Eur Child Adolesc Psychiatry (2010) 19:7581 DOI 10.

1007/s00787-009-0067-y

ORIGINAL CONTRIBUTION

Risk factors of abuse of parents by their ADHD children

Ahmad Ghanizadeh Peyman Jafari

Received: 23 October 2007 / Accepted: 21 September 2009 / Published online: 10 October 2009 Springer-Verlag 2009

Abstract It is interesting that there is scant research of abuse of parents by their children and no study was found on the abuse of parents by their attention decit hyperactivity disorder (ADHD) children. Seventy-four children and adolescents suffering from ADHD and their parents were interviewed. The diagnoses were made according to DSM-IV diagnostic criteria. A questionnaire was developed to assess the childrens abuse toward parents. More than half of the parents are suffering from at least one of the forms of abuse by their ADHD children. Scores of parental abuse were not related to gender. Different types of abuse correlated with oppositional deant disorder (ODD), tic, and separation anxiety disorder (SAD). Fathers and mothers age, the level of education, and type of occupation were not risk factors of the abuse scores. ODD and mothers major depressive disorder were predictors of the abuse. There was a very disturbing high rate of abuse by children against parents. There is an interrelation of different forms of abuse. This study contributes to increasing awareness on the abuse of parents by their ADHD children. Keywords Parent Abuse Children ADHD

Introduction Usually the focus of abuse protection is protection from the abuse of spouse or children. It is a well-studied subject. However, it is interesting that there is scant research of abuse of parents by their children and no study was found on the abuse of parents by their attention decit hyperactivity disorder (ADHD) children. It is an ignored research area [2]. There is a lack of evidence-based information that can assist families or clinicians working with families who are experiencing this type of abuse [8]. Any harmful behavior by a child intended to gain authority and control over one of the parents is dened as parent abuse. Physical abuse includes behaviors such as hitting and pushing. Psychological abuse is a behavior such as calling bad names, creating fear, and threatening to hurt or kill a parent or themselves. Taking things without permission and requesting things that parents cannot afford are examples of nancial abuse [7]. Abuse often begins verbally and progresses to other forms [25]. The terms parental abuse/violence and children violence toward their parents are used interchangeably [26]. Physically abused children exhibit externalizing and aggressive behavior problems that may be directed toward their parents [30]. ADHD children are at increased risk of abuse by their parents [1]. Abusive behavior also affects the siblings. About 0.6% of French parents and 10% of Canadian parents are assaulted by their children [9, 20]. Of course, the emotional, psychological and nancial abuses were not included as a part of abuse denitions and these types of abuse are largely neglected [24]. There is a report that boys physically abuse their parents more than girls and girls more than boys are emotionally abusive of their parents [33]. Parents are blamed for the abusive behavior of their children [2]. Some parents are shameful that they are

A. Ghanizadeh Department of Psychiatry, Hafez Hospital, Shiraz University of Medical Sciences, Shiraz, Iran P. Jafari Department of Biostatics, Shiraz University of Medical Sciences, Shiraz, Iran A. Ghanizadeh (&) Department of Psychiatry, Research Center for Psychiatry and Behavioral Sciences, Hafez Hospital, Shiraz University of Medical Sciences, Shiraz, Iran e-mail: ghanizad@sina.tums.ac.ir

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unable to control their childs behavior and may try to conceal parent abuse. ADHD, oppositional deant disorder (ODD) and conduct disorder (CD) are reported by some as allowing children and parents to use disorder labels to justify violent behaviors [19]. To the best of the authors knowledge, this is the rst study in which the associated factors are placed into a framework. It is new and is necessary as the most effective ways of assisting parents who have been challenged in their role as a care provider. This study surveys the childrens abuse against their parents and it encourages active debate and research about parental abuse.

Methods Subjects The study was conducted in the Departments of Child Psychiatry of Shiraz University of Medical Sciences. Seventy-four convenient children and adolescents suffering from ADHD and referring to the out-patient clinic were included in the study. All the patients were clinically evaluated and diagnosed. The age range of the boys was 5 14 years old and that of the girls was 614 years old. About 85% of the children were boys. 36.5% of the ADHD children had not any sibling. Instrument Interviews Psychiatric diagnoses for the children and adolescents were made by interviews, using DSM-IV diagnostic criteria using the Farsi version of schedule for affective disorders and schizophrenia for school-age children (K-SADS) [13]. The K-SADS Farsi version has sufcient reliability and validity. There is sufcient validity and testretest and inter-rater reliabilities with enough sensitivity and specicity. Positive and negative predictive validities for most of the disorders are good. Testretest and inter-rater reliabilities of ADHD are 0.81 and 0.69, respectively [13]. Diagnostic assessment of their parents was based on direct interviews with each parent, using DSM-IV diagnostic criteria. Its reliability and validity have been mentioned elsewhere and had been used in prior studies in Iran [23]. The abused parent questionnaire No instrument that could be used for assessing the abuse of parents by their children was found. So, in the rst step, a questionnaire was developed from the report of The

National Clearinghouse on Family Violence [9]. They suggested different ways of the abuse. The items were arranged to make the questionnaire. They categorized the abuse items into categories of psychological, physical, verbal, and nancial. Abuse was dened as any child behavior that is deliberately harmful to the parent and used as a form of control of the parents or creating fear in the parents [7]. The statements included different forms of abuse including physical, psychological, verbal, and nancial abuse, e.g. hitting, punching you by your child. The parents and their children were interviewed to provide information regarding the frequency in which the children had committed the indicated behaviors during conicts with the target parent in the previous 2 months. The response categories were 0 for never, 1 for once, 2 for twice, 3 for 35 times, 4 for 610 times, 5 for 1120 times, and 6 for more than 20 times. The questions were not oriented to a specic age group. This scoring system is very similar to a study on child abuse by parents [28]. Another scoring system for analysis was also considered. In this categorical scoring system, each symptom was scored on a scale of Yes or No. The response category of No was responses of never, once, or twice in the last 2 months. The response category of Yes was for responses of more than 3 times. To examine the feasibility of the scale, it had been administered to children in a child and adolescent psychiatry clinic in a pilot study. After approval of its performance and face validity, it was used in the current study. The protocol for the research project conforms to the provisions of the Declaration of Helsinki in 1995 as revised in Edinburgh 2000. It was explained that the information collected would be condential, and would be used for analysis in writing an article to improve the life of children with ADHD and their families by increasing the knowledge about it. The subjects gave informed consent and the patient anonymity has been considered. The participants had the opportunity to refuse their participation. Statistical analysis The data were analyzed by SPSS-11. To study the underlying factor structure, a factor analysis with Varimax rotation was employed. Reliability (internal consistency) was calculated by Cronbachs alpha tests. MannWhitney U tests were used to compare the mean scores between boys and girls. Three separate linear regression model analyses were conducted to examine the predictors of the different types of abuse. Physical and nancial abuse score, psychological abuse score, and verbal abuse score were considered as dependent variables. Co-morbidity with ODD, SAD, ADHD subtypes, and mothers major depressive disorder were considered as independent variables.

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Results In the initial phase of the scale development, item and factor analysis was conducted. Item analysis The three-factor solution factor analysis showed that KaiserMeyerOlkin Measure of sampling adequacy was 0.75. The Bartletts test of sphericity was statistically signicant (P \ 0.001). These indicate that the data are

suitable for conducting factor analysis. The loading of items and the three subscales is displayed in Table 1. The item analysis revealed that 27 out of the 29 items showed moderately low (r = 0.31) to high (r = 0.84) loading with their associated subscale. These two items of stealing money or parents belongings (sometimes referred to as borrowing without permission) and selling possessions, their own or the parents had loading of less than 0.31. These two items were dropped from the subscales. So, 27 items were selected to be included in further analyses. Table 1 shows that there were three factors of

Table 1 Results of factor analysis showing item loadings after Varimax rotation

Questions

Factor loadings Physicalnancial abuse Verbal abuse Psychological abuse

Hitting, punching, slapping or kicking Shoving and pushing Breaking things Punching holes in the walls Throwing things Spitting Intimidating the parent, making the parent fearful Maliciously playing mind games, trying to make the parent think he or she is crazy Making unrealistic demands on parents, such as insisting they drop what theyre doing to comply with the childs demands Purposely not telling the parent where theyre going or what theyre doing Running away from home or staying out all night Lying Threatening to hurt, maim or kill the parent or someone else Making manipulative threats, such as threatening to run away, commit suicide or otherwise hurt themselves without really intending to do so Degrading the parent or other family members Withholding affection Controlling the running of the household Yelling Arguing, challenging (I dont have to do anything you say!) Being sarcastic or critical, belittling Laughing in the parents face Name calling (You bitch!) I hate you Swearing at the parent Destroying the home or parents belongings Demanding parents buy things they dont feel they can afford Total variance accounted for by the factor structure was 51.8% Incurring debts the parents must cover (e.g. as a result of damage to or theft of others property)

0.77 0.77 0.82 0.82 0.84 0.49 0.53 0.31 0.66

0.61 0.63 0.48 0.69 0.79

0.56 0.37 0.71 0.55 0.56 0.74 0.72 0.67 0.80 0.79 0.39 0.50 0.52 .

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physical and nancial abuse, psychological abuse, and verbal abuse. The physicalnancial subscale included 14 items with a range of score of 0 to 84. The numbers of items in the verbal and psychological subscales were 8 and 4, respectively. The ranges of scoring of the verbal and psychological subscales were 0 to 48 and 0 to 24, respectively. Reliability of the questionnaire The internal consistency reliability scores were good to excellent with the physical and nancial subscale at 0.91, the verbal subscale at 0.89, and the psychological subscale at 0.78. The reliability of the whole questionnaire was 0.93. Gender difference of different types of abuse The scores of different types of parental abuse were not related to gender (Table 2).

ADHD subtypes and co-morbidities of other psychiatric disorders with ADHD The numbers of children with ADHD-inattentive, ADHDHyperactive impulsive type, and ADHD-combined type were 18, 22, and 30, respectively. The co-morbidity rates of ODD, CD, and Tic disorder were 45 (60.8%), 4 (5.4%), 13 (17.6%), respectively. The rates of SAD, OCD, and enuresis were 13 (17.6%), 7 (9.5%), and 7(9.5%), respectively. Correlation of the different types of abuse scores with each other There is a signicant relationship between different types of abuse (Table 3). In addition, different types of abuse correlated with ODD (oppositional deant disorder), tic, and separation anxiety disorder (SAD). The different types of abuse did not correlate with the age of the child, number of sibling, children psychiatric disorders of conduct disorder (CD), obsessive compulsive disorder (OCD), and Enuresis. Fathers and mothers age, education level, and type of occupation did not correlate with the different types of abuse scores. ADHD subtypes were not associated with different types of abuse (Table 3). Twenty-seven mothers were suffering from major depressive disorder. Linear regression model analysis shows that only comorbidity with ODD and mothers major depressive disorder predicted the verbal abuse score (Table 4). None of the independent factors predicted the score of psychological abuse or physicalnancial abuse scores.

Table 2 Gender association of childrens abuse towards their parents Abuse of parents Physical and nancial Verbal Psychological Gender (n) Boys (63) Girls (11) Boys (63) Girls (11) Boys (63) Girls (11) Mean (SD) 24.4 (20.5) 17.0 (14.6) 11.7 (12.1) 13.0 (14.5) 4.4 (6.1) 3.1 (3.8) 0.9 0.8 Signicance (P) 0.2

Table 3 Association of different types of abuse with each other, co-morbid psychiatric disorders in the ADHD children and the demographic characteristics of parents

Verbal abuse score Verbal abuse score Physicalnancial abuse score Psychological abuse score ADHD types Gender Age Number of siblings Oppositional deant disorder Conduct disorder Tic disorder Separation anxiety disorder Obsessive compulsive disorder Enuresis Fathers age 1 0.693** 0.577** -0.026 0.036 0.077 -0.016 0.362** -0.057 0.236* 0.003 0.125 -0.032 -0.014 0.005 -0.111 -0.066

Physicalnancial abuse score

Psychological abuse score

1 0.506** -0.111 -0.134 -0.114 0.011 0.336** 0.096 0.297* 0.001 -0.043 0.099 -0.118 -0.094 -0.133 -0.075 1 0.131 -0.077 0.265 -0.036 0.082 0.071 0.143 -0.232* 0.088 -0.046 -0.006 0.025 -0.018 0.085

** Correlation is signicant at the 0.01 level (two-tailed) * Correlation is signicant at the 0.05 level (two-tailed)

Fathers educational level Mothers age Educational level of mother

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Eur Child Adolesc Psychiatry (2010) 19:7581 Table 4 Linear regression model analysis for prediction of verbal abuse score by the independent factors Independent factors ADHD types Oppositional deant disorder Separation anxiety disorder Mothers major depressive disorder df 2 1 1 1 F 0.85 9.82 0.006 5.03 Signicance 0.43 0.001 0.94 0.03

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to comply with the childs demands, yelling, and shoving and pushing are the most common ways of abuse of parents by their ADHD children. More than half of the parents are suffering from at least one of the types of abuse by their children.

Discussion There is a disturbing high rate of abuse by children against parents. There are some studies showing that the children perpetrators who abuse their parents are often victims of child abuse or witnesses of family violence [27]. It may indicate that the parents of ADHD children abuse them frequently or the ADHD children are frequently abused. Previous studies reported a poorer parentchild relationship, less communication, lesser affective responsiveness, and affective involvement in the ADHD family than those in the control group [14]. Even, it is very difcult for them to fulll their role as adults and children may be forced to take on this role [10]. It is a possible explanation for this high rate of child abuse against parents. Another explanation is that the ADHD children accept that abuse of parents is a way of problems solution to their parental conict [22]. Of course, these are simplication of the ndings and the social norms and societal inuences (such as parents acceptability of abuse and threats by children) that encourage the development of parent abuse by their ADHD children should be considered. Another explanation is based on the social learning theory, indicating that as a process of observing parents abusive behavior and then children replicate the observed behavior [6]. This interpretation might alarm that there is a very high rate of child abuse by the parents of ADHD children. It should be noticed that the sample was from a clinical setting and the parents are more subject to the risk of being abused by their children in comparison to non-clinical subjects. Probably, the actual rate of parental abuse by children is higher than this rate since many parents may feel shameful and guilty with abusive children and it leads them not reporting parent abuse. To have a more precise rate of abuse, the parents were interviewed face to face and they were insured about the condentiality. The parents of physically abused children report their youngsters as being less socially skilled and less socially mature than their childrens non-abusive counterparts [32]. Further studies are required if the abusive ADHD children are less interpersonally skilled. Cognitive skills including receptive language, expressive language skills, abstraction abilities, communication, and comprehension of social roles that lead to this abusive behavior also need to be researched. Another interesting nding is that the different forms of parent abuse by the ADHD children are usually related to

Table 5 Frequency of abuse of parent by their ADHD children Abuse variables Hitting, punching, slapping or kicking Shoving and pushing Breaking things Punching holes in the walls Throwing things Spitting Boys (%) 49.2 50.8 34.9 31.7 46 15.9 Girls (%) 45.5 36.4 9.1 9.1 18.2 9.1 27.3 0 63.6

Intimidating the parent, making the parent fearful 22.2 Maliciously playing mind games, trying to make the 0 parent think he or she is crazy Making unrealistic demands on parents, such as 63.5 insisting they drop what theyre doing to comply with the childs demands Purposely not telling the parent where theyre going 36.5 or what theyre doing Running away from home or staying out all night Lying Threatening to hurt, maim or kill the parent or someone else 12.7 20.6 22.2

27.3 0 27.3 27.3 18.2

Making manipulative threats, such as threatening to 33.3 run away, commit suicide or otherwise hurt themselves without really intending to do so Degrading the parent or other family members Withholding affection Controlling the running of the household Yelling 34.9 28.6 27 61.9

36.4 36.4 27.3 45.5 45.5 27.3 18.2 9.1 18.2 9.1 0 36.4 18.2

Arguing, challenging (I dont have to do anything 50.8 you say!) Being sarcastic or critical, belittling Laughing in the parents face Name calling (You bitch!) I hate you Swearing at the parent Destroying the home or parents belongings 33.3 28.6 14.3 9.5 4.8 9.5

Demanding parents buy things they dont feel they 36.5 can afford Incurring debts the parents must cover (e.g. as a result of damage to or theft of others property) 22.2

Table 5 shows the prevalence of different ways of child to parent abuse. It shows that making unrealistic demands on parents, such as insisting they drop what theyre doing

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each other. It is an evidence for the inter-correlation among different forms of abuse. These associations suggest that abusive relationships are not just about one type of abuse but, rather, that different forms of abuse tend to co-occur. Co-morbid psychiatric disorders were not predictors of the different forms of abuse, except for psychological abuse. The only co-morbid psychiatric disorders which predict the verbal abuse were ODD and mothers major depressive disorder. It is well studied that bullying behavior is associated with externalizing behaviors such as ODD [4]. Moreover, a previous study reported that there was a link between ODD and experiencing trauma. More than half of the children with ODD have experienced physical or sexual maltreatment [12]. While the rates for children with ADHD were 25% and 11% for physical or sexual maltreatment, respectively, the rate is 91% when ADHD and ODD cooccur [12]. It is possible that the association of ODD and abuse of parents by the children in the current study is associated with their higher rate of experienced trauma. Different subtypes of ADHD did not predict the abuse score. It should be studied in further studies with larger sample size. Of course, it should be noticed that a recent study reported that different subtypes of ADHD were not different regarding gender, and co-morbid psychiatric disorder [16]. Maternal MDD predicted the verbal type of abuse. Parental psychiatric disorders may decrease a parents involvement in family activities and increase their intolerance for improper behavior by their child because of their own problems [11, 18]. In addition, such disorders may be barriers to effective parental functioning. Poverty and limited nancial resources such as low income, unemployment, inadequate housing, and large family size correlate positively with physical abuse [17]. In Iran, educational level and profession are not strongly associated with income. Therefore, measures of socioeconomic status (SES) representing levels of profession and education were not used. However, parental education level and type of occupation as measures of SES were included. None of them were associated with the abuses. It is possible that parents negative perceptions of their children and poor parenting skills may lead the parents to be less accepting and less empathic toward their children [21, 29]. Further studies should include perception and parenting skills of parents of ADHD children. While there is lack or at least scanty research on parental abuse by their ADHD children and little information about children abuse against parents, clinicians and psychologist and parents struggle to gather or have information about the best ways of dealing with parental abuse. Further studies are necessary to survey if ADHD children abuse against parents.

Limitations The lack of clarity for what is acceptable and what is abusive behavior of children have compounded the slow recognition of children abuse against parents and helping parents, professions and policy makers. The small number of the clinical sample and lack of a control group preclude generalizing the results. This cross-sectional study is unable to determine causality and because assigning children to abuse in experimental conditions is untenable, the study only relied on parents reports of abuse rather than on observations. Moreover, memory and willingness to report affect the reports of the parents. This study did not include violence or abuse between parents and/or parents abusive behavior toward a child. It is an important issue because there is evidence to suggest that where there is violence between parents and/or parents are violent toward a child, there is greater risk for the young person to become violent toward his or her parents [3, 31]. In addition, it is possible that parents who have been abused by their partner, children or their parents, respond to their childs abusive behavior as surrender and it encourages the role of childs abuse [10]. It is likely that children abuse their parents in more widespread ways than the statements mentioned in the current study, for example, considering a wider context such as school and society where these children could concurrently be abused or be abusing [7]. Despite all of the above-mentioned limitations, this study considered the associated factors for abuse including individual child and parent characteristics, and socioeconomic status. Abuse of parents by their ADHD children is a fairly new subject that needs to be studied more. Despite the size and signicance of this problem, there is a lack of sufcient data on its prevalence, causes, and consequences. The authors hope this preliminary report will be a baseline for future studies on parent abuse by their ADHD children. This is critical because ADHD is one of the most common psychiatric disorders in children [15]. Moreover, children are growing and health-risk behaviors are established and persist throughout the life course [5]. Clinical implications Parental maltreatment is not uncommon and should be addressed when providing therapy to a family with a child with ADHD. This adds the role of therapists in the process of evaluation and treatment of the families with ADHD children. The co-occurrence of different forms of abuse has implications both for clinical practice and for research. In terms of practice, different forms of abuse should be screened. Parents and clinicians should be educated and trained for this problem and it should be a focus of the interventions. Further researches should study if

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81 16. Ghanizadeh A (2009) Psychiatric comorbidity differences in clinic-referred children and adolescents with ADHD according to the subtypes and gender. J Child Neurol 24(6):679684 17. Gillham B, Tanner G, Cheyne B, Freeman I, Rooney M, Lambie A (1998) Unemployment rates, single parent density, and indices of child poverty: their relationship to different categories of child abuse and neglect. Child Abuse Negl 22:7990 18. Hurtig T, Ebeling H, Taanila A, Miettunen J, Smalley S, rvelin MR, Moilanen I (2007) ADHD and McGough J, Loo S, Ja comorbid disorders in relation to family environment and symptom severity. Eur Child Adolesc Psychiatry 16:362369 19. Hemphill SA (1996) Characteristics of conduct-disordered children and their families: a review. Aust Psychol 31:109118 20. Laurent A, Derry A (1999) Violence of French adolescents toward their parents: characteristics and contexts. J Adolesc Health 25:2126 21. Mash EJ, Johnston C (1990) Determinants of parenting stress: illustrations from families of hyperactive children and families of physically abused children. J Clin Psychol 19:313328 22. Mitchell KJ, Finkelhor D (2001) Risk of crime victimization among youth exposed to domestic violence. J Interpers Violence 16:944964 23. Mohammadi MR, Ghanizadeh A, Rahgozar M, Noorbala AA, Davidian H, Afzali HM, Naghavi HR, Yazdi SA, Saberi SM, Mesgarpour B, Akhondzadeh S, Alaghebandrad J, Tehranidoost M (2004) Prevalence of obsessivecompulsive disorder in Iran. BMC Psychiatry 14:4:2 24. New Zealand Family Violence Clearinghouse (2006) An agenda for family violence research, vol 1. NZFVC Christchurch. http://www.nzfvc.org.nz/PublicationDetails.aspx?publication=13394. Accessed 14 May 2007 25. Peek CW, Fischer JL, Kidwell JS (1985) Teenage violence toward parents: a neglected dimension of family violence. J Marriage Fam 47:10511058 26. Romans SE, Poore R, Martin J (2000) The perpetrators of domestic violence. Med J Aust 173:484488 27. Rubin G (1996) Teenage behaviourwhen parents cant cope, NSW Health. http://www.mhcs.health.nsw.gov.au/health-publicaffairs/mhcs/publications/3030.html [2004, 27 January]. Accessed 14 May 2007 28. Straus MA, Hamby SL, Finkelhor D, Moore D, Runyan D (1998) Identication of child maltreatment with the parentchild conict tactics scales: development and psychometric data for a national sample of American parents. Child Abuse Negl 22:249270 29. Susman EJ, Trickett PK, Iannotti RJ, Hollenbeck BE, ZahnWaxler C (1985) Child-rearing patterns in depressed, abusive, and normal mothers. Am J Orthopsychiatry 55:237251 30. Swenson CC, Saldana L, Joyner CD (2007) Ecological treatment for parent-to-child violence. http://www.bvs.is/les/le278.pdf. Accessed 14 May 2007 31. Ulman A, Strauss M (2003) Violence by children against mothers in relation to violence between parents and corporal punishment by parents. J Comp Fam Stud 34:4160 32. Wolfe DA, Mosk MD (1983) Behavioral comparisons of children from abusive and distressed families. J Consult Clin Psychol 51:702708 33. World Health Organization (2000) What about boys? A Literature review on the health and development of adolescent boys. Department of Child and Adolescent Health and DevelopmentWHO. http://www.paho.org/English/HPP/HPF/ADOL/boyshealtheng.pdf. Accessed 14 May 2007

experiencing multiple forms of abuse or polyvictimization of parents lead to more serious and long-lasting mental health consequences in the ADHD children and their victims, parents.

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