Attention Deficit/Hyperactivity Disorder (ADHD)

As reviewed by Johnston and Mash (2001), families of children and adolescents with ADHD experience a number of difficulties, in contrast to families who do not have offspring with this diagnosis. First, caregivers report higher levels of family conflict and stress and lower levels of perceived competence in the parenting role. They also report lower rates of authoritative parenting, a style blending warmth, limit setting, and autonomy encouragement typically associated with the child's attainment of social and academic competence (Hinshaw et al. 1997). Second, parents of children with ADHD experience greater marital conflict and less marital satisfaction than families of comparison children. Third, direct observations of parent-child interaction (an important area of research, given the potential for biases in self-reports from parents) have reported high levels of parental negativity and harsh/directive parenting to characterize family interchanges, particularly for mothers interacting with their sons who have ADHD. Fourth, children with ADHD are overrepresented in the population of children who have been adopted (Simmel et al. 2001). As in all aspects of research regarding ADHD, however, far more is known about boys than girls; more is known about mothers than fathers; more is known about majority than ethnic minority children (because of a dearth of research on the latter group); and more is known about youth in middle childhood than in adolescence. Nonetheless, this disorder is clearly characterized by family stress and distress and negative parent-child interactions.

Two issues require comment. First, the family variables noted above may pertain as much to aggressive behavior patterns that frequently accompany ADHD as to the core symptoms of ADHD itself. Harsh and unresponsive parenting, in particular, is causally related to the development of aggressive behavior in children (Patterson, Reid, and Dishion 1992); negative parenting and family variables may therefore pertain more to noncompliance, aggression, and covert antisocial behaviors like stealing than to inattention, impulsivity, and hyperactivity per se ( Johnston and Mash 2001). Insecure attachment in early development predicts subsequent aggression but not ADHD. Second, the processes and mechanisms responsible for the associations between family distress and ADHD remain elusive. Indeed, instead of the usual supposition that negative parenting influences difficult child behavior, it is conceivable (given ADHD's strong heritability) that the same genes are responsible for (a) impulsive, harsh parenting behaviors and (b) noncompliant and negative behaviors in the child. In addition, many of the negative behaviors displayed by parents could be a reaction to, rather than a cause of, the child's noncompliant, difficult temperamental and behavioral style. The chains of risk and causation are likely to be reciprocal (with negative parenting triggered by child impulsivity and defiance but also fueling further difficulty in the child) and transactional (with reciprocal chains of influence proceeding through development). Thus, the picture is of a child with early temperamental difficulties and behavior problems, with less-than-optimal parenting serving to amplify problem behavior and set the stage for further negativity and even aggression.