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Examining subtypes, part II 1

Running Head: SUBTYPES OF BEHAVIOR PROBLEMS, PART II

Examining subtypes of behavior problems among 3-year-old children, Part II: Investigating

differences in parent psychopathology, couple conflict, and other family stressors

Lauren H. Goldstein2, Elizabeth A. Harvey12, Julie L. Friedman-Weieneth2, Courtney Pierce2,

Alexis Tellert2, & Jenna C. Sippel2

This manuscript is in press at Journal of Abnormal Child Psychology

1 Please address correspondence to Elizabeth Harvey, Dept. of Psychology, Tobin Hall, 135 Hicks Way, University of Massachusetts, Amherst, MA 01003; tel: 413-577-2755, fax: 413-545-0996; email: [email protected] Department of Psychology, University of Massachusetts, Amherst, MA 01003This study was supported by National Institute of Mental Health Grant R01MH60132. A portion of these data were presented at the Association for the Advancement of Behavior Therapy in November, 2003, in Boston, MA. This article was based on the doctoral dissertation of Lauren H. Goldstein.We are grateful to the families who participated in this study and to staff from physicians’ offices and community centers who assisted in recruiting families. Thanks also to the many graduate and undergraduate research assistants who assisted with data collection.


Abstract

This study examined family stressors among 3-year-old children who were classified as

hyperactive (HYP), hyperactive and oppositional defiant (HYP/OD), and non-problem based on

mothers’ reports of behavior. Children with HYP/OD were found to experience higher levels of

family stressors than non-problem children on almost every family stressor variable. Compared

to children with HYP, families of children with HYP/OD also tended to report more Axis II

maternal psychopathology, Axis I paternal psychopathology, and high intensity couple conflict

tactics. However, the HYP and HYP/OD group did not significantly differ on maternal Axis I

psychopathology, paternal Axis II psychopathology, parental marital status, negative life events,

frequency of couple conflict, or use of lower intensity couple conflict tactics. Parents of children

with HYP and HYP/OD reported more negative life events, more maternal adult ADHD

symptoms, and more maternal avoidance and verbal aggression during marital conflict than

parents of non-problem children. Implications for treatment and etiology are discussed.

Key words: hyperactivity, oppositional defiance, preschool-aged children, parent

psychopathology, couple conflict


Examining subtypes of behavior problems among 3-year-old children, Part II: Investigating

differences in parent psychopathology, couple conflict, and other family stressors

The present study is the second in a three-part series, which examines how biological

factors, family stressors, and parenting vary across preschool-aged children with hyperactivity,

comorbid hyperactivity/oppositional defiance, and no behavior problems.3 In Part I (Harvey,

Friedman-Weieneth, Goldstein, & Sherman, 2006), we presented a model in which family

stressors were proposed to play a central role in the development of comorbid ADHD/ODD, but

not in the development of ADHD. In particular, family stressors are thought to interact with early

child characteristics and lead to the development and maintenance of behavior problems

(Barkley, 1990). Child impulsivity and a family history of ADHD may also result in elevated

levels of family stressors among children with ADHD who do not have ODD; however, theory

and some research suggest that stressors should be significantly higher among families of

children with ADHD/ODD and ODD than among families of children with pure ADHD (Counts,

Nigg, Stawicki, Rappley, & Von Eye, 2005).

Much of the research linking family stressors with ADHD and ODD has been conducted

with older children (Biederman, Milberger, & Faraone, 1995; Counts et al., 2005). A growing

body of research supporting the validity of ADHD and ODD diagnoses among preschool-aged

children (e.g., Keenan & Wakschlag, 2004; Lahey et al., 1998) highlights the need to examine

the role of family stressors among young children. Moreover, research (Waschbusch, 2002)

points to the importance of taking into account the considerable overlap between ADHD and

ODD among both school-aged children (Biederman, Newcorn, & Sprich, 1991) and preschool-

aged children (Keenan & Wakschlag, 2000; Wilens et al., 2002). The present study examines

3 In part 1, only a small group of children were identified who were reported to display oppositional-defiant symptoms without hyperactivity. There was not sufficient validity for this group based on teachers’ and observers’ ratings to justify further analyses with this group.


family stressors among children with comorbid hyperactivity/oppositional-defiance,

hyperactivity alone, and no problems, to determine whether differences that are consistent with

existing theory can be observed in children as young as 3 years old.

Parent Psychopathology

The link between parent psychopathology and child functioning has been well-

documented (e.g., Lahey et al., 1988). However, few studies have examined children’s behavior

problems multidimensionally. Results have been mixed for parental depression and anxiety with

some studies finding associations with ADHD regardless of co-occurring ODD or CD (Chronis,

Lahey, Pelham, Kipp, Baumann, & Lee, 2003; Cunningham & Boyle, 2002; Jensen et al., 2001;

Johnston, 1996; Nigg and Hinshaw, 1998), while others have not found a clear link between

parental depression or anxiety and pure ADHD (Barkley, Fischer, Edelbrock, & Smallish, 1991;

Lahey et al., 1988). Research suggest that parental substance abuse and ASPD are associated

with ADHD in children only when comorbid ODD or CD are present (e.g., Chronis et al., 2003;

Faroane, Biederman, Keenan, & Tsuang, 1991; Frick, Lahey, Christ, Loeber, & Green, 1991).

Parental history of childhood ADHD (Chronis et al., 2003; Faraone et al., 1991; Frick et al.,

1991; Nigg & Hinshaw, 1998) and paternal adult ADHD symptoms have been associated with

children’s ADHD regardless of comorbid conduct problems (Nigg & Hinshaw, 1998).

A smaller body of research has linked parental anxiety, depression, substance use, and

antisocial behavior to externalizing problems in preschoolers (Puttler, Zucker, Fitzgerald, &

Bingham, 1998; Shaw, Winslow, Owens, & Hood, 1998; Spieker, Larson, Lewis, Keller, &

Gilchrist, 1999; West & Newman, 2003). However, only Cunningham and Boyle (2002) have

examined subtypes of behavior problems in exclusively preschool-aged children.4 They found

that mothers of 4-year-old children with pure hyperactivity and with comorbid hyperactivity/

4Chronis et al. (2003) included some preschool-aged children; participants ranged from age 3-10 to 7 years.


oppositional-defiance reported more depression than did mothers of non-problem children.

Historically, research on the role of parent psychopathology in the development of

children’s behavior problems has focused on mothers (Phares & Compas, 1992), and this trend

has continued over the past decade (Phares, Fields, Kamboukos, & Lopez, 2005). Nonetheless,

research suggests that externalizing problems in children are equally related to maternal and

paternal psychopathology (Connell & Goodman, 2002), though different patterns have emerged

for mothers and fathers. Maternal depression (e.g., Befera & Barkley, 1985), but not paternal

depression (Cunningham, Benness, & Siegel, 1988; Lahey et al., 1988; Nigg & Hinshaw, 1998;

Stewart, DeBlois, & Cummings, 1980), has been linked with ADHD in children. On the other

hand, substance use (e.g., Frick, Lahey, and Loeber, 1992; Lahey et al., 1988; Loukas, Zucker,

Fitzgerald, & Krull, 2003), ASPD (Frick, 1994), and adult ADHD (Nigg & Hinshaw, 1998) have

been linked with child behavior more strongly for fathers than for mothers.

Couple Conflict

The link between interparental conflict and children’s behavior problems has also been

well-established (e.g., Calzada, Eyberg, Rich, & Querido, 2004; Frosch & Mangelsdorf, 2001).

Marital conflict may affect children’s behavior problems through its effect on children’s

emotional arousal (Davies & Cummings, 1994) or through the disruption in the parent-child

relationship (Grych & Fincham, 1990). Identifying which specific characteristics of couple

conflict are most harmful for children is critical to fully understanding this process. For example,

conflict that is high in frequency and intensity (e.g., hostile, aggressive conflict), involves child-

related content, and remains unresolved, may place children at risk for behavior problems

(Cummings, Vogel, & Cummings, 1989; Grych & Fincham, 1990). A pattern of demand-

withdrawal (one person approaches a partner on an issue and the partner avoids discussion)


during marital conflict has been identified as a common cycle in dissatisfied relationships

(Caughlin & Huston, 2002); however this pattern has been linked only with child internalizing

problems (Katz & Gottman, 1993), and not with behavior problems in older children (Lindahl,

1998). Few studies have examined whether marital functioning is associated with hyperactivity,

oppositional-defiance, or a combination of the two, with only one focusing on preschool-aged

children. Most of these have found elevated levels of marital conflict among parents of children

with ADHD/ODD, but not among parents of children with pure ADHD (e.g., Barkley et al.,

1991; Lindahl, 1998; Stormont-Spurgin & Zentall, 1995), with some evidence that differences

may vary across specific marital dimensions (Lindahl, 1998; Stormont-Spurgin & Zentall, 1995).

Contextual Stressors: Negative Life Events, Marital Status, and Low SES

Family stressors may also take the form of structural/contextual stressors, such as

negative life events, single parenthood, and low socioeconomic status. These factors are thought

to influence children primarily through their effects on parents’ well-being and parenting (Crnic,

Gaze, & Hoffman, 2005; Mistry, Vandewater, & Huston, 2002). Families of children with

ADHD tend to be of lower socioeconomic status and are more likely to be headed by single

parents than are families of children without ADHD; however, this appears to be true only for

children with ADHD who have comorbid disorders (Counts et al., 2005; Hinshaw, 1987;

Johnston, 1996). Although theory suggests that negative life events should be linked with

comorbid ADHD/ODD rather than with pure ADHD, the few studies of older children that have

addressed this question have found similar elevations among children with pure ADHD and

children with ADHD/ODD (Barkley et al., 1991; Johnston, 1996).

The Present Study

Theory suggests that family stressors place children with ADHD at risk for developing


ODD, and research on older children provides some, though mixed, support for this. The present

study examined whether differences across 3-year-old children with comorbid hyperactivity/

oppositional-defiance (HYP/OD), hyperactivity alone (HYP), and non-problem children are

consistent with theory regarding the role of family stressors in the development of ADHD/ODD.

Examining such differences provides a step toward understanding the degree to which these

behavior subtypes differentiate from each other at an early age and represent clinically

significant disturbances that share characteristics with ADHD and ADHD/ODD. In particular,

the present study addressed the following questions:

Are there differences across subtypes on maternal and paternal psychopathology?

Theoretical models suggest that while genetic/biological factors underlie both ADHD and ODD,

family stressors also play a significant role in the etiology of ODD. Thus, parent

psychopathology dimensions, other than adult ADHD, should be higher among children with

HYP/OD than among children with HYP and children without problems. While establishing

differences in parent psychopathology would not rule out other causal mechanisms including

shared genetics, it would provide a first step in determining whether early preschool HYP and

HYP/OD share etiological correlates with ADHD and ADHD/ODD. It is critical to examine

dimensions separately given research that mothers may differ more on depression, whereas

fathers may differ more on substance use, ASPD, and adult ADHD. As a result of shared

genetics, adult ADHD should be higher among parents of children with HYP and HYP/OD than

among non-problem children. Elevations in other types of psychopathology may be evident

among parents of children with HYP due to child effects and potential third variables, but should

be smaller than among parents of children with HYP/OD.

Are there differences across subtypes on marital conflict? Research and theory suggest


that compared to parents of HYP and non-problem children, parents of children with HYP/OD

should report more conflict that is high in frequency and intensity, involves child-related content,

is avoidant, and remains unresolved. Although marital conflict is not thought to cause ADHD,

parents of children with pure ADHD may show elevated levels of marital conflict as a result of

child effects or parental ADHD symptomatology, though this comparison was exploratory due to

limited research with conflicting results (Barkley et al., 1991; Johnston, 1996).

Are there differences across subtypes on negative life events, marital status, and

socioeconomic status? It was predicted that parents of children with HYP/OD would more likely

be single, of lower socioeconomic status, and report more negative life events than parents of

HYP and non-problem children. Significant differences were not predicted between HYP and

non-problem children. In Part I, we (Harvey et al., 2006) examined differences in socioeconomic

status in order to provide context for interpreting results, and as predicted, children in the

HYP/OD group had mothers with significantly lower education than mothers of children in the

HYP and non-problem groups. Because these analyses were already completed in Part I, they

will not be repeated, but will be discussed with other family stressors in this paper. Our

prediction regarding negative life events was tentative because theory suggests that they should

occur more frequently among children with HYP/OD than among children with HYP, but

empirical studies have not supported this.

Do race/ethnicity and gender moderate differences across groups in parent

psychopathology, marital conflict, and negative life events? There are thought to be cultural

differences in psychopathology (Hall, Bansal, & Lopez, 1999), marital conflict (McLoyd, Cauce,

Takeuchi, & Wilson, 2000), and stressful life events (Kilmer, Cowen, Wyman, Work, &

Magnus, 1998). Few studies have examined whether the impact of family stressors on child


psychopathology varies across ethnicity, but there is some evidence that it may (Costello, Keeler,

& Angold, 2001). Because ethnic minority groups are underrepresented in research on behavior

disorders in children (Gingerich, Turnock, Litfin, & Rosén, 1998), it is critical to examine

whether relations that are predicted by existing models are supported across different ethnic

groups. There also has been evidence that some family stressors may be more strongly related to

behavior problems in boys than in girls (e.g., Davies & Lindsay, 2001), pointing to the need to

examine whether gender moderates the relation between family stressors and child behavior.

Method

Participants and Procedure

Participants were drawn from 258 children and their 258 mothers and 178 fathers who

were participating in the first year of a longitudinal study of young children’s behavior problems.

One hundred ninety-nine of these children had significant externalizing (hyperactivity and/or

aggression) problems at the time of screening and 59 children did not have behavior problems.

Children were all 3 years old at the time of initial screening and were 36 to 50 months at the time

of the first home visit. In Part I of this series, children were classified into behavior subgroups

using hyperactivity and oppositional-defiance indexes that were created by aggregating across

several rating scales and an interview completed with the mother. Forty-one of these children

were classified as HYP, 96 children as HYP/OD, and 59 children as non-problem. Details about

participants and procedures can be found in the first paper of this series (Harvey et al., 2006).

Measures

Marital status. Families were classified as married/living together if the child lived with

two parents (including stepparents) and as single if the child lived with just one parent.

Millon Clinical Multiaxial Inventory – III (MCMI-III). Parent psychopathology was


measured using the MCMI–III (Millon, Davis, & Millon, 1997), a 175-item questionnaire that

assesses symptoms of DSM-IV disorders. The following Axis I scales were used in the present

study: anxiety, somatoform, bipolar: manic, dysthymia, major depression, posttraumatic stress

(PTSD), and alcohol and drug abuse disorders. The following Axis II scales were included:

schizoid, avoidant, depressive, dependent, histrionic, narcissistic, antisocial, compulsive,

schizotypal, borderline, and paranoid personality disorders. These subscales have demonstrated

good internal consistencies (average α = .82), test-retest reliability (average r = .91), and have

been found to have generally good sensitivity in detecting clinician-based diagnoses (Millon &

Davis, 1997). Base rate (BR) scores were used, which are standard scores tied to empirically

derived population prevalence rates (Millon, Davis, & Millon, 1997).

An initial examination of intercorrelations among Axis II subscales revealed that

narcissistic, histrionic, and compulsive subscales almost always correlated negatively with other

Axis II subscales and with all Axis I subscales (average r = -.29, range = -.49 to -.04), suggesting

that within this nonclinical sample, these subscales may measure healthy narcissism,

flamboyance, and organization. Therefore, these subscales were not included. Intercorrelations

for the cluster A disorders of schizoid, paranoid, and schizotypal ranged from .55 to .65 (p’s

< .001), and therefore were standardized and averaged. For Cluster B, borderline and antisocial

were correlated for both mothers (r = .58, p < .001) and fathers (r = .65, p < .001); however,

because no studies have examined borderline personality disorder, these subscales were kept

separate. Finally, cluster C disorders of dependent and avoidant personality were correlated .60

for mothers and .49 for fathers (p’s < .001), and therefore were standardized and then averaged.

For Axis I disorders, intercorrelations for major depressive disorder, dysthymic disorder,


and depressive personality5 ranged from .52 to .85 (p’s < .001), and were standardized and

averaged. Alcohol abuse and drug abuse were correlated (r = .53 for mothers, r = .64 for fathers,

p’s < .001), and also were aggregated. Intercorrelations for anxiety, PTSD, and somatoform

disorder ranged from .47 to .79 (p’s < .001) and were combined. Finally, bipolar was dropped

from analyses because clinical interviews indicated that bipolar disorder was rare in this sample,

and subclinical and clinical levels of mania are unlikely to have similar effects on families.

Structured Clinical Interview for DSM-IV- Axis I (SCID). The SCID (Spitzer, Williams,

Gibbon, & First, 1990) is an interview designed to assess psychopathology according to DSM-IV

criteria. Each parent was interviewed using the SCID to assess for current and lifetime Axis I

disorders. The SCID has generally demonstrated adequate interrater and test-retest reliability for

these diagnoses (Zanarini et al., 2000). Interviewers all had bachelor’s degrees or master’s

degrees in psychology and most were doctoral students in clinical psychology. All interviewers

underwent extensive training. Because rates of individual anxiety disorders were low, the

following anxiety disorders were combined: panic disorder, PTSD, generalized anxiety disorder,

social phobia, obsessive-compulsive disorder, and anxiety disorder NOS. In addition, the

following substances abuse categories were combined due to low numbers of participants

meeting diagnostic criteria in each drug category: cannabis, cocaine, hallucinogens, opioids,

steroids, sedatives, diet pills, and sleeping pills. Analyses were not conducted for maternal or

paternal dysthymic disorder, bipolar disorder, and current substance abuse, as well as maternal

current alcohol abuse, because fewer than four parents met criteria for each of these disorders.

Interrater reliability (Cohen’s kappa) was calculated using a second clinician’s ratings of 47

audiotaped interviews, and ranged from fair to excellent: current major depression (.55), lifetime

5Although depressive personality was an Axis II scale, it was combined with Axis I depression subscales because it assessed similar symptoms.


major depression (.91), current alcohol abuse (.85), lifetime alcohol abuse (.70), lifetime

substance abuse (.91), current anxiety disorder (.62), lifetime anxiety disorder (.83).

Current Symptoms Scale. Parents’ ADHD symptoms were assessed using the Current

Symptoms Scale (Barkley & Murphy, 1998), which presents 18 items corresponding to DSM-IV

symptoms. Parents rated themselves on a 4-point Likert scale ranging from 0 (rarely or never) to

3 (very often). Scores were calculated by averaging across all 18 items. This scale demonstrated

good internal consistency in this sample (α = .90 for mothers and .86 for fathers).

Conflicts and Problem-Solving Scales – Violence Form (CPS-V). Married or cohabiting

couples completed the CPS-V, a short form of the Conflicts and Problem-Solving Scales (Kerig,

1996). The following subscales were used: conflict frequency (2 items), verbal aggression (10

items), physical aggression (5 items), stalemate (7 items), child involvement (5 items), and

avoidance/capitulation (11 items). Individuals reported on their own and their partners’ use of

each conflict strategy and gave ratings of conflict frequency. These subscales have been shown

to be reliable (α’s ranged from .70 to .87 and test-retest reliabilities all above .53), husbands’ and

wives’ reports have been shown to correlate (r = .59), and this scale is related to other measures

of marital adjustment and to children’s reports of marital conflict (Kerig, 1996). Square root

transformations were conducted on the physical aggression subscales because they were skewed.

In addition, scores that were more than 3.29 standard deviations above the mean were converted

to scores that were one unit above the next highest score (Tabachnick & Fidell, 2001). Each of

the five conflict strategy variables were standardized, and mothers’ and fathers’ reports were

averaged to create five strategies used by mothers (averaging mothers’ reports of self and

fathers’ reports of mother) and five strategies used by fathers (averaging fathers’ reports of self

and mothers’ reports of fathers). When only one member of the couple completed the measure,


that individual’s standardized scores were used to assess conflict strategies6. These variables

were intercorrelated, ranging from .15 to .71 (median r = .48) for mothers and .27 to .69 (median

r = .46) for fathers (all p’s < .05). However, these scales were examined separately in order to

evaluate links between child behavior and specific conflict characteristics.

Life Experiences Survey (LES). The LES (Sarason, Johnson, & Siegel, 1978) is a 57-item

measure of family stress. Respondents rate the valence and severity of events that have occurred

in the past year. The severity of negative events on the LES was calculated by summing across

the negative valence ratings. The LES negative events scale has demonstrated good test-retest

reliability (r = .72) and has been found to correlate with anxiety and depression (Sarason et al.,

1978). The severity scores were skewed so square root transformations were conducted.

Analytic Plan

MANOVAs were conducted separately for continuous measures that contained multiple

subscales, including the MCMI-III and CPS subscales. Significant MANOVAs were followed up

with univariate ANOVAs. ANOVAs were conducted on the remaining continuous variables and

chi-square tests were conducted for categorical variables. Significant or near-significant

ANOVAs were followed up with planned contrasts to test predicted differences and with Tukey

HSD tests to evaluate differences that were not predicted. Significant chi-square tests were

followed-up with 2X2 chi-square tests to compare each pair of groups. To assess effect sizes,

partial eta-squares were reported for ANOVAs, and Cramer’s Phi were used for chi-square tests.

In Part I of this series, we reported that groups differed on demographic variables.

Furthermore, maternal education was significantly correlated with many family stressor

variables, including maternal avoidance (r = -.14, p < .05), maternal physical aggression (r =

6 Mothers’ reports were used to estimate fathers’ conflict for 38 of the families who fell in one of the three groups. Fathers’ reports were used to estimate mothers’ conflict in 5 of the families who fell in one of the three groups.


-.16, p < .05), paternal stalemate (r = -.16, p < .05), paternal child involvement (r = .14, p < .05),

all MCMI-III variables (r’s ranged from -.23 to -.41 for mothers; r’s ranged from -.32 to -.39 for

fathers, all p’s < .001), and with current maternal adult ADHD symptoms (r = -.14, p < .05).

Maternal education was not associated with negative life events for mothers or fathers. Thus, to

control for differences across groups in SES, maternal education was dichotomized (greater than

12 years, 12 years or less) and this was entered as a blocking variable in the ANOVA models.7

These analyses were then also repeated twice, first entering ethnicity (1 = non-European

American, 0 = European American) and then marital status as blocking variables. Marital status

was not used as a blocking variable for marital conflict variables, because these variables were

not completed by single parents. There was not enough power to enter all three demographic

controls simultaneously, so they were entered in separate analyses. No results changed

significance when ethnicity or marital status was entered as blocking variables, instead of

maternal education. Parallel analyses were not conducted for SCID diagnoses because power

would be too low for most variables due to relatively low base rates of the disorders.

Power was somewhat low for some analyses, so using a Bonferroni correction would

have resulted in a high rate of Type II error. Furthermore, using a correction would have made it

more difficult to compare the results with previous studies that have examined subtypes among

preschoolers (Cunningham & Boyle, 2002) and school-aged children (Jensen et al., 2001), which

did not use Bonferroni corrections. Thus, an alpha of .05 was used in this study. Findings with

higher p-values should be interpreted with some caution and will need replication.

Results

Are There Differences Across Subtypes on Maternal and Paternal Psychopathology?

7 We used blocking variables, because of the potential pitfalls of using ANCOVAs to adjust for pre-existing group differences (Keppel & Wickens, 2004).


MCMI-III. Preliminary analyses suggested that there were similar patterns of differences

across groups for schizoid/schizotypal/paranoid, avoidant/dependent, and borderline personality

dimensions. Since these clusters also were intercorrelated (r’s ranged from .54 to .66 for mothers

and .55 to .68 for fathers), they were combined to create a single personality disorder variable.

MANOVAs were then conducted on this new variable together with the other four MCMI-III

variables (personality disorder, antisocial, anxiety, and depression). A significant effect of Group

was found for mothers’ and fathers’ MCMI-III variables, F (10, 316) = 2.36, p = .01 and F (10,

212) = 2.25, p < .05, respectively. Table 1 presents means and standard deviations of MCMI-III

variables. As predicted, mothers of children in the HYP/OD group reported more personality

disorder symptoms on the MCMI-III than did mothers of children in the HYP and non-problem

groups. Mothers of children in the HYP/OD group reported more depression, anxiety, and

alcohol/drug abuse than did mothers of children in the non-problem group. Consistent with

prediction, fathers of children in the HYP/OD group reported more personality disorder

symptoms, anxiety, and depression than did fathers of children in the HYP and non-problem

groups. Contrary to prediction, fathers did not differ across groups on antisocial personality (p

= .12). In addition, fathers of children in the HYP/OD group reported significantly more

alcohol/drug use than did fathers of children in the non-problem group, but were not significantly

different from fathers of children in the HYP group.

SCID. A series of chi-square tests were conducted to compare SCID diagnoses for

parents of children in the three groups (see Table 2). Mothers of children in the HYP/OD group

showed significantly higher rates of current and lifetime major depressive disorder, lifetime

substance abuse, and current and lifetime anxiety disorder than mothers of children in the non-

problem group. In addition, compared to mothers of children in the HYP group, mothers of


children in the HYP/OD group showed significantly higher rates of current anxiety disorder. For

fathers, significant differences emerged for current anxiety disorder and lifetime anxiety

disorder, with fathers of children in the HYP/OD group showing higher rates of current and

lifetime anxiety disorder than fathers of children in the non-problem and HYP groups. Fathers of

children in the HYP group showed significantly higher rates of current alcohol abuse than did

fathers of non-problem children.

Adult ADHD symptoms. As predicted, mothers of children in the HYP/OD and HYP

groups reported significantly more adult ADHD symptoms than did mothers of children in the

non-problem group. Fathers did not differ across the groups.

Are There Differences Across Subtypes on Marital Conflict?

As expected (see Table 3), parents of children in the HYP/OD group reported more

frequent conflict than did parents of children in the non-problem group. MANOVAs for the five

conflict tactics indicated a significant Behavior Group effect for mothers, F (10, 302) = 3.45, p

< .001, but not for fathers, F (10, 286) = 1.50, p = .14. Follow-up univariate analyses revealed

that compared to parents of children in the HYP and non-problem groups, mothers of children in

the HYP/OD group had significantly higher scores on stalemate and physical aggression and

fathers had significantly higher scores on stalemate and avoidance. Mothers in both the HYP and

HYP/OD group scored significantly higher than mothers of non-problem children on avoidance

and verbal aggression. In addition, fathers of children in the HYP/OD group scored significantly

higher than fathers of non-problem children on verbal aggression.

Are There Differences Across Subtypes on Negative Life Events and Marital Status?

As predicted, mothers of children in the HYP/OD and HYP groups reported more

negative stressful life events than did mothers of children in the non-problem group. However,


mothers of children in the HYP/OD group did not report significantly more negative stressful life

events than mothers of children in the HYP group (see Table 3), although the difference was in

the expected direction. The effect for fathers was not significant. Differences across the three

groups on marital status did not quite reach significance, Χ2 = 5.98, p = .05. However, parents of

children in the HYP/OD group were significantly more likely to be single than were parents of

children in the non-problem group, Χ2 = 5.40, p < .05 (42% vs. 24%), but not compared to

parents of children in the HYP group (29%), Χ2 = 2.00, p = .16. The HYP and non-problem

groups did not differ significantly on marital status, Χ2 = .39, p = .54.

Does Race/Ethnicity or Gender Moderate Differences Across Groups in Parent

Psychopathology, Marital Conflict, and Negative Life Events?

A series of 3 X 2 (Behavior Group X Ethnicity) ANOVAs (or MANOVAs for MCMI-III

variables and CPS variables) were conducted for each of the continuous variables. Ethnicity was

dummy-coded so that 0 represented European American children and 1 represented children who

were African American, Latino, or multi-ethnic. (Sample sizes were too small to examine each

ethnic group separately.) No significant Behavior Group X Ethnicity interactions (all p’s > .20)

were found for the maternal or paternal psychopathology variables, conflict frequency or

strategies, or negative life events. This process was repeated entering Gender instead of Ethnicity

as a factor. There were significant Behavior Group X Gender interactions for maternal negative

life events, F (2, 187) = 6.36, p < .05, and for maternal conflict frequency, F (2, 160) = 3.63, p

< .05. Analyses were conducted separately for boys and girls for these two variables, and

indicated that the HYP/OD group was significantly or nearly significantly higher than the non-

problem group for both boys and girls (all p’s < .06). However, there appeared to be gender

differences for the HYP group, with girls with HYP scoring similarly to the girls with HYP/OD


and boys with HYP scoring similarly to non-problem boys. In fact, for boys, the HYP/OD group

scored higher on maternal conflict frequency (p < .001) than the HYP group, but for girls, the

HYP group scored significantly higher than the non-problem group (p’s < .05).

Controlling for Severity of Hyperactivity

To examine whether differences between the HYP/OD and HYP group could be due to

differences in hyperactivity severity (Harvey et al., 2006), 26 children in the HYP/OD group and

1 child in the HYP group were identified who scored above 1.1 on the hyperactivity index (1.1

was selected based on a visual inspection of the distributions of scores for each group). These

children were dropped in order to create a HYP/OD group (n = 70) that had hyperactivity

indexes in the same range as the HYP group (n = 40). ANOVAs were then repeated for outcome

variables in which there were differences between the HYP/OD and HYP groups (with maternal

education entered as a blocking variable). Children in the subset of the HYP/OD group remained

significantly higher on maternal personality disorder (p < .05). They also remained significantly

higher on maternal stalemate and physical aggression (p’s < .05). Fathers of children in the less

severe HYP/OD group remained significantly higher on depression and anxiety than fathers of

children in the HYP group (p’s < .05), but the difference for personality disorder was no longer

significant (p = .10). The differences for fathers’ stalemate scores remained significant (p < .05).

Differences for paternal avoidance were no longer significant (p = .06). Chi-square tests were

also conducted comparing parents of children in the HYP/OD and HYP (again with hyperactivity

scores less than 1.1) on SCID diagnoses on which the two groups had differed. Prevalence rates

for the HYP/OD group consistently decreased by approximately five percentage points.

Differences no longer reached significance for maternal current anxiety disorder and paternal

current and lifetime anxiety disorder (all p’s < .10). Differences between the HYP/OD and non-


problem groups on these variables did remain significant.

Discussion

In Part I of this series (Harvey et al., 2006), we presented a model for the separate and

shared etiological risk factors that contribute to the development of ADHD, ODD, and

ADHD/ODD. In this model, family stressors were proposed to play a central role in the

development of comorbid ODD among children with ADHD, but were not thought to contribute

to the development of ADHD. The goal of the present study was to examine the relationship

between behavior problem subtypes and family stressors among young preschool-aged children

to determine whether theoretically-consistent links could be identified as early as age 3. In

particular, it was predicted that young children with developmentally deviant levels of comorbid

hyperactivity and oppositional-defiance would experience more family stressors than children

without behavior problems or with hyperactivity alone. Children with HYP/OD were, in fact,

found to experience higher levels of family stressors than non-problem children on almost every

family stressor variable. With respect to predicted differences between the HYP and HYP/OD

groups, findings were generally consistent with theory for Axis II maternal psychopathology,

Axis I paternal psychopathology, maternal education8, and high intensity couple conflict tactics.

Differences that were found for paternal Axis II psychopathology were no longer significant

when group differences in hyperactivity severity were controlled. Contrary to prediction,

children with HYP/OD did not differ significantly from children with HYP on maternal Axis I

psychopathology, parental marital status, negative life events, frequency of couple conflict, or

use of lower intensity couple conflict tactics.

Moderating Effects of Ethnicity and Gender

Ethnicity did not significantly moderate any of these relations. However, more in-depth

8 Data on maternal education was presented in Part 1 of this three-part series (Harvey et al., 2006).


research is needed to fully address this issue, taking into account individual variability within

ethnic groups (e.g., differences on ethnic identity, acculturation, or country of origin). Such

analyses were beyond the scope of this paper, but merit further attention. Gender did not

generally moderate relations between family stressors and behavior group with the exception of

maternal conflict frequency and maternal negative life events. These stressors were associated

with pure hyperactivity among girls but not among boys. Since the ratios of boys to girls with

behavior problems tends to be lower during the preschool years than among older children

(Campbell, 1990), hyperactivity among preschool-aged girls may more likely represent a

transient phase triggered by family stressors. However, these gender differences need to be

replicated since they contradict previous research that suggests a stronger relation between

marital conflict and behavior problems for boys than for girls (Davies & Lindsay, 2001).

Parent Psychopathology

This is the first study to examine personality disorder symptoms other than ASPD; our

results suggest that this area warrants further investigation. Further research is needed to examine

whether the mechanisms underlying the relation between comorbid hyperactivity/oppositional-

defiance and maternal Axis II psychopathology are similar to those that have been implicated for

Axis I disorders, including impairment in parenting practices (Lovejoy, Graczyk, O’Hare, &

Neuman, 2000). The possible role of shared genetics should also be considered. Understanding

the mechanisms underlying this relation could point to possible targets of intervention or

prevention. For example, if Axis II psychopathology affects parenting, which in turn leads to

behavior problems in children, then parent training programs may benefit from integrating a

component of treatment for Axis II symptoms for parents who experience such difficulties.

Although there is accumulating evidence that ADHD is familial, this is the first study to


document elevated levels of current ADHD symptoms in mothers of preschool-aged hyperactive

children, regardless of comorbid oppositional-defiance. Surprisingly, there were no significant

differences for fathers’ self-reported current ADHD symptoms. In contrast, Nigg and Hinshaw

(1998) found significant differences in adult ADHD for fathers, but not for mothers. It is not

clear whether the difference between the two studies is due to difference in sample

characteristics or because Nigg and Hinshaw (1998) used a different measure of adult ADHD.

Couple Conflict

This is one of the first studies to examine the relation between parental conflict and

subtypes of behavior problems in children as young as age 3. Consistent with theory and research

on older children (Barkley et al., 1991; Lindahl, 1998), there was evidence of more intense,

unresolved conflict among parents of children with HYP/OD than among parents of non-problem

children and children with HYP. These findings are consistent with the notion that more intense

marital conflict may contribute to the development of comorbid oppositional-defiance among

young children with hyperactivity, although child effects and potential third variables may also

account for the relation. There was also some indication that mothers of children with HYP

engaged in lower intensity conflict strategies (including verbal aggression and avoidance) than

did mothers of non-problem children. If, as theoretical models suggest, family stressors do not

play an important etiological role in the development of hyperactivity, milder forms of conflict

reported by parents of children with hyperactivity may reflect child effects of hyperactivity or the

effects of parental ADHD symptomatology. Further research is needed to explore this possibility.

Other Family Stressors

Although theory suggests that negative stressful life events should be higher in families

of children with HYP/OD than in families of children with HYP, the findings of this and other


studies of older children (Barkley et al., 1991; Johnston, 1996) do not support this. Mothers of

children with HYP and HYP/OD reported more negative life events than mothers of non-

problem children. However, gender may moderate this effect; girls showed this pattern, but boys

showed the predicted pattern of differences between the HYP/OD and HYP group. Research is

needed to replicate this finding and explore possible explanations for this gender difference.

Limitations

A number of limitations of this study should be considered. First, some subgroups were

relatively small, which limited power to detect effects, particularly for low base-rate parental

diagnoses. It will be important to replicate effects that were significant, particularly those with

weaker statistical significance. The present study was cross-sectional and could not tease apart

direction of causality; longitudinal and experimental research is needed to gain insight into

causal relations. In addition, by using maternal reports of stressors and child behavior, some

relations may have been inflated by shared method variance. Similarly, it is possible that

maternal psychopathology may have colored mothers’ perceptions of their children (e.g., Briggs-

Gowan, Carter, & Schwab-Stone, 1996; McFarland & Sanders, 2003), inflating the observed

relations between maternal psychopathology and child behavior, although there is some evidence

that distortions in parents’ reports of their children’s problems are minimal (e.g., Faraone,

Monuteaux, & Biederman, 2003; Youngstrom, Izard, & Ackerman, 1999). Further limiting this

study, there was not sufficient power to analyze ethnic groups separately, so African American,

Latino, and multi-ethnic children were combined to examine the moderating effect of ethnicity.

Future research should examine ethnicity in greater depth. This study was also limited in its

ability to examine children who may be experiencing ODD symptoms without ADHD symptoms

due to the small number of children who exhibited pure oppositional-defiance. Although we


attempted to tease apart whether symptom severity could account for differences between the

HYP and HYP/OD groups, symptom severity and comorbidity were so closely linked that it was

not possible to fully separate the two; particularly among children with the most severe behavior

problems. Finally, caution should be taken in generalizing the findings of the present study to

preschool children diagnosed with ADHD or ODD; children in this study showed

developmentally deviant symptoms but diagnostic criteria were not used to create groups.

Implications and Future Directions

Our finding that children with HYP/OD experienced consistently more family stress than

non-problem children provides evidence of a link between early comorbid

hyperactivity/oppositional-defiance and a set of etiological factors that have been proposed to

play an important role in the development of ADHD/ODD. This adds to a growing literature

suggesting that although behavior problems can be a normal developmental phase for many

young children, developmentally deviant levels of behavior problems may represent clinically

significant disturbances even in children as young as age 3.

Differences between HYP/OD and HYP subtypes on at least some types of family

stressors suggest that behavior subtypes may already be beginning to differentiate in the early

preschool years, and provides some evidence supporting the validity of these subtypes. While

these differences do not establish direction of causality, they provide some further support for

existing theoretical models that posit unique etiological pathways for hyperactivity and

oppositional-defiance, and emphasize the role that family stressors may play in the development

of comorbid ADHD/ODD. At the same time, the lack of differences between HYP/OD and HYP

on a number of stressor variables could mean that these variables do not play a critical role in the

early development of comorbid hyperactivity/oppositional defiance. Alternatively, it is possible


that the differentiation between HYP/OD and HYP may not be as clear at age 3 as it is among

school-aged children. This may be due to difficulties in assessing phenotypes of behavior

disorders at this age. It may also reflect lower temporal stability of behavior problems among

younger preschool-aged children, particularly with respect to subtypes of behavior problems. For

example, if a number of children in the HYP group ultimately develop ADHD/ODD or if some

children in the HYP/OD group develop pure ADHD, differences between the HYP and HYP/OD

group would be less pronounced. Finally, it may be that certain types of family stressors play a

more important role in the early development of behavior problems than do other types of family

stressors. Much of the literature has used aggregate measures of family stressors, and relations

between these aggregate measures and behavior problems may be accounted for by particular

family stressor dimensions. If this is true, models of hyperactivity and oppositional-defiance may

need to consider differential roles of various types of family stressors.

Although not all family stressor variables discriminated children with HYP from

children with HYP/OD, those variables that did discriminate the two groups, including maternal

personality disorder symptoms, paternal anxiety and depression, and intense, unresolved couple

conflict, warrant further attention. Depending on the causal mechanisms underlying these

relations and the temporal stability of HYP/OD, these family stressors may be key points of early

intervention or may serve as markers that could help in identifying those children who may be at

risk for comorbid ADHD/ODD. Future research is needed to replicate the findings of the present

study and to examine whether these early family stressors can predict which children go on to

develop ADHD/ODD. Such research is critical for better understanding the early development of

different types of behavior problems, which will be key in improving early identification and

intervention among preschool-aged children.


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Table 1

Comparison of Subtypes of Children’s Behavior on Maternal and Paternal Psychopathology Reported on the MCMI-III and the

Current Symptoms Checklist.

Psychopathology 1. HYP

M(SD)

2. HYP/OD

M(SD)

3. Nonprob

M(SD)

F Planned Comparisons/

Tukey HSD

Partial Eta-

Squared

Maternal MCMI-III scale n = 40 n = 88 n = 42

Personality disorder -0.19 (0.70) 0.32 (0.87) -0.34 (0.61) 7.67** 2 > 1*, 3*** .09

Antisocial -0.07 (1.01) 0.15 (1.03) -0.20 (0.99) 0.96 .01

Anxiety -0.17 (0.72) 0.32 (0.99) -0.52 (0.50) 10.24*** 2 > 1†, 3*** .11

Depression -0.12 (0.84) 0.33 (1.10) -0.45 (0.51) 6.51** 2 > 3*** .07

Alcohol use/drug use -0.07 (0.93) 0.20 (0.83) -0.25 (0.77) 2.26 2 > 3* .03

Paternal MCMI-III scale n = 30 n = 55 n = 30

Personality disorder -0.14 (0.75) 0.34 (0.88) -0.39 (0.49) 6.02** 2 > 1*a, 3** .09

Antisocial -0.02 (0.92) 0.29 (1.11) -0.32 (0.78) 2.20 .04

Anxiety -0.22 (0.74) 0.39 (0.94) -0.31 (0.63) 5.86** 2 > 1**, 3** .10

table continues

Table 1 continued

Psychopathology 1. HYP

M(SD)

2. HYP/OD

M(SD)

3. Nonprob

M(SD)


Tukey HSD

Partial Eta-

Squared

Depression -0.16 (0.63) 0.44 (1.01) -0.49 (0.56) 9.11*** 2 > 1*, 3*** .14

Alcohol use/drug use -0.08 (0.85) 0.40 (0.99) -0.41 (0.65) 5.53** 2 > 1†, 3** .09

Current symptoms

checklist (Adult ADHD)

Mothers n = 40

0.59 (0.41)

n = 94

0.74 (0.53)

n = 44

0.34 (0.26)

8.86*** 3 < 1*, 2*** .12

Fathers n = 30

0.59 (0.42)

n = 57

0.62 (0.42)

n = 31

0.41 (0.34)

2.04 .05

Note: HYP = Hyperactive, HYP/OD = Hyperactive & Oppositional-defiant, Nonprob = Non-problem. MCMI-III scores are expressed

as z-scores since they were aggregated across subscales.

a This difference was no longer significant when severity of hyperactivity was controlled.

* p < .05, ** p < .01, *** p < .001, † p < .10

Table 2

Rates of Parents’ SCID Diagnoses Across Children’s Behavior Group.

SCID Diagnosis

1. HYP

#(%)

2. HYP/OD

#(%)

3. Nonprob

#(%)Χ2

Group

Comparisons

Mothers n = 35 n = 91 n = 59

Current major depression 2 (5.7%) 18 (19.6%) 1 (1.7%) 12.96** 2 > 1†, 3**

Lifetime major depression 12 (33.3%) 31 (33.7%) 10 (16.9%) 5.51† 3 < 1†, 2*

Lifetime alcohol abuse 5 (14.3%) 13 (14.1%) 4 (6.8%) 2.11

Lifetime substance abuse 5 (13.9%) 16 (17.6%) 2 (3.4%) 6.75* 3 < 1†, 2*

Current anxiety disorder 1 (2.9%) 17 (18.7%) 4 (6.8%) 8.20* 2 > 1*a, 3*

Lifetime anxiety disorder 3 (8.6%) 20 (21.7%) 5 (8.5%) 6.36* 2 > 1†, 3*

Fathers n = 26 n = 56 n = 32

Current major depression 0 (0%) 3 (5.4%) 0 (0%) 3.19

Lifetime major depression 5 (19.2%) 10 (17.9%) 6 (18.8%) 0.03

Current alcohol abuse 3 (11.5%) 1 (1.8%) 0 (0%) 6.61* 1 > 2†, 3*

Lifetime alcohol abuse 11 (42.3%) 24 (42.9%) 9 (28.1%) 2.06

Lifetime substance abuse 8 (32.0%) 10 (18.5%) 6 (19.4%) 1.97

Current anxiety disorder 1 (2.8%) 17 (18.5%) 4 (6.8%) 8.21* 2 > 1*a, 3*

Lifetime anxiety disorder 4 (11.1%) 29 (31.5%) 7 (11.9%) 11.06** 2 > 1*a, 3**

Note: HYP = Hyperactive, HYP/OD = Hyperactive & Oppositional-defiant, Nonprob = Non-problem.


* p < .05, ** p < .01, *** p < .001, † p < .10

Table 3

Comparison of Subtypes of Children’s Behavior on Maternal and Paternal Couple Conflict and Negative Life Events.Stressor Variable 1. HYP

M(SD)

2. HYP/OD

M(SD)

3. Nonprob

M(SD)


Tukey HSD

Partial Eta

Squared

Mothers n = 38 n = 70 n = 52

Frequency of conflict 3.99 (1.81) 4.80 (2.00) 3.52 (1.65) 6.97** 2 > 1†, 3*** .09

Conflict tactic n = 39 n = 71 n = 52

Avoidance 0.17 (0.90) 0.18 (0.91) -0.34 (0.88) 5.81** 3 < 1**, 2* .06

Stalemate -.04 (0.89) 0.41 (0.91) -0.40 (0.96) 12.03*** 2 > 1*, 3*** .12

Verbal aggression 0.11 (0.95) 0.15 (0.95) -0.38 (0.97) 6.70** 3 < 1**, 2* .06

Child involvement -0.04 (0.77) -0.01 (1.05) -0.15 (0.86) 0.81 .00

Physical aggression -0.15 (0.76) 0.25 (1.05) -0.20 (0.66) 4.33* 2 > 1*, 3** .06

Negative life events n = 39

2.31 (1.21)

n = 90

2.66 (1.78)

n = 58

1.60 (0.87)

8.46*** 3 < 1*, 2*** .10

Table continues

Table 3 continued

Stressor Variable 1. HYP

M(SD)

2. HYP/OD

M(SD)

3. Nonprob

M(SD)


Tukey HSD

Partial Eta

Squared

Fathers n = 29 n = 52 n = 38

Frequency of conflict 4.19 (1.89) 4.52 (1.89) 3.42 (1.36) 4.18* 2 > 3** .07

Conflict tactic n = 38 n = 70 n = 46

Avoidance -0.11 (0.83) 0.26 (0.85) -0.29 (0.99) 4.93** 2 > 1*a, 3** .07

Stalemate -0.15 (0.85) 0.32 (0.91) -0.24 (0.89) 4.90** 2 > 1*, 3** .07

Verbal aggression -0.04 (0.78) 0.28 (1.08) -0.21 (0.80) 3.56* 2 > 3** .04

Child involvement -0.15 (0.80) 0.06 (1.12) -0.05 (0.93) 1.37 .01

Physical aggression -0.15 (0.76) 0.19 (1.07) -0.07 (0.96) 2.01 .02

Negative life events n = 32

1.80 (1.21)

n = 61

2.02 (1.50)

n = 41

1.50 (0.86)

1.60 .03

Note: HYP = Hyperactive, HYP/OD = Hyperactive & Oppositional-defiant, Nonprob = Non-problem. Conflict tactics are expressed as z-scores.


* p < .05, ** p < .01, *** p < .001, † p < .10

disruptive behavior problems, including …people.umass.edu/eharvey/publications/part 2...

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