Executive Functions in Parents With ADHD

Over the past two decades, there has been considerable progress in understanding the functions of the prefrontal cortex of the brain and its regulation of mental activities that allow for self-control and goal-directed behaviors. These mental activities are unified under the term executive functions.

Executive functions are thought to enable a person to successfully engage in independent, purposeful and self-serving behaviors. The major executive functions include response inhibition, which permits impulse control, resistance to distraction and delay of gratification; nonverbal working memory, which permits the holding of events in the mind and allows self-awareness across time; verbal working memory, which comprises the internalization of speech and permits self-description, questioning and reading comprehension; and self-regulation of emotion and motivation, which permits motivation, persistence toward a goal and emotional self-control.

Executive functions are thus a collection of varying abilities that involve regulatory control over thought and behavior in the service of goal-directed or intentional action, problem solving, and flexible shifting of actions to meet task demands. Besides formal neuropsychological testing, clinical data about executive function can be obtained by observing an individual's ability to problem-solve in the natural environment and assessing how flexible a person is when faced with a changing routine.

In recent years, the executive functions have been applied as a concept to help explain attention-deficit/hyperactivity disorder (ADHD) pathophysiology. Although the importance of executive functions in understanding ADHD seems clear, a less obvious, yet important, correlation is the relationship between executive functions and the management of families with children who have ADHD. This relationship is significant since one-quarter of children presenting with ADHD will have at least one parent who also has ADHD.

The fact that parents with ADHD probably suffer from impairments in executive functions creates challenges in the treatment of their children. This article discusses some of the specific challenges that I have observed in regard to parents with ADHD and executive function impairments.

Problems with distraction control should be considered when parents display difficulty with group participation treatment programs. Group treatment settings can be overwhelming for parents with ADHD, much as classroom settings can compromise the distraction control of children with ADHD. Even in the office setting, the activities of their children can distract these parents, resulting in failure to understand medication and therapy instructions.

Problems with delay of gratification and impulse control can lead parents with ADHD to feel quickly disenchanted with treatment. Consequently, they are vulnerable to alternative treatments that promise miraculous results. This vulnerability to frustration can also result in these parents feeling that the treating psychiatrist is not sufficiently skilled or motivated to help their child. Conversely, the psychiatrist might perceive such parents as demanding and unreasonable. Empathy with the parents' desire for an acute resolution can help greatly in building a therapeutic rapport.

The consistent inability to keep or be on time for appointments is a typical difficulty for parents with ADHD. Although the psychiatrist might correctly interpret such noncompliance as ambivalence to treatment, they should also consider the possible difficulties that the parent might have with time management, planning, flexibility and memory.

Such difficulties have greater implications when they involve the chronic misplacing of prescriptions for controlled substances such as psychostimulants. I have observed that parents with ADHD often lose their children's prescriptions. Deficits in organizational skills and memory could easily account for this problem, but psychostimulant abuse is always an inescapable consideration.

I usually give parents with ADHD the benefit of the doubt in the first months of treatment and provide them with specific instructions on how I want the medications managed. For example, I might give the parent written instructions to go directly from the office to the pharmacy to fill the prescription, and then to go directly home and put the pill bottle in a mutually agreed-upon area of the house that is both conspicuous and safe. If there is a parent without ADHD involved, I might ask that individual to manage the medication at home. If the prescriptions continue to disappear despite persistent coaching, I then believe it is reasonable to be suspicious.

Motivation, persistence and emotional self-control are essential in dealing with a chronic disorder such as ADHD. Parents with ADHD can demonstrate significant motivational problems, as revealed through difficulty adhering to and following through with treatment instructions, as well as displaying extreme frustration when times are difficult. Quite often, parents with ADHD, much like their children, have a history of difficulty with completing and emotionally managing challenging and stressful endeavors.

A parent with ADHD will sometimes admit feeling uncontrollably reactive to their child's misbehavior and will even recognize a tendency to escalate the child's mood lability. Emotional regulation can be very difficult for both the parent and child. Recognizing this fact can help the psychiatrist to understand better that the treatment of ADHD is best done by treating the dynamics of the entire family, rather than just the behaviors of the identified patient.

There are numerous strategies that the clinician can use in working with the parent to compensate for impairment in executive functions. Instructions to the parent should be given in a quiet office environment with minimal outside distractions. Familiar office procedures and minimal unexpected changes greatly reduce distraction and frustration. Each therapeutic task should be described clearly, one step at a time, with brief and specific directions and frequent summaries of the relevant points, preferably in writing. In particular, medication information should be provided in both oral and written form for the parents' future reference. The clinician should also remember that transition periods are difficult for both the child and adult. This can help explain why the parent will sometimes come into the clinician's office with the emotional intensity typically required for fighting for a space in the crowded parking garage. Frequent reinforcement is essential to prevent discouragement, and good humor and patience are essential tools to help remind the clinician that most parental idiosyncrasies are more likely a function of frustration, rather than malice.

Despite the obvious negative implications of parental executive function impairment upon the outcome of the child's treatment, there are also some positive considerations. A child who observes a parent with insight into their own impairments may be reassured of the therapeutic, rather than punitive, nature of treatment. Such a parent would be in a unique position to provide the child with ongoing education and support regarding the child's particular difficulties. Furthermore, parents who have learned how to monitor and compensate for their symptoms are also likely to be able to model those skills for their children.

In conclusion, recognition of the parent with ADHD and awareness of the impact of impaired executive functions can greatly help in the treatment of the child with ADHD. Recognition of the difficulties shared by the parent and child allows them to share the enthusiasm when they learn adaptive coping strategies and when treatment successes occur.

Dr. Lesaca is a child and adolescent psychiatrist in Sewickley, Pa.

Further Reading

Barkley RA (1997), Attention-deficit/hyperactivity disorder, self-regulation, and time: toward a more comprehensive theory. J Dev Behav Pediatr 18(4):271-279.