Stop Being Difficult

Charlie, an eight-year-old Latino boy, was referred to a community mental health clinic by his school due to academic difficulties and behavioral problems. His teacher reported that Charlie is almost intolerable in the classroom. He tended to throw tantrums, cried often when asked to do something, and was disrespectful to the teacher. In particular, he had a habit of saying no and “I don’t care” to the teacher. Moreover, Charlie tended to talk during class, blurt out answers, would get up without permission and seemed not to pay attention when work needed to be done. This has led to many conferences with the teacher, which his mother has had to miss many days of work to attend. According to his mother, the situation is not any easier in the home. His mother reported that her son seemed to be generally “out of control” at home often not listening to her commands and throwing tantrums until “he gets his way.” She complained that Charlie seemed to forget easily, argued with her a lot about completing chores or finishing homework, and would loose many of his school materials. Finally, she reported he was even more difficult to control when in public places. When Charlie’s mother was probed further, she indicated that he has been “fussy” since he was a child. She recalled that the issues began when Charlie began preschool at around age three.
This scenario may seem familiar to many parents, teachers, and educators. Charlie and children like him most often are labeled as “difficult” or “defiant children”. They may be ostracized from social groups, events, and singled out as “trouble makers.” This may lead them to feel isolated, depressed, frustrated, and often confused about how to control their behavior. Yet, most of these behaviors seen in Charlie and others like him fall under the category of Attention-Deficit/Hyperactivity Disorder (AD/HD). Although these symptoms can be nothing short of exasperating, it is important to remember these children who seem to be inattentive, annoying, or acting embarrassing are not acting willfully. Children with AD/HD want to sit quietly; they want to make their rooms tidy and organized; they want to do everything their parent says to do, but they do not know how to make these things happen.
According to American Psychiatric Association (2000), AD/HD is usually characterized by a persistent and constant pattern of age inappropriate levels of inattention, impulsivity, and/or hyperactivity. In other words, Charlie forgets things, acts without thinking, and cannot sit still. This disorder tends to affect 5-7% of the general child population in the United States and is frequently one of the number one reasons for referrals to mental health professionals (Barkley, 1998). There is no single medical, physical, or other test for diagnosing AD/HD. To be diagnosed there is a wide array of criteria, including measures for testing that assist health care professionals to reach a diagnosis. They may use a number of different tools such as a checklist of symptoms, answers to questions about past and present problems, or a medical exam to rule out other causes for symptoms.
The medical presentation of this disorder places many young children at risk for a plethora of social difficulties across their lifespan. As preschoolers, these children may place tremendous demands on their parents and caregivers and may frequently display aggressive behaviors when interacting with other children or siblings. Furthermore, as they move into the elementary school years, academic problems start taking on increasing importance.
Coupled with ongoing family and peer relationship issues, academic difficulties may set the stage for these children to develop low self-esteem and other emotional disorders. Although similar issues may be ongoing into adolescence, they may appear at a more intense level. New problems may arise such as, experimentation with drugs and alcohol, that may come from the increasing demands for independence placed on them by parents and society. Aside from these individuals being affected by the major symptoms of AD/HD, they are at a higher risk for developing other psychological issues. A few of the most common include depression and anxiety disorders, which may worsen during adolescence. Among adults with AD/HD, they are at a high risk for depression and substance abuse.
Subsequently, when defining and explaining the many characteristics of AD/HD we must also consider the risk factors. That is, the factors that may increase the likelihood that the disorder will develop. Although risk factors make it more likely that a child may develop AD/HD, it is also important to realize that not every child with these risk factors will develop the disorder. While the exact causes of the disorder are not known, children with AD/HD are more likely to have had risk factors such as a first-degree biological relative with the disorder, brain trauma experienced during pregnancy, delivery, or post-partum. Another factor that may increase the likelihood is drug or alcohol use during pregnancy. Conversely, there are also some common misconceptions about the causes of AD/HD. The most prevalent misconception is that bad parenting causes it (though a disorganized home life and school environment can increase symptoms). Others include lack of vitamins, too much sugar, too little sugar, too much television or videogames, and improper diet.
Although parenting styles may not be the cause of AD/HD, it may influence the appearance of the disorder. AD/HD can have a significant impact on the psychological and social functioning of the parents and caregivers of these children. This misconception may be the most difficult to dispel because parenting characteristics (i.e., being critical, commanding, negative) and poor management do make AD/HD symptoms worst and increase the risk for psychological disorders (e.g., oppositional defiance and conduct disorders; Barkley, 1998). While management difficulties influence parent-child conflicts and the maintenance of hyperactivity and oppositional problems in young children, Barkley (1998) concludes that “theories of causation of AD/HD can no longer be based solely or even primarily on social factors, such as parental characteristics, caregiving abilities, child management, or other family environmental factors.” However, research has shown that parents of these children tend to become overly directive and negative in their parenting styles. Parents may experience considerable stress and may view themselves less skilled and knowledgeable in their parenting roles. Other issues such as marital discord and parental depression may also arise. These may be due in part to the increased care taking demands that children with AD/HD place on their parents including, not following through on parental instructions. Additionally, parents often have to deal with getting involved in various school, peer, and sibling difficulties that may begin in childhood and continue through to adolescence (Kazdin & Weisz, 2003). This may place many parents, especially in single parent homes, with the added stress of financial and occupational difficulties due to missing work to attend to such matters.
Conversely, the presence of parental psychological issues may affect the way parents react to children with AD/HD. Parental mental illness may lead to less patience when dealing with the forgetfulness, hyperactivity, or inattention often displayed by these children. Parents may want to react to these issues by imposing stricter sanctions or physical punishment for the perceived misbehavior of the child. This may leave the child further at risk for physical abuse by the parents or caregivers. Furthermore, environmental factors such as poverty, discrimination, lack of services may also play a role in the ability of parents to meet the demands of parenting a child with AD/HD.
In conclusion, AD/HD is a complex disorder dealing with multiple factors that may have long-term effects on the functioning of a developing child. If not diagnosed and treated early in life it may lead to poor social and occupational functioning including other psychological problems. This is why it is imperative that the individuals who are in the front lines, those that work with children, become knowledgeable about the symptoms and surrounding issues of AD/HD.

Written by: Ivette J. Russo MS in Clinical Psychology

References
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed. Text Revision). Arlington, VA: Author.
Barkley, R. A., (1998). Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment (2nd ed.). New York: Guilford Press.
Eiraldi, R. B., Mazzuca, L. B., Clarke, A. T., & Power, T. J (2006). Service utilization among ethnic minority children with AD/HD: A model of help-seeking behavior. Administration and Policy in Mental Health and Mental Health Services Research, 33, 607-622.
Kazdin, A. E., & Weisz, J. R., (2003). Evidence-based psychotherapies for children and adolescents. New York, NY: The Guilford Press.
MediZine LLC, (2010). Retrieved on March 18th from, http://www.neurologychannel.com/AD/HD/causes.shtml#dopa

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