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Section 22
Interventions for the Families of Children with ADHD

Question 22 | Test | Table of Contents

Parent Training and Counseling
Parent training can be effective in reducing activity level, conflict, and anger intensity and in increasing on ­task behavior and compliance of children with ADHD (Fiore, Becker, & Nero). Parent training is the second most widely used treatment (next to medication) for ADHD. It has long been recognized that increased parental competence has a positive effect on the behavior of children (Goldstein & Goldstein; Hunt & Cohen). Parent training may be particularly responsive to the specific needs of children with ADHD and their parents during the preschool period, when noncompliance is acute and parental stress often is at a peak (Pisterman et al). It is my experience that parent training and counseling can generally be delivered together and completed in an 8- to 12-session cognitive-behavioral treatment program that is used either with individual families or with several families in a group therapy format (Anastopoulos & Barkley). Shaywitz and Shaywitz believe that the main therapeutic objective for children and adolescents with ADHD and their parents is to learn methods or techniques of coping and compensating for this ongoing learning and behavioral disability. Generally, parent training and counseling, based on the Anastopoulos and Barkley model, is delivered during the course of 12 or fewer sessions in either an individual or multifamily format. Because no evidence exists for one intervention or approach being superior to the other (Anastopoulos & Barkley), the mental health therapist should carefully consider and probably comply with the parents’ preference. Anastopoulos and Barkley believe that clinicians should not have a specific or inflexible number of parent training or counseling sessions. Rather, parents should be guided by the mental health therapist through the treatment, taking as many sessions as necessary to bring about the desired therapeutic change. The sessions should typically include the following: (a) program orientation; (b) understanding parent-child relationships and principles of behavior management; (c) enhancing parental attending skills; (d) paying positive attention to appropriate independent play and compliance; (e) establishing a home token system; (f) using time out to handle noncompliance; (g) extending time out to other misbehaviors (time out, however, is often less effective with adolescents); (h) managing children’s behavior in public places; (i) handling future behavior problems; and (j) a booster session that may later summarize the content or refine the procedures.

Mental health therapists should be aware that children with ADHD frequently demonstrate other difficulties or co-occurring conditions such as aggression, oppositional defiant disorder, conduct disorder, academic underachievement, low self-esteem, depression, peer and sibling relationship problems, enuresis, and encopresis (Anastopoulos & Barkley). Biederman, Newcorn, and Sprich found that the literature supports considerable comorbidity or co-occurrence of ADHD with oppositional defiant disorder, conduct disorder, mood disorders, anxiety disorders, borderline personality disorder, and learning disabilities. Many children with ADHD have co-occurring language deficits or problems (e.g., with covert speech or in carrying on an internal conversation) and find articulation or verbalizing to be a tenuous function that often is overwhelming (Barkley; Goldstein & Goldstein; O’Brien). These difficulties or co-occurring conditions need to be considered carefully in developing and implementing interventions. In addition, the parents of a child with ADHD can be at a high risk for codependence. Although caring parents feel the distress of their child with ADHD, excessive identification with the child’s problems or pain is unhealthy. Parents who are consumed by caring for the child with ADHD can be attempting to shield themselves or their families from the realities or problems often connected with the disorder. Parents may need to receive counseling and training to change their perspective and make a distinction between the needs of the child with ADHD and their own. Although ADHD is a pervasive condition that affects the entire family and must be viewed in such a context, I believe that there are times when the mental health therapist should depart from the family counseling format. Difficult issues for the child with ADHD, such as low self-esteem and depression, may best be handled in individual sessions unless the child feels comfortable with particular issues in the presence of parents and siblings (Robin).

Focal Points of Intervention
It is my contention from experience as a therapist that effective mental health counseling with a child who has ADHD should focus, in most cases, on the following: Understanding ADHD characteristics and problems and the comorbidity or co­occurring conditions that may accompany the child diagnosed with ADHD. The clinical reality of the lives of clients with comorbidity is complicated (Clarkin & Kendall). • Changing the faulty communication patterns that evolved within the family because of ADHD (e.g., for parents and siblings to stop blaming, punishing, or being angry with the child who has ADHD for behavior that usually arises from the disorder). • Establishing realistic--not heightened--behavioral, academic, and social expectations for the child with ADHD. • Providing the child with ADHD with consistent parental supervision, setting behavioral boundaries that are achievable, and using immediate, but fair, consequences for noncompliance or misbehavior. Kirby and Grimley voiced the concern that ADHD is a self-regulatory difficulty that requires frequent monitoring by parents and teachers. • Observing closely at home and with teachers the role and effects of medication on the child with ADHD. The most common contemporary treatments for ADHD are psychostimulant medications, which often are a routine component of treatment regimens (Barkley; Henker, Buhrmester, Hinshaw, Huber, & Laski; Peiham et al.). • Ensuring that the child with ADHD receives heavy daily doses of positive reinforcement from parents and siblings for appropriate on-task behavior. • Taking advantage of or creating opportunities to enhance social functioning for the child with ADHD. Most children diagnosed with ADHD have extensive and enduring problems in the social realm (Whalen & Henker). • Involving peers at some point in treatment as part of the family counseling program.

In developing a treatment plan for the family, it is important to adopt a multidimensional approach. Goldstein and Goldstein and Satterfield, Satterfield, and Cantwell advocated the combination of medication, parent counseling and training in child management, parent education, cognitive mediational training, social skills training, academic support, classroom consultation, and individual counseling for children with ADHD. Also, factors such as socioeconomic status and family support can positively or negatively influence the outcome of ADHD and need to be considered.

There are no long-term findings or evidence that one counseling strategy or approach is singularly effective in treating children with ADHD. These children usually present a serious range of problems at home and at school and in the community. At present, it seems that a multidimensional or multifaceted treatment model offering a combination of interventions provides effective management of the wide range of problems experienced by children with ADHD (Goldstein & Goldstein).

Finally, in the context of family counseling, it is important for the entire family to obtain help in coping with the problems that result from having a family member with ADHD (Nussbaum & Bigler).The degree to which the family finds successful modes or interventions to cope with the symptoms and problems associated with the disorder will ultimately determine the prognosis for the family. I believe that each child or adolescent with an attention deficit disorder (ADHD) is unique and typically exhibits some combination of symptoms; they can occur with varying degrees of intensity (at school or in the family) depending upon the biological and environmental forces that can be operating. Mental health therapists should be alert to the predominant symptom pattern that is common to the diagnosis for the different subtypes of ADHD (e.g., inattentive type, hyperactive-impulse type, combined type) and consider matching interventions or treatment with the principal behavioral, social, and emotional symptoms. Other interventions, medication, and educational specialists need to be evaluated by the parents and professionals in combination with the recommended interventions. Interventions and their effects have the potential to overlap and are intended to be ongoing or long-term so as to enable optimum outcome.

Conclusion
The prognosis is diminished for children with untreated ADHD and their families (Kirby & Grimley). Counseling that involves the entire family has the potential to motivate children with ADHD, improve their self-esteem and self-concept, and help them improve social skills or functioning. The following could be benchmarks or signposts that reflect the effectiveness of family counseling for a child who has ADHD: (a) improved parent and sibling communication patterns and functioning (e.g., familial harmony), (b) improved academic performance, (c) improved peer relationships, (d) increased compliance with on-task behavior, and (e) decreased moodiness or depression. It is my contention that the unity of the entire family in becoming clinical allies in an ongoing multidimensional treatment plan offers the greatest chance of success in treating the child with ADHD. Accepting and nurturing the family member with ADHD from childhood, to adolescence, to adult life, despite multiple frustrations, may prove to be the best form of assistance or therapy.
- Erk, Robert R; Multidimensional treatment of attention deficit disorder: A family oriented approach; Journal of Mental Health Counseling; Jan97, Vol. 19 Issue 1, p3

Personal Reflection Exercise #8
The preceding section contained information about interventions for the families of children with ADHD.  Write three case study examples regarding how you might use the content of this section in your practice.
Reviewed 2023

Update
Associations between Family Functioning and Symptoms of
Attention-Deficit Hyperactivity Disorder (ADHD): A Cross-Sectional Study

- Choksomngam, Y., Jiraporncharoen, W., Pinyopornpanish, K., Narkpongphun, A., Ongprasert, K., & Angkurawaranon, C. (2022). Associations between Family Functioning and Symptoms of Attention-Deficit Hyperactivity Disorder (ADHD): A Cross-Sectional Study. Healthcare (Basel, Switzerland), 10(8), 1502. https://doi.org/10.3390/healthcare10081502


Peer-Reviewed Journal Article References:
Shahidullah, J. D., Carlson, J. S., Haggerty, D., & Lancaster, B. M. (2018). Integrated care models for ADHD in children and adolescents: A systematic review. Families, Systems, & Health, 36(2), 233–247.

Smith, Z. R., Eadeh, H.-M., Breaux, R. P., & Langberg, J. M. (2019). Sleepy, sluggish, worried, or down? The distinction between self-reported sluggish cognitive tempo, daytime sleepiness, and internalizing symptoms in youth with attention-deficit/hyperactivity disorder. Psychological Assessment, 31(3), 365–375.

Weyers, L., Zemp, M., & Alpers, G. W. (2019). Impaired interparental relationships in families of children with attention-deficit/hyperactivity disorder (ADHD): A meta-analysis. Zeitschrift für Psychologie, 227(1), 31–41.

QUESTION 22
When conducting training for the parents of an ADHD child, what are five of the key topics to include in the sessions? To select and enter your answer go to Test.

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