*These authors contributed equally to this work.
People with attention-deficit/hyperactivity disorder (ADHD) exhibit considerable impairment in social, academic, or occupational functioning. The present study aimed to examine the patterns of associations between ADHD symptoms, depression, and family functioning.
The sample consisted of 1,022 adults randomly selected from a district in Seoul, South Korea. Several self-assessment scales were utilized to rate ADHD symptoms (both past and current), current symptoms of depression, and level of family functioning. ADHD symptoms in the children of these participants were also assessed. Pearson's correlation and multiple linear regression analyses were performed; structural equation modeling (SEM) was conducted to determine the best fitting model.
Adult ADHD symptoms were positively associated with depressive symptoms. Depressive symptoms, in turn, mediated the relationship between adult ADHD symptoms and cohesion among family members. In addition, depressive symptoms mediated the relationship between adult ADHD symptoms and their children's ADHD symptoms.
The relationship between adult ADHD symptoms and family dysfunction may be influenced by depressive symptoms. When treating ADHD in adults, clinicians should pay attention to the presence or absence of depression.
Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder with a symptom complex of inattention, hyperactivity, and impulsivity, affecting about 3-7% of school-aged children, according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV).
Childhood ADHD has been reported to show significant correlation with other psychiatric disorders later in adulthood, including mood and anxiety disorders, antisocial personality disorders, substance use disorders, eating disorders, and sleep disorders.
We evaluated both the current and past severity of ADHD symptoms in a general population of adults. For a comorbid psychiatric disorder, we chose to evaluate the degree of depression, and as an indicator reflecting environmental consequences of the person's functional maladaptation, we chose to evaluate the level of family functioning. The objective of this study was to identify the patterns of interplay among ADHD symptoms, depression, and family functioning in adults. Possible hypothetical models would include, depressive symptoms mediating the relationship between ADHD symptoms and family functioning, or family functioning mediating the other two, or all three directly influencing one another. We also included in our survey the severity of ADHD symptoms found in children of our adult participants, considering the fact that biological offspring of ADHD parents are at higher risk of developing ADHD themselves,
Participants were 1,022 adults living in the Jung-gu district, one of the 25 districts in Seoul, Korea, with a population of over 130,000. They were randomly selected from the general population of the district in collaboration with the Korea Data Network, a professional survey research company, under the administrative support of the local government office, which provided the addresses of its residents. The investigators visited their homes, provided a detailed explanation of the purpose of the study, obtained informed consent from eligible participants, distributed the questionnaires, and collected them on the same day. The questionnaire covered the following assessments, and those participants who had one or more children attending elementary school were also asked to complete an additional questionnaire inquiring about ADHD symptoms in their children. The institutional review board approval was obtained.
The Wender Utah Rating Scale (WURS)
Lee had also introduced a new questionnaire assessing childhood symptoms of ADHD.
The Center for Epidemiologic Studies Depression Scale (CES-D) is an adult self-reporting instrument containing 20 items designed to measure the degree of depressive symptoms experienced within the past week.
The Family Adaptability and Cohesion Evaluation Scale (FACES III),
The Korean ADHD Rating Scale (K-ARS) is a translated version of the ADHD Rating Scale (ARS),
Pearson's correlation tests were performed between each pair of the above-mentioned scale scores using SPSS 19.0 software (SPSS Inc., Chicago, IL, USA). Structural equation modeling (SEM) was conducted with AMOS 5.0 (SmallWaters, Chicago, IL, USA) to determine the best fitting model. The model fit was based on generally accepted thresholds for the root mean square error of approximation (RMSEA), normed fit index (NFI), incremental fit index (IFI), comparative fit index (CFI), goodness of fit (GFI), and adjusted goodness of fit (AGFI). The RMSEA assesses closeness of fit, with values approximating 0.08, 0.05, and 0 indicating reasonable, close, and exact fits, respectively.
One thousand twenty-two adults, comprising 507 (49.6%) men and 515 (50.4%) women, participated in this study. Their age distribution was as follows: 24.9% in their 20s, 24.6% in their 30s, 21.4% in their 40s, 16.7% in their 50s, and 12.4% in their 60s. Among the total participants, 721 (70.5%) were married, and 506 (49.5%) had graduated from high school.
The mean scores of the K-ADHD-Current and -Past were 54.6±19.5 and 24.0±9.2, respectively. The mean CES-D-K score was 17.0±7.4, which is below the customary cutoff score of 23, a suggested threshold for indicating a major depressive disorder.
The K-ADHD-Current score of the adult participants positively correlated with their scores on the K-ADHD-Past, the CES-D-K, the FACES III adaptability, and the K-ARS of their children (
The final models of the SEM are shown in
In the subsequent model including the offspring's ADHD symptoms, significant path from the adult ADHD to their children's ADHD symptoms was partially mediated by the CES-D-K scores of the parents (
Using the CES-D-K score as the outcome variable, the K-ADHD-Past and -Current scores showed significant associations. Using the cohesion subscore from the FACES III as the outcome variable, the CES-D-K scores but not the K-ADHD-Past and -Current scores showed significant association. Using the K-ARS score of the children as the outcome variable, the K-ADHD-Past and the CES-D-K scores showed significant associations. These findings detailed in
As supplemental tests, male and female adult participants were analyzed separately. Then, in males, only the K-ADHD-Past score (B=0.59, p=0.00, 95% CI=0.32, 0.85) remained significantly associated with the K-ARS score of their children. However, in females, the CES-D-K score (B=0.40, p=0.00, 95% CI=0.13, 0.66), and the cohesion (B=-0.38, p=0.03, 95% CI=-0.73, -0.03) and adaptability (B=0.50, p=0.01, 95% CI=0.11, 0.89) subscores from the FACES III were significantly associated with the K-ARS score of their children (
The present study aimed to examine the patterns of interplay among ADHD symptoms, depression, and family functioning in a general population of adults. We used both the past childhood and current adulthood ADHD symptoms to construct the latent variable of adult ADHD, given that the presence of childhood ADHD symptoms is required for the diagnosis of ADHD in adults. As a result, adult ADHD was associated with depressive symptoms. Symptoms of adult ADHD being directly related to concurrent depression is in accordance with the reports on high comorbidity rates of ADHD and depression.
Adult ADHD symptoms were both directly and indirectly related to ADHD symptoms found in their children. The direct relationship might reflect a genetic link, since the heritability of ADHD is among the highest compared to other psychiatric disorders.
It is also noteworthy that depression was inversely associated with family cohesion, but no significant path was observed between family cohesion and the offspring's ADHD symptoms. When interpreting this negative finding, however, caution may need to be taken. In families with higher FACES III cohesion or adaptability scores, parents tended to underestimate the severity of ADHD symptoms in their children.
The multiple regression analyses also replicated the results from our SEM. Interestingly, however, when regression analyses were performed separately in each sex, only the past ADHD symptoms remained significantly associated in males (
The major limitations of this study include the followings. First, it was a cross-sectional study, which had a key shortcoming in assessing the causal relationships. Prospective studies are required to confirm our inferences discussed above. Second, all of the measures in this study were self- or parent-reported, which are prone to reporter bias, and no formal diagnosis was made of either ADHD or depressive disorder. And third, considering the remarkably higher rates of comorbid major depressive disorder in community samples of ADHD youth,
Many have reported associations between ADHD, either in the parent or in the child, and disturbances in family functioning.
The research was performed with the annual budget of the Jung-gu Community Mental Health Center run by the Korean government.
Multiple linear regression of the ADHD, depression, and family functioning scores of adult participants on the ADHD symptom score of their children
Structural equation modeling among the ADHD, depression, and family functioning scores of adult participants. All values are standardized regression weights. *p<0.05, ***p<0.001. The model showed an acceptable fit to the data (RMSEA=0.056, IFI=0.977, NFI=0.970, CFI=0.977, GFI=0.970, AGFI=0.952). ADHD: attention-deficit/hyperactivity disorder, RMSEA: root mean square error of approximation, IFI: incremental fit index, NFI: normed fit index, CFI: comparative fit index, GFI: goodness-of-fit index, AGFI: adjusted goodness-of-fit index.
Structural equation modeling among the ADHD, depression, and family functioning scores of adult participants, and the ADHD symptom score of their children. All values are standardized regression weights. **p<0.01, ***p<0.001. The model showed an acceptable fit to the data (RMSEA=0.083, IFI=0.943, NFI=0.903, CFI=0.942, GFI=0.902, AGFI=0.855). ADHD: attention-deficit/hyperactivity disorder, RMSEA: root mean square error of approximation, IFI: incremental fit index, NFI: normed fit index, CFI: comparative fit index, GFI: goodness-of-fit index, AGFI: adjusted goodness-of-fit index.
Pearson correlations among the ADHD, depression, and family functioning scores of adult participants, and the ADHD symptom score of their children
*p<0.05, **p<0.01, ***p<0.001. ADHD: attention-deficit/hyperactivity disorder, K-ADHD-Past: a Korean ADHD questionnaire-Past childhood status, K-ADHD-Current: Korean ADHD questionnaire-Current adulthood status, CES-D-K: Korean version of the Center for Epidemiologic Studies Depression Scale, FACES III: Family Adaptability and Cohesion Evaluation Scale, K-ARS: Korean version of the ADHD Rating Scale
Structural equation modeling among the ADHD, depression, and family functioning scores of adult participants, and the ADHD symptom score of their children
*p<0.05, **p<0.01, ***p<0.001. ADHD: attention-deficit/hyperactivity disorder, B: unstandardized regression coefficient, β: standardized regression coefficient (direct effect), CR: critical ratio, CES-D-K: Korean version of the Center for Epidemiologic Studies Depression Scale, FACES III: Family Adaptability and Cohesion Evaluation Scale, K-ARS: Korean version of the ADHD Rating Scale, SE: standard error
Multiple linear regressions among the ADHD, depression, and family functioning scores of adult participants, and the ADHD symptom score of their children
*p<0.05, **p<0.01, ***p<0.001. No variance inflation factor was greater than 1.66 (CES-D-K), 2.37 (FACES III Cohesion), and 3.39 (K-ARS), respectively. Adjusted R2s were 0.37 (CES-D-K), 0.12 (FACES III Cohesion), and 0.27 (K-ARS), respectively. For all three models, p values for F statistics were below 0.001. ADHD: attention-deficit/hyperactivity disorder, B: unstandardized regression coefficient, CI: confidence interval, K-ADHD-Past: Korean ADHD questionnaire-Past childhood status, K-ADHD-Current: Korean ADHD questionnaire-Current adulthood status, CES-D-K: Korean version of the Center for Epidemiologic Studies Depression Scale, FACES III: Family Adaptability and Cohesion Evaluation Scale, K-ARS: Korean version of the ADHD Rating Scale, SE: standard error