CHAPTER FOUR: ADHD - EFFECT ON FAMILY LIFE AND
TREATMENT OPTIONS
interaction patterns with their mothers. Such research found that medication improves the compliance of those with ADHD and reduces their negative, talkative and generally excessive behaviour such that their parents reduce their levels of directive and negative behaviour as well (Barkley & Cunningham, 1979; Barkley, Cunningham & Karlsson, 1983; Danforth et al., 1991; Humphries, Kinsbourne &
Swanson, 1978). These medication effects are noted even in the preschool age group of children with ADHD (Barkley, 1988b) as well as those in late childhood (Barkley, Karlsson, Pollard & Murphy, 1985) and in both sexes of ADHD children (Barkley, 1989). Besides a general reduction in the negative, disruptive, and conflictual interaction patterns of these children with parents resulting from stimulant medication, general family functioning also seems to improve when ADHD children are treated with stimulant medication (Schachar, Taylor, Weiselberg, Thorley &
Rutter, 1987).
The interaction conflicts in families with ADHD children are not limited only to parent- child interactions. Increased conflicts have been observed between ADHD children and their siblings relative to normal child-sibling dyads (Mash & Johnston, 1983;
Taylor, Sandberg, Thorley & Giles, 1991). These patterns of disruptive, intrusive, excessive, negative and emotional social interactions of ADHD children have also been found to occur in their interaction with teachers (Whalen et al., 1980). Like the interactions of ADHD children with their parents, the interactions of these children with their teachers have also been shown to be significantly improved by administration of stimulant medication (Whalen et al., 1980).
Interestingly, ADHD children appear to be more compliant and less disruptive with their fathers than their mothers (Tallmadge & Barkley, 1983). According to Tallmadge and Barkley, there are several possible reasons for this. For one, mothers are still the primary custodians of children within the family, even when they are employed outside the home, and may, therefore, be the ones who are most likely to tax or exceed the child’s limitations in the areas of persistence of attention, activity regulation, impulse control, and rule-governed behaviour. Getting children to do chores and schoolwork, perform self-care routines, and control their behaviour in public remain predominantly maternal responsibilities; thus mothers may be more likely to witness ADHD symptoms than are fathers. Another reason may be that mothers and fathers tend to respond to inappropriate child behaviour somewhat differently. Mothers may be more likely to reason with children, repeat their instructions, and use affection as a means of governing child compliance. Fathers
seem to repeat their commands less, to reason less, and to be quicker to discipline children for misconduct or non-compliance. The larger size of fathers and their consequently greater strength may also be perceived as more threatening by children and hence more likely to elicit compliance to commands given by fathers.
Research demonstrates that mother-child conflicts may result in increased father- child conflict when mothers and fathers interact jointly with their hyperactive children, especially hyperactive boys (Buhrmester, Camparo, Christensen, Gonzalez &
Hinshaw, 1992). These negative parent-child interaction patterns occur in the preschool age group (Cohen, Sullivan, Minde, Novak & Keens, 1983) and may be at their most negative and stressful (to the parent) in this age range (Mash & Johnston, 1982, 1990). With increasing age, the degree of conflict in these interactions lessens, but remains deviant from normal into later childhood (Barkley, Karlsson & Pollard, 1985; Mash & Johnston, 1982) and adolescence (Barkley, Anastopoulos, Guevremont & Fletcher, 1992; Barkley, Fischer, Edelbrock & Smallish, 1991).
Negative parent-child interactions in childhood have been observed to be significantly predictive of continuing parent-child conflicts 8 to 10 years later in adolescence in families with ADHD children (Barkley, Fischer et al., 1991).
Important in this line of family research has been the discovery that it is the presence of comorbid Oppositional Defiant Disorder (ODD) that is associated with most of the conflicts noted in the mother-child interactions of ADHD children and adolescents (Barkley, Anastopoulos et al., 1992; Barkley, Fischer et al., 1991). In a sequential analysis of these parent-teen interaction sequences, investigators have noted that it is the immediate or first lag in the sequence that is most important in determining the behaviour of the other member of the dyad (Fletcher, Fischer, Barkley & Smallish, 1996). That is, the behaviour of each member is determined mainly by the immediately preceding behaviour of the other member and not by earlier behaviours of either member in the chain of interactions. The interactions of the comorbid ADHD/ODD group reflected a strategy best characterised as “tit for tat” in that the type of behaviour (positive, neutral or negative) of each member was most influenced by the same type of behaviour emitted preceding it. Mothers of ADHD only and normal teens were more likely to utilise positive and neutral behaviours regardless of the immediately preceding behaviour of their teens, characterised as a “be nice and forgive” strategy that is thought to be more mature and more socially successful for both parties in the long run (Fletcher et al., 1996). Even so, those with ADHD alone are still found to be deviant from normal in these interaction patterns even though
less so than the comorbid ADHD/ODD group. The presence of comorbid ODD has also been shown to be associated with greater maternal stress and psychopathology as well as marital difficulties (Barkley, Anastopoulos et al., 1992; Barkley, Fischer et al., 1991). Yet parents of ADHD children, more than parents of normal children, appear to sense that the disruptive behaviour children is internally rather than externally caused, less controllable by the child, and more stable over development (Johnston & Freeman, 1997). In contrast, they evaluate the pro-social behaviour of their ADHD children as less internal and less stable than do control parents.
4.1.2 Family functioning
Research on the larger domain of family functioning has also shown that parents of children with ADHD children commonly experience considerable stress in their parenting roles (Anastopoulos, Guevremont, Shelton, & DuPaul, 1992; Fischer, 1990). Moreover, they often view themselves as less skilled and less knowledgeable as parents, and derive less value and comfort from their parenting efforts (Mash &
Johnston, 1983). Parents of ADHD children are also at increased risk for increased alcohol consumption (Cunningham, Bennes & Siegel, 1988; Pelham & Lang, 1993).
Pelham and Lang (1993) have shown that the increased alcohol consumption of these parents is, in part, directly a function of the stressful interactions they have with their ADHD children.
Decreased extended family contacts are also noted in families with an ADHD child (Cunningham et al., 1988). Parents may feel blamed for their children’s behaviour by extended family members. Conflicting understandings of ADHD and its treatment may further isolate parents from their families, who might otherwise be a source of support (Alexander-Roberts, 1995). Increased marital conflict, separations, and divorce, as well as maternal depression is also prominent in parents of ADHD children (Befera & Barkley, 1984; Barkley, Fischer et al., 1990; Cunningham et al., 1988; Lahey, Piacentini, McBurnett, Stone, Hartdagen & Hynd, 1988; Taylor et al., 1991).
Again, the comorbid association of ADHD with ODD, or its later stage of Conduct Disorder (CD), is linked to even greater degrees of parenting stress, parental psychopathology, marital discord, and divorce than in ADHD-only children (Barkley, Fischer et al., 1990; Barkley, Fischer et al., 1991; Johnston, 1996; Lahey, Piacentini, et al., 1988; Taylor et al., 1991).
4.1.3 Peer relations
Pelham and Bender (1982) once estimated that more than 50% of ADHD children have significant problems in social relationships with other children. Mothers (Campbell & Paulauskas, 1979), teachers (Barkley, DuPaul & McMurray, 1990), and peers (Johnston, Pelham & Murphy, 1985; Pope, Bierman & Mumma, 1989) find hyperactive children to be significantly more aggressive, disruptive, domineering, intrusive, noisy and socially rejected in their social relations than normal children, especially if they are male hyperactives, and particularly if they are aggressive (Hinshaw & Melnick, 1995; Milich, Landau, Kilby & Whitten, 1982; Pelham & Bender, 1982).
Studies that have directly observed these peer interactions suggest that the inattentive, disruptive, off-task, immature, provocative, aggressive and non-compliant behaviours of ADHD children quickly elicit a pattern of controlling and directive behaviour from their peers when they must work together (Clark, Cheyne, Cunningham & Siegel, 1988; Cunningham & Siegel, 1987; Hinshaw, 1992; Hinshaw
& Melnick, 1995; Whalen, Henker, Collins, Finck & Dotemoto, 1979; Whalen, Henker, Collins, McAuliffe & Vaux, 1979). There also seems to be a tendency for ADHD children to accept other ADHD children as playmates more than do normal children (Hinshaw & Melnick, 1995). In their communication patterns, ADHD children in these studies have been found to talk more, but to be less efficient in organizing and communicating information to peers with whom they are asked to work. Moreover, despite talking more, the ADHD children are less likely to respond to the questions or verbal interaction of their peers. Hence, there is clearly less reciprocity in the social exchanges of hyperactive children with their peers (Cunningham & Siegel, 1987;
Landau & Milich, 1988). ADHD children have also been shown to have less knowledge about social skills and appropriate behaviour with others (Grenell, Glass
& Katz, 1987). Among ADHD children, those who are the most sensation seeking, emotionally reactive, aggressive, and non-compliant received the greatest disapproval from their peers (Hinshaw & Melnick, 1995).
Those ADHD children who are also aggressive may display an additional tendency to over-interpret the actions of others toward them as having hostile intentions and are, therefore, likely to respond with aggressive counterattacks over minimal, if any, provocation (Milich & Dodge, 1984). Such communication problems, skills deficits, attribution biases, and interaction conflicts could easily lead to the ADHD children, especially those who are aggressive, being rejected as playmates by their
classmates and neighbourhood peers in very short order. Many have noted that it takes few social exchanges over a period of only 20 to 30 minutes between ADHD and normal children for normal children to find the ADHD children disruptive, unpredictable and aggressive and hence to react to them with aversion, criticism, and rejection, and sometimes even counter-aggression. Certainly they are likely to withdraw from the ADHD child when opportunities to do so arise (Milich et al., 1982;
Pelham & Bender, 1982; Pelham & Milich, 1984).