Elsevier

Comprehensive Psychiatry

Volume 57, February 2015, Pages 85-96
Comprehensive Psychiatry

Co-occurrence of attention-deficit hyperactivity disorder symptoms with other psychopathology in young adults: parenting style as a moderator

https://doi.org/10.1016/j.comppsych.2014.11.002Get rights and content

Abstract

The extent to which parenting styles can influence secondary psychiatric symptoms among young adults with ADHD symptoms is unknown. This issue was investigated in a sample of 2284 incoming college students (male, 50.6%), who completed standardized questionnaires about adult ADHD symptoms, other DSM-IV symptoms, and their parents’ parenting styles before their ages of 16. Among them, 2.8% and 22.8% were classified as having ADHD symptoms and sub-threshold ADHD symptoms, respectively. Logistic regression was used to compare the comorbid rates of psychiatric symptoms among the ADHD, sub-threshold ADHD and non-ADHD groups while multiple linear regressions were used to examine the moderating role of gender and parenting styles over the associations between ADHD and other psychiatric symptoms. Both ADHD groups were significantly more likely than other incoming students to have other DSM-IV symptoms. Parental care was negatively associated and parental overprotection/control positively associated with these psychiatric symptoms. Furthermore, significant interactions were found of parenting style with both threshold and sub-threshold ADHD in predicting wide-ranging comorbid symptoms. Specifically, the associations of ADHD with some externalizing symptoms were inversely related to level of paternal care, while associations of ADHD and sub-threshold ADHD with wide-ranging comorbid symptoms were positively related to level of maternal and paternal overprotection/control. These results suggest that parenting styles may modify the effects of ADHD on the risk of a wide range of temporally secondary DSM-IV symptoms among incoming college students, although other causal dynamics might be at work that need to be investigated in longitudinal studies.

Introduction

Attention-deficit/hyperactivity disorder (ADHD) is a common childhood-onset disorder, with 5%–10% prevalence in western countries [1] and 7.5% in Taiwan [2]. Prevalence of DSM-IV ADHD in adulthood has been estimated to be 4.4% in the U.S. [3], which is broadly consistent with projections from childhood prevalence estimates based on the findings in longitudinal studies that 30%–60% of children with ADHD persist in having ADHD in adulthood [4], [5], [6].

Numerous studies have demonstrated high psychiatric comorbidity in children and adolescents with ADHD [2], [7], [8], [9]. High comorbidity has also been found for adult ADHD with anxiety disorders [3], major depression [10], bipolar disorders [11], mood disorders [8] and substance use disorders [3], [12] in both cross-sectional [3], [13], [14] and longitudinal [8], [15] studies. Moreover, adolescent–adult ADHD has been found to be associated with borderline [16] and antisocial [8], [15], [17], [18] personality disorders. As ADHD has a very early age of onset, the vast majority of these comorbid disorders are likely to be temporally secondary, in which case ADHD can be seen as a powerful risk marker for the subsequent onset of these other disorders [19].

Sub-threshold ADHD has also received increasing attention in recent years in studies conducted both during childhood–adolescence [20], [21] and adulthood [22], [23]. These studies showed that sub-thereshold ADHD was associated with elevated rates of psychiatric comorbidies [21], [24] and role impairments [20], [23] compared to unaffected adults, although the rates of comorbidity and role impairment in sub-threshold ADHD were less than those found among adults with full ADHD [22], [23], [25]. These studies were limited, though, by clinical samples.

Parenting practice is known to influence the development and maintenance of psychiatric problems in childhood and adolescence [26], [27]. For example, parental rejection and psychological control are linked with more child shyness and increased risk of anxiety disorders [28], depression [29], [30] and delinquency [31] while high level of harsh and inconsistent discipline and low level of warmth and involvement have been found to predict later conduct problems [32], [33]. The relationship between parenting and child behaviors may be coercive. Over time, both the children and mothers are reinforced for their maladaptive behaviors which strengthen and escalate the coercive cycle [34].

Previous studies have shown that parents of children with ADHD diagnosis/symptoms engage in more inappropriate parenting styles than other parents [24], [35] and have lower parental care and higher parental overprotection than other parents [36], [37], [38]. Besides, children’s ADHD symptoms can influence parents’ parenting style [39] while inappropriate parenting style may further exacerbate ADHD symptoms [40]. Moreover, previous studies also found the association between inappropriate parenting style and psychiatric comorbid conditions in ADHD such as oppositional defiant disorder/conduct disorder (ODD/CD) [41], [42], [43], anxiety disorders [44] and major depressive disorder [45], [46].

However, previous studies discussing the association of parenting style and psychiatric comorbid conditions in ADHD were limited to childhood and adolescence. So far, the association of parenting style in childhood and adolescence and co-occurring psychiatric symptoms or personality traits with ADHD symptoms in adulthood is not clear.

Pervasive evidence exists for gender differences in psychiatric symptoms and disorders among adolescents [2], [47], [48], [49] and adults [50], [51], with externalizing disorders such as ADHD to be male dominant and internalizing disorders female dominant [49]. However, no consistent gender difference has been found in comorbid conditions of ADHD with other psychiatric symptoms/disorders. Some studies in both community-based [52], [53], [54] and clinic-based [55] samples, but not others [7], [20], [56], have shown gender differences in ADHD comorbid conditions. Furthermore, despite evidence of significant associations of ADHD with borderline [16] and antisocial [15], [17] personality disorders, only a single recent study suggested that ADHD might be more strongly associated with antisocial personality disorder among men and with borderline personality disorder among women [57].

In view of the above findings, and given the considerable public health importance of ADHD as a risk marker for wide-ranging comorbid conditions, we carried out a survey of the extent to which the associations of ADHD with comorbid conditions vary as a function of childhood exposure to different parenting styles in a sample of incoming college students in Taiwan. The study had three objectives: (1) to replicate previous studies in documenting significant comorbid conditions between ADHD (both threshold and sub-threshold) and a wide range of other Axis I and Axis II psychiatric symptoms; (2) to examine the associations of parenting styles, as retrospectively reported by students, with these symptoms; and (3) to determine the extent to which the associations of ADHD with other symptoms vary as a joint function of gender and childhood exposure to different parenting styles.

Section snippets

Participants and procedures

The study was carried out among incoming freshman at National Taiwan University, Taipei, Taiwan. Recruitment began with a letter describing the purposes and procedures of the study that was mailed to all 3756 incoming students after they were accepted by the university. There were no data about the proportion of eligible students receiving the invitation letter. The students were informed that participation was completely voluntary and that responses would be confidential. These consent

Demographics

Table 1 presents demographic characteristics and both parents’ parenting styles. The ADHD group had higher proportions of males and single child and a lower rate of Taipei residency than the other groups. The two ADHD groups reported that their parents were more protective and less caring than the non-ADHD group. There were no group differences in parental age, education, job types, or marital status.

ADHD and comorbid mental symptoms

Table 2 presents the Pearson’s correlations between ADHD (inattention,

Discussion

The current study is one of the few studies investigating the extent to which the associations of ADHD with comorbid conditions vary as a function of parenting style and gender [43], [46], [56]. First, we found that ADHD symptoms were highly associated with wide-ranging DSM-IV symptoms in new college students. Second, we demonstrated that parenting styles significantly moderated the associations of ADHD with other psychiatric symptoms. Specifically, maternal protection significantly interacted

Conclusions

This community-based study has important clinical implication that clinicians need to be aware of parental styles and pay attention to improve parenting skills before diagnosing and treating a youth who is suspected of having ADHD. In addition, our findings also raise the possibility that early interventions to influence the parenting styles of parents of children with ADHD might help reduce the onset and/or persistence of secondary psychiatric symptoms in young adulthood. Another possibility

Acknowledgment

This work was supported by grants from the National Taiwan University Hospital (NTUH92-S07) and National Health Research Institute (NHRI-EX95-9407PC, NHRI-EX98-9407PC, NHRI-EX100-0008PI), Taiwan. We would like to express our thanks to Ms. Ming-Fong Chen for assistance in data analysis and to school counselors of National Taiwan University for their assistance in this research.

References (103)

  • J.J. Rucklidge et al.

    Psychiatric, psychosocial, and cognitive functioning of female adolescents with ADHD

    J Am Acad Child Adolesc Psychiatry

    (2001)
  • W.S. Sharp et al.

    ADHD in girls: clinical comparability of a research sample

    J Am Acad Child Adolesc Psychiatry

    (1999)
  • L.R. Chang et al.

    Father's parenting and father-child relationship among children and adolescents with attention-deficit/hyperactivity disorder

    Compr Psychiatry

    (2013)
  • S.S. Gau et al.

    Maternal parenting styles and mother–child relationship among adolescents with and without persistent attention-deficit/hyperactivity disorder

    Res Dev Disabil

    (2013)
  • H.N. Yang et al.

    Prediction of childhood ADHD symptoms to quality of life in young adults: adult ADHD and anxiety/depression as mediators

    Res Dev Disabil

    (2013)
  • Y.H. Lin et al.

    Association between morningness–eveningness and the severity of compulsive Internet use: the moderating role of gender and parenting style

    Sleep Med

    (2013)
  • S.S. Gau et al.

    Parental characteristics, parenting style, and behavioral problems among chinese children with Down syndrome, their siblings and controls in Taiwan

    J Formos Med Assoc

    (2008)
  • M.N. Hsiao et al.

    Effects of autistic traits on social and school adjustment in children and adolescents: the moderating roles of age and gender

    Res Dev Disabil

    (2013)
  • J.E. Rogstad et al.

    Gender differences in contributions of emotion to psychopathy and antisocial personality disorder

    Clin Psychol Rev

    (2008)
  • A. Fossati et al.

    History of childhood attention deficit/hyperactivity disorder symptoms and borderline personality disorder: a controlled study

    Compr Psychiatry

    (2002)
  • J.M. Strayhorn et al.

    Follow-up one year after parent–child interaction training: effects on behavior of preschool children

    J Am Acad Child Adolesc Psychiatry

    (1991)
  • M. Latas et al.

    Predictors of comorbid personality disorders in patients with panic disorder with agoraphobia

    Compr Psychiatry

    (2000)
  • G.A. Fabiano et al.

    A comparison of behavioral parent training programs for fathers of children with attention-deficit/hyperactivity disorder

    Behav Ther

    (2009)
  • K. Lieb et al.

    Borderline personality disorder

    Lancet

    (2004)
  • J. Biederman et al.

    Gender effects on attention-deficit/hyperactivity disorder in adults, revisited

    Biol Psychiatry

    (2004)
  • S.V. Faraone et al.

    The worldwide prevalence of ADHD: is it an American condition?

    World Psychiatry

    (2003)
  • S.S. Gau et al.

    A 3-year panel study of mental disorders among adolescents in Taiwan

    Am J Psychiatry

    (2005)
  • R.C. Kessler et al.

    The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication

    Am J Psychiatry

    (2006)
  • J. Biederman et al.

    Age-dependent decline of symptoms of attention deficit hyperactivity disorder: impact of remission definition and symptom type

    Am J Psychiatry

    (2000)
  • S. Mannuzza et al.

    Hyperactive boys almost grown up. V. Replication of psychiatric status

    Arch Gen Psychiatry

    (1991)
  • J. Biederman et al.

    Absence of gender effects on attention deficit hyperactivity disorder: findings in nonreferred subjects

    Am J Psychiatry

    (2005)
  • J. Biederman et al.

    Young adult outcome of attention deficit hyperactivity disorder: a controlled 10-year follow-up study

    Psychol Med

    (2006)
  • T.J. Spencer

    ADHD and comorbidity in childhood

    J Clin Psychiatry

    (2006)
  • L. Tamam et al.

    Comorbidity of adult attention-deficit hyperactivity disorder and bipolar disorder: prevalence and clinical correlates

    Eur Arch Psychiatry Clin Neurosci

    (2008)
  • T.E. Wilens

    The nature of the relationship between attention-deficit/hyperactivity disorder and substance use

    J Clin Psychiatry

    (2007)
  • J.J. McGough et al.

    Psychiatric comorbidity in adult attention deficit hyperactivity disorder: findings from multiplex families

    Am J Psychiatry

    (2005)
  • J. Sprafkin et al.

    Psychiatric comorbidity in ADHD symptom subtypes in clinic and community adults

    J Atten Disord

    (2007)
  • M. Fischer et al.

    Young adult follow-up of hyperactive children: self-reported psychiatric disorders, comorbidity, and the role of childhood conduct problems and teen CD

    J Abnorm Child Psychol

    (2002)
  • J. Modestin et al.

    Antecedents of opioid dependence and personality disorder: attention-deficit/hyperactivity disorder and conduct disorder

    Eur Arch Psychiatry Clin Neurosci

    (2001)
  • K. Rasmussen et al.

    Attention deficit hyperactivity disorder, reading disability, and personality disorders in a prison population

    J Am Acad Psychiatry Law

    (2001)
  • S.R. Pliszka

    Comorbidity of attention-deficit/hyperactivity disorder with psychiatric disorder: an overview

    J Clin Psychiatry

    (1998)
  • S.C. Cho et al.

    Full syndrome and subthreshold attention-deficit/hyperactivity disorder in a Korean community sample: comorbidity and temperament findings

    Eur Arch Psychiatry Clin Neurosci

    (2009)
  • S.V. Faraone et al.

    Diagnosing adult attention deficit hyperactivity disorder: are late onset and subthreshold diagnoses valid?

    Am J Psychiatry

    (2006)
  • C. Johnston

    Parent characteristics and parent–child interactions in families of nonproblem children and ADHD children with higher and lower levels of oppositional-defiant behavior

    J Abnorm Child Psychol

    (1996)
  • S.V. Faraone et al.

    Personality traits among ADHD adults: implications of late-onset and subthreshold diagnoses

    Psychol Med

    (2009)
  • J. Kagan

    Biology, context, and developmental inquiry

    Annu Rev Clin Psychol

    (2003)
  • M. Rutter

    Nature, nurture, and development: from evangelism through science toward policy and practice

    Child Dev

    (2002)
  • J.J. Wood et al.

    Parenting and childhood anxiety: theory, empirical findings, and future directions

    J Child Psychol Psychiatry

    (2003)
  • J. Bowlby

    Developmental psychiatry comes of age

    Am J Psychiatry

    (1988)
  • M. Hoeve et al.

    The relationship between parenting and delinquency: a meta-analysis

    J Abnorm Child Psychol

    (2009)
  • Cited by (20)

    • Longer screen time utilization is associated with the polygenic risk for Attention-deficit/hyperactivity disorder with mediation by brain white matter microstructure

      2022, eBioMedicine
      Citation Excerpt :

      Moreover, due to the high heritability of ADHD, the offspring of adults with ADHD are at increased risk of ADHD. At the same time, ADHD impairs the parenting ability of adults,67,68 resulting in inadequate protection against their children's exposure to digital media, which might lead to the co-occurrence of ADHD and long STU. Our results suggest that the genetic background of ADHD might contribute to prolonged STU, but more research is needed to test this hypothesis in the future.

    • Practical considerations for the evaluation and management of Attention Deficit Hyperactivity Disorder (ADHD) in adults

      2020, Encephale
      Citation Excerpt :

      There are however studies that suggest a common aetiology, such as traits relating to novelty-seeking [54]. Parenting styles, in a setting of a marked genetic component for this disorder, could also be a determining factor in the development of personality traits [55]. Among patients with a personality disorder, specific treatment of ADHD can boost the efficacy of psychotherapeutic treatments [56].

    • Gender-differential associations between attention deficit and hyperactivity symptoms and youth health risk behaviors

      2019, Pediatrics and Neonatology
      Citation Excerpt :

      Inattention did not reveal any relationship with risk behavioral outcomes in both genders. By using the ASRS-6, we detected a higher prevalence of ADHD symptoms than previously reported in youth.9 This discrepant result may be due to methodological differences or other possibilities that make the questionnaire-based screening sensitive to detect subthreshold ADHD symptoms.

    View all citing articles on Scopus
    View full text