Clinical Child and Family Psychology Review, Vol. 4, No.

3, September 2001 ( c 2001)

Families of Children With Attention-Decit/Hyperactivity Disorder: Review and Recommendations for Future Research
Charlotte Johnston1,3 and Eric J. Mash2

This review integrates and critically evaluates what is known about family characteristics associated with childhood Attention-Decit/Hyperactivity Disorder (ADHD). Evidence suggests that the presence of ADHD in children is associated to varying degrees with disturbances in family and marital functioning, disrupted parentchild relationships, specic patterns of parental cognitions about child behavior and reduced parenting self-efcacy, and increased levels of parenting stress and parental psychopathology, particularly when ADHD is comorbid with conduct problems. However, the review reveals that little is known about the developmental mechanisms that underlie these associations, or the pathways through which child and family characteristics transact to exert their inuences over time. In addition, the inuence of factors such as gender, culture, and ADHD subtype on the association between ADHD and family factors remains largely unknown. We conclude with recommendations regarding the necessity for research that will inform a developmental psychopathology perspective of ADHD.
KEY WORDS: ADHD; family; parentchild interactions; conduct problems.

INTRODUCTION Attention-Decit/Hyperactivity Disorder (ADHD) is a serious childhood disorder that affects approximately 46% of the child population (American Psychiatric Association, 2000) and is associated with a range of current and long-term impairments (Barkley, 1998). In recent years, signicant advances have been made in understanding the nature of this disorder. Behavioral and molecular level studies have provided evidence of the role of genes in the disorder (e.g., Faraone et al., 1999; Kuntsi & Stevenson, 2000; Sunohara et al., 2000)
1 Department

of Psychology, University of British Columbia, Vancouver, British Columbia, Canada. 2 Department of Psychology, University of Calgary, Calgary, Alberta, Canada. 3 Address all correspondence to Charlotte Johnston, Department of Psychology, University of British Columbia, 2136 West Mall, Vancouver, British Columbia, Canada V6T 1Z4; e-mail: cjohnston@cortex.psych.ubc.ca.

and several theories have been advanced regarding the core cognitive decits in ADHD (e.g., Barkley, 1997; Berger & Posner, 2000; Sergeant, 2000). In comparison to advancements in understanding the biological and cognitive nature of ADHD, theory and research into the social and interpersonal aspects of the disorder might be described as less robust, less systematic, and even stagnant. In particular, although families of children with ADHD have been studied for more than a quarter of a century (e.g., Battle & Lacey, 1972; Campbell, 1973), recent attention to this topic has waned and its importance has, perhaps prematurely, been downplayed. We argue that many questions concerning the families of children with ADHD remain unanswered. At a descriptive level, the degree of difculty experienced by these families in areas such as family relationships and parental adjustment remains uncertain. Nor do we fully understand the extent to which family difculties may be specic to the conduct problems that frequently co-occur with ADHD. Even more

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184 disconcerting than the unevenness in descriptive knowledge, developmental conceptualizations of how family factors are related to ADHD also have been neglected. Against this backdrop, this review brings together and critically evaluates research on families of children with ADHD. We begin with a brief outline of a developmental psychopathology framework that suggests several pathways through which family factors may be linked to ADHD (e.g., Rutter & Sroufe, 2000). We see such a framework as a tool for integrating existing research and for advancing research to a more sophisticated level that incorporates developmental and dynamic features in explaining the associations between family factors and childhood ADHD. The review is organized into sections reecting various aspects of family life. For each aspect, we rst consider evidence regarding the relationship between the family variable and child ADHD. Then, we consider the inuence of comorbid conduct problems4 on this relationship. This focus on conduct problems, rather than other conditions that co-occur with ADHD, reects both the high prevalence of comorbid conduct problems (Hinshaw, 1987) and the links that have been drawn among ADHD, conduct problems, and family characteristics (Patterson, DeGarmo, & Knutson, 2000). Finally, for each family characteristic, we discuss how its linkage to ADHD ts within a developmental psychopathology framework, including any evidence that speaks more directly to particular pathways of inuence. We close the paper with conclusions and recommendations for future research. By outlining a developmental framework for conceptualizing the role of the family in ADHD and reviewing the results and limitations of existing studies, we hope to illustrate areas where premature conclusions have been offered and where further work is needed. We hope the review will stimulate research and hasten the time when fully informed conclusions regarding the families of children with ADHD can be drawn. To locate papers for the review, we searched the common abstract sources (i.e., medline, psychology abstracts) for reports with keywords ADHD, attention decit, or hyperactivity paired with family,
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Johnston and Mash parent, or social. In addition, we relied on previous reviews of this area (e.g., Frick, 1994; Hechtman, 1996; Whalen & Henker, 1999). We focus our review on papers appearing within the past 20 years, with an emphasis on the most recent ndings. However, where historical or theoretical purposes dictate, we include references to earlier work. The great majority of studies reviewed reect ndings from families of elementary school-aged boys with both inattentive and hyperactive-impulsive symptoms of ADHD. Studies looking at younger or older individuals, girls, or children with other subtypes of ADHD are highlighted when relevant. To foreshadow one conclusion of the review, the inuence of gender, culture, and ADHD subtype on the associations between family factors and ADHD remains largely unknown.

CONCEPTUALIZATIONS OF FAMILIES AND ADHD A developmental psychopathology framework provides predictions of how ADHD characteristics develop over time, and how multiple risk and protective factors, including biology and family environment, transact to impact this development (Hinshaw, 1994; Kazdin & Kagan, 1994; Rutter & Sroufe, 2000). Such a model allows for the possibility that, across children and across time, various inuences weigh differently in the development of the disorder. At one extreme, there may be children for whom ADHD is predominantly determined early in development by biological risk factors, with a relatively lesser role for subsequent contributions from the family or other environmental factors. At another extreme, a highrisk family environment may function as the primary determinant of the ADHD symptoms, when combined with minimal child predisposition. In either instance, the childs nature and the family environment are likely to exert interactive inuences. The individual characteristics and circumstances of each child will result in unique patterns and strengths of mutual inuence operating in the presentation of ADHD symptomatology. Indeed, most experts agree that the heterogeneity of ADHD suggests multiple causal pathways, with genes and environment interacting in a multitude of ways to produce the behavioral prole characteristic of the disorder (Campbell, 2000; Faraone & Biederman, 1998; Rutter & Sroufe, 2000; Taylor, 1999). Within this developmental framework, many suggest that the most common pathway to ADHD

variety of terms have been used, not always with consistency, to describe comorbid conduct problems including aggressive, oppositional, and conduct disordered behavior. In this paper, we attempt to retain the terminology used by study authors when possible, and when specic designations are not possible, we use the term conduct problems to refer to the cluster of aggressive, oppositional deant (ODD), and conduct disordered (CD) behaviors and diagnoses.

Families of Children With ADHD development is one in which children are born with a genetic, or perhaps congenitally acquired, predisposition to ADHD (e.g., Gillis, Gilger, Pennington, & DeFries, 1992; Goodman & Stevenson, 1989; Milberger, Biederman, Faraone, Guite, & Tsuang, 1997). This predisposition is seen as relatively strong (e.g., Levy, Hay, McLaughlin, Wood, & Waldman, 1996). However, most agree that genetics are seldom the sole cause of ADHD as MZ concordance rates do not approach 100% (Faraone & Biederman, 2000; Kuntsi & Stevenson, 2000) and up to 50% of children with ADHD do not show the biological abnormality that is assumed to be inherited (Swanson et al., 1998). Even in a pathway that assumes a strong biological predisposition to ADHD, family environment remains an important consideration in the development, manifestation, and outcome of the disorder. The stressful, demanding, and intrusive nature of the childs ADHD characteristics are likely to evoke negative reactions from other family members and to exert a disruptive inuence on family relationships and on the psychological functioning of parents. Thus, in this commonly accepted model, difculties in families of children with ADHD are seen as originally driven by, and secondary to, the characteristics of the disorder. In considering pathways linking child predispositions and family risk factors, it must be remembered that ADHD may represent a shared genetic risk among family members. In this case, the dynamics between family variables and child ADHD are inuenced, not only by transactional effects, but also by common genetic characteristics of parent and child (Biederman, Faraone, et al., 1995). Sorting the relative contributions of such shared versus nonshared genetic and environmental risks within the families of children with ADHD requires a level of methodological sophistication seldom encountered in existing studies. Even if family difculties primarily arise as consequences of ADHD, or as the result of shared genetic vulnerabilities, it is inevitable that family circumstances must interact in a transactional and ongoing manner with child characteristics. Here, there is less common ground in the assumptions that are made about the pathways that these reciprocal transactions trace over development. In one possible route of development, family dysfunction may serve as a risk factor that interacts with child predisposition to exacerbate the presentation and continuity of ADHD symptoms. In this pathway, family factors become linked to ADHD, not as an original cause, but as an amplifying and maintaining inuence over the course

185 of development. In some instances, a child may have relatively little predisposition to the disorder, but a chaotic or unresponsive family environment serves to exacerbate inattentive, impulsive, and hyperactive child behaviors to a clinically signicant level (e.g., Carlson, Jacobvitz, & Sroufe, 1995). To the extent that responsive, sensitive parenting behaviors form the foundation for the development of child selfregulation skills (e.g., Greenberg, Speltz, & DeKlyen, 1993; Kochanska, 1993; Olson, Bates, & Bayles, 1990), parental difculties in synchronizing their actions to the childs needs may be the mechanism that accounts for the development of disinhibited, poorly regulated behavior in some children. Obviously, child and family characteristics operate in tandem as it is the infant temperament antecedents of inattention and impulsivity that are most likely to create or exacerbate parents difculties in reading and responding sensitively to the infant. In an alternate pathway, it is possible that there are extremely responsive, sensitive family environments that serve as protective factors that facilitate the development of self-regulation and may attenuate or even terminate ADHD symptoms in children with a biological predisposition for the disorder. Perhaps because of a biological focus in much current ADHD research, this pathway has not been given serious consideration. Interestingly, children in this developmental pathway will not be represented in clinical or even community samples of children who are identied on the basis of ADHD symptomatology. As such, this developmental pathway, while offering promise for prevention or early intervention in ADHD, remains only a hypothetical possibility. Other authors have emphasized that family environments exert their inuence, not on ADHD symptomatology, but on the development of co-occurring conduct problems (Frick, 1994; Moftt, 1990). Here, pathways are proposed whereby the childs ADHD nature interacts with family factors and parenting practices to create, or prevent, the development of conduct problems (Loeber, Green, Lahey, Frick, & McBurnett, 2000). These pathways predict links between family factors and conduct problems, with ADHD placed in the role of a risk factor or vulnerability (Taylor, Chadwick, Heptinstall, & Danckaerts, 1996). ADHD may pose this risk through at least two mechanisms, probably operating simultaneously: (1) the presence of inattention and impulsivity make the child more susceptible to the less than optimal parenting practices that have been associated with conduct problems (e.g., inconsistent discipline, poor

186 monitoring of child behavior), and (2) the childs ADHD may act as the stressor that triggers a breakdown in appropriate parenting (e.g., harsh or reactive discipline). Finally, we note that, across the pathways outlined, the effects of parenting and family environment most often are assumed to manifest at the level of changes in the childs phenotype or behavioral display. However, characteristics of the family environment also may, during windows of development, function to create changes in the childs biological make-up that closely resemble the substrates proposed in genetic models of ADHD. For example, Taylor (1999) has speculated that not only is the effect of experience seen at the level of the childs psychological or cognitive processing, but that such experience also is inevitably represented in the structure, function, and organizations of the neurological processes that underlie the behavioral manifestations. In summary, a developmental psychopathology framework reveals a number of possible pathways through which family factors may be associated with the development of ADHD and accompanying conduct problems. Distinctions among the pathways rest on a variety of assumptions regarding the genetic versus environmental etiology of ADHD, the primacy of ADHD versus conduct problems in development, and the presence or absence of an inuence of family environment on ADHD presentation. With these various pathways and assumptions in mind, we turn to a review of the existing research on the families of children with ADHD.

Johnston and Mash dren with ADHD compared to nonproblem controls. Indeed, Biederman, Milberger, Faraone, Kiely, Guite, Mick, Ablon, Warburton, and Reed (1995), in a sample of 140 referred male children with ADHD and 120 controls, found that among numerous measures of family environment and parental psychopathology, only family conict was associated with child functioning as assessed using the Child Behavior Checklist after controlling for socioeconomic status, child IQ, and parent genotype. Other studies, however, have failed to replicate this association between problematic family functioning and child ADHD (e.g., Byrne, DeWolfe, & Bawden, 1998; Cunningham, Benness, & Siegel, 1988). In addition to inconsistencies in ndings, the correlational and cross-sectional nature of these studies offers little evidence as to the developmental pathways that may underlie the linkages. Comorbidity with conduct problems. Since the work of Loney and colleagues in the 1970s, the importance of considering conduct problems as distinct from ADHD has been recognized. Paternite, Loney, and Langhorne (1976) reported that family variables such as socioeconomic status and parenting style were more strongly associated with child aggression than with the symptoms of ADHD. Similarly, Taylor, Schachar, Thorley, and Wieselberg (1986) in a British sample of clinic-referred children found that child deance, but not hyperactivity, was correlated with family functioning (e.g., interparent inconsistency, less warmth, criticism). However, several other studies have not found signicant differences on questionnaire measures of family functioning across groups of clinic-referred boys with ADHD, ODD or CD, comorbid ADHD+ ODD/CD, psychiatric controls, and nonproblem controls (e.g., Ford et al., 1999; Paternite, Loney, & Roberts, 1995; Schachar & Wachsmuth, 1991). For example, Stormont-Spurgin and Zentall (1996) compared clinic-referred children with ADHD, ADHD+aggression, and children with no problems. Although ADHD was associated with family functioning (i.e., in both ADHD groups, mothers used more punishment and fathers were more permissive than parents of nonproblem boys were), differences between the comorbid and ADHD-only groups were not signicant. In community samples where cutoff scores are used to form groups of ADHD and conduct problem children, group differences in family functioning also are inconsistent. In an epidemiological sample, McGee, Williams, and Silva (1984) found that both aggressive-only and hyperactive-only groups differed

FAMILY RELATIONSHIPS Parent Reports of Family Functioning In this section, we review studies that use parentreport measures to characterize the relationships within families on dimensions of functioning such as communication or conict, and to describe parenting practices including discipline and child-rearing attitudes. Across community and clinic-referred samples of preschool and school-aged boys and girls, studies have reported more stressful and conicted family environments (e.g., Biederman et al., 1999; Brown & Pacini, 1989; DuPaul, McGoey, Eckert, & VanBrakle, 2001; Gadow et al., 2000; Scahill et al., 1999), poorer parenting practices (Shelton et al., 1998), and less authoritative parenting beliefs (Hinshaw, Zupan, Simmel, Nigg, & Melnick, 1997) in families of chil-

Families of Children With ADHD from controls in family functioning, but a comorbid group did not differ from controls. Similarly, neither Szatmari, Boyle, and Offord (1989) in a Canadian community sample nor Stormont-Spurgin and Zentall (1995) in a sample of preschoolers identied by parents as hyperactive or aggressive reported differences in family dysfunction, adversity, or child-rearing practices among ADHD, conduct problem, and comorbid children. In contrast, in community samples where a dimensional approach to attentional and conduct problems is taken and/or longitudinal designs are used, comorbidity effects on family measures are more consistent. Fergusson, Lynsky, and Horwood (1997) reported that although attention problems at age 8 were associated with a variety of family problems, in a longitudinal analysis, it was family and child conduct problems that predicted outcome, rather than ADHD symptoms. August, Realmuto, Joyce, and Hektner (1999) also found that mothers discipline methods (as well as parental psychiatric history and general family adversity) were predictive of the continuation of child ODD, even with initial levels of ADHD and ODD controlled. However, these family factors were not predictive of the continuation of ADHD. Finally, Woodward, Taylor, and Dowdney (1998) found that differences in authoritative parenting beliefs and parental sensitivity between parents of boys rated as high and low on ADHD were no longer signicant when child conduct problems and parental mental health were controlled. However, poor parental coping and aggressive discipline did remain associated with ADHD. Speaking to the potential interaction of child predisposition and family factors, August, MacDonald, Realmuto, and Skare (1996) reported that although family functioning and discipline practices did not contribute independently to the prediction of child adaptive functioning over a 3-year period, these family variables did interact with child conduct problems. Family functioning was most important in predicting outcome for children who were initially low on the conduct problem measure. This same interaction did not emerge for child hyperactivity. This suggests that during the early elementary school years, family inuences may moderate outcomes only for children who do not yet show conduct problems. In contrast, already established, more severe conduct problems and ADHD symptoms appear to over-ride family inuences in determining the childs outcome at this age. Similarly, Colder, Lochman, and Wells (1997) found that poor parental monitoring interacted with child

187 activity level in the prediction of child aggression, such that this parenting difculty led to aggression only in children with high activity levels. Thus, studies of parent-reported family functioning in clinic-referred families of ADHD children versus families of children with comorbid ADHD+conduct problems generally are inconclusive and offer no strong evidence of differential associations between family functioning and ADHD versus conduct problems. In contrast, longitudinal designs assessing ADHD symptoms along a continuum in community samples do suggest alternate pathways, whereby family difculties, particularly in the early to middle school years, contribute to the development or continuation of conduct problems, but are not related to ADHD symptoms. Whether the discrepancy in ndings across the two types of studies is due to the continuous versus categorical approach to ADHD, clinic versus community samples, or cross-sectional versus longitudinal designs or some combination of these factors remains unknown. Adding complexity to the picture are studies examining the impact of ADHD subtype on the relationship between family functioning and child ADHD. Paternite, Loney, and Roberts (1996) found that both ADHD subtype and comorbidity with ODD/CD were predictors of mothers reports of family functioning. Among children of the Combined subtype, those comorbid for ODD or CD were more deviant in family functioning than the pure ADHD group. However, families of children with the Combined subtype of ADHD, regardless of conduct problems, had more problems than families of children who did not have ADHD, and families of Inattentive and HyperactiveImpulsive subtype children fell mid-way between. Similarly, Lewis (1992) found that, although all scored within the normative range, families of sons with only inattentive symptoms reported better functioning than families of sons with inattentive-hyperactive symptoms or comorbid ADHD+aggression. These studies suggest that the combination of inattentive and hyperactive-impulsive symptoms is more strongly linked to family functioning than inattention alone. Obviously, more longitudinal research is needed to test the mutual inuences of family factors, specic type of ADHD symptomatology, and conduct problems over time and to trace differences in developmental pathways for children with different symptom proles. Such research will need to begin tracing development at as early an age as possible, in order to clarify the contributions of family functioning to the onset versus the maintenance of child problems.

188 Observations of ParentChild Interactions There are numerous potential biases in parental reports of general family functioning, and more objective evidence of the family interaction patterns associated with ADHD derives from observational studies (Danforth, Barkley, & Stokes, 1991). In this section, we review evidence from observational studies of parentchild interactions in families of children with ADHD, typically focused on motherson interactions in laboratory settings. Parentchild interaction difculties in families of children with ADHD have been observed across a wide developmental range, from preschool age through adolescence. In general, compared to controls, mothers of children with ADHD are more directive and negative and less socially interactive, and children with ADHD are less compliant and more negative (Barkley, Karlsson, & Pollard, 1985; Campbell, Breaux, Ewing, Szumowski, & Pierce, 1986; Cunningham & Barkley, 1979; DuPaul et al., 2001). These difculties are particularly apparent with younger children (Mash & Johnston, 1982). Conicted interactions have been observed for both boys and girls with ADHD (Barkley, 1989; Befera & Barkley, 1985) in interactions with both mothers and fathers (Tallmadge & Barkley, 1983). Other observational studies have focused on more molar aspects of parenting behavior. For example, compared to mothers of nonproblem boys, Winsler (1998) rated mothers of boys with ADHD as having poorer quality of scaffolding during a teaching task, including a failure to modify task demands and assistance to be appropriate to the childs skill. Poor scaffolding was related to child performance, even after controlling for child ability. Extending observations to include triadic motherfatherchild interactions, Buhrmester, Camparo, Christensen, Gonzalez, and Hinshaw (1992) observed discussions of common child-rearing problems in families of sons with ADHD and nonproblem sons. Ratings indicated more aversive and demanding interactions in the families of sons with ADHD compared to nonproblem sons. In summary, observational studies consistently nd high levels of negative and controlling behaviors in both parents and their children with ADHD. Although these difculties have been observed across a range of child ages, there is some evidence that the interaction problems are most severe for young boys interacting with their mothers. However, without longitudinal designs, this cross-sectional evidence

Johnston and Mash of diminishing problems across child age is at best suggestive of a developmental pathway where, as the symptoms of ADHD, particularly high impact behaviors such as overactivity and impulsiveness, lessen with age (Hart, Lahey, Loeber, Applegate, & Frick, 1995), parents may respond with less directive and controlling interactions. Alternately, it is also possible that a history of unsuccessful parental efforts to control child behavior results in a reduction of parental control efforts and a disengagement from parent child interactions, a strategy that may have short-term benets for the parent but long-term costs for both the parent and the child. Comorbidity with conduct problems. Observations of parentchild interactions in children with ADHD with and without comorbid conduct problems yield mixed results. Both Johnston (1996) and Gomez and Sanson (1994) observed motherchild interactions in school-aged children with ADHD, ADHD+conduct problems, and nonproblem groups, and found, as expected, the highest levels of negative child behavior in the comorbid group, followed by the ADHD group, with the control children showing the lowest levels of negative behaviors. Gomez and Sanson also found that mothers in the comorbid group were the most directive and negative and least rewarding, and control mothers and mothers of ADHD-only children did not differ. In contrast, in the Johnston study, neither mother nor father behavior differed across the three groups, and parents in both ADHD groups reported poorer parenting strategies than parents of nonproblem children. However, Shaw, Owens, Giovannelli, and Winslow (2001), using a community high-risk sample, found that boys at age 6 who had comorbid ADHD+ODD/CD had mothers who were observed to be more rejecting (as well as depressed and aggressive) when the child was 2 years old than the mothers of children with ADHD or no problems. Lindahl (1998) combined observations and selfreports to compare families of nonproblem boys and boys with ADHD, ODD, or both. ODD and comorbid groups differed from controls in family cohesion, conict, rejection-coercion, and inconsistent parenting. Although the families of children with ADHD displayed more rejection-coercion and directiveness than controls, they were more cohesive and consistent than families of children with ODD or comorbid ADHD+ODD. Discriminant analysis indicated that although conict distinguished the clinical and nonproblem groups, it was positive family interactions that best discriminated the families of

Families of Children With ADHD children with ADHD from the ODD and comorbid groups. Inconsistent ndings also emerge in studies of adolescentparent interactions. Barkley, Fischer, Edelbrock, and Smallish (1991) compared nonproblem adolescents, adolescents who no longer met diagnostic criteria for ADHD, adolescents who continued to have ADHD, and adolescents with ADHD+ODD. Across both mother-reports and observations of mother behavior, mothers and comorbid adolescents consistently had more negative communication and more conict than the other groups. However, adolescent reports of conict and their observed behavior often did not differ across groups or differed in unexpected ways. Interestingly, both mother directiveness and child conduct problems assessed at age 8 were signicant predictors of adolescent conduct problems. And, sequential analysis of the motheradolescent interactions found that mothers in the comorbid group were particularly likely to continue conict with their adolescents, whereas mothers in the other groups quelled conict by not responding in kind to adolescents negative comments (Fletcher, Fischer, Barkley, & Smallish, 1996). When Barkley, Anastopoulos, Guevremont, and Fletcher (1992) observed parent adolescent interactions among clinic-referred adolescents with ADHD, those with ADHD+ODD, and controls, both observational and questionnaire measures again indicated more conicted interactions in the comorbid group than in controls, with the pure ADHD group in the mid-range and not signicantly different from either the comorbid or nonproblem group. Finally, two studies have specically examined the extent to which parent behaviors predict conduct problems in children with ADHD. In a mixed sample of ADHD and nonproblem boys, Anderson, Hinshaw, and Simmel (1994) combined observed motherson interactions and maternal psychopathology to predict sons antisocial behavior 1 to 2 months later. Negative parenting predicted child noncompliance and stealing, even with the effects of maternal psychopathology and child negative behavior controlled. Johnston, Murray, Hinshaw, Pelham, and Hoza (in press) found that child conduct problems were uniquely associated with observed maternal responsiveness and sensitivity to the child in families of boys with ADHD, whereas child ADHD symptomatology was not related to mother behavior. In sum, substantial inconsistencies across studies mean that observational assessments of parent child interactions in families of children with ADHD

189 offer limited insight into how and when child ADHD, conduct problems, or both may be linked to these interactions. Results often suggest a continuum of disturbance, ranging from the most parentchild conict in the presence of child conduct problems, but with ADHD alone also being associated with elevations in parentchild difculties compared to nonproblem childparent interactions. The few longitudinal studies that have been reported are most consistent with a developmental pathway through which family problems contribute more to the development of child conduct problems than to ADHD symptomatology. However, the heterogeneity of results across studies suggests that multiple pathways are operative in the relationships between ADHD, conduct problems, and parentchild interactions, and it remains a challenge to determine the characteristics of the children and families who follow the different pathways.

Marital Relationships Conicted marital interactions hold the potential for both direct (e.g., modeling) and indirect (e.g., inconsistent parenting) inuences on children (Emery, 1992; Fincham, Grych, & Osborne, 1994) and have been investigated as correlates of childhood ADHD. Although parents of children with ADHD report less marital satisfaction and more conict than parents of nonproblem children, across a range of child ages and levels of severity (e.g., Befera & Barkley, 1985; Murphy & Barkley, 1996; Shelton et al., 1998), this general conclusion is not without exception. Szatmari, Offord, and Boyle (1989) reported that, in a community sample, parents of children who met criteria for ADHD did not report more marital problems than controls. Similarly, although Camparo, Christensen, Buhrmester, and Hinshaw (1994) found that parents of sons with ADHD blamed their sons more for family problems, reports of marital functioning did not differ between these families and controls. Thus, although the bulk of evidence suggests a link between ADHD and marital dysfunction, the ndings are not entirely consistent. In studying marital functioning in families of children with ADHD, care must be taken to distinguish studies of marital satisfaction, which are limited to two-parent families, from studies of marital separation or dissolution. It is possible that failures to nd links between ADHD and marital satisfaction may reect a higher rate of divorce or separation among these families such that the most dissatised

190 couples are no longer represented in studies. However, contrary to this explanation, rates of divorce and separation are not consistently higher in families of children with ADHD than in controls (e.g., Barkley et al, 1991; Brown & Pacini, 1989; Faraone, Biederman, Kennan, & Tsuang, 1991; McGee et al., 1984). Comorbidity with conduct problems. Can the inconsistencies in the link between marital functioning and child ADHD be explained by co-occurring conduct problems? Suggesting that they can, Barkley et al. (1992) reported poorer marital adjustment in parents of adolescents with ADHD+ODD than in ADHD or control groups. Similarly, Lindahl (1998) found that, in general, parents of boys with ODD and ADHD+ODD had more marital difculties than parents of nonproblem boys, who did not differ from parents of ADHD boys. Focusing on co-parenting, Johnston and Behrenz (1993) found that couples with aggressive children with ADHD were more negative when discussing ADHD behaviors than parents of nonaggressive children with ADHD or control children, but couples in both ADHD groups also were more negative than controls when discussing conduct problems. In contrast to these studies linking marital dysfunction to comorbidity, Johnston (1996) found that although marital satisfaction was highest in controls, parents of children with ADHD, who were high and low in aggression, did not differ. Stormont-Spurgin and Zentall (1995) found that although mothers of aggressive and hyperactive-aggressive preschoolers reported more marital conict than mothers of hyperactive children, neither the hyperactive-only nor the comorbid group differed from controls. Several other studies also report no differences in marital functioning in families of boys with ADHD with or without comorbid conduct problems (e.g., Barkley et al., 1991; Barkley, McMurray, Edelbrock, & Robbins, 1989; Biederman, Munir, & Knee, 1987; Prinz, Myers, Holden, Tarnowski, & Roberts, 1983; Reeves, Werry, Elkind, & Zametkin, 1987; Schachar & Wachsmuth, 1991). The inconsistency across these studies suggests caution in assuming that marital dysfunction is exclusively related to comorbid conduct problems in families of children with ADHD. Indeed, the inconsistencies in this area preclude rm conclusions regarding associations between either ADHD or conduct symptoms and marital difculties in children with ADHD. Obviously, further studies incorporating longitudinal designs are needed to inform our understanding of

Johnston and Mash how this aspect of family functioning interacts with ADHD over development.

Discussion of the Associations Between Family Relationships and ADHD As a rst impression, we are struck by the inconsistencies in the research evaluating the associations between family relationships and childhood ADHD and conduct problems. Although the preponderance of evidence suggests difculties in family relationships in families of children with ADHD, particularly those with comorbid conduct problems, the studies are far from unanimous. Beyond this problem of limited evidence regarding the degree and dimensions of family functioning that are problematic in families of children with ADHD, important questions remain regarding the mechanisms and developmental processes that operate to determine the differential associations that exist. However, some research has investigated the direction of inuence in the relationship between family relationships and child ADHD. Studies hypothesizing an effect of families and parenting on the development of child ADHD have typically relied on retrospective or longitudinal designs to assess the inuence of early parenting behaviors on subsequent manifestations of child ADHD. Using retrospective reports, Whitmore, Kramer, and Knutson (1993) compared adult men with childhood histories of ADHD to their brothers and normal controls. Rather than supporting a direct effect of parenting on the development ADHD, the results suggested a more complex or interactive pathway with a mixture of child vulnerability and parenting deciencies. There were no differences in the recalled family relationships of ADHD men and their brothers, but the ADHD men did recall more punishment and less shared parenting than the control men (with the brothers of ADHD men falling mid-way between). Contrary to the idea that family factors are primarily associated with conduct problems, in this study there was a trend for childhood hyperactivity, but not aggression, to be related to parental use of physical punishment. Although not retrospective, a study by Tarver-Behring, Barkley, and Karlsson (1985) is consistent with these ndings. They observed motherchild and mother sibling interactions and found that although ADHD boys were more negative than their brothers, mothers behavior did not differ across ADHD children and siblings.

Families of Children With ADHD Methodologically stronger studies of the early inuence of families and parenting on ADHD use longitudinal designs to follow the relationship over time. Carlson et al. (1995), in a sample of lower socioeconomic status families followed from infancy to the childs early school years, found that maternal insensitivity and overstimulating or nonresponsive physical intimacy during infancy predicted both distractible and hyperactive child behavior at followup, even with the effects of early child temperament controlled. Interestingly, in this study, the inuence of parenting on ADHD was greatest at the youngest ages, suggesting a developmental pathway where family inuences on ADHD may diminish over time. These ndings replicated a similar previous report by Jacobvitz and Sroufe (1987). In contrast to these ndings, Wakschlag and Hans (1999), in a highrisk sample of African American children followed to age 10, reported that lack of maternal responsiveness in motherinfant interactions predicted the childs subsequent ODD and CD, but not ADHD, even after controlling for concurrent parenting and a variety of biological and family risk factors. Finally, the longitudinal studies of Campbell and colleagues also provide information regarding the temporal ordering of parenting and child ADHD and conduct problems (Campbell, 1994; Campbell, Breaux, Ewing, Szumowski, & Pierce, 1986; Campbell & Ewing, 1990; Pierce, Ewing, & Campbell, 1999). Following two groups of parent-identied problem preschoolers to age 13, these reports indicated that, with a few exceptions, family adversity (e.g., social class, maternal depression, parenting stress) and more negative and directive maternal behavior when the child was 3 predicted the continuation of both hyperactive and aggressive symptoms in the children, independent of the initial level of child symptomatology. Interestingly, family problems also predicted the emergence of both types of problems in the control sample of initially nonproblem children. In sum, longitudinal studies offer support for a role for parenting in the origins of both conduct and ADHD behavior and are inconclusive regarding whether or not ADHD and conduct problems share the same or different interactive patterns with parenting and family factors. In addition, these studies remind us that family problems confer a universal risk for the development of child problems and are not specic to children identied as having ADHD. Studies of the effects of behavioral parent training also speak to the inuence of parenting behavior on ADHD. Changing parenting behavior results

191 in reduction in conduct problems among children with ADHD (e.g., Pollard, Ward, & Barkley, 1983; Strayhorn & Weidman, 1989); however, this treatment appears less likely to alter ADHD symptoms (e.g., Pisterman et al., 1989). Even when effects on ADHD symptomatology are evident, they are typically weak (e.g., Kolko, Bukstein, & Barron, 1999; MTA Cooperative Group, 1999). Thus, although changing parent behavior can exert an effect on both conduct problems and ADHD symptoms, these studies are most consistent with a pathway in which parenting factors are most inuential in altering the course of child conduct problems. Although informative, these treatment outcome studies obviously do not speak of the origin of conduct problems in children with ADHD. Turning to studies of the inuence of child ADHD on family functioning, there are several demonstrations of the effects of child medication on parenting behavior. For example, Humphries, Kinsbourne, and Swanson (1978) and Barkley and Cunningham (1979) both found that during free play, children were more compliant and mothers were less directive and more likely to respond to childrens interactions when the children were medicated compared to on placebo. These differences were even greater in task situations. A series of studies by Barkley and colleagues (e.g., Barkley, 1988, 1989; Barkley, Karlsson, Pollard, & Murphy, 1985; Barkley, Karlsson, Strzelecki, & Murphy, 1984) with both school-aged and preschool boys and girls provide general support for a child-to-parent effect by showing that when children with ADHD are medicated, parent behavior improves. However, the results were not entirely consistent. For example, the effects of child medication on parent behavior often were apparent only during task interactions and only at higher medication doses. Schachar, Taylor, Wieselberg, Thorley, and Rutter (1987) also examined the effects of methylphenidate on family functioning. Boys with ADHD and/or ODD/CD were divided into those who showed a positive behavioral response to medication and those who did not. Supporting a child-to-parent effect, if the child did not respond to medication, no differences in family functioning emerged between the placebo and medication conditions. In contrast, for children who responded positively to medication, family functioning was rated as better in the medication than in the placebo condition. Finally, rather than assessing medication-induced changes in child behavior, Ianna, Hallahan, and Bell

192 (1982) trained child confederates to exhibit distractible or on-task behavior and assessed the effects of this child behavior manipulation on adult women. As expected, women interacting with the distractible child were more demanding and controlling than women interacting with the on-task children. In sum, studies that have manipulated child behavior, using either confederates or medication, although not entirely consistent, have strongly suggested that deviations in child behavior can cause disturbances in the parentchild interactions. Although inuential, the importance assigned to these studies demonstrating the effects of child ADHD on parents must be tempered by methodological and theoretical limitations. Concerns include the short-term nature of the childs medication status (typically 12 weeks), the articial nature of the laboratory interactions and child confederates, the relatively small sample sizes, the failure to differentiate changes in ADHD versus conduct problem symptoms, and the inconsistency of the effects across measures and situations. Along the lines of the work conducted by Schachar et al. (1987), further research is needed to address questions of ecological validity, such as whether the same medication-induced changes in parentchild interactions would appear in more naturalistic settings and would maintain over longer periods. Conceptually, it must also be remembered that the demonstration of a causal effect from child to parent behavior does not necessarily speak to the original cause of parentchild interaction problems in families of children with ADHD (Carlson et al., 1995). Nor does the demonstration of such an effect speak to the existence of other causes, or to the interactive effects of child and parent behavior over the course of time. Moving from studies of parentchild interactions to those addressing links between marital interactions and child ADHD, not only are the existing studies inconsistent, but they are exclusively correlational in nature as well. Thus, although studies sometimes point to a co-occurrence of ADHD and marital dysfunction, they fail to indicate how this family factor is related to ADHD or how this relationship develops over time. Using formulations derived in the more general clinical child literature (Emery, 1992), it seems reasonable that marital relationships may be related to ADHD in a number of ways. Marital problems and child ADHD may reect the inuence of shared genetic vulnerabilities in these families. Alternately, the stressful and demanding nature of ADHD symptoms may elicit higher rates of marital miscommunication

Johnston and Mash or disagreement on parenting strategies. In turn, inconsistencies in parenting or low frustration tolerance among maritally discordant parents may create a situation that evokes or at least exacerbates the impulsive and disorganized nature of ADHD childrens behavior, as well as conduct problems. However, such transactional pathways remain hypothetical possibilities until studies can track the development of ADHD and marital conict, and their interaction, over time.

FAMILY STRESS Given difculties in family interactions, it is not surprising that parents of children with ADHD report more stress than comparison parents. Research in this area has relied heavily on the Parenting Stress Index developed by Abidin (1986, 1990), which assesses stress across domains of child, parent, and interaction characteristics, and, in some versions, general life circumstances. As early as 1983, Mash and Johnston (1983a) reported that parenting stress in all domains was signicantly elevated in mothers of children with ADHD, particularly mothers of preschool-age children. In addition, mothers reports of parenting stress were related to observed difculties in the interactions of children with ADHD and their siblings (Mash & Johnston, 1983b). Similar elevations in parenting stress associated with ADHD have been demonstrated across child ages, for both boys and girls, for children with different levels of symptomatology, and generally for both mothers and fathers (Baker, 1994; Beck, Young, & Tarnowski, 1990; Breen & Barkley, 1988; Byrne et al., 1998; DuPaul et al., 2001; Shelton et al., 1998). However, occasional failures to replicate also have been reported (e.g., Murphy & Barkley, 1996). In addition to stress specic to the parenting role, studies have examined general life stress or psychosocial adversity in families of children with ADHD. Although Murphy and Barkley (1996) found no differences in negative life events between families of children with ADHD and controls, Biederman, Milberger, Faraone, Kiely, Guite, Mick, Ablon, Warburton, and Reed (1995) did nd that the odds ratio for ADHD increased signicantly with increases in general family adversity (e.g., maternal psychopathology, socioeconomic status). Highlighting the universality of family adversity as a risk factor for children, this study also reported associations between family adversity and child functioning in control families. Thus, in general, research has linked

Families of Children With ADHD parenting stress and child ADHD, although the nature of the linkage and its specicity to ADHD has not been addressed. Comorbidity with conduct problems. The extent to which parenting stress is linked to ADHD versus conduct problems in children is largely unknown. Anastopoulos, Guevremont, Shelton, and DuPaul (1992), using hierarchical regression analyses, reported that child aggression, severity of ADHD symptoms, child health status, and maternal psychopathology all accounted for signicant variance in mothers reports of parenting stress. However, subgroup analyses found higher levels of parenting stress in mothers of ADHD+ODD children than in mothers of ADHD children. In the realm of general life stress or family adversity, most evidence suggests that in samples of children with ADHD these family factors are not exclusively tied to the presence of conduct problems. Neither Johnston (1996) and Leung et al. (1996) nor Barkley et al. (1989) reported differences in life stress between mothers of aggressive and nonaggressive children with ADHD. Although both Schachar and Tannock (1995) and Schachar and Wachsmuth (1991) found that families of CD and ADHD+CD children experienced more psychosocial adversity (e.g., poverty, unemployment, mental health problems) than pure ADHD or control groups, the later study also found that families of children with only ADHD had more adversity than controls. Similarly, Reeves et al. (1987) reported that families of comorbid children had more adversity than families of ADHD, anxiety, or control children, but unexpectedly, mothers reports of life stress were signicantly higher than controls in both the comorbid and the ADHD-only groups. Finally, in a longitudinal study of boys aged 513, Moftt (1990) found that boys with ADHD+delinquency had greater family adversity than boys with ADHD only or controls and Tiet et al. (2001) also found that most adverse life events were related to childhood ODD and CD, but not to ADHD. A few studies have examined the role of economic and employment status in the relationship between stress and ADHD/conduct problems, and highlight the importance of considering multiple variables, including extra-familial aspects of parental life, in understanding this relationship. In an exclusively lower socioeconomic sample, Baldwin, Brown, and Milan (1995) found that nancial concerns accounted for the most life stress, but child ADHD and parental coping also contributed, even with income controlled. Harvey (1998) reported on relationships

193 among employment, child care workload, parenting well-being (including parenting stress and sense of competence), and child conduct problems in families of children with ADHD. Interestingly, mothers who worked more in paid employment reported lower child care loads, more parenting well-being, and fewer child conduct problems. In contrast, fathers time in paid employment was linked to child conduct problems via an increase in mothers child care load and a decrease in maternal parenting well being. Discussion of the Link Between Family Stress and ADHD Despite knowledge of an association between child ADHD and parenting or family stress, our understanding of how this link functions is far from perfect. More than 10 years ago, Fischer (1990) and Mash and Johnston (1990) reviewed the literature on parenting stress and concluded that the most parsimonious explanation was that ADHD child characteristics led to parenting and family stress. This conclusion appears to stand, as do the acknowledgments that some association may result from a shared genetic substrate of parental and child psychopathology, that parental or family stress may exacerbate existing child problems, and that some of the effects of child behavior on parenting stress may be indirectly mediated via marital discord. However, there are also inconsistencies and weaknesses in the existing data. For example, Mash and Johnston (1983a) reported increased parenting stress among parents of younger compared to older children, which would seem to argue against a cumulative child effect. Also contrary to a child-effect explanation, Pisterman et al. (1992) reported that although parenting stress decreased following parent training, this decrease was not correlated with improvements in child behavior. Recently, in the MTA study, Wells et al. (2000) reported no differences in the effects of medication, behavioral, combined, and community care treatments on parenting stress in families of children with ADHD. Finally, suggesting that general life stress contributes to family difculties independent of child ADHD, Mash and Johnston (1983c) reported that mothers life stress and parenting sense of competence predicted mothers behavior in task interactions with their children, even with the contributions of child behavior controlled. Again, we would argue that a transactional conceptualization that acknowledges bidirectional links between child ADHD and family stress that unfold over time is needed. The challenge remains to design and conduct

194 studies that will adequately test such a conceptualization and illuminate the pathways linking stress to both ADHD and conduct problems.

Johnston and Mash comorbid child conduct problems on parenting sense of competence. Johnston (1996) found that despite few differences in parenting behavior across groups of nonproblem and ADHD children with high and low aggression, both mothers and fathers in the high aggressive ADHD group reported lower parenting competence than parents in the nonaggressive ADHD group, with parents of nonproblem children reporting the highest levels. In sum, parenting sense of competence appears related to both ADHD and conduct problems, although again, the pathways through which these links emerge and function have not been investigated.

PARENTAL COGNITIONS Parenting Sense of Competence Given the parentchild difculties and stress in families of children with ADHD, it is reasonable to ask how these parents view themselves as parents. Shelton et al. (1998) reported diminished parenting satisfaction and efcacy among mothers of preschool hyperactive-aggressive children compared to mothers of nonproblem children. Similarly, Mash and Johnston (1983a) reported that sense of parenting competence was lower in mothers of children with ADHD, particularly older children, than in mothers of nonproblem children. Although this cross-sectional nding suggests a pathway of cumulative effects of unsuccessful parenting of a difcult child, it obviously awaits replication in a longitudinal design. Supporting the inter-related nature of parent and child characteristics, Mash and Johnston reported links between parenting sense of competence and mothers parenting behavior (Mash & Johnston, 1983c) and the behavior of children with ADHD and their siblings (Mash & Johnston, 1983b). Finally, Sobol, Ashbourne, Earn, and Cunningham (1989) reported that consistent with a reduced sense of parenting competence, mothers of children with ADHD saw the causes of their childrens behavior as more unstable and had lower expectancies for success in managing their children than control mothers. In contrast to these ndings, Johnston and Pelham (1990) did not nd a relationship between parenting sense of competence and observed mother or child behavior in families of children with ADHD, nor did Beck et al. (1990) nd differences in sense of parenting competence across mothers of hyperactive and nonproblem boys. And, as with life stress, Pisterman et al. (1992) reported that although parenting sense of competence increased for families who received parent training, these changes in parent self-efcacy were not related to improvements in the behavior of the children with ADHD. Reasons for the discrepancies among studies are not immediately apparent, although differences in the presence of comorbid child conduct problems offer one possible explanation. Comorbidity with conduct problems. We could nd only one study that examined the inuence of

Parental Expectations and Attributions for Child Behavior Sonuga-Barke and Goldfoot (1995) found that mothers of boys with ADHD had lower expectancies for their own childrens development than mothers of nonproblem children, although they did not differ in expectations for the development of a normal child. These differences emerged despite matching of the groups on child IQ, suggesting either that mothers are underestimating their childs abilities or that the children are performing below potential. Other research has focused on the attributions parents offer for the behavior of children with ADHD. Johnston and Freeman (1997) and Johnston, Reynolds, Freeman, and Geller (1998) compared attributions for child behavior among parents of children with ADHD and parents of nonproblem children. Across a variety of assessment methods, parents of children with ADHD saw the symptoms of both ADHD and ODD as caused by uncontrollable, stable factors within the child, and they had more negative reactions to these behaviors than parents of nonproblem children. In contrast, parents of children with ADHD saw their childrens positive behavior as less dispositional. Finally, parents of children with ADHD saw themselves as less responsible for child behaviors. Although research in parental expectations and attributions for child behavior is only beginning, the emerging differences suggest that this is an important avenue of future study. Comorbidity with conduct problems. Freeman, Johnston, and Barth (1997) and Freeman (1999) examined the inuence of the comorbidity of ADHD and ODD on attributions among parents of children with ADHD. ODD behaviors were seen as more controllable by the child than ADHD behaviors (within

Families of Children With ADHD ADHD symptoms, hyperactive-impulsive symptoms were seen as more controllable and intentional than inattention), and views of either ODD or ADHD behaviors as dispositional were related to more negative parenting reactions. When children were described as showing both ODD and ADHD behaviors, the presence of ODD behavior increased attributions of child control or parent responsibility for the symptoms of ADHD in one study (Johnston & Patenaude, 1994), but decreased them in another (Freeman et al., 1997). Barkley et al. (1992) reported that mothers of adolescents with ADHD+ODD attributed greater malicious intent to their adolescents behavior than did mothers of ADHD-only adolescents, although the mothers of nonproblem adolescents did not differ from either of the other groups. Thus, consistent with research in the area of child aggression (e.g., Dix & Lochman, 1990), the presence of conduct problems appears linked to negative parental attributions in families of children with ADHD. However, the inuence of the comorbid behavior on attributions for the symptoms of ADHD remains unclear.

195 Whether different patterns of parental cognitions lead to differences in child ADHD behavior has not yet been investigated. However, studies of externalizing child problems more generally have demonstrated that parental cognitions inuence child behavior, mediated by the inuence of the cognitions on parenting behavior. For example, Hoover and Milich (1994) studied mothers who attributed their sons problem behavior to a sensitivity to sugar. Using a challenge design, prior to motherson interactions, mothers were told that the boys had received either sugar or placebo, when in actuality all boys received placebo. Conrming an inuence of mothers expectancies, mothers in the sugar condition rated their sons as more hyperactive and were more controlling and critical in their interactions, while their sons were actually calmer than boys in the placebo condition. A necessary next step is to determine whether the differences found in attributions across parents of nonproblem children and children with ADHD are related to differences in parenting reactions to the children, and to subsequent differences in child behavior. Recent data from Johnston, Scoular, Ohan, and Gruter-Andrew (2000) suggest that the relationships between parental attributions for and reactions to child behavior are stronger among parents of nonproblem children than parents of children with ADHD. One interpretation of this nding is that variables other than attributions, perhaps affective associations, are more important in determining parenting responses in families of children with ADHD. Further study is needed to map the mutual inuences among child and parent behavior and parental cognitions in families of children with ADHD. Such research will need to address the developmental timing of the inuences, as well as the potentially interactive inuence of conduct problems.

Discussion of the Link Between Parental Cognitions and ADHD Although research has suggested that particular patterns of parental cognitions are associated with child ADHD, how this association develops is unclear. Studies that have manipulated the type of child behavior used to elicit the parental cognitions indicate that it is possible for child behaviors to cause different patterns of parental cognitions (e.g., Bondy & Mash, 1999; Johnston & Freeman, 1997; Sobol et al., 1989). Parents attributions for the behavior of children with ADHD also have been related to the childs treatment status. For example, Johnston et al. (2000) and Johnston and Leung (2001) both found that mothers of children with ADHD rated positive child behavior as more global and stable when the child was medicated, and rated child noncompliance and symptoms of ADHD and ODD as more externally caused, less global and stable, but more controllable by the child when the child was medicated. Although such studies are most important in their implications for the treatment of ADHD, they offer hints suggesting the inuence of child behavior, or changes in child behavior, on parental cognitions. The role of parental attributions in determining childrens responses to various treatment options is an important question for future research (Morrissey-Kane & Prinz, 1999).

PARENTAL PSYCHOLOGICAL FUNCTIONING General Adjustment In this section, we rst review studies of parents of children with ADHD that have examined overall rates of psychopathology or have used multidimensional measures of psychological distress. We then move to studies focusing on specic aspects of parental psychological functioning (e.g., depression, alcohol abuse). We note a general concern in this

196 area that arises because characteristics of fathers often are estimated via maternal report (e.g., Lahey et al., 1988). The womens reports of fathers who are absent (e.g., ex-husbands) likely are not free of bias. Although recent data suggest that mothers reports in these situations do agree with those of absent fathers (Pffner, McBurnett, & Smith, 1999), actual fatherreport data would be preferable. At a general level, most studies reveal an elevation in psychological problems among parents of children with ADHD, across a range of child ages and in both clinic-referred and community samples (e.g., Befera & Barkley, 1985; Murphy & Barkley, 1996; Scahill et al., 1999; Shelton et al., 1998). Biederman et al., (1992) found elevated rates of mood, conduct, substance abuse, and anxiety disorders as well as ADHD among rst degree relatives of children with ADHD compared to controls. However, as in other areas, the extent to which these problems are specic to ADHD or vary across ADHD subtypes (e.g., Gadow et al., 2000) and comorbidity with conduct problems is not revealed in these studies. Comorbidity with conduct problems. In general, studies show higher rates of psychopathology among parents of children with comorbid ADHD and conduct problems than among parents of children with ADHD only (e.g., Barkley et al., 1989, 1991; Faraone et al., 1991; Ford et al., 1999; Lahey et al., 1988; Lahey, Russo, Walker, & Piacentini, 1989; Schachar & Wachsmuth, 1990). However, these comorbidity effects are not always clear and consistent. In an epidemiological sample, McGee et al. (1984) found no differences in rates of psychopathology among mothers of aggressive, ADHD, and comorbid boys, although all clinic groups were higher than controls. Although Barkley et al. (1992) found more psychological problems in mothers of clinic-referred adolescents with ADHD+ODD than in controls, mothers in the ADHD-only group were in the mid-range and not signicantly different from either the comorbid or control group. Similarly, although Johnston (1996) and Nigg and Hinshaw (1998) found more psychological problems in fathers of comorbid ADHD children than in controls, fathers of ADHD-only children less consistently demonstrated the differences, and mothers of both ADHD-only and comorbid groups tended to have more problems than controls. Interestingly, Nigg and Hinshaw also found that maternal neuroticism predicted child aggression only for children with ADHD, not for the control group, suggesting an interaction of maternal dysfunction and child vulnerability. Finally, Kuhne, Schachar, and Tannock (1997) found

Johnston and Mash elevated maternal psychopathology compared to controls only in mothers of children comorbid for ADHD and CD, not for those comorbid for ODD. In sum, evidence regarding the specicity of parental psychological distress to child conduct problems is mixed. Although rates of parental distress almost always are highest among comorbid groups, it is also the case that ADHD-only groups often are more distressed than controls.

Depression and Anxiety Biederman, Munir, Knee, Armentono, et al. (1987) and Faraone, Biederman, Chen, and Milberger (1995) reported more affective disorders in relatives of boys with ADHD compared to families of nonproblem boys, and found that these rates were not specic to the presence of comorbid depression in the child. Perrin and Last (1996) reported elevated rates of anxiety disorders in female relatives of children with ADHD, with rates comparable to those reported in relatives of children with anxiety disorders. Several studies have found more depression in mothers of children with ADHD compared to nonproblem controls (e.g., Befera & Barkley, 1985; Brown, Borden, Clingerman, & Jenkins, 1988; Cunningham et al., 1988), although recent work has suggested that the depression may be specic to mothers of ADHD Combined subtype children or to mothers with more than one child with ADHD (West, Houghton, Douglas, Wall, & Whiting, 1999). However, the association of parental affective disorders and child ADHD is not without exception. For example, Breen and Barkley (1988) failed to nd differences in depression in mothers of ADHD and nonproblem children, although both groups were less depressed than mothers of psychiatric control children. Results for fathers also have been variable. For example, although Cunningham et al. (1988) found no difference in paternal depression across ADHD and nonproblem groups, Brown et al. (1988) did nd elevated depression in fathers of children with ADHD, and Brown and Pacini (1989) reported greater depression in both mothers and fathers of children with ADHD compared not only to nonproblem controls, but to parents of children with developmental and learning disorders. Thus, links between parental affective disorders and child ADHD are inconsistent when conduct problems are uncontrolled. Comorbidity with conduct problems. Unfortunately, when child conduct problems are considered,

Families of Children With ADHD the links between parental affective disorders and child ADHD remain inconsistent. Stormont-Spurgin and Zentall (1995) found no differences in the depression reported by mothers of hyperactive, aggressive, hyperactive-aggressive, and nonproblem preschoolers, and Fergusson and Lynskey (1993) found that maternal depression correlated with both attentional and conduct problems in children, although these relationships were nonsignicant when socioeconomic or marital status were controlled. In sum, in a review of family studies of parental depression and child ADHD, Faraone and Biederman (1997) concluded that there is reasonable evidence for a familial association of these two disorders. They noted that although the link appears strongest in families of children with comorbid ADHD+CD, most evidence also reveals an elevated risk of depression associated with ADHD alone.

197 consumed. This study also found that socioeconomic status accounted for much of the difference in drinking behavior between the clinic and control groups, demonstrating the importance of controlling for demographic characteristics in research of this nature. Comorbidity with conduct problems. Illuminating the links between parental alcohol abuse and ADHD versus conduct problems, Faraone et al. (1991) found elevated risk for substance abuse among relatives of children with ADHD+CD, compared to children with ADHD+ODD, ADHD only, and normal controls. Although Kuperman, Schlosser, Lidral, and Reich (1999) reported that parental alcoholism was associated with an increased child risk for both ADHD and CD, reports of dysfunctional parenting were linked to only CD, not ADHD. In community samples, it is also the case that the associations between parental alcohol abuse and child ADHD are weaker than those between alcohol abuse and conduct problems. For example, Carbonneau et al. (1998) found that physical aggression and low anxiety, not hyperactivity, were the best discriminators of sons of alcoholic versus nonalcoholic fathers. Pelham and associates have investigated the causal links between parental alcohol consumption, parenting behavior, and child ADHD and ODD/CD symptoms. Beginning with a sample of young adults, Lang, Pelham, Johnston, and Gerlernter (1989) found that interacting with a child confederate trained to show both ADHD and CD symptoms increased stress and alcohol consumption, at least for males. Pelham et al. (1997) replicated these ndings in parents of nonproblem children, particularly for fathers and single mothers. However, the result did not replicate in a sample of parents of ADHD and/or ODD/CD children (Pelham et al., 1998). Post hoc analyses suggested that the failure to nd effects was not due to child comorbidity, but that the effect was moderated by family history of alcoholism. Only parents with a family history of alcohol abuse showed increased drinking after interacting with the confederate child. Finally, this group of investigators has examined the inuence of alcohol on parenting behavior (Lang, Pelham, Atkeson, & Murphy, 1999). Across parents of ADHD, comorbid, and nonproblem children, alcohol reduced attending, increased commands, indulgences, and offtask comments, and led parents to rate children as less deviant. Together, these studies strongly suggest a reciprocal pattern of effects. Interacting with children with ADHD/conduct problems can induce higher levels of alcohol consumption in parents, at least among parents at risk for drinking problems, presumably

Alcohol Abuse Although several studies have linked parental alcoholism to general child behavior problems (c.f. West & Prinz, 1988), the extent to which this relationship holds for ADHD is questionable. In community samples, Cadoret and Stewart (1991) did not nd a relationship between alcoholism in the biological fathers and child ADHD, nor did Szatmari, Offord, et al. (1989) report more alcohol problems in families of children with ADHD versus controls. Martin et al. (1994) compared boys with and without a paternal history of alcoholism, and found elevated rates of aggression, inattention, and impulsivity in the children whose fathers histories were positive, but no differences in hyperactivity. Cunningham et al. (1988) and Gadow et al. (2000) did nd that parents of ADHD children self-reported higher rates of alcohol consumption than parents of controls, although Gadow et al. found this only among parents of children with ADHD Combined subtype. Looking beyond rates of alcohol use, Molina, Pelham, and Lang (1997) compared parents of boys with ADHD and parents of nonproblem boys on alcohol consumption and expectations for the effects of alcohol. They found no differences in consumption or general expectancies for alcohol effects. However, mothers of children with ADHD did believe that drinking would increase their negative interactions with their children. Highlighting the link between parental cognitions and behavior, these expectancies accounted for signicant variance in reports of alcohol

198 because of the stressful and demanding nature of these child behaviors. And, parental alcohol consumption leads to ineffective parenting behaviors that might elicit or exacerbate inattentive, impulsive, or hyperactive child behavior. Despite the elegance of these studies in illuminating mechanisms linking parental alcohol use and child problems, ADHD and conduct problems have been inextricably confounded and further work is needed to examine the external validity of these analog ndings and possible differential pathways linking ADHD versus conduct problems to parental drinking. Antisocial Behavior Comorbidity with conduct problems. The studies addressing links between ADHD and parental antisocial behavior have all been careful to account for the presence of conduct problems. Most of these studies suggest that parental antisocial behavior is more strongly associated with conduct problems than with ADHD. For example, Frick, Kuper, Silverthorn, and Cotter (1995) found that maternal antisocial behavior was associated with conduct but not ADHD symptoms in clinic-referred children. Similarly, Biederman Munir, and Knee (1987a) and Biederman et al. (1992) reported higher rates of antisocial personality disorder in relatives of children with comorbid ADHD+ODD/CD compared to relatives of children with ADHD or normal controls, although the risk in relatives of pure ADHD children also was greater than controls. However, Cadoret and Stewart (1991) did nd that criminality in biological parents predicted ADHD in adopted boys, while psychiatric problems in the adoptive parents predicted conduct problems. Thus, although the bulk of ndings link parental antisocial behavior to child conduct problems more strongly than to child ADHD, some inconsistencies have emerged. And again, existing studies yield little insight into the developmental pathways underlying the associations. ADHD Several studies have documented elevated rates of ADHD among the relatives of children with the disorder (e.g., Faraone, Biederman, & Milberger, 1994). Biederman Faraone, et al. (1995) found that, in a sample of 84 parents with a childhood onset of ADHD, 57% of their children had ADHD. Eighty-four percent of the parents had at least one child with ADHD.

Johnston and Mash This rate of ADHD in the children is much higher than that reported in other studies of rst degree relatives of ADHD probands, and suggests that the adult form of the disorder may have a particularly strong familial etiology. The high rate of ADHD among parents of children with the disorder suggests several mechanisms of association. Although it is likely that there is a shared genetic element to the association, mechanisms at the psychological and environmental level, such as psychological distress and parenting practices, may amplify or attenuate the relationships. Rucklidge and Kaplan (1997) found that among mothers of children with ADHD, mothers who had ADHD themselves reported more depression, anxiety, low selfesteem, and more stress and poorer coping compared to mothers without ADHD. Similarly, Weinstein, Apfel, and Weinstein (1998) reported that mothers who had ADHD and had children with ADHD reported more personality and psychiatric problems than mothers without ADHD and who had ADHD children or mothers of nonproblem children. However, both groups of mothers of ADHD children reported more family alcoholism and sexual abuse than the mothers of nonproblem children. Arnold, OLeary, and Edwards (1997) report an interesting set of ndings outlining how adult ADHD may interact with parenting skills. They examined couples with clinic-referred children with ADHD and found that father involvement in parenting was associated with more effective parenting when the father did not report ADHD symptoms, but that father involvement predicted more ineffective parenting when the father did have ADHD. One obvious interpretation of these ndings is that fathers ADHD actively impairs their ability to be consistent and effective parents. In sum, ADHD appears strongly associated between parents and children, and ADHD in parents appears to confer specic impairments in parental functioning above and beyond the inuence of child ADHD. Two treatment case studies support this hypothesized pathway of parent ADHD functioning to create or exacerbate child ADHD and/or conduct problems. Evans, Vallano, and Pelham (1994) described a mother whose ADHD prevented her from monitoring child behavior and being consistent in the implementation of management techniques. Psychostimulant treatment for the mother not only decreased her ADHD symptoms, but also increased her ability to manage her childs behavior. Similarly, Daly and Fritsch (1995) described a mother with ADHD whose

Families of Children With ADHD dgeting and distractibility were signicantly impairing her ability to engage her infant in feeding. Pharmacological treatment of the mothers ADHD was crucial in alleviating failure to thrive in the mothers 2-month-old infant. Comorbidity with conduct problems. Looking at links between parental ADHD and the comorbidity of child ADHD and conduct problems, Frick, Lahey, Christ, Loeber, and Green (1991) found that boys with ADHD had more relatives with ADHD, whereas boys with CD had more fathers with substance-abuse problems and CD, although this later association was no longer signicant with demographic characteristics controlled. Biederman, Munir, and Knee (1987), Faraone et al. (1995), and Schachar and Wachsmuth (1990) all reported elevated rates of ADHD compared to controls in families of boys with ADHD, both with and without comorbid ODD/CD. Finally, Loney, Paternite, Schwartz, and Roberts (1997) found that a fathers childhood history of inattentive-overactive behavior was an exclusive and specic predictor of inattention-overactivity in the sons, but neither inattentive-overactive or aggressive father histories were predictive of son aggression. The link between parent and child inattention-overactivity also held for mothers. Thus, despite minor inconsistencies, most studies show an elevated risk of adult ADHD in families of children with ADHD, independent of the presence of child conduct problems.

199 can be drawn regarding the how and why of the links between dimensions of parental psychopathology and child ADHD and conduct problems.

CONCLUSIONS AND RECOMMENDATIONS FOR FUTURE RESEARCH Two striking revelations derive from this review. First, across existing studies there is tremendous inconsistency in ndings. Second, there is a lack of research that informs us about the developmental progression of ADHD or the processes that underlie observed associations of family characteristics and childhood ADHD. Before discussing these two main conclusions, we briey highlight the limited number of consistent ndings that do appear in the review. From studies of parentchild interactions and adult alcohol abuse, there is reasonable evidence that child ADHD can inuence parent behavior and adjustment, and vice versa that parenting behavior can impact on the presentation, if not the development, of both child conduct and ADHD symptoms. From families studies, there is also reasonable evidence of specicity in families histories for ADHD and conduct problems. That is, parent and child ADHD appear associated, as do parent and child conduct problems. Other family characteristics, such as the inuence of life stress or marital disturbance, do not appear either specic to ADHD or even consistently linked to its appearance. Finally, across all the research, a general impression is formed of a continuum of association, with family factors most strongly linked to child conduct problems, but also linked to child ADHD. However, the number of unsupportive or inconclusive studies seriously limits even these conclusions.

Discussion of the Link Between Parental Psychological Functioning and ADHD Across multiple aspects of parental psychological functioning, although the evidence is inconsistent, the strongest associations typically are found between parental maladjustment and child conduct problems. Although ADHD that is not comorbid with conduct problems shows weaker associations, it does remain linked to parental psychological functioning. In particular, parent ADHD appears associated with child ADHD, rather than with conduct problems. However, these studies offer only preliminary suggestions regarding the mechanisms that underlie these associations and their development over time. What little evidence does exist regarding the pathways of development is consistent with transactional models of inuence, with the effects of parental psychological functioning at least partially mediated via parenting behaviors. Much remains to be done to test these and alternate models of development before conclusions

Inconsistency in Findings We believe that the most justied general conclusion from this review is that great inconsistencies and gaps exist in our knowledge of the families of children with ADHD. Some research nds no associations between family factors and either ADHD or conduct problems, other studies nd ADHD and conduct problems are equally associated with family factors, and yet others show stronger associations between family factors and ADHD than conduct problems. Such inconsistencies are not easily explained by

200 differences in study methods or samples, and appear across multiple dimensions of family functioning. Caution must be exercised in drawing conclusions, and more research is needed before statements regarding which family factors are and are not associated with child ADHD, conduct problems, or both can be made with condence. Methodological and theoretical conundrums might offer some explanation for the inconsistent ndings that characterize this area. For one, research in this area is hindered by the confounding of measures of family functioning and measures of child symptomatology. To the extent that diagnoses of child ADHD and conduct problems are based on parental reports, concern exists as to how difculties in family functioning inuence such reports. For example, some evidence suggests that mothers who are depressed are sometimes negatively biased in their perceptions of child symptomatology (e.g., Fergusson, Lynskey, & Horwood, 1993; Johnston & Short, 1993). Similar concerns have been raised that parents of children with ADHD may report more of the symptoms in themselves because of their familiarity with the disorder (although Faraone, Biederman, & Mick, 1997, found no differences in symptoms reported by parents who did and did not have children with ADHD). To the extent that family factors and child symptoms are confounded at the measurement stage, clear understanding of the association between these variables will be obscured. Future research must routinely incorporate multiple informants and objective assessments so that condence can be placed in the associations that are revealed. Another methodological concern arises in studies comparing ADHD and comorbid ADHD+ conduct problem groups as to the comparability of ADHD symptom severity across groups. Only occasionally is this difference in ADHD symptoms tested or reported (e.g., Barkley et al., 1991; Gomez & Sanson, 1994; Leung et al., 1996; Stormont-Spurgin & Zentall, 1996). Often the possibility of a confounding of comorbidity effects with ADHD severity remains unaccounted for or unacknowledged. Thus, ndings indicating greater family problems in comorbid groups may reect the presence of the comorbid conduct problems or may reect an elevated severity of ADHD symptomatology. Studies of ADHD and conduct problem comorbidity must also struggle with whether the comorbidity reects one condition at different developmental stages, an additive combination of the two disorders, or a distinct condition associated with unique

Johnston and Mash correlates not found in either condition alone (e.g., Biederman, Munir, & Knee, 1987; Faraone, Biederman, Mennin, Russell, & Tsuang, 1998; Jensen, Martin, & Cantwell, 1997; Patterson et al., 2000; Rutter & Sroufe, 2000; Schachar & Tannock, 1995). Other issues arise in considering the inuences operative between family factors and comorbid conduct problems. Carlson, Tamm, and Hogan (1999) in reviewing evidence regarding families of children with ODD and CD, point to the problem of comorbidity with ADHD in interpreting this literature. In particular, they note that few studies have differentiated ODD and CD and those that do suggest that CD is independently linked to family problems, but that ODD may need to be combined with ADHD before family problems appear. A variety of sample differences may be contributors to the differences observed in existing research. Research on family factors in ADHD has seldom considered the inuence of environment beyond the family, particularly the cultural or ethnic context. For example, in the work on parents social cognitions, given the socially construed nature of such cognitions, much greater attention is needed to the cultural specicity or generalizability of this research. Bussing, Schoenberg, and Perwien (1998) compared the explanatory models of ADHD used by white and African American mothers of children with ADHD. Results indicated that African American mothers had less formal knowledge of ADHD, and were less likely to view genetics as important in the disorder, to see ADHD as a medical disorder, or to endorse medication as a treatment. These ethnicity effects maintained even with the socioeconomic status controlled. Thus, in line with the developmental psychopathology perspective that is advocated in this review, consideration of the broader social and cultural context of ADHD must be incorporated in studies of families of children with ADHD (Sameroff, 2000). Alongside culture, gender and ADHD subtype also stand as underrepresented variables in existing work. Future studies must focus careful attention on how the dynamics of family and child factors may differ across these child characteristics. For example, recent work has suggested that the relative contributions of shared and nonshared family and genetic inuences may differ across boys and girls with ADHD (Rhee, Waldman, Hay, & Levy, 1999). Thus, models of family associations with ADHD may need to be considered separately for the two genders. Similarly, some developing work on the nature of the inattentive subtype of ADHD suggests that this may be a distinct

Families of Children With ADHD disorder (Barkley, 1997), and again, models linking family factors to child ADHD will need to pay heed to similarities and differences across subtypes of the disorder. Finally, work is needed to expand what has been a focus primarily on mothers and motherson interactions to include both parents and other family subsystems, including sibling relationships. Knowledge of these domains will not only broaden our understanding, but the similarities and differences in associations between family factors and child ADHD across these multiple arenas may inform us as to the developmental pathways and mechanisms of association operative in each.

201 an approach, identifying different pathways for different children with ADHD, would enhance the regularity of ndings and allow rmer, as well as richer, conclusions regarding the characteristics and functioning of families of children with ADHD. One approach to advancing research in this area is to use longitudinal, genetically informed research designs. Ideally, such studies would begin early in a childs life (perhaps even prenatally) and include repeated, developmentally sensitive measures of characteristics of the child and family (and perhaps the larger environmental context). Although assessment of ADHD and conduct problems is obviously difcult in the early years, recognition of important developmental processes such as emotion regulation, attachment, and language development offers a useful guide to the types of processes that are likely precursors to the patterns of symptoms identied in elementary schoolaged children. Such designs may be maximally informative if they couple extensive and multiple measures of neurological, psychological, and social characteristics with information regarding the genetic make-up of family members (e.g., DNA samples). As examples, such designs might yield information about children who are at risk for ADHD but fail to develop the disorder because of the protective family environment, or information regarding how environmental risk factors may alter the neurological functioning of children with or without vulnerabilities to ADHD. Similarly, longitudinal studies examining the course of parental ADHD (in one or both parents), parentchild interactions, and child development over time may shed light on contributions of genetic factors, parenting factors, or both that underlie the link between parental and child ADHD. A second approach to research in this area, one that is complementary to the longitudinal bio-psychosocial approach outline above, uses focused laboratory or cross-sectional studies to address specic questions regarding pathway inuences. For example, studies using laboratory manipulations of child behavior (e.g., via medication) or parenting behavior (e.g., via stress-induction or attentional load) will continue to be informative regarding whether causal inuence can ow from child to parent and vice versa. Similarly, focused studies of the parenting skills of adults with ADHD, particularly in relation to their interactions with young children, will offer valuable information regarding the nonbiological pathways through which the disorder may exert its familial inuence. Studies of sibling relationships will broaden our understanding of the impact of ADHD across family members,

Lack of a Developmental Psychopathology Approach Our second impression focused on the lack of research that informs a developmental psychopathology approach to ADHD. The majority of the existing studies are correlational in nature and offer little understanding of how associations between family factors and child problems develop over time. Certainly, the heterogeneity of research ndings is a strong indication of the existence of individual differences in how and when family factors are linked to the development of ADHD and conduct problems. As noted in the introduction, family factors and child characteristics are likely to interact in a multiplicity of ways, yielding different developmental trajectories for the unfolding of ADHD symptomatology and conduct problems. To understand these different pathways, both theoretical and empirical steps are needed. We believe that there is a need for greater development of theoretical models concerning family inuences and ADHD. Much of the existing theoretical work in this area has focused either on the biological contributions of families (e.g., Faraone & Biederman, 2000) or the contributions of family environment to the development of conduct problems secondary to ADHD (e.g., Patterson et al., 2000). Despite the value of these models, other models that emphasize direct, indirect, and/or reciprocal contributions of family environment to ADHD are also needed. The ultimate value of each of these theoretical models will be found, not necessarily in their truth, but in their ability to guide research and to move our knowledge forward. Empirically, there is a need for research designed to test the mechanisms and timing of inuences and how these vary across children. We believe that such

202 and comparisons of parents interactions with children with ADHD and their nonaffected siblings may offer insight into the transactional effects that are unique to interactions with ADHD children. In sum, any number of studies of this type could be imagined and, if conducted carefully, each could contribute a valuable piece to the puzzle of multiple developmental pathways. In summary, we argue that the primary challenge for future research concerning families of children with ADHD is to clarify the nature and timing of the inuences that operate in the associations between family and child characteristics. Although a few longitudinal and experimental studies have begun to address this need, much remains for future research development. In particular, greater sophistication is needed in exploring the ways in which genetic vulnerabilities, parenting, parental characteristics, and child experiences interact over time to produce or alter the pathway of development of ADHD. We believe that such research holds tremendous potential to inform intervention and, ultimately, prevention efforts for families and children who suffer from the impairments of ADHD.

Johnston and Mash

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ACKNOWLEDGMENTS During the preparation of this report, Charlotte Johnston was supported by operating grants from the Social Sciences and Humanities Research Council of Canada and the University of British Columbia. During the writing of this paper, Eric Mash was supported, in part, by a University of Calgary Killam Resident Fellowship.

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