Family and Maternal Characteristics of Children With Co-Occurring ADHD and Depression

Abstract

Objective: This study examined differences between children with ADHD and comorbid depression (n = 26), ADHD only (n = 111), and a community control group (n = 130) on measures of family and maternal characteristics. Method: The present study utilized a large, community sample. Diagnoses required positive endorsements from multiple sources. ANOVAs and chi-square tests were conducted to determine group differences. Results: Compared with children with ADHD alone and community controls, mothers of depressed ADHD children reported decreased family cohesion, limited participation in social/recreational activities, increased maternal depressive symptoms, difficulty coping with parenting roles, and higher rates of bipolar and anxiety disorders. Mothers of children with ADHD (with or without comorbid depression) reported increased conflict, decreased cohesion, and poor maternal coping compared with community controls. Conclusion: Findings are consistent with prior literature suggesting that families of children with ADHD and depression demonstrate both similar and unique characteristics. Clinical implications are discussed.

Keywords

ADHD depression family parent psychopathology

Individuals with a diagnosis of ADHD have remarkable continuity in their clinical presentation (Reinke & Ostrander, 2008) along with higher rates of comorbid externalizing, internalizing, and learning problems compared with individuals without ADHD (Biederman, Faraone, Mick, & Lelon, 1995; Hoza, Pelham, Waschbusch, Kipp, & Owens, 2001; P. S. Jensen et al., 2001; Milberger, Biederman, Faraone, Murphy, & Tsuang, 1995). Studies involving clinical and epidemiological samples indicate that 12% to 50% of youth with ADHD also meet concurrent diagnostic criteria for affective disorders (Biederman, Mick, & Faraone, 1998; Biederman, Newcorn, & Sprich, 1991; Daviss, 2008; Elia, Ambrosini, & Berrettini, 2008; J. B. Jensen, Burke, & Garfinkel, 1988; Milberger et al., 1995). Specifically, the median rate of major depressive disorder (MDD) for youth with ADHD is 5.5 times higher (95% confidence interval [CI] = [3.5, 8.4]) than in the general population (Angold, Costello, & Erkanli, 1999). Studies using clinic-referred and community-derived samples, various iterations of the Diagnostic and Statistical Manual of Mental Disorders (DSM), and designs utilizing longitudinal and cross-sectional methods have consistently demonstrated a strong association between ADHD and depressive symptoms (Biederman et al., 1998; Lavigne, LeBailly, Hopkins, Gouze, & Binns, 2009; Ostrander & Herman, 2006; Power, Costigan, Eiraldi, & Leff, 2004).

Youth with comorbid ADHD and depression are at risk for increased negative outcomes and worsened long-term prognosis compared with youth with either disorder alone. When compared with youth with depression alone, those with comorbid ADHD and depression experience depressive episodes with earlier onsets, longer durations, and greater recurrence (Biederman et al., 2008; Rohde, Clarke, Lewinsohn, Seeley, & Kaufman, 2001). Youth with ADHD are more likely to engage in self-injurious behavior and suicide attempts than non-disordered peers (Hinshaw et al., 2012). When ADHD occurs with comorbid MDD, youth have higher rates of hospitalization (Biederman et al., 2008), higher overall health care costs (Fishman, Stang, & Hogue, 2007), more frequent adverse life events associated with their behavior (Daviss & Diler, 2012), and higher rates of suicide completion (James, Lai, & Dahl, 2004).

Available research on the family characteristics that typify depression or ADHD has primarily focused on these respective disorders in isolation but has not explored comorbid presentations. These independent lines of research generally support a bidirectional relationship between the functional impairment associated with ADHD or depression and related family or parenting characteristics (Harpin, 2005; Stark, Banneyer, Wang, & Arora, 2012). Indeed, research concerning the parental and family characteristics associated with children that exhibit high levels of depression or ADHD have yielded remarkably similar findings across studies that have focused on either of these disorders. For example, children with ADHD are more disruptive and less compliant than non-ADHD children (Barkley, 2015); as a result, they require greater parenting resources, more often resulting in increased parenting stress and decreased sense of parent self-efficacy (Cunningham & Boyle, 2002; Johnston & Mash, 2001; Shelton et al., 1998). Similarly, depressed young people are often oppositional and the temperamental or personal qualities of depressed children often evoke negative reactions from parents and other family members (Stark et al., 2012). In conjunction, depressed children tend to have unusually high levels of parental psychopathology in combination with a negative view of their parenting role (Herman, Ostrander, Walkup, Silva, & March, 2007; Stark et al., 2012).

The family characteristics of children with ADHD or depression have also been uniformly characterized by problematic, coercive parent–child interactions, ineffective parenting practices, and increased parental psychopathology (Barkley, Fischer, Edelbrock, & Smallish, 1991; Deault, 2010; Harpin, 2005; Johnston & Mash, 2001; Ostrander & Herman, 2006). At the same time, both disorders have also been associated with a family environment that is unusually insular, conflictual, and unsupportive (Barkley, Anastopoulos, Guevremont, & Fletcher, 1992; Foley, 2011; Johnston & Mash, 2001; Mulligan et al., 2013; Nomura, Wickramaratne, Warner, Mufson, & Weissman, 2002; Stark, Humphrey, Crook, & Lewis, 1990). Given the similar depictions that have been offered for the parental and family characteristics associated with both childhood depression and ADHD, it is unclear whether there are any family or parental characteristics that have a particular association with the overlap between ADHD and depression.

Emerging literature on comorbid ADHD and depression has focused on identifying etiology, developmental course, psychosocial outcomes, and treatment implications. Few studies have directly examined the psychosocial and environmental characteristics of families of children with both ADHD and depression. Notably, Biederman and colleagues (2008) found that maternal depression is a significant predictor of depression in youth with ADHD. Studies have also found that parent–child relationship problems and self-reported parenting skills mediate the relationship between ADHD and depression symptoms (Humphreys et al., 2013; Ostrander & Herman, 2006). Extending research on the family characteristics of youth with comorbid ADHD and depression will serve to clarify whether this specific comorbidity is associated with salient family characteristics, which not only distinguishes children with ADHD from non-pathological peers but will also discriminate between depressed and non-depressed children with ADHD (P. S. Jensen, 2003; P. S. Jensen, Martin, & Cantwell, 1997). In addition to strengthening our understanding of this comorbidity, identifying the distinct family attributes of depressed ADHD children will assist with clarifying critical leverage points for intervention with this population.

The present study sought to examine the family context of depressed and non-depressed ADHD groups as compared with a non-ADHD community control group. While we expected ADHD groups to have some similar characteristics, the existence of a distinct subtype of ADHD characterized by comorbid depression symptoms would likely include a distinct pattern of parental characteristics and family environment correlates. Thus, we hypothesized that depressed and non-depressed ADHD groups would be distinct from non-ADHD community controls with respect to specific parent characteristics and family environment. Specifically, we examined group differences based on maternal psychopathology and maternal perceptions of their personal attributes (i.e., coping, ability to control child behavior, and marital satisfaction), the parent–child relationship, and overall family context.

Method

Participants

Data were drawn from a longitudinal study of children who were identified during elementary school. The present study builds upon prior research using this large, community sample to examine family and individual characteristics of youth with ADHD and internalizing problems (e.g., Blackman, Ostrander, & Herman, 2005; George, Herman, & Ostrander, 2006; Kepley & Ostrander, 2007; Ostrander & Herman, 2006). A community population of 7,231 comprised of children in Grades 1 to 4, attending 22 schools was screened using a sequential, two-stage assessment strategy (see August, Realmuto, Crosby, & MacDonald, 1995, for a detailed description). The initial screening process required elevated teacher and parent ratings (i.e., 1.75 SD units above the mean) on the 10-item Hyperactivity Index (HI) of the Revised Conners’ Rating Scales (CRS-R; Goyette, Conners, & Ulrich, 1978). Of the total school population, 309 (4.3%) children were identified. Children selected through this screening process exhibited broad adaptive impairment and high levels of disruptive, emotional, and problematic behaviors (August et al., 1995). Because of the limited involvement of fathers in this study, we relied exclusively on maternal reports of family and parental factors. In addition to a cross-sectional evaluation of family and parental characteristics, an assessment of parental psychopathology was conducted as part of a 4-year follow-up appraisal.

Selection criteria for ADHD children

ADHD was diagnosed using the Diagnostic Interview for Children and Adolescents–Revised–Parent Version (DICA-R-P; Reich, Shayla, & Taibelson, 1992; Reich & Welner, 1990); however, the ADHD screening process used in the current study conformed to Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association [APA], 2000) criteria by using an algorithm that was developed to meet age of onset criteria and symptom counts pertaining to inattention and hyperactivity listed in DSM-IV-TR. The analog diagnostic approach used in the current study is described elsewhere in detail and has demonstrated good discriminant and convergent validity (Crystal, Ostrander, Chen, & August, 2001; Ostrander, Weinfurt, Yarnold, & August, 1998). An independent rater, who reviewed 20% of the diagnostic interviews, was used to generate interrater reliability. High interrater reliabilities were derived for the analog subtypes of ADHD (i.e., kappa of .96 for the inattentive and hyperactive-impulsive subtypes and 1.00 for the combined subtype). The resulting sample (n = 248) consisted of 50% ADHD-inattentive subtype (n = 123), 43% ADHD-combined subtype (n = 109), and 6% ADHD-hyperactive/impulsive subtype (n = 16).

Selection criteria for depression

A multi-method (i.e., structured interviews, rating scales), multi-informant (i.e., parent, child) assessment approach was used to identify depressed and non-depressed ADHD children. To meet criteria for depression in the current study, both diagnostic interviews with parents and child responses on the Children’s Depression Inventory (CDI; Kovacs, 1992) were considered. The examiner read CDI items to young children or children who could not fluently read assessment items. The depressed ADHD group met the following criteria: (a) they obtained a raw score of 12 or higher on the CDI, and (b) met DSM-IV-TR (APA, 2000) criteria for dysthymic disorder, MDD, or major depression in partial remission. A CDI cutoff score of 12 provides the greatest accuracy in identifying depressed children within high-risk populations (Kazdin, Colbus, & Rodgers, 1986). Approximately 33% (n = 81) of the ADHD children met CDI criteria alone and nearly 12% (n = 30) of the ADHD children met DICA-R-P criteria alone. The final depressed ADHD group for the present study consisted of 26 ADHD children (almost 10%) who met the joint CDI and DICA-R-P criteria. Children with ADHD who did not meet any depression criteria (i.e., CDI or DICA-R-P) were identified as the non-depressed ADHD group (45%; n = 111). This method of identifying depression among children with ADHD has demonstrated very good discriminant and convergent validity (Blackman et al., 2005).

Selection criteria for the non-ADHD community comparison group

Non-ADHD students were selected if they (a) scored less than 1.1 (1 SD above the mean) on the teacher version of the HI, (b) had no history of psychotropic medication use, and (c) had no prior clinical assessment for behavioral problems. Of the eligible students screening negative based on these criteria, 10% were randomly selected from the school population. A stratified random sampling procedure was then used to provide a final sample of children that proportionally matched participants based on school, grade, and gender (August et al., 1995). The final sample consisted of 130 children and parents who agreed to participate in the study and completed assessment measures. Diagnostic interviews were not conducted with parents of comparison students. However, examination of mean scores on the parent and teacher screening measure (i.e., HI) reflected ratings at floor levels, making it unlikely that children would qualify for a diagnosis of ADHD. The comparison group also displayed low mean scores on the CDI (M = 5.02, SD = 4.2).

Dependent Measures

Behavioral Assessment System for Children–Parent Personality Profile (BASC-PPP)

The BASC-PPP (Reynolds & Kamphaus, 1992) is a 95-item parent measure that assesses parents’ personal attributes and perceptions of the parent–child relationship. The BASC-PPP is an unpublished measure that was created and standardized as a complementary questionnaire to the child-focused BASC Scales (Reynolds & Kamphaus, 1992). Subscales for the BASC-PPP include Coping (ability to cope with parenting responsibilities), Communication/Involvement (communication and closeness between parent and child), Depression (parental depressive symptoms), Marital Satisfaction (satisfaction with their marital relationship), and Parental Control (perceived ability to control their child’s behavior). In the current study, the parents of elementary-aged children obtained alpha reliability coefficients ranging from .80 to .88 for the five subscales. Discriminative validity for the subscales has also been found (Bloomquist, August, Brombach, Anderson, & Skare, 1996).

Family Environment Scale (FES)

The FES is one of the most researched measures of family functioning and the reliability and validity of the measure has been reported across a number of studies (Moos & Moos, 2002). The FES (Moos & Moos, 1981, 2002) consists of 10 subscales that assess the social-environmental characteristics of families. Subscales include Cohesion, Conflict, Expressiveness, Independence, Achievement Orientation, Intellectual-Cultural Orientation, Active-Recreational Orientation, Moral-Religious Emphasis, Organization, and Control. The authors report internal consistencies ranging from .61 to .78 for the 10 subscales (Moos & Moos, 1981, 2002).

Structured Clinical Interview for DSM-IV (SCID-I)

The SCID-I (First, Spitzer, Gibbon, & Williams, 1996) is a structured diagnostic interview to assess current and lifetime parental psychopathology. Due to budget limitations in the original study, the SCID-I could not be administered to all families. As a result, 101 of the ADHD and comparison group children and parents were randomly selected to complete this portion of the 4-year follow-up assessment. Diagnostic categories were collapsed into the following classifications: bipolar, depressed, anxious, and substance use disorders (see “Results”). All examiners administering the SCID-I were required to reach a reliability of .90 with a certified trainer prior to beginning interviews with parents.

ADHD checklist for adults

This self-report measure (Murphy & Barkley, 1995) assesses for both current and lifetime ADHD symptoms. It was administered at the same time as the SCID-I interview and to the same randomly selected subset of families as part of the 4-year follow-up assessment. Prior independent research has established adequate reliability and validity (DuPaul et al., 1998).

Results

Table 1 summarizes the means, standard deviations, and number of participants in each group for all subscales of the FES. The results of the data analyses are also reported in Table 1. Univariate ANOVAs indicated significant findings on 6 of the 10 subscales. To determine which groups were significantly different from each other, follow-up paired comparisons using the Bonferroni test were conducted. The respective groups displayed similar characteristics with respect to their level of family member independence, achievement and intellectual-cultural orientation, and amount of control present in family life. As predicted, in comparison with non-ADHD community controls, both of the ADHD groups were consistent in displaying more family conflict and less cohesion. Furthermore, families of depressed ADHD children demonstrated significantly lower cohesion when compared with both community controls and the non-depressed ADHD (i.e., ADHD only) children. The level of emotional expression displayed by community and non-depressed ADHD families were similar; likewise, the emotional expression displayed by depressed ADHD families was similar to non-depressed ADHD families. However, depressed ADHD families reported significantly less emotional expression when compared with the community control group. The families of depressed ADHD children displayed the lowest active-recreational orientation; in contrast, the level of recreational orientation reported by the non-depressed ADHD and community sample families were very comparable.

Table 1.

Means and Standard Deviations for the FES and BASC-PPP Among Controls and ADHD Children With and Without a Depressive Disorder.

Scale	Controls			ADHD only			ADHD and depression			F	η²
Scale	n	M	SD	n	M	SD	n	M	SD	F	η²
Family Environment Scale	87			53			17
Cohesion		61.08^a	7.89		52.62^b	14.74		41.76^c	19.37	21.39***	0.22
Expressiveness		57.16^a	9.22		53.09^a,b	11.31		48.88^b	11.01	5.97***	0.07
Conflict		46.33^a	10.71		54.28^b	9.74		57.00^b	11.09	13.64***	0.15
Independence		47.13^a	11.35		47.87^a	9.87		43.88^a	16.29	0.78	0.01
Achievement		47.18^a	9.78		46.91^a	10.34		46.71^a	13.43	0.02	0.00
Intellectual-Cultural		56.13^a	11.40		52.81^a	11.56		50.24^a	13.94	2.49	0.03
Active-Recreational		57.20^a	8.21		55.32^a	11.07		43.29^b	11.01	15.04***	0.16
Moral-Religious		59.80^a	9.54		56.17^a	9.77		54.94^a	12.13	3.15*	0.04
Organization		56.34^a	11.48		51.81^a	11.01		50.06^a	13.40	3.73*	0.05
Control		54.92^a	8.43		55.94^a	8.34		58.94^a	9.18	1.63	0.02
BASC-PPP	87			48			17
Communication/Involvement		53.36^a	7.02		50.76^a,b	7.76		45.84^b	13.30	6.52**	0.08
Parental Coping		51.00^a	5.00		41.11^b	10.89		33.06^c	15.63	39.53***	0.35
Depression		44.39^a	5.53		47.28^a	6.65		53.70^b	12.71	13.22***	0.15
Marital Satisfaction		49.66^a	10.65		44.83^a	14.23		42.09^a	16.38	3.92*	0.05
Parental Control		55.84^a	4.85		53.93^a,b	5.99		51.30^b	7.94	5.32**	0.07

Note. Different superscripts indicate significantly (p < .05) different means. FES = Family Environment Scale; BASC-PPP = Behavioral Assessment System for Children–Parent Personality Profile.

p < .05. **p < .01. ***p < .001.

As demonstrated in Table 1, mothers of non-depressed ADHD children and community controls reported similar parental characteristics across most domains assessed by the BASC-PPP; however, mothers of the non-depressed ADHD group felt less capable of coping with their parental role than mothers in the control group. In contrast, when compared with community controls, the mothers of depressed ADHD children reported more parental depressive symptoms, decreased perceived capability of coping with their parental role, decreased control or influence on their child’s behavior, and a decreased sense of communication and closeness with their children. The diminished coping capabilities and increased depression demonstrated by mothers of depressed ADHD children were also significantly higher than their non-depressed ADHD counterparts.

Maternal self-reports (SCID) were obtained to examine the prevalence rates of maternal psychopathology across the three diagnostic groups (i.e., community controls, non-depressed ADHD, and depressed ADHD). Diagnostic data were first combined by diagnostic category. Bipolar I, Bipolar II, Bipolar not otherwise specified (NOS), and Cyclothymia diagnoses were collapsed into a single Bipolar category. MDD, Dysthymia, MDD NOS, MDD due to General Medical Condition, and Substance Induced MDD were similarly collapsed. Anxiety disorders, with the exception of Obsessive-Compulsive Disorder, were collapsed; likewise, all substance abuse and dependence disorders were collapsed into a single category. ADHD diagnoses were analyzed from the ADHD checklist.

Table 2 summarizes the diagnostic counts in each of the specified categories by group. A series of chi-square analyses were performed on each of the diagnostic categories. Maternal psychopathology was not significant for depressive disorders, χ²(2, N = 105) = 0.33, p = .85, or substance use disorders, χ²(2, N = 105) = 3.52, p = .17. An overall chi-square for bipolar disorders was significant, χ²(2, N = 105) = 7.69, p < .05. Follow-up chi-square analyses indicated that mothers of depressed ADHD children displayed higher rates of bipolar disorders compared with mothers of community controls, χ²(1, N = 59) = 7.20, p < .01. There was also a trend toward higher rates of bipolar disorders for mothers of depressed ADHD children compared with mothers of non-depressed ADHD children, χ²(1, N = 64) = 2.73, p = .09. There was no difference in rates of bipolar disorders between mothers of non-depressed ADHD children and controls, χ²(1, N = 64) = 1.82, p = .18. An overall chi-square for maternal anxiety was also significant, χ²(2, N = 103) = 11.30, p < .01. Follow-up chi-squares indicated that mothers of depressed ADHD children had higher rates of maternal anxiety when compared with both non-depressed ADHD children, χ²(1, N = 62) = 5.79, p < .05, and community controls, χ²(1, N = 58) = 11.14, p < .001. The non-depressed ADHD and community control groups were not different from each other in terms of maternal anxiety diagnoses, χ²(1, N = 62) = 1.52, p = .21. Finally, the overall chi-square for maternal ADHD reflected a notable trend, χ²(2, N = 125) = 5.76, p = .06, such that non-depressed ADHD children had higher rates of ADHD compared with community controls, χ²(1, N = 108) = 5.80, p < .05. There were no differences in rates of maternal ADHD between the depressed ADHD group and the non-depressed ADHD group, χ²(1, N = 63) = .52, p = .47, or community controls, χ²(1, N = 79) = 1.08, p = .30.

Table 2.

Mother SCID and ADHD Diagnosis Counts by Comparison Group.

Diagnostic category	Group	Endorsement	Non-endorsement
Bipolar	Controls^a	0	41
	ADHD only^a,b	2	44
	ADHD and Depression^b	3	15
Depression	Controls^a	12	30
	ADHD only^a	13	33
	ADHD and Depression^a	6	11
Anxiety	Controls^a	8	33
	ADHD only^a	14	31
	ADHD and Depression^b	11	6
Substances	Controls^a	10	32
	ADHD only^a	18	27
	ADHD and Depression^a	8	10
ADHD	Controls^a	3	59
	ADHD only^b	9	37
	ADHD and Depression^a,b	2	15

Note. Different superscripts indicate significant (p < .05) differences between group diagnosis counts. SCID = Structured Clinical Interview for DSM-IV.

Discussion

Given the limited research on familial factors and parent characteristics linked to the co-occurrence of childhood ADHD and depressive disorders, the current study sought to provide preliminary comparisons between the families of depressed and non-depressed ADHD children and community controls. In many regard, the family characteristics of both non-depressed and depressed ADHD children were indistinguishable from the families of children that were sampled from the community. For example, the mothers from the respective ADHD groups displayed a level of marital satisfaction that was similar to community standards. The respective ADHD families also displayed a level of independence, control, and organizational features that were similar to that found in the community sample. Likewise, the respective groups displayed a comparable family orientation toward achievement and were relatively uniform in their moral/religious pursuits.

The families of depressed ADHD participants were distinguished from the community sample by higher levels of family conflict and lower levels of expressed emotion. Compared with the community sample, the parents of children with co-occurring ADHD and depression were also less likely to control their child’s behavior and/or communicate and be involved with their child. While these parental and family characteristics set the depressed ADHD group apart from the community sample, these features did not differentiate depressed ADHD from ADHD only.

Other characteristics of the family and maternal functioning were particularly salient in children who received a dual diagnosis of ADHD and depression. In particular, the presence of ADHD and comorbid depressive disorder were related to maternal reports of having particular difficulty in coping with their role as a parent; moreover, co-occurring depression and ADHD was also associated with lower levels of family cohesion and lower participation in social and recreational activities than were evident in either the non-depressed ADHD or the community groups. These results support the notion that decreased family cohesion, less involvement in social/recreational activities, ineffective parent coping skills, and negative maternal cognitions were distinguishing family characteristics associated with childhood depression (Garber & Flynn, 2001; Stark et al., 2012; Stark et al., 1990). Notably, the families of non-depressed children with ADHD also displayed some aspects of family functioning (e.g., poor cohesion and parental coping) that were more compromised than the community sample, though less extreme than the depressed ADHD group. Therefore, when depression and ADHD coexist, other considerations may have exacerbated the baseline level of family and parental dysfunction that is more generally found in children with ADHD.

While ADHD may relate to difficulties with family and parental functioning, the high rates of depression in children with ADHD is also likely associated with parental psychopathology. The current study found support for the contention that mothers of depressed ADHD children acknowledged comparatively more depressive symptoms than mothers representing the other groups, yet higher levels of depressive symptoms did not translate into an unusually high likelihood of receiving a depression diagnosis. However, the mothers of depressed ADHD children clearly reported more symptoms of internalizing distress than did the mothers representing the ADHD or community comparison groups. In particular, the rate of anxiety disorders was unusually high in the depressed ADHD group. Moreover, the depressed ADHD group reported a rate of maternal bipolar disorder that was significantly higher than was found in the community and marginally higher than was evident in the non-depressed ADHD group. These findings dovetail with studies that have documented a link between depression and anxiety symptoms in the parents of depressed ADHD children (Harris, Boots, Talbot, & Vance, 2006). Similarly, the link between parental bipolar disorder and depression in children with ADHD is consistent with recent findings that ADHD in offspring of parents with bipolar disorder carries a higher lifetime prevalence of a broad range of Axis I psychiatric disorders, including mood disorders (Kim et al., 2015).

Taken together, the findings from the current study would suggest that the families of all children with ADHD have more conflict than non-ADHD families; however, depressed ADHD children have a family environment that is particularly unsupportive, with low levels of expressed emotion and limited access to recreational outlets that could provide a countervailing positive influence. In a similar vein, the mothers of depressed ADHD children have extreme difficulty in managing their child’s behavior or coping with their role as a parent. High levels of maternal psychopathology overlay these family and parenting characteristics, with evidence of maternal dysphoria along with a psychiatric presentation involving anxiety and/or bipolar disorders representing the most salient areas of impaired maternal functioning associated with the co-occurrence of ADHD and depression.

There are a number of substantive explanations for the co-occurrence of psychopathology in children diagnosed with ADHD. For example, both twin and family studies have suggested that ADHD and depression share genetic linkages. However, the genetic liability found in twin studies may include gene–environment correlation effects (environmental risk resulting from genetic risk). Consistent with this notion, recent twin studies would suggest that there are significant environmental pathways between ADHD and depressive symptoms (Cole, Ball, Martin, Scourfield, & Mcguffin, 2009); moreover, altered parent–child interactions as a consequence of ADHD have been shown to be a plausible environmental link with depression (Ostrander & Herman, 2006). However, the interplay between genetic and environmental factors may be more complex than are represented by such models. For example, the current study found that children with ADHD were uniformly associated with lower levels of family cohesion and their mothers typically had difficulty coping with their parenting role. These characteristics were particularly evident when there was comorbid depression. These findings would suggest that children with ADHD may evoke stereotypical reactions from family members that in turn add incrementally to other sources of risk and collectively trigger a downturn in mood (Humphreys et al., 2013; Ostrander & Herman, 2006).

While the present descriptive study aimed to identify the distinguishing familial and maternal characteristics of children with comorbid ADHD and depression, a discussion of clinical implications requires acknowledgment of the transactional influences of parent and child attributes and behaviors over the course of development. That is, family and parental characteristics (e.g., high levels of conflict, diminished capacity to manage challenging behaviors) are inevitably impacted by children’s symptom severity and complicating factors like comorbidity. Likewise, child symptoms are highly influenced by parents’ personal attributes, behavior management practices, and level of psychopathology. These family or parenting risk factors may mediate and/or moderate the risk associated with ADHD and collectively increase risk for depression. This transactional relationship creates multiple potential leverage points for evidence-based child, parent, and/or family systems interventions that could result in improved outcomes for children with co-occurring ADHD and depression. For instance, studies on one evidence-based intervention, The Incredible Years Parent Training Program, have demonstrated improvements in both child behavior problems and parent-reported depression symptoms (Herman, Borden, Reinke, & Webster-Stratton, 2011; Webster-Stratton & Herman, 2008; Webster-Stratton & Reid, 2003). In addition, many of the distinguishing family characteristics of children with comorbid ADHD and depression are targeted by interventions like The Incredible Years through development of effective behavior management strategies and nurturing/supportive parent–child relationships. It will be important for future studies to expand our understanding of the unique characteristics of children with co-occurring ADHD and depression and the transactional relationships between these children and their families to better inform intervention targets that will result in dynamic improvements within the child and family system.

There were several limitations to this study. First, generalizability of the findings is limited by the community-based, predominantly Caucasian, and middle-class sample as well as mother-only reports. As such, it is unclear how findings may apply to fathers or more diverse, clinical samples. Second, although it is well established that the relation between child psychopathology and family characteristics is bidirectional (Elgar et al., 2004), the present study is restricted by its focus on describing family attributes and is not intended to examine or imply causal relationships. Third, the current study was cross-sectional; therefore, longitudinal studies are clearly needed to better determine the casual relationships between the respective family and maternal factors and their role in explaining the relationship between ADHD and depression. Likewise, it would be worthwhile to explore whether the salience between ADHD, depression, and family/parenting considerations is moderated with the unfolding of development over time. Fourth, the present study did not include a depression-only group; thus, our conclusions in that regard are limited. Finally, the multiple gating method we used to diagnose ADHD and depression favored diagnostic specificity over sensitivity. This process restricted our sample pool, which in turn, placed power restrictions on the analytic approach. Nevertheless, our use of multi-method, multi-informant data yielded rigorously and conservatively defined groupings; in turn, this more restrictive diagnostic approach allowed for greater confidence in identifying the family and parent characteristics that are distinguishing characteristics of children with ADHD (with and without comorbid depression).

Literature on the co-occurrence of ADHD and depression has seldom explored the critical role of familial context and parent characteristics. Notable exceptions have highlighted the mediating roles of dysfunctional parent–child relationships and parent behavior management strategies on the relation between ADHD and depressive symptoms (Humphreys et al., 2013; Ostrander & Herman, 2006). The present study builds upon prior literature by providing a preliminary description of the family and maternal attributes associated with children diagnosed with co-occurring ADHD and depressive disorders, and thus, may serve to enhance existing treatments by clarifying critical intervention targets for this population.

Footnotes

Declaration of Conflicting Interests

The author(s) 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

Lindsay A. Borden, PhD, is currently a staff psychologist in the Division of Child and Adolescent Psychiatry at Johns Hopkins Hospital. Her research focuses on the identification and treatment of mental health problems in children with chronic illness.

Jessica Hankinson, PhD, is a pediatric psychologist and an assistant professor of psychiatry and behavioral sciences within the Division of Child and Adolescent Psychiatry at the Johns Hopkins School of Medicine. Her research examines psychosocial functioning and treatment outcomes in children with chronic health conditions.

Carisa Perry-Parrish, PhD, is an assistant professor of psychiatry and behavioral sciences and the director of the Pediatric Psychology Fellowship within the Division of Child and Adolescent Psychiatry at the Johns Hopkins School of Medicine. Her research examines parental socialization of children’s emotion regulation and family coping with medical stress.

Elizabeth K. Reynolds, PhD, is currently an assistant professor of psychiatry and behavioral sciences, Division of Child and Adolescent Psychiatry at the Johns Hopkins University School of Medicine. Broadly, her research and clinical interests focus on the development and maintenance of health risk behavior among children and adolescents.

Matthew W. Specht, PhD, is an assistant professor of psychiatry and behavioral sciences and the director of the Pediatric OCD and Tourette’s Specialty Clinic (POTSC) within the Division of Child and Adolescent Psychiatry at the Johns Hopkins School of Medicine. His research examines the efficacy of non-pharmacological treatments and the means through which behavioral treatment reduce symptoms.

Rick Ostrander, EdD, is currently an associate professor of psychiatry and behavioral sciences and the director of Pediatric Medical Psychology, Division of Child and Adolescent Psychiatry at the Johns Hopkins University School of Medicine. His research interests have included examining the clinical characteristics associated with ADHD and the specific causal mechanisms leading to comorbid disorders.

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