Steve and Michelle were desperate. Their 6-year-old son, Sam, was diagnosed with ADHD soon after entering first grade. Sam’s behavior seemed outright defiant: He ignored adults when his name was called and was in constant motion. Sam let out bloodcurdling screams when forced to stop playing a game on the iPad. His teacher had struggled to manage similar behaviors in class, and his guidance counselor said Sam “needed to be on medicine.” Steve and Michelle weren’t so sure, but they wondered if they were being negligent by not putting him on Ritalin or something similar.
But despite the relentless advertising for meds, and the occasional coercion by school personnel, your young ADHD child may not need Ritalin. At least not yet.
In 2015, the Centers for Disease Control and Prevention released results from its first national study to look at therapy, medication and dietary supplements to treat kids with ADHD ages 4-17. “Because behavioral therapy is the safest ADHD treatment for children under the age of 6, it should be used first, before ADHD medication for those children,” principal investigator Ileana Arias wrote.
But the CDC study revealed that of the children diagnosed with ADHD, 4 in 10 were treated with medication alone, only 1 in 10 received behavior therapy alone. This study reflects how the medical model pervades the way we think today about most developmental and mental health issues — that psychological and behavioral problems are diseases with underlying biological cause within a person and require a medical solution, most often medicine.
The medical model is appealing because it is logical and is assumed to employ the scientific method of objective and measurable observation. It reflects our implicit theory of humans: That people’s actions are functions of their personalities. While helpful in many instances, it can be woefully inadequate with complex issues such as ADHD, because many of the symptoms of ADHD are problematic only in certain contexts but have the potential for dire social and academic consequences.
ADHD provides an unyielding challenge for parents who people assume should be able to control their kid’s behavior. And so although individuals are diagnosed as having ADHD, after 30 years of clinical work, I believe it is more constructive to think of the family as having ADHD, with most of it concentrated in one person. Concentrating all efforts on the attempt to help or “fix” the child usually falls short.
Most beleaguered families relentlessly strive to solve unrelenting problems, and they often get stuck. That is, the attempts to fix the problem become a problem. While all family members hated Sam’s meltdowns, his howls were most disturbing to Sam’s maternal grandmother, Gail. Gail often reminded Michelle of how “good” she and her brother were at Sam’s age. Her mother tirelessly pointed out how she never allowed her daughter to engage in the behaviors that formed Sam’s default repertoire. Some fortunate parents, like Gail, have the task of raising a kid who came into the world with an easy temperament. And their parents often attribute this to their own excellent parenting. But paraphrasing from baseball, their kid was “born on third base, and these lucky parents think they hit a triple.”
Other parents, like Steve and Michelle, are drafted into raising a kid with ADHD. This experience is similar to a scrappy baseball game that goes into extra innings. Unlike those “born on third base,” these parents are often anxious and stressed. And if a close relative blames them, these parents wind up feeling incompetent. Other problems can also occur. For example, when Steve tried to support Michelle by standing up to Gail, Michelle reflexively felt compelled to defend her mother.
Family therapy is a behavioral therapy based on scientific understanding of family systems. The model doesn’t deny the existence of medical conditions but looks more closely at human connections and the potential they hold to cause and maintain problems or alternately be harnessed to improve things, even mental disorders and diseases. Family therapists look for frames — novel ways of looking at the situation that evoke new behaviors to help get things unstuck.
Despite the perception of an “American Diaspora,” the median distance [nytimes.com] adult Americans live from Mom is 18 miles. In Michelle and Steve’s case, Grandma was about a block away.
Sam came into the world a handful, labeled a “fussy baby” by developmental specialists. Fussy babies are infants who have sleep and eating problems or cry excessively. While a transient phase for most infants or responsive to gastrointestinal tweaking, there are babies that stay inconsolable. Michelle was worried and desperate. While Gail did not raise a “fussy baby” herself, she maintained a sense of calm and confidence that astonished Michelle, who was grateful that her mother was close.
Fussy babies don’t always grow up to have ADHD, but it happens, and it did with Sam. As he grew from toddler to school age, his impulsive behavior and emotional reactivity became more problematic. As is often the case with such frustrating behavior, parents lose their patience. In this family, the situation was worsened by Gail’s criticism that Steve was scaring Sam, while also indulging her grandson. And Michelle was torn as her mother helped her survive the early days, and Gail still seemed as calm and confident as she did back then.
There is an old song that goes “one is the loneliest number” and “two can be as bad as one.” But “three” can really muck things up. A family therapist often thinks in “threes” as a way of understanding “twos” when helping with a stubborn problem within a family. These triangles thrive as emotional triggering bands of energy that take on a life of their own. The Michelle, Steve & Co. predicament is an example of such a dynamic, aptly called “triangulation.”
The troublesome troikas in this tangle were “Michelle-Gail-Steve,” “Michelle-Sam-Gail” and “Michelle-Sam-Steve.” But the Michelle-Gail-Steve trio (mom, her mom, dad) was the most out of tune. Confusing feelings prevented Michelle and Steve from relying on each other in stressful moments with Sam. Michelle had the awful feeling she was “betraying” her mother if she did not convey her mother’s concern that Steve was scaring Sam. If she defended Steve, Michelle also feared that she might lose her mother’s support, something Michelle believed she still critically needed. Michelle wanted a full partner, but defending Steve felt too risky.
This situation improved slowly when Steve was able to grasp how difficult a spot his wife was in. In the heat of battle, Michelle was soothed by a glance or touch from Steve that conveyed “I get it. I am on your side. You don’t have to take care of me this second.” Michelle helped Steve navigate this by expressing gratitude for the ways he adeptly handled Sam with goofy humor she could not.
When Gail jumped in to “protect” Sam from his father’s fearsome, not-very-raised voice, Steve restrained the urge to defend himself, reminding himself that it was not so much an act of submitting to his mother-in-law as much as a little gift to his wife.
It takes a number of behavioral tweaks to change the negative charge of a triangle to positive. These tweaks are the many small (but not easy) changes that accumulate. The bias toward resolution and growth in families is strong once the most significant obstacles are removed, but it is never perfect.
Triangles do not yield gently; the negative emotion can rear its head in a flash. A kid with ADHD will trigger the most Zen parent in the trek of getting through the day. Parenting, like baseball, has a very long season. The players can endure a lot of failures and ultimately succeed. A slugger could have a pretty remarkable career, perhaps even make it into the Hall of Fame with a .333 batting average. That means the Hall-of-Famer struck out two thirds of the time they were at the plate. Family members, too, can bring about big changes even if they get only the small, difficult stuff right — even just a third of the time.
Daniel Griffin is a psychologist, senior teacher and trainer of clinicians, based in Washington D.C.
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