CHILDREN WITH ADHD IN THE KLANG VALLEY

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THE RELATIONSHIP BETWEEN PARENTAL STRESS, COPING, AND DEPRESSION AMONG MOTHERS OF

BY

QAREM MOHAMED MUSTAFA

A thesis submitted in fulfillment of the requirement for the degree of Master of Human Sciences in Psychology

(Clinical and Counseling Psychology)

Kulliyyah of Islamic Revealed Knowledge and Human Sciences

International Islamic University Malaysia

JULY 2018

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ABSTRACT

Research has shown that becoming a parent may come with its occasional stress, especially when parenting children with developmental disorders. One possible negative outcome due to high parental stress is an increase in depressive symptoms.

However, the use of coping strategies could moderate the relationship between parental stress and depressive symptoms. This study examined the relationship between parental stress, coping, and depressive symptoms among mothers of children with attention-deficit hyperactivity disorder (ADHD) in which it was hypothesized that there is a significant interaction between the variables. By using purposive sampling technique, a total of 94 Malay mothers from Klang Valley, Malaysia, with a mean age of 39.67 were identified and participated in the study. This is a cross- sectional study in which the measures used were the Parental Stress Inventory-Short Form (PSI-SF), Brief-COPE, and Centre of Epidemiological Study-Depression (CES- D). The findings of this study showed a significant positive relationship between parental stress and depressive symptoms (β = .368, p < .001) and between age of the child with the use of problem focused coping (r = .277, p < .01). A significant negative relationship was found between problem focused coping and depressive symptoms (β = –.737, p < .001). However, both coping strategies (i.e., problem- focused and emotion-focused) were not significant moderators for the relationship between parental stress and depressive symptoms. The findings partially support the application of the Transactional Model of Stress on the population of mothers of children with ADHD. Practical implications of the findings were also discussed.

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ثحبلا ةصلاخ

ABSTRACT IN ARABIC

لوانتت ةساردلا ىدل يسفنلا طغضلا ينب ةقلاعلا

ضارعأ اذكو ،وعم لماعتلا ةقيرطو ،نيدلاولا

تاهملأا ىدل طابحلإاو بائتكلاا ًةجيتن

ل بارطضا ضرم نوناعي نيذلا ءانبلأا عم لماعتل

( هابتنلاا صقنو ةكرلحا طرف و .)

ADHD

ةساردلا تمدختسا رايتخا في

ةنيعلا ةنيعلا ةقيرط

ةيضرغلا ةفدالهاو

(

Purposive Sampling Technique

ىلع ةساردلا ةنيع رايتخا عقو ثيح )

،جنلاك وبلم ةقطنم نم تايزيلالما تاهملأا رَّدقيو

لياوح نىددع اًّمُأ ٩٧

ام نىرامعأو ، ينب

١٣ - ٣١ وزخلما يسفنلا طغضلا سايقم تانابتسا ىلع ةساردلا هذى تدمتعاو ،ةنس في ن

نيدلاولا (

Parental Stress Inventory-Short Form (PSI-SF

سايقمو ،)

Brief-COPE

،

سايقمو

Centre of Epidemiological Study-Depression

لىإ ةساردلا جئاتن تراشأ دقو ،

فنلا طغضلا ينب تناكف ،ةيبايجلإا ةقلاعلا امأف ،ةيبلس ةقلاعو ،ةيبايجإ ةقلاع دوجو في يس

أ عم نيوبلأا بائتكلاا ضارع

( β =.368, p <.001) رمع ينب ةقلاعلا اذكو ،

يسفنلا طغضلا عم لماعتلا ةقيرطو لفطلا (r=.277, p <.01)

علا امأو ، ـ

ةقلا

سلا ـ ةيبل تلثمتف في

علاـ شم ينب ةقلا ـ

ح ةلك ـ

بائتكلاا ضارعأ عم تلاكشلما ل ( β =-

.737, p <.001) هذى في ةيبلسلاو ةيبايجلإا ةقلاعلا دوجو عمو ،

َّينبت ةساردلا نأ

و .ةطسوتم ةقلاع بائتكلاا عم نيدلاولا ةقلاع سايقم تحضوأ

ب ةساردلا هذى ا

ضعب ن

تلاماعلما طوغض ةيرظن ديؤت ةيئارجلإا اىراثآو اهجئاتن ىلع

ضرم يوذ ءانبأ تاهمأ

(

.ةساردلا هذى في حضوم وى امك )

ADHD

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APPROVAL PAGE

I certify that I have supervised and read this study and that in my opinion, it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a thesis for the degree of Master of Human Sciences in Psychology (Clinical and Counseling Psychology).

………..

Azlin binti Hj. Alwi Supervisor

………..

Intan Aidura Alias Co-Supervisor

I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and quality, as a thesis for the degree of Master of Human Sciences in Psychology (Clinical and Counseling Psychology).

………..

Ruhaya Hussin Examiner

This thesis was submitted to the Department of Psychology and is accepted as a fulfilment of the requirement for the degree of Master of Human Sciences in Psychology (Clinical and Counseling Psychology).

………..

Shukran Abd Rahman

Head, Department of Psychology This thesis was submitted to the Kulliyyah of Islamic Revealed Knowledge and Human Sciences and is accepted as a fulfilment of the requirement for the degree of Master of Human Sciences in Psychology (Clinical and Counseling Psychology).

………..

Mohammad Abdul Quayum Abdus Salam

Dean, Kulliyyah of Islamic Revealed Knowledge and Human Sciences

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DECLARATION

I hereby declare that this dissertation is the result of my own investigations, except where otherwise stated. I also declare that it has not been previously or concurrently submitted as a whole for any other degrees at IIUM or other institutions.

Qarem Mohamed Mustafa

Signature ... Date ...

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INTERNATIONAL ISLAMIC UNIVERSITY MALAYSIA

DECLARATION OF COPYRIGHT AND AFFIRMATION OF FAIR USE OF UNPUBLISHED RESEARCH

THE RELATIONSHIP BETWEEN PARENTAL STRESS, COPING, AND DEPRESSION AMONG MOTHERS OF

CHILDREN WITH ADHD IN THE KLANG VALLEY

I Declare that the Copyright Holders of this Dissertation Are Jointly Owned By the Student and IIUM.

No part of this unpublished research may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without prior written permission of the copyright holder except as provided below

1. Any material contained in or derived from this unpublished research may be used by others in their writing with due acknowledgement.

2. IIUM or its library will have the right to make and transmit copies (print or electronic) for institutional and academic purposes.

3. The IIUM library will have the right to make, store in a retrieved system and supply copies of this unpublished research if requested by other universities and research libraries.

By signing this form, I acknowledged that I have read and understand the IIUM Intellectual Property Right and Commercialization policy.

Affirmed by Qarem Mohamed Mustafa

……… ………...

Signature Date

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ACKNOWLEDGEMENTS

Firstly, I give my deepest gratitude to Allah for His blessings in giving me the strengths, ideas, insights, and knowledge which make the completion of this work possible. All is made possible as He wills it.

It is my utmost pleasure to dedicate this work to my dear parents and my family, who granted me the gift of their unwavering belief in my ability to accomplish this goal: thank you for your support and patience.

A special thanks to my esteemed supervisor Dr. Azlin binti Hj. Alwi and co- supervisor Dr. Intan Aidura Alias for their continuous support, encouragement and leadership, and for that, I will be forever grateful. A special thanks to almarhumah Dr.

Mimi Iznita Mohamed Iqbal who had guided and supported me from the beginning.

You will forever be miss.

I wish to also express my appreciation and thanks to those who provided their time, effort and support for this research specifically, the Malaysia Ministry of Education, the Department of Education Selangor and Wilayah Persekutuan Kuala Lumpur, Pusat Pakar Psikologi Jiwadamai, Dr. Nora Mat Zain from the Department of Psychiatry, IIUM, and parents of children with Attention Deficit/Hyperactivity Disorder.

Finally, I am grateful to all my friends and colleagues who have provided their support throughout my journey in completing this research.

May Allah grant all mentioned above with the best rewards in this world and the Hereafter.

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CHAPTER TWO: LITERATURE REVIEW ... 9

2.1 Introduction... 9

2.1.1 ADHD: A childhood Disorder ... 9

2.2 Parental Stress and Depression ... 11

2.3 Coping and Depression ... 14

2.4 Parental Stress, Coping, and Depression ... 18

2.5 Identification of Research Gaps... 24

2.6 Theoretical Framework ... 24

2.7 Conceptual Framework ... 26

2.8 Conclusion ... 28

CHAPTER THREE: RESEARCH METHOD ... 29

3.2 Study Design ... 29

3.3 Participants ... 29

3.4 Measures ... 33

3.4.1 Parental Stress Inventory-Short Form ... 33

3.4.2 Brief-COPE ... 33

3.4.3 Centre of Epidemiologic Studies-Depression ... 35

3.5 Procedures... 35

3.6 Data Analysis ... 36

3.7 Ethical Consideration... 37

3.7.1 Approval to Conduct Research ... 37

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3.7.2 Informed Consent ... 37

3.7.3 Confidentiality and Anonymity ... 38

CHAPTER FOUR: RESULTS ... 39

4.2 Testing Assumptions ... 39

4.3 Descriptive Analysis ... 42

4.4 Testing for Relationship Among Variables ... 43

4.5 Testing for Moderation ... 47

4.5.1 Parental Stress and Depression ... 47

4.5.2 Coping and Depression ... 48

4.5.3 Parental Stress, Coping, and Depression... 49

CHAPTER FIVE: DISCUSSION ... 50

5.2 Parental Stress and Depression ... 50

5.3 Coping Strategies and Depression ... 51

5.4 Coping as a Moderator... 54

5.5 Implications of Research Findings ... 55

5.6 Limitations and Recommendation ... 58

REFERENCES ... 60

APPENDIX A: APPROVAL FROM MINISTRY OF EDUCATION MALAYSIA ... 66

APPENDIX B: APPROVAL FROM SELANGOR DEPARTMENT OF EDUCATION ... 68

APPENDIX C: THE STUDY’S QUESTIONNAIRE ... 69

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LIST OF TABLES

Table No. Page No.

3.2 Participants‘ Demographic Information 33

4.2.1 Tolerance and VIF Values for parental stress, problem-

focused coping, and emotional-focused coping 41

4.2.2 Durbin Watson Statistics 42

4.3.1 Descriptive Statistics of Parenting Stress, Problem-focused Coping, Emotional-focused Coping, and Depressive

Symptoms 44

4.4.1 Pearson Product-Moment Correlation between Demographic Information, Parenting Stress, Problem-focused Coping,

Emotional-focused Coping, and Depressive Symptoms 46 4.5.1 Hierarchical Regression to Test for Moderation between

Parental Stress, Problem-Focused Coping, Emotional-

Focused Coping, and Depression 48

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LIST OF FIGURES

Figure No. Page No.

2.1 Transactional Model of Stress 26

2.2 The conceptual framework of the proposed research 27 4.2.1 Normal P-P plot of standardized residual values against

the standardized predicted values 33

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CHAPTER ONE INTRODUCTION

1.1 BACKGROUND OF THE STUDY

The development of psychological disorders may start at any stage of one‘s life stage, be it childhood, adolescence, or adulthood. Childhood disorders most often occur and are diagnosed during school age. These disorders are often labeled as developmental or learning disorders which include Attention Deficit/Hyperactivity Disorder (ADHD), Autism Spectrum Disorder (ASD), Global Developmental Delay (GDD), and Specific Learning Disorder (SLD).

ADHD is defined as ―a persistent pattern of inattention and/or hyperactivity- impulsivity that interferes with functioning or development‖ (American Psychiatric Association, 2013, p. 59). The prevalence rate of children with Attention Deficit/Hyperactivity Disorder (ADHD) has increased throughout the years (Barkley, 2014). In Malaysia, the Welfare, Women, and Community Development Minister of Sarawak Datuk Fatimah Abdullah reported the existence of 184 children with ADHD (Lai, 2014). Woo and Teoh (2007) discovered that as compared to Western Australia, with a prevalence rate of 6 percent to 8 percent, the prevalence rate for Malaysia at 9 percent to 12.5 percent. This shows that it is important to focus on ADHD in addition to other psychological disorders to better understand how the symptoms present themselves and how they influence not only the life of the children but also the caregivers.

Taking care of children with ADHD poses a lot of challenges (Deault, 2010, Johnston & Mash, 2001). These parents experience greater stress as compared with

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parents of typically developed children (Deault, 2010; Fischer, Barkley, Fletcher &

Smallish, 1993; Gupta, 2007; Johnston & Mash, 2001) because the needs of those children far exceed the demands of normal children (Lovell, Moss & Wetherell, 2015). A significant number of studies have also found that parents of children with ADHD showed higher stress levels as compared to parents of children with learning disabilities (Baker & McCall, 1995), HIV-affected, asthma (Gupta, 2007), and Autism Spectrum Disorder (ASD) (van Steijn, Oerlemans, van Aken, Buitelaar, & Rommelse, 2013).

Stress experienced by parents who have children with ADHD is usually caused by the disruptive behaviours of these children, as manifested in the form of hyperactivity and inattention (Podolsky & Nigg, 2001). Other behaviours such as angry outbursts, difficulty in following rules, and performing behaviours without thinking of the consequences (Johnson, Frenn, Feetham & Simpson, 2011) are common among these children. Although there are studies that have found no significant difference between the stress experienced by fathers and mothers (Johnston

& Mash, 2001; Thule, Wiener, Tannock, & Jenkins, 2013), there are studies that have found fathers as reporting significantly lower levels of stress as compared to mothers (Chi & Hinshaw, 2002; McCreary, 2002; Narkunam, Hasim, Sachdev, Pillai & Ng, 2012).

In Malaysia, mothers are commonly the primary caregivers to their children (Narkunam et al., 2012). There are also mothers who work full time while caring for their children with ADHD which may exert an added responsibility. As the primary caregiver, working mothers have to balance both the role of a provider and a caregiver of the children, in which the need to manage the two roles places these mothers at risk of various negative health outcomes, including stress, anxiety, and depression (Estes

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et al., 2013; Frone, Russel, & Cooper, 1997). Even without the role conflicts, mothers are still exposed to these negative health outcomes because of the child‘s oppositional behaviours and inattention-disorganization behaviours (Podolski & Nigg, 2001).

Effective coping strategies would help mothers to manage their stress better.

According to Lazarus (1993), coping is ―an ongoing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person‖ (p. 234). There are many types of coping strategies (Folkman & Lazarus, 1985; Carver, Scheier, & Weintraub, 1989). Folkman and Lazarus (1985) identified two main coping strategies related to problem-focused and emotion-focused coping. Carver, Scheier and Weintraub (1989) on the other hand identified several other coping strategies, such as active coping, planning, self-blame, self-distraction, instrumental support, emotional support, positive reframing, acceptance, turning to religion, venting of emotions, denial, behavioral disengagement, humor and substance use. These coping strategies could moderate the relationship between the parental stress and the negative health outcomes (Lazarus, 1993). For example, mothers who are able to reframe the difficulties that they experienced into a more positive experience are able to reduce the negative outcomes of stress (Podolski & Nigg, 2001). Additionally, mothers report less distress when they are able to cope by focusing on how to solve the problem instead of ruminating on the problem (Kim, Greenberg, Seltzer, & Krauss, 2003; Podolski & Nigg, 2001)

In summary, the prevalence of children with ADHD was found to increase every year. It is also evident that parents of children with ADHD are at-risk of various negative health outcomes, such as stress, anxiety, and depression. Thus, it is important to understand the stress experienced by mothers of children with ADHD and its relationship to possible negative health outcomes, such as depression (Estes et al.,

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2013; Frone, Russel, & Cooper, 1997). The present study will also explore the type of coping strategies used by the mothers and how they may or may not contribute as a protective factor for the mothers. This is because the effectiveness of the coping strategies depends on the situation the individuals are in and the stress they are facing.

1.2 STATEMENT OF THE PROBLEM

Mothers of children with ADHD experience higher level of stress than do mothers who are taking care of typically developed children (Deault, 2010) or even parents of children with other illnesses (Fischer et al., 1993; Gupta, 2007; Johnston & Mash, 2001). The increase in stress level could lead to the development of negative mental health outcomes such as depression. If the stress does to some extent significantly relate with depression, the mothers may not be able to provide the necessary and vital care required by their children (Byrne, Hurley, Daly & Cunningham, 2009).

Furthermore, mothers suffering from depression would put their children at a greater risk of difficulties such as the development of emotional and behavioural problems, academic difficulties, and problems in self-regulation in the children (Jaffe & Poulton, 2006). Therefore, it is important to examine how significant the relationship is between parental stress and depression among mothers of children with ADHD in the Malaysian context.

Studies have shown that adequate coping resources can reduce the risk of depression (Dalton, Elias, & Wandersman, 2012; Podolski & Nigg, 2001; Predescu &

Sipos, 2013). However, many mothers of children with ADHD may not necessarily cope well, and as such the coping strategies used by these mothers are inadequate to manage the stress and the depressive symptoms they experience. Therefore, identifying the appropriate coping strategies can be helpful for the mothers to reduce

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stress and depressive symptoms. However, findings differ from one study to another when identifying a significant coping strategy. A study by Kim, Greenberg, Seltzer, and Krauss (2003) found that there is a significant negative relationship between problem-focused coping and depression and a significant positive relationship between emotional-focused coping and depression. This means that the use of problem-focused coping could reduce depression while the use of emotional-focused coping could increase depression. On the other hand, Podolski and Nigg (2001) found that social support, which is also a problem-focused coping strategy, can relate to an increase in mental health problems. This shows that it is possible that the mothers would use coping strategies that are inefficient and counterproductive. Therefore, the present study attempted to identify coping strategies that would significantly reduce or increase the depressive symptoms experienced by the mothers.

1.3 SIGNIFICANCE OF THE STUDY

The proposed study provides two main contributions theoretically and practically. In terms of theoretical contribution, this study contributes to a better understanding of how the Transactional Model of Stress (Lazarus & Folkman, 1987) applies to parental stress of mothers of children with ADHD in relation to coping as a possible moderator and depression as an outcome. The Transactional Model of Stress (Lazarus &

Folkman, 1987) explains the relationship between stress and negative health outcome.

It also takes into consideration that coping is a moderator for the relationship. The theory provides the most logical explanation on how the mothers‘ risk of depression is related to the parental stress they are experiencing and the existence of coping resources. However, the theory is still susceptible to gaps in knowledge especially when tested in a new population or situation. The proposed study would add to the

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theoretical relevance of the Transactional Model of Stress in explaining stress, coping, and the outcomes of stress for mothers of children with ADHD. Having an empirical and theoretical support on this relationship could be useful to reiterate the importance of caring, not only for the mentally ill but also the mothers or caregivers. In addition, the findings provide an empirical explanation for the role of coping in the caregivers of the mentally ill.

By identifying the coping strategies that are significant to the mothers‘ mental health, proper intervention could be proposed for the mothers in the future. This relates to the second significance of the study, which is the practical contribution.

Having the empirical data would also make it possible for future research to start focusing on testing different interventions based on significant coping strategies. This could contribute in helping the mothers to manage their stress and consequently ensuring healthier mental well-being, which may not be as obvious as physical well- being. Recommendation can then be provided to ensure that mothers are able to safeguard both their physical and mental well-being, thereby ensuring a more positive overall well-being. The findings could also be an empirical basis in creating policies in Malaysia to support mothers who are the primary caregivers for their children.

1.4 RESEARCH QUESTION

Three research questions were addressed in this study:

1.3.1. Is there any relationship between parental stress and depression?

1.3.2. Is there any relationship between coping and depression?

1.3.3. How does coping influence the relationship between parental stress and depression?

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The objectives of this research are:

1.4.1. To examine the relationship between parental stress and depression.

1.4.2. To examine the relationship between coping and depression.

1.4.3. To examine the interaction between parental stress, coping and depression.

1.6 DEFINITION OF TERMS 1.6.1 Parental Stress

Parental stress is conceptually defined as the level of stress experienced by parents due to parents-child relationship (Abidin, 1990). In this research, parental stress is the stress that mothers experience due to the relationship with their ADHD child. Parental stress will be measured using Parental Stress Index-Short Form (PSI-SF) (Abidin, 1990). High scores represent high levels of stress experienced by the parents.

1.6.2 Coping

Coping can be conceptually defined as a continuous cognitive and behavioral effort to manage specific external and/or internal demands that are appraised as stressful (Lazarus, 1993). In this research, Brief COPE (Carver, 1997) is used to measure the coping resources used by the mothers. High scores of each coping strategy indicate a higher tendency to use the strategy.

1.6.3 Depression

Depression can be conceptualized as the negative measure of psychological adjustment experienced by an individual (Hackney & Sanders, 2003). This study

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operationally defined depression as the measures of the symptoms of depression as indicated in the DSM-5 through the use of CES-D (Radloff, 1977). High scores indicate the presence of high depressive symptoms.

1.7 CONCLUSION

In this chapter, the increase in the prevalence rate of children with ADHD was discussed. Caring for children with ADHD poses greater risk to mothers‘ mental health. Therefore, it is important to identify coping strategies that would be helpful for the mothers to manage their stress. The identification of the significant coping strategies would contribute theoretically and practically such that the application of Transactional Model of Stress (Lazarus & Folkman, 1987) will be tested within the population of mothers of children with ADHD, and the findings can help mothers identify practical coping strategies that could significantly reduce depression. The next chapter will focus on the reviews of past literature that are relevant to refining the current study.

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CHAPTER TWO LITERATURE REVIEW

2.1 INTRODUCTION

The chapter focuses on literature pertaining to the variables of interest in this study.

Those variables are parental stress, coping, and depression. The literature that was reviewed examined the relationship between parental stress and depression, coping and depression, and the interaction between parental stress, coping, and depression.

While the main focus of the review is on parents of children with ADHD, relevant research that focuses on parents of children with other mental disabilities or learning disabilities emphasizing similar variables is also considered.

2.1.1 ADHD: A Childhood Disorder

One of the most common references for childhood disorders is the Diagnostic and Statistical Manual, Fifth Edition by The American Psychiatric Association (2013).

The manual discusses various disorders which includes ADHD. The age of onset for ADHD is between 2 and 12 years old (American Psychiatric Association, 2013;

Kessler, Berglund, Demler et al., 2005; Spencer, Biederman, & Mick, 2007), which means that when a diagnosis is to be given to an adolescent or an adult that shows symptoms of ADHD, a history of symptoms presentation in the early developmental period is necessary to meet the full diagnostic criteria. This is similar to the diagnostic criteria of ADHD, in which several symptoms of inattentive and hyperactive- impulsive should be present before the age of 12 years old for an individual to be diagnosed with ADHD (American Psychiatric Association, 2013).

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ADHD symptoms can be categorized into predominantly inattention, predominantly hyperactivity and impulsivity, or a combined presentation in which both symptoms of inattention and hyperactivity and impulsivity are met (American Psychiatric Association, 2013). ADHD with predominantly inattention is characterized by difficulty in maintaining attention and concentration, disorganization, and distractibility symptoms; predominantly hyperactivity or impulsivity is characterized by symptoms of restlessness, motor and verbal excesses, and being impulsive; combined presentation is characterized by having both inattentive and hyperactive symptoms (Hogue, Dauber, Lichvar, & Spiewak,, 2014).

Previous studies have not found direct causes of ADHD, but agreed that it is the result of complex a interaction of multiple genes and multiple environmental factors (Sadek, 2014). Some of the contributors to the development of ADHD symptoms are genetic heritability, abnormalities in the frontal cortex that produces dopamine D4 and D5, mothers who smoke cigarettes or consume alcohol during pregnancy, mothers who are exposed to toxins such as pesticides and polychlorinated biphenyl, and low socio-economic status (Sadek, 2014).

The management of the externalizing symptoms, such as interrupting or intruding on others, using the belongings of others without permission, or climbing in situations where it is inappropriate are challenging for the parents (Wilens & Spencer, 2010). A plethora of research has shown a significant positive relationship between symptoms presentation and the level of stress experienced by the mothers (Graziano, McNamara, Geffken, & Reid, 2011; Heath, Curtis, Fan, & McPherson, 2014; Munoz- Silva et al., 2017; van Steijn et al., 2014; Wiener, Biondic, Grimbos, & Herbert, 2015). Furthermore, the symptoms were found to significantly impact mothers‘ social lives and couple‘s relationships, which then increase the level of stress (Graziano et

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al., 2011). The increased cost of living due to the treatment also increases the stress experienced by the mothers (Swensen et al., 2003). Those are some of the reasons that the level of stress experienced by mothers of children with ADHD are higher as compared to children who are typically developed (Deault, 2010; Fischer, Barkley, Fletcher & Smallish, 1993; Gupta, 2007; Johnston & Mash, 2001; Podolski & Nigg, 2001). The stress could then lead to various negative outcomes, with depression being one of them.

2.2 PARENTING STRESS AND DEPRESSION

Parental stress is defined as the experience of stress due to the role of being a parent (Deater-Deckard, 1998). Other terms have been used to denote parental stress, such as caregiver burden and caregiver strain. All these terms refer to the negative effect or stress experienced by the caregiver (Baronet, 1999; Chadda, 2014; Ohaeri, 2003;

Schulze & Rossler, 2005).

Larson, Yoon, Stewart, and dosReis (2011) used caregiver strain to explain the stress experienced by family caregivers of children with ADHD. In addition, caregiver burden was used in a research by Cadman et al. (2012) to explain the difficulties experienced by families with an ADHD child as the child transitions into adolescence and adulthood. Past studies have found that the parental stress experienced by mothers of children with ADHD is significantly higher than other groups (Baker & McCall, 1995; Gupta, 2007; van Steijn et al., 2013). An increase in parental stress is associated with the presence of various negative outcomes, in which numerous studies in the past found a significant association between parental stress and depression being one of the negative outcomes.

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Van der Oord, Prins, Oosterlaan and Emmelkamp (2006) conducted a study on parental stress, depressed mood, and informant agreement of symptoms presentation for ADHD and Oppositional Defiant Disorder (ODD), a disorder that tends to comorbid with ADHD. A total of 56 mothers, 9 fathers, and 67 teachers participated in the research. PSI was used to measure the stress experienced by parents, while the Center for Epidemiologic Studies-Depression (CES-D) was used to measure the level of depression. Although the aim of the research was to identify whether parental stress and depressed mood of the parents are predictors of parents‘ agreement with the diagnosis of ADHD and ODD symptoms from school teachers, preliminary analysis was run to identify the relationship between each variable. The analysis showed that there is a significant positive relationship between parental stress and depressive symptoms (r = .30, p < .05).

Beattie (2016) also found a significant relationship between parental stress and depression among mothers of children with ADHD in his study. The researcher was examining the various predictors associated with parental stress and negative mental health outcomes, namely anxiety and depression. In doing so, he also examined whether parental stress is significantly associated with depression, and found that an increase in parenting stress significantly increases levels of depression (r = .721, p <

.01). It was mentioned that 84 parents participated in the research, but the researcher did not specify how many were mothers, even though the researcher focused on mothers in the analysis. Additionally, the researcher also considered data from teachers during the data collection phase, and did not mention how the data was managed during the analysis phase. This does not reduce the reliability and validity of the findings, as the researcher stated the inclusion and exclusion criteria for the children with ADHD, and ensured that only parents who were able to read participated

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in the research. However, further improvement can be done by ensuring that only mothers are recruited to be part of a study to reduce confounding variables and errors.

The relationship between parental stress and depression can be clearly seen in a meta-analysis done by Theule et al. (2010). The researchers compiled past literatures in which quantitative research had been conducted on ADHD, ADHD symptoms and parental stress. Relevant past studies were obtained from PSYCInfo, ERIC, Medline, Dissertation Abstracts International, and Google Scholar, in which the descriptors of ADHD (i.e., attention deficit hyperactivity disorder, attention deficit disorder, hyperactivity, hyperkinesis, minimal brain dysfunction, behaviours problem) and parental stress (i.e., stress, caregivers burden) were used. A total of 117 studies were identified and further screened based on a number of inclusion criteria, such as quantitative studies that are available up to October 2007 with one or more variables or relationships of interest. Finally, 44 written reports that were found to fulfil all the inclusion criteria which generated 208 effect sizes on a sample of 4991 families were used to answer their research questions. One of the research questions relevant to the current research is the relationship between parental stress and mental health, in which mental health was defined by the existence of depressive symptoms among the participants. Most studies used the Parental Stress Index (PSI), PSI-Short Form (PSI—SF) or an adaptation of PSI to measure parental stress. Beck Depression Inventory (BDI) was used to measure depression, which is the main outcome of the meta-analysis. Theule and colleagues (2010) have found that there is a significant positive relationship between parental stress and depressive symptoms (r = .48, p <

.001). This shows that parents who are experiencing high parental stress are at risk of having more depressive symptoms, or in other words, poorer mental health.

Kulliyyah of

CHILDREN WITH ADHD IN THE KLANG VALLEY

THE RELATIONSHIP BETWEEN PARENTAL STRESS, COPING, AND DEPRESSION AMONG MOTHERS OF

ABSTRACT

ABSTRACT IN ARABIC

DECLARATION

INTERNATIONAL ISLAMIC UNIVERSITY MALAYSIA

ACKNOWLEDGEMENTS

TABLE OF CONTENTS

CHAPTER TWO: LITERATURE REVIEW ... 9

CHAPTER FOUR: RESULTS ... 39

REFERENCES ... 60

LIST OF FIGURES

1.2 STATEMENT OF THE PROBLEM

1.3 SIGNIFICANCE OF THE STUDY

1.4 RESEARCH QUESTION

7 1.5 RESEARCH OBJECTIVES

1.6.2 Coping

1.7 CONCLUSION

2.1.1 ADHD: A Childhood Disorder

2.2 PARENTING STRESS AND DEPRESSION