Running head: ADHD AND PARENTING 1
A Guide for Parents of Teens with Attention Deficit Hyperactivity Disorder: An Adlerian
Approach with a Special Focus on Middle Schoolers
A Research Paper
Presented to
The Faculty of the Adler Graduate School
__________________________
In Partial Fulfillment of the Requirements for
the Degree of Master of Arts in
Adlerian Counseling and Psychotherapy
__________________________
By:
Fayemarie Anderson Carter
March, 2014
ADHD AND PARENTING 2
Abstract
This paper is a review of the effectiveness/usefulness of a manual for parents of teens with
Attention Deficit Hyperactivity Disorder (ADHD). The manual discusses ADHD as a
neurodevelopmental disorder and explores the resulting deficits in executive functioning as
conceptualized by T.E. Brown. The manual also covers the effects of ADHD and co-occurring
disorders on the day to day functioning of the adolescent in terms of interpersonal relationships,
academic progress and increased susceptibility to engaging in high risk behavior. The manual
outlines the basic constructs of positive parenting based on an Adlerian approach gleaned from
the works of Alfred Adler, Rudolf Dreikurs, and Jane Nelsen. Finally, the manual provides tools
and information for parents to use as they advocate for their teens. Included is information on
what to expect from schools, insurance companies and professional caregivers.
ADHD AND PARENTING 3
A Guide for Parents of Teens with Attention Deficit Hyperactivity Disorder: An Adlerian
Approach with a Special Focus on Middle School Aged Children
Attention Deficit Hyperactivity Disorder (ADHD) is the most studied
neurodevelopmental disorder among children (Barkley, 1998; Brown, 2013; NIH, 2011). Yet,
misinformation and controversy continue to derail efforts to effectively educate the public,
medical/mental health professionals, parents and school staff which then affects the availability
of adequate treatment for children with ADHD (Arcia, Fernandez, & Jasquez, 2004; Brown,
2008; Nakamura, 2002; Snider & Arrowood, 2003; Stroh, Frankenberger, Cornell-Swanson,
Wood, & Pahl, 2008). As a mental health provider and a parent of children diagnosed with
ADHD, I found myself professionally and personally faced with many of the same issues such as
what approach to take, what information to trust and what providers to use. In his book, Making
the System Work for Your Child, Jensen says that on average, parents take between 4-7 years to
fully gain the expertise they need to navigate the system in order to procure the necessary
resources (Jensen, 2004). The timeframe of 4-7 years suggests that a great opportunity to provide
the proper resources/supports, while limiting the frustration and deterioration of relationships, is
severely compromised.
Taking the brain’s plasticity (the brain’s ability to make connections in response to
stimuli and to mature properly) into consideration, it seems imperative that there should be a way
to cut that timeframe of 4-7 years significantly (Nakamura, 2002). Many children with ADHD
have difficulty maintaining attention so that they may not be able to learn the skills needed to
process information and develop the connections necessary for maturation of the brain (Mishra,
Merzenich, & Sagar, 2013; Nakamura, 2002; Roman, 2010). These children can experience
ADHD AND PARENTING 4
learning delays leading to failure and early dropout; as much as 35% of students with ADHD fail
to complete high school (Barkley, 1998; Bash, 2011).
There is no lack of information available about ADHD but since there is a strong genetic
component, collecting this information and making decisions can be hard for parents, (Brown,
2013). More often than not, a parent of the child with ADHD also has the diagnosis; about half
of the children diagnosed with ADHD have a parent also diagnosed with ADHD (Chronis, 2012;
Nakamura, 2002). The implication is that wading through all the information, on top of the day
to day stress of parenting children with ADHD, can become very overwhelming for those parents
with ADHD, (Chronis, Lahey, Pelham, Williams, & Ralhouz, 2007; Dawson & Guare, 2009).
Lack of adequate and accurate information can lead to parents making ineffective choices that
further delay proper treatment of their children’s symptoms (Stroh et al, 2008).
Having the right tools and resources available is crucial to treating ADHD because
research indicates that untreated, ADHD symptoms can lead to serious social and legal
consequences for those diagnosed (Brown, 2013; Schroeder & Kelley, 2009). Teens with
untreated ADHD are more likely to become involved in high-risk behavior such as reckless
driving; having multiple sex partners and engaging in substance use; experience failure in
school/work; have poor interpersonal skills leading to few positive relationships if any; and have
legal problems (Centers for Disease Control and Prevention, 2011; Litner, 2003). This has been
associated with a higher risk of developing other mental health issues as adults (Brown, 2013;
Litner, 2003).
Caregivers, in general, seem to react to this by becoming more punitive, disapproving and
controlling (Hectmann, 2004). At the same time, caregivers are also less likely to actively
“notice” and reward positive and appropriate behavior (Harvey, Metcalfe, Herbert, & Fanton,
ADHD AND PARENTING 5
2011). This style of parenting known as the “authoritative style” or “negative parenting” is
associated with increased rejection by peers and increased physical aggressions towards peers
(Harvey et al, 2011; Kaiser, Pfiffner & McBurnett, 2007). Parents involved in this behavior
pattern can experience increased levels of conflict with their child resulting in high levels of
stress, health issues, strained relationships leading to divorce, job loss, alienation of friends and
other family members, substance abuse, and a general poor quality of life (Webster-Stratton,
Reid, & Beauchaine, 2011). Research supports that parent training in positive parenting
techniques results in increased appropriate/productive behavior in the teens and improved
relationships between parents and children (Healey, Flory, Miller & Halperin, 2011; Sheridan &
Dee, 1996;).
These following factors taken into consideration make a compelling argument for the
need for a manual. 1. On their own, parents can take 4-7 years to learn the ins and outs of getting
support. 2. Childhood is short and there is a limited time during which the right opportunities
need to be afforded for the proper maturation of the brain. 3. Parents of children with ADHD
may also share the genetic link so that symptoms like inattentiveness and distractibility might
sabotage even the most determined parent from getting and organizing information in order to
make sound decisions. 4. Research shows that untreated ADHD can be quite costly to the child,
caregivers and to society as a whole. 5. Research also supports the use of positive parenting with
children with ADHD.
ADHD and Parents
National Sources
I was very careful not to deliberately only find information which supported my beliefs
about ADHD or parenting children with ADHD. I searched databases using very broad terms
ADHD AND PARENTING 6
like “ADHD and Parenting” and let the research direct what information I would gather and
share. Much of the research, although not necessarily presented as Adlerian based, supported
exactly what is considered Adlerian, the most useful being the endorsement of positive parenting
as having the best results with children with ADHD (Cheong, Pedersen, Molina, Pelham, &
Wymbs, 2012; Stroh et al 2008). As such, I integrated several different approaches into what I
hope can become a working theory of how to treat ADHD.
Recognized Experts
One of the key elements included in the manual is the approach taken by Brown. Brown
is the Assistant Clinical Professor of Psychiatry at the Yale University School of Medicine and
Associate Director of the Yale Clinic for Attention and Related Disorders. He has written books,
presented his findings all over the world and writes regularly for the online magazine
additudemag.com. His efforts have been directed towards developing an understanding of
ADHD in terms of deficits in the brain’s ability to manage executive functions. He claims that
too many still see ADHD as a “lack of will power” rather than the true underlying issue which is
impaired brain chemistry (Brown, 2013). He divided these executive functions into six main
clusters including: the ability to initiate tasks within a time frame; ability to sustain attention and
the ability to regulate emotions in order to complete tasks (Brown, 2008). Brown says that
having ADHD is like being a musician in an orchestra without a conductor. All the musicians
can play individually but without the right direction, they can’t make great music together
(Brown, 2013). So then, a child with ADHD has many capabilities; he/she just cannot effectively
use them in order to start an action, follow through, or complete it, without support (Brown,
2013). Understanding that a teen is simply unable to do certain things due to neurobiological
processes outside her/his control should change the kinds of expectations that caregivers and
ADHD AND PARENTING 7
professionals have on teens and result in more realistic and attainable goals (Shaw, Evans,
Ekstrand, Sharp, & Blumenthal, 2007).
It is Brown’s Model (Brown, 2008) and his emphasis on executive functioning that led to
the focus on middle school aged children. Middle school is such a time of transition (Hoffman,
2009). Developmentally, it is that in between time of not being a child but not being a teen
either. The influx of hormones leads to a heightened emotionality, increased impulsivity, sexual
awareness, and if that weren’t enough, sleep disregulation (Goodings, Burnett- Heyes, Bird,
Viner, & Blakemore, 2012; Konrad, Firk, & Uhlhaas, 2013; National Institute of Mental Health,
2011). Academically, there are more demands on the student (Jacobson, Williford, & Pianta,
2011). No longer do students have a single homeroom teacher. They have 6-7 different teachers
and must change classrooms for every subject. There is an increase in workload to balance
against an increase in opportunities for extra-curricular activities. Children who may have once
had after school care are now expected to be on their own for those hours between school release
and when their parents get home (Molina, Arnold, & Vitiello, 2008; Public Broadcasting
Systems, 2014; Hoffman, 2009). Middle school demands everything a teen with ADHD already
lacks or is just not proficient in (Brown, 2013, Jacobson et al, 2011). All those skills Brown talks
about as being underdeveloped in a teen with ADHD are exactly the ones that being in middle
school demands. It would seem then that it is very important to provide extra support at this
time. It could be very detrimental for an adolescent to experience continued failure and increased
conflict with parents and teachers as a result of less than adequate support (Nelson, Young,
Young, & Cox, 2010). Providing the right framework, resources and tools can mitigate the
effects of such a challenge (Corkum, McKinnon, & Mullane, 2008; Cheong et al, 2012; Jensen,
2004).
ADHD AND PARENTING 8
Adlerian Parenting Proponents
Adler believed in prevention and in fact was one of the first to promulgate this approach
by developing Child Guidance Clinics where he trained parents and teachers to raise children in
a way that would develop “social interest” or concern for others and the world we live in (Bitter
& Main, 2011). He believed that once children developed that, they would, as adults, act in ways
that benefited themselves and society (Nelsen, 1996).
A basic Adlerian premise is that individuals are “indivisible” and so cannot be
understood in isolation or only in terms of symptoms and diagnoses but rather within the context
of our environment (Dreikurs, 1990). Because Adler believed we are social beings with a desire
to “belong” and feel “significant”, he believed we have the responsibility to foster an
environment which places value on equality and respect for difference (Carlson, Dinkmeyer, &
Johnson, 2008). Without this, a child can become discouraged and act out in maladaptive ways
in order to still feel that sense of belonging and significance, what appears to others as
“misbehaving” (Dreikurs, 1990; Nelsen, 1996). He believed that if you find the “purpose” of
misbehavior rather than a “cause” you can redirect a child to find more positive ways of serving
that purpose and meeting his/her needs (Bitter & Main, 2011). Looking at behavior in terms of
needs rather than causes is very useful because needs don’t necessarily change and still have to
be met (Nelsen, 1996). Eliminating maladaptive behavior necessitates replacement behavior then
so that a teen, in an effort to have her/his needs met, doesn’t resort once more to maladaptive
ways (Dreikurs, 1990; Nelsen, 1996).
In Children: The Challenge by Rudolf Dreikurs (1990) what was striking is how relevant
his work still is even fifty years later. This idea he postulates that we just don’t know what to do
with our children today because our values have changed so much is still exactly where we seem
ADHD AND PARENTING 9
to be today. Dreikurs says that we know that the old “do as I say” model just won’t work today
in a democratic society but we seem to still struggle with finding a replacement parenting
ideology. My own experience as a mental health provider and a parent, together with the
conclusions drawn by others in the plethora of research papers and books I have read as a
student, make it painfully clear that parents, teachers and caregivers are not in agreement with
how to deal children in general, much less children with special needs (Basch, 2011; Carlson et
al, 2008; Chronis & Stein, 2012; Harvey et al, 2011; Healey et al, 2011; Webster-Stratton et al,
2011)
A more current Adlerian is Jane Nelsen, who writes as a professional and a parent of
seven children in her book Positive Discipline (1996). Nelsen wrote her first book because she
found that old parenting techniques just did not work with her children. She found herself using
threats, spanking and yelling and still everyone was miserable and nothing was changing. She
says that as she was studying Child Development in college, she was excited by the all the
information being imparted to her about all the wonderful things she could accomplish with her
children but there was nothing showing her how to do it. This is when she was introduced to
Adlerian thought and as she began to apply what she was learning, she found that her children
were responding so well, that she was able to eliminate most of the negative behavior and found
herself once more enjoying being a parent.
Over the years she has shared her knowledge with thousands. Of note is that she explains
key concepts as well as provides a failsafe by addressing the ways we could misinterpret or
misapply these concepts. That was most evident in how she very carefully outlined the
differences between logical consequences and punishment. She tries to make sure that parents
don’t, out of habit or stubbornness, disguise punishment as a logical consequence thus
ADHD AND PARENTING 10
sabotaging the effectiveness of the technique. She does the same in explaining why praise is not
useful but that encouragement is. Relating the concepts to real life occurrences is very helpful
because it could reduce the amount of frustration and feeling of failure that could happen when a
technique is incorrectly applied.
Other Parenting Experts
Other sources included Taking Charge of ADHD by Russell Barkley (1998); Making the
System Work for Your Child with ADHD by Peter Jensen (2004); Smart but Scattered by Peg
Dawson and Richard Guare (2009) and A New Understanding of ADHD in Children and Adults:
Executive Function Impairments by Thomas Brown (2013). In all of them, there is an urgent
appeal for the education of parents and providers about the far reaching consequences of
untreated ADHD. Brown in his first chapter (Brown, 2013) seeks to dispel over thirty myths
about ADHD. It is baffling that there is still so much controversy surrounding even the existence
of ADHD since it has been discussed in various terms in medical journals since the 18th
Century;
its symptoms in children were described by Sir George Frederick Still in 1902; and formally
treated by Charles Bradley with Benzedrine in 1937 (Pediatrics.com, 2014). In testimony given
before the United States House of Representatives, that is exactly what Nakamura discussed
(Nakamura, 2002). He presented a statement, signed by scientists from all over the world,
asserting there is great concern that even mental health professionals are contributing to the
perpetuation of myths surrounding ADHD.
It would follow then there needs to be a more cohesive path for treatment. Some of the
case studies I read were about how parents, teachers and mental health providers arrive at the
diagnosis of ADHD. Time and time again, teachers interpreted the behavior of the same child
differently while parents focused disproportionately more on what was not working and very
ADHD AND PARENTING 11
little if at all on the strengths of their children (Chronis, Lahey, Pelham, Williams, & Rallouz,
2007; Navarro & Danforth, 2004; Spiro, 2013,). Brown says the problem we continue to face
when trying to get support for our children is too many of us still want to treat ADHD as a
behavioral disorder when it is a neurodevelopmental disorder (Brown, 2013). There is little to
support that Cognitive Behavior Therapy (CBT) works yet it seems the go to for those treating
ADHD (National Institute of Mental Health, 2011). The largest study on ADHD, the
Multimodal Treatment of Attentions Deficit Hyperactivity Disorder or MTA, has found that
parent training in combination with medications seem to have the highest rate of success for
treating ADHD (MTA, 1999, 2009). These results have been replicated in other studies (Cheong
et al, 2012; Hoffman, 2009, Wilens, et al 2011,). It would seem then that all efforts must be made
to facilitate a paradigm shift. The approach to treating ADHD must change from behavior
focused to treating ADHD within the context of deficits in executive functioning.
Advocacy
A parent can be a child’s strongest advocate. As stated before, even the professionals
can’t agree on what to do. Convention was that you leave it to the experts but since the needs of
a child with ADHD are so nuanced, especially when additional diagnoses are made, a parent
must become a child’s strongest ally in getting his/her child’s needs met (Jensen, 2004). Most
children with ADHD will have other co-occurring diagnoses, as many as 70%, so there is a lot to
keep up with (National Resource Center,2003; Patel, Patel & Patel, 2012). What often happens is
that a child with ADHD has many different providers and most of them are not in
communication with each other, things get overlooked and misdiagnosed (Spiro, 2013) Adler
believed the client is the expert on himself/herself. As an extension then, the parent is the expert
of the child until such time he/she can advocate for himself/herself. This is why the final part of
ADHD AND PARENTING 12
the manual discusses how a parent becomes an advocate for his/her child and then ways a child
can advocate for himself/herself.
This section takes the approach that everything is relationship based. It talks about ways
to interact with medical personnel, mental health providers, insurance companies, and school
staff. There is some discussion about communication styles and how to access information and
services. Jensen (2004) believes that the parent must take the stance that she/he is everyone’s
employer while displaying respect for the expertise of those with whom he/she is working. It’s a
tough balance but learning to accept that he/she will make mistakes goes a long way to gaining
experience and savvy about being an advocate (Jensen, 2004). Dr. Peter Jensen reminds parents
that ADHD, like asthma and diabetes, is chronic. Parents must remember that this is for the long
term and many hurdles will need to be overcome. Included in this section is an outline of
Jensen’s guiding principles for parent advocates.
Summary
Personal Evaluation
Writing this manual was many years in the making. Perhaps, it wasn’t clear that a manual
was how the knowledge I have gained would be encapsulated but I kept collecting data
nonetheless. My passion for anything ADHD related is not accidental. My husband and my two
children are diagnosed with ADHD as well as co-occurring disorders. In the early years of my
marriage we were living in the southern United States. The symptoms were not recognized as
ADHD and as a result, a lot of frustration and embarrassment ensued as my children
continuously “misbehaved”. There were many looks of disapproval and outright alienation of my
children. As time went by, invitations for play dates and birthday parties grew less and less until
there weren’t any. Grades suffered and concern deepened.
ADHD AND PARENTING 13
Even as I attended graduate school in Mississippi, no answers came to me. It was not
until I attended Adler Graduate School, Minnesota that in one of my first classes, someone
suggested that my children might have ADHD. My first reaction was not one of relief, but rather
one of horror. It was as if someone gave me a death sentence. All I had was my experience in
Louisiana and Mississippi where ADHD was what “bad children” had. It was what happened
when children had really bad parents who could not discipline them and “raise ‘em right”. I was
ever more determined to employ every behavior modification technique I could find using
sticker charts, coupon books, and token economies all with dismal results. Much to my
frustration, many websites, some notable, still espouse these techniques as an important part of
treating ADHD. Finally, we were all put on a better path as my younger daughter was diagnosed
and then consequently the others.
We all experienced relief at finally having a name for this “thing” but that was not the
“all inclusive” answer we would have wanted it to be. There was a lot of figuring things out and
learning who and what to trust. Some therapists helped, some definitely didn’t. Some
psychiatrists were more willing to try different medications; others weren’t. Sometimes the
teachers were at their wits’ end having tried every intervention and both girls ended up needing
day treatment at different points. I could have used a manual like this very one I wrote.
When I worked as a mental health provider in a classroom with students with emotional
and behavior disorders, parents pretty much said the same thing. By the time they get a
diagnosis, they are at the end of their rope and just want the experts to take over. Then when it
doesn’t quite work that way, given that we are working with children and not treatment plans,
frustration is just too inadequate a word to describe what one experiences. Supervisors want
measureable results to justify the money we charge the schools; schools need those numbers too
ADHD AND PARENTING 14
to justify the existence of the programs to the school board and so on. How does one measure
latent learning and prove inadequate chemistry in the brain without brain scans and the like? Had
I the knowledge of Brown’s Model at the time, I would have been more sure in my estimation of
the issues and “progress”. ADHD was only superficially discussed in those terms and usually
more vaguely under the umbrella of “delayed brain development”. The emphasis was always on
behavior interventions that just went nowhere, often seeing less than 50% compliance. Even if I
couldn’t have directly changed the school’s approach, I could have better educated my parents as
to how to respond to their children as well as emphasized the right types of resources being used
and accommodations being made in the Individualized Education Plans (IEP’s).
Writing this manual forced me to take everything I “know” and put it in terms of
supporting statistics, research findings and well established constructs. It has been quite
beneficial in this way since it can serve me well as a professional and as a parent. I now have a
working set of organized information from which to draw whenever I might need to lend support
to others or to simply remind myself as a parent when I find myself wavering and unsure of what
to do.
Participants Evaluation
Copies of the manual were distributed in several ways: on a personal blog, at a parent-led
group as well as individually to parents of children with ADHD and providers who work with
children and families. Readers found it easy to follow, understand and said that in general, they
learned a lot of new things they feel they can apply.
Proposed Improvements
One overall criticism was that there was not enough time at the oral presentation for
questions. There was a delay at the beginning of the group session as we waited for other
ADHD AND PARENTING 15
members to come. As such we ran out of time at the end for clarifications and questions. This
taught me that I need to be less accommodating to those who are delayed because it affects those
who did show up on time ready to learn. My responsibility should be from now on to the ones
who show up on time first, then to others as time and opportunity allows. I am sure this lesson
will serve me well in the future.
Another shortcoming was that the venue did not have a way for me to do a PowerPoint
presentation. It couldn’t helped this time around because of various circumstances but in the
future, I would definitely want to make sure that there is enough time to plan around those kinds
of issues. I felt that my ability to be a little more at ease in my presentation was limited by this. I
had to refer to the manual very often, which pulled my attention from my audience as I had to
keep looking down at the pages, rather than simply point at something and expound. To make
sure this does not happen again, I definitely need better technology available to me. The more
comfortable I am, the more comfortable my audience will be.
Future Plans for the Manual
This manual is part of my final requirements for completion of my Master’s degree in
Counseling. Even if I never shared it with anyone again, it has already accomplished so much in
my personal journey of learning and developing my own approach to therapy. In the process, I
gained new insight, solidified others and laid the groundwork for more investigation and
continued growth. Writing this manual has reignited a certain passion to reach out to parents of
children with ADHD, not only from the weird intimate yet anonymous world of the internet on
my blog, but once more providing services as a mental health provider . It has been two years
since I have worked in the field. It is time to go back, this time with a firmer grasp on the
ADHD AND PARENTING 16
Adlerian approach and more in depth knowledge about research findings with regards to brain
development.
As for sharing the manual, of course I will. I firmly believe as Adler did that in order to
accomplish anything with one client, there must be a supportive environment in which he/she
should live. The only way to do that is to take every opportunity to educate everyone about the
benefits of a democratic society which extends respect, acceptance of difference and concern for
others. This is an ideology which supports the development of positive parenting as the standard.
That goal is very expansive of course so as my contribution, I will start by making my manual
accessible via my blog and look into the possibility of getting it officially published. I hope to
use it as a resource with clients as well as a presentation tool. It’s been in the back of my mind
for some time, to create a relationship between schools and the mental health community with
the singular intent of educating school staff in a greater understanding of ADHD and more
effective ways of supporting students and parents.
One thing I would like to add would be a section perhaps at the end, about self -care. I
think that as I watched the manual grow in length, I tried to keep the topics to a tighter scope but
that is an aspect that could definitely be included. It is a very useful lesson for parents to teach
their teens to take care of their bodies and prepare their minds for the work of everyday life.
Modeling that healthy lifestyle definitely benefits everyone as it teaches how to handle stress and
withdraw and recharge in a purposeful, planned manner. Indeed, that could be a whole manual
all by itself.
Change takes time and can appear not to be taking place at all. How does one determine
which changes are most important and how does one go about it or measure it or knows when it
has been affected? It is easy to become overwhelmed with the complex challenges presented by
ADHD AND PARENTING 17
ADHD. It has such far reaching effects on so many. It could be easy to forget all the wonderful
things ADHD allows for like creativity; different ways of interpreting data, revealing things not
otherwise observed; risk taking which leads to discoveries made by the adventurous and so on. It
is to all our benefit then that we lend support which allows our children with ADHD to develop
those skills necessary to become productive members of our society. Hopefully, manuals like
mine, continued research and community outreach efforts will get us closer to that end.
ADHD AND PARENTING 18
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