Relation between Attention Deficit Hyperactivity Disorder Among School Age Children and Parent's Stress and Sense of Competence

Introduction

Attention deficit hyperactivity disorder (ADHD) is the most common neurobehavioral disorder of childhood characterized by persistent hyperactivity, impulsivity and inattention and it considers one of the leading diagnosed disorders in school age children around the world; it affects children and can continue into adulthood(1). The symptoms of ADHD are present for six months or more to a degree that is much greater than others of the same age and cause problems in at least two settings (such as school, home, or recreational activities) in order to receive a diagnosis of ADHD (2).

ADHD is thought to be the result of complex interactions between genetic, environmental and neurobiological factors. The Diagnostic and Statistical Manual of Mental Disorders (DSM -5) indicated that there are three subtypes of ADHD of which an individual can be classified into predominantly inattentive type, predominantly hyperactive-impulsive type and combined type. (3) The effects of ADHD are not confined to the individual alone but go beyond and can affect his/her immediate social context, especially the school and family context. (4)

The demands of parenting are usually associated with some stress and elevated levels of stress may affect the parent–child relationships and parenting practices. This is especially the case of families have children with special needs conditions or disorders like ADHD. (5) Moreover, parent caregiver experience is impacted by the needs, expectations and distress of a child with ADHD. As primary caregiver parents of children with ADHD face two major challenges: caring for their child with disabilities, which includes management of problematic behavior and balancing their own stress while overseeing the well-being of the rest of the family. (6)

Parental sense of competence is related to specific parenting behaviors, great breadth of knowledge regarding child development and are more likely to express flexible, less authoritarian child-rearing beliefs and great use of proactive techniques to handle child behaviors and less use of punitive responses. (7) Moreover, parents’ perceptions of their roles as parents significantly impacts their interactions with their children. (8) Children with ADHD makes parent's hard to concentrate, also make them feel irritable, restless and might have more trouble controlling their temper, planning things out, or sticking to a schedule. All these things may affect their roles as parents and their sense of competence (9).

             Nurses have an important role in relation to parents with a child who has ADHD. They are responsible for revealing early signs of special needs in children to follow-up and give support to those children and their parents. Nurses observe, assess and interact with the child and parents to collect the data needed to establish an accurate mental health diagnosis (10).

Significance of the Study

Attention-deficit/hyperactivity disorder (ADHD) is a common neurobehavioral condition which affects 5% to 10% of the pediatric population worldwide. The rate of prevalence is 11 %, and has increased throughout even recent years—from 7.8 % in 2003 to 9.5 % in 2007 and to 11.0 % in 2012. This involves an increase of 3 % per year since 1997. (11) In Egypt, few studies investigated the epidemiology of ADHD, the reported prevalence of ADHD among primary school children ranged between 6.5% and 8% in Menoufia Governorate (12), the overall prevalence of ADHD was 6.5% in Minia Governorate among sample of school children (ages: 4 to 12 years) (13).

The children of ADHD have aggressive behaviors contribute to diminish academic and social functioning and its impact on quality of life for their families. Parents with children of ADHD feel aggression and violence toward these negative behaviors and the demands of their children. The family need emotional support and must make adjustment to care for their needs; modifying their behaviors and performing daily living activities toward their children. So, this study aimed to assess relationship between attention deficit hyperactivity disorder among school age children and parent's stress and sense of competence.

Aim of the Study

This study aimed to assess the relation between attention deficit hyperactivity disorder among school age children and parent's stress and sense of competence.

Research Questions:

• What is the strength of the relationship between ADHD and parent's stress?
• What is the strength of the relationship between ADHD and sense of competence?
• Is there a relation between parent's stress and sense of competence?

Subjects and Method:

Research Design

A descriptive correlational research design was used in this study.

Research Setting:

This study was conducted at the children and adolescent outpatient clinic of Minia hospital for psychiatric health and addiction treatment .The outpatient clinic works two days per week (Monday, and Wednesday from 9 am to 12 pm). The hospital serves Minia governorate and its districts.

Sample

A convenience sample of 100 children and their parents were included in the study.

Inclusion Criteria

• For parents:-
  • Both Gender.
  • Parents having children with ADHD.
  • Parents agree to participate in the research.
  • For children:-  
    • Age of child ranges from (6-12) year. 
    • All children diagnosed with all types of ADHD by the psychiatrist responsible for treatment using Diagnostic and Statistical Manual of Mental Disorders (DSM 5) as diagnostic criteria.

Exclusion Criteria:-

• For parents: - Signs of major medical condition, mental retardation, psychosis, and bipolar disorder.
• For children:-       
  • Children who were diagnosed as (mentally retarded, autistic disorders, conduct, oppositional and deviant disorder) would be excluded from the study.

Data collection tools:-

The following tools were utilized for collecting data in this study.

1-A Structured Interviewing Questionnaire: It was developed by the researcher and revised by supervisors which divided into two parts include data about ADHD children and their parents.

Part I: personal data of parents: such as parents age, gender and level of education, occupation, family history, family size and residence.

Part II: personal data of child: such as child age, gender, school grade and child’s behavior with family.

2-Parent disruptive behavior disorder (DBD) Rating Scale (Mainly for ADHD)

Parent disruptive behavior disorder (DBD) Rating Scale (Mainly for ADHD) it was developed by Pelham (1992). It contains 45 items for (ADHD, conduct disorder, oppositional disorder). The researcher selected 18 items to assess of inattention type; hyperactivity type and combined type of ADHD. This scale includes inattention symptoms 9 items six or more items must be endorsed on the parent DBD to meet the criteria for diagnosis of Attention-Deficit/Hyperactivity Disorder Predominantly inattention Type. Impulsivity / Over activity symptoms 9 items six or more items must be endorsed on the parent DBD to meet the criteria for diagnosis of Attention-Deficit/Hyperactivity Disorder Predominantly Hyperactive-Impulsive Type. 

If 6 or more items are endorsed for Attention-Deficit/Hyperactivity Disorder – inattention type and 6 or more items are endorsed for Attention Deficit/Hyperactivity Disorder-hyperactivity/impulsivity type, then criteria is met for Attention Deficit/Hyperactivity Disorder, Combined Type. The scoring system  was as the following 4-point likert scale. Not at all = 0, Just a Little = 1, Pretty Much= 2, and Very much = 3, scores of the items sum –up. Total score for (DBD) ranged from (0-54), Low level ranged from (0-18), moderate level ranged from (18-36) and high level ranged from (37-54). (14)

3-Parenting Stress Index -short form scale (PSI/SF)

  It was developed by (Abidin, 1995) and utilized to measure stress associated with parents of children with Attention Deficit Hyperactivity Disorder younger than 12 years of age. It was composed of 36-items with three subscales. Each item was rated on a 5-point Likert-type scale anchored by 1 Strongly Disagree” to 5 = “Strongly Agree”. It contains three subscales (parental Distress subscale 12 items, Parent-Child Dysfunctional Interaction subscale 12 items, and Difficult Child subscale 12 items. The total score for (PSI/SF) ranged from (36-180), Low level ranged from (36-84), moderate level ranged from (85-132) and high level ranged from (133-180). (15)

4-Parent Sense of Competency Scale (PSOC)

Parent Sense of Competency Scale was developed by (wellston 1978). The PSOC consisted of 17 items. Each item was rated on a 6 point Likert scale anchored by 1 = “Strongly Disagree” to 6 = “Strongly Agree. Nine (9) items on the PSOC are reverse coded. System score ranged from (17-102). A higher score indicates a higher parenting sense of competency (60-102), Low score indicates Low parenting sense of competency (17-59). (16)

Content Validity

These  tools were translated into Arabic language and the content validity of the translated tools were checked and back translation technique was done by  five panels of experts in psychiatric nursing to test the content validity of the tools (Assuit and Cairo Universities, Faculty of Nursing, Psychiatric Nursing department) and the necessary modifications were done.

Reliability

 Internal consistency was measured to identify the extent to which the items of tools measure the same concept and the extent to which the items are correlated with each other. Internal consistency estimated reliability by Cronbach's alpha coefficient. Cronbach's alpha coefficient of 0.00 indicated no reliability and a coefficient of 1.00 indicates perfect reliability.

Pilot Study

Pilot study was conducted on 10 parents having children with ADHD (10%) who met the inclusion criteria to investigate and ensure the feasibility, objectivity, applicability, clarity and adequacy of the study tools and to determine possible problems in the methodological approach or tool. The results of the pilot study used to test the proposed statistical and data analysis methods. The tools were completed without difficulty, adding support to the validity of the instrument. The time needed to complete the tool was 30-45 minutes according to the needed explanation. No modifications were done in the study tools based on the pilot study and the sample was included to the total study sample.

Methods of data collection

An official permission was granted from the dean of the faculty of nursing Minia University directed to the head of psychiatric health and addiction treatment at Minia Hospital. Children with ADHD and their parents were interviewed and oral consent was obtained on individual basis to explain the nature and purpose of the study. A structured interview was conducted in one room of the out-patient clinic; questions were asked and recorded by the researcher. Measures were taken to protect patient's ethical rights. Data were collected by using a socio-demographic data sheet, Parenting Stress Index (PSI) and ADHD Symptoms Checklist, The researcher was available at the outpatient unit 2 days per week (Monday, and Wednesday from 9 pm to 12 pm). The researcher conducted interviews with all Children with ADHD and their parents and collected data from them; interview taken about 30-45 minutes depending on the degree of understanding and responses of the respondent. Data collection was conducted over a six months’ period extending from March 2018 till Augusts 2018.

Each parent was interviewed individually, after explaining the purpose of the interview and getting agreement of the mother to participate in the research. The researcher assured the voluntary participation and confidentiality to each subject who agreed to participate. The questionnaires were read, explained to the studied sample and the responses were recorded by the researcher for eliminating the systematic error and for more validation of the parent's information, the child's files were revised to help in completion of the needed information.

Ethical consideration

A written initial approval was obtained from the research ethical committee of the Faculty of Nursing, Minia University. Oral informed consent was obtained from the parents after explaining the nature and benefits of the study. Each assessment sheet was coded and patient's name was not appearing on the sheets for the purpose of privacy and confidentiality.  Children and their parents were assured that they could withdraw at any time from the current study without any effect on their treatment and care.

Statistical Analysis:

   The collected data were coded, categorized, tabulated, and analyzed using the Statistical Package for the Social Science (SPSS 20.0). Data were presented using descriptive statistics in the form of percentages, frequency, mean and standard deviation. Inferential statistical tests of significance such as Friedman’s ANOVA, Pearson correlation, and independent t-test were used to identify group differences and the relations among the study variables. Level of significance at p < 0.05 was used as the cut off value for statistical significance.

Results

Table (1):- Socio-demographic characteristics of the parents having children with ADHD (n=100).

Table (1):  showed that, less than half (45 %) of the parents were at the age group from 31 – 40 years and more than three quarters of them (79%) had 4-6 of the family number. Also, this table presented that (48%) of the parents were illiterates. In addition, most of the studied sample (77%) didn't have past history of attention deficits hyperactivity disorders and the majority (83%) of them live in rural area.

Table (2):- Socio-demographic data of ADHD child (N=100).

Table (2):- demonstrated that, more than half (61%) of children with ADHD were at the age group from 6 – 8 years. Also, this table showed that less than half (49%) of them were in the first school grade and only (3%) of them were in six school grade. In addition, the majority of the study sample (93%) lived with both parents, and (61%) of them had aggressive behaviors.

Table (3): Frequency distribution of ADHD level among children (N=100)

Table (3) demonstrated that, more than three quarters of the children (76.9%) had high level of ADHD according to the combined type. While (60%) had moderate level according to hyperactivity type. In addition, (57.1%) had moderate level according to inattention type.

Figure (1): Types of ADHD

Figure (1) showed that, more than three quarters of the children had combined type of ADHD (78%).

Table (4): Differences between ADHD and parents socio-demographiccharacteristics (N=100)

Statistically significant difference (*P value < 0.01)

Table (4) revealed that, there were statistically significant differences between gender and history of disease regarding ADHD (P = .002& 0.004 respectively) and it was observed that, the highest mean score of ADHD was among females (9.10 ± 28.7).

Table (5) :Frequency distribution of parent's stress regarding to the level of the parenting stress index (N=100)

Table (5): demonstrated that, more than two thirds (70.3%) of the parents had high level of stress.In addition the total mean score of the parenting stress index scale was (137.3+5.32).While, only (28%) of them had a moderate level of stress and the mean score was (45.6+6.40).

Table      (6): Differences between parent's stress and parent socio-demographic characteristics (N=100)

*P< 0.01 Significant                                               **P<0.001 highly significant     

Table (6) showed that, there were highly statistically significant differences between parent's gender and job regarding parent's stress (p≤0.000 &0.013 respectively). While, it was observed that the highest total mean score was among female parents (15.9 ±142.1), not working parents (17.4 ± 139.4), parent with history of ADHD (14.3 ± 138.7) and parents living in urban area was (9.95 ±140.4).

Table (7): Frequency distribution of parents competence regarding to level of the parents sense of competence (N=100).

Table (7) demonstrated that, the majority (87%) of the parents had children with ADHD were not competent. While, (13%) of them were competent.

Table (8): Differences between parent's sense of competence and parent's socio demographic data

(Significant at *P< 0.05   ).

Table (8) illustrated that, there were statistically significant differences between gender and job regarding parent's sense of competence (p≤0.03& 0.032 respectively). While, there were no statistically significant differences between history of disease and place of living regarding parents sense of competence.

Table (9) the correlation between ADHD and parents stress and parents sense of competence (n=100)

Table (9) illustrated that, there were highly significant positive correlations between hyperactivity type, combined type and total ADHD with inattention type. Also, there were significant positive correlations between combined type and total ADHD with hyperactivity type. Moreover, there were significant positive correlations between combined type and total ADHD.

In addition, this table showed that, there were highly significant positive correlations among subscales of parenting stress (parent distress subscale, parent child dysfunctional subscale, difficult child subscale) and all types of ADHD (inattention type, hyperactivity type, and combined type). At the same line, there were highly statistically significant positive correlations was found between total ADHD and total parent stress (r=.269, p=.007).while, there were highly significant negative correlation were found between parent's sense of competence and subscales, total parents stress.