Families with a child who has attention deficit disorder (ADHD)
are confronted with many developmental, educational, social, and behavioral
challenges. ADHD symptoms often cause all family members, including siblings,
to experience pressures and stresses far beyond those found in families in
which ADHD is not present. Mental health therapists need to be aware of how
the disorder affects family functioning. In this article, I address probable
causes of ADHD, principles applicable to families with a child who has ADHD,
effects of ADHD on family interactions, counseling, and a multidimensional treatment
approach. ADHD can influence a child’s behavioral, emotional, and social
adjustment (Kelly & Aylward).
Henggler and Borduin concluded that there is considerable evidence that ADHD
disrupts the child’s social systems (e.g., with peers, family, and siblings).
Emery, Fincham, and Cummings pointed out that interdependency exists among
all components of complex systems, such as families. Evidence suggests that
ADHD is one of the most prevalent and complex conditions in our society affecting
children and, in turn, their families. During the past several years, there
has been considerable interest in the dysfunction and disorders of families
with children identified as having ADHD (Brown & Pacini). The dynamics of
the family that has a child with ADHD will undergo pressures and stresses that
are outside the realm created by normal developmental problems. Children with
ADHD can experience extensive and enduring academic, social, and family interaction
problems that may be attributed to other causes (e.g., parenting, academic
expectations, and peer conflict). Mental health therapists need to be aware
of how this disorder affects family functioning.
Children with ADHD, not understanding their predicament, may suffer countless
hours of frustration at home and in school. For example, they can experience
constant prodding from parents, siblings, and teachers to achieve more and
improve performance levels. Frequently, children with ADHD are punished for
their behavior even though their disorder leaves them with no alternative courses
of action. They sense that they are different and often rebel, but continue
to suffer from low self-esteem or a poor self-concept. As a result, the behavior
exhibited by children with ADHD probably reflects, to some extent, their personality
and temperament, complicating the situation further. Although everyone is born
with a biologically determined set of temperament features (Johnston), Carey
believes that ADHD and temperament overlap considerably. Therapists need to
realize that ADHD should not be mistaken for an individual entity that affects
only the client. ADHD symptoms affect all family members. Furthermore, it is
not unusual for ADHD to be unrecognized, diagnosed incorrectly, undiagnosed,
or treated inappropriately by mental health professionals. For example, families
torn by ADHD rarely work well (Hallowell & Ratey). Simply stated, the reality
of ADHD causes myriad problems for both the affected child and the child’s
family. Some families have fallen apart or disintegrated, never knowing that
ADHD afflicted their child and contributed to persistent negative family interactions.
Principles Applicable To Families Affected By ADHD
The first and most important principle is that the family usually attempts
to cope with ADHD problems for a long time before seeking counseling (O’Brien).
There is an obvious difficulty in raising a child who constantly manifests
unpleasant behavior, feelings, and attitudes within the family. It is important
to realize that the stress for family members, including siblings, probably
is at high levels for an extended period of time. The family probably has coped
marginally before seeking treatment. Often the family has fought a battle against
a mysterious enemy that it cannot fully understand or identify (Friedman & Doyal).
For example, it is not uncommon for ADHD to remain undetected and undiagnosed.
It seems that many children with ADHD are not diagnosed until the third grade,
enabling the family to place many previous familial interactions into proper
perspective (Barkley; Copeland & Love).
The second principle is that ADHD affects all areas of family functioning (O’Brien).
The relationships the child with ADHD has within the family may abound with
stress and eventually become impaired. Parents of a child with ADHD typically
feel that they are incompetent in dealing with problems that other parents
handle as routine. The family reports feeling overwhelmed and helpless in coping
with the array of problems (e.g., familial discord and inattention reported
by teachers) that occur on a daily basis with a child with ADHD. The disorder
continually invades and disrupts most areas of the family’s existence
or interpersonal functioning.
The third principle is that the child with ADHD should view his or her family
as being completely understanding of the problems often connected with the
disorder (O’Brien). It is essential that the failures and successes of
children with ADHD are fully accepted by family members, especially siblings.
For example, parental anxiety is often directed at attempting to control or
manage the child’s mistake-prone life. Unfortunately, the child with
ADHD usually is incapable of coping with elevated levels of stress or anxiety.
Therefore, parent and sibling responses to the behavior of the child with ADHD
can either aggravate or improve the child’s condition (Popper).
The fourth principle, based on my experience, is that children with ADHD exist
in a synchronous (and circular) relationship with their families and schools.
Unfortunately for children with ADHD, much of what they do at home and school
is unacceptable behaviorally, socially, and academically to parents and educators.
Hardly a day passes that something serious does not go wrong for the child
with ADHD. Mental health therapists need to be aware that the problems experienced
by children with ADHD at home and in school usually are inseparable and often
have negative reciprocal effects. A negative feedback cycle often develops
between the school and family system, which may interrupt or impede the family’s
social system. For example, constructive criticism in the form of a note from
school regarding the behavior of the child with ADHD can be perceived by family
members as an affront or injury and can elicit defensiveness. Parents can become
reactive, emotional, and defensive over even a minor problem encountered by
their child with ADHD. Conceptions of reciprocal causality increasingly are
seen as important to many parent-child or family problems (Emery, etal.). Furthermore,
Merrill believes that it takes only a small step to understand that human behavior
is shaped through complex, yet mutually influential or reciprocal, parent-child
interactions, whether in the family, the school, or the community. Mental health
therapists who embrace these principles possess a foundation from which to
proceed with family counseling and treatment for ADHD.
How Attention Deficit Disorder Affects Family Functioning
In essence, children with ADHD initiate a dysfunctional system of interactions
within their families. Having a child with ADHD in the family predisposes
all members toward a higher degree of conflict than is found in families
without a child who has ADHD. Families that have a child with ADHD often live
in a state of disarray, accumulate layers of frustration and blame, and endure
unrelieved feelings of guilt. The effects of the disorder can dissolve the
social ecology or connectedness of the family. The mental health therapist
should be prepared to investigate (a) the social-familial
interactions between children who have ADHD and their parents and siblings, (b) how
children with ADHD affect their parents, and (c) the signs
of family interaction problems that can be present in families with children
who have ADHD.
Social-Familial Context: Barkley pointed out the following
reasons for the importance of the social-familial context in understanding
the interactions between children with ADHD and their parents and siblings.
First, the social interactions of children with ADHD and the reactions from
their parents and siblings have been shown to be different from those of families
that do not have a child with ADHD. These interactions are inherently more negative
and stressful to all family members. Second, evidence abounds that parents
and siblings of children with ADHD are more likely to experience their own psychological
distress and psychiatric disorders than are parents and siblings in families
that do not have a child with ADHD. The high level of psychological distress
affects the management and rearing of children with ADHD in unique ways that
may have long-lasting effects on the child or adolescent (e.g., marginal adjustment
to adulthood and frequent employment changes). Third, although many clinicians
endorse a "family systems" approach, a number of clinicians ignore
the strong reciprocal effects of these family interactions. Their focus primarily
is on the impact of parental behavior on children with ADHD and ignores the
substantial effects produced by these children on their parents and family
life in general. For example, parenting behavior has not been found by researchers
to be a cause of ADHD, although some family therapists or clinicians spend an
inordinate amount of time exploring this possibility. In ADHD cases, all family
problems cannot be reduced to parenting problems (Emery, et al.).
Influence of the Child With ADHD on Parents The influence
of children with ADHD on parents has not received the attention it deserves.
What has been overlooked is the way in which parents and other caregiving adults
are "molded" by the children they are trying to rear (Bell & Harper).
Children’s behavior can influence parenting style or can affect parents’ responses
to their children (Fauber & Long; Steuer). For example, in many instances,
ADHD symptoms often elicit specific behavioral responses (e.g., restriction
of privileges, punishment, or rejection) from parents. Henggler and Borduin
believe that parental rejection based on behavior that displeases the parent
can be one of the most serious emotional traumas a child can experience. A
thorough understanding of the interactional patterns of children with ADHD and
their families is advisable before any firm conclusions and treatment regimes
are formulated by the mental health therapist.
Unraveling pertinent family dynamics, however, is far from easy. Barkley found
that parents of a child with ADHD can be scrutinized by therapists for even
the slightest flaw in their parenting methods or family structure and that
therapists believe that these flaws cause the problems within the family. Such
a view, according to Barkley, is inherently one-sided and unfair, certainly
untrue, and perhaps even damaging to children with ADHD if interventions are
founded on it. The interaction patterns of children with ADHD and their families
need to be thoroughly understood before a mental health therapist forms a conclusion
and initiates treatment.
Few disorders have the potential to make as profound an impact on parental
and family functioning as ADHD does. To parents, children with ADHD often exhibit
unpredictable behavior and may even, at times, seem to be out of control physically
or emotionally. Over time, these children can easily exhaust a family’s
coping mechanisms. The activity level of a child with ADHD (e.g., hyperactive,
inattentive, or inactive); his or her mood swings, impulsiveness, lack of organizational
skills, socialization difficulties, and compliance problems; and the constancy
of the child’s behavioral difficulties often create a volatile situation
in the home. Family discord or arguments, which are often negative, are common,
and destructive statements about the child with ADHD are often made out of frustration
or anger. Children or adolescents with ADHD and their parents are more likely
to use aversive behaviors (e.g., insults, complaints, commands, and defensiveness)
during family discussions (Barkley, Guevremont, Anastopoulos, & Fletcher).
Signs of Family Interaction Problems
Copeland and Love listed the following as signs of family interaction problems
that are often found in families that have a child with ADHD: (a) family
has frequent conflicts; (b) activities and social gatherings
are unpleasant; (c) parents argue over discipline because "nothing
really works"; (d) parents spend "hours and
hours" on homework with the child with ADHD, leaving little time for
others in the family; (e) meals frequently are unpleasant; (f) arguments
occur between parents and the child over responsibilities and chores; (g) stress
from the child’s social and academic problems is continuous; and (h) parents
often feel frustrated, angry, helpless, hopeless, guilty, disappointed, alone,
fearful for the child, sad, and depressed. The parents’ interaction
patterns within the family often are faulty because of the high stress level
that constantly exerts itself over the family. To complicate the situation
further, the parents may be undiagnosed adults with ADHD and there could be
undiagnosed siblings with ADHD. Again, the entire family system must be addressed
to ensure successful treatment (Copeland & Love). Finally, it is important
for mental health therapists to realize that parents of a child with ADHD
often feel that their own physical and mental health is threatened by the
flow of daily stressors and problems that accompany the disorder. The parents
may even fear that the family’s well-being or psychological health
will be harmed beyond repair by the ADHD. Family counseling becomes a viable
intervention once all of the implications of ADHD to family functioning are
- Erk, Robert R; Multidimensional treatment of
attention deficit disorder: A family oriented approach; Journal of Mental
Health Counseling; Jan97, Vol. 19 Issue 1, p3
Reflection Exercise #7
The preceding section contained information
about how ADHD affects the family. Write
three case study examples regarding how you might use the content of this section
in your practice.
According to Erk, what are the four principles to consider when evaluating
the family of a child with ADHD? Record the letter of the correct answer