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Parenting children with ADHD : associations with parental ADHD and depression Smit, Sophie 2018

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     PARENTING CHILDREN WITH ADHD:  ASSOCIATIONS WITH PARENTAL ADHD AND DEPRESSION by  SOPHIE SMIT  BSW, University of the Fraser Valley, 2014 BA (Honours), University of the Fraser Valley, 2015   A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF  THE REQUIREMENTS FOR THE DEGREE OF  MASTER OF ARTS   in   THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES  (Psychology)     THE UNIVERSITY OF BRITISH COLUMBIA  (Vancouver)   August 2018   © Sophie Smit, 2018   ii  The following individuals certify that they have read, and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance, the thesis entitled:    Parenting children with ADHD: Associations with parental ADHD and depression   submitted by   __Sophie Smit________ ________  in partial fulfillment of the requirements for   the degree of   __Master of Arts____________________________________________________  in                     __Psychology______________________________________________________  Examining Committee:  Amori Yee Mikami, Psychology Supervisor  Charlotte Johnston, Psychology Supervisory Committee Member  Kiley Hamlin, Psychology Supervisory Committee Member   iii  Abstract  Considerable research documents parents’ difficulty parenting children with Attention-Deficit/Hyperactivity Disorder (ADHD). In addition to the stress associated with parenting a child with ADHD, many parents experience their own symptoms of ADHD and depression. Research has found that parental ADHD and depression affect parenting behaviours, however, the incremental and interactive effects have rarely been considered in the same study. Further, there is inconsistent consideration of oppositional behaviours in children with ADHD, a common comorbidity known to contribute to non-optimal parenting. A parent’s perceived and internalized stigma about their child’s ADHD symptoms, called affiliate stigma, may also be associated with parental psychopathology and parenting behaviours. This study examines the incremental and interactive influence of parental ADHD symptoms and parental depressive symptoms on parenting behaviours and affiliate stigma. It further examines affiliate stigma as a mediator for the relationship between parental depressive symptoms and parenting behaviours.  Participants were 216 parents of children with ADHD. Parents self-reported their ADHD and depressive symptoms, parenting behaviours, and affiliate stigma. Teachers and parents rated child oppositional behaviours. A parent-child interaction task with a smaller sample (n = 142) was also coded for parenting behaviours.   Results revealed that parental depressive symptoms predicted fewer self-reported positive parenting behaviours after controlling for parental ADHD symptoms and child oppositional behaviours. Parental depressive and ADHD symptoms were predictive of more self-reported negative parenting after controlling for child oppositional behaviours and the other psychopathology. An exploratory interaction effect was found, whereby parental ADHD symptoms predicted more self-reported negative parenting when depressive symptoms were low. iv  Parental ADHD and depressive symptoms initially predicted self-reported unstructured parenting, but this association was not significant after controlling for the other psychopathology. Parental ADHD and depressive symptoms did not predict observed parenting behaviours. Although parental depressive symptoms predicted higher levels of affiliate stigma, affiliate stigma did not mediate the relationship between parental depressive symptoms and parenting behaviours.    Findings suggest that parental ADHD and depressive symptoms may have some similarities and also differences in their associations with parenting. Importantly, future research, assessment, and treatment of families with children with ADHD should consider the potential effects of both psychopathologies.   v  Lay Summary This study aimed to further our understanding of how parent mental health (specifically symptoms of depression and ADHD) may be associated with parenting behaviours in families of children with ADHD. It further examined whether these mental health concerns influenced affiliate stigma, or parents’ perceptions that others are judging them negatively because of their child’s behaviour. I found that parents who reported higher levels of depressive symptoms also reported engaging in fewer positive parenting behaviours, and having higher levels of affiliate stigma, over and above the contribution of ADHD symptoms. I further found that parents’ higher levels of ADHD symptoms and higher levels of depressive symptoms were both associated with increased parental reports of negative parenting behaviours. Interestingly, the association between ADHD symptoms and negative parenting was significant only for parents with low depressive symptoms. Findings suggest that parental depression and ADHD may influence parenting behaviours in different ways.   vi  Preface This thesis is submitted in partial fulfillment of the requirements for Master of Arts in Psychology at the University of British Columbia. My research supervisor is Dr. Amori Mikami, who is the principal investigator of the Peer Relationships in Childhood Lab. The identification and design of the research program, the writing of the thesis, and the data analysis has been made solely by the author. Dr. Mikami acted as project supervisor and assisted with study design and data interpretation. I have done my best to provide references to the sources that I have cited in my writing. The data used in the study was collected as part of a larger study conducted by Dr. Mikami, which was approved by the Behavioural Research Ethics Board of the University of British Columbia (approval certificate number: H13-00404). The project reported in this thesis was approved by the Behavioural Research Ethics Board of the University of British Columbia (approval certificate number: H17-02234).  vii  Table of Contents Abstract .......................................................................................................................................... iii Lay Summary .................................................................................................................................. v Preface............................................................................................................................................ vi Table of Contents .......................................................................................................................... vii List of Tables ................................................................................................................................. ix List of Figures ................................................................................................................................. x Acknowledgements ........................................................................................................................ xi Introduction ..................................................................................................................................... 1 Parenting in Families of Children with ADHD ........................................................................... 2 Psychopathology in Parents of Children with ADHD ................................................................ 4 Behaviour Problems in Children with ADHD ............................................................................ 5 Parental ADHD and Parenting Behaviours ................................................................................. 5 Parental Depression and Parenting Behaviours ........................................................................ 12 Parent Psychopathology and Affiliate Stigma .......................................................................... 14 Interaction Effects between Parental ADHD and Depression .................................................. 16 The Current Study ..................................................................................................................... 17 Study Hypotheses ...................................................................................................................... 18 Method .......................................................................................................................................... 20 Participants ................................................................................................................................ 20 Procedure ................................................................................................................................... 20 Measures.................................................................................................................................... 22 Data Analytic Plan .................................................................................................................... 27 Results ........................................................................................................................................... 30 Descriptive Statistics ................................................................................................................. 30 Dimensions of Parenting Behaviours ........................................................................................ 31 Hypothesis 1: Parental ADHD and Parenting Behaviour ......................................................... 32 Hypothesis 2: Parental Depression and Parenting Behaviour ................................................... 32 Exploratory Analyses ................................................................................................................ 33 Discussion ..................................................................................................................................... 35 Positive Parenting Behaviour .................................................................................................... 35 Negative Parenting Behaviour .................................................................................................. 37 viii  Unstructured Parenting Behaviour ............................................................................................ 39 Observed Parenting Behaviour.................................................................................................. 41 Affiliate Stigma ......................................................................................................................... 42 Similarity-Fit and Similarity-Misfit .......................................................................................... 44 Strengths and Limitations.......................................................................................................... 45 Clinical Implications ................................................................................................................. 47 Future Directions ....................................................................................................................... 49 Conclusion ................................................................................................................................. 51 References ..................................................................................................................................... 64 Appendices……………………………………………………………………………………………… 76 Appendix A: Parent-Child Coaching Task Script Excerpts .................................................... 766 Appendix B: Current Symptoms Scale (CSS)......................................................................... 788 Appendix C: Alabama Parenting Questionnaire (APQ) ........................................................... 80 Appendix D: Parenting Scale .................................................................................................... 84 Appendix E: Summary of Relevant Codes from the Parent-Child Coaching Task .................. 88 Appendix F: Affiliate Stigma Questionnaire ............................................................................ 89    ix  List of Tables Table 1: Demographics of Sample………………………………………………………………..52 Table 2: Descriptive Statistics of Study Variables………………………………………………..54 Table 3: Principle Components Analysis of Parenting Variables………………………………...56 Table 4: Correlation Matrix of Study Variables…………………………………………………..57 Table 5: Parental ADHD Symptoms as a Predictor of Parenting Behaviours…………………….58 Table 6: Parental Depressive Symptoms as a Predictor of Parenting Behaviours………………...59 Table 7: Parental ADHD Symptoms as a Predictor of Affiliate Stigma…………………………..60 Table 8: Parental Depressive Symptoms as a Predictor of Affiliate Stigma………………………61    x  List of Figures Figure 1: Affiliate Stigma Mediation Model…………………………………………………….62 Figure 2: Interaction Effect between Parental ADHD and Depressive Symptoms on Negative Parenting Behaviours…………………………………………………………………………….63   xi  Acknowledgements I am incredibly thankful for the mentorship and continuous support from my supervisor, Dr. Amori Mikami, in this project and everything else over the past two years. I feel very lucky to have a supervisor who inspires a passion for research and clinical work, but who also recognizes the importance of a balanced life.  I also extend my gratitude to my committee members, Dr. Charlotte Johnston and Dr. Kiley Hamlin, their questions and suggestions have been essential in the drafting of this thesis.  I also feel exceedingly lucky to be part of a wonderful cohort, Kate Kysow, Alex Terpstra, and Ali Tracy, their friendship and support has both motivated me and allowed me to keep perspective. I am also grateful to be a part of the Peer Relationships in Childhood Lab, which has been an incredibly welcoming and encouraging place. I’m particularly thankful for the grad students, who have provided me with advice and support through the last two years. Finally, my accomplishments would not have been possible without the support of my family and friends. I thank my mom, who always encouraged me to work hard, and my dad, who taught me the value of kindness. Lastly, I thank Kevin York, who continues to be the best partner I could ever hope for, his support means the world to me.    1  Introduction  Considerable research documents that families of children with Attention-Deficit/Hyperactivity Disorder (ADHD) have difficulties with family functioning and parenting (Johnston & Mash, 2001). Children with ADHD are also likely to struggle in their development, both socially and academically (Barkley, 1998). Therefore, it is important that parents engage in the task of parenting children with ADHD in ways that support children’s optimal development, given the known influences of parenting practices on children’s behaviour and adjustment (Collins, Maccoby, Steinberg, Hetherington, & Bornstein, 2000).  Compounding the difficulties of parenting a child with ADHD is that many parents of children with ADHD have elevated levels of psychological problems themselves (Johnston & Mash, 2001). As ADHD is a highly heritable disorder, a child with ADHD is likely to have a parent with ADHD (Johnston & Mash, 2001; Johnston, Mash, Miller, & Ninowski, 2012). In addition, depression affects many adults, and it is a particularly common comorbidity among adults with ADHD (Chronis et al., 2003; Kessler et al., 2006). Numerous studies have demonstrated the negative effects that parental ADHD and depression can have on parenting behaviours (Modesto-Lowe, Danforth, & Brooks, 2008), as well as on children’s developmental outcomes (Berg-Nielsen, Vikan, & Dahl, 2002; Breaux, Harvey, & Lugo-Candelas, 2014). However, an interesting question is whether parental ADHD and depression are incrementally or interactively associated with parenting behaviours, as many studies do not assess both types of parental psychopathology, or look at them both as unique predictors.   An additional relevant concern is parental affiliate stigma, which is a parent’s internalization of perceived stigma related to the child’s behaviour. Affiliate stigma has been found to relate to more negative parenting in samples of parents of children with ADHD 2  (Mikami, Chong, Saporito, & Na, 2015). Importantly, the experience of affiliate stigma may be influenced by the presence of parental ADHD or depressive symptoms. The current study aimed to examine the unique contributions of parental ADHD and depressive symptoms on parenting behaviour and affiliate stigma in a sample of parents of children with ADHD. This study also examined affiliate stigma as a potential pathway via which parental psychopathology influences parenting behaviour. Understanding the contributions of parental ADHD and depressive symptoms on parenting behaviour and affiliate stigma may help children with ADHD receive optimal parenting to support their academic and social functioning (Tarver, Daley & Sayal, 2014).  Parenting in Families of Children with ADHD  There are three types of parenting behaviour commonly researched in the literature on families of children with ADHD: positive parenting, negative parenting, and unstructured parenting. Positive parenting refers to a parent’s level of involvement and engagement with the child, warmth toward the child, and praise of the child. Negative parenting involves a parent’s tendency to criticize the child, attempts to control the child, and to be hostile or over-reactive in response to the child. Lastly, a parent who is unstructured in parenting has difficulty with supervision, is inconsistent with discipline, and does not offer clear or helpful behavioural instruction to support the child.  It is likely that optimal child outcomes and adjustment are encouraged when parents engage in positive behaviours, minimize negative behaviours, and provide structure. For example, positive parenting has been found to act as a protective factor for children with ADHD, as higher levels of praise and engagement were associated with better child psychosocial functioning (Healey, Flory, Miller, & Halperin, 2011). Further, negative parenting was found to 3  be associated with home, homework, and social impairment in children with inattentive ADHD symptoms (Haack, Villodas, McBurnett, Hinshaw, & Pfiffner, 2016). Lastly, parental inconsistent discipline and an inability to structure a child’s behavior have been associated with child behaviour problems, including ADHD and Oppositional Defiant Disorder (ODD; Lindahl, 1998). In summary, positive, negative, and unstructured parenting behaviours appear to influence the outcomes of children with ADHD (Johnston & Mash, 2001; Tarver, Daley, & Saval, 2015).  As a group, parents of children with ADHD are less likely to engage in optimal levels of positive, negative, and unstructured parenting behaviours as compared to parents of typically developing children (Johnston & Mash, 2001; Modesto-Lowe et al., 2008). Parents of children with ADHD are also more likely to report lower parenting competence, satisfaction, and efficacy (Johnston & Mash, 2001). Specifically, parents of children with ADHD tend to engage in less positive parenting behaviours, such as providing warmth and reward, or being involved and responsive (Alizadeh, Applequist, & Coolidge, 2007; Ellis & Nigg, 2009; Johnston & Mash, 2001). They may also engage in more negative parenting behaviours, such as being overcontrolling, over-reactive, and critical (Johnston & Mash, 2001), and may use more physical discipline (Alizadeh et al., 2007). Lastly, these parents have been found to be less consistent with their discipline (Ellis & Nigg, 2009) and to provide less structure and poorer quality scaffolding when teaching tasks to their children (Johnston & Mash, 2001; Winsler, 1998).  In summary, parents of children with ADHD are at higher risk for engaging in parenting behaviours that are less than optimal. This is influenced by the objective difficulty of their children’s behaviours, which make the task of parenting a child with ADHD considerably more challenging than parenting a typical child (Johnston & Mash, 2001; Johnston et al., 2012; Modesto-Lowe et al., 2008). However, parents’ own psychopathology, which may be 4  exacerbated by the stress of raising a child with ADHD, may also be contributing to their difficulties in parenting.  Psychopathology in Parents of Children with ADHD Unfortunately, parents of children with ADHD are more likely to experience their own ADHD and depressive symptoms. ADHD is a highly heritable disorder; parents of children with ADHD have an increased risk of adult ADHD, independent of child externalizing behaviour problems (Chronis et al., 2003; Johnston & Mash, 2001). Between 25-50% of families of children with ADHD have at least one parent reporting significant ADHD symptoms themselves (Chronis et al., 2003; Johnston et al., 2012; Takeda et al., 2010). Regarding depression, Chronis et al. (2003) found that 43% of mothers of children with ADHD and comorbid ODD (and 37% of mothers of children with ADHD and no comorbidities) reported the presence of a mood disorder over their lifetime. This is in contrast to the 22% of comparison mothers reporting a mood disorder over their lifetime. Similarly, Johnston and Mash (2001) state that there is an elevated risk of depression when a parent has a child with ADHD, and the likelihood of parental depression is elevated again when the child also has co-occurring externalizing behaviours such as ODD. Finally, among adults, depression has also been found to be highly comorbid with ADHD (Kessler et al., 2006).   The increased likelihood of parental ADHD and depressive symptoms in families of children with ADHD is a further concern for parenting behaviours and child outcomes. Parental psychopathology has been found to be associated with children’s social and emotional maladjustment (Berg-Nielsen et al., 2002; Breaux et al., 2014), and is a significant predictor of developmental outcomes for children with ADHD (Deault, 2010). The elevated levels of ADHD and depressive symptoms for parents of children with ADHD increase the likelihood of poor 5  parenting. However, ADHD and depressive symptoms are distinct psychopathologies, and therefore may impact parenting in different ways. The current study assessed the unique associations between these parental psychopathologies and parenting behaviours.  Behaviour Problems in Children with ADHD Parenting behaviour, like any social interaction, is affected by reciprocal influences from both parties involved. Therefore, any study examining the contribution of parental psychopathology to parenting practices must also consider the influence of child behaviour problems on these practices. As discussed above, a child’s inattentive and hyperactive/impulsive symptoms of ADHD are stressful for the parent and may elicit poorer parenting practices (Johnston & Mash, 2001; Modesto-Lowe et al., 2008). In addition, childhood ADHD is highly comorbid with externalizing behaviour problems such as ODD (Johnston & Mash, 2001), which is characterized by arguing, defiance, and angry outbursts.  Some research suggests that poor parenting behaviours are more likely to occur in response to children’s comorbid ODD behaviours as opposed to children’s ADHD symptoms (Johnston & Mash, 2001; Johnston et al., 2012). Specifically, previous research indicates that child ODD is associated with negative parenting, more so than child ADHD (Burke, Pardini, & Loeber, 2008; Deault, 2010; Johnston, Murray, Hinshaw, Pelham, & Hoza, 2002; Modesto-Lowe et al., 2008). Therefore, children’s comorbid oppositional behaviours are highly pertinent to consider when examining parenting in a sample of children with ADHD. This study controlled for child behavior problems to more accurately assess the associations between parental psychopathology and parenting behaviours. Parental ADHD and Parenting Behaviours 6   Among families of children with ADHD, research has thus far indicated that parental ADHD symptoms tend to be associated with more parenting struggles. However, this research has been inconsistent in taking into account parental depressive symptoms as well as children’s oppositional behaviours. Another relevant consideration is the similarity-fit hypothesis (Psychogiou, Daley, Thompson, & Sonuga-Barke, 2008), which posits that increased levels of parental ADHD when children also have ADHD is beneficial for parenting, as similarity in parent and child behaviour leads to less conflict and more parental empathy (Psychogiou, Daley, Thompson, & Sonuga-Barke., 2007). Below, I review studies assessing the association between parental ADHD and positive, negative, and unstructured parenting in samples of children with ADHD. How existing findings align with the similarity-fit hypothesis is also briefly addressed.   Positive parenting. Associations between parental ADHD and positive parenting have been inconsistent. One study by Chen and Johnston (2007) found that maternal inattentive symptoms were negatively associated with parental involvement, and impulsive symptoms were negatively associated with positive reinforcement. This finding was obtained after statistical control of parental depression and child behaviour problems. However, only 10% of children in this sample were diagnosed with ADHD.  Chronis-Tuscano et al. (2008), in a sample of mothers with children with ADHD, found an initial relationship between maternal ADHD symptoms and lower levels of self-reported involvement and positive parenting, as well as lower observed positive parenting in a structured task. However, after statistical control of child ODD diagnosis, the negative association between ADHD symptoms and observed positive parenting became non-significant. Child ODD diagnosis was not controlled for in regressions predicting self-reported indicators of positive parenting.  7  Other studies found no relationship even with no statistical control of relevant variables. In a comparison of 30 mothers with ADHD to 30 mothers without ADHD, Murray and Johnston (2006) found no differences between the groups on measures of positive parenting, both with and without controlling for child oppositional behaviours, parental depression, and parental anxiety. Further, Wymbs et al. (2017) found no associations between parental ADHD symptoms and positive parenting in sample where the majority of parents had a child with ADHD.   In summary, the literature thus far on parental ADHD and positive parenting is inconsistent, a sentiment echoed by Johnston et al. (2012) in their review on parenting with ADHD. In addition, any negative association between parental ADHD and positive parenting may become non-significant after controlling for child ODD.   Negative parenting. Parental ADHD symptoms and negative parenting have been found to be associated in some studies. In the study by Chronis-Tuscano et al. (2008), maternal ADHD symptoms were associated with higher levels of observed negative parenting in a free play task (but not in a structured task). This association held after controlling for child ODD. As parental depressive symptoms were not found to be associated with observed behaviour, they were not used in analysis and the authors concluded that the relationship between maternal ADHD symptoms and negative parenting was not accounted for by depressive symptoms. Further, a recent meta-analysis found parental ADHD symptoms to be significantly associated with harsh parenting; neither parental depression nor child ODD moderated this association (Park, Hudec, & Johnston, 2017).  Other studies have found these significant associations to disappear after controlling for various variables. Harvey, Danforth, Eberhardt Mckee, Ulaszek, and Friedman (2003) found fathers’ symptoms of ADHD to be positively associated with self-reported over-reactivity and 8  observed arguing during a parent-child interaction where all parents had a child with ADHD. However, these relationships were no longer significant after controlling for parental depression and alcohol use. In addition, the Chen and Johnston (2007) study found maternal inattentive and impulsive symptoms to be initially correlated with over-reactive parenting; however, this was no longer significant after controlling for other variables, including parental depression and child behaviour problems. At the bivariate level, there are mixed results across studies. Johnston, Scoular, and Ohan (2004), in a sample where all mothers had a child with ADHD, found that mothers’ hyperactive/impulsive symptoms were positively correlated with over-reactive parenting. However, in the Wymbs et al. (2017) study, there were no bivariate associations between parental ADHD symptoms and negative parenting behaviours. Overall, the research appears to indicate that there is a positive association between parental ADHD and negative parenting behaviours, but this relationship may not be significant after controlling for other variables. Further consideration of both positive and negative parenting behaviours is offered below in conjunction with the similarity-fit hypothesis.   Structured parenting. In their review paper, Johnston et al. (2012) conclude that parents with ADHD symptoms are likely to have difficulties with family organization, monitoring of child behavior, and parental problem solving, as well as with consistent and appropriate discipline. All of these practices are indicators of unstructured parenting. They note that these associations typically hold when potential confounds are included as statistical controls, particularly comorbid parent and child psychopathologies. The Chen and Johnston (2007) study found that maternal inattention symptoms were positively associated with inconsistent discipline, even after controlling for parental depression and child behaviour. Murray and Johnston (2006) 9  found that mothers with ADHD self-reported having fewer routines, being more inconsistent, and monitoring their child less, compared to mothers without ADHD. This finding held after controlling for other forms of maternal psychopathology and child oppositional behaviours. In addition, a recent meta-analysis found parental ADHD symptoms to be significantly associated with lax parenting; neither parental depression nor child ODD moderated this association (Park et al., 2017). Some studies have found that associations between parental ADHD and unstructured parenting do not remain after controlling for relevant variables. In the study by Harvey et al. (2003), fathers’ and mothers’ symptoms of ADHD were associated with more self-reported lax parenting. However, the only association to remain significant after depression and alcohol use was controlled for was the association between fathers’ inattentive symptoms and lax parenting. The Chronis-Tuscano et al. (2008) study found that maternal ADHD symptoms were related to inconsistent discipline. However, after controlling for maternal depression this relationship was only significant at the p < .10 level. In the Johnston et al. (2004) study, mothers’ hyperactive/impulsive symptoms were positively correlated with lax parenting, however, they did not control for parental depressive symptoms or child behaviours. In summary, some research finds the association between parental ADHD and unstructured parenting to fade after controlling for relevant variables. However, overall the literature indicates that parental ADHD is associated with a parent’s increased likelihood of being unstructured in parenting.  Similarity-fit hypothesis. The similarity-fit hypothesis, as described by Psychogiou et al. (2007, 2008), speculates that when both children and parents have ADHD, the parent is able to empathize with the child and therefore engage in more positive and less negative parenting, as 10  compared to a parent without ADHD interacting with the same child. The similarity-misfit hypothesis states the opposite: parental ADHD will negatively impact parenting behaviours and this is exacerbated when children also have ADHD. There are mixed results in the similarity- fit/misfit literature at this time. Some studies suggest that parent and child ADHD symptoms interact and amplify parenting difficulties, while others indicate that the similarity between parent and child leads to a buffering of parenting deficits (Johnston et al., 2012).   In support of the similarity-fit hypothesis, Psychogiou et al. (2008) found that mothers with high levels of ADHD symptoms self-reported more positive parenting behaviours and were observed to be more affectionate to their child with ADHD compared to parents with low ADHD symptoms. Psychogiou et al. (2007) found that mothers with high ADHD symptoms self-reported engaging in fewer negative parenting practices. However, they also found that fathers with higher levels of ADHD symptoms engaged in more self-reported negative parenting practices. The authors speculate that perhaps mothers with similar symptoms have more empathy for their children, while fathers are more likely to become overwhelmed. These results were found after controlling for child behaviour problems and parental depressive symptoms.  Some support for the similarity-fit hypothesis also comes from Johnston, Williamson, Noyes, Stewart, and Weiss (2016). Parents with more ADHD symptoms were found to have similar levels of self-reported empathy regardless of child ADHD status, while parents with few symptoms had less empathy for children with ADHD. However, in support of similarity-misfit, higher levels of paternal ADHD symptoms were associated with lower tolerance of child behaviour. Child externalizing behaviours were controlled for in these analyses. In addition, Wymbs et al. (2017) found that higher levels of child ADHD/ODD behaviours, mother ADHD, and father ADHD predicted observed positive communication in parent-child interactions. 11  However, they also found support for the similarity-misfit hypotheses; having only one parent with elevated levels of ADHD is predictive of more negative parenting and communication between both parents and the child. Further support for the similarity-fit hypothesis comes from Griggs and Mikami (2011). They found that parental ADHD symptoms were associated with lower levels of observed irritability toward children with ADHD, and this relationship was not found for parents of comparison children. Summary. Research thus far on parental ADHD and parenting behaviours has been inconsistent and even conflicting. It would appear that parental ADHD does contribute to more unstructured parenting behaviours, which may be explained by the inattentive and hyperactive/impulsive symptoms of ADHD that make organization and consistency difficult. However, associations with positive and negative parenting behaviour are less straightforward.  Research indicates a potential negative association between parental ADHD and positive parenting. This is contrary to some similarity-fit findings where parental ADHD symptoms in samples of children with ADHD are found to be associated with positive parenting behaviours (Psychogiou et al., 2008; Wymbs et al., 2017). Research on negative parenting behaviour also appears inconsistent. Positive associations between parental ADHD and negative parenting behaviours have been found along with some support for the similarity-misfit hypothesis (Johnston et al., 2016; Psychogiou et al., 2007; Wymbs et al., 2017). However, the similarity-fit hypothesis has support as well, finding that parents with high ADHD symptoms are engaging in more positive parenting or less negative parenting compared to parents with low ADHD symptoms (Psychogiou et al., 2007; Psychogiou et al., 2008). These unclear findings are exacerbated by the irregularity in which parental depressive symptoms and child oppositional behaviours are controlled for in analyses.  12  Parental Depression and Parenting Behaviours  As noted, parental depression occurs often in parents of children with ADHD (Chronis et al., 2003), and is also highly comorbid with adult ADHD (Kessler et al., 2006). Parental depression has been linked to poor child outcomes, and one proposed mechanism through which this occurs is parenting (Lovejoy, Graczyk, O’Hare, & Neuman, 2000). Generally, depression has been found to be linked to higher levels of negative parenting and lower levels of positive parenting behaviours. This section reviews studies examining the effects parental depression may have on parenting behaviour in samples of parents of children with ADHD.  Positive parenting. Most research on parental depressive symptoms and positive parenting has found significant associations. Chi and Hinshaw (2002) found that depression-related maternal distortions of a negative discipline style were associated with lower levels of observed warmth in parent-child interactions after controlling for child behaviours, in a sample of children with ADHD. Similarly, Johnston et al. (2002), also in a sample of children with ADHD, found that maternal depressive symptoms were negatively associated with mothers’ responsiveness in observed parent-child interactions, indicating that mothers were less warm and less in tune with their child’s needs. In contrast, Wymbs et al. (2017), with their sample that was comprised mainly of parents with children with ADHD, found that parental depressive symptoms had no association with positive parenting behaviours at the bivariate level. Overall, most studies find that parental depressive symptoms are negatively associated with positive parenting behaviours in samples of children with ADHD. However, to my knowledge no studies to date have taken into account parental ADHD symptoms and few consider child comorbid externalizing behaviours.  13  Negative parenting. The literature thus far includes varied findings for parents with depressive symptoms and negative parenting behaviours, although most studies seem to indicate an association between the two. In the Chi and Hinshaw (2002) study, mother-reported depressive symptoms were positively associated with a self-reported negative discipline style after controlling for child externalizing behaviour. Thomas, O’Brien, Clarke, Liu, and Chronis-Tuscano (2015), in a sample of parents of children with ADHD, found that mothers who were currently depressed were more likely than never depressed mothers to ignore or respond negatively to child compliance and noncompliance in a parent-child interaction task. Gerdes et al. (2007) also found that maternal depression was positively associated with self-reported over-reactive parenting among parents of children with ADHD, and this relationship was mediated by greater parenting stress and lower self-esteem.  Other studies did not find these patterns. The Wymbs et al. (2017) study found no association between parental depressive symptoms and negative parenting behaviours. Similarly, Johnston et al. (2004), in a sample of mothers with children with ADHD, found no association between depression and over-reactive parenting. In summary, the majority of studies indicate that parental depressive symptoms are associated with negative parenting; however, few studies consider child oppositional behaviours and no studies (to my knowledge) consider parental ADHD symptoms in models.  Structured parenting. Research tends to find an association between parental depressive symptoms and indicators of unstructured parenting, however, parent ADHD symptoms and child behaviours have not been controlled for in these analyses. Chronis-Tuscano et al. (2008) found that parental depressive symptoms were significantly associated with inconsistent discipline in a sample of mothers of children with ADHD. Further, the Gerdes et al. (2007) study found that 14  maternal depression was significantly associated with self-reported lax parenting, and that this relationship was mediated by greater parenting stress and an external locus of control. In addition, depression-related distortions about the severity of children’s ADHD symptoms were negatively associated with parents’ ability to prepare their child for upcoming tasks (Chi & Hinshaw, 2002). However, in the Johnston et al. (2004) study, maternal depressive symptoms were not associated with lax parenting behaviours. Again, there are contradictory findings and a lack of consideration of chid behaviors and parental ADHD symptoms.  Summary. The literature on parenting children with ADHD suggests that parental depressive symptoms have a negative impact on all three parenting categories, particularly positive and negative parenting behaviours. However, co-occurring parental ADHD is rarely considered in these studies. This is in contrast to the research that focuses on parental ADHD symptoms, which considers co-occurring parental depressive symptoms more often. Given the likelihood of both ADHD and depressive symptoms among parents of children with ADHD, the existing research that tends to consider only one psychopathology may not present a comprehensive picture of parental mental health and parenting. Parental ADHD and depressive symptoms may be associated with different parenting behaviours, or they may incrementally contribute to the same parenting behaviour when parents have children with ADHD. The current study aimed to address this uncertainty.  Parent Psychopathology and Affiliate Stigma  A potential contributing factor to poor parenting, which may also be linked to parent psychopathology, is a parent’s perception and internalization of stigma about their children’s behaviour problems or mental health condition. Courtesy stigma is stigma directed towards individuals who are associated with someone who is stigmatized, for example, family members 15  or caregivers of a child with a mental illness (Norvilitis, Scime, & Lee, 2002). dosReis, Barksdale, Sherman, Maloney, and Charach (2012) found that 77% of 48 parents of children with ADHD reported stigmatizing experiences related to their child’s condition. The extent to which courtesy stigma is perceived and internalized by the recipient is referred to as affiliate stigma (Mak & Cheung, 2008). Effects of affiliate stigma include cognitive, affective, and behavioural components. These include negative thoughts (cognitive), helplessness regarding the association with the individual being stigmatized (affective), and withdrawing from social situations (behavioural; Mak & Cheung, 2008). Affiliate stigma has been researched in caregivers of people with mental illness (Mak & Cheung, 2012), as well as in parents of children who have intellectual disabilities (Mak & Cheung, 2008), physical disabilities (Ma & Mak, 2016), autism (Werner & Shulman, 2013), and ADHD (Mikami et al., 2015).  Research has found that these parents of children with ADHD perceive and internalize negative judgments from other adults regarding their children’s ADHD symptoms (dosReis et al., 2012; Norvilitis et al., 2002). In regards to parenting behaviour, Mikami et al. (2015) found that after statistical control of child ADHD symptom severity, affiliate stigma predicted more observed parental negativity in a parent-child interaction. To our knowledge, no other research has been conducted on the effects of affiliate stigma on parents of children with ADHD and their parenting behaviours.   There is also limited research on the relationship between psychopathology and affiliate stigma. Research thus far has conceptualized affiliate stigma as contributing to psychological distress (Ma & Mak, 2016; Norvilitis et al., 2002). Ma and Mak (2016) found affiliate stigma to be positively associated with parental depression. In addition, Norvilitis et al. (2002) report that for mothers of children with ADHD, hearing negative comments contributes to decreased 16  psychological well-being. However, parents with depressive symptoms may experience affiliate stigma as part of their symptoms of depression, specifically as a maladaptive cognition (Norvilitis et al., 2002). No research thus far has looked at the association between parents’ ADHD symptoms and their experience with affiliate stigma.  Interaction Effects between Parental ADHD and Depression To my knowledge, there is only one study that has looked at interaction effects between parental ADHD and depression on parenting behaviour in a sample of children with ADHD. Wymbs et al. (2017) examined the interaction effects between one parent’s ADHD or depression symptom levels with the other parent’s ADHD or depression symptom levels. However, the current study sought to assess the interaction between varying levels of ADHD and depression within the same parent.  The inconsistency in the literature about main effects of parental ADHD or depression makes it difficult to predict the direction of a potential interaction effect. One possibility is that the combination of parental ADHD and depression negatively affects parenting behaviour over and above the individual contributions of ADHD and depression alone. Specifically, the combination of high parental ADHD and depressive symptoms may be associated with exacerbated reductions in positive parenting, and exacerbated increases in negative parenting and unstructured parenting. Parents with ADHD symptoms who do not have depressive symptoms are more likely able to compensate, to some extent, for their symptoms to cope in their parenting role. However, if these parents also have depressive symptoms, this ability to compensate may be decreased due to the debilitating symptoms of depression, such as low mood, an inability to concentrate, irritability, and fatigue. Therefore, it is possible that the interaction of high parental 17  ADHD symptoms and high parental depressive symptoms will negatively impact all aspects of parenting behaviour over and above the additive effects of both psychopathologies individually.  In regard to affiliate stigma, symptoms of depression (such as cognitive distortions and feeling hopeless) are theoretically more related to this construct, while the influence of ADHD on affiliate stigma is unknown. Therefore, it seems unlikely that the interaction of parental ADHD and depressive symptoms will be associated with affiliate stigma. The Current Study  Although parental ADHD and depression commonly occur in parents of children with ADHD and are known to affect parenting (Chronis et al., 2003; Johnston & Mash, 2001; Takeda et al., 2010), research inconsistently accounts for one when assessing the effect of the other on parenting behaviours. This inconsistency has led to varying conclusions on which aspects of parental mental health influence which parenting behaviours (independently, or in interaction), as demonstrated by the review of the literature above. Past research has also been inconsistent in accounting for co-occurring child externalizing problems. In addition, little is known about how parental psychopathology may be related to affiliate stigma – a construct that may affect expressed parental behaviours. The present study aimed to advance existing literature on the parenting behaviours in families of children with ADHD by addressing some of these limitations. Specifically, I investigated the incremental and interactive influence of parental ADHD and depressive symptoms on parenting behaviours and affiliate stigma. Child behaviour problems, in particular the oppositional behaviours that commonly occur with ADHD, were controlled for. Lastly, I investigated whether affiliate stigma mediated the relationship between parent depressive or ADHD symptoms and parenting behaviours. Johnston et al. (2012) note that research in this area 18  has relied on self-report measures; the current study addressed this limitation by incorporating both self-report and observational measures for potentially stronger conclusions. Study Hypotheses Hypothesis 1: Parental ADHD and parenting behaviour. Research thus far has not established a consistent negative association between parent ADHD and positive parenting after controlling for child oppositional behaviors, and some literature on the similarity-fit hypothesis has found parental ADHD symptoms to be associated with positive parenting. Due to conflicting findings, I hypothesized that the association between parental ADHD and positive parenting would not be significant after controlling for child oppositional behaviours and parental depressive symptoms.  The literature provides mixed results for the association between parental ADHD and negative parenting as well. On the one hand, it has been found that after controlling for parental depression, the positive association between negative parenting and ADHD is no longer significant. However, in the similarity-fit research, it has been found that parents with ADHD are less likely to engage in negative parenting behaviours. Therefore, I hypothesized that ADHD would not be significantly associated with negative parenting after controlling for child oppositional behaviours and parental depressive symptoms.  Study findings on the association between parental ADHD symptoms and unstructured parenting have been more consistent. Therefore, I hypothesized that, after controlling for child oppositional behaviour and parental depressive symptoms, parental ADHD symptoms would be positively associated with unstructured parenting. Hypothesis 2: Parental depression and parenting behaviour. Research on the association between parental depressive symptoms and both positive and negative parenting 19  behaviours has been more straightforward. Therefore, I hypothesized that, after controlling for child oppositional behaviour and parental ADHD symptoms, parental depressive symptoms would be positively associated with negative parenting behaviour and negatively associated with positive parenting behaviour. I also hypothesized that parental depressive symptoms would initially be positively associated with unstructured parenting, but this association would disappear after controlling for parental ADHD.  Exploratory Hypotheses: I further speculated that parental depressive symptoms may be positively associated with affiliate stigma after controlling for parental ADHD symptoms and child oppositional behaviours. This is in line with research stating that symptoms of depression, particularly maladaptive cognitions, may be linked to the perception of affiliate stigma. Further, I expected that parental ADHD would not be associated with affiliate stigma. In addition, I hypothesized that affiliate stigma would mediate the relationship between parental depressive symptoms and parenting behaviours such that it would account for some of the positive association with negative parenting and some of the negative association with positive parenting. There is also little previous research on the interactive effects of parental ADHD and depressive symptoms on parenting behaviours. I speculated that high levels of parental ADHD and high levels of parental depression would interact to exacerbate the negative association with positive parenting, and the positive associations with negative parenting and unstructured parenting, beyond the individual contributions of ADHD and depression. By contrast, I had no reason to expect that the interaction between parental ADHD and depression would predict affiliate stigma.    20  Method Participants  The parents in the current study were taking part in a larger trial examining the efficacy of interventions to address social problems in their children with ADHD. The data were collected from 2013-2018 and consist of 216 families of children ages 6-11; all children met diagnostic criteria for ADHD. Each child participated with one parent (91% mothers), with whom the child lived at least 50% of the time and, in the case of two-parent families, was the parent who reported being most involved in the child’s social life. Data were collected from two sites, Vancouver and Ottawa/Gatineau, and therefore contain both English and French speaking participants. Families of children with ADHD were recruited through schools, hospital clinics, and practitioners at both sites. These parents represented an ideal population to examine as they had children with ADHD and were therefore likely to endorse some ADHD and/or depressive symptoms themselves due to the high heritability of ADHD and likelihood of depression in this population (Chronis et al., 2003; Takeda et al. 2010). A smaller subsample of parents (n = 142) was used for analyses of observational data as coding of observational data from both sites is ongoing and not all families participated in the observational task.  Procedure Study procedures were approved by the institutional review boards at both sites, written consent was obtained from adult participants, and assent was obtained from child participants. All children met Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) criteria for ADHD. Parents and children’s classroom teachers first completed a screening form where they rated the child on the 18 ADHD symptoms using the 21  Child Symptom Inventory (Gadow & Sprafkin, 2002) and peer problems using the Strengths and Difficulties Questionnaire Peer Problems subscale (Goodman, 1997). Because the interventions in the larger trial focused on addressing children’s social impairment, both parents and teachers had to endorse at least 6 of 9 symptoms of inattention or hyperactivity/impulsivity as “often” or “very often” as well as substantial peer problems (about 1.5 standard deviations above the mean) to be considered for the study. The majority (54%) of children were taking psychotropic medication to address behavioural problems, and this was not an exclusionary criterion.  Once study eligibility was established, parents and children attended an intake session in the lab. At this visit, child ADHD status (any presentation of ADHD) was confirmed in a clinical interview with the parent using the Kiddie-Schedule for Affective Disorders and Schizophrenia (K-SADS; Kaufman et al., 1997). The Wechsler Abbreviated Scale of Intelligence was administered to determine that the child had an estimated IQ of at least 75 (Wechsler, 2003). Exclusion criteria included intellectual disability (IQ below 75), autism spectrum disorder, psychosis, or active suicidality as reported by the parent (because of the urgent need for other interventions).  At this intake session, parents also completed self-report measures about themselves and about their child that were used in the current study. These measures included the Current Symptoms Scale, Beck Depression Inventory, Parenting Scale, Alabama Parenting Questionnaire, the Affiliate Stigma Questionnaire, and the Child Behaviour Checklist. At this time, teachers were also mailed questionnaires to complete about the child’s behaviour. Of these, the Teacher Report Form of the Child Behaviour Checklist was used in the current study.   The parent and child were then invited for a second visit after confirming that the child met inclusion criteria. They were asked to bring a friend of the child for social interaction tasks: 22  a sharing game where the children were encouraged to find a solution in order to split up an odd number of toys, as well as a car racing game that was difficult to navigate. Before the social interactions between the target child and invited friend began, the parent was encouraged to prepare the child to “do well at working and playing together with the friend” and was given 5 minutes to do so. The parent then observed the child and the friend engaging in the tasks from another room. After the social interactions, the parent was given another 5 minutes to “give feedback to the child that will help the child make friends”. The discussions between the parent and child before and after the social interaction with the friend are referred to as the Parent-Child Coaching task (adapted from Mikami, Jack, Emeh, & Stephens, 2010; Russell & Finnie, 1990). See Appendix A for relevant portions of the scripted protocol for this task.   Participants in the current study were taking part in a larger intervention trial. However, only a subset of measures and tasks administered in the larger trial were used in the current study, all of which were completed in the first and second lab visit which occurred prior to receipt of treatment. After the collection of the measures used in the current study (as well as other measures), families went on to be randomized to one of two psychosocial treatments aimed at helping parents understand and deal with their child’s social problems. Treatments lasted for 10 weeks and parents attended post-treatment and 1-year follow ups for further data collection.  Measures  Parental ADHD symptoms. Parent participants completed the Current Symptoms Scale (CSS; Barkley & Murphy, 2006), to assess parental ADHD symptoms (see Appendix B). This normed measure has 18 items, each corresponding to a DSM-V item for inattentive or hyperactive symptoms. Parents rate their behaviour over the past 6 months on a four-point Likert scale, from 0 = rarely or never to 3 = very often, with a higher score indicating that symptoms 23  occur more often. The CSS has been found to have good reliability and construct validity (Gomez, 2011), as well as convergent validity (Ladner, Schulenberg, Smith, & Dunaway, 2011). Internal consistency in this sample for the CSS was .93. The correlation between parental inattention and hyperactivity symptom severity was high, r(206) = .72, p < .001, therefore, the total symptom severity score from this measure was used to indicate the level of parental ADHD symptoms.  Parental depressive symptoms. Parent participants also completed the Beck Depression Inventory II (BDI-II; Beck, Steer, & Brown; 1996) to assess parental depressive symptoms. The 21 items that make up the BDI-II correspond to the criteria used to diagnose depressive disorders in the 4th edition of the DSM. Each item is answered on a four-point scale with higher scores indicating a greater occurrence of that symptom. This is a normed and very widely-used measure. Construct validity in the form of both convergent and discriminant validity has been established, as well as criterion related validity (Beck et al., 1996). The measure has also demonstrated good internal consistency in both outpatient and student samples (Beck et al., 1996). Internal consistency in the current sample was .92. The total score from this measure was used to indicate the level of parental depressive symptoms.  Parenting behaviour. Parenting behaviour was assessed with subscales from two self-report measures and behaviour codes from one observation task1. These sources provide information on positive parenting, negative parenting, and unstructured parenting behaviours.  Parent self-report measures. Participants completed two self-report measures on their parenting behaviour. The Alabama Parenting Questionnaire (APQ; Shelton, Frick, & Wootton,                                                   1 In the initial thesis proposal for this project, two observation tasks were included. However, the Etch-A-Sketch Task (Hay & Pawlby, 2003) could not be included at the time of writing due to insufficient data being ready. 24  1996) asks parents to report their parenting practices on the following four subscales: Involvement, Positive Parenting, Poor Monitoring/Supervision, and Inconsistent Discipline (see Appendix C). Items are rated on a five-point scale from 0 = Never to 4 = Always. Internal consistency of the four scales has been reported as moderate to high in previous research, specifically, Involvement (10 items) = .80; Positive Parenting (6 items) = .80; Poor Monitoring/Supervision (10 items) = .67; Inconsistent Discipline (6 items) = .67. (Shelton et al., 1996). Hurley, Huscroft-D’Angelo, Trout, Griffith, and Epstein (2014) also report acceptable reliability, validity, and factor structure for this measure. In this sample, internal consistency was as follows: Involvement = .62; Positive Parenting = .79; Poor Monitoring/Supervision = .44; Inconsistent Discipline = .67.  The Parenting Scale (Arnold, O’Leary, Wolff, & Acker, 1993) contains Over-Reactive, Hostile, and Lax Parenting subscales (see Appendix D). Parents are presented with scenarios (e.g., When my child misbehaves…) with two possible responses (e.g., I do something about it right away or I do something about it later) and indicate which response is more like them on a seven-point scale. The measure has been found to have adequate reliability, factor structure, and validity in previous research (Arnold et al., 1993; Hurley et al., 2014). Internal consistency in previous work for mothers and fathers respectively are: Over-Reactive (5 items) = .67 and .66; Laxness (5 items) = .74 and .69; and Hostility (3 items) = .52 and .59 (Rhoades & O’Leary, 2007). In this sample, internal consistency was as follows: Over-Reactive = .69; Laxness = .76; Hostility = .49. Parent-Child Coaching Task (adapted from Mikami, et al., 2010; Russell & Finnie, 1990). Parents and their child with ADHD also participated in an unstructured task where parents prepared their child for a social interaction with the child’s invited friend, observed the 25  interaction from another room, and then debriefed with their child after the interaction. This study used both the 5-minute prep session and 5-minute debrief session to assess observed parenting behaviours. The parent-child coaching sessions were recorded and then double coded by two independent coders. Final scores for each session (prep and debrief) on each dimension (described below) are an average of the scores from the two coders.  There are three positive parenting dimensions coded from this task: collaboration, praise, and warmth. Collaboration assesses the extent to which the parent works with the child to come up with strategies to be successful in the peer interaction and genuinely takes in what the child is saying. Praise is the extent to which the parent offers positive feedback to the child about the child’s behaviour or character. Warmth captures how much the parent displays a positive emotional connection with the child. These three parenting behaviours are all rated on a scale from 0 to 5, with a higher score indicating more of that behaviour.  There is one negative parenting behaviour coded from the parent-child coaching task: criticism. Criticism is the extent that the parent conveys to the child that the parent is frustrated with the child or dislikes the child. This is also rated from 0 to 5, with a higher score indicating more criticism.  There is one parenting behaviour that indicates the parent is taking a structured approach: providing strategies for the child. The number of times the parent offers a strategy to the child to help them interact positively in peer situations (group-oriented) was counted. Parents may provide a group-oriented non-specific strategy (i.e. “Play nice”) or a group-oriented specific strategy (i.e. “Remember to take turns with who goes first”). The total number of strategies provided by the parent was used.  26  ICCs (Shrout & Fleiss, 1979) were calculated for each dimension to assess inter-rater reliability and are as follows: Collaboration = .70; Praise = .90; Warmth = .85; Criticism = .73; strategy count = .76. ICC conventions are: below .40 = poor, .40-.59 = fair, .60-.74 = good; .75 and above = excellent (Cicchetti, 1994), indicating the ICCs for this task to be good to excellent. Collaboration, warmth, criticism, and strategy codes from the prep session were found to be significantly correlated with those from the debrief session (rs = .21 - .35; all p < .05), therefore the average of the two was used in analyses. Praise was not found to be correlated across the prep and debrief sessions (r = .04; p = .66), therefore, praise from the debrief session was used in analysis, as it was thought to provide the parent with a more natural situation with the potential to elicit praise. A summary of the coding of the parenting behaviours from the coaching task can be found in Appendix E. Affiliate stigma. Parents completed an Affiliate Stigma Questionnaire adapted from Mak and Cheung (2008) to be specific to children’s ADHD symptoms (see Appendix F). This adapted version has been found in previous research to have an internal consistency of .83 and a factor analysis on the items suggested a single factor (Mikami et al., 2015). Internal consistency in this sample was .90. The measure is comprised of six items assessing parents’ stigma about their child’s inattentive symptoms, and the same six items assessing parents’ stigma about their child’s hyperactive/impulsive symptoms (sample item: At times I feel embarrassed by my child’s inattentive symptoms). Each item is answered on a four-point scale from 1 = Not at all to 4 = Very much. The mean of all 12 items was used, with a higher score indicating greater affiliate stigma. Child oppositional behaviour. Parents completed the Child Behaviour Checklist (CBCL) and teachers completed the parallel Teacher Report Form (TRF; Achenbach & Rescorla 27  2001). The CBCL and TRF are standardized, normed measures of school-age children’s problem behaviour. Parents and teachers rate whether each behaviour is very true, sometimes true, or not true of the child. Both the CBCL and TRF are widely-used in research and clinical practice and have established reliability and validity. The Oppositional Defiant Problems subscale assesses the extent to which the child argues, has a temper, and is defiant. A composite of the parent and teacher reported T-scores for the five-item Oppositional Defiant Problems subscale was used in this study as the parent and teacher report were found to be significantly correlated, r(200) = .45, p < .001.  Other covariates. Child ADHD symptom severity and child medication status may also influence parenting behaviours. Although all children in the study met diagnostic criteria for ADHD, some variability nonetheless existed in their severity of symptoms as rated by parents and teachers on the Child Symptom Inventory (Gadow & Sprafkin, 2002). There was a significant correlation between parent and teacher reported ADHD symptom severity, r(214) = .22, p = .001, therefore a composite was created from the two informants’ scores. Parents also indicated whether the child was taking any medication for ADHD at the start of the study.  Data Analytic Plan Power analysis. Two post-hoc power analyses for linear multiple regression with four predictors and a medium effect size of .15 (f²; Cohen, 1992) were conducted to compute achieved power. Power analysis was conducted using G*Power 3 software (Faul, Erdfelder, Lang, & Buchner, 2007). Previous research studies assessing similar relationships have generally found medium effect sizes (Lovejoy et al., 2000; Murray & Johnston, 2006). Given the sample size of 216, achieved power was 99%. With the reduced sample size for observation data (n = 142), achieved power was 97%.  28  Data Reduction. To reduce the number of analyses conducted, principle components analysis (PCA) with varimax rotation was conducted on the criterion variables assessing parenting behaviours. Factor extraction was guided by Costello and Osborne’s (2005) recommendation of retaining factors above the point of inflexion on the scree plot and Kaiser’s (1960) recommendation of retaining factors with an eigenvalue greater than one.  Data Analysis. Hierarchical multiple regression analyses were conducted to test the incremental contributions of parental ADHD and depressive symptoms in predicting each criterion variable (factors extracted from the PCA and affiliate stigma). Covariates entered in step one of the regressions were child ODD symptoms, child ADHD symptoms, and child ADHD medication status. However, as child ADHD symptoms and child ADHD medication status were not significant in any of the regressions, they were removed in the final analysis in the interest of parsimony. Child ODD symptoms significantly predicted parental affiliate stigma (see Table 7 and 8). Although ODD symptoms did not significantly predict the other outcome measures, because this construct was associated with affiliate stigma and because there was greater theoretical rationale for including it as a covariate based on existing literature (Burke et al., 2008; Deault, 2010; Johnston et al., 2002; Modesto-Lowe et al., 2008), it was retained. All continuous variables were mean centered for analysis (Aiken & West, 1991). Hypothesis 1 and 2. Hierarchical multiple regression analyses were conducted to assess parental ADHD symptoms and parental depressive symptoms as predictors of parenting behaviours. All regressions included child ODD symptoms in Step 1. To test the incremental contributions of parental ADHD and depression, two regressions were conducted, one with parental ADHD symptoms entered in Step 2 and parental depressive symptoms in Step 3, followed by separate analyses with parental depressive symptoms entered in Step 2 and parental 29  ADHD symptoms in Step 3. This determined if parental ADHD symptoms are associated with parenting behaviour, and then whether this association holds after controlling for parental depression. Similarly, these regressions determined if parental depressive symptoms are associated with parenting behaviour and then whether this association holds after controlling for parental ADHD symptoms.  Exploratory Analyses. To explore the potential incremental contributions of parental ADHD and depressive symptoms on affiliate stigma, hierarchical multiple regressions were conducted similarly as described above. A mediation model, where affiliate stigma mediates the relationship between parental depressive symptoms and parenting behaviours, was also tested. The PROCESS SPSS Macro, model four, was used to calculate the pathways in the proposed mediation model (Preacher & Hayes, 2008).  Lastly, to explore the potential for statistical interactions between parental ADHD symptoms and depressive symptoms in predicting parenting behaviours, all regressions testing Hypotheses 1 and 2 included an interaction term reflecting parent ADHD symptoms x parent depressive symptoms in Step 4.    30  Results Descriptive Statistics  Descriptive statistics of demographic and other study variables are presented in Tables 1 and 2. All study variables were normally distributed with skewness and kurtosis less than +/- 2. Notably, 24 parents (11% of the sample), reported depressive symptoms at a level of moderate or higher on the BDI-II, this is comparable to the 6.7% of mothers of children with ADHD who reported a current mood disorder in research done by Chronis et al. (2003). By contrast, 26 parents (12% of the sample) reported significantly elevated ADHD symptoms, as defined as ADHD symptoms > 1.5 SD above the mean for their age group in the norming sample (Barkley & Murphy, 2006). This is lower than what was found by Takeda et al. (2010), who reported that 23% of fathers and 27% of mothers of children with ADHD endorsed significant levels of ADHD symptoms.  There were some differences across the two sites as noted in Table 1 and Table 2. In terms of demographics, at the Vancouver site, parents were more likely to be older, t(202) = 2.70, p < .05, parents were less likely to be employed full time and more likely to be employed part time or be a stay at home parent, χ2(7) = 23.62, p < .05, more children were non-White, χ2(4) = 17.51, p < .05, and fewer children were taking ADHD medication χ2(1) = 10.88, p < .05, compared to Ottawa. As for study variables, there were no site differences on 12 of 17 variables tested. However, Vancouver parents reported lower levels of parental ADHD symptoms, t(205) = -2.07, p < .05, higher levels of affiliate stigma, t(209) = 3.80, p < .05, lower levels of positive parenting, t(210) = -2.20, p < .05, lower levels of inconsistent discipline, t(210) = -3.14, p < .05, and were observed to use more strategies, t(153) = 3.63, p < .05, compared to Ottawa parents. However, statistically controlling for site in the regression models did not change any of the 31  findings obtained for the associations between parental psychopathology and parenting behaviors. Dimensions of Parenting Behaviours  A PCA with varimax rotation was conducted on the 12 parenting variables from the parent self-report measures and the Parent Child Coaching Task. The Kaiser-Meyer-Olkin measure of sampling adequacy indicated that the strength of the relationships among variables was acceptable KMO = .593. This value is considered ‘mediocre’ according to Hutcheson and Sofroniou (1999), however it was still acceptable to proceed with the analysis. Bartlett’s test of sphericity 𝜒2 (66) = 363.78, p < .001, also indicated that the correlations between variables was sufficiently large for PCA. Five factors had an eigenvalue higher then Kaiser’s criterion of 1, and together accounted for 67% of the total variance in the model.  Table 3 shows the factor loadings after rotation. The variables that clustered on the same factor suggested that factor 1 represented self-reported unstructured parenting behaviours, factor 2 represented self-reported negative parenting behaviours, factor 3 represented observed positive verbal parenting behaviours, factor 4 represented self-reported positive parenting behaviours, and factor 5 represented observed parental emotional tone. Factors were created by taking the mean of all the variables (after standardization) that loaded on the factor (DiStefano, Zhu, & Mindrila, 2009). Higher scores on factors 1-4 indicate more of the corresponding behaviour, and a higher score on factor 5 indicates a more positive emotional tone. The obtained factors based on self-reported parenting behaviours were similar to those hypothesized (structured, positive, and negative parenting). The observed parenting behaviours did not load on the same factors as the self-reported behaviours, perhaps due to method variance. These five factors were considered the outcome variables.  32  Correlations between study variables are reported in Table 4. Notably, child ODD symptoms were positively correlated with parental depressive symptoms, self-reported negative parenting behaviours, and parental affiliate stigma. Importantly, parental depressive symptoms were correlated with self-reported unstructured parenting, negative parenting, and positive parenting, and affiliate stigma. Parental ADHD symptoms were correlated with self-reported unstructured parenting, negative parenting, and affiliate stigma. Parental depressive symptoms and ADHD symptoms were also significantly correlated.   Lastly, it should be noted that all analyses were conducted with all parents in the sample, and then with the fathers removed. Running the analyses with only the mothers did not change the pattern of results, and so the full sample is included herein.  Hypothesis 1: Parental ADHD and Parenting Behaviour  As displayed in Table 5, greater parental ADHD symptoms significantly predicted more self-reported unstructured parenting behaviour, however, this association disappeared after controlling for parental depressive symptoms. Greater parental ADHD symptoms also significantly predicted more self-reported negative parenting, and this association held after controlling for parental depressive symptoms. Parental ADHD symptoms did not predict any of the observed parenting behaviours or self-reported positive parenting behaviour.  Hypothesis 2: Parental Depression and Parenting Behaviour  As displayed in Table 6, greater parental depressive symptoms significantly predicted more self-reported unstructured parenting, however, this association disappeared after controlling for parental ADHD symptoms. Greater parental depressive symptoms also significantly predicted more self-reported negative parenting, and this association held after controlling for parental ADHD symptoms. Lastly, greater parental depressive symptoms 33  significantly predicted less self-reported positive parenting behaviour, and again this association held after controlling for parental ADHD symptoms. Parental depressive symptoms did not predict any of the observed parenting behaviours.  Exploratory Analyses  Affiliate stigma. Both greater parental depressive symptoms and greater parental ADHD symptoms initially significantly predicted increased levels of parental affiliate stigma without controlling for the other psychopathology (Table 7 and 8). However, only parental depressive symptoms continued to significantly predict higher levels of affiliate stigma after controlling for parental ADHD symptoms. Child ODD symptoms was a significant predictor of increased levels of affiliate stigma in both models (Table 7 and 8).   The PROCESS SPSS macro was used to determine if affiliate stigma mediated the relationship between parental depressive symptoms and parenting behaviours. Using bootstrapping with 5,000 resamples, the indirect effect yielded a 95% confidence interval that did not include zero for the model of parental depressive symptoms and observed positive verbal parenting factor mediated by affiliate stigma (see Figure 1). However, conditions for mediation were not met, as path b was not significant. Further, the total effect (c = -.02, p = .08) was not found to be significant, while the direct effect (c’ = -.02, p = .03) was significant, indicating that affiliate stigma did not account for the relationship between parental depressive symptoms and observed positive verbal parenting. As path b and c were not significant, c’ was significant, and the signs for path b are not consistent with the proposed mediation process, conditions were not met for mediation (Baron & Kenny, 1986; Preacher & Hayes, 2008). When also taking into account that five potential mediation models were tested, I am hesitant to interpret this finding as significant.  34   Interaction effect. The interaction between parental depressive symptoms and parental ADHD symptoms was a significant predictor of self-reported negative parenting (see Figure 2). Probing of the interaction effect was done in the manner recommended by Holmbeck (2002). Findings indicated that the association between greater parental ADHD symptoms and more self-reported negative parenting was strong for parents with low depressive symptoms (1 SD below the mean; B = .36, p = .001). By contrast, there was no significant association between parental ADHD and self-reported negative parenting for parents with high depressive symptoms (1 SD above the mean; B = .07, p = .44).   35  Discussion  The current study investigated the incremental and interactive influences of parental ADHD and depressive symptoms on parenting behaviours and affiliate stigma. Importantly, child oppositional behaviours were controlled for due to their potential influence on parenting behaviours (Johnston et al., 2012) and inconsistent consideration in past research. Further, I investigated whether affiliate stigma mediated the relationship between parent depressive and parenting behaviours. Results revealed that parental ADHD symptoms and depressive symptoms each initially predicted self-reported unstructured parenting, however, in both cases this association was no longer significant once the other psychopathology was entered into the model. In contrast, both parental ADHD symptoms and depressive symptoms initially predicted self-reported negative parenting, and both continued to significantly predict negative parenting after accounting for the other psychopathology. Further, an interaction effect was found, such that high parental ADHD symptoms were predictive of more negative parenting behaviour only when depressive symptoms were low. Parental depressive symptoms were found to predict lower levels of self-reported positive parenting, and this association held after the addition of parental ADHD symptoms. Both were also initially significant predictors of affiliate stigma, however, only depression continued to predict increased levels of affiliate stigma after statistical control of parental ADHD symptoms. Neither parental ADHD nor depressive symptoms was associated with observed parenting. Lastly, affiliate stigma did not mediate the relationship between parental depressive symptoms and parenting behaviours.  Positive Parenting Behaviour  Positive parenting behaviours include the presence of parental warmth and positive involvement with the child, the lack of which may adversely affect child development. In support 36  of my hypothesis, parental ADHD symptoms were not significantly associated with self-reported positive parenting behaviours, with or without controlling for parental depressive symptoms. The literature is mixed in regard to whether ADHD symptoms affect positive parenting, with some studies finding an association (Chen & Johnston, 2007; Chronis-Tuscano et al., 2008), while others do not suggest any association (Murray & Johnston, 2006; Wymbs et al., 2017). The results of the current study suggest that perhaps regardless of parental levels of inattentive, hyperactive, or impulsive behaviours, parents are able to provide their children with similar levels of positive feedback and be engaged in children’s lives. However, it is also possible that parents with ADHD overestimate their positive parenting behaviours on self-report scales, as has been found in previous research (Lui, Johnston, Lee, & Lee-Flynn, 2013). The positive illusory bias may have influenced these results such that no negative association was found, although notably there were also no associations between parental ADHD and the observed verbal positive parenting behaviours; furthermore, parents with elevated ADHD symptoms did self-report higher levels of negative parenting behaviour.   Parental depressive symptoms, on the other hand, were found to be negatively associated with positive parenting behaviours after controlling for parental ADHD symptoms, as hypothesized. This association appears to be quite consistent in the existing literature (Chi & Hinshaw, 2002; Johnston et al., 2002), however existing studies did not account for parental ADHD symptoms. The core symptoms of depression, including low positive affect and loss of interest in enjoyable activities, as well as general low energy, may make it difficult for parents to be involved with their child and to engage with them in positive ways. These same symptoms are not present in ADHD, which may explain the potentially unique associations between parental depression and lower positive parenting, in contrast to parental ADHD which was not suggested 37  to relate to positive parenting. Notably, the ∆R2 was small, such that depressive symptoms accounted for 4% of the variability after controlling for child ODD symptoms and adding ADHD symptoms to the model did not account for any additional variability.  Negative Parenting Behaviour  Negative parenting behaviour involves being over-reactive and potentially hostile toward the child. Importantly, negative parenting is not just a lack of positive parenting behaviours, it is the addition of behaviours that are harsh. Contrary to my hypotheses, parental ADHD symptoms continued to be a significant predictor of negative parenting after controlling for parental depressive symptoms. Parental depressive symptoms also continued to be a significant predictor of negative parenting after controlling for parental ADHD symptoms, which supported my hypothesis. The results from the current sample suggest that elevated symptoms of both ADHD and depression are incrementally associated with higher levels of negative parenting behaviours. Again, ∆R2 was found to be quite small at both Step 2 and Step 3 in both models (see Table 5 and 6).   Parental depressive symptoms have been more consistently linked to negative parenting behaviours in existing literature (Chi & Hinshaw, 2002; Gerdes et al., 2007; Thomas et al., 2015), although importantly these studies did not control for parent ADHD symptoms. On the other hand, the research on parental ADHD and negative parenting behaviour is mixed. Studies typically find this association to become non-significant once controlling for parent depressive symptoms, such as Harvey et al. (2003), who controlled for parental depression and alcohol use, and Chen and Johnston (2007), who controlled for parental depression, child age, family socioeconomic status, maternal hostility, and child conduct problems. The findings in this sample do echo the conclusion of the recent meta-analysis that did not find this relationship to be 38  influenced by parent depression (Park et al., 2017), as well as findings from Chronis-Tuscano et al. (2008), who found that parental ADHD symptoms (although not depressive symptoms) were a significant predictor of observed negative parenting behaviour.  Although this speculation is post hoc, it is possible that parental ADHD and parental depression are incrementally contributing to negative parenting behaviours through different processes. The irritability, low mood, pessimism, and fatigue associated with depression may result in parents viewing children’s behaviors as more negative and exhausting than a parent without depression would perceive them to be, with little hope for behaviours to improve. Research has demonstrated a link between maternal depressed mood and increased negativity in these parents’ attributions for children’s behaviour (Geller & Johnston, 1995). This more general negative cognitive and emotional style may result in parents responding harshly toward their children. Alternatively, the process through which this might occur for parents with ADHD may have to do with parents’ difficulty regulating their emotions, particularly anger, in the heat of the moment. Poor emotion regulation tends to occur in adults with ADHD (Hirsch, Chavanon, Riechmann, & Christiansen, 2018), therefore, perhaps children’s problem behaviours easily elicit these parents’ frustration. Indeed, research has found that the link between maternal ADHD symptoms and harsh parenting may be partially mediated by difficulties with emotion regulation (Mazursky-Horowitz et al., 2015). As such, parents with ADHD symptoms may be more likely to act on this in the moment frustration in overly reactive or hostile ways. To summarize, perhaps a more general negative perception of child behaviours leads parents with depression to engage in negative parenting behaviours, while parents with ADHD struggle with in the moment regulation of their anger, which contributes to the elevation in negative parenting behaviours.   39   An interesting interaction effect was also found in exploratory analyses, such that high levels of ADHD symptoms were most strongly associated with more negative parenting behaviours when parents had low levels of depression. Perhaps when parents are highly depressed, the process through which depression affects negative parenting- the general irritability, pessimism, and low mood- supersedes any effect of ADHD symptoms on negative parenting. As no research has looked at the interaction between parental ADHD and depressive symptoms within the same parent, this finding emphasizes the importance of considering this possibility. This exploratory finding that parental ADHD symptoms are associated with negative parenting behaviours when symptoms of depression are low also provides potential support for the idea that ADHD and depressive symptoms differentially affect negative parenting behaviours. Perhaps, the unique features of ADHD and depression are driving this association, instead of the underlying similarities.   Unstructured Parenting Behaviour  Unstructured parenting includes parenting that is lax and inconsistent, with little monitoring or supervision of children. Given the rather consistent findings in the literature, it was expected that parental ADHD symptoms would be more strongly associated with a parent being lax in parenting, inconsistent with discipline, and a poor monitor of child behaviour. Although parental ADHD symptoms were associated with unstructured parenting without statistical control of parental depressive symptoms, contrary to my hypothesis, this association disappeared after controlling for depressive symptoms. This finding does not align with the conclusion drawn by Johnston et al. (2012) that there is an association between parental ADHD symptoms and unstructured parenting behaviours, even after controlling for comorbid parent psychopathologies. 40  This is also in contrast to findings from a recent meta-analysis (Park et al., 2017) and other studies looking at this relationship (Chen & Johnston, 2007; Murray & Johnston, 2006).  It is possible that this particular sample of parents, which includes parents who are organized and motivated enough to seek treatment, may be able to provide more structure in the parenting role despite potential elevations in ADHD symptoms. Because there was an initial association between parent ADHD symptoms and unstructured parenting when parental depressive symptoms were not entered into the model, it is also possible that perhaps depressive symptoms account for more of this association than initially considered. Some symptoms of depression, specifically difficulty concentrating and indecisiveness, are theoretically likely to contribute to parental difficulties supervising children, being consistent, and providing structure. Parental depressive symptoms were initially predictive of unstructured parenting, which is consistent with previous research (Chronis-Tuscano et al., 2008; Gerdes et al., 2007). However, parental depressive symptoms were not incrementally associated with unstructured parenting after controlling for parent ADHD symptoms, something previous research had not yet demonstrated.  Perhaps, in contrast to the findings for negative parenting behaviours, the underlying commonalities between parental ADHD symptoms and depressive symptoms are more likely to be contributing to difficulties in structured parenting. Specifically, I wonder if the shared difficulties with concentrating, forgetfulness, and avoiding difficult tasks that characterize both ADHD and depressive symptoms in adults, contribute to unstructured parenting. Indeed, parental ADHD symptoms and parental depressive symptoms were moderately correlated in this sample (r = .52). In this instance, a general psychopathology factor (or p factor; Caspi et al., 2014) might 41  be a more appropriate construct to measure and utilize in predicting unstructured parenting behaviour for parents of children with ADHD.   It should also be noted that in Step 2 for both the ADHD and depression models, the ∆R2 was small. Parental ADHD accounted for an additional 3% of the variability after controlling for child ODD symptoms, and parental depressive symptoms accounted for an additional 4% of the variability after controlling for child ODD symptoms.  Observed Parenting Behaviour  Neither parental ADHD symptoms nor depressive symptoms was a significant predictor of observed positive verbal parenting or emotional tone. It was expected that parental ADHD would not be associated with positive indicators of parenting, however, it was hypothesized that parental depressive symptoms would be negatively associated with levels of praise and collaboration, as well as less warmth and more criticism. Research that examines the effect of these parent psychopathologies on parenting behaviours has increasingly included observational methods and typically finds some association, particularly for depressive symptoms (see, for example, Chi & Hinshaw, 2002; Chronis-Tuscano et al., 2008; Griggs & Mikami, 2011; Harvey et al., 2003; Johnston et al., 2002; Psychogiou et al., 2008; Wymbs et al., 2017). The lack of findings in this study may stem from a number of reasons. It may simply be that in this sample, ADHD and depressive symptoms do not predict the observed level of praise, collaboration, or advice a parent gives a child, or how warm or critical they are toward the child. By contrast, parental ADHD symptoms and depressive symptoms were associated with self-reported parenting behaviours. The extent to which parents’ own perception of their behaviours was worse when they had elevated levels of ADHD symptoms and particularly depressive symptoms may result from cognitive distortions due to these psychopathologies. Indeed, it may be that in 42  observations of such parenting behaviours, parents with elevated ADHD symptoms or depressive symptoms do not actually differ from parents with low levels of symptoms.  It is also possible that the parent-child coaching task in which the observations were obtained was not sufficiently realistic, long, or relevant enough to parents’ typical practices to elicit behaviours that characterize parents struggling with ADHD or depressive symptoms. Given that the observation occurred in a novel situation for the family, both parents and children may have attempted to be on their best behaviour or were more reserved due to unfamiliarity. Children may not have been engaging in typical behaviour that would elicit parent response, and the parent may have been working hard to demonstrate appropriate parenting behaviours. In addition, the coaching task is very specific to parents’ interactions with their children about friendship-making skills. This scenario may not generalize well to parent-child interactions overall. The setup of this task was also very straightforward, in that parents were directly told to talk to the child about ways to navigate the upcoming social interaction. In contrast, the Etch-A-Sketch task which had to be excluded from this study due to not enough data being available at the time of writing, may be more relevant, as it involves the parent and child working together on a difficult task that may easily elicit frustration, and is not specific to friendship-making. Regardless, using observation tasks to measure parenting should continue in this area of research (Johnston et al., 2012). Affiliate Stigma  Parental ADHD symptoms and depressive symptoms were both initially associated with higher levels of affiliate stigma. However, only depressive symptoms remained a significant predictor after statistical control of the other psychopathology. Ma and Mak (2016) also found that parental depressive symptoms were associated with affiliate stigma. The ∆R2 indicated that 43  depressive symptoms accounted for 5% of the variability after controlling for child ODD symptoms, and the addition of parental ADHD symptoms did not account for further variability.  The initial association between affiliate stigma and parental ADHD perhaps reflects the sensitivity these parents might experience as they themselves struggle with similar symptoms experienced by their children. However, this sensitivity might be better accounted for by depression. Parents with depressive symptoms may be more likely to feel the effects of stigma that is directed at them due to their child’s difficult behaviours. The feelings of guilt, worthlessness, self-blame, and general low mood coincide with the cognitive (others think poorly of me), behavioural (avoid seeing others), and affect (embarrassment, guilt), aspects of affiliate stigma. As noted by Norvilitis et al. (2012), the negative and potentially distorted cognitions that go along with affiliate stigma are similar to negative and distorted cognitions that individuals with depression experience.  There were no significant correlations between affiliate stigma and the various parenting variables, and affiliate stigma did not mediate the effect between parental depressive symptoms and parenting behaviours. This is in contrast with past research that has found affiliate stigma to be associated with parenting behaviours (Mikami et al., 2015). Perhaps the effect of affiliate stigma on parenting behaviour becomes evoked predominantly (or exclusively) in social situations where other parents are watching. Indeed, Mikami et al. (2015) found that affiliate stigma was positively associated with negative parenting that was observed in a parent-child interaction immediately after the child had played with three other children, with parents of all children observing the play. This situation may have been conducive to eliciting parental perceptions of stigma, thereby affecting their subsequent behaviour with their children. In the current study, parental self-report about general parenting patterns may be less sensitive to 44  associations with affiliate stigma, because affiliate stigma was unlikely to be triggered at the time that parents were completing the questionnaires about their parenting behaviors. Further in the observation measure in the current study, no other parents were watching the behavior of the child in the study, so this may not have evoked parents’ affiliate stigma. Additionally, the observation measure used may not have been an ideal representation of parenting behaviour, as discussed previously.   Similarity-Fit and Similarity-Misfit The similarity-fit hypothesis proposes that parental ADHD symptoms when a child has ADHD might benefit parenting due to the parent and child being in tune with one another (Psychogiou et al., 2008). However, findings in this sample indicated that parental ADHD symptoms were associated with negative parenting behaviours, particularly when parents had low levels of depressive symptoms. This instead aligns with the similarity-misfit hypothesis. In addition, parental ADHD symptoms did not predict positive parenting, which fails to support either the similarity-fit or the similarity-misfit hypothesis.  Although speculative, it is possible that parental ADHD symptoms were not correlated with positive parenting behaviours one way or the other, on average, because of situational factors that determine whether or not similarity-fit or similarity-misfit is elicited. Perhaps the impulsivity and hyperactivity symptoms of ADHD (and the associated emotion regulation difficulties) result in parents being less positive, and more hostile and over-reactive to their children in structured situations that demand child compliance. By contrast, in unstructured situations with few to no demands where the focus is on fun, perhaps parents with elevated symptoms of ADHD are more in tune with their child and able to engage more positively than those without elevated symptoms of ADHD; negative parenting would be unlikely to be elicited 45  in this fun context. The research thus far on similarity-fit has not taken this interaction context (structured vs unstructured) into account.  Strengths and Limitations  This study systematically investigated the contributions of parental ADHD symptoms and parental depressive symptoms on parenting behaviours and affiliate stigma. As both these psychopathologies are more common in parents of children with ADHD compared to parents of typically developing children (Chronis et al., 2003; Johnston & Mash, 2001; Kessler et al., 2006), it is important to consider the influence of each. This is in contrast to past research that did not account for both psychopathologies’ potential influence on parenting behaviours, particularly in the literature about parental depression. ADHD and depression are distinct diagnostic categories with different core symptoms, and it is important to investigate if they influence parenting in different ways. Another study strength was controlling for child oppositional behaviours in all regression models. Child ODD symptoms are likely to influence parenting behaviours (Burke et al., 2008; Johnston et al., 2012; Modesto-Lowe et al., 2008), so accounting for these is an important step that has been inconsistently done in past research.   Although no significant findings were found for the observational data, a strength of this study was that both self-report data and observational data on parenting behaviour were included. It is interesting that findings were only found for self-reports on parenting behaviours. Further research should continue to utilize observation measures of parenting to determine if associations between parental psychopathology and parenting behaviours are due to parents’ distorted perceptions or to document the situations in which these parents display observed difficulty engaging in ideal parenting behaviours. Multiple informants about child behaviour (both parent and teacher) also provide confidence that children in this sample have clinical diagnoses of 46  ADHD, as well as confidence in the level of oppositional behaviour seen in these children. Further, this study also expanded on affiliate stigma research, and was the first to look at whether parental ADHD symptoms are associated with affiliate stigma.   There are a number of limitations to this study as well. Although the models propose that parental psychopathology influences parenting behaviours, the cross-sectional nature of the design obscures conclusions about the directionality of these findings. Further, the overall level of parental ADHD symptoms and depressive symptoms was low in this sample, although the level of depressive symptoms was seemingly comparable to past research (Chronis et al., 2003). This sample was comprised of treatment-seeking parents who were willing and able to come to a university setting for data collection; therefore, it is possible that they may have better parenting practices and lower psychopathology compared to the population of parents of children with ADHD. Treatment, however, was provided at a community clinic, and this may have encouraged a broader range of parents to participate in this research than if it had taken place at the university. Further, the data used in this study was from the parents’ visits to the lab prior to treatment. A number of parents dropped out of the study after these visits but before treatment began, for reasons which may include being unable to organize attending the treatment consistently or having less investment in treatment. As such, it is possible that results from the current study are slightly more generalizable to the population of families of children with ADHD than they would be from a sample where all parents completed treatment. Finally, this sample was also comprised of only one parent; it is possible that the other parent may have elevated levels of ADHD symptoms or depressive symptoms that also contribute to family interactions but this was not measured. 47   In addition, the observational data in this study may not accurately represent parents’ typical parenting behaviour. The artificial nature of this task (which was also constrained to a specific situation where the parent prepared the child before a playdate and debriefed with them after) may have encouraged parents to engage in parenting behaviours that do not reflect their usual practices. Further, the task included only a 5-minute preparation period and 5-minute debrief period, and it is possible that this small snapshot did not reflect typical parenting behaviour. A more appropriate observational task, such as the Etch-A-Sketch task, which requires the parent and child to work together on a difficult and potentially frustrating task, may better elicit negative or positive parenting behaviours that reflect parents’ typical practices.  A further limitation concerns the low internal consistency obtained on two parenting subscales in the current sample, specifically the APQ Poor Monitoring/Supervision subscale (10 items) and the Parenting Scale Hostility subscale (3 items). The APQ Poor Monitoring/Supervision subscale alpha is lower in this sample (.44) compared to previous studies (.67; Shelton et al., 1996). The Parenting Scale Hostility subscale alpha is also lower in this sample (.49) compared to other samples (mothers = .52, fathers = .59; Rhoades & O’Leary, 2007). Rhoades and O’Leary (2007) note that the small number of items on this scale may explain the low alpha. Regardless, the psychometrics in the current sample suggest that caution should be used when interpreting the results from the self-reported negative parenting and unstructured parenting factors.  Clinical Implications Parental psychopathology has been found to be associated with children’s social and emotional maladjustment (Berg-Nielson et al., 2002; Breaux et al., 2014), including specifically for children with ADHD (Deault, 2010). It is also clear that parental psychopathology can have a 48  negative effect on parenting behaviours, and less than optimal parenting behaviours can also influence child adjustment (Johnston & Mash, 2001; Tarver et al., 2015). Although the effects of parenting on child outcomes were not investigated in the current study, it is interesting to consider the potential clinical implications of the finding that both parental ADHD and depressive symptoms were incrementally associated with more negative parenting, but only depressive symptoms were incrementally associated with less positive parenting. In previous work, negative parenting has been found to be uniquely related to children’s aggressive behavior, homework problems, and home impairment, whereas both positive parenting and negative parenting were related to children’s social skills (Haack et al., 2016; Kaiser, McBurnett, & Pfiffner, 2011). It is possible that the presence of negative parenting carries more adjustment implications for children relative to the lack of positive parenting. As such, perhaps the incremental effect of parental ADHD and depressive symptoms on negative parenting is the most concerning finding from a clinical perspective and could be the most useful target for intervention. The different findings for parental ADHD symptoms and depressive symptoms in this study also support the importance of considering the contributions of both parental ADHD symptoms and depressive symptoms on parenting behaviour in assessment and intervention. Potentially, psychological evaluations of children with ADHD might be improved by the inclusion of measures assessing parent mental health and these different parenting behaviours. Specifically, this study highlights the importance of considering both parental ADHD symptoms and depressive symptoms in families of children with ADHD and how this affects family functioning. Only considering the influence of the child’s ADHD symptoms or one parental psychopathology may do a disservice to the family and provide an incomplete clinical picture. 49  Second, regarding intervention, I speculate that considering all family dynamics and functioning in treatment planning, as opposed to only focusing on child behaviors, is needed to maximally address child adjustment. Empirically-supported psychosocial treatments for children with ADHD, such as behavioural parent training, typically rely on heavy parental involvement and consistent implementation of behavioural management (Evans, Owens, Wymbs, & Ray, 2018). If parents are struggling with their own mental health, expecting them to engage with, and benefit from, behavioural parent training may be challenging. It would be easy to see how a parent with depression or ADHD symptoms may attempt behavioural parent training, experience difficulty with the recommendations, become overwhelmed, and ultimately disengage from treatment. This potentially perpetuates feelings of guilt and self-efficacy doubts, provides parents with another example of how they have “failed” as a parent, and ultimately adds to the distress experienced by the child and family as a whole. Future Directions This research takes a step toward a more thorough understanding of the incremental and interactive contributions of parental ADHD and depressive symptoms on parenting behaviour and affiliate stigma. Future research should consider that both psychopathologies may be associated with different parenting behaviours, and account for this possibility in analyses. The same can be said for the inclusion of child oppositional behaviours.  Future studies should also compare results on both self-reported parenting behaviours and observed parenting behaviours. Ensuring that observation data is ecologically valid will also be important to fully investigate the influence of parent psychopathologies on parenting behaviours. It will be important for research to continue to assess whether parent psychopathologies have an effect on parenting behaviours in the “real world” (as much as can be done with observation 50  tasks), to ensure that shared method variance or distorted cognitions due to parent psychopathology are not driving the association between self-reported symptoms and parenting behaviours.  Further, research has just started to look into the role of affiliate stigma in parental mental health and parenting behaviours. While in this study there was an association found with parent depressive symptoms, affiliate stigma was not found to mediate the relationship between psychopathology and parenting behaviours. The potential effects of affiliate stigma on parenting behaviours or the parent child relationship should be studied further. Ideally this would be done in samples with higher levels of symptoms and perhaps in a scenario that induces the experience of affiliate stigma prior to having to engage in a parenting task (such as having other parents watching child misbehavior). Careful research into the cognitive, behavioural, and affective aspects of affiliate stigma and their effect on parents and parenting behaviours may provide further insight into avenues for interventions to improve family functioning and parenting behaviour.  Further work should also be done to more carefully investigate whether parenting behaviour is a mechanism through which parental psychopathology influences child outcomes. Importantly, research should continue to examine whether addressing parent mental health first improves parenting behaviour, and then whether this also leads to improved child behaviour and positive outcomes. A number of researchers are looking to fill this knowledge gap by evaluating behavioural parent training programs for child ADHD that integrate treatment for parental depression (Chronis-Tuscano et al., 2013) and parental ADHD (Chronis-Tuscano, Wang, Woods, Strickland, & Stein, 2017; Jans et al., 2015). Findings thus far are inconclusive and in order for research in this area to move forward, future studies should consider level of parent 51  functional impairment; assess positive, negative, and structured parenting behaviour as relevant to treatment; assess the influence of both parents; and focus on parents who endorse clinical levels of ADHD and/or depression (Chronis-Tuscano et al., 2017). In addition, studies examining the unique associations between parental psychopathology and parenting (such as this one) might be used to inform treatment design, as the ultimate goal of understanding the influence of both parental ADHD and depressive symptoms on parenting behaviours and attitudes would be so assessment protocols and interventions can apply this information. Conclusion  This research demonstrated that parental ADHD and depressive symptoms appear to make incremental contributions to different parenting behaviours and affiliate stigma in this sample. Findings suggest the importance of accounting for both parental ADHD and depression in research and when assessing parenting behaviours and planning interventions among families of children with ADHD. Although this research does indicate an association between parental ADHD or depressive symptoms with some parenting behaviours, the size of the associations are small. Nonetheless, failure to consider both psychopathologies could result in misleading associations or an incomplete picture of the unique parenting difficulties facing parents of children with ADHD. Further, this research demonstrated that affiliate stigma is associated with parental mental health and should be an additional consideration in assessment and treatment planning. Overall, these findings highlight the importance of considering both parental ADHD and depression symptoms to understand the family functioning of children with ADHD.    52   Table 1 Demographics of Sample  Vancouver (n = 96) Ottawa (n = 120) Total (N = 216)  M(SD) or % Range M(SD) or % Range M(SD) or % Range Parent Demographics    Age* 42.27 (5.64) 30-55 40.04 (5.98) 27-58 41.01 (5.92) 27-58    Gender (% male) 12  9  10     Household Income 113071 .62 (83405.54) 15600- 590000 121107.80 (73802.35) 5277- 540000 117711.07 (77897.43) 5277- 590000    Relationship with child (%)       Biological Mother       Biological Father       Adoptive Mother       Adoptive Father       Grandmother       Other   90 4 4 1 0 1    86 8 3 1 1 1   87 7 4 1 1 1     Education (%)       Some high school       High school graduate       Some college/university       College or technical degree       University graduate       Advanced post-university       degree           1 2 16 23 45 13    2 6 12 27 36 18   1 4 14 25 40 15           53     Employment* (%)       Full time       Part time       Unemployed       Stay at home parent       Disabled       Retired       Student       Other or more than one   55 24 2 11 5 0 0 3   81 7 1 6 1 1 1 3   69 15 1 8 3 1 1 3  Child Demographics    Age 8.66 (1.66) 5-11 8.52 (1.49) 6-11 8.58 (1.57) 5-11    Gender (% male) 74  64  68     Ethnicity* (%)       White       AfroCanadian/Black       Asian       Hispanic/Latino       Mixed   63 1 13 1 22   84 1 1 1 14   75 1 6 1 17     Medication Status*     (% taking)  42  64  54  Note. Percentages may not add to 100% due to rounding.  * indicates significant difference between sites.    54  Table 2 Descriptive Statistics of Study Variables  Vancouver (n = 96) Ottawa (n = 120) Total (N = 216) Variable Mean SD Range Mean SD Range Mean SD Range Parent             ADHD Symptoms* 10.50 8.53 0-42 13.26 10.28 0-49 12.03 9.62 0-49    Depressive Symptoms 8.47 7.64 0-36 10.24 9.16 0-38 9.44 8.54 0-38    Affiliate Stigma* 2.11 0.65 1-3.83 1.79 0.59 1-3.83 1.93 0.64 1-3.83 APQ             Involvement 3.01 0.42 2-4 3.04 0.43 1.5-4 3.03 0.43 1.5-4    Positive Parenting* 3.19 0.51 1.4-4 3.34 0.48 1.83-4 3.27 0.50 1.4-4.0    Inconsistent Discipline* 1.31 0.56 0-2.67 1.57 0.64 0-3.17 1.45 0.61 0-3.17    Poor Monitoring/    Supervision 0.40 0.36 0-1.5 0.43 0.38 0-1.5 0.42 0.37 0-1.5 Parenting Scale             Laxness 2.67 0.83 1.18-4.82 2.56 0.88 1-5 2.61 0.86 1-5    Over Reactivity 3.07 0.86 1.2-5.3 3.03 0.79 1.6-5.1 3.05 0.82 1.2-5.3    Hostility 1.64 0.80 1-4.33 1.72 0.80 1-4.67 1.69 0.79 1-4.67 Observations             Collaboration 2.94 0.78 0.75-4.50 3.01 0.79 1.50-5 2.98 0.78 .75-5    Praise 2.78 1.85 0-5 2.19 1.80 0-5 2.49 1.84 0-5    Warmth 3.23 0.98 1-5 3.27 0.94 0-5 3.25 0.95 0-5 55     Criticism 0.77 1.05 0-4.25 0.83 1.01 0-4 0.80 1.02 0-4.25    Strategies* 2.38 0.95 .5-4.5 1.82 0.99 0-4.5 2.08 1.01 0-4.50 Child             ADHD Symptoms  33.58 7.75 13.50-51 33.72 7.98 14-53 33.66 7.86 13.50-53    ODD Symptoms 63.62 7.26 50-80 62.97 7.37 50-79 63.24 7.31 50-80 Note. ADHD = Attention-Deficit/Hyperactivity Disorder; APQ = Alabama Parenting Questionnaire; ODD = Oppositional Defiant Disorder. Scale ranges are: Affiliate Stigma Questionnaire 1-4; Alabama Parenting Questionnaire 0-4; Parenting Scale 1-7; Collaboration/Warmth/Praise/Criticism 0-5.  * indicates significant difference between sites     56  Table 3 Principle Components Analysis of Parenting Variables  Variable Factor 1 Factor 2 Factor 3 Factor 4 Factor 5 Eigenvalue (after rotation) Inconsistent Discipline .84 .24 -.05 .08 -.15 1.73 Laxness .77 .02 .04 -.29 -.25  Poor Monitoring/Supervision .55 .16 -.18 -.02 .34  Hostility .08 .93 .01 -.06 -.07 1.72 Over Reactivity .29 .85 -.02 -.16 .00  Collaboration -.03 .01 .78 .09 -.09 1.69 Strategies -.01 -.11 .76 -.13 .01  Praise -.10 .11 .53 .01 .30  Involvement .00 -.09 .05 .90 -.01 1.69 Positive Parenting -.15 -.10 -.09 .86 .06  Warmth -.10 -.08 -.06 .06 .76 1.24 Criticism .03 .02 -.42 .02 -.60  Note. Bold faced values represent factor loadings that belong to each extracted factor.                    57  Table 4  Correlation Matrix of Study Variables   1 2 3 4 5 6 7 8 1. Child ODD Symptoms -        2. Parent Depressive Symptoms .15* -       3. Parent ADHD Symptoms .04 .52** -      4. Self-reported Unstructured Parenting .10 .21** .19** -     5. Self-reported Negative Parenting .16* .29** .29** .41** -    6. Observed Positive Verbal Parenting Behaviours -.03 -.15 -.04 -.10 -.04 -   7. Self-reported Positive Parenting .05 -.16* -.05 -.19** -.23** .01 -  8. Observed Emotional Tone -.02 .04 .07 -.15 -.09 .22** .07 - 9. Affiliate Stigma .26** .27** .16* .09 .11 .10 .01 -.04 Note. ODD = Oppositional Defiant Disorder; ADHD = Attention-Deficit/Hyperactivity Disorder. *p < .05; **p < .01     58  Table 5 Parental ADHD Symptoms as a Predictor of Parenting Behaviours   Self-reported unstructured parenting Self-reported negative parenting Observed positive verbal parenting Self-reported positive parenting Observed emotional tone  ∆R2 β ∆R2 β ∆R2 β ∆R2 β ∆R2 β Step 1    Child ODD Symptoms  .01  .09 .02  .13 .00  -.02 .00  .04 .00  -.02 Step 2  Child ODD Symptoms   Parental ADHD Symptoms  .03**  .09 .18** .08**  .13 .28** .00  -.02 -.04 .00  .04 -.05 .01  -.01 .07 Step 3    Child ODD Symptoms       Parental ADHD Symptoms    Parental Depressive Symptoms  .02  .07 .11 .15 .02*  .10 .19* .17* .02  .00 .05 -.17 .04**  .07 .06 -.22** .00  -.01 .08 .00 Step 4    Child ODD Symptoms       Parental ADHD Symptoms    Parental Depressive Symptoms    ADHD X Depression .01  .07 .12 .21* -.14 .03*  .10 .22** .26** -.20* .00  .01 .06 -.16 -.04 .01  .07 .05 -.27 .12 .01  -.01 .05 -.05 .12 Note. ODD = Oppositional Defiant Disorder; ADHD = Attention-Deficit/Hyperactivity Disorder. *p < .05; **p < .01    59  Table 6 Parental Depressive Symptoms as a Predictor of Parenting Behaviours  Self-reported unstructured parenting Self-reported negative parenting Observed positive verbal parenting Self-reported positive parenting Observed emotional tone  ∆R2 β ∆R2 β ∆R2 β ∆R2 β ∆R2 β Step 1    Child ODD Symptoms  .01  .09 .02  .13 .00  -.02 .00  .04 .00  -.02 Step 2    Child ODD Symptoms    Parental Depressive Symptoms  .04**  .06 .21** .07**  .09 .27** .02  .00 -.15 .04**  .06 -.19** .00  -.02 .04 Step 3    Child ODD Symptoms    Parental ADHD Symptoms    Parental Depressive Symptoms  .01  .07 .11 .15 .03*  .10 .19* .17* .00  .00 .05 -.17 .00  .07 .06 -.22** .00  -.01 .08 .00 Step 4    Child ODD Symptoms    Parental ADHD Symptoms    Parental Depressive Symptoms    ADHD X Depression .01  .07 .12 .21* -.14 .03*  .10 .22** .26** -.20* .00  .01 .06 -.16 -.04 .01  .07 .05 -.27 .12 .01  -.01 .05 -.05 .12 Note. ODD = Oppositional Defiant Disorder; ADHD = Attention-Deficit/Hyperactivity Disorder. *p < .05; **p < .01   60  Table 7 Parental ADHD Symptoms as a Predictor of Affiliate Stigma  Affiliate Stigma  ∆R2 β Step 1    Child ODD Symptoms  .05**  .23** Step 2    Child ODD Symptoms    Parental ADHD Symptoms  .02*  .22** .14* Step 3    Child ODD Symptoms    Parental ADHD Symptoms    Parental Depressive Symptoms  .03**  .20** .03 .22** Step 4    Child ODD Symptoms    Parental ADHD Symptoms    Parental Depressive Symptoms    ADHD X Depression .01  .20** .04 .25** -.09 Note. ODD = Oppositional Defiant Disorder; ADHD = Attention-Deficit/Hyperactivity Disorder. *p < .05; **p < .01    61  Table 8  Parental Depressive Symptoms as a Predictor of Affiliate Stigma  Affiliate Stigma  ∆R2 β Step 1    Child ODD Symptoms  .05**  .23** Step 2    Child ODD Symptoms    Parental Depressive Symptoms  .05**  .20** .23** Step 3    Child ODD Symptoms    Parental ADHD Symptoms    Parental Depressive Symptoms  .00  .20** .03 .22** Step 4    Child ODD Symptoms    Parental ADHD Symptoms    Parental Depressive Symptoms    ADHD X Depression .01  .20** .04 .25** -.09 Note. ODD = Oppositional Defiant Disorder; ADHD = Attention-Deficit/Hyperactivity Disorder. *p < .05; **p < .01     62          Figure 1: Affiliate Stigma Mediation Model   a: b = .02; p = .003 c: -.02; p = .08  c’: -.02; p = .03 Parental Depressive Symptoms Parental Affiliate Stigma Observed Verbal Positive Parenting  b: b = .19; p = .06 Bootstrap: b = .004, CI [.0006, .0110] 63   Figure 2. 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Journal of Abnormal Child Psychology, 45(3), 471-484.  doi:10.1007/s10802-016-0220-2   76  Appendix A Parent-Child Coaching Task Script Excerpts Part 1: Parent-Child Coaching Task Prep Period Examiner B: Wait in the Atrium with friend until Examiner A comes to get you. Examiner A: Bring the parent of the target child and the target child to the table together in the Child Room, in the position marked (so that they are visible to the video cameras). WAIT until Supervisor lets you know that the videos are ready to go via walkie-talkie. Hi (parent name, target child name), we are almost ready for you (target child) and (friend’s name) to play some games together. In a few minutes, you (target child) and (friend’s name) will play two games.  In one game, you (target child) and your friend will play a fun racing game together where you will have to be faster than your friend. In another game, you and your friend will be doing something where the two of you will have to work together as a team to come to a solution that both of you are happy with. We can’t tell you more about what exactly you will be doing at this point, but it is a game where you will have to work at it together.  While we are waiting to start these next games, in the meantime we would like for you (parent) to have a talk with (target child’s name). Talk to your child however you think will help prepare your child to do well at working and playing together with (friend’s name) in the next games. You’ll have the next 5 minutes to do this. Do you have any questions?  • If parents have questions, Examiner A may repeat these instructions as often as needed, emphasizing that the upcoming games are something in which the children will have to “play a racing game where they will have to be faster than the friend and also do something where the two children will have to work together at in order to come to a solution that both of them are happy with” and that the “parent should have a talk with the goal of preparing the child to do well at these upcoming games”.  • However, do not give any more information about what the games are, or give any suggestions/advice to parents about how they can best prepare their child.  • Examiner A should step outside the room and wait by the door.  • Examiner A should use a stopwatch to time the interaction and then return to the room when 5 minutes have elapsed.  • Examiner A should go to the Atrium around the 4 minute mark of Part 1 to bring in Examiner B and friend. Examiner A, Examiner B, and the friend should ideally all be standing by the door of the Child Room when the 5 minutes have elapsed and Part 1 is complete.  Part 2: Child and Friend Social Interaction Tasks Examiner B: Tell the target child and friend “(parent name) is going to leave the room now, but (parent name) will be able to see what you guys are doing from another room.” 77    Examiner A: Pass the walkie-talkie to Examiner B. Walk the parent to the Observation Room.  Examiner B: WAIT in the room with the child and friend until Supervisor lets you know that the videos and the parent are ready to go via walkie-talkie.   Examiner B: Facilitates the object trade/sharing task and the car race track with the two children.   NOTE: Scripted details of this section are omitted as they are not relevant in this study. Part 3: Parent-Child Coaching Task Debrief Period Examiner A explains this to the parent of target child in the observation room when parent is alone:  Now that they’re all done, we’d like you (parent) to talk to (target child’s name) about how these games with (friend’s name) went. Give your child any feedback that you think will help your child to be good at making friends. You’ll have 5 minutes to do that next. Do you have any questions? • Again, answer any questions the parent might have by restating the instructions.  • The goal is for the parent to try to give the child feedback about what just happened with the friend, with the intention of helping the child to make friends.  • Don’t give the parent any advice or suggestions about what exactly the parent should say or do with the child.    • Once the parent is clear on the task, Examiner A should then bring the parent back to the room with the target child and seat the parent at the table along with the target child and in view of the cameras.  • At this point, Examiner B will leave with the friend.   Examiner A walks the parent back to the room where the child is, parent and child sit down at the table again. So you (indicate child) and (friend’s name) are done with those games, and you remember that we said your parent (mom/dad/etc.) would be in another room but would be able to see you and (friend’s name). The last thing for today is that you (indicate child) and your parent (mom/dad/etc.) will have a few minutes to talk about how the games with your friend went. We will come back and get you in 5 minutes, okay? • Examiner A should step outside the room and use a stopwatch to time the interaction and then return to the room when 5 minutes have elapsed.     78  Appendix B Current Symptoms Scale (CSS) These questions are about you, not about your child. Please circle the number next to each item that best describes your behavior during the past 6 months.  1. I fail to give close attention to details or make careless mistakes in my work 0 1 2 3 Rarely or Never Sometimes Often Very Often  2. I fidget with hands or feet or squirm in seat 0 1 2 3 Rarely or Never Sometimes Often Very Often  3. I have difficulty sustaining my attention in tasks or fun activities 0 1 2 3 Rarely or Never Sometimes Often Very Often  4. I leave my seat in situations in which seating is expected 0 1 2 3 Rarely or Never Sometimes Often Very Often  5. I don’t listen when spoken to directly 0 1 2 3 Rarely or Never Sometimes Often Very Often  6. I feel restless 0 1 2 3 Rarely or Never Sometimes Often Very Often  7. I don’t follow through on instructions and fail to finish work 0 1 2 3 Rarely or Never Sometimes Often Very Often  8. I have difficulty engaging in leisure activities or doing fun things quietly 0 1 2 3 Rarely or Never Sometimes Often Very Often  9. I have difficulty organizing tasks and activities 0 1 2 3 Rarely or Never Sometimes Often Very Often  10. I feel “on the go” or “driven by a motor” 0 1 2 3 Rarely or Never Sometimes Often Very Often  79  11. I avoid, dislike, or am reluctant to engage in work that requires sustained mental effort 0 1 2 3 Rarely or Never Sometimes Often Very Often  12.  I talk excessively 0 1 2 3 Rarely or Never Sometimes Often Very Often  13. I lose things necessary for tasks or activities 0 1 2 3 Rarely or Never Sometimes Often Very Often  14. I blurt out answers before questions have been completed 0 1 2 3 Rarely or Never Sometimes Often Very Often  15. I am easily distracted 0 1 2 3 Rarely or Never Sometimes Often Very Often  16. I have difficulty awaiting my turn 0 1 2 3 Rarely or Never Sometimes Often Very Often  17. I am forgetful in daily activities 0 1 2 3 Rarely or Never Sometimes Often Very Often  18. I interrupt or intrude on others 0 1 2 3 Rarely or Never Sometimes Often Very Often      80  Appendix C Alabama Parenting Questionnaire (APQ) Here are a number of statements about things you do with your child.  Please read each one carefully and decide how often it occurred in your home in the past 4 weeks.  Circle the number that represents your choice.  Please try to not mark between choices and try to answer every item.  Remember to refer only to the past 4 weeks.    Never Almost never Some times Often Always Not Applicable 1. You have a friendly talk with your child 0 1 2 3 4 N/A         2. You let your child know when he/she is doing a good job with something 0 1 2 3 4 N/A         3. You threaten to punish your child and then do not actually punish him/her 0 1 2 3 4 N/A         4. You volunteer to help with special  activities your child is involved in (such as sports, boy/girl scouts, church youth groups) 0 1 2 3 4 N/A         5. You reward or give something to your  child for obeying you or behaving well 0 1 2 3 4 N/A         6. Your child fails to leave a note or let you know where he/she is going 0 1 2 3 4 N/A         7. You play games or do other fun things with  your child 0 1 2 3 4 N/A         8. Your child talks you out of being punished after he/she has done something wrong 0 1 2 3 4 N/A 81          9. You ask your child about his/her day in school 0 1 2 3 4 N/A         10. Your child stays out in the evening past the time he/she is supposed to be home 0 1 2 3 4 N/A         11. You help your child with his/her homework 0 1 2 3 4 N/A         12. You feel that getting your child to obey you is more trouble than it’s worth 0 1 2 3 4 N/A 13. You compliment your child when he/she  does something well 0 1 2 3 4 N/A         14. You ask your child what his/her plans  are for the coming day 0 1 2 3 4 N/A         15. You drive your child to a special activity 0 1 2 3 4 N/A         16. You praise your child for behaving well 0 1 2 3 4 N/A         17. Your child is out with friends you do not know 0 1 2 3 4 N/A         18. You hug or kiss your child when he/she has  done something well 0 1 2 3 4 N/A         19. Your child goes out without a set time to be home 0 1 2 3 4 N/A         20. You talk to your child about his/her friends 0 1 2 3 4 N/A         21. Your child is out after dark without an adult with him/her 0 1 2 3 4 N/A         82  22. You let your child out of a punishment early (like lift restrictions earlier than you originally said) 0 1 2 3 4 N/A         23. Your child helps plan family activities 0 1 2 3 4 N/A         24. You get so busy you forget where your child is and what he/she is doing 0 1 2 3 4 N/A         25. Your child is not punished when  he/she has done something wrong 0 1 2 3 4 N/A         26. You attend PTA meetings, parent/teacher  conferences, or other meetings at your child’s school 0 1 2 3 4 N/A         27. You tell your child that you like it   when he/she helps out around the house 0 1 2 3 4 N/A 28. You don’t check that your child comes home at the time he/she was supposed to 0 1 2 3 4 N/A          29. You don’t tell your child where you are going 0 1 2 3 4 N/A         30. Your child comes home from school more than an hour past the time he/she was supposed to  0 1 2 3 4 N/A         31. The punishment you give your child depends on your mood 0 1 2 3 4 N/A         32. Your child is at home without adult supervision 0 1 2 3 4 N/A 83   33. You ignore your child when he/she is misbehaving 0 1 2 3 4 N/A         34. You take away privileges or money  from your child as a punishment  0 1 2 3 4 N/A         35. You send your child to his/her room as a punishment     0 1 2 3 4 N/A         36. You yell or scream at your child when  he/she has done something wrong    0 1 2 3 4 N/A         37. You calmly explain to your child why his/her behaviour was wrong when he/she misbehaves   0 1 2 3 4 N/A         38. You use time out (make him/her sit or stand in a corner) as a punishment   0 1 2 3 4 N/A         39. Your give your child extra chores as a punishment   0 1 2 3 4 N/A     84  Appendix D Parenting Scale At one time or another, all children misbehave or do things that could be harmful, that are "wrong," or that parents don't like.  Examples include:  hitting someone, throwing food, not picking up toys, having a tantrum, wanting a cookie before dinner, arguing back, whining, forgetting homework, lying, refusing to go to bed, running into the street, or coming home late.   Parents have many different ways or styles of dealing with these types of problems.  Below are items that describe some styles of parenting.  FOR EACH ITEM, FILL IN THE CIRCLE THAT BEST DESCRIBES YOUR STYLE OF PARENTING IN THE PAST 2 MONTHS.  You’ll fill in the circle that is closest to the response you would do. If what you would do is right in the middle of the two responses, fill in the circle in the middle.  Answer for how you would handle the misbehaviours of the child in the study.  1.  When my child misbehaves…  I do something about it right away Ο—Ο—Ο—Ο—Ο—Ο—Ο I do something about it later    2.  Before I do something about a problem…  I give my child several reminders or warnings Ο—Ο—Ο—Ο—Ο—Ο—Ο I use only one reminder or warning    3.  When I’m upset or under stress…  I am picky and on my child’s back Ο—Ο—Ο—Ο—Ο—Ο—Ο I am no more picky than usual    4.  When I tell my child not to do something…  I say very little Ο—Ο—Ο—Ο—Ο—Ο—Ο I say a lot    5.  When my child pesters me…  I can ignore the pestering Ο—Ο—Ο—Ο—Ο—Ο—Ο I can’t ignore the pestering    6.  When my child misbehaves…  85  I usually get into a long argument with my child Ο—Ο—Ο—Ο—Ο—Ο—Ο I don’t get into an argument    7.  I threaten to do things that…  I am sure I can carry out Ο—Ο—Ο—Ο—Ο—Ο—Ο I know I won’t actually do    8.  I am the kind of parent that…  Sets limits on what my child is allowed to do Ο—Ο—Ο—Ο—Ο—Ο—Ο Lets my child do whatever he/she wants    9.  When my child misbehaves…  I give my child a long lecture Ο—Ο—Ο—Ο—Ο—Ο—Ο I keep my talks short and to the point    10. When my child misbehaves…  I raise my voice or yell Ο—Ο—Ο—Ο—Ο—Ο—Ο I speak to my child calmly    11. If saying “No” doesn’t work right away…  I take some other kind of action Ο—Ο—Ο—Ο—Ο—Ο—Ο I keep talking and try to get through to my child    12. When I want my child to stop doing something…  I firmly tell my child to stop Ο—Ο—Ο—Ο—Ο—Ο—Ο I coax or beg my child to stop    13. When my child is out of my sight…  I often don’t know what my child is doing Ο—Ο—Ο—Ο—Ο—Ο—Ο I always have a good idea of what my child is doing    14. After there’s been a problem with my child…  86  I often hold a grudge Ο—Ο—Ο—Ο—Ο—Ο—Ο Things get back to normal quickly    15. When we’re not at home…  I handle my child the way I do at home Ο—Ο—Ο—Ο—Ο—Ο—Ο I let my child get away with a lot more    16. When my child does something I don’t like…  I do something about it every time it happens Ο—Ο—Ο—Ο—Ο—Ο—Ο I often let it go    17. When there’s a problem with my child…  Things build up and I do things I don’t mean to do Ο—Ο—Ο—Ο—Ο—Ο—Ο Things don’t get out of hand    18. When my child misbehaves, I spank, slap, grab, or hit my child…  Never or rarely Ο—Ο—Ο—Ο—Ο—Ο—Ο Most of the time    19. When my child doesn’t do what I ask…  I often let it go or end up doing it myself Ο—Ο—Ο—Ο—Ο—Ο—Ο I take some other action    20. When I give a fair threat or warning…  I often don’t carry it out Ο—Ο—Ο—Ο—Ο—Ο—Ο I always do what I said    21. If saying “No” doesn’t work…  I take some other kind of action Ο—Ο—Ο—Ο—Ο—Ο—Ο I offer my child something nice so he/she will behave    22. When my child misbehaves…  I handle it without getting upset Ο—Ο—Ο—Ο—Ο—Ο—Ο I get so frustrated or angry that my child can see I’m upset 87     23. When my child misbehaves…  I make my child tell me why he/she did it Ο—Ο—Ο—Ο—Ο—Ο—Ο I say “No” or take some other action    24. If my child misbehaves and then acts sorry…  I handle the problem like I usually would Ο—Ο—Ο—Ο—Ο—Ο—Ο I let it go that time    25. When my child misbehaves…  I rarely use bad language or curse Ο—Ο—Ο—Ο—Ο—Ο—Ο I almost always use bad language    26. When I say my child can’t do something…  I let my child do it anyway Ο—Ο—Ο—Ο—Ο—Ο—Ο I stick to what I said    27. When I have to handle a problem…  I tell my child I’m sorry about it Ο—Ο—Ο—Ο—Ο—Ο—Ο I don’t say I’m sorry    28. When my child does something I don’t like, I insult my child, say mean things, or call my child names…  Never or rarely Ο—Ο—Ο—Ο—Ο—Ο—Ο Most of the time    29. If my child talks back or complains when I handle a problem…  I ignore the complaining and stick to what I said Ο—Ο—Ο—Ο—Ο—Ο—Ο I give my child a talk about not complaining    30. If my child gets upset when I say “No”…  I back down and give in to my child Ο—Ο—Ο—Ο—Ο—Ο—Ο I stick to what I said    88  Appendix E Summary of Relevant Codes from the Parent-Child Coaching Task Code Description Scale Positive Parenting Indicators Collaboration The parent works collaboratively with the child to come up with strategies for behaving in a peer interaction, regardless of what those strategies are. The parent is interested in the child’s input and takes the child’s input in.   0-5 Praise The parent offers praise to the child for positive behaviours or character. The intention is that the parent is showing approval of a child’s behaviour or character and wishes it to continue. 0-5 Warmth This code captures the extent to which the parent is showing the child s/he values the child, cares about the child’s needs (and cares about understanding them), and seeks (and maintains) a positive emotional connection with the child. 0-5 Negative Parenting Indicators Criticism This code captures the extent to which the parent is showing the child s/he is frustrated with the child, experiencing negative emotions toward the child, finds aspects of the child undesirable, or dislikes being in the child’s presence (at that moment, at least). 0-5 Structured Parenting Indicators Strategies Number of times the parent offers the child group-oriented strategies for interacting in a peer situation, whether specific or non-specific. Group-oriented: the end goal/end result of the suggestion is to help the child interact positively in a peer situation. Continuous    89  Appendix F Affiliate Stigma Questionnaire Please note how much you agree with each of the following statements.     Not at all    A little     Some  Very much 1. At times I feel embarrassed by my child’s inattentive symptoms At times I feel embarrassed by my child’s hyperactive and impulsive symptoms 1  1 2  2 3  3 4  4 2. I sometimes avoid situations where other people might see my child showing inattentive symptoms I sometimes avoid situations where other people might see my child showing hyperactive and impulsive symptoms 1  1 2  2 3  3 4  4 3. Other adults sometimes treat me more negatively or discriminate against me because of my child’s inattentive symptoms Other adults sometimes treat me more negatively or discriminate against me because of my child’s hyperactive and impulsive symptoms     1  1 2  2 3  3 4  4 4. Other adults sometimes think more poorly of me when they see my child’s inattentive symptoms Other adults sometimes think more poorly of me when they see my child’s hyperactive and impulsive symptoms 1  1 2  2 3  3 4  4 90  5. As a parent, at times I feel guilty when my child shows inattentive symptoms As a parent, at times I feel guilty when my child shows hyperactive and impulsive symptoms 1  1 2  2 3  3 4  4 6. My child’s inattentive symptoms have led me to cut down some contacts I have with other adults such as friends or family members  My child’s hyperactive and impulsive symptoms have led me to cut down some contacts I have with other adults such as friends or family members 1  1 2  2 3  3 4  4      

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