The Relationship Between Maternal Stress and Boys' ADHD Symptoms and Quality of Life: An Australian Prospective Cohort Study

YJPDN-02090; No of Pages 6 Journal of Pediatric Nursing xxx (xxxx) xxx

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The relationship between maternal stress and boys' ADHD symptoms and quality of life: An Australian prospective cohort study☆ Subhadra Evans, PhD a,⁎, Emma Sciberras, DPsych a,b, Melissa Mulraney, PhD b a b

School of Psychology, Deakin University, Geelong, Australia Community Health Services Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia

a r t i c l e

i n f o

Article history: Received 9 May 2019 Revised 20 September 2019 Accepted 22 September 2019 Available online xxxx Keywords: ADHD Parent stress Quality of life

a b s t r a c t Purpose: This study prospectively examined the role of maternal stress in boys' attention deficit hyperactivity disorder (ADHD) symptoms and quality of life (QoL). Methods: Children with ADHD (5–13 years) were recruited from 21 pediatric practices and followed up 12 months later (n = 166). Maternal stress was examined at baseline, and boys' ADHD symptoms and QoL were examined at baseline and 12 months later. Linear regressions examined whether baseline maternal stress predicted child ADHD symptoms and QoL 12 months later in a series of adjusted models that accounted for child age, ADHD medication use, neighborhood disadvantage, comorbidities and baseline ADHD symptoms or QoL (full model). Results: In the unadjusted model, maternal stress at baseline was significantly associated with more severe parent-reported ADHD symptoms at 12 months, accounting for 5.7% of the variance in ADHD symptoms, but this association was attenuated after adjustments in the full model. Baseline maternal stress was associated with poorer QoL at 12 months in boys in the unadjusted model, accounting for 12.4% of the variance, which remained significant in the full adjusted model. Conclusions: Maternal stress is associated with lowered QoL in boys, and may pose a risk for boys' later QoL. Practice implications: Stress management interventions with mothers of children with ADHD experiencing heightened stress are warranted, and are likely to have a positive impact on mothers as well as children. © 2019 Published by Elsevier Inc.

Introduction Attention-deficit hyperactivity disorder (ADHD) affects as many as 5% of children worldwide (Polanczyk, Willcutt, Salum, Kieling, & Rohde, 2014). ADHD in childhood is associated with a number of negative and interpersonal impacts, including compromised family relationships (Keown & Woodward, 2002) and poor quality of life (QoL) (Danckaerts et al., 2010). Poor health-related QoL, comprising physical and psychosocial domains, is common in children with ADHD and is increasingly being considered an important outcome to assess along with symptoms (Adamo, Seth, & Coghill, 2015). Recent work has demonstrated that changes in core ADHD symptoms are only modestly related to changes in QoL, indicating that both symptom severity and QoL are important aspects of the broad profile of children's functioning (Mulraney et al., 2017). Understanding the factors associated with child ADHD symptoms and QoL is important in developing treatments aimed at improving functioning in these children. ☆ Dr. Sciberras' position is funded by an NHMRC Career Development Fellowship 1110688 (2016-19) and a Veski Inspiring Women's Fellowship. ⁎ Corresponding author. E-mail address: [email protected] (S. Evans).

One key factor associated with the child's functioning in the context of ADHD is the parent's psychological health, and in particular, parent stress. Parental stress is highly prevalent in families dealing with ADHD, especially compared to the general population (Theule, Wiener, & Tannock, 2013). The relationship between parental stress and child functioning is likely to be bidirectional. On the one hand, parenting stress leads to increased behaviour problems in offspring (Breaux & Harvey, 2018; Gordon & Hinshaw, 2017). For example, early parenting stress mediates the relationship between childhood ADHD symptoms and later internalizing and externalizing symptoms, likely due to less adaptive parenting practices that emerge under stress (Gordon & Hinshaw, 2017). On the other hand, caring for a child with ADHD can be highly demanding, feeding into the parent's experience of stress. In another longitudinal study, increased maternal stress and overreactive parenting significantly predicted more severe child ADHD symptoms three years later, while more severe child ADHD symptoms significantly predicted higher parent stress and depressive symptoms, and lower maternal warmth (Breaux & Harvey, 2018). In a recent meta-analysis of 80 studies examining parents' experiences of caring for a child with ADHD, parents reported exhaustion, anxiety, anger, desperation, and helplessness, reflecting high levels of daily stress (Corcoran, Schildt, Hochbrueckner, & Abell, 2017). Compared to parents

https://doi.org/10.1016/j.pedn.2019.09.029 0882-5963/© 2019 Published by Elsevier Inc.

Please cite this article as: S. Evans, E. Sciberras and M. Mulraney, The relationship between maternal stress and boys' ADHD symptoms and quality of life: An Australian ..., Journal of Pediatric Nursing, https://doi.org/10.1016/j.pedn.2019.09.029

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S. Evans et al. / Journal of Pediatric Nursing xxx (xxxx) xxx

of children without ADHD, parents of children with ADHD display higher rates of substance-related disorders as well as depression and anxiety (Cheung & Theule, 2016). Parents who experience such stress and psychopathology are less able to engage in behaviors, including adaptive parenting strategies, that ameliorate their child's psychopathology (Kazdin, 1995; Mash & Johnston, 1990). Research has identified the importance of considering various aspects of parental stress in the context of child ADHD, including parenting stress and general stress. High parenting stress, which is an aversive reaction to a mismatch between the perceived demands of child-rearing and one's capacity to meet those demands (Abidin, 1992), is associated with elevated child ADHD symptoms (Graziano, McNamara, Geffken, & Reid, 2011). Such parenting stress may even affect children at a biological level. High levels of maternal parenting stress have been associated with abnormal cortisol responses in children with ADHD, indicating that negative parental feelings towards children may be associated with neurobiological changes in children (Korpa et al., 2017). Other research has examined general measures of stress, which capture parents' global response to non-specific and chronic wide-ranging sources of stress, demonstrating that such general stress is associated with decreased parent-reported child QoL (Galloway, Newman, Miller, & Yuill, 2016; Graziano et al., 2011). Previous studies have highlighted the importance of parent factors in understanding children's ADHD, but have largely used crosssectional designs. As yet, there is limited understanding of the prospective relationship between early parent stress and children's later ADHD symptoms and QoL. In one longitudinal study of ADHD symptoms, parent stress at baseline significantly predicted the persistence of children's symptoms 30 months later (Miranda, Colomer, Fernandez, Presentacion, & Rosello, 2015), however, the study was limited by a small sample (61 children) and failure to account for children's baseline symptoms and comorbidities. Thus far, studies have not examined the prospective relationship between parent stress and children's QoL when children have ADHD. The present study aimed to describe the relationship between maternal stress and boys' ADHD symptom severity and QoL 12 months later. Given that mothers were more likely to identify as the child's primary care-giver, we focused on maternal stress. Consistent with prior theorizing, a general measure of parent stress was examined, since parents of children with ADHD are at risk of experiencing a myriad psychological and family difficulties (Galloway et al., 2016), which are likely to be reflected in a general, non-specific measure of stress. We thus aimed to measure maternal stress broadly, capturing parental reactions to chronic non-specific events to understand the every-day impact of general parental stress. It was hypothesized that baseline maternal stress would predict 12 month child ADHD symptoms and QoL. In order to control for the high possibility that maternal stress is influenced by ADHD symptoms in the child, all analyses controlled for child functioning at baseline. A better understanding of the relationship between maternal stress and child ADHD outcomes has the potential to inform more holistic treatments, that can consider both the parent and the child, in improving the outcomes associated with ADHD. Methods Design Children were recruited from two related studies on ADHD: (1) Attention to Sleep, which is a cohort study of children with either no or mild sleep problems (Lycett, Sciberras, Mensah, Gulenc, & Hiscock, 2014), and (2) Sleeping Sound with ADHD, a behavioural sleep intervention (Sciberras et al., 2010). Children were recruited from private pediatric practices and outpatient services in metropolitan (n = 37) and regional/rural areas (n = 13) in Victoria, Australia. Given that the sleep intervention improved a number of outcomes (Hiscock et al.,

2015), only children in the cohort who did not receive the sleep intervention were included in the present study. The studies used identical exclusion and inclusion criteria (apart from sleep problem severity), as well as diagnostic and outcome measures. The present study obtained ethical approval from the Hospital and Department of Education Human Research Ethics Committees. Participants In order to be confirmed as meeting criteria for ADHD, children with a diagnosis of ADHD were first identified by paediatricians (who must have seen the child within the past 12 months). ADHD symptoms were then assessed using the ADHD Rating Scale IV (DuPaul, Power, Anastopoulos, & Reid, 1998). To meet eligibility criteria for the study, children were then required to satisfy full DSM-IV-TR criteria for ADHD at the time of recruitment. Primary caregivers, typically mothers, were required to identify at least 6 of 9 symptoms as occurring “often” or “very often” (rated for the child while they were off ADHD medication). In 94% of cases, measures were completed by the child's mother. The present study only includes data reported by mothers. Additional questions were also used to ensure the following criteria were met regarding symptoms: onset occurred before 7-years of age, were present for at least 6 months, and resulted in impairment both at home and at school. The following exclusion criteria were used: if parents could not understand enough English to complete the recruitment call; if parents were receiving help for their child's sleep (apart from their pediatrician); and if the child had an intellectual disability or serious medical issue, or had obstructive sleep apnea (18; 2). Measures Maternal stress Maternal stress was measured by the Stress subscale from the Depression, Anxiety and Stress Scale-21 (DASS-21; (Lovibond & Lovibond, 1995)). Each subscale has 7 items. The Stress subscale is sensitive to levels of chronic non-specific arousal and is related to generalized anxiety disorder (Brown, Chorpita, Korotitsch, & Barlow, 1997). It includes items that assess arousal, problems relaxing, and becoming easily agitated, irritable or over-reactive over the past week. Items are rated on a 4-point scale, from 0 = “did not apply to me at all” to 3 = “applied to me very much, or most of the time”. The scale has acceptable reliability and validity for both men and women (Gomez, Summers, Summers, Wolf, & Summers, 2014). Child ADHD symptoms Child ADHD symptoms were measured by parent- and teacherreport of the ADHD Rating Scale IV (DuPaul et al., 1998). ADHD symptoms are based on descriptions in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders. Respondents rate child behaviors over the previous 6 months on a four point scale from 0 = never or rarely, to 3 = very often. A symptom severity total score was created, with higher scores reflecting more severe symptoms. Good reliability and validity have been reported for both parent and teacher ratings, including internal consistency, test-retest reliability, and crossinformant agreement (DuPaul, Power, Mcgoey, & Ikeda, n.d.). Child health-related QoL Child health-related QoL was measured by parent report of the 23item Pediatric Quality of Life Inventory 4.0 (PedsQL: (Varni, Seid, & Kurtin, 2001). The PedsQL 4.0 Generic Core Scale was developed for children in the general community, as well as children with acute and chronic health issues. The PedsQL assesses physical, emotional, social and school functioning with the items summing to provide a maximum total health-related QoL score of 100. Parents rate the degree to which each item has been a problem for their child over the last month on a five point scale from 0 = never, to 4 = almost always. Higher scores

Please cite this article as: S. Evans, E. Sciberras and M. Mulraney, The relationship between maternal stress and boys' ADHD symptoms and quality of life: An Australian ..., Journal of Pediatric Nursing, https://doi.org/10.1016/j.pedn.2019.09.029

S. Evans et al. / Journal of Pediatric Nursing xxx (xxxx) xxx

indicate better QoL. The Peds QL 4.0 has demonstrated internal consistency reliability, and validity, and correlates with measures of morbidity and illness (Varni et al., 2001). Potential confounding variables These were identified a priori, and based on our previous work (Sciberras, Song, Mulraney, Schuster, & Hiscock, 2017), as child age, ADHD medication use (yes/no), neighborhood disadvantage and the presence of an autism spectrum disorder (ASD) or externalizing and internalizing comorbidities. Area based disadvantage was measured using the Socio-Economic Indexes for Areas Disadvantage Index (SEIFA), based on the family's postcode. Lower scores reflect more disadvantage [M = 1000, SD = 100; (Statistics, 2008). Internalizing and externalizing comorbidities were assessed using the Anxiety Disorders Interview Scheduled for Children, which uses criteria consistent with the DSM-IV. Parents were interviewed on their children's symptoms. Children were classified as having an internalizing problem if they screened positive for 2 or more anxiety disorders (e.g., generalized anxiety and a specific phobia) or one mood disorder (e.g., major depression). This method is highly sensitive to detecting internalizing comorbidities in children with ADHD (Mennin, Biederman, & Mick, 2000). An externalizing comorbidity was classified if children screened positive for conduct disorder or oppositional defiant disorder. ASD status was assessed via whether the child had received a diagnosis from a health professional (parent-report yes/no). Statistical analysis Descriptive statistics were used to examine baseline characteristics of the sample, and to compare baseline sample characteristics between children with complete follow up data and those with missing follow up. We conducted linear regressions to examine whether maternal stress at baseline was associated with ADHD symptoms and QoL 12 months later. ADHD symptoms and QoL were examined individually in bivariate models, and then analyses were repeated in an adjusted model that accounted for the impact of child age, ADHD medication use (yes/no), comorbid internalizing and/or externalizing disorders, comorbid ASD, and neighborhood disadvantage. A third regression model then adjusted for ADHD symptoms and QoL at baseline. All analyses were conducted using Stata version 15.0. Findings Of the 392 original participants, 244 took part in the RCT (122 were excluded as they received an intervention) and 148 took part in the cohort study. We then excluded any participants whose surveys were completed by someone other than the child's mother (n = 18), participants with missing baseline maternal stress data (n = 6), and participants with missing ADHD symptoms and QoL follow up data (n = 55). Finally, given that we only had a small sample of girls (n = 25), we removed girls from the dataset leaving a total sample size of 166 boys. Participants with missing follow up data did not differ in terms of age, socioeconomic disadvantage, maternal stress, ADHD medication use, percentage of internalizing or externalizing comorbidities, or ADHD symptom severity from participants with complete data. Participants with complete data tended to have better baseline QoL than those with missing follow up data. Sample baseline characteristics are displayed in Table 1. Boys' mean age was 10 years (SD = 1.9), and the majority of boys had combined inattentive/hyperactive impulsive ADHD and were taking ADHD medication. The most common comorbidity was externalizing disorders, followed by internalizing disorders, and combined comorbidities. Approximately one third of boys had ASD. Parents reported more ADHD symptoms in their children than did teachers. The mean SEIFA score of 1007.9 indicated that family background was consistent with an average Australian socioeconomic status.

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Table 1 Baseline characteristics. Characteristics Boys Age [mean, (SD)] ADHD subtype [n, (%)] Combined Inattentive Hyperactive/impulsive ADHD medication use [n, (%)] Comorbidities [n, (%)] Internalizing Externalizing Co-occurring internalizing & externalizing ASD Parent reported ADHD symptoms [mean, (SD)] Teacher reported ADHD symptoms [mean, (SD)] Parent report QoL [mean, (SD)] Mother Age [mean, (SD)] Completed high school [n, (%)] SEIFA [mean, (SD)] Stress [mean, (SD)]

N = 166 10.2 (1.9) 103 (62.1) 55 (33.1) 8 (4.8) 129 (77.7) 86 (52.1) 99 (60.0) 60 (36.4) 57 (34.3) 34.8 (9.9) 27.2 (12.5) 59.3 (14.1) 40.6 (5.3) 93 (56.4) 1007.9 (59.8) 15.0 (8.8)

Of particular note, boys' mean QoL score of 59 was substantially lower than means reported previously for healthy children (88), chronically ill children (74) and acutely ill children (80) (Varni et al., 2001). In addition, the mean maternal DASS stress score of 15.0 is categorized as indicating ‘severe’ stress (Lovibond & Lovibond, 1995). These findings indicate that boys had relatively low QoL, even when compared to chronically ill children, and that their mothers were highly stressed. At a group level, parent-reported ADHD symptoms decreased from baseline to 12 months (baseline mean = 34.7, SD = 9.9, 12 month mean = 30.2, SD = 12.0; t(166) = 5.8, p b .001) and QoL improved (baseline mean = 59.1, SD = 13.9, 12 month mean = 62.8, SD = 15.1; t(153) = −3.4, p b .001). While teacher-reported ADHD symptoms also decreased from baseline to 12 months, this difference was not statistically significant (baseline mean = 27.7, SD = 12.4, 12 month mean = 25.5, SD = 13.1; t(114) = 1.8, p = .08). Relationships between maternal stress and 12 month outcomes Bivariate correlations are displayed in Table 2 and demonstrate that higher baseline maternal stress was significantly associated with elevated child ADHD symptoms and lower QoL (mother-report) at 12 months, but not with teacher-reported child ADHD symptoms at baseline or 12 months. Maternal stress was also significantly associated with child internalizing and externalizing disorders, such that higher maternal stress was associated with elevated internalizing and externalizing symptoms in boys. Table 3 shows the unadjusted and adjusted multivariate analyses of the relationships between baseline maternal stress and boys' functioning (ADHD and QoL) 12 months later. At step 1 of the first adjusted regression, a number of important covariates were included, including the child's internalizing and externalizing behaviour. At step 2 of the second adjusted regression (full model), the child's ADHD symptoms or QoL was also included. Adding these variables allowed for the control of the possible confounding effects of internalizing and externalizing symptoms, which are common comorbidities, and allowed for the inclusion of the stability of ADHD symptoms and QoL. Doing so enabled a conservative examination of the unique contribution of early maternal stress, once the continuity in boys' behaviour was accounted for. In the unadjusted models maternal stress at baseline was associated with both parent-reported child functioning measures at 12 months, including ADHD symptoms and QoL. Baseline maternal stress explained 5.7% and 12.4% of the unique variance in boys' ADHD symptoms (p b .01) and QoL (p b .001), respectively. However, once child age, ADHD medication use, comorbidities, and neighborhood disadvantage were adjusted for, the association between maternal stress at baseline and

Please cite this article as: S. Evans, E. Sciberras and M. Mulraney, The relationship between maternal stress and boys' ADHD symptoms and quality of life: An Australian ..., Journal of Pediatric Nursing, https://doi.org/10.1016/j.pedn.2019.09.029

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S. Evans et al. / Journal of Pediatric Nursing xxx (xxxx) xxx

Table 2 Correlations between baseline variables and 12-month variables.

1. Baseline maternal stress 2. Baseline parent report ADHD 3. Baseline teacher report ADHD 4. Baseline child quality of life 5. 12m parent report ADHD 6. 12m teacher report ADHD 7. 12m quality of life 8. Baseline child age 9. SEIFA 10. ADHD medication 11. Internalizing disorder 12. Externalizing disorder 13. ASD

1.

2.

– 0.32⁎⁎⁎ −0.07 −0.35⁎⁎⁎ 0.24⁎⁎ 0.06 −0.35⁎⁎⁎

– 0.25⁎⁎ −0.29⁎⁎⁎ 0.59⁎⁎⁎ 0.30⁎⁎⁎ −0.25⁎⁎

−0.09 0.02 0.06 0.23⁎⁎ 0.22⁎⁎ 0.11

−0.10 −0.04 −0.03 0.19⁎⁎ 0.31⁎⁎⁎ 0.06

3

– −0.03 0.24⁎⁎ 0.46⁎⁎⁎ −0.16 −0.00 −0.02 −0.11 0.10 0.19⁎ −0.06

4

5

– −0.21⁎⁎ −0.11 0.57⁎⁎⁎

– 0.37⁎⁎⁎ −0.44⁎⁎⁎

0.01 0.07 0.01 −0.46⁎⁎⁎ −0.27⁎⁎⁎ −0.23⁎⁎⁎

−0.02 −0.03 −0.05 0.22⁎⁎ 0.30⁎⁎⁎ −0.03

6

7

8

9

10

11

12

– −0.19⁎ 0.00 −0.14 0.04 0.07 0.20⁎ −0.10

– −0.02 0.03 0.05 −0.34⁎⁎⁎ −0.23⁎⁎ −0.16⁎

– 0.06 0.04 0.04 −0.06 −0.03

– −0.04 0.05 −0.20⁎⁎ 0.17⁎

– 0.05 0.03 −0.07

– 0.20⁎⁎ 0.26⁎⁎⁎

– 0.00

⁎ p b .05. ⁎⁎ p b .01. ⁎⁎⁎ p b .001.

parent reported ADHD symptoms attenuated (p N .05). The association between maternal stress at baseline and QoL remained robust after adjustment for a priori confounders, and the association weakened but held once baseline QoL was added to the model. Thus, once child age, ADHD medication use, comorbidities, and neighborhood disadvantage were adjusted for, the strength of the association between maternal stress at baseline and parent reported boys' QoL reduced but was still significant, with maternal stress contributing an additional 6.2% of variance in boys QoL scores (p = .001). Once the full model was run, including the previous covariates as well as boys' baseline QoL, maternal stress still emerged as a significant predictor of boys QoL 12-months later, accounting for a unique 2.4% of variance (p b .05). Aside from baseline QoL (β = 0.46, 95% CI 0.30–0.61, p b .001) no other potential confounding variables were associated with QoL at 12 months. As demonstrated in Table 3, there was no evidence for a relationship between maternal stress and teacher reported ADHD symptoms.

Evidence from prior research indicates that boys may be impacted by disruptions to maternal mental health across development. For example, maternal prenatal stress has been associated with later sustained attention and self-regulation problems in boys (van den Bergh et al., 2006). Longitudinal research across the toddler years indicates that early symptoms of depression in mothers are associated with boys' lowered attachment security at 18 months of age (Beeghly et al., 2017). Maternal prenatal depressive symptoms are related to boys' externalizing behavior at 24 months (Edwards & Hans, 2016). General parent psychological distress has also been found to influence boys' internalizing symptoms in children across middle childhood (Schleider, Chorpita, & Weisz, 2014). One potential mechanism explaining the link between early maternal mental health and boys' relatively poorer outcomes relates to parenting behaviors, with stress in parents contributing to dysfunctional parenting strategies. The role of stress in dysfunctional parenting has been documented in a number of populations, including parental depression and community samples (Pinderhughes, Dodge, Bates, Pettit, & Zelli, 2000; Venta, Velez, & Lau, 2016). When compared to parents of children without ADHD, parents of children with ADHD experience higher levels of stress (Modesto-Lowe, Danforth, & Brooks, 2008), with such stress associated with psychopathology including depression (Cheung & Theule, 2016) and engagement in suboptimal parenting, specifically greater parent-child conflict and parenting anger (Bhide, Sciberras, Anderson, Hazell, & Nicholson, 2019; Theule et al., 2013). Our study did not measure parenting behaviors, but future research should examine whether dysfunctional parenting practices known to relate to parent stress mediate the relationships seen here. For example, it has been hypothesized that maternal stress leads to poor quality parenting and unfavourable parent-child relationships, which in turn impact poorly on children (Gau & Chang, 2013). It would be valuable to test this model in children with ADHD. Overall, maternal stress may represent a distal risk factor, impacting children through more direct processes such as impaired parenting behaviors and disruptions. The relationship between maternal stress and children's functioning is likely to be bidirectional, such that parents and children reciprocally

Discussion This study examined the longitudinal relationship between maternal stress and boys' functioning (ADHD symptoms and QoL) 12 months later. It is the first time that the prospective role of parent factors in children with ADHD's QoL has been examined. We initially found that maternal stress was associated with mother-reported 12 month ADHD symptoms and QoL. However, once controlling for child age, ADHD medication use, internalizing/ externalizing comorbidities, neighborhood disadvantage, and baseline ADHD and QoL respectively, maternal stress only predicted boys' QoL and not symptoms. Baseline maternal stress was not associated with teacher reported ADHD symptoms. Our findings represent an important and unique contribution to the literature understanding the functioning, and potential treatment of families dealing with ADHD. It is known that children with ADHD have poor QoL, with calls to include QoL as a key indicator of ADHD treatment success (Adamo et al., 2015). If early maternal stress represents a risk factor for poor QoL in children with ADHD, treatment efforts should target such stress.

Table 3 Association between parental stress and child functioning 12 months later. Adjusted 1a

Single variable model

Parent report ADHD Teacher report ADHD QoL a b

n

β

95% CI

165 136 153

0.23 0.05 −0.34

0.09 −0.11 −0.48

0.38 0.21 −0.19

Adjusted 2b

P

β

95% CI

0.002 0.51 b0.001

−0.01 −0.03 −0.25

−0.13 −0.20 −0.40

0.11 0.13 −0.10

P

β

95% CI

0.86 0.69 0.001

−0.01 0.05 −0.16

−0.13 −0.12 −0.30

P 0.11 0.22 −0.02

0.86 0.54 0.02

Model adjusted for child age, ADHD medication use, comorbidities and neighbourhood disadvantage. Model adjusted for child age, ADHD medication use, comorbidities, neighbourhood disadvantage, and baseline ADHD symptoms or QoL.

Please cite this article as: S. Evans, E. Sciberras and M. Mulraney, The relationship between maternal stress and boys' ADHD symptoms and quality of life: An Australian ..., Journal of Pediatric Nursing, https://doi.org/10.1016/j.pedn.2019.09.029

S. Evans et al. / Journal of Pediatric Nursing xxx (xxxx) xxx

shape each other across development (Neece, Green, & Baker, 2012). Parenting children with ADHD is typically highly stressful (Theule et al., 2013). Longitudinal research has demonstrated that not only do parent factors, including increased maternal stress and overreactive parenting, contribute to children's later ADHD symptoms, but an increase in children's ADHD symptoms predicts more parent stress, depressive symptoms, and less optimal parenting (Breaux & Harvey, 2018). Over time, this transactional relationship between mothers' stress and boys' functioning may become increasingly entrenched. In an attempt to understand the unique contribution of maternal stress on boys' ADHD symptoms and QoL with the ultimate goal of understanding whether stress interventions for parents may be beneficial for children, we controlled for children's baseline functioning. In reality, the transactional dynamics between mothers and children may be best understood by statistically examining the impact of each upon the other across longer periods of development to gain a more complete understanding of when to intervene, and who to focus upon. It is prudent to place the findings in context. After controlling for covariates and children's symptoms, maternal stress played a significant, but small role in boys' QoL. This indicates that other factors also influence children's QoL and should be explored in further research. For example, the role of fathers should be examined. It is important to note that maternal stress did not predict ADHD symptoms once baseline ADHD symptoms were accounted for, suggesting that maternal factors are not as important in understanding future ADHD behaviour as children's own behaviors. Also, maternal stress was not related to teacher-reported symptoms. The discrepancy between the parentand teacher-reported findings are consistent with prior research indicating relatively low levels of agreement between parents and teachers in ratings of child ADHD symptoms (Achenbach, McConaughy, & Howell, 1987; Keown, 2012). These discrepancies may reflect disparate rater perceptions, or teachers having the opportunity to examine children's behaviour in a different context to parents. Most of the children were taking ADHD medication, which indicates that teachers may not have had the same opportunity to observe symptoms as parents. Alternatively, given that our findings are limited to mother-reported QoL, our results may indicate that mothers who are highly stressed are more likely to report problems in their children. A previous crosssectional study found a relationship between higher maternal stress and lowered QoL in children with ADHD, but only for parent-reported QoL and not child-reported QoL (Galloway et al., 2016). Parent-report of child functioning tends to be biased by the parents' own beliefs and mental health difficulties, with mothers likely to report outward manifestations of problem behaviour in their sons (Jensen & Watanabe, 1999; Najman et al., 2001). Even if our findings are in line with this alternative explanation that stressed mothers may be biased towards seeing negative behaviour in their sons, intervention efforts to reduce maternal stress are still warranted. Research indicates that high maternal negative emotionality translates into independently-observed problem behaviors in children, likely through high expression of negative emotion (Slatcher & Trentacosta, 2012). Should mothers express such biases, over time, boys may increasingly respond with problem behaviors consistent with the bias. The self-fulfilling influence of adult expectations on children's behaviour has been established in diverse areas of research, including education outcomes, and teen risk behaviors (Madon, Guyll, Spoth, Cross, & Hilbert, 2003; Rosenthal, 1991). At the least, our findings suggest that targeting maternal stress in families with ADHD may be beneficial in minimizing mothers' negative perceptions of their sons. Future longitudinal research should include childreported QoL to determine whether the relationship seen here reflects an independently observed reduction in child QoL, or whether stressed mothers are particularly sensitive towards their sons' behaviour. Future studies should also explore the role of fathers in children's ADHD symptoms and QoL. Previous research has indicated that maternal and paternal influences may differ in their associations to child

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ADHD symptoms. In a 3-year longitudinal study of maternal and paternal parenting predictors of boys' ADHD in a community sample, lower paternal sensitivity and maternal positive regard predicted elevated levels of child inattentiveness, while intrusive paternal behaviour predicted higher levels of child hyperactive-impulsive behaviour (Keown, 2012). These findings suggest that paternal factors may be differentially (and possibly more consistently) related to boys' ADHD symptoms than maternal factors. If so, this may explain why we failed to find a significant relationship between parental stress and later boys' ADHD symptoms. Perhaps paternal stress is a stronger predictor of boys' functioning than maternal stress. Prior research highlights the particular role of paternal sensitivity for lower externalizing behaviour in children (NICHD, 2004), but the role of paternal stress in children's ADHD symptoms and QoL has yet to be examined. The current study has a number of strengths, including the large sample size, inclusion of teacher-reports and the longitudinal design. However, the short follow-up period is a limitation. Future studies should examine the bidirectional relationship between parental stress (including mothers and fathers) and children's ADHD symptoms and QoL (including boys and girls) across multiple years. Examining the impact of each member of the family upon the other across development would allow greater insight into how and when interventions should be considered, and to whom they should be tailored. Interventions targeting children's ADHD are increasingly recognizing the role of managing parent stress and psychopathology. For example, mindful parenting interventions that seek to target parent issues (including stress and reactive parenting) and child outcomes, including reduced ADHD symptoms, have shown promising findings for both parents and children (Evans et al., 2018). Stress management interventions that combine behavioural parent training, and cognitive behavioural therapy for parents also appear helpful for parents raising children with developmental disabilities (Singer, Ethridge, & Aldana, 2007). Conclusions This study suggests that increased maternal stress may play a role in lowered QoL in boys with ADHD over time. Boys' QoL may potentially improve by addressing maternal stress. Reduced QoL is a substantial issue for children with ADHD. Research indicates that children with ADHD score 2 standard deviations below their peers on QoL measures (Danckaerts et al., 2010), with medication improving QoL, but not returning it to typical functioning (Coghill, 2010). Clearly, efforts to improve QoL in children with ADHD are warranted, and treating maternal stress may prove to be one valuable approach. At the very least, the findings indicate that stressed mothers are at risk of viewing their sons' behaviour in a poor light, with efforts to reduce maternal stress needed to ameliorate the potential negative effect of maternal biases on children's functioning. CRediT authorship contribution statement Subhadra Evans: Conceptualization, Writing - original draft, Writing - review & editing. Emma Sciberras: Conceptualization, Writing - original draft, Writing - review & editing. Melissa Mulraney: Conceptualization, Writing - original draft, Writing - review & editing. References Abidin, R. (1992). The determinants of parenting behavior. Journal of Clinical Child Psychology, 21(4), 407–412. Achenbach, T. M., McConaughy, S. H., & Howell, C. T. (1987). Child/adolescent behavioral and emotional problems: Implications of cross-informant correlations for situational specificity. Psychological Bulletin, 101(2), 213–232. Adamo, N., Seth, S., & Coghill, D. (2015). Pharmacological treatment of attention-deficit/ hyperactivity disorder: Assessing outcomes. Expert Review of Clinical Pharmacology, 8(4), 383–397. https://doi.org/10.1586/17512433.2015.1050379. Beeghly, M., Partridge, T., Tronick, E., Muzik, M., Rahimian Mashhadi, M., Boeve, J. L., & Irwin, J. L. (2017). Associations between early maternal depressive symptom

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Please cite this article as: S. Evans, E. Sciberras and M. Mulraney, The relationship between maternal stress and boys' ADHD symptoms and quality of life: An Australian ..., Journal of Pediatric Nursing, https://doi.org/10.1016/j.pedn.2019.09.029