PARENT-CHILD INTERACTIONS WITH ADHD CHILDREN: PARENTAL EMPATHY AS A PREDICTOR OF CHILD ADJUSTMENT Michelle A. Warren, B.A., M.S. Dissertation Prepared for the Degree of DOCTOR OF PHILOSOPHY UNIVERSITY OF NORTH TEXAS August 2003 APPROVED: Patricia L. Kaminski, Major Professor Paul Lambert, Committee Member Garry L. Landreth, Committee Member Judy McConnell, Committee Member Ernest Harrell, Chair of Department of Psychology C. Neal Tate, Dean of the Robert B. Toulouse School of Graduate Studies Warren, Michelle A., Parent-child interactions with ADHD children: Parental empathy as a predictor of child adjustment. Doctor of Philosophy (Psychology), August 2003, 179 pp., 25 tables, 2 figures, references, 157 titles. Parent-child interactions tend to be problematic among families of children diagnosed with Attention-Deficit/Hyperactivity Disorder (ADHD). Although much attention has been paid in research and therapy to negative cycles of interaction between parent and child, it is equally important to consider how positive family interactions can be promoted, as these are likely to help prevent or reduce behavior problems and facilitate the best possible outcomes for children. Major contributors to the fields of psychology and child therapy have postulated that parental empathy is of primary importance in facilitating healthy child personality development. However, the effect of parental empathy has not been systematically studied with ADHD children. Thus, this study investigated the relationship between parental empathy and child adjustment factors in children with ADHD. It was hypothesized that among parent-child dyads with ADHD children, higher levels of parental empathy would predict higher levels of child self- esteem, social skills, and compliance, and lower levels of child aggression. Participants were 56 children who were previously diagnosed with ADHD and their parent/guardian. Thirty-seven parent-child dyads served as a control group. The study included parent-child participation in a videotaped analogue observation procedure and completion of parent-, child-, and teacher-report measures. Results indicated that higher levels of parental empathy predicted higher child self-esteem regarding their relationships with their parents. Before bonferroni adjustment, parental empathy also predicted lower levels of aggression among ADHD children. Parental empathy did not predict peer acceptance or compliance for these children. Children of high empathy parents scored higher on peer acceptance and lower on child aggression measures than children of low empathy parents. Scores on self-esteem and compliance, however, did not differ across groups. Although there were no differences between ADHD and non-ADHD children on self-esteem, peer acceptance, or compliance measures, children with ADHD were significantly more aggressive. These results suggest the importance of interventions for ADHD children that focus on increasing parental empathy in parent-child interactions. TABLE OF CONTENTS Page LIST OF TABLES(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133). iii LIST OF FIGURES(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)vi CHAPTER 1: Introduction(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 1 Parental Empathy and Child Adjustment Overview of Attention Deficit/Hyperactivity Disorder (ADHD) ADHD and Child Adjustment Parenting Children with ADHD Parental Empathy with ADHD Children Significance of Child and Parent Influences Implications for Treatment of Child ADHD Parent Training Interventions Empathy and Parent Training Summary of Literature Statement of the Problem Hypotheses CHAPTER 2: Method(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 36 Participants Measures Procedure CHAPTER 3: Results(cid:133)..(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133).(cid:133)(cid:133). 62 CHAPTER 4: Discussion(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)..(cid:133). 70 APPENDIXES(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)... 92 REFERENCES(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133).. 159 ii LIST OF TABLES Table Page 1 Diagnostic Criteria for Attention-Deficit/Hyperactivity Disorder(cid:133). 93 2 Descriptive Statistics for Child Participants in ADHD and Control Groups(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)..(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133).. 95 3 Descriptive Statistics for Parent/Guardian Participants in ADHD and Control Groups(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 96 4 Descriptive Statistics on the Age of the Sample(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 98 5 Intercorrelations for ADHD Children(cid:146)s General Self-Esteem as Measured by the SDQ-I and Parental Empathy Predictor Variables(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 99 6 Regression Analysis Summary for Parental Empathy Variables Predicting ADHD Children(cid:146)s General Self-Esteem as Measured by the SDQ-I(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133).. 100 7 Intercorrelations for ADHD and Control Group Children(cid:146)s General Self-Esteem as Measured by the SDQ-I and Parental Empathy Predictor Variables(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133). 101 8 Regression Analysis Summary for Parental Empathy Variables Predicting ADHD and Control Group Children(cid:146)s General Self-Esteem as Measured by the SDQ-I(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 102 9 Intercorrelations for Children(cid:146)s Parent Relations Self-Esteem as Measured by the SDQ-I, and ADHD Group Status and Parental Empathy Predictor Variables(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133). 103 10 Hierarchical Regression Analysis Summary for ADHD Group Status and Parental Empathy Variables Predicting Children(cid:146)s Parent Relations Self-Esteem as Measured by the SDQ-I(cid:133)(cid:133)(cid:133)(cid:133). 104 11 Intercorrelations for ADHD Children(cid:146)s Peer Acceptance as Measured by the LSDQ and Parental Empathy Predictor Variables(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 105 iii Table Page 12 Regression Analysis Summary for Parental Empathy Variables Predicting ADHD Children(cid:146)s Peer Acceptance as Measured by the LSDQ Total Score(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 106 13 Intercorrelations for ADHD Children(cid:146)s Peer Acceptance as Measured by the TRS and Parental Empathy Predictor Variables(cid:133) 107 14 Regression Analysis Summary for Parental Empathy Variables Predicting ADHD Children(cid:146)s Peer Acceptance as Measured by the TRS(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133).. 108 15 Intercorrelations for ADHD Children(cid:146)s Compliance as Measured by the PCIA and Parental Empathy Predictor Variables(cid:133)(cid:133)(cid:133)(cid:133)... 109 16 Regression Analysis Summary for Parental Empathy Variables Predicting ADHD Children(cid:146)s Compliance as Measured by the PCIA(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133).. 110 17 Intercorrelations for ADHD Children(cid:146)s Aggression as Measured by the CBCL and Parental Empathy Predictor Variables(cid:133)(cid:133)(cid:133)(cid:133).. 111 18 Regression Analysis Summary for Parental Empathy Variables Predicting ADHD Children(cid:146)s Aggression as Measured by the CBCL(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133). 112 19 Intercorrelations for ADHD Children(cid:146)s Aggression as Measured by the PCIA and Parental Empathy Predictor Variables(cid:133)(cid:133)(cid:133)(cid:133)... 113 20 Regression Analysis Summary for Parental Empathy Variables Predicting ADHD Children(cid:146)s Aggression as Measured by the PCIA(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133).. 114 21 Intercorrelations for Children(cid:146)s Aggression as Measured by the PCIA, and ADHD Group Status and Parental Empathy Predictor Variables(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 115 22 Hierarchical Regression Analysis Summary for ADHD Group Status and Parental Empathy Variables Predicting Children(cid:146)s Aggression as Measured by the PCIA(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)... 116 iv Table Page 23 Mean Scores and Standard Deviations for Measures of Child Adjustment as a Function of ADHD Group Status and Parental Empathy Level(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)... 117 24 Multivariate and Univariate Analyses of Variance F Ratios for ADHD Status X Parental Empathy (PE) Level for Measures of Child Self-Esteem (SDQ-I) and Peer Acceptance(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133). 118 25 Multivariate and Univariate Analyses of Variance F Ratios for ADHD Status X Parental Empathy (PE) Level for Measures of Child Compliance and Aggression(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133) 119 v LIST OF FIGURES Figure Page 1 A model of stress in parent-child interactions(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)121 2 Hypothesized effects of parental empathy and ADHD status on child adjustment(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133)(cid:133). 35 vi CHAPTER 1 Introduction Parental empathy plays a highly significant role in a child(cid:146)s life, as an empathic home environment nourishes the child(cid:146)s emotional needs and cultivates a climate for growth and development (Kohut, 1977; Rogers, 1939, 1951). This type of climate may be especially important for children who experience behavioral and emotional difficulties, such as those related to Attention-Deficit/Hyperactivity Disorder (ADHD). ADHD is a chronic mental health disorder characterized by abnormally high levels of inattention and/or hyperactivity-impulsivity (American Psychiatric Association [APA], 1994). It is one of the most common behavior disorders of childhood, with a prevalence rate of 3% to 5% of the school-age population, occurring four to nine times more often in boys than in girls, depending on the sample (i.e., community or clinical population) (APA). Researchers and clinicians suggest this disorder has a profound and pervasive effect on many areas of the child(cid:146)s functioning, including performance and behavior in school, relationships with parents and siblings, and peer relationships (Barkley, 1997; Barkley, Anastopoulos, Guevremont, & Fletcher, 1992; Pelham, Wheeler, & Chronis, 1998). Thus, parenting children with ADHD often presents a considerable challenge. Many studies have focused on the manner in which the inattention, impulsivity, and overactivity commonly seen in children with ADHD is related to the way in which they interact with their parents and how parents respond to them. Evidence indicates that 1 not only are hyperactive children more negative and less compliant to parental instructions, but parents of ADHD children are also more negative, controlling, and disapproving (Barkley, Fischer, Edelbrock, & Smallish, 1991; Cunningham & Barkley, 1979; Gomez & Sanson, 1994). In addition, parents of children with behavior problems have demonstrated a lack of empathy, warmth, and involvement with their children (East, 1991; Pettit & Bates, 1989; Stormshak, Bierman, McMahon, & Lengua, 2000). Without these key parenting elements, the child(cid:146)s emotional development may be at risk. Thus, the purpose of this study was to examine the relationship between parental empathy and child adjustment factors in children with ADHD. This relationship would support the need for parent training interventions that emphasize the importance of enhancing parent relational skills, such as the expression of empathy. A review of the literature is presented, including the importance of parental empathy in child adjustment, an overview of ADHD diagnostic criteria, the relationship between parental attitudes and ADHD, and implications for interventions. Finally, the present study is discussed, outlining the statement of the problem, hypotheses, method, and results. Directions for future studies and treatment implications are also discussed. Parental Empathy and Child Adjustment (cid:147)The child that is to survive psychologically is born into an empathic-responsive human milieu just as he [sic] is born into an atmosphere that contains an optimal amount of oxygen if he is to survive physically(cid:148) (Kohut, 1977, p. 85). Comparing a child(cid:146)s need for empathy to his or her need for oxygen implies the crucial role of parental empathy in fostering healthy child psychological development. Likewise, Carl Rogers (1939), the 2