גילה קדוש דדון - דוקטורנטית חינוך מיוחד

מאמר Attention deficit and hyperactivity disorder/learning disabilities

Patient Education and Counseling 57 (2005) 96–100
Attention deficit and hyperactivity disorder/learning disabilities
(ADHD/LD): parental characterization and perception
Uzi Brook a,∗, Mona Boazb
a Department of Pediatrics, Sackler Faculty of Medicine, Edith Wolfson Medical Center, Tel Aviv University, P.O. Box 5, Holon
58100, Israel
b Epidemiology Unit and the Institute for Cardiovascular Research, Sackler Faculty of Medicine, Edith Wolfson Medical Center,
Tel Aviv University, Holon 58100, Israel
Received 12 November 2003; received in revised form 5 February 2004; accepted 4 March 2004
Abstract
Sixty-six parents of adolescents (mean age, 14.8 years), who attended special education classes and who were diagnosed as having
attention deficit and hyperactivity disorder/learning disabilities (ADHD/LD), were interviewed. The comorbidity of the ADHD group
included emotional lability and/or depression, 70%; oppositional defiant disorder (ODD), 67%; obsessive-compulsive disorder (OCD),
44%; addiction to buying, 44%; and aggressiveness, 62%. Twenty-one percent were either involved in the past or presently using drugs.
Nine percent had attempted suicide. According to their parents, the main characteristic of these adolescents was low self-image. Parents
enumerated five negative characteristics: impulsiveness; nervousness; angered easily (‘short fused’); aggressiveness with cursing and
outbursts; and impaired sociability with impoliteness.
© 2004 Elsevier Ireland Ltd. All rights reserved.
Keywords: Attention deficit and hyperactivity disorder/learning disabilities (ADHD/LD); Parental perceptions
1. Introduction
Attention deficit and hyperactivity disorder (ADHD) is a
neuro-behavioral disorder [1]. It is accompanied by impaired
inhibition in children [2,3], and its symptoms include sustained
attention disorder and hyperactivity/impulsivity [4,5].
It has a genetic origin [6], with functional damage involving
the frontal–cortical–basal ganglia connection [5], and
some of its comorbidities include mood lability, anxiety, disruptive
behavior, interpersonal relationship difficulties, and
academic failure [7]. It is common to diagnose learning disabilities
(LD) among this population of ADHD adolescents
[8]. Michael and Lewandowski pointed out that these adolescents
are at a higher risk for developing psychological adjustment
problems and emotional distress [9]. Females were
at twice the risk of attempting suicide and being involved in
violence as compared with their male peers [10]. The difficulties
become familial as a result of other family members
living with constant stress [11]. A follow-up of these adolescents
shows that most of them were working in unskilled
jobs [12].
∗ Corresponding author. Tel.: +972 3 502 8422; fax: +972 3 502 8422.
E-mail address: brookuzi@post.tac.ac.il (U. Brook).
ADHD is defined as a psychiatric-behavioral condition
which includes anxiety [13,14], depression [15–17], and aggressiveness
[18]. These adolescents are also at risk for developing
a conduct disorder (CD) with addiction to smoking,
consumption of alcohol and drugs, and problems of delinquency.
The ADHD/LD adolescents suffer from social disabilities
and have to face social problems [19] originating from difficulties
with peer relationships [20]. Frequently, they find
themselves socially isolated [21]. The self-esteem of these
adolescents is impaired [22]. Mannuzza and Klein state that
their low self-esteem stays with them even after adolescence
[23].
Accumulation of suffering and frustration bring them to
the brink of suicide. Levinson et al. [24] found that psychosocial
characteristics of these adolescents who carried
out suicide attempts include: school difficulties [10,15,16];
recurrent depressions; and existence of psychiatric disturbances.
ADHD is also a familial problem. It is influenced by the
severity of parental impulsiveness, as well as, their hostility
[25–27]. The quality of life (QOL) in these families is
low [28], while financial costs are high [29]. Murphy and
Barkley state that there was more psychological impairment,
as well, among their parents [30]. Neiderfer et al. state that
0738-3991/$ – see front matter © 2004 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.pec.2004.03.018
U. Brook, M. Boaz / Patient Education and Counseling 57 (2005) 96–100 97
familial cohesion has a beneficial influence on the mode of
coping: a broken family exacerbates the difficulties of these
adolescents [31].
Biederman et al. pointed out that over a period of years,
there was a decrease of hyperactivity, impulsivity and inattention
symptoms [32]. Hill and Schoener pointed out that
there was a decrease of 50% in the severity of ADHD every
5 years [33]. Mannuzza and Klein state that their low
self-esteem stays with them even after adolescence [23].
Their antisocial behavior can also be combined with drug
abuse. Tsai and Gar state that a delay in the diagnosis of
ADHD can be the cause of the development of serious social
problems [34]. Hechtman mentions that the IQ and temperament
of the child/adolescent will influence the prognosis
[26]. Paternite et al. state that childhood aggressiveness is a
predominant factor, as well, in their prognosis [35]. Bagwell
et al. found that the relationship with peers is an important
factor, as well, in the prognosis of ADHD [36]. Greene et al.
mention social disabilities as negative markers in the outcome
[37]. Toupin et al. [38] and Fisher et al. [39] mention
that having a childhood with CD is a negative predictor in
their future. Kruger and Kendell suggest there is room to
help these adolescents by developing in them an early sense
of responsibility [40].
The aims of the present study are:
1. To learn about parental perception concerning the
ADHD/LD of their children.
2. To verify the comorbidity of ADHD/LD.
3. To examine the parental hopes and fears concerning the
future of the ADHD/LD adolescents.
4. To learn about positive and negative characteristics that
parents observed in their ADHD/LD children.
2. Methods
Sixty-six parents of adolescents, diagnosed as having
ADHD/LD, were interviewed. The adolescents were
attending special education classes (grades, 7–12). The
background of participants is summarized in Table 1. A
questionnaire was prepared by the authors and had passed
Table 1
Background characteristics of participants (n = 66)
Father Mother
Age of the parents (years) 46.2 7.6 42.2 7.4
Parental professions (%)
Academic 18.2 15.2
Teaching 1.5 16.7
Technical 51.5 22.7
Commercial 28.8 9.1
Housekeeper – 36.4
Adolescents
Age (years) 14.8 1.9
Boy to girl ratio (%) 62.1:37.9
judgement validity by pediatricians (3), neurologists (2),
psychiatrists (2), social workers (2), and an educational advisor
[2]. Out of 115 items in the first version, 88 were left
in the final questionnaire. All parents who were invited to
the interview agreed to come specially to the school. The
school is under the framework of ‘special education’ in the
city of Bat Yam with 250 pupils attending; most of them
diagnosed as having ADHD and/or LD. Their deficiencies
at school and results of neuro-education examinations (at
school and elsewhere) were noted and confirmed by didactic
tests conducted by outside specialists. The statistical
analysis was done by the Epidemiology Unit, utilizing averages;
the non-parametrical Kolmogorov–Sminov test; and
linear correlations.
3. Results
Parental reports concerning adolescents’ ADHD symptoms
are summarized in Table 2. Data of pupils concerning
LD are summarized in Table 3. Table 4 summarizes the comorbidity.
Only 39.4% of the parents received explanation/information
from professionals; 71.2% of the parents were criticized
by their families for not knowing how to discipline their
ADHD/LD child and 65.2% of the parents reported experiencing
economic difficulties as a result of their child’s condition.
Parents were asked to relate three positive and three
negative characteristics in their children/adolescents. These
are summarized in Table 5.
Characteristics found in the ADHD/LD adolescent’s reaction
to various situations are summarized in Table 6.
Table 2
Data about the ADHD of adolescent pupils
Types of conditions
ADHD (%) 83.3
Impulsivity (%) 81.1
Outbursts (monthly, no.) 5.2
First age of presenting symptoms (years) 5.2 3.0
Age of diagnosis (years) 8.14 3.2
Adolescents treated with Ritalin (%) 30.3
Length of treatment (months, mean) 10
Table 3
Characteristis of pupils having LD
Characteristics %
Types of difficulties
Reading (dyslexia) 78.8
Writing (dysgraphia) 80.3
Mathematics (dyscalculia) 68.2
Problems with foreign language 62.1
Problems with fine motor skills 53
Existence of LD in family 54.5
Read a book within the last year 12.1
Read weekly magazines 37.9
98 U. Brook, M. Boaz / Patient Education and Counseling 57 (2005) 96–100
Table 4
Comorbidities of ADHD/LD adolescents as reported by parents
Cormobidity %
Fears and anxieties 59.1
Mood changes 75.8
Depression 69.7
Obsessive-compulsive disorder (OCD) 43.9
Oppositional defiant disorder (ODD) 66.7
Aggressive speaking 71.2
Threatening and aggressive behavior 62.1
Smoke cigarettes regularly 53
Consume alcoholic beverages regularly 31.8
Tried in the past or consume drugs at present 21.2
Had thought of suicide 37.9
Attempted suicide 9.1
Table 5
Positive and negative characteristics of ADHD/LD (view of adolescents)
Characteristics %
Positive
Likes to help 17.7
Compassionate 13.1
Friendly, sociable, and giving credit to others 13.1
Love for animals 5.4
Creative 2.3
Negative
Nervous, angry, short-tempered, and yells 18.7
Aggressive, curses, and outbursts 18.6
Impolite and does not consider other’s needs 6.5
Wastes money (without calculation) 4.7
Stubborn and does not know how to give-up 4.7
An introvert (without friends) 2.8
Excessive sleeping (hypersomnia) 2.8
Table 6
Characteristics of ADHD/LD (according to parents)
Recognizes his/her handicaps and limitations (%) 45.5
Self-image (out of 10) 3.8 1.8
Sociability and friendliness 5.9 2.3
Intensity of dispute with parents (out of 10) 7.1 1.8
4. Discussion and conclusions
Impulsivity was mentioned by 82% of parents as the most
difficult aspect of ADHD/LD to live with. Murphy et al.
points out that impulsivity can be a predictor for future antisocial
behavior [2]. Vitacco and Rogers, as well, consider
impulsivity as a marker for development of psychopathology
with conduct disorders [41].
Ritalin (methylphenidate (MPH)) is the principal medication
for ADHD patients, in use since 1930 [42]. Side
effects include headaches, stomachaches, insomnia, and
decreased appetite [43]. It is surprising that only 30% of
parents mentioned that their children had ever received this
medication. Paternite et al. confirmed the opposite, in that,
higher doses of MPH (Ritalin) were associated with fewer
diagnosed cases of alcoholism or suicide attempts [35].
Concerning LD, the majority of parents still complain
about the school teachers’ lack of comprehension and encouragement
to their adolescents. Parents hope that, in the
future, all these teachers would undergo a continuing yearly
orientation concerning the handicaps and the problems of
these LD children [44].
Seventy-one percent of parents reported that they are
criticized frequently by other family members, teachers
at school, or educational advisers that they donot know
how to educate their child/adolescent or how to extract
filial obedience. Teachers should have non-judgmental
attitudes—neither blaming the parents nor seeing them as
responsible for the behavior of their child.
Rey et al. pointed out that a lower economic familial environment
predicts a worse future outcome [45]. In the present
study, 65% of parents reported having economic difficulties.
In spite of all these difficulties, Podolski and Nigg recommend
that these parents adopt a positive way of thinking
and face all these ADHD/LD connected problems with the
conviction that it is possible to overcome them [46].
Aggressiveness is one of the most difficult behaviors of
the children/adolescents. The child/adolescent reacts with
aggressive speech and expressions of anger towards any of
the people in his/her vicinity. The outburst can end in an
actual physical violence. Seventy-one percent of parents reported
aggressive talking by their child, when he/she is under
stress. Sixty-two percent of parents complained about
being repeatedly threatened and about aggressiveness towards
them. Diamond and Siqueland pointed out the many
violent encounters within these families of ADHD/LD children
[47]. Correspondingly, ADHD/LD adolescents can find
themselves at odds with the law and subject to investigation
by the police for criminal prosecution.
Parents gave a low score (3.8 1.7, out of 10) for
their child’s/adolescent’s self-image. Kruger and Kendell
emphasized the low self-esteem of these adolescents [40].
Hoza et al. noted the low self-esteem which the parents of
ADHD/LD children have of themselves [48].
Adolescents, with severe ADHD/LD, have difficulty resisting
social pressures and are drawn to addictive activities.
Drug addiction is the most risky and dangerous habit
as these adolescents can develop conduct disorders and become
delinquent.
In regards to suicide, 40% of these adolescents reported
about being occupied with suicidal thoughts; 10% actually
tried physically to attempt suicide. However, the accumulation
of frustration and suffering is enormous; and when
pain exceeds the resources for coping, then suicide attempts
occur.
The pressures at home, school, and with friends cause
these adolescents to be in permanent conflict with people
around them. They are tense and angry (frequently at home)
and argue constantly with parents and/or siblings. Parents
gave a score of 7.1 (out of 10) for intensity of quarrels. They
also have permanent emotional scars from years of studying
under so much strife.
U. Brook, M. Boaz / Patient Education and Counseling 57 (2005) 96–100 99
According to their parents, positive characteristics of these
adolescents include: willingness to help others and great
empathy with domestic animals, and negative characteristics
include: their anger; nervousness; and short temper, which is
the main complaint, as it was difficult to face the outbursts,
the aggressiveness and cursing of these adolescents. A third
complaint reported was non-consideration of the needs of
others.
4.1. Conclusions
ADHD/LD should be considered as a disability of the
child/adolescent as well as a problem of the entire family.
The most prominent comorbidities accompanying ADHD
are impulsivity and outbursts, obsessive-compulsive disorders
(OCD), addictions and depression, even up to and including
suicide. The most efficacious mode of coping is to
increase their self-esteem, and as a result, their negative characteristics
and lack of consideration for others will hopefully
be decreased.
4.2. Practice implications
• ADHD/LD of the child/adolescent is, in many cases, a
familial neuro-behavioral disability that can last for their
whole lifetime.
• As ADHD/LD is influenced by genetic and neuro-chemical
factors, there is no reason to blame the child/adolescents
or his/her parents for this disability, but to counsel all
concerned about how to cope with it.
• As the list of comorbidities is long, and behavioral problems
distrub the normal functioning of the ADHD/LD
child/adolescent (in school, home, or elsewhere), parents
should seek professional help for them.
• As ADHD/LD is a familial matter, parents should participate
themselves and accompany the child/adolescent in
supportive group therapy organized by professionals until
his/her behavior stabilizes.
• As there is a possibility for positive improvement in the
child/adolescent with ADHD/LD, all concerned should be
encouraged and never lose hope.
Acknowledgements
We wish to extend our appreciation to Ms. Judy Brandt for
her skillful English editing and word processing expertise
and contributions.
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