NASET ADHD SERIES
By
By Monika Lopez
This issue of NASET’s ADHD series was written by Monika Lopez. Attention-Deficit/Hyperactivity Disorder (ADHD) is a mental health disorder that has affected children, adolescents, and adults worldwide. Characterized by behavioral and social-emotional impediments and impairments, ADHD presents challenges for both the diagnosed individual and family members living alongside them. Family life becomes negatively impacted when children or adolescents are diagnosed with ADHD. Significant measures of impulsivity cause behavioral outbursts (tantrums) for children and adolescents with ADHD. As a result, there is a significant impact on the social-emotional wellbeing of the diagnosed individual, parents/caregivers, siblings, and other family members who live in the same home or spend a considerable amount of time participant of the behavioral management of these ADHD-typical responses. Additional implications like parent-child relationships, sibling relationships, family social life, and marital life are negatively impacted. Families must take special consideration into the parenting styles and communicative approaches to which they are handling the behavioral management of their children or adolescents. Above all, family resilience is a critical component of effective behavioral management and is impactful towards positive family life.
Abstract
Attention-Deficit/Hyperactivity Disorder (ADHD) is a mental health disorder that has affected children, adolescents, and adults worldwide. Characterized by behavioral and social-emotional impediments and impairments, ADHD presents challenges for both the diagnosed individual and family members living alongside them. Family life becomes negatively impacted when children or adolescents are diagnosed with ADHD. Significant measures of impulsivity cause behavioral outbursts (tantrums) for children and adolescents with ADHD. As a result, there is a significant impact on the social-emotional wellbeing of the diagnosed individual, parents/caregivers, siblings, and other family members who live in the same home or spend a considerable amount of time participant of the behavioral management of these ADHD-typical responses. Additional implications like parent-child relationships, sibling relationships, family social life, and marital life are negatively impacted. Families must take special consideration into the parenting styles and communicative approaches to which they are handling the behavioral management of their children or adolescents. Above all, family resilience is a critical component of effective behavioral management and is impactful towards positive family life.
Keywords: Attention-Deficit/Hyperactivity Disorder (ADHD), Family Life, Behavioral Management, Social-Emotional Wellbeing
Introduction
Attention-Deficit/Hyperactivity Disorder (ADHD) is a mental health disorder that is characterized by severe behavioral measures of inattentiveness, hyperactivity, and impulsivity. Individuals that are impacted by and diagnosed with ADHD generally demonstrate significant impediment in behavioral and social-emotional health domains. Due to the increased measures of inattentiveness, hyperactivity, and impulsivity, individuals with Attention-Deficit/Hyperactivity Disorder experience hardship with prosocial behavioral management and exhibition. Thus, social-emotional health (e.g., self-esteem, self-concept, self-regulation) suffers and presents other impediments like academic achievement and peer relationship building. Considering ADHD’s associative behavioral and social-emotional impediments, its impact on family life should be investigated.
Familial influences are an integral component of a child and adolescent’s daily behavioral management. A parents’/caregivers’ state of mental health, resulting stress level management, parenting styles, and adherence to ADHD-focused interventions all influence the quality of life within the home setting, and as a result, influence a child or adolescent with ADHD’s responsiveness to treatment. Furthermore, other familial influences such as sibling relationships and measurements of family resilience affect a child or adolescent’s daily behavioral and social-emotional responses. Eric Bronfenbrenner’s Ecological Systems Theory illustrates how family members encompass an individual’s Microsystem, or closest network of environmental influences. This theory, alongside the familial influences noted, therefore, support the need for further exploration into who, what, and how, family members and family life affect children and adolescents with ADHD.
The following literature review will assess various familial life factors that have been widely contributive to children and adolescents’ daily experiences with ADHD-specific behavioral criteria (e.g., inattentiveness, hyperactivity, impulsivity, and resulting diagnoses). It is integral that parents/caregivers of children and adolescents with ADHD are constantly aware of their behaviors, attitudes, and communicative approaches. Moreover, parents/caregivers should conceptualize any Attention-Deficit/Hyperactivity Disorder (ADHD)-specific treatment as a collective effort amongst themselves, clinicians, school and mental health practitioners, and most importantly, the child or adolescent themselves. Existing influences and efforts that family members should keep into consideration when raising children and adolescents with ADHD diagnoses are explored.
Literature Review
Attention-Deficit/Hyperactivity Disorder (ADHD) is a widely referenced diagnosis. Alongside clinician-appointed diagnoses, Likert-Rating Scales surveys are completed by parents/caregivers and educators to either support or disagree with ADHD identification. There is, however, an existing discrepancy in the ADHD prevalence rate for children in the United States. Song et al. (2019) analyzed the data collected throughout the 2007-2012 National Survey of Children’s Health (NSCH) and found that parent self-reporting surveys could contribute to NSCH’s 80% documentation of “Definite” ADHD behaviors, thereby suggesting an overreporting and overrepresentation of ADHD prevalence. Parents’ overreporting and overrepresentation of ADHD prevalence lends to a discussion of how parents/caregivers acknowledge their child’s or adolescent’s behavioral diagnosis. Such considerations are critical to the efforts and approaches made toward consultation and treatment. Thus, the influential power of these parents’ or caregivers’ parenting styles are assessed and are done so in respect to its impact on family life (Munoz-Silva et al., 2017).
ADHD-typical behaviors create a great challenge for parents, as frequency and duration measures of behavioral outbursts (i.e., tantrums, acts of impulsivity) could present significant barriers to the parent-child relationship. Munoz-Silva et al. (2017) presents a study that examines how much a child (6-11 years of age) with an ADHD diagnosis impacts family life and particularly, parenting styles. Parents or caregivers of children with ADHD normatively engage in either one of the two parenting styles: Authoritarian or Permissiveness (Munoz-Silva et al., 2017). Therefore, parents either become discipline enforcers and transmit a sense of “criticism” by means of high expectations (criticism-rejection), or practice friendly parenting and demonstrate “permissive” behaviors such as significant acts of love and care, and not as much discipline-related demands (permissiveness-indulgence) (Munoz-Silva et al., 2017). To assess the effects of children’s ADHD behavioral patterns on family life, both Criticism-rejection and Permissiveness-indulgence parenting styles were analyzed with respect to the parents’ marital relationship, the parents’ feelings toward their children, and family social life (Munoz-Silva et al., 2017). Results indicated an existing bidirectional relationship amongst ADHD behavioral impacts on family life. Furthermore, with each of the variables assessed (e.g., parents’ marital relationship, parents’ feelings toward their children, family social life) there was a mediating effect amongst the two parenting styles (Munoz-Silva et al., 2017). The two parenting styles were, therefore, strongly associated with the children’s behavior within family life.
While the three variables (e.g., parents’ marital relationship, parents’ feelings toward their children, family social life) were clear indicators of the children’s behaviors within the Criticism-rejection parenting style, child behavior problems were observed as a critical indicator within marital relations when Permissiveness-indulgence parenting styles were practiced (Munoz-Silva et al., 2017). Thus, it was concluded that child behavior problems and family life variables, e.g., parents’ marital relationship, the parents’ feelings toward their children, family social life bidirectionally influence one another. Moreover, regardless of parenting style, instrumental support is a positive influence on family life. For instance, having a familial support system could generate a positive home environment and thereby influence parents and caregivers to partake in positive parenting practices, so that children with significant behavioral impediments or impairments do not have to experience negative social encounters in addition to what they may experience outside of the home. If children with ADHD are constantly positively reinforced and provided with effective parenting practices, family life variables such as stress measures, will not be negatively impacted. Moreover, a child or adolescent with ADHD’s social and emotional impairment will be less likely when effective parenting styles are utilized, and family life stressors are reduced.
ADHD’s Social & Emotional Impact on Family Life
Wehmeier et al. (2010) differentiates between social impairments (e.g., social impairment within the family, social impairment with peers), and emotional impairments (e.g., emotion dysregulation inherent within ADHD disorder, comorbidity with other psychiatric disorders, secondary emotional consequences from environment), all of which are associated with ADHD. Due to ADHD’s disruptive and impulsive characteristic behaviors, emotional stresses are more likely to impact familial relationships. For instance, social gatherings are less attainable for families with children who engage in frequent behavioral tantrums or an adolescent who reacts aggressively or is hostile toward a parent when a command or request is given (Wehmeier et al., 2010). Emotional stressors result when parents’/caregivers’ are increasingly involved throughout the implementation of their child or adolescent’s behavioral intervention plans, medication treatment plans, and self-regulation practices (e.g., self-esteem, self-concept, identity formation). Munoz-Silva et al. (2017) identifies the major influential predictors that contribute to parental stress: child/adolescent ADHD conduct problems, child/adolescent ADHD severity measures, child/adolescent existing emotional health (emotional dysregulation), parental/caregiver marital and social life, social support from extended family members or peers. After assessing the mediation effects of parental stress factors, it was clear that parents of children with ADHD severities (significant behavioral/social emotional impediments or impairments), experience stressors like regression of family social life and family togetherness (Munoz-Silva et al., 2017). Preceding stresses concerning how a child with severe behavior tantrums or adolescent with severe aggression and impulsive behaviors is going to behave at a family outing or social event significantly impacts a family’s quality of life.
Limbers et al. (2011) explains how ADHD’s associated social and emotional impairments and mediated stresses are not solely conclusive to parent or caregiver relationships, but with siblings as well, thereby supporting Munoz-Silva et al.’s (2017) finding of decreased family togetherness. Due to the stressful and social-emotional impact of ADHD behavioral patterns, sibling conflict is more likely to arise (Davis et al., 2012). To further illustrate the impact of ADHD on family life, families were given the opportunity to provide their perspectives on these researched participating effects. When families were interviewed, parental stressors and social-emotional and mental health-related impacts were emphasized. These families’ active participation and contribution to the study extended ADHD’s negative impact on family life. Davis et al. (2012) notes that 39% of families expressed worries that ADHD’s causal family life stresses would in turn, cause them to have their own emotional or mental health difficulties or impediments (i.e., anxiety). A family-centered or conjoint model of family and child/adolescent intervention is suggested for prosocial family life outcomes.
Family-Centered Programs & Practices
Shared decision-making amongst family members, mental health and school professionals, and the child or adolescent themselves (with the appropriate age and skill set) is critical within an ADHD intervention model or plan (David et al., 2012). To be most effective, a child or adolescent’s behavioral or social-emotional impairment should be treated alongside the consideration of family-oriented ideals, practices, and home applications. A conjoint, family-based model of intervention is beneficial to both a child or adolescent’s behavioral and social-emotional needs, as well as family life variables (e.g., parent stress, mental health, parent-child/adolescent relationship). The outcomes of the Collaborative Life Skills Program (CLS), a psychosocial intervention program that treats both behavioral and social-emotional impediments and that has been utilized within ADHD treatment, is explored (Villodas et al., 2014). When 57 school-age students (with an existing ADHD diagnosis) were provided with the CLS program, statistically significant improvement was observed in the children’s classroom behaviors (Villodas et al., 2014). To extend this program’s effect, parents/caregivers were asked to extend it into the home setting, and a large effect size (75%) was observed for “parent self-reporting scores” when child problem behaviors were assessed with respect to improvement (Villodas et al., 2014). The prosocial results of this collaborative intervention framework illustrate the positive impacts that such frameworks place on family life variables.
Family stressors are mitigated by family resilience (Uddin et al., 2020). A great practice of family resilience foreshadows a positive and reinforcing environment for children and adolescents with an existing ADHD diagnosis. Furthermore, Uddin et al. (2020) suggests that family resilience is a contributive factor to improved familial relationships. If family members institute a home environment that is positive, reinforcing, and resilient to behavioral management, ADHD’s characteristic behaviors are less likely to have a negative impact on family life. Therefore, it is important to constantly assess a child or adolescent’s quality of life, as it is impactful and suggestive to daily behavioral patterns. From programs that constitute behavioral, psychosocial, or medicinal treatments, to conjoint (Parent-School Professional) models of therapeutic intervention and consultation, all intervention plans influence a child or adolescent’s quality of life to differentiated degrees. It is critical that families provide these professionals with “real life” expectations so that a successful replication of taught behaviors and social-emotional responses are generalized and contributive to a prosocial quality of life. A prosocial quality of life is not beneficial to solely the child or adolescent but also to the family members who provide them with the necessary social-emotional support (i.e., self-regulation) when disruptive behavioral patterns are likely to occur.
Limbers et al. (2011) emphasizes the importance and severity of children’s health-related quality of life (HRQOL). Depending on the treatment program implemented, treatment effects vary. Parents/caregivers observe firsthand how positively, or negatively impactful a treatment program’s effects are on their child’s maladaptive behavioral and social-emotional patterns, thereby leading to an impact on quality of life. For instance, when parents/caregivers were asked to compare their child’s ADHD treatment by means of either a General Pediatric Clinic or Psychiatric Clinic, parents/caregivers observed that a General Pediatric Clinic’s services created a significantly better HRQOL for not only ADHD treatment but family life (Limbers et al., 2011). In accordance with this research, parents/caregivers associate intervention programs that implement behavioral and psychosocial evidence-based practices (EBP’s) with a social-emotionally healthier quality of life for both ADHD treatment and family life variables.
Family Life & ADHD
For families with children or adolescents who have an existing ADHD diagnosis, family life is likely to be negatively impacted. Parent/caregiver stress, social-emotional/mental health declination, sibling conflict, marital relationship hardships, parenting styles, and social activity engagement all deter family togetherness. However, alongside appropriate treatment programs that mediate ADHD treatment and family life variables, family resilience is reinforced. Family resilience promotes a lesser impact on family life and significant health-related quality of life (HRQOL) for both the child or adolescent and family. Attention-Deficit/Hyperactivity Disorder (ADHD) may be greatly impactful on family life but as the research suggests, there are resources within the mental health and educational community that could help mitigate the causal stressors.
References
Davis, C.C., Claudius, M., Palinkas, L.A., Wong, J.B., & Leslie, L.K. (2012). Putting families in the center: Family perspectives on decision making and ADHD and implications for ADHD care. Journal of Attention Disorders, 16(8), 675-684. doi: 10.1177/1087054711413077
Limbers, C.A., Ripperger-Suhler, J., Boutton, K., Ransom, D., & Varni, J.W. (2011). A comparative analysis of health-related quality of life and family impact between children with ADHD treated in a general pediatric clinic and a psychiatric clinic utilizing the PedsQL. Journal of Attention Disorders, 15(5), 392-402. doi: 10.1177/1087054709356191
Munoz-Silva, A., Lago-Urbano, R., & Sanchez-Garcia, M. (2017). Family impact and parenting styles in families of children with ADHD. Journal of Child and Family Studies, 26(10), 2810-2823. doi: 10. 1007/s10826-017-0798-1
Munoz-Silva, A., Lago-Urbano, R., Sanchez-Garcia, M., & Carmona-Marquez, J. (2017). Child/Adolescent’s ADHD and parenting stress: The mediating role of family impact and conduct problems. Frontiers in Psychology, 8(2252). doi: 10.3389/fpsyg.2017.02252
Song, M., Dieckmann, N.F., & Nigg, J.T. (2019). Addressing discrepancies between ADHD prevalence and case identification estimates among U.S. children utilizing NSCH 2007-2012. Journal of Attention Disorders, 23(4), 1691-1702. doi: 10.1177/1087054718799930
Uddin, J., Alharbi, N., Uddin, H., Hossain, M.B., Hatipoglu, S.S., Long, D.L., & Carson, A.P. (2020). Parenting stress and family resilience affect the association of adverse childhood experiences with children’s mental health and attention-deficit/hyperactivity disorder. Journal of Affective Disorders, 272, 104-109. doi: 10.1016/j.jad.2020.03.132
Villodas, M.T., McBurnett, K., Kaiser, N., Rooney, M., & Pfiffner, L.J. (2014). Additive effects of parent adherence on social and behavioral outcomes of a collaborative school-home behavioral intervention for ADHD. Child Psychiatry and Human Development, 45(3), 348-360. doi: 10.1007/s10578-013-0405-7
Wehmeier, P.M., Schacht, A., & Barkley, R.A. (2010). Social and emotional impairment in children and adolescents with ADHD and the impact on quality of life. Journal of Adolescent Health, 46(3), 209-217. doi: 10.1016/j.jadohealth.2009.09.009
