Interpersonal Relationships

This weekend we had a really massive bust-up. Huge. It was really bad. I just went wild. I was asked to leave home this weekend. My Dad said "go on just pack your bags, go pack up", and I was like "right I will, see you. I don't care. I'll see you in a couple of days and we'll sort it out then". The problem is nobody cares...nobody talks... and all the emotions come out.

People with ADHD often have difficulties maintaining positive relationships within their family, with peers and romantic partners. In addition to these problems, ADHD may influence the type of people with whom relationships are formed, and the nature of these relationships. Both the behaviour of the person with ADHD and the reactions of others towards them are important in determining the success of their interpersonal relationships.

Family Relationships

ADHD can impact on the whole of family life and can cause strain in relationships with parents and siblings. Children and adolescents with ADHD have been reported to display significantly more attention seeking, disruptive and aggressive behaviour than those without, and this can have a negative effect on relationships within the home [1]. This may be because they lack self-regulation and can be emotionally labile. This can lead to negative and confrontational cycles within families and, if effective strategies are not implemented to understand and manage the behaviour of the young person with ADHD, then ‘typical’ family disagreements may escalate rapidly and frequently, and cause tension within the family. It is important that when ADHD is diagnosed, parents are made aware of ways that symptoms can be managed at home in order to reduce the impact of the condition on other family members.

Parenting and the Cycle of ADHD

ADHD is a highly heritable condition with prevalence among first degree relatives in the range of 20-50% [2]. Thus young people with ADHD are likely to become parents with ADHD and have ADHD children. Parents often remain symptomatic as around two-thirds of adults experience persisting ADHD symptoms [3]. Many parents present to services in adulthood because their children have been diagnosed and they recognise the symptoms and history in themselves.

This cycle of ADHD means that parent-child relationships are characterised by ADHD-related difficulties on both sides, with each probably exacerbating the other. For example, one study of mothers with and without ADHD (all of whom had children with ADHD) reported that mothers with the condition were poorer at monitoring their child’s behaviour, less consistent with discipline, and less effective at problem solving around child behaviour issues [4]. These findings persisted even after controlling for child oppositional and conduct-disordered behaviours. This parental style may be a risk factor for accidental injuries and contribute to elevated rates for accidental injuries in ADHD children [5]. The risk may not be limited to ADHD parent/child relationships, but also influence the parent/child relationships of non-ADHD siblings.

Sibling Relationships

I think it puts a big strain on the family - a really, really big strain on the family when you've got an ADHD child.

Children with ADHD are reported to experience greater interpersonal conflict with siblings, and those with comorbid externalising problems experience less close and more aggressive sibling relationships [6]. ADHD children demand more time and attention from parents than their non-ADHD siblings which leads siblings to feel peripheral and less important within the family and, in turn, this can cause tension both between siblings and with parents. Siblings of ADHD children may thus experience increased disruption in their own lives [7] as the home may be a chaotic place, characterised by unpredictable emotional outbursts and inconsistent parenting. Furthermore they may be expected to share responsibility to monitor their ADHD sibling, help with schoolwork and keep them out of trouble.

Peer Relationships

Relationships outside of the family can also be affected by ADHD. Children and adolescents who are inattentive may come across as distant or shy, whilst those with high levels of hyperactivity/impulsivity may alienate others through disruptive behaviours such as difficulty waiting their turn in games or conversations. Adolescents with ADHD may experience peer rejection due to aggressive behaviour, yet lack insight into how their behaviour is perceived by others. Many adolescents know that they are ‘different’ in some way to their peers and they feel confused and misunderstood. They do and say things without thinking things through which often upsets people they care about. They look back with many regrets and wish things had been different, but feel frustrated that they can’t seem to change the situation. These kinds of problems can lead to feelings of low self-esteem, and may lead to teenagers with ADHD forming more superficial friendships than those enjoyed by their peers [8,9].

I don't have arguments with my friends, but I'd say I struggle to keep friends, contact wise, so I lose contact with people a lot

The consequences of peer rejection and failure to form appropriate peer relationships can push a ‘rejected’ individual to seek membership of peer groups wherever they are available [8]. This may be involvement in street gangs where impulsive, reckless and risky behaviours that, in other settings would lead to school exclusions and conflict at home, are seen as desirable interpersonal qualities (see Module 7 on antisocial behaviour and delinquency). While this may be more typical for males, females may also fall into relationships of this nature and, if these are perceived as rewarding, may lead to antisocial behaviour to maintain the relationships with the view that any friends are better than no friends.

Intimate and Romantic Relationships

I just split up with my girlfriend, ex girlfriend now obviously. I do have relationships, but it's very difficult for me to uphold them because of my distractions.

The effort to obtain peer acceptance may lead some young people to engage in promiscuous sexual behaviour. Research has shown that those growing up with ADHD begin having sex earlier, are more likely to be involved in an unwanted pregnancy and contract a sexually transmitted infection [10,11].

Within their romantic relationships those with ADHD may be more likely to experience conflict and arguments with partners. While research has been inconclusive in terms of marriage and divorce rates, results from a large study in the USA suggest that those with ADHD experience poorer quality dating relationships or, if married, lower marital satisfaction than their non-ADHD peers [10].

Managing Interpersonal Problems

It is normal for family relationships to become challenged as teenagers become independent from parental control but in ADHD families, these 'normal' problems may escalate to intolerable levels. At the same time, peer group membership changes in the teenage years as children select their own friendships. At this age there is a lot of pressure to ‘fit in’ and be accepted which can be hard for a child who has always felt 'different' insome way.

Of course, not all individuals with ADHD will fail to form successful relationships, but many experience negative family and social outcomes. It is important that negative family cycles are avoided and positive peer relationships are facilitated through constructive social activities, such as membership of sports and social clubs.

ADHD children may perceive positive parenting relationships [8] and one positive relationship with a family member or peer is better than many superficial relationships and/or membership of a 'bad crowd'. Parents can play a proactive role in helping younger children who find peer relationships difficult but this becomes problematic in the teenage years when young people want more freedom and less interference from parents in their lives. Nevertheless parents can show an interest in their child’s friendships and encourage positive behaviour and interactions in these relationships.

If I've had an argument I'll go out and do a sport as afterwards I need to do something.

A variety of programmes and information packages exist to help parents and families affected by ADHD (see Useful Resources) and there is a large evidence base supporting parenting interventions for younger ADHD children. In adolescence and adulthood interventions are delivered directly to the individual [12, 13]. However the severe family disruption that may be encountered during adolescence may require direct interventions involving the ADHD child and other members of the family. Family therapy, for example, may improve family relationships by addressing the problem behaviours of the ADHD child and the way that parents and siblings respond to these behaviours. This may include helping siblings feel less marginalised, improving parenting styles and monitoring techniques, development of disciplinary consistency, and mediation of sibling problems.

Key Points from Module 6

Box 1: Key points from Module 6 - ADHD and Interpersonal Relationships
  • ADHD can impact on the whole of family life and cause strain in relationships with parents and siblings; direct interventions such as family therapy may be helpful.
  • ADHD is highly heritable and a parenting cycle may exist with ADHD children becoming ADHD parents who lack the skills to effectively manage young children.
  • A failure to fit in with peers can lead to feelings of rejection and low self-esteem.
  • Teenagers may compensate by seeking membership of delinquent peer groups and/or attempt to obtain peer acceptance by engaging in promiscuous behaviours.
  • Teenagers with ADHD become sexually active at a young age; they are more likely to contract sexually transmitted diseases and have unwanted pregnancies.
  • Positive peer relationships can be facilitated through constructive social activities, such as membership of sports and social clubs.
  • Parenting programmes and/or direct intervention programmes for young people are helpful in providing prosocial competence.

References

[1] Coghill, D., Soutullo, C., d’Aubuisson, C., Preuss, U., Lindback, T., Silverberg, M., & Buitelaar, J. (2008). Impact of attention-deficit/hyperactivity disorder on the patient and family: results from a European survey. Child and Adolescent Psychiatry and Mental Health, 2(1), 31-46.

[2] Faraone S.V., Biederman, J., & Monuteaux, M.C. (2000). Toward guidelines for pedigree selection in genetic studies of attention deficit hyperactivity disorder. Genetic Epidemiology, 18(1), 1-16.

[3] Faraone, S., Biederman, J., & Mick, E. (2006). The age-dependent decline of attention deficit hyperactivity disorder: A meta-analysis of follow-up studies. Psychological Medicine, 36(2), 159-165.

[4] Murray, C., & Johnston, C. (2006). Parenting in mothers with and without attention-deficit/ hyperactivity disorder. Journal of Abnormal Psychology, 115(1), 52-61.

[5] Barkley, R.A. (2006). Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment (3rd ed.) New York: Guilford Press.

[6] Mikami, A.Y., & Pfiffner, L.J. (2008). Sibling relationships among children with ADHD. Journal of Attention Disorders, 11(4), 482-492.

[7] Kendall, J. (1999). Sibling accounts of attention deficit hyperactivity disorder (ADHD). Family Process, 38(1), 117-136.

[8] Young, S., Heptinstall, E., Sonuga-Barke, E.J.S., Chadwick, O., & Taylor, E. (2005). The adolescent outcome of hyperactive girls: Interpersonal relationships and coping mechanisms. European Child & Adolescent Psychiatry, 14(5), 245-253.

[9] Young, S., Heptinstall, E., Sonuga-Barke, E.J.S., Chadwick, O., & Taylor, E. (2005). The adolescent outcome of hyperactive girls: Self-report of psychosocial status. Journal of Child Psychology and Psychiatry, 46(3), 255-262.

[10] Barkley, R.A., Murphy, K.R., & Fischer, M. (2007). ADHD in adults: What the science says. New York: The Guilford Press.

[11] Flory, K., Molina, B.S.G., Pelham, W.E, Gnagy, E., & Smith, B. (2006). Childhood ADHD predicts risky sexual behaviour in young adulthood. Journal of Clinical Child and Adolescent Psychology, 35(4), 571-577.

[12] Young, S., & Amarasinghe, J.M. (2010). Practitioner Review: Non-pharmacological treatments for ADHD: A lifespan approach. Journal of Child Psychology and Psychiatry, 51(2), 116–133.

[13] Young, S., & Bramham, J. (2012). Cognitive Behavioural Therapy for ADHD Adolescents and Adults: A Psychological Guide to Practice, Second Edition. Chichester: John Wiley & Sons.

Further Reading and Useful Resources

Bramham, J, Young, S., Bickerdike, A., Spain, D., MacCartan, D., & Xenitidis, K. (2009). Evaluation of group cognitive behavioural therapy for adults with ADHD. Journal of Attention Disorders, 12(5), 434-441.

Emilsson, B., Gudjonsson, G., Sigurdsson, J.F., Einarsson, E., Baldursson, G., Olafsdottir, H., & Young., S. (2011). R&R2 Cognitive Behaviour Therapy in Medication-Treated Adults with ADHD and Persistent Symptoms: A randomized controlled trial. BMC Psychiatry, 11:116, http://dx.doi.org/10.1186/1471-244X-11-116

National Institute for Clinical Excellence. (2009). Attention deficit hyperactivity disorder: Diagnosis and management of ADHD in children, young people and adults. NICE clinical guideline 72. London.

Young, S.J., & Ross, R.R. (2007). R&R2 for ADHD Youths and Adults with ADHD: A Prosocial Competence Training Program. Ottawa: Cognitive Centre of Canada (www.cognitivecentre.ca)

Young, S. (2013). The 'RAPID' cognitive behavioral therapy program for inattentive children: preliminary findings. Journal of Attention Disorders, 17(6), 519-526.

Young, S., Fitzgerald, M., & Postma, M.J. (2013). ADHD: making the invisible visible An Expert White Paper on attention-deficit hyperactivity disorder (ADHD): policy solutions to address the societal impact, costs and long term outcomes, in support of affected individuals, www.europeanbraincouncil.org/pdfs/ADHD%20White%20Paper_15Apr13.pdf

Young, S., Hopkin, G., Perkins, D., Farr, C., Doidge, A., & Gudjonsson, G.H. (2013). A controlled trial of a cognitive skills program for personality disordered offenders. Journal of Attention Disorders, 17(7), 598-607,

www.addiss.co.uk/final.pdf

www.additudemag.com/channel/parenting-adhd-children/index.html

www.adhd-made-simple.com/adhd_peer_relationships.html

www.adders.org/research59.htm

www.helpforadd.com/add-impact-on-siblings