Abstract
This study examined the impact of inattention and hyperactivity symptoms in children and mothers, opposition problems in children, maternal depression, and perceived family support on the quality of life (QOL) of mothers. Mothers of children in one elementary school were contacted. The relationship between sociodemographic variables, the levels of inattention and hyperactivity symptoms in children and mothers, oppositional symptoms in children, maternal depression, perceived family support, and maternal QOL were examined. Three hundred and eighty‐two participants were included in this study. Consistent factors related to the mother's QOL in the four domains were maternal depression, perceived family support, and housing status after controlling for several family, maternal, and child variables. Maternal QOL was more related to her own and family factors including maternal inattention, hyperactivity and depression symptoms, perceived family support, and housing status, instead of parent‐rated inattention and hyperactivity symptoms of the child. Screening for maternal inattention, hyperactivity and depression symptoms, and mental health services for these mothers are warranted based on these findings.
Keywords: Children, Depression, Mothers, Quality of life, Symptoms of ADHD
Introduction
Recent health surveys have reported increasing prevalence rates of attention deficit hyperactivity disorder (ADHD) progressively in the USA, that is 7.8% in 2003 and 9.5% in 2007 [1]. Children with ADHD have also been reported to have wide‐ranging functional impairments, lower quality of life (QOL), diminished family functioning, and hindered parental well‐being [[2], [3]]. QOL has become increasingly important in health care practice and related research. Nevertheless, very few studies have discussed the impact of childrens' symptoms (i.e., inattention, hyperactivity, and opposition) on the QOL of parents. One study from the USA national survey showed that children with ADHD had a profound negative effect on parents' QOL as compared to unaffected controls [4]. Another study in Hong Kong also showed that parents of children with ADHD had a worse QOL as compared with the community norm [5].
A social ecological systems model proposes that stress on any person in the family may influence the well‐being of all family members [[6], [7]]. Studies of QOL of parents of children with ADHD, however, did not take into account the effect of the parents' own inattention, hyperactivity, and depression symptoms and perceived family support. A previous study showed that ADHD was related to a mothers' psychological stress in Taiwan [8]. Therefore, the present study strived to investigate the impact of inattention and hyperactivity symptoms in children and in mothers, opposition problems in children, and maternal depression on the mother's QOL in Taiwan. In addition, we examined if family support buffers the negative impact of child and maternal inattention and hyperactivity, the child's opposition, as well as maternal depression on maternal QOL.
Methods
Participants
This study was conducted at an elementary school in Taichung City, Taiwan, from April 2009 to June 2009. Half of the classes in the school from Grade 1 to Grade 6 were randomly selected. A total of 634 questionnaires were sent to the parents; 581 caregivers responded and 398 agreed to participate. Three hundred and eighty‐two mothers who signed informed consent letters and completed the questionnaires were enrolled in this study, with a return rate of 60.3%.
Instruments
-
1.
The Swanson, Nolan, and Pelham rating scale version IV was used to measure child's AD, HD, ODD (Results section, in 1, 2, 3).
-
2.
The World Health Organization Quality of life ‐BREF was used t o measure maternal QOL (Results section, in 2, 3).
-
3.
Adult ADHD self‐report Scale was used to measure mother's AD and HD (Results section, in Tables 1, 2, 3).
-
4.
Chinese version of the Center for Epidemiologic Studies Depression Scale was used to measure mother's depression (Results section, in 1, 2, 3).
-
5.
The Family Adaptation, Partnership, Growth, Affection, Resolve was used to measure maternal perception of family support (Results section, in 1, 2, 3).
Table 1.
Sociodemographic characteristics of the study participants.
| Variable | N | Mean (SD) |
|---|---|---|
| Age of father (y) | 365 | 42.39 (4.74) |
| Age of mother (y) | 382 | 39.10 (4.33) |
| Age of child (y) | 378 | 10.03 (1.63) |
| Number of children | 382 | 2.07 (0.71) |
| Child AD symptom | 381 | 8.52 (5.22) |
| HD symptom | 382 | 5.95 (5.04) |
| OD symptom | 382 | 6.76 (4.71) |
| Maternal AD symptom | 380 | 12.84 (5.50) |
| HD symptom | 380 | 8.53 (4.93) |
| Family support | 379 | 9.90 (3.77) |
| Variable | N | % |
| Boy | 193 | 50.66 |
| Full‐time job (father) | 335 | 91.53 |
| Full‐time job (mother) | 241 | 63.93 |
| Education (college or above, father) | 199 | 53.78 |
| Education (college or above, mother) | 199 | 52.51 |
| Renting house | 75 | 19.79 |
| Two‐parent family | 329 | 92.68 |
| Allergic rhinitis | 178 | 47.98 |
| Maternal depression | 94 | 25.68 |
AD = attention deficit; HD = hyperactivity/impulsivity; OD = opposition defiance; SD = standard deviation.
Table 2.
Association of sociodemographic and clinical variables with maternal quality of life (QOL).
| Statistical variable | Domain of QOL | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| Physical capacity | Psychological well‐being | Social relationship | Environment | ||||||
| r | r | r | r | ||||||
| Pearson correlation | |||||||||
| Age (child) | −0.005 | 0.069 | 0.057 | 0.033 | |||||
| Age (mother) | 0.149** | 0.137** | 0.169** | 0.192*** | |||||
| Age (father) | 0.041 | 0.058 | 0.069 | 0.047 | |||||
| Number of children | −0.021 | −0.015 | 0.059 | 0.043 | |||||
| Child AD symptom | −0.226*** | −0.310*** | −0.241*** | −0.291*** | |||||
| HD symptom | −0.204*** | −0.230*** | −0.204*** | −0.239*** | |||||
| OD symptom | −0.243*** | −0.320*** | −0.246*** | −0.282*** | |||||
| Maternal AD symptom | −0.340*** | −0.394*** | −0.313*** | −0.369*** | |||||
| HD symptom | −0.305*** | −0.375*** | −0.270*** | −0.343*** | |||||
| Family support | −0.337*** | −0.479*** | −0.483*** | −0.449*** | |||||
| t test | Mean (SD) | t | Mean (SD) | t | Mean (SD) | t | Mean (SD) | t | |
| Sex of child | Boy (n = 193) | 15.05 (1.88) | −1.60 | 12.61 (2.00) | −0.86 | 14.27 (2.25) | −0.69 | 14.02 (2.09) | −2.09* |
| Girl (n = 188) | 15.37 (1.99) | 12.79 (1.98) | 14.43 (2.29) | 14.48 (2.19) | |||||
| Allergic rhinitis | Yes (n = 178) | 15.01 (2.09) | −1.73 | 12.43 (2.12) | −2.69** | 14.05 (2.31) | −2.34* | 14.07 (2.19) | −1.29 |
| No (n = 193) | 15.37 (1.80) | 12.98 (1.79) | 14.60 (2.22) | 14.35 (2.11) | |||||
| Job (father) | Full time (n = 335) | 15.30 (1.92) | 1.36 | 12.77 (2.00) | 1.50 | 14.47 (2.28) | 1.87 | 14.40 (2.06) | 2.07* |
| Part time or no work (n = 31) | 14.80 (2.06) | 12.22 (1.79) | 13.68 (2.01) | 13.59 (2.22) | |||||
| Job (mother) | Full time (n = 241) | 15.362 (1.91) | 1.81 | 12.90 (1.94) | 2.64** | 14.51 (2.20) | 1.76 | 14.39 (2.01) | 1.62 |
| Part time or housewife (n = 136) | 14.99 (1.92) | 12.34 (2.07) | 14.08 (2.41) | 14.00 (2.37) | |||||
| Education (father) | College or above (n = 199) | 15.52 (1.81) | 2.90** | 12.91 (1.95) | 1.99* | 14.66 (2.09) | 2.46* | 14.81 (1.87) | 4.91*** |
| High school or below (n = 171) | 14.94 (2.03) | 12.50 (2.03) | 14.09 (2.41) | 13.74 (2.23) | |||||
| Education (mother) | College or above (n = 199) | 15.57 (1.84) | 3.81*** | 13.01 (2.02) | 3.30** | 14.70 (2.24) | 3.18** | 14.78 (1.89) | 5.06*** |
| High school or below (n = 180) | 14.82 (1.98) | 12.34 (1.93) | 13.97 (2.26) | 13.68 (2.28) | |||||
| Maternal depression | Screen negative (n = 272) | 15.73 (1.75) | 9.68*** | 13.34 (1.56) | 11.83*** | 14.98 (1.93) | 10.15*** | 14.89 (1.81) | 10.38*** |
| Screen positive (n = 94) | 13.75 (1.62) | 10.99 (1.92) | 12.57 (2.13) | 12.55 (2.06) | |||||
| Marital status | Single (n = 26) | 15.03 (2.17) | 0.57 | 12.59 (1.68) | 0.36 | 13.69 (2.60) | 1.54 | 13.73 (2.61) | 1.39 |
| Not single (n = 329) | 15.26 (1.95) | 12.73 (2.01) | 14.40 (2.25) | 14.34 (2.12) | |||||
| Renting house | Renting house (n = 75) | 14.23 (1.79) | −5.03*** | 11.97 (2.08) | −3.58*** | 13.36 (2.42) | −4.28*** | 12.76 (2.00) | −7.22*** |
| Own house (n = 304) | 15.45 (1.91) | 12.88 (1.92) | 14.59 (2.18) | 14.63 (2.00) | |||||
* p < 0.05.
** p < 0.01.
*** p < 0.001.
AD = attention deficit; HD = hyperactivity/impulsivity; OD = opposition defiance; SD = standard deviation.
Table 3.
Multiple regression for maternal quality of life (QOL).
| Domain of QOL a | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Variables/models | Physical capacity | Psychological well‐being | Social relationship | Environment | |||||||||
| 1 b | 2 c | 3 d | 1 b | 2 c | 3 d | 1 b | 2 c | 3 d | 1 b | 2 c | 3 d | ||
| Child | AD symptom | −0.035 | −0.003 | 0.003 | −0.079** | −0.036 | −0.020 | −0.044 | −0.013 | 0.008 | −0.063* | −0.019 | −0.008 |
| HD symptom | 0.010 | −0.001 | −0.004 | 0.051 | 0.036 | 0.034 | −0.002 | −0.020 | −0.023 | 0.020 | 0.011 | 0.007 | |
| OD symptom | −0.072** | −0.020 | −0.014 | −0.133*** | −0.067* | −0.057* | −0.097** | −0.038 | −0.024 | −0.084** | −0.033 | −0.022 | |
| Mother | AD symptom | −0.050* | −0.044* | −0.048* | −0.033*** | −0.065* | −0.046 | −0.055* | −0.042 | ||||
| HD symptom | −0.042 | −0.040 | −0.062* | −0.060* | −0.013 | −0.010 | −0.052* | −0.049* | |||||
| Depression | −1.329*** | −1.246*** | −1.801*** | −1.652*** | −1.469*** | −1.267*** | −1.374*** | −1.200*** | |||||
| Family support | −0.069** | −0.148*** | −0.200*** | −0.131*** | |||||||||
* p < 0.05.
** p < 0.01.
*** p < 0.001.
AD = attention deficit; HD = hyperactivity/impulsivity; OD = opposition defiance.
All models were adjusted with significant sociodemographic and clinical variables associated with the specific domain of maternal QOL.
Additional adjustment for child level of AD, HD, and OD symptoms.
Additional adjustment for maternal AD and HD symptoms and screening status of depression.
Additional adjustment for perceived family support.
The Swanson, Nolan, and Pelham rating scale version IV
The 26‐item Swanson, Nolan, and Pelham rating scale version IV (SNAP‐IV) assesses the core symptoms of ADHD as defined by the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM‐IV) and has been found to have good psychometric properties in Taiwan [[9], [10]]. Higher scores for inattention, hyperactivity/impulsivity, and opposition subscales of SNAP‐IV meant more symptoms.
The World Health Organization Quality of Life‐BREF
The World Health Organization Quality of Life‐BREF (WHOQOL‐BREF) is a 26‐item questionnaire used to measure respondents' subjective feelings of their QOL [11]. Two items of local importance (i.e., feeling respected and favorite food accessibility) have been added to the Taiwanese version, and it has been found to have good psychometric properties including reliability and validity [[12], [13]]. The Taiwanese version of the WHOQOL‐BREF is rated on a five‐point scale and scored over four domains: Physical Capacity, Psychological Well‐being, Social Relationship, and Environment. A higher score indicates a higher QOL.
Adult ADHD Self‐report Scale
The Adult ADHD Self‐report Scale (ASRS) is an 18‐item scale that measures the frequency of DSM‐IV adult ADHD symptoms over the previous 6 months. The ASRS consists of two subscales, inattention and hyperactivity/impulsivity. Items over the past 6 months were rated on a five‐point Likert scale [14]. The Chinese version of ASRS was translated and validated in a Taiwanese sample of 4329 adults [15].
Chinese version of The Centre for Epidemiologic Studies Depression Scale
The Chinese version of The Centre for Epidemiologic Studies Depression Scale (CESD‐C) is a 20‐item self‐rating scale to assess levels of depressive symptoms during the previous week [[16], [17]]. The sensitivity and specificity of the CESD‐C in screening depression in community participants were 92% and 91%, respectively, with a classification rate of 91.8% at a cut‐off point of 15 [16]. Mothers with CESD‐C scores > 16 were screened as depressed.
The Family Adaptation, Partnership, Growth, Affection, Resolve
The Family Adaptation, Partnership, Growth, Affection, Resolve (Family APGAR) was used to evaluate the satisfactory level of support and communication in the family [[18], [19]]. A higher score indicates poor support and communication. The Chinese version of Family APGAR has been validated and found to be a reliable and valid instrument in Taiwan [[18], [19]].
Procedure
The Research Ethics Committee (iInstitutional rReview bBoard, IRB) of the Tsaotun Psychiatric Center approved this study prior to the start of data collection. Half of the classes at the school from Grade 1 to Grade 6 were randomly selected, and a package of questionnaires along with an informed consent letter was taken home by the students. After being completed by the mother at home, the questionnaires were returned to the teachers by the students.
Data analysis
Independent sample t test and Pearson Correlation Coefficient statistics were used to examine the association of sociodemographic and clinical variables with maternal QOL. Multiple regression analyses were employed to investigate the relationship between the four domains of QOL and the maternal rating of the child's inattention, hyperactivity, and oppositional symptoms with statistically significant variables in the association of sociodemographic and clinical variables with four domains of maternal QOL in Model 1. Maternal inattention and hyperactivity symptoms and depression were further adjusted in Model 2, and finally perceived family support in Model 3. Data analyses were performed using SPSS version 16.0 (SPSS Inc., Chicago, IL, USA). An alpha level of 0.05 was used to determine statistical significance.
Results
Participants' characteristics
Among the 382 participants, the average child's age was 10.03 years and maternal age was 39.10 years. About half of the children were reported as having allergic rhinitis, and 25.68% of mothers were screened positively for depression. Most of the participants came from a two‐parent family and 19.79% of the families rented a place to stay. The sociodemographic characteristics of the participants are presented in Table 1.
Association between mother's QOL and sociodemographic and clinical variables
The four domains of maternal QOL scores were significantly associated with maternal age, levels of education, inattention, hyperactivity and depression symptoms, child's levels of inattention, hyperactivity, and opposition symptoms, family residence status, paternal levels of education, and perceived family support. Mothers who were older and screened negatively with depression, had higher education and less inattention and hyperactivity symptoms, and more perceived family support had higher QOL. Mothers who rated their child as having more inattention, hyperactivity, and opposition symptoms and lived in rented accommodation had worse QOL in all four domains. The associations of sociodemographic and clinical variables with maternal QOL are reported in Table 2.
To further evaluate the impact of the child's (i.e., attention, hyperactivity, and opposition symptoms), maternal (i.e., attention, hyperactivity, and depression) and family (level of support) variables on maternal QOL, multiple regression models were performed separately for four domains of maternal QOL.
When the child's attention, hyperactivity, and opposition symptoms were adjusted with the significant sociodemographic and clinical variables, the child's levels of attention and opposition symptoms were both significant in the psychological and environment domains of maternal QOL (Table 3, Model 1); however, in the physical and social domains, only the level of opposition symptoms was significant. When adding the level of maternal inattention and hyperactivity symptoms and depression into Model 2, the child's opposition symptoms and maternal attention and hyperactivity symptoms as well as depression were significant predictors in the psychological domain of maternal QOL; maternal attention and hyperactivity symptoms as well as depression in the environment domain; and maternal attention symptoms and depression in the physical and social domains were noted. When maternal perceived family support was finally added in Model 3, the child's level of opposition symptoms, maternal attention and hyperactivity symptoms and depression, and perceived family support were significant predictors in the psychological domain; maternal attention symptoms and depression and perceived family support in the physical domain; maternal hyperactivity symptoms and depression and perceived family support in the environment domain; and maternal depression and perceived family support in the social domain.
Discussion
To the best of our knowledge, this is the first report exploring the role of maternal inattention and hyperactivity symptoms, depression, and perceived family support in the relationship between inattention, hyperactivity, and opposition symptoms in children and maternal QOL. The main findings of the present study showed that a child's inattention and opposition symptoms were associated with maternal QOL. However, when maternal inattention and hyperactivity symptoms, maternal depression, and perceived family support were sequentially adjusted, the child's inattention symptoms were no longer a significant predictor of maternal QOL. Consistent factors related to the mother's QOL in the four domains were maternal depression, perceived family support, and residence status after controlling for several family, maternal, and child variables. Perceived family support did not buffer the effect of the child's inattention, hyperactivity, and opposition symptoms, as well as maternal inattention, hyperactivity, and depression on their QOL.
Maternal QOL was more related to the mother's own variables and family factors instead of parent‐rated inattention and hyperactivity symptoms of the child. Mothers who screened positive for depression, perceived less family support, and lived in rented accommodation showed worse maternal QOL. For the specific QOL domains, mothers with more inattention symptoms had worse physical QOL; those with more hyperactivity symptoms had worse environmental QOL; those with more hyperactivity and inattention symptoms and a child with more oppositional symptoms had worse psychological QOL.
Consistent with studies of parental QOL of children with developmental disorders or chronic medical conditions [[20], [21], [22], [23]], the present study found an association between maternal depression and QOL across all four domains. Children with ADHD have been shown to be significantly associated with higher levels of depression among mothers [[24], [25]], and maternal distress is associated with dysfunctional parenting practice and maladjustment of the child [[26], [27]]. Recent studies in Taiwan found that depressed mothers exhibited a flat affect when communicating with their children with ADHD [27], while maternal affection served as a buffer for children with attention problems from developing social adjustment problems [28]. Self‐care of mothers is important when working towards maintaining the mental health and well‐being of the whole family [6]. Depression prevention, screening, and intervention may be important when attempting to improve the QOL of the mothers of elementary school‐aged children, and may be potentially related to the long‐term health and well‐being of both the mothers and their children [[27], [29]].
Family support is considered a significant predictor of maternal QOL. However, in our study, it did not buffer the negative effect of maternal depression, inattention, and hyperactivity symptoms on maternal QOL. The stressor/support specificity model of the buffering process, which argued that support will be effective only when it provides the resources for fulfilment of the coping requirements elicited by stressful events, may explain this nonsignificant finding. In addition to family support, mothers with depression and more inattention and hyperactivity symptoms may need informational and emotional supports from friends or others with similar experience and professional support to provide effective strategies for coping with the impact of maternal depression, inattention, and hyperactivity as well as opposition behavior in children.
The present study also noted the association between lower socioeconomic status (i.e., living in rented accommodation) and QOL. This result was consistent with previous studies of adults with ADHD and borderline IQ (low income) [[30], [31]] and parents of children with ADHD (lower educational level, low household income) [5]. It has been hypothesized that people with a higher socioeconomic status can have better access to relevant information and treatment strategies in dealing with the stress caused by inattention, hyperactivity, and depression [5].
The mother's QOL in the psychological domain was related to the child's opposition symptoms instead of attention and hyperactivity. Reviews of parenting in children with ADHD have found greater stress within the family of children with ADHD comorbid with oppositional problems than that of children with ADHD only [[24], [25]]. In addition, maternal psychological problems are more likely to be associated with oppositional problems than with ADHD [32].
In the final model (Model 3) when all child, maternal, and family variables were considered, maternal inattention symptoms were predictive in their physical and psychological QOL and hyperactivity symptoms in the psychological and environmental QOL. One recent review concluded that symptoms of ADHD in adults exert a substantial negative impact on daily life, including work, social life, and relationships [33]. Most studies investigated how overall ADHD symptom severity impacted on adult QOL [[34], [35]], but they did not address the role of inattention and hyperactivity symptoms separately and adjust the role of comorbid depression, contextual factors such as levels of inattention, hyperactivity, and opposition symptoms in children, and perceived family support on specific domains of QOL as we did in the present study. Adults with ADHD are more likely to have children with ADHD [36]. ADHD and comorbidity in mothers and children may lead to a cycle of difficulties [[25], [37]]. Future studies may need to include children and mothers with ADHD and investigate how child and maternal ADHD subtype, comorbidity of oppositional defiant disorder in the child, maternal depression, and family function interact to impact maternal QOL.
Inconsistent with previous studies [[4], [5]], the present study showed that maternal QOL was more related to maternal and family variables than the inattention and hyperactivity symptoms of the child. Including maternal ADHD symptoms and depression and family function in this study may account for the inconsistent results. In addition, children with ADHD in the study of Xiang and colleagues [5] were recruited from an outpatient clinic where they received treatment. Participants in the present study were recruited from a school and might represent a wider range and overall a lesser degree of ADHD symptoms and did not receive any intervention for their inattention and hyperactivity symptoms. Also, the levels of inattention and hyperactivity symptoms of the children were rated by mothers in this study whereas ADHD in children was diagnosed using DSM‐IV in Xiang's study [5]. Lee and colleagues [4] surveyed a large and representative sample but measured QOL through limited sets of QOL questions rather than by a well‐established QOL instrument.
We further examined whether and how the responding rate, 60.3% in this study, may skew the relationship between maternal QOL and inattention and hyperactivity symptoms of children and their mothers. Mothers with the highest levels of inattention and hyperactivity symptoms may not return the questionnaires and could perhaps encompass a large proportion of the nonrespondents. If this assumption is sustained, participants in this study are mostly mothers with middle or low levels of inattention and hyperactivity symptoms. Nevertheless, their inattention and hyperactivity status was still found to consistently and significantly interfere with their QOL. A higher response rate coupled with severe maternal inattention and hyperactivity symptoms might provide similar or even more significant results.
Adding maternal variables in the model of maternal QOL (Model 2), the effect of child inattention and opposition problems (Model 1) were eliminated and no longer statistically significant except for opposition problems in maternal psychological QOL. It is possible that the experience of caring for a child with inattention and opposition problems is not directly related to poor maternal QOL, but rather is related to the increased levels of depression, inattention, and hyperactivity experienced by the mothers. However, since all child and maternal measures were rated by the mothers themselves, it is likely that mothers with more depressive symptoms negatively biased the reports of their child's ADHD and opposition symptoms [38]. Mothers with depression appear to be less attentive to their child's positive behaviors [[27], [39]].
Strengths and limitations
The present findings are of interest in that they draw attention to the consistently poor influence of child and maternal inattention and hyperactivity symptoms, maternal depression, and family context (i.e., family support and socioeconomic level) on the mother's QOL. The findings suggest a need to improve the awareness of students' inattention and opposition symptoms in school and to identify high‐risk mothers (i.e., depression, inattention, and hyperactivity) so as to provide essential support and intervention for these students and their mothers. Inattention is a common symptom in children with developmental disabilities [[40], [41]]. Future studies may need to evaluate the impact of the child's level of inattention on parental QOL of children with developmental disabilities. Clinicians also need to monitor inattention and hyperactivity symptoms and depression of mothers. Screening, assessments, and interventions for depression, inattention, and hyperactivity in mothers are important areas for professionals working in school systems to consider. The effect of treatment for inattention and opposition symptoms in children on QOL in mothers is also important for further research.
There are several limitations regarding this study that are worth considering. First, the large sample dataset was based on a school sample. The lack of a clinical sample implies the need for further replication of the findings in this study with participants with clinical diagnoses of ADHD. Therefore, it is important not to generalize the findings of this study to children with a clinical diagnosis of ADHD. Second, the measures of maternal and child inattention and hyperactivity, child opposition, maternal depression, and perceived family support are determined only by maternal self‐report measures, and most of the results could be due to shared method variance. Future studies may use a multi‐informant approach and include clinical samples of children with ADHD diagnosed by structured interviews and teachers' ratings of ADHD and opposition symptoms in children. Third, other maternal mental health factors (e.g., anxiety) and the father's level of inattention and hyperactivity, which might be significant to maternal QOL, are not assessed in this study. Fourth, because the participants of the present study are mothers of children from a single school with a limited response rate, these results may be prone to selection bias and generalization of the findings may be limited. Fifth, this study adopted a cross‐sectional design that encompasses the problem of reverse causality, such as the relationship between inattentive and hyperactive symptoms and the QOL of mothers. Mothers with poor QOL or depression may exaggerate their children's and their own inattention and hyperactivity symptoms. For these reasons, further research using a longitudinal design, recruiting a sample drawn from multiple schools, and assessing the impact of other parental risk factors (e.g., paternal depressive, inattentive, and hyperactive symptoms) on maternal QOL are required. In addition, studies investigating the effect of inattention and opposition treatment on the QOL of mothers are also needed.
Acknowledgments
This research was supported in part by grants from the Chung Shan Medical University Hospital, Taichung, Taiwan (CSH‐2009‐B‐004) to V.C.‐H.C. The authors would like to thank the staff, teachers, parents, and students at the Taichung Municipal Shiwei Elementary School, Taichung, Taiwan for their participation and assistance in the data collection for this study.
Conflicts of interest: All authors declare no conflicts of interest.
References
- [1]. Visser S.N., Bitsko R.H., Danielson M.L., Perou R., Blumberg S.J.. Increasing prevalence of parent‐reported attention‐deficit/hyperactivity disorder among children—United States, 2003 and 2007. MMWR. 2010; 59: 1439–1443. [PubMed] [Google Scholar]
- [2]. Blanchard L.T., Gurka M.J., Blackman J.A.. Emotional, developmental, and behavioral health of American children and their families: a report from the 2003 National Survey of Children's Health. Pediatrics. 2006; 117: 1202–1210. [DOI] [PubMed] [Google Scholar]
- [3]. Danckaerts M., Sonuga‐Barke E.J., Banaschewski T., Buitelaar J., Dopfner M., Hollis C., et al. The quality of life of children with attention deficit/hyperactivity disorder: a systematic review. Eur Child Adolesc Psychiatry. 2010; 19: 83–105. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [4]. Lee L.C., Harrington R.A., Louie B.B., Newschaffer C.J.. Children with autism: quality of life and parental concerns. J Autism Dev Disord. 2008; 38: 1147–1160. [DOI] [PubMed] [Google Scholar]
- [5]. Xiang Y.T., Luk E.S., Lai K.Y.. Quality of life in parents of children with attention‐deficit‐hyperactivity disorder in Hong Kong. Aust N Z J Psychiatry. 2009; 43: 731–738. [DOI] [PubMed] [Google Scholar]
- [6]. Witt W.P., DeLeire T.. A family perspective on population health: the case of child health and the family. WMJ. 2009; 108: 240–245. [PMC free article] [PubMed] [Google Scholar]
- [7]. Armstrong M.I., Birnie‐Lefcovitch S., Ungar M.T.. Pathways between social support, family well being, quality of parenting, and child resilience: what we know. J Child Fam Stud. 2005; 14: 269–281. [Google Scholar]
- [8]. Gau S.S.F.. Parental and family factors for attention‐deficit hyperactivity disorder in Taiwanese children. Aust N Z J Psychiatry. 2007; 41: 688–696. [DOI] [PubMed] [Google Scholar]
- [9]. Gau S.S., Shang C.Y., Liu S.K., Lin C.H., Swanson J.M., Liu Y.C., et al. Psychometric properties of the Chinese version of the Swanson, Nolan, and Pelham, version IV scale ‐ Parent form. Int J Methods Psychiatr Res. 2008; 17: 35–44. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [10]. Liu Y.C., Liu S.K., Shang C.Y., Lin C.H., Tu C.L., Gau S.S.F.. Norm of the Chinese version of the Swanson, Nolan and Pelham, version IV scale for ADHD. Taiwanese J Psychiatry. 2006; 20: 290–304. [Google Scholar]
- [11]. Skevington S.M., Lotfy M., O'Connell K.A.. The World Health Organization's WFOQOL‐BREF quality of life assessment: Psychometric properties and results of the international field trial. A report from the WHOQOL Group. Qual Life Res. 2004; 13: 299–310. [DOI] [PubMed] [Google Scholar]
- [12]. The WHOQOL‐Taiwan Group . Introduction to the development of the WHOQOL‐Taiwan version. Taiwan J Public Health. 2000; 19: 315–324. [Google Scholar]
- [13]. The WHOQOL‐Taiwan Group . Manual of the Taiwanese Version of WHOQOL‐BREF. Taipei: Taiwan WHOQOL Group. 2000. [Google Scholar]
- [14]. Kessler R.C., Adler L., Ames M., Demler O., Faraone S., Hiripi E., et al. The World Health Organization adult ADHD self‐report scale (ASRS): a short screening scale for use in the general population. Psychol Med. 2004; 35: 245–256. [DOI] [PubMed] [Google Scholar]
- [15]. Yeh C.B., Gau S.S., Kessler R.C., Wu Y.Y.. Psychometric properties of the Chinese version of the adult ADHD self‐report scale. Int J Methods Psychiatr Res. 2008; 17: 45–54. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [16]. Chien C.P., Cheng T.A.. Depression in Taiwan: epidemiological survey utilizing CES‐D. Seishin Shinkeigaku Zasshi. 1985; 87: 335–338. [PubMed] [Google Scholar]
- [17]. Radloff L.S.. The CES‐D Scale: a self‐report depression scale for research in the general population. Appl Psychol Measurement. 1977; 1: 385–401. [Google Scholar]
- [18]. Smilkstein G., Ashworth C., Montano D.. Validity and reliability of the family APGAR as a test of family function. J Fam Pract. 1982; 15: 303–311. [PubMed] [Google Scholar]
- [19]. Chau T.T., Hsiao T.M., Huang C.T., Liu H.W.. A preliminary study of family Apgar index in the Chinese. Kao‐Hsiung i Hsueh Ko Hsueh Tsa Chih. 1991; 7: 27–31. [PubMed] [Google Scholar]
- [20]. Kaya K., Unsal‐Delialioglu S., Ordu‐Gokkaya N.K., Ozisler Z., Ergun N., Ozel S., et al. Musculo‐skeletal pain, quality of life and depression in mothers of children with cerebral palsy. Disabil Rehabil. 2010; 32: 1666–1672. [DOI] [PubMed] [Google Scholar]
- [21]. Lv R., Wu L., Jin L., Lu Q., Wang M., Qu Y., et al. Depression, anxiety and quality of life in parents of children with epilepsy. Acta Neurol Scand. 2009; 120: 335–341. [DOI] [PubMed] [Google Scholar]
- [22]. Litzelman K., Catrine K., Gangnon R., Witt W.P.. Quality of life among parents of children with cancer or brain tumors: the impact of child characteristics and parental psychosocial factors. Qual Life Res. 2011; 20: 1261–1269. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [23]. Valenca M.P., de Menezes T.A., Calado A.A., de Aguiar Cavalcanti G.. Burden and quality of life among caregivers of children and adolescents with meningomyelocele: measuring the relationship to anxiety and depression. Spinal Cord. 2012; 50: 553–557. [DOI] [PubMed] [Google Scholar]
- [24]. Johnston C., Mash E.J.. Families of children with attention‐deficit/hyperactivity disorder: review and recommendations for future research. Clin Child Fam Psychol Rev. 2001; 4: 183–207. [DOI] [PubMed] [Google Scholar]
- [25]. Deault L.C.. A systematic review of parenting in relation to the development of comorbidities and functional impairments in children with attention‐deficit/hyperactivity disorder (ADHD). Child Psychiatry Hum Dev. 2010; 41: 168–192. [DOI] [PubMed] [Google Scholar]
- [26]. Goodman S.H., Tully E.. Depression in women who are mothers: an integrative model of risk for the development of psychopathology in their sons and daughters. In Keyes C.L.M., Goodman S.H., eds. Women and depression: a handbook for the social, behavioral and biological sciences. New York: Cambridge University Press. 2007, 241–280. [Google Scholar]
- [27]. Lee P.C., Lin K.C., Robson D., Yang H.J., Chen V.C.H., Niew W.I.. Parent–child interaction of mothers with depression and their children with ADHD. Res Dev Disabil. 2013; 34: 656–668. [DOI] [PubMed] [Google Scholar]
- [28]. Kawabata Y., Tseng W.L., Gau S.S.F.. Symptoms of attention‐deficit/hyperactivity disorder and social and school adjustment: the moderating roles of age and parenting. J Abnorm Child Psychol. 2012; 40: 177–188. [DOI] [PubMed] [Google Scholar]
- [29]. Goodman S.H.. Depression in mothers. Annu Rev Clin Psychol. 2007; 3: 107–135. [DOI] [PubMed] [Google Scholar]
- [30]. Rimmerman A., Yurkevich O., Birger M., Azaiza F., Elyashar S.. Quality of life of Israeli adults with borderline intelligence quotient and attention‐deficit/hyperactivity disorder. Int J Rehabil Res. 2007; 30: 55–60. [DOI] [PubMed] [Google Scholar]
- [31]. Rimmerman A., Yurkevich O., Birger M., Araten‐Bergman T.. Quality of life of men and women with borderline intelligence and attention deficit disorders living in community residences: a comparative study. J Atten Disord. 2005; 9: 435–443. [DOI] [PubMed] [Google Scholar]
- [32]. Chronis A.M., Lahey B.B., Pelhem W.E., Kipp H.L., Baumann B.L., Lee S.S.. Psychopathology and substance abuse in parents of young children with attention‐deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2003; 42: 1424–1432. [DOI] [PubMed] [Google Scholar]
- [33]. Rosler M., Casas M., Konofal E., Buitelaar J.. Attention deficit hyperactivity disorder in adults. World J Biol Psychiatry. 2010; 11: 684–698. [DOI] [PubMed] [Google Scholar]
- [34]. Chao C.Y., Gau S.S., Mao W.C., Shyu J.F., Chen Y.C., Yeh C.B.. Relationship of attention‐deficit‐hyperactivity disorders symptoms, depressive/anxiety symptoms, and life quality young men. Psychiatry Clin Neurosc. 2008; 62: 421–426. [DOI] [PubMed] [Google Scholar]
- [35]. Brod M., Johnston J., Able S., Swindle R.. Validation of the adult attention‐deficit/hyperactivity disorder quality‐of‐life Scale (AAQoL): a disease‐specific quality‐of‐life measure. Qual Life Res. 2006; 15: 117–129. [DOI] [PubMed] [Google Scholar]
- [36]. Macek J., Gosar D., Tomori M.. Is there a correlation between ADHD symptoms expression between parents and children. Neuro Endocrinol Lett. 2012; 33: 201–206. [PubMed] [Google Scholar]
- [37]. Harpin V.A.. The effect of ADHD on the life of an individual, their family, and community from preschool to adult life. Arch Dis Child. 2005; 90: i2–i7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [38]. Chi T.C., Hinshaw S.P.. Mother‐child relationships of children with ADHD: the role of maternal depressive symptoms and depression‐related distortions. J Abnorm Child Psychol. 2002; 30: 387–400. [DOI] [PubMed] [Google Scholar]
- [39]. Bylsma L.M., Morris B.H., Rottenberg J.. A meta‐analysis of emotional reactivity in major depressive disorder. Clin Psychol Rev. 2008; 28: 676–691. [DOI] [PubMed] [Google Scholar]
- [40]. Baker B.L., McIntyre L.L., Blacher J., Crnic K., Edelbrock C., Low C.. Pre‐school children with and without developmental delay: behaviour problems and parenting stress over time. J Intellect Disabil Res. 2003; 47: 217–230. [DOI] [PubMed] [Google Scholar]
- [41]. Neece C.L., Baker L.B., Crnic K., Blacher J.. Examining the validity of ADHD as a diagnosis for adolescents with intellectual disabilities: clinical presentation. J Abnorm Child Psychol. 2013; 41: 597–612. [DOI] [PubMed] [Google Scholar]