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«Are Executive Function Difficulties Reported by Parents and Teachers Associated with Elevated Levels of Parenting Stress for Children Diagnosed with ...»

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Are Executive Function Difficulties Reported by Parents and

Teachers Associated with Elevated Levels of Parenting Stress

for Children Diagnosed with

Attention-Deficit/Hyperactivity Disorder,

with and without Oppositional Defiant Disorder?

by

Alan McLuckie

A thesis submitted in conformity with the requirements

for the degree of Doctor of Philosophy

Graduate Department of Social Work

University of Toronto

© Copyright by Alan McLuckie 2011

ARE EXECUTIVE FUNCTION DIFFICULTITES REPORTED BY PARENTS AND

TEACHERS ASSOCIATED WITH ELEVATED LEVELS OF PARENTING STRESS

FOR CHILDREN DIAGNOSED WITH ATTENTION-DEFICIT/HYPERACTIVITY

DISORDER, WITH AND WITHOUT OPPOSITIONAL DEFIANT DISORDER?

Doctor of Philosophy, 2011 Alan McLuckie Facator-Inwentash Faculty of Social Work, University of Toronto Abstract Parents raising children with Attention-deficit/hyperactivity disorder (ADHD) experience high levels of parenting stress, especially when ADHD is accompanied by comorbid Oppositional Defiant Disorder (ADHD/ODD). Children with ADHD experience difficulties with their executive functions in such areas as inhibition control, working memory, and emotional regulation. Despite evidence linking ADHD with parenting stress, and ADHD with executive function difficulties (EFDs), there is little research exploring whether EFDs within an ADHD population are associated with parenting stress.

This dissertation’s main objective is to determine whether parent-reported and teacherreported childhood EFDs are associated with elevated levels of parenting stress. A secondary data analysis was completed on a cross-section of parent and teacher completed psychiatric assessment measures for children (n=243) diagnosed with ADHD. Measures included the Behavior Rating Inventory of Executive Function, the Conners’ Parent Rating Scale and the Parenting Stress Index, Long Form.

A number of important findings were produced; key of which was the finding that a strong association exists between parent-reported EFDs and Child Domain parenting stress.

Consistent with prior ADHD research, difficulties with emotional control and inhibition were found to be potent predictors of Child Domain parenting stress. To a lesser degree, children’s difficulties with initiation and self-monitoring were associated with Child Domain parenting ii stress, suggesting that daily hassles pose challenges for parents, especially when the child attends a new school. Also important was the finding that parent-reported oppositionality partially mediated the relationship between EFDs with emotional control, inhibition and shift, and Child Domain parenting stress. Despite teachers’ reports that children displayed more severe behaviours than were reported by parents, teacher-reported EFDs were not significantly associated with Child Domain parenting stress, with a few exceptions. Although not a well-explored concept within the literature on ADHD and parenting stress, parental acceptance of the child emerged as source of Child Domain parenting stress and a potential focus for assessment and treatment. Findings from the current study suggest that early identification and intervention with emotional control difficulties and ODD are vital due to their strong association with clinically significant levels of Child Domain parenting stress.

–  –  –

I would like to thank my committee for their guidance and support throughout the dissertation process. I am indebted to Dr. Faye Mishna, Chair of my committee, whose support, encouragement and guidance have been present since the first day of my doctoral studies. I would also like to thank Drs. Judith Wiener, Aron Shlonsky and Abel Ickowicz for their support and for generously sharing their time and expertise.

Thanks to the staff of the ADHD Clinic at the Scarborough Hospital, including Ms.

Penny Duncan, Dr. David Ng and Dr. Michael Schwartz. Their commitment to excellence in mental health care is an inspiration. I would also like to thank the young people and parents who participated in this study, without whom, this research would not have been possible. I dedicate this dissertation to the memory of Dr. Atilla Turgay, who helped launch my career as a mental health therapist at the Scarborough Hospital and supported my ambition to become a clinician-researcher in the field of children’s mental health. His contribution to the field and his compassion for all those impacted by ADHD will be missed.

I am grateful for the support of Dr. Tahany Gadalla, of the Factor-Inwentash Faculty of Social Work, whose knowledge of statistics and skill as an educator helped me grow as a researcher. I would also like to pay tribute to my friend and colleague, Dr. Michael Saini, who mentored and inspired me throughout my journey at the Factor-Inwentash Faculty of Social Work. I am also thankful for the friendship and counsel of Ms. Melissa Rowbotham, whose unfaltering wisdom helped keep me focused on what was important throughout this process.

Thanks to Dr. Stan Kutcher for taking me under his wing upon arriving in Halifax, Nova Scotia. His support, encouragement and guidance were invaluable in the final stages of the dissertation process.





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enduring support throughout my journey in the field of Social Work. I am also grateful for my favourite aunt, Mrs. Moira Leitch, who had no doubt that my aptitude would be better suited to working with children and families than programming computers. To all my friends, with special mention to Mr. Ryan Ford and Mr. Matthew Overton, thank you for your ongoing support and continued friendship despite my singular focus on my dissertation.

Finally, I would like to recognize my wife, Nicole Godbout, for her special contribution to this dissertation process beyond her tireless assistance with editing. Her love, dedication, sacrifice and belief in me allowed this dissertation to become a reality.

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vi Measures……………………………………………………………………………………………………. 81 Data Analysis……………………………………………………………………………………………… 89 CHAPTER V - SAMPLE CHARACTERISTICS…………………………………………………………………. 93 Composition of the Secondary Data Set……………………………………………………………. 93 Sample Demographics and Characteristics…………………………………..…………………… 98 Family Structure and Background………………………………………….…………………… 98 Child Demographics and Characteristics………………………………..…………………… 102 Descriptive Analysis of the Independent and Dependent Variables…..……………… 110 Descriptive Statistics Related to EFDs – Independent Variable..…………..……… 110 Descriptive Statistics Related to Parenting Stress –Dependent Variable……… 121 Chapter Summary………………………………………………………..…………………………… 126 CHAPTER VI – MAIN RESULTS………………………………………………………………..………………… 129 Summary Regarding the Statistical Assumptions………………….…………………………… 143 Main Analyses and Findings……………….…………………………………………………………….. 145 Predicting Parenting Stress with Parent/Teacher Reports of Childhood EFDs (Objective 1) Characteristics……………………………………

What Specific EFD Subcomponents Best Predict Parenting Stress (Sub-objective 1)………………………………………………………………………………………… 149 Does Childhood ODD Mediate ‘Hot’ EFDs and Child Domain Stress (Objective 2)…………………………………………………………………………….………………… 153 Potential Moderators of EFDs and Parenting Stress (Objective 3)….…………… 160 CHAPTER VII – DISCUSSION……………

Discussion of Preliminary and Descriptive Analyses………………………..………………… 169 Summary of the Descriptive Findings Related to EFDs…………….………………..… 169 Summary of the Descriptive Findings Regarding Parenting Stress……..……….. 172 Discussion of the Main Analyses……………………………………………………..……………….. 176 Predicting Parenting Stress with Parent/Teacher Reports of Childhood…………… 176 Parenting Stress Specific to Child Characteristics………………………..……………… 176 Parenting Stress and EFDs as Rated by Teachers………………………………………… 182 Parenting Stress Specific to Parental Characteristics…………………………..……… 185 Summarizing the Prediction of Parenting Stress with EFDs……….………………… 187 Oppositional/Defiance as a Mediator of EFDs and Parenting Stress…..……………… 188 Primary Appraisal: Threats to Parental Control and Parenting Stress..……….. 192 Secondary Appraisal: Balancing Controlling the Child with Parental Self-Control………………………………………………………………………………….. 194 Acceptance and Attributions of Controllability……………………………………………. 195 Summary of Oppositional/Defiance as a Mediator………………..…………………… 200 Moderators of EFDs and Parenting Stress………………………………………….……………… 202 Child Age as a Moderator…………………………………………………………………………… 202 Child Gender as a Moderator……………………………………………………………………… 203 Stressful Life Events as Moderators…………………………………………….……………… 203 Interaction Effects of ADHD Subtypes on EFDs and Parenting Stress………….. 206 Summary: Moderators of EFDs and Parenting Stress……………………………..….. 207 vii CHAPTER VIII – LIMITATIONS AND CONCLUSIONS…………………………………………………… 209 Strengths and Limitations of the Current Study………………………………………………… 210 Possible Sample-Related Limitations……………………………………..…………………… 213 Possible Measurement Related Limitations…………………………..…………………… 215 Limitations Arising from Unmeasured Confounding Variables……….…………… 221 Direction of the Relationship between EFDs and Parenting Stress….…………… 222 Conclusions: Clinical Implications and Relevance to Social Work…………..……….… 223 Role of Social Work………………………………………………………………………….………… 226 Working with Children and Parents Impacted by ADHD……………………………… 230 Working with the Schools…………………………………………………………………………… 246 Challenging Stigma………………………………………………………………..…………………… 248 Conclusions: Future Research Child or Parent Characteristics..…………………….…… 251 References………………..……………………………………………………………………………………………. 254

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ix List of Appendices Appendix A DSM-IV-TR Criteria for ADHD……………………………………………………………………………. 316 Appendix B DSM-IV-TR Criteria for ODD………………………………………………………………………………. 318 Appendix C Ethical Approval from the Scarborough Hospital………………………………………………. 319 Appendix D Ethical Approval from the University of Toronto.……………………………………………… 320

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CHAPTER I – INTRODUCTION, OBJECTIVES AND BACKGROUND

Attention-Deficit/Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder typified by symptoms of inattention, hyperactivity and impulsivity. First recognized as a medical/psychiatric condition at the turn of the 20th century by paediatrician George Still (1902), this disorder is one of the most diagnosed and treated children’s mental health issues in North America (Barkley, 1998; Cantwell, 1996; Dulcan, 1997; Pliszka, 2000; Pliszka et al., 2007; Waschbusch, 2002). The estimated prevalence among school-aged children in North America is between 3-7% (American Psychiatric Association [APA], 2000; Faraone, Sergeant, Gillberg, & Biederman, 2003) with a worldwide prevalence around 5% (Polanczyk & Rohde, 2007; Polanczyk, de Lima, Horta, Biederman, & Rohde, 2007). In North America, this translates into approximately one child with ADHD enrolled in every regular education classroom (DuPaul & Stoner, 1994). Children diagnosed with ADHD are prone to experience a range of comorbid psychiatric conditions and learning difficulties (Bird, Goud, & Staghezza, 1993; Pliszka, 2000; Semrud-Clikeman et al., 1992), the most prevalent of which being Oppositional Defiant Disorder (ODD). ODD, typified by patterns of rule defiance, anger and behavioural difficulties, is estimated to affect between 30-50 % of the childhood ADHD population (Acosta, Arcos-Burgos, & Muenke, 2004; August, Realmuto, Joyce, & Hektner, 1999; Biederman, Newcorn, & Sprich, 1991).

The etiology of ADHD is largely due to genetic inheritance rather than environmental factors (Castellanos, Sonuga-Barke, Milham, & Tannock, 2006; Tannock, 2003; Faraone & Biederman, 2000; Thapar, Holmes, Poulton, & Harrington, 1999; Waldman & Rhee, 2002), although this does not diminish the role environmental factors play in shaping the overall functional ability and/or symptom presentation of children diagnosed with this disorder (Barkley, 2006; Nigg, 2006). Leading ADHD theories assert that genetic aberrations contribute to neurological impairments with the executive functions (Tannock, 2003), which are believed to underpin many of the behavioural symptoms associated with ADHD (Nigg, 2006; Doyle, 2006; Jonsdottir, Bouma, Sergeant, & Scherder, 2006).



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