Journal for Specialists in Pediatric Nursing
ORIGINAL ARTICLE
A comparison of family adversity and family dysfunction in
families of children with attention deficit hyperactivity disorder
(ADHD) and families of children without ADHD
Marie Foley
Marie Foley, PhD, RN, is Associate Professor, Seton Hall University, College of Nursing, South Orange, New Jersey, USA
Search terms
ADHD, family adversity, family dysfunction,
nursing.
Author contact
marie.foley@shu.edu, with a copy to the Editor:
roxie.foster@UCDenver.edu
Acknowledgments
This study was funded in part by a grant to Marie
Foley from the Burrell Family Foundation of the
American Nurses Foundation.
First Received April 5, 2010; Revision received
September 13, 2010; Accepted for publication
September 25, 2010.
doi: 10.1111/j.1744-6155.2010.00269.x
Attention deficit hyperactivity disorder (ADHD)
is one of the most common behavioral disorders
diagnosed in children and adolescents. Individuals
who have this disorder have difficulty regulating
their emotions and activities, maintaining attention,
and controlling impulses. Although prevalence
varies among different communities and is depen-
dent upon the criteria used for diagnosis, national
estimates indicate an ADHD prevalence rate of
3–8% in children and adolescents (Pastor & Reuben,
2008, Pliszka & AACAP Work Group on Quality
Issues, 2007).
ADHD affects children’s functioning in all areas of
their environments due to difficulties with cognitive
effectiveness, behavioral control, and social interac-
tions with family, teachers, and peers (Antshel,
Macias, & Barkley, 2009). Secondary problems asso-
ciated with a diagnosis of ADHD include learning
difficulties, behavioral problems, lack of peer
acceptance, low self-esteem, and low self-efficacy,
Journal for Specialists in Pediatric Nursing 16 (2011) 39–49 © 2010, Wiley Periodicals, Inc.
jspn_269 39..49
Abstract
Purpose. This study examined the presence of family adversity and
family dysfunction in 32 families who had children diagnosed with
attention deficit hyperactivity disorder (ADHD) compared with 23 families
with similar sociodemographic characteristics whose children did not have
ADHD.
Design and Methods. A descriptive comparative design was used to
investigate family adversity and family dysfunction.
Results. Families of children with ADHD had significantly higher levels of
family dysfunction than families whose children did not have ADHD.
Practice Implications. Earlier identification and intervention with fami-
lies of children who have ADHD may result in healthier family and child
outcomes.
all leading to poor social and academic outcomes
(Antshel et al., 2009). Identified intrinsic factors,
including individual child temperament (Bussing,
Gary, & Mason, 2003; Foley, McClowry, & Castell-
anos, 2008) and genetics (Kebir, Tabbane, Sengupta,
& Joober, 2009), as well as extrinsic family environ-
mental factors (Biederman et al., 1995a; Copeland,
Shanahan, Costello, & Angold, 2009; Scahill et al.,
1999) have been identified as variables contributing
to an ADHD diagnosis.
Parents of children with ADHD report more
family dysfunction (Cunningham & Boyle, 2002)
along with family environmental adversity (Bieder-
man et al., 1995a; Copeland et al., 2009; Scahill
et al., 1999) than families of children without a
diagnosis. Family environmental risk factors that
have been consistently identified as predictors
of an ADHD diagnosis include low socioeconomic
level, foster care placement, large family size, mater-
nal history of psychiatric illness, and paternal
39
Family Adversity and Family Dysfunction in Families of Children with and without ADHD
criminality (Biederman et al., 1995a, 1995b; Cope-
land et al., 2009; Scahill et al., 1999). Family dys-
function in relation to communication, problem
solving, and relationships has been noted in families
with children who have a diagnosis of ADHD (Cun-
ningham & Boyle, 2002). While socioeconomic
status seems to universally mediate variables of
family dysfunction (Bradley & Corwyn, 2002), in
families with higher socioeconomic levels who have
children diagnosed with ADHD, levels of family dys-
function remain high (Sentse, Veenstra, Lindenberg,
Verhulst, & Ormel, 2009). The aim of this study was
to examine the presence of extrinsic family factors
and family dysfunction in families who have chil-
dren with a diagnosis of ADHD compared to those
who do not.
BACKGROUND
ADHD
In the United States, a diagnosis of ADHD is based on
the criteria cited in the fourth edition (text revision)
of the Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV-TR), which includes high activity,
inattention, impulsivity, and low task persistence
(American Psychiatric Association [APA], 2000).
According to the DSM-IV-TR, ADHD is defined
as “a persistent pattern of inattention and/or
hyperactivity–impulsivity that is more frequent and
severe than is typically observed in individuals at a
comparable level of development. . . . These mani-
festations occur in all facets of a child’s life and fre-
quently worsen in situations requiring sustained
attention” (American Psychiatric Association [APA],
2000, p. 85).
Manifestations of ADHD occur in all aspects of a
child’s and adolescent’s life. The DSM-IV-TR lists nine
behaviors associated with each of the inattention
and hyperactivity-impulsivity categories of ADHD.
Behaviors with the inattentive category include
failing to pay close attention to details or making
careless mistakes, having difficulty sustaining atten-
tion, not listening, not following through, having dif-
ficulty organizing, having low task persistence, losing
things, being easily distracted, and being forgetful.
Behaviors associated with the hyperactivity category
include fidgeting, being out of seat, running or climb-
ing excessively, being unable to play quietly, con-
stantly moving, and talking excessively; impulsivity
includes calling out answers, having difficulty
waiting in turn, and interrupting. A clinical diagnosis
includes the presence of six or more symptoms in
40
M. Foley
either of the two groups; symptoms must be present
before age 7 and problematic for at least 6 months;
inconsistent with development; and impairment
must be identified in two or more settings, including
social and academic functioning (American Psychiat-
ric Association [APA], 2000).
It is estimated that 44% of children with ADHD
have at least one comorbid condition (Antshel et al.,
2009; Barkley, 2006), and between 15 and 84% of
children who are diagnosed with ADHD have a
coexisting conduct disorder (CD) and/or oppositional
defiant disorder (ODD; Kieling, Goncalves, Tannock,
& Castellanos, 2008; Monastra, 2008; Pliszka &
AACAP Work Group on Quality Issues, 2007). These
comorbid conditions include mood disorders,
depression, anxiety, obsessive–compulsive disorder,
Tourette syndrome, pervasive developmental disor-
ders, and intellectual disability (Antshel et al., 2009;
Barkley, 2006; Kieling et al., 2008; Pliszka & AACAP
Work Group on Quality Issues, 2007). Undoubtedly,
parenting children with ADHD and other comorbid
disorders can be challenging for parents despite many
available resources.
Family characteristics
There has been ongoing interest in the importance
of assessing multiple domains of children’s environ-
ments as variables contributing to a diagnosis of
ADHD. A number of risk factors have been consis-
tently associated with family adversity and may be
predictive of a diagnosis of ADHD (Biederman et al.,
1995a; Copeland et al., 2009; Scahill et al., 1999).
Family adversity can be defined as risk factors or
stressors found in families causing some degree of
hardship. Rutter and Quinton’s (1977) seminal
work looking at indicators of adversity in two
diverse communities in Great Britain found that
an increase in the number of adversity indicators
increased the likelihood of child behavior problems.
These indicators included large family size, maternal
psychiatric illness, paternal criminality, marital
discord, and foster care placement. The researchers
found that when two or more indicators were
present in families, the risk of child behavior prob-
lems increased 2- to 4-fold (Rutter, Cox, Tupling,
Berger, & Yule, 1975). Examining Rutter’s Indicators
of Adversity along with socioeconomic status in
relation to ADHD, researchers found the odds of
being diagnosed with ADHD increased significantly
with each increase in the number of adversity indi-
cators. The factors with the strongest statistical
contribution related to an ADHD diagnosis were
Journal for Specialists in Pediatric Nursing 16 (2011) 39–49 © 2010, Wiley Periodicals, Inc.
M. Foley
maternal psychopathology and lower socioeco-
nomic status (Biederman et al., 1995a; Scahill et al.,
1999).
Family dysfunction has been defined as less than
optimal functioning in the areas of communication,
relationships, and problem solving within the family
unit (Kabacoff, Miller, Bishop, Epstein, & Keitner,
1990; Schroeder & Kelley, 2009). Family dysfunc-
tion has been noted to be higher in families who
have children with ADHD compared with control
families (Biederman et al., 1995a; Cunningham &
Boyle, 2002; Scahill et al., 1999). Families of chil-
dren with ADHD most commonly report dysfunc-
tion in the areas of relationship conflict and family
organization (Schroeder & Kelley, 2009).
Research has shown that higher socioeconomic
status supports more optimal levels of family
functioning. When parents have more available
resources, there tends to be more positive parenting
strategies (Mistry, Vandewater, Huston, & McLoyd,
2002), leading to a more positive family environ-
ment and less conflict (Copeland et al., 2009; Cos-
tello, Compton, Keeler, & Angold, 2003). Parents
with higher levels of income can manage difficult
behavior using more supportive strategies rather
than using harsh punishments or adopting coercive
parenting practices. They tend to communicate
more with their children and discuss consequences
of rebelliousness and inappropriate behaviors
(Pinderhughes, Dodge, Bates, Pettit, & Zelli, 2000).
Furthermore, studies have shown that higher
socioeconomic status seems to be protective of
childhood and adolescent psychopathology (Cope-
land et al., 2009; Costello et al., 2003; Mistry et al.,
2002). In families with higher socioeconomic
levels, there are also fewer indicators of adversity
(Rutter, 2009). However, Cunningham and Boyle
(2002) found significantly poorer family function-
ing on the General Functioning Subscale of the
Family Assessment Device (FAD) in middle-class
families with preschool children having symptoms
of ADHD, but no significant difference between
the at-risk and control group in relation to levels of
adversity.
As noted above, secondary problems associated
with ADHD can lead to poor outcomes in all areas
of functioning, including academic underachieve-
ment, difficulties in social arenas, associated risk-
taking behaviors, depression, and family disruption
(Sentse et al., 2009). Indisputably, children diag-
nosed with ADHD are more challenging to parent,
and these families often experience disruption and
discord in the family relationships. Therefore, it
Journal for Specialists in Pediatric Nursing 16 (2011) 39–49 © 2010, Wiley Periodicals, Inc.
Family Adversity and Family Dysfunction in Families of Children with and without ADHD
would be helpful for pediatric and school nurses
working with families who have children with a
diagnosis of ADHD to know whether or not these
families tend to have a high rate of family dysfunc-
tion and therefore need supportive interventions to
prevent child and family decline.
PURPOSE
The purpose of this study was to examine the pres-
ence of family adversity and family dysfunction in
families who had children diagnosed with ADHD
compared with those who did not. This study was
part of a larger study that looked at both the intrin-
sic, individual child characteristics, including child
temperament, as well as extrinsic family factors
and family dysfunction noted in children who are
diagnosed with ADHD. The findings related to the
extrinsic family factors, including family dysfunc-
tion will be discussed here. The following questions
were explored in this study: Is the level of family
adversity higher in families who have a child diag-
nosed with ADHD compared with those who do
not? Do families who have a child diagnosed with
ADHD have greater levels of family dysfunction
than families who do not have a child diagnosed
with ADHD?
DESIGN AND METHODS
A descriptive comparative design was used to investi-
gate the variables of family adversity (socioeconomic
status, large family size, paternal criminality, history
of maternal mental disorder, foster-care placement)
and family dysfunction (less than optimal function-
ing related to communication, relationships, and
problem solving) and the diagnosis of ADHD. A con-
venience sample of 55 children (36 boys and 19 girls)
between the ages of 6 and 11 years (M = 8.71, SD =
1.67) and their primary caregivers (52 biological
mothers, 3 adoptive mothers, and 2 biological
fathers) was used for data collection. The sample
included White (78.2%), African American (16.4%),
Hispanic or Latino (3.6%), and Asian (1.8%) chil-
dren. Table 1 summarizes the age, sex, and race of the
participants by sample group. The majority of the
parents in both the ADHD (78.1%; n = 25) and com-
parison (91.3%; n = 21) samples were married. In the
comparison sample, 8.7% (n = 2) were separated,
while in the ADHD sample, 12.5% (n = 4) were
divorced, 6.3% (n = 2) were separated, and 3.1% (n =
1) were single, never married.
41
Family Adversity and Family Dysfunction in Families of Children with and without ADHD
Table 1. Age, Gender, and Race of Participants
Comparison Group ADHD Group
Children’s age
Range 6–11 years 6–11 years
Mean 8.87 years 8.59 years
Standard deviation 1.66 1.68
Children’s sex
Female 53% (n = 12) 22% (n = 7)
Male 48% (n = 11) 78% (n = 25)
Children’s race
White 82.6% (n = 19) 75.0% (n = 24)
African American 13.0% (n = 3) 18.8% (n = 6)
Hispanic 4.3% (n = 1) 3.1% (n = 1)
Asian 0 3.1% (n = 1)
ADHD, attention deficit hyperactivity disorder.
The ADHD group consisted of 32 children with
ADHD who were referred to a developmental neu-
rology clinic at a large university children’s hospital
for problems associated with the symptoms of
ADHD. A comparison group of 23 children in the
community was attained during the time of a
normal well-child visit at a pediatric clinic associated
with the same university hospital. Inclusion criteria
included a signed consent of the participating
parent-informant, assent of the child being studied,
and the parent’s ability to speak and read English.
Children with a known psychiatric disorder or
any comorbid disorders were excluded from the
study.
Data collection
Approval for the study was obtained from the hospi-
tal and university institutional review boards. Addi-
tionally, permission for recruitment was obtained
from the pediatric neurologists, the pediatricians,
the nursing staff, and the chairperson of the depart-
ment of pediatrics at the hospital. Data collection
occurred in two phases. After parental consent
forms and child assents were obtained, the family
was given a packet containing a demographic and
family assessment sheet, the General Functioning
Subscale of McMaster Family Assessment Device
(Byles, Byrne, Boyle, & Offord, 1988), and the
Revised Conners’ Parent Rating Scale (Conners,
Sitarenios, Parker, & Epstein, 1998). Parents were
requested to complete the questionnaires and return
them to the researcher using a stamped self-
addressed envelope. The second phase of the data
collection consisted of an interview using the
Diagnostic Interview Schedule for Children-
ADHD module (Shaffer, Fisher, Lucas, Dulcan, &
42
M. Foley
Schwab-Stone, 2000). Parents could choose to be
interviewed wherever it was convenient for the
family—at their home, at the clinic, at another des-
ignated site, or via telephone. After data collection
was completed, each participating parent and child
dyad received a movie theater gift card as an hono-
rarium for their time.
Instruments
ADHD was assessed using two instruments: the
Revised Conners’ Parent Rating Scale Question-
naire, Short Form (CPRS-R:S; Conners et al., 1998)
and the ADHD module of the Diagnostic Interview
for Children (DISC; Shaffer et al., 2000). The
27-item CPRS-R:S is a 4-point Likert-type scale
(rated as 0 = not at all to 3 = very much) that takes 10
minutes to complete and yields four mutually exclu-
sive scales defined by factor analysis: The Opposi-
tional Scale, The Cognitive Problems/Inattention
Scale, the Hyperactivity Scale, and the ADHD Index.
The items from the CPRS-R:S contain the most
clinically useful factor-derived subscales of the
longer form, the CPRS-R:L. Conners et al. (1998)
reported that alphas ranged between .86 and .94
across all scales. Six-week test–retest correlations
were between .62 and .85. In this study, Cronbach’s
alphas ranged from .88 to .96.
The DISC, based on the DSM, was developed
through epidemiological studies (Shaffer et al.,
2000) to screen for common psychiatric disorders
in children. The complete DISC assesses more than
30 psychiatric diagnoses in 6 diagnostic modules
(anxiety disorders, mood disorders, disruptive disor-
ders, substance-use disorders, schizophrenia, and
miscellaneous disorders); all of the modules can be
used separately. The tool was designed to be used in
research to assess inclusion or exclusion criteria, but
it can be used in clinical settings as an adjunct to
usual clinical diagnosis. This study used the parent
interview module for disruptive disorders to assess
ADHD, which took about 30 minutes to administer.
Questions in the interview were highly structured,
and response options were limited to yes, no, and
sometimes. Validity of the ADHD module on a sample
of 247 subjects was reported as a kappa statistic of
.72. Test–retest reliability was reported as a kappa
statistic of .79 (Shaffer et al., 2000). In this study,
Cronbach’s alpha was .73.
To determine the level of family adversity, a ques-
tionnaire was developed based on Rutter’s indica-
tors of adversity (Rutter & Quinton, 1977). Rutter
described indicators of adversity as family size,
Journal for Specialists in Pediatric Nursing 16 (2011) 39–49 © 2010, Wiley Periodicals, Inc.
M. Foley
history of paternal criminality, history of maternal
mental disorder, socioeconomic status, and foster
care placement; however, a tool was never devel-
oped to assess these indicators. To assess these indi-
cators in this study, a questionnaire was developed
based on questionnaires used in prior studies (Bied-
erman et al., 1995a; Scahill et al., 1999; Szatmari,
Offord, & Boyle, 1989) to determine the following
variables: large family size, paternal criminality,
maternal mental disorder, foster care placement,
and socioeconomic status.
The questionnaire developed for this study con-
sisted of both open-ended questions and questions
requiring a yes or no answer. Examples of the
dichotomous questions include: Has the child’s
father ever been in jail? Does the child’s father have
a criminal record other than traffic violations? Has
the child’s mother ever been treated for a psychiatric
illness, either with medication or therapy? Is the
child currently, or has he or she ever been in foster
care? The following open-ended question was also
asked: How many children live in your household?
Large family size was defined as four or more chil-
dren living in the household (Biederman et al.,
1995a; Rutter & Quinton, 1977; Scahill et al., 1999).
Traditional SES measures include occupation,
education, and income (Hauser, 1994; Shavers,
2007). Because of the role occupation plays in posi-
tioning individuals within the social structure, it is
often used as an indicator of SES in health research.
Education is perhaps the most widely used measure
of SES. Maternal education is particularly important
in studies of child development (Hauser, 1994;
Shavers, 2007). In this study, socioeconomic status
was based on maternal education and the occupa-
tion of the major family wage earner.
Family dysfunction was measured using the
General Functioning subscale of the McMaster
Device FAD (Byles et al., 1988). The 12-item self-
report instrument was developed to measure overall
family functioning, and takes about 10 minutes to
complete. Items were scored from 1 to 4 (strongly
agree to strongly disagree). Reliabilities on the General
Functioning Scale ranged from .83 to .86 (Kabacoff
et al., 1990). Cronbach’s alpha was .93 in this study.
RESULTS
Preliminary analyses were conducted to determine
any demographic differences between the children.
Chi-square was used to compare the children
regarding sex. The ADHD group had significantly
more males, c2 (1, n = 55) = 5.43, p = .02, as would
Journal for Specialists in Pediatric Nursing 16 (2011) 39–49 © 2010, Wiley Periodicals, Inc.
Family Adversity and Family Dysfunction in Families of Children with and without ADHD
be expected, given that males are diagnosed two to
three times more frequently than females (Barkley,
2006). An independent t test analysis revealed no
significant differences in children’s age between the
ADHD group (M = 8.59, SD = 1.68) and the compari-
son group (M = 8.87, SD = 1.66), t (53) = -.60, p = .55
(two-tailed). In the ADHD group, all of the children
screened positive on the DISC for ADHD. Nineteen
percent (n = 6) were identified as inattentive, 3%
(n = 1) were classified as hyperactive/impulsive, and
78% (n = 25) were identified as combined. In the
comparison group, three children were identified as
ADHD on the DISC. One child (4.3%) was identified
as hyperactive/impulsive and two children (8.7%)
were identified as combined subtype.
As stated earlier, socioeconomic status was evalu-
ated based on maternal education and the occupa-
tion of the major family wage earner. Education
levels of the mothers varied from those with a
graduate equivalent degree (GED) to those with
graduate education. Table 2 summarizes the educa-
tional level of the mothers. Occupation of the
major wage earner was defined as unskilled laborer
(security guard, sales clerk, laborer) and semi-
professional (skilled workman, secretary, police
officer)/professional (doctor, lawyer, nurse, engi-
neer). In the comparison group, 13% (n = 3) classi-
fied the major wage earner as unskilled and 86%
(n = 20) as semi-professional or professional. In the
ADHD group, 21.8% (n = 7) classified the major
wage earner as unskilled and 79% (n = 21) as
semi-professional/professional. Maternal education
was collapsed to two levels to preserve degrees of
freedom in a small sample: (a) those with a GED,
graduated high school, and attended some college or
specialized training and (b) those with an under-
graduate college degree (bachelor’s or associate) or
graduate degree. No significant differences for level
of maternal education were found between the
two groups, c2 (1, n = 55) = .001, p = NS. The occupa-
tion of the major wage earners in both the ADHD
and control groups were predominantly either
Table 2. Level of Maternal Education of Study Participants
Maternal Education Comparison Group ADHD Group
GED 0% 3.1% (n = 1)
HS graduate 13.0% (n = 3) 21.9% (n = 7)
Partial college or training 17.4% (n = 4) 9.4% (n = 3)
College graduate 47.8% (n = 11) 37.5% (n = 12)
Graduate degree 21.7% (n = 5) 28.1% (n = 9)
ADHD, attention deficit hyperactivity disorder; GED, general equiva-
lency degree; HS, high school.
43
Family Adversity and Family Dysfunction in Families of Children with and without ADHD
semi-professional or professional, and likewise, no
significant differences for occupation of the major
wage earner were found between the two groups,
c2 (1, n = 55) = .001, p = NS.
Research question no. 1
To assess the level of family adversity, Rutter’s
indicators of adversity were used. These variables
include family size (more than four children living in
a household), history of paternal criminality, history
of maternal mental disorder, socioeconomic status,
and foster care placement (Rutter & Quinton, 1977).
Rutter’s indicators of adversity by sample group are
depicted in Table 3. A number of steps were taken to
derive a score that was a composite of indicators of
adversity. A score of 1 was given to families on each
indicator if they had a history of paternal criminality,
maternal psychiatric disorder, and foster care. If the
family did not have a history of these indicators, a 0
score was assigned to each indicator. Families with
four or more children were given scores of 1, and
families with three or fewer children living in the
household were given scores of 0. Families where
maternal education equaled a high school diploma,
graduate equivalent degree, or less, and whose
primary wage earner was recorded as unskilled,
were assigned a score of 1. Families with maternal
education levels of college attendance through
graduate degrees and whose primary wage earner
was recorded as semi-professional or professional
were assigned scores of 0. These indicator scores
were then summed. Scores ranged from 0 to 3.0,
with a mean score of .89 (SD = .90, n = 55) for both
groups (.97 ADHD, .78 control). A t-test showed that
the composite scores of Rutter’s indicators of adver-
sity were not significantly different between the two
groups (M = .97, .78, t (.757), p = .452).
Table 3. Rutter’s Indicators of Adversity
Comparison
Indicators Group ADHD Group
Children living in the home
<4 82.6% (n = 19) 100% (n = 32)
>4 17.4% (n = 4) 0%
Paternal incarceration 0% 0%
Maternal psychiatric illness
No 87.0% (n = 20) 81.3% (n = 26)
Yes 13.0% (n = 3) 18.8% (n = 6)
Foster care placement
No 95.7% (n = 22) 93.8% (n = 30)
Yes 4.3% (n = 1) 6.3% (n = 2)
ADHD, attention deficit hyperactivity disorder.
44
M. Foley
Research question no. 2
Family dysfunction was calculated using the General
Functioning Subscale of the McMaster FAD (Byles
et al., 1988). Scores range from 1 (healthy) to 4
(unhealthy). There were only .27 points separating
the mean scores between the two groups; however,
t-test results indicated that family functioning was
significantly different between the comparison fami-
lies (M = 1.96, SD = .23), t (53) = 3.43, p = .001, and
the ADHD families (M = 2.23, SD = .35). Families in
the ADHD group were less healthy than those in the
comparison group.
DISCUSSION
This study sought to examine the level of family
adversity and family dysfunction in families of
children diagnosed with ADHD as compared with
families of children without a diagnosis of ADHD.
Although much research has shown that children
with ADHD tend to live in families with high levels
of adversity (Biederman, 2005; Counts, Nigg, Staw-
icki, Rappley, & von Eye, 2005; Efron, 2006; Laucht
et al., 2007), there is some evidence that socioeco-
nomic status is protective of indicators of adversity
(Copeland et al., 2009; Costello et al., 2003; Mistry
et al., 2002). Evidence also shows that while most
indicators of adversity may not be problematic for
children with ADHD living in middle-class families,
family dysfunction remains a problem (Cunning-
ham & Boyle, 2002). The participants in this study
were primarily White, middle-class children, and
there were no significant differences in levels of
adversity. However, the parents of children in the
ADHD group reported significantly higher levels of
family dysfunction.
What this study does elucidate is that socioeco-
nomic status is not protective of family dysfunction.
Despite a mostly middle-class composition, the chil-
dren diagnosed with ADHD lived in homes with
poorer family functioning than did those in the com-
parison group. The results suggest that parents of
children with a diagnosis of ADHD have more
difficulties maintaining family organization and
cohesiveness regardless of available resources and
economic status. It has been shown that dysfunction
can be exacerbated when the parent also has ADHD,
in which case maintaining family organization
and cohesiveness is even more challenging. In fami-
lies where a parent has ADHD, there is greater
divergence between parental decision-making,
less family structure and support, and less communi-
Journal for Specialists in Pediatric Nursing 16 (2011) 39–49 © 2010, Wiley Periodicals, Inc.
M. Foley
cation, sensitivity, and connection (Biederman,
Faraone, & Monuteaus, 2002; Biederman et al.,
1995a; Lange, Sheerin, & Carr, 2005; Pressman
et al., 2006).
While much research has shown that genetics
is a key variable in understanding the emergence
of ADHD symptoms (Faraone et al., 2005; Mick
& Faraone, 2008; Thapar, Langley, Owen, &
O’Donovan, 2007), researchers also stress the
importance environmental factors play in deter-
mining outcomes for children with ADHD, even if
they are not a primary cause of the behaviors. The
results of this study are consistent with those of
Cunningham and Boyle (2002), who also found
that family dysfunction in middle-class families
was a salient factor in the risk for a diagnosis of
ADHD. Not only does family dysfunction affect the
family unit as a whole, but it can have a profound
effect on the child with ADHD (Pagani, Japel, Vail-
lancourt, Côté, & Tremblay, 2008). Therefore, prac-
titioners need to pay close attention to risk factors,
including genetics, child characteristics, and family
functioning to better understand variability in the
trajectories of developmental outcomes for chil-
dren with ADHD.
There is a growing body of literature showing
that positive parenting styles, using appropriate limit
setting, as well as warmth, kindness, and expressive-
ness is associated with children’s level of attention,
self-regulation (Eisenberg et al., 2005), and behav-
ior problems (Bradley & Corwyn, 2005). Parents of
children with ADHD display more directive and
commanding behavior, more disapproval, fewer
rewards, and overall negative behavior (Hinshaw,
Owens, & Wells, 2000; Keown & Woodward, 2002).
Family environment and parenting skills have been
shown to affect the development of children’s abili-
ties related to behavioral self-control, regulation,
and organization (Frick & Morris, 2004; McCarty,
Zimmerman, Diguiseppe, & Christakis, 2005). Fur-
thermore, higher levels of parental conflict related
to decision-making, and less family structure and
support are related to externalizing problems,
including ADHD (Crowley & Kazdin, 1998; Pruett,
Williams, Insabella, & Little, 2003). A study by the
National Institute of Child Health and Human
Development Early Child Care Research Network
Taskforce (2005) also found that the family environ-
ment was related to attention and memory:
unhealthy environments decreased attention and
memory. Nonsupportive parenting styles and family
dysfunction can lead to less than optimal child and
family outcomes.
Journal for Specialists in Pediatric Nursing 16 (2011) 39–49 © 2010, Wiley Periodicals, Inc.
Family Adversity and Family Dysfunction in Families of Children with and without ADHD
Research examining family functioning in fami-
lies who have children with ADHD demonstrates
that in addition to high levels of dysfunction, there
are fewer intact marriages (Cohen, Adler, Kaplan,
Pelcovitz, & Mandel, 2002; Heckel, Clarke, Barry,
McCarthy, & Selikowitz, 2009). Although not
examined in this study, there is also support in the
literature to suggest that this increase in marital
discord correlates with greater symptom severity in
children with ADHD (Burt, Krueger, McGue, &
Iacono, 2003; Heckel et al., 2009; Hurtig et al.,
2007; Taylor & Warner-Rogers, 2005) and more
difficulties with social functioning (Heckel et al.,
2009). Clearly, the challenges experienced by
parents raising children with ADHD extend beyond
the symptoms of ADHD alone. Evidence shows
that families with children diagnosed with ADHD
do exhibit significantly more symptoms of dysfunc-
tion, and that dysfunction translates into more
severe symptoms in the child.
The findings from this study raise questions
for future research in relation to strategies and
resources needed by families of all socioeconomic
levels to assist them in parenting their children with
ADHD and minimize the amount of dysfunction
experienced by the family as a whole. While the lit-
erature supports the relationship between ADHD
and family adversity in families of lower socioeco-
nomic levels, in this study of mainly middle-class
families, family adversity was not different between
the groups. However, while family dysfunction
was higher in the families of children with ADHD,
what was unclear was whether family variables con-
tributed to increased symptoms in children, or if
the reverse was true; the child’s behaviors lead to
increased levels of family dysfunction. Furthermore,
since ADHD does have a genetic component, it
would also be important to note whether or not
the parent(s) also have ADHD, which would lead to
more difficulties in family functioning.
Limitations
Limitations of this study include small sample size
and absence of tools to measure maternal mental
disorder, including anxiety, depression, and ADHD.
The ADHD group had significantly more males, c2
(1, n = 55) = 5.43, p = .02 than the control group, as
would be expected, given that males are diagnosed 2
to 3 times more frequently than females (Barkley,
2006). However, a larger sample size would have
allowed for a closer match between groups.
45
Family Adversity and Family Dysfunction in Families of Children with and without ADHD
It would have also been beneficial to use the entire
FAD, and not just the general functioning subscale.
While the general functioning subscale measures
overall family functioning, there are six other sub-
scales on the FAD that look at specific dimensions of
family functioning, including problem solving, com-
munication, roles, affective responsiveness, affective
involvement, and behavior control. A larger sample
would have allowed a better comparison among the
individual Indicators of Adversity between groups
using advanced multivariate statistical techniques;
and assessing maternal mental health and parental
diagnosis of ADHD more objectively and compre-
hensively may show associations between these
variables and family dysfunction. And lastly, using
the entire McMaster FAD and not only the general
functioning subscale would have given a more
precise picture of specific areas of family dysfunc-
tion. Since this study was a part of a larger study also
looking at individual child characteristics associated
with a diagnosis of ADHD, the researcher did not
want to inundate families with too many surveys
while still examining the major extrinsic variables
associated with a diagnosis of ADHD. A replication of
the study with a larger sample and attention to these
limitations is recommended.
How Do I Apply This Evidence to Nursing Practice?
From a clinical perspective, the results of this study
emphasize that all families, including families of
greater economic means, experience significant
family dysfunction and challenges in raising their
children with ADHD. Upon detection and diagnosis
of ADHD, parents need to be educated regarding the
role of dysfunction a child and family may experi-
ence, and the need for supportive services for not
only the child but the family as well. Comprehen-
sive intervention strategies to support these families
include mental health care, anger management
classes, social skills training, parenting classes,
behavioral management techniques, family inter-
vention strategies, family and marital therapy, and
support groups. Assistance by members of the com-
munity including teachers, coaches, and others to
advocate for the child and family is necessary
(Kendall & Shelton, 2003).
School and pediatric nurses working with chil-
dren and their families in schools, the community,
and primary and acute care settings need to be cog-
nizant of difficulties experienced by these families
and consider genetic, child, and family factors
46
M. Foley
when planning interventions for children and families.
Nurses need to encourage parents to act as advocates for
their children and families and to communicate to nurses
and other health professionals the challenges they may
be experiencing at home, which may assist in making
referrals for services and support to achieve optimal out-
comes for children with ADHD and their families.
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