Mental health and psychosocial status in mothers of children with Attention De�cit Hyperactivity Disorder (ADHD): differences by maternal ADHD tendencies

This study aimed to clarify differences in mental health, psychosocial status, and mental health-related factors among mothers of ADHD children between those with and without ADHD tendencies of their own. The data from 149 mothers of children with ADHD, collected through an online survey, were analyzed. Mothers with ADHD tendencies had poorer mental health, more ADHD children, and felt a lack of understanding of their surroundings than mothers without ADHD tendencies. There were differences in mental health-related factors depending on the mother's ADHD tendencies. Therefore, individualized interventions based on the presence or absence of the mother's ADHD tendencies may be important to maintain mental health in mothers of ADHD children.


Introduction
Attention de cit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by inattention, hyperactivity, and impulsivity.Therefore, mothers of children with ADHD experience higher parenting stress [1] and more mental health problems [2][3][4][5][6] than those of children with neurotypical development.Poor mental health leads to dysfunctional parenting skills, such as corporal punishment, lack of discipline, overly strict discipline [7][8][9], worsening children's ADHD symptoms, behavioral problems, and oppositional de ant disorder [10][11][12][13].Furthermore, previous studies also reported that parents of children with ADHD had an increased risk of family separation, such as divorce [14][15] and di culties in their employment [14] compared to parents of children without ADHD.
Therefore, it is important to maintain mental health in mothers of children with ADHD.Previous studies have reported factors related to their mental health.For example, depressive symptoms in mothers of children with ADHD and caregivers were related to children's features (e.g., severity of behavioral disturbance, hyperactivity-impulsivity dominant and mixed features, child's introversion problems [16][17][18]), mothers' socioeconomic attributes (e.g., low income, being the sole caregiver in the family, baseline marital status [17,18]), and parenting stress [1].
On the other hand, Genetic factors are strongly involved in ADHD psychopathology, and 25-50% of ADHD children have ADHD parents [19,20].Furthermore, adult ADHD is often associated with secondary disorders such as depression and anxiety disorders [21,22], impaired work functioning [23], and nancial di culties [23].Therefore, mothers of children with ADHD, especially those with ADHD tendencies of their own, may have more children with ADHD, high parenting stressors, poor socioeconomic status, and mental health problems.However, it has not been studied how mental health, psychosocial status, and mental health-related factors of ADHD children's mothers differ due to the mother's ADHD tendencies.Therefore, this study aimed to clarify the differences in mental health, psychosocial status, and mental health-related factors among mothers of ADHD children between those with and without ADHD tendencies of their own.We hypothesized that mothers with ADHD tendencies would have poorer mental health and worse psychosocial status, such as unmarried, lower income, and higher parenting stressors compared to mothers without ADHD tendencies, and that mental health-related factors would differ by the presence or absence of maternal ADHD tendencies.

Study design and participants
An online survey was conducted between September 24, 2021, and October 19, 2021.Eligible participants were mothers of children (under 18) with ADHD that had been diagnosed by medical experts.The survey link was distributed to the participants by two peer groups for parents of children with developmental disabilities, a provider of after-school care services, and a support group for children with developmental disabilities.A checkbox was set up on the top page of the survey form to con rm that mothers of children with ADHD diagnosed by medical experts were the targets of the survey.Only those who clicked on this checkbox were allowed to participate in the survey.Of the 164 respondents who responded during the survey period, 149 were included in the analysis after excluding six respondents with incomplete data and nine who did not live with their children.

Survey instrument
Attributes, ADHD tendencies, ADHD child's attributes and severity of ADHD symptoms, parenting stressors, and mental health were assessed.

Attributes
Attributes included age, education, marital status, occupation, living with a spouse, household income, medication status, number of children, and number of children with ADHD.The mothers' medication use for mental health problems (antidepressants, anxiolytics, hypnotics) and ADHD (ADHD medications) were questioned.A list of the generic drug names of such medications approved in Japan was provided in the questionnaire.

ADHD tendencies
Part A of the Adult ADHD Self Report Scale (ASRS-v1.1)[24] was used to de ne ADHD tendencies.The ASRS is a validated scale to screen adults for ADHD.The tool comprises 18 items, with six items for screening (Part A) and 12 additional questions (Part B).Respondents are considered positive on the ASRS when they answer four or more Part A questions at the threshold level [24].The ASRS Part A screening has a sensitivity of 68.7% and speci city of 99.5% [24].Cronbach's alpha coe cient of the ASRS Part A in the present study was 0.831.In this study, mothers who tested positive on the ASRS Part A screening were de ned as having ADHD tendencies.

ADHD child's attributes and severity of ADHD symptoms
The attributes of child with ADHD included age, sex, diagnosis of comorbid developmental disorders (ASD, LD, DCD, other), and severity of ADHD symptoms.If the respondents had more than two children with ADHD, they were asked to respond regarding the child with the highest burden.The Japanese version of the home form of the ADHD-RS [25] was used for the severity of ADHD symptoms.The total ADHD-RS score was de ned as the severity of ADHD symptoms.A higher score indicated more severe ADHD symptoms.Cronbach's alpha coe cient of the ADHD-RS in the present study was 0.878.

Parenting stressors
The Developmental Disorder Parenting Stressor Index (DDPSI) [26] was used for parenting stressors.The DDPSI is designed to measure stressors in parents of children with developmental disabilities and has an 18-item questionnaire composed of four factors: (1) di culties in understanding the child and coping with the child's needs, (2) anxiety about the child's future and independence, (3) inadequate understanding of the childʼs disorder from others, and (4) con icting emotions with regard to the childʼs disorder.A higher score indicated higher stress experienced by the respondents.Cronbach's alpha coe cients of the four factors in the respondents were 0.721-0.868.

Mental health
The Japanese version of the Kessler 6-Item Psychological Distress Scale (K6) [27] was used.This scale is used in the Comprehensive Survey of Living Conditions conducted triennially by the Ministry of Health, Labour, and Welfare in approximately 300,000 Japanese households to investigate basic matters of national life, such as health, medical care, welfare, pension, and income.Cronbach's alpha coe cient of K6 for the respondents was 0.866.

Statistical methods
The 149 respondents were divided into two groups according to the presence or absence of ADHD tendencies assessed by the ASRS Part A screening.Group comparisons were conducted for attributes, ADHD child's attributes and severity of ADHD symptoms, parenting stressors, and mental health.A student's t-test was used to compare quantitative variables, and Pearson's chi-square test or Fisher-Freeman-Halton test was used to compare qualitative variables.
We then analyzed the association between mental health (K6 scores) and the variables of attributes, ADHD child's attributes and severity of ADHD symptoms, and parenting stressors in each group.Pearson's correlation analysis was used for associations with quantitative variables.Student's t-test, Welch's t-test, or one-way analysis of variance was used for associations with qualitative variables.SPSS Statistics version 27 for Mac was used for all statistical analyses, and the statistical signi cance level was set at 5%.

Characteristics differences by maternal ADHD tendencies
The characteristics by maternal ADHD tendencies are shown in Table 1.Mothers with ADHD tendencies had signi cantly more children with ADHD (p=0.007),higher scores on "inadequate understanding of the childʼs disorder from others" stressor (p=0.029), and higher K6 scores (10.4 ± 4.7 vs. 7.8 ± 5.3, p=0.009) than those without ADHD tendencies.
[Table 1 will be here] Factors associated with mental health in mothers with ADHD tendencies Table 2 presents the results about factors associated with mental health in mothers with ADHD tendencies.Signi cant associations were found between K6 scores and the following items: age (r=-0.401,p=0.014), "di culties in understanding the child and coping with the child's needs" stressor (r=0.469,p=0.003), and "inadequate understanding of the childʼs disorder from others" stressor (r=0.332,p=0.045).
[Table 2 will be here] Factors associated with mental health in mothers without ADHD tendencies Table 3 presents the results about factors associated with mental health in mothers without ADHD tendencies.Signi cant associations were found between K6 scores and the following items: medications for mental health problems (yes vs. no:12.4±6.6 vs. 7.0±4.6,p=0.006), the severity of ADHD symptoms in child with ADHD (r=0.271,p=0.004), "di culties in understanding the child and coping with the child's needs" stressor (r=0.504,p<0.001), "anxiety about the child's future and independence" stressor (r=0.421,p<0.001), "inadequate understanding of the childʼs disorder from others" stressor (r=0.294,p=0.002), and "con icting emotions with regard to the childʼs disorder" stressor (r=0.360,p<0.001).
[Table 3 will be here] Discussion Currently, mothers of children with ADHD are known to experience higher parenting stress [1] and more mental health problems [2][3][4][5][6] than those of children with typical development.However, it is unknown how the mental health and psychosocial status among mothers of children with ADHD differ according to the presence or absence of their own ADHD tendencies.This study aimed to clarify the differences in mental health, psychosocial status, and mental health-related factors between mothers with and without ADHD tendencies.
First, the results of this study showed that mothers with ADHD tendencies had signi cantly poorer mental health, a higher number of children with ADHD, and higher stressor regarding "an inadequate understanding of the child's disorder from others" compared to mothers without ADHD tendencies.
Regarding mental health, our results support previous studies reporting that adults with ADHD have a higher incidence of depression and other psychiatric disorders than adults without ADHD [21,22].In addition, our nding that mothers with ADHD tendencies had more ADHD children is also consistent with the genetic psychopathology of ADHD [19,20].Furthermore, the result that "inadequate understanding of the childʼs disorder from others" stressor was higher in mothers with ADHD tendencies may re ect social life di culties that adults with ADHD have, such as "I get into arguments or ghts easily," "I lose friends easily because of my impulsive behavior, " and "I am quick to lose my temper with my partner or loved one," as reported in a previous study [23].
Contrary to our hypothesis, there were no differences in socioeconomic status, such as marital status or household income, between the two groups, which might be due to the small sample size of this study.
Second, the results of this study showed that mental health-related factors differed according to the presence or absence of ADHD tendencies in mothers.Among mothers with ADHD tendencies, younger individuales had poorer mental health.This suggests that younger mothers with ADHD tendencies are especially at high risk for poor mental health among mothers of children with ADHD.Additionally, in mothers with ADHD tendencies, parenting stressors of "di culties in understanding the child and coping with the child's needs" and "inadequate understanding of the childʼs disorder from others" were related to poor mental health.When combined with the nding that mothers with ADHD tendencies had a higher stressor of "inadequate understanding of the child's disorder from others" than mothers without ADHD tendencies; improving this stressor seems particularly important for mothers with ADHD tendencies to prevent mental health problems.Moreover, medication use was not related to mental health in mothers with ADHD tendencies, contrary to previous ndings that poor mental health is associated with antidepressant medication use [28][29][30][31].This may indicate that mothers with ADHD tendencies do not have adequate access to medical resources even when they have mental health problems; therefore, it is necessary to support by experts in medical institutions and welfare centers.
On the other hand, in mothers without ADHD tendencies, poor mental health was related to medications, more severe ADHD symptoms in their child, and various kinds of parenting stressors such as "di culties in understanding the child and coping with the child's needs," "anxiety about child's futures and independence," "inadequate understanding of the childʼs disorder from others" and "con icting emotions with regard to the childʼs disorder."Regarding medications in mothers without ADHD tendencies, unlike mothers with ADHD tendencies, our nding supports previous ndings that poor mental health is associated with antidepressant medication use [28][29][30][31].In addition, our ndings suggest that varied parenting stressors and severity of child's ADHD symptoms are the main factors related to poor mental health among mothers without ADHD tendencies.Therefore, it seems to be particularly important to improve these parenting stressors to maintain the mental health of mothers without ADHD tendencies.This study had some limitations.First, as this was a cross-sectional study, causal relationships were not possible to prove.Longitudinal research is necessary to verify causal relationships.Second, since the voluntary nature of the online survey might have led to a selection bias, the respondents of this study may not be representative of the population.Thus, future studies should be conducted using a larger representative study sample.Third, data were collected using self-report questionnaires.Therefore, a reporting bias cannot be ruled out.Further studies using expert assessments of clinical symptoms and diagnostic criteria are needed in the future.Despite these limitations, this is the rst study to cralify differences in mental health, psychosocial status, and mental health-related factors among mothers of children with ADHD, depending on the presence or absence of mothers' own ADHD tendencies.The results of this study showed as following.Mothers with ADHD tendencies had poorer mental health and psychosocial status than mothers without ADHD tendencies.Some factors related to the maternal mental health, which are parenting stressors such as "di culties in understanding the child and coping with the child's needs" and "inadequate understanding of the childʼs disorder from others" were common regardless of the mother's ADHD tendencies, while other factors differed depending on the mother's ADHD tendencies.Threfore, to maintain the mental health of mothers with ADHD children, individualized interventions based on the presence or absence of the mother's ADHD tendencies, while improving common factors, are seemed to be important.These ndings should help explore measures of mental health promotion in mothers of children with ADHD in the future.

Conclusions
Mothers with ADHD tendencies were found to have poorer mental health, more children with ADHD, and a higher stressor regarding "inadequate understanding of the childʼs disorder from others" compared to mothers without ADHD tendencies.Poor mental health in mothers with ADHD tendencies was related to younger age and higher parenting stressors such as "di culties in understanding the child and coping with the child's needs" and "inadequate understanding of the childʼs disorder from others."Poor mental health in mothers without ADHD tendencies was related to medication use, more severe ADHD symptoms in the child, and higher parenting stressors such as "di culties in understanding the child and coping with the child's needs," "anxiety about child's futures and independence," "inadequate understanding of the childʼs disorder from others," and "con icting emotions with regard to the childʼs disorder."Summary Mothers of children with ADHD are known to have poor mental health and more psychosocial di culties than mothers of children without ADHD and it is important to improve mental health problems in mothers of ADHD children.Whereas genetic factors are known to be involved in the psychopathology of ADHD and it is possible that mothers with ADHD tendencies of their own may especially have more mental health problems and psychosocial di culties.Therefore, this study aimed to clarify differences in mental health, psychosocial status, and mental health-related factors among mothers of children with ADHD depending on the presence or absence of their own ADHD tendencies.Data from 149 mothers of children with ADHD obtained through a cross-sectional online survey were analyzed.The presence or absence of ADHD tendencies in the mothers was de ned by ASRS screening.Mothers with ADHD tendencies had poorer mental health, more ADHD children, and felt a lack of understanding of their surroundings than mothers without ADHD tendencies.Poor mental health in mothers with ADHD tendencies was related to younger age and higher parenting stressors regarding "di culties in understanding the child and coping with the child's needs" and "inadequate understanding of the childʼs disorder from others."Poor mental health in mothers without ADHD tendencies was related to medication use, more severe ADHD symptoms in their child, and higher parenting stressors such as "di culties in understanding the child and coping with the child's needs," "anxiety about child's futures and independence," "inadequate understanding of the childʼs disorder from others" and "con icting emotions with regard to the childʼs disorder."The ndings of this study imply the need for individualized interventions based on the presence or absence of ADHD tendencies in mothers to maintain the mental health among mothers of children with ADHD.

Table 2 .
Relationship between mental health and psycho-social status in mothers with ADHD tendencies a: Pearson's correlation analysis, b: One-way analysis of variance, c: Student's t-test, d: Welch's t-test SD: standard deviation

Table 3 .
Relationship between mental health and psycho-social status in mothers without ADHD a: Pearson's correlation analysis, b: One-way analysis of variance, c: Student's t-test, d: Welch's t-test SD: standard deviation