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Interpersonal Coping among Boys with ADHD

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Title: Interpersonal Coping among Boys with ADHD
Language: English
Authors: Hampel, Petra, Manhal, Simone, Roos, Thomas, Desman, Christiane
Source: Journal of Attention Disorders. 2008 11(4):427-436.
Availability: SAGE Publications. 2455 Teller Road, Thousand Oaks, CA 91320. Tel: 800-818-7243; Tel: 805-499-9774; Fax: 800-583-2665; e-mail: journals@sagepub.com; Web site: http://sagepub.com
Peer Reviewed: Y
Page Count: 10
Publication Date: 2008
Document Type: Journal Articles
Reports - Research
Descriptors: Stress Management, Attention Deficit Disorders, Adolescents, Coping, Males, Interpersonal Relationship, Hyperactivity, Foreign Countries, Comparative Analysis, Children, Antisocial Behavior, Interpersonal Competence, Behavior Problems, Stress Variables
Geographic Terms: Austria, Germany
DOI: 10.1177/1087054707299337
ISSN: 1087-0547
Abstract: Objective: The authors investigate self-reported coping with interpersonal stressors among boys with and without ADHD in two studies and provide initial evidence for effects of different subgroups of ADHD on coping in Study 2. Method: In Study 1, 20 Austrian adolescents with ADHD were compared to 20 healthy controls. In Study 2, 44 German children and adolescents with ADHD (35 without and 9 with conduct disorders) were compared to 44 healthy controls matched by age and grade level, respectively. Results: Increased maladaptive coping was found in both studies. Study 2 revealed heightened maladaptive coping among both subgroups of ADHD, but the subgroup of ADHD with conduct disorders was more affected compared to healthy controls than the subgroup with ADHD alone. Conclusion: Results suggest an impaired interpersonal coping style in ADHD and point to the potential benefit of stress management and social skills trainings for boys with ADHD. (Contains 2 tables.)
Abstractor: Author
Number of References: 54
Entry Date: 2008
Accession Number: EJ793570
Database: ERIC
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  Value: <anid>AN0053241536;gs001jan.08;2010Sep08.14:38;v2.2.460</anid> <title id="AN0053241536-1">Interpersonal Coping Among Boys With ADHD </title> <p>427 ArticlesInterpersonal Coping Among Boys With ADHD SAGE Publications, Inc.200810.1177/1087054707299337 PetraHampel Center of Clinical Psychology and Rehabilitation, University of Bremen, Germany, petra@uni-bremen.de SimoneManhal Department of Psychology, Karl-Franzens-University Graz, Austria ThomasRoos Rehabilitation Clinic Neuharlingersiel, Germany ChristianeDesman Center of Clinical Psychology and Rehabilitation, University of Bremen, Germany Authors' Note: Address correspondence to Prof. Dr. P. Hampel, Center of Clinical Psychology and Rehabilitation, University of Bremen, Grazer Str. 6, 28359, Bremen, Germany; Tel.: 011 49 421 Objective: The authors investigate self-reported coping with interpersonal stressors among boys with and without ADHD in two studies and provide initial evidence for effects of different subgroups of ADHD on coping in Study 2. Method: In Study 1, 20 Austrian adolescents with ADHD were compared to 20 healthy controls. In Study 2, 44 German children and adolescents with ADHD (35 without and 9 with conduct disorders) were compared to 44 healthy controls matched by age and grade level, respectively. Results: Increased maladaptive coping was found in both studies. Study 2 revealed heightened maladaptive coping among both subgroups of ADHD, but the subgroup of ADHD with conduct disorders was more affected compared to healthy controls than the subgroup with ADHD alone. Conclusion: Results suggest an impaired interpersonal coping style in ADHD and point to the potential benefit of stress management and social skills trainings for boys with ADHD. (J. of Att. Dis. 2008; 11(<reflink idref="bib4" id="ref1">4</reflink>) 427—436) ADHD children adolescents coping Attention-deficit/hyperactivity disorder (ADHD) is a highly prevalent disorder in childhood (Barkley, 1998; for review, see Biederman, 2005; Biederman & Faraone, 2005). Prevalence rates between 3% and 12% have been reported for schoolchildren (Barkley, Edwards, Laneri, Fletcher, & Metevia, 2001; Biederman & Faraone, 2005; Faraone, Sergeant, Gillberg, & Biederman, 2003). Consistent among these reports is the finding that boys are more frequently affected than girls. Accordingly, male-to-female ratios of 3:1 in community samples and 10:1 in clinically referred samples have been reported (Biederman, 2005). Coexisting disorders are common among children and adolescents with ADHD, in particular, oppositional defiant disorders con- duct disorders, mood disorders, anxiety disorders, and learning disorders (Gillberg et al., 2004; see also Biederman, 2005). Moreover, ADHD is a considerably persistent disorder. In a recent meta-analysis investigat- ing the persistence into early adulthood, 15% of young adults have shown syndromatic persistence, and 65% have shown symptomatic persistence (Faraone, Biederman, & Mick, 2006). Especially early onset of ADHD increases the risk of further externalizing problems such as opposi- tional defiant disorder and conduct disorders (cf. Jensen, Martin, & Cantwell, 1997; Kutcher et al., 2004). Accordingly, the lifetime prevalence rates for all categories of psychiatric disorders were significantly increased in young adults (Biederman et al., 2006). Finally, associated symptoms are common. These symptoms interact with the core symptoms in predicting the negative prognosis of ADHD (Melnick & Hinshaw, 2000): Interpersonal relation- ship problems with peers, parents, and teachers are typical (Barkley, 1997; MTA Cooperative Group, 1999). Thus, manifestation and the course of ADHD are assumed to be affected by psychosocial stressors such as academic and 428 interpersonal stressors related to peers, parents, and other adults. Barkley (1997) has postulated that ADHD is caused by a general deficiency in behavioral inhibition. This deficit is assumed to be mediated mainly by a dysfunction in frontal-striatal-pallidal-thalamic circuits and a dysfunc- tional feedback to the cortex (Biederman, 2005; Seidman, Valera, & Makris, 2005). According to Barkley, this inhibitory deficit is characterized by an impairment of four core executive functions: (a) working memory; (b) self- regulation of affect, motivation, and arousal; (c) internal- ization of speech; and (d) reconstitution (behavioral analysis and synthesis). Previous research has focused on behavioral and cognitive deficits in ADHD, but processes of emotional regulation in ADHD and their importance for its etiology have been widely neglected. Consistent with Barkley's hypothesis, some studies have shown impaired emotional regulation among children and adolescents with ADHD. Thompson et al. (2004), investi- gating children and adolescents with ADHD aged 5 to 17, reported impaired empathy and a high incidence of exter- nal locus of control, aggression, anxiety, and depression. A study by Whalen, Jamner, Henker, Delfino, and Lozano (2002) supports an emotional deficit among adolescents with severe symptomatology, showing more negative and fewer positive moods as well as lower alertness. Additional studies suggest an impaired psychosocial functioning, indi- cated by impaired self-esteem as well as a decreased school- and social-related quality of life compared to healthy controls, physically disabled children, and individ- uals with other psychiatric disorders (Bastiaansen, Koot, Bongers, Varni, & Verhulst, 2004a; Bastiaansen, Koot, Ferdinand, & Verhulst, 2004b; Escobar et al., 2005; Klassen, Miller, & Fine, 2004; Sawyer et al., 2002; Thompson et al., 2004; Topolski et al., 2004). Assuming different etiological factors of ADHD subtypes, Barkley (1997) hypothesized that not the predomi- nantly inattentive type (ADHD-I) but the combined ADHD type (ADHD-C) and the predominantly hyperactive/ impulsive ADHD type (ADHD-H/I) are characterized by this self-regulatory deficit. Several studies seem to sup- port this assumption. Braaten and Rosén (2000) found impairments in several components of emotional regula- tion among 24 boys with ADHD-C or ADHD-H/I com- pared to 19 healthy controls, suggesting an impaired perception of simple and negative emotional situations and a general impaired emotional interpretation. Furthermore, the analysis of parental reports pointed to a dysfunctional emotional expression with higher manifes- tations of sadness, anger, and guilt. Similarly, poor emo- tional regulation was more pronounced in 21 boys with ADHD compared to 42 healthy boys (Berlin, Bohlin, Nyberg, & Janols, 2004), and there is evidence for the differentiation of the predominantly inattentive subtype. As shown by Wheeler Maedgen and Carlson (2000) a dysfunctional emotional regulation and increased aggres- sive behavior in an experimental frustration-inducing task were specifically related to children with ADHD-C and were not found among children with ADHD-I and the healthy control group. This negative emotional expres- sion is assumed to cause peer rejections of children and adolescents with ADHD (Hodgens, Cole, & Boldizar, 2000; Rielly, Craig, & Parker, 2006; Wheeler Maedgen & Carlson, 2000), which have been found to be associated with psychological maladjustment. However, it remains an open question whether this impaired emotional regulation is specific to ADHD or is associated with coexisting disorders such as aggressive behavior or conduct disorders (Melnick & Hinshaw, 2000; Treuting & Hinshaw, 2001; Young, Chadwick, Heptinstall, Taylor, & Sonuga-Barke, 2005). Some results point to the relevance of coexisting aggressive behavior. Compared to healthy controls and a low-aggressive sub- group of ADHD, boys of the high-aggressive subgroup of ADHD were found to have an increased depressive symp- tomatology and decreased self-esteem (Treuting & Hinshaw, 2001). Moreover, in an experimental frustration task, only the boys of the high-aggressive ADHD sub- group showed less effective emotional coping. They responded more negatively to the stressful situation and used less situation control in comparison with the 23 low- aggressive and 34 healthy control children (Melnick & Hinshaw, 2000). Finally, coping with problems within the peer relationship tended to be associated with conduct problems but not with the presence of hyperactivity among adolescent girls (Young et al., 2005). Only hyper- active girls with conduct problems scored higher on the Kidicope subscale emotion regulation, which reflects inef- fective coping responses like yelling, screaming, and get- ting mad (cf. Spirito, Stark, Grace, & Stamoulis, 1991). Additionally, the coping strategy of blaming others was increased among the fourth group, consisting of girls with conduct problems alone. Taken together, some evidence suggests that ADHD is also characterized by impairments in emotional regula- tion. Several results confirm Barkley's assumption of a general deficit in self-regulation of affect, differentiating the combined ADHD subtype and the predominantly hyperactive/impulsive ADHD subtype with an impaired emotional regulation from the inattentive ADHD sub- type, whose etiology seems to be linked with cognitive deficits (sluggish cognitive tempo) rather than with emo- tional deficits (Carlson & Mann, 2002). First results seem to contradict the assumption of a specific deficit to 429 ADHD-C, showing an impaired emotional regulation depending on coexisting aggressive behavior or conduct problems. However, given that emotional impairments among the ADHD-C and ADHD-H/I subtypes have been found, we agree with Barkley's (1997) hypothesis of a general self-regulation deficit of affect in the ADHD-C and ADHD-H/I subtypes. Following this line of reason- ing suggests that the regulation of negative emotional sit- uations seems to be affected in particular, and therefore coping with stress is predicted to be predominantly impaired. The presence of coexisting conduct problems may further deteriorate the ability to cope with emotional situations. Research in healthy children and adolescents supports the importance of coping abilities in buffering the adverse stress effects on child development. Thus, mal- adaptive coping was associated with social (e.g., Eisenberg, Fabes, & Losoya, 1997) as well as emotional dysfunction (e.g., Compas, Connor-Smith, Saltzman, Harding Thomsen, & Wadsworth, 2001). Despite the high interpersonal stress among children and adolescents with ADHD, research on coping among children and adolescents with ADHD has been widely neglected. We regard coping as a mechanism of emotional regulation, which is defined according to Melnick and Hinshaw (2000, p. 75) as the ability to “(a) inhibit inappropriate behavior related to strong negative and positive affect, (b) self-soothe any physiological arousal that the strong affect has induced, (c) refocus attention, and (d) organize for coordinated action in the service of an external goal.” By distinguishing coping styles into more direct cop- ing modes (i.e., problem-focused, primary control, or approach coping) and more indirect coping efforts (i.e., emotion-focused, secondary control, or avoidance cop- ing), problem-focused coping was negatively related to internalizing and externalizing disorders but (destruc- tive) emotion-focused coping was positively linked with child psychopathology (Compas, Malcarne, & Fondacaro, 1988). Further studies suggest that adaptive and maladaptive coping strategies are confounded in these dichotomized dimensions. Accordingly, evidence available so far supports a three-dimensional differentia- tion of coping styles into 2 adaptive coping styles and 1 maladaptive coping style. Coping styles can be distin- guished into active, internal, and dysfunctional coping (Lewis & Frydenberg, 2002; Seiffge-Krenke, 2000) or problem-focused, emotion-focused, and maladaptive coping (Hampel & Petermann, 2005). Both concepts propose that maladaptive coping includes strategies such as aggression, avoidance, rumination, and resignation. In sum, prior research has shown that these adaptive coping styles were associated with better psychological adjust- ment, but maladaptive coping was correlated with less adjustment (Connor-Smith & Compas, 2002; Galaif, Sussman, Chou, & Wills, 2003; Garnefski, Boon, & Kraaij, 2003; Hampel & Petermann, 2006; Kraaij et al., 2003; Liu, Tein, & Zhao, 2004; Seiffge-Krenke, 2000; Wadsworth & Compas, 2002). The two studies presented here investigate coping with interpersonal stressors among boys with ADHD. In an initial pilot study and a subsequent second study, dif- ferences in adaptive and maladaptive coping strategies between boys with and without ADHD were examined. Based on findings showing an impaired emotional regu- lation in ADHD (Berlin et al., 2004; Braaten & Rosén, 2000; Thompson et al., 2004; Wheeler Maedgen & Carlson, 2000), we hypothesized that boys with ADHD would show a maladaptive coping pattern. The second study addressed differential effects on interpersonal cop- ing in the ADHD subgroups with and without conduct disorders. We predicted that both subgroups would differ in coping from healthy controls, but that the effects would be more prominent among the ADHD subgroup with conduct disorders. Study 1 Method Sample and procedure. Participants of the first study were 40 adolescent boys. The ADHD group included 20 participants recruited from an outpatient psychosomatic clinic in Graz (Austria) and diagnosed by a clinician using semistructured interviews based on the DSM-IV (Döpfner & Lehmkuhl, 2000). Boys also completed the German version of the Youth Self-Report (YSR; Achenbach, 1991; Döpfner, Berner, & Lehmkuhl, 1994). The predominantly hyperactive/impulsive type of ADHD was diagnosed among 16 adolescents, and the combined type of ADHD was diagnosed among 4 boys; only 1 boy was diagnosed with coexisting conduct disor- ders. Healthy controls were recruited from 3 junior high schools and matched by age and grade level to the patient sample. Based on parental reports it was ensured that the healthy controls were free of any psychiatric disorders. Compared to healthy controls, boys with ADHD scored significantly higher on attention problems measured by the YSR; healthy controls: M = 4.25, SD = 2.85; ADHD: M = 6.65, SD = 2.74; F(<reflink idref="bib1" id="ref2">1</reflink>, 38) = 7.39, p = .010, η2 = 0.16. Comparisons regarding coping strategies revealed that healthy controls were not statistically different from a representative normative sample. Participants ranged in age from 11 to 13 years (M = 12.35, SD = 0.58) and attended the sixth and seventh 430 grades. The two groups did not differ regarding the fathers' (M = 43.00, SD = 7.39) or mothers' ages (M = 40.36, SD = 5.49). Finally, there were no significant differences between groups in fathers' and mothers' educational and professional levels or socioeconomic status; parents of both groups evaluated their socioeconomic status as good (12%), average (32%), or low (60%). All participants and their parents gave their written, informed consent prior to the start of the study. Twenty percent of the parents of healthy controls and partici- pants who were approached refused to participate in the study. Adolescents of the control group were asked to complete measures during class time supervised by trained graduate students of psychology. Adolescents with ADHD completed the questionnaires alone under supervision of a trained graduate student of psychology. Measure. The German Coping Questionnaire for children and adolescents (Stressverarbeitungsfragebogen für Kinder und Jugendliche, SVF-KJ) developed by Hampel, Petermann, and Dickow (2001; cf. Hampel & Petermann, 2005) provides the multidimensional measure- ment of coping. This self-report measure consists of 9 cop- ing strategies, which are represented by 4 items each and are answered in relation to 2 individually generated com- mon stressors: an interpersonal stress situation (“When other children are bothering me and I am really upset, e.g., a conflict with peers or malicious gossip expressed by peers”) and an academic stress situation (“When some- thing at school bothers me and I am really worried, e.g., taking a difficult exam or dealing with too much home- work”). In the present study, only interpersonal coping was assessed, as coping with social stressors was assumed to be more important in relation to emotional and behavioral problems (cf. Compas et al., 1988). Thus, 36 coping responses whose likelihood of occurrence were rated on a 5-point Likert-type scale (0 = not at all, 4 = in any case) were applied. The factorial validity of the SVF-KJ was investigated by Hampel et al. (2001), who reported that factor analy- sis of the 9 subscales resulted in 3 coping styles. In accordance with Lazarus and Folkman (1984), 2 adap- tive coping styles were labeled emotion-focused coping and problem-focused coping. Emotion-focused coping consisted of minimization (e.g., “I say to myself: It isn't serious”) and distraction/recreation (e.g., “I'm reading something fun”). Problem-focused coping was repre- sented by situation control (e.g., “I try to figure out what the problem is”), positive self-instructions (e.g., “I say to myself: I can make it”), and social support (e.g., “I'm asking for somebody's advice”). The third factor was named maladaptive coping and included passive avoid- ance (e.g., “I'd like to stay in bed”), rumination (e.g., “The situation rushes into my mind over and over again”), resignation (e.g., “I want to give up”), and aggression (e.g., “I'm getting a bad temper”). Coping strategies showed suf- ficient to good internal consistency in both groups (median Cronbach's alpha = 0.71). Data analysis. To investigate differences in coping strategies between the ADHD group and the healthy con- trols, 2 one-way MANOVAs separated for the 5 adaptive and 4 maladaptive strategies were conducted. With regard to multiple tests, the alpha level of the 2 MANOVAs was corrected using the Bonferroni procedure (p < .025). To locate effects of the group (ADHD group vs. healthy con- trols) on the 9 subscales, subsequent univariate ANOVAs were carried out. Results Adaptive coping strategies. The MANOVA revealed a significant main effect of the group: Wilks's F(<reflink idref="bib5" id="ref3">5</reflink>, 34) = 3.24, p = .017, η2 = 0.32. Means and standard deviations for both groups are depicted in Table 1. Follow-up uni- variate ANOVAs yielded significant group main effects on distraction, positive self-instructions, and social sup- port; compared to healthy controls, boys with ADHD scored lower on these adaptive coping strategies. Moreover, both groups differed marginally in situation control, indicating that boys with ADHD tended to employ this problem-focused strategy less than their healthy contemporaries. Maladaptive coping strategies. A significant main effect of the group was ascertained by the MANOVA: Wilks's F(<reflink idref="bib4" id="ref4">4</reflink>, 35) = 9.26, p < .001, η2 = 0.51 (see Table 1). Univariate ANOVAs indicated that the ADHD group had higher levels of resignation than the healthy controls. Furthermore, they tended to apply more passive avoid- ance on interpersonal stressors. Discussion Study 1 revealed an impaired coping with interper- sonal stressors among boys with ADHD in comparison with age- and grade-matched healthy controls. Similar to previous results on emotional regulation in ADHD (Berlin et al., 2004; Braaten & Rosén, 2000; Thompson et al., 2004; Wheeler Maedgen & Carlson, 2000), boys with ADHD showed a maladaptive coping pattern with less employment of problem-focused coping strategies and the emotion-focused strategy distraction. Moreover, maladaptive coping was significantly increased. Whereas the small sample sizes used in this study call for a moderate interpretation, the effect sizes found support the conclusion that these group differences were of sub- stantial size. 431 Table 1 Means (M) and Standard Deviations (SD) for Coping Strategies Measured by the German Coping Questionnaire for Group Main Effects and Summary of ANOVA Results for Study 1 *p < .10. **p < .05. ***p < .01. ****p < .001. Study 2 The aim of Study 2 was to find out whether the find- ings of Study 1 could be replicated. In addition, possible differences in coping dependent on coexisting conduct disorders were explored. Method Sample. This study included 88 adolescent boys. The ADHD group consisted of 44 participants recruited from an inpatient rehabilitation clinic in Neuharlingersiel (Germany). ADHD diagnosis was based on parents' answers to a semistructured interview according to the ICD-10 (Döpfner & Lehmkuhl, 2000). Furthermore, parents rated psychological problems using the German version of the Child Behavior Checklist (Achenbach, 1991) and the Conners' Abbreviated Parent Rating Scale (Steinhausen, 1995). Hyperkinetic disorder without con- duct disorders was diagnosed among 35 adolescents and hyperkinetic disorder with conduct disorders among 9 boys. The mean hyperactivity score measured by the Conners' Abbreviated Parent Rating Scale was M = 20.32 (SD = 4.10), with a possible range between 0 and 30 and a cutoff score of 15. The following comorbid diagnoses existed: learning disorders (n = 13), mood disorders (n = 3), adjustment disorders (n = 4), enuresis (n = 2), and sleep disorders (n = 1). Because of the small sample size, 4 girls with hyperkinetic disorder had to be excluded. Healthy controls were recruited from 3 pri- mary and 3 junior high schools and matched regarding age and grade level. According to parental reports, healthy controls were free of any psychiatric disorders. ANOVAs indicated that the 44 healthy controls were representative of a normative sample with regard to cop- ing and socioeconomic measures. Participants ranged in age from 8 to 12 years (M = 10.24, SD = 1.15) and attended the third through seventh grades. Ages of fathers and mothers did not differ between groups (fathers: M = 42.31, SD = 6.07; mothers: M = 39.24, SD = 4.79). The maternal educational level of the healthy control group was significantly higher than that of the ADHD group, showing more mothers with high school and college degrees; χ2 (<reflink idref="bib5" id="ref5">5</reflink>) = 11.5, p = .042. Finally, the groups differed neither in fathers' educa- tional and professional levels nor in socioeconomic sta- tus; parents rated their socioeconomic status as good (55%), average (30%), or low (15%). Procedure and measure. The procedure was identical to Study 1, and the same self-report measure was admin- istered. The groups did not differ in internal consisten- cies with regard to the coping strategies. The median Cronbach's alpha was 0.70, indicating adequate internal consistencies for these situation-specific subscales. Data analysis. Again, one-way MANOVAs on adap- tive and maladaptive coping strategies were calculated with subsequent ANOVAs. The two MANOVAs were conducted at the Bonferroni-corrected significance level of p < .025. The effect of the presence of conduct disor- ders was explored by students' t-tests comparing the fol- lowing three groups: hyperactivity without conduct disorders, hyperactivity with conduct disorders, and comparison group. 432 Results Adaptive coping strategies. The one-way MANOVA did not reveal a significant main effect of group: Wilks's F(<reflink idref="bib5" id="ref6">5</reflink>, 82) = 0.97, p = .44, η2 = 0.06. Means and standard deviations for both groups are illustrated in Table 2. Maladaptive coping strategies. A significant group main effect was obtained by the MANOVA: Wilks's F(<reflink idref="bib4" id="ref7">4</reflink>, 83) = 3.00, p = .023, η2 = 0.13 (see Table 2). Univariate ANOVAs yielded significant group effects on passive avoidance, resignation, and aggression, suggesting that the ADHD group scored higher on these maladaptive coping strategies. Post hoc students' t-tests, conducted to locate differ- ences between the ADHD groups with and without con- duct disorders as well as the healthy control group, revealed the following results: Mean comparisons of both ADHD groups failed to show significant differences in coping strategies. However, compared to controls, the ADHD group without conduct disorders had signifi- cantly higher scores on aggression; ADHD-CD: M = 1.68, SD = 0.94; controls: M = 1.20, SD = 0.79; t(<reflink idref="bib68" id="ref8">68</reflink>) = –2.31, p = .024. Furthermore, they reported marginally more resignation; ADHD-CD: M = 1.57, SD = 0.69; controls: M = 1.26, SD = 0.76; t(<reflink idref="bib68" id="ref9">68</reflink>) = –1.77, p = .081. In compari- son with healthy controls, the ADHD group with conduct disorders scored significantly higher on aggression and resignation; aggression: ADHD-CD: M = 1.83, SD = 0.77; controls: M = 0.94, SD = 0.61; t(<reflink idref="bib16" id="ref10">16</reflink>) = –2.71, p = .015; res- ignation: ADHD-CD: M = 1.86, SD = 0.80; controls: M = 1.06, SD = 0.51; t(<reflink idref="bib16" id="ref11">16</reflink>) = –2.54, p = .022. Moreover, they applied marginally more passive avoidance and rumination; passive avoidance: ADHD-CD: M = 1.97, SD = 0.91; con- trols: M = 1.19, SD = 0.68; t(<reflink idref="bib16" id="ref12">16</reflink>) = –2.06, p = .056; rumina- tion: ADHD-CD: M = 2.28, SD = 0.64; controls: M = 1.58, SD = 0.87; t(<reflink idref="bib16" id="ref13">16</reflink>) = –1.93, p = .071. Discussion Study 2 confirmed impaired coping with interpersonal stressors among boys with ADHD in comparison with age- and grade-matched healthy controls, thereby repli- cating the main results of Study 1. In particular, mal- adaptive coping was significantly increased in the clinical group. These results are in agreement with pre- vious research supporting an impaired emotional regula- tion among children with ADHD (Berlin et al., 2004; Braaten & Rosén, 2000; Thompson et al., 2004; Wheeler Maedgen & Carlson, 2000). However, the impaired adaptive coping found in Study 1 could not be replicated. The problem-focused coping strategy situation control was marginally reduced at the univariate level. Post hoc comparisons, which were performed to locate differences in coping between the subgroups of hyperkinetic disorders, revealed interesting results. Consistent with former studies showing impaired emo- tional regulation in boys with ADHD to go along with high aggressive behavior (Melnick & Hinshaw, 2000; Treuting & Hinshaw, 2001), maladaptive coping was more increased in the ADHD group with conduct disor- ders. These results on differences in coping between sub- groups of ADHD are promising because they can guide the development of more individualized psychotherapeu- tic regimens. However, more research is needed to fur- ther clarify differential patterns of emotional regulation in ADHD subgroups. General Discussion Prior research focused on behavioral and cognitive deficits in ADHD and research on how children and ado- lescents regulate emotional stimuli is scarce (Braaten & Rosén, 2000). Those investigating the general emotional well-being of children and adolescents with ADHD indi- cate an impaired quality of life and increased anger, anx- iety, and depression (Bastiaansen et al., 2004a, 2004b; Escobar et al., 2005; Klassen et al., 2004; Sawyer et al., 2002; Thompson et al., 2004; Topolski et al., 2004; Treuting & Hinshaw, 2001). However, the underlying emotional processes responsible for these results remain unclear. Initial studies examining the emotional regula- tion in self-report or experimental studies suggest an impaired emotional regulation, which primarily has been seen in the combined ADHD subtype and the predomi- nantly hyperactive/impulsive ADHD subtype but not in the inattentive ADHD subtype (Wheeler Maedgen & Carlson, 2000). Thus, these and our results support Barkley's hypothesis of a general self-regulation deficit in affect, motivation, and arousal, which should be spe- cific to the ADHD-C and ADHD-H/I subtype (Barkley, 1997). The ability to cope with interpersonal stressors, which is regarded as an essential mechanism of emo- tional processing, has especially been widely neglected, although interpersonal stressors among children and adolescents with ADHD are frequently increased and psychosocial stressors can worsen the course of disease. Moreover, research among healthy children and adoles- cents supports the predictive validity of coping strategies and suggests a close relationship between coping and child development (e.g., Compas et al., 2001). Results of the two studies presented lend support to the assumption that boys with ADHD employ maladap- tive coping on interpersonal stressors. Our findings are in 433 Table 2 Means (M) and Standard Deviations (SD) for Coping Strategies Measured by the German Coping Questionnaire for Group Main Effects and Summary of ANOVA Results for Study 2 *p < .10. **p < .05. ***p < .01. agreement with the results, showing impairments in competencies dealing with emotional situations. In par- ticular, the regulation of negative emotions seems to be affected. Accordingly, Braaten and Rosén (2000) empha- sized the important role of impaired empathy, which may be related to the reduced prosocial behavior and may cause the social rejection often found to be a major prob- lem in ADHD. Impairments in the emotional perception were restricted to simple and negative emotional situa- tions. Moreover, emotional interpretation was decreased and expression was increased. Taken together, our results of an increased maladaptive coping are in agreement with evidence available thus far. In addition, they foster the assumption of an impaired emotional regulation and highlight the role of coping with interpersonal stress as an impaired emotional mechanism in ADHD. Longitudinal correlations reported by Seiffge-Krenke (2000) and cross-correlations between maladaptive cop- ing with interpersonal stressors and anger control prob- lems, emotional distress, and negative self provided by Hampel and Petermann (2006) were found to be sub- stantial, supporting the significant moderating role of this internal resource in child psychopathology. Contradictory results concerning adaptive coping were found in both of our studies. In Study 1, the adap- tive coping strategies of distraction/recreation, positive self-instructions, and social support were significantly decreased in ADHD. In contrast, only a marginally reduced situation control was found in Study 2, which was also demonstrated in Study 1. These inconsistencies may be attributed to different sample characteristics. Besides examining a German sample in contrast to an Austrian sample, the sample in Study 1 consisted of older participants, and post hoc analyses of Study 2 pointed to the assumption that the older age group was affected in particular. Although age effects on coping were not consistently significant, the seeking of social support was less common among the ADHD group consisting of 11- to 13-year-olds than among the younger ADHD group. Furthermore, the majority of the Austrian sample was diag- nosed as predominantly hyperactive/impulsive ADHD sub- type, whereas the German sample included participants of the combined ADHD subtype. Recent studies of emotional regulation do not seem to differentiate the predominantly hyperactive/impulsive ADHD subtype from the combined subtype. The predominantly inattentive ADHD subtype exclusively showed fewer emotional impairments than the combined ADHD subtype (Wheeler Maedgen & Carlson, 2000). Finally, the socioeconomic status differed; we examined a sample with average to low socioeconomic sta- tus in Study 1 and a sample with average to high socioeco- nomic status in Study 2. It is possible that children and adolescents with ADHD and low socioeconomic status may show more substantial impairments in adaptive and maladaptive coping. Thus, further research should be con- ducted to illuminate the important impact of age, subtype, and socioeconomic status. Our second study provides initial evidence of differen- tial coping effects for ADHD subgroups. In agreement with our hypothesis, both clinical groups showed increased mal- adaptive coping compared to healthy peers but effects were more profound among the ADHD group with conduct dis- orders. Additionally, these results are consistent with pre- vious findings from Hinshaw and colleagues (Melnick & Hinshaw, 2000; Treuting & Hinshaw, 2001), suggesting an impaired emotional regulation among the high-aggressive 434 ADHD subgroup in comparison with the low-aggressive ADHD subgroup and healthy controls. Similarly, self- report data on coping with interpersonal stress from Young et al. (2005) suggest that the presence of coexist- ing conduct problems is associated with an increased use of emotional ventilation and blaming others. Some limitations of the present results have to be men- tioned. First, the small sample size precluded an investi- gation of the impact of further moderating factors. Besides assuming an important influence of age, severity of dis- ease could not be considered in the present study, though it has been shown to be important. In a study by Whalen and colleagues (2002), only adolescents with severe ADHD symptomatology were affected in emotional well- being and showed unhealthy lifestyle behaviors. Secondly, our results are limited to boys with ADHD having rather less comorbid disorders. A higher impairment in coping could be expected in more affected samples (cf. Whalen et al., 2002). Thirdly, because of our small number of cases of girls with ADHD, we were not able to include females in the analyses. Thus, our results are restricted to boys with ADHD, although recent research suggests that girls with ADHD, who are at high risk to be misdiagnosed as suffering from other disorders like internalizing prob- lems, also show impairments in emotional regulation (Young et al., 2005). Finally, future studies should incor- porate a fourth group of participants who have conduct disorders but do not show symptoms of ADHD, to detect the isolated and interacting effects of hyperactivity and conduct disorders. In summary, our results support an impaired coping with interpersonal stress among children and adolescents with ADHD compared to healthy controls. Thus, Barkley's assumptions of a general self-regulatory deficit of negative affect in ADHD-C and ADHD-H/I are strengthened by our results. Our findings in Study 2 emphasize the importance of a differentiation of ADHD into subgroups. Extensive research with greater sample sizes of subgroups is needed, to identify patterns of emo- tional regulation differentiated by subgroups with and with- out conduct disorders. Overall, previous evaluation studies have supported the effectiveness of standard psy- chotherapeutic components including behavior therapy and cognitive-behavioral techniques such as training of self- instructions and self-management (e.g., Döpfner et al., 2004; MTA Cooperative Group, 1999; for a critical com- ment on the effectiveness of psychosocial treatments, see Diller & Goldstein, 2006). Our results suggest that cogni- tive-behavioral stress management and social skills train- ing should be applied complementarily (for the effectiveness of social skills training in groups or peer dyads, see Evans, Langberg, Raggi, Allen, & Buvinger, 2005; Hoza, Mrug, Pelham, Greiner, & Gnagy, 2003). We assume that boys with ADHD would benefit from such programs by improving their emotional and social compe- tencies, which are essential protective factors in child devel- opment. Based on those and further studies, more effective treatment regimens could be constructed. These should be matched to the individual's needs and evaluated in future research. As Diller and Goldstein (2006) already empha- sized, psychosocial treatments should be applied particu- larly to children and adolescents with borderline and moderate ADHD. Conclusively, if factors like age, gender, subtype, subgroup of ADHD, and coexisting disorders are considered in the applied treatment, efficacy of treatments may significantly be ameliorated and the persistence of ADHD as well as the development of other externalizing disorders could be prevented. References Achenbach, T.M. (1991). Manual of the Youth Self-Report and 1991 profile . Burlington: University of Vermont, Department of Psychiatry. Barkley, R.A. (1997). Behavioral inhibition, sustained attention, and executive functions: Constructing a unifying theory of ADHD. Psychological Bulletin, 121, 65-94. Barkley, R.A. (1998). Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment (2nd ed.). 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Eisenberg, N., Fabes, R.A., & Losoya, S. (1997). Emotional responding: Regulation, social correlates, and socialization. In P. Salovey & D. J. Sluyter (Eds.), Emotional development and emotional intelligence (pp. 129-163). New York: Basic Books. Escobar, R., Soutullo, C.A., Hervas, A., Gastaminza, X., Polavieja, P., & Gilaberte, I. (2005). Worse quality of life for children with newly diagnosed attention-deficit/hyperactivity disorder, compared with asthmatic and healthy children. Pediatrics, 116, e364-369. Evans, S.W., Langberg, J., Raggi, V., Allen, L., & Buvinger, E.C. (2005). Development of a school-based treatment program for middle school youth with ADHD. Journal of Attention Disorders, 9, 343-353. Faraone, S.V., Biederman J., & Mick, E. (2006). The age-dependent decline of attention-deficit hyperactivity disorder: A meta-analysis of follow-up studies. Psychological Medicine, 36, 159-165. Faraone, S.V., Sergeant, J., Gillberg, C., & Biederman, J. (2003). 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Journal of Adolescent Health, 38, 409-415. Hampel, P., Petermann, F., & Dickow, B. (2001). Stressverarbeitungsfragebogen von Janke und Erdmann angepasst für Kinder und Jugendliche (SVF-KJ) [The German Coping Questionnaire by Janke and Erdmann adapted for children and adolescents]. Göttingen: Hogrefe. Hodgens, J.B., Cole, J., & Boldizar, J. (2000). Peer-based differences among boys with ADHD. Journal of Clinical Child Psychology, 29, 443-452. Hoza, B., Mrug, S., Pelham, W.E., Greiner, A.R., & Gnagy, M. (2003). A friendship intervention for children with attention-deficit/hyperactivity disorder: Preliminary findings. Journal of Attention Disorders , 6, 87-98. Jensen, P.S., Martin, D., & Cantwell, D.P. (1997). Comorbidity in ADHD: Implications for research, practice, and DSM-IV. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 1065-1079. Klassen, A.F., Miller, A., & Fine, S. (2004). Health-related quality of life in children and adolescents who have a diagnosis of attention-deficit/hyperactivity disorder . Pediatrics, 114, 541-547. Kraaij, V., Garnefski, N., de Wilde, E.J., Dijkstra, A., Gebhardt, W., Maes, S., et al. (2003). Negative life events and depressive symptoms in late adolescence: Bonding and cognitive coping as vulnerability factors? Journal of Youth and Adolescence, 32, 185-193. Kutcher, S., Aman, M., Brooks, S.J., Buitelaar, J., van Daalen, E., Fegert, J., et al. (2004). International consensus statement on attention-deficit/hyperactivity disorders (DBB): Clinical implications and treatment practice suggestions . European Neuropsychopharmacology, 14, 11-28. Lazarus, R.S., & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer. Lewis, R., & Frydenberg, E. (2002). Concomitants of failure to cope: What we should teach adolescents about coping. British Journal of Educational Psychology, 72, 419-431. Liu, X., Tein, J.Y., & Zhao, Z. (2004). Coping strategies and behavioral/emotional problems among Chinese adolescents. Psychiatry Research, 126, 275-285. Melnick, S.M., & Hinshaw, S.P. (2000). Emotion regulation and parenting in AD/HD and comparison boys: Linkages with social behaviors and peer preference. Journal of Abnormal Child Psychology, 28, 73-86. MTA Cooperative Group. (1999). A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Archives of General Psychiatry, 56, 1073-1086. Rielly, N.E., Craig, W.M., & Parker, K.C.H. (2006). Peer and parenting characteristics of boys and girls with subclinical attention problems. Journal of Attention Disorders, 9, 598-606. Sawyer, M.G., Whaites, L., Rey, J.M., Hazell, P.L., Graetz, B.W., & Baghurst, P. (2002). Health-related quality of life of children and adolescents with mental disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 530-537. Seidman, L.J., Valera, E., & Makris, N.M. (2005). Structural brain imaging of attention-deficit/hyperactivity disorder. Biological Psychiatry, 57, 1263-1272. 436 Seiffge-Krenke, I. (2000). Causal links between stressful events, coping style, and adolescent symptomatology. Journal of Adolescence , 23, 675-691. Spirito, A., Stark, L.J., Grace, N., & Stamoulis, D. (1991). Common problems and coping strategies reported in childhood and early adolescence. Journal of Youth and Adolescence , 20, 531-544. Steinhausen, H.-C. (1995). Hyperkinetische Störungen—eine klinische Einführung [Hyperkinetic disorders. A clinical introduction]. In H.-C. Steinhausen (Ed.), Hyperkinetische Störungen im Kindes- und Jugendalter (pp. 11-33). Stuttgart: Kohlhammer. Thompson, M.J.J., Brooke, X.M., West, C.A., Johnson, H.R., Bumby, E.J., Brodrick, P., et al. (2004). Profiles, co-morbidity and their relationship to treatment of 191 children with AD/HD and their families. European Child and Adolescent Psychiatry, 13, 234-242. Topolski, T.D., Edwards, T.C., Patrick, D.L., Varley, P., Way, M., & Buesching, D.P. (2004). Quality of life of adolescent males with attention-deficit hyperactivity disorder. Journal of Attention Disorders, 7, 163-173. Treuting, J.J., & Hinshaw, S.P. (2001). Depression and self-esteem in boys with attention-deficit/hyperactivity disorder: Associations with comorbid aggression and explanatory attributional mechanisms. Journal of Abnormal Child Psychology, 29, 23-39. Wadsworth, M.E., & Compas, B.E. (2002). Coping with family conflict and economic strain: The adolescent perspective. Journal of Research on Adolescence , 12, 243-274. Whalen, C.K., Jamner, L.D., Henker, B., Delfino, R.J., & Lozano, J.M. (2002). The ADHD spectrum and everyday life: Experience sampling of adolescent moods, activities, smoking, and drinking. Child Development, 73, 209-227. Wheeler Maedgen, J., & Carlson, C.L. (2000). Social functioning and emotional regulation in the attention deficit hyperactivity disorder subtypes. Journal of Clinical Child Psychology, 29, 30-42. Young, S., Chadwick, O., Heptinstall, E., Taylor, E., & Sonuga-Barke, E.J. (2005). The adolescent outcome of hyperactive girls. Self-reported interpersonal relationships and coping mechanisms. European Child and Adolescent Psychiatry, 14, 245-253. Petra Hampel received her PhD from the Free University of Berlin (Germany) in 1993. She is professor of rehabilitation psychology at the Center of Clinical Psychology and Rehabilitation, University of Bremen, Germany. Her major research interests are stress, coping, adjustment, and stress management in children and adolescents. Simone Manhal is a doctorate student at the Karl-Franzens- University of Graz, Austria, and works in the Department of Psychology. Her major research interests are stress and coping in children and adolescents with ADHD. Thomas Roos received his MD from the University of Hamburg (Germany) in 1994. He is medical director of the Rehabilitation Clinic Neuharlingersiel, Centre for Rehabilitation of Psychosomatics, Allergies, Skin, and Airway Diseases. His major fields of interest are psychosomatics and pharmacology. Christiane Desman received her PhD from the University of Bremen (Germany) in 2005. She works at the Center of Clinical Psychology and Rehabilitation, University of Bremen, Germany. Her major research interests are stress and coping in children and adolescents with ADHD.</p> <aug> <p>By Petra Hampel; Simone Manhal; Thomas Roos and Christiane Desman</p> </aug> <nolink nlid="nl1" bibid="bib4" firstref="ref1"></nolink> <nolink nlid="nl2" bibid="bib1" firstref="ref2"></nolink> <nolink nlid="nl3" bibid="bib5" firstref="ref3"></nolink> <nolink nlid="nl4" bibid="bib68" firstref="ref8"></nolink> <nolink nlid="nl5" bibid="bib16" firstref="ref10"></nolink>
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  Data: <searchLink fieldCode="DE" term="%22Stress+Management%22">Stress Management</searchLink><br /><searchLink fieldCode="DE" term="%22Attention+Deficit+Disorders%22">Attention Deficit Disorders</searchLink><br /><searchLink fieldCode="DE" term="%22Adolescents%22">Adolescents</searchLink><br /><searchLink fieldCode="DE" term="%22Coping%22">Coping</searchLink><br /><searchLink fieldCode="DE" term="%22Males%22">Males</searchLink><br /><searchLink fieldCode="DE" term="%22Interpersonal+Relationship%22">Interpersonal Relationship</searchLink><br /><searchLink fieldCode="DE" term="%22Hyperactivity%22">Hyperactivity</searchLink><br /><searchLink fieldCode="DE" term="%22Foreign+Countries%22">Foreign Countries</searchLink><br /><searchLink fieldCode="DE" term="%22Comparative+Analysis%22">Comparative Analysis</searchLink><br /><searchLink fieldCode="DE" term="%22Children%22">Children</searchLink><br /><searchLink fieldCode="DE" term="%22Antisocial+Behavior%22">Antisocial Behavior</searchLink><br /><searchLink fieldCode="DE" term="%22Interpersonal+Competence%22">Interpersonal Competence</searchLink><br /><searchLink fieldCode="DE" term="%22Behavior+Problems%22">Behavior Problems</searchLink><br /><searchLink fieldCode="DE" term="%22Stress+Variables%22">Stress Variables</searchLink>
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  Data: 10.1177/1087054707299337
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  Data: Objective: The authors investigate self-reported coping with interpersonal stressors among boys with and without ADHD in two studies and provide initial evidence for effects of different subgroups of ADHD on coping in Study 2. Method: In Study 1, 20 Austrian adolescents with ADHD were compared to 20 healthy controls. In Study 2, 44 German children and adolescents with ADHD (35 without and 9 with conduct disorders) were compared to 44 healthy controls matched by age and grade level, respectively. Results: Increased maladaptive coping was found in both studies. Study 2 revealed heightened maladaptive coping among both subgroups of ADHD, but the subgroup of ADHD with conduct disorders was more affected compared to healthy controls than the subgroup with ADHD alone. Conclusion: Results suggest an impaired interpersonal coping style in ADHD and point to the potential benefit of stress management and social skills trainings for boys with ADHD. (Contains 2 tables.)
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