PARENTING STYLES AND MENTAL HEALTH IN PARENTS OF CHILDREN WITH ADHD

The study evaluated associations between behavioral profiles, perceptions of quality of life and social support, and parenting practices adopted by 26 parents of children and adolescents with ADHD through the Parenting Styles Inventory, WHOQOL-BREF, Inventory of Perceived Family Support and SelfAssessment Inventory for Adult 18-59 years. Spearman correlation analyzes were performed to verify associations between the measures. It was found that patterns characterized by negative practices are associated with a higher frequency of behavioral problems, and less indicators of adaptive functioning in caregivers. Negative parenting practices are also most often used by people with low social and family support indicators as well as quality of life. The positive practices are associated with appropriate behaviors and better adaptive functioning, social support and quality of life.

In Brazil, Gomide, Salvo, Pinheiro and Sabbag (2005) adopted the same theoretical model.  stablished seven parenting practices, of which two are considered positive and are related to children's prosocial behavior development (positive monitoring and moral behavior) and the other five are negatives and associated with development of antisocial behavior by children (negative monitoring, neglect, inconsistent punishment, physical abuse, relaxed discipline). These practices are described as: 1) Positive monitoring: refers to any practice that involves attention, demonstration of warmth or affection towards the child. 2) Moral behavior: refers to the ability of parents to convey to their children values such as a sense of justice and honesty, 3) Negative monitoring: comprises an excessive attempt to control the lives of their children and the use of frequent instructions, of which the children usually take no notice, producing a hostile family environment; 4) Negligence: failure to meet the needs of the children, be these emotional or practical; 5) Inconsistent punishment: giving punishment or reinforcing a behavior according to the mood of the parent rather than according to the behavior of the child; 6) Physical abuse: the use of physical force to attack and hurt their children with the justification of it being for their education; and 7) Relaxed discipline: the rules parents set for their children are not met, i.e., parents only threaten to punish their children, but when the unwanted behavior occurs, the children are not punished. Gomide et al (2005) founded that parents who adopted positive parenting styles (i.e. predominance uses of positive educative practices), compared with those who had negative parenting styles, showed higher social abilities and fewer depression and stress symptoms, indicating the relevance of studying parenting practices (and consequently, parenting styles).
Thereby, it is necessary to identify how parental practices, for the care of a child with ADHD, can be affected by other variables unrelated to the disorder. This knowledge can contribute to the development of intervention actions among family members and children with ADHD. In this sense, the objective of the study was to identify parenting practices used by parents of children diagnosed with ADHD and to verify associations between their parenting practices and parents behavioral and emotional difficulties, as well as their perceptions of quality of life and social support.

Method
The sample was selected through a neuropsychological, behavioral and clinical assessment protocol for children and adolescents with complaints of inattention and hyperactivity delivered at a national reference center that provides services to the community in the identification of signs compatible with ADHD (Carreiro et al., 2014), and was approved by the ethics committee for research involving human beings. The protocol assessed 159 children and adolescents between 2014 and 2016. Initially, 56 of them were diagnosed with ADHD, but only 26 parents agreed to fill in the Parenting Style Inventory. The study group comprised 23 biological mothers, one adoptive mother, one biological father and one biological grandmother, as the status of the primary caregiver, of 26 children with ADHD. The mean age was 9.5 years (±2.84), with participants from the 1st year of primary school to the 1st year of high school. Regarding the socioeconomic level of participants, there were families from classes A1 through C2, and there weren´t families from the poorest classes. The level of schooling of the main caregivers was predominantly high school and college. All children were evaluated by the same child neurologist who had delivered the initial assessment protocol in 2014 and were diagnosed with ADHD based on the DSM-IV clinical criteria (APA, 2000), with the combined presentation form being predominantly diagnosed (65%). The presence of cognitive impairment was controlled in the group using IQ, obtained by the Wechsler Scale of Intelligence for Children (WISC-III) (Figueiredo, 2002), as well as other physical and psychiatric diseases. The exclusion of participants with other conditions such as genetic syndromes and Autism Spectrum Disorder, in which inattentive patterns are recurrent, was conducted through a clinicalmedical evaluation by a child neurologist.

Measures
Parenting Styles Inventory (PSI). The inventory assesses seven parenting practices, two positive (positive monitoring and moral behavior) and five negative (negative monitoring, inconsistent punishment, relaxed discipline, negligence and physical abuse), which, together, characterize the adopted parenting style. Comprising 42 items, the inventory is completed by the parents in respect of the strategies adopted to guide and raise their child . Sampaio e Gomide (2007) conducted internal consistency analysis and founded alpha coefficients varying from 0,43 to 0,87. The inventory has norms for Brazilian population and internal and external validity evidences.
Short measure for assessing the quality of life "WHOQOL-BREF". a reduced version of the WHOQOL-100 (Fleck et al., 2000) which aims to reflect the perception that the person assessed has of their cultural, social and local environment. Developed by the World Health Organization's Quality of Life Group, the instrument comprises 26 questions, two general questions about quality of life and the others representing the 24 facets of the WHOQOL-100, divided into four domains: Physical, Psychological, Social Relationships and Environment. To analyze the data, we used Excel software developed by Pedroso, Pilatti, Gutierrez and Picinin (2010). Cruz, Polanczyk, Camey, Hoffmann and Fleck (2011) provide normative scores of WHOQOL-bref in a general population sample in Brazil and described differences in mean scores according to socio-demographic characteristics. The WHOQOL-bref proved to be a sensitive measure and a useful tool for identifying vulnerable groups and describing the profile of quality of life of the population in Brazil.
Inventory of Perceived Family Support (IPFS). comprising 42 statements related to family situations from which the subject must select the frequency with which each situation happens in their family. The IPFS assesses how strongly people perceive their family support, according to three factors entitled: affective-consistent, autonomy and family adaptation. The affective-consistent factor refers to the expression of affection, and communication aimed at problem solving among family members, as well as clarity of family rules. The autonomy factor evaluates if there are relationships of trust, freedom and privacy among members. The family adaptation factor refers to the existence of negative behaviors and feelings of the respondent in relation to the other members of the family, such as anger, irritation, shame, lack of understanding and the existence of aggressive family relationships (Baptista, 2010). IPFS has alpha coefficients of factors and total scale varying from 0,78 to 0,93, indicating adequate internal consistency. The instrument has norms for Brazilian population (Baptista, 2007).
Self-Assessment Inventory for Adult 18-59 years / Adult Self-Report (ASR). comprising 126 items in a self-report format, this inventory is used to obtain information on behavioral problems and adaptive functioning in adults aged 18-59 years old. Only the syndrome and the adaptive functioning scales were used in the present study. The syndrome scale includes problems related to isolation/depression, anxiety/depression, somatic complaints, thought problems, attention problems, rule breaking behavior, aggressive behavior and intrusive behavior. The adaptive function scale obtains information about friends, family, work, partner, and education (Achenbach, & Rescorla, 2003;Ivanova, Achenbach, Rescorla et al., 2015). Lucena-Santos, Moraes and Oliveira (2014) analyzed the factorial structure of ASR in a Brazilian sample. They observed that the internal consistency ranged from α = 0.70 to α = 0.86. The factorial structure founded has consistent theoretical factors and satisfactory reliability index.

Data analysis procedures
Spearman correlation analyzes were performed between the scores of the Parenting Styles Inventory (PSI) and the Inventory of Perceived Family Support (IPFS) scores, and the Quality of Life Assessment Tool (WHOQOL-Bref) scores to verify associations between parental educational practices and levels of perception of quality of life and social support. In order to assess the relationship between parental educational practices andthe behavioral profiles of the parents, Spearman correlations made between the scores of the Parenting Styles Inventory (PSI)  and the T scores of the syndromes and adaptive functioning scales of the Self-Assessment Inventory for Adults/18-59 (ASR). Values of p ≤ .05 were adopted as level of statistical significance. The data analyzes were performed using the Statistical Package for Social Sciences -SPSS, version 20.0 Table 1 shows the results of the Spearman correlation analysis between the scores of the Parenting Styles Inventory (PSI) with the Inventory of Perceived Family Support (IPFS) scores and the Quality of Life Assessment Tool (WHOQOL-Bref) scores.

Results
The negative parental practices of inconsistent punishment and physical abuse were those that presented greater correlation with indicators of social support and quality of life. These practices are associated with lower satisfaction of parents/caregivers in all domains of quality of life (Table 1), as well as with lower scores in the family adaptation factors and in the affective-consistent factors. Also, the parenting style correlated positively with some indicators of social support and quality of life, suggesting that the more positive is the style adopted, more elevated is the communication clarity among family members, as well the affection expressed among them, less aggressiveness in the members´ relationship and higher quality of life perceived in social relationships and psychological domains.  2019, Vol., 53, No. 3, pp. 417-430 Table 2 shows the results of the Spearman correlation analysis between educational practices and parenting styles from the PSI, and the behavioral problems and the adaptive functioning of parents from the ASR. The parental practice of inconsistent punishment was again the one that presented the highest number of correlations with these indicators, and was strongly associated with higher aggression rates, externalizing problems and with lower means of adaptation.
It is also possible to observe in Table 2, moderate associations between the practice of relaxed discipline and the rule breaking index of the ASR, as well as between physical abuse and lower satisfaction with the partner. Finally, there is also a moderate inverse correlation between total parental style and externalizing problems of parents as shown by the ASR, which indicates that parents who use a predominance of positive practices (positive parenting style) have less probability to present externalizing problems, especially aggressiveness, because they are parents who should use an authoritative style characterized by high acceptance, involvement and high strictness/imposition.  2019, Vol., 53, No. 3, pp. 417-430  .63 ** Average adaptation .54 ** Note: PSI = Parenting Scale Inventory; ASR = Adult Self-Report; a Two participants did not answer the ASR. b The "Partner" and "Work" scales were optional, so five participants did not complete these scales. * p < .05; ** p ≤ .001

Discussion
The aim of the study was to identify parenting practices used by parents of children diagnosed with ADHD and verify the association between their parenting practices and parents´ behavioral and emotional difficulties, as well as their perceptions of quality of life and social support. Regarding positive parental practices, the data in table 1 revealed that the practice of positive monitoring was positively correlated with the affective-consistent factor of the IPFS, which indicates that this practice is more commonly used by people reporting high levels of expression of affectivity among family members, that is, there is a reciprocity in the family regarding the demonstration of affection, and it is possible to affirm that the environment itself favors the use of this practice. The practice was also associated with better communication among family members to solve problems, indicating that there is openness to dialogue in family dynamics. Those parents who frequently use positive monitoring must necessarily have a strong repertoire of social skills (Gomide, 2003), allowing them to be able to ascertain the facts of their children's lives, without being invasive. Taylor, Conger, Robins and Widaman (2015), in a longitudinal study, found that parents who perceive greater social support tend to engage in positive parenting practices, which indirectly also influence the development of social skills in their children. The association between social skills in children and parental involvement was also found by Nokali, Bachman and Votruba-Drzal (2010).
The results shown in table 2 indicate that parents who frequently use positive monitoring practice had fewer indicators of aggressiveness, which reinforces their ability to solve problems through dialogue, without the need to use aggressive behavior. Previous studies have shown the beneficial effect of the occurrence of positive parental practices in the management of children's behaviors (Barbosa, Neumann, Alves, Teixeira, & Wagner, 2017;Teixeira, Marino & Carreiro, 2015). This parenting style will help the child with ADHD to develop self-regulation skills, with greater expression of appropriate behaviors for problem solving and a reduction in aggressive and defiant behaviors. It was also found that the greater was the satisfaction of the parent regarding friends and their partner, the greater was the frequency of the use of positive parenting practices with their children, which reinforces the development of social skills in parents that use this practice.
Contrary to expectations, the more satisfied parents were with their family relationships, the lower was the frequency of use of the positive parental educational practice in respect of moral behavior. The hypothesis for this result is that, because of the good relationship within the family and the frequent contact of the child with the other members of the family, parents do not need to be constantly explicitly explaining what is fair or not in terms of values, but rather the children learn through direct observation through family contact, because the behavior of parents alone is enough for transmission of this learning. This is corroborated by Taylor et al. (2015), who verified that having parents with a broad social network, correlates positively with the social competence of the child. In fact, the observation of adequate models of social interaction can contribute to the development of adaptive repertoires of behavior in children (Celen & Kusdil, 2009;Taylor, Conger, Robins & Widaman, 2015). However, further studies are needed to corroborate this hypothesis.
Regarding negative parental practices, it was found that inconsistent punishment and physical abuse were found in parents who reported having less daily physical energy and lower self-esteem, as well as those less satisfied with their established social relationships and the physical environment in which they lived. Regarding social relationships, there was less satisfaction in these parents both in relationships with friends, having few close friends, and in respect of their relationship with their partner. In addition, the use of both practices was also associated with those who had lower levels of family adaptation, and a family environment in which a hostile climate prevailed, with little expression of affection between family members, and little clarity in the established family rules. These results indicate that the social environment itself favors the use of these practices, as it provides a low level of support and feeling of security, which shows that these caregivers urgently need support on how to handle their children (Donoso & Ricas, 2009;Gallo & Williams, 2005).
It was also found that the greater the frequency of both negative practices, inconsistent punishment and physical abuse, the greater was the occurrence in parents of both externalizing and internalizing problems, including at risk behaviors, which may threaten the physical safety of both the parent and those around them. Weiss (2002) found that low social support contributes significantly to the intensification of stress experienced by parents, directly impacting their mental health. According to the literature, parents with difficulties in emotional control and with high indicators of aggression, anxiety, depression and rule breaking behavior are more likely to be involved in physical abuse practices (Crandall, Deater-Deckard & Riley, 2015;Trepat, Granero & Ezpeleta, 2014).
The negative practice of neglect was associated with less frequent reporting of thought problems by parents responsible. This finding allows us to create the hypothesis that in respect of the meaning of the term 'neglectful style or negligence', parents with this practice, characterized by low acceptance, involvement and low strictness and imposition, may not perceive their behavior as inappropriate or strange, which may lead them not to identify such problems when asked through inventories such as the ASR. This leads one to think that these parents have misguided self-perception, and a tendency to underestimate their own internalizing emotional difficulties. A study by Gomide et al. (2005) found that parents who opted for negative practices did not have an enough repertoire of social skills and had symptoms of depression and high levels of stress.
The high frequency of associations between negative practices and the occurrence of behavioral problems in parents, and the low adaptive functioning indicators found in this study confirm the fact that factors external to the child (such as parental mental health and social and family support) influence how they educate their children. According to Moghaddam, Assareh, Heidaripoor, Rad and Pishjoo (2013), the families of children with ADHD have less family support and more troubled relationships among members. In addition, the authors also found that parents of children with ADHD tend to be less permissive and more rigid, with strict rules and constant monitoring of children (negative monitoring) when compared to the parents of children without the disorder. Klassen, Miller and Fine (2004) found that parents of children with ADHD reported significantly more emotional, behavioral, mental health issues, and lower self-esteem compared to parents of children without the disorder. Szymańska and Dobrenko (2017) report that when parents experience difficulties in parenting, there is a tendency to react according to their personal characteristics, temperament and coping strategies, which may lead them to isolate themselves from the situation or put pressure on their children. Thus, the correlation of parental characteristics and the management strategies used by the parents are clear. Teixeira, Marino and Carreiro (2015) have shown that positive parenting practices are also associated with a reduction in behavioral problems in children with ADHD, while the use of negative parenting practices has been positively correlated with several behavioral problems. Therefore, mental health, and the perception of family support and the quality of life of caregivers, as well as the child's own mental health, influence the choice of parental practices adopted. In this respect, the study by Martin et al. (2014) demonstrated the importance of developing emotional support groups for families of children with developmental disorders, since the perception of support was related to the lower occurrence of anxiety, depression and stress indicators in parents of children with atypical development. This reinforces the need for intervention programs for mental health care in parents in order to promote positive parenting practices that will benefit children with ADHD.

Conclusion
It was possible to demonstrate how different parental educational practices in relation to children with ADHD may be associated with different patterns of behavior and perceptions of family support of the parents/caregivers. Patterns characterized by negative practices are associated with a higher frequency of behavioral problems with fewer indicators of adaptive functioning in caregivers. Conversely, positive behaviors were associated with adequate parental management behaviors of the children, and with better adaptive functioning. It was also possible to showed that negative parenting practices are more often chosen and used by those with low social and family support indicators, as well as low quality of life. A relevant result of the study was to identify how parental neglect, as an educational practice, was also associated with lower parental recognition of internalizing types of emotional difficulties. This data indicates that these parents are unlikely to be aware of the type of parental practice they adopt, and the consequences on their child's behavior and family functioning. In addition, this lack of self-awareness also increases the difficulty they have in developing alternative solutions to these problems. Furthermore, this article advocates for the importance of developing social skills in parents in order they be able to use positive parenting practices in place of negative ones, such as physical abuse practice which is incorrectly understood in the common sense as a practice that helps to develop adaptive behaviors in children with ADHD. The data showed that parental practices with high warmth, high strictness and physical abuse are not related to the best results for children's adjustment.
Generally, the major concern regarding children with ADHD is related to reducing the impacts of the behavior's characteristic of the disorder in the school environment, which means that the family setting often gets neglected. The study identified factors related to parental practices and family functioning that should be considered in the intervention actions for the treatment of children with ADHD, because in doing so, we develop skills in those responsible for managing the difficulties arising from the symptomatology of the disorder, ensuring an improvement in the symptoms over the long term.
As an important limitation we have the small sample size due to the choice of selecting only children who was been diagnosed with ADHD. Therefore, there is a need for further studies with larger samples.