"The Impact of a Child with Attention Deficit Hyperactivity Disorder (ADHD) on Parents"

Thesis of Graduation, Undergraduate, By Sothy Eng (2002), Royal University of Phnom Penh, Cambodia, Unpublished.

Abstract:

Objective: To investigate the impact of having children with Attention Deficit Hyperactivity Disorder (ADHD) on their parents by researching the most common stress symptoms present in a sample population of parents with diagnosed ADHD children. Method: Sixteen families, 1 father (6.3%) and 15 mothers (93.8%) of 16 children with ADHD attending an outpatient clinic at Chey Chum Neas Hospital, Center for Child Mental Health (CCMH), Takhmao, Cambodia, completed questionnaires, Brief Symptoms Questionnaire, measuring the symptoms of physical, anxiety, depressive, occupational and social problems. The children have already been diagnosed by a child psychiatrist as having ADHD by using the ADHD Rating Scale (DuPaul, 1991), a 14-item instrument with 4 point rating scale. Results: Anxiety symptoms were significantly the highest affecting parents of ADHD children. Those parents also identified some problems with their occupations, but they were not momentous. Depressive symptoms tended to be the lowest recognized stress by parents. Similarly, physical and social stresses were less recognized by the parents as significant impacts. Conclusion: The psychological well being of parents who have children with ADHD is at risk, especially in the areas of anxiety disorders. Therefore, greater efforts and interventions should be focused on parents of ADHD children in order to help reduce anxiety symptoms during treatment sessions. Key Words: attention deficit hyperactivity disorder, anxiety, depression, social interacted isolation, family dysfunction.

I- Introduction


Although Cambodia is known for its ancient civilizations, today Cambodia is a young nation with more than 40% of its population below 18 years of age (National Census, 1998). There are many difficulties facing school age children, hindering their chances of getting a good education and daily living. An increasingly recognized obstacle is mental health. Studies both in developed and developing nations reveal 10% to 15% of children suffer from mental health problems (CCMH, 2001). About 3% to 5% of school age children may suffer from Attention Deficit Hyperactivity Disorder (ADHD) (DSM-IV, 1994). Awareness of this problem is growing in Cambodia according to the clinical experiences.

Over the past two decades, ADHD has been focused on extensively by a large number of researchers in the United States and in other European countries. In addition to young children, the number of adolescents and adults with this disorder have grown, helping researchers record new insights (Wiener, 1999).

Unfortunately it is very different in Cambodia. Not much has been researched related to ADHD in Cambodia due to Cambodia’s experiences over the last 25 years. The genocidal era during the Pol Pot regime and the civil war that followed destroyed whole structures in society as well as killed most of the educated class of Cambodian people. The last two decades have seen small steps and efforts to rebuilding basic infrastructure in the country as well institutions of learning and research. The Center for Child Mental Health is the only place in the country that is treating children with psychiatric disorders and it has only been running for five years. It is safe to say that most of the Cambodian people in the city as well as in the countryside still do not know or have a clear understanding about different kinds of mental health problems.

Psychologists refer to ADHD in terms of difficulties related to restlessness and inattentiveness (and sometimes impulsiveness as well)” (page, 50) (Goodman & Scott, 1997). As is already known from the literature, ADHD is a behavioral disorder commonly affecting school age children and it is not uncommon for those children to experience peer rejection because they do not have an ability to pay attention and even sit still in one place (JAACAP, 2000). If this disorder remains untreated, some ADHD children may face new problems as an adolescent and/or as an adult such as conduct problems, drug abuse, and antisocial behavior (JAACAP, 2000).

Interestingly, most Cambodian people just ignore children who present mental health problems, particularly ADHD. They may even see this disorder as normal behavior in children noting waking up a lot at night and very high levels of energy and activity. However, the parents who bring their children to treatment sessions have definite concerns for the well being of their children and often express difficulties in their families.

It is believed that the parents of these children do indeed experience concern due to the distractibility, hyperactivity, impulsivity, and inattention of their children. There is evidence from Rabiner (2000) who works with children with ADHD and their parents that “the level of stress that many families seemed to experience was strikingly” and “the daily life with an ADHD child could be so filled with struggle that all of the parents’ time and energy was devoted to discipline and making sure that certain important things got done.”

This research study was chosen in order to add to the understanding of the characteristics of children with ADHD and to find out more about the effects of this disorder on their parents in Cambodia. Additionally, and, perhaps more importantly, after identifying those effects, it may point to possible intervention efforts that can be aimed at reducing stress among the parents of ADHD children. As DuPaul et al. (2001) recommended, “Screening for ADHD among young children with behavior difficulties may be important not only for the identification of this disorder but also to promote evaluation of associated problems such as poor social behavior, parental stress, and family coping difficulties.” Thus based on what is known concerning stress created in families with (ADHD) children, this proposed research will assess the impact those children have on their parents.

The following is a case documented in Cambodia describing the characteristics of a child with ADHD and the difficulties of the parents. It was one that inspired my thoughts on the issue and my desire to learn more.


BT, a 5 year-old boy, the first one in two siblings, comes from a non-consanguineous marriage. He was brought by his mother from Phnom Penh. His mother complained that he is hyperactive, has unclear speech, and often throws things after playing. All of the above symptoms have occurred for 2 years now. The ADHD Rating Scale (DuPaul, 1991) showed high levels in the areas of: difficulty in remaining seated, difficulty awaiting turn in groups, often shifts from one uncompleted activity to another, difficulty playing quietly, often talks excessively and often engages in physically dangerous activities without considering consequences. The parent rating scored 21 on the Inattention-Hyperactivity and 19 on Impulsive-Hyperactivity. These scores clearly mark a disorder. In addition, the child shows other symptoms, particularly oppositional and defiant behaviors. It may be that the child has had another co-morbid disorder (Oppositional Defiant Disorder). He is now being prescribed the anti-psychotic drugs (Haldol1.5mg), which helped to reduce BT’ s hyperactivity level. Behavior modification and parent training are being done by the clinical psychologists. Now he is integrated in a kindergarten in order to make him socialize with other preschoolers and to bring down his behavior problems. BT’ s mother clearly feels that her family has become dysfunction and more stressful. She cannot continue her small business at home and even visits her relatives or friends because her child still behaves the same as before.


II- Review of Relevant Concepts

A- ADHD in Children

Some behaviors that the parents often consider as symptoms of ADHD in their children include sleep disturbances, talking too much, excessive running around, like making other children cry, playing a lot, etc. Professionals in psychiatry and psychology define it in a different way. The first definition that has been given by Laufer, a child psychiatrist and Denhoff, a pediatrician neurologist (Laufer & Denhoff, 1957), is as follows:


Hyperactivity, short attention span and poor powers of concentration, variability in performance and behavior, impulsiveness and inability to delay satisfaction, irritability, explosiveness, and poor schoolwork. School difficulties were noticed as an outcome of the conduct disturbances as well as a complex of problems in the Visio-motor perception and concentration areas (p 464).

According to the Diagnostic and Statistical Manual of Mental Disorders, there are many symptoms organized into a list of criteria used to diagnose ADHD. Symptoms may include problems related to either inattention and/or hyperactivity-impulsivity. Symptoms must start before the age of 7 and be observed for at least six months. They must also be linked to significant academic or occupational difficulties. (See appendix 2, Diagnostic Criteria).

The causes of this disorder are not clearly known (Kaplan et al. 1994; Wiener, 1999) and there are likely multiple causes. According to Hales & Hales, (1995), 40% of ADHD cases are genetic. It appears that the children will be at risk for this disorder if they have relatives or close family members with ADHD (Kaplan et al. 1994). However, the culprit gene has not yet been clearly identified, thus providing an area for researchers to continue to explore. A strong link has also been made to traumatic brain injury in children and even older youth. Max et al., (1998) found that Attention Deficit Hyperactivity Symptomatology occurred within 2 years following a traumatic brain injury and was positively diagnosed at follow-up sessions. Additionally, psychosocial factors are also known to contribute to an ADHD diagnosis (for example, children raised in institutions, instability in the family, marital discords and separation, low socio-economic status, dysfunctional parenting). A study in a large community sample, Szatmari et al, (1989c) found that “youngsters with diagnosed ADHD were nearly twice as likely to come from a single-parent household, 1.5 times more likely to live in an urban area, and greater than 3 times more likely to be receiving public assistance.”

The rate of associated disorders in children with ADHD is quite high and often inevitable. A study done by Zarin et al., (1998) using a clinical sample found that 69% of the cases were associated with comorbid psychiatric disorders (oppositional defiant disorder and conduct disorder, 31%; mood disorder, 20%; anxiety disorder, 10%; learning disorder, 7%; and mental retardation, 5%) and the rest were cases of pure ADHD, 31%. Some areas of study such as comorbidity of ADHD with mental retardation (MR) are relatively new (Aman et al, 1991). A report from the Centers for Disease Control and Prevention (CDCP) in the US in 1997-98 stated, “one-half of the 1.6 million school-aged children diagnosed with AD/HD have been identified with an accompanying learning disability” (CHADD, 2002). Interestingly, comorbid disorders in boys and girls seemed to be statistically similar (girls 69%, boys 71%) (Sharp et al, 1999).

Epidemiological surveys over the years have produced varying reports due to the use of very different samples, methods and biases in making diagnoses (Wiener, 1999). Different countries often report different rates of prevalence. The American Psychiatric Association (1994) estimates that 3% to 5% of the school age children in the United States are affected by ADHD, especially those children already under psychiatric treatment. However, a study reported by Milberger et al (1995) found that 6% to 9% of school age children are affected. Statistics in Great Britain report that less than one percent of children there are affected by ADHD (Kaplan et al, 1994). In contrast, rates in Hong Kong reach 3 times that of children in Great Britain (Luk & Leung, 1989). Interestingly, in one study, boys were found to be more affected than girls with the ratio anywhere between 2.5-5.6 boys to every one girl (Wiener, 1999). In contrast, an epidemiological study conducted by Wendy et al. (1999) using a clinical sample found that there was not a significant difference between boys and girls, a reported ratio of 2.1 boys to every girl.

Even though this disorder affects many children in the world, treatments and behavior management techniques for these children are available. ADHD can be treated by psychopharmacologic medications, for example, methylphenidate or dextroamphetamine. Individual and family psychotherapy and educational interventions can also be helpful options (JAACAP, 1997). Of those management techniques, family intervention has become a big area of research. Sonuga-Barke et al. (2001), conducted a research study on the parent-based therapies. They looked explicitly at effective interventions with the parents of children with ADHD. Rather than providing counseling or support groups, they found that taking time to train parents how to deal with their ADHD children significantly improved their child’s behavior problems and increased the parents’ ability to cope with the ADHD. Psychotherapy for the children themselves can be helpful, however, there have not been any controlled trials of psychodynamic psychotherapy. One research study investigated by Fonagy & Target, (1994) showed that insight-oriented psychotherapy for children with disruptive behavior problems was not so helpful but could be helpful for those children with significant emotional problems.


B- The Impact on Parents:

Researchers throughout the world have been looking at the correlation between symptoms exhibited by children with ADHD and the stress that those symptoms place both on their parents and other family members (Kaplan et al., 1998; Anastopoulos et al., 1992; DuPual et al, 2001; Mash & Jonhston, 1983; Pololski & Nigg, 2001, etc.). However, no studies have yet been done regarding that correlation in Cambodia. Thus, the results from this study may be different from what has been documented in most journals and reports. This idea may especially be new for Cambodians working in the psychiatric field.

Anastopoulos et al. (1992) investigated what kinds of factors related to different types of stress affected parents. They found that “child and parent characteristics, more so than family-environment circumstances, are associated with the higher levels of parenting stress that are commonly found among ADHD populations” (page 517). Commonly experienced lack of social support from within and outside the family (Mulsow & Murry, 2001), negative communication, intense anger (Brochin & Horvath, 1996), parental coping difficulties (Pololski & Nigg, 2001) compound stress levels. Moreover, a negative self-image, low self-esteem, and feelings of depression, anxiety, fatigue, and isolation are often manifested in the mothers of aggressive boys (Patterson, 1980).

There is another research study by Kaplan et al. (1998) which investigated the feelings of the parents of children with ADHD in daily living within families. In comparing parents of ADHD children with those of children with primarily academic difficulties, parents who have children with ADHD were much more frustrated and dissatisfied with family life than were the mothers of the other children. This result was also consistent with current research by Pololski & Nigg (2001) showing that more stress and discouragement were described by mothers of children with ADHD than by those of other children. Family dysfunction was also showed more strongly allied with ADHD than the control group. A research study conducted by Mash & Johnston, (1983) found that parents reported a very low self-esteem and a lot of stress. They perceived their children as more problematic than other children.

The impact of this disorder on families, individuals, schools, and society has also been discussed in a conference organized by the National Institute of Health (NIH) in the United States on a topic of “Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder (ADHD)” (JAACAP, 2000). The conference agreed that:

The impact of ADHD on individuals, families, schools, and society is profound and necessitates immediate attention (page, 187).

Although there has been much growth in research findings, we still do not know specifically which problems most commonly affect those parents. And there is little, if any, research that has been conducted to find the paternal psychopathological symptoms. Most of the research focuses on levels of stress and the dysfunction in the families rather than identifying the specific kinds of stress that many families have experienced (For example, DuPaul, et al. 2001; Kaplan et al. 1998; Anastopoulos et al. 1992; etc.). Additionally, as Steward et al. (1979) said, “the specificity of the association with ADHD was left in doubt.” So, this study will attempt to make a link between specific problems parents face and those commonly associated with ADHD children. The research will categorize these problems as related to physical stress, anxiety, depression, occupational difficulties and social problems that parents have experienced as a result of having an ADHD child.

III- Methodology

A- Subjects:

The subjects of the study consisted of 16 parents, 1 father and 15 mothers, of ADHD children who were brought to the Center for Child Mental Health (CCMH). All of the parents and children were able to come to CCMH with an appointment given by the child psychiatrist. The participants were selected according to the documents that had already been diagnosed as ADHD using the 14-item ADHD Rating Scale (DuPaul, 1991) (See appendix 3) and parallel with the DSM-IV diagnostic criteria.

B- Procedure:

First, all the cases with ADHD were recruited via the patients’ documents. Then interviews were held coinciding with the routine visits of the clients, thus, it took more than two months to collect all the data. Interviews were conducted in the hospital because several of the cases lived far from the hospital. Only three of the parents were able to complete the instrument by themselves. Since the literacy rate and general knowledge levels in Cambodia are so low, it was expected that the concept of the survey and terminology would be difficult for most of the parents to understand, let alone fill out themselves. Thus, the rest of the surveys were completed by asking the questions verbally.

C- Description of Instrument:

The questionnaire developed for this study was created by myself, although many of the items were adapted from other research instruments. Many questions needed to be re-worded in order to fit the Cambodian context, attitude and understanding. Effort was also made to make it simple enough so that it could be completed rather quickly. The 25-item Brief Symptom Questionnaire is about somatic and psychosocial symptoms. There are five domains of this tool asking about physical symptoms, emotional-depression symptoms, anxiety symptoms, occupational difficulties, and social problems. The items are rated on a 4-point scale rating the effective symptoms from “never” (0) to “always” (3).

D- Style of Analysis:

This study was analyzed using the SPSS-Version 10 Statistical Analysis Computer Program. Frequency was computed to find out the numbers and percentages of the parents who rated in the questionnaires. Mean scores of the 4-point scale were computed. Then, the percentages were graphed and tabled in Excel. This research study is only a descriptive presentation. The results were interpreted based on the score of the 4-point scale: “never,” “once in a while,” “often” and “always,” as shown in each table. It was divided into five categories and all of them were analyzed separately.


IV- Results

· Data Overview and Tables and Graphs

Tables and Figures below were error due to the technical problem, please go to PDF


Table 1: General Characteristics of the parents and the child

Parents Characteristics n %
Sex
Male 1 6.3
Female 15 93.8
Number of visits
Less than 5 times 2 12.5
5 to 10 times 2 12.5
10 to 15 times 5 31.3
15 to 20 times 2 12.5
More than 20 times 5 31.3
Occupational
Farmer 1 6.3
Gov/NGOs 1 6.3
Small Business 2 12.5
Housewife 12 75
Original Places
Koh Kong 1 6.3
Kandal 2 12.5
K Spue 2 12.5
PP 11 68.8
Child Characteristics    
Sex
Male 13 81.3
Female 3 18.8
Age 7.06 (mean)


As we can see in Table 1 above, all but one respondent were mothers (94%). Only one father (6%) responded. However, overall, mothers have been most faithful in coming to treatment sessions. Almost 75% of the parents have come back to treatment sessions more than 10 times. Most of the mothers were housewife, 75%. There were also a high number of the parents who came from Phnom Penh, 69%. If we look at the child characteristics, 81% were boys and only 19% were girls. The mean age of those children were 7.06 years old.

Figure 1

Table: 2 Parents Reported on Physical Effects (%)    
Once
Never in a while Often Always Mean

I
sleep poorly at night 18.75 25 43.75 12.5 1.5

I feel aching in any parts of my body 25 43.75 18.75 12.5 1.19

I get headaches 31.25 37.5 18.75 12.5 1.13

I eat too much or not enough 62.5 12.5 12.5 12.5 0.75

I get tired (easily) 0 31.25 37.5 31.25 2
Note: 0= never, 1= once in a while, 2= often, 3= always

Figure: 1


Physical Effects:

Results for items assessing physical symptoms are given in table 2. All of
the parents (n=16) responded to the questionnaires but nearly all the respondents were mothers. As we can see in the physical subscale, the mothers reported higher levels of tiredness than the other four items including poor sleeping pattern, aching in any parts of the body, headaches, and eating problem. Over 31% of the parents reported that they always get tired easily (Mean= 2.00). Furthermore, 43.75% of the parents reported that they often sleep poorly at night (Mean= 1.5) comparing to the feeling of aching in any parts of the body (18.75%, M= 1.19) and headaches (18.75%, M= 1.13). However, 62.5% of the respondents said that they don’t have any problems with eating (M= 0.75) and, too, another 31.25% said that they don’t have any problems with headaches (M=1.13). It means that eating and headaches are not the problem for those mothers.



Table: 3 Parents Reported on Anxiety Effects (%)    

Never Once in a while Often Always Mean

I feel restless and easily distracted 12.5 31.25 31.25 25 1.69

I feel nervousness 25 31.25 18.75 25 1.44

I feel embarrassed about my child with other people around me 12.5 12.5 62.5 12.5 1.81

I am over-concern about my child's present & future 0 6.25 31.25 62.5 2.5

I tend to worry about many things 0 25 43.75 25 2
Note: 0= never, 1= once in a while, 2= often, 3= always

Figure: 2


Anxiety Effects:

Table 3 shows that the parents have got higher percentages on the anxiety subscale. Over 62% of the parents reported that they are always over-concerned about their child’s present and future, which is the most significantly affected (M= 2.50). In addition, 62.5% of the participants said that they often feel embarrassed about their child with other people around them (M= 1.81). Another 43.75% of them reported that often they tend to worry about many things (M= 2.00). In contrast, there were no significant affects mentioned from the items of “restlessness” and “nervousness” which had mean scores of 1.69 and 1.44 respectively.



Table: 4 Parents Reported on Depressive Effects (%)  
Never Once in a while Often Always Mean

I have felt depressed or sad 12.5 25 43.75 18.75 1.69

I am easily frustrated & give up 6.25 43.75 37.5 12.5 1.56

I have difficulty concentrating 12.5 25 31.25 31.25 1.81

I don't think I am a good parents 62.5 31.25 6.25 0 0.44

I feel like my child doesn't love me 68.75 6.25 18.75 6.25 0.63
Note: 0= never, 1= once in a while, 2= often, 3= always

Figure:3

Depressive Effects:

The depressive subscale is shown in table 4 with 5 items determining depressive symptoms. Over 31% of the respondents strongly disagreed with the negative statement of “I have difficulty concentrating” meaning that they always have (M= 1.81). Whereas, 43.75% of the parents reported that, often they feel depressed or sad mood (M= 1.69), which is higher than 37.5% of those who reported that they are often easily frustrated and give up (M= 1.56). In contrast, more than 60% of them said that they don’t have any problems in the items of “I don’t think I am a good parent” (M= 0.44) and “I feel like my child doesn’t love me” (M=0.63). Therefore, depression is not as significantly affecting the parents of ADHD children.



Table: 5 Parents Reported on Occupational Effects (%)  
Once
Never in a while Often Always Mean
While I am working, I always think of
my child 0 6.25 37.5 56.25 2.5
I sometimes have a feeling that I can't handle tasks well 18.75 43.75 25 12.5 1.31

I fail to complete tasks 37.5 43.75 12.5 6.25 0.88
I don't feel confident enough to make decisions on how to solve problems 6.25 56.25 25 12.5 1.38

I forgot to do things 25 12.5 31.25 31.25 1.69
Note: 0= never, 1= once in a while, 2= often, 3= always

Figure: 4

Occupational Effects:

The occupational effects subscale is presented in table 5 with five items recognized as occupational problems. In this subscale, 56.25% of the respondents said, “while they are working they always think of their child” (M= 2.50). This indicates a high level of distress while they are working and it might harm their occupational concentration. However, 31.25% of the parents reported that they always forget to do things (M= 1.69) and 31.25%, too, often forget to do things. As far as confidence, 56.25% said that, once in a while, they don’t feel confident enough to make decisions on how to solve problems (M= 1.38). Moreover, 43.75% scored both items, “I have a feeling that I can’t handle tasks well” and “I fail to complete tasks,” as experiencing that once in a while.



Table: 6 Parents Reported on Social Effects (%)    
Once
Never in a while Often Always Mean

I am afraid my child may destroy things or hit others 6.25 18.75 37.5 37.5 2.06

I am too busy to take part in social or recreation activities 6.25 37.5 43.75 12.5 1.63

I feel I don't have time to socialize with other people like talking or visiting friends 25 31.25 25 18.75 1.38

I have lost my interest with other people around me 37.5 31.25 12.5 18.75 1.13

I am not happy with my family relationships 56.25 18.75 12.5 12.5 0.81
Note: 0= never, 1= once in a while, 2= often, 3= always

Figure: 5
Social Effects:

Social effects are presented in table 6 with also 5 items recognized as social interaction problems. Parents perceived that their ADHD children would destroy things or hit others and it was scored significantly higher than the other four items (37.5% said that they always experienced, mean= 2.06). Over 43% said that often they are too busy to take part in social or recreational activities (M= 1.63). In contrast, 56.25% responded that they don’t have any problems with their family relationships (M= 0.81).


V- Discussion
A- Data Analysis

One purpose of this study was to assess the impact of children with ADHD on their parents. The hope was to determine what are the most common stress symptoms present in parents with ADHD in Cambodia: physical effects, anxiety, depression, occupational difficulties or social concerns. It was interesting to note that mostly mothers were the ones to come to the hospital. This seems to be common in many countries, but especially in Cambodia where child care and education is the role of the mother. As Rabiner (2001) said, in his clinical experiences, “in many couples it seemed that fathers were not willing or prepared to accept a diagnosis of ADHD in their child, and were unwilling to get involved in their child’s treatment in a supportive way.”

Goodman & Scott (1997) stated that children with psychiatrically disturbed can impact family characteristics. For example, parental depression, anger, or other psychological symptoms could be evoked by a disturbed child. The results of this study in Cambodia indicated that parents of children with ADHD reported significantly higher levels of anxiety symptoms than the other four categories, whereas, depressive symptoms were less likely to occur in those parents according to the anxiety and depression subscales. This means that depression was not as a significant issue identified in this population. It may presumably that Cambodian parents get stressed, or depressed when children are not respectful and many times ADHD children are impulsive and not respectful. Prior research has supported this idea (Pololski & Nigg, 2001) showing that parenting stress also due to the child’s oppositional and defiant behaviors rather than ADHD itself. The results of this study were not consistent with other research which shows that “depression occurs more often in ADHD families than in normal populations” (Cunningham, Benness, & Siegel, 1988).

Not only anxiety affected the parents, but also stresses seemed to impact their occupational abilities. Most of the parents said that they always think of their child while they are working, so they don’t feel free to work on their tasks. Usually parents worry about their children even if their children do not have any problems. But these parents felt a specific link between the fact that their children had ADHD and that they would be thinking and worrying more. They worried that their children would show a lot of unaccepted behaviors such as not paying attention in school, destroying things, hitting other children, demanding things, etc. These kinds of behaviors may cause the family a bad reputation or bring shame to the parents. Therefore, the parents were afraid that their family might become more dysfunctional because they cannot do anything if their children still behave those activities. About 13% of the parents reported that “they don't feel confident enough to make decisions on how to solve problems” and about 13% reported that they “sometimes have a feeling that they can't handle tasks well”. In fact, Cambodia there is no special school for the child with ADHD, so the child stays with parents, especially with mothers all the time, then the parent-child interaction might become difficulty from day to day. Prior research study has also documented higher levels of stress in parents is associated with child behavioral problems and dysfunctional interactions (DuPaul et al, 2001). Sham is also a significant social stigma for the parents who have a disturbed child. In this study, there is a child that the parents have tied all days in order to protect him going out from home and destroying other people’s things. If the child demolish the other properties then they have to pay as compensation.

It is difficult to determine the exact reason that parents have these sorts of problems, because, as mentioned before, the parents who responded to the questionnaire may have other psychological effects from other stresses in their lives or stressful events from their pasts. And the children may be struggling with symptoms of associated disorders. However, the stressors related to the ADHD may pile up with other stressors that all families face (Mulsow et al 2001).

In fact, this is a very interesting point that should be carefully noted as Cambodians have struggled a lot in the past 30 years with surviving war and poverty. Even though today there is relative peace, these factors are bound to affect the perspective of parents struggling with ADHD children and trying to raise their families. Interestingly, it is very possible that the parents who completed the surveys may struggle with ADHD themselves (Mulsow & Morry 2001; Rabiner 2001). Thus, the authors noted that when the mothers responded to the questionnaire they could have been expressing frustrations that they have related to having husbands with ADHD.

B- Limitations of the study

The problems that limit the generalization of these findings include the small number of parents studied (n= 16). Again, no contribution from a non-ADHD clinic-referred control group makes it difficult to compare in general with ADHD clinic-referred. Moreover, input from more fathers in this study would perhaps have given more diverse results from which to draw conclusions. Finally, the questionnaires were not validated by previous researchers, but rather, were designed according to the needs of the study and those who were studied.

VI. Conclusion

A- Summary from the Literature Reviews:

In conclusion, ADHD has been diagnosed in children in other countries, especially in the United States, which estimates 3% to 5% of children are affected. ADHD is more likely to occur in boys than in girls. It is a behavioral disorder that characterized by impulsivity, hyperactivity and inattentiveness. The explicit causes of this disorder are not clear. Most causes of it include genetic, brain damage or psychosocial problems, for example, chaotic families, institutional up-bringing, single-parent families, etc. ADHD is usually accompanied by various disorders including oppositional defiant disorder (ODD), conduct disorder (CD), Depression, etc. Further research on comorbid conditions with ADHD has been recommended by the NIH (JAACAP, 2000). However, insights into effective ways of treating this disorder are available. Family intervention is more effective in decreasing behavioral problems of these children and increasing a parent’s sense of psychological well being. On the other hand, medication can help, but not without a combination of psychosocial intervention.

Parents of children with ADHD experience a broad array of stress in daily life in the family. Parental psychopathology and other psychosocial problems are strongly associated with ADHD children.

B- Summary of Results:

The results of the present study conclude that parents of ADHD children in Cambodia were experiencing psychological problems, especially anxiety symptoms. In contrast, depressive symptomatology was not as a significant effected on that population. Occupational and social problems were also identified but were less overt. Therefore immediate attention should be paid to that population, especially in the area of anxiety.


C- Recommendation:

The results of this study have several implications. First, it is important that practitioners working with children with ADHD, not only treat the ADHD itself, but also assess the kinds of stress the parents are feeling. Second, parents of ADHD children should be given more counseling and training on how to be a good parent of an ADHD child in order to reduce their anxiety symptoms and reduce their child behavior problems during treatment sessions. Further research should focus more these issues. Additionally, research should be done on the parents of non-referred ADHD children in Cambodia, for example, in school settings, so that comparisons can be made as to the levels of stress among the parents of referred and non-referred ADHD children.

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Appendixes 1

Brief Symptom Questionnaire

-Age: ……… Sex: Male ú Female ú NoofVisit:… times
-From: …………….; Occupation: Farmer ú Worker (Labor) ú
Gov't/NGO ú Small Business ú
-Date: ……………… Soldier ú Others ................

-Please circle the number in the one column, which best describes for you.

I feel that:


Never
Once in a while Sometimes Always
1. I sleep poorly at night
2. I feel aching in any parts of my body
3. I get headaches
4. I eat too much or not enough
5. I get tired (easily)
6. I feel restless and easily distracted
7. I feel nervousness
8. I feel embarrassed about my child with other people around me
9. I am over-concern about my child's present & future
10. I tend to worry about many things
11. I have felt depressed or sad
12. I am easily frustrated & give up
13. I have difficulty concentrating
14. I don't think I am a good parents
15. I feel like my child doesn't love me
16. While I am working, I always think of my child
17. I sometimes have a feeling that I can't handle tasks well
18. I fail to complete tasks
19. I don't feel confident enough to make decisions on how to solve problems
20. I forgot to do things
21. I am afraid my child may destroy things or hit others
22. I am too busy to take part in social or recreation activities
23. I feel I don't have time to socialize with other people like talking or visiting friends
24. I have lost my interest with other people around me
25. I am not happy with my family relationships

Appendix 2:
Diagnostic Criteria

How can we know if a problem is truly attention deficit disorder? According to the Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition (DSM-IV), a diagnosis of ADHD should be based on these criteria:

Either (1) or (2):

Inattention: six (or more) of the following symptoms of inattention have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level:
Often fails to give close attention to details or makes in schoolwork, work, or other activities
Often has difficulty sustaining attention in tasks or play activities
Often does not seem to listen when spoken to directly
Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
Often has difficulties organizing tasks and activities
Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
Often loses things necessary for tasks or activities (e.g., school assignments, pencils, books, or tools)
Is often easily distracted by extraneous stimuli
Is often forgetful in daily activities
Hyperactivity-impulsivity: Six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level:

Hyperactivity

Often fidgets with hands or feet or squirms in seat
Often leaves seat in classroom or in other situations in which remaining seated is expected
Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
Often has difficulty paying or engaging in leisure activities quietly
Is often “on the go” or often acts as if “driven by a motor”
Often talks excessively

Impulsivity

(a) Often blurts out answers to questions before the questions have been completed
(b) Often interrupts or intrudes on others (e.g., butts into conversations or games)

Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.
Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home).
There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.
The symptoms do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder, and are not better accounted for by another mental disorders (e.g., mood disorder, anxiety disorder, dis-associative disorder, or a personality disorder).

Code based on type:

Attention-deficit/hyperactivity disorder, combined type: if both criteria
A1 and A2 are met for the past 6 months
Attention-deficit/hyperactivity disorder, predominantly inattentive type: If criterion A1is met but criterion A2 is not met for the past 6 months
Coding note: For individuals (especially adolescents and adults) who currently have symptoms that no longer meet full criteria, “remission” should be specified.

Source: American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV).




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