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Parenting a child with AD/HD? This is the AD/HD Issue....

 Winter 2012, Vol. 5 (4)

          The PracticaParent

For Parents, Educators and Mental Health Professionals Who Care About Teens

 

 Parents, Teens and AD/HD: A Quick Primer

 

 
The following is a section from a much longer piece I’m writing entitled, “AD/HD: A Widely Misunderstood Disorder.”  I wanted to share portions of the piece with parents in hopes of making the process of getting help easier and more meaningful for you by highlighting some of the widespread misunderstandings about AD/HD.
 

 
We know a lot about Attention-Deficit/Hyperactivity Disorder (AD/HD).  It is a heavily studied neurobiological disorder with wide-ranging consequences and unfortunately, with a well-documented, growing body of research showing impairment associated with AD/HD, well into adulthood. There is a tremendous amount of research on the neurological bases of AD/HD, on medication treatment and efficacy, and on psychosocial treatments (and problems with these approaches) for AD/HD. There is exciting work going on with longitudinal, prospective studies of ADHD, allowing us to understand how AD/HD looks over time in the same individual, from childhood into middle adulthood. And yet, AD/HD remains one of the most misunderstood, misdiagnosed, argued about, stigmatized, and mistreated conditions. So, as we quickly approach 2013, what can we say we know about AD/HD and how can this knowledge be used to support parents and youth dealing with (or possibly dealing with) AD/HD?  Here are some myths and facts about AD/HD.
 
1. You can call it AD/HD if you want to, but it confuses the issue. AD/HD has very little, if anything to do with a deficit of attention. Your child doesn’t have “too little” attention. He or she cannot simply “pay attention” more or “get more” attention. He’s not missing attention. As you’ve seen, your son might devote plenty of sustained attention to preferred goal-directed activities like video games that provide immediate, ongoing “point of performance” feedback about right and wrong choices and plenty of opportunity for risk-taking (as this is how I refer to the neurobiological pursuit of novel experience). Folks with AD/HD have difficulty shifting their attention from one task to another or regulating their attention, in general.  This is not the same as having a "deficit." There is a lot of wrangling over the name of the disorder because names matter for diagnosis, treatment, reimbursement from insurance companies, determining prevalence rates of the disorder in the general and in specific (e.g., girls v. boys) populations, determining to whom and how much money goes for research and hundreds of other political, economic and sociological questions. But AD/HD shapes every single person in slightly different ways, which leads to our next point.
 
2. AD/HD doesn’t have subtypes. You can keep referring to the subtypes of AD/HD—a disorder that is woefully misnamed to begin with—as predominantly hyperactive/impulse or inattentive or a combination of the two (the most common type of AD/HD), but AD/HD doesn’t have subtypes. This typology doesn’t hold up to scientific examination, clinical experience or actual experience of the person or family dealing with AD/HD. Because of excellent, prospective longitudinal studies there are now plenty of scientific data demonstrating that a child can begin with a diagnosis in early childhood as “primarily hyperactive/impulsive,” slowly add more “inattentive-type” symptoms as they move into adolescence and then no longer meet the DSM criteria for AD/HD at all by adulthood, despite continuing to have significant impairment in academic, work and social areas of functioning.
 
3. AD/HD doesn’t “go away” in adulthood; it’s a lifelong disorder. The way that AD/HD looks (the “presentation of symptoms” of AD/HD”) changes from childhood to adulthood, and this is exactly what we would expect with a syndrome made up of a “confluence of neurobiological, genetic and environmental factors.”
 
4. AD/HD is best worked with by establishing a thorough but flexible taxonomy of the ways in which the individual is being effected—for good and for bad. We need to know the current strengths and weaknesses possessed and in possession of the individual. Early weaknesses can become later strengths and vice-versa. But there are always both in play, and better outcomes are associated with an emphasis on building strengths and a positive, but realistic assessment of strengths and struggles. The collection of this knowledge is one step in the building of the healing community for the individual and family that are dealing with AD/HD. Parents play a key role in keeping track of this listing of problems, strengths and challenges.  But it's also important to note here that AD/HD is a heritable disorder and many kids with AD/HD have parents with AD/HD.  This can make "tracking," record-keeping and accurate reporting of challenges and strengths difficult for parents. This leads to our next point.
 
5. Reducing and eliminating stigma about AD/HD and all so-called “mental health” disorders should always be approached as part of the treatment plan.
The stigma of having a “mental health” disorder is very apparent in the adolescent with AD/HD, in particular. UC Berkeley Professor and Researcher Stephen Hinshaw writes elegantly about this in The Mark of Shame: Stigma of Mental Health and an Agenda For Change. In my experience, most teens don’t want a mental health diagnosis of any kind, let alone an AD/HD diagnosis. They will hide or cease their use of medication in order that other people don’t see them taking the medication. They don’t want to feel different or be different or have “anything wrong with them.” They’ll often choose to have all manner of impairment in academics and social relationships rather than admit they have something wrong/have a diagnosis of AD/HD, which they oftentimes think isn’t “real.” Teens, especially, internalize the stigma of mental illness.  Your practitioner should be fully prepared to talk about AD/HD as a neurobiological difference, and even prepared to work with the problems associated with the AD/HD, and jettison the label, if the teen won’t accept the diagnosis. But, as kids with AD/HD are often the offspring of parents with AD/HD (and related conditions, like anxiety or depression), the problem of stigma can run deep in the family. Teens don't want to be different or have something "wrong" with them and neither do parents. This can lead to significant delays in getting help and support for everyone.
 
6. We don’t actually know the definitive cause of AD/HD. There are likely multiple causes. Scientific studies show strong hereditary factors involved in having AD/HD. If your child has AD/HD, there is a much greater chance that you or your spouse has the disorder. And conversely, if you or your partner has AD/HD, the chances of your offspring having AD/HD are significantly increased. Is AD/HD the result of structural defects visible in imaging the brain? Maybe. But these structural and developmental differences don’t show up in every single AD/HD patient.
 
There is also some evidence that exposure to environmental toxins may increase the risk for developing AD/HD. If AD/HD is caused by an interaction of genes and environment, then is it your fault if you were unwittingly exposed to environmental toxins that interfered with the transcription of certain genetic proteins during your early development? How about if the axons in your dorsolateral prefrontal cortex (DPFC) don’t seem to work well with the neuronal signals involved in dopamine production? Is that your fault or indicative of something “wrong” about you? If you’re walking down the street and you get hit by a car and have a limp for the rest of your life, is that about something “wrong” with your leg? Is this a “leg” problem or a “getting whacked by a car” problem? How do you see it?
 
One thing we seem to be lousy at is separating out thinking about causation from thinking about morality. We generally think that if we get cancer, it’s “not our fault.” But there are doubters. Many believe you can “give yourself cancer” by your attitudes towards life or you can cure your cancer by your attitudes.  This is a quintessentially American argument. If you’re not rich, it’s your fault. If you’re not happy, it’s your fault (or at least, there is something you can and should do about it). Pull yourself up by your bootstraps. Come on, get happy. Come on, try harder. I haven’t yet read one, but someone should do a study on attitudes of self-sufficiency and beliefs about whether AD/HD is a “real” disorder or not. I would bet that people who tend to believe that they’re in charge of their life and their fate would tend to believe there is no such thing as AD/HD…its all about not trying hard enough or being too negative about reaching their goals…which leads to our next point.
 
7. Whatever you call it or don’t call it, AD/HD is real.
It is not a disorder made up by the pharmaceutical industry or by teachers or parents who just don’t know what to do with their difficult kids. There are many thousands of studies of AD/HD. It is a well-studied disorder. Part of the difficulty, though, in getting everybody to understand that AD/HD is “real,” has to do with the variability of how the disorder presents in people over their developmental life span and how it defined, diagnosed and treated differently throughout the world. Prevalence estimates for childhood AD/HD worldwide range from 1% to 18%, largely based upon the geographic area of the study of prevalence, which influences the methods by which the disorder is defined.  There is no single, uniform definition of AD/HD or diagnostic procedure or criteria for determining AD/HD. This creates problems.
 
8. AD/HD is a highly comorbid condition, meaning that it is not unusual for it to show up with other disorders such as
Oppositional Defiant Disorder (ODD), Conduct Disorder (CD), Anxiety Disorders, Mood Disorders (like Major Depressive Disorder), Bipolar Disorder, Sleeping Disorders, Verbal or Nonverbal Learning Disabilities or Executive Function Disorder (EFD).
 
Most kids who are referred for psychiatric evaluation have AD/HD with additional disorders. This is one, among many reasons, that it is difficult for mental health professionals to accurately diagnose AD/HD—its symptoms overlap with and can exacerbate, hide or otherwise complicate other symptoms and disorders. Severe AD/HD can look just like childhood bipolar disorder. In adolescence, mild generalized anxiety and a learning disability can look exactly like moderately severe AD/HD, Inattentive Type.  In fact, all three may be present. An 8-year-old with a sleep disorder could be easily misdiagnosed with AD/HD, Inattentive Type.
 
9. Treatment of AD/HD is complicated. One size doesn’t fit all. It’s all about finding the right treatment for each individual—which seems obvious, but isn’t at all obvious in practice. I’m sad to say that in my professional and personal experiences most teachers, psychiatrists, learning specialists, licensed professional counselors, clinical social workers, neuropsychologists, marriage and family therapists, psychologists, internists, general practitioners, pediatricians, behavioral pediatricians get it wrong. This isn’t because they’re “bad” at what they do or necessarily poorly trained; it’s more often that they are not keeping up with the scientific research or are not critically evaluating the scientific research on AD/HD, and failing to evaluate not only the potential negative side effects of medication but also the negative side effects of individual or psychosocial interventions. They don’t all get it wrong or get it all wrong, and even when they do “get it wrong” it doesn’t mean they don’t or can’t help kids and adults. Some get it really right, and the ones that do are all in connection with the current literature, researchers in the field, regularly receive continuing education and are aware of the controversies in the field and are flexible in their diagnosis and treatment practices.
 
So, what are all of us out here in treatment land getting wrong?  Well, we get wrong most of the information contained in this piece—that’s why I’m writing it. More specifically, treatment professionals get wrong the understanding of AD/HD because they don’t keep up with the research. If they even know about AD/HD and believe its “real,” they think of AD/HD as one thing, with three presentations, and they use the DSM to diagnose and determine treatment for the disorder. They don’t know or act on the knowledge, for example, that AD/HD, as described in the DSM, was developed in relation to young children and has really nothing to do with anyone over 16 years of age. In other words, the DSM has really nothing useful or scientifically accurate to say about adult AD/HD or AD/HD as a disorder whose presentation will fluctuate over time, based upon environmental, genetic and developmental factors.
 
Many of my colleagues—in my experience—don’t know about AD/HD Inattentive Type, if they know about AD/HD at all. A good portion of them think that if there are no hyperactive or impulse symptoms, there is no AD/HD. Among the more highly-trained colleagues like the neurologists or neuropsychologists, they are aware of the Inattentive “subtype” of AD/HD but still diagnose young adults (say, aged 16 and over) in accordance with the DSM criteria, relying primarily on self-reports and cognitive measures, favoring these indicators over parent reports, which have been shown to be much more accurate in determining impairment and impairment due to AD/HD.
 
Folks in the Learning Disabilities communities often say that these kids have EFD (Executive Function Disorder), and that EFD can overlap with AD/HD or Learning Disabilities like dyslexia and others. But since there is no EFD in the DSM, well, OMG.  This is where we all want to pull our hair out.  To get treatment reimbursement or recognized disabilities for an IEP or Section 504 accommodation, you have to have a “diagnosed mental disorder.”  EFD isn’t going to cut it for accommodations like extra time on tests, nor is it going to allow most insurers to pay for your child’s treatment. Sometimes even AD/HD isn’t going to cut it for these purposes as insurance companies, doctors, educators and the like still struggle with whether AD/HD is “real” or not.  To me, these kids have the same neurobiological disorder (that we now call AD/HD), with a slightly different presentation. They may also have a learning disability, too, but it doesn’t mean they don’t have “AD/HD.” Let’s use our common sense.
 
AD/HD is always going to involve issues with executive functioning, by its very definition, even if it’s a bad definition, because executive functioning is always about goal-direction, response inhibition, risk and threat-detection, regulation of attention and affect, etc. If the child or young adult has EFD, does that tell you what medication will work?  No.  If the child or young adult has AD/HD, does that tell you what medication or how much of that medication will work?  Nope.
 
So, the takeaway to parents is: don’t get lost on what your practitioner-of-the-moment tells you is the diagnosis, not when it comes to AD/HD.  Focus on the struggles your and your child is having and seek help for those. If the solutions your practitioner suggests become constrained based upon the diagnosis they give or insist upon, politely ignore their narrow view and focus on what works, safely and effectively.
 
The most common treatment of AD/HD (in all its presentations) is psychostimulant medication, which, among other things, modifies the reuptake process of dopamine in the brain and appears to normalize brain activation and behavior. The use of psychostimulant medication, contrary to popular lore, has been well studied and is not just part of a conspiracy among drug companies to medicate our kids. I’ll be the first person to criticize big pharma, so I’m not an apologist for the use of drugs. Does medication work?  Sometimes. Does it still work if you stop the medication? We don’t know. Certain drugs, in certain doses, for certain periods of time, work for certain people. Sometimes they stop working or don’t address the problems that the person is having at 18, but didn’t have at 13 ½. Sometimes the medications don’t work for someone at 9 ½ or problems can be better addressed in other ways, but at 22, it might be time to try a psychostimulant medication. Sometimes non-stimulant-based medications can be effective. New medications are being developed right now. But there is no one treatment for AD/HD that works all the time, and anyone who says there is, is just wrong; that claim is unsupported by research and practical experience with people and families dealing with AD/HD every single day.
 
Next, if you treat your child for AD/HD once during their childhood, it will likely have no measurable, positive outcome later in life. If you treat your child a lot during their childhood (medications, groups, hospitalizations, individual therapy, etc.), it will more likely have no positive outcome later in life. In fact, more treatment is associated with poorer outcomes.  This doesn’t mean you shouldn’t seek treatment. It may very well reflect the fact that the more severe the disorder, the more treatment resistant it is, and that a child with a long treatment history just reflects a much more severe baseline level of the disorder.
 
So what should parents do, as they approach assessment and treatment? Your description and close tracking of what your child can and does or cannot or doesn’t do is probably the most important thing you can bring to the table, because this is going to form the basis of understanding and helping your child, yourself and your family—not whether your child is diagnosed with AD/HD:C, (Attention-Deficit/Hyperactivity Disorder, Combined Type) AD/HD:I, (Attention-Deficit/Hyperactivity Disorder, Predominately Inattentive Type) AD/HD:HI (Attention-Deficit/Hyperactivity Disorder, Hyperactive/Impulse Type ), SCT (“Sluggish Cognitive Tempo”).  Try to make good notes about your child’s school and social history, and just what they have trouble doing and what they do well. This will be tremendously helpful.
 
Try to be a knowledgeable consumer of services
When you approach a practitioner, whether it’s a psychologist, MFT, neuropsychologist or behavioral pediatrician, you can ask them the following 5 questions, as a way of seeing whether you’ve found a qualified practitioner to work with you around AD/HD issues. I’m not suggesting you go in charging with this list, though. If a clinician turns out to not be too knowledgeable, it doesn’t mean he or she is lousy clinician. There are plenty of areas that are not my scope of experience or training, since I choose to focus on some things and not others.  But if you are feeling pretty lost about how to evaluate whether your clinician has expertise in this area, these questions might really help orient you towards an answer.
 
1. What is your experience in working with children and adolescents who have AD/HD? The answer should include a long history of working with children and adolescents, especially if your son/daughter is a teen. Experience with grade-school kids does not equal experience with teens; they are different animals, in most important ways. If your practitioner doesn’t have a long history working with adolescents, they should at least be specifically and well-trained in working with teens—understanding adolescent development and the ways in which AD/HD shows up differently in adolescence than in childhood…and how it will likely change, moving into adulthood.

2. How do you diagnose AD/HD? The answer should include mention of a combination of rating scales (for the patient, parents and teachers), in-depth clinical interviews of parents and student (usually), “paper and pencil testing” for AD/HD and other learning disabilities, as well as psychological testing (and hopefully neuropsychological testing) to rule out disorders that both mimic and overlap AD/HD. You could ask your practitioner if they use the BDEFS-CA (Barkley Deficits in Executive Functioning Scale).  If they don’t use it, you ask them why they don’t. The BDEFS-CA is an empirically-based tool for evaluating clinically significant dimensions of child and adolescent executive functioning. The BDEFS-CA is far more predictive of impairments in daily life activities than most traditional measures of executive functioning deficits.

3. If you find out that my child has AD/HD, what treatments do you suggest? The answer should be complicated, not cut and dry. What you should hope to hear is that the practitioner doesn’t have a pre-set treatment protocol, and says something like, “we wait to see what the testing shows, to make sure we’re matching the right treatment to the right child—and we can’t possibly know that in advance of gathering the data.” The practitioner can recommend a host of approaches, including medication, but they should be knowledgeable about the research on what types of treatment have been clinically proven to be effective for specific types diagnostic profiles. If the practitioner recommends psychostimulant medication regardless of the diagnostic profile, find another practitioner.

4. Do you read and keep up with the research on AD/HD assessment, treatment and efficacy?  First of all, you could ask them to recommend 3 of the best comprehensive books or articles on the topic. Most clinicians who keep up with the research and writing in the field would mention Steve Hinshaw, Russell Barkley or Kevin Murphy. If they don’t know their work, it doesn’t mean this practitioner is awful, but it does mean they aren’t reading the work of people that are generally considered tops in their field. Many people think that Dr. Barkley’s work is the first and last word on AD/HD. I don’t.  But if you don’t know his work, you probably don’t know what you need to know about AD/HD.

5. How do you feel about the description of AD/HD as a problem of having a deficit of attention?  If the practitioner doesn’t understand the controversy in the field or can’t speak somewhat fluently about the issues outlined in this article, I think one has to consider looking for a more experienced practitioner.
 
Am I being hard on my profession and on my colleagues?  I sure hope so.  We’re talking about intelligently and competently helping our children and it's our professional, ethical responsibility to get continuing education about the research, diagnosis and treatment of AD/HD and other disorders that impact the lives of the families with which we work.
 
Selected resources/readings
 
First and foremost, contact:
1. CHADD (Children and Adults with Attention Deficit/Hyperactivity Disorder) online at http://www.chadd.org/
 
2. The HALP (Hyperactivity, Attention, and Learning Problems) Clinic at UCSF, Director, Linda J. Pfiffner.
 
HALP’s mission includes three goals:
Service: To make “evidenced-based” clinical services (diagnosis and treatment), factual information, and consultation available to families and community agencies in Northern California.
Research: To discover new knowledge about the possible causes and best ways to treat ADHD and other DBDs (disruptive behavior disorders).
Clinical Education: To train mental health practitioners in the diagnosis and treatment of ADHD and other DBDs.

 
Services: Comprehensive Evaluation, Superparenting 101, Social and Life Skills Training, School Consultations, Medication and Medication Management.
 
How to Make an Appointment
For an appointment call the intake and referral service at 415-476-7500 or 800-723-7140 (toll free).
 
Readings
 
Barkley, R. Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment, Third Edition, Guilford Press, 2006. (if you want to read what the researchers and clinicians are reading)
 
Barkley, R. The Important Role of Executive Functioning and Self-Regulation in ADHD, 2012. Available online at: http://russellbarkley.org/content/ADHD_EF_and_SR.pdf
 
Barkley, R, Murphy, K and Fischer, M. ADHD in Adults: What the Science Says. Guilford Press, 2007.
 
Barkley, R and Robin, A. Your Defiant Teen: 10 Steps to Resolve Conflict and Rebuild Your Relationship, Guilford Press, 2008.
 
Dawson, P. and Guare, R. Smart but Scattered: The Revolutionary “Executive Skills” Approach to Helping Kids Reach Their Potential. Guilford Press, 2009.
 
Hinshaw, S. Is ADHD an impairing condition in childhood and adolescence? In P. S. Jensen & J. R. Cooper (Eds.), Attention-deficit hyperactivity disorder: State of the science, best practices (pp. 5-1--5-21).  Kingston, NJ: Civic Research Institute, 2002.
 
Hinshaw, S. The Mark of Shame: Stigma of Mental Health and an Agenda For Change. Oxford University Press, 2009.
 
Hinshaw, S. P., Carte, E. T., Fan, C., Jassy, J. S., & Owens, E. B. Neuropsychological functioning of girls with attention-deficit/hyperactivity disorder followed prospectively into adolescence: Evidence for continuing deficits?  Neuropsychology, 21, 263-273, 2007.
 
Hinshaw, S. P., Klein, R., & Abikoff, H. Childhood attention-deficit hyperactivity disorder: Nonpharmacologic treatments and their combination with medication.  In P. E. Nathan & J. Gorman (Eds.), A guide to treatments that work (3rd ed., pp. 3-27). New York: Oxford University Press, 2007.
 
Robin, A. L. ADHD in Adolescents: Diagnosis and Treatment. New York. Guilford Press, 1998.
 
Pera, G. Is it You, Me or Adult AD/HD? 1201 Alarm Press, 2008.
 
Quinn, P. and Maitland, T. On Your Own: A College Readiness guide for Teens with ADHD/LD. Magination Press, 2011.
 
Semrud-Clikeman, M. Social Competence in Children. New York: Springer, 2007.
 
Semrud-Clikeman, M. Neuroscience and Neuropsychology of ADHD: Implications for Clinical Practice. Presentation to the 24th Annual CHADD International Conference on ADHD. San Francisco, California, 2012.  Reprints of this talk may be available from Dr. Semrud-Clikeman at (517) 353-9604, semrudcl@msu.edu.
 
Teach, J. “Lost and Unidentified: The Plight of the ADHD Inattentive Female.” Presentation to the 24th Annual CHADD International Conference on ADHD. San Francisco, California, 2012.  Reprints available from Dr. Teach at Kids Enable, Inc., 404-784-0521; email: info@kidsenabled.org.
 
Weinberg, H. “ADHD Comorbidity: Bridging Science and Practice.” Presentation to the 24th Annual CHADD International Conference on ADHD. San Francisco, California, 2012.  Reprints available from Dr. Weinberg at haweinbe@gundluth.org.
 
Zeigler-Dendy, C. Teenagers with ADD and ADHD: A Guide for Parents and Professionals. Woodbine House, 2006.
 
 

 
  
 



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Abour our Organization...


Founded by adolescent specialist Michael Y. Simon, Licensed Marriage and Family Therapist (Lic. MFC 38305), interim high school counseling director at Marin Academy (in San Rafael), noted speaker/educator and psychotherapist in private practice, Practical Help for Parents provides real-life solutions as you parent, support and understand the teens and pre-teens in your life. PHFP offers informative, entertaining, research-based workshops for students and parents, keynotes and presentations to high school and middle school parents, 
teachers and administrators; access to online Practical Help Tips, articles and web resources; and program development and consultation to mental health professionals, policymakers and schools/school districts.

Suggested References for Parents


Chess , S., & Thomas, A. Know Your Child: An Authoritative Guide for Today’s Parents. New York: Basic Books, 1989.

 

Dreikurs, R., & Soltz, V. Children: The Challenge. The Classic Work on Improving Parent-Child Relations—Intelligent, Humane & Eminently Practical. New York: Plume, 1991.

 

Hinshaw, S., & Kranz, R. The Triple Bind: Saving Our Teenage Girls from Today’s Pressures. New York: Ballantine Books, 2009.

 

MacKenzie, R. J. Setting Limits with Your Strong-Willed Child: Eliminating Confl ict by Establishing Clear, Firm, and Respectful Boundaries. New York: Three Rivers Press, 2001.

 

Nelsen, J. N, & Erwin, C. Parents Who Love Too Much: How Good Parents Can Learn to Love More Wisely and Develop Children of Character. New York: Three Rivers Press, 2000.

 

Nelsen, J. N., & Glenn, H. S. Raising Self-Reliant Children in a Self-Indulgent World: Seven Building Blocks for Developing Capable Young People. New York: Prima Lifestyles, 1988.

 

Nelsen, J. N., Lott, L., & Glenn, H. S. Positive Discipline A-Z, Revised and Expanded 2nd Edition: From Toddlers to Teens, 1001 Solutions to Everyday Parenting Problems. New York: Three Rivers Press, 1999.

 

Neumark-Sztainer, D. “I’m, Like, SO Fat”: Helping Your Teen Make Healthy Choices about Eating and Exercise in a Weight-Obsessed World. New York: The Guilford Press, 2005.

 

Ponton, L. The Romance of Risk: Why Teenagers Do the Things They Do. New York: Basic Books, 1998.

 

Roffman, D. Talk to Me First: Everything You Need to Know to Become Your Child's "Go-To" Person About Sex.  New York: De Capo Lifelong Books, 2012.
 

Simmons, R. Odd Girl Out: The Hidden Culture of Aggression in Girls. New York: Mariner Books, 2003.

Simon, M. The Approximate Parent: Discovering the Strategies That Work with Your TeenagerOakland: Fine Optics Press, 2012.

 

Wallerstein, J. S. What About the Kids? Raising Your Children Before, During, and After Divorce. New York: Hyperion, 2003.


 

 

 

Ask Michael...


I have a 16 year-old son with ADHD.  House rules are midnight curfew on weekend nights, and I am if going to a party where we have the name and address of the  party-giver.
One overnight per weekend, and as above, we have to know name and address of where the sleepover is, unless we already know the parents.  He has to let us know by 10:30 pm what his plans for the evening are. He says we are the strictest, meanest parents, and that NO ONE else has these rules.  I'm wondering if we're too strict.



   So, first let me say that no two teens are the same, and ESPECIALLY no two teens with ADHD. You don't say whether your son has ADHD Inattentive, Combined or Hyperactive subtype or when he was diagnosed.  While the new DSM (Diagnostic and Statistical Manual, version 5) is about to do away with the subtypes--there never were verifiable subtypes, anyway, since a child who starts out more hyperactive can often become more Inattentive, and then have many of these childhood symptoms "disappear" in adulthood--knowing how your teen is right now is really important in coming up with the right strategy for him.
 
Teens who are more hyperactive in their ADHD presentation (or who have the combined type) are often more risk-taking (meaning that they more readily seek out novel experience, get bored with the status quo and are more able and willing to argue with parents and externalize blame). They find negotiation difficult because their emotions about how unfair a situation is usually rule. Also, ADHD is a highly comorbid condition, meaning that teens often have another diagnosis in addition to ADHD (like anxiety, depression or a learning difficulty). These other, related diagnoses can often exacerbate the risk-taking, moody or defiant behavior during adolescence.
 
Let me say here that your guidelines are beautiful...very fair, very clear, very reasonable. I don't think, though, that your guidelines are the issue. It's likely that your son was going to argue about them anyway, and most teens need to argue and get a "win" whenever they can...this is a very normal aspect of adolescent development. However, ADHD teens will sometimes argue relentlessly and have trouble seeing the parental side of things (since empathy is a learned set of skills related to executive functioning). Even teens without ADHD often play the "you're the strictest parents in the world" card and insist that no other parents have these boundaries or any boundaries--that's what made me smile so broadly.  I work with hundreds of parents in my role as a part-time school counselor and have worked with or spoken with thousands of teens and their families. Of course other families have these kinds of limits/boundaries. Your "rules" are actually more generous than many.  I suspect you'll hear this response from other parents.  However, "am I too strict?" is neither the point, nor is it the question you'd do well to have answered.
 
I think a more productive question is, "What is the best approach for my son, given his capabilities, strengths and weaknesses?"
 
In other words, what strategy is likely to minimize unproductive conflict, but keep him safe and growing his capacity to respond to these kinds of challenging situations? I think of this as a process of strategizing around limit-setting, given his biology (all his diagnoses, his temperament, his executive functioning capabilities at this point in time, his current state of health, etc.) and his biography (his past history with risk-taking, our ability to negotiate solutions as a family, i.e., how much should i negotiate? do i consider extending the rules a bit and seeing how he does, allowing him to earn broader freedoms or am I certain that this will backfire given his past?
 
Sorry if this sounds overly complicated, but I think that's the truth of the situation of parenting in general.  There is no "one size fits all" approach to parenting that is going to work for every child. Figuring out the "right" limits, whether you're being too strict and not allowing your son to grow his capacity for responsibility, is always about figuring out where your son is starting from, what his current strengths and weaknesses are, and supporting his learning.  What worked for your neighbor will only work for you if you somehow got lucky and came upon an approach in this situation that happened to work well.  Luck is great...and we need it in parenting. But I gravitate more towards a scientific approach that involves studying and knowing your teen well, knowing yourself, and putting together a strategy based upon some knowledge of how adolescents normally develop (or how adolescents with your son's particular strengths and weaknesses) normally develop.
 
A strategy that works will be one that fits your situation best.  If he's a high risk-taker and had accidents often (as many ADHD kids, do), you know you have to keep some firm limits in place, regardless of whether he thinks you're too strict.  You're the parent, you know better...end of story.  So, does he rail at your limits and tell you you're crazy for setting them, but then pretty much follow them, with occasional violations? If so, you're doing absolutely fine.  Teens argue. On the other hand, if he's on the defiant side and will act up and "up the ante" when you (calmly) enforce the limits you've arrived at, you might want to trade his CALM reasoning and negotiating with you for more relaxed limits.  This reinforces his executive functioning, helps him with managing his feelings and gives him a "win" in the negotiating realm...but basically teaches him to rationally "make his case" about changing the limits by insisting that screaming at you about how unfair you are is never going to make it as a technique in your household.
 
You can also (and always) validate his point of view during the discussion--which should in any case, NOT happen at the moment of figuring out whether he's going out that evening or when he's coming up. Discussion of limits shouldn't happen when something is immediately on the line because teens (and parents) are almost never in a state of neurological calmness, and that is the gold standard for a discussion that is productive and progressive.  But what I mean is that you can always say things like, "I can absolutely see why you want to stay out later and why you feel these are unfair rules. If I were 16 and had good friends like you do, and am doing okay in school...I'd feel it was really unfair not to basically get all the freedom I wanted. But since my job as your parent is to keep you safe and make sure that the amount of freedom you get is matched with your ability to handle that freedom without getting into trouble or having negative consequences...well, I'm going to have to keep setting limits.  Those limits could change over time, based upon certain things...so lets talk about what those "things" or conditions are, that could change the limits, ok?  And by the way, any discussion we have, has to be respectful of each other.  If it gets too heated, we'll postpone it and try when we both feel calmer."
 
This approach may or may not work for your son.  You know him best. You know his biology and his biography.  The idea, though, is to talk with your partner, your friends, etc., and use the scientific method: come up with a hypothesis of what will work best for him, try an experiment, gather data, reassess and implement a new strategy.  Gather data and try again. To me, that's parenting.
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