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The Ripple Effect: Quality of Life and Mental Health of Parents of children with ADHD in Saudi Arabia a Cross-Sectional Study
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24 March 2024
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26 March 2024
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Abstract
Introduction: Attention Deficit Hyperactivity Disorder (ADHD) is a prevalent neurodevelopmental condition in children in Saudi Arabia based on the results of the national mental health survey. ADHD significantly impacts the child and their family dynamics, particularly causing increased stress and diminished life quality for parents. In Saudi Arabia, there is a research gap regarding the quality of life and coping mechanisms of parents managing children with ADHD. This study assesses levels of depression and anxiety, quality of life, and coping strategies used by parents of children diagnosed with ADHD.
Methods: We conducted a cross-sectional online survey with 151 parents of ADHD-diagnosed children, utilizing the WHOQOL-BREF for life quality, the brief-COPE for coping strategies, and the Patient Health Questionnaire (PHQ): depression (PHQ9-9 items) and generalized anxiety (GAD7-7 items) modules.
Results: Among the parents surveyed, 36% reported moderate to severe depression, while 39.1% experienced moderate to high anxiety levels. Quality of life positively correlated significantly with higher household monthly income (HHI), employment status, sibling count, and effective coping strategies. Conversely, a parent's age, educational level, and particularly maternal status were inversely related to anxiety levels, with fathers displaying higher maladaptive coping scores.
Conclusion: The study sheds light on the considerable anxiety and depression experienced by parents of children with ADHD, significantly affecting their quality of life. Lower parents' quality of life is associated with high levels of depression, anxiety, and ineffective coping strategies. These insights highlight the critical need for interventions to aid parental mental health, thereby improving their overall quality of life amidst ADHD challenges.
Keywords:
Subject: Medicine and Pharmacology - Psychiatry and Mental Health
1. Introduction
The World Health Organization (WHO) identifies Attention Deficit Hyperactivity Disorder (ADHD) as a widely occurring neurodevelopmental condition that affects children’s learning and daily activities. ADHD is characterized primarily by three symptoms: inattention, or a persistent difficulty in sustaining focus; hyperactivity, which involves excessive, situationally inappropriate movements like constant fidgeting, tapping, or talking; and impulsivity, which entails hasty actions that can be harmful to oneself or others. Individuals with ADHD may exhibit predominantly inattentive or hyperactive/impulsive symptoms, or a combination of both (Ather and Salmon 2010; Cappe et al. 2017).
In Saudi Arabia, ADHD prevalence varies between 2.7% (using DSM-IV-TR criteria) and 16.4% (based on the Attention Deficit Disorders Evaluation Scale, both school and parent versions), averaging at 9.2%. This rate exceeds the average for Arab countries, which stands at 5.5%, as well as the global prevalence of 6-7%, as reported by the first global review in 2014 that analyzed 135 studies (AlZaben et al. 2018).
ADHD significantly affects both the individuals diagnosed and their families, creating a complex interplay of stress and behavior. Children’s ADHD symptoms can elevate parental stress, and a strained home life may exacerbate ADHD outcomes (Durukan et al. 2008). Studies have shown that many parents of children with ADHD report increased stress (Cappe et al. 2017) and deal with heightened familial and marital discord, parental stress, guilt, susceptibility to depression, increased alcohol use, and diminished quality of life (QOL), especially in emotional and family activity domains. They exhibit less warmth, higher rates of depression and anxiety, and lower WHO Quality of Life (WHOQoL) scores in social relationships and environmental areas, suggesting that ADHD treatment should involve caregivers (Andrade et al. 2016).
Additionally, ADHD is a significant risk factor for poor QOL, with links to non-adaptive coping, emotional, physical, and coordination issues, as well as parental mental health problems. Such parents face more familial issues and are prone to health disorders (Ahmed et al. 2022).
Studies have demonstrated the negative impact of ADHD on parents’ QOL, particularly in psychological well-being, personal fulfillment, and daily activities (Cappe et al. 2017; Ahmed et al. 2022). A study done in Hong Kong noted a significant association of some features such as severity of hyperactivity/inattention symptoms, presence of a comorbid pervasive developmental disorder, having major medical conditions, lower household income, and lower educational level with having lower scores in QOL (Xiang et al. 2009).
The growing burden of ADHD increases the psychological strain on parents, with mothers of children with ADHD particularly affected by anxiety, depression, and stress (Ramli et al. 2007). Moreover, parents of ADHD children have a higher likelihood of depression compared to controls (Margari et al. 2013). Research on parent-child dynamics in ADHD has highlighted the influence of demographic factors like the child’s age and sex, and the parents’ marital and socioeconomic status on parents’ psychological distress (Harrison et al. 2002). With the challenges of raising a child with ADHD, factors like more siblings, learning difficulties, and comorbid conditions in children with ADHD may exacerbate parental depression and anxiety. Research combining QOL, depression, and anxiety among these parents is sparse, thus this study aims to investigate the impact of children with ADHD on their parents’ QOL, depression, and anxiety levels. Therefore, this study aim to explore how previously reported variables such as the number of siblings, comorbid learning difficulties, and other psychiatric disorders affect parents’ QOL, anxiety, and depression.
2. Methodology
2.1. Study Design, Participants, and Setting
This is a cross-sectional study that was conducted between August 2022 and November 2022. Participants were parents of children that have been diagnosed by a psychiatrist with any type of ADHD (inattention, hyperactivity or their combination) based on the diagnostic criteria of DSM-V TR at neurodevelopmental centers in Saudi Arabia. An online survey was created using Google Forms and participating centers were encouraged to send to their beneficiaries based on their database.
2.2. Measures
- I.
- The quality-of-life scale (World Health Organization Quality of Life-Brief (WHOQOL-BREF): is a 26-item instrument consisting of four domains: physical health (7 items), psychological health (6 items), social relationships (3 items), and environmental health (8 items); it also contains QOL and general health items. Each individual item of the WHOQOL-BREF is scored from 1 to 5 on a response scale, which is stipulated as a five-point ordinal scale. The physical health domain includes items on mobility, daily activities, functional capacity, energy, pain, and sleep. The psychological domain measures include self-image, negative thoughts, positive attitudes, self-esteem, mentality, learning ability, memory concentration, religion, and mental status. The social relationships domain contains questions on personal relationships, social support, and sex life. The environmental health domain covers issues related to financial resources, safety, health and social services, living physical environment, opportunities to acquire new skills and knowledge, recreation, general environment (noise, air pollution, etc.), and transportation. The Arabic version from the WHO website was used, and it has been demonstrated in different studies to have good reliability and validity (HF Dalky, et al. 2017, JU Ohaeri, et al. 2009, and JU Ohaeri, et al. 2007).
- II.
- The generalized anxiety disorder scale (GAD7): include seven items calculated by assigning scores of 0, 1, 2, and 3 to the response categories, respectively, of “not at all,” “several days,” “more than half the days,” and “nearly every day.”. GAD-7 total score ranges from 0 to 21, in which “0–4: minimal anxiety” “5–9: mild anxiety” “10–14: moderate anxiety” “15–21: severe anxiety”.
- III.
- The depression scale (PHQ9): is a nine-item self-administered version of the PRIME-MD diagnostic instrument for common mental disorders. The PHQ-9 is the depression module, which scores each of the 9 DSM-IV criteria as “0” (not at all) to “3” (nearly every day). Both GAD7 and PHQ9 where translated and validated on Saudi population and showed great validity and reliability (AN AlHadi, et al. 2017).
- IV.
- The Brief-COPE scale: is a 28 item self-report questionnaire designed to measure effective and ineffective ways to cope with a stressful life event. The scale consists of three subscales: Problem-Focused Coping, Emotion-Focused Coping, and Avoidant Coping. Scores are presented for three overarching coping styles as average scores (sum of item scores divided by number of items), indicating the degree to which the respondent has been engaging in that coping style: (1= I haven’t been doing this at all, 2= A little bit, 3= A medium amount, 4= I’ve been doing this a lot). This tool showed to be valid and reliable instrument among the Saudi population (Alghamdi 2020).
2.3. Procedure
Following approval from the International Review Board (IRB) at King Saud University—College of Medicine, the research team contacted all neurodevelopmental disorders clinics across Saudi Arabia, utilizing publicly available information from the Ministry of Health Website. Subsequently, an electronic survey was meticulously designed, incorporating socioeconomic variables identified through a comprehensive literature review alongside other instruments: WHOQOL-BREF for assessing life quality, the brief-COPE for analyzing coping strategies, and the Patient Health Questionnaire (PHQ) modules for depression (PHQ9-9 items) and generalized anxiety (GAD7-7 items). The survey was disseminated to gather responses from parents of confirmed ADHD cases. Members of the research team oversaw the review and collection of pertinent data from medical charts. Stringent measures were implemented to ensure the security and confidentiality of collected data, with its utilization strictly confined to research objectives.
2.4. Internal Consistency and Reliability of the Measured Questionnaire
The questionnaires were assessed for internal consistency using Cronbach’s alpha test. The analysis revealed that the COPE-Brief questionnaire demonstrated good internal consistency, with a Cronbach’s alpha coefficient of 0.89. Similarly, the PHQ-9 questionnaire showed sufficient internal consistency, with a Cronbach’s alpha coefficient of 0.88. The Generalized Anxiety GAD7 questionnaire also exhibited high internal consistency, with a Cronbach’s alpha coefficient of 0.92. Furthermore, the WHOQoL-Bref, which consists of twenty-six indicators assessing parents’ perceived quality of life, demonstrated excellent internal consistency, with a Cronbach’s alpha coefficient of 0.940 (refer to Table A in the appendix). These findings suggest that all four questionnaire measures were reliably understood and completed by parents, indicating uniformity in their measurement reliability.
2.5. Statistical Analysis
Continuous variables were described using mean and standard deviation, while variables violating the normality assumption were described using median and interquartile range. Categorical variables were summarized using frequencies and percentages. The internal consistency of measured questionnaires was assessed using Cronbach’s alpha. Bivariate correlations between metric-measured perceptions were evaluated using Spearman’s (Rho) test of correlation.
To assess the statistical significance of predictors for each measured parental perception/concept (Anxiety, Depression, Adaptive & Maladaptive coping), Generalized Linear Multivariable Modeling was employed. Due to skewness in error modeling, Gamma Regression was used. The association between predictor variables and dependent outcome variables was expressed as multivariate-adjusted Risk Rates (RR) with a 95% confidence interval.
Parental Quality of Life (QoL) was regressed using standard multivariable Linear Regression Analysis against parental and child characteristics and ADHD-related factors. The association between predictor-independent variables and the parental perceived QoL score was expressed as an Unstandardized Beta coefficient with its associated 95% confidence interval.
Statistical data analysis was conducted using IBM SPSS software version 21, while figures and depictions were generated using Excel spreadsheets. A significance level of 0.050 was considered for all tests.
Table A.
The internal consistency analysis of the measured questionnaires.
| Number of items | Cronbach’s alpha | |
| Brief COPE questionnaire | 28 | 0.89 |
| Patient health questionnaire (PHQ9) | 9 | 0.880 |
| Generalized Anxiety Disorder (GAD7) scale | 7 | 0.923 |
| World Health Organization Qol (WHOQOL-bref) questionnaire | 26 | 0.940 |
3. Results
Parental Characteristics and Characteristics of ADHD Children
The yielded analysis findings for the sociodemographic characteristics of the measured sample of ADHD-diagnosed children and their parents are displayed in Table 1.
According to the GAD7 scale 18.6% of parents were considered to have moderate anxiety and 20.5% high anxiety levels (Figure-A). Moreover, the PHQ-9 Scale showed 23.1% of parents were considered to have mild depression and 15.4% moderate depression level, while 10.3% and 10.3 % were found to have high and severe depression levels, respectively (Figure-B).
The study’s bivariate correlations unveiled several noteworthy insights concerning parents’ perceived quality of life (WHOQol-bref) scores and their relationships with various factors, as illustrated in Table 2.
The findings highlighted that parents’ perceived quality of life scores exhibited positive correlations with the subscale scores of physical, psychological, social, and environmental well-being. Additionally, parents’ general life and health satisfaction scores demonstrated positive and significant associations with their mean perceived quality of life scores.
Conversely, significant negative correlations were observed between parents’ mean perceived quality of life scores and their perceived generalized anxiety and depression scores (rho=-0.541, p<0.010, rho=-0.725, p-value<0.010, respectively). These findings suggest that as anxiety levels and depression increased, perceived quality of life scores tended to decrease.
Furthermore, the study revealed that a higher utilization of maladaptive coping strategies among parents of children with ADHD predicted lower perceived quality of life (rho=-0.426, p-value<0.010). Interestingly, no significant correlation was found between parents’ perceived adaptive coping scores and their mean perceived quality of life scores.
Moreover, parents’ mean perceived depression scores exhibited positive correlations with their mean perceived maladaptive and adaptive coping scores (p-value<0.010), indicating that as depression levels increased, both maladaptive and adaptive coping strategies tended to increase.
To gain a deeper understanding of the factors influencing parents’ perceived quality of life, standard multivariable linear regression analysis was employed to regress the parents’ mean perceived overall WHO-QoL BREF score against various sociodemographic characteristics, ADHD child outcomes and other relevant factors. The resulting findings, presented in Table 3, unveiled several significant correlations.
Firstly, parents’ household monthly income level exhibited a significant and positive correlation with their mean perceived quality of life score. Specifically, parents with a household monthly income of >=5000 SAR/Month reported significantly higher mean perceived quality of life scores compared to those with a household income of <5000 SAR/Month, with a beta coefficient of 2.482 and a p-value<0.001.
Additionally, parents’ employment status emerged as a significant factor correlated with their mean perceived quality of life score. Employed individuals reported significantly higher mean perceived quality of life scores compared to unemployed individuals, with a beta coefficient of 3.748 and a p-value of 0.030.
Unsurprisingly, parents’ mean perceived depression scores (PHQ9) demonstrated a significant negative correlation with their mean perceived quality of life score. Higher levels of depression among parents of ADHD-diagnosed children predicted significantly lower mean perceived quality of life scores, with a beta coefficient of -1.091 and a p-value<0.001.
Furthermore, the parental mean perceived adaptive coping score exhibited a significant and positive correlation with their mean perceived quality of life score. Greater utilization of adaptive coping strategies among parents of ADHD-diagnosed children predicted significantly higher mean perceived quality of life scores, with a beta coefficient of 4.982 and a p-value<=0.001.
The number of siblings in the household also demonstrated a significant positive correlation with parents’ mean perceived quality of life score, with a beta coefficient of 0.874 and a p-value of 0.035.
In a Multivariable Generalized Linear Gamma Regression analysis examining parental perceived Anxiety scores (GAD7), several significant correlations emerged, as detailed in Table 4. Parents’ age and educational attainment displayed significant negative correlations with their mean perceived Anxiety (GAD7) scores. With each additional year of parental age, anxiety tended to decrease by a factor of 2.68% on average (p-value<0.001). Moreover, parents holding a diploma degree or higher education reported significantly lower mean perceived Anxiety (GAD7) scores—36.4% times less compared to those with a high school or lower education level (p-value<0.001). A noteworthy correlation was observed between parents’ gender. Fathers, on average, reported 19.8% lower mean perceived Anxiety (GAD7) scores compared to mothers (p-value=0.030). Interestingly, households with a monthly income below 5000 SAR/Month were associated with a 28.5% lower mean perceived Anxiety (GAD7) score compared to those earning >=5000 SAR/Month (p-value=0.003). The severity of ADHD symptoms in children exhibited a significant correlation with parental mean perceived Anxiety (GAD7) scores. Parents of children diagnosed with severe ADHD reported significantly higher mean perceived Anxiety (GAD7) scores—26.5% times higher than those with moderate or less severe ADHD (p-value=0.002). A significant positive correlation was found between parental mean perceived depression scores and their mean perceived Anxiety (GAD7) scores.
When applying Gamma Analysis to the parents’ mean perceived depression score (PHQ9), the results presented in Table 5 revealed several significant findings; There was no significant correlation found between parents’ mean perceived maladaptive coping score and their mean perceived depression score (PHQ9). However, a significant positive correlation was observed between parents’ mean perceived adaptive coping score and their mean perceived depression score. On average, for every one-point increase in the mean perceived adaptive coping score, the mean predicted depression score increased by 30.9% (p-value<0.001). A significant negative correlation was found between parents’ mean perceived quality of life score and their mean perceived depression score (PHQ9). For each additional one-point rise in parents’ mean perceived quality of life score, their mean perceived depression score declined by a factor equal to 2.9% on average (p-value<0.001).
These findings highlight the intricate relationship between coping mechanisms, quality of life, and parental depression levels, shedding light on factors influencing parental mental well-being in the context of raising children with ADHD..
A Gamma regression employing the Generalized multivariate model was utilized to explore parental coping strategies using their mean maladaptive coping score. The findings derived from the analysis, as presented in Table 6, yielded several significant insights. Fathers of children diagnosed with ADHD reported a significantly higher mean maladaptive coping score compared to mothers, measuring 9.7% higher on average (p-value=0.019) Furthermore, parents diagnosed with a history of mental or psychological illness demonstrated significantly higher mean maladaptive coping scores compared to parents without a known history of mental illness. Specifically, their scores were 14.5% higher on average (p-value=0.024). Interestingly, parental perceived anxiety exhibited a significant and positive correlation with their mean perceived maladaptive coping score (p-value=0.004). Higher levels of parental anxiety predicted significantly higher levels of maladaptive coping in general.
The analysis of parents’ mean Adaptive coping score (Table 7) revealed several significant findings. The parents’ mean perceived quality of life score (Qol) exhibited a positive and significant correlation with their mean Adaptive coping score (p-value<0.001). Higher perceived quality of life among parents predicted significantly higher perceived adaptive coping.
Interestingly, household income did not correlate with parents’ mean perceived adaptive coping. However, their educational level showed a positive correlation, with parents holding a diploma or higher educational level reporting significantly higher mean perceived adaptive coping scores (13.2% times higher) compared to those with a high school or lower educational level on average (p-value=0.017).
Furthermore, parents’ mean perceived maladaptive coping score positively correlated with their mean perceived adaptive coping score. This suggests that parents may utilize both adaptive and maladaptive coping strategies simultaneously. For each additional one-point increase in parents’ maladaptive coping score, their mean predicted adaptive coping score tended to rise by 30.9% on average (p-value<0.001).
Additionally, parents’ mean perceived activities of daily living (ADL) difficulties associated with anxiety positively and significantly correlated with their mean perceived adaptive coping score. As parents’ mean perceived ADL difficulties due to anxiety increased by one point on average, their mean adaptive coping tended to rise incrementally by a factor equal to 11.4% on average (p-value<0.001).
These findings underscore the complex interplay between various factors, such as parental perceived quality of life, education level, maladaptive coping, and ADL difficulties associated with anxiety, in shaping parents’ adaptive coping strategies in the context of raising children with ADHD.
4. Discussion
Parenting is a continuous, challenging endeavor that places a substantial burden on parents, potentially limiting their ability to maintain the lifestyle they enjoyed before their child’s birth. The behavior of a child with ADHD introduces additional challenges to parenting, as highlighted by Harrison and Sofronoff (2002). This discussion aims to examine the relationship between parental anxiety, depression, and quality of life within the context of ADHD, along with the coping mechanisms parents utilize to manage these challenges.
Our study’s findings indicate that anxiety is a prevalent issue among parents of children with ADHD, with over 39% reporting medium to high levels of anxiety. This aligns with prior research, consistently demonstrating that parents of children with ADHD often face increased levels of anxiety (Durukan et al., 2008; Ramli et al., 2007; Segenreich et al., 2009). We observed significant negative correlations between parents’ age and educational attainment and their mean perceived anxiety scores, suggesting that older and more educated parents tend to experience lower levels of anxiety, corroborated by Oguzoncul and colleagues (AF Oguzoncul et al., 2019). A notable correlation was also found between parents’ gender, with fathers reporting lower mean perceived anxiety scores compared to mothers. Given that mothers typically serve as the primary caregivers and spend more time with the children, they encounter greater challenges in managing ADHD (Barkley, 1998). While some studies suggest that mothers of children with disabilities experience higher stress levels than fathers (Uguz et al., 2004), other research indicates that fathers are comparably affected (AF Oguzoncul et al., 2019). The disparity in mental illness prevalence between mothers and fathers and its impact on children’s functionality requires further investigation.
Notably, the severity of ADHD symptoms in children was significantly correlated with parental mean perceived anxiety scores. The combined subtype of ADHD was strongly associated with increased parenting stress, life stress, marital discord, and parenting anxiety compared to inattentive presentation (Tzang et al., 2009). These findings echo qualitative studies highlighting the daily caregiving burdens parents of children with ADHD endure due to their children’s behaviors (Mofokeng & van der Wath, 2017).
Depression is common among caregivers of children with ADHD (Al-Balushi et al., 2017). Mood disorders were the most prevalent psychiatric disorders among these parents, with major depression rates at 48.1% for mothers and 43.0% for fathers (Ghanizadeh et al., 2008). Our result of 35% of parents reporting moderate to severe depression. Previous studies have identified several risk factors for caregivers’ depression, including gender, income level, being the sole caregiver, and the absence of a living spouse (Al-Balushi et al., 2017; Durukan et al., 2018; Wesseldijk et al., 2018). Child-related factors such as hyperactivity, impulsivity, and the combined type of ADHD also emerged as significant depression markers (Al-Balushi et al., 2017). It is crucial for clinical practice to focus on treating depression in caregivers of children with ADHD and to screen for depressive symptoms (Durukan et al., 2018). The significant impact of depression on parents’ daily functioning and overall well-being underscores the need for targeted interventions and support services.
Quality of life among parents of children with ADHD was a significant focus of our study. Previous research indicates that these parents experience a lower quality of life compared to parents of healthy children (Xiang et al., 2009). Our use of the WHOQOL-BREF questionnaire to assess parental satisfaction across various life aspects provided valuable insights. Despite reports of moderate overall life satisfaction, parents exhibited high satisfaction with their work capacity, daily activity performance, personal relationships, and support from friends. The strong link between family support and improved outcomes for parents of chronically ill patients is well-documented (Finzi-Dottan et al., 2011), and our findings reinforce the importance of family support in maintaining the mental health of caregivers of children with ADHD. This contrasts with studies reporting parents’ feelings of isolation and intolerance from others towards their children’s behavior (Leitch et al., 2019; Moen et al., 2011). Furthermore, a study revealed that two-thirds of ADHD caregivers experienced a low quality of life, with all quality-of-life variables significantly worse than those of non-ADHD children’s parents. Caregivers of ADHD children who had never worked or had a history of medical conditions reported an excellent degree of self-liking but only a fair level of quality of life and self-competence (Ahmed et al., 2022).
Several studies have highlighted that parents of children with ADHD often face more marital conflicts and report lower marital satisfaction than parents of children without ADHD (Johnston & Mash, 2001). Interestingly, our study found that parents of ADHD children reported higher levels of marital satisfaction, underscoring the beneficial impact of social support on their well-being. Yet, it’s important to note that these parents expressed lower satisfaction regarding their need for medical treatment to function effectively, pointing to potential physical health challenges stemming from their caregiving roles, which could affect their overall well-being (Schulz & Sherwood, 2008).
Our analysis also indicated that household income and employment status significantly influenced the perceived quality of life. Parents with higher incomes and those who were employed reported a better quality of life. Furthermore, higher levels of depression and maladaptive coping were associated with a poorer quality of life, whereas adaptive coping correlated with a better quality of life, aligning with previous findings that non-working parents are more adversely affected than their working counterparts (Alwhaibi et al., 2018).
Research on the coping processes among parents of children with ADHD has been limited. This study reveals that fathers of ADHD-diagnosed children scored significantly higher on maladaptive coping strategies (9.7% higher) than mothers. A systematic review by Craig et al. (2020) found only two studies addressing the coping strategies of both parents, with one study by Podolski and Nigg (2001) reporting no significant differences between mothers and fathers in coping strategies. However, the scant representation of fathers in these studies limits our understanding of gender-based differences in coping strategies, highlighting the need for further research with a larger sample of fathers.
Additionally, our findings showed that parents with a prior mental illness diagnosis exhibited significantly higher maladaptive coping scores (14.5% higher) than those without a mental health history. These parents may face unique challenges in managing stress related to their parenting role, underscoring the importance of considering parental mental health in coping strategy assessments and support provisions. Stress management for parents of ADHD children is critical, as stress significantly affects family functioning and, consequently, children’s socioemotional development (Fernandes et al., 2015).
Parents engaging in maladaptive coping reported a lower quality of life, whereas those employing adaptive coping mechanisms experienced a higher quality of life. Adopting problem-focused coping strategies, such as seeking information about ADHD, attending workshops or therapy, and establishing structured routines, can empower parents to manage their children’s symptoms more effectively, thus reducing anxiety (Berenguer et al., 2021).
Furthermore, the study unveiled intriguing correlations among parental coping, quality of life, anxiety, and depression scores. Parents employing positive coping strategies reported higher depression levels, suggesting that those with adaptive coping strategies might be more conscious of their depressive symptoms. A significant negative correlation was observed between parents’ quality of life scores and their depression scores, indicating that higher quality of life is associated with lower depression levels. Additionally, a positive correlation between parents’ anxiety and depression scores was found, reinforcing the notion that these conditions often coexist and are closely related (Kalin, 2020). This underscores the complex interplay between parental coping mechanisms, mental health, and quality of life in the context of parenting a child with ADHD.
5. Conclusion
Living with a child with ADHD presents significant challenges, particularly for parents who must develop specialized coping skills. Our study revealed high levels of anxiety and depression among these parents. Notably, ADHD in children adversely affects their parents’ quality of life, with notable detriments to social well-being and environmental interactions. Our findings indicate that higher levels of depression and anxiety correlate with a lower perceived quality of life among parents. The quality of life scores was inversely related to the parents’ maladaptive coping scores; the most frequently reported maladaptive strategies involved self-criticism, self-blame for past events, and verbalizing negative feelings as a release. Furthermore, a greater reliance on maladaptive coping strategies was linked to a diminished quality of life.
In summary, the study underscores the profound effects of depression, anxiety, and coping strategies on the quality of life for parents of children with ADHD. It accentuates the critical need for targeted support and interventions to enhance mental well-being and coping mechanisms within this demographic.
6. Limitations
The study delineates specific limitations that could affect the interpretation and generalizability of its findings. Firstly, the small sample size poses a significant constraint, making it difficult to extend the results to a broader population. Secondly, the lack of a control group is a notable limitation. Including parents of children without ADHD could provide a comparative baseline to discern if the observed variables are uniquely prevalent or intensified in the ADHD context.
Additionally, the methodological design restricts the breadth of possible interpretations due to its inability to assess causality. Without the ability to ascertain the directionality of the effects, it remains unclear whether variables such as depression and anxiety are outcomes of coping with a child’s ADHD or if they precede and potentially contribute to the perceived challenges of parenting.
Lastly, the cross-sectional nature of the research does not account for the longitudinal impact of environmental factors on the variables studied. This restricts the study’s capacity to understand the evolving nature of parental experiences and the potential for changes in mental well-being, coping strategies, and quality of life over time. Future research could address these limitations by incorporating larger, more diverse samples, control groups, methodological designs capable of assessing causality, and longitudinal approaches to explore the enduring effects of environmental influences.
7. Recommendation
In Saudi Arabia, limited studies have addressed the importance of early intervention for psychological distress in parents of ADHD children. Conducting more studies on prevention methods and psychological screening for parents of ADHD children is recommended.
Author Contributions
Each author contributed significantly to the conception and design of the study, acquisition of data, and analysis and interpretation of the findings. Furthermore, all authors actively participated in drafting the manuscript and revising it critically for important intellectual content. Finally, each author provided final approval for the version of the article to be published and committed to being accountable for all aspects of the work.
Funding
The authors are grateful to the Deanship of Scientific Research, King Saud University, for funding through the Vice Deanship of Scientific Research Chairs.
Ethical Considerations
This study was approved by the International Review Board at King Saud University—College of Medicine on June 13th, 2022 (Ref. No. 22/0483/IRB). The data was encrypted and analyzed to maintain participants’ confidentiality.
Informed Consent Statement
Informed consent was obtained from all subjects involved in the study. The consent to participate was obtained by including a page before starting the survey, where we informed the participants about the aim of the study at the start of the survey and then asked them to click on “yes” if they agreed to participate.
Data Availability Statement
The data presented in this study are available upon reasonable request from the corresponding author.
Acknowledgments
The authors extend their gratitude to all parents of ADHD children who participated in the survey. They also express appreciation to the Saudi ADHD Society for their continuous support of scholarly endeavors. Additionally, the authors acknowledge the SABIC Psychological Health Research and Applications Chair (SPHRAC), Department of Psychiatry, College of Medicine, King Saud University, for their ongoing support of mental health research. Funding for this study was provided by the Deanship of Scientific Research, King Saud University, through the Vice Deanship of Scientific Research Chairs.
Conflict of Interest
The authors declare that the research was conducted without any commercial or financial relationships that could be construed as a potential conflict of interest.
Abbreviations
| ADHD | Attention Deficit Hyperactivity Disorder |
| QOL | Quality of Life |
| ADL | Activities of Daily Living |
| KSUMC | King Saud University Medical City |
| WHO | World Health Organization |
| HHI | Household monthly income |
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Table 1.
Descriptive analysis of the parent and child sociodemographic characteristics and child ADHD disease related factors.
Table 1.
Descriptive analysis of the parent and child sociodemographic characteristics and child ADHD disease related factors.
| Frequency | Percentage | |
|---|---|---|
| Relation to the child | ||
| Mother | 93 | 59.6 |
| Father | 63 | 40.4 |
| Age ( years), mean (SD) | 40.90 (7.32) | |
| Age group | ||
| 25-35 years | 38 | 24.4 |
| 36-45 years | 80 | 51.3 |
| >=46 years | 38 | 24.4 |
| Educational Level | ||
| High school or less education | 27 | 17.3 |
| Diploma degree | 15 | 9.6 |
| University degree | 82 | 52.6 |
| Higher studies | 32 | 20.5 |
| Employment status | ||
| Not employed | 58 | 37.2 |
| Employed | 98 | 62.8 |
| Households Monthly Income (HHI) | ||
| <5000 Riyals/M | 35 | 22.4 |
| 5000 - 10,000 Riyals/M | 43 | 27.6 |
| 10,000-15,000 Riyals/M | 42 | 26.9 |
| More than 15,000 Riyals/M | 36 | 23.1 |
| Parental separation | ||
| No | 138 | 88.5 |
| Yes | 18 | 11.5 |
| Comorbidity | ||
| No | 122 | 78.2 |
| Yes | 34 | 21.8 |
| What chronic illness | ||
| Diabetes | 10 | 28.6 |
| Hypertension | 8 | 22.9 |
| Thyroid Disease | 8 | 22.6 |
| Skin disease | 3 | 8.6 |
| Other disease | 12 | 34.3 |
| autoimmune disease | 7 | 20 |
| Have you been previously diagnosed with mental illness | ||
| No | 140 | 89.7 |
| Yes | 16 | 10.3 |
| Are still diagnosed with mental illness | ||
| No | 138 | 88.5 |
| Yes | 18 | 11.5 |
| Affected ADHD child sex | ||
| Female | 29 | 18.6 |
| Male | 127 | 81.4 |
| Affected ADHD child age ( years), mean (SD) | 10.03 (3.63) | |
| Number of live siblings, median (IQR) | 2 (2) | |
| Does the child receive ADHD treatments? | ||
| No | 68 | 43.6 |
| Yes | 88 | 56.4 |
| Does the child have from any of these disorders?, n=110 | ||
| Separation Anxiety | 4 | 3.6 |
| Learning difficulties | 89 | 80.9 |
| Autism | 31 | 28.2 |
| Asperger’s syndrome | 4 | 3.6 |
| Residence | ||
| Riyadh city | 123 | 78.8 |
| Other cities | 33 | 21.2 |
Table 2.
Spearman’s (Rho) correlations between the parents measured perceptions.
| WHOQol-Bref | Phys | Psych | SOC | ENV | GL | GH | GAD | GAD_DIFF | PHQ | PHQ_DIFF | MADAPT | |||||
| QOl_bref100 Quality Of Life (0-100%) score | 1.000 | |||||||||||||||
| Physical_Dom100 Physical Well-Being | .845** | |||||||||||||||
| Psych_Dom100 Psychological Well-Being | .859** | .672** | ||||||||||||||
| Social_Dom100 Social Well-Being | .824** | .590** | .543** | |||||||||||||
| Environm_Dom100 Environmental satisfaction | .833** | .612** | .713** | .611** | ||||||||||||
| Qol_1 How would you rate your life | .539** | .456** | .439** | .469** | .454** | |||||||||||
| Qol_2 How satisfied are you with your health: | .502** | .496** | .445** | .453** | .270** | .466** | ||||||||||
| GAD7_score Generalized Anxiety Disorder score | -.541** | -.566** | -.501** | -.381** | -.353** | -.490** | -.431** | |||||||||
| GAD7_DIFF Perceived ADL difficulties associated with anxiety feeling | -.491** | -.568** | -.402** | -.336** | -.356** | -.450** | -.408** | .540** | ||||||||
| PHQ9_score General Health Anxiety PHQ9 scale score | -.725** | -.727** | -.630** | -.575** | -.464** | -.589** | -.617** | .789** | .640** | |||||||
| PHQ9_DIFF Perceived ADL difficulties associated with depression | -.522** | -.558** | -.498** | -.354** | -.378** | -.476** | -.444** | .574** | .780** | .668** | ||||||
| Maladaptive ( Negative) coping | -.426** | -.445** | -.376** | -.255** | -.304** | -.282** | -.269** | .417** | .336** | .509** | .323** | |||||
| Adaptive ( Positive) coping | -.019 | -.061 | .044 | -.058 | .060 | -.126 | -.083 | .151 | .275** | .232** | .222** | .475** | ||||
* correlation is significant at 0.050 level, ** correlation is significant at 0.010 level ,.
Table 3.
Multivariate Linear Regression Analysis of the ADHD Children parental perceived Quality Of Life (Qol). (N=155).
Table 3.
Multivariate Linear Regression Analysis of the ADHD Children parental perceived Quality Of Life (Qol). (N=155).
| Unstandardized Beta Coefficients | 95.0% CI for Beta coefficient | p-value | ||
| Lower Bound | Upper Bound | |||
| (Constant) | 66٫567 | 53٫262 | 79٫871 | <0.001 |
| Age of the parent | ٫144- | ٫384- | ٫097 | ٫239 |
| Relationship to the child= Father | ٫485 | 3٫117- | 4٫086 | ٫791 |
| Educational Level | 1٫080- | 2٫842- | ٫681 | ٫227 |
| Households Monthly Income level =>5000 SAR/M | 2٫482 | ٫889 | 4٫075 | ٫002 |
| Employment state= employed | 3٫748 | ٫375 | 7٫122 | ٫030 |
| General Health Anxiety PHQ9 scale score | 1٫091- | 1٫353- | ٫829- | <0.001 |
| Maladaptive coping | 4٫369- | 7٫885- | ٫853- | ٫015 |
| Adaptive coping | 4٫982 | 2٫468 | 7٫497 | <0.001 |
| Number of siblings | ٫876 | ٫064 | 1٫688 | ٫035 |
| Parents history of psychological illness | 3٫574- | 8٫359- | 1٫210 | ٫142 |
| Childs ADHD severity Level | ٫840 | 1٫667- | 3٫347 | ٫509 |
DV= Parental mean perceived Overall Qol score . Model overall statistical significance : f(11,144)=18.41, p-value<0.001Model R=0.764, model adjusted R-squared=0.553.
Table 4.
Multivariable Generalized Linear Gamma Regression analysis for parental perceived Anxiety( GAD7) score (N=156).*.
Table 4.
Multivariable Generalized Linear Gamma Regression analysis for parental perceived Anxiety( GAD7) score (N=156).*.
| Parameter | Multivariate adjusted Risk Rate (RR) | 95% CI for RR | ||
| Lower | Upper | p-value | ||
| (Intercept) | 10٫674 | 4٫971 | 22٫917 | <0.001 |
| Age of the parent (years) | ٫973 | ٫961 | ٫986 | <0.001 |
| Relation=father | ٫802 | ٫656 | ٫979 | ٫030 |
| Households Monthly Income <5000 | ٫715 | ٫572 | ٫894 | ٫003 |
| Educational Level = Diploma/University/High studies | ٫636 | ٫498 | ٫812 | <0.001 |
| Employment status= employed | 1٫139 | ٫935 | 1٫389 | ٫197 |
| Parental current Mental illness= Positive | 1٫219 | ٫933 | 1٫592 | ٫147 |
| Childs ADHD severity Level = Moderate/ High | 1٫265 | 1٫090 | 1٫467 | ٫002 |
| Parents mean perceived depression (PHQ9) Score | 1٫066 | 1٫050 | 1٫083 | <0.001 |
| Parents mean perceived ( negative ) coping score | 1٫100 | ٫894 | 1٫352 | ٫369 |
| Parents mean perceived ( Positive ) coping score | 1٫058 | ٫913 | 1٫226 | ٫454 |
*Dependent Variable: parents mean perceived anxiety (GAD7) score.
Table 5.
Multivariable Generalized Linear Gamma Regression analysis for parental perceived depression (PHQ9) score. N=156.
Table 5.
Multivariable Generalized Linear Gamma Regression analysis for parental perceived depression (PHQ9) score. N=156.
| Parameter | Multivariate adjusted Risk Rate (RR) | 95% CI for RR | ||
| Lower | Upper | p-value | ||
| (Intercept) | 10.885 | 4.089 | 28.976 | <0.001 |
| Age of the parent (years) | .997 | .984 | 1.010 | .606 |
| Relation to the child= Father | .903 | .746 | 1.092 | .294 |
| Educational Level | 1.127 | .892 | 1.424 | .316 |
| Employed parent | 1.156 | .961 | 1.392 | .124 |
| Childs ADHD severity Level = Moderate/ High | 1.091 | .953 | 1.250 | .206 |
| Parents mean perceived ( maladaptive / Negative ) coping score | 1.033 | .856 | 1.246 | .737 |
| Parents mean perceived ( Adaptive / Positive ) coping score | 1.309 | 1.140 | 1.503 | <0.001 |
| Parental mean perceived Quality Of Life QoL score | .971 | .963 | .979 | <0.001 |
| Parental perceived Generalized Anxiety GAD7 score | 1.075 | 1.055 | 1.095 | <0.001 |
| Households Monthly income | .960 | .883 | 1.043 | .337 |
Dependent Variable: Patients Health Questionnaire ( depression) score.
Table 6.
Multivariable Generalized Linear Gamma Regression analysis for parental perceived maladaptive coping score. N=156.
Table 6.
Multivariable Generalized Linear Gamma Regression analysis for parental perceived maladaptive coping score. N=156.
| Parameter | Multivariate adjusted Risk Rate (RR) | 95% CI for RR | |||
| Lower | Upper | p-value | |||
| (Intercept) | 1.565 | 1.123 | 2.180 | .008 | |
| Age of the parent (years) | .996 | .991 | 1.002 | .219 | |
| Relation to the patient = father | 1.097 | 1.016 | 1.186 | .019 | |
| Prior diagnosis with mental Illness | 1.145 | 1.018 | 1.289 | .024 | |
| Sex of the ADHD diagnosed child= Male | .946 | .883 | 1.014 | .115 | |
| Age of the ADHD affected child ( years) | 1.010 | .999 | 1.020 | .083 | |
| Parental mean perceived Quality Of Life QoL score | .993 | .990 | .996 | <0.001 | |
| Parents mean perceived ( Positive ) coping score | 1.258 | 1.193 | 1.326 | <0.001 | |
| Parental perceived Generalized Anxiety GAD7 score | 1.010 | 1.003 | 1.017 | .004 | |
| Having an ADHD child with Learning difficulties | .912 | .848 | .979 | .012 | |
| Having An ADHD child with Autistic traits | .891 | .813 | .976 | .013 | |
Dependent Variable: Maladaptive coping score.
Table 7.
Multivariable Generalized Linear Gamma Regression analysis for parental perceived Adaptive coping score. N=156.
Table 7.
Multivariable Generalized Linear Gamma Regression analysis for parental perceived Adaptive coping score. N=156.
| Parameter | Multivariate adjusted Risk Rate (RR) | 95% CI for RR | |||
| Lower | Upper | p-value | |||
| (Intercept) | .669 | .430 | 1.040 | .074 | |
| Age of the parent (years) | .999 | .994 | 1.005 | .763 | |
| Relation to the patient = father | .976 | .898 | 1.060 | .564 | |
| Child receives ADHD treatments/therapy | 1.030 | .959 | 1.107 | .410 | |
| Parental mean perceived Quality Of Life QoL score | 1.009 | 1.005 | 1.012 | <0.001 | |
| Households Monthly income <5000 SAR/Months | 1.075 | .978 | 1.183 | .135 | |
| Parental educational level = Diploma degree or higher | 1.132 | 1.023 | 1.254 | .017 | |
| Parents mean perceived ( negative ) coping score | 1.309 | 1.216 | 1.410 | <0.001 | |
| Parental perceived ADL difficulty associated with anxiety | 1.114 | 1.052 | 1.180 | <0.001 | |
Dependent Variable: parents mean Adaptive coping score.
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