Sibling relationships among firstborn preschoolers with ADHD: a Chinese population- based retrospective cohort study

Sibling relationships among firstborn preschoolers with ADHD: a Chinese population- based retrospective cohort study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Sibling relationships among firstborn preschoolers with ADHD: a Chinese population- based retrospective cohort study Danxia Xian, Jingyu Zhang, Jianbo Wu, Xiaona Yin, Yan Zhang, Shuangyan Qiu, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2908694/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective: Attention-Deficit/Hyperactivity Disorder (ADHD) are significantly impaired in social relationships, such as poorer parent-child and peer relationships. However, fewer study to explore sibling relationships in ADHD. Thus, this study is to investigate the quality of sibling relationships among firstborn preschooler with ADHD relative to those without ADHD. Methods: This was a population-based cohort study involving 69634 children enrolled in 234 kindergartens in Longhua District of Shenzhen, China. Sibling relationships were assessed with Sibling Inventory of Behavior (SIB) and ADHD symptoms were assessed with the 18-item Swanson, Nolan, and Pelham Rating Scale (SNAP-IV). Logistic regression and ordinal logistic regression models were performed to examine the associations between ADHD symptoms and sibling relationships among preschoolers. Results: This study included 8419 first-born children with siblings. Of them, 831 children (9.87%) have ADHD symptoms. Children with ADHD showed significantly higher scores of negative sibling relationships in rivalry, aggression and avoidance, and significantly lower scores of positive sibling relationships in involvement, empathy and teaching compared to non-ADHD group. Rivalry, aggression and child gender (boys) were positively correlated with children with ADHD, while involvement (companionship), teaching and household income were negatively correlated with children with ADHD. In ordinal logistic regression models, rivalry, aggregation, involvement and teaching entered the model, while rivalry and aggregation were risk factors of ADHD, and involvement and teaching were protective factors of ADHD. Conclusion It is important to pay more attention to the sibling relationships of children with ADHD. Sibling relationships ADHD Children firstborn preschoolers Sibling Inventory of Behavior Figures Figure 1 1 Introduction A large body of research suggests that children with attention-deficit/hyperactivity disorder (ADHD) as one of the most common neurodevelopmental disorders are significantly impaired not only in academic achievement, well-being but also in social interactions ( 1 ). Children with ADHD face more difficulties in both peer and parent-child relationship than children without ADHD. Children with ADHD are quickly and consistently rejected by peers, tend to have fewer friends, and lower quality friendships, and experience greater peer victimization than those without ADHD ( 2 ). Numerous studies show that parents of children with ADHD have reported more parenting stress and more depressive symptoms ( 3 ), demonstrate lowers the quality of life, lower happiness ( 4 , 5 ) than parents of children without ADHD. Little study, however, is concerned about potential impairment in sibling relationships among children with ADHD. Children may spend more time interacting with siblings than with parents by middle childhood ( 6 ) and sibling relationships as intensive peer relationships are usually the most enduring relationships during the lifetime ( 7 ). Positive sibling relationships can help with the acquisition of skills that are important in social interaction, where children learn to negotiate conflicts with their siblings ( 8 ). Positive sibling relationships are also helped by cognitive development, emotional support, later adolescent adjustment and wellbeing ( 9 – 11 ). Poor sibling relationships can have negative influences on emotional problems (e.g., loneliness, anxiety, depression and self-harm) ( 12 , 13 ) and behavior problems (e.g., hyperactivity, conduct disorders and high-risk behavior) ( 14 , 15 ). The impaired interactions with peers and parents among ADHD children would occur in the relationship between the children with ADHD and their siblings because of the likelihood for reciprocal associations between peer, parent, and sibling relationship domain. However, research of sibling relationship among children with ADHD is quite limited. As known, only seven studies but no study from China that have addressed this topic. Mash and Johnston ( 16 ) observed forty-six hyperactive and normal boys interacting with their siblings in an unstructured play and mother‐supervised task situation, and found that hyperactive boys showed significantly higher levels of conflict. They also found that negative behavior in hyperactive children was unrelated to either the sex or ordinal position (younger versus older) of the sibling. In qualitative interviews and diary data with 12 ADHD boys and 13 non-ADHD siblings lived in 11 families (no control group), Kendall ( 17 ) reported that non-ADHD siblings felt victimized by their ADHD sibling and that their experience of victimization was often minimized or overlooked in the family. However, this study is limited by its small sample and standardized measurement. In a large study of 267 children (127 girls) with ADHD and 234 controls (114 girls), Greene and colleagues ( 18 ) suggested that children with ADHD no matter boys or girls were reported by parents to have significant deficits in interpersonal functioning. Nonetheless, this study is limited by its report only from parents. Smith and colleagues ( 19 ) examined the relationships between mothers, their sons with ADHD (n = 30), and younger siblings and found significant associations among ADHD behaviors, family conflict variables, conflict in the relationship between mother and child with ADHD, and conflict in the relationship between the child with ADHD and the younger sibling. This study is limited by its small sample and its report only based from self-report. Mikami and Pfiffner ( 20 ) investigated the quality of sibling relationships among children with ADHD (n = 77) relative to those without ADHD via three informants: mother report, self-report, and sibling report. They found that children with ADHD showed increased conflict in sibling relationships, relative to nonproblem children. Less warmth/ closeness as one kind of impaired sibling relations is associated with both comorbid externalizing problems and comorbid internalizing problems. King and colleagues ( 21 ) explored siblings' perceptions of the impact a sibling diagnosed with ADHD has within the family system, and found that the non-diagnosed siblings perceive themselves to be particularly negatively impacted by having ADHD sibling. However, Tseng and colleagues ( 22 ) found that children with ADHD were significantly more impaired only in social adjustment at schools, but not for siblings and parents at home. More research with large sample need to addressed this topic. To the end, the aim of this study was to examine the sibling relationships among children with ADHD and without ADHD during preschool age. Birth order of the sibling dyads may have impact on the sibling relationships, so we only focus on the first-born preschoolers with young siblings in this study. In addressing different dimensions of sibling relationships, we give careful attention to different types of ADHD and different dimensions of sibling relationship using standardized tools and to explore their relationships. 2 Methods Study population The Longhua Child Cohort Study (LCCS) initiated in 2014 has been performed annually among children enrolled in kindergartens in Longhua District of Shenzhen City in Mainland China. LCCS is an ongoing population-based cohort study aiming to evaluate the impact of early-life family and school environments on preschoolers' psycho-behavioral development. The current study was based on the 2021 wave survey involving 234 kindergartens conducted between 2021 November and December. Demographic measures and structured questionnaire were collected by parents through a mobile App. The details of the study design and implementation procedures of LCCS have been described previously ( 23 ). Total 69,634 mother-child pairs completed the questionnaires, with a response rate of 80% (81081 preschoolers in Longhua District of Shenzhen City). After excluding children with single child status (n = 23795), or non-firstborn-children (n = 37390), or with missing or invalid data (n = 30) on sibling relationship and other important covariates, a total of 8419 mother-child pairs were included in the current analysis. The data selection procedure was described in Fig. 1 . The study was approved by the Ethics Committee of Shenzhen Longhua Maternity and Child Healthcare Hospital and informed consent was provided by participants’ guardian. Sibling Inventory of Behavior (SIB) The SIB used to measure the sibling relationships in families was originally developed by Schaefer and Edgerton ( 24 ) and modified as 32-item SIB by Hetherington and colleagues ( 25 , 26 ). The 32-item SIB consisted of 6-subscale structure is based on a 1 to 5 rating score from “never” to “always”. This included (a) a 5-item empathy/concern scale, (b) 6-item companionship/involvement scale, (c) a 4-item teach/directiveness scale, (d) a 5-item conflict/aggression scale; (e) a 5- item avoidance scale, and (f) 7-item rivalry scale. The Chinese 32-item SIB demonstrated good internal reliability and satisfactory test-retest reliability in a previous study ( 27 ). Parent-rating Swanson, Nolan, and Pelham (SNAP) ADHD symptoms were assessed by 18-item Parent-rating Swanson, Nolan, and Pelham (SNAP-IV) scale as previous study ( 28 ). This scale derived from the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for ADHD is based on a 0 to 3 rating scale from “not at all” to “very often”. It consisted of two subscales of symptoms as inattention (items 1–9) and hyperactivity/impulsivity (items 10–18). The subset scores were calculated by summing the item scores of each subset. ADHD was defined as an inattention score of ≥ 13 (inattention type) or/and a hyperactivity/impulsivity score of ≥ 13 (hyperactivity/impulsivity type). The Chinese SNAP-IV demonstrated good internal reliability and satisfactory test-retest reliability in a previous study ( 29 ) Statistical analysis Analysis of variance and χ2 tests were used to compare the maternal, paternal, child characteristics and subscales of sibling relationships among children with or without ADHD. A logistic regression model was used to examining the association between ADHD and social-demographic characteristics and subscale of sibling relationship. Covariates related to socio-demographics had impact on ADHD development were included in the logistic regression model. Ordered logistic regression analysis were used to explore the influence of different dimensions of sibling relationship on the different subtypes of ADHD. All analysis was done using SPSS version 23.0 and a P-value of ＜0.05 (both sides) was considered statistically significant. 3 Results 3.1 Prevalence of firstborn preschooler with ADHD, and Comparison of baseline characteristics and sibling relationships between ADHD and non-ADHD groups. A total of 8419 mother-child pairs were included in the current study. Overall, 831 (9.87%) children had ADHD symptoms, with 269 inattention type ADHD, 292 hyperactivity/impulsivity type ADHD, and 270 combined type ADHD. As shown in Table 1 , children with and without ADHD were compared on demographic measures and sibling relationships. They were not significantly different in target child age, or maternal age at child delivery, nor maternal education, nor maternal marital status, nor paternal education difference between target child with and without ADHD. However, they were significantly different in registered residence ship of child, household income and paternal age at child delivery difference between target child with and without ADHD. Also, child with ADHD was more common in boys than child without ADHD (62.0% vs. 45.7%, respectively, p ＜0.01). Preschool children with ADHD show significantly higher scores of negative sibling relationships in rivalry, aggression and avoidance and significantly lower scores of positive sibling relationships in involvement, empathy and teaching compared to control group. Table 1 Comparison of baseline characteristics and sibling relationships between ADHD and non-ADHD groups. ADHD(n = 831) Non-ADHD (n = 7588) F / X 2 Child Characteristics Age 5.03 ± 0.83 5.04 ± 0.83 0.115 Gender (boys) 62.0% 45.7% 79.796** Registered residence ship 4.709* Shenzhen 49.2% 53.2% Non-Shenzhen 50.8% 46.8% Maternal Characteristics Maternal age at child delivery (years) 25.95 ± 3.47 26.43 ± 3.61 12.935 Education, n (%) 3.102 Middle school or less 16.4% 14.1% High school 29.6% 20.1% College or above 64.0% 65.8% Marital status, (%) 0.002 Married 99.1% 99.2% Unmarried/Divorced/Windowed 0.9% 0.8% Household income, RMB/month, (%) 15.221** < 10,000 14.0% 16.8% 10,000–20,000 35.9% 39.1% 20,000–30,000 21.9% 21.4% 30,000- 9.7% 11.6% ＞40,000 12.9% 16.6% Paternal Characteristics Paternal age at child delivery (years) 27.99 ± 3.88 28.46 ± 4.29 9.066** Education, n (%) 0.230 Middle school or less 13.7% 13.2% High school 20.6% 21.0% College or above 65.7% 65.8% Sibling Relationships in SIB Rivalry 16.66 ± 4.58 14.73 ± 4.09 162.289*** Aggression 13.37 ± 3.82 11.71 ± 3.38 175.393*** Avoidance 7.11 ± 2.15 6.40 ± 1.80 109.681*** Involvement (companionship) 22.02 ± 4.17 24.07 ± 3.84 209.145*** Empathy 17.94 ± 3.62 19.49 ± 3.32 159.239*** Teaching 13.69 ± 3.02 15.23 ± 2.79 224.356*** Note: *p＜0.05; **p＜0.01; ***p＜0.001 SIB = Sibling Inventory of Behavior 3.2 Logistic regression model examining the association between ADHD and social-demographic characteristics and subscale of sibling relationship Taking ADHD = 1 and non-ADHD = 0 as dependent variables and taking the statistically significant results in Table 1 above as independent variables, and then substitute them into the binary logistic regression model by the stepwise method. The results showed that rivalry, aggression and child gender (boys) were positively correlated with children with ADHD, while involvement (companionship), teaching and household income were negatively correlated with children with ADHD (See in Table 2 ) Table 2 Logistic regression model examining the association between ADHD and social-demographic characteristics and subscale of sibling relationship B OR (95%CI) P Child gender (boys) 0.588 1.800 (1.544–2.098) < 0.001 Household income -0.077 0.926 (0.871–0.984) 0.013 Sibling relationships Rivalry 0.070 1.073 (1.046-1.100) < 0.001 Aggression 0.040 1.041 (1.008–1.075) 0.014 Involvement (companionship) -0.058 0.944 (0.915–0.974) < 0.001 Teaching -0.140 0.869 (0.830–0.910) < 0.001 3.3 To explore the influence of different dimensions of sibling relationship on the different subtypes of ADHD Taking ADHD and non-ADHD as dependent variables, and then coded non-ADHD = 0, inattention type ADHD = 1, hyperactivity/impulsivity type ADHD = 2, combined type ADHD = 3. The independent variables as X1-X6 are rivalry, aggression, avoidance, involvement, empathy and teaching, respectively. And then explore the influence of different dimensions of sibling relationship on the different subtypes of ADHD by ordered logistic regression analysis model. The results showed that rivalry, aggregation, involvement and teaching entered the model, while rivalry and aggregation were risk factors of ADHD, and involvement and teaching were protective factors of ADHD (See in Table 3 ). Table 3 Ordered logistic regression analysis of sibling relationships among first-born preschooler with and without ADHD b S b Wald P 95%CI Rivalry 0.061 0.013 23.346 < 0.001 0.037–0.086 Aggression 0.054 0.016 11.611 0.001 0.023–0.086 Involvement (companion-ship) -0.054 0.016 11.075 0.001 -0.085–0.022 Teaching -0.138 0.023 35.742 < 0.001 -0.184–0.093 Note: ADHD = attention-deficit/hyperactivity disorder 4 Discussion This population-based study investigated the sibling relationship among Chinese children with ADHD and children without ADHD during preschool age. We confirmed that 9.87% children have ADHD symptoms, and children with ADHD showed significantly higher scores of negative sibling relationships in rivalry, aggression and avoidance, and significantly lower scores of positive sibling relationships in involvement, empathy and teaching compared to non-ADHD group. Further analysis shows that rivalry, aggression and child gender (boys) were positively correlated with children with ADHD, while involvement (companionship), teaching and household income were negatively correlated with children with ADHD. This study expands the domain of social difficulties among children with ADHD, extending previous findings of negative parent-child interactions and peer interactions to the sibling relationship. Significant impaired sibling relationship among children with ADHD have been reported ( 18 – 20 , 30 – 31 ), which was consistent with our study. Non-ADHD siblings usually felt victimized by their ADHD sibling and reported lower happiness with life overall ( 5 ). Our study further extends the knowledge of previous studies by demonstrating the different dimensions of sibling relationship among large sample of Chinese first-born preschooler with ADHD using standardized tools (SIB). However, the mechanism that ADHD has poor sibling relationships remains unclear. Possible reasons why children with ADHD usually have poor sibling relationships are that the lack of social skills and behavioral disinhibition in ADHD ( 32 ) which may lead to the difficulties in reading social cues, following game rules and restraining physical aggression ( 33 ). Thus, these behaviors will contribute to higher conflict and less warmth among children with ADHD. In addition, parent’s differential treatment to their children with or without ADHD may contribute to the negative relationships between the two, given the study evidence suggesting that siblings tend to have more positive relationships with each other when their parents treat them similarly ( 34 ). Rivalry and aggregation were risk factors of ADHD, and involvement and teaching were protective factors of ADHD in ordinal logistic regression models in our study. Aggressive behavior was more common in ADHD presumably because ADHD itself has been linked to disturbances in the adrenergic, dopaminergic and serotonergic systems ( 35 ) and the serotonin and dopamine system have been found to influence aggression ( 36 , 37 ). More aggression may deteriorate sibling relationships among children with ADHD. Previous research focus on the sibling relationships of ADHD is mostly in Western countries, while there are significant differences between the Eastern and the Western cultures. Chinese cultures always advocate collectivism which highly emphasized maintaining good relationships with others and responsiveness to others’ need ( 38 ). Chinese children growing up in these collectivistic cultures are always expected to be compliant and cooperative, and to maintain interpersonal and group harmony. In order to avoid violating the social norm, and to meet the expectations from people around them, children in these environments need to restrain their personal desires and to address the interests of others. Therefore, it is reasonably that in Chinese culture, children with ADHD who tend to be disruptive and poor at social skill, self-monitoring and self-regulation may be at a greater risk of having negative sibling relationships and being rejected by their sibling in comparison to children without ADHD ( 22 ). Chinese parents, on the other hand, may view ADHD symptoms as particularly unacceptable for their higher expectations for children’s good self-regulation and compliance ( 39 ). Therefore, it is plausible that these disruptive behaviors in children with ADHD in the Chinese culture may impair the quality of parent–child interactions. In other words, the parent–child relationships in the Chinese families of children with ADHD may be characterized by more conflicts and less warmth, while less warmth as one kind of impaired sibling relations is significantly associated with a series externalizing problems and internalizing problems ( 20 ). The major strengths of this study are its large sample size and standardized tools to assess the sibling relationships in Chinese cultures differ from Western cultures. However, there are some limitations that should be considered when interpreting these findings. First, the ADHD symptoms and the sibling relationships are evaluated mainly based on parent-reported information; therefore, the results should be treated with caution because only parent’s perspective was included in the assessment of children’s performance. Second, only basic information of parents included in this study and the lack of the parenting style of parents which was considered importantly in the sibling relationship prevented us from investigating its confounding effects, which might bias our findings. In conclusion, it is important to pay attention to the issue of sibling relationships and to incorporate problems in sibling relationships into theories of social impairment including poor parent-child interaction, peer interaction, and so on. Further studies are needed to confirm our findings. Declarations Ethics approval and consent to participate The studies involving human participants were reviewed and approved by the Ethics Committee of Shenzhen Longhua Maternity and Child Healthcare Hospital and have been performed in accordance with the Declaration of Helsinki. Written informed consent was provided by the participants’ parents or egal guardian. Consent for publication Not applicable in this section. Availability of data and materials The datasets used and analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Funding This work was supported by the Scientific Research Projects of Medical and Health Institutions of Longhua District，Shenzhen（Nos. 2020192）and the Shenzhen Fundamental Research Program (Nos. JCYJ20210324122609025). Author contributions DX and DL researched data, wrote, and edited the manuscript. JZ, JW, XY, YanZ, SQ and YaZ contributed to the data collection and review of the manuscript.WK contributed to the discussion, reviewed, and edited the manuscript. DX, DL and WK conceptualized the study, contributed to the discussion, and reviewed and finalized the manuscript. All authors have read and approved the final manuscript. 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Eur J Pharmacol. 2005;526:51–64. Mogavero F, Jager A, Glennon JC. Clock genes, ADHD and aggression. Neurosci Biobehav Rev. 2018;91:51–68. Chen X, French DC. Children's social competence in cultural context. Ann Rev Psychol. 2008;59:591–616. Mah JW, Johnston C. Cultural variations in mothers' attributions: influence of child attention-deficit/hyperactivity disorder. Child Psychiatry Hum Dev. 2007;38(2):135–53. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2908694","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":202881428,"identity":"adc20101-8b92-46ac-a731-507ab836d549","order_by":0,"name":"Danxia Xian","email":"","orcid":"","institution":"Shenzhen Longhua Maternity and Child Healthcare Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Danxia","middleName":"","lastName":"Xian","suffix":""},{"id":202881429,"identity":"7491bc93-e7f0-4238-ac76-85a3370a6839","order_by":1,"name":"Jingyu Zhang","email":"","orcid":"","institution":"Shenzhen Longhua Maternity and Child Healthcare Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jingyu","middleName":"","lastName":"Zhang","suffix":""},{"id":202881430,"identity":"e83db750-f4f8-48bb-b3c0-186e7bab14cc","order_by":2,"name":"Jianbo Wu","email":"","orcid":"","institution":"Shenzhen Longhua Maternity and Child Healthcare Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jianbo","middleName":"","lastName":"Wu","suffix":""},{"id":202881431,"identity":"d6b1ca63-2241-4d09-8688-b865779e9eaa","order_by":3,"name":"Xiaona Yin","email":"","orcid":"","institution":"Shenzhen Longhua Maternity and Child Healthcare Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Xiaona","middleName":"","lastName":"Yin","suffix":""},{"id":202881432,"identity":"f094875e-28c3-4207-ac1c-bf2b786f6a82","order_by":4,"name":"Yan Zhang","email":"","orcid":"","institution":"Shenzhen Longhua Maternity and Child Healthcare Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yan","middleName":"","lastName":"Zhang","suffix":""},{"id":202881433,"identity":"c5b7c258-af69-43e2-8e2f-49c6b6828a30","order_by":5,"name":"Shuangyan Qiu","email":"","orcid":"","institution":"Shenzhen Longhua Maternity and Child Healthcare Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Shuangyan","middleName":"","lastName":"Qiu","suffix":""},{"id":202881434,"identity":"9cd27d2e-02c2-4b07-9855-b7217b643484","order_by":6,"name":"Yafen Zhao","email":"","orcid":"","institution":"Shenzhen Longhua Maternity and Child Healthcare Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yafen","middleName":"","lastName":"Zhao","suffix":""},{"id":202881435,"identity":"8b20e928-23af-4503-bc5e-c1af2721b6c8","order_by":7,"name":"Weikang Yang","email":"","orcid":"","institution":"Shenzhen Longhua Maternity and Child Healthcare Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Weikang","middleName":"","lastName":"Yang","suffix":""},{"id":202881437,"identity":"2eea6d1c-3613-4d09-b491-b7caf66e099d","order_by":8,"name":"Dali Lu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6ElEQVRIiWNgGAWjYDACCcbGAzxAmp+ZsfHBBwMbO2K0NIC1SLY3NxvOKEhLJkILAwNYi8GZ423SPB8OMTYQ0sE/u7nhwNsddYkNNxIbpG0MDjAzsB8+ugGvJXcONhyce+ZwYuOMxAbjHIM7fAw8aWk38GkxkEhsOMzbdiCxGchIzjF4xswgwWNGjJa6xDYQw8LgMGMDkVqYE3t4DjY2MxCjRQLoa5BfjGewNzYz9hikJbMR8gv/jPSHD4AhJrv/MPvzHz/+2Njxsx8+hlcLGADjwrEBxmEjqByqxZ4ohaNgFIyCUTAyAQCfiFZwIogd5AAAAABJRU5ErkJggg==","orcid":"","institution":"Shenzhen Longhua Maternity and Child Healthcare Hospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Dali","middleName":"","lastName":"Lu","suffix":""}],"badges":[],"createdAt":"2023-05-08 16:44:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2908694/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2908694/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":37442996,"identity":"bc203cff-01c1-4809-a082-9706fbbcb542","added_by":"auto","created_at":"2023-05-24 15:17:36","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":47046,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of participant selection\u003c/p\u003e\n\u003cp\u003eNote: ADHD= attention-deficit/hyperactivity disorder; A type-ADHD=predominantly inattentive presentation of attention-deficit/hyperactivity disorder; H type-ADHD=predominantly hyperactivity/impulsive presentation of attention-deficit/hyperactivity disorder; C type-ADHD= combined presentation of attention-deficit/hyperactivity disorder\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-2908694/v1/212d28167c3f49fec4be2e1d.jpg"},{"id":58137246,"identity":"b22ffc6b-7f90-4784-84ce-d469587e1cf8","added_by":"auto","created_at":"2024-06-11 16:06:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":729810,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2908694/v1/81586240-68e5-400e-902d-e1073b5b682b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Sibling relationships among firstborn preschoolers with ADHD: a Chinese population- based retrospective cohort study","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eA large body of research suggests that children with attention-deficit/hyperactivity disorder (ADHD) as one of the most common neurodevelopmental disorders are significantly impaired not only in academic achievement, well-being but also in social interactions (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Children with ADHD face more difficulties in both peer and parent-child relationship than children without ADHD. Children with ADHD are quickly and consistently rejected by peers, tend to have fewer friends, and lower quality friendships, and experience greater peer victimization than those without ADHD (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Numerous studies show that parents of children with ADHD have reported more parenting stress and more depressive symptoms (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), demonstrate lowers the quality of life, lower happiness (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) than parents of children without ADHD.\u003c/p\u003e \u003cp\u003eLittle study, however, is concerned about potential impairment in sibling relationships among children with ADHD. Children may spend more time interacting with siblings than with parents by middle childhood (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) and sibling relationships as intensive peer relationships are usually the most enduring relationships during the lifetime (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Positive sibling relationships can help with the acquisition of skills that are important in social interaction, where children learn to negotiate conflicts with their siblings (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Positive sibling relationships are also helped by cognitive development, emotional support, later adolescent adjustment and wellbeing (\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Poor sibling relationships can have negative influences on emotional problems (e.g., loneliness, anxiety, depression and self-harm) (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) and behavior problems (e.g., hyperactivity, conduct disorders and high-risk behavior) (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe impaired interactions with peers and parents among ADHD children would occur in the relationship between the children with ADHD and their siblings because of the likelihood for reciprocal associations between peer, parent, and sibling relationship domain. However, research of sibling relationship among children with ADHD is quite limited. As known, only seven studies but no study from China that have addressed this topic. Mash and Johnston (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) observed forty-six hyperactive and normal boys interacting with their siblings in an unstructured play and mother‐supervised task situation, and found that hyperactive boys showed significantly higher levels of conflict. They also found that negative behavior in hyperactive children was unrelated to either the sex or ordinal position (younger versus older) of the sibling. In qualitative interviews and diary data with 12 ADHD boys and 13 non-ADHD siblings lived in 11 families (no control group), Kendall (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) reported that non-ADHD siblings felt victimized by their ADHD sibling and that their experience of victimization was often minimized or overlooked in the family. However, this study is limited by its small sample and standardized measurement. In a large study of 267 children (127 girls) with ADHD and 234 controls (114 girls), Greene and colleagues (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) suggested that children with ADHD no matter boys or girls were reported by parents to have significant deficits in interpersonal functioning. Nonetheless, this study is limited by its report only from parents. Smith and colleagues (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) examined the relationships between mothers, their sons with ADHD (n\u0026thinsp;=\u0026thinsp;30), and younger siblings and found significant associations among ADHD behaviors, family conflict variables, conflict in the relationship between mother and child with ADHD, and conflict in the relationship between the child with ADHD and the younger sibling. This study is limited by its small sample and its report only based from self-report. Mikami and Pfiffner (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) investigated the quality of sibling relationships among children with ADHD (n\u0026thinsp;=\u0026thinsp;77) relative to those without ADHD via three informants: mother report, self-report, and sibling report. They found that children with ADHD showed increased conflict in sibling relationships, relative to nonproblem children. Less warmth/ closeness as one kind of impaired sibling relations is associated with both comorbid externalizing problems and comorbid internalizing problems. King and colleagues (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) explored siblings' perceptions of the impact a sibling diagnosed with ADHD has within the family system, and found that the non-diagnosed siblings perceive themselves to be particularly negatively impacted by having ADHD sibling. However, Tseng and colleagues (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) found that children with ADHD were significantly more impaired only in social adjustment at schools, but not for siblings and parents at home. More research with large sample need to addressed this topic.\u003c/p\u003e \u003cp\u003eTo the end, the aim of this study was to examine the sibling relationships among children with ADHD and without ADHD during preschool age. Birth order of the sibling dyads may have impact on the sibling relationships, so we only focus on the first-born preschoolers with young siblings in this study. In addressing different dimensions of sibling relationships, we give careful attention to different types of ADHD and different dimensions of sibling relationship using standardized tools and to explore their relationships.\u003c/p\u003e"},{"header":"2 Methods","content":"\u003cp\u003e \u003cb\u003eStudy population\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe Longhua Child Cohort Study (LCCS) initiated in 2014 has been performed annually among children enrolled in kindergartens in Longhua District of Shenzhen City in Mainland China. LCCS is an ongoing population-based cohort study aiming to evaluate the impact of early-life family and school environments on preschoolers' psycho-behavioral development. The current study was based on the 2021 wave survey involving 234 kindergartens conducted between 2021 November and December. Demographic measures and structured questionnaire were collected by parents through a mobile App. The details of the study design and implementation procedures of LCCS have been described previously (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTotal 69,634 mother-child pairs completed the questionnaires, with a response rate of 80% (81081 preschoolers in Longhua District of Shenzhen City). After excluding children with single child status (n\u0026thinsp;=\u0026thinsp;23795), or non-firstborn-children (n\u0026thinsp;=\u0026thinsp;37390), or with missing or invalid data (n\u0026thinsp;=\u0026thinsp;30) on sibling relationship and other important covariates, a total of 8419 mother-child pairs were included in the current analysis. The data selection procedure was described in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The study was approved by the Ethics Committee of Shenzhen Longhua Maternity and Child Healthcare Hospital and informed consent was provided by participants\u0026rsquo; guardian.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eSibling Inventory of Behavior (SIB)\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe SIB used to measure the sibling relationships in families was originally developed by Schaefer and Edgerton (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) and modified as 32-item SIB by Hetherington and colleagues (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). The 32-item SIB consisted of 6-subscale structure is based on a 1 to 5 rating score from \u0026ldquo;never\u0026rdquo; to \u0026ldquo;always\u0026rdquo;. This included (a) a 5-item empathy/concern scale, (b) 6-item companionship/involvement scale, (c) a 4-item teach/directiveness scale, (d) a 5-item conflict/aggression scale; (e) a 5- item avoidance scale, and (f) 7-item rivalry scale. The Chinese 32-item SIB demonstrated good internal reliability and satisfactory test-retest reliability in a previous study (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eParent-rating Swanson, Nolan, and Pelham (SNAP)\u003c/b\u003e \u003c/p\u003e \u003cp\u003eADHD symptoms were assessed by 18-item Parent-rating Swanson, Nolan, and Pelham (SNAP-IV) scale as previous study (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). This scale derived from the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for ADHD is based on a 0 to 3 rating scale from \u0026ldquo;not at all\u0026rdquo; to \u0026ldquo;very often\u0026rdquo;. It consisted of two subscales of symptoms as inattention (items 1\u0026ndash;9) and hyperactivity/impulsivity (items 10\u0026ndash;18). The subset scores were calculated by summing the item scores of each subset. ADHD was defined as an inattention score of \u0026ge;\u0026thinsp;13 (inattention type) or/and a hyperactivity/impulsivity score of \u0026ge;\u0026thinsp;13 (hyperactivity/impulsivity type). The Chinese SNAP-IV demonstrated good internal reliability and satisfactory test-retest reliability in a previous study (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cb\u003eStatistical analysis\u003c/b\u003e \u003c/p\u003e \u003cp\u003eAnalysis of variance and χ2 tests were used to compare the maternal, paternal, child characteristics and subscales of sibling relationships among children with or without ADHD. A logistic regression model was used to examining the association between ADHD and social-demographic characteristics and subscale of sibling relationship. Covariates related to socio-demographics had impact on ADHD development were included in the logistic regression model. Ordered logistic regression analysis were used to explore the influence of different dimensions of sibling relationship on the different subtypes of ADHD. All analysis was done using SPSS version 23.0 and a P-value of ＜0.05 (both sides) was considered statistically significant.\u003c/p\u003e"},{"header":"3 Results","content":"\u003cp\u003e \u003cb\u003e3.1 Prevalence of firstborn preschooler with ADHD, and Comparison of baseline characteristics and sibling relationships between ADHD and non-ADHD groups.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eA total of 8419 mother-child pairs were included in the current study. Overall, 831 (9.87%) children had ADHD symptoms, with 269 inattention type ADHD, 292 hyperactivity/impulsivity type ADHD, and 270 combined type ADHD. As shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, children with and without ADHD were compared on demographic measures and sibling relationships. They were not significantly different in target child age, or maternal age at child delivery, nor maternal education, nor maternal marital status, nor paternal education difference between target child with and without ADHD. However, they were significantly different in registered residence ship of child, household income and paternal age at child delivery difference between target child with and without ADHD. Also, child with ADHD was more common in boys than child without ADHD (62.0% vs. 45.7%, respectively, \u003cem\u003ep\u003c/em\u003e ＜0.01). Preschool children with ADHD show significantly higher scores of negative sibling relationships in rivalry, aggression and avoidance and significantly lower scores of positive sibling relationships in involvement, empathy and teaching compared to control group.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eComparison of baseline characteristics and sibling relationships between ADHD and non-ADHD groups.\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eADHD(n\u0026thinsp;=\u0026thinsp;831)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon-ADHD (n\u0026thinsp;=\u0026thinsp;7588)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eF\u003c/em\u003e/\u003cem\u003eX\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChild Characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.03\u0026thinsp;\u0026plusmn;\u0026thinsp;0.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.04\u0026thinsp;\u0026plusmn;\u0026thinsp;0.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.115\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender (boys)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e79.796**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegistered residence ship\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.709*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShenzhen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-Shenzhen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMaternal Characteristics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaternal age at child delivery (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.95\u0026thinsp;\u0026plusmn;\u0026thinsp;3.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.43\u0026thinsp;\u0026plusmn;\u0026thinsp;3.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12.935\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.102\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle school or less\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCollege or above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarital status, (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e99.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e99.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnmarried/Divorced/Windowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHousehold income, RMB/month, (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15.221**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;10,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10,000\u0026ndash;20,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20,000\u0026ndash;30,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30,000-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e＞40,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePaternal Characteristics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePaternal age at child delivery (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27.99\u0026thinsp;\u0026plusmn;\u0026thinsp;3.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.46\u0026thinsp;\u0026plusmn;\u0026thinsp;4.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.066**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.230\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle school or less\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCollege or above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSibling Relationships in SIB\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRivalry\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.66\u0026thinsp;\u0026plusmn;\u0026thinsp;4.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.73\u0026thinsp;\u0026plusmn;\u0026thinsp;4.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e162.289***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAggression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.37\u0026thinsp;\u0026plusmn;\u0026thinsp;3.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.71\u0026thinsp;\u0026plusmn;\u0026thinsp;3.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e175.393***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAvoidance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.11\u0026thinsp;\u0026plusmn;\u0026thinsp;2.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.40\u0026thinsp;\u0026plusmn;\u0026thinsp;1.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e109.681***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInvolvement (companionship)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.02\u0026thinsp;\u0026plusmn;\u0026thinsp;4.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.07\u0026thinsp;\u0026plusmn;\u0026thinsp;3.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e209.145***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmpathy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.94\u0026thinsp;\u0026plusmn;\u0026thinsp;3.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.49\u0026thinsp;\u0026plusmn;\u0026thinsp;3.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e159.239***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTeaching\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.69\u0026thinsp;\u0026plusmn;\u0026thinsp;3.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.23\u0026thinsp;\u0026plusmn;\u0026thinsp;2.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e224.356***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eNote: *p＜0.05; **p＜0.01; ***p＜0.001\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eSIB\u0026thinsp;=\u0026thinsp;Sibling Inventory of Behavior\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003e3.2 Logistic regression model examining the association between ADHD and social-demographic characteristics and subscale of sibling relationship\u003c/b\u003e \u003c/p\u003e \u003cp\u003eTaking ADHD\u0026thinsp;=\u0026thinsp;1 and non-ADHD\u0026thinsp;=\u0026thinsp;0 as dependent variables and taking the statistically significant results in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e above as independent variables, and then substitute them into the binary logistic regression model by the stepwise method. The results showed that rivalry, aggression and child gender (boys) were positively correlated with children with ADHD, while involvement (companionship), teaching and household income were negatively correlated with children with ADHD (See in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eLogistic regression model examining the association between ADHD and social-demographic characteristics and subscale of sibling relationship\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOR (95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChild gender (boys)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.588\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.800 (1.544\u0026ndash;2.098)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHousehold income\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.077\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.926 (0.871\u0026ndash;0.984)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.013\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSibling relationships\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRivalry\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.070\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.073 (1.046-1.100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAggression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.040\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.041 (1.008\u0026ndash;1.075)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.014\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInvolvement (companionship)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.058\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.944 (0.915\u0026ndash;0.974)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTeaching\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.140\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.869 (0.830\u0026ndash;0.910)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003e3.3 To explore the influence of different dimensions of sibling relationship on the different subtypes of ADHD\u003c/b\u003e \u003c/p\u003e \u003cp\u003eTaking ADHD and non-ADHD as dependent variables, and then coded non-ADHD\u0026thinsp;=\u0026thinsp;0, inattention type ADHD\u0026thinsp;=\u0026thinsp;1, hyperactivity/impulsivity type ADHD\u0026thinsp;=\u0026thinsp;2, combined type ADHD\u0026thinsp;=\u0026thinsp;3. The independent variables as X1-X6 are rivalry, aggression, avoidance, involvement, empathy and teaching, respectively. And then explore the influence of different dimensions of sibling relationship on the different subtypes of ADHD by ordered logistic regression analysis model. The results showed that rivalry, aggregation, involvement and teaching entered the model, while rivalry and aggregation were risk factors of ADHD, and involvement and teaching were protective factors of ADHD (See in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOrdered logistic regression analysis of sibling relationships among first-born preschooler with and without ADHD\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eb\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eS\u003c/em\u003e\u003csub\u003e\u003cem\u003eb\u003c/em\u003e\u003c/sub\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eWald\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e95%CI\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRivalry\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.061\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23.346\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.037\u0026ndash;0.086\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAggression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.054\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.611\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.023\u0026ndash;0.086\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInvolvement (companion-ship)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.054\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.075\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-0.085\u0026ndash;0.022\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTeaching\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.138\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e35.742\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-0.184\u0026ndash;0.093\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eNote: ADHD\u0026thinsp;=\u0026thinsp;attention-deficit/hyperactivity disorder\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eThis population-based study investigated the sibling relationship among Chinese children with ADHD and children without ADHD during preschool age. We confirmed that 9.87% children have ADHD symptoms, and children with ADHD showed significantly higher scores of negative sibling relationships in rivalry, aggression and avoidance, and significantly lower scores of positive sibling relationships in involvement, empathy and teaching compared to non-ADHD group. Further analysis shows that rivalry, aggression and child gender (boys) were positively correlated with children with ADHD, while involvement (companionship), teaching and household income were negatively correlated with children with ADHD. This study expands the domain of social difficulties among children with ADHD, extending previous findings of negative parent-child interactions and peer interactions to the sibling relationship.\u003c/p\u003e \u003cp\u003eSignificant impaired sibling relationship among children with ADHD have been reported (\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e), which was consistent with our study. Non-ADHD siblings usually felt victimized by their ADHD sibling and reported lower happiness with life overall (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Our study further extends the knowledge of previous studies by demonstrating the different dimensions of sibling relationship among large sample of Chinese first-born preschooler with ADHD using standardized tools (SIB). However, the mechanism that ADHD has poor sibling relationships remains unclear. Possible reasons why children with ADHD usually have poor sibling relationships are that the lack of social skills and behavioral disinhibition in ADHD (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) which may lead to the difficulties in reading social cues, following game rules and restraining physical aggression (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Thus, these behaviors will contribute to higher conflict and less warmth among children with ADHD. In addition, parent\u0026rsquo;s differential treatment to their children with or without ADHD may contribute to the negative relationships between the two, given the study evidence suggesting that siblings tend to have more positive relationships with each other when their parents treat them similarly (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRivalry and aggregation were risk factors of ADHD, and involvement and teaching were protective factors of ADHD in ordinal logistic regression models in our study. Aggressive behavior was more common in ADHD presumably because ADHD itself has been linked to disturbances in the adrenergic, dopaminergic and serotonergic systems (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) and the serotonin and dopamine system have been found to influence aggression (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). More aggression may deteriorate sibling relationships among children with ADHD. Previous research focus on the sibling relationships of ADHD is mostly in Western countries, while there are significant differences between the Eastern and the Western cultures. Chinese cultures always advocate collectivism which highly emphasized maintaining good relationships with others and responsiveness to others\u0026rsquo; need (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Chinese children growing up in these collectivistic cultures are always expected to be compliant and cooperative, and to maintain interpersonal and group harmony. In order to avoid violating the social norm, and to meet the expectations from people around them, children in these environments need to restrain their personal desires and to address the interests of others. Therefore, it is reasonably that in Chinese culture, children with ADHD who tend to be disruptive and poor at social skill, self-monitoring and self-regulation may be at a greater risk of having negative sibling relationships and being rejected by their sibling in comparison to children without ADHD (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Chinese parents, on the other hand, may view ADHD symptoms as particularly unacceptable for their higher expectations for children\u0026rsquo;s good self-regulation and compliance (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Therefore, it is plausible that these disruptive behaviors in children with ADHD in the Chinese culture may impair the quality of parent\u0026ndash;child interactions. In other words, the parent\u0026ndash;child relationships in the Chinese families of children with ADHD may be characterized by more conflicts and less warmth, while less warmth as one kind of impaired sibling relations is significantly associated with a series externalizing problems and internalizing problems (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe major strengths of this study are its large sample size and standardized tools to assess the sibling relationships in Chinese cultures differ from Western cultures. However, there are some limitations that should be considered when interpreting these findings. First, the ADHD symptoms and the sibling relationships are evaluated mainly based on parent-reported information; therefore, the results should be treated with caution because only parent\u0026rsquo;s perspective was included in the assessment of children\u0026rsquo;s performance. Second, only basic information of parents included in this study and the lack of the parenting style of parents which was considered importantly in the sibling relationship prevented us from investigating its confounding effects, which might bias our findings.\u003c/p\u003e \u003cp\u003eIn conclusion, it is important to pay attention to the issue of sibling relationships and to incorporate problems in sibling relationships into theories of social impairment including poor parent-child interaction, peer interaction, and so on. Further studies are needed to confirm our findings.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe studies involving human participants were reviewed and approved by the Ethics Committee of Shenzhen Longhua Maternity and Child Healthcare Hospital and have been performed in accordance with the Declaration of Helsinki. Written informed consent was provided by the participants\u0026rsquo; parents or egal guardian.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable in this section.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Scientific Research Projects of Medical and Health Institutions of Longhua District，Shenzhen（Nos. 2020192）and the Shenzhen Fundamental Research Program (Nos. JCYJ20210324122609025).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDX and DL researched data, wrote, and edited the manuscript. JZ, JW, XY, YanZ, SQ and YaZ contributed to the data collection and review of the manuscript.WK contributed to the discussion, reviewed, and edited the manuscript. DX, DL and WK conceptualized the study, contributed to the discussion, and reviewed and finalized the manuscript. All authors have read and approved the final manuscript. \u003cstrong\u003eAcknowledgments\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe sincerely acknowledge the participants for their support of this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eDepartment of Pediatric Psychology, Shenzhen Longhua Maternity and Child Healthcare Hospital, Shenzhen 510089, China; \u003csup\u003e2\u003c/sup\u003eDepartment of Child Health Care, Shenzhen Longhua Maternity and Child Healthcare Hospital, Shenzhen 510089, China\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWolraich ML, Hagan JF Jr, Allan C, Chan E, Davison D, Earls M et al. Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics. 2019;144(4):e20192528. 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Child Psychiatry Hum Dev. 2007;38(2):135\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Sibling relationships, ADHD, Children, firstborn preschoolers, Sibling Inventory of Behavior","lastPublishedDoi":"10.21203/rs.3.rs-2908694/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2908694/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective:\u003c/h2\u003e \u003cp\u003eAttention-Deficit/Hyperactivity Disorder (ADHD) are significantly impaired in social relationships, such as poorer parent-child and peer relationships. However, fewer study to explore sibling relationships in ADHD. Thus, this study is to investigate the quality of sibling relationships among firstborn preschooler with ADHD relative to those without ADHD.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eThis was a population-based cohort study involving 69634 children enrolled in 234 kindergartens in Longhua District of Shenzhen, China. Sibling relationships were assessed with Sibling Inventory of Behavior (SIB) and ADHD symptoms were assessed with the 18-item Swanson, Nolan, and Pelham Rating Scale (SNAP-IV). Logistic regression and ordinal logistic regression models were performed to examine the associations between ADHD symptoms and sibling relationships among preschoolers.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eThis study included 8419 first-born children with siblings. Of them, 831 children (9.87%) have ADHD symptoms. Children with ADHD showed significantly higher scores of negative sibling relationships in rivalry, aggression and avoidance, and significantly lower scores of positive sibling relationships in involvement, empathy and teaching compared to non-ADHD group. Rivalry, aggression and child gender (boys) were positively correlated with children with ADHD, while involvement (companionship), teaching and household income were negatively correlated with children with ADHD. In ordinal logistic regression models, rivalry, aggregation, involvement and teaching entered the model, while rivalry and aggregation were risk factors of ADHD, and involvement and teaching were protective factors of ADHD.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eIt is important to pay more attention to the sibling relationships of children with ADHD.\u003c/p\u003e","manuscriptTitle":"Sibling relationships among firstborn preschoolers with ADHD: a Chinese population- based retrospective cohort study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-05-24 15:17:32","doi":"10.21203/rs.3.rs-2908694/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"731f8684-7049-497f-babc-8bc6adae2a61","owner":[],"postedDate":"May 24th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-06-11T16:06:13+00:00","versionOfRecord":[],"versionCreatedAt":"2023-05-24 15:17:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-2908694","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2908694","identity":"rs-2908694","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}