Parent–child interaction of mothers with depression and their children with ADHD

Research in Developmental Disabilities 34 (2013) 656–668

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Research in Developmental Disabilities

Parent–child interaction of mothers with depression and their children with ADHD Pei-chin Lee a,b, Keh-chung Lin c,d, Deborah Robson e, Hao-jan Yang f, Vincent Chin-hung Chen g,h,1, Wern-ing Niew i,1,* a

School of Occupational Therapy, Chung Shan Medical University, 110, Sec. 1, Jiang-Gou N. Road, Taichung, Taiwan Occupational Therapy Room, Chung Shan Medical University Hospital, 110, Sec. 1, Jiang-Gou N. Road, Taichung, Taiwan School of Occupational Therapy, College of Medicine, National Taiwan University, 17, F4, Xu Zhou Road, Taipei, Taiwan d Division of Occupational Therapy, Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, 1, Changde St., Taipei, Taiwan e King’s College London, Health Service and Population Research Department, Institute of Psychiatry, London SE5 8AF, UK f Department of Public Health, Chung Shan Medical University, 110, Sec. 1, Jiang-Gou N. Road, Taichung, Taiwan g Department of Psychiatry, Chung Shan Medical University, 110, Sec. 1, Jiang-Gou N. Road, Taichung, Taiwan h Department of Psychiatry, Chung Shan Medical University Hospital, 110, Sec. 1, Jiang-Gou N. Road, Taichung, Taiwan i Department of Special Education, National Kaohsiung Normal University, 116, Heping 1st Rd., Kaohsiung, Taiwan b c

A R T I C L E I N F O

A B S T R A C T

Article history: Received 7 July 2012 Received in revised form 14 September 2012 Accepted 14 September 2012 Available online 1 November 2012

Attention deficit/hyperactivity disorder (ADHD) is a developmental disorder that may have a chronic and pervasive impact on the child’s function and cause long-term stress to parents. A higher rate of depression is associated with mothers of children with ADHD. This observational study aimed to investigate the effect of maternal depression and the child’s ADHD on the quality of the parent–child interaction in children with ADHD and their mothers with depression. The study participants comprised 39 mother–son dyads including children with ADHD and mothers with depression, children with ADHD and mothers without depression, and children without ADHD and mothers without depression. The Specific Affect Coding System, 20-code version was used to code interactional affect, including positive engagement, negative engagement, negative disengagement, and neural affect. There were no statistically significant group-by-context interaction effects or group effects on all affective variables between the group of children with ADHD and mothers without depression and the group of children without ADHD and mothers without depression. Stimulant medication may account for these nonsignificant findings. No significant difference of positive affect between neutral and conflict-solving contexts was observed in depressed mothers whose children were diagnosed as ADHD. Children with ADHD whose mothers were depressed were less positive in their parent– child interaction compared with children in the other groups. Maternal depression may play an important role in the affective presentation of dyads of children with ADHD and mothers with depression. Implications for clinical practice and future research are provided. ß 2012 Elsevier Ltd. All rights reserved.

Keywords: Children Attention deficit hyperactivity disorder Mother Depression Parent–child interaction

* Corresponding author. Tel.: +886 77172930x2317; fax: +886 77174977. E-mail addresses: [email protected] (P.-c. Lee), [email protected] (K.-c. Lin), [email protected] (D. Robson), [email protected] (H.-j. Yang), [email protected] (V. C.-h. Chen), [email protected] (W.-i. Niew). 1 These authors contributed equally to this study. 0891-4222/$ – see front matter ß 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ridd.2012.09.009

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1. Introduction Attention deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by three core symptoms – inattention, hyperactivity, and impulsivity – and effects on family, peer, and academic relationships (American Psychiatric Association, 2000). Environmental support or stressors appear to contribute modestly to outcomes of this disorder (Barkley, 2005; Hudziak, Derks, Althoff, Rettew, & Boomsma, 2005). There has been little research exploring the transaction between contextual variables within the family and the functioning of children with ADHD (Deault, 2010). Disruptive parent–child interaction in children with ADHD has been observed across different age ranges, from preschool to adolescence (Deault, 2010; Johnston & Mash, 2001). In a developmental analysis, Reid, Patterson, and Snyder (2002) indicated that parent–child interactions of children with behavioral problems are stressful and contribute to the development of more severe behavioral problems in children such as noncompliance, oppositional defiant disorder (ODD), or aggression (Patterson, 1982). Interactions are characterized by negative cycling: parental demand for compliance, the child’s refusal to comply, and parental surrender or fierce control over the child occurs. Parents and children negatively reinforce each other in ways that increase the probability and severity of the child’s problem behavior and decrease parental control over their child’s disruptive behavior. 1.1. Affect in parent–child interaction of children with ADHD In addition to behavioral contingency exchanged between parents and children, Granic and Patterson (2006) proposed the socioemotional process in the negative dyadic interaction. Emotions emerge with personal evaluations of the interactions relative to the individual’s goal. Through many conflicting interactions, parents and children both might be angry or distressed, perceive the other as intentionally frustrating some goal, and demonstrate extreme negative behavior or emotion trying to control the other (Granic, 2000). Interaction behaviors, emotion, and goal evaluation between parents and children may work together to constitute a persistent and self-maintaining relationship. Although most observational studies of children with ADHD have examined the behavioral dimension of the parent– child interaction (e.g., Campbell, Breaux, Ewing, Szumowski, & Pierce, 1986; DuPaul, McGoey, Eckert, & VanBrakle, 2001; Keown & Woodward, 2002), the affective interaction is receiving more attention but remains underinvestigated (Feng, Shaw, Skuban, & Lane, 2007). Expressed emotion is an attitudinal construct, a measure of the emotional climate experienced by family members, and is related to the association between maternal depression and the child’s maladjustment (Bolton et al., 2003; Peris & Baker, 2000; Peris & Hinshaw, 2003). Emotional regulation of children with ADHD during the parent–child interaction in a frustration task is a pivotal variable that predicts the child’s noncompliance and peer relationships (Melnick & Hinshaw, 2000). Predictors of noncompliance and peer relationships include a child’s diminished capacity to reinterpret the frustration in an acceptable way and a tendency to focus on the negative or threatening parts of the condition (Melnick & Hinshaw, 2000). Children with ADHD may maintain high levels of negative emotion in a frustrated interaction and prompt them to disengage or interrupt significant interpersonal relationship. Conflict with parents is pervasive and frequent in preadolescence (e.g., 10–12 years old, 5th–7th grade) and may decline over time (Laursen, Coy, & Collins, 1998). Melnick and Hinshaw (2000) studied emotional regulation of children with ADHD, ages 6–12 years with a frustrating task, but did not specifically analyze how children in preadolescence manage their emotion when interacting with their parents in a difficult condition. Conflict resolution is emotionally arousing and critical to parent–child relationship (Riesch et al., 2003). Seventh graders in Taiwan go to junior high school, while 4th to 6th-grade children go to elementary school and have a similar educational and social interaction experience. Therefore, this study was designed to explore how 4th to 6th grade children with ADHD and their mothers communicate their emotion when discussing neutral and conflict topics. 1.2. Maternal depression, child’s ADHD, and their parent–child interaction Observational studies of children or adolescents with ADHD mostly focus on examining the effect of the child’s behavioral difficulties (i.e., ADHD alone or ADHD combined with other disruptive behaviors) on parent–child interactions (Barkley, Fischer, Edelbrock, & Smallish, 1991; Barkley, Anastopoulos, Guevremont, & Fletcher, 1992; Woodward, Taylor, & Dowdney, 1998). The parents of children with ADHD in these studies were reported to have significantly more psychopathology, such as depression or parental stress, than parents of children in the control group, but the role of maternal distress on parent– child interaction of children with ADHD has not yet been explored. Parent–child interaction is a reciprocal process: parents influence their children and the children’s behaviors may influence the way they are treated by their parents (Maccoby, 2000). Another line of research found mothers with depression were more negative, coercive, and disengaged, as well as less positive, when interacting with their children compared with mothers without depression (Downey & Coyne, 1990; Goodman & Tully, 2006; Lovejoy, Graczyk, O’Hare, & Neuman, 2000). A meta-analysis of 33 studies found children of mothers with depression generally had more behavioral problems than children of mothers without depression (Beck, 1999). Exposure to the mother’s negative and/or maladaptive cognitions,

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behaviors, and affect was considered to be one of the key mediating factors contributing to the possible causal relationships between maternal depression and the child’s behavioral or emotional problems (Goodman & Gotlib, 1999; Goodman, 2007). This study aimed to investigate the differences in the quality of affect in parent–child interaction among three groups: (1) boys with ADHD and mothers with depression, (2) boys with ADHD and mothers without depression, and (3) boys without ADHD and mothers without depression. We hypothesized that among the three groups, boys with ADHD and mothers with depression would have the significantly highest percentages of time of negative engaging emotion and negative disengaging emotion and the lowest percentages of time of positive emotion when discussing conflict topics. Boys with ADHD and mothers without depression were hypothesized to have higher percentages of time of negative engaging emotion and negative disengaging emotion and lower percentages of time of positive emotion than boys without ADHD and mothers without depression when discussing conflict topics. We also hypothesized that there would be no significant differences in the percentages of time of negative engaging emotion, negative disengaging emotion, and positive emotion among the three groups when discussing neutral topics. 2. Methods 2.1. Participants Participants were recruited from April 2008 to July 2009. Boys with ADHD and their mothers were recruited from a child psychiatric clinic of a university-affiliated hospital in a city in middle Taiwan through fliers and posters. Boys without ADHD and their mothers were recruited from three elementary schools in middle Taiwan by invitation and using a snowball technique. A boy was eligible if he was a fourth to sixth grader and his mother was his primary caregiver and had not been separated from her son in the previous 6 months. A boy was eligible for the diagnosis of ADHD if he met the DSM-IV-TR criteria by a psychiatrist’s interview (American Psychiatric Association, 2000). Boys in the control group were screened negative for ADHD and ODD using the Chinese version of the Swanson, Nolan, and Pelham, version IV Scale (SNAP-IV) (MTA Cooperative Group, 1999). The Chinese version of SNAP-IV is validated with good psychometric properties in Taiwan, including test–retest reliability (ICC = .59–.72), internal consistency (a = .88–.90). It can discriminate children with ADHD from a community sample and discriminate children with ADHD and ODD from those with ADHD only (Gau et al., 2008; Liu et al., 2006). Children with other neuropsychiatric disorders such as bipolar disorder, schizophrenia, obsessive compulsive disorder, pervasive developmental disorder, serious medical conditions or sensory disorders were excluded, because these conditions might influence the parent–child interaction. Mothers also rated their child’s level of aggression and delinquency, and emotion competence using the aggressive and delinquent behavior subscales of the Chinese version of Child Behavior Checklist (CBCL) (Achenbach & Rescorla, 2001) and Behavioral and Emotional Rating Scale (BERS) (Epstein & Sharma, 1998; Yang, 2001), respectively. Higher scores of CBCL mean more aggressive and delinquent problems. The BERS is a strength-based assessment to measure one’s ability to deal with adversity and stress, as well as the emotional and behavioral skills important to the child’s significant relationships with family, peers and teachers (Epstein & Sharma, 1998). Taiwanese norms and cut-off scores are available to screen children with severe emotional problem (Yang, 2001). A higher score of the BERS indicates better emotional competence. No child was screened as having severe emotional problem with BERS in this study. Both of the Chinese versions of CBCL and BERS were reported to have good psychometric properties (Rescorla et al., 2007; Yang, 2001; Yang, Chen, & Soong, 2001). All mothers were screened for depression using the Chinese version of the Beck Depression Inventory–Second Edition (BDI-II) (Beck, Steer, & Brown, 1996; Chen, 2000). Mothers with BDI-II scores larger than 13 were screened as depressed (Chen, 2000). The Chinese version of BDI-II is a sensitive tool that was shown to discriminate five different levels of depression (a = .92) (Pan & Hsu, 2008). Only one mother was prescribed antidepressants. With considerable effort, only four dyads of children without ADHD and mothers with depression completed the recoding procedure. The sample size in the group of children without ADHD and mothers with depression was too small for between-group comparison and were excluded from the data analysis. This study was approved by the Institute Review Board of Chung Shan Medical University Hospital. 2.2. Measures 2.2.1. Issues checklist The Issues Checklist (IC) is a 44-item checklist of topics that parents and children may argue about at home (Robin & Foster, 1989). Test–retest reliability is .49 to .80 (Enyart, 1984). The IC can discriminate parent–adolescent dyads with and without relationship problems (Robin & Foster, 1989). Mothers and their sons completed the IC 1 week before recording. Mothers and their sons reported if they had discussed the conflict topic in the past 2 weeks at home, and, if so, approximately the frequency, length of time, and intensity of anger they felt was rated on a 5-point Likert scale. A weighted frequency/ intensity score is the anger intensity weighted by the frequency with which the conflict happened in the past 2 weeks. 2.2.2. The Specific Affect Coding System 20-code version The Specific Affect Coding System (SPAFF) is designed to capture the affect in the conversation between family members (Gottman, McCoy, Coan, & Collier, 1996) and is a reliable and valid coding system for studying parent–child interaction

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(Hollenstein, Granic, Stoolmiller, & Snyder, 2004; Hollenstein & Lewis, 2006). The interaction of each mother–son dyad in this study was coded using the 20-code version of the SPAFF (Gottman, 1994; Gottman, Woodin, & Coan, 1998; Shapiro & Gottman, 2004). Each code is based on a combination of facial expressions, gestures, posture, voice tone and volume, speech rate, and content to capture a gestalt of the affective tone of behavior. The SPAFF 20-code version included positive (interest, low validation, high validation, affection, humor and surprise/joy), negative engagement (disgust, contempt, belligerence, low-intensity domineering, high-intensity domineering, criticism and anger), negative disengagement (tension, tense humor, defensiveness, whining, sadness and stonewalling), and neutral categories of affective expression (Jones, Carre`re, & Gottman, 2005; Shapiro & Gottman, 2004). The negative engagement category included codes that designate active and negative social engagement, whereas the negative disengagement category included codes that designate more withdrawn or disengaged types of affective behavior. The neutral code is affect that appears nonemotional in nature. For example, the boy might face his mother when she was talking. When there were no clear cues showing his affect such as interest or defensiveness, it was coded as neutral affect. To be a mutually exclusive and exhaustive coding system, behavior that did not fit into the other SPAFF codes was also coded as neutral. The SPAFF was translated into Chinese by the first author. The Chinese SPAFF was reviewed by a Western researcher who was familiar with both English and Chinese, culture and parent–child interaction patterns in Taiwan and in the Western counties. We also incorporated descriptions or definitions of the same codes or codes with similar constructs used in an observational study of parent–child interaction for children with ADHD in Taiwan (Hsu, 1996). A panel of five researchers who had experience of conducting or supervising studies of parent–child or teacher–student interaction in Taiwan was invited to review the description of the SPAFF, the revision process, the affective categories and codes in each category, and the description of each code. The Chinese SPAFF was finalized by the panel as having the same affective categories and codes in each category as the original SPAFF. Minor revisions were added in the descriptions of the codes to better fit with the parent–child interaction patterns in Taiwan. 2.3. Procedures During one observation session, lasting approximately 30–60 min, each dyad sat together in a comfortable research room. Mothers and boys first participated in a neutral condition for at least 10 min, followed by a conflict-solving condition for at least 10 min. The two conditions were conducted in a fixed order, with the neutral condition first, followed by the conflictsolving condition, because the emotionally arousing nature of the conflict-solving condition might have influenced mothers’ and boys’ behavior and affect during the neutral condition. In the neutral condition, topics for discussion included ‘‘planning a trip for the family with an unlimited budget’’ and ‘‘planning a dream house/apartment for the family’’. In the conflict-solving condition, three topics of highest weighted frequency/anger intensity scores were chosen from the mother’s and child’s respective IC. Half of the dyads engaged in one of the child’s generated problems first, followed by his mother’s, then the child’s, etc. The other half of dyads started with one of the mother’s generated problems first. Dyads were requested to discuss each problem until they agreed on a practical solution or until 10 min had lapsed. Each session was videotaped. The videotapes were coded using the SPAFF-20 in a random order by four undergraduate students. Coders were blinded to the group status of the dyads and the study hypotheses and coded the first 10-min videotape of each condition for each participant separately. Observers were extensively trained to a criterion of 75% agreement between any two of the coders before coding of the videotaped interactions began. Weekly recalibration training took place to minimize coder drift. Four coders coded 10% of all the sessions twice within 2 to 4 weeks to assess code–recode reliability (82–94% agreement). The four coders were randomly assigned into pairs to code 20% of all recordings independently, and the between-coder agreement on the occurrence of SPAFF codes (using a 6 s window) was 74–89%. Behaviors were coded at the same time the discussion took place, resulting in continuous records for affect of both mother and child. Scores were computed post hoc from the coded records. Duration scores of each participant in each condition were calculated by subtracting onset time from offset time for each entry and summing for each code and each affective category. Percentage of time was calculated by dividing the time of positive and negative engagement, negative disengagement, and neutral affect by the total interaction time in the neutral and conflict-solving condition, respectively. 2.4. Data analysis The affect variables were analyzed using a two-way 3  2 mixed analyses of variance (ANOVAs) with the diagnostic group (children with ADHD and mothers with depression, children with ADHD and mothers without depression, children without ADHD and mothers without depression) as the between-subject factor and condition (neutral or conflict-solving) as the withinsubjects factor. Dependent variables were percentage of time of mother–son positive and negative engagement, negative disengagement, and neutral affect categories in mother–son communication. When significant group-by-condition interaction effects were observed, post hoc simple main group effect and simple main condition effect were further explored. All analyses in the repeated-measure ANOVAs were tested by the Mauchly’s Sphericity test to check if the groups were homogenous. No significant differences were found on any tests. The Least Significant Difference test was used for post hoc pairwise comparisons between groups when significant group differences were obtained. To reduce the influence of outliers, we excluded dyads with any of the mother’s or child’s affective variables 3 standard deviations away from the mean of the individual group. Data

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analyses were performed using SPSS 16.0 software (SPSS Inc., Chicago, IL, USA). A probability cutoff level of .05 was used to determine statistical significance. Results of trends were reported if they presented important findings. 3. Results 3.1. Participant characteristics The study recruited 47 boys and their mothers, while 2 dyads in the group of children without ADHD and mothers without depression, and 2 dyads in the group of children with ADHD and mothers without depression were excluded from data analysis because one of their affective variables was 3 standard deviations away from the means of the individual groups. Four dyads of children without ADHD and mothers with depression were also excluded. Therefore, this study included 39 dyads, 10 boys with ADHD and their mothers with depression, 13 boys with ADHD and their mothers without depression, and 16 boys without ADHD and their mothers without depression for data analysis. The child’s ages ranged from 8.92 to 12.08 years old. Table 1 reports the descriptive and inferential statistics of sociodemographic and clinical variables among the three groups. Among the 39 dyads, with regards to the neutral discussions, 22 dyads finished the planning a trip topic less than 10 min, and moved to the ‘‘dream house’’ topic. The most frequent topics talked about in the conflict discussion were doing homework, arguing or fighting with siblings, and eating issues. 3.2. Effects of diagnostic group and communication condition on mother’s affect Means, standard deviations, and results of the two-way 3  2 mixed design ANOVAs of mother’s affect are presented in Table 2. A significant and large interaction effect (F (2, 36) = 3.35, p = .047, h2 = .15) was found in mother’s positive affect, indicating that the three groups of mothers had differential reactions to the neutral and conflict-solving conditions. Since a significant interaction effect was found, post hoc analyses were used to further explore how group and condition variables interact in mother’s positive affect. There was no significant simple main group effect in the neutral condition (F(2, 36) = 2.87; p > .05), and in the conflict-solving condition (F(2, 36) = 1.18, p > .05). However, post hoc analyses of simple main condition effect confirmed that mothers who screened negative with depression had significantly higher percentages of positive affect in the neutral condition compared with that in the conflict-solving condition, regardless of whether their children were diagnosed with ADHD. Mothers who screened positive with depression and whose children were diagnosed as

Table 1 Comparison of sociodemographic and clinical variables among three groups. Variables

Child ADHD () Mother depression () (n = 16) Mean (SD)

Child ADHD (+) Mother depression () (n = 13) Mean (SD)

Child ADHD (+) Mother depression (+) (n = 10) Mean (SD)

Child’s age CBCL Aggression scale (raw score) Delinquent scale (raw score) BERS overall competence Maternal age Maternal BDI

10.83 (.76)

10.22 (.86)

10.82 (.85)

10.31 3.44 51.41 39.99 6.31

16.23 4.85 44.67 37.81 7.54

19.60 5.50 39.44 38.80 23.60

Variables

Child’s ODDa Y N Paternal education Senior high school Collage Graduate school Maternal education Junior high school Senior high school Collage Graduate school

(5.71) (1.86) (10.07) (4.44) (4.30)

(6.83) (2.54) (7.51) (3.98) (4.26)

(7.72) (3.78) (9.90) (4.04) (7.35)

F(2, 36)

2.35 6.57** (2 > 1; 3 > 1) 2.05 5.00* (1 > 3) .89 38.42*** (3 > 1; 3 > 2)

Child ADHD () Mother depression () (n = 16) N (percentage)

Child ADHD (+) Mother depression () (n = 13) N (percentage)

Child ADHD (+) Mother depression (+) (n = 10) N (percentage)

x2

0 (0%) 16 (100%)

7 (53.8%) 6 (46.2%)

6 (60%) 4 (40%)

13.66** (2 > 1; 3 > 1)

8 (50%) 6 (37.5%) 2 (12.5%)

7 (53.8%) 6 (46.2%) 0 (0%)

6 (60%) 4 (40%) 0 (0%)

3.24

0 6 7 3

0 8 4 1

1 5 3 1

4.99

(0%) (37.5%) (43.8%) (18.8%)

(0%) (61.5%) (30.8%) (7.7%)

(10%) (50%) (30%) (10%)

Note: ADHD, attention deficit hyperactivity disorder; CBCL, Child Behavior Checklist; BERS, Behavioral and Emotional Rating Scale; BDI, Beck Depression Inventory; ODD, oppositional defiant disorder. a Numbers of symptoms on the ODD subscale of SNAP-IV were greater than 3. ** p < .01. *** p < .001.

Affect

Condition

Group

Condition effect

Group effect

Condition  group effect

Child ADHD () Mother depression () (n = 16) Mean (SD)

Child ADHD (+) Mother depression () (n = 13) Mean (SD)

Child ADHD (+) Mother depression (+) (n = 10) Mean (SD)

F (1, 36)

h2 a

F (2, 36)

h2 a

F (2, 36)

h2 a

Positive

Neutral Conflict

.8157 (.1686) .4390 (.1520)

.8375 (.1051) .5215 (.1840)

.6921 (.1803) .5460 (.2453)

55.59*** (N > C)

.61

.81

.04

3.35*

.15

Negative engagement

Neutral Conflict

.1032 (.0877) .5136 (.1392)

.1165 (.0909) .4407 (.2113)

.1350 (.1470) .3611 (.2330)

65.40*** (C > N)

.65

1.24

.06

1.79

.09

Negative disengagement

Neutral Conflict

.0038 (.0076) .0130 (.0195)

.0028 (.0070) .0018 (.0045)

.0080 (.0180) .0123 (.0199)

1.60

.04

2.16

.11

.94

.05

Neutral

Neutral Conflict

.0774 (.1503) .0344 (.0923)

.0432 (.0617) .0361 (.0548)

.1641 (.1791) .0807 (.0983)

8.49** (N > C)

.19

1.99

.10

1.88

.10

Note: N, neutral condition; C, conflict-solving condition. a According to Cohen’s (1988) guidelines for the interpretation of the effect size (h2), a larger effect is represented by an h2 of at least .138, a moderate effect by .059, and a small effect by .01. * p < .05. ** p < .01. *** p < .001.

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Table 2 Means, standard deviations and results of mixed design ANOVA of mother’s affect.

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Table 3 Results of the simple main condition effect with mother’s positive affect as dependent variable. Group

df (effect)

MS (effect)

df (error)

MS (error)

F

Child ADHD () Mother depression () Child ADHD (+) Mother depression () Child ADHD (+) Mother depression (+)

1

1.135

15

.024

47.361*** (N > C)

1

.649

12

.027

24.200*** (N > C)

1

.107

9

.030

3.558

Note: N, neutral condition; C, conflict-solving condition. *** p < .001.

ADHD had no significant difference of positive affect between these two conditions. Table 3 presents the results of simple main condition effect with the mother’s positive affect as dependent variables. Fig. 1 illustrates the group by condition interaction in maternal affect among the three groups. No significant group-by-condition interaction effects were observed in the mother’s negative engagement, negative disengagement, and neutral affect. However, there was a tendency for mothers who were screened positive with depression and whose children were diagnosed as ADHD to have the highest percentage of time of negative engagement in the neutral

Fig. 1. The group by condition interaction in maternal affect among the three groups. The x-axis represents the percentage time of the specific affect in each condition.

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condition and the lowest percentage of time of negative engagement in the conflict-solving condition among the three groups of mothers. No significant group effects were found in mothers’ negative engagement, negative disengagement, and neutral affect. Significant condition effects were found in mothers’ negative engagement and neutral affect. However, because these comparisons were not the primary aims of this study and were confounded with order, they will not be discussed further. 3.3. Effects of diagnostic group and communication condition on child’s affect Means, standard deviations, and results of the two-way 3  2 mixed ANOVAs of child’s affect are presented in Table 4. Fig. 2 illustrates the group by condition interaction in child’s affect among the three groups. No significant interaction effects were found in the four categories of child’s affect, indicating that the three groups of children did not have differential reactions to the neutral and conflict-solving conditions. A significant and large group effect (F (2, 36) = 4.53, p = .02, h2 = .21) was found in the child’s positive affect. Post hoc pairwise analyses were conducted to explore the differences between groups. Post hoc comparisons revealed children who were diagnosed with ADHD and whose mothers screened positively with depression displayed less positive affect than children without ADHD and whose mother screened negative with depression. A marginally significant and large group effect was found on the measure of child negative engagement (F(2, 36) = 3.34, p = .06, h2 = .15). Post hoc pairwise comparisons revealed that children with ADHD and whose mothers were depressed displayed more negative engagement affect than children with ADHD and whose mothers were not depressed (.0985 versus .0372, p = .03) and than children without ADHD and whose mothers were not depressed (.0985 versus .0449, p = .04). Significant condition effects were found in the children’ positive engagement, negative engagement, and negative disengagement affect. 4. Discussion Notwithstanding the considerable number of observational studies of parent–child interaction of children with ADHD or mothers with depression, this is the first observational study examining maternal depression on mother–child interaction of children with ADHD in two communication contexts. The results of this study underline the importance of screening, prevention, and treatment for depression in mothers of children with ADHD. The findings support transactional models in which both the mother’s and child’s affect in interaction were linked to maternal depression. Mothers who screened positive with depression and had sons with ADHD were significantly more indifferent on the measure of positive affect in contrast contexts. Trends of flat negative engagement affect in response to contexts were also observed in mothers with depression. Boys with ADHD and whose mothers were depressed were significantly less positive compared with children without ADHD and whose mothers were not depressed. Boys with ADHD and whose mothers were depressed appeared to have more actively and negatively expressed affect compared with boys of mothers without depression. 4.1. Comparison of children with ADHD and mothers without depression and children without ADHD and mothers without depression No significant differences were observed in any child’s and maternal affective variables between children with ADHD and mothers without depression and children without ADHD and mothers without depression. Stimulant medication may account for these nonsignificant findings. Stimulants were taken on the day of recording by 19 of the 25 children with ADHD, including 11 boys (73%) in the group of children with ADHD and mothers without depression and 8 boys (80%) in the group of children with ADHD and mothers with depression. Parent–child interactions of children with ADHD were improved with stimulant medication (Danforth, Barkley, & Strokes, 1991). Therefore, the mother–son dyads in the group of children with ADHD and mothers without depression may act similar to those in the group of children without ADHD and mothers without depression. Maternal depression, rather than their child’s ADHD symptoms, may have impacted the affective expression of dyads in children with ADHD and mothers with depression. 4.2. Flat affect of mothers with depression in parent–child interaction in contrast contexts Consistent with a systematic review of the etiology of maternal depression and the parent–child relationship (Burbach & Borduin, 1986), mothers with depression experienced difficulties in parent–child relationships that reflect the symptoms of depression, such as blunted affect in response to contexts, found in this study. Recent biologic models of depression have emphasized hyposensitivity to reward and impairments in the use of affective information to guide behavior (Bylsma, Morris, & Rottenberg, 2008; Eshel & Roiser, 2010). Mothers with depression may be less sensitive to their child’s positive behavior, fail to respond on the occasions of positive parent–child interaction, and therefore, display a smaller range of positive affect between pleasurable and conflict-solving contexts. Maternal positive engagement with the child plays an important role in the association of child behavioral problems and maternal depression (Foster, Garber, & Durlak, 2008; Goodman, 2007; Leckman-Westin, Cohen, & Stueve, 2009) and protects children with ADHD from developing more severe behavior problems such as ODD and conduct behaviors (Chronis et al., 2007). Flat in positive affect among mothers with

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Affect

Condition

Group

Condition effect

Group effect

Condition  group effect

Child ADHD () Mother depression () (n = 16) Mean (SD)

Child ADHD (+) Mother depression () (n = 13) Mean (SD)

Child ADHD (+) Mother depression (+) (n = 10) Mean (SD)

F (1, 36)

h2 a

F (2, 36)

h2 a

F (2, 36)

h2 a

Positive

Neutral Conflict

.8692 (.1450) .7214 (.1441)

.8549 (.1312) .6148 (.1804)

.6732 (.2054) .5726 (.2644)

23.07** (N > C)

.39

4.53* (3 > 1)

.20

1.38

.07

Negative engagement

Neutral Conflict

.0326 (.0367) .0572 (.0640)

.0347 (.0478) .0400 (.0594)

.0514 (.0685) .1455 (.1824)

5.50* (C > N)

.13

3.34y (3 > 1; 3 > 2)

.15

2.05

.10

Negative disengagement

Neutral Conflict

.0234 (.0347) .1564 (.1301)

.0090 (.0152) .1728 (.1566)

.0584 (.1051) .1334 (.1299)

25.24** (C > N)

.41

.02

.00

.99

.05

Neutral

Neutral Conflict

.0750 (.1479) .0663 (.1280)

.1016 (.1012) .1725 (.1216)

.2170 (.2367) .1485 (.1978)

.00

2.13

.11

2.96

.14

.01

Note: N, neutral condition; C, conflict-solving condition. a According to Cohen’s (1988) guidelines for the interpretation of the effect size (h2), a larger effect is represented by an h2 of at least .138, a moderate effect by .059, and a small effect by .01. y p = .06. * p < .05. ** p < .001.

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Table 4 Means, standard deviations and results of mixed design ANOVA of child’s affect.

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Fig. 2. The group by condition interaction in child’s affect among the three groups. The x-axis represents the percentage time of the specific affect in each condition.

depression when interacting with their children with ADHD raises concerns of not only the well-being of the mothers but also the long-term development of children with ADHD, especially given the high comorbidity rate of other behavioral problems such as ODD or conduct disorder (Brown, 2009; Goodman, 2007). Mothers with depression appeared to express flat negative engagement affect in contrast contexts compared with the other two groups in this study, although the statistical examination did not reach a significant level. Previous studies found mothers with depression were more critical and irritable when interacting with their children (Lovejoy et al., 2000) or with their preadolescent children with disruptive behaviors (Tarullo, DeMulder, Martinez, & Radke-Yarrow, 1994). It is possible that examination of contextual differences on parenting affect in this study accounted for the different trend of findings in parental negative affect compared with investigation of general parenting affect without the consideration of contexts in previous studies (Lovejoy et al., 2000; Tarullo et al., 1994). On average, 82.28% of parental negative engagement affect in the neutral condition (range: 0–100%, median: 82.28%) and 86.18% in the conflict-solving condition (range: 41.21–100%, median: 85.61%) were from the code low-intensity domineering. Low-intensity domineering was characterized by a parent trying to force compliance from the child with a low intensity, including lecturing, incessant speech, and invalidation. Parents may deal with disagreements with their children by setting clear expectations, negotiating, and giving feedback on the child’s viewpoints (Riesch et al., 2003). It is possible that depressed mothers are too tired to express adult perspectives and expectations to correct the child’s viewpoints that conflict with theirs. However, this result represents only a trend finding and is based on a small sample size. Further studies are needed to examine the effect of maternal depression on negative parenting affect in contrast contexts with a larger sample size.

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4.3. Impact of maternal depression on children with ADHD in parent–child interaction This study found that maternal depression had a negative impact on children with ADHD in their parent–child interaction. Across contexts, children with ADHD and whose mothers are depressed had significantly less positivity and marginally significantly more actively expressed negativity compared with children of mothers without depression in their parent–child communication. Consistent with the results of observed affect in parent–child interaction, children with ADHD and whose mothers were depressive were rated as less emotionally competent by their mothers compared with children without ADHD in this study. These results are consistent with Tarullo and colleagues’ work (1994) and studies investigating the effect of maternal depression on child’s behavior or affect in their parent–child interaction (Downey & Coyne, 1990). Whereas mothers with depression had flat affective expression in contrast contexts, children of mothers with depression were in a general state of less positivity and more negativity, irrespective of contexts. Children with ADHD demonstrated greater enhancement of task performance with positive facial expressions (Kohls, Herpertz-Dahlmann, & Konrad, 2009). Lack of timely positive affective feedback from mothers may be a mediating factor between flat affect in mothers with depression and less positivity and more active negativity in children with ADHD. 4.4. Strength of this study and implications for clinical practice and future research This study has a number of strengths: firstly, quantitative and microsocial methodology was used to evaluate the quality of parent–child interaction in real time. Secondly, this study adopted the affect perspective to study parent–child interaction and capture the core problem of depression. Thirdly, we intended to examine the double effect of child’s ADHD and maternal depression. No differences were observed between the group of children with ADHD and their mothers without depression and the group of children without ADHD and their mothers without depression. The major reason may be stimulant medication, which improved the impact of the child’s ADHD on their parent–child interaction. However, maternal depression still had a negative impact on both children with ADHD and their mothers who screened positive for depression compared with the other two groups. Mental health professionals who work with children with ADHD may need to screen for and treat maternal depression and pay attention to their positive parenting affect and the child’s reaction to his mother. Future studies could evaluate the effectiveness of an intervention for maternal depression on the mother and child’s affect in different contexts of parent–child interactions for children with ADHD. Fourthly, this study examined maternal depression on parent–child interaction of children with ADHD in two contrast contexts. Findings of group-by-context interaction effects have potential implications for assessment and intervention planning of children with ADHD and parents with depression. Assessment of parent–child communication in the conflictsolving and neutral conditions provides efficient contexts for observing strength and difficult areas of parent–child interaction. Identification of strength and impairment in parent–child interaction may provide clinically useful information for planning interventions to improve their relationship. 4.5. Limitations of this study The study has several limitations: firstly, the sample size in this study was relatively small. Secondly, most of the children with ADHD and their mothers had been receiving treatment for a long time and the children took stimulant medication on the day of recording. The children continued the medication to present their daily parent–child interaction patterns before recording. Therefore, the findings of this study may represent parent–child interaction when a child is under medication effect. Future studies may recruit children with ADHD before the implementation of any intervention or request children to stop medication before recording. Thirdly, previous studies found maternal depression history, chronicity, and severity were critical to maternal and child interaction behavior (Goodman, 2007), but this study screened current level of depressive symptoms and did not trace depression history and chronicity. Fourthly, this study screened maternal depression with a psychometrically sound questionnaire but did not use a formal diagnostic interview. However, a meta-analysis of observational studies of parent–child interaction in mothers with depression found using diagnostic interviews and self-report measures had similar effects (Lovejoy et al., 2000). Fifthly, this study was intended to examine the effect of the child’s ADHD and maternal depression on their parent–child interaction. In an attempt to recruit mothers with depression but without professional intervention, this study invited mothers with depression and children without ADHD from three elementary schools. However, the sample size of mothers with depression and children without ADHD was too small for group statistical comparison. Mothers with depression but without intervention lack motivation to participate novel activities, which may have impeded their participation in this study (American Psychiatric Association, 2000). Future studies may recruit mothers with depression from clinics or self-help groups for people with depression. Sixthly, this study included only boys and their mothers and no daughters or fathers. Gender effects are observed in children with ADHD (i.e., boys compared with girls) and their parents (i.e., mothers compared with fathers) (Beffra & Barkley, 1985; Buhrmester, Camparo, Christensen, Gonzalez, & Hinshaw, 1992; Tallmamadge & Barkley, 1983) and mothers with

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depression and their children (i.e., girls compared with boys) (Tarullo et al., 1994). Seventhly, the child’s levels of intelligence, comorbidity with learning disabilities, temperament and family social economic status might confound the results of this study, but were not assessed. Future studies could include measures of these variables and evaluate their impacts on parent– child interaction of children with ADHD. Finally, mothers of children with ADHD are more likely to present with ADHD (Macek, Gosar, & Tomori, 2012) or other psychopathology such as substance abuse or suicide attempts (Lindblad, Weitoft, & Hjern, 2011). Adult with ADHD have been found to have more interpersonal problems including parent–child conflicts (Barkley, Fischer, Smallish, & Fletcher, 2006). This study did not screen for parental ADHD and other psychopathology. Future studies could examine the status of parental ADHD, substance abuse or other impairments in mothers of children with ADHD and evaluate their impacts on parent–child interaction of children with ADHD. 5. Conclusion The examination of affective measures in parent–child interactions in late childhood has demonstrated associations between interpersonal behaviors and maternal depression in children with ADHD, even when the child is taking stimulant medication. The influence of maternal depression on maternal interactional affect reflects core symptoms of depression, mainly flat positivity. The impact of maternal depression on interactional affect of children with ADHD is less positive across contexts. These findings begin to move toward a broader and deeper understanding of the interactive process through which maternal psychopathology may be perpetuated in families of children with ADHD. 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