Tuesday, November 29, 2011

"Daily Distress in Moms of Children with ADHD"

This article was written by David Rabiner, Ph.D, and accessed from http://www.helpforadd.com/2011/november.htm

Daily Distress in Moms of Children with ADHD

Parents of children with ADHD have been found to experience elevated levels of parenting stress and distress in multiple studies. This is not surprising given the greater challenges associated with raising a child who consistently exhibits high levels of ADHD symptoms.

Studies of child ADHD and parenting stress have typically relied on global and static measures of both children's behavioral problems, e.g., having parents complete rating scales and parents' reports of stress/distress. Correlating these reports provides useful information on how children's ADHD symptoms relate to parents' average distress level, but say little about the moment-to-moment fluctuations in parents' stress that may occur in response to fluctuations in their child's behavior. This dynamic aspect of the parent child relationship can only be captured by relating parents' stress to children's behavior as it occurs in real time.

Examining the ebb and flow of parents' distress in relation to children's behavior was the focus of an interesting study published recently in the Journal of Family Psychology [Whalen et al., (2011). Dissecting daily distress in mothers of children with ADHD: An electronic diary study. Journal of Family Psychology, 25, 402-411. Participants were 51 8- to 12-year old children with ADHD and their mothers (about 70% boys) and 58 comparison dyads where the child did not have ADHD. The authors had intended to include fathers but were unable to recruit a sufficient number. All children with ADHD were being treated with a long acting medication during the study and were reported by their mothers to be doing well on medication.

Over a 7-day period during nonschool hours, mothers and children rated their moods and behavior using Personal Digital Assistants, i.e., PDAs, roughly every thirty minutes when prompted by a beep from the device. Each time the beep occurred, mothers rated the child's level of attention/concentration, hyperactive-impulsive behavior, and oppositional behavior. They also rated how stressed, worried, worried about their child, and sad they were feeling in the moment. These ratings were averaged to obtain a measure of moms' overall distress at each recording point.

Children used their eDiary device to rate their mood and behavior by indicating how angry, restless, impatient, and focused they were feeling each time they were prompted.

Moms and children were instructed to completed their diaries independently and privately without consulting each other so as not to influence one another's ratings. Compliance was excellent with mothers and children in the ADHD and comparison group completing ratings at over 90% of the prompts. Thus, researchers were able to obtain data that provided an especially fine-grained look at how mothers' distress varied directly in relation to children's behavior over the course of a typical week.

Additional Measures

The researchers also obtained measure of 'maternal risk' at baseline using a composite of mothers' self-reported ADHD symptoms, depression, and the intensity of child-related stressors that she experienced during the prior 6 months. Obtaining an estimate of maternal risk at baseline enabled the researchers to test whether mothers at higher risk were more negatively reactive to their child's behavior in the moment.


Baseline characteristics of mothers

Not surprisingly, baseline risk scores were substantially higher in mothers of children with ADHD compared to other mothers. These mothers were more depressed, reported more ADHD behaviors in themselves, and were experiencing significantly greater stress related to their children.

Question 1: Do ongoing child behaviors and maternal distress fluctuate together?

As expected, the answer to this question was clearly yes. In both groups of mothers, elevated levels of distress were reported during times when the mother perceived her child to be hyperactive, oppositional, or lacking in concentration. Similarly, maternal distress was higher when the child reported him or herself to be angry, impatient, or restless.

Question 2: Are mothers of children with ADHD more reactive to their child's negative behaviors?

Again, the answer was yes. The increase in maternal distress reported by moms whose child had ADHD was significantly greater when the child displayed negative behaviors/moods compared to the other mothers. Thus, even though distress increased during these times for all mothers, distress levels in moms in the ADHD group were negatively affected to a greater degree.

Question 3: Is the link between negative child behavior and maternal distress stronger in moms at higher risk?

The answer to this question was also clearly yes. Moms with higher baseline scores on the risk index reported greater increases in distress when their child displayed negative behaviors than did moms with lower risk scores. This was true for both groups of moms but recall that moms of children with ADHD had substantially higher risk scores to begin with. Thus, this was especially problematic for these mothers.

Summary and Implications

Results from this study go beyond prior research demonstrating that mothers of children with ADHD have higher parenting stress by documenting how this association operates during the ebb and flow of daily life. When children display negative behaviors or mood states, e.g. oppositional behavior, hyperactivity, anger, mothers' distress level increases significantly. And, these increases are greater in moms whose child has ADHD and who report higher rates of ADHD symptoms, depression and child-related stress to begin with. These moms appear to be especially sensitive to negative behaviors in their child and are prone to respond by experiencing increasing distress.

Results from this study have several important implications. First, the higher baseline risk scores in mothers from the ADHD group, and the greater reactivity of these moms to their child's behavior, highlights the importance of recognizing the impact that ADHD can have on parents and of providing parents with necessary treatment and support. Too often, children themselves are the sole focus of ADHD treatment and important issues that parents are struggling with do not receive sufficient attention.

Second, these findings highlight the particular struggles that mothers experience dealing effectively with the negative behaviors that occur more frequently in children with ADHD. Because such behavior triggers significant increases in what may already be high levels of distress, responding consistently in the ways that are often discussed in behavioral parent training programs may be especially difficult. This suggests that there would be important value in helping mothers develop skills to manage their distress in the moment, and to learn to recognize particular triggers of increased distress. This could decrease the ":..cumulative emotional toll of raising a child with a chronic disorder." And, reducing negative emotional reactions to challenging child behavior could make it easier for mothers to follow through consistently with behavioral strategies they are trying to implement.

In future work it would be important to include fathers so that the processes studied here can be investigated in dads as well. It would also be valuable to include larger number of females so that potential differences in mothers' reactions to sons and daughters could be investigated. Using these findings to develop ways to help mothers manage their distress in the moment would also be valuable to pursue.

In sum, results from this study highlight the links between mothers' distress and children's negative behavior and the fact that these links are stronger in families where a child has ADHD. As the authors conclude "This type of information can help guide not only interventions targeted on improving quality of life in families of children with ADHD, but also programs to help all parents recognize and manage the daily stressors of child rearing."


Thanks again to Cogmed for supporting this issue of Attention Research Update

Information presented in Attention Research Update is for informational purposes only, and is not a substitute for professional medical advice. Although newsletter sponsors offer products and services that I believe will be of interest to subscribers, sponsorship of Attention Research Update does not constitute a specific endorsement or guarantee of any company's product or services.

(c) 2011 David Rabiner, Ph.D.

Copyright © 2011 by David Rabiner

Wednesday, November 16, 2011

Anxiety, Manipulation or Both? What should a Parent do?

Here is the scenario: Your teenager with ADHD has fallen behind in some of his subjects, and has finally agreed to stay after school for extra help, which is a huge, positive decision on his part. In order to stay after school, however, he has to take the late bus home.

He has already successfully taken the late bus home several times. One day, he goes on the bus and there is a new driver who seemingly to your child, does not know the route as well as he should. In fact, your teenager tells you that he had to tell the driver how to get to his house. He then tells you that he is very annoyed because his stop is the last one on the driver’s route.

He goes to school the next day when he is supposed to stay for extra help again. When it comes to the time that he is supposed to take the late bus home, he starts continuously leaving voice mail messages and text messages for you, becoming more and more anxious with each message. The messages that he leaves for you state that he is afraid to take the late bus home. He tells you over and over again that he is afraid to take the bus because the driver does not know the stops, and that he wants you to pick him up immediately.

You finally go to pick him up, but you ask yourself: Will this be a constant problem that may only be solved by my picking him up, instead of him taking the late bus like the other students? Is your teenager manipulating you? Did he not say that he was annoyed because his stop was the last one?

Is it possible that he just does not WANT to take the bus and is more comfortable when you drive him home? Do you not have a right to stay at your job and finish the work that YOU have to do, or go to do some errands in a relaxed and less stressful rush than hurrying to his school to pick him up?

What should you do? Should you pick him up the two or three days that he stays after school for help? If you do so, will you allay his anxiety, or will you prevent him from dealing with his anxiety over a problem that may not be as looming as his perception of it. (You already called the school bus company and the supervisor told you that the driver is new, but knows the location of all of the stops.

Have any of you experienced this problem? What strategies did you use?

Thursday, November 3, 2011

ADHD, Anxiety, Learned Helplessness and their Impact upon Academics

What happens when children with ADHD become teenagers with ADHD, in terms of their ability to complete their academic work? In elementary and middle school, the quantity of school work that is required by children may seem to be more than when we were growing up. However, the quantity and quality of academic work that is required of teenagers in high school grows exponentially with each year. The symptoms of these teenagers’ ADHD impact their academic work to an even greater extent than in the earlier grades. Additionally, if a teenager is characterized by ADHD and anxiety, their executive function difficulties become all the more complicated. Let me give you an example.

One of the teenagers with whom I work who has ADHD and anxiety, had an assignment in which he was required to write a continuation of what he thought might have have happened next in a Shakespearean play that his class had been reading. The students were not required or even asked to write this scene in Elizabethan English. This young man is a voracious reader and has a reading level that is well beyond his years, both in terms of decoding and comprehension  

However, his anxiety froze any ability that he might have had to write the required scene. I worked with him and together we traced what he could write. For example, if the main character had stayed in the room instead of running out, what might have happened next. We talked about several scenarios and he chose one.

He was supposed to go home and tell his Mom (who acts as a scribe for him due to the fact that he has a written language disability) what he wanted to say. Then, she would type the scene for him. You may be asking yourself why he does not type on the computer himself. He types very slowly, so for now, we are having his Mom write/type these assignments for him, just at the very least, to get him to complete his assignments.

We had an overall power outage this past week due to the October snowstorm, so he did not have school. The afternoon of the first day back at school, I met with this teenager, and asked if he had completed the English assignment. He began to behave in a very immature way, rolling his top lip over his bottom lip, and making sort of whining sounds. He finally told me that he had not done the English assignment. I asked why he had not completed the assignment.

He told me that he had asked the teacher in the learning center for help, but that she had helped him with another essay that he had not completed that was worth 100 points. I then redirected the conversation to find out the reason why he had not done the assignment. It appeared that due to the anxiety of the assignment, he just could not get himself to do it.

He told me that more straight- forward assignments, such as math or social studies were not a problem for him. He then told me that when he had to make things up, i.e., in this case a scene from a play, that he could not do it himself. I truly believe that this young man’s anxiety caused a type of writer’s block.

I have to tell you about another problem that I truly believe contributed to him not completing this assignment. He definitely has a type of learned helplessness, in addition to his ADHD and anxiety. He has learned over the years that he thinks that cannot accomplish certain things, which I believe is more directly related to his anxiety than his ADHD. Therefore, he will only complete those tasks with help.

When he first had this assignment, his first comment to me was “I can’t do this assignment. Ms. Smith will help me in the learning center.” The question was: How could I get him to do the assignment himself?  I told him that he could most certainly complete this assignment. However, there was no way that he believed what I said. I gave him several reasons why he could complete the assignment, but he did not agree with any of them.

I explained to him that this assignment was really no different than the scenes that he had made up with his brother when they were young and used imaginative play. I finally used humor to help him to understand that he could complete his assignment. He laughed, but still stated that he could not do the assignment.

Yesterday, I spoke to him in a very direct manner and told him that oftentimes teachers do not understand the impact of either ADHD or anxiety, in terms of students having difficulty completing assignments due to those issues.  They certainly understand that teenagers with ADHD need some help.
I continued our conversation by saying that since this is high school, however, the teachers also assume that students have learned self-regulatory skills which help them to complete and hand in all assignments on time. I then told him that I do not blame those teachers, because all assignments should be handed in on time by every student in the class.

In an effort to move this fifteen year old young man past his learned helplessness, I also told him that it is possible that some teachers might think that he was being lazy, or perhaps that he simply did not want to do the required work. He thought about what I said and was upset at the thought of the teachers thinking in that way. However, he still insisted that he could not do that English assignment.

I told him that he is so bright that his teachers expect him to hand in all of the assignments on time. I told him that he is the same as everyone else, in terms of handing in assignments. Then, he said to me, “But I am not the same as everyone else. I am different.” Before I give you my opinion of this young man’s comments, what do you think????

Tuesday, November 1, 2011

Do Children with ADHD have a Developmental Delay that will Diminish as they Mature? YES!!

“Since its earliest description, there has been debate as to whether the disorder is a consequence partly of delay in brain maturation or as a complete deviation from the template of typical development” (Shaw et al., 2007, p. 19649). In a study funded by the NIH, Shaw et al. (2007) found, in groundbreaking research, “that in youth with attention-deficit/hyperactivity disorder brain (ADHD), the brain matures in a normal pattern but is delayed three years in some regions, on average, compared to youths without the disorder.” The areas of the brain that reflect difficulties for children with ADHD are those that control self-regulation in their thinking, attention, and planning. Therefore, the maturation of the brain is quite normal, but merely delayed, which should assure teachers and parents alike that these children’s symptoms should diminish as they mature because at some point, the child will have normal brain maturation. This new information should offer teachers and parents great optimism concerning the academic prognosis of children with ADHD. So have the symptoms of ADHD changed? Most certainly not. However, perhaps we are beginning to gain a clearer understanding of ADHD that will help teachers to instruct children with ADHD in a more effective way.

Thet title of the Shaw et al. (2007) article is Attention-deficit/hyperactivity disorder is characterized by a delay in cortical maturation.

If you would like me to email the actual article to you, please contact me, and I will be happy to do so.

Child Psychiatry Branch, National Institute of Mental Health, Room 3N202, Building 10, Center Drive, Bethesda, MD 20892; and §Montreal Neurological

Institute, McGill University, Montreal, QC, Canada H3A 2T5

How do Children with ADHD Build Good Character?

Good character? How do we describe good character? Of course, everyone defines good character differently. I would include the following, among others, in a list of traits that describes  a  person
 of good character:
  • Being considerate of others
  • Being kind to others
  • Following through on what you say you are going to do
  • Being honest
  • Being reliable and dependable
  • Thinking about others’ needs before satisfying your own needs
  • Being fair to others in social interactions

How do children build good character? One way is for parents to model good character. However, we all know that children with ADHD are distractible and may not have focused on their parents’ modeling of those positive behaviors. You can try to write social stories with children who have ADHD about incorporating the above qualities within their behavior. You can also role play with these children as well, giving them opportunities to behave as someone who is exhibiting the positive behaviors that are associated with good character.

Here is another method that you might try, which involves an open-ended questioning of the child with ADHD: Ask the child with ADHD the following questions based on certain scenarios. The topics listed incorporate the qualities of having good character that I delineated above.

Being considerate of others: You are traveling on a bus. You have a seat, but an older woman does not have a seat and has to stand. What could you do to show consideration to this woman?

Being kind to others: A child in school has asked to play with some of the other children. He walks by them as they are playing kickball. He asks if he can play and they say “We have the teams picked already.” What could you say to the child who was rejected in order to show how
the other children could have behaved toward him in a kinder way?

Following through on what you say you are going to do: On Fridays after school, many of the children have playdates. Sam’s (the child with ADHD) mom made plans for him to play with Eric right after school. In fact, they were supposed to travel to Sam’s house on the school bus. As
the boys were playing in recess in school, Sam said to Eric, “I do not want to have a playdate today. I want to play my video games by myself.” What would you do to teach Sam how to rectify the situation when he did not do what he said he was going to do? What would you instruct Sam to say and to do next time?

Being honest: You are walking down the hallway of school and see a five dollar bill on the floor. What would be the honest thing to do?

Being reliable and dependable: Maria and her parents had a fifteen-year-old dog who had trouble walking due to arthritis. Both of her parents worked late, but Maria came home from school at 4:00 every day. What should Maria do each day when she comes home that would be reliable and dependable?

Thinking of others’ needs before satisfying your own needs: Every day when Erin walks off the bus, she runs home to go on the computer and plays computer games. Steven, a classmate of hers, is also on the bus. He has a club foot that has not yet been operated on. Steven has difficulty getting off the bus and has to walk home by himself because his mom worked. He walked home very slowly, and by the time he approached his house, it was almost dark outside. What is it that Erin could do that would involve thinking of others’ needs before satisfying her needs in this situation?

Being fair to others in social interactions: Jim is playing Monopoly with Phil. Jim has played Monopoly for a long time with his brothers. Phil, however, does not have much experience playing Monopoly or any other board game. What could Jim do to behave fairly with Phil in their social interactions, as they played Monopoly?