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New Study Reinforces Importance of Testing Parents of Kids Who Are Diagnosed With Attention-Deficit Hyperactivity Disorder

By Matt McMillen Special to The Washington Post Tuesday, January 20, 2004; Page HE01

The parents of a child with attention-deficit hyperactivity disorder (ADHD) should be tested for the condition themselves soon after the child’s diagnosis, the authors of a new study conclude.

The study, which was conducted by University of Maryland researchers and published in the December issue of the Journal of the American Academy of Child & Adolescent Psychiatry, found that parents of children who have ADHD are more than 20 times more likely to have ADHD than parents whose children do not. And if their children also have other serious behavioral problems, the study says, the parents’ risk for other psychological disorders, such as depression, anxiety and substance abuse, is as much as five times the norm. Why the need to quickly identify parents of recently diagnosed children?

“It’s critical to have parents performing at their best,” says Andrea Chronis, director of the ADHD program at the University of Maryland and the study’s lead author, “so that the child can perform as well as possible. . . . [But] if a child has ADHD and the parents do, too, you can imagine the difficulties.” ADHD, which affects an estimated 3 to 7 percent of school-age children, often continues into adulthood. The inability to organize and to pay attention, two hallmark symptoms of the disorder, can cause parents to miss their child’s doctor’s appointments, forget to give the child medication and fail to stick with a treatment plan.

Parents with disorders such as depression and anxiety, says Chronis, tend to be withdrawn and irritable; they laugh and smile less, and engage less with their children. Such problems, she writes, “likely contribute to reciprocal patterns of negativity between parents and children.”
The study involved 98 children ages 3 to 7 who had been diagnosed with ADHD and 116 non-ADHD children of similar age. The mother of each child was interviewed to determine whether she and/or the child’s father had a history of ADHD, depression, anxiety, substance abuse or antisocial personality disorder. Fathers were not interviewed.

According to the study, 0.9 percent of the mothers in the control group met the criteria for having had ADHD as children. Among mothers of ADHD kids, 16.7 percent had had ADHD symptoms themselves. (The study did not assess whether they continued to meet the diagnostic criteria as adults or whether they had been diagnosed or treated for ADHD as children.)

Markedly high levels of other psychological disorders were noted among the parents whose children had ADHD, especially those whose children also had accompanying behavioral problems such as opposition defiant disorder (ODD) and conduct disorder (CD).

This finding was not surprising to several experts on ADHD. “Disorders tend to go together in individuals and families,” says Stephen Faraone, clinical professor of psychiatry at Harvard Medical School and author of “Straight Talk About Your Child’s Mental Health” (Guilford Press, 2003). “Co-morbidity is the rule rather than the exception.”

Why? According to Faraone, part of the answer lies in the genes. ADHD, he says, is one of the most heritable disorders in psychiatry: If you have ADHD, he says, it appears there’s a 20 to 50 percent chance that you will pass it along to your child. The disorders that often travel with it — depression, anxiety, substance abuse — also have a strong genetic component. But genes aren’t destiny: “If the parent has [a gene for] alcoholism or depression or antisocial personality, the child is at risk for those,” says Faraone, “but it doesn’t mean the child will get [that] disorder. . . . Genes play a substantial role, but they may need to be triggered.”

One trigger, he says, could be exposure to a parent’s depression or alcoholism: “The additional chaos [caused by a parent’s disorder] will [increase] the chances of getting the disorder.”

Despite strong evidence that a disorder in one family member is a strong predictor of disorders in other family members, treatment traditionally focuses on the individual rather than the family as a whole.

This study is “a clear sign that a very comprehensive assessment of the family is needed,” Faraone says. “A pediatrician is a very busy guy, but it’s easy to ask some questions about [the parents’] past history of mental disorders, drinking, etc.”

A simple paper-and-pencil test filled out in the doctor’s waiting room could go a long way toward determining the parent’s need for a complete evaluation, says Russell Barkley, a professor at the Medical University of South Carolina and author of “Taking Charge of ADHD, Revised Edition” (Guilford Press, 2000).

“It’s not rocket science — any nurse or office secretary could [tally the score],” he says. Yet such assessments remain rare: “[There are] time limits due to managed care, but really it is the ignorance of clinicians that prevents them from getting this on their radar.”

James Perrin, professor of pediatrics at Harvard Medical School, agrees. “We don’t do that as well as we should,” says Perrin, who co-wrote the ADHD diagnosis guidelines for the American Academy of Pediatrics. When a child is being evaluated for ADHD, says Perrin, pediatricians should be asking the parents about the entire family’s history of mental disorders. Often they don’t because they don’t have the time: “This is not a simple diagnosis,” he says. “The way we pay for services, it’s hard to get reimbursement for the kind of time necessary to gather information.”

Spend enough time with the family, though, and the diagnostic information often surfaces, says John Pleasant, a licensed clinical social worker with the Family Group of Washington. “You look for it in certain ways, [asking questions like] ‘How come Billy is missing appointments and medications?’ ” Responses would likely reveal much about the parent’s problems. Pleasant says he makes time to work with the parents as well as the child to address problems that both may be having, but he admits that the time he is able to give is often not enough. “Is the child shortchanged when you address the parent? You do what you can in one hour.”

Patrick Kilcarr finds in his counseling practice that most parents are upfront about their problems if they are asked. “What happens when [your son] is just staring at his desk?” Kilcarr, who is also the director of Georgetown University’s Center for Personal Development, asks parents. “What are your responses? Anger? Frustration?” The answers help him evaluate the parents’ need for treatment, something he says that many parents don’t expect: “The parent is really showing concern for their child, but they hadn’t planned on going into their own psyche and patterns. . . . [But] if we are going to repair the problem, it has to be done on all fronts.”

A parent of a child with ADHD has to be an “advocate for that child — attending and scheduling school meetings [for example],” says Kilcarr. “You need energy in reserve to organize. If you are too scattered or depressed to do that. . . .” Or as Pleasant puts it, “[Parents] have to be stable enough to deal with things.”

That means addressing their own problems as well as their child’s. If they don’t, Pleasant says, “their kid [will have] trouble being on board about accepting his or her own diagnosis and treatment. I see that all the time.”
In Kilcarr’s view, parents and children who address their problems simultaneously can greatly enrich their relationships: “When you have a parent going through change, it becomes a partnership,” he says. If the child is at least 11 or 12 when this occurs, he says, “it can be an amazing partnership.”

Chronis, the report’s author, is now at work on two studies of mothers with ADHD. “Do treatments [for the parents] improve functioning?” she asks. “Does it improve the ability to parent?”

One study, funded by McNeil Consumer and Specialty Pharmaceuticals, will focus on the effectiveness of the company’s stimulant medication Concerta. Eli Lilly & Co. is considering funding research by Chronis on Strattera, Lilly’s non-stimulant drug for ADHD.

Does this signal a trend away from focusing simply on the child and toward taking into account the entire family? Maybe. “Just identifying the index patient might not be sufficient,” says Calvin Sumner, a senior clinical research physician at Lilly who has studied ADHD for 30 years. “Address the environment. Optimize the environment. That has not been a priority, but we are moving toward this.”

Matt McMillen has written frequently for the Health section about ADHD.

© 2004 The Washington Post Company