5	The Family Context of a Child with ADHD

Children with ADHD do not exist in a vacuum. They occupy specific places within various social networks or systems, the most significant of these systems being the most immediate one, the family. Forgive me for stating the obvious, but traditionally our theories, assessment, and treatment of these children focus so heavily on them as individuals and their behavior in isolation from others that we forget this important point. No one can fully appreciate the disorder—its causes, impairments, course, and outcome—without recourse to this social environment and a child’s interactions with others within it. The very diagnosis of ADHD hinges on our understanding this point. The reports of others within this social network are what determine which children get referred, diagnosed, and treated. The prognosis of ADHD for any given child surely revolves around this factor as well. To understand who develops ADHD, who continues to have ADHD over time, which children with ADHD develop additional problems, which children will fare well despite these problems, and which individuals will fare poorly in adulthood requires reference to this social network. Therefore, knowing that children have ADHD is of limited importance in predicting their future or in designing treatment for them. We must consider further the various contexts in which specific children live and interact, with whom they interact, and who in turn act on them.

Knowing what impact children with ADHD have on their families, how their families act on the children, and how their behavior is managed by parents will help you understand not just your child but also yourself, and even your family as a whole. The journey of discovery that led you to this book must also be a journey of self-exploration for you as a parent. As you read this chapter, consider how you typically respond to your child’s appropriate behavior, and especially to inappropriate, disruptive, or demanding behaviors. Also consider how your child treats you, what reactions your child brings out in you, and the overall quality of your relationship. Then examine, in turn, how your child affects others in the family and how they treat this child. Are you married or living with a partner? If so, do you have marital or cohabiting problems that spill over into your relationships with your children, particularly the child with ADHD? Or is your marriage or other intimate relationship a source of strength for you in dealing with the day-to-day demands of raising children and managing a household? Do you work outside the home? Does this bring stress into your home and affect your relationship with your children? Or is your job also a source of personal growth and success that feeds your strength as a parent? Although I describe here the results of research on the family interactions of children with ADHD, the ultimate purpose of this chapter is to encourage you to examine your own family relative to these scientific findings. See if there are things about your family that you would like to change. Then make a commitment to change them. The later chapters of this book are intended to help you with that goal. In any case, it should be obvious that you are at least seeking to change the quality of your relationship with your child, or you probably would not have started reading this book.

The family context of a child with ADHD is critically important in understanding the child, for several reasons. First, the parent–child and sibling–child interactions in a family of a child with ADHD have been shown to be inherently more negative and stressful for all family members than the typical interactions in other families. Despite the view taken in this book that the development of ADHD has a strong biological (largely hereditary) predisposition, not even the strongest advocate of this view could deny the powerful effects this difference in social interaction must produce on the additional problems a child with ADHD is likely to experience.

Second, much evidence exists that the parents and siblings of a child with ADHD are more likely to be experiencing their own psychological distress and psychiatric disorders, including their own ADHD symptoms, than parents and siblings of a child without ADHD. In fact, there is about a 25–40% chance that at least one of the parents of a child with ADHD also has the disorder. These difficulties that other family members are experiencing surely have some influence on the manner in which the child with ADHD is perceived, managed, reared, loved, and then launched into adulthood. This influence acts in unique ways that seem to have long-lasting effects for the adolescent and adult outcomes of such children. Perhaps it starts a vicious cycle much like the following:

1. Parents who are having personal problems often perceive their child with ADHD as showing more disruptive behavior, and that behavior is perceived as more demanding of their time and more difficult for them to manage than it is for parents without such problems.

2. These perceptions affect the way the parents react to the child’s behavior, sometimes resulting in unnecessarily high levels of expressed negative emotion, harsh punishment, or a general irritability toward the child no matter what the child does.

3. The child may also receive much less encouragement, praise, approval, and general warmth than would otherwise be given.

4. This treatment of the child in turn influences how the child behaves toward the parents, perhaps increasing the level of defiance, stubbornness, argument, and general conflict.

5. This behavior may reinforce the parents’ view that the child is a problem or difficult to manage.

6. The cycle starts anew.

This does not mean that one or both parents are the chief cause of the child’s disruptive or defiant behavior; it only suggests that the parent–child relationship can affect the severity of a child’s behavioral problems and a parent’s perceptions of how stressful the child is to raise.

Since 1980 or so, a large number of scientific studies have been published on the way in which children with ADHD behave toward their parents and the reactions of their parents to them. I devoted much of my own early scientific career to understanding these interaction patterns and how they are changed by various treatments. What does the research tell us?

THE INTERACTIONS OF CHILDREN WITH ADHD AND THEIR MOTHERS

The first studies to directly observe the interactions of mothers and their children with ADHD were done more than 40 years ago. For instance, in 1975 Dr. Susan Campbell and her colleagues at the University of Pittsburgh observed that boys with hyperactivity (present-day ADHD) initiated more interactions than other boys when working with their mothers to complete a task. These children also talked more with their mothers and requested more help. In short, these children seemed to require more attention from, talk more to, and seek more help from their mothers during interactions with them. The mothers of the children with ADHD gave them more suggestions, approval, disapproval, and directions on impulse control than the mothers of the other children. In other words, mothers of children with ADHD had to manage the behavior of their children more and involve themselves in their children’s self-control more than mothers of children without ADHD did. Extended over time, this degree of interaction and supervision can be quite stressful and exhausting to mothers.

In my own early studies, I found that children with ADHD were much less compliant, more negative, more likely to get off-task, and less able to persist in complying with their mothers’ directives. Their mothers gave more commands, were also more negative, and at times were less responsive to their children’s interactions than I observed in the relations of other children. I also found, as did Dr. Campbell, that children with ADHD talked more during these exchanges.

Later I found that these interaction conflicts changed with age (but were the same problems for boys and girls with ADHD). Younger children both with and without ADHD had far more mother–child conflicts than older children in both groups. However, at none of the ages studied did the children with ADHD behave like their peers without ADHD—and, of course, the two groups of mothers did not behave alike either. So there is hope that these family relationships improve somewhat, but there is some evidence that they do not become fully normal or typical.

THE INTERACTIONS OF CHILDREN WITH ADHD AND THEIR FATHERS

“I have a lot of problems in managing my child, but my husband has far fewer problems. Why?”

One of the things I have heard repeatedly from mothers of children with ADHD is that the children seem to behave better for their fathers. When Dr. James Tallmadge and I were working together at the Medical College of Wisconsin more than 30 years ago, we compared videotaped interactions between mothers and children with ADHD to those between the fathers and children. Overall we did not find much difference. We did notice, however, that the children were less negative with their fathers and were more likely to stay on task than when with their mothers.

I am not sure why this should be so. It might have to do with the fact that mothers still typically carry more of the responsibility than fathers for interacting with children with ADHD at home—especially in getting work and chores done, even when the mothers work outside the home. A parent who taxes the self-control deficits of a child with ADHD will clearly have greater conflicts with that child (an illuminating example of this problem is related in Chapter 17). Mothers also appear to rely somewhat more on verbal explanations, reasoning, and affection in gaining their children’s compliance with instructions. Because children with ADHD cannot use their language as well as others for following through on instructions and are not as sensitive to praise, this approach is less likely to manage or motivate them to behave well. Fathers may reason and repeat commands less and may impose swifter punishment for noncompliance. So perhaps a parent who talks less and acts quickly to provide some consequence for a child’s good and bad behavior may get more compliance. We also cannot rule out the fact that the greater physical size and strength of the father may be more intimidating to a child with ADHD.

Regardless of why the discrepancy exists, the fact that it does exist can cause problems in the parents’ marriage or relationship. The father in such a case may attribute the mother’s reports of serious problems with the child to exaggeration or decide that the child’s worse behavior with her results from her being too permissive. He may then conclude that it is the mother, not the child, who needs professional assistance. I have also heard of similar scenes being played out in the pediatrician’s office: when a male physician has no difficulty managing a child with ADHD, he labels the mother as hysterical and incompetent. It is time for fathers and male professionals to realize that children, especially children with ADHD, differ in their responses to mothers and fathers. Any parents who doubt this assertion should let the father assume greater responsibility for the day-to-day care of the child with ADHD for a while and see if his view of the child’s behavior problems begins to resemble the mother’s more closely.

THE INTERACTIONS OF CHILDREN WITH ADHD AND THEIR SIBLINGS

The relationship of children with ADHD to their brothers and sisters also seems to differ from that seen in other families. Children with ADHD argue more, play more disruptively, yell at siblings more, and are more likely to encourage inappropriate behavior or mischief, so it’s no surprise that conflict is greater than normal. Again, this difference is more marked when children with ADHD are younger.

“How do we get our other kids to understand why their sister acts the way she does, that she is different from them? They think she’s lucky for all the help she gets.”

How do the siblings without ADHD feel? Brothers and sisters tend to grow tired and exasperated by living with such a disruptive—and baffling—force, with some coming to resent the greater burden of work they often carry, compared to a child with ADHD. Certainly the greater time and attention the child with ADHD receives from the parents is often a source of envy, especially when the siblings without ADHD are younger. Little additional research exists to tell us how these sibling interactions might contribute to problems for both the child with ADHD and the siblings. But let’s not forget that the siblings of a child with ADHD have approximately one chance in three or four of having ADHD themselves. When they do, it exacerbates the situation for the whole family.

HOW DOES ADHD AFFECT PARENT–CHILD INTERACTIONS?

What effects does ADHD have on parent–child interactions? An obvious starting place is the ADHD symptoms themselves. The inattentive, impulsive, and overactive behavior patterns of children with ADHD and their general deficits in self-regulation often conflict with the demands all parents must make on their children. Many daily tasks place heavy demands on a child’s ability to show self-restraint, sustain attention, persist in effort, manage time well, organize materials, and ignore things that might be more fun to do at the moment. When a child with ADHD has trouble complying with instructions or getting routine work completed, the parents cannot help reacting with greater direction, control, suggestion, encouragement, and ultimately anger. But even when no task is required of the child, the excessive behavior, activity, speech, emotion, and vocal noises are likely to be viewed as intrusiveness and aversive by others, especially over extended periods of time.

So who is causing this cycle-of-interaction conflict? Both the child and the parents contribute to the upward spiral of conflict, but the child contributes more than the parents may realize. Keep in mind, of course, that the child does not do this intentionally. Research on the interactions between children with ADHD and other adults and children outside the family, such as teachers and peers, shows that when the children with ADHD are placed in a classroom, teachers, like mothers, are likely to increase their commands to, reprimands of, and discipline of the children. Likewise, when children with ADHD first enter a new play group, the other children will start to act like “little mothers”—giving more commands, directions, and help to the children with ADHD. When this doesn’t squelch the hyperactive and disruptive behavior, the other children may get angry, tease, or insult the children with ADHD. Failing this, they will pull away to find some peace from this unruly, intrusive, and domineering child with ADHD.

Studies have shown that when children with ADHD are placed on ADHD medication, the use by mothers, teachers, and peers of commands, disapproval, and general control diminishes to that seen with children who do not have ADHD, and the interactions become generally more positive. If the parents of children with ADHD were the major cause of the conflict, medicating their children should produce little change in the parents’ behavior or little decline in the conflicts. This was hardly the case in our studies, which suggested that the chief origin of the interaction problems rested with the child’s ADHD.

HOW PARENTS SEEM TO REACT TO CHILD MISCONDUCT OVER TIME

Although there is little research on the issue, I have been impressed clinically that the parents of children with ADHD may move through several steps in their efforts to control their children’s disruptive behavior. When one strategy fails to work, they move on to the next step in this sequence. My experience suggests that parents initially try to ignore or withhold attention from their children when the children show disruptive behavior. Perhaps they believe that some of this behavior is intended merely to get attention and therefore ignoring the children should decrease the problem. But the children’s behavior is not merely the result of bids for attention, so these techniques are unlikely to succeed. As the disruptive behavior continues or intensifies, parents give more commands and directives, especially those aimed at controlling the children’s impulses. These commands are often restrictive, calling for the children to stop what they are doing, and parents will find themselves repeating them frequently. It is as if the parents have to take over the child’s self-regulation and become the child’s executive abilities, sort of a proxy for the child’s immature prefrontal “executive” brain.

At some point, frustration and exasperation may result in the parents issuing threats along with these repeated directives. When this approach fails (as it often does) to get the children with ADHD to listen and obey, parents may move on to the actual use of physical discipline or other forms of punishment (loss of privileges or time-out) to regain control over their children’s unruly behavior. Some parents may simply give up at this point, giving in to the children and perhaps even doing the children’s task themselves or simply walking away, leaving the task undone. If the children have begun to comply but the quality of compliance is poor, parents step in and assist the children in doing the chore. In general, the parent is getting frustrated with the child’s noncompliant behavior and the child is learning that stalling in compliance leads to someone stepping in to help get it done, doing it himself, or just walking away, leaving the job undone.

Over time, parents do not start at the beginning of this sequence whenever they have to step in to control their children with ADHD. Instead, they may proceed straight to the last strategy of management that produced some partial success. This can readily lead to immediate negative reactions or harsh physical discipline when the children start to show even minimal disruptive behavior. Some parents appear to have reached such a severe state of failure in their management of their children that they could best be described as being in a state of “learned helplessness.” They make no, or minimal, effort to give or enforce commands to their children, leaving them to do as they please. They begin to withdraw from the children, ultimately providing little if any supervision. At this point many such parents report depression, low self-esteem in their role as parents, and little satisfaction with or involvement in their parenting responsibilities. In some cases such parents may shift between complete disengagement and overly harsh reactions to their children’s misbehavior, depending on their own mood and irritability at the time. The parents may even start to spend progressively less time in leisure activities with the child because the interactions can be so stressful or unpleasant. In short, living with a child who has ADHD can seriously tax a parent’s mental health and commitment to parenthood. If that parent is already experiencing personal emotional problems, it can make them far worse.

PARENTAL PSYCHIATRIC PROBLEMS

Parents and relatives of children with ADHD are in fact more likely to have psychological problems than those of children without ADHD. Some of these come about from the difficulty of living with someone who has ADHD; others are rooted in the parents’ own psychological and even biological makeup.

Parenting Stress

There is no question that parents of children with ADHD, especially mothers and particularly when the children are young, experience greater stress than caretakers of children without ADHD. Mothers of children with ADHD tell us that they have lower levels of parenting self-esteem and experience markedly more depression, self-blame, and social isolation than mothers of children without ADHD. The more severe are a child’s behavior problems, the more severe the mother’s stress. Obviously, other factors that are affecting a mother’s psychological well-being can distort how she views her child and thus how much stress she feels, but our studies show that the major source of parenting stress comes from a child’s ADHD and especially its associated defiant and disruptive behavior, rather than from other sources in the family.

“I’m at my wits’ end with him. I’m afraid I’m going to hurt him. He’s driving me crazy and won’t listen. I can’t cope with him anymore. I may have to send him away.”

We also have found that both the stress of raising a child with ADHD and the greater risk for personal emotional problems in the parents can greatly strain a marriage or relationship, especially when the child has serious oppositional, defiant, or aggressive behavior. My associates and I have found that over an 8-year period, during which we followed a large number of families of children with ADHD, their parents were three times more likely to have separated or divorced than in families of children without ADHD.

Parents of children with ADHD also may be deprived of the encouragement, warmth, and assistance of a supportive family. They tell us that they have fewer contacts with their extended family members than in families without children with ADHD and that these contacts are less helpful to them as parents and more aversive or unpleasant. So parents of children with ADHD may experience a form of social isolation that is detrimental both to their caretaking abilities with their children and to their own emotional well-being.

Psychiatric Disorders

As I have said, the biological parents of children with ADHD are themselves more likely to have ADHD or at least some of the residual characteristics of the disorder. About 15–20% of the mothers and 20–30% of the fathers of children with ADHD may have ADHD at the same time as their children. The biological siblings of these children also share this risk: approximately 26% of brothers and sisters may have the disorder. In general, the risk of ADHD among the first-degree biological relatives of children with ADHD is between 25 and 33%.

Parents of children with ADHD are more likely to experience a variety of other psychiatric disorders as well, the most common being conduct problems and antisocial behavior (25–28%), alcoholism (14–25%), mood disorders like depression or excessive emotional responding to distress (10–27%), and learning disabilities. Even if they are not abusing alcohol, parents of children with ADHD consume more alcohol than do those of children without ADHD. Recall, though, that these psychiatric problems are associated mainly with aggressive and antisocial behavior in the children and not so much with the children’s ADHD itself. The more aggressive and antisocial a child is, the more numerous and severe are the psychiatric problems among the relatives. Only ADHD and a history of school problems seem to be more common in the family members of children with ADHD who are not seriously aggressive or antisocial. This certainly suggests that parent and family psychiatric problems may be giving rise to aggressive and antisocial behaviors in cases where a child with ADHD exhibits these. They do so by the influence the parental problems have on the child-rearing skills of the parents and the emotional climate of family life in the home.

WHAT DOES ALL OF THIS MEAN FOR YOU AS A PARENT?

All of the preceding information can be boiled down to the simple fact that having a child with ADHD places great stress on parents, particularly mothers. This stress is as great as or greater than that experienced by parents who have children with autism, a far more serious developmental disorder than ADHD. The excessive, demanding, intrusive, poorly self-regulated, and generally high-intensity behavior of children with ADHD, as well as their clear impairment in self-control, naturally elicit greater efforts at direction, help, supervision, and monitoring by parents—efforts far in excess of what parents of children without ADHD need to do. Parents with more than one child with ADHD are assured that their stress levels will be more than twice those of any other family with just one such child. It therefore is easy to see how you could become overwhelmed by the demands the child or children place on you as a parent. I am sure you are aware that when people are exposed to high levels of chronic stress they are more likely to have medical problems, especially those related to immune disorders, such as colds, flu, and other infections. They are also more likely to have mental health problems, such as depression. So you may find yourself similarly affected and find your overall energy level lower since having a child with ADHD.

Short of placing your child with ADHD up for adoption, which no one would suggest, there are many ways to make life at home easier that we consider in Parts II, III, and IV of this book (see Chapters 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19). Above all, do not give up as a parent. Children with ADHD do have a positive side, and raising such a child to adulthood can give you tremendous satisfaction, provided you learn to cope with the extra stress such parenting brings with it. Draw on the seven principles of effective parenting discussed in the Introduction, and, particularly, do not ignore opportunities for your own personal renewal (see Chapter 10). Strive to be a principle-centered, executive, and scientific parent, and you should find that the stress of raising a child with ADHD is substantially diminished.