Attention-deficit hyperactivity disorder: A family and ecological systems perspective

Bernier, James C

SYSTEMS THEORY PROVIDES social workers with a useful perspective for understanding the effect of childhood behavior disorders on the family (Nichols, 1984). It broadens the clinician's perspective to incorporate relevant factors beyond the individual child's disorder in the assessment and intervention processes (Germain & Gitterman, 1980; Compton & Galaway, 1989). However, incomplete use of family-systems theory has led some professionals to view family dynamics as the primary source of difficulty in families with a child with a behavior disorder. Neurological underpinnings of the child's difficulties with psychosocial functioning have received insufficient attention; clinicians have focused almost exclusively upon circular causality in family behavior patterns, disregarding important aspects of behavior that reside in the child's biological composition. Furthermore, societal and environmental forces contributing to these families' problems have sometimes received insufficient attention in assessment and intervention. In other words, some clinicians locate the problem primarily or exclusively within the family.

As a result of this narrow focus, families with a child with attention-deficit hyperactivity disorder (ADHD) sometimes feel blamed for the dysfunction. Because families with a child with ADHD often exhibit dysfunctional interactions, family- and ecological-systems approaches must take into account all of the biopsychosocial factors relevant to their dysfunction. Practitioners must attempt to understand the complex interactions among family members and the societal institutions and forces surrounding them.

Social workers have used family-systems theory to understand the reciprocal nature of parent-child interactions in general (Hartman & Laird, 1983) and, in particular, have noted problematic interactions in families with a child who has ADHD (Coker & Thyer, 1990). However, few practitioners have fully explored the intricate, subtle, and powerful reciprocal interactions among the neurological dynamics of ADHD, the educational and human services systems, and the adaptive maneuvers of families with a child with ADHD. The following sections explore the family and ecological-systems issues often encountered by families with a child with ADHD as well as the stresses experienced by family members.

THE NATURE OF ADHD

Individuals with ADHD are distinguished by marked impulsivity, aggressiveness and oppositional behavior, inattention, distractibility, fidgetiness, hyperactivity, excessive talking, lack of perseverance, and problems in social interactions (American Psychiatric Association, 1987). The disorder typically begins before the age of seven and extends into adulthood (Kaplan & Shachter, 1991); it affects 3% to 9% of the population (Szatmari, Offord, & Boyle, 1989; Johnson, 1988). "Its impact on society is enormous in terms of financial cost, stress to families, disruption in schools, and the potential for leading to criminality and substance abuse" (Biederman, Newcorn, & Sprick, 1991, p. 564).

Attention-deficit hyperactivity disorder has had various names over the years (e.g., minimal brain dysfunction, hyperactivity, hyperkinetic impulse disorder). Debate continues as to whether the symptoms of the disorder constitute a true diagnosis or are simply indicative of other problems (Conrad, 1976; Rubinstein & Brown, 1984; Taylor, 1986).

The disorder is a biologically or constitutionally based disability whose etiology is unclear and heterogeneous (Tannock, Schachar, Carr, Chajczyk, & Logan, 1989; Anastopolous & Barkley, 1988; Biederman et al., 1991; Johnson, 1989; Hartsough & Lambert, 1985; Logan Cowan, 1984; Silver, 1981). In some cases, it appears that ADHD might be caused by the prenatal or perinatal environment; brain injury due to illness, trauma, or exposure to toxins (Melina, 1990); food allergies (Parker, 1988); or a family genetic history of ADHD. According to Wender, "How the child is treated and raised can affect the severity of his problem but it cannot cause the problem" (Melina, 1990, p. 1). In many cases, none of the commonly recognized precipitants of ADHD is apparent. Thus, our knowledge of etiology is incomplete (Parker, 1988).

Research on treatment indicates that a multimodal approach is most effective: psychostimulant medication; behavior-management-skills training for the child's parents and teachers to help them utilize structured positive-reinforcement programs and other behavior-management strategies to elicit desired behaviors; cognitive, supportive, and play therapy for the child to develop self-esteem and interpersonal problem-solving skills; and supportive counseling for parents, including psychoeducational groups (Melina, 1990).

LITERATURE ON FAMILIES OF CHILDREN WITH ADHD

Review of the literature reveals four interrelated themes that often emerge in families of children with ADHD: (1) family instability and marital disruption, (2) conflict-laden parent-child interactions, (3) high levels of parental stress, and (4) maternal depression. Practitioners need to understand these thematic forces and dynamics to assess the family and design an effective multimodal intervention package that addresses all of the systems of which the child is a part. Marital disruption contributes to child-behavior problems (Porter & O'Leary, 1980; Emery, 1982), and divorce or marital problems may aggravate a child's hyperactivity (Peterson & Zill, 1986).

Other sources of family stress such as low income, insecure employment, and frequent moves may exacerbate ADHD symptomatology (Hartsough & Lambert, 1985; Campbell, Breaux, Ewing, & Szumowski, 1986; Cadoret & Stewart, 1991). Lack of family stability is the most consistent predictor of risk in children with minimal brain dysfunction (Werner, 1980).

However, one must not assume that family instability causes ADHD (Block, Block, & Gjerde, 1986; Brown & Pacini, 1989; Prinz, de Rosset, Holden, Tarnowski, Roberts, 1983; Befera & Barkley, 1985). Marital dysfunction may result from dealing with deviant behavior in children and may not be the cause of the misbehavior (Barkley, Fischer, Edelbrock, & Smallish, 1990).

The literature also indicates common parent-child themes in families with a child with ADHD. In experimental studies, researchers have observed that parents of children with ADHD are more directive, giving more negative and less positive feedback than do parents of children who do not have the disorder. "The manner in which [the parent and child] typically reinforce each other seems primarily to vary along a continuum of more or less negative feedback with few supportive comments" (Humphries, Kinsbourne, & Swanson, 1978, p. 21). With minor differences, these findings are supported by other researchers (Campbell, 1975; Campbell et al., 1986; Mash & Johnston, 1982).

In laboratory settings, parents' behaviors change after their children are administered medicines that help them become more attentive and compliant and less impulsive. In the unmedicated state, children with ADHD were less compliant and the mothers more likely to be directive. However, after the children were medicated, the parent-child interactions became more benign (Barkley, 1988, 1989; Barkley, Karlsson, Pollard, & Murphy, 1985; Barkley, Karlsson, Strzelecki, & Murphy, 1984; Cunningham & Barkley, 1978). Whalen, Henker, and Dotemoto (1980) also observed that teacher directives became more normalized when children were medicated during school hours.

Tarver-Behring, Barkley, and Karlsson (1985) found that mothers with children with ADHD interacted with their nonhyperactive offspring in ways closely resembling those of other mothers of nonhyperactive children. However, their interactions with their hyperactive children tended to be negative and directive.

Other researchers confirm the negative interactions between parents and children with ADHD or behavior problems (Anderson, Lytton, & Romney, 1986; Bugental & Shennum, 1984; Patterson, 1980, 1982). Both children and parents attempt to control each other, reinforcing undesirable behaviors and perpetuating negative patterns of interaction. Often, parents eventually rely solely upon aversive controls.

Parents of children with ADHD experience more difficulties and fewer gratifications in their parental role than do other parents (Anderson et al., 1986; Breen & Barkley, 1988; Konstantareas Homatidis, 1989; Fischer, 1990). Although much stress arises from parent-child interactions, a significant amount of stress is also generated from sources external to the family, such as school, scouts, church, sports teams, neighbors with whom their children with ADHD come into conflict, and the juvenile-justice system. Also, publicly funded respite services for overstressed parents are minimal, and private programs are either costly or unavailable. Parents are held responsible for their child's behavior, regardless of the severity of the child's disorder or the availability of resources to sustain the family. External stressors such as social isolation and poverty exacerbate family problems (Garbarino, 1976; Dumas Wahler, 1985).

Mothers of children with ADHD are also more likely to be depressed (Befera & Barkley, 1985; Lahey, Piacenti, McBurnett, Stone, Hartdagen, & Hynd, 1988; Sandberg, Wieselberg, & Shaffer, 1980; Webster-Stratton, 1988; Webster-Stratton Hammond, 1988; Brown Pacini, 1989). Given the unique and relentless demands of parenting a child with ADHD, and the primary parenting role that mothers usually shoulder, this finding is not surprising.

Parental depression may be related to self-esteem. Mash and Johnston (1983) found that

mothers and fathers of hyperactives see themselves as less competent than parents of normals in respect to their skill/knowledge in being good parents and the degree of valuing/comfort derived from the parent role (p. 95).

Breen and Barkley (1988) also noted decreased self-esteem among parents of children who frequently act out.

Although parental depression and stress appear to be associated, the direction of the relationship is unknown. It seems plausible that parental depression could lead to lower tolerance for child misbehavior and more irritable responses directed toward the child, which would thus exacerbate the child's misbehavior. This can be viewed as a complementary process, that is, the stresses of helping a child with ADHD to achieve self-control undermine parental self-esteem and precipitate or aggravate parental problems such as depression. Conversely, the parents' irritability negatively affects the child's self-esteem, thus diminishing the child's capacity for impulse control and enhancing her or his anger, anxiety, depression, and so forth.

A FAMILY- AND ECOLOGICAL-SYSTEMS APPROACH TO ADHD

Clearly, the studies cited above indicate the importance of taking into account the family and ecological systems of which the child with ADHD is a part. Systems theory provides a framework with which to understand the various problems faced by families of children with disabilities (Bernier, 1990).

Family-systems theory (Hartman & Laird, 1983; Kerr & Bowen, 1988) helps practitioners understand the dynamics of families with a child with ADHD. It provides an evolutionary, ecological, biopsychosocial perspective of how individuals and groups adapt to and mold one another. Miller (1976) states,

In order to survive the system must interact with and adjust to its environment, the other parts of the suprasystem. These processes alter both the system and its environment. Living systems adapt to their environments, and in return mold it. The result is that after some period of interaction, each in some sense becomes a mirror of the other (p. 306).

Behavior can be evaluated only when transactions and interactions are viewed within relationships and not in isolation. Bateson (1979) understood that it is impossible to know an event or situation objectively, but that by identifying the widening levels of context, the clinician gains greater understanding to develop effective interventions.

The context in which behavior is evaluated is crucial to understanding families of children with ADHD. In a sense, the problem is defined by the violation of behavioral norms in the systems in which the child participates as well as by the tolerance, adaptability, and other dynamics of those systems. For example, school classrooms, which rely on order and attention, create stress for children with ADHD, their peers, and teachers. The classroom setting affects both the evaluation of and responses to behavior. In schools with constrained resources, school authorities are likely to prefer that children with ADHD receive medications rather than attempting to develop systematic behavior-modification plans that require highly individualized approaches to students with ADHD. Schools that Lack the resources or expertise needed to meet the special needs of children with ADHD often create additional stress for parents by demanding that the parents assume complete responsibility for helping their children become compliant at school. Frustrated teachers and administrators may undermine parental confidence by attributing responsibility for the child's misbehavior to deficits in the child's character and/or the parents' skill. On the other hand, cooperative relationships between the school and family offer children, parents, and teachers support and may reduce the need for medications. Skilled parents and teachers can collaborate in designing and implementing behavior-modification programs that maximize the child's opportunities for academic success and positive social interactions at school, which, in turn, reduce stress in the family and in the classroom. Additional research is needed to determine the reciprocal influences of ADHD behavior at home and school.

Families with children with ADHD face significant challenges regarding boundaries, homeostasis, and feedback. These families require support from outside resources, yet often receive misdiagnoses and unhelpful advice that merely exacerbate their troubles. Commonly, physicians, teachers, or social workers tell parents of children with ADHD that their child will "grow out of it" or that the parents must be firmer and more consistent with their child. Such advice, however, creates frustration and thus may lead to the closing of family boundaries, screening out of potentially useful feedback, and creation of dysfunctional family interactions. In seeking homeostasis, the overstressed family may end up using the same unproductive "solutions" for its problems. Or fragmentation of services and conflicting directives may lead to chaos.

Parents' controlling, negative responses to the child's irritating behaviors may produce the desired behavioral outcome for the moment, but in the long run may contribute to oppositional stances among family members. In other words, the temporary short-term solution is counterproductive in the long term.

Parents in these families often say, "We've tried everything, and nothing works." For example, a parent may let the child cry and scream rather than give in to his or her demands. However, if the tantrum persists, the parent is likely to give in eventually, which silences the tantrum while teaching the child that lengthy tantrums work. Thus, long-term goals are habitually sacrificed for temporary relief and a functional steady-state system is never achieved. Family members may become enmeshed or, conversely, members may seek solace by disengaging from one another. Either way, the family does not achieve functional homeostasis. Watzlawick, Weakland, and Fisch (1974) call this phenonemon first-order change, that is, change within a system that remains unchanged, at the expense of second-order change, or change that alters the system itself.

The literature on the interactions between parents and their children with ADHD suggests that self-reinforcing dysfunctional behavior patterns occur in many of these families. The child's noncompliant, disruptive behavior contributes to chronic stress in parents, which in turn produces unproductive parenting behaviors that exacerbate the ADHD symptoms.

For example, we have often observed that parents of children with ADHD often criticize, correct, and command their children in angry and exasperated tones, even when the child's behavior is not disruptive or age inappropriate. The commands are often vague ("be a good boy now"), worded negatively ("don't touch that"), not followed by an immediate consequence, and repeated without obtaining the desired result. In this way, both parents and children feel frustrated, helpless, angry, and incompetent. The child feels unable to meet parental expectations and consequently may misbehave to express his or her anger at the critical parent. The cycle continues, and negative behaviors of parents and children escalate.

In addition, the child with ADHD is often cast in the role of the "bad child" in the family, whereas siblings are considered the "good kids." These roles create intrapsychic and interpersonal distress within the family (Reitz & Watson, 1992). The situation is further aggravated by family friends, school personnel, and health and mental health professionals who are unfamiliar with the dynamics of ADHD and who alternately blame parents and children for the situation.

School personnel may instruct parents to ensure that their child completes unfinished school assignments at home. When parents fail to accomplish this task or do not attempt it because they know from past experience that the effort is futile, school personnel may assume that the parents are unmotivated or incompetent. In turn, parents may become hostile or withdraw from school personnel, thus "confirming" the teachers' and administrators' conclusions. School personnel, social workers, and other "helpers" may turn a deaf ear to parents and fall into the same sort of blame-shifting patterns that occur within the family.

Assessment and intervention on behalf of children with ADHD must be based upon a systems perspective that takes into account both the family and the environment. Federal and state policies affect the availability and delivery of educational, recreational, medical, income, respite, and other family supports. Although therapy should provide parents and children with insight, emotional nurturance, information, and behavior-management skills, clinicians must also collaborate actively with physicians, teachers, school administrators, child-care providers, community support programs, advocates, and legislative lobbyists who seek to create and expand educational and other services on behalf of children with ADHD. With such collaboration, second-order change can be achieved.

Macro-systems issues, such as unemployment, poverty, noncustodial parents' default on child-support payments, inadequate training for teachers who work with children with ADHD, lack of after-school child care and recreational programs that can accommodate children with ADHD, and financial stresses, increase family stress. Although these issues may be more difficult to address than are individual and family issues, they are nevertheless important. Intervention that produces second-order change must address the macro, mezzo, and micro systems of children with ADHD.

CASE EXAMPLE

The following case example offers guidelines for effective intervention with children with ADHD:

T, a 25-year-old divorced mother whose ex-husband was deceased, presented at a community mental health center for help with her six-year-old son, J, who had been diagnosed by his pediatrician as having ADHD. T and J's interactions were typical; although they felt deep love for each other, they also felt intense anger, frustration, and helplessness as they tried to cope with each other's behavior. J's first-grade teacher asked T to get counseling for J because he often got out of his seat, spoke out of turn, threw things, failed to complete his work, and was bossy with his peers, who generally disliked him. T's mother, who cared for J after school while T worked full-time as a nurse's aide, complained daily that J was "impossible" and "bratty." T said, "I'm ready to tear my hair out, because J just won't listen." It was impossible to get him dressed, fed, and out of the house on time ill the mornings and to keep him in his bed at night. He hit, kicked, and pinched T daily. Her arms were covered with bruises.

This case illustration provides a composite of features typically found in families with a child with ADHD. Often, clinicians focus on the parent and child, to the exclusion of other system components. Interventions might typically include a weekly clinical hour (often limited by the agency or insurance policy to 12 weeks) at the agency, during which time the worker teaches the mother specific behavior-management methods; provides support and validation; and explores intrapsychic and situational obstacles to implementing behavior change plans. Mother and child may occasionally be seen conjointly to observe their interactions and to initiate behavioral contracting. Individual sessions with the child may be used to assess the child, bolster his or her self-esteem, and teach social, relaxation, and impulse-control skills.

Although such interventions are very important, interventions based on a systems perspective would also incorporate the following tasks in the case of J.

* Refer J to a neurodevelopmental specialist to assess the accuracy of the ADHD diagnosis and to explore possible medications. Collaborate with the specialist throughout the course of intervention to increase coordination of services.

* Conduct some sessions in the home, so the social worker can observe parent-child interactions in the natural environment, model alternative parenting behaviors, experience some of T's frustration, and therefore better appreciate the challenges she and J face. This approach would require practitioners to abandon the traditional office-based, one-hour-per-session model.

* Recruit J's teacher as an ally in the helping process, design a classroom-based behavior-management program, and monitor efforts on an ongoing basis, either via telephone or school-based meetings.

* Include J's grandmother in some sessions, develop a therapeutic alliance with her, educate her about ADHD issues and behavior-management techniques, and monitor her efforts.

* Have a conjoint meeting with T, the grandmother, teacher, and J to map out a coordinated approach for school, home, and after school care. Other adults with whom J has regular contact might also be included (e.g., scout leader, Sunday school teacher).

* Locate or create a social-skills group in which J can participate.

* Provide in-service training for agency staff on how to obtain an accurate diagnosis for ADHD and how to implement systems interventions.

* Provide training for physicians, educators, and other child-care providers who have contact with children with ADHD to educate them about the disorder and the need for a systems perspective in their work.

* Create a consortium of community agencies that deal with children with ADHD (e.g., community mental health centers, family service agencies, public and private child welfare agencies, day-care centers, schools, diagnostic and assessment centers) to join forces with child advocates in lobbying for special services by children with ADHD and their families. Such services include respite and child-care providers who work with children with ADHD, parent education and support groups specific to this population, and funding for parent aides and counseling services. Funding is needed for social programs that address prenatal and perinatal risk factors such as low income, lack of prenatal care, and alcohol abuse as well as for research on causes of and interventions for ADHD. Schools of social work need to ensure that graduates who plan to work with families and children have specialized training in ADHD.

* Concrete, observable, and measurable goals must be articulated, and data-collection procedures must be designed and implemented so that outcomes are evaluated empirically.

CONCLUSION

Although the prescription for clinical intervention presented here may seem overwhelming, it is consistent with the social work profession's long-standing focus on the interface between individual problems and public issues. Social workers need to collaborate with professionals whose work affects children with ADHD, including direct-service providers and legislators and others who determine public policy.

Knowledge of social policies, organizational dynamics, community services, family dynamics, and the needs of individuals affected by ADHD enables social workers to act not only as therapists but also as brokers, legislative lobbyists, community organizers, and advocates. All of these roles are essential in addressing the needs of children with ADHD.

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Families in Society CEU Program 11700 West Lake Park Drive Milwaukee, WI 53224

James C. Bernier is a school social worker, Central Falls High School, Central Falls, Rode Island, and is in private practice, Governor Diagnostic and Treatment Center, Providence, Rhode Island. Deborah H. Siegel is Professor, School of Social Work, Rhode Island College, Providence, Rhode Island.

Copyright Family Service America Mar 1994
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