Parental Emotion Regulation and Mentalization in Families of Children With ADHD

Abstract

Objective: The aim of this study is to examine the role of parental emotion regulation (ER) and parental mentalization as possible contributors to hostile and coercive parenting in families of children with ADHD. Method: Seventy-four Israeli families (64 mothers and 48 fathers) seeking parent training for child ADHD completed measures during the intake session. Measures included parental ER; parental mentalization; hostile, coercive, and submissive parenting; and child symptoms. Results: Findings suggested a relationship between parental ER and coercive parenting independent of child age, symptom level, and parental mentalization. Parental mentalization appeared to buffer against hostility specifically among parents with low ER capacities. Patterns were parallel for mothers and fathers. Conclusion: Study findings highlight the importance of evaluating and addressing parental ER in interventions attempting to reduce coercive parenting. The findings also highlight the potential role of parental mentalization as a protective mechanism against hostile parenting in families of children with ADHD.

Keywords

ADHD parental mentalization parental emotion regulation coercive parenting protective mechanisms

ADHD is one of the most prevalent neurodevelopmental disorders (Rowland et al., 2013) and a common cause for referral for psychological and psychiatric services. Children with ADHD are at elevated risk for developing comorbid disorders, academic difficulties, and substance abuse, as well as for suffering accidents (M. Shaw et al., 2012). Although inattention and hyperactivity/impulsivity are core symptoms characterizing the disorder (Diagnostic and Statistical Manual of Mental Disorders [5th ed.; DSM-5]; American Psychiatric Association, 2013), longitudinal studies have shown that family processes, including parental hostility toward the child, are important shaping factors for the developmental course of ADHD (Burt, Krueger, McGue, & Iacono, 2003; Drabick, Gadow, & Sprafkin, 2006; Harold et al., 2013). Moreover, children’s posttreatment symptom improvement has been found to be mediated by changes in parenting quality, in particular improvements in parents’ negative and ineffective discipline methods (Hinshaw & Arnold, 2015).

Whereas the negative impact of harsh, inconsistent, and hostile parenting is well described in the literature, still little is known about the mechanisms underlying these parenting practices. In particular, though past research has identified parenting stress and parental psychopathology (including parental ADHD) as predictors of negative parenting (for review, see Johnston & Chronis-Tuscano, 2015; Johnston & Mash, 2001), these constructs explain only a small portion of the variability in parenting practices (Park, Hudec, & Johnston, 2017). Moreover, as difficult child temperament and early regulatory deficits have been found to contribute to parental stress level (Laugesen & Gronkjaer, 2015) and parental hostility (Feldman, 2015; Harold et al., 2013), there is a need to look for protective mechanism that may prevent the development of negative parent–child relationships. The current study therefore is aimed at improving the scientific understanding of cognitive and affective mechanisms underlying hostile, coercive, and submissive parenting behaviors in families of children with ADHD and behavior problems. In particular, it is interested in assessing the role of parental mentalization and parental emotion regulation (ER) as possible explanatory mechanisms.

Parenting and ADHD

Children with ADHD are described as a parenting challenge. The proclivity of children with ADHD for emotional and behavioral dysregulation (Melnick & Hinshaw, 2000; P. Shaw, Stringaris, Nigg, & Leibenluft, 2014; Wehmeier, Schacht, & Barkley, 2010) may explain the high level of emotional and behavioral support required from their parents (Laugesen & Gronkjaer, 2015). It may also explain the detrimental impact of hostile parenting on the exacerbation of ADHD symptoms and the development of behavioral symptoms in ADHD (Burt et al., 2003; Drabick et al., 2006). Angry and reactive parents may be less able to provide their children with adequate levels of emotional and behavioral scaffolding or support to regulate children’s arousal effectively (Bernier, Carlson, & Whipple, 2010; Feldman, 2015). In addition, parents’ unmodulated arousal may further exacerbate children’s arousal, and contribute to children’s lack of emotional organization and ongoing feelings of threat and distress (Thompson & Meyer, 2007). Nonetheless, attempting to regulate a chronically dysregulated child can be a challenging parenting task. Parents of children with ADHD describe living in a “roller coaster,” wherein they often experience stress, frustration, exhaustion, guilt, anger, and helplessness (Laugesen & Gronkjaer, 2015). The high level of emotional demand and daily stress experienced by parents of children with ADHD can challenge parents’ own regulatory capacity and contribute to the development of hostile parenting.

Patterson and MacCoby (1980) suggested that in a bidirectional process, children’s impulsive and oppositional tendencies can contribute to the creation of both parental demand withdrawal (when the parent “gives in” or submits to the child’s demands to avoid conflict) and aggressive reactions to the child. Patterson and MacCoby described this dynamic as leading to cycles of coercion and escalation in the parent–child relationship and contributing to the magnitude and severity of the disruptive symptoms, as both parental submission and aggressive behavior reinforce the child’s negative behaviors.

In fact, based on Patterson and MacCoby’s model, studies on parenting and ADHD have identified two parenting practices that are typical of parents of children with ADHD (Molina & Musich, 2016; Park et al., 2017): coercive behaviors, characterized by commands, threats, and attempts to impose the parents’ will on the child, and lax or submissive parenting behaviors, described as behaviors that refrain from making demands or from exerting any control over the child’s behaviors. Within the frame of the escalation cycle, parents not only refrain from making demands but also give in to the child’s coercive demands, often as a result as an attempt to “buy peace” or avoid conflicts (Omer, 2004). Recent studies also have provided support to the bidirectional path between genetic disposition to ADHD/early child impulsivity and parental emotional dysregulation (Harold et al., 2013; Lifford, Harold, & Thapar, 2008), suggesting that, with time, parents’ behavior becomes more congruent with their child’s temperamental disposition (Feldman, 2015).

From the transactional model perspective, coercive parenting or submissive parenting that withdraws making demands can be viewed as an outcome of years of a cycle of dyadic dysregulation, rather than a planned and controlled parental approach to the child’s behaviors. As such, and to find paths for effective interventions, it is important to identify protective parenting mechanisms. Protective parenting mechanisms might enable parents to manage their own arousal more effectively—to get off the emotional roller coaster—to respond to the child’s dysregulation in more containing and contingent ways. In the following sections, we will describe parental ER and parental mentalization as possible protective mechanisms for parents of children with ADHD.

Parental ER

In a review article on parental ER, Rutherford, Wallace, Laurent, and Mayes (2015) described that in the transition to parenting, parents’ capacity for ER plays a crucial role in their ability to respond sensitively to children’s distress. A review of the literature suggests that parents who can attend to their own emotions and regulate their own arousal in the face of a dysregulated child may be better able to respond in a soothing and containing ways to the child’s needs (Kim, Teti, & Cole, 2012; Leerkes et al., 2015). The important role of parental ER in child development has also been demonstrated in relation to parents’ disciplinary reactions. In a review article on intergenerational transmission of self-regulation, Bridgett, Burt, Edwards, and Deater-Deckard (2015) described that parental difficulties with ER, and in particular higher levels of impulsivity and lower capacity for effortful control, were linked to more negative disciplinary strategies and harsh responses to child conduct problems. Wang, Deater-Deckard, and Bell (2016) showed that maternal emotion dysregulation, as indicated by high negative affect and low resting respiratory sinus arrhythmia (RSA), moderated the relationship between maternal attribution of child problematic behaviors and maternal levels of hostility. Likewise, Deater-Deckard, Li, and Bell (2016) showed that maternal ER moderated the relationship between level of stressors and maternal negative affect during interactions with her child. Pinderhughes, Dodge, Bates, Pettit, and Zelli (2000) found that, while parental socioeconomic status (SES) and stress levels accounted for a major portion of parental reactions of harsh discipline, it was the parents’ capacity to use stress-regulation techniques as well as their beliefs about the child that moderated this relationship.

In relation to parents of children with ADHD, while much research has been dedicated to parental ADHD in relation to parenting (Park et al., 2017), few studies have focused on specific coping or self-regulatory mechanisms that contribute to parenting behaviors in these families. McKee, Harvey, Danforth, Ulaszek, and Friedman (2004) measured parental coping style (e.g., planning, seeking social support, positive reinterpretation, acceptance, and denial) in relation to lax and over-reactive parenting. Their results indicated that avoidant-focused coping strategies (e.g., denial, behavioral disengagement, and mental disengagement) were a significant predictor of maternal lax and over-reactive parenting and of father’s lax parenting. In another study of parental coping strategies, Podolski and Nigg (2001) showed that in a sample of children with ADHD, parental positive reframing was associated with lower levels of parent distress and lower levels of child misbehavior. Although coping style covers only part of the ER process (Gross & Thompson, 2007), these preliminary results in relation to parents of children with ADHD point to the possibility that the developmental path described above is relevant also to the ADHD population. Taken together, this body of research suggests that parental ER may serve as a buffer between the stress level imposed by parenting a dysregulated child and parental emotional and behavioral reactivity. Enhanced capacity for ER may enable parents to handle the highly demanding dual task of regulating their own negative arousal and responding to the child’s arousal contingently. In the case of children with ADHD, it is possible that parents with higher capacity for ER may be better at finding effective regulatory means to manage their own negative arousal, and therefore less prone to react impulsively or punitively to children and less susceptible to enter an escalation cycle.

Parental Mentalization

While parental ER enables parents to regulate negative arousal once it has occurred, alternative theories suggest that it is the meaning parents apply to children’s behaviors that determine the emotional/physiological level of arousal the parent experiences in reaction to them. In a classic study, Dix and Reinhold (1991) showed that maternal attributions about the causes and perceived level of responsibility for children’s disobedience impacted mothers’ affective and disciplinary reactions to children. Strassberg (1997) showed that mothers of aggressive children demonstrated different attributional patterns than mothers of nonaggressive children, attributing children’s misbehavior and unresponsiveness to noncompliance, defiance, and hostile intent and failing to distinguish between mild and acute situations. Subsequently, these mothers used coercive discipline more frequently. These findings are evident also in the ADHD literature. Mothers of children with ADHD have been found to make more negative attributions for children’s behaviors compared with mothers of non-ADHD children (Williamson & Johnston, 2015), and maternal negative attributions have been linked to negative parenting (Johnston et al., 2017).

Prior research has suggested that the type of attributions that parents apply to their children’s behaviors relates to parents’ capacity to think about the mental processes underlying children’s expressed emotions and behaviors. This capacity has been conceptualized in the developmental literature as parents’ level of mind-mindedness (MM) or capacity for mentalization (Sharp & Fonagy, 2008). Fonagy, Steele, Moran, Steele, and Higgitt (1991) defined mentalization as the individual’s capacity to envision mental states—thoughts, feelings, desires, beliefs, and intentions—in oneself and in others. Ordway, Sadler, Dixon, and Slade (2014) described parental mentalization (operationalized through the concept Reflective Functioning) as involving an understanding of the child’s emotions and behaviors within a developmental framework, a capacity to consider alternative explanations for the child’s behaviors, and an understanding that their child may experience things differently from them. Although the capacity for mentalization overlaps with concepts like empathy and attribution accuracy (e.g., it will be easier to empathize once you understand the reasons behind someone’s behaviors), it differs significantly from these constructs. The focus in mentalization is not on the product of the cognitive activity but instead on the capacity of the parent to carry on this activity—to think about the child as a mental agent, with thoughts, feelings, and motives that may be different than his (Sharp & Fonagy, 2008). It has been suggested that the capacity for mentalization can help parents remain curious and open-minded in relation to the child and improves parents’ ability to observe and contain the child’s emotional and physical needs (Fonagy & Target, 1997). Consequently, this reflective stance may lead to fewer negative attributions, may foster more empathic reactions, and may improve the parents’ ability to manage the child’s distress (Lok & McMahon, 2006; Rutherford, Goldberg, Luyten, Bridgett, & Mayes, 2013; Schechter et al., 2006).

Studying dyads of mothers and preschool-aged children, Lok and McMahon (2006) showed that maternal MM was related to lower hostility and better understanding of children’s behavior. Supporting this model, Schechter et al. (2006) found that intervention with a clinical sample of traumatized mothers focused on improving maternal capacity for mentalization resulted in a significant decrease in mothers’ negative attributions about the child. Relatedly, Koren-Karie, Oppenheim, and Goldsmith (2007) studied maternal insightfulness in a clinical intervention with parents of children with behavior problems, showing that improving mother’s insightfulness was associated with a decrease in behavior problems in the child. The study also indicated that lack of change in mother’s insightfulness was associated with an increase in behavior problems. Likewise, in a sample of children exposed to family and community violence, Gray, Forbes, Briggs-Gowan, and Carter (2015) showed that caregivers’ insightfulness level was related to lower behavior problems among children exposed to violence.

Within the potentially strained relationship between children with ADHD and their parents, it is possible that parental mentalization may serve as a buffer to automatic and negative attributions of children’s behaviors that contribute to angry, hostile, or submissive parenting reactions. As Schechter et al. (2006) suggested, mentalization may improve the parents’ understanding of the underlying reasons for the child’s behavior, reduce the parents’ experience of helplessness, and improve their capacity to attend to the child’s needs. It is therefore possible that parents of children with ADHD with higher capacities for mentalization may be better able to think about children’s behaviors through the lenses of their constitutional regulatory deficits, age, emotional state, and context. As a result, they may be less reactive emotionally to children’s behaviors and better able to regulate children’s arousal.

Parental ER and Parental Mentalization: Are They Related to Parental Hostility in Families of Children With ADHD?

While parental ER and mentalization have been established as significant contributors to parenting, enabling parents to remain attentive and responsive to the child’s distress, further work is needed to establish the role of parental ER and mentalization in families of school-aged children and in families of children with clinical problems. For children with ADHD who often struggle with emotion dysregulation and require higher level of parental emotional containment and support (P. Shaw et al., 2014), parental ER and mentalization may serve as important protective mechanisms. Parents with high capacity for ER may be better able to regulate their own physiological and emotional reactivity to children’s anger and may therefore respond more contingently and with less hostility and coercion. Parents with high capacity for mentalization may be better able to understand children’s behaviors in the context of their neurodevelopmental difficulties and therefore less susceptible to experience anger in response to their emotional outbursts or dysregulated behaviors. As a result, these parents may be better able to understand children’s regulatory needs and tailor their demands to children’s abilities rather than withdraw them altogether. Despite the importance of identifying parenting mechanisms that contribute to parental hostility, coercion, and submission, to date, no published study has measured the role of parental ER and parental mentalization in relation to parenting practices in a population of parents seeking services for children with ADHD. The current study assesses the role of parental ER and mentalization in relation to parental hostility, coercive behaviors, and submission/demand withdrawal in families arriving for parent training for children with ADHD.

In addition to their relationship to parenting processes, ER and mentalization are theorized to interact with one another. Fonagy, Gergely, and Jurist (2002) described the development of individuals’ capacity for mentalization as intertwined with the capacity for affect regulation. Both depend on the quality of early caregiving. When young children no longer depend on the caregiver for regulation, the capacity to regulate affect may rely to some extent on the capacity to notice and mark emotional experiences within oneself and others (mentalize emotional states). Likewise, the capacity for mentalization has been described as embedded within an interpersonal context, where higher levels of affective arousal can curtail the capacity to mentalize (Hughes, Aldercotte, & Foley, 2017; Rutherford, Booth, Luyten, Bridgett, & Mayes, 2015; Schechter et al., 2006). Thus, it may be the case that mentalization and ER interact with one another to predict interpersonal behaviors, including parenting. The theoretical model of the relationship between ER, mentalization, and parenting is presented in Figure 1.

Figure 1.

Proposed relationship between emotion regulation, mentalization, and parenting.

Despite the theoretical links described in the literature, few studies to date have examined directly the relationship between ER and mentalization. Sharp et al. (2011) reported no correlation between ER and global level of mentalization. Rutherford, Booth, et al. (2015) showed that only distorted mentalization was directly linked to maternal distress tolerance. As little is known about the relationship between parental ER and parental mentalization, both in general and in particular in relation to parenting, we were interested in further exploring this relationship and in assessing whether these constructs correlate or interact with each other. Finally, as both ER and mentalization are described as embedded within an interpersonal context, we were interested in assessing them within a family context, examining both fathers’ and mothers’ ER and mentalization as well as whether patterns varied by parent gender. Assessing paternal ER and mentalization is of particular importance, as most extant studies have focused on mother–child dyads.

We had several hypotheses:

Hypothesis 1: Parental capacity for mentalization would be associated with capacity for ER.

Hypothesis 2: Low capacity for ER and low capacity for mentalization would each independently predict elevated levels of parental hostility, coercive behaviors with the child, and submissive parenting behaviors.

Hypothesis 3: Parental ER and mentalization would predict parenting, beyond child symptom severity.

As parent–child conflict has been found to contribute significantly to the exacerbation of child behavior symptoms (Burt et al., 2003), establishing the role of parental ER and mentalization in families of children with ADHD may improve the scientific understanding of factors contributing to effective parenting and potentially suggest a clinical focus for treatment interventions for ADHD.

Method

Participants

Participating parents were seeking services for parent training for ADHD and behavior disorders at an outpatient ADHD clinic in Schneider’s Children’s Hospital in Israel. The children for whom the parents sought treatment had an established diagnosis for ADHD from providers in the community (e.g., neurologists or psychiatrists). Many of the children additionally were diagnosed with behavioral difficulties, including oppositional defiant disorder (ODD) and conduct disorder (CD). In addition to the Child Behavior Checklist (CBCL) questionnaires, child ADHD symptoms and behavior difficulties were evaluated in an intake session conducted by a licensed clinical psychologist. The intake interview included a developmental history, a history of the presented problem, prevalence and duration of presenting symptoms, and description of family dynamics at home. The intake interviewer determined the centrality of the ADHD diagnosis. Two families with main diagnosis of anxiety and mental retardation were referred out and were not included in the study. This ratio of acceptance is consistent with the clinic’s acceptance rate (Schorr Sapir, 2018).

Inclusion/exclusion criteria for the study were as follows: (a) The identified patient was between 6 and 18 years old, (b) the child had no diagnosed intellectual deficit or history of psychosis, and (c) the primary referral problem was ADHD and behavior problems occurring for more than 6 months (e.g., noncompliance, social aggression, and oppositional behaviors).

Of the families accepted to treatment at the clinic, 80 children and their parents were invited to participate in the study. Of these 80 families, one family refused to participate and their records were excluded; five families agreed to participate but did not complete study measures and were excluded. Of the remaining 74 families, 70 had some data from both fathers and mothers; four had data from mothers only (total participating parent N = 144). Of these 144 participating parents, 32 had incomplete data on a subset of study measures and were excluded from multilevel analyses, resulting in a multilevel analytic sample of 112 parents (64 mothers and 48 fathers) and 74 children. Parents with missing data were not significantly different from the analytic sample on predictors (ER, mentalization) or outcomes (parenting), nor were they significantly different from the analytic sample on child age, child behavior problems (CBCL Total Problems T-Score), marital status, or parent educational level (ps = .11-.75).

The majority (89%) of parents were married to one another and living together, and had more than 12 years of education (years of education—mothers: M = 15.29, SD = 2.51; fathers: M = 14.47, SD = 2.38). All families were Jewish Israelis. The majority of parents identified as secular (68%). A measure of crowdedness in the house (Person per Room) was consistent with previous studies on the Jewish population in Israel (The Israeli Central Bureau of Statistics, 2015) and yielded an average of one person per room in the apartment (M = 1.01, SD = 0.28). Child participants (n = 74) included 60 boys and 14 girls ranging in age from 6 to 15 years (M = 9.63, SD = 2.47), with 64.6% of children between 6 and 10 years old. Twelve percent of children attended special education classes. Overall, the demographics of the sample were comparable with that of the area in which the study was conducted in regard to education, marital status, ethnicity, and SES.

Procedures

Each family arriving to an intake session at the outpatient clinic was asked to complete the research questionnaires (see “Measures” section) prior to their arrival as part of the clinic intake package to support clinical assessment. Families arriving to intake were offered to participate in the study as part of a larger trial assessing the efficacy of the treatment procedure and the addition of complementary treatment modules. Only after informed consent, families’ questionnaires were included in the study. It was explained to parents that their decision to participate or withdraw from the study would not affect their treatment. Parents who agreed to participate were audio-recorded during the intake session while describing their child, yielding data coded for mentalization.

All procedures performed in the study were approved by the institutional review board of Long Island University and by the Helsinki committee of the hospital where the study took place. Informed consent was obtained from all individual participants included in the study.

Measures

CBCL

Parent perception of their child’s problems was assessed using the Total Problems scale of the CBCL. The CBCL (Achenbach, 1991) is a widely used measure of emotional and behavioral difficulties that has been translated into more than 80 languages, and research has indicated that its validity has been maintained across cultures and genders (Crijnen, 1999; Ivanova et al., 2007). The Hebrew version of the questionnaire was used in the current study, which has shown good reliability and validity (Zilber, Auerbach, & Lerner, 1994). In the current study, for children with more than one parent participating, the CBCL was completed by the parents together. T-score of the CBCL Total Problem scale was used. Cronbach’s alpha for the scale used in the current study was α = .78. We chose the Total Problems scale of the CBCL as we were interested in the parents’ perception of the overall severity of the child’s emotional and behavioral difficulties, beyond the diagnosis of ADHD.

Mentalization

Parental capacity to use mentalization (Meins et al., 2003) while describing their child was measured using a single question interview, in which parents were asked to “describe your child.” Responses were audiotaped and transcribed verbatim. Two trained coders, blind to other measures completed by the parents, rated each parental attribute into one of four categories described in the MM scoring manual (Meins & Fernyhough, 2010): Mental Attributes (e.g., “She doesn’t like her sister playing with her stuff”), Behavioral Attributes (e.g., “talkative,” “aggressive”), Physical Attributes (e.g., “he is three feet tall”), and General Descriptors for comments that were not compatible with any of the previous three categories (e.g., “he is a lovely little boy”). Based on the manual, the MM score was computed as the percentage of mental attributes out of the total comments provided by the parents. A previous study of maternal MM under low-to-high parenting stress demonstrated 0.46, 0.31, and 0.24 for low, medium, and high stress levels, respectively (McMahon & Meins, 2012). Lundy (2013) documented an average MM score of 0.23 for fathers in a nonclinical sample. Interrater reliability analyses in the current study yielded an intraclass correlation coefficient (ICC) of .77 for mothers and .86 for fathers.

The MM interview and scale has been used broadly as a measure of parental mentalization (Sharp & Fonagy, 2008). Consistent with mentalization theory, published research on the measure has shown significant correlations between maternal and paternal MM and parenting sensitivity (Laranjo, Bernier, & Meins, 2008; Rosenblum, McDonough, Sameroff, & Muzik, 2008), child attachment patterns (Arnott & Meins, 2007), and the development of children’s theory of mind (Meins et al., 2003). For the current study, the MM measure was chosen over other measures of mentalization for two reasons: First, the measure has established reliability for both mothers and fathers and for parents of school-aged children. Second, the MM requires a substantively shorter time for administration compared with other measures of parental mentalization and was therefore more feasible for use in a clinical setting with parents who are often unable to dedicate additional time for a separate interview.

Difficulty in Emotion Regulation Scale (DERS)

Parents’ capacity for ER was measured using the 36-item self-report DERS (Gratz & Roemer, 2004). Higher scores indicate greater difficulties in ER, and the total score represents a global index of affect regulation difficulties. Cronbach’s alpha in Gratz and Roemer’s (2004) study showed excellent internal consistency for both the total score (α = .93) and for the subscales (α > .80). A recent study that identified clusters of regulated and dysregulated mothers reported average DERS scores of 65.11 and 77.02 for well-regulated and dysregulated, respectively (Shaffer, Whitehead, Davis, Morelen, & Suveg, 2018).

The DERS has been translated to German, Portuguese, Turkish, and Spanish, and has been found to differentiate between populations with high and low stress levels (Coutinho, Ribeiro, Ferreirinha, & Dias, 2010; Ruganci & Gençöz, 2010; Sighinolfi, Pala, Chiri, Marchetti, & Sica, 2010). In the current study, permission was granted from the author of the measure to translate to Hebrew. A translation validation was conducted using a translation back to English by an independent translator. Cronbach’s alpha for the current study was α = .89 for mothers and α = .93 for fathers. An additional validation of the translation to Hebrew with mothers yielded similar psychometric results (Pat-Horenczyk et al., 2015).

Escalation Questionnaire

Parents’ hostility, coercive behaviors, and submissive behaviors toward their children were measured using the 21-item Escalation Questionnaire (Lavi-Levavi, 2009). This measure assesses parental emotional and behavioral reactions in accordance with Patterson’s theory of escalation that views escalation as a complex construct involving both parental attempts to force the child to comply and parental demand withdrawal. In the current study, three of the four scales of the measure were used: Parental Negative Feelings toward the child (e.g., “I am angry with my child”), parental Coercive Behavior (e.g., “When me and my child argue, it is important for me to win”), and parental Submission (e.g., “I allow my child to do things I oppose of so I could get some quiet time”).

The measure was developed in Hebrew and validated with parents receiving parent training. The measure demonstrated good sensitivity to treatment change for both mothers and fathers (Lavi-Levavi, Shachar, & Omer, 2013). Average scores in the validation study with parents of children with behavior difficulties for mothers and fathers were 17.5 (M) and 16.8 (F) for submission; 19.25 (M) and 17.65 (F) for coercion, and 15.35 (M) and 13.6 (F) for negative emotions. Cronbach’s alpha for the current study achieved low to medium level of consistency (mothers’ negative feelings, α = .79; fathers’ negative feelings, α = .81; mothers’ coercive behavior, α = .70; fathers’ coercive behavior, α = .65; mothers’ submission, α = .74; fathers’ submission, α = .75).

Analysis Plan

A multilevel modeling (MLM) approach was used to assess simultaneously the contribution of parent-level and child-level factors to the parenting of children beginning treatment for ADHD. A multilevel approach offers several benefits to a traditional regression approach. These benefits include (a) capturing and accounting for the dependence of mother and father outcome data (Kenny & Kashy, 2011), (b) allowing for the testing of both individual parent-level factors (such as ER and mentalization) and child-level factors (such as behavior problems) vis-à-vis parenting constructs simultaneously, and (c) enabling the statistical testing of differences in parent role (father vs. mother) in the relation of predictor variables to outcome variables through interaction testing.

Raudenbush and Bryk’s (2002) hierarchical linear modeling (HLM, Version 7) program was used to estimate a two-level hierarchical model, in which individual parents (mothers and fathers, n = 112) were nested within families (n = 74); while the sample size is relatively small, simulations have indicated that group-level samples sizes of 50 or greater typically do not lead to biased estimates of standard errors (Maas & Hox, 2005). A series of multilevel models was run for each of the three parenting constructs of interest (Coercive Parenting, Submissive Parenting, and Negative Feelings). First, fully unconditional models were run to estimate the proportion of variance in outcomes attributable to family-level factors. Next, main effects models were run with predictors of interest at both Level 1 (parent sex, dummy coded as 0 = mother, 1 = father, and ER and mentalization, grand mean centered) and Level 2 (child age and child CBCL Total Problems, grand mean centered). In addition, for each of the three parenting constructs, a two-way interaction effects model was run, with two-way interactions between parent sex and mentalization, parent sex and ER, and mentalization and ER, in addition to all main effects terms at Levels 1 and 2; thus, in all models, child age and parent sex were covaried. All interaction terms were calculated with grand mean centered variables in SPSS prior to inputting to HLM. Finally, for all three parenting outcomes, a three-way mentalization-by-ER-by parent sex term was also tested; however, this model was nonsignificant for all outcomes. Full maximum likelihood estimation was used for all models. The model we tested is presented in Figure 2.

Figure 2.

A graphical representation of the model tested.

Results

Preliminary Analyses

Descriptive statistics and correlations for variables of interest can be found in Table 1. In comparison with previous studies, parents in the current sample demonstrated relatively high level of difficulties in ER and below average level of mentalization, comparable with parents under medium levels of stress in other studies (McMahon & Meins, 2012; Shaffer et al., 2018). In bivariate analyses, difficulties in ER was positively correlated with all three parenting constructs (coercive, submissive, negative feelings); however, mentalization was not significantly correlated with either difficulties in ER or parenting constructs. Paired-sample t tests indicated no significant differences between mothers and fathers on any study measures. Mothers’ and fathers’ scores on the difficulties in ER scale were significantly positively correlated, as were mothers’ and fathers’ scores on the Negative Feelings scale (see Table 2); no significant correlations were observed between maternal and paternal mentalization or between maternal and paternal coercive behaviors or submission. There were no significant differences between boys and girls on any of the study variables (ps > .14).

Table 1.

Descriptives for and Correlations Between Study Variables.

	Child age	CBCL total	Parent sex	Mentalization	DERS	Coercive parenting	Submissive parenting	Negative feelings
CBCL total	.05
Parent sex	.00	.00
Mentalization	−.17	.04	−.13
DERS	.03	.12	−.05	−.14
Coercive parent	.14	−.06	−.00	−.08	.38**
Submissive parent	.09	.09	−.15	−.12	.22*	.08
Negative feelings	.44***	.21*	.12	−.06	.22*	.43***	.16
M (SD)	9.63 (2.47)	67.20 (6.80)	NA	0.30 (0.17)	77.96 (19.69)	15.12 (5.26)	17.11 (7.36)	13.65 (5.12)
n	74	74	112	112	112	112	112	112

Note. Correlations are Pearson’s with exception of parent sex, which is point biserial. Parent sex coded as 0 = mother, 1 = father. CBCL total = Child Behavior Checklist Total Problems T-Score; DERS = Difficulty in Emotion Regulation Scale.

p < .05 (two-tailed). **p < .01 (two-tailed). ***p < .001 (two-tailed).

Table 2.

Correlation Matrix for Mothers and Fathers.

	DERS M	DERS F	MT M	MT F	NF M	CP M	SU M	NF F	CP F	SU F
DERS M	1.00
DERS F	.28*	1.00
MT M	−.16	−.17	1.00
MT F	.02	−.14	.07	1.00
NF M	.31**	.13	−.30**	.06	1.00
CP M	.30*	.10	−.03	−.21	.40**	1.00
SU M	.13	.12	−.19	.16	.34**	.18	1.00
NF F	.33**	.41**	−.13	.00	.40**	.06	.24*	1.00
CP F	.45**	.31*	.03	−.12	.15	.12	.08	.47**	1.00
SU F	.33**	.38**	−.08	−.03	.08	.10	.17	.32**	.27**	1.00
M (SD)	79.15 (18.51)	76.07 (21.32)	0.33 (0.18)	0.27 (0.16)	13.80 (4.85)	14.88 (5.44)	17.88 (8.56)	13.44 (5.50)	15.45 (5.06)	16.10 (5.28)

Note. DERS = Difficulty in Emotion Regulation Scale; M = mother; F = father; MT = mentalization; NF = negative feelings; CP = coercive parenting; SU = submissive parenting.

p < .05 (two-tailed). **p < .01 (two-tailed).

Coercive Parenting

In multilevel models, for coercive parenting, 19.6% of the variance was explained by family group (χ² = 102.74, p = .01). In the main effects model, including individual-level predictors of parent sex, ER, and mentalization and family-level predictors of child age and CBCL total problems, only parent’s ER significantly predicted coercive parenting strategies (see Table 3; β = .10, p = .002), with higher difficulties in ER predicting more usage of coercive parenting; no main effect of mentalization was observed. In the model with two-way interaction terms, including parent sex by mentalization, parent sex by ER, and mentalization by ER, no interaction terms were significant, suggesting that the main effects model best represents the data (see Table 3).

Table 3.

Models for Coercive Parenting.

	Main effects model			Interaction model
	Coefficient	SE	p value	Coefficient	SE	p value
Family level
Intercept	14.55	0.65	<.001	14.54	0.66	<.001
Child age	0.26	0.19	.19	0.29	1.20	.15
CBCL total	−0.08	0.08	.32	−0.07	0.08	.35
Individual level
Parent sex	0.87	0.91	.35	0.86	0.90	.35
DERS	0.10	0.03	.002	0.10	0.04	.01
Mentalization	0.84	2.75	.76	3.18	3.37	.35
Parent Sex × ER				−0.00	0.05	.93
Parent Sex × Mentalization				−5.35	4.72	.27
ER × Mentalization				0.13	0.12	.31
Parent Sex × Mental × ER				−0.22	0.25	.40

Note. p values < .05 are marked in bold. Parent sex coded as 0 = mother, 1 = father. CBCL total = Child Behavior Checklist Total Problems T-Score; DERS = Difficulty in Emotion Regulation Scale; ER = Emotion Regulation.

Submissive Parenting

For submissive parenting, 10.0% of the variance was explained by family; notably, this variance term was not statistically significant (χ² = 79.00, p = .30), suggesting that there was not sufficient variability around each mean score accounted for by family grouping to warrant testing Level 2 predictors; nonetheless, we retained the multilevel model for analyses to account for dependence of mothers’ and fathers’ data. In neither the main effects nor the interaction term models did any of the predictor variables at the individual or family level significantly predict submissive parenting behavior (see Table 4, ps > .12).

Table 4.

Models for Submissive Parenting.

	Main effects model			Interaction model
	Coefficient	SE	p value	Coefficient	SE	p value
Family level
Intercept	17.92	1.16	<.001	18.03	1.27	<.001
Child age	0.10	0.32	.75	0.06	0.36	.87
CBCL total	0.11	0.09	.22	0.09	0.08	.25
Individual level
Parent sex	−1.97	1.38	.16	−1.97	1.35	.16
DERS	0.05	0.03	.11	0.02	0.04	.71
Mentalization	−5.73	5.25	.28	−9.13	8.48	.29
Parent Sex × ER				0.06	0.05	.21
Parent Sex × Mental				7.45	9.79	.45
ER × Mental				−0.14	0.15	.33
Parent Sex × Mental × ER				−0.51	0.28	.08

Parental Hostility

For parental hostility as measured on the Parental Negative Feelings scale, 53.3% of the variance was explained by family group (χ² = 202.47, p < .001). In the main effects model, which included the individual-level predictors of parent role, ER regulation, and mentalization as well as family-level predictors of child age and behavior problems, a main effect was observed for the individual-level variable of ER (β = .08, p = .002) as well as for the family-level variables of child age (γ = 0.84, p < .001) and total problems (γ = 0.14, p = .02), with higher child age and higher total problems both predicting higher parental hostility.

However, the main effect of ER on parental hostility was qualified by a significant interaction between the two individual-level predictors of ER and mentalization in the interaction term model (β = –.25, p = .04); in this model, the family-level variables of child age (γ = 0.83, p < .001) and behavior problems (γ = 0.12, p = .04) also retained significance (see Table 5).

Table 5.

Models for Hostile Parenting.

	Main effects model			Interaction model
	Coefficient	SE	p value	Coefficient	SE	p value
Family level
Intercept	13.61	0.49	<.001	13.60	.49	<.001
Child age	0.84	0.19	<.001	0.83	−0.20	<.001
CBCL total	0.14	0.06	.02	0.12	0.06	.04
Individual level
Parent sex	−0.02	0.73	.98	−0.07	0.69	.92
DERS	0.08	0.03	.003	0.05	0.03	.11
Mentalization	−1.66	2.31	.48	−3.47	2.53	.18
Parent Sex × ER				0.03	0.04	.45
Parent Sex × Mental				3.36	4.45	.46
ER × Mental				−0.26	0.12	.04
Parent Sex × Mental × ER				0.06	0.21	.76

To decompose the significant interaction, Preacher’s computational tool for probing interactions in multilevel models was employed (Preacher, Curran, & Bauer, 2006), estimating simple slopes at low (–1 SD), medium (mean), and high (+1 SD) levels of mentalization (see Figure 1). Simple slopes indicated that the relation between difficulties with ER and parental hostility was significant and positive only at low levels of mentalization (t = 3.15, p = .004); specifically, the region of significance was from just below the mean of the centered mentalization term (lower bound of region = –.008). Thus, while there was no relation between ER and parental hostility at high levels of mentalization, a significant and positive effect of difficulties with ER on parental hostility was observed for parents with low mentalization (below the sample mean). The interaction effect is presented in Figure 3.

Figure 3.

Difficulties in emotion regulation predict parental hostility only at low levels of parent mentalization.

Discussion

The current study seeks to expand the understanding of cognitive and emotional parenting processes among families of children with ADHD. We assessed the role of parental ER and mentalization in relation to negative parenting reactions to identify protective parenting mechanisms among these families. Using a sample of families arriving for parent training at an outpatient clinic for ADHD, we assessed child symptoms, parental ER, parental mentalization of the child, and parenting, including parental hostility, coerciveness, and submissive behaviors. We hypothesized that parents with higher capacity for ER and mentalization would experience lower levels of hostility toward the child and would report engaging in less coercive and submissive behaviors.

Our data analyses indicated different paths between parenting cognitive and affective processes and parenting reactions, and these patterns were parallel across mothers and fathers in this sample. In relation to coercive parenting (as measured on the Coercive scale), we found that parental capacity for ER accounted for significant variance in coercive parenting. The effect of ER did not vary by parental role (father vs. mother), child symptoms, or parental mentalization abilities, suggesting that parents who struggle to manage negative affect are more likely to react coercively to the ADHD child, even when children’s symptomatology level is relatively low. This finding highlights the role of parental regulatory capacities in relation to parental coercive reactions. It is consistent with findings from nonclinical samples, including young child–parent findings that suggest that parents’ dysregulation, measured physiologically, is linked to less sensitive behavior (Leerkes et al., 2015), as well as studies with older dyads, where parental impulsivity and emotion dysregulation have been linked to parental aggressiveness (Mammen, Kolko, & Pilkonis, 2002) and negative disciplinary strategies (Bridgett et al., 2015).

Our finding that parental mentalization did not predict parental coerciveness suggests that coercive parenting may be an outcome of the level of negative arousal experienced by the parent and his or her capacity to manage this arousal, rather than the parents’ capacity to think about the child’s mind and needs. It is possible that during moments of elevated arousal, the capacity for mentalization, which relies on higher order cognitive capacities, may be less relevant for predicting escalating and coercive parent–child dynamics. This finding is consistent with some recent research on mentalization that has found that during moments of stress, the capacity to mentalize may be compromised, as it relies on higher brain circuits that may be less engaged during moments of elevated distress (Nolte et al., 2013).

In relation to parental hostility (as measured on the Negative Feelings scale), the results of our study indicate that multiple factors impact the level of hostility experienced by parents toward their children. Parents with older children and children with elevated symptomatology reported significant elevations in parental hostility. In addition, our analysis indicated an interaction effect between parental mentalization and ER on parental hostility. This moderating pattern suggests that parents’ capacity for mentalization may serve as a buffer against parental hostile feelings specifically among parents who struggle with ER. This finding suggests that parental hostility toward the child is a complex process involving both cognitive and affective processes working in concert, specifically both parents’ ER and their capacity to think about the child’s mental life. A reactive and dysregulated parent who has a strong capacity to reflect on his or her child’s behavior may be able to maintain positive feelings toward the child, despite the child’s difficulties and his or her own dysregulation. Likewise, a reactive and dysregulated parent who is less able to mentalize may not be able to apply this cognitive process even during times of lower arousal.

The role of parental mentalization as a buffer, reducing negative parenting even in the face of parental dysregulation, has been suggested by previous research with nonclinical samples. For example, Rutherford, Booth, et al. (2015) showed that higher capacity to mentalize explained a significant portion of the time mothers persisted in soothing a distressed baby simulator. Wang et al. (2016) also demonstrated an interaction effect between cognitive and affective processes, showing that maternal negative affect and resting RSA moderate the relationship between child behavior difficulties and maternal hostile attributions. For mothers with higher emotion dysregulation, the relationship between child behavior problems and hostile attributions about the child was the strongest. Taken together, the results of our study and the studies described above highlight the important role of both affective and cognitive parenting processes in relation to parental hostility. The distinct roles indicated in our study for parental ER and parental mentalization across parenting constructs provide a path for thinking about parent–child negative dynamics in relation to momentary escalation (coercion) versus the quality of the relationship (parental hostility). While coercive dynamics seem to rely on the parents’ ability to regulate negative affect, the parents’ experience of the relationship with the child may be related to both the parent’s level of dysregulation and their ability to reflect on the child’s behavior outside the moments of conflict with the child. In the context of parenting children with ADHD, which includes chronic difficulties and the continuous need for external regulation, both cognitive and affective parenting paths seem to play an important and complementary role in helping parents maintain a positive and nonhostile attitude toward the child. This formulation echoes Laugesen and Gronkjaer’s (2015) finding that parents who had a more thorough understanding of ADHD were better able to accept children’s behavior and be more optimistic in the relationship.

Interestingly, in relation to parental demand withdrawal (as measured on the Submission scale), no child or parenting variable measured in our study served as significant predictor. This finding was contrary to our hypotheses that assumed an important role for parental mentalization and ER in relation to the parents’ capacity to maintain demands and respond contingently to the child. The small relations observed between study variables and parents’ submission level raise the possibility that other mechanisms not captured in this analysis are involved in parental submission. Examples include availability of alternative disciplinary responses, parents’ experience of efficacy, or parenting attitudes and beliefs about child discipline, all constructs demonstrated in previous research as mediators of the relationship between parental stress and parenting discipline (Pinderhughes et al., 2000).

Finally, while moderation analyses suggested that these patterns of relations were similar for mothers and fathers, we did observe significant correlations between paternal and maternal capacity for ER as well as between paternal and maternal hostility level. These results are in line with current theories on ER that view ER as an interpersonal process that needs to be studied and addressed within the family system (MacPhee, Lunkenheimer, & Riggs, 2015; Reeck, Ames, & Ochsner, 2016). Fosco and Grych (2013), who studied the impact of the emotional climate of the family on the child’s ER, showed a significant correlation between paternal and maternal ER as well as between paternal and maternal warmth toward the child. Our finding underscores the importance of measuring parenting processes within the family system and highlights the need to consider both parents’ affective experience in parent training.

Parental ER and Parental Mentalization: A Possible Model

The results of our study indicated no direct relationship between parental ER and parental mentalization. This finding surprised us, as the literature on mentalization links the ability to reflect on and process mental states tothe capacity to reappraise stressful situations in a way that reduce negative affect (e.g., Hughes et al., 2017; Rutherford, Wallace, et al., 2015). It was assumed that mentalization during interpersonal interactions would improve the accuracy of attributions assigned and reduce the experience of anger in reaction to the child’s behaviors (Schechter et al., 2006). Nonetheless, published studies attempting to demonstrate the hypothesized link between ER and mentalization have provided mixed results on these assumptions. Sharp et al. (2011), for example, in a clinical sample of youth diagnosed with borderline personality disorder, failed to find a correlation between ER and global level of mentalization. Rutherford, Booth, et al. (2015) showed that only one component of parents’ mentalization, measured by the self-report Parental Reflective Functioning Questionnaire (PRFQ), was directly linked to maternal distress tolerance.

These mixed results point to the complexity of these constructs and the variability of measurement approaches that may impact our findings and others’. It is possible that some aspects of mentalization, such as distorted mentalization or lack of mentalization, are directly linked to ER, while other, more global and metacognitive aspects of mentalization may have only an indirect or moderating relationship to ER. Given the findings of previous research on mentalization during stress (Nolte et al., 2013) and the results of our study, it is possible that significant difficulties with ER curtail mentalization, while high mentalization may diminish the long-term outcomes of emotional dysregulation and may reduce the parental proclivity for further dysregulation. Nonetheless, as these processes may vary depending on the context (e.g., during a stressful interaction with the child or a calm moment), there is an ongoing need to further explore the relationship between ER and mentalization in different parenting contexts, using a multimethod approach for the study of both ER and mentalization.

Limitations

The current study includes several limitations. First, our sample consisted of a relatively small sample of families seeking parent training for ADHD. While enabling description of patterns among families in clinical distress, this sample did not include a nonclinical comparison group, which would have allowed us to assess whether observed trends are unique to ADHD families. In addition, most of our sample consisted of married and heterosexual couples cohabiting together who were able to seek out treatment and pay for it. It is possible that these characteristics limit the applicability of our results to families from lower socioeconomic backgrounds or different family constellations.

In addition, conclusions are limited by reliance on parent report. Parent experiences of stress and overall perceptions of the child may have impacted reports of child symptoms as well as parents’ report about their own level of ER. The parents’ reports may therefore be biased and represent the parents’ mind state at the time of intake. Moreover, in terms of measurement use, parenting quality and parental ER are both complex constructs. As such, the measurements we used to capture them here may have covered only partial aspects of them, leaving out, for example, aspects like parenting warmth or more nuanced aspects of ER, such as the capacity for reappraisal or for effortful control. Additional, future studies that include observational measures of parenting and child behavior, as well as additional measures of ER, would strengthen confidence in the observed patterns. Last, while our study results indicated relationships between the constructs observed, the collection of all data at one time point precludes our ability to identify directions of the impacts observed. Moreover, the multiple comparisons conducted raise the Type I error rate. Additional studies using a larger sample as well as longitudinal and experimental design will be needed to verify the relationships suggested by our study.

Conclusion and Clinical Implications

The present study contributes uniquely to the understanding of cognitive and emotional parenting processes in families of children with ADHD. It is the first that we are aware of to assess these parenting processes within the family context and the first to assess both parental mentalization and parental ER in relation to parental hostility, coerciveness, and submission among families with children with ADHD. The results of the study underscore the role of parental ER in contributing to coercive parenting. In addition, the current study demonstrated that parents’ experience of negative feelings and hostility toward the child may be an outcome of their ability both to think about the child’s mind and to regulate their negative affect. The interaction identified in our study between parental ER and mentalization suggests that parental mentalization can serve as a buffer for the development of hostile parent–child relationships when parents struggle with emotion dysregulation. Last, our study was unique in assessing both mothers and fathers. While patterns between variables were consistent across mothers and fathers, our results indicated interconnectedness between mothers and fathers within families in relation to parental ER and hostility level, suggesting that interventions aiming at improving parenting of children with ADHD may benefit from considering the entire family system.

In addition, although implications should be drawn with caution due to the cross-sectional nature of the research, the findings may begin to inform clinical practice. First, the central role of parental ER in relation to coercive parenting that was demonstrated in our study calls for the development of parenting interventions that address parental ER effectively. To date, most behavioral parenting programs still focus on the behavioral aspects of parenting while overlooking the role of parental ER in relation to parental capacity to execute behavioral changes while feeling dysregulated (Colalillo & Johnston, 2016).

Paying attention to parental ER at baseline may be the first step in helping clinicians identify highly dysregulated parents who may drop out early or may not benefit from regular parent training (Zachary, Jones, McKee, Baucom, & Forehand, 2019). Identifying highly dysregulated parents may enable clinicians to address parental emotion dysregulation earlier in the process, for example, by adding stress reduction or mindfulness component to treatment. While these components may not be required for most parents, with highly dysregulated parents, changing the level of emotion dysregulation may be a prerequisite before any behavior change can take place.

Second, the interaction observed in our study between parental ER and mentalization in relation to ER suggests that changing parental negative perceptions about the child may be a multifaceted process involving both affective and cognitive processes. As such, changing negative parental attributions may require two complementary interventions: first, improving the parents’ capacity to feel more regulated in the presence of the child, and second, once regulated, helping parents to think about the child’s behaviors in terms of the mental processes that may underlie it (to mentalize). This process may involve, for example, teaching parents to pay attention to both positive and negative behaviors of the child, using psychoeducation about ADHD to improve parental understanding of the mental mechanisms underlying the child’s difficulties, and helping parents to reflect more carefully on negative interactions with their child, for example, by reviewing the step-by-step sequence of the interaction.

Research on parental mentalization and parental attributes from the past 10 years has indicated that maternal capacity for mentalization can be improved following mentalization-based interventions with mothers and their toddlers (for review, see Camirano, 2017). Nonetheless, to date, it is unclear what active mechanisms are involved in improving maternal mentalization and whether mentalization can be improved following parent training . Therefore, though the techniques suggested above encourage parents to think about the child’s mind, additional research is required to assess the impact of these techniques on the parents’ capacity to mentalize. Moreover, the results of the current study suggest that attempts to improve parental mentalization and to correct parental attributional biases may not be effective as long as the level of emotional dysregulation experienced by the parents is high.

Footnotes

Acknowledgements

Special thanks to Irit Schorr Sapir, director of the ADHD clinic at Schneider Children’s Medical Center of Israel, for her invitation to conduct the study at the clinic and for her generous support throughout the process. We would also like to thank Michael Partas and Eyal Ronen Ackerman for their significant help in data collection.

Authors’ Note

The results of the study described in the article were presented at the Society for Research in Child Development (SRCD) Annual Conference, Austin, Texas, 2017.

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

Naama Gershy is an assistant professor at the Program for for Child Clinical and School Psychology at the Hebrew University of Jerusalem and a licensed clinical psychologist. Her work focuses on parenting processes and parenting interventions with parents of children with ADHD and behavior problems.

Sarah Gray is an assistant professor at the Department of Psychology at Tulane University and a licensed clinical psychologist. Her work focuses on developmental psychopathology, with a particular interest in the role of relationship-based processes in the context of exrly stress and trauma.

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