WHAT ARE THE CHALLENGES OF MOTHERS WITH ATTENTION DEFICIT HYPERACTIVITY DISORDER CHILDREN IN HEBRON DISTRICT: CROSS-SECTIONAL STUDY

Aim: To identify the most frequent challenges of mothers raising ADHD children. Background: Attention Deficit Hyperactivity Disorder (ADHD) is a neurobehavioral childhood disorder. The impulsivity and inattention by the child make parenting challenging. Methods: A cross-sectional study with67 mothers of ADHD children recruited from ADHD child management center, filled out the Zarit Burden Interview (ZBI), simple linear regression analysis was used to find an association between total burden score and variables (p<0.05) Results: 70% of mothers had a high Burden of care,24% with a moderate burden of care, and 6% with a low burden. Feelings of loss of control and insufficient time for self were the most significant correlated variables to the high burden of care (p<0.05), deterioration of the mother's health and social life, stigma, mistrust about proper treatment, and lack of school cooperation Conclusions: Mothers of ADHD children face difficulties and challenges in raising ADHD children, high level of burden among mothers correlated to psychological and social difficulties. Relevance to clinical practice: Positive parenting programs are recommended for parents with ADHD children to empower them in the management of their ADHD children's behavior to gain a better quality of life for ADHD children and their caregivers.

3 The prevalence of ADHD seems to have increased during the last decades (Moore et al., 2017).The estimated number of children ever diagnosed with ADHD according to a national 2016 USA parent survey is 6.1 million (9.4%) (Moore et al., 2017).According to the Centers of Disease Control and Prevention (2020),11% of ages 4-17 are diagnosed with ADHD which increases the probability of having at least one student with ADHD in a classroom (CDC, 2020).
An analysis by the National Health Interview Survey (NHIS) determined the prevalence of ADHD increased from 1997 to 2016 in US children from 6.1% to 10.2% (Xu et al., 2018).A similar prevalence rate was observed internationally during the years 2017 to 2022 (Li et al., 2023).The condition's impact has also contributed to a global burden of increase in disabilityadjusted life years (DALYs) across 204 countries from 1990 to 2019 (Cortese et al., 2023).In the Arab world the prevalence of ADHD was found to be 1.3-16% in a systematic review study matching 22 articles (Alhraiwil et al., 2015), in another study conducted in Jeddah -Saudi Arabia where 929 students screened for ADHD, the prevalence found to be 5% (AlZaben et al., 2018), in another systemic review study conducted in Oman found the burden of ADHD to be 34% (Al-Balushi et al., 2019).In Gaza-Palestine in a sample of 388 participants aged 12-15 years, 4.4% of children were rated by teachers while 9.8% were rated by parents as having combined ADHD (Elumour & Thabet, 2014).Attention Deficit Hyperactivity Disorder (ADHD) is the most common chronic neurobehavioral childhood disorder affecting school-age children (Huntington, 2005).According to (the NICE)national institute for health and care excellence for ADHD diagnosis only by a healthcare professional psychiatrist or pediatrician appropriately qualified healthcare with training and expertise, and based on a full clinical and psychosocial assessment of the child's symptoms, with the presence of social, educational, and psychological impairments in the different domains of child's everyday life and settings, not solely on rating scales, in addition to that it should meet the diagnostic criteria in DSM-5 or ICD-10(Dalrymple et al., 2020).Having a child with ADHD means a life full of challenges and difficulties in the environment, difficulty sustaining attention, increased distractibility, poor impulse control, and decreased self-inhibitory capacity, in addition to motor overactivity and restlessness are the main characteristics of ADHD (Posner & Greenhill, 2013).ADHD children commonly experience academic underachievement, low self-esteem, and problems with interpersonal relationships with family members and peers, it often co-occurs with other emotional, behavioral, language, and learning disorders (Dalrymple et al., 2020).40-50% of affected children appears to continue with varying manifestations into adulthood, and leads to  Kliegman, 2016).The impulsivity and inattention by the child makes parenting difficult and challenging as it put their skills to the test (Adeosun et al., 2017).One of the treatment approaches other than pharmacological options is the psychological education, school accommodation learning, academic support, parental interventions for a child's symptoms, and behavior modification (Posner & Greenhill, 2013).
Little attention has been paid to ADHD in Palestine and mainly to their mothers of what difficulties they are facing, and how they endure the burden of care or what would be their quality of life.Having a child with ADHD puts the parent in a demanding situation (Moen et al., 2011).ADHD symptoms and behaviors not only impact the child's social and academic life, but also affect their parents and thereby influence the whole family's functioning (Balagan & Tarroja, 2021), assessing the concerns and challenges of caregivers with ADHD children would provide the caretakers a greater sense of authority and control over the state of the child while ignoring the requirements of caregivers would also make the child's and family's difficulties worse (Pahlavanzadeh et al., 2018a).The mother's well-being and mental health will affect the child's well-being (Leitch et al., 2019).This study aims to explore the difficulties and challenges quantified by the burden of care level that may hinder the effective parenting of ADHD children.The burden of care can cause depression symptoms among caregivers (del-Pino-Casado et al., 2019), in addition to poor and deteriorated care outcomes for the recipient of care (Kuzuya et al., 2011), the necessity of identifying those challenges will increase the sensitivity of the healthcare provider to support mothers to perform better care with more understanding to their children (Mostafavi et al., 2020).So, it hypothesized that mothers raising children with ADHD in Hebron District will experience a significantly higher burden of care related to managing their child's hyperactivity and impulsivity.A considerable body of literature examined challenges facing mothers of ADHD children, the burden of care, and social, psychological, and academic difficulties were among the top.Caregiver burden was defined by Zarit and colleagues as "the extent to which caregivers perceive the adverse effect that caregiving has on their emotional, social, financial, and physical functioning."(Hildebrand, 2016).The burden of care was mostly related to parental stress caused by difficulties in work balance with a demanding diagnosed ADHD child care, in addition to social activity avoidance despite being on pharmacotherapy (Fridman et al., 2017;Mofokeng & van der Wath, 2017).ADHD children who have comorbid conditions have the highest levels of burden and stress (Rockhill et al., 2013), this was aligned to (Adeosun et al., 2017)that found higher levels of caregiver burden with co-morbid opposition defiant disorders, as 24.6% had sever burden in Nigeria while it was found to be lower in Almadinah as 18.8% of mothers had sever burden (Alnakhli et al., 2020), combined types of ADHD had a significant relation to the severity of burden of care level (Al-Balushi et al., 2019;Fridman et al., 2017;Mostafavi et al., 2020),on the other hand lower level of burden significantly (p<0.001) was associated with good social support (Adeosun et al., 2017),and increased medication adherence with their children decreased caregiver burden (Fridman et al., 2017),better understanding to burden components may ease caregiver burden while high level of caregiver burden may undermine the support and care for these children (Adeosun et al., 2017).

STRESS AND EDUCATIONAL CHALLENGES
Stress is the outcome of continuous efforts and struggles to cope with conflicts and to manage the child's disruptive behaviors according to (Mofokeng & van der Wath, 2017), mothers of ADHD showed to have high level of parenting stress and anxiety (González & Depaula, 2023),it was also reported that the intensity of stress will correlate to greater daily parenting hassles with ADHD children than parents without (Walerius et al., 2016), loss of control increase feelings of frustration, stress, and anger which will add another burden and their families (Harazni & Alkaissi, 2016), depression and anxiety high scores were the dominant factors hindering family function (Chen et al., 2014), it was found that 51.67% of ADHD Egyptian mothers had sever anxiety score (Jamal et al., 2018).Academic under-achievements is one of the major challenges for mothers of ADHD children (Balagan & Tarroja, 2021; Mofokeng & van der Wath, 2017), overwhelming stress impact mothers' mental health (Barahmand et al., 2015), in addition to feelings of blame and criticism for their children's disruptive behaviors (Gwernan-Jones et al., 2015), difficulty in concentration and inattention are obstacles to their achievement which will put another source of the burden on the mother (Harazni & Alkaissi, 2016)in addition to the responsibility of managing children's health status and the educational requirement while adapting the social system (Pajo & Cohen, 2013).6

STIGMA, LACK OF COPING SKILLS AND SOCIAL SUPPORT
Living with an ADHD child is challenging, parents struggle to cope with the child's unpredictable behavior and symptoms (Mofokeng & van der Wath, 2017).Moreover, they experience stigmatizing attitudes from the people in addition to mental pressure, fear of having labels related to raising a child with ADHD, facing difficulties and disruptive behavior (Pahlavanzadeh et al., 2018b), the stigmatizing attitude of community and family make the parents struggle to cope with their child's symptoms (Mofokeng & van der Wath, 2017), according to (Pahlavanzadeh et al., 2018b)negative feelings and fear from labels will add an extra burden on their parenting behavior, so they hide the disease and do not pursue treatment.
Inadequate social and familial support creates ambiguity in dealing with the child which makes the care difficult for the mother (Harazni & Alkaissi, 2016;Pahlavanzadeh et al., 2018b), inadequate knowledge and skills in addition to insufficient emotional preparation for caring of an ADHD child, will cause stress on the mother which leads to poor care management (Balagan & Tarroja, 2021).Extensive previous evidence of literature showed Mothers of ADHD children are facing a lot of challenges in their children's context of care, represented by the burden of care, stigma, lack of social and emotional support in addition to insufficient coping skills.

METHODOLOGY
This is a descriptive cross-sectional study design, as the information from mothers was taken at a single point in time.The preliminary step started by scanning the region for different specialized centers for the treatment and management of ADHD children at Hebron district; two centers were found as a setting for data collection, mothers were contacted according to the 7 version showed high variance and concurrent validity supported by significant negative associations with caregiver well-being and positive associations with depression and emotional exhaustion and showed high percentages of adequate internal consistency for each factor and for the entire scale (Bachner, 2013).The global survey used to quantify caregiving burden which is the Zarit Burden Interview (ZBI) validated in 1980 (Hébert et al., 2000), the original 29item version measured multidimensional aspects of emotional, physical, social and financial aspects, it demonstrated concurrent and construct validity (Zarit et al., 1980), a shorter 12-item scale revealed two factors: personal strain (3 items) and role strain (9 items), item responses are rated on a 5-point Likert scale from 0 (never) to 4 (almost always), with a higher score of 48 representing a higher sense of burden.The range 0-10 means no to a mild burden, 10-20: mild to moderate burden, and>20: high burden.The Cronbach's alpha value for the ZBI items was 0.93 (Yap, 2010).Data were analyzed using SPSS software V 25.Measures of central tendency were used.Continuous variables were reported as mean (± standard deviation SD).Participants' scores (representing the total burden score) were interpreted as scale-dependent variables.
Additionally, significant predictors of the burden score were determined using simple linear regression analysis to find an association between the perceived total burden score to the variables in the tool and the demographic variables.A confidence interval of 95% (p<0.05) was applied to represent the statistical significance of the variables.

PARTICIPANT'S CHARACTERISTICS
A sample of sixty-seven mothers participated in the study.The mean age for mothers was 35.7, SD ±8.5, and the minimum age of mothers was 21years old, whereas 56 is the maximum age,(98,5%,n=66) of the mothers were married except for (1.5%,n=1) mother was divorced, (25.4 %,n=17) was employed while (74.6%,n=50) were unemployed, the highest percentage of mothers had only a primary school level of education ( 37.3%,n=25)followed by (34.3%,n=23) with a bachelor degree, and( 20.9%,n=23) completed the high school (Tawjihi).
Only a small number had higher education master's degrees (7. 8 mothers reported that their children were not on a pharmacological treatment for ADHD on the contrary of (16.4%,n=11) who were not on a pharmacological treatment.(22.4%,n= 15)of the children had other diseases while (77.6%,n=52) didn't have other diseases than ADHD, the highest number of ADHD children were affiliated with specialized centers for their education of (68.7%,n=46) and( 19.4%,n=13) getting their education in private schools, a small percentage went for governmental schools(7.5%,n=5),while(4.5%,n=3) was not affiliated to the school.(Table 1) 9 support, however a small percentage of (19.4%,n=13) approved their relative support in addition to the medical center support.

Personal feelings:
The majority of mothers (37.3%,n=25) reported that they sometimes don't have sufficient time for self, while( 34,4%,n=23) reported that they always don't have self-time after the child's diagnosis, moreover( 31,3%,n=21)of mothers reported feeling a loss of control and deterioration of their social life after their child's diagnosis with ADHD, followed by (29.9%,n=20) for those who reported deterioration of their health, however (28%,n=19) reported sometimes feeling of stress around their ADHD child, but other( 25.4%,n=17) felt almost always of stress while being around their child, however( 37.7%,n=25)of the mother's response stated that there was no influence on the relationship of other children, compared to (29.9%,n=20)who reported that they do sometimes have been influenced negatively in their relationship with other children, while ( 16.4%,n=11) of the mother replied of always having negative relationships with other children.
proper management: percentage of mothers who trusted their children's proper way of treatment ( 40%,n=27), while 32% of them reported that they sometimes felt mistrust about the proper treatment, while (16.4%,n=11) of the mothers were almost all the time in mistrust of the proper treatment for their children, the majority of mothers responded that they sometimes were unable to cover the expenses of their children's treatment (34.3%,n=23) compared to (26.9%,n=18) of mothers who were almost always unable to cover the expenses of their children's treatment, yet(24%,n=16) had no problems in covering the treatment expenses, (32,8%,n=22) of the mothers were satisfied with their care to their children, while about (30%,n=20) of the mother were sometimes feeling that they could provide better care for their children and( 19.4%,n=13) of them felt almost always that they could do better on their provided care for their ADHD children( Ttable2).

Table2
Participant's Responses for The Burden Scale Items  A simple linear regression indicated that the model was influenced by different variables while other variables did not by their relevant coefficient β and their significance of p<0.05.
Perceived burden found to be increased by different significant factors , Feeling loss of control by the mother was the highest significant coefficient of .7,followedby feelings of not having sufficient time for self in addition to reported deterioration of health since the child had been 11 diagnosed , deterioration of social life ,feeling of stress and feeling the need for psychological support in addition to presence of negative relationship with other children were positive variables in predicting the total score of burden by their relevant 0.5 coefficient ,other variables such as feeling of stigma and mistrust about the treatment in addition to uncertainty about giving the proper treatment was also a positive significant variables for the perceived burden score, school environment cooperation was a positive predictor of the mother burden of al lower coefficient of .2,sameas for having a husband support, while there were a negative relation between the marital status and the perceived burden score.(Table 4).Other variables such as inability to cover expenses, medical centers support, presence of learning difficulties, mother's age, working status, and education, in addition to child's other diseases, being on treatment, and presence of other diagnosed children were not significant predictors for the perceived burden score and caused no differences.The mean total mean burden score was 24.8, with ±8.7 SD, the minimum score was 6 while the maximum score was 40, the level of burden score was classified according to the original Zarit total score of 48 cut-off,(70.1%,n=40) of the score was classified as a high burden while( 23.9%,n=16) were in moderate burden and only (6%,n=4) with low burden(table 5).

DISCUSSION
The study showed that there were a lot of difficulties and challenges that may face the mothers of ADHD children which directly affected their level of burden, the findings revealed the presence of a high level of burden (70%,n=47), this was higher than other Arabic previous studies where sever burden estimated to be 18.8% in a sample of 80 Saudi mothers, while 43.8% with the moderate burden (Alnakhli et al., 2020), in another study conducted in Nigeria Severe burden was reported to be 24.6% (Adeosun et al., 2017), this was lower than the Iranian study where the mean of mothers' caregiver burden was 40.43% (Mostafavi et al., 2020).Other challenges found in this study are parental stress, a feeling of loss of control, and stigma which were mostly related to the high level of burden, this finding was in line with different previous studies.Leitch et al.(2019) in a qualitative study found the challenges of raising a child with ADHD affected the parent's well-being through feelings of stress and frustration, similar to another qualitative study which highlighted the feelings of frustration and exhaustion in addition to social and emotional issues by the parents to be the main themes generated from their study (Mofokeng & van der Wath, 2017), on the other hand, the child's severity of behavior was mostly related to stress in addition of feelings of stigma as the intensity of stress increases parents problems with ADHD children (Walerius et al., 2016).In this study the burden of care in the family with an ADHD child was found to be increased by feelings of loss of control, stress, and anger, the same findings were reported in qualitative study results (Harazni & Alkaissi, 2016) whereas fear from labels and the mental pressure were the main sources of stigma attitudes (Pahlavanzadeh et al., 2018b), as these factors hampered the family with ADHD child coping mechanisms (Mofokeng & van der Wath, 2017).ADHD children who have comorbid conditions have the highest levels of burden and stress according to (Adeosun et al., 2017;Rockhill et al., 2013), this was contrary to this study in which the presence of other child diseases was not significantly related to total burden mean score.Learning problems and type of school have no significant relationship for the perceived total burden score, this was contrary to previous studies which found that academic difficulties may increase stress on the mother ___________________________________________________________________________ Rev. Gest.Soc.Ambient.| Miami | v.18.n.7 | p.1-16 | e08185 | 2024.

What
Are the Challenges of Mothers with Attention Deficit Hyperactivity Disorder Children in Hebron District: Cross-Sectional Study ___________________________________________________________________________ Rev. Gest.Soc.Ambient.| Miami | v.18.n.7 | p.1-16 | e08185 | 2024.4 significant under-and unemployment, increased risk of antisocial behaviors including substance abuse, difficulty in maintaining social relationships and encounters with the law (M
child's diagnosis, any child with comorbid conditions like autism or others were excluded, mothers were told to consider the first diagnosed child of ADHD in the study.Approval of the IRB related to the Arab American University of Palestine was taken, in addition to the approval of the two specialized centers, the consent form was signed by a mother with a diagnosed child of ADHD ages 5-13 years old who agreed to participate in the study, the questioner was anonymized, mothers where informed about the research purpose and their elective choice to participate.The sample was composed of sixty-seven conveniently selected mothers who agreed to fill out the questionnaire on caregiver burden which is a validated translated Arabic version used after obtaining the original article author's permission.The Arabic-translated What Are the Challenges of Mothers with Attention Deficit Hyperactivity Disorder Children in Hebron District: Cross-Sectional Study ___________________________________________________________________________ Rev. Gest.Soc.Ambient.| Miami | v.18.n.7 | p.1-16 | e08185 | 2024.
5%, n=5), most of the sample mothers didn't have other children diagnosed with ADHD (91%, n=61) while only (9%, n=6) had other diagnosed children.The mean years for the child diagnosis was 4 years, from newly diagnosis of zero years to a maximum of fourteen years since diagnosis,(83.6%,n=56) of the What Are the Challenges of Mothers with Attention Deficit Hyperactivity Disorder Children in Hebron District: Cross-Sectional Study ___________________________________________________________________________ Rev. Gest.Soc.Ambient.| Miami | v.18.n.7 | p.1-16 | e08185 | 2024.

Table 1
Participants Demographics for their child's diagnosis and management while about( 15%,n=22) didn't get any husband support, (32.8%,n=22) of the mothers reported both no relative nor getting any medical center What Are the Challenges of Mothers with Attention Deficit Hyperactivity Disorder Children in Hebron District: Cross-Sectional Study ___________________________________________________________________________ Rev. Gest.Soc.Ambient.| Miami | v.18.n.7 | p.1-16 | e08185 | 2024.

Table 3
Other Item Variables Used in The Tool

Table 4
Significant Predictors of The Total Burden Score Relationships.