Adhd and Attachement

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Conceptualizing ADHDas a contextual response to parental attachment

Phyllis Erdman(The American Journal of Family Therapy(Ne) *ork:#+r'Jun1,,-(.ol(2/$ !ss( 20 +g( 1$ , +gs

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ub3ects: %amly counselng$ 4hldren 5 youth$ Beha6or dsorders$#ttenton defcdsorder$ 7y+eract6ty

#uthor8s9: Phylls rdman

Document ty+es: %eature

Publcaton ttle: &he #mercan Journal of %amly &hera+y( Ne) *ork:#+r'Jun 1,,-( .ol( 2/$ !ss( 20 +g( 1$ , +g

ource ty+e: Perodcal

!N;!BN:


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exceedng 2 mllon re+orted cases naton)de n 1,,?( 4hldren )th ADHDdagnoses account fora++roxmately half of the chld referrals n chld mental health agences 8Da)$ 1,,/9( !n s+te of them+act these chldrenFs beha6ors ha6e on famly nteractons$ famly thera+sts ha6e g6en mnmalattenton to the assessment and treatment of ADHD( &he ma3orty of the research done on ADHDchldren has been re+orted n educatonal and chld +sychology 3ournals$ and some of the more recent

research e6en challenges the accuracy of many ADHDdagnoses 8#rmstrong$ 1,,/0 melter$ Rasch$%lemng$ NaGos$ 5 Barano)sk$ 1,,/9(

!t has been suggested Hthat the dagnoss meets the needs of the +arents more than t does those ofthe chldH 8melter et al($ 1,,/$ +( =


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may be re+eated 8e(g($ a chld )ho refused attachment to a6od the +anful conseCuences ofantc+atng the re+etton of a +re6ous traumatc loss9( Ithers 84rttenden$ 1,,20 Delyen$ 1,,/0eberman 5 Pa)l$ 1,,


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ADHDB7#.!IR #ND 4IR4!. !N&R#4&!IN

ADHDs classfed n the Dagnostc and tatstcal "anual of "ental Dsorders =thed( LD"'!.M0#mercan Psychatrc #ssocaton$ 1,,=9 as one of the dsru+t6e beha6or dsorders$ along )thI++ostonal Defant Dsorder and 4onduct Dsorder( 4hldren )th ADHDare descrbed as ha6ng

de6elo+mentally na++ro+rate degrees of nattenton$ m+uls6eness$ and hy+eract6ty( #t home$ theyfal to follo) through )th othersF reCuests$ shft from one uncom+leted task to another$ and oftennterru+t or ntrude on other famly members( %amlal en6ronments that are dsorganGed$ chaotc$ orneglectful are 6e)ed as +reds+osng factors n ADHDdagnoses 8#mercan Psychatrc #ssocaton$1,,=9(

mth 81,,=9 descrbed smlar ty+es of beha6ors n chldren she )as treatng$ )ho ranged n age fromnfancy to 1- years( &hese chldren exhbted classcal sym+toms of ADHD$ and they also sho)edextreme 6olent outbursts( mthFs study )as ntended to sho) ho) treatng the serotonnneurotransmtter system of the chldren e6entually brought the 6olent beha6ors under control after allother ty+es of thera+eutc nter6entons and beha6or management +rograms had faled( #ddtonally$ho)e6er$ t exem+lfed ho) out'of'control beha6ors n chldren can enforce unrealstc demands on+arents that e6entually result n +arents de6elo+ng lo) self'esteem and +erce6ng themsel6es asfalures( &hs$ n turn$ makes t dffcult for +arents to establsh a++ro+rate herarches n the famly$renforcng o++ortuntes for chldren to domnate the famly( &)enty'f6e +ercent of the nfants n thsstudy screamed and cred 6olently unless ther mothers carred them e6ery)here throughout the day(4onseCuently$ the mothers became hostle and re3ectng to)ard the chldren and reacted n adsattached )ay to)ard them( @hen the aggress6e beha6ors )ere controlled$ the mothers )ere ableto bond and attach to ther chldren(

4am+bell et al( 81,,19 noted ho) the nteracton bet)een noncom+lance and o6eract6ty n chldren+redcted hgh le6els of negat6e control by +arents and that noncom+lance and negat6e maternalcontrol cooccur n +arent'chld relatonsh+s( reenberg and +eltG 81,--9 noted that nsecure chldrencoerce +arents nto carng for them by actng dsru+t6ely and demandng( uch beha6ors$ )hencou+led )th o6ercontrollng +arents$ result n com+ett6e attem+ts on both sdes to +re6al( Patterson81,-/9 found that such tr6al beha6ors as )hnng$ teasng$ and yellng can mark the begnnng ofaggress6e famly nteractons( Parents )ho start out )th +oor management sklls and encounter such

+roblem beha6ors n chldren react by threatenng$ naggng$ and scoldng the chld( &hey seldomfollo) through )th ther threats$ ho)e6er$ and become frustrated and e6entually ex+los6e( &hechldren react by counterattackng the +arent$ )hch creates an attack'counterattack +attern( &hechldren and +arents both become more sklled at ther coerc6e attacks to)ard the other$ untl the chldbecomes com+letely out of control( By ths +ont$ both ha6e also begun to emotonally detach from theother( !t s easy to see ho) a +arent may de6elo+ a smlar +attern of attack'counterattack bybecomng emotonally and +hyscally unattached at the onset of the +roblem beha6ors$ renforcng thechldFs )hnng and naggng beha6ors(

4rttenden 81,,29 descrbed ho) nsecurely attached chldren de6elo+ strateges to allo) themsel6esto ex+lore the en6ronment n s+te of ther careg6ersF una6alablty( &hey alert ther careg6ers tofearful stuatons by usng anger$ )hch g6es the chld a false sense of +o)er( uch demandng andhel+less beha6ors from the chld$ )ho s actually +o)erless$ encourage negat6e n6ol6ement from theattachment fgure$ )hch only ncreases the chldFs feelngs of anxety and 6ulnerablty(

"orett et al( 81,,=9 descrbed ho) careg6ers of coerc6e chldren are freCuently unres+ons6e to therneeds$ and )hen they do res+ond t s )th anger and negat6e affect( &hese chldren alternatebet)een a facade of 6ulnerablty$ )hch lures the careg6er nto carng for them$ and aggress6elyforcng ther +arents to meet ther needs( !n nteractons such as these$ attachment fgures res+ond toonly the most ntens6e and extreme beha6ors( &herefore$ t s ncumbent on the chld to do )hate6er ttakes to successfully engage the careg6er 8yons'Ruth$ 1,,/0 @ebster'tratton$ 1,,


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scenaro abo6e$ sets nto moton a rec+rocal exchange of coerc6e and demandng beha6ors bet)eenthe +arent and chld(

&he knds of coerc6e +atterns descrbed here that exst n the context of +arental msmanagement aresmlar to the knds of beha6ors descrbed by +arents of ADHDchldren( &o obtan an ADHDdagnoss$ chldren are reCured to meet at least sx beha6oral crtera n at least t)o settngs( &hesecrtera nclude nd6dual beha6ors$ such as fdgetng$ nattent6eness$ and excess6e mo6ement andtalk and also address nter+ersonal beha6ors$ such as dffculty +layng or engagng )th +eers$nterru+tng and ntrudng on others$ and not lstenng )hen s+oken drectly to 8#mercan Psychatrc#ssocaton$ 1,,=9( &he smlarty bet)een chldren beng brought to thera+y for ADHDbeha6ors andthe chldren reactng to attachment ssues s startlng( !t s at ths +ont that the Cueston s +resented:H!s ths chld truly an ADHDchld$ or s he or she sm+ly engagng the necessary defenses to sur66e nsuch an nsecure en6ronmentH &he only )ay to kno) s to consder the context n )hch thesebeha6ors thr6e( #lthough nsecurely attached chldren may not meet all of the ADHDcrtera$ many ofthem are freCuently obser6ed( 6en more so$ chldren are often brought to clncans )th dubous andncom+lete ADHDdagnoses( ADHDdagnoses are usually determned from beha6or ratng scales$)hch de+end on sub3ect6e 3udgments by teachers$ +arents$ or both$ )ho may ha6e a 6ested nterestn the outcome 8#rmstrong$ 1,,/9( #nother concern s that t s dffcult to clearly dfferentate bet)een)hat s normal hgh act6ty n chldren and )hen t becomes ADHD( !t has been my o)n clncalex+erence that chldren are often referred )th ADHDafter a sngle assessment that freCuently hasbeen com+leted by only one +erson( 6en the dagnoses that are clncally 6ald send a message tothe +arent and to the chld that the +roblem les )thn the chld$ )hen n realty t s a famly ssue(4lncal obser6atons also ndcate that +arents freCuently enter thera+y n a state of des+eraton$ afterha6ng tred harder and harder to correct the chldFs +roblem$ usually by dong more of the same orncreasng the ntensty of correct6eness( &he ob6ous result s a neutral effect on the chld$ at best$and more lkely results n an angry$ aggress6e$ resstant chld(

!"P!4#&!IN #ND &R#&"N&

&he re+ercussons of 6e)ng ADHDas an nd6dual +roblem to be treated solely )th medcaton$beha6oral management strateges$ or both$ has serous m+lcatons( 4hldren )ho are alreadyfrustrated and anxous o6er the lack of a +arental bond )ll feel more 6ctmGed f they are focused on

as the +roblem( &he one +ost6e sde of such a unlateral a++roach as medcaton s that t +robably)ll m+ro6e some of the +roblem beha6ors and nduce a calmng$ +ost6e reacton n the chld$ thus+ossbly reducng the coerc6e beha6or +atterns( 7ence$ the mother and chld both could more easlyengage n +ost6e$ su++ort6e beha6ors rather than the attack'counterattack +attern that s so famlarto them(

# second concern s that beha6oral strateges$ such as re)ard systems and token economes$ may+ro6de a Band'#d effect on the +arent'chld relatonsh+( !t has been noted that chldren canselect6ely ds+lay ADHDbeha6ors n one stuaton )hle a++earng normal n another 8%achn$ 1,,/9(&hs alludes to the ca+rcousness of ADHDbeha6ors n chldren and ho) they can so effect6elymantan a dstant and detached +arent'chld relatonsh+(

Because ADHDbeha6ors are usually frst dentfed n school settngs$ t s m+ortant for schoolcounselors to ha6e o++ortuntes to consult )th famly thera+sts regardng chldrenFs +roblembeha6ors( &hera+sts traned n systems theory are more lkely to consder the context of chldrenFsbeha6ors and less lkely to label dsru+t6e$ aggress6e$ a6odant beha6ors n chldren as ADHDorconduct dsorders( By a++roachng these +roblems systemcally$ thera+sts can )ork to)ardaddressng the attachment ssues bet)een the +arent and chld and alle6atng the functon of thedsru+t6e beha6ors( !t also s m+ortant to a6od a lnear +ers+ect6e of these famles$ )hch tends toblame the +arent for the chldFs beha6or(

"orett et al( 81,,=9 descrbed a


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ssues by reframng the beha6oral +roblems nto attachment terms( &he result s a rec+rocalmodfcaton of dynamcs bet)een the +arents and the chldren( #s the +arents learn to modfy thernter+retatons of the chldrenFs beha6ors$ the chldren feel less crtcGed and become more com+lant$thus allo)ng the +arents to become more res+ons6e to ther needs( &he crcularty of ths a++roach+ro6des an en6ronment n )hch mutual connectedness can de6elo+(

Bo)lby 81,--9 also dentfed f6e thera+eutc tasks to hel+ clents restructure ther re+resentatonalmodels of attachment( &hese nclude +ro6dng a secure base for clents to ex+lore +anful as+ects ofther +asts and to hel+ them become a)are of ho) ther current +erce+tons are +roducts of ther +astmemores and belefs( !t s ho+ed that an a++roach such as ths )ll allo) the +arent8s9 n thera+y toreassess ther role n ther chldFs beha6or +atterns and to begn to mend some of these )ounds(

Byng'7all 81,,


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#eference"Byng'7all$ J($ 5 te6enson'7nde$ J( 81,,19( #ttachment relatonsh+s )thn a famly system( !nfant "ental7ealth Journal$ 12$ 1-'2


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Author Affiliation"#ddress corres+ondence to Phylls rdman$ De+artment of 4ounselng$ &exas #dc" An6ersty'4ommerce$&K ?=2,'

Adhd and Attachement

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