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