Research in Developmental Disabilities 113 (2021) 103944

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Research in Developmental Disabilities

journal homepage: www.elsevier.com/locate/redevdis

Health-related quality of life in mothers of children with attention

deficit hyperactivity disorder in Taiwan: The roles of child, parent,
and family characteristics
Sophie Hsin-Yi Liang a, b, Yi-Chen Lee c, *, Brent Allan Kelsen d,
Vincent Chin-Hung Chen e, f
a
Section of Department of Child and Adolescent Psychiatry, Department of Psychiatry, Chang Gung Memorial Hospital at Taoyuan, Taiwan
b
Department of Psychiatry, Chang Gung University College of Medicine, Taoyuan, Taiwan
c
School of Occupational Therapy, National Taiwan University, Taipei, Taiwan
d
Language Center, National Taipei University, New Taipei City, Taiwan
e
Department of Psychiatry, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan
f
School of Medicine, Chang Gung University, Taoyuan, Taiwan

A R T I C L E I N F O A B S T R A C T

The paper is part of a special issue on Parental Background: No study has examined how child and maternal psychopathological difficulties and
Involvement. family factors contribute to the health-related quality of life (HRQOL) of mothers of children with
attention deficit hyperactivity (ADHD).
Keywords: Aims: To investigate the impact of children’s diagnosis of ADHD, children’s and maternal psy­
Health-related quality of life
chopathology and significant sociodemographic variables of the children, parents and family on
Parents
HRQOL of mothers of children with ADHD and those of children with typical development (TD) in
Mothers
Children Taiwan.
Adolescents Methods and procedures: Children with ADHD (n = 257) and children with typical development (n
Attention deficit hyperactivity disorder = 324) and their mothers were recruited from a psychiatric clinic of a medical center and 10
Psychopathology elementary schools and four high schools in northern Taiwan. Maternal HRQOL was assessed with
the World Health Organization Quality of Life – BREF, while the other factors were screened using
the Chinese version of the Childhood Autism Spectrum Test for autistic traits, the Swanson,
Nolan, and Pelham, version IV scale for ADHD symptoms, the Child Behavior Checklist for
behavioral and emotional problems, The Center for Epidemiologic Studies Depression Scale for
maternal depression and interpersonal problems, the Adult ADHD Self-report Scale for maternal
ADHD symptoms, and the Family APGAR for family support.
Outcomes and results: Mothers of children with ADHD had significantly worse HRQOL in all four
domains compared with those of children with typical development. Multiple regressions found
that factors consistently related to the HRQOL of mothers of children with ADHD and those of
children with TD were maternal depression and perceived family support after controlling for
several familial, parental and child variables. HRQOL of mothers of children with ADHD and
those of children with TD was more closely related to her own and family factors rather than
mother- or teacher-rated ADHD symptoms, clinical diagnosis of ADHD or psychopathology of the
child.

* Corresponding author at: School of Occupational Therapy, National Taiwan University, 4F., No.17, Xuzhou Rd., Zhongzheng Dist., Taipei City
100, Taiwan.
E-mail address: peggylee599@gmail.com (Y.-C. Lee).

https://doi.org/10.1016/j.ridd.2021.103944
Received 21 September 2020; Received in revised form 10 March 2021; Accepted 19 March 2021
Available online 6 April 2021
0891-4222/© 2021 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
S.H.-Y. Liang et al. Research in Developmental Disabilities 113 (2021) 103944

Conclusions and implications: Screening for maternal HRQOL, depressive symptoms and family
support systems and mental health services for mothers of children with ADHD are warranted
based on these findings.

What this paper adds?

This paper addressed the roles of child, parental and family factors in HRQOL of mothers of children with ADHD and found higher
levels of maternal depression and low perceived family support were associated with poor HRQOL in mothers of children with ADHD.
Comprehensive family-centered intervention for children with ADHD and their mothers is warranted, especially addressing prevention
or intervention for maternal depression and family support.

1. Literature review

Attention deficit hyperactivity disorder (ADHD) is one of the most prevalent childhood disorders with worldwide prevalence rates
in community studies ranging from 2.2–7.2% (Sayal, Prasad, Daley, Ford, & Coghill, 2018). In addition to the core symptoms of
inattention, hyperactivity, and impulsivity (American Psychiatric Association, 2013), children and adolescents with ADHD have been
reported to have impairments in a wide range of academic, familial and social contexts. These include problems with interpersonal
relationships, conflictual parent-child interaction, high risk for accident injury and problem behaviors such as substance use, academic
underachievement and employment difficulties across the life span (Hinshaw, 2018), resulting in reduced health-related quality of life
(HRQOL) (Lee et al., 2016). Parenting children with ADHD can be stressful and may involve threats to parents’ physical and psy­
chological health as well as marital and social well-being (Corcoran, Schildt, Hochbrueckner, & Abell, 2017, 2017b).
Quality of life has been defined as “an overall general well-being that comprises objective descriptors and subjective evaluations of
physical, material, social, and emotional well-being together with the extent of personal development and purposeful activity, all
weighted by a personal set of values” (Felce & Perry, 1995), while HRQOL concerns the health aspects of quality of life (Karimi &
Brazier, 2016). HRQOL is defined as levels of one’s functions in his or her life and the subjective feelings of well-being in physical,
mental and social domains of health (Hays & Reeve, 2010). HRQOL has become an important goal in health care practice and research
including for children with ADHD. However, the impacts of having a child with ADHD on parental HRQOL remain under investigated
(Dey, Paz Castro, Haug, & Schaub, 2019). A social ecological perspective recognizes the inter-relatedness and dynamic nature of
interpersonal interaction among family members (Armstrong, Birnie-Lefcovitch, & Ungar, 2005; Witt & DeLeire, 2009). Stress on, or
change in, any person in the family may have an impact on the other family members.
Traditionally, ethnic Chinese mothers in Taiwan provide a secure and loving environment within the home and an intense,
enduring emotional relationship with their children (Chao & Tseng, 2002). However, both children and adolescents with ADHD and
their mothers in Taiwan reported decreased maternal affection/care and perceived worse family function than those without ADHD
and their mothers (Gau, 2007; Gau & Chang, 2013).
Ethnic Chinese families in Taiwan have been influenced by Confucianism and collectivism which values filial piety and family
hierarchy in parent-child relationships as reflected in children’s respect and obedience of parental demands and authority (Leung,
Wong, Wong, & McBride-Chang, 2010) and parental roles in the development of children’s proper social behaviors as well as academic
excellence (Huang & Gove, 2015). Mothers in Taiwan hold the primary responsibility for their children’s early training of socially
appropriate behaviors and academic competence (Chao, 1994). Training, “guan” or “chiao shun” are indigenous styles of parental
control for Taiwanese, which can be translated as “to govern the child with a firm control” and act as a preventive approach for child’s
misbehavior, and have very positive connotations of parental care, concern, love and involvement in child rearing practices in Taiwan
(Chao, 1994; Chao & Tseng, 2002). Mothers, or caregivers in Taiwan will continuously monitor, teach or correct children’s behaviors
and academic or extracurricular achievement by appraising whether children are meeting their expectations or standards across
contexts, and by comparing children to each other. Without guan, control or governance of the child, mothers or caregivers would be
blamed as negligent, uncaring, or not fulfilling their responsibilities (Chao & Tseng, 2002). Therefore, this study investigated HRQOL
of mothers of children with ADHD compared with those of children with typical development (TD) in Taiwan.
Although a few studies investigated the HRQOL of caregivers of children with ADHD and found negative impacts of children’s
ADHD on parental HRQOL, several methodological issues in these studies raised concerns in interpreting the results. Concerns
included lack of a comparable control group (Azazy, Nour-Eldein, Salama, & Ismail, 2018; Xiang, Luk, & Lai, 2009), unclear diagnostic
criteria of children’s ADHD (Lee, Harrington, Louie, & Newschaffer, 2008) and small sample sizes of participants (i.e., around 100 or
less) (Avrech Bar, Jlole Majadla, & Bart, 2015; Hadi, Saghebi, Ghanizadeh, & Montazeri, 2013; Kandemir, Kiliç, Ekinci, & Yüce, 2014;
Schreyer & Hampel, 2009; Zare, Jafari, & Ghanizadeh, 2017). Two previous studies showed that children’s ADHD had a negative
impact on parental HRQOL as compared to unaffected controls (Lee et al., 2008) or a regional norm (Xiang et al., 2009). Children’s
variables (e.g., severity of ADHD or socioemotional symptoms) and several sociodemographic variables (e.g., education, age, incomes
or marital status) of parents were related to caregiver’s HRQOL (Azazy et al., 2018; Xiang et al., 2009).
Chen et al. (2014) further explored the role of maternal inattention and hyperactivity symptoms, depression and perceived family
support in the relationship of HRQOL of mothers of children in an elementary school. HRQOL of mothers of school-aged children was
more related to the mother’s own variables (e.g., ADHD symptoms or depression) and family factors (i.e., incomes and perceived
family support) instead of children’s variables such as parent-rated ADHD symptoms (Chen et al., 2014). However, Chen and

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colleagues’ study (2014) recruited parents and children from an elementary school and measured children’s ADHD symptoms and
parental ADHD and depression using parent self-reports. Lack of a clinical sample of children with ADHD and problems of shared
method variance (i.e., reports of children’s ADHD, parental depression and perceived family support all by parent self-report) limited
the generalizability of the results (Chen et al., 2014). Therefore, this study replicates and extends Chen et al. study (2014) by including
a group of children with ADHD diagnosis following DSM-5 criteria and a group of controls and having both parent- and teacher-reports
of children’s ADHD symptoms. In addition, this study further examines the effects of levels of children’s autistic traits, symptoms of
oppositional defiant disorder, emotional and behavioral problems, as well as subtype and medication of children’s ADHD on HRQOL of
mothers of children with ADHD and those of children with TD.

2. Methods

2.1. Participants

Participants were recruited from February 2016 to March 2019. Children with ADHD and their mothers were recruited from a child
psychiatric clinic of a university-affiliated hospital in northern Taiwan through fliers and posters. Children with TD and their mothers
were recruited from ten elementary schools and four junior high schools in northern Taiwan by invitation. A child or adolescent aged
between 6 and 15 was eligible if he or she received a diagnosis of ADHD utilizing the DSM-5 diagnostic system by a psychiatrist’s
interview (American Psychiatric Association, 2013). Caregiver depression has been described as leading to overreport of child
behavior problems (Gartstein, Bridgett, Dishion, & Kaufman, 2009). Gartstein et al.’s study showed a modest effect of mother’s
depression influence on the overreport of children’s behavior problems. They suggested the need to consider multiple influences on
parental perceptions of child behavior and psychopathology in research and clinical settings in order to reduce the potential impact of
mother-related depression impacting perceptions toward their child’s behavior (Chi & Hinshaw, 2002). Therefore, ADHD diagnosis
procedure included comprehensive assessment (i.e., in-depth psychiatric interview and evaluation of medical, developmental,
educational and psychosocial areas with multiple informants including reports from family, schools and psychologists). Psychiatric
diagnostic interviews were conducted by senior child psychiatrists with Broad certification in our research team. In addition, high
correlation between maternal reported and teacher reported SNAP-IV (r = .68 for inattention subscale, r = .63 for hyperactivity
subscale, and r = .48 for oppositional subscale, all p < .001, N = 581) in this study confirmed the validity of maternal ratings of child
ADHD symptoms and lessened the potential susceptibility of maternal depression symptoms on reports of children’s ADHD symptoms.
The diagnosis of ADHD, subtypes of ADHD and psychiatric comorbidities (such as autism spectrum disorder, anxiety disorder and
tic disorder) were made during the psychiatric interview based on the criteria of DSM-5. Children with other neuropsychiatric dis­
orders such as bipolar disorder, schizophrenia, obsessive compulsive disorder, pervasive developmental disorder, serious medical
conditions or sensory disorders were excluded because these conditions might influence the HRQOL of their mothers. In addition,
screening of children with TD were included if the children had (1) diagnosis of ADHD and medication, (2) physical or psychiatric
condition, developmental or learning related diagnosis and (3) disability certification by the Taiwanese government. The Research
Ethics Committee (IRB) of Chang Gung Memorial Hospital, Linkou approved this study prior to the start of data collection. For par­
ticipants in schools, a package of questionnaires along with an informed consent letter was taken home by the students. After being
completed by the mothers at home, the questionnaires were returned to the teachers by the students. Since we aimed to investigate the
HRQOL of mothers and exclude fathers/non-mothers, a decision which was made a priori, reports of non-mother responders including
31 fathers and 7 non-parents were excluded from this study. The sample size of this study was estimated based on our previous pilot
study (Chen et al., 2014) with an alpha level of 0.05 and a power level of 0.80. We did not include participants from a prior publication
(Chen et al., 2014) in this study.

2.2. Instruments

This report forms a part of a study comparing mother and child HRQOL between a group of children with ADHD and that of children
with TD and examining significant child, parent and family factors associated with child and maternal HRQOL. Except for children’s
HRQOL as measured by child reported and parent reported PedsQL, the other measures of child, parent and family variables are
reported in this study.

2.2.1. Child variables

2.2.1.1. The Swanson, Nolan, and Pelham rating scale version IV (SNAP-IV). The Chinese version of SNAP-IV was used and rated by
parents and teachers to assess the core symptoms of ADHD including 9 items for inattention, 9 items for hyperactivity/impulsivity, and
8 items for oppositional symptoms. The total score of inattention, hyperactivity/impulsivity and oppositional subscales were used in
this study. Higher scores of the subscales indicate higher levels of symptoms. The Chinese SNAP-IV demonstrated satisfactory
test–retest reliability (intraclass correlation = 0.59 ~ 0.72 parent report, 0.60 ~ 0.84 teacher report), internal consistency (alpha =
0.88 ~ 0.90 parent report, 0.88 ~ 0.95 teacher report), and concurrent validity (Pearson correlations = 0.42 ~ 0.67 parent report, 0.61
~ 0.84 teacher report with Strengths and Difficulties Questionnaires) (Gau et al., 2008, 2009). The internal consistency of maternal
report of participants in this study was Cronbach alpha 0.92 ~ 0.94 and teacher report 0.94 ~ 0.96.

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2.2.1.2. Child Behavior Checklist (CBCL). The CBCL for ages 6–18 assesses a child’s behavior and emotional problems and compe­
tencies (Achenbach & Rescorla, 2001). The Chinese version of CBCL has been validated and found to have excellent psychometric
properties with internal consistency of Cronbach alpha 0.55 ~ 0.90 and one-month test-retest reliability ICC 0.51 ~ 0.74 (Rescorla
et al., 2007; Yang, Chen, & Soong, 2001). Confirmatory factor analysis based on Achenbach’s cross-informant syndrome model found
that GFI = 0.726, AGFI = 0.709 and RMR = 0.0637. The internal consistency of participants in this study was 0.74 ~ 0.92. The Chinese
version of anxious/depressed, somatic complaints, delinquent behavior, aggressive behavior and attention problems subscales was
used in this study. Excluding certain CBCL subscales based on previous literature was made a priori. Higher scores of these subscales
indicated higher levels of problem behaviors or symptoms.

2.2.1.3. Childhood Autism Spectrum Test (CAST). The CAST is a parent report tool to obtain a child’s level of autistic traits. There are
39 items covering the three domains of autistic spectrum disorder (i.e., social interaction, communication, and restriction in activity
and interest) (Scott, Baron-Cohen, Bolton & Brayne, 2002; Sun et al., 2014). The Chinese version of the CAST was examined with 737
school-aged children and 50 children with autistic spectrum disorder and found a good-fit for a model with a two-factor solution
including social and communication, and inflexible/stereotyped language and behaviors (Goodness of fit indices: RMSEA = 0.029, CFI
= 0.957, TLI = 0.950, SRMR = 0.064) (Sun et al., 2014). The 2–4 month test-retest reliability of 70 parents was good (kappa = 0.64)
(Sun et al., 2013). The internal consistency of participants in this study had a Cronbach alpha of 0.57. The higher the score on the CAST
the higher the probability of having more autistic features.

2.2.2. Parent variables

2.2.2.1. The World Health Organization Quality of Life - BREF (WHOQOL-BREF). The WHOQOL-BREF is used to obtain one’s subjective
perceptions of HRQOL (Skevington, Lotfy, & O’Connell, 2004). The Taiwanese version of the WHOQOL-BREF has two items of local
importance (i.e., feeling respected and favorite food accessibility) and 26 items in total (The WHOQOL-Taiwan Group, 2000a, 2000b).
Exploratory and confirmatory factor analyses found a four-factor (i.e., physical, psychological, social and environmental) model and
the 2–4 week test-retest reliability ranged from 0.76 to 0.80 (The WHOQOL-Taiwan Group, 2000a, 2000b). The internal consistency
coefficient (Cronbach alpha) of participants in this study ranged from 0.52 to 0.85. Item 26 “perception of negative feeling” in the
psychological domain overlapped with the item “I feel sad” in the Chinese version of The Centre for Epidemiologic Studies Depression
Scale (CESD-C). Internal consistency of the psychological domain was Cronbach alpha .60 (6 items), and .84 (5 items) after deleting
item 26. The items in the social domains of WHOQOL-BREF such as “satisfaction with support from friends (item 22)” and “satisfaction
with one’s interpersonal relationship (item 20)” measured constructs closely related to interpersonal problems, and perceived family
support. Internal consistency of the social domain was Cronbach alpha .80 (4 items), and .62 (2 items) after deleting items 20 and 22.
WHOQOL-BREF has been widely used across different populations in Taiwan including mothers of school-aged children (Chen et al.,
2014). Four domains of HRQOL are included: Physical Capacity (7 items), Psychological Well-being (6 items), Social Relationship (4
items), and Environment (9 items) in the WHOQOL-BREF. All items are rated on a 5-point Likert scale and a higher score indicates a
higher HRQOL.

2.2.2.2. Adult ADHD Self-report Scale (ASRS). The ASRS is an 18-item scale for reporting the frequency of inattention and
hyperactivity-impulsivity symptoms in the past six months. The items of ASRS are developed mapped on the DSM-IV diagnostic criteria
of adult ADHD. The Chinese version of ASRS was translated and validated with 4,329 adult participants in Taiwan (Yen, Gau, Kessler,
& Wu, 2008). Two-week test-retest reliability (intraclass correlations = 0.80 ~ 0.85) and internal consistency (Cronbach’s alpha =
0.83 ~ 0.91) among the ASRS subscales were good and reported moderate to high correlations between the subscales and the Wender
Utah Rating Scale (Pearson’s correlations = 0.37 ~ 0.66). The internal consistency coefficient (Cronbach alpha) of participants in this
study ranged from 0.88 to 0.90. A higher score in ASRS subscales means a higher level of inattention and hyperactivity-impulsivity
symptoms.

2.2.2.3. Chinese version of The Centre for Epidemiologic Studies Depression Scale (CESD-C). The CESD-C is used to report levels of
depressive symptoms and interpersonal problems in the previous week on a 5-point Likert scale (Cheung & Bagley, 1998; Chien &
Cheng, 1985; Radloff, 1977; Ross & Mirowsky, 1984). Results of a study examining use of CESD-C for screening depression in com­
munity participants showed good sensitivity and specificity; that is 92 % and 91 %, respectively, with a classification rate of 91.8 % at a
cut-off point of 15 (Chien & Cheng, 1985). The internal consistency of the participants in this study had Cronbach’s alpha of 0.89
(depression subscale) and 0.69 (interpersonal problem subscale). Item 18 “I feel sad” overlapped with one item in the psychological
domain of WHO-QOL. The internal consistency of the participants in this study had Cronbach’s alpha of 0.88 after deleting item 18
(depression subscale).

2.2.3. Family variables

2.2.3.1. The Family Adaptation, Partnership, Growth, Affection, Resolve (The Family APGAR). The Family APGAR was used to report
one’s level of satisfaction with family support and communication (Good, 1979). Higher scores mean worse support and communi­
cation. The Chinese version of Family APGAR has been found to be reliable with maternal reports (4-week test-retest reliability ICC =
0.69) and discriminate the ADHD group from the non-ADHD group (Gau & Chang, 2013) in Taiwan. The internal consistency of the

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Table 1
Demographic and clinical characteristics between children with ADHD and children with TD.
Children with ADHD Children with TD Comparison

Variables n % Mean (SD) n % Mean (SD) X2/t (df) Cohen’s da

Child characteristics
Gender
Boy 218 84.8% 166 51.2% 72.16 (1)***
Girl 39 15.2% 158 48.8%
Grade
Grade 1− 3 111 43.2% 86 26.5% 20.73 (2)***
Grade 4− 6 89 34.6% 123 38.0%
Grade 7− 9 57 22.2% 115 35.5%
Developmental problems or disease
Yes 90 35.2% 3 0.9% 124.46 (1)***
No 166 64.8% 321 99.1%
Disability certificationb
Yes 7 2.7% 0 0 8.97 (1)**
No 249 97.3% 324 100%
Sleep Problems
Yes 48 18.8% 8 2.5% 43.52 (1)***
No 207 81.2% 315 97.5%
ADHD Subtypes
PI 76 29.6% – –
HI 11 4.3% – –
Combined 170 66.1% – –
ADHD Medication
Never 33 12.9% – –
Ever used 8 3.1% – –
Current use 214 83.9% – –
Child’s Age (years) 257 10.50 (2.51) 324 11.36 (2.40) 4.20 (579)*** .35

Children with ADHD Children with TD Comparison

Variables n % Mean (SD) n % Mean (SD) X2/t (df) Cohen’s da

Child Symptoms
IA (Mother SNAP) 257 14.78 (5.57) 324 6.02 (4.96) − 20.03 (579)*** 1.66
HI (Mother SNAP) 257 10.85 (5.89) 324 3.48 (3.94) − 17.24 (426.79)*** 1.47
OP (Mother SNAP) 257 9.91 (5.82) 324 4.47 (4.14) − 12.67 (446.11)*** 1.08
IA (Teacher SNAP) 257 13.63 (6.00) 324 2.92 (4.51) − 23.76 (463.07)*** 2.02
HI (Teacher SNAP) 257 4.37 (2.97) 324 .54 (1.50) − 15.32 (377.33)*** 1.63
OP (Teacher SNAP) 257 8.78 (6.72) 324 1.62 (3.71) − 11.29 (390.02)*** 1.32
Autistic Traits (Mother CAST) 257 11.12 (5.33) 324 5.80 (3.42) − 13.91 (415.06)*** 1.28
IA (Mother CBCL) 257 8.78 (6.72) 324 1.62 (3.71) − 15.32 (377.33)*** 1.32
AD (Mother CBCL) 257 13.63 (6.00) 324 2.92 (4.51) − 23.76 (463.07)*** 2.02
SC (Mother CBCL) 257 4.37 (2.97) 324 .54 (1.50) − 18.89 (359.30*** 1.63
DB (Mother CBCL) 257 2.49 (2.84) 324 .35 (1.26) − 11.27 (335.56)*** .97
AB (Mother CBCL) 257 6.23 (5.80) 324 1.63 (3.38) − 11.29 (390.02)*** .97
Parental characteristics
Maternal Work
Full time 155 62.2% 260 80.5% 25.99 (2)***
Part time 32 12.9% 14 4.3%
No work or housewife 62 24.9% 49 15.2%

Children with ADHD Children with TD Comparison

Variables n % Mean (SD) n % Mean (SD) X2/t (df) Cohen’s da

Paternal Work
Full time 228 95.0% 310 97.2 % 3.74 (2)
Part time 10 4.2% 5 1.6%
No work 2 0.8% 4 1.3%
Maternal Education
College or above 139 55.2% 196 60.7% 1.78(1)
High school or below 113 44.8% 127 39.3%
Paternal Education
College or above 108 43.5% 131 40.8% 13.72 (1)***
High school or below 140 56.5% 190 59.2%
Maternal Age 250 40.02 (5.39) 318 40.08 (4.46) .13 (480.40) .01
Paternal Age 243 42.66 (6.13) 314 43.08 (5.27) .86 (555) .07
Maternal Symptoms
Depression (CES-D all except Q15 + Q19) 257 14.31 (8.84) 324 9.71 (6.66) − 6.93 (464.09)*** .59
Interpersonal Problems (CES-D Q15 + Q19) 257 .84 (1.13) 324 .55 (.95) − 3.31 (501.12)** .28
IA (ASRS) 257 11.62 (5.36) 324 10.17 (5.83) − 3.08 (579)** .26
HI (ASRS) 257 7.26 (5.54) 324 7.25 (5.08) − .02 (579) .002

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Children with ADHD Children with TD Comparison

Variables n % Mean (SD) n % Mean (SD) X2/t (df) Cohen’s da

Family characteristics
Family Income
NTD 0 ~ 30000 31 12.3% 21 6.6% 12.99 (3)**
NTD 30001 ~ 80000 140 55.3% 164 51.2%
NTD 80001 ~ 160000 63 24.9% 118 36.9%
NTD 160001 ~ 19 7.5% 17 5.3%
Marriage
Singlec 58 23.0% 48 15.9% 4.50 (1)*
Not Single 194 77.0% 254 84.1%
Perceived Family Support (Family APGAR) 257 6.22 (4.11) 324 4.56 (3.77) − 5.07 (579)*** .42
Number of children in family 251 2.02 (.73) 319 2.07 (.61) .75 (568) .07

ADHD: Attention Deficit Hyperactivity Disorder, PI: Predominantly inattention, HI: Hyperactivity/Impulsivity, IA: Inattention, SNAP: Swanson,
Nolan, and Pelham, version IV scale, OP: Oppositional symptoms, CAST: Childhood Autism Spectrum Test, AD: Anxious/Depressed, CBCL: Child
Behavior Checklist, SC: Somatic Complaints, DB: Delinquent Behavior, AB: Aggressive Behavior, CES-D: Center for Epidemiologic Studies Depression
Scale, ASRS: Adult ADHD Self-report Scale.
*
p < .05.
**
p < .01.
***
p< .001.
a
According to Cohen (1988), effect size d larger than .8 is large, .5 median and .3 small.
b
Disability certification was referred to pass certification of disability and receive associated stipend and benefits from the Taiwan government.
c
Single included divorced, widow, and having a child but not married.

participants in this study had a Cronbach’s alpha of 0.92.

2.3. Data analysis

Independent sample t tests were used to compare differences between groups of children with ADHD and children with TD. Pearson
correlation coefficient statistics were used to examine the associations of socio-demographic and clinical variables with HRQOL of
mothers of these two groups of children. Univariate regressions were used to determine the relative importance of predictors on the
four domains of HRQOL. Multiple regressions were employed to investigate the relationship between the four domains of HRQOL of
these two groups of children with significant child, parental and family sociodemographic and clinical variables. We simultaneously
performed a sensitivity analysis, using dominance analysis (Budescu, 1993; Navarrete & Soares, 2020) to find the relative contribution
of each predictor to the multiple regression equation for physical, psychological, social and environmental HRQOL. The top ten in­
dependent variables contributing to the target HRQOL domains were identified through multiple regressions. Dominance analysis was
used to estimate the average contribution of R squared of each predictor. Predictors with R squared equal to or larger than .01 were
selected and entered in multiple regressions for physical, psychological, social and environmental HRQOL, respectively.
Two culturally specific items (i.e., question 27: being respected or accepted and question 28: favorite food accessibility) were
analyzed with X2 between the two groups of mothers. Data analyses were performed using SPSS version 22.0 (SPSS Inc., Chicago, IL,
USA). An alpha level of 0.05 was used to determine statistical significance.

3. Results

3.1. Sociodemographic and clinical characteristics of the participants

The participants of this study included 257 children with ADHD and 324 children with TD and their mothers. Children with ADHD
were significantly younger (p < .001, d = .35) and had more boys (p < .001), and less mothers working full time (p < .001) than
children with TD. Children with ADHD had significantly more behavioral problems (i.e., attention, hyperactivity, oppositional defi­
ance, autistic traits, aggression, and delinquency) (all p < .001, d = 0.97 ~ 2.02) and emotional problems (i.e., anxiety, depression, and
somatic complaints) (all p < .001, d = 1.63–2.02) than children with TD by maternal and teacher reports. Children with ADHD had
significantly longer sleeping hours (p = 0.03, d = 0.18) but higher percentages of them were reported to have sleep problems (p < .001)
than children with TD. Mothers of children with ADHD had significantly higher levels of inattention (p = .002, d = 0.26) and
depressive symptoms (p < .001, d = 0.59) as well as interpersonal problems (p = .001, d = 0.28), perceived less family support (p <
.001, d = 0.42) compared with those of children with TD. Table 1 presents the sociodemographic and clinical characteristics and
comparisons of the two groups.

3.2. Quality of life of mothers of children with ADHD and related factors

Mothers of children with ADHD had significantly lower HRQOL in physical, psychological, social and environmental domains
compared with those of children with TD (p < .001, effect size d = 0.38 ~ 0.55) (Table 2). Mothers of children with ADHD were
compared with those of children with TD in culturally specific items (i.e., question 27: being respected or accepted, and question 28:

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S.H.-Y. Liang et al. Research in Developmental Disabilities 113 (2021) 103944

favorite food accessibility) of WHOQOL-BREF Taiwanese version. Significantly less mothers of children with ADHD perceived
themselves as being respected or accepted than those of children with TD (X2 (4) = 23.63, p < .001). There were no significant dif­
ferences between mothers of children with ADHD and those of children with TD in favorite food accessibility (X2 (3) = 1.51, p = .68).
Table 3 presents the results.
HRQOL of mothers of these two groups of children was significantly correlated with children’s sleep problems, behavioral (i.e.,
inattention, hyperactivity, oppositional defiance, aggression, delinquency and autistic traits) and emotional (i.e., anxiety, depression
and somatic complaints) problems, maternal education, depressive, inattention and hyperactivity symptoms, interpersonal problems
and family support and income in all four domains (i.e., physical, emotional, social and school performance) (Table 4).
Univariate regression analyses found all significant variables reported in Table 4 were predictors of the four domains of HRQOL.
Both maternal and teacher’s ratings of children’s SNAP-IV were significant predictors of HRQOL of mothers of children with ADHD and
those of children with TD (Table 5). However, the magnitudes of beta coefficients (− .13 ~ − .22) of the teacher’s ratings of SNAP-IV
were approaching half of the magnitudes of those (− .24 ~ − .38) of the maternal ratings.
A series of multiple regression were performed separately for the four domains of HRQOL of mothers of children with ADHD and
those of children with TD to elucidate the roles of significant children’s, parental and family socio-demographic and clinical variables
on HRQOL of mothers of these two groups of children. Method enter was chosen for multiple regressions in which all variables in a
block were entered in a single step. To evaluate the roles of children’s clinical characteristics on maternal HRQOL, significant chil­
dren’s (i.e., age, gender, attention, hyperactivity, opposition, aggressive, delinquent, anxious/depressive, somatic complaint symp­
toms and autistic traits), parental (i.e., age, educational level, work), and family (incomes and number of children) variables were
adjusted in model 1. Multiple regression analysis (Table 6) showed mother-reported child inattention symptoms (beta coefficients =
− .30 ~ − .21, p < .01) and autistic traits (beta coefficients = − .23 ~ − .16, p < .01) were significant variables associated with all four
domains of HRQOL of mothers of children with ADHD and those of children with TD. In addition, family income, and children’s sleep
problems were related to maternal physical HRQOL; family income, paternal and maternal education levels, and mother-reported
attentional symptoms related to psychological HRQOL; marital status, children’s opposition (mother-report) and aggressive behav­
iors related to social HRQOL; and family incomes related to environmental HRQOL (Table 6).
Maternal clinical (i.e., depressive, inattentive and hyperactive symptoms and interpersonal problems) variables were sequentially
added in model 2, and perceived support from family was included in model 3. When maternal clinical variables were considered in
multiple regression analysis, the effects of several child clinical variables for maternal HRQOL were diminished, and maternal
depressive symptoms (beta coefficients = − .45 ~ − .31, p < .001) was associated with all four domains of HRQOL (Table 6, model 2). In
addition, maternal physical HRQOL was associated with family incomes (beta coefficients = − .10, p < .05), child attention symptoms
(beta coefficients = − .18, p < .01) and sleep problem (beta coefficients = − .08, p < .05). Psychological HRQOL was related to family
income (beta coefficients = − .10 ~ − .11, p < .05), paternal education (beta coefficients = − .09, p < .05), child’s autistic traits (beta
coefficients = − .10, p < .05) and maternal attention symptoms (beta coefficients = − .16, p < .01). Maternal social HRQOL was related
to marital status (beta coefficients = .10, p < .01), child’s autistic traits (beta coefficients = − .09, p < .05) and aggressive behaviors
(beta coefficients = .14, p < .01) and maternal inattentive (beta coefficient = − .13, p < .01) and interpersonal problems (beta co­
efficient = − .16, p < .001). Maternal environmental HRQOL was related to child autistic traits (beta coefficient = − .14, p < .01) and
interpersonal problems (beta coefficient = − .13, p < .01), as well as family incomes (beta coefficients = − .17 ~− .18, p < .001).
When all child, parental, and family variables were considered in model 3, HRQOL of mothers of these two groups of children was
more related to maternal and family variables rather than children’s ADHD diagnosis or psychopathology. Specifically, factors related
to HRQOL of mothers of children with ADHD and those of children with TD in all four domains were maternal depressive symptoms
(beta coefficients = − .19 ~ − .36, p < .001) and perceived family support (beta coefficients = − .17 ~ − .27, p < .001). Additionally,
maternal physical HRQOL was related to family income (beta coefficient = − .10, p < .05), mother-reported child inattention (beta
coefficient = − .18, p < .01) and sleep problems (beta coefficient = − .09, p < .05). Maternal psychological HRQOL was associated with
maternal inattentive symptoms (beta coefficient = − .16, p < .01), paternal education (beta coefficient = − .10, p < .05) and family
incomes (beta coefficients = − .11 ~ − .10, p < .01). Maternal social HRQOL was associated with child’s aggressive behavior (beta
coefficient = .14, p < .05), maternal inattentive symptoms (beta coefficient = − .14, p < .01) and interpersonal problems (beta co­
efficient = − .14, p < .001), and marital status (beta coefficient = .09, p < .01). Maternal environmental HRQOL was associated with
children’s autistic traits (beta coefficient = − .12, p < .01), maternal interpersonal problems (beta coefficient = − .11, p < .01) and
family incomes (beta coefficients = − .18 ~ − .19, p < .001).

Table 2
Comparison of HRQOL of mothers of children with ADHD and those of children with TD.
Mothers of children with ADHD Mothers of children with TD Comparison

Variables n Mean (SD) n Mean (SD) t (df) Cohen’s da

Physical HRQOL 257 11.91 (1.68) 324 12.55 (1.61) 4.69 (579)*** 0.39
Psychological HRQOL 257 12.90 (2.01) 324 13.70 (1.98) 4.80 (579)*** 0.40
Social HRQOL 257 13.30 (2.33) 324 14.56 (2.26) 6.64 (579)*** 0.55
Environmental HRQOL 257 13.90 (2.22) 324 14.73 (2.15) 4.54 (579)*** 0.38

HRQOL: Health-related quality of life, ADHD: Attention Deficit Hyperactivity Disorder.

***
p< .001.
a
According to Cohen (1988), effect size d larger than .8 is large, .5 median and .3 small.

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S.H.-Y. Liang et al. Research in Developmental Disabilities 113 (2021) 103944

Table 3
Comparison of Cultural Specific Itemsa of HRQOL in Taiwan.
Mothers of children with ADHD Mothers of children with TD

Items Rating n % n % X2 (df) p

Not at all 6 2.3 3 0.9

A little 42 16.3 23 7.1
Feeling respected Moderate 123 47.9 137 42.3 23.63 (4) < .001
Often 79 30.7 141 43.5
All the time 7 2.9 20 6.2
Seldom 12 4.7 10 3.1
Half the time 69 26.8 80 24.7
Favorite food accessibility 1.51 (3) .68
Often 123 47.9 165 50.9
All the time 53 20.6 69 21.3
a
WHOQOL-BREF Taiwanese version included two cultural specific items (i.e., question 27: feeling respected and question 28: favorite food
accessibility) (The WHOQOL-Taiwan Group, 2000a, 2000b).

Results of multiple regressions with predictors selected by dominance analysis found maternal depressive symptoms (beta co­
efficients = − .22 ~ − .37, p < .001) and perceived family support (beta coefficients = − .17 ~ − .30, p < .001) were consistently
associated with all four domains of HRQOL in mothers of children with ADHD and those of children with TD. In addition, independent
predictors included child sleep problems and mother-reported child oppositional symptoms for physical HRQOL, family income for
psychological HRQOL, marriage, mother-reported child oppositional symptoms, maternal interpersonal problems, and attention
symptoms for social HRQOL and family income, child autistic traits, maternal interpersonal problems, and attention symptoms for
environmental HRQOL. Table 7 presents the results.

4. Discussion

Consistent with previous studies (Lange et al., 2005; Xiang et al., 2009), mothers of children with ADHD had significantly worse
HRQOL across all four domains than those of children with TD. Significantly more mothers of children with ADHD perceived
themselves as “losing face” or not being respected or accepted compared to those of children with TD. This item is in the social domain
and is related to the influential Chinese cultural concept of “face”. With face being a representation of oneself, “loss of face” expresses
one of the Chinese notions for shame (Li, Wang, & Fischer, 2004). Such feelings of embarrassment are similar to the self-stigma or
negative attitudes someone may entertain towards those with mental illness when considering oneself as a member of the stigmatized
group.
A recent study in Taiwan found female caregivers of children with ADHD were associated with a significantly higher level of
affiliate stigma than male caregivers (Chang et al., 2020). In addition, based on the findings of another recent study in Taiwan, 44 % of
caregivers of children and adolescents with ADHD reported failure of caregivers in disciplining the child as one of the etiologies of
children’s ADHD (Chou et al., 2020a). With respect to the sociocultural background regarding maternal role expectation in Taiwan,
mothers of children with ADHD may be blamed or self-blame for their children’s uncooperativeness with rules, disobedience to au­
thority, social incompetence and academic failures (Chou et al., 2020a; Gau & Chang, 2013). Mothers of children with ADHD may have
lower parenting competence, elevated care burden and psychological distress, socially isolate themselves from those who have a low
tolerance of children with ADHD including colleagues, neighbors, friends, and family members and have restricted social participation
by excluding those contexts or environments in which their children cannot fit in appropriately (Chang et al., 2020; Chou et al.,
2020b). Therefore, children’s ADHD coupled with traditional role expectations of mothers in Taiwanese culture (Chao & Tseng, 2002;
Huang & Gove, 2015) may be associated with decreased HRQOL of mothers of children with ADHD and those of children with TD
across physical, psychological, social and environmental domains.
When child, parental and family variables were all considered in the four domains of HRQOL of mothers of children with ADHD and
those of children with TD, maternal HRQOL was more related to the mother’s own factors (i.e., depressive symptoms) and family
variables (i.e., perceived support from family) compared to child psychopathology. Consistent with studies of parental well-being of
children with chronic physical or mental conditions (Armstrong et al., 2005; Witt & DeLeire, 2009), mothers who perceived less family
support had worse HRQOL including physical, psychological, social and environmental HRQOL. Interpersonal problems were inde­
pendent predictors of maternal social and environmental HRQOL. Mothers who perceived themselves as having more interpersonal
problems had worse social and environmental HRQOL. Support system from family, friends and neighbors, or from the community was
a significant variable of HRQOL in mothers of children with ADHD (Leitch et al., 2019). In addition to family support, mothers of
children with ADHD need informational and emotional support from friends or others with similar experiences and professional
support to provide effective strategies for coping with the influence of children’s ADHD and maternal depression, inattention, and
interpersonal problems (Leitch et al., 2019).
Overlapping questionnaire items might have a role in the associations of maternal depressive symptoms, interpersonal problems,
perceived family support and HRQOL. For example, the item “perception of negative feelings” in the psychological domain of
WHOQOL-BREF had similar wordings with items of depressive symptoms as measured by CEDS-C (e.g., I feel sad.). The items in the
social domains of WHOQOL-BREF such as “satisfaction with support from friends” and “satisfaction with one’s interpersonal rela­
tionship” measured constructs closely related to interpersonal problems, and perceived family support.

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S.H.-Y. Liang et al. Research in Developmental Disabilities 113 (2021) 103944

Table 4
Association of sociodemographic and clinical variables with HRQOL of mothers of children with ADHD and those of children with TD.
Domain of Health-related Quality of Life

Variables Physical Psychological Social Environmental

Pearson Correlation §
r r r r
Age (Child) − .006 .03 .03 .05
Age (Mother) − .04 .004 − .05 .05
Age (Father) .004 − .01 − .07 − .02
Number of children in family .01 .02 .03 .06
Sleep hour .03 .03 .05 .03
Child’s symptom: IA (Mother − .30*** − .28*** − .37*** − .34***
SNAP)
HI (Mother SNAP) − .25*** − .27*** − .36*** − .34***
OP (Mother SNAP) − .24*** − .28*** − .38*** − .32***
IA (Teacher SNAP) − .15*** − .15*** − .22*** − .19***
HI (Teacher SNAP) − .14** − .17*** − .22*** − .18***
OP (Teacher SNAP) − .13** − .13** − .16*** − .17***
Autistic traits (Mother CAST) − .31*** − .30*** − .36*** − .36***
IA (Mother CBCL) − .14** − .17*** − .22*** − .18***
AD (Mother CBCL) − .15*** − .15*** − .22*** − .19***
SC (Mother CBCL) − .14** − .13** − .20*** − .17***
AB (Mother CBCL) − .13** − .13** − .16*** − .15***
DB (Mother CBCL) − .11** − .13** − .19*** − .17***
Maternal symptoms: IA (ASRS) − .25*** − .38*** − .39*** − .37***
HI (ASRS) − .22*** − .31*** − .33*** − .34***
Depression (CES-D all except − .56*** − .59*** − .58*** − .56***
Q15 + Q19)
Interpersonal problems (CES-D − .37*** − .38*** − .46*** − .42***
Q15 + Q19)
Maternal perceived family support − .44*** − .52*** − .55*** − .51***
(Family APGAR)

t-test§ Mean t/F Mean t Mean t Mean t

(SD) (SD) (SD) (SD)
Gender of Child (N = 581) Boy (n = 384) 12.12 − 3.01 13.25 − 1.65 13.79 − 2.99 14.17 − 2.96
(1.68) ** (2.05) (2.35) ** (2.25) **
Girl (n = 197) 12.56 13.54 14.41 14.74
(1.61) (1.98) (2.36) (2.11)
Educational Grade (N = 581) Grade 1− 3 (n = 197) 12.24 .30 13.18 1.08 13.86 1.74 14.15 1.53
(1.65) (1.98) (2.37) (2.19)
Grade 4− 6 (n = 212) 12.34 13.39 13.90 14.42
(1.60) (1.93) (2.25) (2.00)
Grade 7− 9 (n = 172) 12.21 13.48 14.28 14.54 (2/
(1.78) (2.21) (2.51) 48)
ADHD subtypes (N = 257) PI (n = 76) 11.98 .80 13.05 .43 13.50 .48 14.37 2.88
(1.69) (1.96) (2.39) (2.13)
HI (n = 11) 12.47 12.55 13.45 14.26
(1.44) (2.92) (3.44) (2.56)
Combined (n = 170) 11.84 12.85 13.19 13.67
(1.69) (1.97) (2.22) (2.21)
Medication (N = 255) Never (n = 33) 11.71 .89 12.73 .25 13.49 .32 13.62 .36
(1.49) (2.04) (2.08) (2.13)
Ever used (n = 8) 12.57 13.25 13.75 13.72
(1.59) (1.69) (1.83) (1.48)
Currently use (n = 11.93 12.92 13.25 13.95
255) (1.69) (2.00) (2.35) (2.24)
Sleep problems (N = 578) Yes (n = 56) 11.39 4.31 12.94 1.62 12.98 3.50 13.72 2.33*
(1.77) *** (1.93) (2.59) *** (2.27)
No (n = 522) 12.38 13.40 14.13 14.44
(1.62) (2.03) (2.31) (2.20)
Diseases or/and developmental Yes (n = 93) 11.51 4.94 12.62 3.87*** 12.81 5.52 13.59 3.76***
problems (N = 580) (1.76) *** (1.97) (2.23) *** (2.26)
No (n = 487) 12.42 13.49 14.24 14.52
(1.60) (2.01) (2.32) (2.18)
Disability card (N = 580) Yes (n = 7) 11.59 1.10 12.29 1.40 13.71 .34 13.65 .86
(2.05) (2.07) (1.60) (1.17)
No (n = 573) 12.28 13.37 14.02 14.38
(1.66) (2.02) (2.37) (2.22)
Job (Father) (N = 559) Full time (n = 538) 12.32 .61 13.43 2.09 14.13 2.65 14.49 3.63*
(1.65) (2.00) (2.33) (2.15)
Part time (n = 15)
(continued on next page)

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S.H.-Y. Liang et al. Research in Developmental Disabilities 113 (2021) 103944

Table 4 (continued )
Domain of Health-related Quality of Life

Variables Physical Psychological Social Environmental

11.85 12.36 12.80 12.95

(1.64) (2.29) (2.81) (2.91)
No work (n = 6) 12.19 13.56 13.33 14.52
(2.07) (1.96) (1.51) (2.85)
Job (Mother) (N = 572) Full time (n = 415) 12.35 1.60 13.47 2.67 14.14 2.73 14.49 2.39
(1.67) (1.97) (2.29) (2.21)
Part time (n = 46) 12.02 13.17 13.43 13.92
(1.74) (2.10) (2.29) (2.00)
No work or housewife 12.10 12.99 13.75 14.10
(n = 111) (1.60) (2.19) (2.63) (2.28)
Education (Father) (N = 569) College or above (n = 12.45 − 2.62 13.52 − 1.92 14.13 − 1.04 14.77 − 4.30
298) (1.67) ** (1.99) (2.31) (2.08) ***
High school or below 12.08 13.20 13.92 13.99
(n = 271) (1.64) (2.06) (2.42) (2.27)
Education (Mother) (N = 575) College or above (n = 12.44 − 2.61 13.61 − 3.65 14.24 − 2.65 14.71 − 4.42
335) (1.64) ** (1.91) *** (2.19) ** (2.10) ***
High school or below 12.08 12.98 13.70 13.89
(n = 240) (1.65) (2.13) (2.54) (2.30)
Family income (N = 573) Less than NTD 30000 11.53 7.33 12.32 12.32 13.01 7.91 12.80 27.22
(n = 52) (1.46) *** (2.14) *** (2.47) *** (2.27) ***
NTD 30001 ~ 80000 12.15 13.13 13.83 14.03
(n = 304) (1.64) (1.95) (2.34) (2.16)
NTD 80001 ~ 160000 12.59 13.81 14.40 15.05
(n = 181) (1.71) (1.92) (2.21) (1.91)
NTD 160001 ~ (n = 12.71 14.33 15.06 16.09
36) (1.47) (2.14) (2.48) (1.88)
Marital status (N = 554) Single (n = 106) 12.05 1.56 12.96 2.23* 13.22 3.84 13.94 2.21*
(1.56) (2.04) (2.29) *** (2.26)
Not single (n = 448) 12.33 13.45 14.18 14.47
(1.68) (2.02) (2.35) (2.21)

IA: Inattention, SNAP: Swanson, Nolan, and Pelham, version IV scale, HI: Hyperactivity/Impulsivity, OP: Oppositional, CAST: Childhood Autism
Spectrum Test, AD: Anxious/Depressed, CBCL: Child Behavior Checklist, SC: Somatic Complaints, DB: Delinquent Behavior, AB: Aggressive Behavior,
ASRS: Adult ADHD Self-report Scale, CES-D: Center for Epidemiologic Studies Depression Scale, ADHD: Attention Deficit Hyperactivity Disorder, PI:
Predominantly inattention.
*
p < .05.
**
p < .01.
***
p < .001.

Previous studies have found that mothers of children with ADHD have higher rates of psychopathology, especially depression and
ADHD symptoms (Sfelinioti & Livaditis, 2017), but the roles of maternal depression and ADHD symptoms in HRQOL of mothers of
children with ADHD have not yet been explored. This study found maternal depression was a significant predictor associated with their
HRQOL across all domains and maternal inattentive symptoms was an independent predictor associated with social and environmental
HRQOL. It is possible that children’s psychopathology such as inattention, oppositional behaviors and autistic traits may increase
maternal caregiving stress or parenting difficulties which may be associated with interaction problems within the family such as
mother-child or sibling problems, or outside the family difficulties, and produce chronic distress in mothers of children with ADHD,
thereby displaying negative associations with social and environmental HRQOL of mothers of children with ADHD and those of
children with TD (Agha, Zammit, Thapar, & Langley, 2017; Deault, 2010). Screening of, and intervention for, mental health needs of
mothers of children with ADHD are necessary especially for depression (Cianchetti et al., 2018) and inattentive symptoms (Perez
Algorta et al., 2018) to enhance HRQOL of mothers of children with ADHD.
In addition to maternal depression, children’s sleep problems were an independent predictor of maternal physical HRQOL. Sleep
problems are prevalent in children with ADHD; however, no studies have ever examined the impact of children’s sleep problems on
HRQOL of mothers of children with ADHD. Children with ADHD and sleep problems may lead to more inconsistent daily life routines,
especially before bedtime, which might demand more parenting time and reduced parental sleep hours (Noble, O’Laughlin, & Bru­
baker, 2011). Mothers of children with ADHD and sleep problems were reported to have more sleep problems (Bar, Efron, Gothelf, &
Kushnir, 2016) and were significantly more likely to be late for work, which may increase fatigue and sleepiness during the daytime
(Sung, Hiscock, Sciberras, & Efron, 2008) and therefore reduced physical HRQOL. However, this study only used one single
sleep-related question (i.e., if your child had sleep problems) answered by mothers. Future studies may further investigate how
objective and subjective measures of children’s sleep problems are related to parental HRQOL in mothers of children with ADHD.

4.1. Strengths and limitations of this study and implications for clinical practice and future research

This study extended our previous pilot study (Chen et al., 2014) by including a group of children with ADHD diagnosed following

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Table 5
Univariate Regression for HRQOL of Mothers of Children with ADHD and Those of Children with TD.
Domains of HRQOL

Physical Psychological Social Environmental

Beta p Beta p Beta p Beta p

Child gender .12 .003 .12 .003 .12 .003

Sleep Problems (Child) − .18 <.001 − .14 .003 .12 .003
Developmental problem or disease − .20 <.001 − .16 <.001 − .22 <.001 − .15 <.001
Family Income − .18 <.001 − .22 <.001 − .18 <.001 − .30 <.001
(NTD 0 ~ 30000)
(NTD 30001 ~ 80000) − .13 .002 − .19 < .001 − .13 .002 − .26 < .001
Marriage .09 .03 .16 <.001 .09 .03
Father Job (Full time) .20 <.001
Father Education .10 .02 .22 <.001
Mother Education .11 .009 .10 .01 .08 .048 .19 <.001
Child IA (Mother) − .30 <.001 − .28 <.001 − .38 <.001 − .34 <.001
Child HI (Mother) − .25 <.001 − .27 <.001 − .36 <.001 − .34 <.001
Child OP (Mother) − .24 <.001 − .28 <.001 − .38 <.001 − .32 <.001
Child IA (Teacher) − .15 <.001 − .15 <.001 − .22 <.001 − .19 <.001
Child HI (Teacher) − .14 .001 − .17 <.001 − .22 <.001 − .18 <.001
Child OP (Teacher) − .13 .002 − .13 .002 − .16 <.001 − .17 <.001
CAST − .31 <.001 − .30 <.001 − .36 <.001 − .36 <.001
CBCL IA − .14 .001 − .17 < .001 − .22 < .001 − .18 < .001
CBCL AD .01 <.001 − .15 <.001 − .22 <.001 − .19 <.001
CBCL SC − .14 .001 − .15 <.001 − .22 <.001 − .19 <.001
CBCL AB − .13 .002 − .13 .002 − .16 <.001 − .17 <.001
CES-D Dep − .56 <.001 − .59 <.001 − .58 <.001 − .56 <.001
CES-D Inter Pro − .37 <.001 − .38 <.001 − .46 <.001 − .42 <.001
ASRS IA − .25 <.001 − .38 <.001 − .39 <.001 − .37 <.001
ASRS HI − .22 <.001 − .31 <.001 − .33 <.001 − .34 <.001
Family Support − .44 <.001 − .52 <.001 − .55 <.001 − .51 <.001

NTD: New Taiwan Dollar, IA: Inattention, HI: Hyperactivity/Impulsivity, OP: Oppositional, CAST: Childhood Autism Spectrum Test, CBCL: Child
Behavior Checklist, AD: Anxious/Depressed, SC: Somatic Complaints, DB: Delinquent Behavior, AB: Aggressive Behavior, CES-D: Center for Epide­
miologic Studies Depression Scale, Dep: Depression, Inter Pro: Interpersonal Problems, ASRS: Adult ADHD Self-report Scale.

DSM-5 criteria and a group of children with TD. Results of this study suggested HRQOL of mothers of children with ADHD was worse
than that of mothers of children with TD. The findings suggest assessment and intervention for children with ADHD should include
caregivers HRQOL especially for mothers. When child, parental and family socio-demographic and clinical variables were all
considered on HRQOL of mothers of children with ADHD and those of children with TD, maternal HRQOL was more related to
maternal (i.e., depression and inattention symptoms, or interpersonal problems) or family factors (i.e., family income and perceived
family support). The findings support the social-ecological systems perspective. Raising children with ADHD may be stressful for
mothers and other family members, and family resilience such as family income and perceived family support may be an enabling
factor for mothers of children with ADHD. Family-centered assessment and intervention is warranted for children with ADHD and their
families, especially mothers.
The associations of children’s ADHD and HRQOL of mothers of children with ADHD were evaluated with reports of both mothers
and teachers as well as diagnosis of psychiatrists following DSM 5 criteria. When child, parental and family variables were all
considered, maternal reports of child inattentive symptoms and sleep problems were related to physical HRQOL of mothers. Maternal
reports of autistic traits were related to environmental HRQOL of mothers. For schooling children and adolescents, child inattentive
symptoms rated by mothers may be related to reduced academic or daily task performance including difficulties in completion of
homework (Costa Dde et al., 2014) and need maternal supervision or assistance.
The limitations of this study included cross-sectional study design, which included the problems of reverse causality among var­
iables such as the relationship between child and maternal psychopathology and HRQOL of mothers of children with ADHD and those
of children with TD. Mothers with poor HRQOL may exaggerate the child’s and maternal psychopathology. Therefore, a longitudinal
study design is needed to examine the relationship among child, maternal, paternal and family variables on HRQOL of mothers of
children with ADHD and those of children with TD. Second, maternal (i.e., ADHD and depression symptoms, and interpersonal
problems) and children’s (i.e., autistic traits, anxious/depressive and somatic complaints) psychopathology and perceived family
support were measured only with maternal reports. The results tended to be largest when information was from one source (i.e.,
mothers) due to shared method variance (Izquierdo-Sotorrio, Holgado-Tello, & Carrasco, 2016). The magnitudes of association be­
tween teacher-report SNAP-IV and HRQOL of mothers of children with ADHD and those of those of children with TD were about half
the magnitudes of association found by maternal reports of SNAP-IV in this study. Mono-informant bias might exist in the findings and
could derive from the knowledge and judgement of mothers about themselves and their children, as well as the observability and social
desirability of these assessed variables. Therefore, this study’s findings should be interpreted with caution.
Third, other maternal mental health variables (e.g., anxiety and coping strategies) as well as paternal ADHD symptoms may play
significant roles in HRQOL of mothers of children with ADHD and those of children with TD but were not assessed in this study. Forth,

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Table 6
Multiple Regression for HRQOL of mothers of children with ADHD and those of children with TD.
Variables Physical Psychological Social Environment

1α 2β 3μ 1α 2β 3μ 1α 2β 3μ 1α 2β 3μ

Family Income
(Less than NTD30000 vs − .13** − .10* − .10* − .16** − .11** − .11** − .21** − .18 − .19
other) *** ***
(NTD30001-80000 vs − .09* − .15** − .10* − .10** − .21** − .17 − .18
other) *** ***
Mother Education .12*
Father Education − .13** − .09* − .10*
Marriage .10* .10** .09**
Child IA (Mother) − .30 − .18** − .18** − .21** − .21** − .21**
***
Child OP (Mother) − .18**
CAST − .16** − .20 − .10* − .18 − .09* − .23 − .14** − .12**
*** *** ***
Sleep Problems (Child) − .11* − .08* − .09*
CBCL IA − .17*
CBCL AB .14* .14** .14**
CES-D Dep − .45 − .36 − .45 − .32 − .32 − .19 − .31 − .19
*** *** *** *** *** *** *** ***
CES-D Inter Pro − .16 − .14 − .13** − .11**
*** ***
ASRS IA − .16** − .16** − .13** − .14**
Family Support − .17 − .26 − .27 − .25
*** *** *** ***
R .40 .59 .60 .45 .65 .68 .49 .66 .69 .50 .65 .68
R2 .16 .35 .36 .20 .42 .46 .24 .43 .48 .25 .42 .46

NTD: New Taiwan Dollar, IA: Inattention, OP: Oppositional, CAST: Childhood Autism Spectrum Test, CBCL: Child Behavior Checklist, AB: Aggressive
Behavior, CES-D: Center for Epidemiologic Studies Depression Scale, Dep: Depression, Inter Pro: Interpersonal Problems, ASRS: Adult ADHD Self-
report Scale.
All models were adjusted for significant socio-demographic and clinical variables (i.e., child’s age, gender, and sleep problems; parents’ age, edu­
cation level, job and marital status; number of children and income of the family) associated with specific HRQOL domains of mothers of children with
ADHD and those of children with TD.
*
p < .05.
**
p < .01.
***
p < .001.
α
Adjusted for child’s level of inattention, hyperactivity and opposition symptoms rated by mothers and teachers, child’s level of autistic traits,
anxious-depression, aggression, delinquency, somatic complaints and psychiatrist diagnosis of child’s ADHD.
β
Adjusted for maternal attention, hyperactivity and depression symptoms and interpersonal problems.
μ
Adjusted for perceived family support.

Table 7
Multiple Regression for HRQOL of Mothers of Children with ADHD and Those of Children with TD as a sensitivity analysis.
Domains of HRQOL

Physical Psychological Social Environmental

Beta p Beta p Beta p Beta p

Family Income
(Less than NTD 30000 vs others) − .11 .001 − .25 < .001
(NTD 30001 ~ 80000 vs others) − .10 .006 − .26 < .001
Marriage .11 .001
Sleep Problems (Child) − .10 .006
Child OP (Mother) .09 .048 − .08 .01
CAST − .10 .003
CES-D Dep − .37 <.001 − .37 < .001 − .23 < .001 − .22 < .001
CES-D Inter Pro − .14 < .001 − .11 .005
ASRS IA − .18 < .001 − .09 .04
Family Support − .17 < .001 − .26 < .001 − .30 < .001 − .23 < .001

R .52 .64 .68 .67

R2 .35 .41 .46 .46

NTD: New Taiwan Dollar, OP: Oppositional symptoms, CAST: Childhood Autism Spectrum Test, CES-D: Center for Epidemiologic Studies Depression
Scale, Dep: Depression, Inter Pro: Interpersonal Problems, ASRS: Adult ADHD Self-report Scale IA: Inattention.

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this study recruited children with ADHD and their mothers from one child psychiatric clinic and children with TD voluntarily.
Therefore, selection bias may impact the results and generalizability of our findings. Fifth, maternal interpersonal problems were a
significant variable related to HRQOL of mothers of children with ADHD and those of children with TD, but were assessed with only
two questions (Q15, Q19) in CES-D. Further studies may assess maternal interpersonal problems or social support with objective
measures or comprehensive self-report measures. In addition, levels of depression symptoms were assessed in this study, but the
history and chronicity (Sfelinioti & Livaditis, 2017) and their importance to maternal mental health and HRQOL were not evaluated.
Sixth, most of the associations of significant variables with HRQOL of mothers of children with ADHD and those of children with TD
were small in magnitude (e.g., most Pearson correlations were less than .3 in Table 4). Thus, the clinical or practical significance of the
findings may be limited.

5. Conclusions

In conclusion, the findings show that all domains of HRQOL of mothers of children and adolescents with ADHD were significantly
worse than those of children and adolescents with TD. These findings showed that maternal psychopathology such as depressive and
inattentive symptoms and interpersonal problems were related to reduced HRQOL in psychological, social and environment domains
in mothers of children with ADHD. These findings confirmed that comprehensive and multi-dimensional approaches including child,
parental and family perspectives should be considered when evaluating HRQOL of caregivers of children and adolescents with ADHD.
This information is critical for effectively intervening with families of children with ADHD and could ultimately help improve health
outcomes of caregivers and children with ADHD.

Acknowledgements

The authors would like to thank Professor Charles Tzu-Chi Lee for his consultation with the R dominance analysis package and Miss
Shu-Tin Liao for her assistance in data collection. The present study was supported by a grant from Chang Gung Memorial Hospital at
Linkou, Taiwan (CMRPG5F0041).

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