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My name is David Rabiner, and I am a child psychologist living in Durham, NC. I teach in the psychology department at UNC-Greensboro, and practice in conjunction with a group of pediatricians. I am married and have two daughters. As a child psychologist, I have worked with many children and parents who came in because of ADHD and the difficulties that often go along with it. Working with ADHD children and their families has become a special interest of mine that I try to combine in my clinical and academic work.
It is important to recognize that, although this information may be helpfulto you, it is not intended to substitute for professional medical advice. While it may be useful to discuss ideas you find here with your child's doctor, but they are not intended to substitute for his or her recommendations. Now, let's get to the questions parents have been asking me....
Many questions deal with problems that often accompany ADHD. Thus, several parents asked about the difficulties their child was having making friends; others asked about antisocial behavior and whether ODD (i.e. Oppositional Defiant Disorder) and ADHD were the same thing; there were questions about sleep problems, the relationship between ADHD and self-esteem, and problems with anger control.
All these questions deal with the key issue about the relationship between ADHD and other difficulties. It is important to remember that the core symptoms used to diagnose ADHD are inattention, hyperactivity, and impulsivity. When you look carefully at the specific diagnostic criteria you will not see any mention of defiant behavior, problems making friends, poor self esteem, sleep difficulties, etc.
Although these other problems are not used to diagnose ADHD, they often occur in children with ADHD. Thus, many children with ADHD develop problems with oppositional behavior, making friends, self-esteem, and anger control. Other children with ADHD, however, do not develop these associated problems. Often these associated problems create more difficulty for children and parents than the core ADHD symptoms themselves. Let's look specifically at several of these associated problems.
Oppositional and Defiant Behavior
Suppose you tell your child to go to his room and put away his toys. Ten minutes later you find that he is back, playing instead. How come? If your child headed towards his room intending to put the toys away, but quickly got caught up on the way in playing with a real neat toy, his/her "non-compliance" is not necessarily intentional and may represent the distractibility and difficulty completing tasks that is characteristic of ADHD. If, however, your child argued about having to pick up the toys, and basically refused to do it, the non-compliance is deliberate and willful, and is no longer attributable to ADHD per se.
Although most mental health professionals do not believe that family factors or parenting influence the development of ADHD, interaction patterns between parents and children can influence the development of oppositional behavior. Because of the unique challenges that children with ADHD can present, unhealthy patterns are more likely to develop between parents and a child with ADHD. Discipline practices that often work fine with other children may not work. Parents can become frustrated, and find themselves in frequent arguments with their child. An escalation of oppositional behavior frequently ensues.
It is generally agreed that such problems are best addressed by learning the specific parenting techniques and strategies that are often helpful and necessary to deal with the challenges a child with ADHD can present. To review this in detail is not possible, but basically, what is needed is a structured and consistent framework of rewards and consequences to reduce oppositional behavior and increase socially appropriate behavior. I'm sure that many of you are well aware of this approach, and know that it involves lots of hard work but that the results can be worth it. You can find an excellent discussion of this approach in a book titled Taking Charge of ADHD by Dr. Russell Barkley.
The point I want to stress is that it is very important not to confuse extreme oppositional behavior with ADHD. I have seen many parents who thought that if their child was receiving medication for ADHD, and yet still had behavior problems, there wasn't anything else to do. Physicians may inadvertently contribute to this misimpression by focusing exclusively on medication as a treatment option. Stimulant medication helps primarily with the core symptoms of inattention, hyperactivity, and impulsivity. Sometimes, it also brings a reduction in angry and oppositional behavior. If your child displays important problems with oppositional and defiant behavior after receiving stimulant medication, however, additional types of treatment are necessary.
Your child's physician may prescribe an additional medication to address such behavior problems. In these cases, however, most child psychologists believe that it is essential for parents to consult with someone who can help them design and implement a good behavior plan.
Problems Making Friends
Unfortunately, many children with ADHD have difficulty making and keeping friends. The behaviors that are irritating and annoying to adults (e.g. interrupting, impulsiveness, etc.) can be irritating to peers as well. This leads many children with ADHD to be disliked.
Being rejected by peers can be a painful experience that can lead to the development of emotional problems (e.g. reduced self esteem, depressed mood). Also, children without friends often gravitate towards other children on the periphery of the peer group, and can become involved with peers who are heading for trouble.
What can help with these social difficulties and what can parents do?
First, some evidence suggests that the medications used to treat ADHD improve social relations for many children. This is probably because when medication reduces the symptoms of inattention, hyperactivity, and impulsivity, a child with ADHD is less likely to engage in behaviors that peers find irritating.
Many children with ADHD, however, may not have developed the "social skills" that are necessary to make friends and get along with others. "Social Skills Training" is designed to address this problem most directly. It is believed that children can be taught the skills they need to get along better with peers. For example, a counselor might work with a child to teach him/her how to: enter groups of other kids without barging in; how to be a good conversation partner; how to solve problems or conflicts that come with other kids, etc. In many schools, the guidance counselor conducts groups to help children learn these friendship making skills. It is a good idea to inquire about the availability of such a group at your child's school. In some communities, a child psychologist may also conduct such groups for children.
Another way parents can help in with social skills development is to provide supervised peer activities for their child. If you know that your child's friendships tend to break down because he or she gets into frequent conflicts when play is unsupervised, you may need to take an active supervisory role to help things go well. A parent's presence can help keep conflict from occurring, or from escalating to the point that it disrupts the relationship should it occur.
When you have observed the conflict, you can use it as an excellent opportunity to help your child learn more appropriate compromise and negotiation skills. Reviewing with your child what he or she needs to remember to be a "good friend" prior to the get together (e.g. sharing, taking turns, listening to your friend's ideas) and then trying to discuss how or she did with these things afterwards can be quite helpful. As always, it's important to be positive in these discussions and to find things to praise. This is another area where consulting with a mental health professional to help focus on specific issues relevant to your child can be quite helpful. Your efforts here are very important as helping your child develop and sustain even a single good friend can make a tremendously important difference in his or her life.
Self-esteem and Emotional Difficulties
It is not surprising that many children with ADHD develop poor self esteem or even more serious emotional problems, such as depression. The academic problems, peer problems, and conflicts with parents and teachers that are frequently experienced can make daily life a struggle. Imagine getting so much negative feedback day in and day out. After a while, it would have most of us feeling down. It is not uncommon for secondary emotional problems to develop in children with ADHD.
How can parents help to prevent low self-esteem?
Several things can be helpful. First, it is important that children with ADHD have a clear understanding of what ADHD is and what it means to have it. It can be confusing and discouraging to a child to experience the struggles that ADHD creates: to have trouble finishing things despite trying; to try hard in school but do poorly; to get into trouble for things like talking out of turn or getting out of one's seat. In the absence of understanding why these things happen, some children start to feel that they must be stupid and that they can't do anything right.
Providing a child with an age appropriate understanding of what ADHD is, what kinds of things it will make difficult for them, and how they can be quite successful despite this, can be very comforting. I have seen children who were taking medication for years without knowing why —imagine how confusing that can be. There are several books available that do a nice job of explaining ADHD in a way that children can understand. For example, you may want to take a look at Distant Drums, Different Drummers: A Guide for Young People with ADHD by Dr. Barbara Ingersoll. This book is intended for children between the ages of 8 and 14. (editor's note: Putting on the Brakes by Patti Quinn, M.D. is a helpful book for the younger ages.)The other way to help protect the self-esteem for a child with ADHD is no different from what is important for any child. For all children, being competent and successful in the important parts of their lives are the basis for positive feelings about self. Children who do well in school generally develop positive feelings about their academic competence. Children who can make friends and get along with peers will develop positive feelings about their social competence. Getting along with parents and feeling that parents are proud of you also contributes to positive feelings about self. When these aspects of a child's life are going poorly, negative feelings about self often develop.
It is not having ADHD, however, that is the direct cause of self esteem problems. Instead, when the symptoms of ADHD make it difficult for a child to succeed in important life areas, negative feelings about self are likely to develop.
The best way parents can prevent this from happening is to make sure that problems their child may be having in specific areas are being addressed. If academics are going poorly, make sure your child is getting the special assistance they require. Social problems should be addressed as discussed above. Problems in the parent-child relationship that yield frequent conflict can be targeted with behavioral treatment or other types of counseling.(editor's note: In addition, try to get your child engaged in activities where he/she can perform well and get positive recognition.
For children struggling with poor self esteem or even depression, individual counseling can also be very helpful. Having worked with many children and parents around such issues, I realize that none of this is easy and there are no miracle solutions. Good, consistent hard work to help your child in these areas can, however, pay off.
This article was originally published in ADHD News, which was published by Brandi Valentine and is now archived at www.adhdnews.com. Dr. David Rabiner is a child psychologist and Senior Research Scientist at Duke University.and produces a monthly online newsletter, Attention Research Update, that helps parents, professionals, and educators keep informed about new research on ADHD. To sign up for a free subscription, please visit http://www.helpforadd.com.
