Infant and Child Development

Inf. Child. Dev. 20: 148161 (2011) Published online 12 April 2010 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/icd.682

Maternal Positive Parenting Style is Associated with Better Functioning in Hyperactive/Inattentive Preschool Children
Dione M. Healeya,, Janine D. Floryb,c, Carlin J. Millerd and Jeffrey M. Halperinb,c
a

Department of Psychology, University of Otago, Dunedin, New Zealand Department of Psychology, Queens College of the City University of New York, Flushing, NY, USA c Department of Psychiatry, Mount Sinai School of Medicine, New York, NY, USA d Department of Psychology, University of Windsor, Windsor, Ont., Canada
b

Many preschoolers are highly inattentive, impulsive, and hyperactive; but only some are impaired in their functioning. Yet factors leading to functional impairment, above and beyond the severity of inattentive and hyperactive symptoms, have not been systematically examined. This study examined a model suggesting that after controlling for attention-decit/hyperactivity disorder (ADHD) symptom severity, child temperament is uniquely associated with parenting stress; that parenting stress affects parenting style, above and beyond child characteristics; that parenting style is related to the level of child impairment, above and beyond the effects of child symptoms, temperament, and parenting stress; and nally that parenting style moderates the relationship between ADHD symptom severity and child functioning. Child measures included parent- and teacher-rated ADHD symptom severity, teacher-rated temperament, and clinician-rated functioning in a sample of 138 inattentive/hyperactive preschoolers. Maternal self-ratings of parenting style and parenting stress were obtained. Analyses indicated that, after controlling for symptom severity, child temperament was related to maternal parenting stress, which was additionally related to both maternal parenting style and child functioning. Maternal positive parenting style moderated the relationship between ADHD symptom severity and child impairment, indicating that a positive parenting style plays a protective role in the functioning of

*Correspondence to: Dione M. Healey, Department of Psychology, University of Otago, P. O. Box 56, Dunedin, New Zealand. E-mail: dionehealey@psy.otago.ac.nz
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  hyperactive/inattentive preschoolers. Copyright r 2010 John   Wiley & Sons, Ltd.    Key words: ADHD; child temperament; maternal factors; child  functioning

MATERNAL POSITIVE PARENTING STYLE IS ASSOCIATED WITH BETTER FUNCTIONING IN HYPERACTIVE/INATTENTIVE PRESCHOOL CHILDREN
Attention-decit/hyperactivity disorder (ADHD) is a common and oftentimes debilitating life-long psychiatric disorder associated with high levels of activity, impulsivity, and difculties with sustained mental effort. According to the DSM-IV, a diagnosis of ADHD requires symptoms to: (1) be present before 7 years of age; (2) occur across two or more settings; and (3) cause signicant impairment in the individuals functioning (American Psychiatric Association, 2000). It is important to note that without signicant functional impairment (e.g. difculties in making and keeping friends, disruptive at home and school, academic under achievement) as a result of the symptoms, a diagnosis cannot be made. Moreover, the degree to which symptomatic individuals are impaired in their functioning varies greatly; for instance Healey, Miller, Castelli, Marks, and Halperin (2008) examined the proportion of symptomatic preschoolers who met impairment criteria using various cut-offs and found that only 2354% met both symptom and impairment criteria, depending on cut-off levels applied. Similarly, in older children, Gordon et al. (2006) found that when imposing impairment criteria on a group who met the symptom criteria for ADHD, only 33% met the full diagnostic criteria (i.e. symptoms and functional impairment). They also reported that correlations between symptoms and impairment were modest, at best, and that symptom severity rarely accounted for more than 25% of the variance in impairment. In line with this discrepancy between symptoms and impairment, several studies have shown that treatment-induced reductions in ADHD symptoms oftentimes do not ameliorate functional impairment in children with the diagnosis. For example, despite improved attention or reduced activity levels following the use of medications, many children with ADHD continue to have trouble making and keeping friends, have poor social skills, or do poorly in school (Frankel, Myatt, Cantwell, & Feinberg, 1997; Pelham, Schnedler, Bologna, & Contreras, 1980). Thus, it is clear that symptom severity and impaired functioning are not completely overlapping. Yet little attention has focused on why some symptomatic children function quite poorly, while others do relatively well. As such, the eld could prot considerably from a better understanding of additional factors that are associated with impairment in functioning so as to better assess and treat the wide array of decits in everyday functioning that are experienced by children with ADHD. A number of factors are known to be involved in child functioning. One important contributor, particularly in young children, is temperament. An extensive body of literature has demonstrated the link between temperament and psychopathology. Children with difcult temperaments have repeatedly been shown to develop more psychopathology than those with more easy going temperaments (Campbell, Pierce, March, Ewing, & Szumowski, 1994; Huey & Weisz, 1997; Sanson, Smart, Prior, & Oberklaid, 1993).
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Parental characteristics have also frequently been linked to child functioning. Observational studies of parentchild interactions have shown that mothers of children with ADHD are more controlling, more negative, and less socially interactive than mothers of children without ADHD (Barkley, Karlsson, & Pollard, 1985; Campbell, 1995; Johnston & Mash, 2001; Keown & Woodward, 2002; Winsler, 1998). Campbell, Shaw, and Gilliom (2000) found that those preschoolers who continued to have externalizing problems in middle childhood were ones whose mothers used high levels of negative control. Using a genetically sensitive, longitudinal design to investigate the direction of the relationship between parental hostility and ADHD symptom severity, Lifford, Harold, and Thapar (in press) found that symptom severity in boys with ADHD impacted upon motherson hostility, both within and across time, but there was no signicant relation in the opposite direction (i.e. motherson hostility leading to ADHD symptom severity). This nding suggests that difcult child behaviour drives parental hostility rather than the other way around. Parents of children with ADHD have also, not surprisingly, been reported to experience considerable stress (Fisher, 1990; Johnston & Mash, 2001). Wolfson and Grant (2006) found that, among mothers of children with developmental difculties, high parenting stress was associated with a more authoritarian parenting style, suggesting that high stress as a result of their childs difcult behaviour, may impact upon the level of negative control used by parents of difcult children. Therefore, because difcult children elicit more stress and negative control, and negative parental control has been associated with adverse trajectories in disruptive preschool children (Campbell et al., 2000) it is likely that a childs ADHD symptom severity, as well as their temperament, will inuence how parents interact with their child (e.g. difcult children eliciting more stress leading to a more hostile parenting style), which in combination impacts upon child outcome. We propose a model where both ADHD symptom severity and difcult child temperament will account for unique variance in maternal parenting stress, with parents of children displaying more severe symptomatology and more difcult temperament exhibiting higher levels of parenting stress. It is further predicted that, above and beyond individual child characteristics, high parenting stress will be associated with a more punitive and less positive parenting style. Finally it is predicted that this type of parenting style will be associated with poorer child functioning, above the effects of individual child characteristics and parenting stress; and that parenting style will moderate the relationship between ADHD symptom severity and child functioning (Figure 1).

Child ADHD symptom severity & temperament

Maternal Parenting Stress

Maternal Parenting Style

Child Functioning

ADHD Symptom Severity

Figure 1. Proposed model of the relations between parent and child factors and level of functioning in hyperactive/inattentive preschoolers.
Copyright r 2010 John Wiley & Sons, Ltd. Inf. Child. Dev. 20: 148161 (2011) DOI: 10.1002/icd

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METHOD
Participants The participants were 138 (105 male, 33 female) 3- and 4-year-old (M 5 4.36, S.D. 5 0.47), children who were recruited through preschools (n 5 68) and clinical referrals (n 5 70) from an urban area. The children were all classied as hyperactive/inattentive as determined by the endorsement of at least six symptoms of hyperactivityimpulsivity and/or inattention across parent and teacher ratings on the Attention Decit/Hyperactivity Disorder Rating Scale-IV (ADHD-RS-IV; DuPaul, Power, Anastopoulos, & Reid, 1998). For example, a parent may have endorsed four symptoms of hyperactivity/impulsivity and the teacher ve symptoms of hyperactivity/impulsivity, with two of them being different from those endorsed by the parent, resulting in six individual symptoms of hyperactivity/impulsivity being endorsed across settings (i.e. four by parent and an additional two by teacher). By design, this requirement resulted in a sample with a wide range in severity of symptoms, with some (21.7%) not meeting full DSM-IV diagnostic criteria for any of the three subtypes of ADHD diagnosis (i.e. predominantly hyperactive/impulsive, predominantly inattentive, or combined), but all being characterized as symptomatic in at least one setting. Within the sample 18.8% were rated as meeting ADHD symptom criteria (i.e. six or more symptoms of hyperactivity and/or inattention) by parent only, 30.4% by teacher only, and 50.7% by both. With regard to ADHD subtypes 13.8% were rated as predominantly inattentive, 36.2% as predominantly hyperactive, and 50% as combined type. The ethnicity of the sample was diverse; 40.6% of the children were White, Non-Hispanic; 19.6% were White, Hispanic; 13.0% were Black, Non-Hispanic; 2.2% were Black, Hispanic; 5.8% were Asian; and 18.8% reported mixed or other ethnicity/race. Socio-economic status (SES) was measured using the Nakao-Treas Socioeconomic Prestige Index (Nakao & Treas, 1994) where high scores are indicative of higher SES. The SES of this sample was variable (range: 2089), but most of the children were living in homes with moderate SES (M 5 53.12, S.D. 5 15.52). Measures ADHD-RS-IV (DuPaul et al., 1998): ADHD symptom severity was assessed using the ADHD-RS-IV, a rating scale based on the 18 DSM-IV-specic ADHD symptoms for which a score on a 4-point scale is assigned by the rater (i.e. Never or rarely 5 0, Sometimes 5 1, Often 5 2, Very often 5 3) and the maximum possible score is 54. The psychometric properties of this scale, which can be completed by parents and teachers, have been well-established for children above the age of 5 years (DuPaul et al., 1998). More recent data similarly indicate that the scales are highly reliable and valid when used with preschool children (McGoey, DuPaul, Haley, & Shelton, 2007). Consistent with this, in our sample of 3- and 4-year-old children, reliability, as assessed by coefcient a, was found to be quite strong for both parent (a 5 0.92) and teacher (a 5 0.94) ratings. For the analyses in this study, a composite score representative of combined parent and teacher ratings was created using a variant of the or-rule which is a common method for combining information from two informants (Costello et al., 1988; Hartman, Rhee, Willcutt, & Pennington, 2007; Lahey et al., 1994; Piacentini, Cohen & Cohen, 1992). Because some ADHD symptoms are more likely to be
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observed or to occur in particular settings (Hartman et al., 2007), for each item on the ADHD-RS-IV the higher of the two ratings (i.e. parent and teacher) was the item score used in developing the composite, which served as the index for symptom severity in this study (maximum score 5 54; sample range: 1754; M 5 38.48, S.D. 5 7.82). This approach for combining parent and teacher ratings has the advantage over averaging the two ratings of maximally capturing the impact of symptoms that are generally manifest in only one setting (e.g. the child who has severe difculty sustaining attention in school, but no such demands are made at home, or loses things at home but this is not apparent to the teacher). Childrens Global Assessment Scale (CGAS; Shaffer et al., 1983). This scale assesses global functioning across settings, and ratings take into consideration the childs level of functioning at home and in school, as well as the nature and quality of peer relations. Scores on this measure range from 0 to 100 with lower scores indicating more impairment. Information regarding (1) developmental history/ demographics; (2) psychosocial functioning (as reported by the parent via direct interview; and both parents and teachers on the Behavioural Assessment Scale for Children (BASC-2; Reynolds & Kamphaus, 2004), a measure of general psychosocial functioning, and the Childrens Problems Checklist (CPC; Healey et al., 2008) a brief measure of child impairment); (3) behavioural observations across two 3-h cognitive testing sessions, rated by the evaluator on the Behavioural Rating Inventory for Clinicians (Gopin, Healey, Castelli, Marks, & Halperin, in press), a brief 4-item measure of hyperactivity, inattention, mood, and sociability; (4) as well as neuropsychological functioning were presented to a group of 410 trained clinicians who each independently rated the level of impairment experienced by the child on the CGAS. Clinician raters were blind to all child temperament and maternal parenting stress and parenting style scores. The median of all ratings was assigned to each child, and served as the primary measure of impairment for this study. Ratings across clinicians showed considerable consistency; the mean within-subject standard deviation, which is analogous to the standard error of measurement, was 4.88 points. Median CGAS scores for this sample ranged from 32.5 to 84.0, with a mean of 49.25 (S.D. 5 9.94). Temperament Assessment Battery for ChildrenRevised (TABC-R; Martin & Bridger, 1998). Teachers rated each childs temperament on this 29-item questionnaire. Each item was rated on a scale from 1 (hardly ever) to 7 (almost always). This measure generates four subscales: Inhibition, Negative Emotionality, Activity Level, and Lack of Task Persistence. Three of these subscales (i.e. Negative Emotionality, Activity Level, and Lack of Task Persistence) can be combined to form a single dimension named Impulsivity (Martin & Bridger, 1998). The three measures loading onto the Impulsivity dimension were signicantly inter-correlated in our sample (all po0.001). Thus, for this study the two broad dimensions of Inhibition (i.e. shyness) and Impulsivity (i.e. dysregulation) were used in the analyses. Scores are converted into T-scores. The Mean (S.D.) of scores in this sample were 45.7 (11.23) for Inhibition and 59.1 (9.56) for Impulsivity. As reported in the TABC-R manual, the internal consistency (as range from 0.860.95), inter-rater reliability (rs range from 0.34 to 0.66), and temporal stability (rs range from 0.47 to 0.71) for this teacher-rated temperament scale has been found to be adequate (Martin & Bridger, 1998). Within our sample, internal consistency was only slightly lower with as ranging from 0.81 to 0.89. Alabama Parenting QuestionnairePreschool Revision (APQ-PR; Clerkin, Marks, Policaro, & Halperin, 2007). Mothers completed this self-report measure of parenting style. The APQ-PR, a downward extension of the original APQ that was designed for school-age children (Shelton, Frick, & Wootton, 1996), consists of 32
Copyright r 2010 John Wiley & Sons, Ltd. Inf. Child. Dev. 20: 148161 (2011) DOI: 10.1002/icd

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items rated on a 5-point scale ranging from 1 (never) to 5 (always). This measure generates three parenting dimensions: Positive, Inconsistent, and Punitive Parenting. Possible scores for the Positive Parenting dimension range from 0 to 60 with high scores indicating more praise and positive engagement. The Mean (S.D.) for our sample was 52.97 (4.34). The Inconsistent Parenting dimension has a possible range from 0 to 35, with higher scores indicating more ambivalent and inconsistent engagement and discipline. The Mean (S.D.) for our sample was 15.40 (3.96). The Punitive Parenting dimension has a range of possible scores from 0 to 25, with higher scores indicating more yelling and use of physical punishment. The Mean (S.D.) for this sample was 9.61 (2.30). All three factors have been shown to have adequate internal consistency (as range from 0.63 to 0.82) and temporal stability (rs range from 0.52 to 0.80) in preschool aged children (Clerkin et al., 2007). In our sample, coefcient a for the Inconsistent Parenting subscale was somewhat low (a 5 0.57), but internal consistency indices for the Positive and Punitive parenting factors were good (as 5 0.70 and 0.77, respectively). Parenting Stress IndexShort Form (PSI-SF; Abidin, 1995). This 36-item rating scale is a measure of stress related to parenting. Three individual indices are generated: Parenting Distress, Difcult Child, and ParentChild Dysfunctional Interaction. These are combined to form a composite Total Stress, which is the measure used for the analyses in this study. Higher Total Stress scores indicate more stress experienced in relation to parenting the target child. All PSI data used in this study was based on maternal self-report on this measure. Scores for this measure were converted into T-scores and the Mean (S.D.) for this samples Total stress score were 81.23 (19.22). The internal consistency (as range from 0.80 to 0.91) and testretest reliability (rs range from 0.68 to 0.85) have been found to be adequate (Abidin, 1995). Within our sample, internal consistency for the Total stress score was excellent (a 5 0.91). Procedures In screening children for suitability to participate in the study, parents and teachers completed the ADHD-RS-IV. These questionnaires were rst distributed to parents in local preschools, along with consent forms, and returned in postagepaid addressed envelopes. After receiving the parent rating and consent, the ADHD-RS-IV was sent to the childs teacher. Once being deemed eligible and agreeing to participate, parents were sent out a package containing additional questionnaires. They completed the Demographics Questionnaire, BASC-2, CPC, APQ-PR, and PSI either just before attending their rst laboratory session, or while waiting for their child to complete the laboratory session. Consent was also given for teachers to complete the TABC-R and return it in a postage-paid addressed envelope. During the initial laboratory session parents provided signed informed consent and participants were reimbursed $20/h for their time spent attending laboratory sessions. This study was approved by the relevant local Institutional Review Board. Data Analysis Hierarchical Linear Regression analyses were conducted to examine the pattern of relationships between variables depicted by the proposed model. We evaluated whether parenting style moderated the relationship between
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child ADHD symptom severity and impairment by including interaction terms in the hierarchical regression equation. In this case, the predictor variables (i.e. ADHD symptom severity and maternal parenting style) were centered, by subtracting the sample mean from the individual score, prior to calculating interaction terms between these variables. The plotted moderation model then indicated under which conditions the main effects occur (Jose & Huntsinger, 2005).

RESULTS
Relationship between Child Temperament and Maternal Parenting Stress (After Controlling for Childs ADHD Symptom Severity) The rst step of the proposed model suggests that ADHD symptom severity and child temperament will each account for unique variance in the level of maternal parenting stress, with higher symptom severity and a more difcult temperament relating to higher maternal parenting stress. Hierarchical Linear Regression analysis indicated that both ADHD symptom severity and the child temperament dimension Impulsivity (indicating the level of behavioural, emotional and cognitive dysregulation) accounted for signicant unique variance in maternal parenting stress (Table 1). As expected, higher ADHD symptom severity and Impulsivity were associated with higher maternal parenting stress. Relationship between Maternal Parenting Stress and Parenting Style (After Controlling for Childs ADHD Symptom Severity and Impulsivity) The second step in the proposed model suggests that maternal parenting stress is associated with maternal parenting style, above and beyond individual child factors. Three Hierarchical Linear Regression analyses were conducted to examine whether maternal parenting stress accounted for unique variance in each of the three maternal parenting styles (punitive, inconsistent, and positive). Results indicated that the level of maternal parenting stress was signicantly related to all three parenting styles, with higher stress associated with more punitive and inconsistent, and less positive parenting styles (Table 2).

Table 1. Hierarchical Linear Regression examining whether ADHD symptom severity and child temperament account for unique variance in maternal parenting stress
Variables Model 1 ADHD symptom severity Model 2 ADHD symptom severity Inhibition Impulsivity Ba 0.413 0.688 0.068 0.473 S.E. 0.208 0.237 0.148 0.201 b 0.168 0.280 0.040 0.233 t 1.990 2.910 0.460 2.354 p 0.049 0.046 0.004 0.646 0.020 0.039 2.773 Adjusted R2 0.021 DR2 0.028 DF 3.962

Note: The bolded values are the p-values which indicate level of signicance. a Unstandardized coefcients. Copyright r 2010 John Wiley & Sons, Ltd. Inf. Child. Dev. 20: 148161 (2011) DOI: 10.1002/icd

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Table 2. Hierarchical Linear Regression examining whether ADHD symptom severity, Impulsivity and maternal parenting stress account for unique variance in maternal parenting styles (i.e. punitive, inconsistent, and positive)
Variables Predictors of punitive parenting Block 1 ADHD symptom severity Impulsivity Block 2 ADHD symptom severity Impulsivity Maternal parenting stress Predictors of inconsistent parenting Block 1 ADHD symptom severity Impulsivity Block 2 ADHD symptom severity Impulsivity Maternal parenting stress Predictors of positive parenting Block 1 ADHD symptom severity Impulsivity Block 2 ADHD symptom severity Impulsivity Maternal parenting stress Ba S.E. b t p Adjusted R2 DR2 0.008 0.003 0.033 0.009 0.081 0.935 0.022 0.027 0.090 0.817 0.416 0.045 0.026 0.033 0.089 0.800 0.426 0.006 0.027 0.025 0.224 0.823 0.031 0.011 0.257 2.710 0.008 0.018 0.001 0.056 0.003 0.024 0.981 0.000 0.046 0.000 0.003 0.998 0.027 0.039 0.057 0.077 0.686 0.494 0.025 0.046 0.061 0.545 0.587 0.049 0.020 0.239 2.497 0.014 0.122 0.061 0.219 2.008 0.047 0.045 0.050 0.100 0.913 0.363 0.057 0.083 0.062 0.149 1.340 0.183 0.019 0.050 0.042 0.384 0.702 0.051 0.021 0.226 2.397 0.018 0.047 5.744 0.018 0.035 2.033 0.053 6.237 0.000 0.000 0.061 7.344 DF

0.009 0.520

Note: The bolded values are the p-values which indicate level of signicance. a Unstandardized coefcients.

Relations between Maternal Parenting Style and Child Functioning (After Controlling for Childs ADHD Symptom Severity and Impulsivity, and Maternal Parenting Stress) The third step in the model suggests that above and beyond the effects of child symptom severity and temperament, as well as maternal parenting stress, maternal parenting style will be additionally associated with child functioning. A Hierarchical Linear Regression analysis revealed that while ADHD symptom severity, impulsivity, and maternal parenting stress all accounted for signicant unique variance in child functioning, none of the parenting styles reached signicance, although maternal positive parenting style approached signicance (p 5 0.051; Table 3). Does Parenting Style Moderate the Relationship between a childs ADHD Symptom Severity and Their Level of Impairment? The nal aspect of the model suggests that the relationship between ADHD symptom severity and the childs level of functioning will be moderated by maternal parenting style. For moderation analyses, the independent (ADHD symptom severity) and moderator (maternal parenting styles) variables were centered and interaction terms were calculated between each of the moderator
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Table 3. Hierarchical Linear Regression examining whether ADHD symptom severity, impulsivity, maternal parenting stress, and maternal parenting styles account for unique variance in child functioning
Variables Predictors of child functioning Block 1 ADHD symptom severity Impulsivity Block 2 ADHD symptom severity Impulsivity Maternal parenting stress Block 3 ADHD symptom severity Impulsivity Maternal parenting stress Punitive parenting style Inconsistent parenting style Positive parenting style Ba S.E. b t p Adjusted R2 DR2 0.348 0.440 0.104 0.338 4.248 o0.001 0.380 0.086 0.353 4.429 o0.001 0.394 0.357 0.103 0.274 3.462 0.001 0.435 0.084 0.404 5.156 o0.001 0.122 0.036 0.230 3.339 0.001 0.405 0.330 0.434 0.107 0.325 0.177 0.316 0.103 0.084 0.038 0.308 0.178 0.160 0.253 0.403 0.203 0.075 0.071 1.38 3.187 0.002 5.183 o0.001 2.814 0.006 1.054 0.249 0.999 0.320 1.973 0.051 0.024 1.872 0.049 11.146 DF

0.357 37.556

Note: The bolded values are the p-values which indicate level of signicance. a Unstandardized coefcients.

variables and the independent variable. These variables were then subjected to a hierarchical regression analysis predicting the level of child impairment. Block 1 included the centered ADHD symptom severity composite, followed by the centered moderator variables (punitive, inconsistent, and positive parenting styles) in Block 2, and the interaction terms (ADHD symptom severity punitive parenting style, ADHD symptom severity inconsistent parenting style, and ADHD symptom severity positive parenting style) in Block 3. Results showed that symptom severity and positive parenting style were both associated with the level of child impairment, as was the interaction between these two (Table 4 for standardized regression coefcients). Figure 2 depicts that among children who meet symptom criteria for ADHD, positive parenting style was protective among those with a less severe symptom presentation (i.e. X1 S.D. below the mean; ADHD-RS mean score for this group 5 30.66). However, when symptom severity was extreme (i.e. X1 S.D. above the mean; ADHD-RS mean score for this group 5 46.30), the benecial effect of positive parenting is negligible. Additional Control Variables To ensure that the above ndings were not accounted for by the childs age, gender, and SES, the regression analyses were rerun entering these variables as controls in the rst block. None of these variables accounted for a signicant amount of variance and none appreciably altered the ndings. Revised Model Based on the results of the analyses in this study, Figure 3 depicts the revised representation of the proposed model where ADHD symptom severity and high levels of dysregulation (i.e temperamental impulsivity) in the child are both associated with higher maternal parenting stress, which is related to both more
Copyright r 2010 John Wiley & Sons, Ltd. Inf. Child. Dev. 20: 148161 (2011) DOI: 10.1002/icd

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Table 4. Hierarchical Linear Regression examining whether parenting styles moderate the relationship between ADHD symptom severity and child functioning
Variables Block 1 ADHD symptom severity Block 2 ADHD symptom severity Punitive parenting style Inconsistent parenting style Positive parenting style Block 3 ADHD symptom severity Punitive parenting style Inconsistent parenting style Positive parenting style ADHD punitive ADHD inconsistent ADHD positive Ba S.E. b t p Adjusted R2 DR2 0.277 0.297 DF

0.672 0.097 0.532 6.908 o0.001 0.633 0.352 0.298 0.350 0.661 0.386 0.278 0.450 0.049 0.013 0.058 0.098 0.501 6.480 o0.001 0.358 0.079 0.984 0.327 0.201 0.118 1.483 0.141 0.183 0.150 1.912 0.058 0.098 0.353 0.021 0.185 0.056 0.029 0.024 0.523 0.086 0.110 0.193 0.080 0.039 0.200 6.734 o0.001 1.095 0.276 1.384 0.169 2.427 0.017 0.882 0.380 0.434 0.665 2.481 0.015

0.283 47.726 0.038 2.172

0.320

0.039

2.321

Note: The bolded values are the p-values which indicate level of signicance. a Unstandardized coefcients.

Figure 2. Moderating effect of maternal positive parenting style on the relationship between ADHD symptom severity and child functioning.

punitive and inconsistent, and less positive parenting style, and to lower child functioning (i.e. more impairment). When a positive parenting style was present, it moderated the relationship between child symptom severity and impairment, playing a protective role.

DISCUSSION
The aim of this study was to examine factors, above and beyond symptom severity, that are associated with the functioning of preschool children exhibiting elevated levels of hyperactivityimpulsivity and/or inattention. Based on the
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Child ADHD Symptom Severity & Dysregulation

Maternal Parenting Stress

Child Functioning

Maternal Punitive Parenting Maternal Inconsistent Parenting Maternal Positive Parenting

ADHD Symptom Severity

Figure 3. Rened model of the relation between child and maternal characteristics and level of functioning in hyperactive/inattentive preschoolers.

existent literature, it was hypothesized that difcult child temperament would be additionally associated with high parenting stress, and that high parenting stress would be associated with a parenting style high in negative control and low in positive interactions, which in turn would be associated with the level of child impairment. The data indicated that after controlling for symptom severity, high levels of temperamental impulsivity (i.e. negative emotionality, attention problems, and lack of task persistence) in the child were associated with high levels of maternal parenting stress (i.e. how stressful the mother nds parenting her child), which in turn was additionally associated with higher levels of punitive and inconsistent parenting, and lower levels of positive parenting. While ADHD symptom severity, impulsivity, and maternal parenting stress were all uniquely associated with child functioning, parenting style did not account for any additional variance in functioning. However, maternal positive parenting style was found to moderate the relationship between ADHD symptom severity and functioning such that in children with a less severe (albeit above threshold) level of symptoms, positive parenting was protective as high levels of positive parenting were associated better child functioning. These data indicate that maternal parenting style plays a substantial role in inuencing how impaired their childs psychosocial functioning is, and may inuence the likelihood of the child receiving a diagnosis of ADHD. No studies to date have examined the impact of parent factors on the functioning of hyperactive/inattentive children despite existing literature suggesting that more negative and controlling parenting styles are common reactions among parents of children with ADHD (Barkley et al., 1985; Campbell, 1995; Johnston & Mash, 2001; Keown & Woodward, 2002; Winsler, 1998). In addition the results of this study reiterate the role that maternal parenting stress plays in parenting styles and that high maternal stress is related to more inconsistent and punitive, and less positive parenting styles (Wolfson & Grant, 2006). Finally, these data suggest that a childs temperamental style (in particular their self regulatory skills) uniquely impacts upon their level of impairment both directly, and indirectly through increasing parenting stress. It was somewhat surprising that punitive and inconsistent parenting styles were not associated with child functioning, given the repeated ndings relating high negative parental control with ADHD symptom severity (Barkley et al.,
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1985; Campbell, 1995; Johnston & Mash, 2001; Keown & Woodward, 2002; Winsler, 1998). This may be explained by the fact that parenting style was assessed through maternal self-report and the Mean (S.D.) for inconsistent and punitive parenting were both low in this sample. The low incidence of punitive and inconsistent parenting styles in this sample could be due to a number of factors such as a positive skew in their reporting (many of the past studies have used observational measures of parentchild interactions), a reduced likelihood of these parenting styles being used in a sample of moderate SES, or may be parents of young preschoolers have not yet developed the more hostile parenting behaviours exhibited by parents of older children whom they have struggled to manage for longer. Finally, past studies have all examined the relations between parenting style and ADHD symptom severity (Barkley et al., 1985; Campbell, 1995; Johnston & Mash, 2001; Keown & Woodward, 2002; Winsler, 1998) and not looked at its unique effect on child functioning, nor did they control for symptom severity and parenting stress when examining the relation between parenting style and child behaviour. Given that this past work has also mostly been conducted cross-sectionally, it may be that in the case of ADHD difcult child behaviours drive negative parent behaviours more than the opposite way round, as indicated in Lifford et al.s (in press) study. Identication of additional factors associated with the functioning of children with ADHD, as well as the relations among predictors, has important implications for understanding and treating this disorder. While the use of medication is frequently successful in reducing symptoms it oftentimes does not ameliorate functional impairment for children with ADHD (Frankel et al., 1997; Pelham et al., 1980). Additionally, the use of parent management training, while often successful in the short term, is seldom successful in reducing long-term impairment in these children (Eyberg, Edwards, Boggs, & Foote, 1998; Webster-Stratton, 1990). Given the results of this study, targeting child self-regulation, as well as parental stress and coping, within the treatment of ADHD may compliment our current treatment regimens, assist in signicantly improving the functioning of these children, and have more long-lasting effects; as once the parent and child learn these skills they may become both internalized and generalized. As with all studies, this one is not without limitations. First, this study was testing a novel model that integrated evidence from several previous studies and it is therefore essential that these ndings be replicated in further samples. Second, the maternal variables (i.e. parenting stress and parenting style) in this study were self ratings, thus introducing the possibility of rater bias; although importantly, a teacher report was used to assess the childs temperament. Third, the use of cross-sectional data in this study makes causal inferences difcult, and thus longitudinal studies of these relationships are needed. Fourth, this study used a preschool sample only and thus generalization of these results to older children is difcult. Finally, although controlling for gender did not change the pattern of results, the sample was too small to examine whether these relations between child and parent factors are similar or different for boys and girls. It is possible that sex differences exist.

Implications for Research Policy and Practice These preliminary ndings suggest that, while symptoms do account for a signicant amount of the variance in a childs impairment, difcult child temperament (particularly high impulsivity/dysregulation) is associated with
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higher maternal parenting stress, which in turn is related to less positive and more punitive and inconsistent parenting styles. However, those hyperactive/ inattentive preschoolers whose mothers displayed a positive parenting style were functioning much better. Thus by improving coping skills and reducing parenting stress, mothers may be better able to manage their childs dysregulation, help their children to learn to self-regulate and thus improve their functioning (Calkins & Fox, 2002). Additionally, aiding children in their own self regulation may reduce parenting stress. Thus, these data suggest that treatments for children with ADHD should focus on symptom reduction, as well as improving behavioural, cognitive, and emotional regulation skills in the child and coping skills in the parent, in order to best attempt to alleviate impairment in the childs functioning.

ACKNOWLEDGEMENTS
This research was supported by NIMH grant R01 MH68286.

REFERENCES
Abidin, R. R. (1995). Parenting Stress Index, Short Form. Florida: Psychological Assessment Resources, Inc. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders: DSM-IV-TR (4th ed.: text revision). Washington: American Psychiatric Association. Barkley, R. A., Karlsson, J., & Pollard, S. (1985). Effects of age on the motherchild interactions of ADD-H and normal boys. Journal of Abnormal Child Psychology, 13, 631637. Calkins, S. D., & Fox, N. A. (2002). Self-regulatory processes in early personality development: A multilevel approach to the study of childhood social withdrawal and aggression. Development and Psychopathology, 14, 477479. Campbell, S. B. (1995). Behavior problems in preschool children: A review of recent research. Journal of Child Psychology and Psychiatry, 36, 113149. Campbell, S. B., Pierce, E. W., March, C. L., Ewing, L. J., & Szumowski, E. K. (1994). Hardto-manage preschool boys: Symptomatic behaviour across contexts and time. Child Development, 65, 836851. Campbell, S. B., Shaw, D. S., & Gilliom, M. (2000). Externalizing behavior problems: Toddlers and preschoolers at risk for later maladjustment. Development and Psychopathology, 12, 467488. Clerkin, S. M., Marks, D. J., Policaro, K. L., & Halperin, J. M. (2007). Psychometric properties of the Alabama parenting questionnaire-preschool revision. Journal of Clinical Child and Adolescent Psychology, 36, 1928. Costello, E. J., Costello, A. J., Edelbrock, C., Burns, B., Dulcan, M. K., Brent, D., et al. (1988). Psychiatric disorders in pediatric primary care. Archives of General Psychiatry, 45, 11071116. DuPaul, G. J., Power, T. J., Anastopoulos, A. D., & Reid, R. (1998). ADHD Rating Scale-IV: Checklists, norms, and clinical interpretations. New York: Guilford Press. Eyberg, S. M., Edwards, D., Boggs, S. R., & Foote, R. (1998). Maintaining the treatment effects of parent training: The role of booster sessions and other maintenance strategies. Clinical Psychology: Science and Practice, 5, 544554. Fisher, M. (1990). Parent stress and the child with attention decit hyperactivity disorder. Journal of Clinical Child Psychology, 19, 337346. Frankel, F., Myatt, R., Cantwell, D., & Feinberg, D. (1997). Parent-assisted transfer of childrens social skills training: Effects on children with and without attention-decit hyperactivity disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 10561064.
Copyright r 2010 John Wiley & Sons, Ltd. Inf. Child. Dev. 20: 148161 (2011) DOI: 10.1002/icd

Maternal Positive Parenting Style

161

Gopin, C. B., Healey, D. M., Castelli, K. L., Marks, D. J., & Halperin, J. M. (2010). Usefulness of a clinician rating scale in identifying preschool children with ADHD. Journal of Attention Disorders, 13, 479488. Gordon, M., Antshel, K., Faraone, S., Barkley, R., Lewandowski, L., Hudziak, J. J., et al. (2006). Symptoms versus impairment: The case for respecting DSM-IVs criterion D. Journal of Attention Disorders, 9, 465475. Hartman, C. A., Rhee, S. H., Willcutt, E. G., & Pennington, B. F. (2007). Modeling rater disagreement for ADHD: Are parents or teachers biased? Journal of Abnormal Child Psychology, 35, 536542. Healey, D. M., Miller, C. M., Castelli, K. L., Marks, D. J., & Halperin, J. M. (2008). The impact of impairment criteria on rates of ADHD diagnoses in preschoolers. Journal of Abnormal Child Psychology, 36, 771778. Huey, S. J., & Weisz, J. R. (1997). Ego control, ego resiliency, and the Five-Factor model as predictors of behavioural and emotional problems in clini referred children and adolescents. Journal of Abnormal Psychology, 106, 404415. Johnston, C., & Mash, E. J. (2001). Families with children with attention decit hyperactivity disorder: Review and recommendations for future research. Clinical Child and Family Psychology Review, 4, 183207. Jose, P. E., & Huntsinger, C. S. (2005). Moderation and mediation effects of coping by Chinese American abd European American adolescents. The Journal of Genetic Psychology, 166, 1643. Keown, L. J., & Woodward, L. J. (2002). Early parentchild relations and family functioning of preschool boys with pervasive hyperactivity. Journal of Abnormal Child Psychology, 30, 541553. Lahey, B. B., Applegate, B., McBurnett, K., Biederman, J., Greenhill, L., Hynd, G. W., et al. (1994). DSM-IV eld trials for Attention Decit Hyperactivity Disorder in children and adolescents. American Journal of Psychiatry, 151, 16731685. Lifford, K., Harold, G. T., & Thapar, A. (2009). Parentchild hostility and child ADHD symptoms: A genetically sensitive and longitudinal analysis. Journal of Child Psychology and Psychiatry, 50, 14681476. Martin, R. P., & Bridger, R. C. (1998). Temperamental Assessment Battery for ChildrenRevised: A tool for the assessment of temperamental traits and types of young children. Brandon, VT: Clinical Psychology Publishing Co. McGoey, K. E., DuPaul, G. J., Haley, E., & Shelton, T. L. (2007). Parent and teacher ratings of attention decit/hyperactivity disorder in preschool: The ADHD Ratings Scale-IV Preschool Version. Journal of Psychopathology and Behavioral Assessment, 29, 269276. Nakao, K., & Treas, J. (1994). Updating occupational prestige and socioeconomic scores: How the new measures measure up. Sociological Methodology, 24, 172. Pelham, W. E., Schnedler, R. W., Bologna, N. C., & Contreras, J. A. (1980). Behavioral and stimulant treatment of hyperactive children: A therapy study with methylphenidate probes in a within-subject design. Journal of Applied Behavior analysis, 13, 221236. Piacentini, J. C., Cohen, P., & Cohen, J. (1992). Combining discrepant diagnostic information from multiple sources: Are complex algorithms better than simple ones? Journal of Abnormal Child Psychology, 20, 5163. Reynolds, C. R., & Kamphaus, R. W. (2004). BASC-2: Behavioral Assessment System for Children (2nd ed.). Circle Pines, MN: AGS. Sanson, A., Smart, D., Prior, M., & Oberklaid, F. (1993). Precursors of hyperactivity and aggression. Journal of the American Academy of Child and Adolescent Psychiatry, 32, 12071216. Shaffer, D., Gould, M., Brasic, J., Ambrosini, P., Fisher, P., Bird, H., et al. (1983). A Childrens Global Assessment Scale (C-GAS). Archives of General Psychiatry, 40, 12281231. Shelton, K. K., Frick, P. J., & Wootton, J. (1996). Assessment of parenting practices in families of elementary school-age children. Journal of Clinical Child Psychology, 25, 317329. Webster-Stratton, C. (1990). Long-term follow-up of families with young conduct problem children: From preschool to grade school. Journal of Clinical Child Psychology, 19, 144149. Winsler, A. (1998). Parentchild interaction and private speech in boys with ADHD. Applied Developmental Science, 2, 1739. Wolfson, L., & Grant, E. (2006). Authoritative parenting and parental stress in parents of preschool and older children with developmental disabilities. Child Care, Health and Development, 32, 177184.
Copyright r 2010 John Wiley & Sons, Ltd. Inf. Child. Dev. 20: 148161 (2011) DOI: 10.1002/icd

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