The Role of Mothers’ Psychiatric Symptoms, Practices of Emotion Socialization and Emotion Regulation among Children Diagnosed with Attention Deficit and Hyperactivity Disorder

Emotion regulation involves the process of experiencing, managing, and modifying emotions as well as their behavioral expression [10, 11]. Effective emotion regulation helps initiate adaptive behaviors, engage in goal-directed activities, reduce stress levels, and prevent maladaptive responses [12]. Gratz and Roemer [13] conceptualize emotion regulation as a multidimensional process, emphasizing emotional awareness, understanding, acceptance, impulse control, and the ability to use various strategies flexibly to modulate emotions. Emotion regulation difficulties, on the other hand, refer to the dysfunctional experience, interpretation, and maladaptive responses to emotional states, which impair functioning [14].

Research suggests that parents of children with ADHD are more likely to exhibit higher rates of psychiatric conditions, including ADHD, anxiety, depression, substance abuse, and personality disorders [15]. Among these disorders, ADHD and borderline personality disorder (BPD) frequently co-occur in adults, with both disorders sharing core characteristics such as impulsivity and emotion regulation difficulties [16]. Deficits in emotion regulation have significant consequences for daily functioning [17, 18]. Parents with traits of BPD may struggle to respond empathetically to their children, maintain a stable and secure home environment, and utilize effective parenting strategies. These struggles can lead to feelings of inadequacy in their parenting role, which further undermines their ability to parent effectively [19], leading to negative outcomes within the family [20‐23]). Similarly, ADHD symptoms in parents can disrupt cognitive processes, self-regulation, and motivation, thereby diminishing both parental competence and satisfaction [22, 24] (Sonuga-Barke et al., 2002). This can, in turn, exacerbate negative outcomes for both the parent and child [23, 25]. Research has established links between both parental ADHD and BPD traits and the severity of ADHD symptoms in children [20, 26‐29].

Children diagnosed with ADHD often face challenges in emotion regulation [30] (Braaten & Rosen, 2000; Bunford et al., [17, 31, 32]. For instance, in a study of 8,681 children and adolescents with an ADHD diagnosis, approximately one-third were found to have difficulties regulating their emotions [33]. Studies suggest that one of the mechanisms linking parental psychopathology to children’s symptoms is the transmission of emotion regulation difficulties within the family [34, 35]. This highlights the importance of addressing emotion regulation within family-based interventions, especially when parental mental health issues are present. Parents who struggle with emotion regulation often respond to their children’s negative behaviors with overly controlling approaches or emotional disengagement. These types of parenting behaviors are linked to the development of maladaptive emotion regulation strategies in children [36]. Emotional dysregulation in parents often hinders their ability to respond effectively to their children’s emotional needs, leading to negative impacts on the child’s emotional development [37, 38]. In addition, emotional challenges of parents with ADHD or BPD can have significant implications for their children’s emotional and behavioral development, as these maladaptive strategies may be passed on or modelled by their children.

Parental attitudes toward children’s emotional expressions play a key role in children’s emotional development [39, 40]. Eisenberg et al. [41] emphasize that parental emotion socialization approaches—how parents respond to their children’s emotions—significantly influence the development of children’s emotional and social competence. Parents engage in emotion socialization through three main pathways: (a) their responses to children’s emotions, (b) discussions about emotions, and (c) parental emotional expression [41, 42].

Supportive parental responses, such as validating and encouraging emotional expression, promote better emotion regulation, emotional awareness, and social competence in children [43]. In contrast, unsupportive responses—such as punitive or dismissive reactions to negative emotions like anger or sadness—signal to the child that these emotions should be suppressed. This can lead to increased emotional arousal, prolonged negative emotional states, and difficulties in regulating behaviors [44]. Such patterns are linked to poorer emotional regulation and behavioral problems, ultimately increasing the risk for psychopathology [45, 46]. Research suggests that there is a significant relationship between psychopathology symptoms in parents and unsupportive emotion socialization practices [35, 47‐49].

In addition, parents of children with clinical diagnoses, such as ADHD, tend to exhibit more unsupportive emotional socialization behaviors compared to parents of typically developing children [50, 51]. Children with ADHD often face greater emotional challenges than their typically developing peers, struggling with problem-solving when upset and focusing more on negative aspects of situations [52]. As a result, unsupportive parental behaviors can exacerbate these difficulties or increase the risk of related issues [53]. A few studies investigating emotion socialization practices of mothers’ of children with ADHD suggest that supportive emotion socialization approaches are linked to improvements in both emotional regulation and social functioning in these children [54‐57]. An emotion socialization program developed for families of hyperactive preschool-aged children includes components such as teaching parents emotion socialization strategies to enhance children’s emotion regulation such as helping children identify and label emotions, managing negative emotions, promoting positive emotional experiences, and modeling emotion regulation and expression for children [56]. The results of this study largely confirmed the program’s effectiveness in decreasing ADHD symptom levels, reducing children’s emotional instability, and enhancing parental emotion socialization practices. Another study conducted with young children and their mothers evaluated the effectiveness of an emotion socialization program and reported that enhancing mothers’ emotion regulation skills and supportive emotion socialization approaches was associated with a reduction in behavioral problems in children [58].

Although previous studies have explored the relationship between mothers’ psychiatric symptoms and their emotion socialization approaches, the specific link between ADHD and BPD symptoms in mothers of children diagnosed with ADHD and these socialization strategies remains largely unexamined. Moreover, research on the cognitive emotion regulation strategies employed by school-aged children diagnosed with ADHD is limited. Investigating this area will help fill a critical gap in the literature, providing insights into both the cognitive strategies employed by children and the parenting dynamics influenced by ADHD and BPD symptoms in their parents. The hypotheses are as follows:

Participants included 90 Turkish children (67 boys; 23 girls) aged 8–12 years (M = 9.71, SD = 1.33) diagnosed with ADHD and their mothers. When evaluating the ADHD profiles of the child participants, it was found that 27.8% (n = 25) had a predominantly inattentive type, while 12.2% (n = 11) exhibited a predominantly hyperactive-impulsive type, and 60% (n = 54) had a combined type. Additionally, 93.3% (n = 84) of the participants were taking medication, with 6.7% (n = 6) not using any medication. Regarding the types of medication used for ADHD, 90% (n = 81) were using methylphenidate, 3.3% (n = 3) were using atomoxetine, and 6.7% (n = 6) were not on any medication. In terms of comorbid diagnoses, 13.3% (n = 12) of the children had an anxiety disorder, 3.3% (n = 3) had conduct disorder, 8.9% (n = 8) had a specific learning disability, and 73.4% (n = 66) did not have any comorbid diagnoses. Mothers’ age ranged from 28 to 53 (M = 38.6, SD = 5.6). The education levels of the mothers were also assessed: 22.2% (n = 20) had completed primary education, 16.7% (n = 15) secondary education, 33.3% (n = 30) high school, 5.6% (n = 5) had an associate degree, 21.1% (n = 19) held a bachelor’s degree, and 1.1% (n = 1) had a graduate-level education. When the employment status of the mothers is examined, it was found that 68.9% (n = 62) are not working and 31.1% (n = 28) are working.

The study included children who were diagnosed with ADHD according to DSM-5 diagnostic criteria and their mothers. The participants in this study were recruited from the Child and Adolescent Psychiatry Clinic of the University of Health Sciences Erenkoy Research Hospital, located in Istanbul, Turkey. The hospital is situated in a densely populated urban area and serves a diverse population including individuals from both urban and rural areas. The inclusion criteria for children were 8–12 years of age and having no DSM-5 diagnosis of autism spectrum disorder, bipolar disorder, neurological disorders, and intellectual disability. For mothers, inclusion criteria were having no known diagnosis of bipolar disorder, psychotic disorders, intellectual disability, and dementia. Eligible children and their mothers were referred to the researcher after undergoing psychiatric evaluations by a child and adolescent psychiatrist. Information about the study was provided and written informed consent was obtained from mothers who voluntarily agreed to participate and assent was obtained from all children included in the study. Mothers completed Adult Attention Deficit and Hyperactivity Disorder Self-Report Scale, Borderline Personality Inventory, DSM-IV Based Disruptive Behavior Disorders Rating Scale, Coping with Children’s Negative Emotions Scale, Difficulties in Emotion Regulation Scale-Brief Form. Children filled out the Cognitive Emotion Regulation Questionnaire for Children.

All analyses were carried out using IBM SPSS Statistics software, version 24. Pearson’s Correlation was used for correlation analyses. For comparisons of the scale scores across ADHD subtypes, one-way ANOVA (Analysis of Variance) was conducted. Post-hoc analyses were applied in cases where significant differences were observed, considering the homogeneity of variances. In the present study, The Variance Inflation Factor (VIF) values for the predictor variables in the mediation models were all below the threshold of 10, and the tolerance values were above 0.10, indicating that there was no significant multicollinearity among the variables [71]. All the mediational relationships were estimated by the Hayes’ Process macro using bootstrap analysis through 5000 samplings. Mediation effects were determined based on the 95% confidence intervals, with the intervals not containing zero [72].

Descriptive statistics and correlations of the study variables are presented in Table 1. The mean score on the Borderline Personality Inventory (M = 8.96) in the current study was below the clinical cut-off score of 15/16, suggesting that, on average, the participants did not exhibit clinically significant levels of borderline personality traits. For the remaining measures, no established cut-off scores exist; therefore, the results are interpreted based on relative scores (e.g., mean, SD, range).

For group comparisons (predominantly inattentive type, predominantly hyperactive-impulsive type, and combined ADHD types of children) of mothers’ emotion socialization strategies, one-way ANOVA tests showed significant differences in mothers’ dismissive responses across groups (F(2, 87) = 4.885, p =.010). LSD (The Least Significant Difference) post hoc tests indicated that mothers of children with predominantly inattentive type exhibited significantly lower dismissive responses than those of children with combined type (Mean_diff = − 0.55, 95% CI [-0.92, − 0.17], p =.005). Regarding children’s cognitive emotion regulation strategies, self-blame scores differed significantly across groups (F(2, 87) = 3.586, p =.032). According to the LSD post hoc test results, children in the predominantly inattentive group had significantly higher self-blame scores compared to those in the predominantly hyperactive-impulsive group (Mean_diff = 3.14, 95% CI [0.75, 5.54], p =.011). In addition, it was found that the self-blame scores of children in the combined group were also significantly higher than those in the predominantly hyperactive-impulsive group (Mean_diff = 2.62, 95% CI [0.43, 4.81], p =.020). In addition, acceptance scores differed significantly across groups (F(2, 87) = 3.546, p =.033). According to the LSD post hoc test, participants in the predominantly inattentive group had significantly higher acceptance scores compared to those in the predominantly hyperactive-impulsive group (Mean_diff = 3.26, 95% CI [0.75, 5.77], p =.011). Similarly, children in the combined group also showed significantly higher acceptance scores than those in the predominantly hyperactive-impulsive group (Mean_diff = 2.75, 95% CI [0.45, 5.04], p =.019).

Reported direct effects include standardized regression coefficients and unstandardized confidence intervals; indirect effects are accompanied by standardized regression coefficients and standardized confidence intervals.

First mediation model examined the mediating role of mothers’ punitive reactions in the relationship between mothers’ ADHD symptom levels and children’s ADHD symptom levels. The model was significant (F(2, 87) = 14.702, p =.000, R² = 0.252), explaining approximately 25% of the variance in children’s ADHD scores. Results showed a significant total indirect effect (β = 0.074, SE = 0.037, 95% CI [0.006, 0.152]) and revealed that punitive reactions were found to significantly mediate the relationship.

Second mediation model examined the mediating role of mothers’ distress reactions in the relationship between mothers’ ADHD symptom levels and children’s ADHD symptom levels. This model was also significant (F(2, 87) = 16.252, p =.000, R² = 0.272), explaining 27% of the variance in children’s ADHD scores. In addition, mothers’ distress reactions significantly mediated the relationship (β = 0.143, SE = 0.047, 95% CI [0.061, 0.242]).

Third mediation model investigated the mediating role of mothers’ punitive reactions between mothers’ BPD symptom levels and children’s ADHD symptom levels and the model was significant, (F(2, 87) = 9.036, p =.000, R² = 0.172) with punitive reactions acting as a significant mediator (β = 0.131, SE = 0.045, 95% CI [0.044, 0.230]).

Forth mediation model examined mothers’ distress reactions as a mediator in the relationship between mothers’ BPD symptom levels and children’s ADHD symptom levels. The model was significant (F(2, 87) = 13.993, p =.000, R² = 0.243), explaining 24% of the variance in children’s ADHD symptom levels, and distress reactions were a significant mediator (β = 0.108, SE = 0.038, 95% CI [0.037, 0.189]).

Fifth model examined dismissive reactions as a mediator in the relationship between mothers’ BPD symptom levels and children’s ADHD symptom levels. This model was significant (F(2, 87) = 8.941, p =.000, R² = 0.17), with dismissive reactions mediating the relationship (β = 0.108, SE = 0.038, 95% CI [0.037, 0.189]).

Model 6 assessed mothers’ emotion regulation difficulties as a mediator between mothers’ ADHD symptom levels and children’s ADHD symptom levels. The model was significant (F(2, 87) = 10.626, p =.000, R² = 0.196), However, total indirect effect of mothers’ emotion regulation difficulties was not significant (β = 0.101, SE = 0.056, 95% CI [-0.014, 0.208]).

Model 7 examined mothers’ emotion regulation difficulties between mothers’ BPD symptom levels and children’s ADHD symptoms levels. The model was significant (F(2, 87) = 6.874, p =.002, R² = 0.136), explaining %14 of variance in children’s ADHD symptoms. There was a significant indirect effect (β = 0.160, SE = 0.066, 95% CI [0.030, 0.289]), meaning a significant mediator effect of mothers’ emotion regulation difficulties in the relationship between mothers’ BPD scores and children’s ADHD scores.

Model 8 investigated children’s other-blame cognitive regulation strategy as a mediator between mothers’ punitive reactions and children’s ADHD symptom levels. Although the model was significant (F(2, 87) = 9.950, p =.000, R² = 0.186), the mediation effect was not significant (β = 0.049, SE = 0.034, 95% CI [-0.003, 0.130]).

Model 9 tested the role of children’s other-blame cognitive regulation strategy in the relationship between mothers’ dismissive reactions and children’s ADHD symptom levels. The model was significant (F(2, 87) = 9.869, p =.000, R² = 0.169). Also, total indirect effect was significant the mediation was significant (β = 0.048, SE = 0.036, 95% CI [0.000, 0.136]), revealing that children’s other-blame strategy mediates the relationship between mothers’ dismissive reactions and children’s ADHD symptom levels. Mediated models can be seen in Figs. 1, 2 and 3, and 4.

When interpreting the study’s findings, a few limitations must be considered. First, the cross-sectional design of the study limits the ability to establish causal relationships. Research suggests a reciprocal relationship between children’s externalizing behaviors and parenting, where children’s behavioral difficulties increase negative parenting, which in turn worsens the child’s problems [85‐87]. Second, the study relied on self-report scales without incorporating observational tools, potentially affecting the objectivity of the responses. Future research could include observational measures to evaluate variables such as emotion socialization and emotion regulation. Third, in assessing children’s ADHD symptoms and other variables, information was gathered exclusively from mothers, under the assumption that they play a more significant role in children’s emotional and behavioral difficulties. Future studies could explore both maternal and paternal psychiatric symptoms and emotion socialization approaches, and additionally gather data from teachers when assessing children’s ADHD symptoms. Fourth, the distress reactions subscale of the CCNES used in this study demonstrated lower internal consistency reliability (α = 0.54). This limitation has been noted in previous research and the Turkish adaptation of the scale, where items with low factor loadings and face validity issues were excluded, leading to a refined subscale structure [88]. Despite these revisions, similar challenges in achieving higher internal consistency have been reported in Western samples as well [89]. The findings related to this subscale should be interpreted cautiously, taking into account its psychometric limitations and situating the results within the broader context of maternal emotional socialization strategies. Fifth, The CERQ-C demonstrated lower reliability coefficients for certain subscales such as positive reappraisal and acceptance which may have impacted the robustness of the findings related to those specific domains. Future studies should interpret results associated with these subscales with caution and consider employing alternative measures or additional reliability assessments to ensure the accuracy and consistency of the data. Lastly, while evaluating mothers’ responses to children’s negative emotions, these emotions were examined under a broad framework. Future research could examine emotion socialization responses towards specific negative emotions, such as anger, sadness, fear, frustration, and shame, in families of children with ADHD.

The findings offer valuable insights into the impact of maternal ADHD and BPD symptoms on parenting dynamics and their children’s emotional development. First, the study reveals that unsupportive maternal emotion socialization approaches, such as punitive and dismissive reactions, mediate the relationship between maternal ADHD/BPD symptom levels and children’s ADHD symptom levels. This highlights the importance of parent training programs that aim to reduce the use of punitive and dismissive responses, promoting healthier emotion regulation strategies in children with ADHD. Second, the mediating role of maternal emotion regulation difficulties in the relationship between maternal ADHD and BPD symptoms and children’s ADHD symptoms emphasizes the need to address maternal mental health in treatment interventions, as supporting mothers’ emotion regulation can positively influence both their parenting and their children’s ADHD symptoms.

The sample in the present study predominantly consists of boys (%74.4) which likely reflects the increased visibility of ADHD symptoms in boys, which facilitates their identification and referral to clinical settings [4]. However, this also raises the concern that ADHD symptoms in girls may be underrecognized or overlooked. Therefore, it is essential to consider this gender distribution when interpreting the study findings, as it may influence the generalizability of the results. In addition, the majority of participants in the present study were receiving medication, which reflects a clinically representative sample (Hauck et al., 2017). However, this limits the generalizability of the findings to children with ADHD who are not on medication. Future research should aim to include and examine children diagnosed with ADHD who are not undergoing pharmacological treatment, to provide a more comprehensive understanding of this population. Lastly, future studies could examine mothers with clinically diagnosed ADHD or BPD to further explore how these diagnoses influence emotion socialization and child development.