio, TX: PsychologicalCorporation.

Wechsler, D. (1991b). Manual for the Wechsler Intelligence Scale forChildren (3rd ed.). San Antonio, TX: PsychologicalCorporation.

Whalen, C. K., & Henker, B. (1999). The child with attention-deficit/hyperactivity disorder in family contexts. In H. C. Quay & A. E.Hogan (Eds.), Handbook of disruptive behavior disorders (pp.139–155). New York: Kluwer.

Whalen, C. K., Henker, B., Buhrmester, D., Hinshaw, S., Huber, A.,& Laski, K. (1989). Does stimulant medication improve the peerstatus of hyperactive children? Journal of Consulting and Clini-cal Psychology, 57, 545–549.

Williams, E. J. (1959). The comparison of regression variables. Jour-nal of the Royal Statistical Society, Series B, 21, 396–399.

Manuscript received May 23, 2000Final revision received March 27, 2001