Responsiveness in interactions of mothers and sons with ADHD: Relations to maternal and child characteristics - attention-deficit hyperactivity disorder - Statistical Data Included

Journal of Abnormal Child Psychology, Feb, 2002 by Charlotte

Johnston, Candice Murray, Stephen P. Hinshaw, William E. Pelham,

Jr., Betsy Hoza

Charlotte Johnston (1,5)

Candice Murray (1)

Stephen P. Hinshaw (2)

William E. Pelham Jr. (3)

Betsy Hoza (4)

**********

It is widely known that children with attention-deficit/hyperactivity

disorder (ADHD) have difficulties in interactions with their parents

(Johnston & Mash, 2001). However, experts agree that parenting is

unlikely to be the ultimate cause of ADHD (Barkley, 1998). Instead,

studies have suggested that parenting variables are most closely

related to the presence of comorbid oppositional defiant (ODD) or

conduct disordered (CD) behavior among children with ADHD

(Whalen & Henker, 1999). It has also been hypothesized that

problems in parent--child interactions are associated with

exacerbations or continuation of ADHD symptoms (Barkley, 1998;

Biederman et al., 1996). It is important to note that many studies of

the associations between parenting and increased child ADHD

symptoms or ODD/CD behaviors do not directly address causality.

The theoretical model most often used is transactional, with child

symptoms and parenting behavior reciprocally related, and exerting

mutual influences over time (Campbell, 1994). We sim ilarly adopt a

transactional approach and do not imply that our correlational

findings speak to the causes of either child symptoms or parenting

behavior.

Previous studies of parent--child interactions in families of children

with ADHD consistently demonstrate that in contrast to nonproblem

children (a) ADHD children are less compliant and more negative in

parent--child interactions, and (b) their parents use more

commands, more negative statements, and less praise (e.g.,

Cunningham & Barkley, 1979; Mash & Johnston, 1982). As noted

above, recent studies suggest that although ADHD children and

parents usually show more interaction difficulties than controls, the

greatest problems are often among ADHD children with comorbid

ODD/CD behavior. At both elementary-school ages and in

adolescence, studies have found higher levels of observed child

negative behavior and maternal directiveness and negativity in

families of children with comorbid ADHD and conduct problems,

compared to children with only ADHD or to control children (Barkley,

Anastopoulos, Guevremont, & Fletcher, 1992; Gomez & Sanson,

1994). Anderson, Hinshaw, and Simmel (1994) also found that

observed mater nal negativity predicted conduct problems in sons

with ADHD over a 1-2-month period, even with the effects of

maternal psychopathology and child negative behavior controlled.

Thus, although these observational findings are not entirely

consistent (e.g., Johnston, 1996), most studies support an

association between negative parenting behaviors and child conduct

problems.

Despite the contributions of this previous research, a focus on

discrete parenting behaviors may not capture the complex,

multidimensional nature of parent-child interactions. Theorists have

argued that combined patterns of parenting behaviors, or parenting

styles, are more strongly related to child behaviors than are discrete

parenting behaviors (Darling & Steinberg, 1993) and some empirical

support for this argument has been presented (Rothbaum & Weisz,

1994). The classic works in this area are those of developmental

psychologists such as Baumrind (1968, 1983), who differentiated

authoritarian, authoritative, and permissive styles of parenting

control, and Maccoby and Martin (1983), who conceptualized

parenting behaviors as falling along dimensions of responsiveness

and demandingness. Using meta-analysis, Rothbaum and Weisz

(1994) identified responsiveness-acceptance and restrictiveness as

the two important dimensions of parenting, with responsiveness

being the more important and the most strongly related t o child

externalizing behavior. Based on factor analytic studies, these

authors include variables such as parental approval of the child,

synchrony, affection, and noncoercive or authoritative control within

the construct of responsive parenting.

We argue that responsive parenting is particularly relevant in

understanding parent-child interactions among ADHD children.

Monitoring and interpreting ongoing child behavior as the basis for

adapting one's own behavior is more difficult when interacting with a

child who, by definition, displays impulsive, disorganized, and poorly-

regulated behavior. Also, given that responsive parenting has been

posited as a prerequisite for the child's development of self-

regulation skills (Kochanska, 1997; Winsler, 1998), we hypothesize

that diminished maternal responsiveness may be associated with the

severity of both ADHD and ODD/CD symptoms in children with

ADHD.

Some existing research supports this hypothesized link between an

unresponsive style of parenting and ADHD and ODD child behaviors,

particularly in high-risk samples. Among lower socioeconomic status

families followed from infancy to early school years, Carlson,

Jacobvitz, and Sroufe (1995) found that early ratings of maternal

insensitivity and overstimulating or nonresponsive physical intimacy

predicted distractible and hyperactive child behavior. However, this

study did not include children with formal diagnoses of ADHD.

Comparing the mother-child teaching task interactions of a small

group of boys with ADHD (primarily without ODD/CD problems) to

controls, Winsler (1998) found less effective maternal scaffolding in

the ADHD dyads. Scaffolding was defined as including elements such

as whether mothers modified task demands and their level of

assistance to be appropriate to the child's skill. Together, these

studies suggest a link between child ADHD symptoms and low

maternal responsiveness, but the results are limited by

nondiagnosed or small samples and the measurement of

responsiveness only at young child ages or in teaching-type

situations.

Other studies have looked at the relations between maternal

responsiveness and both ADHD and CD child behaviors. Campbell

and colleagues (Campbell, Breaux, Ewing, & Szumowski, 1986;

Campbell & Ewing, 1990) followed a sample of hard-to-manage

children from age 3 to 9, and reported that negative maternal control

(including inappropriateness of direction, lack of enjoyment of the

child, and mother-child conflict) when the child was 3 was positively

related to both ADHD and ODD/CD child behaviors at ages 6 and 9.

Only a few studies have examined maternal responsiveness in

samples of children who meet formal diagnostic criteria for ADHD or

ODD/CD. Wakschlag and Hans (1999), in a high-risk sample of

African American children, reported that maternal responsiveness as

rated in infancy negatively predicted subsequent ODD or CD

diagnoses for the child, even after controlling for the effects of

concurrent parenting and a variety of biological and family risk

factors. However, responsiveness was not related to child ADHD

symptoms. Similarly, comparing nonproblem boys and boys rated by

parents as meeting criteria for ADHD, ODD, and both ADHD and

ODD, Lindahl (1998) found that parents in all three clinical groups

were rated as showing more rejection-coercion and directiveness

than control parents. In contrast, family cohesion (including

elements of parental responsiveness) was problematic only in the

ODD and comorbid groups. Summarizing this research, it appears

that maternal responsiveness has a negative association with child

conduct problems, although only the Lindahl study included children

classified according to diagnostic criteria. Unfortunately, in that

study, observations of responsiveness were combined with other

aspects of family functioning. The current study will add important

information regarding the link between maternal responsiveness and

child behavior in school-aged children meeting diagnostic criteria for

ADHD. We predict that maternal responsiveness will be negatively

related to both ODD/CD problems and AD HD symptom severity in

boys with ADHD.

In addition to child characteristics, maternal responsiveness also has

been related to parental difficulties such as depressed mood. Using

unfamiliar children to eliminate effects due to one's own child,

Goldsmith and Rogoff (1995) reported that dysphoric women showed

less sensitivity to children than nondysphoric women. Harnish,

Dodge, Valente, and the Conduct Problems Prevention Research

Group (1995) reported that in first-grade children, the relation

between maternal depressive symptoms and child externalizing

problems was partially mediated by the level of maternal

unresponsiveness in mother-child interactions. Although not

examined extensively in prior research, impulsive or inattentive

characteristics in the parent also may interfere with the ability to

monitor and respond sensitively to child behavior. For example, in a

case report, Evans, Vallano, and Pelham (1994) found positive

associations between a mother's own ADHD symptoms and her

difficulties managing her child's behavior. In this study, we pre dict

that maternal responsiveness will be negatively related to mothers'

depressive symptoms and history of ADHD symptoms.

Many existing measures of responsiveness focus on mothers of

infants and preschool-aged children and the measures used with

older children have assessed limited aspects of responsiveness or

have combined responsiveness with other aspects of family

functioning. Therefore, one challenge for this study was to adapt

existing measures to create an observational system for maternal

responsiveness that would be developmentally appropriate for

parents of elementary-school-aged children. Based on previous

measures, as well as theoretical considerations, we examined several

dimensions of parenting behavior, including style of control,

sensitivity and responsiveness, acceptance of the child, affection,

and involvement. We assessed the validity of the observations by

examining differences in parenting behavior across situations with

different demands and correlating the behaviors with maternal

reports of family functioning. We predicted that play interactions,

because of their low structure and demands, would reveal high levels

of maternal affection and low levels of authoritarian control. In

situations where the mother was busy, we predicted low involvement

with the child. The teaching nature of a pencil-paper task situation

was expected to elicit maternal sensitivity and responsiveness to the

child's abilities and needs, and the demands of a clean-up task were

expected to lead to high levels of control. In addition, we predicted

that observed responsiveness would be related to mothers' reports of

the parent-child relationship and of parenting practices.

METHOD

Participants

Videotaped interactions of 136 mothers and their sons with ADHD

were used in this study. The data were from baseline observations

conducted at the University of California at Berkeley (n = 71) and

the University of Pittsburgh (n = 65), two of six sites involved in the

Multimodal Treatment Study of Children with ADHD (MTA). The

choice of only two sites was based on a balance between obtaining a

sufficient sample size and practical limitations on the amount of data

that could be coded. Mother-daughter interactions were excluded

because of the relatively small sample of girls. Recruitment and

assessment procedures are described in detail in previous

publications (Hinshaw et al., 1997). Although treatment outcome

data from the MTA study have been published (MTA Cooperative

Group, 1999), this investigation employs only baseline data and

focuses on pretreatment relations among maternal and child

variables.

All boys in the sample met DSM-IV criteria for ADHD, combined type.

Thirty-eight percent of the sample had comorbid ODD, 3% had

comorbid CD, 21% were comorbid for both ODD and CD, and 38%

had ADHD alone. Sixty-five percent of the mothers identified their

child's ethnicity as white, 25% as African American, 2% as

Latino/Latina, and 8% as mixed. Demographic characteristics for the

sample are presented in Table I.

Procedure

Videotaped mother-son interactions were part of the baseline

assessment battery used in the MTA study. Interactions were

conducted in furnished laboratory rooms (e.g., equipped with a table

and chairs, magazines, toys) and were videotaped through a one-

way mirror or with a camera mounted in the upper corner of the

room. Each mother-son interaction lasted 17 min and consisted of

four situations designed to elicit typical child-rearing interactions:

free play (4 min), parent busy (3 min), a paper and pencil task (5

min), and clean-up (5 min).

Mothers received verbal and written instructions for each of the four

situations. For the free-play period, with toys and magazines

available in the room, mothers engaged in an activity of their choice

with their sons.

During the parent-busy period, mothers completed questionnaires

and had their sons sit quietly in a chair, without interrupting them.

For the paper and pencil period, mothers instructed their sons to

work on either a math or a handwriting task. Last, for the clean-up

period, mothers had their sons pick up small paper dots from the

floor, put the toys away, and place the materials from the paper and

pencil task on a small table.

Measures

Observations

Maternal behavior was assessed by observation of the videotaped

mother-son interactions. Observers considered maternal behavior in

the context of the child's needs, developmental level, and the

situation. Responsiveness was conceptualized as a multidimensional

construct that included several aspects of parenting behavior. The

coding manual was derived from work of others (Campbell et al.,

1986; Carlson et al., 1995; Goldsmith & Rogoff, 1995; Harnish et al.,

1995; Kochanska, 1997) with modifications to increase the

appropriateness of the definitions for mothers' interactions with their

7-10-year-old sons. (6)

Six dimensions of maternal behavior were observed. Each dimension

was measured on a 7-point rating scale, with higher scores reflecting

more of the construct measured:

1) Authoritative Control reflected the extent to which the mother

used an authoritative method of controlling the child's behavior.

Mothers rated low on this dimension imposed high levels of structure

on their child's activities, using control strategies ranging from direct,

harsh commands (without explanations) to physical restraint. In

contrast, mothers rated as high in authoritative control encouraged

their children to participate in decision making and offered

explanations for commands. (7)

2) Sensitivity of Control measured the degree to which mothers

exerted control in a manner that was sensitive to the child's needs

and abilities. As some situations naturally require more control (e.g.,

clean up) than others (e.g., free play), and some children need more

assistance than others, this rating involved an assessment of how

much direction the child required. Mothers who were low on

Sensitivity of Control made demands that were unreasonable for the

situation (e.g., too much control in free play or too little structure in

clean up). Mothers who were high in Sensitivity of Control were able

to match their instructions to the child's level and only intervened

when their child needed assistance.

3) Responsiveness referred to the mother's overall ability to

appropriately adapt her behavior to her child's abilities, needs,

requests, and interests, as well as his ongoing behavior. Mothers low

in Responsiveness were intrusive and operated according to their

own agenda. They appeared unaware of their child's needs and their

behavior was not congruent with their child's (e.g., changed the

child's activity during play even though the child was content). In

contrast, mothers high in Responsiveness synchronized their

behavior with the affect, ability, or desire of their child, even if this

meant deviating from the instructions given.

4) Positive Affect reflected the mother's verbal and nonverbal

emotional expression in the interaction. A low score indicated that

the mother displayed frequent and/or intense negative affect (e.g.,

anger, sadness), whereas a high score indicated frequent and/or

intense positive affect (e.g., happiness, warmth). Neutral scores

reflected relatively equal amounts of negative and positive affect or

neutral affect.

5) Acceptance of the Child was based on the degree to which the

mother approved, praised, and/or showed affection toward her son.

Mothers with low scores were rejecting and cold toward their sons.

They made negative comments or expressed disapproval of their

sons' behavior in a derogatory manner. Mothers high on Acceptance

displayed genuine positive feelings for their sons, praising their

efforts regardless of the outcome.

6) Involvement with Child was assessed as the amount of time the

mother spent in verbal and nonverbal interactions with her child.

Mothers rated low on Involvement may have read magazines while

their child played whereas mothers who were high in Involvement

stayed in close proximity or engaged in conversations with their

child.

A seventh behavior category (Percent No Control) was created from

the Authoritative Control dimension and reflected the percentage of

intervals in which no maternal control was exercised.

Coders began by watching the entire interaction to gain an

understanding of the child's needs and abilities. Then, coders

watched the interaction a second time, stopping at 1-min intervals to

rate the mother's behavior across the seven categories. Coders were

trained to rate each of the dimensions of behavior independently so

that a high score on one dimension did not imply a high score on

another dimension. Two undergraduate students and the first two

authors were trained to use the coding system, through reading the

coding manual and attending regular coding meetings. Training

continued until a minimum of 80% agreement (defined as ratings

within 1-point of each other on the 7-point scale) across the

dimensions was reached between independent coders. Then,

reliability checks between independent coders continued throughout

the coding process. Thirty-five percent of the interactions were coded

independently to check for reliability. Cohen's kappas calculated for

each of the four situations ranged from .79 to . 86 for

Responsiveness, .84 to .92 for Authoritative Control, .75 to .87 for

Sensitivity of Control, .97 to .99 for Positive Affect, .96 to .99 for

Acceptance of Child, and .80 to .89 for Involvement with Child. All

coders were blind to the mothers' and children's scores on the other

measures used in the study.

Maternal Characteristics

The level of depressive symptoms in mothers was measured using

the Beck Depression Inventory (BDI; Beck, Rush, & Emery, 1979).

The BDI is a 21-item, self-report scale designed to assess adult

depressive symptoms in cognitive, somatic, and affective realms. The

BDI has high test-retest reliability (rs = .60-.90) and high internal

consistency ([alpha] = .81; Beck, Steer, & Garbin, 1988).

The level of childhood ADHD symptomatology in mothers was

measured using the Wender Utah Rating Scale (WURS; Ward,

Wender, & Reimherr, 1993). The WURS is a 5-point, 61-item, self-

report scale used to assess adults' recall of childhood levels of

inattentiveness, impulsivity, hyperactivity, oppositional behavior,

medical problems, and learning difficulties. The 25-items from this

scale that best discriminate adults with ADHD from non-problem and

psychiatric controls were used in this study. (8) The 25-item scale

has high split-half reliability (r = .90), correlates with parents'

ratings, and predicts response to medication (Ward et al., 1993). It

also correlates with current adult ADHD symptoms (Greenfield et al.,

2001; Nigg et al., 2001).

Child Characteristics

Children's levels of ADHD symptoms were assessed using both

mothers' and teachers' reports on the SNAP-IV (Swanson, 1992).

The SNAP-IV uses a 4-point scale for rating the child on the nine

inattentive and nine impulsive-hyperactive symptoms from the DSM-

IV symptom list for ADHD. Scores were added across all 18 items.

Although psychometrics have not been reported for the SNAP-IV, the

Disruptive Behavior Rating Scale, which is similar in content and

format, yields high test-retest reliability (r = .85) and internal

consistency ([alpha] = .92; DuPaul, Power, Anastopoulos, & Reid,

1998).

The child's level of conduct disordered behavior was assessed by

both mothers and teachers using the Conduct Problem scale from the

Conners' Parent Rating Scale (CPRS; Conners, 1990) and the

Conners' Teacher Rating Scale (CTRS; Conners, 1990). The Conners'

rating scales measure problematic behaviors in 4--12-year-old

children by using a 4-point scale. The manual for the Conners' scales

reports reasonable internal consistency, interrater agreement, and

test-retest reliability for the scales.

Maternal Reports of the Parent--Child Relationship and Parenting

Practices

The quality of the relationship between mothers and sons and the

level of maternal power assertion were assessed using the brief

version of the Parent--Child Relationship Questionnaire (PCRQ;

Furman & Giberson, 1995). This is a 40-item scale that assesses

parental perceptions of the quality of the parent--child relationship

on a 5-point scale. The measure includes five subscales, and three,

Personal Relationship, Warmth, and Power Assertion, were chosen

for the present study. These subscales have high levels of internal

consistency ([alpha]s > .85).

The Alabama Parenting Questionnaire (APQ; Shelton, Frick, &

Wootton, 1996) is a 42-item measure of parenting practices and

uses a 5-point scale. The Parental Involvement and Positive

Parenting subscales were used in the current study and both have

acceptable internal consistencies ([alpha]s > .80). In addition, the 3-

item Corporal Punishment subscale was used despite its lower

internal consistency ([alpha] = .46). The validity of this subscale is

suggested by its negative correlations with child age and SES and its

ability to distinguish normal and disturbed families (Shelton et al.,

1996).

RESULTS

Descriptive Information

Means, standard deviations, and ranges for variables indexing

mothers' reports of the parent--child relationship, and maternal and

child characteristics are presented in Table I.

Situational Effects on Maternal Behavior

Prior to correlating observations of maternal behavior with maternal

and child characteristics, we investigated cross-situational differences

in behavior. Using the average rating across the 1-min intervals on

each of the seven maternal behavior dimensions as dependent

measures, we tested for differences across the free-play, parent-

busy, pencil-paper task, and clean-up task periods by using a

repeated-measures MANOVA.

The overall effect for situation was significant, F(21, 112) = 27.10, p

< .001. At the univariate level, situational differences were found for

Authoritative Control, F(3, 396) = 6.63, p < .001, Sensitivity of

Control, F(3, 396) = 6.08, p < .001, Responsiveness, F(3, 396) =

4.50, p < .004, Positive Affect, F(3, 396) = 32.57, p < .001,

Acceptance of Child, F(3, 396) = 2.85, p < .04, Involvement with

Child, F(3, 396) = 115.84, p < .001, and Percentage of Intervals

with No Control, F(3, 396) = 23.56, p < .001. The situation

differences for each dimension, as revealed through post hoc tests,

are shown in Table II. In general, these differences are consistent

with expectations and support the validity of the coding system.

During free play, mothers used the most authoritative methods of

control and showed the most positive affect. Free-play and parent-

busy situations were similar in that mothers used less control in

them (more intervals with no control) than in the other situations.

Parent-busy periods were charac terized by the least involvement

and by less positive affect than the other two task periods (clean-up

and pencil-paper). The teaching context of the pencil-paper task

elicited the highest levels of sensitive control and responsiveness,

and the clean-up task was characterized by the fewest intervals with

no control and by less responsiveness than other situations involving

structured tasks.

Data Reduction for Observational Measures

To reduce the number of maternal behaviors, principal components

analyses with varimax rotations were conducted on the seven

dimensions of behavior coded during each Situation (free-play,

parent-busy, pencil-paper task, and clean-up task). In each of the

four situations, the first component, labeled Responsiveness, had an

eigenvalue between 3.34 and 3.87 and accounted for approximately

half of the variance (48-55%). Authoritative Control, Sensitivity of

Control, Responsiveness, Positive Affect, and Acceptance of Child

loaded above .60 on this component, with Responsiveness and

Sensitivity of Control having the highest loadings (.80-.90 range).

Factor loadings are shown in Table III. In the free-play situation,

Involvement with Child also loaded primarily on this component.

Across the four situations, a second component emerged with

eigenvalues between 1.10 and 1.70, which accounted for 15-24% of

additional variance. Involvement and the Percentage of Intervals

with No Control generally loaded on this component , typically in the

.80-.90 range, and the component was labeled Involvement. Across

the four situations, no other components emerged with eigenvalues

above 1.

Using items with factor loadings above .60 and unit weighting of

items, a factor score was calculated for the Responsiveness

component for each situation. Across the four situations, correlations

among Responsiveness scores ranged from .58 to .81, and all were

significant at p < .01. Thus, mothers who were more responsive in

one situation, were also more responsive in the other situations.

Internal consistency for a Responsiveness score summed across the

four situations was .94. Therefore, an overall Responsiveness score

was calculated for each mother-son dyad by summing across the

four situations (M = 75.01, SD = 11.09, range 36.05-100.64). For

Involvement, because the two items loading above .60 on the

component were measured with different metrics, scores were

standardized and the control item was reversed before they were

summed to form an Involvement score for each situation.

Correlations for Involvement scores across the situations were low to

moderate (rs = .05-.49) and four of six were significant at the p <

.01 level. The alpha for an Involvement score summed across the

situations was only .68, and was not improved by omitting any

behaviors or situations. Because the Involvement score captured

only two of the coding categories and produced lower crosssituational

agreement and internal consistency than desired, we excluded it

from further analyses.

Responsiveness and Demographic Characteristics

Mothers' overall Responsiveness scores were related to the

demographic variables of child age, mother age, mother education,

and maternal marital status. Both mother age and education were

related to Responsiveness, r(129) .19, p = .03 and r(127) = .33, p <

.001, respectively. Older and better-educated mothers were more

responsive with their sons. t tests indicated that marital status (two-

parent vs. single-parent) also was related to Responsiveness, t(l,

127) = 2.02, p = .05. Single mothers were less responsive with their

sons.

Responsiveness and Reports of the Parent-Child Relationship and

Parenting Practices

To further assess the validity of the observations of maternal

behavior, Responsiveness scores were correlated with mothers'

reports of the parent-child relationship and parenting practices.

Partial correlations were used to control for mother age, education,

and marital status. Responsiveness was significantly, negatively

related to reports of harsh parenting strategies, as measured by both

questionnaires; for the Power Assertion scale of the PCRQ, r(107) = -

.35, p < .001, and for the Corporal Punishment scale of the APQ,

r(107) = -.51, p < .001. Responsiveness was not significantly related

to maternal reports of Warmth, Personal Relationship, Involvement,

or Positive Parenting (rs = .01 to -.08).

Responsiveness and Reports of Maternal and Child Characteristics

Partial correlations between maternal Responsiveness and maternal

and child characteristics were also conducted, controlling for mother

age, education, and marital status. Although controlling for the

demographic variables reduced the strength of the predicted

associations, many of the correlations confirmed predictions.

Maternal depressive symptoms, but not maternal childhood ADHD,

were negatively related to Responsiveness in interactions with their

children; for the BDI, r(92) = -.23, p = .02, and for the WURS, r(92)

= -.15, p = .16. In addition, Responsiveness was inversely related to

mothers' reports of child conduct problems, r(92) = -.26, p = .01.

The correlation between Responsiveness and teachers' reports of

conduct problems was significant at the bivariate level, r(l01) = -.23,

p = .0l, but was reduced, r(92) = -.13, p = .23, when demographic

variables were controlled. Responsiveness was not related to child

ADHD symptoms (rs = -.03 and -.01 for mothers' and teachers'

reports, respectively).

Regression Analyses

The unique contributions of maternal and child characteristics to

predicting Responsiveness were tested. Four blocks of variables were

created containing (1) relevant demographics, (2) maternal

depressive and maternal childhood ADHD symptoms, (3) child ADHD

symptoms as rated by the mother and teacher, and (4) child conduct

problems as rated by the mother and teacher. A series of regression

analyses were conducted, with each block forced into the prediction

model in last place to see if it could account for unique variance in

observed Responsiveness. This method allowed us to test the unique

contribution of each block of variables, over and above the variance

accounted for by all other predictor variables. The full regression

model was significant, but only the blocks of demographic

characteristics and child conduct problems made significant unique

contributions once all other variables were entered in the model,

F(3,87) = 2.93, p = .04, [DELTA][R.sup.2] = .07 and F(3,87) =

3.06, p = .05, [DELTA][R.sup.2] = .0 5, respectively. Thus, child

conduct problems were uniquely and negatively related to maternal

Responsiveness. Standardized beta coefficients from the full model

are shown in Table IV. Maternal education and mother's reports of

conduct problems were significant individual predictors of

Responsiveness, as was maternal depressive symptoms, even

though the maternal characteristics block as a whole did not

contribute unique variance.

DISCUSSION

We hypothesized that a stylistic aspect of parenting, responsiveness,

would be related to maternal and child characteristics in families of

ADHD children. Results confirmed that maternal responsiveness was

negatively and uniquely related to child conduct problems and also

was negatively, although not uniquely, related to maternal

depressive symptoms. Maternal responsiveness, however, was not

related to the severity of the child's ADHD symptoms. Thus, this

study adds to existing literature, suggesting that parenting

difficulties are most closely related to conduct problems in families of

children with ADHD.

As noted, mothers' responsiveness to the needs and behaviors of

their sons with ADHD was negatively related to child conduct

problems, even after the variance in responsiveness due to

demographic characteristics, maternal depressive and maternal

childhood ADHD symptoms, and severity of child ADHD symptoms

was controlled. Bivariate correlations also indicated that this

association was found, not just with mothers' reports of the child's

conduct problems, but also using teachers' reports. However, the

correlation with teachers' reports was reduced when demographic

variables were controlled and teachers' reports did not emerge as

significant predictors in the regression analyses. The link between

responsiveness and child conduct problems is consistent with

previous reports (e.g., Campbell & Ewing, 1990; Lindahl, 1998) and

likely reflects an interactive and transactional process. For example,

unresponsive parenting may be associated with increased difficulties

in child self-regulation that lead to oppositional or conduct problems

in children with ADHD, and these child problems in turn challenge

responsive parenting.

In contrast to conduct problems, child ADHD symptoms were not

related to maternal responsiveness. Although all children were

diagnosed with ADHD combined type, the standard deviations and

ranges, as well as inspection of score distributions, indicated that

there was considerable variability in the range of symptom severity.

Thus, restriction of range and distribution skew do not appear likely

explanations for the lack of association. Instead, this finding is

consistent with the emerging consensus that parental and family

characteristics are more closely related to comorbid ODD/CD

behavior, than to ADHD behavior (Johnston & Mash, 2001; Whalen &

Henker, 1999). Our findings are also consistent with the suggestion

that if an association is found between child ADHD behavior and

maternal unresponsiveness, it is most likely to occur in community

samples (e.g., Campbell & Ewing, 1990) or in structured teaching

tasks (e.g., Winsler, 1998). Although responsiveness was not related

to child ADHD symptoms, without the inc lusion of families of

nonproblem children or children with only ODD/CD behavior, we

cannot speak to whether responsiveness would discriminate among

such groups. Similarly, the present findings are limited to boys with

combined subtype of ADHD.

Also consistent with previous research (e.g., Harnish et al., 1995),

observed maternal responsiveness was negatively associated with

the maternal depressive symptoms. Mothers of children with ADHD

have been reported to experience elevated rates of depressive

symptoms (Whalen & Henker, 1999), and the present study suggests

that responsiveness in parenting may function as a mediating

mechanism through which depressive symptoms are linked to

conduct problems in children with ADHD. Specifically, a mother's

experience of depressive symptoms may interfere with her ability to

respond appropriately and sensitively to her child's behavior and this

lack of responsiveness may create or exacerbate problematic child

behavior. Although the average score on the Beck Depression

Inventory in this sample was in the nondepressed range, the highest

scores were well within the range typical of individuals with clinical

depression. However, caution must be exercised in distinguishing

reports of depressive symptoms from more formal clinical diagnoses

of depressive disorder. In contrast to the findings for depressive

symptoms, mothers' reports of their childhood symptoms of ADHD

were not related to observed parenting style. This may reflect the

limitations of the WURS as a measure of ADHD symptomatology,

including its focus on childhood rather than current symptoms and its

inclusion of symptoms that are not clearly aspects of ADHD.

In this study, we adapted previous measures of responsiveness to be

developmentally appropriate to mother-child interactions in 7-10-

year-old children, and presented evidence of the reliability and

validity of this observational measure of parenting style. In addition

to usual measures of interrater reliability, the ratings of maternal

responsiveness were internally consistent and stable across the four

observational situations. A comparison of the dimensions of maternal

behavior across four different interaction contexts supported the

validity of the measure. For example, mothers were rated as using

the most authoritative style of control and showing the most positive

affect in free play, a situation with few demands. In addition to

situational effects, the validity of the responsiveness observations

was supported by their inverse correlations with maternal reports of

harsh discipline techniques. However, responsiveness was not

related to more positive dimensions of parenting style, such as

warmth or involve ment. We speculate that the discrepancy in

relations for positive and negative aspects of reported parenting

behavior may arise because of a difference in how responsiveness

was observed versus how parenting is assessed in questionnaires. An

integral aspect of our observational measure was that maternal

behavior was coded depending on the child behavior (e.g., needs or

abilities). For example, mothers were rated as responsive if they

provided a level of instruction that was appropriate for the child's

needs. For some, this meant providing a great deal of instruction,

but for others the child needed little instruction. In contrast,

questionnaire measures are more likely to assess the absolute

quantity of a parent behavior (e.g., how often do you give

instructions). Thus, the lack of association between responsiveness

and reports of positive parenting may reflect this difference in

methods of assessment. In contrast, for harsh discipline, it can be

argued that any amount of this behavior is inappropriate and no

nresponsive and hence, the quantitative assessment offered by

questionnaires corresponds more closely to the observational

assessment.

Unexpectedly, a second component emerged in the observation

ratings that reflected aspects of the mothers' involvement with their

children. In contrast to Responsiveness, the Involvement component

accounted for less variance in the observations and revealed

relatively low internal consistency and cross-situational stability. For

these reasons, we did not include the Involvement score in our

analyses and suggest that future research is needed to explore the

meaning of observational ratings of involvement as a dimension of

parenting style.

Obviously, the correlational nature of the investigation cannot offer

evidence regarding the direction of the operative effects. We suspect

that the most likely possibility is that child conduct problems,

maternal depressive symptoms, and maternal responsiveness are

linked in a reciprocal and transactional fashion, with each component

influencing the development of each other component over time

(Sameroff & Fiese, 2000). It seems plausible that mothers who are

experiencing depressive symptoms will be impaired in their ability to

monitor and respond appropriately to their child's behavior, and that

it is harder for mothers to be responsive to children who are

oppositional and difficult to manage, and that over time, the

presence of unresponsive parenting, maternal psychological

dysfunction, and child conduct problems will fuel the maintenance of

each other. Obviously, alternate explanations are possible. More

complex, longitudinal designs that marry assessment of

environmental and genetic influences are needed to address these

possibilities. In addition, more work is needed to specify the

particular individual or relational characteristics that trigger the cycle

of difficult child behaviors and nonresponsive parenting. However,

recognition of the concurrent associations among parenting style and

parent and child characteristics in families of children with ADHD

provides a starting point for this research and for potential

interventions.

One implication of the current findings is that psychosocial

interventions in families of children with ADHD may benefit from

inclusion of more content designed to improve parental

responsiveness. Such content would not be intended to target the

ADHD symptomatology, but rather to lessen or prevent child

difficulties with comorbid conduct problems. Available data already

suggest that psychosocial treatments for children with ADHD are

particularly important for targeting child oppositional behavior and

problems in the parent-child relationship (MTA Cooperative Group,

1999). Although behavioral parenting programs often include some

degree of responsiveness training (e.g., positive attending),

additional training in this aspect of parenting may be important.

Preliminary research (e.g., Wahler & Bellamy, 1997; Wendland-

Carro, Piccinini, & Millar, 1999) demonstrates the promise of such an

approach.

ACKNOWLEDGMENTS

We extend our sincere appreciation to the entire MTA group for their

willingness to allow us to use data from that project for this report.

In addition, we thank all the families who participated in the study.

Finally, we thank Irene Kim and Catherine McDonald who offered

invaluable assistance with data coding and entry.

This work was supported by a grant from the University of British

Columbia, Hampton Fund to Dr Johnston. Dr Pelham was supported

by Grant Nos. AA06267, MH50467, MH48157, MH45576, and

MH53554; Dr Hinshaw by Grant Nos. MH50461 and MH45064; and

Dr Hoza by Grant Nos. MH47390, MH48157, and MH50467 from the

National Institute of Mental Health.

The Multimodal Treatment Study of Children with Attention-

Deficit/Hyperactivity Disorder Cooperative Group Principal

Collaborators: National Institute of Mental Health, Rockville, MD:

Peter S. Jensen, MD (Office of the Director); L. Eugene Arnold, MD

(Department of Psychiatry, Ohio State University); John E. Richters,

PhD (Developmental Psychopathology and Prevention Research

Branch); Joanne B. Severe, MS (Research Projects and Publications

Branch); Donald Vereen, MD (Office of Drug Control Policy); and

Benedetto Vitiello, MD (Child and Adolescent Treatment and

Preventive Interventions Research Branch). Office of Special

Education Programs, U.S. Department of Education, Washington, DC:

Ellen Schiller, PhD. Principal Investigators and Coinvestigators

University of California, Berkeley/University of California, San

Francisco: Stephen P. Hinshaw, PhD (Department of Psychology,

University of California, Berkeley); Glen R. Elliott, MD, PhD

(Department of Psychiatry, University of California, San Francisco).

Duke U niversity, Durham, NC: C. Keith Conners, PhD, Karen C.

Wells, PhD, and John March, MD (Department of Psychiatry and

Behavioral Sciences). University of California, Irvine/University of

California at Los Angeles: James Swanson, PhD, and Timothy Wigal,

PhD (Department of Pediatrics and Cognitive Science, University of

California, Irvine); Dennis P. Cantwell, MD (deceased) (Department

of Psychiatry, Neuropsychiatric Institute, University of California at

Los Angeles). Long Island Jewish Medical Center, New York,

NY/Montreal Children's Hospital, Montreal, Quebec: Howard B.

Abikoff, PhD (Department of Psychiatry, New York University School

of Medicine); Lily Hechtman, MD (Department of Psychiatry, McGill

University, Montreal). New York State Psychiatric Institute/Columbia

University/Mount Sinai Medical Center, New York, NY: Laurence L.

Greenhill, MD (Department of Psychiatry, Columbia University);

Jeffrey H. Newcorn, MD (Department of Psychiatry, Mount Sinai

School of Medicine). University of Pittsburgh, Pittsburg h, PA: William

E. Pelham, PhD (Department of Psychology, State University of New

York at Buffalo); Betsy Hoza, PhD (Department of Psychological

Sciences, Purdue University, West Lafayette, IN). Statistical and

Design Consultation Helena C. Kraemer, PhD (Department of

Psychiatry and Behavioral Science, Stanford University, Palo Alto,

CA).

Table I

Sample Characteristics

Variable (a) M SD Range

Demographic characteristics

Child age in months 100.46 10.47 84-124

Maternal age in years 37.70 6.95 24-60

Maternal education 4.12 1.19 1-6

Percent two-parent families 65

Child characteristics

Conduct problem

Mother report 1.34 0.55 0.21-

2.81

Teacher report 1.30 0.76 0.00-

2.92

ADHD symptoms

Mother report 1.99 0.62 0.61-

3.00

Teacher report 2.04 0.57 0.57-

2.96

Maternal characteristics

Beck Depression Inventory 7.03 6.47 0-30

Wender Utah Rating Scale 48.45 18.09 25-

103

Mother reports of the parent-child

relationship and parenting

practices

PCRQ warmth 4.28 0.52 2.17-

5.00

PCRQ personal relationship 3.58 0.48 2.30-

4.80

PCRQ power assertion 2.76 0.61 1.33-

4.50

APQ positive parenting 4.11 0.54 2.67-

5.00

APQ parental involvement 3.72 0.54 2.10-

4.90

APQ corporal punishment 2.08 0.65 1.00-

4.75

Note. Maternal education was classified from 1 (eighth

grade or less) to

6 (advanced graduate education). Conners' Parent and

Teacher Rating

Scale Conduct Problem and DSM-IV ADHD scores can range

from 0 to 3. Beck

Depression Inventory scores can range from 0 to 63 and

Wender Utah

Rating Scale (WURS) scores can range from 25 to 125. PCRQ

= Parent Child

Relationship Questionnaire, scores can range from 1 to 5.

APQ = Alabama

Parenting Questionnaire, scores can range from 1 to 5.

(a)Sample size varies slightly across measures because of

missing

information.

Table II

Observed Maternal Behavior in Free Play, Parent Busy,

Pencil-Paper Task,

and Clean-Up Task

Behavior Free play Parent busy

Authoritative Control 3.20 (a) (0.63) 2.96 (b) (0.73)

Sensitivity of Control 3.61 (a) (0.97) 3.74 (a) (1.12)

General Responsiveness 3.83 (a,c) (1.16) 3.99 (a,b)

(0.93)

Positive Affect 4.28 (a) (0.58) 3.80 (b) (0.50)

Acceptance of Child 4.04 (a) (0.59) 3.94 (b) (0.43)

Involvement with Child 5.19 (a) (1.28) 3.07 (b) (1.16)

Percent No Control (a) 26 (a) (26) 26 (a) (27)

Behavior Pencil-paper Clean-up

Authoritative Control 3.07 (b) (0.58) 2.98 (b) (0.72)

Sensitivity of Control 3.98 (b) (1.11) 3.68 (a) (1.12)

General Responsiveness 4.07 (b) (1.11) 3.76 (c) (1.12)

Positive Affect 3.97 (c) (0.44) 3.93 (c) (0.55)

Acceptance of Child 4.09 (a) (0.57) 4.02 (a,b) (0.63)

Involvement with Child 5.18 (a) (1.18) 4.65 (c) (1.23)

Percent No Control (a) 13 (b) (20) 01 (c) (15)

Note. Ratings are on a 1-7 scale, Higher ratings indicate

more

authoritative control, more sensitive control, more

responsiveness, more

positive affect, greater acceptance of the child, and more

involvement

with the child. Means with different superscripts differ

statistically

at p < .05.

(a)The percentage of intervals in which control ratings

were not made

because the mother did not engage in control of the

child's behavior.

Table III

Factor Loadings for Observational Ratings of Maternal

Behavior

Free play

Parent busy

Rating Resp. Invol. Resp.

Invol.

Authoritative Control .73 -.01 .68

-.27

Sensitivity of Control .84 -.14 .81

-.08

Responsiveness .87 -.21 .89

.16

Positive Affect .63 .07 .85

.17

Acceptance of child .80 -.04 .84

.03

Involvement with Child .61 -.55 .07

-.88

Percent No Control .06 .94 .10

.89

Pencil-Paper

Clean-up

Rating Resp. Invol. Resp.

Invol.

Authoritative Control .77 .21 .67

.04

Sensitivity of Control .89 .01 .89

.01

Responsiveness .92 .03 .89

-.01

Positive Affect .76 .07 .79

.13

Acceptance of child .83 .05 .79

.07

Involvement with Child .44 .73 .26

.77

Percent No Control .15 -.91 .14

-.86

Note. Resp.: Responsiveness; Invol.: Involvement. Loadings

above .60 are

given in italics.

Table IV

Regression Analyses Indicating contribution of Maternal

and Child

Characteristics to the Prediction of Maternal

Responsivensess

Predictor [beta] p

Marital status -.07 ns

Mother's age .11 ns

Mother's education .24 .02

Mother's depressive symptoms -.21 .04

Mother's ADHD symptoms -.04 ns

Child ADHD symptoms

Mother's report .19 ns

Teacher's report -.09 ns

Child conduct problems

Mother's report -.29 .03

Teacher's report -.04 ns

Note. Full model: F(9,87) = 3.47, p = .001, [R.sup.2] =

.26. [beta]s and

significance levels from the full regression model.

Received October 26, 2000; revision received March 22, 2001;

accepted May 17, 2001

(1.) Department of Psychology, University of British Columbia,

Vancouver, British Columbia, Canada.

(2.) Department of Psychology, University of California, Berkeley,

California.

(3.) Department of Psychology, University of New York, Buffalo, New

York.

(4.) Department of Psychological Sciences, Purdue University, West

Lafayette, Indiana.

(5.) Address all correspondence to Charlotte Johnston, Department

of Psychology, 2136 West Mall, University of British Columbia,

Vancouver, British Columbia Canada V6T 1Z4; e-mail:

cjohnston@cortex.psych.ubc.ca.

(6.) The coding manual is available from the first author on request.

(7.) The Authoritative Control dimension was originally constructed

to also include a permissive style of control, with autocratic control

rated 1, authoritative control rated 4, and permissive control rated 7.

However, only 2% of ratings on this dimension were higher than 4.

Therefore, the dimension is reconceptualized as ranging from 1

(autocratic) to 4 (authoritative).

(8.) Analyses were also conducted using the full 61-item Wender

Utah Rating Scale and the Attention Problem Scale derived from

factor analyses by Stein et al. (1995). Results were identical across

the three measures.

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