The relationship model among parent-child relationship, coping responses and behavioral problems in children with attention deficit hyperactivity disorder

doi:10.21203/rs.3.rs-1565704/v1

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The relationship model among parent-child relationship, coping responses and behavioral problems in children with attention deficit hyperactivity disorder

https://doi.org/10.21203/rs.3.rs-1565704/v1

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Background: Attention Deficit Hyperactivity Disorder (ADHD) constitutes a prevalent behavioral problem. The present study was conducted to examine the parent-child relationship model and investigate strategies to cope with behavioral problems in children with ADHD.

Methods: This descriptive study selected 300 children with ADHD using convenience sampling. The data collected using the child behavior checklist, the parent-child relationship scale (PCRS), the Billings and Moos Coping Checklist, the socioeconomic status questionnaire, the general health questionnaire-28 (GHQ-28) and a demographic checklist were analyzed in SPSS-25 and LISREL 8.8.

Results: According to the results of the path analysis on the relationship model among parent-child relationship domains, coping responses and children’s behavioral problems, parent-child dependency domain (B=0.22) in the direct path, disease duration (B = 0.085) in the indirect path, and conflicts in the domain of parent-child relationship (B=0.366) in both direct and indirect paths had the most positive causal effect on behavioral problems. Furthermore, intimacy in the said domain (B = -0.42) had the most negative causal effect in both direct and indirect paths. The extent to which parents used coping responses via the direct path had positive causal effect on behavioral problems (B = 0.12).

Based on the findings of the path analysis test in the relationship model among positive parent-child relationship, coping responses and children’s behavioral problems, the positive parent-child relationship score had the most negative causal effect via the direct path (B = -0.56), and the child's age had the highest positive causal effect via the indirect path (B=0.1) on behavioral problems in children.

Conclusion: Based on findings, there is a causal and significant relationship between the parent-child relationship and extent to which coping responses are used. It is recommended that training programs be developed to strengthen communication skills, coping responses and problem-solving techniques in parents.

Parent-child relationship

coping responses

behavioral problems in children

ADHD

Childhood plays a key role in humans’ comprehensive development and formation of their identify and personality [1]. The majority of conflicts and behavioral disorders in adolescents and adults are a result of neglecting emotional-behavioral dimensions and failing to properly guide their growth and development in their childhood [2].

As a major neurodevelopmental disorder in children [3], ADHD is characterized by patterns of inattention and hyperactivity-impulsiveness that impair performance or growth. The symptoms emerging before the age of seven years and lasting for at least six months are associated with dysfunction at home and school and relationship problems with playmates.

The global prevalence of ADHD among children and adolescents is estimated at 3–7% [5]. About 63 million children and adolescents suffer from this disorder in the world [6]. The prevalence of this disorder in Iran is insignificantly different from the global average and the differences observed can be explained by differences in the prevalence in different provinces of the country [7].

Behavioral problems in these children include irritability, aggression, opposing behaviors, emotional dysregulation, disappointment, isolation and depression [8]. All these symptoms adversely affect the family life of the patient. Stress levels are higher and self-esteem is lower in the parents of these children compared to in the parents of normal children. These parents experience an intolerable life and their disappointment, stress, depression and numerous socioeconomic and physical problems affect their quality of life [9].

Early interventions are essential for children with ADHD. Treatment instructions, environmental recommendations and psychosocial and psychiatric interventions are recommended based on the severity of the disorder in these children [10]. The parents and how they deal with their child play a key role in the treatment and quality of life of their affected children. It has been recommended that behavioral problems be treated in children in collaboration with their parents and based on family-oriented programs [11]. According to Carnes-Holt, the parent-child interaction is the first point of contact for the child in communicating with the world and an important and vital relationship for creating security and love, consisting of a combination of behaviors, feelings, and expectations which are unique to a particular parent and a particular child [12].

The components of parent-child interactions constitute the predictors of externalizing problems in children. According to the conceptual model of mother-child relationship and relationships of positive and negative emotions with anxiety disorders (Fig. 1), intimacy negatively and conflicts positively and significantly relate to anxiety disorders [13]. Anxiety and hostility in children are a result of their parents’ behaviors such as rejecting them and adopting hostile attitudes rather than accepting and establishing relaxing relationships with them [14].

As discussed earlier, the parents of these children resort to certain strategies to reduce their stress in the face of numerous problems. Adopting proper coping responses by parents significantly affects their relationship with and behavioral problems in their child [8, 15]. A fitted model introduced in Iran suggested the causal relationships of interactions between parent-child relationships with behavioral problems in preschool children based on an inhibitory mediator (2020) (Fig. 2) [16].

The factors associated with behavioral problems in these children include their age and disease duration and number of children in their family [8, 9]. The relationships of these factors, parent-child relationships and coping responses of parents with behavioral problems in children have rarely been addressed in literature. Given the growing prevalence of this disorder in children and importance of paying attention to this age group, the present study was conducted to examine the parent-child relationship model and coping responses for behavioral problems in children with ADHD.

2.1. Study design and participants

This descriptive study was conducted in 2021 in Imam Ali and Imam Hossein psychiatric clinics affiliated to Alborz University of Medical Sciences in Karaj as the capital of Alborz Province, Iran’s 4th largest city and 22nd most populous city in the Middle East.

According to a study by Keshavarz et al. [17] and the following formula, the sample size was estimated at 300 with a correlation coefficient of 0.16 between the score of parent-child relationship and coping behaviors and type I and type II errors of 0.05 and 0.2, respectively.

Convenience sampling was performed until the sample was completed.

Inclusion criteria:

Children

Children of both genders, aged 6–12 years, with a profile in the study clinics, diagnosed with ADHD by a psychiatrist as the study consultant and without other psychiatric disorders as confirmed by their parents were included.

Parents

Literate Iranian parents with no psychological disorders based on the GHQ and no addiction to psychedelics and drugs were also included.

Exclusion criteria

Withdrawal from the study at the time of completing the questionnaires in a way that accessing the subject was impossible and leaving the questionnaires incomplete.

2.2. Data collection and definition of terms

The data were collected using a demographic checklist, the child behavior checklist (CBCL), the parent-child relationship scale (PCRS), the Billings and Moos Coping Checklist, the socioeconomic status questionnaire and the general health questionnaire-28 (GHQ-28).

2.2.1. Demographic checklist

The demographic details of the children and their parents obtained using a researcher-made questionnaire as the demographic checklist included gender and age of the parents and child, marital status of the parents, child’s weight, education and employment status of the parents, duration of current marriage of the parents, number of children, birth order of the affected child, ethnicity and alcohol consumption over the previous six months and smoking status in the parents.

2.2.2. Child behavior checklist (CBCL)

The present study employed the CBCL (Achenbach and Rescorla) to measure emotional-behavioral problems in the children. This checklist measures emotional-behavioral problems, strengths and socio-educational competency in 6-18-year-olds from the perspective of their parents. This tool can be used in interviews and as a self-report instrument. The CBCL should be completed by the parents or guardian of the child. The items were scored on a three-point Likert scale ranging from 0 to 2, with 0 denoting the absence of a behavior in the child, 1 denoting behaviors that occasionally emerge and 2 suggesting those that always or frequently occur. Eight problematic dimensions measured in children and adolescents using this questionnaire included anxiety/depression, isolation/depression, somatic complaints, social problems, thinking problems, attention problems, rule-breaking behaviors and aggressive behaviors. Normalizing this checklist in the Iranian population respectively obtained the retest validity coefficient and the internal consistency coefficient as 0.58 and 0.79 for the entire competency scale, 0.58 and 0.83 for emotional-behavioral problems, 0.48 and 0.86 for internalizing problems, 0.97 and 0.88 for externalizing problems, 0.39 and 0.80 for attention deficits, 0.38 and 0.78 for thinking problems and 0.48 and 0.69 for social problems [18].

2.2.3. Parent-child relationship scale (PCRS)

Pianta introduced this 33-item scale in 1994 to measure the perception of parents of their relationship with their children in the subscales of conflicts (17 items), dependence (6 items), intimacy (10 items) and overall positive relationship. Conflicts involve negative aspects of the relationship such as conflict with each other, anger against each other, disobedience, rejection of restraint and unpredictability. Intimacy refers to the degree to which parents perceive their relationship with their child as warm, emotional and comfortable. Dependence assesses the degree of abnormal dependence of children on their mother. The overall positive relationship also emphasizes intimate parent-child relationships. As a self-report instrument, the PCRS is scored on a five-point Likert scale with 5 denoting definitely applies and 1 definitely does not apply [19]. The reliability and validity of this scale were also confirmed in Iran. Moreover, the reliability of this tool was confirmed by calculating a Cronbach's alpha of 0.84 for conflicts, 0.69 for dependence and 0.80 for overall positive relationship [20].

2.2.4. Billings and Moos coping checklist) coping responses)

Billings and Moos (1984) designed this 32-item checklist to investigate how individuals respond to stressful events and measure coping responses, including problem-focused coping (3 items), emotion-focused coping (11 items), coping based on cognitive evaluation (5 items), coping based on physical inhibition or somatization of problems (6 items) and coping based on achieving social support (4 items). The items were scored on a four-point Likert scale defined as 0: never, 1: sometimes, 2: often and 3: always [21]. The validity and reliability of this questionnaire were confirmed in Iran by calculating a Cronbach's alpha of 0.79 [22].

2.2.5. Socioeconomic status questionnaire

The socioeconomic status questionnaire (Ghodratnama), including 5 main items and 6 demographic items, was used to evaluate four dimensions of the socioeconomic status (2013), i.e. income, economic class, education and housing status. The 5-choice items were scored as 1: very low to 5: very high. Eslami et al. confirmed the face and content validity of this questionnaire in Iran (2013) and its reliability was confirmed by calculating a Cronbach's alpha of 0.83 [23].

2.2.6. General health questionnaire (GHQ)

Goldberg and Hiller (1979) designed this 28-item questionnaire with four 7-item subscales, i.e. somatic symptoms (items 1–7), anxiety and insomnia (items 8–14), social dysfunction (items 15–21) and severe depression (items 22–28). The items were scored on a scale of 0–3 with a cutoff point of 23. In other words, the higher than 23 the score obtained from this questionnaire, the worse the mental health. Najarkolaei et al. confirmed the validity and reliability of this instrument in Iran in 2014 by calculating a Cronbach's alpha of 0.85 [24].

2.3. Procedure:

The present study began after receiving the approval of the Ethic Committee of Alborz University of Medical Sciences (IR.ABZUMS.REC.1399.238). After presenting to Imam Ali and Imam Hossein psychiatric clinics affiliated to the university, the researcher identified eligible candidates, briefed them on the study objectives and asked their parents to sign written consent forms. To evaluate mental health in the parents accompanying their child, they were asked to complete the GHQ. The parents receiving a score of below 23 from the GHQ, suggesting absence of psychological problems, were included in the study. The questionnaires were completed online given the limitations on the presence of the participants in the clinics caused by the COVID-19 pandemic and social distancing rules at the time of the study. The links of the questionnaires were sent to the parents and they were asked to complete them within two weeks. In case of inability to complete the questionnaires online, the PCRS, the coping responses questionnaire, the socioeconomic status questionnaire, the GHQ-28 and the demographic checklist were distributed in calm conditions among the parents and they were assured of the confidentiality of their information. The researcher constantly monitored the procedure and responded in person to the potential queries of the participants completing the questionnaires at the clinic and through the phone to those communicating online. In case of inability to complete the questionnaires in one session, the participant was asked to participate in the following sessions at their own convenience.

2.4. Statistical analysis:

Developing a conceptual model based on a review of literature and previously-proposed models and theories constitutes the first step in testing the relationship model [25]. The parent-child relationship and coping responses of parents were therefore examined based on the conceptual model of relationship (Fig. 3). The distribution normality of the quantitative variables was investigated using the Kolmogorov-Smirnov test. As generalized ordinary regression, the path analysis was performed to explain direct and indirect relationships and effects of individual variables on dependent variables. The obtained results were used to logically interpret the relationships and correlations. The data were analyzed in SPSS-25 and LISREL 8.8. The Pearson correlation coefficient was used for investigating the correlations and the path analysis was expressed as Standardized Beta with a significance level of T-value > 1.96.

The present study recruited 300 children aged 6–12 with ADHD and profiles in the selected clinics. The mean age of the children was 8.1 ± 2.4 years and duration of their disease 2.9 ± 1.7 years. Mean scores obtained were 59.6 ± 29.8 for CBCL, 42.1 ± 9.7 for the coping responses, and 96.6 ± 13.6 for the positive score of parent-child relationship (Table 1).

Table 1: Frequency distribution of individual-social characteristics of participants in 2021
Variables(quantitative)		Mean ± SD	minimum		maximum
Age child(year)		8.1±2.4	3		13
Age mother		36.4±7.2	20		56
Age father		40.3±6.9	28		64
disease duration (year)		2.9±1.7	1		10
Child-parents relation		96.6±13.6	71		135
Child behavior problem		59.6±29.8	4		136
Coping Strategies Scale		42.1±9.7	17		67
Variables(qualitative)		F (%)	Variables		F (%)
Child birth rating	1	194(64.7)	Number of children	1	115(38.3)
	2	86(28.7)		2	147(49)
	≥3	20(6.7)		≥3	38(12.7)

The Pearson correlation test suggested the significant relationships between behavioral problems in children and variables of number of children, conflicts, dependence, intimacy, positive parent-child relationship and coping responses. The highest positive correlation (r = 0.45) was related to positive parent-child relationship and the highest negative (r=-0.58) to behavioral problems.

Based on the findings of the path analysis test on the relationship model among parent-child relationship domains, coping responses, and children’s behavioral problems, the dependency domain from the parent-child relationship (B = 0.22) had the most positive causal effect on behavioral problems in children in the direct path such that an increase in the score of dependency increased children’s behavioral problems. In the indirect path, disease duration (B = 0.085) exerted the highest positive causal effect on behavioral problems in the children. As such, the longer the disease duration, the more frequent the behavioral problems. Among the effective variables in both direct and indirect paths, conflicts (B = 0.366) exerted the highest positive causal effect and intimacy (B=-0.42) the highest negative effect. In fact, increases in conflicts and intimacy scores respectively increased and decreased behavioral problems in the children. The extent to which the parents used coping responses exerted positive causal effects on behavioral problems on the direct path (B = 0.12). In other words, increasing parental use of coping responses was associated with increasing behavioral problems in the children (Table 2, Fig. 4).

Table 2

direct and indirect effect of relationship model among parent-child relationship domains, coping responses and children’s behavioral problems in children with ADHD
	Standard B			Un standard B
Variables	Direct Effect	Indirect effect	total	Direct Effect	Indirect effect	Total
Child age	0.006	0.07*	0.07*	0.086	0.97*	0.97*
Children number	-0.12*	-0.055*	-0.17*	-4.79*	-2.36*	-7.15*
disease duration	-0.036	0.085*	0.085*	-0.66	1.61*	1.61*
Socioeconomic status	-0.07	0.019*	0.019*	-1.187	0.304*	0.304*
coping responses Scale	0.12*	-	0.12*	0.40*	-	0.40*
conflicts	0.34*	0.026*	0.366*	0.99*	2.32*	3.31*
dependence	0.22*	-0.007	0.22*	2.33*	-0.08	2.33*
Intimacy	-0. 44*	0.016*	-0. 42*	-4.33*	0.172*	-4.158*

According to the findings of the path analysis in the relationship model among positive parent-child relationship, coping responses and children’s behavioral problems, the positive score of parent-child relationship had the most negative causal relationship (B=-0.56) in the direct path, and child’s age had the most positive causal relationship (B = 0.1) with behavioral problems in the indirect path. As such, the higher the positive parent-child relationship score, the fewer the children's behavioral problems, and the older the child, the more behavioral problems the children have. The use of coping responses was indirectly and positively associated with behavioral problems (B = 0.07) (Table 3) (Fig. 5).

Table 3

direct and indirect effect of relationship model among positive parent-child relationship, coping responses and children’s behavioral problems in children with ADHD
	Standard B			Un standard B
Variables	Direct Effect	Indirect effect	total	Direct Effect	Indirect effect	Total
child age	0.01	0.1*	0.1*	0.12	1.35*	1.35*
Children number	-0.14*	-0.051	-0.14*	-5.88*	-0.051	-5.88*
disease duration	0.04	-0.011	0.029	0.69	-0.003	0.687
Socioeconomic status	-0.04	0.012*	0.012*	-0.62	0.18*	0.18*
coping responses Scale	0.06	0.07*	0.07*	0.19	0.25*	0.25*
positive parent-child relationship	-0.56*	-	-0.56*	-1.32*	-	-1.32*

The fitted model indices showed the desirability, high model fit and rationality of the adjusted relationships of the variables based on the conceptual model. The fitted model was therefore insignificantly different from the conceptual model (Table 4).

Table 4

The fitted model index
	X²	df	X²/df	NFI	NNFI	CFI	GFI	AGFI	RMSEA
Fitted model index with parent-child relationship domains	5.55	5	1.11	0.91	0.92	0.98	0.99	0.96	0.01
Fitted model index with among positive parent-child relationship	3.93	4	0.98	0.99	1	1	1	0.97	0.000
Standard	X²/df < 5			> 0.90	> 0.90	> 0.90	> 0.90	> 0.90	< 0.05

Psychologists have always addressed ADHD as a prevalent disorder with negative consequences for children. The present research was conducted to examine the parent-child relationship model and strategies to cope with behavioral problems in children with ADHD.

According to the results of the path analysis of the relationship model among parent-child relationship domains, coping responses, and children’s behavioral problems, among variables that had the most causal relationship with children's behavioral problems, parent-child dependency domain from the parent-child relationship had the most positive relationship. In other words, as dependence in the parent-child relationship increased, so did the children's behavioral problems. Varasteh et al. (2016) reported the positive and significant effects of a positive parenting program on conflicts, intimacy, dependence and overall positive effect. They reported less frequent behavioral problems in children with decreased dependence and conflicts in the parent-child relationship [26]. According to Adili et al. (2019), using intervention methods such as play therapy decreases dependence in the parent-child relationship and significantly reduces conflicts and improves dimensions of health in children [27]. The excessive emotional care and attention received by these children appears to intensify dependence on their parents, increase their expectations and create different problems in their future, which is consistent with the present findings.

The disease duration was positively, significantly and indirectly related to behavioral problems in the children on a single path. Increases in the disease duration increased behavioral problems in the children. As a major daily issue in patients with ADHD, establishing social relationships is exacerbated with age[28]. Attention and concentration problems persist despite the gradual improving effect of age on the symptoms of ADHD as reflected in numerous studies [29]. In line with the present research, a study by Sohrabi et al. (2014) on oppositional defiant disorder in preschool children showed no gradual changes in the symptoms of disobedience in the controls and this disorder persisted over the course of time [30].

Among the effective variables on both paths, conflicts exerted the highest positive causal effect on behavioral problems in the children. Increases in conflicts in the parent-child relationship increases the behavioral problems. Shafiei et al. (2018) found conflicts in parent-child relationships to cause externalizing disorders in children. They also found treatments focusing on patterns of sensory processing in children with behavioral-emotional problems, training their parents in individual differences and resolving conflicts and increasing positive interactions to decrease problems in these patients [31]. Shapurabadi et al. (2012) found designing positive group parenting programs for the mothers of children with ADHD to significantly decrease conflicts and dependence, increase intimacy and improve mother-child relationships [32]. Memarbashi et al. (2020) found inhibitory control to mediate the relationships of parent-child interactions with social skills and behavioral problems. In other words, parent-child interactions were found to relate to social skills and behavioral problems both directly and indirectly through inhibitory control. Disabilities and lack of concentration in these children cause their failure to complete their normal tasks, increase pressure on their parents in terms of supervision and therefore create conflicts in parent-child relationships [33].

As a dimension of parent-child relationships, intimacy exerted the highest negative effect on behavioral problems in the children in both direct and indirect paths. In fact, the higher the intimacy score, the lower the behavioral problems in the children. A study by Abbasi et al. (2017) on the mother-child relationship model and effects of positive and negative emotions on anxiety disorders showed that, among the dimensions of parent-child relationships, intimacy was negatively and significantly and conflicts positively and significantly related to anxiety disorders. Conflicting behaviors in a mother towards their children decrease their sense of responsibility and develop their insecurity, anxiety, isolation, carelessness and submissiveness. In contrast, increasing parent-child intimacy reduces anxiety disorders and behavioral problems in children. In other words, parent-child relationships based on intimacy and empathy create joy and positive emotions in children. Conversely, parent-child relationships based on conflicts create doubts about parental support, undesirable feelings and negative emotions in children [13].

The path analysis suggested positive relationships between coping responses used by parents and behavioral problems in their children. Research suggests properly using coping responses by parents significantly affects the quality of their relationship with and behavioral problems in their child [8, 15]. Hojjati et al. (2018) found behavioral problems to increase stress in children through increasing fatigue and ineffective coping responses in mothers. Fatigue and lack of energy in mothers associated with their children’s behavioral problems cause their adoption of ineffective, emotion-driven and avoidance coping responses, which in turn exacerbates behavioral problems in their child [34].

Based on the results of the test in the relationship model among positive parent-child relationship, coping responses and children’s behavioral problems, a positive parent-child relationship had the most negative causal relationship with the child's behavioral problems. In other words, increases in the positive score of parent-child relationship decreased behavioral problems in the children. This finding can be explained by the significant effects of positive parent-child relationships on improving the mother-child relationship, reducing conflicts and dependence and increasing intimacy [29]. Research suggests parenting skills and familiarity of parents with training methods and efficient communication with children exert the most significant effect on the emergence or persistence of behavioral problems in children. Positive parent-child interactions can modify this flawed relationship and help improve behavioral problems in children [35, 36]. According to Pajooh et al. (2018), mothers’ familiarity with the nature of behavioral problems in their children, their increased awareness of communication skills and their change in inefficient parent-child patterns to reduce behavioral problems in their children, improve their understanding of their children’s behavior and help them more effectively communicate with their children [37].

The age of the child indirectly exerted the highest positive causal effect on behavioral problems. Research suggests associations between ADHD and socio-behavioral problems in children. Untreated ADHD can also persist until adolescence and adulthood [38]. Despite the improving effect of age on behavioral problems in children, recovery before the age of 12 years is unlikely and symptoms persist until adulthood in 15–20% of cases [39]. The positive and significant causal relationship observed between the children’s age and their behavioral problems in the present study can be explained by their age being below 12 years. Khoddam et al. (2009) reported a varying incidence of symptoms with age and observed the highest incidence in children aged at most 11 years [40]. The symptoms begin to emerge in 67% of children with ADHS at their preschool age [41]. Research suggests the maximum prevalence of this disorder in children aged 3–5 years. Failing to timely diagnose and treat this disorder, especially in acute cases with social problems, can prolong the condition until the next stages of life [42, 43].

The present study limitations included using questionnaires for recording data and recruiting school-age children with this disorder as in the case of numerous similar studies that failed to address preschool children. The other limitations associated with the COVID-19 pandemic and social distancing rules included limited face-to-face contact with the parents.

The present findings suggested significant causal relationships between the parent-child relationship and the extent to which coping responses were used by the parents to deal with behavioral problems in their children. It is therefore recommended that ADHD be diagnosed before the school age and entrance to social settings, mothers be familiarized with the nature of behavioral problems in their children and training programs be developed to improve communication skills, coping responses and problem-solving skill in mothers.

CON

conflict

DEPE

dependence

INTI

intimacy

COP

parents' coping responses

CBCL

Child behavior checklist

SES

Socio economic Statues

Disease Duration

Children number

child Age

CPRS

positive Child-Parent Relationship Scale

Ethics approval and consent to participate:

Informed consent was obtained from all the participants and also from the parents/legal guardians of the children entering the study. Relevant guidelines and regulations were observed for all methods. All experimental protocols were approved by the Ethics Committee of Alborz University of Medical Sciences (IR.ABZUMS.REC.1399.238). All methods were carried out in accordance with relevant guidelines and regulations.

Consent for publication

All Of Authors have Consent for publication.

Availability of supporting data

The data that support the findings of this study are available from the corresponding author upon reasonable request

Competing interests

The authors declare that they have no competing interests

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors' contributions

S, T. designed and collected the data, performed the statistical analysis and wrote the manuscript. Z, M. supervised the study, contributed to the study design and conducted the analysis, and also helped write the manuscript. M, Q. analyzed the data and helped write the manuscript. A, Z. served as the study’s scientific advisor, designed and helped write the manuscript. F. M. helped to analysis the data and write the manuscript. N.M. contributed to the study design and write the manuscript.

All author) s (have read and approved the final manuscript.

Acknowledgements:

The present study is the result of a master's thesis in midwifery counseling that was conducted with the support of the Research Deputy and the Education Deputy of Alborz University of Medical Sciences. The researchers wish to express their gratitude to these organizations and all the participating students

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No competing interests reported.

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The relationship model among parent-child relationship, coping responses and behavioral problems in children with attention deficit hyperactivity disorder

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Version 1

Abstract

Figures

1. Background

2. Methods

2.1. Study design and participants

2.2. Data collection and definition of terms

2.2.1. Demographic checklist

2.2.2. Child behavior checklist (CBCL)

2.2.3. Parent-child relationship scale (PCRS)

2.2.4. Billings and Moos coping checklist) coping responses)

2.2.5. Socioeconomic status questionnaire

2.2.6. General health questionnaire (GHQ)

2.3. Procedure:

2.4. Statistical analysis:

3. Results

4. Discussion

5. Limitation:

6. Conclusion

Abbreviations

Declarations

References

Competing Interests

Status:

Version 1