Family Functioning and Parental Bonding During Childhood in Adults Diagnosed With ADHD

Abstract

Objective: This work assesses family functioning, parental bonding, and the relationship between the two in adults diagnosed with ADHD. Method: The study used a retrospective, ex post facto design and consisted of 100 adult participants, who were distributed into two groups: with and without diagnosis of ADHD. Two family assessment instruments were applied: the Family Adaptability and Cohesion Evaluation Scale short spanish version (FACES-20esp)) and the Parental Bonding Instrument (PBI). The diagnosis of ADHD was done by using a semistructured interview for Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) criteria (Conners’ Adult ADHD Diagnostic Interview for DSM-IV [CAADID]). Results: The results showed that higher rigidity and lower emotional connection were significantly associated with ADHD family functioning. Regarding parental bonding, the results showed significant differences only in the care dimension, with the ADHD group reporting lower care than the control group. Conclusion: The results suggest that ADHD families present dysfunctional family functioning with a rigid, separated typology, and parental bonding based on control without affection.

Keywords

ADHD family functioning parental bonding

Introduction

The chronic effects of ADHD and its repercussions on the family are aspects that are of great importance to assess due to their implications on family relationships throughout the life cycle. As described by Agha, Zammit, Thapar, and Langley (2013), the parental problems of children diagnosed with ADHD are associated with severe clinical symptoms and greater family adversity. Schei, Jozefiak, Stene Novik, Lydersen, and Indredavik (2016) studied the impact of coexisting emotional and conduct problems on family functioning and quality of life among adolescents with ADHD; their results showed that the participants diagnosed with ADHD reported lower quality of life and family functioning. The purpose of this study is to explore family functioning variables during childhood in adults diagnosed with ADHD.

According to Modesto-Lowe, Danforth, and Brooks (2008), regarding the relationship between ADHD and parent variables, education styles are one of the most important areas. McKee, Harvey, Danforth, Ulaszek, and Friedman (2004) observed that in families with one child with ADHD, the parents tend to exercise greater control and criticism; they react excessively to impulsive conduct, use reprimands and punishments with greater frequency, and value their children less than in the control groups. At the same time, they are less affectionate, feel less confidence in their ability to bring up children, and have greater levels of distress. In the same way, the studies of Raya, Herreruzo, and Pino (2008) in children and of Buschgens et al. (2010) among preadolescents showed that authoritarian and permissive education brings about hyperactive and exaggerated conduct. Foley (2010) observed that families with children diagnosed with ADHD show greater levels of family dysfunction than those with children who have not been diagnosed with ADHD. Moreover, Weiss and Hechtman (1993) reported than an emotional and/or hostile climate in the home is a bad predictor of ADHD at adult age. These studies indicate greater severity of ADHD when there are disagreements between parents and siblings; in such cases, it is more difficult for children with ADHD to hide their impulses and obey orders, provoking behavior problems that are difficult to manage. The parents are more coercive and inconsistent with their children, causing the feeling of lack of competence as parents. This frustration has repercussions on the child and brings about negative results that influence the symptoms of the disorder and cause disagreeable family situations (Grau-Sevilla, 2007).

According to Linares (1996), the family is one of the most significant contexts in the development of a child. It plays a crucial part in the process of bringing up a child, during which the parents provide the nutritive relationship that is absolutely necessary for the child’s maturity as a person.

To the best of our knowledge, no studies have focused on family functioning, parental bonding, and the relationship between the two in adults diagnosed with ADHD. In this sense, the systemic theory offers a theoretical framework appropriate for such study because it does not center on the cause of the dysfunctions but focuses on the interaction between family variables and the expression of the disorder, as well as on their circular causality. This also has clinical implications: When considering relational and bidirectional variables in the study of ADHD, the treatment possibilities increase. Although the notion that parents have an enduring influence on their children has intuitive appeal, the behavior and temperament of the child can also affect the quality of parenting (Cunningham, 2007).

The Olson Circumplex Model (Olson, Russell, & Sprenkle, 1983) is widely used in systemic studies to evaluate family behavior but not in relation to psychopathology. It comprises three key concepts. The first is cohesion, defined as an emotional bond (degree of separation or connection) that family members have among themselves. The second is adaptability, expressed as the ability of the family or conjugal system to adapt its power structure, its roles, and the norms of the relationship in response to stress caused by a concrete situation or by the vital development of the whole family. The third concept, communication, refers to positive communicative abilities used in the family (Olson & Gorall, 2003).

This model facilitates the identification of 16 types of conjugal and family systems distributed into three groups: balanced, extremes, and intermediate. The communication dimension exercises a facility function on family behavior. The other two dimensions are curved lines, which means that the extremes are dysfunctional (little or excessive cohesion and/or adaptability). The Circumplex Model is dynamic and presumes that persons and families will change. It formulates the hypothesis that change can favor the maintenance or improvement of family behavior and leave room for change within reasonable limits (Lopez Larrosa, 2002).

Parental bonding, understood as the significant dyadic and stable relationship between children and their parents, is an important environmental factor to consider in the study of ADHD across the life span. The model developed by Parker, Tupling, and Brown (1979) classified such bond into four types based on the dimensions of care and overprotection. The care dimension refers to emotional warmth, concern for the welfare of the child, and positive acceptance/appreciation of the same. However, the overprotection dimension refers to control, intrusion, excessive contact, and prevention of independent behavior of the child. The optimal parenting offers acceptance and appreciation, guides affection and care, and promotes child autonomy. An affectionate constraint bond comes from an ambience of controlled warmth and acceptance, but it does not foster either autonomy or growth. An affectionless control bond is intrusive, based on norms and forced autonomy. Finally, neglectful parenting comes about when the child receives neither affection nor recognition, nor are his needs for protection taken into account.

Following this model, numerous previous investigations have associated a dysfunctional bond with the expression of schizophrenia (Willinger, Heiden, Meszaros, Formann, & Aschauer, 2002), mood disorders (T. Narita et al., 2000), obsessive and compulsive disorder (Wilcox et al., 2008), and general psychopathology (Heider, Matschinger, Bernert, Alonso, & Angermeyer, 2006; Klensmeden Fosse & Holen, 2002; K. Narita et al., 2010; Parker, 1983). High levels of care dimension in both parents diminish the probability of provoking mood disorders (Heider et al., 2006). A style of education based on control without affection has also been associated with externalizing problems (Iglesias & Romero, 2009). Vilaregut (2003) used these two models to study the connection between drug use, family functioning, and parental bonding, concluding that the families of patients with drug abuse disorders show low adaptability, extreme cohesion, and an affectionless control bond. Gau and Chang (2013) found that ADHD adolescents reported less affection or care and more overprotection and control from their mothers and perceived less family support.

The aim of the present study is to explore and analyze family functioning, parental bonding, and the relationship between the two during the childhood of ADHD adults. The revision carried out leads us to propose the following hypothesis. On one hand, families with a member diagnosed with ADHD would be situated in the two extremes of the adaptability dimension (rigid or chaotic) and of cohesion (enmeshed or disengaged) regarding family functioning. On the other hand, they would show a greater prevalence of parental bonding based on affectionless control. However, control group would present flexible or structured adaptability and separated or connected cohesion in family functioning. In parental bonding, they would show an optimal parenting. In addition, we expect no significant differences between groups in relation to age, gender, or socioeconomic status.

Method

Design

This study used an ex post facto, retrospective design with two groups: an experimental group and a quasi-experimental control group.

Participants

The participants consisted of 100 adults, 50 for the experimental group and the other 50 for the control group. All of them signed a consent form indicating their agreement to participate in the study. The study was approved by the ethics committee of Hospital Universitari Vall d’Hebron (Barcelona, Spain). The selection of participants was based on an intentional and nonprobabilistic sample. The experimental group consisted of male (65.9%) and female (34.1%) patients, ages between 18 and 47 years (M = 31.69, SD = 9.20), who attended the adult ADHD program of the Department of Psychiatry of Hospital Universitari Vall d’Hebron. Diagnosis of ADHD was established by experienced senior psychiatrist using semi-estructured interviews .The Spanish version of the Conners Adult ADHD Diagnostic Interview for DSM-IV was used. (CAADID, where DSM-IV represents Diagnostic and Statistical Manual of Mental Disorders [4th ed.]; American Psychiatric Association, 1994). The presence of comorbid disorders was evaluated with the Structured Clinical Interview for DSM-IV Axis I(SCID-I) and Structured Clinical Interview for DSM-IV Axis II(SCID-II) . Participants who showed oral and/or written comprehension difficulties in Catalan or Spanish were excluded, as were those with an IQ below 80 and/or comorbidity with other mental disorders, such as substance use disorders, mood disorders, anxiety disorders, or personality disorders.

The control group consisted of participants with similar sociodemographic characteristics to the experimental group. In this group, the sample was equally distributed between males and females, and the mean age was 30.76 years (SD = 10.73). The inclusion criterion for this group was absence of ADHD diagnosis or other mental disorders among the participants or their family members. After the data collection, six participants were excluded from the experimental group due to comorbidity with other psychiatric disorders. We also excluded six participants from the control group, choosing to retain only those who shared the same sociodemographic characteristics to preserve the homogeneity of the sample. We decided to exclude comorbidity (either in patients or in relatives) because previous studies have proven that oppositional defiant disorder, conduct disorder in children with ADHD, and psychiatric disorders in parents correlate with greater family dysfunction (Modesto-Lowe et al., 2008). All the participants included in the experimental group (ADHD) were diagnosed with ADHD for the first time at adulthood. The definitive sample consisted of 88 participants of Spanish nationality.

Instruments

All participants completed a questionnaire, including items on sociodemographic data, and the following instruments.

Family Adaptability and Cohesion Evaluation Scale short Spanish version (FACES-20esp)

This is a short, 20-item version of the American FACES II (Family Adaptability and Cohesion Evaluation Scale) (Olson, Portner, & Bell, 1982), culturally adapted to Spain by Martínez-Pampliega, Iraurgi, Galindez, and Sanz (2006). The instrument measures family functioning from the perspective of children, and it is based on cohesion and adaptability dimensions (following the Olson model). The 10-item cohesion scale assesses emotional ties and internal and external borders (in relation to space, time, decision making, interests, and leisure time).

The 10-item adaptability scale refers to assertiveness, leadership, control, discipline, and negotiation concepts. All items are rated on a 5-point Likert-type scale. The reliabilities of both theoretical dimensions are good (Cronbach’s alpha of .89 for the cohesion score and of .87 for the adaptability score), with a test–retest reliability of .83 for cohesion and .80 for adaptability. The construct validity is endorsed through factor analysis (goodness-of-fit index [GFI] = .92, normed fit index [NFI] = .89, root mean square error of approximation [RMSEA] = .07), according to Martínez-Pampliega et al. (2006).

Parental Bonding Instrument (PBI)–Orthodox version

This was designed by Parker et al. (1979), but we used the Spanish-adapted version by Ballús Creus (1991). The instrument is a self-report device that assesses an individual’s perception of parental bonding experiences, based on his or her memories up to 16 years old. The instrument considers two significant dimensions: care and overprotection. It consists of 25 items (13 in the Overprotection subscale and 12 in the Care subscale), rated on a scale ranging from 0 to 3 (strongly agree, moderately agree, moderately disagree, and disagree). Each scale is duplicated to find the perception of bonding with father and with mother, respectively. The reliabilities of these two dimension scales are Care α = .76 for mothers and α = .82 for fathers, and Overprotection α = .70 for mothers and α = .72 for fathers, according to Sánchez-Queija and Oliva (2003). The score intersection in each dimension allows the determination of the type of parental bonding. The test–retest reliability is high, even for long periods of more than 10 years (Parker, 1990).

Statistical Analysis

Descriptive analysis was used for the sociodemographic data and ADHD diagnosis. The means, standard deviations, and Student’s t test were used to compare the experimental and control group scores on the FACES-20esp and PBI.

Given that parental bonding and family functioning typologies are categorical variables, we applied the chi-square test to find significant differences between the ADHD and control groups.

We used Pearson’s correlation to evaluate the correlations between the cohesion/adaptability variables of the FACES-20esp and the care/overprotection variables of the PBI. Finally, to determine whether age, gender, socioeconomic status, and educational level were related to family functioning and parental bonding in the ADHD and control groups, Pearson correlations were used.

The independent variables were group (ADHD vs. control), age, gender, socioeconomic status, and academic level. The significance level used was .05, two-tailed. The SPSS software (Version 19.0) was used to analyze all the data.

Results

Family Functioning

Family functioning was assessed by using the FACES-20esp. The scores on the adaptability and cohesion scales were significantly lower in ADHD participants than in controls (see Table 1). Family functioning is the result of combining the subscale scores of Cohesion and Adaptability. As shown in Figure 1, the major percentage of the ADHD group was classified under the rigid-disengaged family functioning type (31.8%), whereas the participants without ADHD were distributed into two family types: chaotic-enmeshed (22.7%) and flex-connected (20.5%).

Table 1.

Comparison of the FACES Subscale Results of the ADHD and Control Groups.

	ADHD group		Control group
	M	SD	M	SD
FACES–Cohesion	33.43**	9.15	38.05	7.48
FACES–Adaptability	29.16**	8.11	35.18	7.24

Note. FACES = Family Adaptability and Cohesion Evaluation Scale.

p ≤ .05.

Figure 1.

Sixteen types of the family dynamics in the experimental and control groups.

Parental Bonding

Parental bonding was assessed by using the orthodox PBI. We found that parental care scores were significantly lower in the ADHD group. The scores for maternal care resulted in M = 24.7 ± 8.01 versus M = 28.73 ± 6.05 (t = −2.657, p < .05). The scores for paternal care were M = 19.22 ± 8.42 versus M = 24.86 ± 6.05 (t = −3.567, p < .05). The two groups did not differ significantly in parental overprotection.

Figure 2 shows the parental bonding types obtained by combining the care and overprotection scores. The ADHD group mostly remembered a dysfunctional bond with mother and father, defined as affectionless control. The group without ADHD recalled an optimal bond with mother and father.

Figure 2.

Four types of parental bonding in the experimental and control groups.

The results shown in Table 2 reveal a positive association between family functioning and parental care and negative correlations between family functioning and parental overprotection. Significant correlations were found between family cohesion and parental care (r = .605 with the mothers and r = .540 with the fathers) and between family adaptability and parental care (r = .602 with the mothers and r = .569 with the fathers). Family cohesion was negatively correlated with parental overprotection (r = −.101 with the mothers and r = −.155 with the fathers). Family adaptability was also negatively correlated with parental overprotection (r = −.071 with the mothers and r = −.185 with the fathers).

Table 2.

Correlations Between Dimensions of Parental Bond and Dimensions of Family Functioning.

Dimensions	PBI
Dimensions	Maternal overprotection	Maternal care	Paternal overprotection	Paternal care
FACES–Cohesion	−.101	.605**	−.155	.540**
FACES–Adaptability	−.071	.602**	−.185	.569**

Note. PBI = Parental Bonding Instrument; FACES = Family Adaptability and Cohesion Evaluation Scale.

The correlation is significant at p ≤ .05.

The influence of the demographic variables on parental care and family functioning was also analyzed. Paternal care in the ADHD group was found to be higher in lower socioeconomic levels (R = .443). Maternal care in the ADHD group was directly and significantly related to age (R = .342). Also, significant gender differences were found, with females associated with higher family cohesion (R = .343).

Discussion

Following the Circumplex Model of family functioning proposed by Olson et al. (1983), significant differences were found between the experimental and control groups. A high percentage of participants with ADHD remember their families as rigid-disengaged. Consistent with our hypothesis, this corresponds to an extreme, and therefore dysfunctional, family type.

Regarding adaptability, a high percentage of participants with ADHD reported rigidity, recalling difficulties in their families in negotiating rules, patterns, and leadership throughout the life cycle and in response to stressful events. Regarding cohesion, most of the participants with ADHD reported little or poor emotional connection between family members and little sharing among them.

These data support our hypothesis that most families with a member diagnosed with ADHD are dysfunctional types. Controller, repetitive, and forceful parenting styles in response to impulsive behavior, as observed by McKee et al. (2004), are consistent with a dysfunctional and rigid adaptability to stressful situations. The impulsivity and hyperactive behavior are strongly controlled with rigid and strict rules. Little changes are introduced during childhood and youth. Negative feedback patterns in interactions between parents and children with ADHD (Grau-Sevilla, 2007) and a lower quality of affection and communication (Foley, 2010) may increase the feelings of emotional distance in this kind of family. Less family cohesion may hinder the planning of leisure time, provoking less interest in doing activities together and difficulties in decision making.

We observed that the control group was divided into two types of family functioning. The first type, the chaotic-enmeshed extreme, obtained a representative percentage. This kind of family style tends toward excessive proximity between members, with defined limits to outside relationships, as noted in Spanish families by Lopez Larrosa (2002). High scores on adaptability, in turn, are related to lack of control, lax discipline, and excessive negotiation and permissiveness between parents and children. The second type is the flexible-connected group, which is concerned about the needs of its members, enhances the expression of different opinions, negotiations, and problem solving, and promotes the perception of fair discipline.

Following the PBI developed by Parker et al. (1979), we found that young adults with ADHD have significantly lower scores in the care dimension and showed an affectionless control bond (the intersection of lack of care and overprotection). Their parents tend to be indifferent, rejecting, and lacking in emotional warmth.

The parenting dimensions obtained by the PBI showed that parental behavior and attitudes in the ADHD group had significantly more control, less warmth, and more disapproval, as McKee et al. (2004) observed. Also, Raya et al. (2008) and Buschgens et al. (2010) related an authoritarian education style (more criticism, colder approach, and strict rules) with externalizing behavior. The parental style of low care/high overprotection (affectionless control) reported by this group is associated with problems in multiple adaptive functioning areas, such as school and social relationships. These findings are related to the theory of emotional nurture for the healthy development of a child described by Linares (1996). We observed that in families with ADHD members, weak emotional ties and rigidity are associated with low care and overprotection, increasing the probability of developing problematic profiles (low values of identity and self-esteem, self-control problems, and bad relationships with peers, such as personal and social conflicts). This generates new difficulties in the family functioning, perpetuating a cycle of negative feedbacks (Grau-Sevilla, 2007). The influence of a family style characterized by little capacity to adapt to changes, excessive discipline and control, and rigid, hardly negotiable relational rules contributes to a set of poor family relationships (rigidly unrelated families).

The findings of our study make it clear that we cannot ignore family relationships in ADHD research. There must be a joint effort to promote comprehensive intervention at all levels, as proposed by Alegret (2007), whereas the multimodal treatment, pharmacological intervention, and psychoeducation should be complemented by family therapy. Family therapy in patients with ADHD should aim to improve communication, promote the adjustment of parents regarding changes in behavior, and facilitate emotional connection between family members.

One limitation of this study is that we analyzed only the information reported by patients through the FACES-20esp and the dimensions proposed by the Circumplex Model. Comparative scales are necessary for family functioning analysis in relation to the presence of symptoms associated with pathology. Another limitation is the dilution of the sample, which was distributed into 16 family types. In subsequent studies, a larger sample should be considered. Besides, the FACES-20esp and PBI are retrospective self-report measures, which can result in biased memories. For this kind of study, a longitudinal design would be optimal so as to gather responses referring to the present time. Finally, the results of this study cannot be extrapolated to adults with ADHD in the general population because the ADHD sample was selected from a specialized university hospital program.

Conclusion

The results show that participants with ADHD obtained a high score on dysfunctional family functioning with a rigid, separated typology. The parental bonding results show that most participants with ADHD obtained a low score on the care dimension and remember a maternal bond based on control without affection. Regarding their relationship with their parents, the highest recall indicated a bond based on control without affection.

The obtained results support the evidence regarding the influence and impact of family relationships on each of the family members, regardless of the existence of mental illness. We believe it is necessary to continue investigating family variables in the field of ADHD and to develop comprehensive programs that include family intervention to ensure optimal treatment and better prognosis in families with a member with ADHD.

Footnotes

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The author MC was on the speakers’ bureau and/or acted as consultant for Eli-Lilly, Janssen-Cilag, Shire, Lundbeck, Ferrer and Rubió in the last 3 years. He also received travel awards (air tickets + hotel) for taking part in psychiatric meetings from Janssen-Cilag, Shire, and Eli- Lilly. The Department of Psychiatry chaired by him received unrestricted educational and research support from the following pharmaceutical companies in the last 3 years: Eli-Lilly, Rovi, Ferrer, Lundbeck, Shire, and Rubió.

The author J.A.R.Q was on the speakers’ bureau and/or acted as consultant for Eli-Lilly, Janssen-Cilag, Shire, Lundbeck, Almirall, Ferrer and Rubió in the last 3 years. He also received travel awards (air tickets + hotel) for taking part in psychiatric meetings from Rubió, Shire, and Eli- Lilly. The ADHD Program chaired by him received unrestricted educational and research support from the following pharmaceutical companies in the last 3 years: Eli-Lilly, Rovi, Ferrer, Lundbeck, Shire, and Rubió.

The others authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

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

Author Biographies

José E. Montejo, MD, is a psychiatrist, family therapist, and researcher of the Department of Psychiatry and Psychotherapy of the Family Therapy School at Hospital de la Santa Creu i Sant Pau and researcher of the Department of Psychiatry at Hospital Universitari Vall d’Hebron Universitat Autònoma de Barcelona, Spain. His research interests include adolescence, ADHD, substance use disorders and family therapy.

Mariona Durán is a psychologist and family therapist, as well as a researcher of the Department of Psychiatry and Psychotherapy of the Family Therapy School at Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Spain.

María del Mar Martínez is a psychologist and family therapist, as well as a researcher of the Department of Psychiatry and Psychotherapy of the Family Therapy School at Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Spain.

Ainoa Hilari is a psychologist and family therapist, as well as a researcher of the Department of Psychiatry and Psychotherapy of the Family Therapy School at Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Spain.

Nicoletta Roncalli is a psychologist and family therapist, as well as a researcher of the Department of Psychiatry and Psychotherapy of the Family Therapy School at Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Spain

Anna Vilaregut, PhD, is a full professor of psychology at Universitat Ramón Llull de Barcelona, Spain, and the coordinator of research at the Family Therapy School of Hospital de la Santa Creu i Sant Pau de Barcelona, Spain.

Montserrat Corrales, PhD, is a psychologist of the Department of Psychiatry at Hospital Universitari Vall d’Hebron. Her research interests include ADHD in adulthood.

Mariana Nogueira, PhD, is a psychologist of the Department of Psychiatry at Hospital Universitari Vall d’Hebron. Her research interests include ADHD in adulthood.

Miguel Casas, MD, PhD, is a full professor of the Department of Psychiatry and Legal Medicine at Universitat Autònoma de Barcelona, Spain, and head of the Department of Psychiatry at Hospital Universitari Vall d’Hebron (CIBERSAM). His research interests include ADHD and substance use disorders.

Juan Luis Linares, MD, PhD, is a full professor of the Department of Psychiatry at Universitat Autònoma de Barcelona, Spain, and head of the Department of Psychotherapy of the Family Therapy School at Hospital de la Santa Creu i Sant Pau de Barcelona, Spain.

J. Antoni Ramos-Quiroga, MD, PhD, is an associate professor of the Department of Psychiatry and Legal Medicine at Universitat Autònoma de Barcelona, Spain, and the coordinator of the ADHD Program of the Department of Psychiatry at Hospital Universitari Vall d’Hebron (CIBERSAM). His research interests include ADHD across the life span.

References

Agha

S. S.

Zammit

Thapar

Langley

(2013). Are parental ADHD problems associated with a more severe clinical presentation and greater family adversity in children with ADHD? European Child & Adolescent Psychiatry, 22, 369-377. doi:10.1007/s00787-013-0378-x

Alegret

(2007). Un protocolo para el déficit de atención y una tipologia de las familias de los menores que lo manifiestan [A protocol for children with attention deficit disorder and a typology of their families]. Redes, 18, 87-124.

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

Ballús Creus

(1991). Adaptació del Parental Bonding Instrument a població barcelonesa [Parental Bonding Instrument Adaptation for Barcelona Population] (Unpublished doctoral thesis). Professional School of Clinical Psychology, University of Barcelona, Spain.

Buschgens

Van Aken

Swinkels

Ormel

Verhulst

Buitelaar

(2010). Externalizing behaviors in preadolescents: Familial risk to externalizing behaviors and perceived parenting styles. European Child & Adolescent Psychiatry, 19, 567-575. doi:10.1007/s00787-009-0086-8

Cunningham

C. E.

(2007). A family-centered approach to planning and measuring the outcome of interventions for children with attention-deficit/hyperactivity disorder. Journal of Pediatric Psychology, 32, 676-694. doi:10.1093/jpepsy/jsm021

Foley

(2010). A comparison of family adversity and family dysfunction in families of children with attention deficit hyperactivity disorder (ADHD) and families of children without ADHD. Journal for Specialists in Pediatric Nursing, 16, 39-49. doi:10.1111/j.1744-6155.2010.00269.x

Gau

S. S.

Chang

J. P.

(2013). Maternal parenting styles and mother-child relationship among adolescents with and without persistent attention-deficit/hyperactivity disorder. Research in Developmental Disabilities, 34, 1581-1594. doi:10.1016/j.ridd.2013.02.002

Grau-Sevilla

M. D.

(2007). Family context analysis of children with ADHD (Doctoral thesis, University of Valencia). Retrieved from http://www.tdx.cat/handle/10803/10230

10.

Heider

Matschinger

Bernert

Alonso

Angermeyer

M. C.

(2006). Relationship between parental bonding and mood disorder in six European countries. Psychiatry Research, 143, 89-98. doi:10.1016/j.psychres.2005.08.015

11.

Iglesias

Romero

(2009). Estilos parentales percibidos, psicopatología y personalidad en la adolescencia [Perceived parenting styles, psychopathology and personality in adolescence]. Revista de Psicopatología y Psicología Clínica, 14(2), 63-77. Retrieved from http://e-spacio.uned.es/fez/eserv.php?pid=bibliuned:Psicopat-2009-14-2-0001&dsID=Documento.pdf

12.

Klensmeden Fosse

Holen

(2002). Childhood environment of adult psychiatric outpatients in Norway having been bullied in school. Child Abuse & Neglect, 26, 129-137. doi:10.1016/S0145-2134(01)00312-X

13.

Linares

J. L.

(1996). Identidad y narrativa.La terapia familiar en la práctica clínica [Identity and narrative.Family therapy in clinical practice]. Barcelona, Spain: Paidós Ed.

14.

Lopez Larrosa

(2002). El FACES II en la evaluación de la cohesión y la adaptabilidad familiar [FACES II in evaluating family cohesion and adaptability]. Psicothema, 14, 159-166.

15.

Martínez-Pampliega

Iraurgi

Galindez

Sanz

(2006). Family Adaptability and Cohesion Scale (FACES): Desarrollo de una versión de 20 ítems en español [Family Adaptability and Cohesion Scale (FACES): Development of a Spanish 20-item version]. International Journal of Clinical and Health Psychology, 6, 317-338. Retrieved from http://www.aepc.es/ijchp/articulos_pdf/ijchp-180.pdf

16.

McKee

T. E.

Harvey

Danforth

J. S.

Ulaszek

W. R.

Friedman

J. L.

(2004). The relation between parental coping styles and parent-child interactions before and after treatment for children with ADHD and oppositional behavior. Journal of Clinical Child & Adolescent Psychology, 33, 158-168. doi:10.1207/S15374424JCCP3301_15

17.

Modesto-Lowe

Danforth

J. S.

Brooks

(2008). ADHD: Does parental style matter? Clinical Pediatrics, 47, 865-872. doi:10.1177/0009922808319963

18.

Narita

Takei

Suda

Aoyama

Uehara

Kosaka

. . . Mikuni

(2010). Relationship of parental bonding styles with gray matter volume of dorsolateral prefrontal cortex in young adults. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 34, 624-631. doi:10.1016/j.pnpbp.2010.02.025

19.

Narita

Sato

Hirano

Gout

Sakado

Uehara

(2000). Parental child-rearing behavior as measured by the Parental Bonding Instrument in a Japanese population: Factor structure and relationship to a lifetime history of depression. Journal of Affective Disorders, 57, 229-234. doi:10.1016/S0165-0327(99)00071-3

20.

Olson

D. H.

Gorall

D. M.

(2003). Circumplex model of marital and family systems. In Walsh

(Ed.), Normal family processes: Growing diversity and complexity (pp. 514-548). New York, NY: Guilford Press.

21.

Olson

D. H.

Portner

Bell

R. Q.

(1982). FACES II. St. Paul: University of Minnesota.

22.

Olson

D. H.

Russell

C. S.

Sprenkle

D. H.

(1983). Circumplex model of marital and family systems: VI. Theoretical update. Family Process, 22, 69-83.

23.

Parker

(1983). Parental overprotection: A risk factor in psychosocial development. New York, NY: Grune & Stratton.

24.

Parker

(1990). The Parental Bonding Instrument. A decade of research. Social Psychiatry & Psychiatric Epidemiology, 25, 281-282.

25.

Parker

Tupling

Brown

L. B.

(1979). A Parental Bonding Instrument. British Journal of Medical Psychology, 52, 1-10.

26.

Raya

A. F.

Herreruzo

Pino

M. J.

(2008). El estilo de crianza parental y su relación con la hiperactividad [Parenting style and its relationship with hyperactivity]. Psicothema, 20, 691-696.

27.

Sánchez-Queija

Oliva

(2003). Vínculos de apego con los padres y relaciones con los iguales durante la adolescencia [Parental bond and peer relationships during adolescence]. Revista de Psicología Social, 18(1), 71-86. Retrieved from http://personal.us.es/oliva/vinculos.pdf

28.

Schei

Jozefiak

Stene Novik

Lydersen

Indredavik

M. S.

(2016). The impact of coexisting emotional and conduct problems on family functioning and quality of life among adolescents with ADHD. Journal of Attention Disorders, 20, 424-433.

29.

Vilaregut

(2003). Family addictions: Family dynamics, parental bonding and marital relationships in families with a young adult member with addiction (Doctoral thesis, Universitat Ramon Llull, Barcelona). Retrieved from http://www.tdx.cat/bitstream/handle/10803/52307/Tesis%20Anna%20Vilaregut.pdf?Sequence=1

30.

Weiss

Hechtman

(1993). Hyperactive children grown up (2nd ed.). New York, NY: Guilford Press.

31.

Wilcox

H. C.

Grados

Samuels

Riddle

M. A.

Bienvenu

O. J.

III Pinto

. . . Nestadt

(2008). The association between parental bonding and obsessive compulsive disorder in offspring at high familial risk. Journal of Affective Disorders, 111, 31-39. doi:10.1016/j.jad.2008.01.025

32.

Willinger

Heiden

A. M.

Meszaros

Formann

A. K.

Aschauer

H. N.

(2002). Maternal bonding behaviour in schizophrenia and schizoaffective disorder, considering premorbid personality traits. Australian & New Zealand Journal of Psychiatry, 36, 663-668.