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Section 21
How ADD Affects the Family

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Families with a child who has attention deficit disorder (ADD) are confronted with many developmental, educational, social, and behavioral challenges. ADD symptoms often cause all family members, including siblings, to experience pressures and stresses far beyond those found in families in which ADD 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 ADD, principles applicable to families with a child who has ADD, effects of ADD on family interactions, counseling, and a multidimensional treatment approach. ADD can influence a child’s behavioral, emotional, and social adjustment (Kelly & Aylward). Henggler and Borduin concluded that there is considerable evidence that ADD 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 ADD 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 ADD (Brown & Pacini). The dynamics of the family that has a child with ADD will undergo pressures and stresses that are outside the realm created by normal developmental problems. Children with ADD 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 ADD, 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 ADD 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 ADD 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 ADD and temperament overlap considerably. Therapists need to realize that ADD should not be mistaken for an individual entity that affects only the client. ADD symptoms affect all family members. Furthermore, it is not unusual for ADD to be unrecognized, diagnosed incorrectly, undiagnosed, or treated inappropriately by mental health professionals. For example, families torn by ADD rarely work well (Hallowell & Ratey). Simply stated, the reality of ADD causes myriad problems for both the affected child and the child’s family. Some families have fallen apart or disintegrated, never knowing that ADD afflicted their child and contributed to persistent negative family interactions.

Principles Applicable To Families Affected By ADD
The first and most important principle is that the family usually attempts to cope with ADD 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 ADD to remain undetected and undiagnosed. It seems that many children with ADD 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 ADD affects all areas of family functioning (O’Brien). The relationships the child with ADD has within the family may abound with stress and eventually become impaired. Parents of a child with ADD 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 ADD. The disorder continually invades and disrupts most areas of the family’s existence or interpersonal functioning.

The third principle is that the child with ADD 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 ADD 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 ADD usually is incapable of coping with elevated levels of stress or anxiety. Therefore, parent and sibling responses to the behavior of the child with ADD can either aggravate or improve the child’s condition (Popper).

The fourth principle, based on my experience, is that children with ADD exist in a synchronous (and circular) relationship with their families and schools. Unfortunately for children with ADD, 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 ADD. Mental health therapists need to be aware that the problems experienced by children with ADD 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 ADD 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 ADD. 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 ADD.

How Attention Deficit Disorder Affects Family Functioning
In essence, children with ADD initiate a dysfunctional system of interactions within their families. Having a child with ADD in the family predisposes all members toward a higher degree of conflict than is found in families without a child who has ADD. Families that have a child with ADD 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 ADD and their parents and siblings, (b) how children with ADD affect their parents, and (c) the signs of family interaction problems that can be present in families with children who have ADD.

Social-Familial Context: Barkley pointed out the following reasons for the importance of the social-familial context in understanding the interactions between children with ADD and their parents and siblings. First, the social interactions of children with ADD 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 ADD. These interactions are inherently more negative and stressful to all family members. Second, evidence abounds that parents and siblings of children with ADD 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 ADD. The high level of psychological distress affects the management and rearing of children with ADD 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 ADD 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 ADD, although some family therapists or clinicians spend an inordinate amount of time exploring this possibility. In ADD cases, all family problems cannot be reduced to parenting problems (Emery, et al.).

Influence of the Child With ADD on Parents The influence of children with ADD 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, ADD 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 ADD 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 ADD 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 ADD if interventions are founded on it. The interaction patterns of children with ADD 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 ADD does. To parents, children with ADD 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 ADD (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 ADD are often made out of frustration or anger. Children or adolescents with ADD 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 ADD: (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 ADD, 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 ADD and there could be undiagnosed siblings with ADD. 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 ADD 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 ADD. Family counseling becomes a viable intervention once all of the implications of ADD to family functioning are sufficiently understood.
- Erk, Robert R; Multidimensional treatment of attention deficit disorder: A family oriented approach; Journal of Mental Health Counseling; Jan97, Vol. 19 Issue 1, p3

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Personal Reflection Exercise #7
The preceding section contained information about how ADD affects the family.  Write three case study examples regarding how you might use the content of this section in your practice.

QUESTION 21
According to Erk, what are the four principles to consider when evaluating the family of a child with ADD? Record the letter of the correct answer the Answer Booklet.