In this issue...

* A new theory of ADHD from Dr. Russell Barkley

* Social problem solving in boys with ADHD

* Stimulant medication treatment and sleep problems in children

* How does having a child with ADHD influence parents' satisfaction
  with family life?

- READER QUESTION -

"What suggestions do you have for helping my child figure out what to say
  to children who ask him about the medication he takes?"
________________________________________________________________

Dear Subscriber:

In response to a number of requests, I have started to include complete
reference information for each study that I review.  For those of you who
are interested in tracking down and reading the complete article, this should
help you out.

The journals from which articles are reviewed would not be generally found
in a general public library.  Instead, you would need to have access to a
college/university/medical school libary in order to locate them.  I am
fortunate to have access to the libraries at Duke University, and would not
be able to put the newsletter together without this incredible resource.

I hope you enjoy this issue of ADHD RESEARCH UPDATE and find it to
be both helpful and informative.

Sincerely,

David Rabiner, PhD
Licensed Psychologist
 

* A NEW THEORY OF ADHD  FROM DR. RUSSELL BARKLEY

Dr. Russell Barkley is widely recognized as one of the world's
leading authorities - if not THE leading authority - on ADHD.
Recently, Dr. Barkley published a book called "ADHD and the
nature of self-control" in which he lays out a theory of ADHD
and the implications that follow from his theory (Barkley, R.A. (1997)
ADHD and the nature of self control, NY: Guilford Press.) As I read it,
Dr. Barkley intends for his theory to apply more to individuals
who have hyperactive/impuslive symptoms of ADHD in addition to
problems with attention, rather than to children who show the
inattentive symptoms alone.

This is a really excellent and thought-provoking book. For those
of you who are interested in the latest cutting edge thinking
about ADHD, I would strongly recommend it. I certainly can
not do justice to this work in the brief overview below, but
will do my best to give you an understanding of the major
ideas in Dr. Barkley's theory.

As implied in the title, Dr. Barkley argues that the fundamental
deficit in individuals with ADHD is one of self-control, and
that problems with attention are a secondary and not universal
characteristic. Dr. Barkley emphasizes that during the course
of development, control over one's behavior gradually
shifts from being primarily controlled by the external environment
to being increasingly governed by internal rules and standards.

Young children have very little ability to refrain from
acting on an impulse - i.e. to "inhibit" their behavior. Instead,
it is more typical for a young child to just "act out" the things
that pop into his or her mind. In addition, when they are able to
refrain from acting on an impulse, it is generally because of
something in the immediate surroundings that keeps them from doing so.
For example, a young child may refrain from throwing a toy when
frustrated because his mother is around, and he knows he will be
punished if he throws it.

This is very different from a child who is able to refrain from
acting out impulsively even when there is nothing immediately
present to require this. For example, consider a child who feels
a similar urge to smash a toy but is able to keep from acting on
this impulse because he/she realizes this would be a bad idea for one
or more of the following reasons:

1. he won't have the toy to play with later on;
2. his parents would be upset if he broke his new toy;
3. he would be upset for letting down his parents;
4. he would be upset because he let his temper get out of
control - he let himself down

This child has learned how to "inhibit" and regulate his own
behavior based on an internal standard of rules and guidelines.
Rather than requiring external consequences to guide and direct
his behavior, in other words, this child has developed the
capacity to guide and direct his behavior on his own.

Although it is a vast oversimplification of his work, Dr. Barkley
argues that the critical deficit associated with ADHD is the
failure to develop this capacity for "self-regulation". In
Dr. Barkley's theory, this failure results primarily for
biological reasons, and not because of things that parents either
did or did not do. He goes on to describe specific
psychological processes and functions whose development is
impaired by this core deficit in self-regulation. Although I can
not describe these in detail, here is a brief overview of some
areas that are touched on:

* Working Memory - the ability to recall past events and manipulate
them in one's mind so as to be able to make predictions about the
future. This is an important part of dealing effectively with
day-to-day situations that Barkley feels is diminished in
individuals with ADHD.

* Internalization of Speech - the ability to use internally
generated speech to guide one's behavior and actions. Think
about how often you find yourself talking to yourself about
what to do or not do, and how to solve particular problems
that may confront you. Dr Barkley argues that this capacity
develops later and less completely in individuals with ADHD.

* Sense of Time - the ability to keep track of and monitor the
passage of time and to change/alter one's behavior in relation
to time. Think for a moment about how often one needs to evaluate the
amount of time it will take to accomplish a particular task
and/or the time you are devoting to a particular task/activity
in relation to what is available. Dr. Barkley suggests that for
individuals with ADHD, the psychological sense of time is
impaired, which prevents them from being able to modify/alter
their behavior in response to real world time demands.

* Goal Directed Behavior - the ability to establish a goal in
one's mind and to use the internal image of that goal to shape,
guide, and direct one's actions. This is an incredibly important
capacity as it underlies consistent effort and persistence.
Imagine how much harder it would be to persevere through
difficult and frustrating times if you were not able to hold a
long-term goal in your mind. Dr. Barkley argues that individuals
with ADHD have great difficulty doing this, and are thus less
able to persist towards the attainment of important goals.
 

Thinking about ADHD as a disorder of self-regulation rather
than as a disorder of attention has enormous implications for
understanding the nature of the difficulties experienced by
individuals with ADHD. This also has important implications
for thinking about how to assist them in overcoming and coping
more effectively with those difficulties. Trying to convey
the depth and richness of Dr. Barkley's discussion of these
issues is not possible in this brief review, but I will
try to highlight what I think are some especially important
points.

First, Dr. Barkley believes individuals with ADHD do not
necessarily lack the skills and knowledge to be successful,
but rather, that their problems with self-regulation keeps them
from applying their knowledge and skills at the necessary times.
As Dr. Barkley puts it, "ADHD is more a problem of doing what one
knows rather than knowing what to do."

For example, the child with ADHD may "know" that
sharing and cooperating are an important part of making
and keeping friends, but not apply this knowledge when
needed because the immediate rewards associated with
getting one's way overpowers the less salient goal
of keeping a friendship. Or, the child may be able to tell
what steps are required to do a good job on a school project,
but be unable to put this knowledge into practice because of
problems with managing time, and directly one's behavior
according to a long-term goal.

In regards to treatment, Dr. Barkley emphasizes that based on
his conceptualization, treatment needs to help individuals
to do what they may already know when it needs to be done, rather
than on teaching them specific knowledge and skills.
This will require providing them with frequent external cues and
reminders to guide their behavior because their internal guides for
behavior are much less effective.

For example, consider the child mentioned above who does not
share and cooperate because the immediate payoff associated with
getting what he wants is so much more salient than the long-term
consequences for his friendships. Dr. Barkley would argue that this
child may not need to be taught "social skills" since he already
knows the right thing to do. Instead, he needs to be frequently
reminded, as his interactions with peers are actually taking
place, about the ways he needs to behave.

This could take the form of having the child review a short
set of "social rules" to focus on immediately before a
play time with peers. Providing the child with feedback
and reminders about this during the actual play session
could also be very important.

In regards to following rules in the classroom and getting
work done, Dr. Barkley again emphasizes the need to provide
external prompts. Writing the rules down on signs around
the classroom are one way to do this. Posting class rules
on an index card taped to the child's desk are another.
During work times, one possibility is to have the child
wear headphones and listen to a tape that provides frequent
reminders to stay on task, to write neatly, and to check
one's work. In all of these examples, the principle is
to compensate for the child's inability to control his or
her behavior through internal means by providing as many
external prompts and reminders as possible.

Even when this is done to the greatest extent possible,
however, Dr. Barkley believes that success is likely to be
partial and temporary if internal sources of motivation
are not augmented by external sources as well. In other
words, treatment needs to go beyond simply providing the child
with external prompts and reminders about what to do, because this
would still rely solely on the child's internal motivation to follow
those rules he or she has been reminded of. There may, however, be
more attractive alternatives to act on, and as noted above, a
core feature of ADHD in Barkley's model is a deficit in the capacity
for self-regulation that would permit the child to refrain from
acting on these more attractive alternatives. To compensate for this
deficit, the environment must be arranged so that the behaviors one
is trying to encourage become more attractive than the alternative.
This can be done by providing the child with rewards and privileges
for meeting the behavioral expectations that have been set. In
other words, the consequences associated with the desired behavior
must be made more attractive and appealing than those associated
with alternative behaviors the child could engage in.

What makes this more difficult to do for children with ADHD
is that using long term goals to guide their behavior is
so difficult for them. For example, the problem with telling a child
with ADHD that a good week at school will result in a special treat
over the weekend is that it assumes he or she can use this long
term goal to guide and direct their behavior over an entire week.
In other words, it requires the child to refrain from pursuing more
attractive immediate activities because of their desire to obtain
a specific outcome down the road. According to Dr. Barkley, however,
this is exactly the type of internalized control of behavior that is so
difficult for individuals with ADHD.

What this means is that attainment of the long-term
objective must be broken down into numerous shorter
term goals, each of which has its own associated reward.
For example, the special weekend treat may need to
be supplemented by daily privileges that are contingent
on the child's meeting specific behavioral expectations
each day. Frequent reminders to the child about what those
expectations are, and what will be attained by meeting
them, may also need to be incorporated.

Even when these principles are faithfully applied, the
notion of an underlying deficit in self-regulation
implies that gains associated with treatment will not
persist when the treatment is not in place. In other
words, improvements that may occur when the strategies described
above are utilized would not be expected to persist when
these strategies are discontinued. Instead, this is an ongoing
approach to helping children with ADHD cope with the difficulties
that it causes. It is an attempt to provide treatment and
relief from the symptoms of ADHD rather than "curing"
the disorder.

Of course, Dr. Barkley also notes that as children with
ADHD mature, their diminished capacity for self-regulation
will mature as well. Thus, even though they may never
fully catch up to their peers in this regard, their ability
to guide and govern their behavior via internal means
will nonetheless grow and develop. Over time, therefore,
one could expect to diminish their reliance on external
sources of motivation and the intensity and frequency
with which these external source are provided. Eventually, the
adolescent or young adult with ADHD may be able to arrange their
own external prompts in the form of lists and other types
of cues that prove to be effective, and to provide themselves
with their own rewards for meeting their self-imposed
standards.

The other important treatment implication that follows from
Dr. Barkley's model is that medication treatment may be effective
because it normalizes, or at least improves, the underlying deficit
in behavioral inhibition that he believes is the core feature of
ADHD. Dr. Barkley reviews evidence for this contention
in the book, and argues that medication is the only treatment
known to date to produce such results. As such, he believes that
it should be the predominant treatment approach for individuals with
ADHD.

Let me close by sharing with you an insight of Dr. Barkley's
that I think is especially important. One thing I still
hear with distressing frequency is that ADHD is just an
"excuse" for laziness and other forms of misbehavior. Dr.
Barkley points out that ADHD is not an excuse for behavior,
but that it is an explanation for the kinds of behavior that
parents, teachers, and even children themselves can find
to be so frustrating. The basis of this explanation is the
deficit in the development of self-regulation that is regarded
as the core feature of the condition. What follows from this,
according to Dr. Barkley is that:

"...the required response of others to the poor self-control
shown by those with ADHD is not to eliminate the outcomes of
their actions and to excuse them from personal accountability.
It is to temporally tighten up those consequences, emphasizing
more immediate accountability."

In other words, a child with ADHD is not "let off the hook"
because of their condition. Instead, one needs to heighten
the child's accountability in the form of more frequent
checks and feedback on their behavior, supplemented by the provision
of appropriate rewards and privileges when desired standards
of behavior have been met.

Please believe me when I say that the above summary in
no way does justice to the scope of Dr. Barkley's work.  It also should
be kept in mind that this set of ideas represent a theory rather
than an established set of facts.  Like any theory, it needs to be
tested in a rigorous way, and I am certain that a number of
studies based on Dr. Barkley's ideas, and the predictions that
follow from them, are already underway.

I hope that this brief overview may piqued your interest enough to possibly
read this book yourself
 

* SOCIAL PROBLEM SOLVING IN BOYS WITH ADHD

For many children with ADHD making friends and getting
along with peers is an important part of the difficulties
that they experience.  In recent years, considerable
research has been conducted on children's peer relations
in an effort to better understand how to help children
who are struggling in this area.  Within this broad area
of research, a particular aspect that has received
much attention has been looking at children's social problem
solving skills and how this relates to children's ability
to get along with others.

The current issue of the Journal of the American Academy of
Child and Adolescent Psychiatry (March, 1999; pages 311-321)
presents an interesting article in which the social problem
solving skills of 7-12 year old boys with ADD are examined.
(Matthys, W., Cuperus, J.M., & Van Engeland, H. (1998).
Deficient social problem solving in boys with ODD/CD, with
ADHD, and with both disorders. Journal of the American Academy
of Child and Adolescent Psychiatry, Vol. 38(3), 311-321.)

Before getting into the specifics of their study, let me
first provide some background on efforts to understand social
competence from a social problem solving perspective.  A very
influential set of ideas in this area have been proposed and
developed by Dr. Ken Dodge of Duke University.  Dr. Dodge
has developed a model of the sequence of internal mental events
that individuals go through in determining how to respond in
any particular situation.

First, one must take in the various social cues that are
present in the situation.  For example, imagine a child who
is standing at the water fountain and has just gotten bumped
a peer.  Before deciding how to respond, the child must first
attend to various cues that could help him or her decide on
an appropriate response.  These could include such things as
the "offending" peers facial expression (i.e., does he look
contrite or provocative?), the expressions of others who may
have witnessed the event, the tone of voice when the "offending"
child apologizes (i.e., does he sound sincere or sarcastic?).
The point here is that there are generally multiple cues in
the social environment that can help one to accurately
interpret what is going on, and the better able one is to attend
to, and take in, those cues, the more accurate picture of the
situation one can arrive at.

After the relevant cues have been taken in, the child must
then "interpret" the information available.  In many social
situations, the intentions of others is not clear cut, but
can be ambiguous.  Think of how many times you may find yourself
asking the question "What did he/she really mean by that?"
"Is she really sorry about what happened or is she just saying
that?" "Was that really an accident, or was it intentional?"
The point is, that in many cases, there is room for multiple
interpretations of the same event.  In the example given
above about a child being bumped, one child might decide it
was just an accident and not become upset, while another might
interpret the same situation as reflecting an intentional insult
and thus feel some need to retaliate.  You can easily see how
problems at the first stage - not fully taking in the relevant
cues - could have an adverse impact on the accuracy of a
child's interpretation of events at the second stage.

After the interpretation of an event has been arrived at, the
child (by the way, this model certainly applies to adults as
well) must develop and consider possible responses to the
situation.  In virtually all social situations, there are
many different ways that one can respond.  So at this stage,
the child's task is to generate alternative ways that he or
she might respond, and to then evaluate the costs/benefits of
each different option.  One can see here how problems could
emerge in either of two ways.  First, a child may not be able
to generate many alternatives, and thus has a limited range
of options to choose from.  Or, a child might consistently
select options that are problematic.  For example, a child
could tend to favor aggressive, retaliatory responses over
those that would promote better social relations.  The goals
that a child has for social interactions are likely to come
into play here.  Thus, a child whose primary objective is to
be in charge and not get pushed around is likely to choose
different responses from a child whose primary goal is to
establish and maintain good relations with peers.

Finally, after a response has been selected, the child must
be able to skillfully enact it.  In this model, therefore,
social competence is not just a matter of "knowing what to
do" - one also has to be able to do it.  This, as we all know,
is not always so easy.  Think about how many times you feel
fairly certain about the way you ought to respond in a particular
situation but are unable to skillfully pull it off.

Considerable research has been conducted based on this
framework, and in general, it has shown that children
who have difficulty in their social relationships, especially
aggressive children, demonstrate deficient skills at each step
outlined above.  Thus, aggressive children tend to encode fewer
social cues, to be overly prone to interpret other people's
intentions as hostile even when this is not clear from the
situation, to generate fewer and especially more aggressive
responses, to evaluate aggressive responses more favorably, and
to be more confident of their ability to successfully enact an
aggressive response.

Although the above discussion is no more than a brief overview
of this important and interesting area of research, it will
hopefully provide a reasonable basis to discuss the study of
social problem solving skills in children with ADHD that is
the focus of the current article.

In this study, the authors sought to determine how the social
problem solving skills of boys with "pure" ADHD compared to a
control group of boys without ADHD, and to boys with other types of
behavioral disorders (e.g. Oppositional Defiant Disorder and
Conduct Disorder), and to boys who had both ADHD and these other
behavioral disorders.  In particular, the authors were interested
in determining which steps of the social problem solving sequence
outlined above tend to be most problematic for boys with ADHD.

In this study, boys were shown short videotapes that depicted
children their age engaged in a variety of problematic social
situations.  For example, one vignette depicted one child
struggling to build a model plane.  Another child offers to
help him, and in the process of doing so, the plane breaks into
pieces.

After observing each short vignette, boys were asked questions to
evaluate their problem solving skills at each of the stages
described above.  For the model plane example above, each child
was first asked whether the boy who was helping intended to
break the plane.  This question assesses children's interpretation
of events and is geared towards evaluating the tendency to
make hostile interpretations.  Next, the child would be asked
what he observed on the tape that helped to make his interpretation.
This question is designed to look at a child's ability to notice
and take in the multiple cues that are present in most social
situations.  Children were then asked to think of different
ways one could respond to assess their ability to generate
alternative problem solving strategies.  Finally, they were asked
to evaluate different ways that a child could and should respond
in such a situation.  The responses they were asked to evaluate
included both prosocial and antisocial types of responses.  In
addition to evaluating how good an option each strategy was, they
were also asked whether they felt they would be able to enact
such a response.  In other words, even if they thought a particular
strategy was a good idea, did they think they would be able
to do it?

Several interesting and potentially clinically important
differences in problem solving between children in the different
diagnostic groups were found.  There is A LOT of data presented
in this article, but I will try to highlight what seem to me
to be the major findings.

* Compared to boys in the control group (i.e., boys without any
  diagnosis), boys with ADHD were found to encode significantly
  fewer cues and to also generate fewer alternative strategies
  for dealing with the different problematic situations.  They did
  not, however, evaluate alternative responses differently from
  control boys nor did they differ in their expectations about
  being able to enact different types of responses.

  For boys with ADHD alone, therefore, the main problem solving
  deficits indicated by this study is that they are not as
  attentive to social cues that are important for accurately
  sizing up a situation.  They also may have less options available
  to them as they were unable to generate as many alternative
  strategies.

* For boys with ADHD and an additional behavior disorder, these
  same deficits relative to control boys were found.  In addition,
  however, these boys also provided more favorable evaluations
  of aggressive problem solving strategies and felt more confident
  in their ability to enact aggressive responses.

  Thus, for these boys, not only do they take in fewer cues and
  generate fewer alternative strategies, but they also tend to
  regard aggressive problems solving strategies as the superior
  choice and to feel quite confident about their ability to
  successfully enact such strategies.
 

The results of this study may have important clinical implications
for helping boys with ADHD, as well as boys who have ADHD plus a
co-occurring behavioral disorder.  For boys with ADHD alone, efforts
to increase their attention to social cues and nuances may be
especially important.  They may also need assistance in learning
how to broaden the repertoire of problem solving strategies that
they are able to generate and then choose from.

For boys with ADHD who also have a serious behavioral disturbance,
the task of improving their problem solving skills is likely to
be more difficult.  These boys have come to over value aggressive
problem solving strategies - perhaps because they have frequently
been successful for them in the past - and to be quite confident
about their ability to employ these strategies.  For these boys,
therefore, enhancing the perceived value of non-aggressive and
prosocial problem solving strategies may need to be an important
aspect of helping them.

A few caveats.  First, one can not assume that these results would
also be found with girls.  Hopefully, a follow-up study that
includes girls as participants will be conducted.  Second, just
because differences between groups of children with the different
diagnoses was found does not mean that every child in the group
showed a similar pattern.  This is virtually never the case.

The value of this study, and the problem solving model on which
it is based, however, is that it can provide parents and
practitioners with a useful framework for thinking about their
child's social difficulties.  For example, if your child is having
difficulty in peer relationships, thinking about how skillful and
competent they are at the different stages of the model described
above can be a valuable exercise.  Paying attention to such
questions as:

* Is my child sensitive and attentive to social cues?

* Is my child able to accurately interpret the intentions of others
  or is he or she prone to misinterpret other's intentions as
  hostile?

* Is my child able to generate a good variety of ideas for handling
  different situations or is his/her ability to come up with
  alternative strategies too limited?

* Does my child tend to overvalue certain types of problem solving
   strategies and undervalue others?

* Does my child lack confidence in his or her ability to
   successfully enact certain types of problem solving strategies?
   Is he or she too confident about being successful with other
   kinds of strategies that can lead to problems?
 

Paying attention to such questions, and trying to learn the
answers, is bound to provide you with a richer understanding of
your child's social world and how you may be able to help him
or her.  In thinking about these issues, keep in mind that
different social situations are characterized by different
demands, and a child can certainly have good problem solving
skills in one type of situation but not in others.  For
example, a child may be quite skillful when the task is
making a friend but be less skillful when the task is keeping
a friend, or standing up to a friend who has a different idea
about something.

Research has shown that well designed interventions that focus
on children's social problem solving skills can produce important
benefits for children's peer relations.  This is an area where
parents can be of help to their child, especially when working
in cooperation with a skilled professional who can help in the
design and implementation of a program suited for a child's
unique and individual needs.
 

* STIMULANT MEDICATION TREATMENT AND SLEEP
   DISTURBANCE

One potential side effect of stimulant medication treatment
that parents and physicians are often concerned about is
the adverse effect that stimulant medication can have on
children's sleep.  In fact, I am often told by parents
that their child's physician would not consider a dose
of medication in the late afternoon because of the problems
this would create for the child's sleep.

A study which appeared in the August 1998 issue of the
"Journal of Clinical Psychology" (pages 701-716) provides
information that indicates that this needs to be carefully examined
on a case by case basis. (Day, H.D., Abmayr, S.B. (1998). Parent
reports of sleep disturbances in stimulant-medicated children with
attention-deficit hyperactivity disorder. Journal of Clinical Psychology,
Vol. 54(5), 701-716.)

Participants in this study were 20 children diagnosed with ADHD
who were taking stimulant medication, 20 unmedicated children with
a different psychiatric diagnosis,and 20 control subjects with no psychiatric
diagnosis. The parents of these children responded to a 40-question structured
interview designed to evaluate the frequency and intensity of their child's sleep
difficulties during the prior month.

Parents of children with ADHD reported more problems with
settling down and going to sleep, more disruptions during
sleep, and more difficulties with morning activities.
Between 25-50% of parents of children with ADHD reported
very frequent difficulties with their child settling and
going to sleep.  The authors conclude that it is important
to monitor the sleep-related behaviors of children with
ADHD who receive stimulant medication and to provide
adjunctive treatment for children experiencing sleep
related disturbance.

Other studies that have been reviewed recently in ADHD
RESEARCH UPDATE have also described data that indicate
a greater incidence of sleep difficulties in children
with ADHD.  I completely agree that attending to this
area is important, and it is very likely to be the case
that sleep problems can exacerbate the symptoms of ADHD
for many children.  Some have argued that sleep problems
can be misdiagnosed as ADHD, although I have yet to see
data to support such a contention.

This is a very important connection for parents to be
aware of because I imagine that many providers fail
to inquire about this.  As a result, many children with
ADHD who experience such sleep difficulty may be missing
out on some much-needed help.

At the same time, however, one can not conclude from a
study such as this one that the reason for the greater
incidence of sleep disturbance in the children with
ADHD was the result of their taking stimulant medication.
It is just as possible that it was the ADHD itself, and not
the medication used to treat it, that was responsible for
the greater frequency of sleep difficulties.

Certainly, some children do experience adverse effects on
their sleep as a result of stimulant medication.  The
important point to keep in mind, however, is that this is
by no means true for every child.  Even in the current study,
if one assumes that it was the medication that was responsible
for the sleep problems in the ADHD participants, over 50% were
not experiencing any significant sleep problems according to
their parents.

What does this mean in terms of the day-to-day management of
a child with ADHD?  To me, it clearly indicates that if
there seem to be good reasons for a child to be on medication
in the afternoon (i.e., to assist with homework, behavior at
home, peer activities, etc.), one should not automatically
shy away from this based on the assumption that it will
impair the child's sleep. In the large, multi-site treatment
study of ADHD funded by the National Institute of Mental
Health, it was standard practice for children receiving
medication treatment to receive 3 doses of Ritalin per
day, with the last dose coming in the mid afternoon. (This
final dose was, however, generally half of what the
two earlier administrations had been).  Apparently, most
of the children were able to tolerate it well. One
can never really tell in advance how a particular child
will react, but if it makes good clinical sense to try,
talking with your doctor about a careful trial of
an after-school dose would be sensible.

* THE IMPACT THAT HAVING A CHILD WITH ADHD HAS ON
  PARENTS' SATISFACTION WITH FAMILY LIFE

During my years of working with children who have ADHD and
their parents, the level of stress that many families seemed
to experience was striking.  I have seen many parents who
felt incredibly burned out by the daily struggles around
behavior, homework, etc., and this was often compounded
by frustrations associated with trying to make certain that
their child's needs were getting adequately addressed at
school.  In many instances, I felt like one of the most
helpful services I - or any other mental health professional
could provide - was simply giving parents the opportunity
to discuss their struggles and frustrations. In the process,
we were sometimes able to help identify ways to manage these
frustrations more effectively, although this was not always
an easy task.

There is a very nice study that appeared in the November 98
issue of the "Journal of Attention Disorders"
that looks explicitly at how parents who have a child with
ADHD feel that things are going in their family (Kaplan, B.J.,
Crawford, S.G., Fisher, G.C., & Dewey, D.M. (1998). Family
dysfunction is more strngly associated with ADHD than with general
school problems.  Journal of Attention Disorders, Vol. 2(4), 209-216).

The authors of this study start with the premise that having a child who
is struggling in school is likely to create stress for parents,
and perhaps lead to problems with how parents feel that things
are going in the family.

They wondered, however, whether this differed depending on what
the reason for the child's school difficulties were.
Specifically, they wanted to learn whether having a child with
ADHD poses an additional challenge above and beyond the stresses
and difficulties encountered due to general school problems.

In order to evaluate this, the authors obtained information
on family functioning from parents whose children were having
difficulties at school for different reasons.  These included
49 parents whose child had a primary diagnosis of ADHD, 59
parents of children with a primary reading disability, 50 children
who had both ADHD and a reading disability, and 90 control children
who had neither type of difficulty.

Parents of these children completed a 12-item questionnaire
that had been derived from the McMaster Family Assessment
Device.  Each item was rated on a 4-point scale from
"Strongly Agree" to "Strongly Disagree". Examples of some of the
items that parents were asked to respond to are shown below.  :

"There are lots of bad feelings in the family."

"We don't get along well together."

"We are not able to make decisions on how to solve problems."

As can be gleaned from the examples above, parents reporting high
levels of agreement with these items were acknowledging higher
levels of  dissatisfaction with how things were going in their
family.  For all 4 groups of children, the parent who
responded to the questionnaire items was almost always the mother.
(This was not something the authors chose to do deliberately but
is simply how things worked out.)

The results of this study indicated that parents of children
with ADHD reported significantly higher levels of dissatisfaction
about family life than did mothers of children with a primary
reading disability.  What I found particularly interesting was
that even after the authors reanalyzed the data after removing
the children in the ADHD sample who also had been
diagnosed Oppositional Defiant Disorder, the results did not
change.  In other words, even for parents whose child with ADHD
did not have a serious co-occurring behavior disorder, significantly
greater dissatisfaction with how things were going in the family
was still reported.

There is no way of knowing with any certainly from this data
what the reasons for this higher level of dissatisfaction actually
was.  The authors note that although it could be a direct result
of having a child with ADHD, it could also reflect the fact
that parents of children with ADHD are more likely to have
ADHD themselves.  Thus, the mothers completed these forms could
have been expressing frustration they experienced as a result of
having a husband with ADHD in addition to frustrations brought
about by difficulties with their child.

From my own clinical experience, I believe that many different
explanations for this finding are possible and that no single
explanation is correct in all instances.  One thing I will say -
although let me be clear that this is based on clinical experience
and not on research data - is that with the parents I have worked
with, there often seemed to be real disagreement about the best way
to handle their child's difficulties.

For reasons that I won't even begin to speculate on, in many
couples it seemed that fathers were not willing or prepared
to accept a diagnosis of ADHD in their child, and were
unwilling to get involved in their child's treatment in a
supportive way.  In an unfortunate number of instances, they
were not even willing to allow treatment of any sort to proceed.
(Please understand that I have no intention of offending anyone
here and there are many couples who clearly work together to
help their child in a cooperative and supportive manner. I
sincerely hope that has been your experience.)

In contrast to this situation, I almost never saw this level of
disagreement in a child who had a reading disability.  In such
situations, parents seemed to invariably accept and understand
the nature of their child's difficulties, and were in agreement
about the help that needed to be obtained.  It is possible that
this experience was idiosyncratic to my own practice, but
from many conversations that I have had with colleagues, I
don't believe this is likely to have been the case.

Certainly, this type of disagreement could be one important
factor contributing to dissatisfaction with family life more
generally.  Regardless of the reasons for this, however, I
think the important implication of this study is the need
to recognize that their can be unique frustrations about
parenting a child with ADHD that can spill over to create
difficulties for an entire family. I found that parents
I worked with were often reluctant to bring these issues up,
perhaps because they were so focused on trying to attend
first and foremost to the problems experienced by their
child.

My experience has also been, however, that providing parents
with an opportunity to discuss the frustrations associated
with their child, and how this was affecting the entire family,
were often experienced as enormously helpful.  Thus, if you
have found yourself experiencing some of what the parents in
this study reported, I hope that it is helpful to recognize
that yours is by no means an isolated experience.  Perhaps
developing a way to address some of these issues may prove
to be useful to you as well, and that finding a good person
to discuss these issues with could be something to consider.
 

- READER QUESTION -

"What suggestions do you have for helping my child figure out
what to say  to children who ask him about the medication he takes?"

This is a really excellent question and an important issue for parents
to think about.  There is no doubt that children who take medication
for ADHD can be asked about this by peers and it can be difficult
for a child to know how to respond.   Unfortunately, this can be
something that a child gets teased about as well.  I know that this
has been an issue for some of the children I have worked with over
the years.  Helping a child develop ways that he or she feels comfortable
with for handling this type of situation is quite important.

Let me begin by saying there is no single, straightforward answer to
this question - at least not in my opinion.  I'm not trying to get off the
hook here, but how a child chooses to address this can depend on a
multitude of factors, including:
 

How does your child feel about being asked the question?

Is this something your child feels embarrassed about?  Does it make him or her
mad?  Or, is he or she comfortable with it?  Learning how your child feels
about this, as well as the reasons for those feelings can be quite important for
helping your child think through how to respond.  For example, if you learn that
your child feels very embarrassed about this, then helping him or her deal with
those feelings could be important to do before even considering the issue of
how to respond.

Who is asking the question?
 

There are a number of other factors that one could add to this list, but I think you
get my main point which is that there can be a multitude of ways for a child to
handle a situation like this.

This being said, I think a really important role that parents can take here is to
help their child think through the different issues involved, the different ways
he or she might respond, and how he or she feels about the different alternatives.

In other words, one can really apply the social problem solving model described
above to a situation like this.  As a parent, one can help their child learn to be
more skillful at handling issues like this by helping him or her to think the
situation through.  Questions such as:

"Why do you think the person asked?"

This will help you to learn what your child's interpretation is of the motivation
behind the question - e.g., Is it genuine curiosity and interest or do they infer some
type of hurtful intent?

"What are some different kinds of answers you might be able to give?"

This is a great way to help your child recognize that there are different ways one
can choose to respond in a situation like this and to develop the recognition that
this characterizes many social situations.  Brain storming with your child about
different responses will help you to learn about your child's ability to generate
alternative strategies while simultaneously giving them practice with this
important skill.

"What do you think would happen if you said..."

After generating different possibilities you can help  your child learn to think
through the consequences of different actions.  In learning about the types of
consequences your child anticipates for the different strategies you have both
come up with you can get an important insight into how he or she thinks about
their peer interactions.  You'll also have the opportunity to engage your child
in a discussion about the reasons for anticipating certain consequences and
how reasonable your child's thinking seems to be.

I hope the above doesn't come across too much like a psychologist making
a big deal about a simple question.  For some children, this really would
be a simple question that would be easy and comfortable for them to
deal with.  For other children, however, this would not be the case. (On an amusing note, probably
the most original response I have heard to this type of question was from a fiesty
8 year-old I was seeing who used to tell kids that he needed the pills to help control his gas.)

I guess the main point I am trying to make is that rather than focusing on
"What should I tell my child to say?" one can also think about this as an
opportunity to help your child think through the different factors to take
into account, the different ways one could handle a situation like this, and
the reasons for favoring one option over another.

In approaching things in this way, you can be helping your child develop the
skills that he or she needs to deal more effectively with all types of situations.
As an added benefit, having this kind of discussion with your child can go a long
way to building a closer relationship characterized by excellent communication.

 One more thing...

One other important point related to this general
issue about children being asked about their medication. At
some point, it is certainly possible that your child, or a child
that you treat, may be approached to either sell or
share medication.

Ideally, this would never be possible because
all medication should be stored in a locked cabinet at a
child's school to be dispensed only by the designated person at
the school. At home, the medication should be under parental
supervision so a child could not take pills to school.

Unfortunately, such a thing can and does occur
- how frequently, no one really knows. In any event, you
would want to clearly go over this possibility with your
child and make sure that he/she is aware that this should never
be done under any circumstances. They should also be
aware that violating this rule would get both them and the other
child into serious trouble.

That's all for this month...

I hope you enjoyed this issue of ADHD RESEARCH UPDATE and found it
to be informative.  Please feel free to share information in this issue with
others you know who may be interested in it.

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I hope things are going well for you.
 

Sincerely,
 

David Rabiner, PhD
Licensed Psychologist

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