ADHD: A Brief Introduction A neurodevelopmental disorder of childhood characterized by...

ADHD: A Brief Introduction

A neurodevelopmental disorder of childhood characterized by developmentally inappropriate levels of

hyperactivity and impulsivity and/or attention problems.

Prevalence rate is from 3 - 5% in the general population (APA, 1994)

Prevalence is estimated to be between 4 and 12 % in pediatric primary care settings (American Academy of Pediatrics, 2000).

A common reason for referral to pediatricians, child psychiatrists & psychologists

ADHD: Common Comorbid Conditions

Oppositional Defiant Disorder (ODD): up to 50%

Conduct Disorder (CD): 30-50% Anxiety Disorder: 20-25% Mood Disorder: 15-20% Learning Disability: 19-26%

(AACAP, 1997)

ADHD-related Behavior: As a Source of Family Stress

The behavior of children with ADHD, can be highly disruptive and contribute to increased levels of parental/family stress. This stress results from:

core symptoms themselves comorbid features that often accompany

this disorder the demands and family disruptions

experienced by parents as a result of the child’s behavior.

ADHD: Common Family Stressors

Parents often get calls from teachers regarding their child behavior or school difficulties.

They are often restricted socially. They often feel they must “explain” their child’s

behavior to others. They often have to miss work to attend clinic

appointments. Many worry incessantly (with some justification)

about the possibility of accidental injury to their child as a result of his/her behavior.

These represent only a few of the stressors experienced by parents of children with ADHD.

Parenting and Caretaker Stress Relevant to the disruptive behaviors often seen in

children with ADHD, research has suggested that even everyday parenting events can be sources of caretaker stress.

Crnic and Acevedo (1995) describe "daily parenting hassles as “routine childrearing tasks that parents may find irritating, frustrating, annoying, and distressing.

Research by Crnic & Acevedo, (1995) and Crnic & Greenberg (1990) has shown high levels of parenting hassles to relate to lower life satisfaction, more negative mood and affect, and increased maternal distress

ADHD and Family Stress Crnic and Greenberg (1990) have also found that parenting

hassles are more stressful to parents than major life events. Other studies (Dumas (1986; Patterson, 1983) have

suggested that parents experiencing high levels of daily parenting hassles

tend to display more negative affect towards their children

respond in ways that increase child negativityand

engage in more aversive or irritable/coercive interactions with their children when experiencing high rates of parenting hassles.

Given these findings with normal families, it would not be surprising that parents of children with ADHD display even greater stress

ADHD and Family Stress

This concept of daily parenting stress or family burden is important to understanding the functioning of families of children with ADHD.

Parents of children with ADHD often have to deal with problem behaviors at much higher rates and at a higher level of intensity than is found in families of normal children.

Parenting stressors may be of special significance in terms of their impact on parent, child, and family functioning.

Outcomes may include: the development of parenting styles that increase

negative child behavior parental psychopathology strained marital relationships other negative outcomes.

ADHD and Parent Adjustment

Regarding the potential impact of ADHD-related stress on parents, studies have shown that

Mothers of children with ADHD have higher rates of psychological difficulties (Fischer, 1990)

They seek treatment for psychological difficulties significantly more often than mothers of normal children (Gillberg, Carlstrom, and Rasmussen, 1983).

In the latter study, treatment-seeking behavior was also found to be correlated with the severity or pervasiveness of the child's hyperactivity (Gillberg, et al., 1983).

ADHD and Parent Adjustment

Several studies have shown That mothers of children with ADHD show higher rates of

depressive symptoms than mothers of normal children (Befera & Barkley, 1985; Brown & Pacini 1989; Cunningham, Benness, & Siegel, 1988).

That parents of children with ADHD display increased levels of alcohol consumption (Cunningham et al., 1988; Pelham & Lang, 1999).

That parents of children with ADHD show increased marital discord and strained interpersonal relationships (Johnston, 1996).

While not actually measuring “stress” these findings suggest that having a child with ADHD in the home is often associated with a range of psychological, interpersonal and family difficulties.

ADHD and “Parenting Stress” Other studies have attempted to study stress in families

of children with ADHD, using the Parenting Stress Index (PSI) developed by Abidin(1995).

The PSI is designed to assess sources of stress resulting from the Child, the Parent, and the Environment that place strain on the parent-child system.

This measure includes: Child Domain

Adaptability Acceptability Demandingness Mood Distractibility/Hyperactivity Child Reinforces Parent

Parent DomainDepression Attachment Parental Role Restriction Sense of Competence Social Isolation Relationship with SpouseParent Health

Life Stress (optional).

ADHD “Parenting Stress” Findings

Breen and Barkley (1988) have found mothers of hyperactive clinic-referred girls to display higher PSI stress levels than mothers of normal girls.

Severity of child aggression, conduct problems, and hyperactivity were found to be most highly related to parent stress levels.

These findings suggest that stress levels, not only increase with the severity of ADHD symptoms, but also as a function of comorbid features that often accompany ADHD.


Mash and Johnston (1983), found mothers of hyperactive children to report higher levels of overall parenting stress than parents of normal children.

Child characteristics such as “distractibility” & “perceived degree of bother” accounted for the most variance in parenting stress scores.

Mothers of hyperactive children also reported more feelings of social isolation and role restriction on the PSI compared to parents of normal children.


The view that parenting stress can be increased by comorbid conditions is also supported by findings from Anastopoulos, et al (1992).

In addition to finding increased levels of stress among parents of children with ADHD, they also found the severity of ADHD symptoms and aggressive and oppositional-defiant behavior to account for some 43% of the variance in parenting stress scores.

Such studies these provide general support for the view that ADHD-related behavior is associated with significant levels of parental stress.

On The Assessment of Specific Stressors

Despite studies suggesting a link between ADHD and “parenting stress”, these studies with the PSI provide little information regarding the specific types of day-to-day stressors experienced by parents of children with ADHD.

Indeed, a careful look at the nature of the PSI Parent Domain scale suggests that scores on this measure are probably best viewed as indirect reflections of stress resulting from having a child with ADHD.

These measures may be best thought of as “stress related outcomes” that may also be influenced by factors other than child behavior.

So What Do Findings to this Point Suggest?

That children with ADHD display a range of behaviors that can serve as stressors.

That parents of children with ADHD often display negative outcomes in terms of personal adjustment and family functioning.

That measures designed to assess specific stressors, resulting from ADHD-related behavior, are needed.

Centers for Disease Control: Focus on ADHD and Family Burden

The need for research related to ADHD family stress has been most obviously highlighted by the proceedings of a Centers for Disease Control conference, convened in 1999.

The purpose of the conference was to develop a research agenda for studying the public health costs of ADHD.

This conference resulted in a range of conclusions and recommendations


Here the conference proceedings suggested that it is reasonable to assume – That family members of a child with ADHD are

significantly impacted by this condition, That the magnitude of the social and economic

burden of ADHD on the family has not been systematically documented, and

That families of children with ADHD may be more likely to experience conflict and increased family stress.


It was also suggested That, to understand the nature of ADHD, it is

imperative to understand its effects on families. That increased research is needed to clarify those

aspects of the family it impacts and in what ways the family is impacted.

Finally, it was suggested, That since the development of effective

interventions for ADHD is dependent on having reliable and valid measures to assess the impact of the disorder,

the development of standardized burden measures are central to this process.

Assessing ADHD-Related Stress

In line with the CDC recommendations, we have focused on developing a reliable and valid measure of ADHD-related stress (e.g. family burden).

The goal has been to develop a measure that provides information regarding the occurrence and perceived stressfulness of family changes, family disruptions, and other circumstances resulting from having a child with ADHD.

The focus has been on assessing specific ADHD behavior-related family stressors, rather than more global indices of family stress or measures of stress-related outcomes experienced by family members.

Assessing ADHD-Related Stress Our belief has been that a measure of this

type Should be of value in providing family

assessment data for comprehensive ADHD clinical assessments.

Should serve as a useful treatment outcome measure, and

Should be useful as a research tool in studying the impact of ADHD related stress on the family.

Indeed, the development of such a measure appears to be a prerequisite for conducting meaningful research on the nature and impact of ADHD on families.

Development of the Disruptive Behavior Inventory: Item Selection

Our work on this measure, the Disruptive Behavior Stress Inventory (DBSI; Johnson & Reader 2000, Reader, McCallister and Johnson, in press), began with the development of an initial item pool.

Here, preliminary items were obtaining from parents of children with ADHD (the population of interest)

Parents, bringing their children to the clinic for evaluation, were asked to complete an open-ended “Family Stress Survey” by listing the five most significant stressors or family disruptions experienced as a result of their child's behavior.

This survey generated a total of 134 items described as highly stressful by parents.

Assessing ADHD Related Stress:Item Refinement

Irrelevant items were discarded and items with similar content and meaning were joined into single items.

Items that described child behavior problems and symptoms of ADHD were excluded.

The reduced item pool was then given to three doctoral-level, clinical-child/pediatric psychologists for evaluation and input regarding item wording, relevance, and appropriateness.

40 items were retained for the final measure.

Format of the DBSI

DBSI InstructionsListed below are a range of potential stressors that are sometimes experienced as a result of having a child who displays behavioral difficulties.Read each of the following items carefully and indicate those situations you have experienced as a result of your child’s behavior during the past six months. Circle "Yes" if you have experienced what is described in the item. Circle "No" if you have not.For each item circled "Yes", indicate on the following 4 point scale the extent to which it was/is stressful to you:0 (Not at all Stressful); 1 (Somewhat Stressful); 2 (Moderately Stressful); 3 (Very Stressful).Please be sure to respond to each item.

Sample Items From the DBSI

1. Getting complaints from teachers about your child’s behavior.2. Problems paying for services your child needs.3. Having other parents complain about your child’s behavior.4. Getting calls from teachers regarding your child’s school

performance.5. Disagreement with spouse about managing child’s behavior.6. Having your child embarrass you in front of others.7. Not having enough time for yourself due to child’s behavior.8. Having to miss work because of your child’s behavior9. Not being able to work outside of home due to child’s

behavior.10. Having other parents tell you how to manage your child.

--------------When scored, the DBSI yields a Stress Experience score (number of stressors experienced) and a Stress Degree score (sum of the ratings for each reported stressor).

Click to Download Measure

Development of the DBSI: Initial Findings

Preliminary validity and reliability data for the DBSI were obtained from two groups of parents;

1) A group of 55 parents of children (47 boys and 8 girls), age 4 - 15, with a primary diagnosis of ADHD – Mean age 9.6 (SD = 2.84.

2) A comparison group of 38 parents of children (20 boys and 18 girls) without ADHD or other diagnosed disorder - Mean age 8.0 (SD = 3.11).

Twenty-two parents of children with ADHD completed the measure a second time (1-2 week interval) to provide test-retest reliability data.

Note. Preliminary analyses suggested significant group differences regarding child age; as a result group comparisons involved covariance analyses with age as the covariate.

Reliability Assessment Initial analyses evaluated aspects of the reliability of

the Stress Experience and Stress Degree scales completed by parents in the ADHD group.

Corrected item-total correlations were obtained to assess the degree of relationship between individual items and the total scale scores.

The internal consistency of the Stress Experience and the Stress Degree scale was analyzed to determine the degree of scale homogeneity (e.g. the degree to which items in each of the two scales measure similar constructs (Cronbach's alpha).

Test-retest reliability was evaluated by examining the Pearson’s product moment correlation coefficients for both scale scores over a 1-2 week interval.

DBSI Reliability Findings Corrected item-total correlations were calculated for all

40 items on both the Stress Experience and Stress Degree scales.

The mean corrected item-total correlation for the Stress Experience scale was .48 (range = .09 - .72)

For the Stress Degree scale it was .58 (range = .23 - .81). Based on analyses of 43 measures, Cronbach’s

coefficient alpha was .93 for the Stress Experience scale.

Based on analyses of 41 measures (due to the failure of two parents to complete the Stress Degree scale) coefficient alpha for the Stress Degree scale was .96.

Test-retest reliability coefficients for both scales were based on analyses of 22 completed measures.

The test-retest reliability coefficient for the Stress Experience Scale was .76 (p < .001)

Test-retest reliability for the Stress Degree scale was .65 (p < .001).

Development of the DBSI: Discriminative Validity Findings

Tests of discriminative validity involved overall comparisons of the ADHD and Comparison groups in terms of scores on the DBSI Stress Experience and the Stress Degree scales.

As preliminary analyses found significant differences between groups in terms of child age, analyses involved ANCOVA’s with age considered as the covariate.

Group comparisons indicated that both the DBSI Stress Experience and Stress Degree scale scores differentiated between groups

In the case of both, Stress Experience and Stress Degree scales scores provided by parents of children with ADHD were significantly higher.

Development of the DBSI: Discriminative Validity Findings

Subsequent ANCOVA’s, with child age as covariate, were also used to test for group differences on the Stress Experience and Stress Degree scales, as a function of ADHD subtype.

Post-hoc analyses (with Bonferroni correction) were employed, following the finding of overall significant differences in group means (p<.001).

For both measures, stress scores of parents of children with Combined type ADHD were found to be significantly higher than those of parents of children with Inattentive type ADHD, as well as those in the comparison group.

Stress scores of the Predominately Inattentative type group did not differ from the non-ADHD comparison group.

Scale Normal ADHD

M SD M SD F (1) d

Stress Experience

8.42 5.38 19.05 9.09 36.89*** 1.36

Stress Degree

12.18 12.68 35.98 24.43 28.55*** 1.17

Comparison of DBSI Mean Scale Scores between Normal and ADHD Groups

*** p < .001 Note. Cohen’s d = Effect size

Scale Normal CombinedHyperactive-Impulsive

Inattentive Unknown

M SD M SD M SD M SD M SD F (4)

Stress Experience

8.42a 5.38 22.55a,b 9.13 14.00 8.29 13.50b 5.81 18.50 8.75 14.89***

Stress Degree

12.18c 12.68 44.78c,d 26.21 26.00 20.69 18.50d 8.49 40.00 23.13 12.88***

Comparison of DBSI Mean Scale Scores Across Normal and ADHD Subtype Groups

*** p < .001Note. Means in a row sharing subscripts are significantly different

Frequencies of Specific ADHD Family Stressors

Since items included in the DBSI were derived from reports of family stressors, experienced by parents of children with ADHD, it was of interest to look at the frequency with which specific stressors were reported by parents of children with and without ADHD.

This data is provided in following slides.


(N = 126) Age Range (Patient): 4 – 15; Mean Age = 8.86 Age Range (respondent): 24 – 72; Mean Age = 36.79 76.4% Male; 23.6% Female Medication: 73.2% Yes; 25.2% No Ethnicity: Caucasian 35.4 %; African American 11.8%;

Latino-American 4.7%; Mixed/Other 3.1% Family Income Range: $5,772 - $170,000; Mean Income

= $38,699 ADHD Subtype: Combined 35.4%; Hyperactive-Impulsive

6.3%; Inattentive 8.6%; Unknown 48.8%


Item # % Reporting

Conflicts with your child over homework 81.1 Dealing with teachers’ complaints about your child. 80.3 Dealing with your child’s academic difficulties. 78.0 Having to explain your child's behavior to others. 78.0 Spending an excessive helping child with homework 74.0 Not knowing how to deal with your child’s behavior 74.0 Having to watch child so he/she doesn’t get into trouble 68.5 Having your child embarrass you in front of others 67.7 Being concerned about your child being injured 63.0 Being interrupted when taking care of other children. 62.2 Not able to take your child shopping because of behavior 60.6 Disagreements with spouse about child’s behavior 59.8 Calls from school regarding your child's behavior 59.1 Dealing with your child’s conflicts with other children 59.1 Other people telling you how to parent your child 58.3


Item # % Reporting

Not having enough time for self due to child’s behavior 57.5 Calls from school regarding child's academic problems 57.5 Not getting work done at home due to child’s behavior 53.5 Difficulties getting school-based services for your child 48.7 Not knowing how to explain child’s behavior to others 46.5 Not being able to go out to eat because of child’s behavior 46.5 Difficulties finding professional services for your child 44.1 Not getting support from others for child’s problems 42.5 Not able to spend enough time with your other children 40.9 Having less time with partner because of child’s behavior 40.9 Not being able to leave your child with a baby sitter 40.2 Not able to get to bed at decent hour due to behavior 39.4 Having to miss work because of your child’s problems 38.6 Problems paying for services your child needs 38.6 Problems related to medication side effects 38.6


Item # % Reporting

Being unable to take your child to public places37.8

Difficulties getting your child to appointments 35.4

Dealing with complaints from other parents about child34.6

Having to miss important social events due to 29.1

Having to miss/leave church because of child’s behavior25.2

Getting complaints from school bus driver 24.4 Difficulties finding adequate after school placement 22.8 Difficulties dealing with your child’s doctors 20.5 Dealing with complaints from neighbors about behavior

18.1 Not able to work outside home due to child’s behavior17.3


As can be seen, very high frequencies of many specific stressors are found in this group of children with ADHD.

18 of 40 items were endorsed by at least 50% of the sample.

Frequency of Specific Family Stressors in Non-ADHD Families

The frequency data just presented can be contrasted with the frequency of experiencing these same family stressors by parents of children without ADHD (N = 119).

These data are presented in the following slides.

Frequencies of Specific Family Stressors in Non-ADHD Families

Item # % Reporting

Conflicts with your child over homework 46.8 Being interrupted when taking care of other children. 46.8 Disagreements with spouse about child’s behavior 46.8 Not knowing how to deal with your child’s behavior 43.5 Dealing with teachers’ complaints about your child 39.5 Other people telling you how to parent your child

37.9 Dealing with your child’s conflicts with other children 37.1 Being concerned about your child being injured

34.7 Having your child embarrass you in front of others 33.9 Dealing with your child’s academic difficulties.

31.5 Spending excessive time helping with homework

29.8 Having to explain your child's behavior to others

25.8 Not being able to take your child shopping 24.2 Not being able to leave your child with a baby sitter 23.4 Calls from school regarding your child's behavior

21.8


Item # % Reporting

Not able to spend enough time with your other children 21.0 Not having enough time for self because of behavior 20.2 Having less time with partner because of child’s behavior 20.2 Having to watch your child so doesn’t get into trouble 19.4 Not being able to go out to eat because of behavior 18.5 Not able to get to bed at decent hour because of behavior 18.5 Not getting work done at home because of behavior 16.9 Calls from school regarding child's academic problems13.7 Having to miss work because of your child’s problems 12.9 Problems paying for services your child needs 12.1 Having to miss or leave church because of your behavior 12.1 Difficulties finding adequate after school placement 9.7 Not knowing how to explain child’s behavior to others 8.9 Difficulties getting your child to appointments 8.9 Difficulties finding professional services for your child 8.9


Item # % Reporting

Not getting support from others with child’s problems 8.9 Being unable to take your child to public places

8.1 Difficulties dealing with your child’s doctors 6.5 Getting complaints from school bus driver 5.6 Difficulties getting school-based services for your child

4.8 Dealing with complaints from other parents about child

4.8 Problems related to medication side effects 4.0 Having to miss social events due to your child’s behavior

4.0 Dealing with complaints from neighbors about behavior

3.2 Not able to work outside home because of child’s behavior

.8

Family Correlates of ADHD-Related Stress: Some Preliminary Findings

Given preliminary findings from two studies supporting the validity of the DBSI as a measure of ADHD-related stress, we have begun to focus on collecting data to look at the relationship between DBSI stress scores and measures of family functioning.

To date, we have obtained preliminary data on a small sample of children with Combined type ADHD and have begun to look at the correlations between DBSI stress indices and

1) ADHD symptom severity measures, 2) PSI Parent Domain Measures, and 3) Indices of marital satisfaction

Assessing ADHD Related Stress:A Replication and Extension

In second recently completed study (Reader, McCalister & Johnson, In Press), we attempted to replicate and extend the initial DBSI findings with an additional larger sample.

One focus was on replicating some of our initial reliability and validity findings.

A second focus was on determining the degree to which each of the 40 individual DBSI items differentiated parents of children with and without ADHD.

That is - how well do individual DBSI item discriminate between parents of children with and without ADHD?

Replication Study: ADHD Group Characteristics

The ADHD Caregiver Group consisted of 71 primary caregivers (68 female and 3 male), with a mean age of 37.37 years (SD = 10.09) and range between 24 and 71 years.

Caucasians (70%) made up the majority of primary caregivers in the ADHD group, with African-American (23%) and Latino American (7%) caregivers also included in the sample.

Measures were completed on 49 boys and 22 girls (N = 71), made up of 63% Caucasians, 23% African-Americans, 7% Latino-Americans, and 7% of Mixed/Other race.

The mean age of children in the ADHD group was 8.21 (SD = 2.53), with a range between 4 and 15 years.

Replication Study: Comparison Group Characteristics

The Comparison Group was made up of 79 primary caregivers (68 females and 11 males), with a mean age of 37.37 years (SD = 6.91); (range 25 – 51).

Caucasians (73%) made up the majority of primary caregivers in this group, with African-American (18%), Latino American (5%), Asian American (1%), and Mixed/Other (1%) race caregivers also included in the sample (2% missing data).

Measures were completed based on 39 boys and 40 girls (N = 79), made up of 68% Caucasians, 20% African-Americans, 5% Mixed/Other race, 4% Latino-Americans, and 1% Asian-Americans (2% missing data).

Mean age of children in this group was 8.19 (SD = 2.25), with a range of between 4-14 years.

Replication Study: Reliability Findings

For the ADHD sample, the mean corrected item-total correlation for the Stress Experience scale was .41 (range = .07 - .60); for the Stress Degree scale it was .49 (range = .24 - .67).

Item 18 (“Disagreements with spouse about managing child behavior”) consistently showed the lowest item-total correlation.

The internal consistency of both scales was analyzed, using Cronbach’s coefficient alpha.

For the ADHD sample, Cronbach’s coefficient alpha was found to be .90 (n = 69) for the Stress Experience scale and .93 (n = 68) for the Stress Degree scale.

Replication Study: Preliminary Analyses

The discriminative validity of the Stress Experience and Stress Degree scales was again assessed by comparing scores of primary caregivers of children with and without ADHD.

Preliminary analyses indicated no significant group difference in terms of child age.

A significant difference in Stress Experience scores of boys and girls in the ADHD group was found (Boys > Girls).

Given these findings, subsequent group comparisons involved analyses of covariance with gender as a covariate.

Given the small number of children diagnosed with the primarily hyperactive/impulsive (n = 1) and inattentive (n = 4) subtypes of ADHD, analyses based on subtype were not conducted.

Replication Study: Discriminative Validity

Stress Experience Scale An analysis of covariance was used to determine whether

scores on the Stress Experience scale differentiated between caregivers of children with and without ADHD.

The ANCOVA showed significant mean score differences between groups, F (1, 147) = 94.95, p < .001., with caregivers of children with ADHD experiencing more stressors (M = 20.45, SD = 8.34) than caregivers of children in the comparison group (M = 7.47, SD = 7.17).

The Cohen’s f value of .84 represented a large effect size (Cohen, 1988).

Child gender was a significant covariate (p < .05), and explained approximately 3% of the variance in the Stress Experience index scores.

Replication Study: Discriminative Validity

Stress Degree ScaleAgain using child gender as a covariate, an ANCOVA found that mean scores on the Stress Degree scale significantly differentiated caregivers of children with ADHD from caregivers of children from the comparison group, F (1, 147) = 80.22, p < .001.

Caregivers of children with ADHD showed higher mean Stress Degree scores (M = 40.45, SD = 22.92) than caregivers in the comparison group (M = 11.39, SD = 14.50).

The Cohen’s f value of .77 represented a large effect size (Cohen, 1988).

Child gender was not found to be a significant covariate (p = .22).

Extension Study:Sample Characteristics

Data for the extension segment of this study was derived from combining the data collected from participants in the replication segment of this study as well as from participants in the original Johnson and Reader (2002) investigation .

The total ADHD group consisted of 124 primary caregivers (113 female and 11 male). Measures were completed on 94 boys and 30 girls (N = 124).

The mean age of children in the ADHD group was 8.70 (SD = 2.66), with a range of 4-15 years.

Of these children, 88 were taking medication to treat ADHD symptoms.

The comparison group was made up of 118 primary caregivers (103 females and 15 males). Measures were completed based upon 60 boys and 58 girls (N =118).

Mean age of children in this group was 8.17 (SD = 2.58), with a range of between 4-14 years.

Extension Study: Individual Item Analyses

This study, was designed to evaluate the degree to which individual DBSI items were able to differentiate between parents of children with and without ADHD.

Chi-square analyses using Yates’ Continuity Correction (Yates, 1934) were used to analyze the ability of each of the 40 items on the Stress Experience index to differentiate between the two groups.

The continuity correction was used because the observed cell counts in the 2 x 2 tables were less than 5 for some items. The expected cell count, however, was not less than 5 for any of the 2 x 2 matrices generated by the 40 items on this index.

Given the number of analyses required to individually evaluate each of the 40 items on the DBSI, a Bonferroni correction was used to control for experimental error rates.

Statistical significance was set at a criterion of p < .001.

Extension Study: Item Analysis of the DBSI Stress Experience Measure Of the 40 items on the DBSI Stress Experience

scale, 33 were found to be significantly (p < .001) related to group membership.

Parents of children with ADHD were significantly more likely to endorse having experienced each of these specific stressors during the past 6 months than parents of children in the comparison group.

Note. While it was necessary to conduct these analyses at a protected level given the significant risk of Type I error, it is interesting to note that 39 out of 40 items on the Stress Experience index displayed a magnitude of difference that would have reached significance at the < .01 level; the one item that would have not been significant at this level was “disagreements with spouse about managing child behavior” (p = .013).

Analysis of Stress Degree Measures: Preliminary Analyses

Tests of normality were initially conducted to assess the distribution of responses for the Stress Degree index for both groups. Results of these analyses indicated significant levels of

skewness and kurtosis in the distribution of scores across groups, particularly in the comparison group.

Levene’s test for equality of variances between groups was also significant for all 40 items.

As a result of these preliminary analyses, chi-square analyses were deemed more appropriate than t-tests for assessing the relationship between stress ratings and group status.

The Bonferroni correction was again used to control for error rates with statistical significance set at p < .001.

Extension Study: Item Analysis of the DBSI Stress Degree Measure

Significant differences were found for 33 of the 40 items on the Stress Degree subscale (p < .001), suggesting that parents of children with ADHD reported significantly higher levels of stress on each of these 33 items.

Overall, Cramer’s V values, suggested that the strength of the association between group status and degree of stress endorsed, ranged from .20 to .55.

Replication and Extension: Summary

Findings from this replication study suggest that the DBSI continues to show evidence of acceptable item-total correlations and strong internal consistency, as evidenced by Cronbach’s coefficient alpha of .90 for the Stress Experience index and .93 for the Stress Degree index.

These results are very similar to unpublished results found by Johnson and Reader in analyses of their original combined sample (coefficient alphas of .94 and .96, respectively).


Overall DBSI scores showed good discriminative validity in differentiating between the ADHD and the comparison group.

As predicted, mean scores on both the Stress Experience and Stress Degree scales were significantly higher for primary caregivers of children with ADHD compared to caregivers in the comparison group.

These results confirmed initial predictions, and replicate the results from the original Johnson and Reader (2002) study.

The results are also consistent with previous studies that have found higher levels of stress, assessed by other methods, in primary caregivers of children with ADHD (Breen & Barkley, 1988; DuPaul, et al., 2001; Mash & Johnston, 1983).


Finally, item analyses of the 40 individual items making up the DBSI suggest that the vast majority of the items (e.g., 33 of 40) are valuable in terms of discriminating between children with and without ADHD.

Such findings, along with the initial study, seem to provide additional support for the item structure of the DBSI and its potential usefulness as a clinical and research measure with this clinical population.

Family Correlates of ADHD-Related Stress: Some Very Preliminary Findings

Given preliminary findings from two studies supporting the validity of the DBSI as a measure of ADHD-related stress, we have begun to focus our efforts on collecting initial data on the relationship between DBSI scores and measures of family functioning.

To date, we have obtained preliminary data on a very small sample of children with Combined type ADHD and have begun to look at the associations between DBSI stress indices and 1) ADHD symptom severity measures, 2) PSI Parent Domain Measures, and 3) Indices of marital satisfaction

Family Correlates of ADHD-Related Stress: Preliminary Findings

Participants (N = 31) consisted of parents of children seen for psychological evaluation and/or treatment through the UF Interdisciplinary ADHD program or through the UF Psychology Clinic, based in Shands Teaching Hospital.

All had received a DSM-IV diagnosis of ADHD (combined type) as a result of a comprehensive psychological evaluation.

Family Correlates of ADHD-Related Stress: Participants

N = 31; 2 fathers, 27 mothers, 1 Grandmother, 1 Other Guardian)

Medication: 87% on medication for ADHD Ethnicity: 77.4% Caucasian, 16.1% African

American, 6.5% Latino American Caregiver Age: M = 38.19, SD = 9.86 Child Gender: 55% males, 45% females Child Age: M = 8.48, SD = 2.47

Relationship Between ADHD Symptom Severity & DBSI Stress Scores

CPRS-R:L Subscale Stress Experience Stress Degree

ADHD Index .383* .505**

DSM-IV Inattentive .381* .531**

DSM-IV Hyperactive/ Impulsive .450* .588***p<.05, **p<.01

Note. Here it was predicted that there would be a positive and significant relationship between level of ADHD symptom severity and DBSI Family stress indices.

Relationships between DBSI Stress and Indices of Parent and Marital Functioning

PSI Subscale Stress Experience Stress Degree Scale

---------------------------------------------------------------------------------PARENT MEASURES

Social Isolation .338 .396*Role Restriction .353 .437*Relation/Spouse .429* .503**---------------------------------------------------------------------------------*p<.05, **p<.01, ***p<.001Note. Other PSI Parent Domain measures were non-significant

The DBSI Stress Degree Scale also significantly correlated with the Dyadic Consensus (r=-.41, p<.05) and Affectional Expression (r=-.50, p<.05) Subscales from the Dyadic Adjustment Scale.

Dimensions of ADHD Related Stress: Factor Structure of the DBSI

Despite reasonable preliminary support for the validity and reliability of the DBSI, questions remain regarding the factor structure of the DBSI and the specific dimensions of ADHD-related stress assessed by this measure.

The potential multidimensional nature of this measure is of interest as the DBSI includes a range of items, presumably reflective of different types of stressors experienced by families of children with ADHD.

Should it be possible to define meaningful, reliable, and well-validated dimensions of behavior-related stress, it would be possible to investigate the relationships between overall levels of ADHD-related stress and family functioning and study relationships between specific dimensions of family stress and specific aspects of family functioning.


Gaining information regarding existing dimensions of ADHD-related stress is also important in terms of developing a measure that is optimal for treatment planning.

Since ADHD-related stress appears to have a negative impact on family functioning, it seems important to consider the possible development of adjunctive treatment approaches to minimize family stress and reduce it’s impact on family functioning.

Multidimensional measures that yield information regarding specific dimensions of stress experienced by a specific family may be more valuable in developing targets for treatment.

The present investigation represented an attempt to define a factor structure representing meaningful reflected in parent response to DBSI items. dimensions of ADHD-related stress

Factor Structure of the DBSI: Participants

Participants were parents of 246 children aged 4 to 15 years-old.

Of these, 127 were parents of children with ADHD (115 mothers and 12 fathers; Child Age: M = 8.77, SD = 2.69; Gender: 76% males, 24% female)

Children in this group had all received a DSM-IV diagnosis of ADHD based on a thorough psychological evaluation.

Participants also included parents of 119 children drawn from the general population (Child Age: M= 8.17, SD= 2.57; Child Gender: 50% male, 50% female)

Children in the non-ADHD group did not have a diagnosis of ADHD or other psychological disorder, based on parent report.


Analyses involved a principal axes factor analysis with Promax (oblique) rotation.

An oblique rotation was selected, as it was believed that factors would be reasonably correlated , as all tap the related dimension of ADHD family stress.

Data provided by participants on the DBSI Stress Experience scale was not considered in these analyses as this data involves dichotomous reports of the experiencing of specific stressors.

Present findings are based on analyses derived from the DBSI Stress Degree scale, which provides parental ratings (on a four-point scale) of the stressfulness of experienced events.


A determination of the number of factors to rotate in these analyses was made by inspection of the pattern of eigenvalues (Kaiser Criterion) and examination of the resulting scree plot (Cattell, 1966).

A subsequent principal axes factor analysis, with normalized Varimax rotation (orthogonal) was also accomplished for purposes of comparison with the results of the Promax solution.


As noted above, initial analyses involved a principal axis factor analysis followed by an oblique Promax rotation.

The number of factors with eigenvalues > 1.0 was initially considered.

A total of eight factors met these criteria, which together accounted for 65.44 % of the variance.

Since this method has been shown to frequently result in an excess number of sometimes uninterpretable factors, it was desirable to also inspect the scree plot of eigenvalues.

It was assumed that, taken together, these two methods were likely to provide the upper and lower bounds on the number of meaningful factors, respectively.

Inspection of the scree plot suggested the likelihood of between two and three interpretable factors.

Factor Structure of the DBSI: Scree Plot

Scree Plot

Factor Number

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Dimensions of ADHD Related Stress: Initial Two-Factor Solution

An extraction of two rotated factors was initially accomplished.

Factor 1, composed of 24 items with factor loading in excess of .40, appears to represent a constellation of Social and Interpersonal Stressors, experienced by families of children with ADHD.

Factor 2, labeled Academic/School Stressors, was composed of 12 items with factor loading exceeding the .40 factor loading cut-off.

While this factor had a significant number of high loading items, dealing specifically with school-related issues, there were also a number of non-academic/school items.

Dimensions of ADHD Related Stress: Three-Factor Solution A subsequent analysis yielded an interpretable

three-factor solution with a 14-item Social/Interpersonal stressor factor.

Also extracted was an 11-item Academic/School stressor factor, similar to those found in the analyses described above.

This three-factor solution also resulted in the extraction of a third interpretable factor, labeled Family Functioning stress, composed of four items with factor loading above .40.

This latter factor reflects the relevance of ADHD-related stress as it is experienced in, and may impact on, the home environment.

Inspection of the following tables highlights item content and corresponding factor loadings for the three factor solution.

Three Factor SolutionFactor I: Social and Interpersonal Stressors

DBSI Factor Factor Loading Social/Interpersonal Stressors 1 2 3 Being unable to take your child to public places .949 -.128 -.064 Having to miss important social events because of your child’s behavior .803 -.015 .098 Not being able to go out to eat because of your child’s behavior .699 -.050 .067 Dealing with complaints from neighbors about your child’s behavior .665 -.047 -.070 Not being able to take your child shopping because of his/her behavior .652 .009 .025 Not being able to leave your child with a baby-sitter .606 .010 .069 Not being able to work outside home because of your child’s behavior .589 -.076 .125 Having to miss or leave church because of your child’s behavior .579 -.146 .163 Dealing with complaints from other parents about your child’s behavior .515 .069 .046 Not being able to get to bed at a decent hour because of child’s behavior .506 -.105 .336 Having your child embarrass you in front of others .486 .286 .054 Having to watch your child so he/she doesn’t get in trouble .476 .308 .029 Not knowing how to explain your child’s behavior to others .446 .316 -.006 Being concerned about your child being injured .436 .041 .131

Three Factor SolutionFactor II: School and Academic Stressors

DBSI Factor Factor Loading Academic/School Stressors 1 2 3 Dealing with your child’s academic difficulties -.422 .896 .302 Calls from school regarding your child’s behavior problems .315 .789 -.448 Dealing with teachers’ complaints about your child .135 .787 -.249 Calls from school regarding your child’s academic problems -.047 .748 -.002 Conflicts with your child over homework -.195 .740 .163 Spending an excessive amount of time helping your child with homework -.146 .674 .215 Difficulties finding professional services for your child .193 .557 .064 Having to explain your child’s behavior to others .294 .551 -.056 Not knowing how to deal with your child’s behavior .192 .507 .045 Difficulties getting school-based services for your child .027 .481 .236 Having to miss work because of your child’s problems .123 .422 .059

Three Factor SolutionFactor III: Home and Family Related Stressors

DBSI Factor Factor Loading Family Functioning Stressors 1 2 3 Disagreements with spouse about managing your child’s behavior -.148 .025 .584 Not being able to spend enough time with your other children .227 -.167 .580 Having less time with partner because of your child’s behavior .213 .003 .579 Not getting work done at home because of your child’s behavior .308 .113 .429

Dimensions of ADHD Related Stress While the factor analytic findings described here

must be considered preliminary in that they need to be replicated with a larger sample, they do seem to provide support for viewing the DBSI as a multidimensional measure.

Additional research, building on this initial study, should provide the basis for further investigations that focus on the specific types of ADHD-related stressors that may relate to specific types family difficulties.

This research should also enhance the usefulness of the DBSI as a clinical assessment tool in terms of its providing more detailed clinical information regarding the varied nature of behavior-related stressors that may impact on family functioning.

An Overview & A Look to the Future Overview

The DBSI as a clinical/research measure The DBSI as a treatment outcome measure

The Future: More work on the correlates of ADHD stress with more varied

measures of family functioning and larger samples Work that addresses the relationship between empirically

derived dimensions of ADHD family stress and family functioning Work focusing on the role of varied comorbid conditions as

contributors to family stress The use of the DBSI with other disruptive behavior disorders DBSI Norms Perhaps developing adjunctive family stress interventions

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