When ADD Means 'Acceptance Deficit Disorder'?

We all tend to parent the way we were parented. Some parents may react to that pattern from their past by rejecting it, but then may have no good parenting plan of their own, and may explode at the end of the day from the infinite number of "wrong" things that their child with ADHD managed to fit into the past 12 hours. This accumulated rage is worse from the child’s point of view, because the ultimate size of the explosion seems undeserved by the last little behavior that finally set it off. Plus, with their time disconnect, children with ADHD probably couldn’t remember the last thing they did wrong, much less all their other faults for that day, making the explosion seem even more unfair. To the child, the parent’s outrage may have the impact of an undeserved assault, which is something that often provokes a tendency for opposition over time. It takes some work to convince parents that their conclusion (that is, that the huge number of little misbehaviors means the parents need to step up their correction) is backwards. Asking them to consider "ignoring more" presents a shift in how they thought family life was going to be, but it is good advice in setting a happier tone at home. And asking the nit-picking parent, "How is it working?" and ultimately, "What would you like your relationship with him to be like 10 years from now?" helps him or her reorient to the Big Picture.

"Maybe if you just let him know who is boss" is the kind of input parents may hear from family and friends that can push them to feel that their management is lacking. Even teachers may subtly (or not so subtly) suggest that consequences at home "might make him act better at school," even when evidence is clear that the core features of ADHD are not improved by actions taken long after the time of the behavior. You can often find out about these pressures by asking parents, "What have others been telling you about your child’s behavior?" so that you can counter this notion with facts.

Do our patients deserve all the bad press we hear from their parents? Any clinician who has spent 20 minutes in the room with a hyperactive 7-year-old – protecting the box of medical gloves, catching him as he flies off the exam table, sweeping up the crumbs after she leaves – can identify with parental desperation. You can reflect that "she is a bundle of energy," but be sure to ask, "How are you and your partner holding up?" The stress is real and deserves to be addressed. Behavior management counseling has been shown to improve outcomes for the child, but don’t forget that parents also may need referral for themselves or their marriage to cope with the child with ADHD.

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Elsevier. E-mail her at pdnews@elsevier.com.