Family Difficulties in Children with ADHD, the Role of Integrated Psychopharmacology Psychotherapy Treatment

Children with ADHD and their families face many challenges. The chapter discusses these difficulties with a case illustration. The write up of the case will demonstrate the difficulties faced by children with ADHD and their families; highlighting how the dif‐ ficulties in the parents impact the child’s ADHD symptoms. The case illustration will demonstrate how “normal” the cases can be, and often are missed or dismissed, yet it causes distress to the children and the adults. The chapter hopes to raise awareness that not only does the child needs assistance so do his/ her family members. Helping the parents will significantly aid in the progress of the child.


Introduction
Children with ADHD have difficulties in their social and adaptive behavior which are related to the core symptoms of the disorder [1,2]. The difficulties are felt within and outside the family setting [1,[3][4][5] with factors in their environment increasing the risk of impairment. Families of children with ADHD have consistently been shown to experience more burdens including stress [1,6,7].
Her parents brought Alice, a 12-year-old Asian girl to a child and adolescent psychiatry service. Her parents were upset that Alice would not follow their instructions at home. Alice would daydream and procrastinate with her school assignments despite constant reminders, and her grades were deteriorat-times was unwilling to inhibit her impulses, resulting in the emergence of inappropriate or disruptive behaviors. One of the most complained about behaviors by Alice's parents was that Alice was excessively responding to things when she was stressed. This caused their communication and interaction to deteriorate quickly as many times Alice responded by answering back to her parents instead of taking time to assess the task or requests from them and to come to a reasonable response. Alice's reactions angered her parents as they expected Alice to respond to them more appropriately and most importantly to comply with their requests.
Behavioral disinhibition is central to understanding many behavioral complications seen in ADHD, and it is described as being impulsive/ impulsiveness. Behaviors such as uncontrollable silly and clown-like conduct, giggling too much, and involvement in risk-taking behaviors, e.g., sexual misconduct, substance use or abuse, engagement with online friends or interest in prohibited actions, are behaviors often seen as annoying and causing disturbances or distress to others. These behaviors are beyond the definition of normal behavior and signify the impulsive behavior seen in people with ADHD.
Inhibition is defined as the ability to control one's attention, behavior, thoughts, and/or emotions [12]. In humans, the ability to use one's inhibition is necessary to override many strong internal vulnerability and external lure [13]. Inhibition is part of executive function, which is regulated in the frontal lobe [14].
Appropriate regulation of emotions is reliant on having effective behavioral inhibition [12]; and when this is deficient or defective, this often results in many emotional and behavioral problems [3,15]. Many researchers have emphasized the presence of poor behavioral inhibition as the central impairment of the disorder [12,16]. The poor behavior inhibition and poor impulse control is evident in people with ADHD having greater disinhibition and being less effective at regulating their emotions [12,16]. As the consequence, they have the inability to delay responding long enough to consider the social situation and the consequences of their behavior [12,16,17]. Thus they make frequent hasty decisions and actions that occur in the moment without them thinking and considering the possibility of high potential of harm, failure or disappointment to the individual. Learning from their mistakes does not often occur or is difficult. They are repeatedly unable to use appropriate self-regulation strategies and social skills [12,16]. They are unable to persist long enough to complete tasks and are unable to regulate them from being easily distracted.
Children with ADHD are seen as being disruptive and annoying. Again, this is as a consequence of their inability to regulate their behaviors and emotions. Their behaviors are highly intense, unmodulated and often inappropriate in the given context and insensitive to social expectations [3,5,18,19]. They are often described as interrupting and intruding on others. The disruptive behaviors often emerge as early as in the preschool years and in many children persisting into adolescence [20]. Children with ADHD are described as less attentive to social cues, not listening to adults, and ignoring parental requests.
These difficulties impair their academic and social functioning, use of their recreational time as well as the relationship with their parents [21]. They are often seen as being less compliant even oppositional towards adults [22,23]. It makes it hard for the parent of a child who is often annoyed and over-reacting to things around him/ her. Just as frustrating and worrying, many parents have been called in to their child's school to listen to numerous negative reports of their child and some may have triggered negative reactions from their teachers.
Further neurobiological information on impulsivity and inhibition has been suggested to be as a result multiple pathway models [16,24,25] and discussed in-length elsewhere in the book.
Alice felt over controlled being home, and expressed that she chose to keep to herself. Alice added she would usually confide and feel better when she chatted with friends online. She felt miserable, as she had no longer had any access to them after her father cut-off the Internet access.
Alice felt she was walking on eggshells when she was at home. She added that she felt tense at home, and was not able to be herself. She feared that her father would be angry, and he often was angry when he came home. In many of his angry outbursts, father has asked Alice's mother to leave the house.
Alice had symptoms of ADHD, which was clearly impacting her performance at school and putting a strain on her relationship with her parents. Her impulsivity resulted in her making hasty and unwise decisions, as seen in her risk-taking behavior. The dispute and conflict at home between her parents and her, her parent's negative perception of her, further drove her to seek comfort and acceptance with online friends. Her anger and frustration at her predicament appeared to be taking a toll on her ability to regulate her emotions. She was seen to be moody and irritable at the time of presentation, and it worsened the interaction between her and her parents.

ADHD Oppositional Defiant Disorder
Difficulties with Primary support group

Reactive attachment disorder
The diagnoses arrived at were purely based on detailed psychiatric assessment which involves thorough history taking and mental state examination of the child and her family. No other assessment devices/ rating scales were employed.
The writers were based in a child and adolescent mental health facility where the service has only child and adolescents psychiatrists. There are many such services operating with the lack of staffs e.g. child psychiatrists or allied health personnel, and funding. This should not prevent clinicians or any mental health professionals assessing any child presenting to mental health facilities with symptoms suggestive of ADHD. It is most logical to gather enough data from the parents regarding symptoms of ADHD, i.e. look for any behavioral, emotional and academic difficulties.
Neuropsychological testing, speech-language assessments, and computerized testing of attention or inhibitory control may not be available in many centers or settings. These assess-ments are not required as part of a routine assessment for ADHD, but may be indicated by the findings of the initial psychological assessment [26]. Having no such assessment tools should not prevent any child and their families to be assessed.

Emotional dysregulation
children with ADHD are viewed as being more unsuccessful with regulation and this can be easily seen as they are easily upset when faced with faced with daunting and frustrating tasks [12,13,27]. As demonstrated in Alice, they respond impulsively.
Emotion regulation refers to the ongoing process of responding to one's environment with emotions that are both socially acceptable and context-appropriate for any given situation [13]. It is a process that allows the individual to select, attend and appraise emotionally arousing stimuli [28]. The expression of emotions is pertinent and it has to be appropriate to help promote adaptive and goal-oriented behaviors and to fit in with others [29]. These processes trigger behavioral and physiological responses that can be modulated through understanding of what influences these components of emotions, with dysregulation of one's emotion appearing when these adaptive processes are impaired [28,30].
From the history Alice seemed easily frustrated, moody and irritable. Alice was not able to regulate her emotions adequately, giving rise to her being irritable at home especially when she felt she was confronted by her parents. These clearly complicated things between Alice and her parents; despite them telling her to consider issues brought up by her parents, Alice was not able to delay responding.
Emotional dysregulation can be seen in three domains from temper control, affective lability and emotional over reactivity [31]. Emotion dysregulation is prevalent in ADHD and is a major contributor to impairment [13,32,33]. Reports estimates, prevalence of between 24% and 50% children with ADHD has emotional dysregulation [33][34][35], and it is more severe in males [13].
Furthermore, children with ADHD has been described as emotionally explosive [1,13]. The difficulties with self-regulating their emotions is seen in them being easily frustrated, and having low frustration tolerance, with frequent temper outbursts and mood lability [16,36]. They are seen seen to be easily angry, hot-tempered, sensitive thus easily annoyed and reacts to the slightest comments. They fight with parents, teachers and even their peers [1,37,38]. Many children end up facing numerous limitations in their activities with friends at school or within the neighborhood, with some children consequently having no friends. Peers avoid being with the child due to their negative, harsh and at times aggressive behavior.
It has been proposed that genetic factors play a role in the etiology of emotional dysregulation in children with ADHD [33,39,40]. Failures of parental emotion regulation, high levels of parental criticism contribute to the development of emotion dysregulation in children with ADHD [41,42], and these issues were illustrated in Alice and her family.
Emotional dysregulation is thought to have a greater impact than hyperactivity and inattention on an individual's well-being and self-esteem [33]. Individuals with combination of ADHD and emotional dysregulation face more impairment in peer relationships, family life, occupational attainment, and academic performance than those with ADHD alone [1,33]. Other than it is a major source of impairment, the presence of emotional dysregulation indicates poorer clinical outcome [30].
The presence of oppositional behavior and difficulties with self-regulation are often an indication of more serious difficulties [12,16].

Peer and school challenges in ADHD
Having friends is important; children learn to socialize, communicate, cooperate, and negotiate having friends. They also learn to manage disagreements and challenges. Friends are an important source of influence, both positive and negative, especially outside the home environment [43,44]. Friends play a key role in the development of personal competence and identity, with having friends predictive of the child's later psychological functioning as they are an important source of support [45]. Peer relationships are important especially for adolescents with presence of peer rejection linked to long-term negative outcomes including academic problems, school dropout, delinquency, even cigarette and substance use [5,19,45].
The core symptoms of ADHD, i.e. inattention and hyperactivity/impulsivity impede effective functioning with peers [19,46,47]. Between 50% and 80% of children with ADHD are rejected by peers [19,48]. Inattentiveness limits opportunities to acquire social skills through observational learning and to attend to social cues necessary for successful social interaction, while hyperactive and impulsive behaviors contribute to unrestrained and overbearing social behavior that makes children with ADHD highly aversive to their peers [3,5,46,47].
Peers often report children with ADHD exhibit more negative behaviors, such as "interrupting or intruding on others", are noisy and others often find them as socially immature. This is primarily because these children exhibit deficits in social skills such as reduced capacity for social reciprocity and difficulties in understanding social cues [49]. In addition, children with ADHD have reduced ability to monitor and evaluate their own behaviors [19,50]. They are unable to wait for their turn or to learn from being told before, resulting in them to be lower on social preference among their peers. They are less well-liked and have fewer dyadic friendships [19,50]. The deficits in peer rejection often occur early in age and these children are often excluded from popular social groups [47].
To add to their challenges in school, even among their teachers, children with ADHD are perceived as being less socially competent [58] and at times challenging. Teachers play an important role in the lives of children, including in children with ADHD. They have daily contact with the children, and they are often the first to notice the difficulties in the children with ADHD. Teachers often make inferences about the child's present and future academic achievement and general classroom behavior of their students, thus creating expectations for and perception of the child [54,59,60]. Like parents, teachers report feeling more stressed when handling and interacting with children with ADHD as the interactions are more negative [61]. Similarly the perceptions and expectations of teachers affect their interactions with the children, which in turn affect the children's behavior and academic success [59,60].

Co-morbidity
Approximately two thirds of children with ADHD have at least one other coexisting condition [62,63]. Disruptive behavior is one of the most common behavioral difficulties with an estimate of between 30% and 50% of children with ADHD have them [63][64][65]. Children with ADHD, particularly those exhibiting more impulsivity, are likely to be diagnosed with oppositional defiant disorder. They have more difficulties restricting their behavior in conformance with instructions especially from adults, deferring gratification and resisting temptations [12]. Additionally the presence of conduct disorder or oppositional defiant disorder significantly complicates the acute presentation of ADHD and its management. The disruptive behavior is associated with more aggression and delinquency, and disrupts academic achievement [12,[66][67][68][69]. The emergence of disruptive behavior in Alice clearly caused a lot of animosity between her parents and Alice.

Depression
Alice did not have sufficient symptoms to warrant a diagnosis of a depressive disorder, however she did reveal some symptoms to suggest she was depressed. Many children with ADHD describe chronic unhappiness even though they do not fulfill the criteria of major depression (MD). Presence of depression is common with between 5% and 40% of children with ADHD meeting the criteria for MD [62,70,71]. Major depression in children with ADHD is often recurrent and the prevalence increases significantly around puberty [72]. Presence of depression further complicates the picture as it is linked with increasing disruptive behavior, and further impairments in academic performance, peer relationships, and family relationships [71,73]. The presence of MD in ADHD children is as well associated with significant long-term psychiatric morbidity [72].
Adolescents with ADHD and co-morbid mood disorders are at increased risk for suicide attempts [72,74]. The rate of suicide is much higher in patients with both ADHD and MD as compared to patients with MD alone because both disorder may aggravate the symptoms of the other [75]. Even though Alice did not have any suicide attempt, she did express death wishes; hence, it was crucial that the clinician closely monitored her mood symptoms. This was done with regular and close follow-up visitation. With the ongoing difficulties within her family still continuing, Alice was at definite risk of developing depression. Noticeably, her relationship with her parents had deteriorated.
Alice found solace in friends online. Both inattention and hyperactive-impulsivity domains in ADHD are important risk factors for excessive use of Internet. Internet addiction is also found to be associated with symptoms of ADHD [76]. Significant associations have been found between the level of ADHD symptoms and the severity of Internet addiction in children [76,77]. It is postulated that the rapid response and immediate reward of the Internet makes it attractive for children with ADHD who easily bored and have aversion to delaying rewards. Thus it is not surprising the lack of self-control and inhibition makes them vulnerable to Internet Addiction [76,77].
Other difficulties, i.e., bipolar and substance use and abuse, are discussed elsewhere.

Subsequent Sessions
Over the subsequent sessions, Alice established a comfortable relationship with the clinician. She would walk in and eagerly share her difficulties. In one of the session, Alice shared she was upset that her teacher complained to her parents that Alice had kissed a boy outside school. At this point, her relationship with her parents was at its worst.
Her clinician was able to explore the family dynamics. The authoritarian parenting characteristics, the family environment, its lack of emotional warmth and support, and the parental psychopathology were clearly impacting Alice. Her behaviors may have served an important purpose within the family. It appeared to be an avenue for focus to be directed to her, instead of the very evident conflict between her parents. The clinician felt Alice was attempting to keep her parents together, as they appeared to be united in their stance and approach handling her. The high levels of conflict at home had conferred Alice at a heightened state of anxiety and hypervigilance, which were clearly taking a toll on her ability to regulate her emotions.
The clinician felt at this point it would be essential to make Alice's parents conscious of the dysfunctionality within the family. This was very difficult as her father was suspicious and untrusting of the clinician. To the clinician, it appeared that the father was fearful of the loss of autonomy over his family. Hence it showed showed in the father's presentation to the clinic. Her father portrayed a very defensive and almost aggressive stance. In view of the clinician's difficulty with the client's father, the clinician decided to engage the mother in order to facilitate some changes.

Family background
Alice came from an upper class family. Her father was a businessman, while her mother was a housewife. She had an older sister with whom she did not have a close relationship. She felt looked down upon by her sister, and her parents made constant comparison between her and her sister. Her sister was doing exceptionally well.

Alice's mother
Alice's mother had a difficult childhood. Her father passed away when she was very young. At the age of 10 years, she was expected by her mother to look after her younger siblings, whilst her mother worked.
Mother was expected to be independent and she was constantly reminded of her role as the eldest, and to not be a burden to her mother. Alice's mother lost a normal childhood, and grew up with a mother who showed no warmth, was critical, and imposed huge demands on her that she carried out dutifully. When the clinician asked her what she saw when she looked at her own daughter, mother added that she saw a lazy child, who was so different from how she was, as a child. Upon reflection, mother then added that she indeed had become exactly like her own mum. At this juncture mother became very distressed and tearful.
When the clinician asked her how she felt when she had discovered those letters, mother added that she was not surprised. Alice had, over past 6 months, placed letters of death wishes on mum's pillow. The clinician asked her how she responded to Alice, on reading the letters. Mother mentioned that she never asked Alice about the letters, as she felt her daughter was seeking attention, and if she asked her, it would encourage her further. Once again, she cried upon realizing the impact of what she had just said. It was a difficult session for mother, but one that allowed her to self-reflect, and impelled her to make changes, for the sake of her daughter. Mother realized she did love her daughter still, but mother had great difficulties to express her love, to show she cared, and it affected her bonding and ability to secure a loving relationship.

Parenting and parent-child relationship in children with ADHD
Parenting is challenging enough and the case demonstrates the reality that parenting children with ADHD is a big challenge to many parents. Symptoms of the disorder such as hyperactivity, impulsivity and inattention make parenting a child more difficult [65,78,79]. Although the presentation may change throughout the developmental years, the difficulties are often ongoing [9,63]. It is often more challenging during the adolescent years.
For school-going children like Alice, the inability to focus, attend to lessons, listen and obey instructions, difficulties in play or recreational activities and to interact pleasantly with others clearly impairs their academic and social functioning [7,9] as well as the relationship with their parents [80]. It is stressful dealing with a child's noncompliance and oppositional behavior. Parents frequently misinterpret their child's behavior and intentions, and are often frustrated as "correcting their child's behaviors" is every so often associated with more oppositional behaviors from the child. This was how Alice's parents felt towards their daughter. Children with ADHD tend to exhibit higher than average rates of noncompliance [81], and in adolescents with ADHD, as discussed, it is not uncommon to see an increased in emotionality, especially in the form of anger [82]. This results in parents expressing their child as being non-compliant and oppositional [22,23,81]. Parents are not aware of their child having a disorder, or even aware what behaviors are related to the disorder. All they think about is how frustrating it is for them to handle their child.
Alice's parents felt managing their daughter was indeed challenging, especially in her adolescent years; they felt Alice was the major source of stress for the family. The problematic parent child interactions are often ongoing and repetitive, characterized by parents requesting for compliance, followed by the child's refusal to comply. This often results in either escalation of parents control and demanding compliance. This eventually leads to occurrence of occurrence of annoyance and increasing control control over the child while in other instances the parents give up. Despite this, there is still presence of frustration and anger in the environment. Many are unaware that the parent child interactions negatively reinforce each other in ways that increase the probability and severity of the child's problematic behaviour(s) and the deterioration of the parent child relationship.
Presence of negative emotions and cognitions, e.g., in a distress parent consistently influences one's evaluations of others with major consequences on their interactions with their children [83][84][85]. As the case demonstrates, the parents and the child are both angry and distressed with each other. There is as well presence of distrust milieu, both parties perceiving the other as intentionally frustrating resulting in the behavior of being noncompliant with the other. The presence of many conflicting interactions between parents and children often results in angry or distraught interactions, with each perceiving the other as intentionally frustrating, being uncooperative. This often results in both sides trying to out-do the other. The environment is often of greater negative affect, with less positive involvement and parenting responsiveness. It is no wonder that both parties could not exert some control on their own behaviour and emotions, and to try to find a compromise. Each party feel, they are right.
Unresolved parental reactions to their own or family crisis impacts the parents' parenting styles [84,85]; with Pianta and Marvin [84] and Sheeran, Marvin [85] stating the resolution of the matter, influences their mental representation of strategies in managing their difficulties. The lesser positive parenting responsiveness invariably leads to the use of more harsh and inconsistent discipline, and more coercive exchanges than in families of nonproblematic children [86].
Like any parents, parents of ADHD children may have their own difficulties. However, parents of ADHD children are at increased risk of having other psychiatric disorders as low selfconfidence [22,87] and depression [88,89]. Presence of parental stress, marital disharmony, high expressed emotions etc. affects parental functioning, family involvement and the parent child interaction [90,91]. Without doubts, problematic parent child relationships adds to the parenting distress [37,92].
Aspects of parenting are significant and are often over-shadowed by the difficulties in children with ADHD. Parenting style is a constellation of attitudes, behaviors and interactional styles or patterns of parenting practices [93]. Invariably how parents behave and interact with their children creates an emotional climate for the parent-child relationship [20,[93][94][95]. Parenting practices and behaviors are directly linked to children's emotional, behavioral regulation, social and interpersonal competence [93]; with substantial associations demonstrated between undesirable parenting behaviors/ styles with problems in their off-springs [96]. Other than maladaptive parenting practices [92,97], parental perceptions and ideas [37,97], differences in parenting and disagreements between the couple [81,86,90,98] are factors which contribute to the development and escalation of the child's problematic behaviors [99]. These issues distract the parents towards finding a more workable intervention for their child with difficulties.
The psychodynamic model emphasizes the importance of emotional relationships between parents and their child plays a significant role in the development course of children. The emotional relationships between parents and child are thought to be as a result of parenting behaviors and attitudes influencing the parents and their child's behaviors, and later influencing the child's relationships with other adults and peers [100][101][102]. In this dynamic family system, the internal representation of each party is just as influential [100,103]. This notion is supported by Maccoby [104] who stated that the parent child interaction is a reciprocal process with parents influencing their children and the children's behaviors may influence the way they are treated by their parents. While it is evident that parents often exhibit a range of emotions toward their children, in Alice's parents there is a predominant and persistent feeling of hostility and displeasure. Their interaction with their daughter was often distant, hostile, and at times disengaged, which supports the hypothesis that parental beliefs and perceptions influence specific parental behaviors and the emotional climates concerning their child [93,95,105].
Perception toward the child's symptoms is important as it significantly influences parents' interaction with their children [106]. In parents of ADHD children Alizadeh, Applequist [87] reported parents showed less warmth and involvement in the parenting of their children and they are more prone to greater use of corporal punishment. Similarly, Gau [107] found mothers of children with ADHD were less affectionate, more overprotective and controlling toward their children than mothers of controls. Margari, Craig [108] found parents with ADHD children tend to be more controlling, disapproving and rejecting of their children. The parents tended to use more verbal direction, repeated commands, added with more verbal reprimands and correction of their children. Margari, Craig [108] reported in these parents, they are also less rewarding and responsive than parents of children without ADHD. This is not surprising surprising as having a child with chronic difficulties and different from others affects the parents' beliefs, perceptions, attributions, etc. about the child and of other things faced by the parents.
Parents are often unaware of their reactions to the children's behaviors and emotions, which are often modeled by the children and affecting most notably their self-image. Alice's mother was getting more and more tired and irritable having to deal with her daughter's chronic difficulties and she was feeling alone and unsupported. Having to handle their daughter alone aggravated the marital disharmony. Many parents may not be aware of the symptoms and the severity of the problems that their child has. In this instance, Alice's parents labeled her as "bad, stubborn", they were unable to acknowledge their daughter was struggling as well. The parents' expectations and their beliefs, perceptions, and attribution about the child affect the parents' behavior toward the child. Thus if the parents feel their child is exhausting for them, it creates more tension in their relationship. Some parents may initially be overwhelmed with guilt feelings and blamed themselves for the children's misbehaviors however when the situation deteriorates, and things worsened, feelings of hopelessness and helplessness creep in. In other parents, they may have difficulty accepting the fact that their child is suffering from a disorder, given the stigma attached to the illness.
Mothers are the principal caregivers in many families across different cultures and countries. In countless instances, mothers are the parent who interacts and has to deal with their children in situations where the child exhibits most of the ADHD symptoms. Mothers are the ones most often helping their child do their school work, even organizing their school bag, their room, getting their children organized and to get through their daily activities. Inevitably, mothers are more likely to be blamed for their child's poor academic and social performances [109]. It is not surprising mothers of children with ADHD often report greater psychological distress and receiving lesser support from their families than do mothers of normal children [107,110].
Maternal affection buffers children with attention problems from developing social and adjustment problems [50], and this was considerably absent in the family discussed. Alice's mother was not able to offer comfort to her daughter, as the mother was distressed with having to handle her daughter on her own. This is not surprising as seen in the case described. As the situation continued and with no end insight, the severity of the difficulties increased. Predictably, the impairment increases, and it seemed the parents are the ones who often feel the impact more than their children [79]. Alice's parents, especially her mother, had become averse to being with Alice. Mother felt distress knowing her daughter was around. By the time the family was seen, the parents were very critical of their daughter, and it worried the clinician. The adults were not able to see any strength in Alice. Their perception of their daughter and the difficulties made the child parent interaction and parenting challenging.
Additionally, the difficulties are complicated by the presence of comorbidity and psychosocial stressors in the parents themselves. Family dysfunction or disadvantage is associated with early conduct complications [20]. This was clearly happening in Alice's family as her parents were struggling in their own marital relationship and often reacted hastily and angrily to their daughter's struggles.
Alice's father was impatient and often angry, and in his outburst he had told his wife to leave their matrimonial home. Unaware to the couple, it made Alice anxious and worried. Alice's father displayed poor emotional regulation resulting in frequent anger outbursts. Further history revealed that the father was brash in his manner with his family. In the clinical sessions, the clinician found father had difficulties to engage in the session. This raised the possibility of undiagnosed ADHD in the father.
ADHD is one of the most heritable psychiatric disorder [111,112]. Parents of children with ADHD are more likely to have ADHD themselves [113,114]. Subsequently, the parenting difficulties observed in families of children with ADHD may be accounted for, at least in part, by parental ADHD [114]. Presence of parental ADHD symptoms significantly impairs parents' parenting of their children, affecting the parental and child interactions and relationship [37,114,115]. Adults with ADHD have similar impairment in their executive functioning such as self-regulation of attention, inhibition, and organization. This effects their time management, planning, memory, motivation, persistence, and emotional regulation, i.e., they are likely to have more difficulties managing their child particularly those with oppositional behaviors [79,115,116].
In most parents, their ADHD symptoms have not been assessed. Many of the adults are not aware of the symptoms and how the symptoms may affect their functioning as parents. The symptoms of inattentiveness and impulsivity are likely to cause adults with ADHD to engage in harsh or lax parenting behaviors when dealing with their child's problems [113,117]. It is more difficult for parents to refrain themselves during discipline encounters therefore they are likely to use more negative and coercive methods. As the presence of ADHD results in difficulties with self-regulating, this may effect parents ability to think through about longterm gains [113,118]. The short attention span and impulsivity may make it difficult for a parent to stay focused or be consistent in monitoring or carrying out rules [81,118]. Additionally, they have problems with decision-making, e.g., they will have hitches with monitoring their child's behaviors, progress, or whereabouts. The consistency of the external feedback provided by parents of ADHD children is an important element for these children to remain on track with tasks, behaviors, etc. Harvey, Danforth [118] reported mothers with ADHD tended to use more repetitions during mothers with ADHD tended to use more repetitions during attempts to get their child to comply. This often results in arguments because repeated and angry requests from mothers are often ignored.
Affective lability is also seen in adult ADHD [113]. Fathers displaying features of impulsivity were found to have more arguments with their children during the interactions [118]. They were more demanding, are more power-assertive and they are less likely to express warmth toward these children [119]. When fathers do attend to their children's noncompliance, they demand more compliance and obedience at the expense of not or less expressing nurturance [118][119][120]. Similarly in mothers with ADHD, they are more emotionally reactive, causing likely to use more to use harsh or physical forms of punishments [116]. Like-wise maternal ADHD symptoms have been associated with lower level of positive parenting, lesser involvement and inconsistent discipline [113,118]. In adolescences, this dyadic interaction with their parents often results in the relationship to be hostile or distant.
Fathers are often less talked about as the source of emotional support and attachment. Fathers are equally an important source of support and resource for their children's well-being, cognitive development, and social competence [119,[121][122][123]. Studies of fathers with ADHD children found fathers' parenting style play a significant role in their interaction with their children [119] including the engagement and progression of adolescent delinquent behaviors [118,122,124]. Fathers of children with ADHD, particularly when handling their sons, are more demanding and controlling [125,126] and argumentative [118]. Other than being demanding, both Buhrmester, Camparo [126] and Gerdes, Hoza [120] reported fathers of ADHD children were less likely to express warmth towards their children while Harvey, Danforth [118] found in fathers with ADHD, the inattentiveness and impulsivity results in lax parenting. The presence of a supportive father may certainly help lift the burden of mothers handling the child alone. Likewise, support between parents and parenting similarity has been found to be associated with greater marital adjustment and and lesser marital conflict among parents of ADHD children [81].

Impact: Why the need to be aware of parenting difficulties?
It is not easy to parent a child with ADHD. Lower quality of life has been reported in families with ADHD children [79,115,127], complicated by the presence of adversities, conflicts [23,[128][129][130][131], and psychological difficulties [88,89]. These factors significantly impact family functioning which may precipitate and/or aggravate the child parent relationship and parenting difficulties [131]. Hence it is important for clinicians and mental health workers to consider these difficultieswhen interacting with a family of a child or adolescent with ADHD.
In psychiatry, family factors are taken into consideration in the formulation of clients' presentation and symptoms, i.e., in precipitating, perpetuating, predisposing or aggravating patient's symptoms, in treatment and in prognosis [132]. Over the past decade, much attention has been given to the understanding of the parent child interaction, with regards to attachment styles and parental behaviors, etc. and their impact on children. A significant number of researches have recognized the family environment plays an important role in the development, outcomes, and manifestation of difficulties in children with ADHD [37,50,128]. Both parental psychopathology and parenting behavior have been identified as important environmental risk and/or protective factors in children with ADHD [37,133]. Family dysfunction impacts not only the family functioning and certainly clinical outcomes. Family functioning influences continuity and/or exacerbation of the child's ADHD symptoms [37,86]. The difficulties related to the parents and family dysfunction are often linked to the frequency and severity of ADHD symptoms [20,[134][135][136]. Whereas improvement in outcomes linked to ongoing family engagement particularly active parental involvement and participatory collaborations between care-givers and healthcare providers [97,137].
These phenomena can be explained as the family interaction is continuous and ongoing, and invariably children are affected by the dynamics in the family. Parents are the main source of their children's socialization and emotional regulation [44,96], and children often model their parents' regulation and expression of emotions [44,138]. Accordingly, positive parenting constitutes having parenting attitudes and behaviors which are accepting and nurturing (acceptance), while negative parenting practices encompasses parenting styles which are rejecting and controlling [95]. In negative parenting practices, there is a constant need need for parents set fixed rules with rigid boundaries, with the necessity for constant supervision [139,140]. The parents often make endless demands on their children and readily confronts the child who disobeys with more continuous demands made [140]. In this style of parenting there is often presence of hostility when dealing with the child [141]. As studies have indicated, parents with ADHD children often are controlling, disapproving and hostile of their children [20,37,108].
It is not unusual for parents to react to their child's noncomplaint and disruptive behavior in a less positive manner, and this is often seen among parents with ADHD children [86,125]. The use of punishment and harsh discipline are often thought to be associated with good parenting. Parents feel using frequent punishment allows them by doing so, they are able to control their children's behaviors. Likewise, parents often exert control on their children in the pretext of having to protect their children from possible harm or from going astray. Many parents often believe their parenting is adequate, appropriate or the best for their for their children. Many parents parenting styles with them having to be able to control and to discipline their child. The reality is, using more control with presence of punitive interactions, often results in retaliation and noncomplaint behavior from the child, especially among adolescents. Many parents are unaware of the importance and the need for them to be equally nurturing and supportive of their children.
Evidence supports findings of reciprocal pathways between child disruptive behavior and parent-child interaction difficulties. Being in a chaotic, harsh, unsupportive or unresponsive family environment exacerbate inattentive, impulsive, and hyperactive behaviors [37]. Cunningham and Boyle [20] found mothers with pre-school children with ADHD and oppositional behavior cope with their children's behaviours using more controlling and negative strategies. The mothers used more reprimands and corporal punishments. Often this does not settle the child. Querido, Warner [142] and Carpenter and Mendez [143] found harsh parenting is predictive of worsening behavior as the presence of punitive interactions and low level of warmth do not offer any comfort, feeling safe, and support to the child [15]. The presence of harsh, punitive, and controlling parenting behaviors as seen in authoritarian parenting styles hinders the development of a child's social competence. This parenting style is linked to the presence of aggressive and defiant behavior in children [15,69,136,142,144,145].
Over the recent years, studies have focussed on the attachment theory specifically on the quality of parenting and understanding how socio-emotional dysfunction impacts children's behavior and development. Attachment is the deep and lasting affective and close relationship between a child and their care-giver(s), which is established in the early years of a child's life [100,101]. The parent child relationship is crucial as it lays the foundation of attachment and socialization which eventually dominates and affects the child's emotional, interpersonal development, and well-being [146]. Consequently in vulnerable children, the presence of secure attachment provides safety and protection through the existence of a trusting, safe, and secure environment [147,148]. The presence of a secure, supportive, and trustworthy caregiver allows distressed children to use their care-givers as a secure base to regulate their anxiety and distress; the child finds comfort and support when confronted with stressful stimuli or situations [148].
Growing up with an insensitive and unresponsive, or unavailable caregiver often puts the child at risk for developing an insecure attachment relationship [102]. Alice could not find comfort from her parents as the adults were entrapped in their own burden. Her parents were unable to provide relief and nurturance to their daughter, especially in her times of need. This is not surprising as parents who lack or not able to provide self regulation skills are unable to offer the framework necessary for the development of such skills in their children [20,137]. Thus, they are less able to support their child, which leaves the child feeling insecure and vulnerable. Insecurely attached individuals are indeed more vulnerable to problems concerning affective and behavioral regulation [149]. Lower levels of conduct problems even in children as young as pre-school-going age has been reported in parents exhibiting parental warmth in combination with other positive parenting behaviors [123,150]. The presence of a secure attachment and base allows a child with with ADHD the awareness and security they will be supported as they work through their difficulties.

What elements constitute negative parenting behaviors and interfere with establishment of a secure family base?
Researchers have shown negative parenting behaviors as:

1.
Over-controlling [151,152]: This describes the parenting styles which resembles the nononsense parenting with decrease in responsiveness and increase in demandingness. In this parenting style, parents are involved in all decision-making, and are overprotective.
There is presence of frequent instructions to children, e.g., on how to behave, think, or feel, in view to influence the child. This style of parenting has been shown to mediate higher risk for anxiety and depression [141] and delinquency in children [123,136].

2.
Harsher discipline characterized by presence of constant yelling, nagging, threatening or the use of physical aggression (hitting, beating). This harsh parenting relates to the emergence and escalation of aggressive and defiant behavior in children [15,123,143].

3.
Over-indulgent: This style of parenting reduces the child's opportunities for learning. There is constant parental interference with parents over doing their role. Their parenting style interferes with the child's attempts at gaining age normative autonomy and emotional independence. There is no restrictions, and no boundaries to what the child wants and desire [94,153].

4.
Inconsistent parenting [119], often exhibits inconsistent availability and therefore discipline. It is akin to low parental involvement and often may worsen the child's ADHD symptoms [137].

5.
Rejection and hostile parenting characterized by presence of disapproval, and low levels of parental warmth and responsiveness. Parents often exhibit coldness or are unresponsive, dismissive and disapproving of their child. They often respond to their children's expressions of needs or emotions with criticizing or minimizing and even nagging. This often convinces a child that positives, especially from a significant other, are difficult to obtain and are independent of the child's actions. Presence of high levels of parental rejection is often associated with poor child emotion regulation [138] and increasing sensitivity to develop anxiety and depression [153].

7.
Dissimilarity in parenting [81]: dissimilarities between parents would not only impact on the problems in the child, it will as well cause higher marital conflicts and dissatisfaction between the couple.

8.
Higher levels of parenting stress are often associated with the presence of marital disharmony, divorce, separation, remarriage, parental depression [37,136]. Stressed parents exhibit either hostility, over-protectiveness or are unavailable when dealing with their children.
The negative parenting behavior as stated above, i.e., hostile, unavailable, inconsistent parenting along with parental stress and psychopathology often influences the parent child interactions and family functioning. In children these circumstances predict treatment outcomes [110].
Parents from every background love their children and want to protect them from all sorts of harm and misfortune. Qualities in parents such as the presence of parental affection and sensitivity, the amount and nature of control strategies, and monitoring are key aspects of healthy child development [104,155]. The existence of warmth, acceptance, and communication becomes increasingly important during adolescence. Parents are an important source of support, especially among adolescents. They can still exert influence over their children's behavior by providing the existence of being responsive and sensitive while creating a caring and safe family environment, and not just the presence of strict control. As a matter of fact, strict control, especially during adolescence, is associated with deviance and misconduct [156][157][158].
The manner in which parents respond to their children's emotions and behaviors, their perception and managing of their children's behaviors impacts the outcomes of the difficulties, the child's self-image and problem-solving skills. Bowlby [159] hypothesized early experiences with primary caregivers are internalized by the child as generalized mental representations or internal working models i.e. the child's image of the self as well as the image of others. These cognitive representations of early relationships serve as templates for functioning in future relationships [100,103] and shapes how the child responds to external events [102,160]. These mental representations (organize a person's adults' later attachment-related representations and) play a key role in guiding interpersonal behavior and regulating affect during adolescence and adulthood [161,162].
In positive parenting, parents create an environment of secure attachment by balancing giving the child their attention while creating the presence of a nurturing environment. In this style of parenting, appropriate attention is given, and there is often positive affect felt through the expression presence of positive emotions. Communication is encouraged; there is presence of proper discipline and structure, with clear rules, instructions. There are, and consistent monitoring of how things are balanced with use of praises [163,164]. Parents react positively, allowing their children to learn to control their impulses using their cognition [149]. This style of parenting serves as protective factor that results in and facilitates the development of proper self-regulation [149].
In dealing with children with ADHD, parents need loads of patience and consistency as the case demonstrates. It is not easy dealing with a child who is active, has difficulties to stay focus to listen to parents, to follow as parents want them to. It is not surprising that parents with ADHD children tend to be more controlling and disapproving of their children. They frequently give their attention to their child's overactive and impulsive behaviors. They invariably repeat their commands, and become increasingly impatient with little reaction from their child. More verbal commands follows accompanied by them attempting to correct their child's behavior and subsequently trailed by verbal reprimands. This is a common scene with parents of children with ADHD.
Positive family environments are crucial in promoting children's emotional and behavioral wellbeing. Positive and secure bonding the child's trust in themselves and others, while inadequate and defective bonding results in patterns of insecurity and self-doubt. Being in a positive family environment also buffers the difficulties associated with the disorder. The authoritative parenting style has been shown to be associated with better social competence, fewer behavioral problems [142,143,165], decreases the development of conduct problems [20,37,136], and even has impact on aspects of children's school readiness [165,166]. Parental warmth, in combination with other positive parenting behaviors, has been associated with lower levels of conduct problems [150] even in kindergarten and first grade children [20].
Johnston [125] found among parents with older ADHD children with higher oppositional behaviors, report of feeling less competent as parents than those of ADHD children without or exhibiting less oppositional behaviors. This has been seen in other studies [87,110,116]. This is not surprising as it is indeed difficult handling a child with ADHD, and when stressed, parents are often left feeling frustrated or irritable and accompanied by feelings of being powerless and insufficiency. Being in this state often leads to ineffective parenting and often has negative consequences the child.
Qualities in parents such as the presence of parental affection and sensitivity with the existence of warmth, acceptance, and appropriate involvement are key aspects of healthy child development. Appropraite parenting behaviors result in a positive interaction with the child, such that the child feel safe and reassured. There are more active listening, expressions of encouragement, with opportunities and experiences for the child by allowing them to learn through trial and error, while tolerating their child's negative affect.

Role of professionals
The families of children with ADHD experience difficulties in many areas of functioning as illustrated with Alice. The presence of the difficulties in the child as well as comorbidities signifies risk factors for insecure attachment with impact on the parent child relationship. The existence of these factors and its consequences must be recognized.
ADHD creates a huge impact not only on the child alone but also upon the whole family. From the very initial consultation, parental factors, such as perception of parents/caregivers, the dynamics within the family, emotional difficulties of parents themselves, and their parenting skills, areas of concernin the family that needs consideration.
In pharmacological treatment of ADHD, the effectiveness of medication has been well established. However, medication alone cannot and should not serve to be the sole modality of treatment. Of recent, increasing evidence has demonstrated the role of multi-modal treatment for effectively addressing the diverse difficulties of children with ADHD [167].
To be most effective in helping children and their families, it is commended that health care professionals have a good understanding of the individual and their family development.
Family difficulties are common as discussed in Alice's family, i.e., parental depression, aggression, marital discord, and hostile parent child interactions. While child characteristics are important, the discussion emphasizes on the need to look at what other factors contribute to attachment difficulties and family destabilization. Thus, the assessment should include family factors that may have an impact on the child and their family functioning, which is often related to the origins of behavior problems in the child [135,136].
Understanding family dynamics is most essential, in order to examine the interactions among family members, and identify factors that are triggering or maintaining undesirable behaviors. These dynamic interactions between social, biological, and psychological factors of the child often lead to longstanding distress in the child and their family. The family environment if often viewed as the earliest setting for dysfunctional attitudes, behaviors and interactional patterns which often results in self-esteem issues, symptoms of depression and anxiety [94,153,168] as well as learning antisocial behaviors [169]. In order to facilitate the child's progress towards recovery, positive changes within the child's family must be addressed.
Positive parenting styles are significantly associated with development of more appropriate behavior in children including their inhibition capacities [164]. Parents often misunderstand the use of punishment in changing a child's behavior. It has well been demonstrated that once punishment ceases, children often return to their previous behavior(s). Using harsh punishment does not help establish new and wanted behaviors; in fact, it is linked to the presence of more undesired behavior, including withdrawal of the child from their parents. Additionally, children often model their parents' behavior(s). In clinical setting it is common parents report their children hitting back their parents when in anger or frustrated.
Much of the evidence indicates family therapy being efficacious for children with ADHD refers to multimodal forms of family therapy. This often includes pharmacological treatment along with family therapy or parent training, and individual therapy for children [170][171][172]. Though further research is still necessary examining the effectiveness of family therapy as an relevant intervention for children with ADHD [173], other clinicians and researchers emphasize the need to routinely focus on children's attachment and attachment difficulties in clinical settings and to incorporate it in the treatment option [149,172].
There is now increasing evidence of the implication of parent training programs, with results showing the improvement of the child's behavior [170]. In working with children like Alice, parent work and individual therapy with the parent(s), are essential. A broad-based psychodynamic approach was taken working with Alice's mother. To begin with, a client-centered approach was initiated. It was discovered Alice's mother was vulnerable and needed emotional support. Alice's mother needed to work through her own challenging childhood experiences and a conflictual marriage with an over controlling husband. With psychotherapy, Alice's mother was able to mourn her losses she had sustained since her childhood. It was through reflection that she was finally able to view herself, her needs and the needs of her child, and how pathological her responses to Alice had been. With the employment of object relations theory in therapy, Alice's mother was able to view that she was parenting Alice similarly, to her own mother, whom she had vowed never to become.
Clinicians work to facilitate changes in the internal working model of many of their clients. After several sessions, Alice's mother no longer perceived Alice negatively. Alice too was able to form a more trusting and comfortable relationship with her mother. Parenting skills were later introduced. Alizadeh, Applequist [87] further emphasize the usefulness to educate parents in their recognition that ADHD is not their fault, nor is it a consequence of something that they have done in the past.
The clinician had hoped to engage Alice's father into therapy however, the huge resistance that Alice's father demonstrated made it difficult. Father was unhappy that his wife was attending therapy, and made it apparent. Alice's father's own difficulty in managing his emotions, his own psychological issues and immense need for control, and most immediate, a very high likelihood of Adult ADHD, would need to be addressed at some point.

Current progress:
Alice still attends treatment, where she now is on daily long-acting stimulant, and doing well in school. Her much improved relationship with mum at times does have difficult phases, where she struggles to communicate and at times hides the truth from her mother. Overall their relationship had improved significantly. The difficulties with dad remain.
Alice was noted to be less impulsive, she was more able to think through things carefully, and was able to make wiser choices on her own. One of them was her choosing to end the strained relationship with her boyfriend, who himself had significant emotional difficulties. The triumph for the year for Alice was she was awarded a prize of being the student with the most improvement shown in the year The purpose of this chapter was to illustrate the magnitude of complexity in dealing with a child with ADHD. The interplay of roles within their families, and the huge impact that family difficulties have on a child with ADHD warrants the need for mental health professionals to look beyond the core symptoms of the disorder. In recognizing, assessing and treating family difficulties of children with ADHD, clinicians often need to incorporate several modalities of treatment demonstrated. This is to increase the likelihood. This brings us back to the very core hallmarks of child psychiatry, which serves to remind us that one cannot treat children without treating their families. There is no denying that the mental well-being of parents is utmost important; the captain of the ship has to be working well to maintain the mental health and well-being of the members of the ship (called family).
In the best attempt to maintain confidentiality, the real name of the child was not used. Her ethnicity, place of residence, the name of her parents, and socio-demographic details have been intentionally omitted. This was in order to preserve, in the best interest of the child and her family, to disguise her identity. This is also in accordance to adhere to the ethics of publishing.