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Attention-Deficit/ Hyperactivity Disorder

ADHD is a complex disorder which can markedly impair cognitive functioning, behavior and emotional stability with its symptoms of inattentiveness (the most common manifestation) and hyperactivity/impulsivity in youth and in adults.

Numerous other psychiatric disorders and psychological conflicts are associated with similar symptoms and need to be considered in the evaluation and treatment of youth and adults.

For example, excessive anger can be expressed in passive ways by many of the symptoms of inattentiveness.  Youth can deliberately act to in ways to avoid responsibility and ignore the reasonable requests of teachers and parents.  These manifestations of passive-aggressive anger can even be a source of pleasure associated with a sense of rebelliousness.  Many studies have demonstrated that ADHD is highly associated with the most common anger disorder in youth, Oppositional Defiant Disorder.

Excessive anger in ADHD and in other psychiatric disorders contributes to marked emotional and behavioral instability and can interfere with treatment and can contribute to relapses.  Therefore, we recommend that parents and youth identify the degree of anger by completing the anger checklist

Another important conflict that needs to be explored in regard to inattentiveness in the degree of selfishness in youth which can also result in a refusal to act responsibly with school work and in the expression of anger.  In fact, selfishness is one of the most common causes of excessive anger and impulsivity in our work with youth and with adults. Therefore, we encourage parents and youth to complete the selfishness checklist.

ADHD is regularly seen in association with depressive and anxiety disorders, substance abuse and learning disorders. These need to be evaluated also in youth and adults.

Far More Common in Males

Attention-deficit/hyperactivity disorder (ADHD) is the most prevalent psychiatric disorder of children. In July 2008 the Center for Disease Control reported that in a study of 23, 000 about 5% of the U.S. children aged 6-17 have been diagnosed with attention deficit hyperactivity disorder. .  ADHD was also more common among adolescents than younger children. Also, the CDC reported a 3% average annual increase in childhood ADHD diagnoses from 1997 to 2006.

In a study of 10,000 adolescents, the prevalence of ADHD was 8.7%, with three times as many males affected as females (Merikangas, et al, 2010).

One reason for this finding may be that male strength in youth and the challenges of mastering it may be misdiagnosed by educators, health professionals and parents as hyperactive/impulsive ADHD.  Another reason may be the restlessness that results from boredom in the home or school.

Three Types of ADHD

The three subtypes of ADHD are the predominantly inattentive type, the combined hyperactive-and inattentive type, and the predominantly hyperactive-impulsive type. Also, in major European study of 6,622 children followed from childhood and evaluated into adolescence (ages 16-18), 64% had the inattentive type, 28% the combined type and 8% hyperactive-impulsive (Smalley, S, et al, 2007).  The estimated prevalence of ADHD among teenagers in this study recent was 8.5% with a male/female ratio of 5.7 to 1.

Please rate your child for ADHD on the following criteria of the Diagnostic and Statistical Manual of the APA.

Here are the criteria for diagnosing ADHD in shortened form. Please note that they are presented just for your information. Only trained health care providers can diagnose or treat ADHD.

DSM-5 Criteria for ADHD

People with ADHD show a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development:

Inattention

Six or more symptoms of inattention for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level:

  •  Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities

  •  Often has trouble holding attention on tasks or play activities

  •  Often does not seem to listen when spoken to directly

  •  Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).

  •  Often has trouble organizing tasks and activities.

  •  Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).

  •  Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).

  •  Is often easily distracted

  •  Is often forgetful in daily activities

 

Hyperactivity and Impulsivity

Six or more symptoms of hyperactivity-impulsivity for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person's developmental level:

  •  Often fidgets with or taps hands or feet, or squirms in seat.

  •  Often leaves seat in situations when remaining seated is expected.

  •  Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).

  •  Often unable to play or take part in leisure activities quietly.

  •  Is often "on the go" acting as if "driven by a motor".

  •  Often talks excessively.

  •  Often blurts out an answer before a question has been completed.

  •  Often has trouble waiting his/her turn.

  •  Often interrupts or intrudes on others (e.g., butts into conversations or games).

In addition, the following conditions must be met:
  •  Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.

  •  Several symptoms are present in two or more setting, (e.g., at home, school or work; with friends or relatives; in other activities).

  •  There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning.

  •  The symptoms do not happen only during the course of schizophrenia or another psychotic disorder. The symptoms are not better explained by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

 

Possible Passive-Aggressive Anger Symptoms in DSM criteria

The following behaviors could be viewed as the unconscious or covert/sneaky expression of passive-anger, which may not even be conscious:

    • Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.

    • Often does not seem to listen when spoken to directly.

    • Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).

    • Often has trouble organizing tasks and activities.

    • Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).

    • Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).

    • Is often easily distracted

    • Is often forgetful in daily activities.

 

Marital Conflicts in Families of Youth with ADHD

Numerous studies have asserted the prevalence of marital conflict among families of children with attention-deficit/hyperactivity disorder (ADHD), Parents of children with ADHD report less marital satisfaction, fight more and communicate in a more negative way during child rearing discussions than do children without ADHD. Also, family adversity has been shown to be related to ADHD combined type (hyperactive-inattentive) in children and may be related specifically to ADHD symptoms (Counts CA, et al., 2005.)

Also, one major study demonstrated that maternal and paternal education level; paternal antisocial behavior; and child age, race/ethnicity, and oppositional-defiant/conduct problems each uniquely predicted the timing of divorce between parents of youths with ADHD. These data underscore how parent and child variables likely interact to exacerbate marital discord and, ultimately, dissolution among families of children diagnosed with ADHD (Wymbs BT, et al., 2008.)

A Scottish study found that ADHD placed a significant strain on family relationships. Almost three quarters of the parents of children with ADHD reported that the disorder had a negative impact on their relationship with the child, and just over 50% reported problems with relationships between the child with ADHD and his or her siblings or peers. In contrast, fewer parents of children without ADHD reported problems in the relationships with their child (43%), or between their child and siblings (29%) or other children (12%), (Coghill D, et al, 2008.)

These studies highlight the importance of uncovering and addressing directly the anger in all children with ADHD and in their parents.

 

Other Causes of Inattention are:

  • passive-aggressive anger – rebel quietly against reasonable expectations

  • oppositional defiant disorder – venting anger by acting irresponsibly

  • intense selfishness with pleasure experiencing in treating others with a lack of respect

  • severe weaknesses in confidence that interferes with task performance

  • severe anxiety or depression that harms cognitive functioning such as concentration and memory

    • sadness about conflicts within the family

    • Fatherless homes

    • Post divorce sadness

  • a desire to control others arising male strength that needs to be balanced with growth in virtues

 

Other causes of  Hyperactivity and Impulsivity are:

  • being treated in a controlling manner

  • forcing children into an educational mold that is not appropriate for them

  • sadness or anxiety which can cause restlessness and irritability

  • The epidemic of loneliness in youth today from the lack of

    • An intact family

    • A father in the home

    • A brother or a sister

  • numerous sources of anger cause impulsivity which should be explored

  • abuse trauma

  • substance abuse.

Anger and ADHD

A leading expert on ADHD has stated that many, if not the majority, of those with ADHD have problems with aggression and emotional control (Barkley 1990). In more than one-half of patients with attention-deficit hyperactivity disorder (ADHD), Oppositional Defiant Disorder (ODD) is also part of the clinical picture, (Turgay, A. 2009). Also, the importance of identifying and treating the anger in this disorder is supported by studies which reveal that ADHD is associated with a ten-fold increased incidence of antisocial personality (Klein, 1991; Weiss, et al.,1985), a twenty-five fold excess risk for institutionalization for delinquency (Satterfield, et al. 1982), up to a five-fold increased risk of drug abuse (Gittelman, et al. 1985; Klein, 1991), and up to a nine-fold increased risk of incarceration (Mannuzza, et al., 1989.). In more than one-half of patients with attention-deficit hyperactivity disorder (ADHD), Oppositional Defiant Disorder (ODD) is also part of the clinical picture (Turgay, A. 2009.)

In addition, ADHD is the most common comorbidity in teenagers with substance abuse disorders.

We have found that the therapeutic use of forgiveness is effective in diminishing the excessive anger in ADHD, particularly in the hyperactive and impulsive types. The expression of anger in ADHD is not limited to the active release of this emotion. Some of the symptoms in the inattentive type of ADHD in some children may be the passive-aggressive expression of anger. These include not listening, failing to follow through with instructions, forgetfulness, or careless mistakes. Some youngsters engage in these behaviors deliberately by not cooperating with teachers or parents as a way to vent anger.

Many children and teenagers with ADHD are not aware of being overly angry, or, if they are aware, they are unable to identify the origin of their anger. In the uncovering phase of treatment, they begin to identify major disappointments in their lives and the anger associated with the hurts they experienced. Some decide to learn how to use forgiveness, although others discover benefits gained from holding onto their anger.

Also, ADHD is strongly associated with ODD (oppositional defiant disorder.) The failure to uncover and to treat the excessive anger in ODD, in our clinical experience, can interfere with the successful treatment of ADHD.  In fact, when children with ADHD are not responding to medication, it is important to evaluate the person's anger and the willingness to let go of this anger.

The old habit of relying on the expression of anger is hard to break and the development of a new habit of employing forgiveness to deal with excessive anger is acquired slowly. The following case study on treating anger in ADHD is from Helping Clients Forgive.

Case Study

Earl was a seven-year-old who was finishing first grade and presented with symptoms of ADHD, hyperactive and impulsive types, and symptoms of oppositional defiant disorder. He had almost no ability to control his angry behavior. Both of his parents were adult children of angry alcoholic fathers and they had been in marital therapy for over a year working on controlling their tempers through the use of forgiveness. The level of excessive anger in the marital relationship had diminished significantly.

Earl was able to recognize that he had been very angry with his parents as a result of their fighting. His parents asked for his forgiveness, promised to try to work to overcome their bad tempers and to curtail their fighting. Earl nodded in agreement. The therapist responded, Earl, I would like you to see whether you can tell your parents now that you want to try to forgive them. He proceeded to verbalize his desire to forgive them and then went over to them and gave each a hug.

The therapist next asked his parents to explain to him the causes of the their fighting. They told Earl that each of them had brought a great deal of anger into their marriage from their family backgrounds from the paternal grandfather, the maternal grandfather, and grandmother. Without realizing what they were doing, they related that they had misdirected this anger toward each other. With an attempt at a smile, he said, I'm glad you told me. At least I'm not the reason you're always mad. At the end of the session Earl was given a note from the therapist which suggested that daily he think, I want to forgive mommy and daddy for all their fights. At the succeeding sessions his ability to use forgiveness to control his anger was reviewed. Although he continued being angry, the episodes were somewhat less frequent and less intense.

Neither Earl or his parents were able to identify anyone in else in neighborhood or at school with whom he might be angry. After an initial diminishment in his anger, it erupted again and he had great difficulty controlling his rageful feelings. Ritalin then used. Shortly thereafter, another major source of previously denied anger was identified.

His mother visited the after-school program he attended, and was extremely upset by the way the older boys taunted him. Earl was ashamed of this treatment and had never told his parents. After an attempt to remedy the situation failed because of the failure of those in the after-school program to control the bullies, Earl's mother removed him from this program and his explosive anger diminished greatly.

In the deepening phase, Earl was pleased that he had learned of a way to control his temper and that he was able to help his younger brother to work at controlling his anger by talking with him about forgiving others.

ADHD and later depression and other psychiatric disorders

All subtypes of ADHD in young children predict adolescent depression, (Chronis-Tuscano, A., et al, 2010).  A longitudinal study of 96 adolescents with ADHD, who were diagnosed when they were 7 through 11 years old, demonstrated that they were at increased risk for the development of borderline, antisocial and avoidant or narcissistic personality disorders. Those with persistent ADHD were at higher risk for antisocial and paranoid personality disorders (Miller, C.J., et al., 2008).

Among adults with ADHD, several studies have indicated elevated rates of comorbid mood, anxiety and substance abuse disorders.  In addition, adults with ADHD are often characterized by affective volatility, occupational instability, poor social relationships and impulsive and self-destructive behaviors.  Investigators have begun to explore the degree to which personality disorders might account for some of the functional impairment associated with ADHD in adults (Miller, CJ, et al, 2008).

ADHD and ODD Risks

When ADHD is associated with Oppositional Defiant Disorder (ODD),  research has shown an significant increased risk of major depression and bipolar disorder (Biederman, et al. 2008). Chronic aggression among children with ADHD poses a common clinical challenge.  A substantial proportion of children with ADHD do not experience satisfactory reductions in aggressive behavior.  Prescription of antipsychotic and anti-manic mood stabilizing medications has surged in the past 10 years.   A 2009 study demonstrated that the addition of Depakote increases the likelihood that aggressive behaviors will diminish (Blader, J., et al.)

Later Violence and ADHD

In a national longitudinal study of adolescent health those youth with hyperactivity/ impulsivity, but not in attention, independently predicted intimate partner violence later in young adult life, (Fang, X., et al., 2010.)    It was previously known that conduct disorder in children was associated with intimate partner violence in young adult life, but now is also apparent that there is also an association between ADHD and intimate partner violence.  This research demonstrates the importance of initiating a specific treatment plan for the excessive anger in youth with attention deficit hyperactivity disorder, hyperactive/impulsive type.

A treatment  protocol for aggressive impulses in ADHD could involve initially uncovering the anger with the parent who has disappointed the youth the most, as well as any unjust treatment by a sibling or peers.  Next, a recommendation could be given to try to let go of any impulses for revenge against the parent, most often the father, sibling, or peer so that this rage is not misdirected later at those who do not deserve it.  Also, an attempt should be made to determine if the youth has modeled unconsciously after an aggressive parent.  If this is identified, the benefit of repeating that parent's good qualities but not excessive anger should be discussed.  In our clinical experience, the more the youth works at forgiving an aggressive parent, the less likely they are to repeat the violent behavior.  Finally, it can be beneficial to suggest to young men, in particular, that male strength is not determined by aggressiveness but by having a strong, healthy personality.

 

Parents

Parents have a serious responsibility to request that the health professional who evaluates their child for ADHD takes a comprehensive approach and evaluates the other psychological conflicts that have been demonstrated to be associated with ADHD.  These would include Oppositional Defiant Disorder, anxiety disorders including social anxiety, depression and possible conflicts with loneliness, the degree of confidence, substance abuse, and any narcissistic (selfish) personality traits.  Too often, the diagnosis of ADHD is made solely on completion of the DSM V criteria, many of which again are present in other psychiatric disorders.

Parents also play a vital role as the primary educators of their children in helping them learn how to understand and work on any other psychological conflicts that may influence their ADHD symptoms. In particular, teaching youth how to master anger in a mature manner is certainly indicated in many youth with ADHD.  In addition, efforts to protect youth from anxiety, sadness/loneliness, selfishness and feelings of insecurity, which is often present, should be pursued. Articles on this website may be helpful in these areas.

The understanding that there is another option. other than expressing anger, when a youth feels this powerful emotion is an essential aspect of treating ADHD and all psychiatric disorders. Parents can teach their children that they have three options for dealing with anger, that is, denial, expression and forgiveness.  Then, they recommend the benefits of using forgiveness therapy to decrease their anger, especially the passive-aggressive anger they may attempt to cover up and to deny.  The empirically proven effective treatment of irritability and anger is described in the anger chapter on this website and in our American Psychological Association book, Forgiveness Therapy: An Empirical Guide for Resolving Anger and Restoring Hope, 2014. 

As a result of our 40 years of clinical experience with children with ADHD, we believe that it is helpful to uncover, identify and then treat the anger in many youth with this disorder. Future research in all likelihood will demonstrate the many benefits of forgiveness therapy in helping children with ADHD.

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