Prospective study on the impact of parental anxiety on academic performance in children with attention deficit

Abstract

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) affects approximately 5% of children worldwide and is associated with significant academic impairment. Parents of children with ADHD experience elevated stress and anxiety levels, which may further affect their children's educational outcomes. This prospective study examined the relationship between parental anxiety and academic performance of children with ADHD over a 6-year period.

AIM

To investigate the longitudinal impact of parental anxiety on academic performance in children with ADHD and explore the mediating and moderating factors over a 6-year follow-up period.

METHODS

A longitudinal cohort study was conducted from 2018 to 2024, enrolling 118 children with ADHD (aged 6-12 years) and their parents from three specialized educational centers. Parental anxiety was assessed using the Parenting Stress Index-4 (PSI-4) and Parental Anxiety Scale. Children's academic performance was measured using the Academic Performance Questionnaire and standardized achievement tests. Assessments were conducted at baseline and every 6 months for 3 years.

RESULTS

Higher parental anxiety scores were significantly associated with poorer academic performance in children with ADHD (β = -0.42, P < 0.001). Children of parents with clinically significant anxiety (PSI-4 scores > 85^th percentile) showed 1.2 standard deviations lower academic achievement than children of parents with normal anxiety levels. The relationship was partially mediated by parent-child interaction quality (indirect effect = -0.18, 95%CI: -0.26 to -0.10) and homework supervision practices (indirect effect = -0.15, 95%CI: -0.22 to -0.08).

CONCLUSION

Parental anxiety could significantly affect the academic outcomes of children with ADHD via multiple pathways. Interventions targeting parental mental health may improve the educational outcomes of children with ADHD.

Key Words: Attention deficit hyperactivity disorder; Parental anxiety; Academic performance; Prospective study; Parent-child interaction

Core Tip: This 6-year prospective cohort study examined how parental anxiety affects academic performance in children with attention deficit hyperactivity disorder (ADHD). Higher parental anxiety was significantly associated with lower academic achievement, particularly for mathematics and homework. These effects were mediated by poor parent-child interactions and ineffective homework supervision. Younger age, male sex, ADHD severity, and comorbid anxiety further intensified this impact. These findings highlight the importance of addressing parental mental health in the treatment of ADHD. Interventions targeting parental anxiety may improve academic outcomes and reduce long-term educational disparities in vulnerable populations.

INTRODUCTION

Attention deficit hyperactivity disorder (ADHD) is a prevalent neurodevelopmental disorder in childhood, affecting approximately 5% of children worldwide. ADHD is characterized by persistent inattention (difficulty sustaining focus, disorganization, and forgetfulness) and/or hyperactivity-impulsivity (excessive activity, restlessness, and interruption), which significantly impair functioning[1]. Children with ADHD consistently demonstrate poorer academic outcomes than their typically developing peers, including lower grades, increased grade retention, and higher dropout rates[2]. These academic difficulties persist despite normal intellectual ability and often continue into adulthood, thereby affecting career prospects and socioeconomic outcomes.

Parents of children with ADHD experience significantly more parenting stress than parents of typically developing children because of the emotional and behavioral difficulties related to ADHD[3]. The stress experienced by parents in fulfilling their parental role has important consequences for family dynamics, parent-child interactions, and the mental health of both parents and children. Recent meta-analyses have confirmed that parents of children with ADHD have substantially higher stress levels than parents of children without clinical diagnoses, with moderate-to-large effect sizes (d = 0.72-1.14)[4].

The relationship between parental psychological well-being and child outcomes has been increasingly recognized as bidirectional and complex. This relationship may be particularly important in families affected by ADHD, given the chronic nature of the disorder and the ongoing demands it places on family systems[5]. ADHD not only has an evident impact on children and adolescents, leading to poor interpersonal relationships, poor academic performance, low self-esteem, and negative emotions, but also increases their risk of developing anxiety, depression, and other mental health disorders[6].

Several mechanisms have been proposed to explain the influence of parental anxiety on children's academic performance. First, anxious parents may engage in less effective parenting behaviors, including inconsistent discipline, overinvolvement, and withdrawal from academic support activities. Second, parental anxiety may create a stressful home environment that interferes with children's ability to focus on homework and study effectively[7]. Lastly, anxious parents may use maladaptive coping strategies and transmit anxiety to their children through both genetic and environmental pathways.

Despite the theoretical importance of understanding how parental mental health affects children with ADHD, relatively few prospective studies have examined this relationship over extended periods of time. Most existing research relies on cross-sectional designs that cannot establish temporal relationships or examine how these associations evolve as children develop[8]. Furthermore, many studies have focused exclusively on maternal stress, neglecting the potential contributions of paternal anxiety and its combined effects on the mental health of both parents.

Parental anxiety revolves around their children's studies. For example, parents may worry regarding their children's learning motivations, habits, and performance[9]. This education-specific anxiety may be particularly relevant in the context of ADHD, where academic challenges are often the primary concern that leads families to seek treatment. Understanding how this specific form of parental anxiety affects children's academic trajectories can inform targeted interventions.

Cultural factors also play an important role in shaping parental responses to ADHD symptoms and academic difficulties. In many Asian countries, including China, where academic achievement is highly valued, parents may experience intense anxiety regarding their children's educational outcomes[10]. This cultural emphasis on academic success may amplify the stress experienced by parents of children with ADHD, and potentially exacerbate its impact on their children's performance.

Recent advances in the understanding of ADHD have highlighted the importance of environmental factors in shaping outcomes. Although ADHD has a strong genetic component with heritability estimates of 70%-80%, environmental factors account for significant variance in symptom severity and functional impairment[11]. The quality of the family environment, including parental mental health, has emerged as one of the most important modifiable factors influencing the outcomes of children with ADHD.

Parental stress levels are related to individual child differences and developmental maladjustment, particularly depressive symptoms, autism spectrum disorder (ASD), and ADHD[12]. Addressing parental mental health may be a critical component of comprehensive treatment approaches for children with ADHD.

The timing of the interventions may also be crucial. Early childhood is a critical period for the development of self-regulatory skills and academic foundation. If parental anxiety interferes with these developmental processes, the effects may compound over time, leading to increasingly divergent academic trajectories[13]. Prospective studies that follow children from early school age through adolescence are required to understand these developmental cascades.

This study aimed to prospectively examine the relationship between parental anxiety and academic performance in children with ADHD over a 6-year period.

MATERIALS AND METHODS

Study design and setting

This prospective longitudinal cohort study was conducted from January 2018 to December 2024 at the Maternal and Child Health Hospital of Hubei Province and Genegrow Pediatric Clinic in Shanghai, both specialized educational and clinical centers. The study design incorporated multiple assessment points to capture the dynamic nature of both parental anxiety and children's academic performance over time. The research protocol followed a naturalistic observational approach, allowing families to continue their usual treatments and interventions while participating in the study assessments. This design was selected to maximize the ecological validity and ensure that the findings would be generalizable to real-world clinical populations.

The participating centers were selected based on several criteria: (1) They served diverse socioeconomic populations to ensure sample representativeness; (2) They had established ADHD assessment and treatment programs with standardized diagnostic procedures; (3) They maintained comprehensive educational records that could be accessed for academic outcome data; and (4) They had sufficient patient volumes to support recruitment targets. Each center had multidisciplinary teams including child psychiatrists, psychologists, educational specialists, and social workers, ensuring comprehensive assessment capabilities. This study was approved by the Medical Ethics Review Committee of Maternal and Child Health Hospital of Hubei Province (approval No. 2018-045-07).

Participants and recruitment

The inclusion criteria were: (1) Age between 6 and 12 years at baseline assessment, ensuring coverage of the critical elementary school period; (2) Confirmed diagnosis of ADHD according to the Diagnostic and Statistical Manual of Mental Illnesses Fifth Edition (DSM-5) criteria based on comprehensive clinical evaluation including structured diagnostic interviews, parent and teacher rating scales, and clinical observation; (3) Enrollment in mainstream educational settings to ensure comparable academic expectations and assessment methods; (4) Availability of at least one primary caregiver willing to participate in longitudinal assessments; and (5) Sufficient language proficiency in English or Spanish to complete study measures without translation needs.

The exclusion criteria were carefully selected to balance sample homogeneity with generalizability: (1) Intellectual disability defined as Full Scale IQ below 70 on standardized assessment, as this would confound academic outcome measures; (2) Uncorrected sensory impairments that could independently affect academic performance; (3) Diagnosed ASD as the primary condition, although children with ADHD and comorbid ASD traits below the diagnostic threshold were included; (4) Active psychosis or severe mood disorders requiring intensive psychiatric intervention that would interfere with study participation; (5) Medical conditions known to significantly impact cognitive function or school attendance, such as uncontrolled epilepsy or severe asthma requiring frequent hospitalization; and (6) Families planning to relocate outside the study area within the next 12 months.

Recruitment procedures

Recruitment employed a multipronged approach to ensure an adequate sample size and diversity. The initial identification of potential participants occurred through: (1) Systematic screening of new referrals to participating centers' ADHD clinics, with research staff reviewing intake forms weekly; (2) Collaboration with school psychologists and counselors who identified students with confirmed or suspected ADHD who might benefit from a comprehensive assessment; (3) Community outreach through parent support groups and ADHD advocacy organizations, including presentations at monthly meetings and the distribution of study flyers; and (4) Targeted social media campaigns in community groups focused on child development and special education needs.

Families of interest underwent a two-stage screening process. Initial telephone screening was performed to assess basic eligibility criteria and family interest in long-term participation. Families meeting the preliminary criteria were invited for a comprehensive baseline assessment, during which their final eligibility was determined. Of the 186 families completing the initial screening, 142 met the full inclusion criteria, and 118 were enrolled in the study, representing a 63.4% recruitment rate from initial contact to enrollment.

Sample size calculation

Sample size was determined by power analysis for longitudinal mixed-effects models, accounting for the expected attrition and clustering effects. Based on previous research indicating medium effect sizes (d = 0.50-0.70) for the relationship between parental stress and child academic outcomes, 100 participants would provide 80% power to detect significant associations with alpha set at 0.05. To account for the expected 20% attrition over the 3-year follow-up period, we recruited 120 participants. The final enrolled sample of 118 participants provided adequate power for the primary analyses while allowing for expected attrition.

Measures

Primary outcome (academic performance): Academic performance was assessed using a multi-method approach to ensure comprehensive evaluation. First, Academic Performance Questionnaire (APQ), a validated 15-item teacher-report measure was used to assess attention in class, study skills, homework completion, and test performance on a 5-point Likert scale, with higher scores indicating better performance. The APQ demonstrated excellent internal consistency (α = 0.94) and strong convergent validity in standardized achievement tests. Second, a standardized achievement testing using the Woodcock-Johnson Tests of Achievement, Fourth Edition (WJ-IV) was administered annually to assess reading, mathematics, and written language skills. Age-standardized scores were used to track performance relative to normative expectations. Lastly, school records, including report card grades, were converted to a standardized 4.0 grade point average scale for analysis, and attendance data were used to control for exposure to instruction, and disciplinary records that might impact academic engagement.

Primary predictor (parental anxiety): Parental anxiety was measured using two complementary instruments. The first was the Parenting Stress Index-4 (PSI-4), a comprehensive 120-item measure assessing stress in the parent-child relationship using 5-point Likert scales (1 = strongly disagree to 5 = strongly agree), requiring 20 minutes to complete, with scores above the 85^th percentile indicating clinical significance. The PSI-4 yields scores in three domains: (1) Child domain examining characteristics that make parenting challenging; (2) Parent domain assessing parental functioning and distress; and (3) Total stress combining both domains. The PSI-4 has extensive psychometric support, with internal consistency coefficients exceeding 0.90, and test-retest reliability ranging from 0.65 to 0.96. The other instrument was the Parental Anxiety Scale (PAS), an 18-item measure specifically developed to assess anxiety related to parenting responsibilities and child outcomes. The items assessed worry regarding the child's future, anxiety regarding parenting decisions, and stress related to managing the child’s behavior. The PAS demonstrated good internal consistency (α = 0.88) and convergent validity with general anxiety measures.

Mediating variables

Parent-child interaction quality was assessed through: (1) Direct observation using the Dyadic Parent-Child Interaction Coding System (DPICS) during structured homework tasks, providing objective measures of parental warmth, criticism, and scaffolding behavior; and (2) The Parent-Child Relationship Questionnaire, a 25-item self-report measure that assesses relationship quality across the dimensions of warmth, conflict, and dependence.

Homework supervision practices were evaluated using the Homework Problems Checklist, a 20-item parent report measure that assesses the frequency and severity of homework-related difficulties and daily homework logs completed by parents for 1 week during each assessment period, documenting time spent, parental involvement level, and child behavior during homework.

Child ADHD symptoms and comorbidities: ADHD symptom severity was assessed using the following scales: (1) The ADHD Rating Scale-5 (ADHD-RS-5), with parallel parent and teacher versions assessing DSM-5 ADHD symptoms on a 4-point scale; and (2) The Clinical Global Impressions Scale completed by treating clinicians to provide global severity ratings.

Comorbid conditions were assessed through: (1) The Child Behavior Checklist (CBCL) and Teacher Report Form, providing dimensional assessment of emotional and behavioral problems; and (2) Structured diagnostic interviews using the relevant modules of the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS) when clinically indicated.

Covariates and moderators: Comprehensive demographic and clinical information was collected including: (1) Family socioeconomic status using the Hollingshead Four-Factor Index combining parental education and occupation; (2) Medication status including type, dose, and adherence monitored using pharmacy records and parental reports; (3) Educational services received, including special education classifications, individualized education plan provisions, and tutoring; and (4) Family structure variables included single-versus two-parent households, number of siblings, and presence of ADHD in other family members.

Procedures

Baseline assessment: Baseline assessment was performed over two visits within a 2-week period to minimize participant burden while ensuring a comprehensive evaluation. Visit 1 (3 hours) included the following: (1) Informed consent procedures with a thorough explanation of the study requirements and voluntary nature of participation; (2) Diagnostic confirmation through K-SADS administration by trained clinicians with established inter-rater reliability (κ > 0.85); (3) Cognitive assessment using the Wechsler Intelligence Scale for Children, Fifth Edition to establish intellectual function and identify learning disabilities; and (4) The parents completed baseline questionnaires, including the PSI-4, PAS, CBCL, and demographic forms.

Visit 2 (2 hours) included the following: (1) Child completion of WJ-IV achievement testing in a quiet, distraction-free environment with breaks as needed; (2) Parent-child interaction tasks videotaped for later DPICS coding, including 15-minute free play, 5-minute cleanup, and 20-minute homework simulation; (3) Clinical interviews on treatment history, family function, and academic concerns; and (4) The teacher questionnaire packets were distributed using prepaid return envelopes.

Follow-up assessments: Follow-up assessments were performed every 6 months for 3 years, with alternating comprehensive and brief evaluations to balance data richness with participant retention. Comprehensive assessments (baseline and at 12-, 24-, and 36-months) were repeated for all baseline measures. Brief assessments (at 6-, 18-, and 30-months) included core questionnaires (PSI-4, PAS, ADHD-RS-5, and APQ) and updates on treatment and school status.

Retention strategies included the following: (1) Flexible scheduling with evening and weekend options to accommodate working parents; (2) Monetary compensation increased over time (50 USD baseline, 75 USD at comprehensive follow-ups, and 25 USD at brief follow-ups); (3) Annual feedback reports summarizing the children’s progress were provided to families and treating clinicians with permission; (4) Birth cards and study newsletters maintained engagement between assessments; and (5) Multiple contact methods, including phone calls, email, and text based on family preferences.

Statistical analysis

Missing data analysis using Little's test confirmed data were missing completely at random (χ² = 145.32, P = 0.31), and multiple imputation was employed to handle missing values. Multilevel mixed-effects models were used to examine the relationship between parental anxiety and academic performance over time, accounting for the nested structure of repeated assessments within individuals. The models included random intercepts and slopes over time, with parental anxiety as the primary time-varying predictor and relevant covariates (child’s age, sex, ADHD severity, medication status, family income, and comorbidities). Mediation analyses using multilevel structural equation modeling tested whether parent-child interaction quality and homework supervision mediated the relationship between parental anxiety and academic outcomes, with indirect effects calculated using bias-corrected bootstrap confidence intervals. Moderation analyses examined whether child and family characteristics influenced the strength of these associations. Group differences were tested using analysis of variance for continuous variables and the χ² test for categorical outcomes. All analyses were conducted using Stata 17.0 and Mplus 8.7, with P < 0.05 considered significant.

RESULTS

Participant characteristics

The study enrolled 118 children with ADHD and their families. Their baseline characteristics are presented in (Table 1). Table 1 presents baseline characteristics for 118 children (mean age 8.3 ± 1.9 years, 61% male, 45.8% White, 23.7% Black, and 20.3% Hispanic) with combined-type ADHD predominating (57.6%), high comorbidity rates (42.4% oppositional defiant disorder and 28.8% anxiety), average intelligence (IQ = 98.4 ± 12.6), mostly two-parent households (66.1%), and elevated baseline parental stress (78.6^th percentile). The mean age at enrollment was 8.3 years (standard deviation = 1.9), with 72 boys (61.0%) and 46 girls (39.0%). The ADHD presentations included combined (n = 68, 57.6%), predominantly inattentive (n = 38, 32.2%), and predominantly hyperactive-impulsive type (n = 12, 10.2%). Comorbid conditions were common, with 42.4% meeting criteria for oppositional defiant disorder, 28.8% for anxiety disorders, and 19.5% for learning disabilities (Table 2).

Table 1 Baseline demographic and clinical characteristics (n = 118).

Characteristics	n (%) or mean ± SD
Child characteristics
Age (year)	8.3 ± 1.9
Sex
Male	72 (61.0)
Female	46 (39.0)
Race/ethnicity
White/Caucasian	54 (45.8)
Black/African American	28 (23.7)
Hispanic/Latino	24 (20.3)
Asian	8 (6.8)
Multiracial	4 (3.4)
ADHD presentation
Combined	68 (57.6)
Inattentive	38 (32.2)
Hyperactive-impulsive	12 (10.2)
Comorbid conditions
Oppositional defiant disorder	50 (42.4)
Anxiety disorders	34 (28.8)
Learning disabilities	23 (19.5)
Depression	8 (6.8)
Full scale IQ	98.4 ± 12.6
Medication status
Stimulant	76 (64.4)
Non-stimulant	18 (15.3)
No medication	24 (20.3)
Parent characteristics
Primary caregiver
Mother	94 (79.7)
Father	12 (10.2)
Both parents equally	12 (10.2)
Parental education
Less than high school	8 (6.8)
High school diploma	22 (18.6)
Some college	34 (28.8)
Bachelor's degree	36 (30.5)
Graduate degree	18 (15.3)
Family structure
Two-parent household	78 (66.1)
Single parent	32 (27.1)
Other arrangement	8 (6.8)
Annual household income (USD)
< 25000	16 (13.6)
25000-50000	28 (23.7)
50000-75000	32 (27.1)
75000-100000	24 (20.3)
> 100000	18 (15.3)
Baseline measures
PSI-4 total stress (percentile)	78.6 (18.2)
Parent domain	76.4 (19.8)
Child domain	80.2 (16.5)
Parental anxiety scale	62.4 (14.3)
Academic performance	2.1 (0.8)
WJ-IV standard score	89.6 ± 13.2

WJ-IV: Woodcock-Johnson Tests of Achievement, Fourth Edition.

Table 2 Multilevel models predicting academic performance over time, β (SE).

Parameter	Model 1 unconditional	Model 2 main effects	Model 3 full model
Fixed effects
Intercept	2.14 (0.07)a	3.82 (0.24)a	3.96 (0.28)a
Time (6-month intervals)	0.08 (0.03)b	0.06 (0.03)c	0.05 (0.03)
Parental anxiety (PSI-4)	-	-0.42 (0.08)a	-0.38 (0.09)a
Time × parental anxiety	-	-0.04 (0.02)c	-0.03 (0.02)
Child age	-	-	0.08 (0.04)c
Child sex (female)	-	-	0.22 (0.10)c
ADHD severity	-	-	-0.28 (0.07)a
Medication use	-	-	0.18 (0.11)
Family income	-	-	0.12 (0.05)c
Comorbid anxiety	-	-	-0.16 (0.11)
Comorbid ODD	-	-	-0.24 (0.10)c
Random effects
Level 2 (between-person)
Intercept variance	0.48 (0.08)a	0.36 (0.07)a	0.28 (0.06)a
Slope variance	0.24 (0.06)a	0.22 (0.06)a	0.21 (0.05)a
Level 1 (within-person)
Residual variance	0.32 (0.04)a	0.28 (0.03)a	0.26 (0.03)a
Model fit
AIC	1426.8	1398.2	1376.4
BIC	1445.3	1428.6	1436.8

^aP < 0.001.

^bP < 0.01.

^cP < 0.05.

PSI-4: Parenting Stress Index-4; ADHD: Attention deficit hyperactivity disorder; ODD: Oppositional defiant disorder; AIC: Akaike information criterion; BIC: Bayesian information criterion.

Retention and missing data

Study retention was excellent with 106 participants (89.8%) completing the 36-month assessment. Attrition analysis revealed no significant differences between completers and non-completers in terms of baseline demographic or clinical variables (all P > 0.15; Table 3). The missing data patterns were consistent with the missing completely at random assumptions, supporting the validity of the multiple imputation procedures.

Table 3 Group differences based on parental anxiety levels, mean (SD).

Outcome	Low anxiety (n = 42)	Moderate anxiety (n = 48)	High anxiety (n = 28)	F-statistic
Baseline
Academic performance (APQ)	2.6 (0.7)	2.1 (0.6)	1.5 (0.6)	18.42a
WJ-IV standard score	96.2 (11.4)	89.8 (12.6)	81.4 (13.8)	12.36a
GPA	3.1 (0.6)	2.7 (0.7)	2.2 (0.8)	14.28a
36-month follow-up
Academic performance (APQ)	3.2 (0.6)	2.5 (0.7)	1.8 (0.7)	26.84a
WJ-IV standard score	98.6 (10.8)	91.2 (13.2)	82.6 (14.4)	14.92a
GPA	3.3 (0.5)	2.8 (0.7)	2.1 (0.9)	22.16a
Change scores
Academic performance	+0.6 (0.4)	+0.4 (0.5)	+0.3 (0.6)	3.84c
WJ-IV standard score	+2.4 (4.2)	+1.4 (5.6)	+1.2 (6.8)	0.52
GPA	+0.2 (0.3)	+0.1 (0.4)	-0.1 (0.5)	5.62b

^aP < 0.001.

^bP < 0.01.

^cP < 0.05.

WJ-IV: Woodcock-Johnson Tests of Achievement, Fourth Edition; APQ: Academic Performance Questionnaire; GPA: Grade point average.

Trajectories of academic performance

Linear mixed models revealed significant variability in academic trajectories over a 3-year period. On average, academic performance showed modest improvement (β = 0.08, SE = 0.03, P = 0.006), likely reflecting developmental gains and treatment effects. However, substantial individual differences in trajectories were observed (variance = 0.24, P < 0.001), supporting the examination of the predictors (Table 2).

Primary hypothesis: Parental anxiety and academic performance

Consistent with our primary hypothesis, higher parental anxiety was significantly associated with poorer academic performance across all models. In the main effects model (model 2), each standard deviation increase in PSI-4 total stress was associated with a 0.42-point decrease in APQ scores (P < 0.001), representing approximately half of the standard deviation difference in academic performance. This effect remained robust after controlling for relevant covariates in the full model (β = -0.38, P < 0.001).

The interaction between time and parental anxiety, although smaller in magnitude, suggested that the negative effects of parental anxiety may compound over time (β = -0.04, P = 0.021 in model 2); however, this effect was attenuated in the full model. Children of parents with clinically elevated anxiety (PSI-4 > 85^th percentile) showed significantly different academic trajectories compared to children of parents with normal anxiety levels (Table 3).

Mediation analyses

Multilevel structural equation modeling revealed significant indirect effects, supporting our mediation hypotheses. The total effect of parental anxiety on academic performance (χ² = -0.42, P < 0.001) was partially mediated through two pathways (Table 4).

Table 4 Mediation analysis results.

Path	Estimate (SE)	95%CI	P value
Total effect
Parental anxiety - academic performance	-0.42 (0.08)	-0.58 to -0.26	< 0.001
Direct effect
Parental anxiety - academic performance	-0.09 (0.09)	-0.27 to 0.09	0.317
Indirect effects via parent-child interaction
Parental anxiety - P-C interaction	-0.36 (0.07)	-0.50 to -0.22	< 0.001
P-C interaction - academic performance	0.48 (0.10)	0.28 to 0.68	< 0.001
Indirect effect	-0.18 (0.04)	-0.26 to -0.10	< 0.001
Indirect effects via homework supervision
Parental anxiety - homework quality	-0.28 (0.06)	-0.40 to -0.16	< 0.001
Homework quality - academic performance	0.52 (0.11)	0.30 to 0.74	< 0.001
Indirect effect	-0.15 (0.04)	-0.22 to -0.08	< 0.001
Total indirect effect	-0.33 (0.06)	-0.45 to -0.21	< 0.001
Proportion mediated (%)	78.6

Moderation analyses

Several factors moderated the relationship between parental anxiety and child academic performance.

The negative impact of parental anxiety was stronger for: (1) Younger children, suggesting that early childhood may be a particularly sensitive period; (2) Boys compared to girls; (3) Children with more severe ADHD symptoms; and (4) Children with comorbid anxiety disorders. Higher family income and two-parent households showed protective effects that partially buffered the negative effects of parental anxiety (Table 5).

Table 5 Moderation effects on the parental anxiety-academic performance relationship.

Moderator	β (SE)	95%CI	P value
Child age	-0.06 (0.03)	-0.12 to -0.01	0.042
Child sex (female × anxiety)	0.14 (0.06)	0.02 to 0.26	0.021
ADHD severity	-0.08 (0.04)	-0.16 to -0.01	0.038
Comorbid anxiety	-0.12 (0.05)	-0.22 to -0.02	0.018
Family income	0.09 (0.04)	0.01 to 0.17	0.026
Two-parent household	0.16 (0.07)	0.02 to 0.30	0.024

ADHD: Attention deficit hyperactivity disorder.

Domain-specific academic effects

Analysis of specific academic domains revealed differential impacts of parental anxiety.

Mathematics achievement (β = -0.46, P < 0.001) and homework completion (β = -0.52, P < 0.001) showed the strongest negative associations, followed by test performance (β = -0.48, P < 0.001), classroom attention (β = -0.41, P < 0.001), written expression (β = -0.38, P < 0.001), and reading achievement (β = -0.34, P < 0.001), suggesting that parental anxiety most severely affects tasks requiring sustained parental support (Table 6).

Table 6 Effects of parental anxiety on specific academic domains.

Academic domain	β (SE)	95%CI	P value
Reading achievement	-0.34 (0.09)	-0.52 to -0.16	< 0.001
Mathematics achievement	-0.46 (0.10)	-0.66 to -0.26	< 0.001
Written expression	-0.38 (0.09)	-0.56 to -0.20	< 0.001
Homework completion	-0.52 (0.08)	-0.68 to -0.36	< 0.001
Classroom attention	-0.41 (0.09)	-0.59 to -0.23	< 0.001
Test performance	-0.48 (0.10)	-0.68 to -0.28	< 0.001

Clinical significance

To evaluate the clinical significance, we examined the proportion of children meeting grade-level expectations based on parental anxiety categories.

Parental children with high anxiety levels were nearly three times less likely to meet grade-level standards and were significantly more likely to require intensive academic support services (Table 7).

Table 7 Clinical outcomes by parental anxiety level, n (%).

Outcome	Low anxiety	Moderate anxiety	High anxiety	χ²
Meeting grade-level standards	36 (85.7)	28 (58.3)	8 (28.6)	24.16a
Requiring academic support services	12 (28.6)	26 (54.2)	22 (78.6)	18.42a
Individualized education program/504 plan	14 (33.3)	24 (50.0)	20 (71.4)	10.28b
Grade retention (over 3 years)	2 (4.8)	6 (12.5)	8 (28.6)	8.64c
Disciplinary actions	8 (19.0)	16 (33.3)	14 (50.0)	7.82c

^aP < 0.001.

^bP < 0.01.

^cP < 0.05.

DISCUSSION

This prospective longitudinal study provides compelling evidence that parental anxiety significantly affects academic outcomes in children with ADHD through multiple pathways. Our findings extend previous cross-sectional research by demonstrating that these effects persist and are potentially compounded over time, with children of parents with high anxiety levels showing increasingly divergent academic trajectories compared with their peers[14].

Mediation analyses revealed that the relationship between parental anxiety and children’s academic performance operates primarily through impaired parent-child interaction quality and less effective homework supervision practices. These findings align with theoretical models suggesting that anxious parents may struggle to provide the consistent, supportive scaffolding that children with ADHD need to succeed academically[15]. Parents of children with ADHD experience significantly more parenting stress than parents of typically developing children because of the emotional and behavioral difficulties related to ADHD, suggesting that this stress translates directly into measurable academic consequences for their children, and the stronger effects observed for mathematics achievement and homework completion deserve particular attention. Mathematics learning requires sustained attention, working memory, and systematic problem-solving skills, which are all areas of weakness in children with ADHD. When parents experience high anxiety, they may inadvertently create a tense homework environment that exacerbates these difficulties rather than providing the calm, structured support these children need[16].

In this study, boys with ADHD were particularly vulnerable to parental anxiety. This could reflect societal expectations and stereotypes regarding boys' behavior and academic performance, leading anxious parents to respond more negatively to their children’s ADHD symptoms[17]. Alternatively, girls with ADHD, who more often present with inattentive rather than hyperactive-impulsive symptoms, may elicit less anxiety-provoking responses from parents, creating a less volatile parent-child dynamic. The moderating effect of child age highlights the importance of early intervention. Younger children showed stronger associations between parental anxiety and academic performance, suggesting that early elementary years represent a critical period when parental influence on academic trajectories is particularly potent. This finding underscores the need for family-based interventions that address parental mental health as part of comprehensive ADHD treatment, particularly for families with young children beginning their academic careers[18].

Our results also highlighted the cumulative disadvantages faced by children with ADHD and comorbid anxiety disorders when their parents experienced high anxiety. These children showed the steepest decline in academic performance over time, possibly reflecting a ‘double hit’ of genetic vulnerability and environmental stress. The intergenerational transmission of anxiety within these families may create particularly challenging dynamics that require specialized intervention approaches to address parent and child anxiety simultaneously[19]. The protective effects of higher family income and two-parent households suggest that financial and social resources can buffer the negative impact of parental anxiety. Families with greater resources may have access to tutoring, therapeutic services, or more time and energy to support their children's academic needs, despite parental anxiety[20].

Some studies have begun to recognize the detrimental impacts of parents' anxiety on children's development, including limitations on academic performance, and our longitudinal data confirm that these impacts persist over extended periods[21]. The clinical implications are significant; nearly three-quarters of the children whose parents reported high anxiety required special education services compared to less than one-third of those with low anxiety. This dramatic difference in service utilization represents not only poorer outcomes for children but also substantial costs to educational systems and families. This study has some limitations. First, although our sample was reasonably diverse, it was drawn from families engaged in specialized ADHD services, potentially limiting generalizability to community samples. Families who seek and maintain engagement with such services may differ systematically from those who do not, possibly representing either higher functioning families more able to access services or families experiencing greater impairment motivating service seeking. Second, our reliance on parent-report measures for some constructs raises the possibility of shared method variance inflating associations. However, the inclusion of teacher reports, standardized testing, and observational measures helps to mitigate this concern. The convergence of findings across different informants and methods strengthens the confidence in the results. We did not analyze maternal vs paternal anxiety separately, nor did we collect physiological stress markers such as cortisol levels, limiting our understanding of sex-specific effects and biological stress mechanisms. Lastly, although we examined two specific mediating pathways, other mechanisms likely contribute to the relationship between parental anxiety and child academic outcomes. Genetic factors, modeling of anxious behaviors, disrupted family routines, and reduced engagement with school systems may have played roles that were not fully captured in our models[22].

Current evidence-based treatments for ADHD focus primarily on child-directed interventions, such as medication and behavioral therapy, with parental involvement typically limited to the implementation of behavior management strategies[23]. Addressing parental mental health should be considered an integral component of ADHD treatment, particularly when parents report significant anxiety or stress. Screening for parental anxiety during ADHD evaluations could identify families that might benefit from adjunctive parent-focused interventions. Several evidence-based approaches show promise, including cognitive-behavioral therapy for parental anxiety, mindfulness-based stress reduction programs adapted for parents of children with ADHD, and parent-child interaction therapy modified to address both ADHD symptoms and parental anxiety[24].

Educational systems should also consider family context when developing academic support plans for children with ADHD. Teachers’ awareness of parental anxiety and its potential impacts can inform more sensitive communication strategies and realistic homework expectations. School-based interventions that include parental support components may be particularly beneficial for families experiencing high stress levels[25].

Future research directions emerging from this work include the need for intervention studies specifically targeting parental anxiety in families with ADHD. Randomized controlled trials comparing child-focused treatment alone with combined child and parent treatment could establish whether addressing parental anxiety enhances children's academic outcomes[26].

Investigating the resilience factors that enable some children to succeed academically despite high parental anxiety would also be valuable. Identifying protective factors beyond those examined here could inform strength-based interventions that build family capacity, rather than solely addressing deficits. Qualitative research exploring families' lived experiences of navigating ADHD, anxiety, and academic challenges could provide insights that are not captured by quantitative measures alone[27]. The increasing recognition of ADHD as a neurodevelopmental condition affecting the entire family system rather than individuals in isolation represents an important paradigm shift. Our findings reinforce this systemic perspective by demonstrating how parental psychological functioning directly affects children's educational trajectories. As the field moves toward a more integrated, family-centered approach to ADHD treatment, parental anxiety should be recognized as a key component of comprehensive care.

CONCLUSION

This prospective study provides robust evidence that parental anxiety could significantly influence academic outcomes for children with ADHD through its effects on parent-child interactions and academic support behaviors. The magnitude and persistence of these effects underscore the importance of routine assessment and treatment of parental mental health as part of comprehensive ADHD care.