The Relationship Between Mental Health and Coping Strategies in Primary Caregivers of ADHD Patients

Abstract

Taking care of a child with attention-deficit hyperactivity disorder (ADHD) has been linked to emotional problems. However, using effective coping strategies positively impact the mental health of caregivers for children with ADHD. This study aimed to investigate the relationship between ADHD caregivers’ coping strategies and their mental health. This cross-sectional study was conducted with 84 caregivers of ADHD children. The Coping Response Inventory and the General Health Questionnaire were completed by them. In the caregivers studied, emotion-focused coping’s score was positively correlated with somatic symptoms (r = .45, p < .001), anxiety and insomnia (r = .52, p < .001), social dysfunction (r = .27, p < .05), and depression (r = .49, p < .001). Similarly, physical inhibition or somatization of problem’s score was positively correlated with somatic symptoms (r = .66, p < .001), anxiety and insomnia (r = .54, p < .001), social dysfunction (r = .32, p < .01), and depression (r = .36, p < .001). Our findings indicate that ineffective coping strategies can potentially increase mental health problems in caregivers of children with ADHD.

Keywords

caregivers attention-deficit hyperactivity disorder ADHD coping strategy mental health

Introduction

Attention-deficit hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders that begins in childhood and is characterized by excessive amount of inattention, impulsivity, and hyperactivity, which must be diagnosed before the age of 12 (Frank-Briggs, 2011). Nearly 63 million children and adolescents have this diagnosis worldwide (Polanczyk et al., 2015). Although it is diagnosed in childhood, its consequences often continue to adulthood (Wender et al., 2001). This serious and debilitating condition can lead to dysfunction in several life areas, including family, social, academics, and occupation (Widiger et al., 2013). Some symptoms such as response disinhibition, impaired attention, learning disability, impulsiveness cause persistent problems and negative mental health concerns for the caregivers of these children (Bussing et al., 2003). Disruptive behaviors among these children cause conflict within families that affect the structure and functions of the family and their excessive controls on the children’s behavior (Kashdan et al., 2004).

Caregiving is a normal part of parenting a young child but parents who care for children with ADHD experience problems related to childcare and high prevalence of mental disorders (Hamed et al., 2015). This essential need for improving problems within the family and broader systems of ADHD children has been discussed in the recent literature (Timimi, 2017). Compared with parents of neurotypical children, parents of children with ADHD experience stress, anxiety (Theule et al., 2013), and depression over time (Chou et al., 2021). This is especially true for mothers who play a more active role in caregiving (Theule et al., 2013). Sepehrmanesh’s (2017) survey showed that 58% of these mothers have mental health disorders and the most is anxiety, panic disorders, agoraphobia (Cappe et al., 2017; Mirzaaghas et al., 2014), as far as certain lifestyle issues are concerned, such as divorce (Mirzaaghas et al., 2014), internal restlessness, hostility, and concerns about their children’s current and future lives (Ambikile & Outwater, 2012). Furthermore, it has a pervasive impact on the mothers’ quality of life, their depression, parent–child relationship (Chen et al., 2014), and psychological burden scale (Balushi & Samir, 2017). No parenting stress difference was reported between mothers and fathers; however, it was found that parents of hyperactive girls reported less stress than parents of hyperactive boys (Theule et al., 2013).

Caregivers of children with ADHD can improve mental health using conscious, adaptive, and problem-oriented coping strategies rather than defensive and incompatible ones. In general, it has been determined that one of the personality traits that mediates the understanding of the intensity of tension and the ability to compromise with it is the way a person copes with their stress (Craig et al., 2020).

Parents of children with ADHD often feel overwhelmed by the challenges they face and seek support (İmren et al., 2013). It was shown that the stress and behavioral-emotional problems in the mothers of ADHD children were significantly higher than the normal group with mediation of coping strategies (Kimonis et al., 2019). Coping strategies have an effect on the relationship between parental stress and depressive symptoms (Theule et al., 2013). A positive significant relationship was shown between the child’s age and the use of problem-oriented coping strategies by parents. There was also a significant negative relationship between problem-oriented coping strategies and depression symptoms (Mustafa et al., 2021).

Problem-oriented coping strategies and social support are highly related to the low depressive symptoms of their mothers (Mustafa et al., 2021) and mental health of both caregivers (Chen et al., 2014). Mental health is influenced by the use of effective coping strategies.

In addition, emotion-focused coping strategies impacts physical symptoms, anxiety, social dysfunction, and depression (Shah et al., 2010). While mothers use more emotion-oriented strategies such as wishful thinking, distancing, avoidance, and positive reappraisal, fathers use problem-oriented strategies (Durukan et al., 2008). Caregivers who use problem-oriented solutions feel less burden (Picci et al., 2015).

Previous studies have shown that the caring of ADHD children has a stressful impact on the caregivers, which may cause different psychological problems. However, Iranian records show a dearth of studies on the types of coping strategies used by the caregivers of children with ADHD. We hypothesized that the type of coping strategies has different impacts on the mental health of caregivers of children with ADHD. This study aims to investigate the association between the types of coping strategies used and the development of depression, anxiety, social dysfunction, and somatic symptoms in the primary caregivers of children with ADHD living in Yazd city of Iran. We speculate that this association differs between caregivers of boys and girls. Findings of this study will add to the existing knowledge about the psychological issues among primary caregivers of children with ADHD in Yazd and identify caregivers who are at risk of developing mental illnesses due to their caregiving responsibilities.

Method

Procedure

In this survey, 84 caregivers of children with ADHD were selected by convenience sampling. The inclusion criterion for this study was the literacy of caregivers of ADHD children aged 4 to 10 years who provided informed consent, and the exclusion criteria were physical and psychiatric illness of caregivers and children and marital discord among parents.

In this research, caregivers of ADHD children referring to Imam Hossein counseling center were asked to complete the demographic form and Conners Hyperactivity Scale (parent form) at the same time after interview with clinical psychologist or psychiatrist. If the Conners form showed symptoms of ADHD in child, they were asked to complete Billings and Moos’s Coping Strategies Questionnaire and General Health Questionnaire-28 (GHQ-28).

Measures

Demographic Survey Checklist

This form includes all the personal information of the child and the caregiver. These characteristics include the child’s age, the child’s gender, the caregiver’s gender, the caregiver’s age, the treatment used until now, current treatment, the duration of ADHD disorder, the duration of the treatment, family history, and other comorbid disorders with this problem.

Coping Response Inventory

The Coping Response Inventory (CRI) has 32 items designed by Billings and Moos to investigate how individuals respond to stressful events (Billings & Moos, 1981). This questionnaire measures five types of coping strategies; problem-focused coping (three questions), emotion-focused coping (11 questions), coping based on the evaluation of the situation (five questions), coping based on physical inhibition or on the somatization of problems (nine questions), and coping based on achieving social support (four questions). Each 4-point scale, ranging from 0 to 3, was summed to show a total score of each subscale. Test–retest reliability coefficient of this questionnaire was .79, and the reliability for the subscales of it was 0.9 for problem-focused coping, 0.65 for emotion-focused coping, 0.68 for coping based on the evaluation of the situation, 0.9 for coping based on physical inhibition or on the somatization of problems, and 0.9 for coping based on achieving social support (Hosseni Ghadamgahi et al., 1998).

GHQ-28

Goldberg (1978) presented the 28-item form of the questionnaire that consists of four subscales (somatic symptoms, anxiety and insomnia, social dysfunction, and severe depression); each of them has seven questions. In Iranian population, the reliability coefficients assessed by test–retest and Cronbach’s alpha were of .70 and .90, respectively. The concurrent validity of the GHQ was conducted through simultaneous implementation with the Middlesex Hospital Questionnaire (MHQ) (correlation coefficient = .55; Taghavi, 2002).

Conners’ Parent Rating Scale–Revised: Short Version

This questionnaire was standardized by Conners et al. in 1991 (Conners, 1999). It is a 26-item scale that is completed by parents, and the following indicators are extracted from this scale: opposition-seeking problems, hyperactivity-impulsivity problems, attention-deficit problems, and hyperactivity index. The scoring is done on four levels (0 = never, 1 = just a little, 2 = a little much, 3 = very much). The minimum score obtained from this questionnaire in each subscale is 35 and the maximum score obtained is 90. It has been used to evaluate the severity of symptoms in this study. Tehrani Doost (2011) found that Conners’ Parent Rating Scale–Revised (CPRS) was a useful instrument to discriminate children with ADHD from typically developing individual in Iran.

Statistical Analysis

Sample size calculation was based on r = .3, the probability of Type 1 error and power to be .05 and .8, respectively. By this setting, at least n = 84 cases were needed to participate in this study. After completing these two questionnaires by the caregivers, the relationship between each of the coping strategies and mental health subscales was determined using Pearson’s correlation coefficient. Regression modeling was used to predict the impact of coping strategies on mental health. Independent t-test was also used to detect a significant difference between groups concerning the type of coping strategies. This study was approved by the ethical committee of Shahid Sadoughi University of Medical Sciences. The ethical code for this study is IR.SSU.REC.1394.27. This research was conducted in accordance with the ethical standards set forth in the 1975 Declaration of Helsinki and its subsequent amendments. Informed consent was obtained from the parents of the ADHD children.

Results

A total of 84 caregivers with mean age of 32.18 ± 5.35 years participated in this correlational and cross-sectional study. Caregivers were predominately women (n = 76, 88.4%) and with a diploma degree (n = 32, 37.2%). Most of the children were wanted child (n = 73, 84.9%) and boy (n = 66, 76.7%). Nearly 60% of the caregivers reported not having any family history of ADHD (Table 1).

Table 1.

Sociodemographic Characteristic of Caregivers and Children With ADHD Disorder (N = 84).

Variables	Category	n	%
Child’s sex	Boy	66	76.7
	Girl	18	23.3
Type of birth	Wanted	73	84.912.8
	Unwanted	11	84.912.8
Caregiver’s education	Illiterate	1	1.2
	Under diploma	25	29.1
	Diploma	32	37.2
	Bachelor	22	25.6
	Master &Upper	3	3.5
Caregiver’s sex	Male	8	9.3
	Female	76	88.4
		M	SD
Child’ age		8.30	2.14
Caregiver’s age		32.18	5.35
Onset age of disorder		4.75	2.19
Treatment duration		1.9	1.47

Pearson’s correlation coefficient was conducted to examine the relationship between each of the coping strategies and mental health subscales. This test revealed emotion-focused coping is positively correlated with somatic symptoms, anxiety symptoms, depression (p < .001), and social dysfunction (p < .05). Coping based on physical inhibition or on the somatization of problems is also correlated with somatic symptoms, anxiety, depression (p < .001), and social dysfunction (p < .01). Analysis based on caregivers’ sex is reported in Table 2.

Table 2.

Correlation Between Each of the Coping Strategies and Mental Health Subscales.

		Somatic symptoms		Anxiety and insomnia		Social dysfunction		Depression
Coping strategy’s sub-scales	Category	r	p−value	r	p−value	r	p−value	r	p−value
Problem−focused coping	Male	−.608	0.110	−0252	0.548	−0.858	0.006**	0.645	0.084
	Female	−0.193	0.118	−0.170	0.157	−0.235	0.064	−0.67	0.587
	Total	−0.178	0.124	−0.144	0.201	−0.218	0.064	−0.084	0.463
Coping based on the evaluation of the situation	Male	−0.699	0.080	−0.406	0.366	−0.588	0.165	−0.626	0.132
	Female	−0.021	0.870	0.061	0.614	0.032	0.803	−0.084	0.496
	Total	0.024	0.842	0.083	0.466	0.066	0.585	−0.058	0.614
Emotion−focused coping	Male	−0.056	0.895	−0.222	0.597	0.193	0.647	0.595	0.120
	Female	0.464	0.001***	0.506	0.001***	0.307	0.017*	0.472	0.001***
	Total	0.457	0.001***	0.522	0.001***	0.275	0.021*	0.497	0.001***
Coping based on achieving social support	Male	−0.398	0.329	−0.123	0.771	−0.538	0.169	−0.595	0.120
	Female	−0.045	0.717	−0.003	0.981	0.019	0.881	−0.035	0.772
	Total	−0.033	0.779	0.004	0.973	−0.022	0.857	−0.082	0.472
Coping based on physical inhibition or on the somatization of problems	Male	−0.431	0.286	−0.224	0.595	0.125	0.768	0.176	0.678
	Female	0.657	0.001***	0.538	0.001***	0.260	0.038*	0.376	0.001***
	Total	0.662	0.001***	0.544	0.001***	0.320	0.005**	0.368	0.001***

p < .05. **p < .01. ***p < .001.

Table 3 indicates that there is a significant difference between male and female caregivers in the use of some coping strategies. According to independent t test, the rates of emotion-focused coping (13.47 vs. 9.37) and coping based on physical inhibition or on the somatization of problems (6.36 vs. 2.87) were higher in female than male.

Table 3.

Comparison of Coping Strategies Between Two Sexes of Caregivers (Male and Female).

	Male	Female	p value
Coping strategy’s subscales	M (SD)	M (SD)	p value
Problem-focused coping	4.75 (2.05)	4.97 (1.63)	0.722
Coping based on the evaluation of the situation	7.71 (2.87)	9.12 (2.64)	0.185
Emotion-focused coping	9.37 (5.23)	13.47 (5.06)	0.033*
Coping based on achieving social support	9.00 (3.74)	10.98 (3.18)	0.103
Coping based on physical inhibition or on the somatization of problems	2.87 (2.41)	6.36 (6.64)	0.004**

p < .05. **p < .01.

Table 4 shows the correlation between the subscales of the coping strategy scale and GHQ separately among caregivers of hyperactive boys and hyperactive girls. As displayed in the table, emotion-focused coping as well as coping based on physical inhibition or on the somatization of problems is correlated with all subscales of GHQ in caregivers of boys with ADHD.

Table 4.

Relationship Between Coping Strategies and Mental Health in Caregivers of Girls and Boys.

		Somatic symptoms		Anxiety and insomnia		Social dysfunction		Depression
Coping strategy’s subscales	Sex	r	p value	r	p value	r	p value	r	p value
Problem−focused coping	Boy	−0.255	0.051	−0.259*	0.042	−0.149	0.277	−0.048	0.717
	Girl	0.126	0.631	0.135	0.582	−0.45	0.061	−0.189	0.439
Coping based on the evaluation of the situation	Boy	−0.024	0.860	0.031	0.816	0.132	0.343	−0.008	0.953
	Girl	0.183	0.482	0.199	0.414	−0.136	0.590	−0.189	0.438
Emotion−focused coping	Boy	0.463**	0.001	0.489**	0.001	0.286*	0.034	0.493**	0.001
	Girl	0.491	0.075	0.744**	0.001	0.161	0.567	0.555*	0.021
Coping based on achieving social support	Boy	−0.026	0.843	−0.022	0.864	−0.139	0.306	−0.065	0.618
	Girl	−0.122	0.653	0.144	0.568	0.147	0.575	−0.141	0.576
Coping based on physical inhibition or on the somatization of problems	Boy	0.668**	0.001	0.564**	0.001	0.416**	0.001	0.408**	0.001
	Girl	0.627**	0.001	0.478*	0.045	−0.095	0.708	0.190	0.451

p < .05. **p < .001.

Caregivers of boy and girls with ADHD have a significant difference in terms of coping based on achieving social support (t = 2.66, p = .009) (Table 5).

Table 5.

Differences in Coping Strategies Between Caregivers of Girls and Boys With ADHD Disorder.

Coping strategy’s sub-scales	Boy	Girl	p value
Coping strategy’s sub-scales	M (SD)	M (SD)	p value
Problem-focused coping	4.95 (1.66)	4.80 (1.70)	0.722
Coping based on the evaluation of the situation	9.08 (2.58)	8.65 (2.88)	0.531
Emotion-focused coping	13.35 (5.20)	11.76 (4.89)	0.259
Coping based on achieving social support	11.29 (3.22)	9.10 (2.82)	0.009*
Coping based on physical inhibition or on the somatization of problems	6.35 (4.62)	5.10 (4.22)	0.295

p < .01.

Based on the linear regression model, coping based on the evaluation of the situation, emotion-focused coping, and coping based on physical inhibition or on the somatization of problems had a significant effect on the GHQ level. It is expected that an increase of one unit in coping based on the evaluation of the situations can result in an increase of 2.21 of the GHQ score. In the same way, an increase of one unit in emotion-focused coping and coping based on physical inhibition or on the somatization of problems can result in an increase of 0.96 and 0.84 of the GHQ score, respectively (Table 6).

Table 6.

Regression Analysis for Prediction of GHQ Based on Coping Strategies.

Coping strategy’ subscales	B	SE	p value
Problem-focused coping	−2.733	1.395	0.059
Coping based on the evaluation of the situation	2.206	0.827	0.012
Emotion-focused coping	0.958	0.344	0.009
Coping based on achieving social support	−0.762	0.625	0.232
Coping based on physical inhibition or on the somatization of problems	0.837	0.384	0.037
Treatment duration	0.130	1.119	0.908

Discussion

ADHD is one of the most important topics in the field of children’s mental health, and so far, many studies have been conducted on the predisposing factors and treatment of this disorder. However, few studies have been conducted on the relationship between the mental health of the caregivers of these children and the coping strategies they use. The present study focused on this gap by examining the relationship between coping strategies and mental health in primary caregivers of children with ADHD in Iran. These findings provide a better understanding of the mental health status of caregivers and can help improve their well-being by creating a context for teaching effective coping strategies to caregivers.

In addition, this study examines the associations between the subscales of GHQ and coping strategies among caregivers of individuals with ADHD. Although in a previous study parents’ coping mechanisms among children with disability did not have a significant relationship with their distress (Cauda-Laufer, 2017), in the present study, significant positive correlation was found between emotion-focused coping and all subscales of the GHQ (somatic symptoms, anxiety and insomnia, social dysfunction, and depression) in ADHD caregivers. Although only a handful research examines the association of these two components among ADHD caregivers, our findings are consistent with previous studies on caregivers of children with HIV who reported high levels of daily stress and emotional coping styles (Bachanas et al., 2001). Lyons et al. (2010) also found a relationship between the emotion-focused coping strategies with more problems of parents of children with autism. It can be concluded that caregivers who use emotion-focused coping strategies when facing their child’s disorder are more susceptible to mental health problems.

Furthermore, there is a significant positive relationship between physical inhibition or somatization of problems and all the subscales of GHQ. While research has supported an association between optimistic assessment of stressors and positive mental health outcomes for caregivers of Alzheimer’s patients (Goode et al., 1998), to our knowledge, we are the first to examine the association of this subscale of coping strategies with mental health of caregivers of children with ADHD in Iran. Our finding that emotion-focused coping strategies are associated with all subscales of GHQ among female caregivers is supported by the research by Woodman and Hauser-Cram (2013). They found that mothers of adolescents with developmental disabilities use emotional coping strategies such as behavioral/mental disengagement and it is related to more depressive symptoms among mothers (Woodman & Hauser-Cram, 2013). Moreover, workshops on manageability of mothers of hyperactive children impact reduction of the emotion-oriented coping strategies (Srebnicki & Wolańczyk, 2019). Our results expand these findings, by assessing this type of coping strategy and its relationship with all subscales of GHQ among primary caregivers. In our research, a significant positive relationship was also found between the somatization coping strategies and all subscales of mental health among female caregivers, which shows that female caregivers show the stress of parenting in a physical way, which leads to mental health problems.

Examining the child’s gender in caregivers’ use of a coping strategy was suggested by Gomes et al.’s research, which showed that most caregivers of people with mental and developmental disabilities use confrontation, withdrawal, self-control, social support, acceptance, and escape (Silva et al., 2022). However, these findings were not precisely differentiated regarding the gender of the child. In the current study, caregivers of boys were found to use social support more. It can be explained that the family with an ADHD daughter tries to mask or hide this disorder due to its stigma (Chang et al., 2020).

In a prospective cohort study, the relationship between mother’s stress, boy’s ADHD symptoms, and their quality of life was investigated, and the results showed that mother’s stress was associated with more severe ADHD symptoms and decreased quality of life of boys with ADHD (Evans et al., 2020), but this research did not focus on the coping style of mothers on their mental health. Therefore, in the current study, this study gap has been resolved to a large extent, and the relationship between parents’ coping strategies and their mental health has been carefully investigated with regard to children’s sex.

Studies on the regression between these two scales are scarce. Despite the belief that accessibility of emotional support is a significant predictor of perceived stress in caregivers of children with learning disabilities (Isa et al., 2017), we found that coping based on the evaluation of the situation, emotion-focused coping, and coping based on physical inhibition or on the somatization of problems have a significant effect on the GHQ score. This means a better understanding of caregivers’ coping strategies can predict the mental health outcomes of this group, which provide implications for intervention in this domain.

Major strength of our study was a strong association which was found between coping strategies and mental health among ADHD caregivers in Yazd. Therefore, we can establish preventive intervention on this basis for these caregivers and also control for other psychiatric disorders that have been indicated as potential confounders in previous research too (Balushi & Samir, 2017). Due to relatively large number of individuals diagnosed with ADHD, the results of our study can help them for having a better mental health. Continuing research in this area may provide valuable feedback for primary caregivers about optimal coping strategies in the face of ADHD child. In addition, these findings may have implications for appropriate intervention with parents with high scores on GHQ subscales.

Limitations and Recommendation for Further Research

Interpretation of the results should be done with the following limitations in mind. First and foremost, insufficient sample size for male caregivers. Another important one is the reliance on correlational data. An experimental design in further study will lead to the causality inferences. Perhaps, future study should consider studying other normal children to be compared with ADHD group.

Implications for Practice

Caregiving for children with ADHD needs to demonstrate an awareness of the power relations inherent in any diagnostic process and make attempts to address these at both the individual and sociocultural levels. This study, with a practical focus, will help in health nursing practice among ADHD children’s caregivers (particularly among female caregivers) by emphasizing their abilities, such as effective coping styles, rather than solely focusing on the psychiatric diagnosis and their mental health problems. Considering the impact of dysfunctional coping strategies as a risk factor for mental health, psychologists should implement preventive intervention especially female ones. Moreover, Emotionally Focused Family Therapy (EFFT) can be an effective treatment due to the high prevalence of emotion-focused coping among caregivers. EFFT is an innovative transdiagnostic approach to treating mental health issues across the lifespan, emphasizing the healing power of caregivers. EFFT can be utilized to address various behavior- or emotion-based disorders. The primary goal of EFFT is to empower parents, partners, and other caregivers to enhance their role in promoting the health and well-being of their loved ones, especially their children. One of the key strengths of the EFFT approach is that clinicians can guide caregivers in providing home-based support, even when their loved ones refuse or are unable to access services.

Conclusion

Our findings suggest that a significant proportion of primary caregivers of children with ADHD are their mothers who tend to use more emotion-focused coping strategies. These coping strategies can have considerable effects on their mental health. Based on our research, it can be concluded that this type of treatment primarily affects female caregivers. To better understand male caregivers, further research is needed with a larger sample size.

Footnotes

Acknowledgements

We would like to express our gratitude to all the participants for their cooperation in the data collection process. We are especially indebted to Bahaur Amini, who provided feedback as a native English speaker.

Correction (December 2024):

In the published version of the article, the city “Shiraz” was inadvertently omitted from Mina Bozorg’s affiliation. This has now been corrected, and the article has been updated online to reflect this change.

Disposition editor: Cristina Mogro-Wilson

Author Contributions

Bonnie Bozorg, Samira Shayegh, and Mohammad Nadi Sakhvidi participated in the design of the study. Mina Bozorg conducted literature search, and drafted the manuscript. Mahshid Namdari assisted in data analysis and critically reviewed the original manuscript. Tahereh Abbaslou wrote the primary draft of manuscript. Tahereh Sadeghiyeh helped in collecting data. All the authors have approved the final manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Bonnie Bozorg

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