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twenty-five tips on the management of add within families


Excerpted from Driven to Distraction (Touchstone 1994)

Copyright Edward M. Hallowell, M.D., and John J. Ratey, M.D. Reprinted with permission.

1. Get an accurate diagnosis. This is the starting point of all treatment for ADD.

2. Educate the family. All members of the family need to learn the facts about ADD as the first step in the treatment. Many problems will take care of themselves once all family members understand what is going on. The education process should take place with the entire family, if possible. Each member of the family will have questions. Make sure all these questions get answered.

3. Try to change the family "reputation" of the person with ADD. Reputations within families, like reputations within towns or organizations, keep a person in one set or mold. Recasting within the family the reputation of the person with ADD can set up brighter expectations. If you are expected to screw up, you probably will; if you are expected to succeed, you just might. It may be hard to believe at first, but having ADD can be more a gift than a curse. Try to see and develop the positive aspects of the person with ADD, and try to change his family reputation to accentuate these positive aspects. Remember, this person usually brings a special something to the family--special energies, special creativity, special humor. He (or she) usually livens up any gathering he attends, and even when he is disruptive, it's usually exciting to have him around. He punctures bombast and does not tolerate fools. He is irreverent and not afraid to speak his mind. He has a lot to give, and the family, more than any group of people, can help him reach his potential.

4. Make it clear that ADD is nobody's fault. It is not Mom's or Dad's fault. It is not brother's or sister's fault. It is not Grandmother's fault, and it is not the fault of the person who has ADD. It is nobody's fault. It is extremely important that this be understood and believed by all members of the family. Lingering feelings that ADD is just an excuse for irresponsible behavior or that ADD is caused by laziness will sabotage treatment.

5. Also make it clear that ADD is a family issue. Unlike some medical problems, ADD touches upon everybody in the family in a daily, significant way. It affects early-morning behavior, it affects dinner-table behavior, it affects vacations, and it affects quiet time. Let each member of the family become a part of the solution, just as each member of the family has been a part of the problem.

6. Pay attention to the "balance of attention" within the family. Try to correct any imbalance. Often, when one child has ADD, his siblings get less attention. The attention may be negative, but the child with ADD often gets more than his share of parents' time and attention day in and day out. This imbalance of attention can create resentment among siblings, as well as deprive them of what they need. Bear in mind that being the sibling of a child with ADD carries its own special burdens. Siblings need a chance to voice their concerns, worries, resentments, and fears about what is going on. Siblings need to be allowed to get angry as well as to help out. Be careful not to let the attention in the family become so imbalanced that the person with ADD is dominating the whole family scene, defining every event, coloring every moment, determining what can and cannot be done, controlling the show.

7. Try to avoid the Big Struggle. A common entanglement in families where ADD is present but not diagnosed, or diagnosed but unsuccessfully treated, the Big Struggle pits the child with ADD against his parents, or the adult with ADD against his spouse, in a daily struggle of wills. The negativity that suffuses the Big Struggle eats away at the whole family. Just as denial and enabling can define the alcoholic family, so can the Big Struggle define (and consume) the ADD family.

8. Once the diagnosis is made, and once the family understands what ADD is, have everybody sit down together and negotiate a deal. Using the principles outlined earlier, try to negotiate your way toward a "game plan" that everyone in the family can buy into. To avoid the family gridlock of the Big Struggle, or to avoid an ongoing war, it is wise to get into the habit of negotiation. This can take a lot of work, but over time negotiated settlements can usually be reached. The terms of any settlement should be made explicit; at best they should be put into writing so they can be referred to as needed. They should include concrete agreements by all parties as to what is promised, with contingency plans for meeting and not meeting the goals. Let the war end with a negotiated peace.

9. If negotiation bogs down at home, consider seeing a family therapist, a professional who has experience in helping families listen to each other and reach consensus. Since families can be explosive, it can be very helpful to have a professional around to keep the explosions under control. Also consider buying a book to help in negotiation, such as Fisher and Ury's Getting to Yes.

10. Within the context of family therapy, role-playing can be helpful to let members of the family show each other how they see them. Since people with ADD are very poor self-observers, watching others play them can vividly demonstrate behavior they may be unaware of rather than unwilling to change. Video can help in this regard as well.

11. If you sense the Big Struggle is beginning, try to disengage from it. Try to back away. Once it has begun, it is very hard to get out of. The best way to stop it, on a day-to-day basis, is not to join it in the first place. Beware of the struggle's becoming an irresistible force.

12. Give everyone in the family a chance to be heard. ADD affects everyone in the family, some silently. Try to let those who are in silence speak.

13. Try to break the negative process and turn it into a positive one. Applaud and encourage success when it happens. Try to get everyone pointed toward positive goals, rather than gloomily assuming the inevitability of negative outcomes. One of the most difficult tasks a family faces in dealing with ADD is getting onto a positive track. However, once this is done, the results can be fantastic. Use a good family therapist, a good coach, whatever--just focus on building positive approaches to each other and to the problem.

14. Make it clear who has responsibility for what within the family. Everybody needs to know what is expected of him or her. Everybody needs to know what the rules are and what the consequences are.

15. As a parent, avoid the pernicious pattern of loving the child one day and hating him the next. One day he exasperates you and you punish him and reject him. The next day he delights you and you praise him and love him. It is true of all children, but particularly true of those with ADD, that they can be little demons one day and jewels of enchantment the next. Try to keep on an even keel in response to these wide fluctuations. If you fluctuate as much as the child, the family system becomes very turbulent and unpredictable.

16. Make time for you and your spouse to confer with each other. Try to present a united front. The less you can be manipulated the better. Consistency helps in the treatment of ADD.

17. Don't keep ADD a secret from the extended family. It is nothing to be ashamed of, and the more the members of the extended family know about what is going on, the more help they can be. In addition, it would not be unlikely for one of them to have it and not know about it as well.

18. Try to target problem areas. Typical problem areas include study time, morning time, bedtime, dinnertime, times of transition (leaving the house and the like), and vacations. Once the problem area has been explicitly identified, everyone can approach it more constructively. Negotiate with each other as to how to make it better. Ask each other for specific suggestions.

19. Have family brainstorming sessions. When a crisis is not occurring, talk to each other about how a problem area might be dealt with. Be willing to try anything once to see if it works. Approach problems as a team with a positive, can-do attitude.

20. Make use of feedback from outside sources--teachers, pediatrician, therapist, other parents and children. Sometimes a person won't listen to or believe something someone in the family says, but will listen to it if it comes from the outside.

21. Try to accept ADD in the family just as you would any other condition and normalize it in the eyes of all family members as much as possible. Accommodate to it as you might a family member's special talents or interests like musical ability or athletic skills whose development would affect family routines. Accommodate to it, but try not to let it dominate your family. In times of crisis this may not seem possible, but remember that the worst of times do not last forever.

22. ADD can drain a family. ADD can turn a family upside down and make everybody angry at everybody else. Treatment can take a long while to be effective. Sometimes the key to success in treatment is just to persist and to keep a sense of humor. Although it is hard not to get discouraged if things just seem to get worse and worse, remember that the treatment of ADD often seems ineffective for prolonged periods. Get a second consultation, get additional help, but don't give up.

23. Never worry alone. Try to cultivate as many supports as possible. From pediatrician to family doctor to therapist, from support group to professional organization to national convention, from friends to relatives to teachers and schools, make use of whatever supports you can find. It is amazing how group support can turn a mammoth obstacle into a solvable problem, and how it can help you keep your perspective. You'll find yourself saying, "You mean we're not the only family with this problem?" Even if this does not solve the problem, it will make it feel more manageable, less strange and threatening. Get support. Never worry alone.

24. Pay attention to boundaries and overcontrol within the family. People with ADD often step over boundaries without meaning to. It is important that each member of the family know and feel that he or she is an individual, and not always subject to the collective will of the family. In addition, the presence of ADD in the family can so threaten parents' sense of control that one or another parent becomes a little tyrant, fanatically insisting on control over all things all the time. Such a hypercontrolling attitude raises the tension level within the family and makes everybody want to rebel. It also makes it difficult for family members to develop the sense of independence they need to have to function effectively outside the family.

25. Keep up hope. Hope is a cornerstone in the treatment of ADD. Have someone in mind whom you can call who will hear the bad news but also be able to pick up your spirits. Always bear in mind the positive aspects of ADD--energy, creativity, intuition, good-heartedness--and also bear in mind that many, many people with ADD do very well in life. When ADD seems to be sinking you and your family, remember, things will get better.

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