Journal of Psychosocial Nursing and Mental Health Services

CNE Article 

Effect of Psychoeducation on Stress in Parents of Children With Attention-Deficit/Hyperactivity Disorder: A Randomized Controlled Study

Funda Gümüs, PhD, RN; Gül Ergün, PhD, RN; Gül Dikeç, PhD, RN

Abstract

The current experimental pre-/posttest study sought to determine the effect of psychoeducation on the stress levels of parents of children with attention-deficit/hyperactivity disorder (ADHD). A total of 172 parents participated and were randomly assigned to experimental (n = 86) and control (n = 86) groups. There was no significant difference between mean pretest scores of parents in the experimental and control groups on the Caregiver Stress Scale (p > 0.005); however, significant differences were found between pre- and posttest scores in the experimental group after psychoeducation and at 6-month follow up (p < 0.001). There were also significant differences between pre- and posttest scores and pretest scores and 6-month follow-up scores in the experimental group (p < 0.05). In the light of the findings, psychiatric nurses can use psychoeducation programs to support families of children with ADHD to reduce their stress levels. [Journal of Psychosocial Nursing and Mental Health Services, 58(7), 34–41.]

Abstract

The current experimental pre-/posttest study sought to determine the effect of psychoeducation on the stress levels of parents of children with attention-deficit/hyperactivity disorder (ADHD). A total of 172 parents participated and were randomly assigned to experimental (n = 86) and control (n = 86) groups. There was no significant difference between mean pretest scores of parents in the experimental and control groups on the Caregiver Stress Scale (p > 0.005); however, significant differences were found between pre- and posttest scores in the experimental group after psychoeducation and at 6-month follow up (p < 0.001). There were also significant differences between pre- and posttest scores and pretest scores and 6-month follow-up scores in the experimental group (p < 0.05). In the light of the findings, psychiatric nurses can use psychoeducation programs to support families of children with ADHD to reduce their stress levels. [Journal of Psychosocial Nursing and Mental Health Services, 58(7), 34–41.]

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by lack of attention, as well as hyperactivity and impulsivity, and is one of the most common reasons children and adolescents attend mental health outpatient clinics (Sabuncuoglu et al., 2015). ADHD is a common disorder with adverse effects on both children and their families. The worldwide prevalence of ADHD is 5.9% to 11% (Visser et al., 2014); however, in a recent epidemiological study, prevalence of ADHD was 19.5% in Turkey (Ercan et al., 2019). When left untreated, ADHD may lead to permanent psychiatric and social disorders and reduce the quality of life of children and their families (Andrade et al., 2016). In addition, this disorder causes self-reproach, stress, social isolation, anxiety disorders, caregiver burden, economic problems, and depression in families (Al-Balushi et al., 2019; Johnston & Chronis-Tuscano, 2015; Sasser et al., 2016; Vander Stoep et al., 2017).

Background

In addition to psychopharmacology, the use of psychosocial practices for ADHD, such as psychoeducation and cognitive-behavioral therapy, may increase long-term treatment success. More than one treatment approach is recommended in cases where medication cannot provide a full recovery (Daley et al., 2018; National Institute for Health and Care Excellence [NICE], 2018). Psychosocial interventions may sometimes be costly because they require special training and experience. However, one psychosocial intervention, psychoeducation, is more practical than others because of its ease of use and low cost (Gümüs & Buzlu, 2018).

Caregiving is a stressor and negatively affects the health of caregivers (Yigitalp et al., 2017). In a qualitative study conducted with mothers of children with ADHD, mothers stated that they experienced caregiver burden (e.g., academic, psychological, and emotional issues), inadequate support (lack of support from spouse, relatives, school, and community), and problems related to their child's behavior (e.g., excessive activity, impulsivity, hatred). According to these mothers, they were under stress because of their worries about the future of their children. They also expressed their needs for information and support about the disorder, its treatment and prognosis, and assistance to improve their children's academic achievement (Harazni & Alkaissi, 2016). In another study, it was reported that the parents of children with ADHD experienced stress and that the source of stress was often problems in their children's social and school lives and their inability to express themselves (Hutchison et al., 2016). In addition, parents have been reported to behave in unintentionally negative and punitive ways as a result of the symptoms of ADHD and to subsequently regret their actions and experience more stress, thus, having a higher tendency to experience depression (Corcoran, 2016; Miguelez-Fernandez et al., 2018). These events have been reported to increase the severity of children's symptoms, therefore manifesting more negative behaviors (Nelson et al., 2019).

In recent studies, it has been reported that parents' perceptions about the disorder (e.g., its severity and knowledge about the causes of ADHD) (Harazni & Alkaissi, 2016) and acceptance of treatment affect children's adherence to treatment. It has also been determined that parents of children with ADHD are not well informed by health professionals and that this situation can change with psychoeducation about ADHD (Corkum et al., 2015). Studies have reported that psychoeducation programs given to parents enhanced the treatment compliance of children and decreased clinical symptoms (Bai et al., 2015; Haydicky et al., 2015). Thus, it is important to inform parents of children with ADHD about the risks that may affect their children in the future in terms of helping them accept the disorder, providing early diagnosis and treatment, and assisting in coping with the stress they experience. For these reasons, it is important to inform families about ADHD and involve them in the treatment process.

Objective and Hypotheses of the Study

The current study was conducted to determine the effect of psychoeducation on the stress levels of parents of children with ADHD. Two hypotheses were formed:

(H0) No significant differences would be found on Caregiver Stress Scale (CSS) scores between parents in experimental and control groups after 6 months.

(H1) CSS scores of parents in the experimental group will be lower than scores of parents in the control group 6 months after the psychoeducation program.

Method

Study Design

A randomized controlled study was performed using pre-/posttest scores in experimental and control groups. The CONSORT 2010 checklist was used (Figure 1).

CONSORT diagram of study sample selection.

Figure 1.

CONSORT diagram of study sample selection.

Participants

The study was conducted between September 2017 and May 2018 with parents of children and adolescents with ADHD who attended a child and adolescent psychiatric outpatient clinic of a public hospital.

The sample size was calculated before and after the study. Prior to the study, the sample was analyzed by power analysis using S-PLUS. The minimum number of participants was calculated to be 43 in each group (i.e., experimental and control, 86 individuals total) to prove significance with an alpha error rate of 5% (95% reliability) and beta error rate of 20% (80% reliability = power of the test).

At the end of the study, G*power software version 3.1 was used in the sample calculation (Erdfelder et al., 1996). The effect size, which was calculated according to the CSS, was 0.6 when the number of participants was accepted as 43 for the control and experimental groups (p = 0.05). According to the post-hoc independent groups t test, the power of the study was 0.86. A total of 86 parent dyads (172 people) participated in the study; 43 dyads were in the experimental group and 43 were in the control group. Inclusion criteria for both groups were: (a) having a child diagnosed with ADHD at least 6 months prior to the study who was receiving standardized clinical follow up and treatment, (b) age 18 to 65, (c) having no mental illness, and (d) agreeing to participate in the study.

Three hundred sixty children with ADHD in the hospital system were coded with numbers from 1 to 360. Parents of these children were contacted to create the study sample. Parent inclusion in the experimental and control groups was determined using the systematic sampling method. Matching and randomization methods (Çuhadar & Çam, 2014) were used to ensure homogeneity between the experimental and control groups in terms of the characteristics that might affect the outcome of the study. Parents included in the sample were pre-tested. Parents were divided into groups randomly according to sociodemographic characteristics (e.g., social security status, educational status, family type) by using the pretest results.

Outcome Measures

The Personal Information Form and Caregiver Stress Scale were used in the study.

Personal Information Form. This form, prepared by the researchers using the existing literature (Al-Balushi et al., 2019; Andrade et al., 2016; Bai et al., 2015; Ben-Naim et al., 2019), included 15 questions regarding sociodemographic characteristics of parents, such as age, gender, marital status, family type, education level, employment status, social security status, and whether they had a chronic disease and another child.

Caregiver Stress Scale. To determine the subjective care burden of caregivers and quickly identify families with care concerns, the CSS, developed by Robinson (1983), was used. This scale comprises 13 items, including caregiver's financial, physical, and social status and time management, scored as yes (1) or no (0). Total score is calculated by summing 0 and 1 responses, where scores ≥7 show a high level of stress and perceived subjective caregiver burden (Ugur & Fadiloglu, 2010). Turkish validity and reliability of the scale was conducted by Ugur and Fadiloglu (2010), with Cronbach's alpha of 0.75 and test–re-test reliability of 0.75. Cronbach's alpha in the current study was 0.66 in the pretest.

Intervention

Parents in the experimental and control groups were informed about the objective of the study and invited to participate. Those who agreed to participate were given an appointment for the first interview.

Parents in the experimental group attended four meetings. In the first meeting, parents were informed about the objective of the study in detail, took the pretest, determined dates and times of the psychoeducation, and were provided with an appointment. In the second and third meetings, two sessions of psychoeducation were provided by a psychiatric nurse (G.E.) in the training room of the hospital. Parents of each child were educated as couples and each training session lasted 45 to 60 minutes for each family. The first 5 minutes of training were used for warm-up, 25 minutes were used for basic ADHD knowledge, and the last 15 minutes for questions and answers. The psychoeducation included discussion about the causes, symptoms, and signs of ADHD; the course and characteristics of the disorder according to age; the treatment process; medications used in treatment and their side effects; correct and incorrect information about medications; other symptoms that can coexist with ADHD and their treatment; and what parents can do about these issues. The posttest was applied after the two sessions of psychoeducation. The fourth meeting was held 6 months after the psychoeducation. In this interview, parents' questions were answered and follow-up tests were performed.

Parents in the control group attended two meetings. In the first meeting, parents were informed about the objective of the study, took the pre-test, and determined a follow-up date. Parents in this group did not undergo any intervention, and their children continued their current treatment plans. The second meeting was conducted 6 months later and follow-up tests were administered.

Data Analysis

The data were analyzed in SPSS version 22.0. Sociodemographic variables were reported as mean, standard deviation, number, and percentage, whereas homogeneity tests were performed using chi-square and Student t tests in dependent and independent groups. The mean scores on the scales before and after the psychoeducation were evaluated by kurtosis and skewness values; paired t test was used for in-group comparisons, whereas Student's t test was used for intergroup comparisons. p < 0.05 was accepted as statistically significant for all statistical analyses.

Ethical Considerations

Ethics committee approval was obtained from the Non-Interventional Clinical Research Ethics Committee of the researcher's university. To conduct the study, written permission was obtained from the General Secretariat of the Provincial Public Hospitals and the Provincial Health Directorate. Informed consent and verbal permission were obtained from participants.

Results

No significant differences were found between parents in the experimental and control groups in terms of age, gender, marital status, education level, family type, presence of social security, and presence of a chronic disease (Table 1).

Sociodemographic Characteristics of Parents in The Experimental and Control Groups (N = 172)

Table 1:

Sociodemographic Characteristics of Parents in The Experimental and Control Groups (N = 172)

In the pretest, no significant difference was found in total mean scores of the CSS between experimental and control groups. However, a significant difference was noted in mean post-test and 6-month follow-up scores between experimental and control groups (p < 0.001) (Table 2). When the pretest, posttest, and 6-month follow-up scores of parents in the experimental group were evaluated, significant differences were found between the pre- and posttest and pretest and 6-month follow-up scores, whereas no significant difference was found between posttest and 6-month follow-up scores (Table 3). On the other hand, when pretest and 6-month follow-up scores of parents in the control group were evaluated, a significant difference was noted (p < 0.05) (Table 3).

Comparison of Caregiver Stress Scale Scores of Parents in Experimental and Control Groups (N = 172)

Table 2:

Comparison of Caregiver Stress Scale Scores of Parents in Experimental and Control Groups (N = 172)

Comparison of Pretest, Posttest, and 6-Month Follow-Up Scores of Parents in the Experimental and Control Groups on the Caregiver Stress Scale (CSS)

Table 3:

Comparison of Pretest, Posttest, and 6-Month Follow-Up Scores of Parents in the Experimental and Control Groups on the Caregiver Stress Scale (CSS)

According to results, H0 hypothesis was unfounded, whereas H1 hypothesis was accepted.

Discussion

The objective of the current study was to determine the effect of psycho-education for parents of children with ADHD. Findings showed that the psychoeducation applied to the experimental group decreased parents' stress immediately and 6 months after the psychoeducation compared to the control group.

Caring for an individual with a chronic disease affects the lives of family members in many ways. The health of caregivers is primarily affected by caregiving, with many caregivers experiencing high levels of stress (Cappe et al., 2017), which may lead to possible depression (Wang et al., 2016). In one study, one third of families had health problems related to their children's diagnoses, which affected the family harmony (Cappe et al., 2017). In addition, it was determined that stress experienced by children increased the stress levels of their mothers (Ben-Naim et al., 2019; Muñoz-Silva et al., 2017). In a study conducted in Taiwan, 25.7% of mothers of children with ADHD were reported to be at risk for depression (Chen et al., 2014). In another study, the effectiveness of case management in nursing for children with ADHD and their mothers was evaluated, and no significant difference was found between experimental and control groups in terms of maternal stress (Churchill et al., 2018). In a randomized controlled study conducted by Enebrink et al. (2012), parents received web-based training. After this intervention, parents stated that their children had fewer behavioral problems and fewer problematic behaviors, which continued for 6 months (Enebrink et al., 2012). Ferrin et al. (2020) conducted a 12-week group psychoeducation with parents of children with ADHD. Although they reported no difference between experimental and control groups in terms of the stress experienced by families after psycho-education, they stated that psychoeducation can reduce the emotional and social effects of the disorder on the family and make the lives of children/adolescents with ADHD easier in the long term. In the same study, they stated that psychosocial interventions in ADHD can be adapted to individual patients and their families, and that the identification of specific components may thus affect the outcome of the interventions (Ferrin et al., 2020). However, Ferrin et al. (2020) did not find any difference in the stress index between parents in experimental and control groups after a six-session group psychoeducation program provided to families of children with ADHD.

There are several possible reasons why findings of the current study are different from results of previous studies, and why parents' posttest and 6-month follow-up CSS scores decreased. First, when the literature was examined, limited studies were found on the effect of psychoeducation on parents' stress levels and most of these programs were administered to groups of eight to 10 people for between two and 12 sessions (Bai et al., 2015; Ferrin et al., 2020). In the current study, mothers and fathers of each child were seen together and psychoeducation was provided to them as couples, which enabled them to ask questions specific to the status of their own child, express their feelings and thoughts, identify their concerns, and think about the solution as a family. A strength of the current study is the application of the psychoeducation to both parents. No study considering both parents of children with ADHD was found in the literature. However, family-oriented psychoeducation programs for bipolar disorder have been implemented for many years and have provided positive results (Reinares et al., 2016).

Second, it has been reported that the severity of ADHD symptoms and comorbidity rates are higher in children of parents with ADHD than those in children of parents without ADHD. In the current study, the absence of an ADHD diagnosis in the parents was a criterion for inclusion in the study. This criterion may be one reason that the psychoeducation had more positive results than previously reported. In addition, the ability to address the lack of information, inadequate home care services, and inadequate access to psychosocial treatments except pharmacotherapy through the psychoeducation reduced the stress felt by many families, particularly those of low socioeconomic or sociocultural status (Çengel Kültür & Öztekin, 2017; Özaslan & Bilaç, 2015).

Third, it is possible that individuals in Turkey are able to share their problems with other people because the traditional family structure remains common and levels of perceived social support are generally high (Çam & Topçu, 2019). However, comparable studies to support this claim are lacking. Finally, the stress level of parents in the control group increased without any intervention. The experimental group received two sessions of psychoeducation and a total of four meetings, whereas parents in the control group received treatment as usual, which may have affected the study results.

Limitations

The inability to generalize the results due to the monocentric design of the study, lack of culture-specific standards, and structured psychoeducation programs are among the limitations of the current study. In addition, the CSS reliability score was <0.70 in the current study. Parents in the control group did not receive any psychoeducation or counseling and only had two meetings compared to the experimental group, which had four meetings and thus more contact with researchers.

Clinical Implications

As a result of the psychoeducation administered by a clinical nurse, the stress levels of parents of children with ADHD were reduced. Child and adolescent psychiatric nurses can provide psychoeducation programs aimed to increase knowledge and coping skills of parents of children with mental disorders. In Turkey, it is among the duties, authorizations, and responsibilities of psychiatric nurses to plan, conduct, and evaluate psychoeducation programs (Turkish Nurses Association, 2018). However, nurses usually apply psychoeducation programs to adult patients with schizophrenia and bipolar disorder and their relatives. Psychoeducation programs could also be used for other disorders that cause stress to parents. The findings of the current study support the recognition and use of psychoeducation practices. In light of this study, psychoeducation programs that support families of adults and children with ADHD and aim to reduce stress levels can be used successfully by psychiatric nurses in clinical practice.

As mental disorders increase during childhood and adolescence, it is possible to prevent them from becoming chronic by increasing the insight related to these disorders and adherence to treatment. There is a need for structured psychosocial interventions that can be applied to parents of children and adolescents. In this context, comprehensive and longitudinal research can be planned to develop psychoeducation programs for parents of individuals who experience ADHD or other disorders, such as autism and conduct disorders.

Conclusion

The psychoeducation provided to parents of children with ADHD reduced parental stress. To prevent the disorder from worsening and reduce physical and psychological issues, it is important to understand the symptoms experienced by children with ADHD, including their frequency, severity, and effects, as well as to define the problems experienced by children during the treatment process, involve families in the treatment process, and ensure cooperation between families and health professionals. Professionals working in the field of mental health and psychiatry could benefit from this psychoeducation program.

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Sociodemographic Characteristics of Parents in The Experimental and Control Groups (N = 172)

CharacteristicExperimental GroupControl GroupStatistical Analysis (ta or χ2b/p Value)
Age (years) (mean [SD])35.41 (5.91)34.16 (5.11)1.46a/0.14
Gender (n, %)
  Female43 (50)43 (50)
  Male43 (50)43 (50)
Educational level (n, %)2.12b/0.54
  Primary school17 (19.8)21 (24.4)
  Middle school29 (33.7)26 (30.2)
  High school26 (30.2)20 (23.3)
  University14 (16.3)19 (22.1)
Family type (n, %)0.69b/0.40
  Extended4 (4.7)2 (2.3)
  Nuclear82 (95.3)84 (97.6)
Social security status (n, %)0.441b/0.507
  Yes62 (72.1)58 (67.4)
  No24 (27.9)28 (32.6)
Chronic disease (n, %)2.65b/0.103
  Yes14 (16.3)7 (8.1)
  No72 (83.7)79 (91.9)
Other children (n, %)
  Yes74 (86)74 (86)
  No12 (14)12 (14)

Comparison of Caregiver Stress Scale Scores of Parents in Experimental and Control Groups (N = 172)

Caregiver Stress ScaleaExperimental GroupControl Groupt/p Value
Pretest5.76 (2.22)5.52 (2.58)0.66/0.508
6-month follow up4.72 (2.21)6.29 (2.83)−4.04/<0.001

Comparison of Pretest, Posttest, and 6-Month Follow-Up Scores of Parents in the Experimental and Control Groups on the Caregiver Stress Scale (CSS)

GroupCSS Score a (Mean [SD])t/p Value
PretestPosttest6-Month Follow UpPretest/PosttestPretest/6-Month Follow UpPosttest/6-Month Follow Up
Experimental5.76 (2.22)4.75 (1.92)4.72 (2.1)9.06/<0.0016.23/<0.0010.22/0.822
Control5.52 (2.58)6.29 (2.83)3.25/0.002
Authors

Dr. Gümüs is Associate Professor and Doctor of Psychiatric Nursing, Department of Nursing, Atatürk School of Health, University of Dicle, Diyarbakir; Dr. Ergün is Associate Professor and Doctor of Psychiatric Nursing, Department of Nursing, Faculty of Health Sciences, Burdur Mehmet Akif Ersoy University, Burdur; and Dr. Dikeç is Assistant Professor of Psychiatric Nursing, Department of Psychiatric Nursing, Hamidiye Nursing Faculty, University of Health Sciences, Istanbul, Turkey.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Gül Ergün, PhD, RN, Associate Professor and Doctor of Psychiatric Nursing, Department of Nursing, Faculty of Health Sciences, Burdur Mehmet Akif Ersoy University, Istiklal Campus, Burdur, 15030, Turkey; email: ilkem79@hotmail.com.

Received: February 05, 2020
Accepted: April 14, 2020
Posted Online: May 12, 2020

10.3928/02793695-20200506-01

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