Attention Deficit Hyperactivity Disorder (ADHD) is recognized as a common neurodevelopmental disorder among children; in the United States, the prevalence is thought to be between 5 percent and 11 percent of children ages 4 through 17 in 2011 or approximately 6.4 million children (American Psychiatric Association, Attention Deficit/Hyperactivity Disorder ; CDC.gov, Attention-Deficit / Hyperactivity Disorder). Kessler places the adults with ADHD at 1 percent to 6 percent of the population (Kessler 717). A meta-analysis of 32 published research articles concluded that when children met the full diagnostic criteria for Attention Deficit Hyperactivity Disorder, 15 percent continued to show symptoms at age 25 (Farone, Biederman, and Mick 160). The rate rises to around 65 percent when the adult is in partial remission from the indicative behaviors. The focus of our case study, Brad, falls into this category.
The diagnostic manual for the American Psychiatric Association, the DSM-V, was reclassified from the category of disruptive behavior disorders to better allow for consideration of the presentation in adults and older adolescents (Rabiner, “New Diagnostic Criteria for ADHD”). The symptoms that prompt assigning ADHD to a child include behavioral problems with being impulsive, hyperactive, and having difficulty concentrating. The consequences to a child exhibiting ADHD behavior range from poor social skills and subsequent trouble making friends, substandard academic performance, and disruption of family dynamics. Family relationships are strained due to emotional outbursts, inadequate affection, lack of intellectual interests, and periods of significant conflict (American Psychiatric Association, Attention Deficit/Hyperactivity Disorder). As a result, dynamics within the home tend to revolve around the ADHD child in an effort to create a more stable environment for every family member. For this reason, although ADHD is considered to be genetically and biologically based, there has become a more recent focus in research on the influence of variables in the child’s environment (Pheula, Rohde, & Schmitz 137; Snowling, Muter, and Carroll 609; Shur-Fen Gau 688).
It is interesting to note that due to blood type incompatibility (mother is Rh negative), Brad experienced high levels of jaundice directly after birth and his uncle was one of the first children in the United States to received a total blood transfusion for the same reason; his uncle also has ADHD. This condition has recently been researched and concluded as placing a child at high risk of the disorder (Wei et al. 460). Brad’s siblings did not have severe neonatal jaundice because his mother received an injection to prevent antibody incompatibility reactions. Learning disabilities have been found to have a strong genetic component and further research is needed to determine if parents with the same problems influence their children by inheritance or the family environment provided (Robledo-Ramn and Garca-Snchez 688).
The “Smith” (name changed) family raised a son found to be almost textbook in his presentation of Attention Deficit Hyperactivity Disorder symptoms. The mother is known to the author casually and consented to allow the experiences of raising “Brad” as an ADHD child. The information was collected over a series of three interviews; two with Bradley’s mother, “Shelly”, and one with his two siblings, “Frank” and “Beth”. The interviews took place within a one-week period in March 2016.
Shelly was a single mother during most of Brad’s upbringing. She worked as a registered nurse during most of Brad’s childhood and also earned a bachelor’s degree in Psychology before she married. Shelly divorced Brad’s father when he was four years old, shortly after his brother was born. There were no family in the area for support and no church involvement until Beth was in middle school. Shelly remarried when Brad was thirteen years old and his sister was born from that marriage; however, that relationship also ended when Beth was only two years old and Brad was sixteen. Shelly did not remarry again. Brad’s father and step-father were not strong influences in his life and he did not maintain solid relationships with either man after they left the home.
Brad was an outgoing, bright, vivacious child even as a toddler. His behavior began to become disruptive when he entered school. Shelly was not aware of any significant problems except when during parent-teacher conferences, she was told he was the “class clown” and had problems turning in homework Shelly had reviewed at home. However, when she went to school one day when he was nine years old to pick him up for a doctor’s appointment, she could not locate him in his classroom. She eventually found him with a different group of children and, as they were leaving the building, Brad told her, “I’m the stupidest kid in the class”. This did not, however, appear to bother him.
Concerned, Shelly scheduled Brad for testing with his pediatrician and it was determined that he scored positively for 19 out of the 20 symptoms of ADHD; the only symptom he did not exhibit was a problem with sleeping. At that time, his physician suggested a trial of low doses of Ritalin to attempt to improve Brad’s ability to focus. Ritalin (methylphenidate) is a stimulant which, paradoxically, calms the mind of an individual with hyperactivity (Drugs.com, “Ritalin: Uses, Dosage, Side Effects & Warnings”). Shelly was not able to see any significant change in his behavior and eventually stopped the medication, thinking perhaps his behavior problems were an issue with maturity.
Brad’s relationship with his brother would alternate between close and bullying. Only three years apart in age, they played the same sorts of games as they grew up, although Brad’s body build allowed him to be more athletic than his more slender sibling. There was a pivotal incident in their lives that changed their relationship to the present day. Shelly had placed both the boys into martial arts classes in order to have a strong male role model missing from their day-to-day living. After both boys had been in training for over a year, Frank came down the stairs to once again complain that his brother had hit him. Shelly told him, “You’re a blue belt! Protect yourself!” She states that she heard a thud, which she presumed was a punch, followed by a howl. Then another thud, and a different boy howled. This continued for over twenty minutes. She says that this was the last time the boys ever fought and are extremely close even as adults.
When Brad was fourteen, his mother became pregnant with his sister. Brad was always resentful of Shelly’s second husband, but from the moment Beth was born, Brad adored her. He was present in the delivery room at his mother’s head and was the first person to hold the baby. Almost every picture of Beth as a baby and toddler was in Brad’s arms. Today, his sister is married and just had her first child and Brad travels to visit his “baby sister” three or four times a year and plans to accept a job offer less than an hour from her home. There is actually an issue with jealousy toward Beth’s husband, who Brad feels “keeps her from doing things” with him; in other words, taking her “away” from Brad.
Brad also exhibited a less common symptom of ADHD while still in elementary school: encopresis (American Psychiatric Association, Encopresis). Encopresis is categorized as an elimination disorder by the DSM-V and in Brad’s case, was severe fecal retention. A study in 2013 found that children with ADHD were 1.8 times more likely to develop encopresis that non-ADHD children (Mellon et al. 322). Brad’s physician father had moved out of state and his mother was single. She began to notice extremely large stools in the toilet and became worried about a medical condition or possible sexual assault. After a visit to the pediatrician, the doctor told her that some ADHD children stop passing feces as a way of controlling their environment and Brad was perhaps doing so as a response to his father leaving. After approximately six months of laxatives and inspecting each bowel movement, the issue was resolved. Brad was never embarrassed about telling his mother to check his stools and took the laxatives without complaint.
Despite Brad’s behavioral issues, he could be very happy and affectionate. He had two close friends in the neighborhood, although Shelly knew of no others. He performed very well in the martial arts classes and was so successful in sparring that it was recommended to his mother that he be placed in the Olympic Training Center when he graduated from high school. He enjoyed hard physical training and the triumph and accolades of winning, but problems that arose when he became a teenager precluded moving in the direction of Olympic competition.
The financial demands of an ADHD child increase the tension within the dynamics of a family unit. Pelham, Foster and Robb examined the economic impact of caring for a child with ADHD (Pelham, Foster and Robb, 121). Conducting a review of 13 different studies, they estimated that the average additional cost in treating an ADHD child was $14, 576 for each individual. The expenses included special assistance with education, medications and doctor’s visits for physical and mental needs, evaluations, lost parental wages spent in time dealing with needs, and legal expenses if the child/adolescent breaks the law. A study by Swensen states that families with an ADHD member had 1.6 times more insurance claims that those without an ADHD family member (Swensen 1415. Earlier research by Sayal, Taylor, and Beecham received survey answers from parents of ADHD children that indicated the financial impact on the family strongly determined if the parent(s) felt the disorder to be a serious problem (Sayal, Taylor, and Beecham 1410). Parents who stated their child’s ADHD was a serious problems were 17.6 times more likely to say there was a financial impact to their child’s disorder than parents who did not perceive it as a serious problem. The findings of the Swensen and Sayal, Taylor, and Beecham strongly show that when the cost of maintaining a child with ADHD is financially stressful, the impact on the family is probably negative in terms of relationships.
Brad began to break the law. After putting him back on Ritalin, Shelly found he was selling it as “speed” and that he felt it “slowed him down”. He would leave school and started to come to the attention of the law. Shelly was first notified of the problem when he was arrested for car theft, the first of many. Although she sought the assistance of social services, they were of little help. Brad began to find ways to obtain alcohol and became a binge drinker, leaving home for days at a time. After a stint in the juvenile detention center at fourteen years of age, Shelly tried to place him in alcohol rehabilitation and was told he was “too young to be an alcoholic”. He was sent to a juvenile training center for eight months and even a “boot camp” for four months. Finally, after a burglary that resulted in battery (not by Brad) when he was seventeen years old, Brad was sentenced to nine years in the state penitentiary.
On his release at the age of 26, Brad began to do construction work and readjust to being “on the outside”. He had some parole violations that were not discovered. He returned to martial arts training as a successful instructor and started to work as a private fitness trainer. However, when he was 32, he told Shelly he wanted white-collar employment and started to college. His ADHD was an obstacle to him, particularly in mathematics. To his mother’s surprise, he decided to major in Finance. Despite his struggle with numbers, he was able to obtain grades high enough to place him on the Dean’s list. Shelly was amazed at the extra effort he expended to overcome his ADHD, spending hours with mentors in the school library every day. “Mom,” he said, “These guys are just sitting around wanted to help and no one’s there but me!” He went on to complete classes in higher mathematics, including Calculus. He is in his last semester at a prestigious university and has accepted a job offer with a starting income of $120,000 annually.
Shelly states that she was told by a pediatrician that most children with ADHD were of high intelligence. She has always told Brad that he was extremely smart even though he had to struggle with school. Shelly tells of a conversation she had with Brad when he was a teenager. He asked, “Mom, what can I do for a living when I can’t spell and I can’t do math?” She says she replied, “Brad, you run the company and have a secretary to write for you and an accountant to do your math.” Little did she know he would overcome his adult ADHD through sheer effort.
First, the child must understand that his parents love him in spite of his behavior. After Brad had started college and was doing well in the face of his ADHD, Shelly asked him what else she could have done to have helped him as he was growing up. Brad replied, “Mom, there was nothing else you could have done. I was just a bad boy.” He knew she loved and supported him and although she did not condone his actions, she knew his disorder was the root of the problem.
The entire family must become involved. Beth was never the brunt of Brad’s behavior, but she was exposed to the legal issues and the loss of him in the home during his imprisonment. She visited him every week for two hours and understood the prison environment. Frank also saw firsthand the consequences of Brad’s behavior and, although he did not have ADHD, applied himself to his schoolwork and had a wide network of friends that did not engage in illegal activities.
The entire family celebrated Brad’s successes, even small ones, reinforcing their strong ties.
Throughout their lives, Shelly made a point of spending time with each child independently, shopping or going out to eat. Brad was treated differently only when necessary. Chu et al. found in his study that families with ADHD were less relaxed, more authoritarian, and less cheerful, but this does not generally appear to be the case with Brad’s family (Chu et al. 279).
Murray Bowen developed the Family Systems Theory which proposes that a family should be seen as one unit rather than as each member within it (Hooper 220). The interpersonal relationships impact the family unit because most people remain attached to the rest of their family in a number of ways throughout their life (Bitter and Corey 409). “In this sense, a family system’s perspective holds that individuals are best understood through assessing the interactions between and among family members” (Bitter and Corey 412). The behavior of the child with ADHD is connected to other members of the family and symptoms may be related to dysfunction in the unit as much as the physical influences on the child. Behaviors attributed to the disorder may be the same type exhibited by non-ADHD children such as seeking attention.
With so many adults exposed to friends and family with an ADHD child it is no longer socially unacceptable, but Shelly refused to use it as an excuse for Brad’s behavior. She states that once when he came in from school, she asked him how his day was. He snapped back, “Why are you always poking into my business?!” She says she calmly asked him, “Brad, have you taken your pills today?” He had not. Shelly attempted to work with the school, demonstrating to them that he had the ability to look like he was listening by nodding and making eye contact, but that he was not really paying attention. He was given a checklist that each teacher had to sign daily that he had his homework and had turned in his assignments. One day when Brad was in the eighth grade, he came home and one teacher had not signed the list. Shelly returned with him to the school and waited in the hall. She saw the teacher throw the notebook back at Brad. Shelly took her sons out of the school and attempted to homeschool them for three months, but they begged her to let them go back so they could be with their friends.
Tancred and Greeff conducted a study addressing the parenting style of the mothers with a child with ADHD and the coping strategies they used (Tancred and Greeff 442). The population used was 98 families in South Africa and addressed how mothers seem to carry the most amount of stress related to familial challenges. Beginning with Baumrind’s Parenting Style Typologies (1) with modifications by Maccoby and Martin 20) along with Darling and Steinberg (490), there are categories of authoritarian, permissive, and authoritative with added dimensions of levels of demandingness, responsiveness, and uninvolved. Casual analysis of Shelly’s style as primarily the sole parent in the household was authoritative and responsive. Berns (120) views this type of parenting style as the most effective for raising a child with ADHD.
It is apparent that treating the child diagnosed with Attention Deficit Hyperactivity Disorder must go beyond medication and behavioral modification therapies. Further research is needed to study the variables that are stable within the dynamics of family interactions. This will allow therapists, physicians, parents, and teachers to offer multiple forms of treatment that contain interventions with multiple components in an effort to promote the best possible academic and socialization of these children. As more adults within cultures are recognized as having symptoms of ADHD past the age of childhood, research becomes increasingly important for them to be able to function to the best of their abilities by helping them recognize that the dynamics of their families in the past, present, and future continue to exert influences on behavior.
Today at age 36, Brad’s story is one of success. While his fellow students were usually fifteen years younger than he, his future appears bright. His charismatic personality has served him to make connections that have helped him make top grades in college and secure a promising career. Although he has never had a serious relationship with a girlfriend, he looks forward to marriage after establishing himself and craves having children. He manages his personal finances well, drives a Lexus automobile, and has already established an impressive retirement account from working full-time while he was in school. Brad’s family supports him in everything he does and he is applying to have his criminal record expunged, which appears to be highly probable since he has committed no crimes since he was seventeen years old and has shown exemplary achievements. Attention Deficit Hyperactivity Disorder does not have to be devastating to the family and the individual. Brad has demonstrated that with careful attention and personal application, a diagnosis of ADHD does not have to be an indicator of future failure.
Words Cited
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th
ed. Arlington, VA: American Psychiatric Publishing, 2013. Print.
Baumrind, D. "Current Patterns of Paternal Authority”. Developmental Psychology Monographs
4 (1971): 1-102. Print.
Berns, Roberta. Child, Family, School, Community. Belmont, CA: Wadsworth/Thomson
Learning, 2004. Print.
Bitter, J. R., and G. Corey. "Family Systems Therapy". Theory and Practice of Counseling And
Psychotherapy. G. Corey. 1st ed. Belmont, CA: Thomson Brooks/Cole, 2009. 409-443.
Print.
Chu, Kangkang et al. "Family Dynamics in Families with Children with Attention Deficit
Hyperactivity Disorder". Shanghai Arch Psychiatry. 24.5 (2012): 279–285. Web.
Darling, Nancy, and Laurence Steinberg. "Parenting Style As Context: An Integrative Model.".
Psychological Bulletin 113.3 (1993): 487-496. Web.
Drugs.com. "Ritalin: Uses, Dosage, Side Effects & Warnings - Drugs.Com". Drugs.com. N.p.,
2016. Web. 21 Mar. 2016.
Farone, Stephen V., Jolseph Beiderman, and Eric Mick. "The Age-Dependent Decline of
Attention Deficit Hyperactivity Disorder: A Meta-Analysis of Follow-Up Studies".
Psychological Medicine 36.02 (2005): 159. Web.
Hooper, Lisa. "The Application f Attachment Theory and Family Systems Theory To The
Phenomena of Parentification". The Family Journal 15.217 (2007): 216-224. Web. 22
Mar. 2016.
Kessler, Ronald. "The Prevalence And Correlates Of Adult ADHD In The United States: Results
163.4 (2006): 716. Web.
Maccoby, E. E., and J. A. Martin. "Socialization in The Context Of The Family: Parent–Child
Interaction." Handbook of Child Psychology: Socialization, Personality and Social
Development. P. H. Mussen and E. M. Hetherington. 4th ed. New York: Wiley, 1983. 1-
101. Print.
Mellon, Michael W. et al. "Incidence of Enuresis and Encopresis Among Children With
Attention-Deficit/Hyperactivity Disorder in a Population-Based Birth Cohort". Academic
Pediatrics 13.4 (2013): 322-327. Web. 21 Mar. 2016.
Pelham, W. E., E. M. Foster, and J. A. Robb. "The Economic Impact of Attention-
Deficit/Hyperactivity Disorder in Children And Adolescents". Journal of Pediatric
Psychology 32.6 (2007): 711-727. Web.
Pheula, Gabriel Ferreira, Luis Augusto Rohde, and Marcelo Schmitz. "Are Family Variables
Associated With ADHD, Inattentive Type? A Case–Control Study in Schools". European
Child & Adolescent Psychiatry 20.3 (2011): 137-145. Web.
Rabiner, David. "New Diagnostic Criteria for ADHD". Helpforadd.com. N.p., 2013. Web. 21
Mar. 2016.
Robledo-Ramn, Patricia, and Jess-Nicasio Garca-Snchez. "The Family Environment of Students
With Learning Disabilities and ADHD". Learning Disabilities (2012): n. pag. Web. 21
Mar. 2016.
Sayal, Kapil, Eric Taylor, and Jennifer Beecham. "Parental Perception Of Problems And Mental
Health Service Use For Hyperactivity". Journal of the American Academy of Child &
Adolescent Psychiatry 42.12 (2003): 1410-1414. Web.
Shur-Fen Gau, Susan. "Parental and Family Factors for Attention-Deficit Hyperactivity Disorder
In Taiwanese Children". Australian New Zealand Journal of Psychiatry 41.8 (2007): 688-
696. Web.
Snowling, Margaret J., Valerie Muter, and Julia Carroll. "Children at Family Risk of Dyslexia: A
Follow-Up In Early Adolescence". Journal of Child Psychology & Psychiatry 48.6
(2007): 609-618. Web.
Swensen, Adnrine R. et al. "Attention-Deficit/Hyperactivity Disorder: Increased Costs for
Patients And Their Families". Journal of the American Academy of Child & Adolescent
Psychiatry 42.12 (2003): 1415-1423. Web. 22 Mar. 2016.
Tancred, Elise-Marie, and Abraham P. Greeff. "Mothers’ Parenting Styles and the Association
With Family Coping Strategies and Family Adaptation in Families of Children With
ADHD". Clinical Social Work Journal 43.4 (2015): 442-451. Web. 21 Mar. 2016.
Wei, Chang-Ching et al. "Neonatal Jaundice and Increased Risk of Attention-Deficit
Hyperactivity Disorder: A Population-Based Cohort Study". Journal of Child Psychology
and Psychiatry 56.4 (2014): 460-467. Web. 21 Mar. 2016.
