The family dimension to ADHD cases

Awareness of attention deficit hyperactivity disorder varies but, if the condition is suspected, social workers would do well to look at the whole family context, writes Gordon Carson

It is estimated to affect up to 9% of ­children and young people in the UK*, but there is a sense that attention deficit hyperactivity disorder can be an unknown quantity for some social workers. Andrea Bilbow, chief executive of the National Attention Deficit Disorder Information and Support Service (ADDISS), claims that, although local authorities may have dedicated teams for children with autism or learning disabilities, support for children with the condition is not institutional and “tends to be down to individual social workers who have a personal interest”.

ADHD is characterised by the onset before age seven of hyperactivity, inattention and impulsiveness, and a diagnosis – usually by a child psychiatrist or paediatrician – will generally be considered if these three traits can be observed persistently in a child in more than one setting for at least six months.

The condition can also co-exist with other disorders, including mood and anxiety disorders and learning disabilities, and can have severe implications for a child and their family if it goes unnoticed or untreated.

Family life can become “chaotic”, and parents may have diagnosed or undiagnosed ADHD or traits of it themselves, says Debbie Lyons, a child and adolescent mental health services social worker at the Brookvale Adolescent Service, which works with 14- to 18-year-olds in Southampton. In fact, guidance from the Social Care Institute for Excellence points out that research has indicated ADHD is “highly heritable”.

“Young people with ADHD may be more impulsive, may not be able to stick to routine, may have educational issues leading to non-attendance or poorer outcomes, and there may be involvement from the youth offending team,” says Lyons, who adds that at least 15% of children in contact with her team have ADHD, while others may display traits but not receive a diagnosis.

Frustration and aggression

To exacerbate matters, ADHD can cause increased frustration and aggression for parents and siblings as well as the sufferer, says Alison Roy, editor of the Association of Child Psychotherapists’ monthly bulletin and lead child and adolescent psychotherapist at East Sussex Camhs. Along with tiredness and relationship difficulties, this can lead to the “demonising and rejection of the child who appears to be the cause of all the family difficulties, creating safeguarding issues and concerns”.

Ferelyth Watt, head of child and adolescent psychotherapy at Haringey Camhs, and the author of a Community Care Inform guide to ADHD, says it is crucial for social workers to consider the whole family context if they suspect a child has ADHD.

“If it looks like there may be difficulties at home and at school, you may need to look a bit further,” she says. “That’s where the social work expertise in looking at the whole family context is particularly important.”

She also believes this could be a more probable explanation for problems in younger children, and says it is unlikely that children as young as four will have ADHD. “We see it at aged six and above as a possible diagnosis,” she says. “Before that, social workers should be looking more at the family context.”

However, one child psychotherapist warns that children may be labelled as having ADHD when they are suffering from the impact of different problems, such as early childhood trauma and neglect.

“The experience of trauma often gives rise to hyper-vigilant responses in children and difficulties in concentrating and being still,” says Graham Music, of the Tavistock and Portman NHS Foundation Trust. “To such children the world does not feel safe enough to allow them to feel at ease. Such ‘jumpy’, vigilant responses can be mistaken for ADHD and treated medically when psychological understanding is needed.”

Roy says social workers should turn to Camhs for diagnosis and support, and also stay involved with the children and their families.

Funding cuts

There are serious concerns, though, that support for children with ADHD from Camhs services could deteriorate due to widespread funding cuts. A survey of health trusts and councils by charity YoungMinds found that more than half of 55 respondents had cut their budgets for children and young people’s mental health services for 2011-12, with some reducing funding by up to 25%.

So, although awareness of ADHD among social workers may need to improve, it seems they will struggle to secure the support required by all children with the condition.

What the latest findings suggest

Those who have ADHD can be both lethargic and hyperactive, very focused and lack concentration, and very impulsive and in control, according to new research which has identified a theory of “polarisational existence” experienced by people with the condition.

Dr Madan Mall, a psychologist from the West Midlands who carried out the study for his doctorate with Dr Paul Holland of City University London, says the findings are significant because the experience of participants challenges the view of ADHD as being unipolar, which is how it is described in the Diagnostic and Statistical Manual of Mental Disorders (this is published by the American Psychiatric Association and used worldwide for diagnosis).

Mall and Holland studied 17 adults, aged 18 to 24 and diagnosed with ADHD as children. Eight of them took part in semi-structured interviews while the others attended focus groups.

The participants reported their experiences as being intense at all times and across all domains.

But, for example, the participants said it was inaccurate that they were unable to sustain attention. Although in some circumstances they experienced inattention, they became “hyper-focused” and able to sustain attention for enduring periods of time when they found something interesting or of motivational value.

Meanwhile, emotions could “dramatically fluctuate from one extreme to another”, from being “constructive”, such as feeling happy or relaxed, to “destructive”, becoming anxious or angry.

In addition, participants perceived professionals to be either congruent or incongruent, which affected the way they subsequently interacted and behaved. They were very sensitive to other people’s reactions, which at times resulted in them feeling the need to argue their case to justify their behaviour. However, this could be perceived by observers as manipulative, defensive, dangerous and lacking in self-awareness.

Mall admits further research is needed to test the theory of polarisational existence, but says it is a new concept that has not been discussed in literature on ADHD. He also hopes that an academic journal will publish his paper.

For more on the findings, email madan.mall@lindsworth.bham.sch.uk or telephone 0121 693 5363

Tips for social workers

Although children and young people with ADHD may require specialist medical support and drug treatment to deal with their condition, social workers can also play a role.

For example, if they are already working with a family in which a child is suspected to have ADHD, they can provide extra information about the family’s home environment to help with assessments, says Alison Roy, lead child and adolescent psychotherapist at East Sussex Camhs.

“If social workers know the family well it is helpful to include knowledge about impulsivity, lack of emotional regulation and sleep patterns,” she adds.

They can also help families to take practical steps to manage the condition, according to Community Care Inform’s guide to ADHD.

These include parents and children agreeing on ground rules to be followed daily, using a reward chart to record success in improving behaviours, and helping parents to set aside time to spend with their children.

Nice guidance, p6

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