Australian and New Zealand Journal of Psychiatry http://anp.sagepub.

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Parental and Family Factors for Attention-deficit Hyperactivity Disorder in Taiwanese Children
Susan Shur-Fen Gau Aust N Z J Psychiatry 2007 41: 688 DOI: 10.1080/00048670701449187 The online version of this article can be found at: http://anp.sagepub.com/content/41/8/688

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Parental and family factors for attention-decit hyperactivity disorder in Taiwanese children
Susan Shur-Fen Gau

Objective: The present study aimed to examine the association between attentiondeficit hyperactivity disorder (ADHD) and maternal psychological distress, parenting style and perceived family support, and the childs interaction with parents and behavioural problems at home in Taiwan. Methods: The sample included 375 medicated pediatric patients with DSM-IV ADHD, and 750 school controls selected based on the age and gender structures of the ADHD group. Mothers reported on the Chinese Health Questionnaire, the Chinese versions of the Parental Bonding Instrument, the Family Adaptation, Partnership, Growth, Affection, and Resolve, and the Home Behaviours of the Social Adjustment Inventory for Children and Adolescents. Results: Mothers of children with ADHD reported greater psychological distress and perceived less support from their families than did mothers of controls. Moreover, mothers of children with ADHD were less affectionate and more overprotective and controlling toward their children than were mothers of controls. This difference was more apparent in boys than in girls. Children with ADHD were less likely to interact with their parents, yet demonstrated more severe behavioural problems at home. Conclusions: Although the Taiwanese children with ADHD were under treatment with methylphenidate, they and their families still encountered a variety of difficulties in interaction, support, and communication with each other. Therefore, the parental approach should be integrated into the medication treatment for ADHD in Taiwan. Key words: attention-decit hyperactivity disorder, family support, maternal psychological distress, parent child interaction, parenting style. Australian and New Zealand Journal of Psychiatry 2007; 41:688 696

Attention-deficit hyperactivity disorder (ADHD) has been recognized as an early onset neuropsychiatric disorder with typical core symptoms of inattention, hyperactivity, and impulsivity [1], lasting until adolescence and even adulthood [2]. Due to its high prevalence in Western countries at 5 10% [3], and in

Susan Shur-Fen Gau, Attending Staff Psychiatrist, Department of Psychiatry, National Taiwan University Hospital and Associate Professor, Department of Psychiatry, College of Medicine, National Taiwan University Department of Psychiatry, National Taiwan University Hospital and College of Medicine, No. 7, Chung-Shan South Road, Taipei 10002, Taiwan. Email: gaushufe@ntu.edu.tw Received 7 April 2007; accepted 14 May 2007.

Taiwan at 7.5% [4], and its persistent, pervasive behavioural problems and associated academic underachievement [5,6], an investigation of the extent of its influence on a variety of domains of parental and family function, in addition to the well-known shortterm and long-term impacts of ADHD on individuals [6,7], is warranted. Western studies suggest that the presence of ADHD in children is associated with varying degrees of disturbances in family and marital functioning [8,9], disrupted parent child relationships [8], high parental expressed emotion [10], more negative and conflicting communication [11], reduced parenting self-efficacy [12], increased levels of parenting stress

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[13,14], maternal psychological stress [14,15], and parental psychopathology [8,16 18], particularly when ADHD is comorbid with conduct problems [19]. Both inattentive and hyperactive/impulsive symptoms are equally challenging to parents [10,20]. Although these parental/family processes may not cause the onset of ADHD, they have been reported to contribute to the severity [21] and persistence [22] of ADHD symptoms, adherence to treatment [23], psychiatric comorbidities [21,24], and long-term outcome [25]. Western literature has documented the impact of ADHD on family functioning, and the latter may modify the course of ADHD [26]; but little is known about the parental/family processes in relation to children with ADHD in non-Western countries. Ethnic Chinese families in Taiwan are greatly influenced by Chinese culture with its Confucian tradition, which emphasizes the patriarchal family, the family over the individual, childrens obedience, childrens academic achievement, and hierarchical relationships and responsibilities [27]. Like mothers in Western culture, Chinese mothers have the primary responsibility for child care, and are subjected to most of the difficulties of their childrens ADHD symptoms and poor school performance [27,28]. It is expected that having a child with ADHD would be a big challenge for ethnic Chinese parents, particularly mothers. In view of this, the present study aimed to examine the mothers psychological distress, parenting styles, and perceived family support, and the childs active interaction with parents and behavioural problems at home; and to identify the most correlated parental/family factors for ADHD among a large sample of clinical patients with ADHD, as compared with school-based controls. We anticipated that given the nature of the early onset of ADHD and its core symptoms within the context of ethnic Chinese families, raising a child with ADHD should have increased maternal psychological distress and adverse parental and family processes.

purpose and procedure of the study; there was no obligation to participate in the present study, and reassurance of confidentiality was given in a letter from the investigator before recruitment.

Patients with ADHD

The clinical sample included 375 patients (329 boys and 46 girls), with a mean age of 10.792.9 years. There was no age difference between male (10.792.9 years) and female children (10.692.7years) with ADHD (p 0.1); 274 clinical subjects were recruited consecutively from the psychiatric clinic of a medical center and 101 were recruited through the ADHD Educational Foundation in Taiwan from October 2003 to December 2003. The inclusion criteria for the ADHD group included 6 15-year-old children with a clinical diagnosis of DSM-IV ADHD and/or ICD-10 hyperkinetic disorder, who had been treated with immediate-release methylphenidate (IR MPH) for at least 6 months; and whose mothers were able to complete the questionnaires. Those ADHD patients who were under treatment for psychiatric disorders other than oppositional defiant disorder and conduct disorder, and/or systemic disease, were excluded from the study. Because mothers are the main caregivers of children in Taiwan and most clinical subjects were accompanied by their mothers during their visits, mothers of all the subjects were asked to complete the questionnaires about their psychological distress, parenting, and perceived family support, and their childrens behaviours with them.

School controls
The original school-based population consisted of 2584 grades 1 9 students from 108 classes in Taipei, in which all the students were recruited using a multiple stage sampling method. The sampling has been described elsewhere [29]. Parents and teachers reported on the Chinese versions of the Conners Parent Rating Scale Revised: Short Form (CPRS-R:S), and the Conners Teacher Rating Scale-Revised: Short Form (CTRS-R:S), respectively [29]. Each of the CPRS-R:S, a 27-item parent-reported rating scale, and the CTRS-R:S, a 28-item teacher-reported rating scale, consist of four subscales: the Inattention, Hyperactivity, Oppositional, and ADHD Index subscales with items rated on a 4-point Likert scale from 0 for not true at all (never, seldom) to 3 for very much true (very often, very frequent) [30]. According to the sex and age structures of the ADHD group, 750 control students were randomly selected from the original school-based subjects whose t-scores on the CPRS-R:S and CTRS-R:S were B70 at the ratio of 1 case to 2 controls.

Methods Sample recruitment

The Institutional Review Board of the Department of Health, Taiwan, and National Taiwan University Hospital approved this study prior to the recruitment of clinical subjects and multistage sampling of school controls in September 2003. Written informed consent was obtained from parents and teachers of school-based subjects and parents of clinical subjects after explanation of the

Diagnosis of ADHD
The diagnoses of ADHD were made based on clinical interviews in accordance with the diagnostic criteria of DSM-IV ADHD and ICD-10 hyperkinetic disorder, and further confirmed by the ADHD supplement from the Schedule for Affective Disorders and Schizophrenia for School-Age Children Epidemiologic Version (Kiddie-SADS-E). The Chinese Kiddie-SADS-E has been

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widely used in epidemiological studies on childhood and adolescent mental disorders in Taiwan [4,31]. The clinical diagnosis was made by board-certified child psychiatrists with extensive clinical research experience, who obtained information from parent and child interviews, observation of childs behaviours, and rating scales reported by parents and teachers. The first assessment took around 1.5 2 h. The final clinical diagnosis was made usually after at least three visits of assessment. Methylphenidate and behavioural therapy were the main treatment modalities. In general, methylphenidate was prescribed to those patients with either DSM-IV ADHD combined type or ICD-10 hyperkinetic disorder. The exclusion criteria for the ADHD group have minimized the heterogeneity of the ADHD group.

aggression toward parents. The psychometric properties of the Chinese SAICA have been described elsewhere [38].

Chinese version of the Family APGAR

Family APGAR, a 5-item measure, is designed to assess the five dimensions of perceived family support by asking whether I am satisfied (i) with the help that I receive from my family when something is troubling me (Adaptation), (ii) with the way my family discusses items of common interest and shares problem-solving with me (Partnership), (iii) that my family accepts my wishes to take on new activities or make changes in my lifestyle (Growth), (iv) with the way my family expresses affection and responds to my feelings such as anger, sorrow, and love (Affection), and (v) with the amount of time my family and I spend together (Resolve). Each item was rated on a 3-point Likert scale: 0, hardly ever; 1, some of the time; 2, almost always. A higher score indicates a more highly functional family [39]. The Chinese Family APGAR has been used in assessing perceived family support for individuals with mental problems [40] and for student populations in Taiwan [39].

Measures Chinese Health Questionnaire

The Chinese Health Questionnaire (CHQ), a 12-item selfreporting questionnaire modified from the General Health Questionnaire [32], includes symptoms of anxiety, depression, insomnia, and somatic complaints, and has been widely used to identify those who have minor psychiatric disorders in primary care and the community in Taiwan [33].

Statistical analyses
Statistical analyses were performed using SAS 9.1 (SAS Institute, Cary, NC, USA) and RTREE statistic software [41,42]. The descriptive results of comparing the demographics between the case and control groups were demonstrated in frequency, percentage, and x2 statistics for categorical variables; and mean, SD, and t statistics for continuous variables. Analysis of covariance was used to compare the mean scores of parental and family measures between the ADHD and control groups with control for parental age and educational level. The maternal CHQ score was controlled in the model for the analysis of parenting, home behaviours, and perceived family support. Cohens d was used to compute the effect size (standardized difference between the two means) for the two groups [43]. Three-way interactions between sex and school grade levels and the other covariates, as well as two-way interactions between sex or school grade level and the other covariates and all the main effects from parental and family measures were tested in the multivariate logistical regression model with backward selection to identify most associated parental and family factors for ADHD. RTREE statistical software was used to conduct a tree-based risk factor analysis, a non-parametric multivariate statistical method [41]. Its advantages over parametric multivariate modelling include the fact that it requires no assumption regarding a linear combination of explanatory variables; it is easy to assess the interaction or effect modification because no a priori contrast needs to be specified; it can deal with missing data; and it is suitable for hypothesis-generation analyses. Thus, it provides an integrated picture of explanatory factors that interact with each other, and defines subgroups that are at higher or lower risk. The x2 test was used to prune the regression tree. The critical value of x2 test statistics at 1 df was presented, and a probability 0.01 was used to prune the tree. The odds ratio (OR) and 95% confidence intervals (CI) were provided for each splitting variable based on the Cochran-Mantel-Haenszel test. The aforementioned independent

Chinese version of the Parental Bonding Instrument

The Parental Bonding Instrument (PBI) is a 25-item instrument (item-rated on a 4-point Likert scale from very likely to very unlikely) measuring parenting styles during the childs first 16 years with three principal dimensions: care/affection (12 items), overprotection (seven items) and authoritarianism (six items) [34]. A high score on the care/affection subscale reflects affection and warmth, while a low score indicates rejection, or indifference. Overprotection reflects overprotective parenting and denial of the childs psychological autonomy; authoritarianism reflects the degree of parental authoritarian control over the childs behaviour [35]. The reliability and validity of the Chinese PBI has been described elsewhere [36].

Chinese version of the Social Adjustment Inventory for Children and Adolescents
The Social Adjustment Inventory for Children and Adolescents (SAICA), a 77-item scale, is designed for parental reporting about their childrens four domains of functioning [37]. A higher mean score (items rated on 4-point Likert scale from 1 to 4) indicates either poorer social functioning or a more severe social problem [37]. Interactions with mother and father, and problems at home were the three selected dimensions of Home Behaviours for this study. Items for the Interactions with Mother (Father) included Does things with mother (father), Is friendly/affectionate toward mother (father), and Talks with mother (father). Items for the Problems at Home included Reject parents instruction, Risky behaviours at home, Destroys household property, and Physical

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variables were used to distinguish the ADHD group from the control group.

Results Sample description

There was no difference in sex and age distributions between the ADHD group (329 boys and 46 girls, mean age9SD 10.79 2.9 years) and school controls (658 boys and 92 boys, 10.69 2.5 years, F1,1122 0.77, p 0.38). The ratio of male to female was 7.2. Mothers of children with ADHD (college and above, 42.9%; senior high, 45.0%; junior high and below, 12.1%) were more highly educated than those of the controls (college and above, 40.3%; senior high, 39.3%; junior high and below, 20.5%; x2  11.95, df 2, p B0.003). Fathers of children with ADHD (college and above, 53.1%; senior high, 35.8%; junior high and below; 12.1%) were higher educated than those of controls (college and above, 49.4%; senior high, 30.5%; junior high and below, 20.1%; x2 14.41, df 2, p B0.001). Despite statistical significance (p  0.002) due to large sample size, there were similar ages between mothers of ADHD children (40.295.1 years) and mothers of school controls (39.294.8 years). There was no difference in fathers ages between the two groups (p 0.099).

Regarding the modification effect of age, the gap between the less maternal perceived family support in the ADHD group and the control group increased with the childrens age only in the domains of family adaptation (b 0.032, t 2.14, p 0.033). There was no interaction between age and ADHD status on other parental or family measures. Moreover, the magnitude of difference in parental and family measures between the ADHD and controls did not vary between boys and girls.

Final fitted model

Table 2 presents the OR and 95%CI for the parental and family variables significantly associated with ADHD after backward selection in the multivariate logistical regression model. The most significant correlates for ADHD were less active interaction with fathers and mothers, more severe behavioural problems at home, and maternal perception of less family support. Maternal psychological distress and parenting styles were not included in the final fitted model.

Multivariate analysis using tree-based regression model

Figure 1 presents the results of tree-based regression analysis. The circles represent internal nodes, including the root node. The internal node is defined as a node with daughter nodes. The square boxes represent terminal nodes, which are defined as nodes without any daughter nodes. The number of subjects with ADHD and controls, and the x2 statistic are shown inside the circles or square boxes. The identifying number of nodes and each terminal node are shown at the borders of nodes [44]. Figure 1 also displays the splitting variables and values for each note of the regression-tree model for the ADHD and control groups. Table 3 provides the OR and its 95%CI corresponding to each internal node in Figure 1. Figure 1 shows that behavioural problems at home was used to split the entire sample (the root node). Four pathways favour ADHD, as shown by the most significant terminal nodes (i.e., IV, VIII, IX, and X). One pathway comprised more problems at home with perception of less (NODE X) or more (NODE IX) family support measured by the Family APGAR. The other two pathways, given less severe behavioural problems at home were: one comprising less interaction with father, greater maternal distress, and greater maternal authoritarian control (Node VIII); and the other, given more interaction with father, less interaction with mother and less affectionate/caring parenting from mothers (Node IV). In short, the leading familial variables to distinguish the ADHD group from the control group included childs behavioural problems at home and less active interaction with his/her father, and decreased maternal perceived family support.

Individual effects
Table 1 presents the mean scores of the CHQ and the subscales of the Chinese PBI, Family APGAR, and Home Behaviours of the Chinese SAICA for the ADHD and control groups. The analyses were controlled for the parents current ages and education levels, and maternal CHQ score. Compared to the mothers of the controls, the mothers of children with ADHD had greater psychological distress, perceived less family support, and showed less affection/ caring parenting style (effect sizes ranging from 0.43 to 0.69). Compared to the controls, children with ADHD had less active interaction with their mothers and fathers and had more severe behavioural problems at home (effect sizes ranging from 0.78 to 0.85). Moreover, mothers of children with ADHD may have greater overprotection, and an authoritarian controlling parenting style toward their children than their counterparts with small effect sizes (Table 1).

Modification from age and sex

There was no sex or age difference in most of the parental/family measures (p 0.062 0.880) with the following exceptions. Boys had less active interaction with their fathers (p 0.003) and mothers (p B0.0001), and experienced more authoritarian control from their mothers (p 0.003) than girls. In terms of the age effect, increased age of subjects was associated with decreased affection/ care (p 0.0003) and authoritarian control (p 0.0018) from their mothers, and less active interaction with their mothers (p B0.0001) and fathers (p B0.0001).

Discussion The major findings of the present study are that many more boys than girls with ADHD were identified in clinical settings; and mothers of children with ADHD in Taiwan tended to report anxious/depressive

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Table 1. Parental and family measures

ADHD (n 375) (Mean9SD) 2.4192.71 25.7594.92 7.5093.53 7.3492.90 6.5692.88 1.2890.72 1.1790.71 1.3290.71 1.2590.71 1.5590.64 Control (n 750) (Mean9SD) 1.2791.96 28.1595.19 6.3394.50 6.4293.08 8.2892.35 1.6490.57 1.6290.58 1.6090.60 1.6190.58 1.8290.43

Measures Mothers reports on themselves Total score of CHQ$ Parental Bonding Inventory% Affection/care Overprotection Authoritarian control Family APGAR% Total score Adaptation Partnership Growth Affection Resolve Mothers reports on the children Home Behaviours of the SAICA% Active interaction with mother Active interaction with father Behavioural problems at home parents

Statistics F statistics***

Cohens d 0.48 0.47 0.29 0.28 0.65 0.55 0.69 0.43 0.56 0.50

F(1,1117) 59.73 F(1,1116) 50.53 F(1,1116) 17.45 F(1,1116) 18.34 F(1,1116) 69.08 F(1,1116) 53.24 F(1,1116) 81.69 F(1,1116) 24.47 F(1,1116) 47.93 F(1,1116) 38.58

1.7590.60 1.9890.71 1.6090.57

1.3390.46 1.4790.60 1.0990.20

F(1,1116) 132.82 F(1,1116) 116.24 F(1,1116) 387.54

0.79 0.78 0.85

ADHD, attention-deficit hyperactivity disorder; CHQ, Chinese Health Questionnaire; Family APGAR, Family Adaptation, Partnership, Growth, Affection, and Resolve; SAICA, Social Adjustment Instrument for Children and Adolescents.; $Controlling for subjects gender, and parents age and education levels; %controlling for subjects gender, parents age and education levels, and mothers CHQ score. ***All P B0.0001.

symptoms, to have less affectionate and probably more controlling/ overprotective parenting styles, to perceive less family support from their family, and to report that their children interacted less with them and the fathers and had more severe behavioural problems at home. The increased inappropriate parenting, Table 2. Final fitted model for ADHD
Odds ratio 1.74 95%CI (1.30 2.33) p B0.001

Less active interaction with father$ Less active interaction with father$ Behavioural problems at home$ Perceived family support%

1.57

(1.08 2.27)

0.018

31.35

(16.70 58.84)

B0.001

0.92

(0.86 0.98)

0.011

ADHD, attention-deficit hyperactivity disorder; CI, confidence interval.; $Measured with the Home Behaviours of the Chinese version of the Social Adjustment Instrument for Children and Adolescents; %measured with the total score of the Chinese version of the Family Adaptation, Partnership, Growth, Affection, and Resolve (Family APGAR).

parent child conflicts, and inadequate parental support cannot be explained by maternal psychological distress. Both the parametric (multivariate logistic regression model) and non-parametric (tree-based regression model) approaches identified decreased interaction with parents, behavioural problems at home, and low maternal perceived family support as the most associated parental/family variables to distinguish children with ADHD from school controls. These results strongly support the notion that the overrepresentation of boys in clinical subjects with ADHD and the relationship between ADHD and parental/family dysfunction not only exists in Western countries, but also in Taiwan, which is substantially influenced by traditional Confucian principles that emphasize parental authority and childrens obedience and academic achievement [45]. In Chinese families, mothers play the leading role in child-rearing and are responsible for childrens academic performance [27,28]. In addition, good school grades and diplomas have been emphasized in a way that children are expected to bring honour to the family by getting good grades and entering a good senior high school and college [27,28]. In such situation, having a child with ADHD brings even greater pressure to Chinese parents, particularly the mothers. Also, mothers of children with ADHD may

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N o de no.

375 750
2 1 = 3 5 0. 8 2

No. ADHD subjects

No. Controls
1 Behavioural problems at ho m e

R o o t no de
>1

I nt e r n a l no d e 2
1

Splittin g va l u e 3 210 47

21=42 . 01

165 703

Sp l i t t i n g v a r i a b l e

>1

Ter min al no d e > 8 5 112 281 6

IX 44 23 21=3. 7 1

21=15 . 60

4
1

21=46 . 69

53 422

Le s s inte ra c tio n w it h fa the r

F a m il y AP G AR

8 7
X 2

21=14 . 54

166 24 1 =3. 4 6

Le s s inte ra c tio n w it h m o t h e r

>1

M a te rna l C HQ s c o re

>4

21=11. 15

34 395

21=14. 76

19 27

10

21=9. 63

86 256

11

21=7. 7 5

26 25

Ter min al no de no.

>3

O v e rp ro t e c t io n

>3

> 29
Af fe c tio n /C a re

29

10 A u t h o ri t a r ia n c o n t ro l

> 10

3 A u t h o r i t a ria n c o ntro l

12
I 2

2 137 1 =3. 1 9

13
II

32 258 21=2. 6 5

14
III

1 17 21=0. 0 0

15
IV

18 10 21=1. 0 8

16
V

70 238 21=8. 9 1

17
VI

16 18 21=4. 2 5

3 12 2 V II 1=0. 00

18

19
V III

23 13 21=3. 4 9

Figure 1. Regression-tree models of attention-decit hyperactivity disorder (ADHD). CHQ, Chinese Health Questionnaire; Family APGAR, Family Adaptation, Partnership, Growth, Affection, and Resolve. be blamed for their childrens behavioural problems and academic underachievement [26,27]. Although a lack of psychiatric diagnoses for mothers limits our ability to examine whether mothers of children with ADHD are more likely to suffer from mental disorders such as ADHD, anxiety disorders, and major depression [17,18], we found increased symptoms of anxiety, depression, somatic complaints, and sleep problems in mothers of children with ADHD. The present study demonstrates similar findings to Western studies [14,16] that mothers of children with ADHD were more likely to suffer from psychological distress. The results of the present study lend evidence to support the notion that families of children with ADHD are more likely to have inappropriate parenting strategies [15], impaired family relationship [9], and increased parent child conflicts [11]. Moreover, like others, the present study also suggests that low parental care and high parental overprotection may be associated with ADHD [46 48], and negative parent child relationships are more prevalent in families of children with ADHD than in control families (reviewed by Johnston and Mash) [19]. We assume that persistent ADHD symptoms may be attributable to maternal psychological distress, inappropriate parenting styles, and problems in parent child interactions [16]. Similar to the findings of previous studies that parenting stress and inappropriate parenting and parent child interactions are related not only to childrens behavioural problems but also to maternal psychopathology, such as depressive symptoms [13,25,49], our findings showed that maternal psychological distress was low to moderately correlated (Pearson correlation) to decreased perceived family support ( 0.35), problems with parents at home (0.33), and less interaction with mothers (0.18) and fathers (0.25). Surprisingly, maternal psychological distress was not correlated with their parenting styles (0.04 0.07). This may imply that parenting styles are more like a characteristic or trait, in which mothers demonstrate their attitudes toward their children with little influence from their current psychological status. This assumption should be investigated in future studies. In

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Table 3.
Node no. 1 2 3 4 5 8 9 10 11

Association between ADHD and splitting variable at each node

OR 19.04 3.17 3.62 8.18 3.10 30.60 8.50 3.02 7.08 95%CI (13.30 27.25) (2.21 4.55) (1.87 7.01) (4.13 16.19) (1.70 5.65) (3.53 265.30) (2.01 35.99) (1.46 6.24) (1.68 29.76)

Splitting variable Problems with parents score$ 1 vs 51 Less Interaction with father score$ 1 vs 51 Family APGAR sum score 58 vs 8 Less interaction with mother score$ 1 vs 51 CHQ total score 4 vs 54 Affection/care score% 529 vs 29 Overprotection score% 3 vs 53 Authoritarian control score% 10 vs 510 Authoritarian control score% 3 vs 53

ADHD, attention-deficit hyperactivity disorder; APGAR, Family Adaptation, Partnership, Growth, Affection, and Resolve; CHQ, Chinese Health Questionnaire; CI, confidence interval; OR, odds ratio.; $Measured with the Home Behaviours of the Chinese version of the Social Adjustment Instrument for Children and Adolescents; %measured with the Chinese version of the Parental Bonding Inventory. Data correspond to information in Figure 1.

contrast to previous studies showing that parental emotional distress may bias their reports on parental and child problems [50], maternal psychological distress cannot explain our findings of increased inappropriate parenting, inadequate family support, impaired parent child relationships, and the more severe behavioural problems at home of methylphenidate-treated children with ADHD. Therefore, the finding of increased parental/family dysfunction in families of children with ADHD is convincing in our Taiwanese sample.

Limitations Several methodological limitations should be considered while interpreting our results. First, the cross-sectional study design limits the inferences that can be drawn about causal relationships on ADHD and parental/family measures as addressed by other studies [46,51]. However, longitudinal studies have provided evidence of a bi-directional association between negative parenting and persistence of behavioural problems among children with ADHD [24,52,53]. Second, lack of psychiatric interviews in the school controls limited the ability to ensure that the controls were free from ADHD; but the likelihood of ADHD among controls was thought to be very low because of the screening procedure. Third, because the controls were not recruited from the clinically referred sample as the cases, the findings of group differences in parental/family process may have been related to referral rather than to ADHD. For example, the present study may have over-sampled clinical subjects who had more severe behavioural problems or whose parents were distressed by their ADHD symptoms;

and the finding of the parental/family difference possibly can be found with any child psychiatric disorder. The potential sampling bias should be considered when we interpret the findings. Fourth, the present study did not examine the effect of ADHD subtypes and other comorbid conditions. Because previous studies have shown that ADHD subtypes [10,20] and oppositional defiant symptoms [15] do not influence the severity of parental distress and coping related to ADHD, the lack of examination of the effect of subtypes and comorbid conditions of ADHD on parental/family measures in the present study is justified. Fifth, the finding of higher parental education in the case group suggests that the ADHD patients who visit the medical center or their parents who agreed to participate in the present study may be more educated than the general population. Because parental educational level was not used to match the selection of controls, the influence of this unequal distribution was adjusted for by controlling for parental education in all the analyses. Last, the mothers were the only informants in the present study and may not accurately report the nature of the child relationship with the father. Moreover, maternal psychological distress may have biased their reports on parenting/family measures [50]; therefore, it was controlled for in the statistical models to minimize its potential confounding effect. Counteracting the limitations, several major features of the current study constitute improvements over previous research on this topic. In addition to the clinical samples from a medical center, subjects with ADHD were recruited from several community psychiatric clinics through the ADHD Educational Foundation in Taiwan, thereby increasing the

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representative nature of the sample of patients with ADHD. The controls were recruited from a representative school-based sample with a very high response rate. Moreover, the sample size of the present study was large compared to those of similar studies. Last, four Chinese versions of the cross-culturally valid instruments were used to assess different aspects of parental/family domains. Clinical implications The present finding shows that medicated children with ADHD still significantly encounter more impaired parental/family function in Taiwan, suggesting that stimulant medication alone may not be enough in managing behavioural problems and improving parental processes. Because stimulants have been reported to be effective in improving negative parental practice and parent child interaction [54 56], assessment of medication adherence and optimal dose of medication should be emphasized in clinical practice. Although some studies failed to prove the effectiveness of psychosocial or parenting training on the improvement of positive [54 56] or negative parental practice [54,55] or family distress [56], there is some evidence supporting the idea that behavioural/parental intervention produces beneficial changes in negative parental practice [56,57] and parent child interaction [54,58]. Hence, the combination of medication with good drug adherence and behavioural/parental intervention should be the optimal treatment strategy for ADHD in terms of improvement in maternal distress, parental practice, and child behavioural problems, particularly in the ethnic Chinese families. Acknowledgements This work was supported by grants from the National Science Council (NSC91-2314-B-002-223, NSC 93-3112-H-002-005), Taiwan. The preparation of this manuscript was supported by a grant from National Health Research Institute (NHRI-EX949407PC), Taiwan The author would like to thank all the participants and their teachers and parents for their contribution.

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