INTRODUCTION
Attention Deficit and Hyperacitivity Disorder (ADHD) has a high frequency as a diagnosis made in pediatric mental health and diseases polyclinics. Despite its high prevalence, treatments can relieve the many symptoms. ADHD is a stubborn problem that can start at preschool ages and continue through adulthood with various symptoms depending on the development. It can cause great developmental and functional difficulties in individuals’ life (1). It can have negative impacts on the relations between child, mother and father especially throughout the childhood (2). Beside the devastating effects on cognitive and social processes, presence of comorbidity cases increases the communication difficulties. It is reported that half or more than half of the children having ADHD has various other diagnoses as well (1,3,4). 40% and/or more of children who have symptoms of hyperactivity have oppositional defiant disorder and conduct disorder. In such cases along with oppositional defiant disorder and conduct disorder, it is claimed that the family functions is being affected much more (4).
When it comes to what extent the parents of children having ADHD feel themselves competent about their parenting skills, researches show that those parents have self-confidence difficulties, think themselves as insufficient in coping with the problems, need for continual support for raising their children (5).
Children with ADHD can cause serious problems in families (6). In this situation, professional support and education about ADHD are essential for the family during the treatment. Certain information about disorder, how to approach the child, organization of context or environment shall not only decrease the disruptive behaviors, but also increase the parents’ self-respect, and relieve the stress among the family members (6,7).
The assessment and treatment of parenting psychophatalogies are of importance in terms of the evaluation of family functioning. Satterfield et al. (7) reported that besides the psychotherapy and medication used for treating the children with ADHD, the guidance and education for the family and support groups are significant for the treatment process. Furthermore, it is found that such programs help to decrease conduct disorder, increase academic success and adaptation level.
ADHD is a heterogeneous disorder. Even though it has three main symptoms, the interaction and/or dissociation of those among each other initiated the concept of sub-type. The effect of the disorder on the functioning of the individual and family may vary according to the sub-types. For instance, children with ADHD-Predominantly Inattentive Subtype (ADHD-I) have academic difficulties; in ADHD-Predominantly Hyperactive-Impulsive Subtype (ADHD-HI) conduct disorder is predominant (8,10); for the ADHD-Combined Subtype (ADHD-C) existing problems diversify, issues related with cognitive processes are present (11). Examination of the effects of ADHD subtypes on family functioning may influence the treatment. Researches on the effects of ADHD subtypes on family functioning demonstrated that the ADHD dissolves the interaction and the bonds among the family members; causes problems in orientation toward organization and success; creates more conflict (12). Especially in particular cases with comorbidity stories, functionality has been heavily affected (13). Regarding to the subtypes, exhausted family by hyperactivity and impulsivity, and impacts of attention difficulties on learning and negatively affected social communication have negative influence on the family functioning. In this respect, the clarification of the differences between the subtypes is of significance for the treatment process.
The objective of this study is to investigate how the family functioning is affected with respect to the ADHD subtypes in particular ADHD cases with no explicit cognitive, physical and social lost, and without any comorbidity story. Therefore, it is aimed to determine the family characteristics varying merely according to the disorder.
METHOD
Participants
According to the clinical sample data, ADHD is a disorder diagnosed among the boys more likely than girls (the ratio ranges between 2:1 to 10:1) without any evident reason (12). In Turkey, it is reported that the range according to the gender is 6:1 in favor of boys (13,14). Considering this, study group consists of only boys.
The study group includes 1st - 5th grades children of 6-10 years-old (72-131 months), either applied first time and/or diagnosed as ADHD before but have not taken medication for at least 2 months, without any different/co-existing psychiatric, neurological and/or pediatric disorder (such as specific learning difficulties, anxiety disorder, mood disorder, etc.), evaluated as at least on average intelligence level, with no uncorrected visual and/or hearing impairment.
The diagnosis group has been selected among the children of 6-10 years old (8.00±2.11), who admitted to the Gazi University Pediatric Neurology and Pediatric Psychiatry Policlinics as having the symptoms of inattention and hyperactivity, with respect to the exclusion criteria of the study. As a result, the diagnosis group consists of 27 children diagnosed with ADHD- Predominantly Inattentive Subtype, 18 children diagnosed with ADHD-Predominantly Hyperactive-Impulsive Subtype, and 32 children diagnosed with ADHD-Combined Subtype, 77 children in total.
Control group was balanced in terms of gender and age. Children with low academic success were excluded. The parents and teachers of the healthy children were asked to fill Connors forms. The children who are under the cut-off score were included. A semi-structured diagnostic interview regarding to DSM-IV diagnosis criteria was held with the all children, who were considered to be included in control group, and their families. Among them, children who were not diagnosed with DSM-IV Axis I disorder were included in the study. As a result, the control group included 35 (31.3%) healthy male children, who had similar features with the diagnosis group, met the exclusion criteria, and studying secondary schools in Ankara.
Furthermore, 112 mothers, whose age ranged between 27 to 46 (35.00±4.46), participated to the study. In terms of family patterns of those participants, the 87% of the diagnosis group is nuclear family, 5.2% of those are extended family, and %7.8 is single-parent family. For the control group, the percentage of the nuclear families is 88.6%, of the extended families is 5.7%, and of the single parent ones is 5.7%.
The participant mothers were informed about the research and they had consented to have the study performed.
Data Collection Tools
Wechsler Intelligence Scale for Children - Revised (WISC-R): It was developed by Wechsler in 1949. In 1974, it was revised. It was adapted by Savaşır and Şahin (17) in Turkish in 1986. Within the scope of this study, Information, Similarities, Arithmetic, Digit Span, and Comprehension subtests of Verbal test, Picture Completion, Picture Concepts, Block Design, Picture Concepts, Object Assembly, and Coding subtests of Performance set were used (15).
Conners’ Parent Rating Scale: It has 48 items. Dereboy and et al. (18) have translated and adapted in Turkey. Conners’ Parent Rating Scale has subscales assessing Inattention, hyperactivity, conduct disorder, and oppositional defiant disorder.
Family Assessment Device: It was developed by Bolwin, and Bishop. The Turkish version of the device was adapted by Bulut (19). The device was designed to assess the family functioning generally, and outline the problematic dimensions of family functioning. It can be practiced with individuals over 12 years-old. It consists of 60 items covering 7 different subtests (Problem Solving, Communication, Roles, Affective Responsiveness, Affective Involvement, Behavior Control, and Common Functions). The scores range between 1.00 (healthy) and 4.00 (unhealthy). Although there are empirical studies going on, generally, the mean scores above 2.00 are accepted as an indication existence or initiation of unhealthy dimensions in family functioning. Test – retest reliability of the device is between 0.62 – 0.90. Regarding to the construct validity, the difference between the mean scores of the device used to assess women having a divorce, and one of the parents having normal marriage, in t test, was found significant between 0.001 and 0.01 for the all subtests.
Data Collection Form: It was developed to gather socio-demographical data of the admitted participants by the researchers of this study.
Procedure
In the first stage of diagnosing ADHD cases, all the participants with primary symptoms of inattention and hyperactivity, who were directed to polyclinics, were assessed according to the DSM-IV-TR diagnosis criteria. Then, all the criteria of Inattention and Disruptive Behavior Disorder were questioned in participants and the mothers according to the DSM-IV. The participants, who have continued at least 6 items from 1 group for ADHD-I, ADHD-HI, and ADHD-C subtypes inappropriate for their developmental level according to the diagnosis criteria, were determined. In rating the ADHD, moreover, parents were assessed with Conners’ Parent Rating Scale, and teachers were assessed with Conners’ Teachers Rating Scale. The assessed participants were examined according to the clinical cases uncovered by the scope of ADHD. Participants having ADHD without comorbidity and pediatric disease stories were identified. As a result, 27 children with ADHD-I, 18 children with ADHD-HI, and 32 children with ADHD-C were admitted to the study.
The control group consisted of 35 (31.3%) healthy male children having average or above IQ, without any psychiatric, neurological and pediatric disease similar to that of diagnosis group, and studying at any elementary school in Ankara.
Children were assessed with WISC-R during the morning times. In the meantime, mothers were assessed with Family Rating Score. The same psychologist made IQ test. Psychologists – researchers of the study after having informed the family, used those tools and got their permission to have the study performed.
Approval for the study was achieved from the Ethics Committee.
Statistical Analysis
Statistical Program for Social Sciences – SPSS v. 13.0 was used for the analysis of the data gathered with the tools mentioned above. Descriptive statistics was used for the socio-demographic data. One-way ANOVA was made for quadruplet comparisons. For the significant basic effects, in order to determine the source of difference between the groups, post-hoc analyses (Bonferroni) were made. The lowest significance level was assumed as 0.05 for the statistical tests.
RESULTS
The survey covers a group of male children who had ADHD diagnosis with subtype classification according to DSM-IV diagnosis criteria; and a group of healthy children. The ages of the groups ranged between 6-10 (8.00±2.11). The diagnosis group consisted of 27 boys (24.1%) with ADHD-I, 18 boys (16.1%) with ADHD-HI, and 32 boys (28.6%) with ADHD-C. The control group included 35 (31.3%) healthy boys. The one-way ANOVA showed that there is no significant difference between the age groups of the admitted participants (p>0.05).
According to the administered WISC-R for children, Children had mean IQ scores of 103.75±9.77 on verbal IQ, 104.62±11.31 on performance IQ, 104.38±10.44 on total IQ. Regarding the groups, children with ADHD-I had mean IQ scores of 100.25±6.86 on verbal IQ, 99.00±8.28 on performance IQ, and 99.44±6.7 on total IQ; children with ADHD-HI had mean IQ scores of 106.94±10.65 on verbal IQ, 110.38±13.50 on performance IQ, 108.72±12.08 on total IQ; children with ADHD-C had mean IQ scores of 101.46±11.49 on verbal IQ, 105.31±13.54 on performance IQ, and 106.54±8.07 on total IQ. The control group had mean IQ scores of 106.71±8.27 on verbal IQ, 105.387±7.95 on performance IQ, and 106.54±8.07 on total IQ.
A one-way ANOVA showed that the children in control group had better scores than the ones in the diagnosis group. Considering the verbal IQ, the difference between ADHD-I diagnosed children and control group was significant; considering the performance and total IQ, the differences between ADHD-I<ADHD-HI and ADHD-I<Control Group were significant (p<0.05).
The mean and standard deviation of the scores participants had got from the ADHD rating scales, and the results of one-way ANOVA applied to those scores showed in Table 1.
Family assessment device administered to 112 mothers whose age ranged between 27-46 (35.00±4.46). 33% (n=37) of them was graduate of a primary school, 37.5% (n=42) was graduate of a high school, and 29.5% (n=33) was graduate of a university. 60.7% (n=68) of the mothers was housewife. 1.8% (n=2) was retired. 37.5% (n=42) was working. The percentage of mothers with no health issue was 81.3%. It was figured out that 7 of 21 mothers having illness story was being monitored with the diagnosis of major depression. 6 of those mothers had a child with diagnosed ADHD.
The percentage of nucleus family was 87, that of extended family was 5.2%, and that of single-parent family was 7.8% in diagnosis group. In the control group, there were 88.6% nucleus family, 5.7% extended family, and 5.7 single-parent families.
The mean and standard deviation scores of the subtests of Family Assessment Device showed that ADHD-HI type children had higher scores with regard to Problem Solving dimension, ADHD-I type children had higher scores with regard to Communication dimension, ADHD-C type children had higher scores with regard to Roles dimension, ADHD-HI and ADHD-I type children had higher scores with regard to Affective Responsiveness dimension, ADHD-HI type children had higher scores with regard to Common Functions dimension. A one-way ANOVA of the scores of Family Assessment Device showed that there was a difference between the groups in terms of all the subscales except Behavior Control Dimension. The results are given in the Table 2.
There is not a significant correlation between Connors’ Family Rating Scale and Family Assessment Device (p>0.05).
DISCUSSION
The familial genetic factors have been researched in ADHD etiology for 40 years (18-20). It is, generally, claimed that the genetic factors and environmental ones work together to manipulate the symptoms and disorder of attention deficiency and hyperactivity. Surveys covering the bothers, sisters and parents of ADHD diagnosed children picture out the probable genetic factors in the etiology of the subject matter disorder. The presumption about the role of the environmental factors in the etiology has not been proved yet. Biederman et al. (21) outlined and made surveys about the relations between ADHD and disadvantages/problems (such as serious marriage conflicts, low social status, extended family, outlaw father, mother’s mental illness, foster family care, etc.) that are accepted as the familial and environmental risk factors. They stated that it is about the factors making the situation worse for the ADHD diagnosed patients, instead of factors triggering the the disorders’ development. They determined that those disadvantages increase the stories of co-existing illnesses (21).
In this survey, the effects of the ADHD symptoms on family functioning. The process, however, is thought as mutual. Since the inherited predisposition is of significance considering ADHD, it is highly probable one or both parents of children with ADHD to have ADHD. Therefore, it is possible to say that parental pathologies might have been contributing to the family dysfunction. The scope of this study covers mainly the children based effects.
Even though the ADHD diagnosed individuals have the symptoms of both Inattention and hyperactivity/Impulsive activities, in some cases only one symptom pattern can be predominant. For that reason, 3 subtypes are defined for ADHD diagnosis in DSM-IV (22). The frequency of ADHD-I and ADHD-C subtypes are approximately the same for the school age children (23,24). In another survey made in Turkey stated that the distribution of ADHD with regard to subtypes is 1% ADHD-I, 1.5% ADHD-HI, and 4% ADHD-C (13). In our survey, the rating of ADHD diagnosed participants according to the subtypes is as follows: ADHD-C is the first, ADHD-I is the second, and ADHD-HI is the third. The frequency rating of this study in consistent with the rating reported from clinical sample (25,26).
Attention deficiency and hyperactivity disorder diagnosis has a phenomenological basis. Therefore, it is of importance to identify the implications of child’s behavior on different facets of daily life, along with the clinical assessment. For this reason, certain data is gathered from the parents and teacher. Behavior assessment and rating scales are administered to collect that data. Those scales are economic and contribute to both the diagnosis and monitoring of the participants. Their particularity and sensitivity have been proven (27). It is, however, stressed so often that it is important to be careful in evaluating those data (28). Because, it is known that the percentage of inconsistent assessments based on the data gathered from parents and teachers of children with ADHD is 10-20% (29). Those different reports and opinions are caused by the structured context of the school, and the more clear defined tasks and expectations, compared to the home environment.
In our study, the relation between family functioning and level of the disorder. It is possible to interpret the result showing that there was no significant correlation between Connors’ Parent Rating Scale and Family Assessment Device as families could not have describe the ADHD characteristics. Another reason for this might be that the admitted children is lack of serious problems.
In this study, there were low scores in 5 subtests of Family Assessment Device. It demonstrates that there is a common failure in family functions. There are studies reporting there is evidence about the family functions are broken in families having a member with psychiatric illness, and the family functions influence the clinic progress of the illness (30,31). According to certain studies held in Turkey, the family functioning is generally poorer in families having psychiatric illness diagnosed members than the control group families. The dimension of Affective Responsiveness is where the highest level of unhealthiness is seen (32). At this point, our study differs from the previous surveys. This study demonstrates that the highest level of unhealthiness is seen in Communication dimension, which makes a difference among the ADHD subtypes.
The mean and standard deviation scores of the Family Assessment Device showed that ADHD-HI type children had higher scores with regard to Problem Solving dimension, ADHD-I type children had higher scores with regard to Communication dimension, ADHD-C type children had higher scores with regard to Roles dimension, ADHD-HI and ADHD-I type children had higher scores with regard to Affective Responsiveness dimension, ADHD-HI type children had higher scores with regard to Common Functions dimension. There was a difference between the diagnosis and control groups in terms of all the subscales except Behavior Control Dimension. Pekcanlar et al. (13) evaluated the family functioning of the ADHD diagnosed children within the limits of normal. On the other hand, there are researches reporting that communication and behavior control dimensions are problematic when conduct disorder and oppositional disorder co-exist with ADHD (4,33). Our study has revealed the diversification of the subtypes of ADHD according to the family functioning as a contribution to the literature. Previous studies had compared the cases with co-existing different psychiatric matters.
In our survey, it was found out that there were statistically meaningful differences between Communication and Roles dimension scores of Family Assessment Device with respect to ADHD subtypes. The structure in ADHD-I was determined as unhealthy in terms of Communication Dimension, and one in ADHD-C in terms of Roles (see the Table 2). The reason for the low communication subtest scores of parents of children with ADHD-I could be related with the cognitive processes of the children. When the mean scores of the WISC-R administered to the children were examined, it was seen that lowest scores belonged to the children with ADHD-I. It is a fact that those children with ADHD-I are having academic failure mostly (3,34). Such a child who cannot meet the expectations of his/her family because of attention deficit regardless of parents’ endless efforts can cause a decrease in the self-respect of the parents. Those parents might feel like “I am not good enough as a parent, if I had taken care of his/her much more, he/she would have been more successful”.
There are researches that assessed family functioning with respect to demographic data and reported different results. Bulut (34) reported that family functioning failed more when the patient was a male, and this situation appeared especially in dimensions of Roles and Behavior Control. Our study covered only male children. Unhealthiness was determined most in Roles dimension scores of ADHD-C subtype. Considering the evidences, it is possible to think that there is a obvious lost in expectations in particular areas such as family order, traditional roles attributed to the parents, expectations related with male children, and the value of the child.
As a conclusion, family should be assessed along with the children during the treatment process, while evaluating the ADHD cases. The effects of family dynamics on treatment should be examined. Therefore, particular skills of the child, such as problem solving, social judgment, emotional responsiveness, vital for the adaptation to the social life would be strengthened. Parental / familial problems were reported as predictor of decrease in the adaptation to treatment or less positive results from the treatment (13). The education of the families, sharing problems and search for the solutions together, collaboration of teacher, parents and clinician as a team shall have positive impacts on treatment process. Problem solving skills should be improved by working with the families. It is important to investigate if the cause of the failure of the family functioning is the attitude of the parents or burnout syndrome depending on the ADHD case. In this respect, it was important for us to have mothers in depressive mood in our study. The probable role of the mothers’ mood should not be ignored considering the overall picture.
Moreover, it is of significance to have a extended survey covering female children sample in future in order to examine place and importance of the gender roles in family functioning. Our study covered only the mothers’ reports. Assessment of the fathers and brothers/sisters would provide remarkable data. Furthermore, the assessment of the both parents in terms of psychopathology beside the family functioning evaluation would be helpful and useful in finding problems and proceeding the treatment.
