Skip to main content
Download PDF
Download ePub
  • Research article
  • Open access
  • Published:

Family, personal, parental correlates and behavior disturbances in school-aged boys with attention-deficit/hyperactivity disorder (ADHD): a cross-sectional study

Child and Adolescent Psychiatry and Mental Health volume 16, Article number: 30 (2022) Cite this article

Abstract

Background

To evaluate the relationship among family, personal, parental correlates, and behavioral disturbances in boys with attention-deficit/hyperactivity disorder (ADHD).

Methods

We performed a hospital-based cross-sectional study. School-aged boys who first visited the hospital between 2000 and 2011 with ADHD were identified. Through medical records review, demographic information, family characteristics, personal characteristics, parental characteristics, and the Child Behavior Checklist (CBCL) collected during the first outpatient visit were retrieved. A T-score higher than 63 in the internalizing or externalizing subscale of the CBCL indicated severe behavioral disturbances in each domain. Multivariable logistic regression was used to evaluate the relationship between the correlates and behavioral disturbances. Eligible patients were further classified into groups without behavioral disturbance, with either only severe internalizing or only severe externalizing behaviors, or with both behaviors. Multivariable ordinal logistic regression was used to investigate the association between the correlates and the number of types of behavioral disturbances.

Results

A total of 1855 boys with ADHD were included. In the multivariable logistic regression, family factors, including being first-born, living in a family not with both parents, and family history of mental disorder, were associated with severe internalizing and externalizing behaviors. Personal factors, including prenatal complications, perinatal complications, and medical and psychiatric comorbidities, were associated with severe internalizing behaviors, but only prenatal complications and medical comorbidities were associated with severe externalizing behaviors. Parental factors were only associated with severe externalizing behaviors. A higher paternal education level had a protective effect, but younger motherhood increased the risk. In ordinal logistic regression, these factors were also associated with more types of behavioral disturbances.

Conclusions

Multiple factors are related to behavioral disturbances in ADHD. Our study reported the association among family, personal, parental factors, severe internalizing behavior, severe externalizing behavior, and number of behavioral disturbances in boys with ADHD. However, the impacts differed as the behavior phenotypes varied. Further research is needed to better understand the heterogeneity of ADHD behavior.

Introduction

Attention-deficit/hyperactivity disorder (ADHD), a common psychiatric disorder among children, is associated with long-term negative consequences [1,2,3,4]. Coexisting emotional and behavioral disturbances may exaggerate the negative influence of ADHD on children, resulting in further impairment. Conceptually, children’s emotional and behavioral disturbances can be categorized into internalizing and externalizing behaviors. Internalizing behaviors are linked to over-controlled and inner-directed problems [5, 6], manifesting as symptoms of anxiety, depression, or withdrawal behavior [5,6,7]. Externalizing behaviors often involve inadequate regulation, such as behavior disinhibition or outward behaviors [5, 7, 8]. The presentation of internalizing or externalizing behaviors contributes to the heterogeneous behavioral phenotypes of children. Children with ADHD are more vulnerable to the occurrence and influence of problematic internalizing and externalizing behaviors. Children with ADHD with severe internalizing or externalizing behaviors often experience more negative outcomes than those without such behaviors [9]. The risk of other risk-taking behaviors also increases [9,10,11]. Moreover, behavioral disturbances in ADHD may result in work incapacity, inappropriate sexual behaviors, excessive medical utilization, or other detrimental life outcomes and persist into adulthood [12,13,14,15]. Because of the negative impact of internalizing and externalizing behaviors on child development, the evaluation of behavioral disturbances in children with ADHD is important.

The pathogenic mechanism of behavioral disturbances in children with ADHD is complex. Although most contemporary research on ADHD focuses on biological factors such as genetic characteristics and structural or functional abnormalities of the brain, the role of socioenvironmental factors should not be underrated. Although several different classes of genome variants have been found to be associated with ADHD, some observational epidemiological studies have also shown that exposure to environmental toxins, dietary factors, low income, and family adversity is related to ADHD [16]. Other studies also reported that numerous demographic, personal, and parental factors all influence child development [17,18,19]. Previous studies have reported the impact of prenatal and perinatal complications, such as maternal physical, social, or psychological problems during pregnancy, complicated delivery, low birth body weight, and jaundice on child behaviors [17]. The effect of family structure and birth order on child aggressive behaviors was also reported in a hospital-based study [20]. The influence of parental characteristics on child development has also been emphasized in many studies [21,22,23]. However, the effect of socioenvironmental factors on the heterogenous behavioral phenotypes of ADHD is scarcely investigated. Furthermore, although most studies have been performed in Western countries, few have been conducted in Asian populations.

Methods

Aim

The aim of this study was to evaluate the relationship among family, personal, parental factors, and behavioral disturbances among school-aged boys with ADHD using a medical record database from a public psychiatry hospital in Taiwan, a country in the Asia-Pacific region nurtured by Eastern culture.

Data source

The Tao-Yuan Psychiatric Center (TYPC) is a public psychiatric hospital located in northern Taiwan. Covered by the National Health Insurance system, TYPC provides services for patients with mental disorders with a catchment area for more than 2 million residents. The Department of Child and Adolescent Psychiatry in TYPC provides psychiatric service for patient younger than 18 years. A comprehensive assessment is performed on the first visit. First, a questionnaire about demographic, personal, parental, and family information of the child and the Child Behavior Checklist (CBCL) must be completed by the caretaker. Second, the main caretaker is interviewed by a trained interviewer to verify the collected information. Third, a semi-structured interview based on the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR), is performed by board-certified psychiatrists with both the child and the main caretaker to make a diagnosis and decide further treatment plans. All data collected are stored in either electronic or paper forms in the medical record database.

Study design and participants

We performed a hospital-based cross-sectional study using the TYPC medical records database. First, we identified outpatients who first visited the Child and Adolescent Psychiatry Department between 2000 and 2011. Second, male patients aged 6 to 11 years at the first visit were considered. Third, patients receiving either a primary or secondary diagnosis of ADHD (ICD-9-CM: 314.XX) at the first visit were included in the study. No exclusion criteria were applied. After ascertainment of our study population, the medical records of eligible patients were reviewed. Information including personal characteristics, parental characteristics, family characteristics, diagnosis at the first visit, and the CBCL were collected for analysis.

Measurements

Family factors

Family factors, including birth order (first-born or not), sibling status (with or without siblings), family structure (with both parents or not with both parents), and family history of mental disorders (with or without a family history of mental disorders), were collected and dichotomously classified. The characteristics of the family structure, such as living in a family with both parents, with single parents, with only grandparents or other relatives, or living in a foster institute, were also collected and classified into categories as living in a family with both parents and not with both parents.

Personal factors

Demographic information regarding age and sex was collected. Additional information during prenatal and perinatal periods, including birth mode (categories as normal spontaneous delivery or cesarean section), birth term (categorized as full-term if the child was delivered after a pregnancy for more than 37 weeks, or alternatively as preterm), birth body weight (categorized as normal if the birth weight was equal or more than 2500 g or alternatively as low birth weight), prenatal complications (categorized as having any prenatal complication or not), and perinatal complications (categorized as having any perinatal complications or not) were also collected. Medical or psychiatric comorbidities recorded during the first visit were also collected and categorized as having comorbid diseases.

Parental factors

Information about parental characteristics, including education level, occupational status, and age at childbirth, were also collected. Parental educational level was classified as receiving education for more than 12 years. Parental occupational status at the first visit was classified as being employed or not. Parental age at childbirth was classified as younger than 20 years of childbirth or not. Both paternal and maternal information were collected.

Behavioral disturbances

The CBCL, which includes items on a three-point Likert scale, is a common instrument for measuring problematic behaviors in children. In this study, the CBCL was used to assess behavioral disturbances in boys with ADHD [24, 25]. First, the CBCL completed by the caretaker during the first visit was retrieved from the medical record database. Second, the raw scores of the internalizing and externalizing subscales were calculated and transformed into T scores according to norms established in a previous domestic study in Taiwan. Anxious/depressed, withdrawn/depressed, and somatic complaint subscales were included in the internalizing subscale. The rule-breaking and aggressive behavior subscales were included in the externalizing subscale. A T score higher than 63 in the internalizing or externalizing subscale indicated the existence of severe behavioral disturbances in each domain. Boys with ADHD were then categorized as having severe internalizing behaviors or not and having severe externalizing behaviors or not for further analysis. Eligible patients were further categorized according to the number of types of severe behavioral disturbances. Patients with a T score lower than 63 in both internalizing and externalizing subscales were classified as the group without severe behavioral disturbance. Patients with T scores higher than 63 in only one of the internalizing or externalizing subscales were classified as having one type of behavioral disturbance, that is, either only severe internalizing behaviors or only severe externalizing behaviors. Patients with T scores higher than 63 in both internalizing and externalizing subscales were classified as having two types of behavioral disturbances, that is, both severe internalizing and externalizing behaviors. This classification indicated the presence of diversities of behavioral disturbances in boys with ADHD.

Statistical analysis

Descriptive statistics were computed, and the differences between school-aged boys with ADHD with and without internalizing or externalizing behaviors were compared. Categorical variables were analyzed with chi-square tests, whereas continuous variables were analyzed using Student’s t-test.

The associations between correlates and behavioral disturbances among school-aged boys with ADHD were assessed using logistic regression. Both unadjusted and adjusted estimates with simultaneous control of all relevant variables were reported. Ordinal logistic regression was performed to assess the association between the correlates and numbers of types of behavioral disturbances. Both crude and adjusted estimates were reported.

A two-tailed P value < 0.05 was considered statistically significant. Association estimates were indexed as odds ratios (ORs) and 95% confidence intervals (CIs). All statistical analyses were performed using SAS version 9.4 (SAS Institute, Inc., Cary, NC, USA).

Results

A total of 1855 school-aged boys with ADHD were included in our study. The mean age was 8.3 years. A total of 818 boys (44.1%) had severe internalizing behaviors, 982 boys (52.9%) had severe externalizing behaviors, 552 (29.8%) had only one type of behavioral disturbance in either severe internalizing or externalizing behaviors, and 624 (33.6%) had behavioral disturbances in both classes. The characteristics of the participants are presented in Table 1. Compared with school-aged boys without severe internalizing behaviors, those with severe internalizing behaviors were more likely to be first-born, to be living in a family not with both parents, to have a family history of mental disorders, to have prenatal complications, to have perinatal complications, to have medical comorbidities, and to have psychiatric comorbidities. There were no significant differences in the parental characteristics.

Table 1 Characteristics of school-aged boys with ADHD with and without severe internalizing/ externalizing behaviors
Full size table

With regard to externalizing behaviors, school-aged boys with ADHD with such behaviors were more likely to be first-born, to be living in a family not with both parents, to have a family history of mental disorders, to have prenatal complications, and to have medical comorbidities than those without such behaviors. Moreover, boys with ADHD with severe externalizing behavior problems were more likely to have parents with a lower education level and to be born to mothers younger than 20 years.

Table 2 presents the estimate of logistic regression among family, personal, and parental factors and severe internalizing behaviors in school-aged boys with ADHD. Being first-born, living in a family not with both parents, having family history of mental disorders, having prenatal complications, having perinatal complications, having medical comorbidities, and having psychiatric comorbidities were associated with severe internalizing behaviors in boys with ADHD. The role of the parental factors was not significant.

Table 2 Family factors, personal factors, parental factors, and severe internalizing behaviors among school-aged boys with ADHD
Full size table

In the analysis of severe externalizing behaviors, most results were similar to internalizing behaviors. However, some differences, particularly the effects of parental factors, existed (Table 3). Being first-born, living in family not with both parents, having a family history of mental disorders, prenatal complications), and having medical comorbidities were associated with severe externalizing behavior problems in boys with ADHD. However, the association among perinatal complications, psychiatric comorbidities, and severe externalizing behaviors was not significant. Moreover, a higher paternal education level was associated with a lower risk and maternal age younger than 20 years at childbirth was associated with a higher risk of severe externalizing behaviors only. This association was not noted in internalizing behaviors.

Table 3 Family factors, personal factors, parental factors and severe externalizing behaviors among school-aged boys with ADHD
Full size table

Table 4 reports the results of ordinal logistic regression that assessed the association between the correlates and the numbers of types of behavioral disturbances in boys with ADHD. Family factors including being first-born, living in family not with both parents, and family history of mental disorders were associated with more types of behavioral disturbances. The role of personal factors, including prenatal complications, perinatal complications, psychiatric comorbidities, and medical comorbidities were also identified. With parental factors, higher paternal education level was related to a lower risk of more types of behavioral problems in boys with ADHD. Maternal age younger than 20 years at childbirth was associated with a higher risk. The role of the other parental factors was not significant.

Table 4 Ordinal logistic regression of risk factors and numbers of types of behavioral disturbances among school-aged boys with ADHD
Full size table

Discussion

This study evaluated the relationship among family, personal, parental factors, and behavioral disturbances among school-aged boys with ADHD using medical records from a public psychiatry hospital in Taiwan, and the results showed that family, personal, and parental factors contribute to the occurrence and heterogeneity of behavioral disturbances in school-aged boys with ADHD. Both internalizing and externalizing behaviors are associated with family factors, including being first-born, living in a family not with both parents, and family history of mental disorders. Among personal factors, prenatal complications, perinatal complications, and medical or psychiatric comorbidities are associated with severe internalizing behaviors, but only prenatal complications and medical comorbidities are associated with severe externalizing behaviors. Regarding parental factors, higher paternal education level is protective, whereas maternal age younger than 20 at childbirth increases the risk of externalizing behaviors; however, such an association is not noted with regard to severe internalizing behaviors. Assessment of the association between the correlates and the numbers of types of behavioral disturbances showed that the results were similar.

In our study, several family factors were associated with severe internalizing behaviors, externalizing behaviors, and the number of types of behavioral disturbances. The negative effect of an altered family structure on child development has been reported in previous studies [26, 27]. Living in a family not with both parents is associated with limited social resources, lower family support levels, and poorer family functioning [28]. The altered family structure also causes higher stress for caretakers [29, 30]. Problems of adjustment and self-regulation have also been reported to be common among children raised in families without an intact structure [29, 31]. All these disadvantages can establish a negative environment for children with ADHD and lead to severe behavioral disturbances through the interaction of the environment and impulsive tendency, which is consistent with our findings.

Family history of mental disorders and being first-born are two other important family factors associated with severe behavioral disturbances in boys with ADHD. Several hypothetical mechanisms can explain how a family history of mental disorders influences child behaviors. First, the effect of genetic transmission of mental disorders may have a direct influence on child behaviors, resulting in both the incidence and coexisting behavioral disturbances in ADHD [32,33,34,35]. Second, psychopathology in family members may have an adverse effect on parenting skills, the family atmosphere, parent–child relationship, adaptive strategies to child behaviors, and medical resource utilization [36], which are all important for children with ADHD. Third, family cohesion is disturbed by other mentally ill members. The child may imitate behaviors through modeling or social learning processes [37, 38]. Such behaviors may be used to elicit attention from others or to compensate for the feeling of being neglected. Consequently, a series of inappropriate behaviors may occur [37].

Being first-born is another risk factor for the development of severe behavioral disturbances in boys with ADHD. Several studies have reported that the first-borns often face unique challenges, such as the changed interaction between parents after the birth of a new child or the issue of sibling rivalry as they grow up [39]. In addition, inexperienced child rearing, attitude, and the capability of the parents also influence the behavior development of the first-born child [40, 41]. Additionally, first-born boys are often viewed as the heirs of the family in Eastern countries. Coexisting ADHD in first-born boys may result in experiences of failure, frustration, and greater stress. Internalizing and externalizing behaviors can, therefore, be a way for them to cope with such difficulties.

Prenatal and perinatal complications can interfere with the normal development of children through changes in both neurophysiological mechanisms and the dopaminergic system [42, 43]. Our study also reports that prenatal and perinatal complications are associated with behavioral disturbances in boys with ADHD, which is consistent with other studies [44]. However, although prenatal complications are associated with both internalizing and externalizing behaviors, perinatal complications are associated with internalizing behaviors only. Previous studies have also shown that prenatal and perinatal complications occurring during different stages of child development may have different effects on child behavior [45, 46]. This helps explain the discrepancies observed in our study.

Comorbid conditions are also related to behavioral disturbances in boys with ADHD. This result can be explained in several ways. First, from the perspective of children, having coexisting diseases may cause distress [47,48,49]. The interaction between distress and impulsive tendencies related to ADHD may result in further behavioral disturbances. Second, from the perspective of caretakers, a higher rearing burden may be related to a sense of fatigue and exhaustion [50, 51], interfering with parent–child interaction and child development. In our study, medical comorbidities were associated with both internalizing and externalizing behaviors in boys with ADHD, but psychiatric comorbidities were associated with internalizing behaviors only. Although this finding might be affected by a type II error, the discrepancy also implies that the relationship between comorbid status and ADHD outcomes may be more complex and requires further evaluation.

Two parental factors, paternal education level and maternal age at childbirth, are associated with the occurrence of severe externalizing behaviors and heterogeneity in behavioral disturbances in boys with ADHD. The higher education level of parents is associated with efficient parenting, flexibility in interactions, stress buffering, and management of children’s problems [52,53,54,55]. Therefore, it is reasonable that a higher parental education level is protective against severe externalizing or more problematic behaviors in children with ADHD. ADHD is often related to academic achievement. Parents who do not attain higher education levels may also have ADHD-like traits or similar behavioral problems. The possible transmission of susceptibility genes to their children may also help to explain the relationship [56].

The association between parental age at childbirth and behavioral disturbances can be explained by common genetic and socioeconomic mechanisms [57]. Parents giving birth to younger children may have heritable impulsive or novelty-seeking characteristics and influence their offspring [57, 58]. Disadvantaged families, lower social support, financial or social difficulties, and disturbed maturation of parents are also associated with early childbearing. Such disadvantages may interfere with the quality of nourishing and maturity of young parents [56, 58], resulting in both the incidence of ADHD and consequential behavioral disturbances in their children [58, 59].

Although our findings support the association between parental education level and age of childbirth on behavioral disturbances in boys with ADHD, the results between parents vary. The effect of parental gender on child development has been discussed in several studies. Parental gender may play a role in social development, quality of life, and family interactions of the child [21, 22, 60]. One study also emphasized the effects of parental education level on the general well-being of children with specific diseases [61]. While explaining our results, some cultural-specific characteristics of Asian families should be considered. In Eastern culture, paternal and maternal roles in social participation, social expectation, labor diversion in child-rearing, and decisions regarding family affairs differ. Fathers are often dominant and the authority figure in Eastern families, explaining the significant role of paternal education level in our findings. Furthermore, teenage pregnancy and early motherhood often face higher social criticism, less support, and more stress in Eastern society, constituting an unfavorable environment for child nourishment and development. Such a phenomenon can explain the influence of early motherhood on child behavioral disturbances. Although the impact of cultural context can be used to explain our results, further investigations are needed.

Our study has some limitations. First, because of the cross-sectional study design, the causal relationship should be interpreted conservatively. Second, the study population was identified from a hospital-based medical record database, and only male patients were included. The representativeness of our study was limited. In addition, the study population was recruited from a public psychiatric hospital. In Taiwan, disadvantaged families, which are also a risk factor for more severe disturbances in children, often visit public hospitals for medical treatment. This may result in referral bias in our study and interfere the inference of our results. Third, some possible unmeasured confounders, such as child temperament, parenting patterns, or family atmosphere, were not considered. Therefore, residual confounding effects still exist.

Regardless of these limitations, our study has several strengths. First, our study provides a broader perspective on ADHD, focusing on the severity and diversity of behavioral disturbances. Second, our study highlights the important role of environmental factors in children with ADHD. Third, our results reflect the association between the correlates and child behaviors in Eastern society, which has been less investigated in previous studies. Fourth, our findings can be used to identify higher-risk school-aged boys with ADHD who may have more negative outcomes and need further intervention.

Conclusions

ADHD is a highly heterogeneous condition, and the unique family, personal, and parental characteristics of children with ADHD who have behavioral disturbances should be identified. Our study reports that family structure, birth order, family history of mental disorders, prenatal complications, perinatal complications, comorbid status, paternal education level, and maternal age at childbirth are associated with severe and heterogeneous behavioral disturbances in boys with ADHD. More research is needed to elucidate the underlying mechanism for early identification of children with ADHD at risk, adequate treatment referral, and resource allocation.

Availability of data and materials

The datasets analyzed during the current study are not publicly available because of the regulations of the institutional review board, but are available from the corresponding author upon reasonable request.

Abbreviations

ADHD:

Attention-deficit/hyperactivity disorder

CBCL:

Child Behavior Checklist

CI:

95% confidence interval

DSM-IV-TR:

Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision

OR:

Odds ratio

TYPC:

Tao-Yuan Psychiatric Center

References

  1. Cherkasova M, Sulla EM, Dalena KL, Ponde MP, Hechtman L. Developmental course of attention deficit hyperactivity disorder and its predictors. J Can Acad Child Adolesc Psychiatry. 2013;22(1):47–54.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Quintero J, Ramos-Quiroga JA, Sebastian JS, Montanes F, Fernandez-Jaen A, Martinez-Raga J, et al. Health care and societal costs of the management of children and adolescents with attention-deficit/hyperactivity disorder in Spain: a descriptive analysis. BMC Psychiatry. 2018;18(1):40.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Ruiz-Goikoetxea M, Cortese S, Aznarez-Sanado M, Magallon S, Alvarez Zallo N, Luis EO, et al. Risk of unintentional injuries in children and adolescents with ADHD and the impact of ADHD medications: A systematic review and meta-analysis. Neurosci Biobehav Rev. 2018;84:63–71.

    Article  PubMed  Google Scholar 

  4. Erskine HE, Norman RE, Ferrari AJ, Chan GC, Copeland WE, Whiteford HA, et al. Long-Term Outcomes of Attention-Deficit/Hyperactivity Disorder and Conduct Disorder: A Systematic Review and Meta-Analysis. J Am Acad Child Adolesc Psychiatry. 2016;55(10):841–50.

    Article  PubMed  Google Scholar 

  5. Symeou M, Georgiou S. Externalizing and internalizing behaviours in adolescence, and the importance of parental behavioural and psychological control practices. J Adolesc. 2017;60:104–13.

    Article  PubMed  Google Scholar 

  6. Madigan S, Atkinson L, Laurin K, Benoit D. Attachment and internalizing behavior in early childhood: a meta-analysis. Dev Psychol. 2013;49(4):672–89.

    Article  PubMed  Google Scholar 

  7. Chao M, Li X, McGue M. The causal role of alcohol use in adolescent externalizing and internalizing problems: a mendelian randomization study. Alcohol Clin Exp Res. 2017;41(11):1953–60.

    Article  CAS  PubMed  Google Scholar 

  8. Eisenberg N, Cumberland A, Spinrad TL, Fabes RA, Shepard SA, Reiser M, et al. The relations of regulation and emotionality to children’s externalizing and internalizing problem behavior. Child Dev. 2001;72(4):1112–34.

    Article  CAS  PubMed  Google Scholar 

  9. Leaberry KD, Rosen PJ, Fogleman ND, Walerius DM, Slaughter KE. Comorbid Internalizing and Externalizing Disorders Predict Lability of Negative Emotions Among Children With ADHD. J Attent Disord. 2017;1087054:717734647.

    Google Scholar 

  10. Pedersen MU, Thomsen KR, Heradstveit O, Skogen JC, Hesse M, Jones S. Externalizing behavior problems are related to substance use in adolescents across six samples from Nordic countries. Eur Child Adolesc Psychiatry. 2018;90:234.

    Google Scholar 

  11. Kang T, Wood JM, Eno Louden J, Ricks EP. Prevalence of internalizing, externalizing, and psychotic disorders among low-risk juvenile offenders. Psychol Serv. 2018;15(1):78–86.

    Article  PubMed  Google Scholar 

  12. Narusyte J, Ropponen A, Alexanderson K, Svedberg P. Internalizing and externalizing problems in childhood and adolescence as predictors of work incapacity in young adulthood. Soc Psychiatry Psychiatr Epidemiol. 2017;52(9):1159–68.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Jokela M. Life-course fertility patterns associated with childhood externalizing and internalizing behaviors. Eur Child Adolesc Psychiatry. 2014;23(12):1201–10.

    Article  PubMed  Google Scholar 

  14. Okado Y, Ewing E, Rowley C, Jones DE. Trajectories of mental health-related service use among adolescents with histories of early externalizing problems. J Adolesc Health Soc Adolesc Med. 2017;61(2):198–204.

    Article  Google Scholar 

  15. Englund MM, Siebenbruner J. Developmental pathways linking externalizing symptoms, internalizing symptoms, and academic competence to adolescent substance use. J Adolesc. 2012;35(5):1123–40.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Thapar A, Cooper M. Attention deficit hyperactivity disorder. Lancet (London England). 2016;387(10024):1240–50.

    Article  Google Scholar 

  17. Buschgens CJ, Swinkels SH, van Aken MA, Ormel J, Verhulst FC, Buitelaar JK. Externalizing behaviors in preadolescents: familial risk to externalizing behaviors, prenatal and perinatal risks, and their interactions. Eur Child Adolesc Psychiatry. 2009;18(2):65–74.

    Article  PubMed  Google Scholar 

  18. Burt SA, Barnes AR, McGue M, Iacono WG. Parental divorce and adolescent delinquency: ruling out the impact of common genes. Dev Psychol. 2008;44(6):1668–77.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Wakschlag LS, Pickett KE, Cook E Jr, Benowitz NL, Leventhal BL. Maternal smoking during pregnancy and severe antisocial behavior in offspring: a review. Am J Public Health. 2002;92(6):966–74.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Hsu YC, Chen CT, Yang HJ, Chou P. Family structure, birth order, and aggressive behaviors among school-aged boys with attention deficit hyperactivity disorder (ADHD). Soc Psychiatry Psychiatr Epidemiol. 2019;54(6):661–70.

    Article  PubMed  Google Scholar 

  21. Gau SS, Chang JP. Maternal parenting styles and mother-child relationship among adolescents with and without persistent attention-deficit/hyperactivity disorder. Res Dev Disabil. 2013;34(5):1581–94.

    Article  PubMed  Google Scholar 

  22. Chang LR, Chiu YN, Wu YY, Gau SS. Father’s parenting and father-child relationship among children and adolescents with attention-deficit/hyperactivity disorder. Compr Psychiatr. 2013;54(2):128–40.

    Article  Google Scholar 

  23. Vrolijk P, Van Lissa CJ, Branje SJT, Meeus WHJ, Keizer R. Longitudinal linkages between father and mother autonomy support and adolescent problem behaviors: between-family differences and within-family effects. J Youth Adolesc. 2020;49(11):2372–87.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Katsuki D, Yamashita H, Yamane K, Kanba S, Yoshida K. Clinical subtypes in children with attention-deficit hyperactivity disorder according to their child behavior checklist profile. Child Psychiatry Hum Dev. 2020;51(6):969–77.

    Article  PubMed  Google Scholar 

  25. Fogleman ND, Leaberry KD, Rosen PJ, Walerius DM, Slaughter KE. Relation between internalizing behaviors, externalizing behaviors, and peer victimization among children with and without ADHD. Atten deficit hyperactivity disorders. 2018;10(3):209–22.

    Article  Google Scholar 

  26. Rydell AM. Family factors and children’s disruptive behaviour: an investigation of links between demographic characteristics, negative life events and symptoms of ODD and ADHD. Soc Psychiatry Psychiatr Epidemiol. 2010;45(2):233–44.

    Article  PubMed  Google Scholar 

  27. Flouri E, Midouhas E, Ruddy A. Socio-economic status and family structure differences in early trajectories of child adjustment: Individual and neighbourhood effects. Health Place. 2016;37:8–15.

    Article  PubMed  Google Scholar 

  28. Gach EJ, Ip KI, Sameroff AJ, Olson SL. Early cumulative risk predicts externalizing behavior at age 10: The mediating role of adverse parenting. J Fam Psychol Am Psychol Assoc. 2018;32(1):92–102.

    Article  Google Scholar 

  29. Daryanani I, Hamilton JL, Abramson LY, Alloy LB. Single mother parenting and adolescent psychopathology. J Abnorm Child Psychol. 2016;44(7):1411–23.

    Article  PubMed  Google Scholar 

  30. Mitchell C, Brooks-Gunn J, Garfinkel I, McLanahar S, Notterman D, Hobcraft J. Family structure instability, genetic sensitivity, and child well-being. Am J Sociol. 2015;120(4):1195–225.

    Article  Google Scholar 

  31. Garnefski N, Diekstra RF. Adolescents from one parent, stepparent and intact families: emotional problems and suicide attempts. J Adolesc. 1997;20(2):201–8.

    Article  CAS  PubMed  Google Scholar 

  32. Kendler KS, PirouziFard M, Lonn S, Edwards AC, Maes HH, Lichtenstein P, et al. A National Swedish twin-sibling study of alcohol use disorders. Twin Res Hum Genetics. 2016;19(5):430–7.

    Article  Google Scholar 

  33. Kendler KS, Prescott CA, Myers J, Neale MC. The structure of genetic and environmental risk factors for common psychiatric and substance use disorders in men and women. Arch Gen Psychiatry. 2003;60(9):929–37.

    Article  PubMed  Google Scholar 

  34. Beardslee WR, Keller MB, Seifer R, Lavori PW, Staley J, Podorefsky D, et al. Prediction of adolescent affective disorder: effects of prior parental affective disorders and child psychopathology. J Am Acad Child Adolesc Psychiatry. 1996;35(3):279–88.

    Article  CAS  PubMed  Google Scholar 

  35. Zhang C, Brook JS, Morojele NK, De La Rosa M, Leukefeld CG, Brook DW. Psychosocial Factors Related to the Intergenerational Transmission of Externalizing Behaviors in Early Midlife. Subst Use Misuse. 2017;52(10):1328–37.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Kingston D, Kehler H, Austin MP, Mughal MK, Wajid A, Vermeyden L, et al. Trajectories of maternal depressive symptoms during pregnancy and the first 12 months postpartum and child externalizing and internalizing behavior at three years. PLoS ONE. 2018;13(4):e0195365.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Grabow AP, Khurana A, Natsuaki MN, Neiderhiser JM, Harold GT, Shaw DS, et al. Using an adoption-biological family design to examine associations between maternal trauma, maternal depressive symptoms, and child internalizing and externalizing behaviors. Dev Psychopathol. 2017;29(5):1707–20.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Campbell JC, Woods AB, Chouaf KL, Parker B. Reproductive health consequences of intimate partner violence. A nursing research review. Clin Nurs Res. 2000;9(3):217–37.

    Article  CAS  PubMed  Google Scholar 

  39. Volling BL. Family transitions following the birth of a sibling: an empirical review of changes in the firstborn’s adjustment. Psychol Bull. 2012;138(3):497–528.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Kwok MK, Leung GM, Schooling CM. Associations of Birth Order with Early Adolescent Growth, Pubertal Onset, Blood Pressure and Size: Evidence from Hong Kong’s “Children of 1997” Birth Cohort. PLoS ONE. 2016;11(4):e0153787.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  41. Ghanizadeh A, Abotorabi-Zarchi M, Mohammadi MR, Firoozabadi A. Birth order and sibling gender ratio of a clinical sample of children and adolescents diagnosed with attention deficit hyperactivity disorder. Iran J psychiatry. 2012;7(3):109–13.

    PubMed  PubMed Central  Google Scholar 

  42. Wiggs K, Elmore AL, Nigg JT, Nikolas MA. Pre- and Perinatal Risk for Attention-Deficit Hyperactivity Disorder: Does Neuropsychological Weakness Explain the Link? J Abnorm Child Psychol. 2016;44(8):1473–85.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Ben Amor L, Grizenko N, Schwartz G, Lageix P, Baron C, Ter-Stepanian M, et al. Perinatal complications in children with attention-deficit hyperactivity disorder and their unaffected siblings. J Psychiatry Neurosci. 2005;30(2):120–6.

    PubMed  PubMed Central  Google Scholar 

  44. Abdulkadir M, Tischfield JA, King RA, Fernandez TV, Brown LW, Cheon KA, et al. Pre- and perinatal complications in relation to Tourette syndrome and co-occurring obsessive-compulsive disorder and attention-deficit/hyperactivity disorder. J Psychiatr Res. 2016;82:126–35.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Park S, Cho SC, Kim JW, Shin MS, Yoo HJ, Oh SM, et al. Differential perinatal risk factors in children with attention-deficit/hyperactivity disorder by subtype. Psychiatry Res. 2014;219(3):609–16.

    Article  PubMed  Google Scholar 

  46. Ketzer CR, Gallois C, Martinez AL, Rohde LA, Schmitz M. Is there an association between perinatal complications and attention-deficit/hyperactivity disorder-inattentive type in children and adolescents? Revista Brasileira Psiquiatria. 2012;34(3):321–8.

    Article  Google Scholar 

  47. Lee YS, Kim SH, You JH, Baek HT, Na C, Kim BN, et al. Attention deficit hyperactivity disorder like behavioral problems and parenting stress in pediatric allergic rhinitis. Psychiatry Invest. 2014;11(3):266–71.

    Article  Google Scholar 

  48. Bennett KE, Haggard MP, Silva PA, Stewart IA. Behaviour and developmental effects of otitis media with effusion into the teens. Arch Dis Child. 2001;85(2):91–5.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  49. Soylu E, Soylu N, Yildirim YS, Sakallioglu O, Polat C, Orhan I. Psychiatric disorders and symptoms severity in patients with adenotonsillar hypertrophy before and after adenotonsillectomy. Int J Pediatr Otorhinolaryngol. 2013;77(10):1775–81.

    Article  PubMed  Google Scholar 

  50. Smith G, Wagner J, Andrews J, Austin J, Mueller M, Carter E, et al. Caregiving in pediatric epilepsy: results of focus groups and implications for research and practice. Epilepsy Behav. 2014;34:34–41.

    Article  PubMed  Google Scholar 

  51. Pinquart M. Do the parent–child relationship and parenting behaviors differ between families with a child with and without chronic illness? A meta-analysis. J Pediatr Psychol. 2013;38(7):708–21.

    Article  PubMed  Google Scholar 

  52. Di Giunta L, Iselin AR, Lansford JE, Eisenberg N, Lunetti C, Thartori E, et al. Parents’ and early adolescents’ self-efficacy about anger regulation and early adolescents’ internalizing and externalizing problems: A longitudinal study in three countries. J Adolesc. 2018;64:124–35.

    Article  PubMed  PubMed Central  Google Scholar 

  53. Fong VC, Hawes D, Allen JL. A systematic review of risk and protective factors for externalizing problems in children exposed to intimate partner violence. Trauma violence Abuse. 2017;89:1524838017692383.

    Google Scholar 

  54. Pinquart M. Associations of parenting dimensions and styles with externalizing problems of children and adolescents: An updated meta-analysis. Dev Psychol. 2017;53(5):873–932.

    Article  PubMed  Google Scholar 

  55. Wang M, Liu L. Reciprocal relations between harsh discipline and children’s externalizing behavior in China: a 5-year longitudinal study. Child Dev. 2018;89(1):174–87.

    Article  PubMed  Google Scholar 

  56. Russell AE, Ford T, Russell G. Socioeconomic Associations with ADHD: findings from a mediation analysis. PLoS ONE. 2015;10(6):e0128248.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  57. Hvolgaard Mikkelsen S, Olsen J, Bech BH, Obel C. Parental age and attention-deficit/hyperactivity disorder (ADHD). Int J Epidemiol. 2017;46(2):409–20.

    PubMed  Google Scholar 

  58. Chang Z, Lichtenstein P, D’Onofrio BM, Almqvist C, Kuja-Halkola R, Sjolander A, et al. Maternal age at childbirth and risk for ADHD in offspring: a population-based cohort study. Int J Epidemiol. 2014;43(6):1815–24.

    Article  PubMed  PubMed Central  Google Scholar 

  59. Sauver JL, Barbaresi WJ, Katusic SK, Colligan RC, Weaver AL, Jacobsen SJ. Early life risk factors for attention-deficit/hyperactivity disorder: a population-based cohort study. Mayo Clinic proceedings. 2004;79(9):1124–31.

    Article  Google Scholar 

  60. Janecka M, Haworth CMA, Ronald A, Krapohl E, Happé F, Mill J, et al. Paternal age alters social development in offspring. J Am Acad Child Adolesc Psychiatry. 2017;56(5):383–90.

    Article  PubMed  PubMed Central  Google Scholar 

  61. Iqbal M, Amirsalari S, Radfar S, Haidari MR. Effects of parental gender and level of education on the quality of life and general health of pediatric patients with epilepsy: An outpatient cross-sectional survey. Epilepsy Behav. 2016;60:118–23.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

We thank the team at the Tao-Yuan Psychiatric Center for data collection and management. We also appreciate the helpful suggestions from the professors and students at the Institute of Public Health of National Yang Ming Chiao Tung University, Taiwan.

Funding

This work was supported by a grant from the Ministry of Health and Welfare, Taiwan, for data collection and analysis.

Author information

Authors and Affiliations

  1. Department of Child and Adolescent Psychiatry, Tao-Yuan Psychiatric Center, Ministry of Health and Welfare, 71 Long-Shou St. Tao-Yuan District, Taoyuan City, Taiwan

    Yuan-Chang Hsu & Chih-Tsai Chen

  2. Institute of Public Health, National Yang Ming Chiao Tung University, Hsinchu, Taiwan

    Yuan-Chang Hsu & Pesus Chou

  3. Department of Public Health, Chung-Shan Medical University, Taichung, Taiwan

    Hao-Jan Yang

  4. Community Medicine Research Center, National Yang Ming Chiao Tung University, Hsinchu, Taiwan

    Pesus Chou

Authors
  1. Yuan-Chang Hsu
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Chih-Tsai Chen
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Hao-Jan Yang
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Pesus Chou
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

YCH, CTC, and PC conceptualized and designed the study. YCH, CTC, and HJY participated in the data collection, management, and analysis. YCH and PC participated in data interpretation. YCH drafted the manuscript CTC and PC reviewed the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Yuan-Chang Hsu.

Ethics declarations

Ethics approval and consent to participate

This study was approved by the institutional review board of the Tao-Yuan Psychiatric Center and was exempted from obtaining informed consent.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Hsu, YC., Chen, CT., Yang, HJ. et al. Family, personal, parental correlates and behavior disturbances in school-aged boys with attention-deficit/hyperactivity disorder (ADHD): a cross-sectional study. Child Adolesc Psychiatry Ment Health 16, 30 (2022). https://doi.org/10.1186/s13034-022-00467-w

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s13034-022-00467-w

Keywords

Child and Adolescent Psychiatry and Mental Health

ISSN: 1753-2000