Stress Management for AD/HD Parents
By Edward Cable, Psy.D.

What is STRESS?

You're late!!! You were supposed to pick up your child at school 15 minutes ago to take her to a dentist's appointment that you've rescheduled twice. You were delayed at the auto emissions testing station where you had to go today because you already got a ticket for not having your car inspected on time. After the dentist appointment you've got to make dinner and then take your son to his scout troop meeting tonight. You're wondering if the family can stand macaroni and cheese one more time - when - suddenly the Honda Civic on your left swerves into your lane, forcing you to veer onto the shoulder and stop, missing the guard rail by inches. You slam down on the horn as the Civic driver gestures. Your heart is pounding. Your palms are soaked with sweat. You're taking short and rapid breaths. It takes you some time to calm down enough to resume driving. You collect your daughter and get to the appointment late -which the receptionist loudly points out to you in front of others in the waiting room. A tightness forms in your stomach and you suddenly feel exhausted and nauseous. How are you going to be able to keep going when you feel so badly? It feels like the world is bearing down on your shoulders. And it's only Monday!

Today the term "stress" is often used to describe anxiety, conflict, frustration, emotional disturbance, and the strain of survival. It has also been defined as any event that causes a person to adapt or to react. Some stress is bad and some is good. For example, if you find out that you will be laid off (negative stress), then you must adapt by searching for another job and tightening your budget. If you win the 6 million dollar lottery (positive stress), then you have to make the tough decision of whether to keep your job or to go on vacation permanently. You may also decide to get a larger place and go through the process of buying a new mansion. Both events involve changes and adaptation and, therefore, cause stress.

Stress can have a strong impact upon you. There is an old saying: "If it doesn't kill you, it will make you stronger." This may or may not be true. Surviving unfavorable events may make you wiser and more experienced, but repeated exposure to adversity can also lead to damaged physical and mental health. We may not be able to control the kinds of stress that we encounter, but we can control how we react to and how we cope with stressful events. Often it is how you respond to stress that determines the impact it will have on your life.

Stress comes from 4 basic sources. The environment produces changes to which we must adjust everyday. Rain, snow, the brown cloud, traffic, and noise are conditions we deal with daily. Social demands are another source of stress that taxes our energy and emotions. We struggle to meet deadlines, negotiate with co-workers, appease bosses and supervisors, haggle with salesclerks, provide for our families, and spar with relatives. We perform emotional and psychological acrobatics to satisfy the social expectations that others place upon us. Physiological sources of stress include injuries, illness, aging, lack of exercise, obesity, poor nutrition, and sleep disturbances. Physical ailments can hamper us as we try to deal with people and the environment. Sometimes we have physiological reactions to other stressors in the way of headaches, muscle tension and spasms, stomach irritations, or even panic attacks.

Our own thoughts and beliefs can also produce stress when we interpret events as being emergencies and react with fear and anxiety. How you interpret and appraise a situation can put you at ease or increase the tension that you feel. For example, if your child brings in a note from his teacher asking you to call, your immediate thought might be, "He's in trouble again and I'm going to get lectured about being a bad parent." You may fret and lose sleep that night before you call the teacher the next day. When you call, you discover that the teacher only wanted to report that your child has made great progress in math and to see if it would be O.K. for him/her to help other children in class. If we appraise an event or situation incorrectly, it can lead to unnecessary worry and anxiety.

What Impact can Stress have on us?

What happens when we experience stress? Of course it depends upon the situation, but there are some general reactions:

1. When a situation is judged to be an "emergency" by the cerebral cortex (the part of the brain that controls thinking, evaluation, and decision making) a signal is sent to the hypothalamus (the part of the brain that acts like a 911 controller).

2. The hypothalamus alerts the sympathetic nervous system (the link to the heart, muscles, pancreas, lungs, stomach, etc.) to prepare for disaster.

3. Your heart rate increases and your blood pressure rises. Your breathing shortens and becomes more frequent. Your muscles tense, your hands and feet get cold and may sweat. Blood is pumped away from the extremities and the digestive system into the larger muscle groups to help you to fight or to run. If you were on the Starship Enterprise you would be on "Red Alert." This reaction is referred to as the "fight or flight" response because in primitive times those were the two options you had if you were being attacked by a saber tooth tiger. It has also been called the "emergency" response. Think of times that you have experienced this reaction: almost being in a car accident, being called to the office in school, learning that you have to have surgery, or hearing that relatives are coming to visit.

4. The adrenal gland which secretes substances called corticoids plays an important part in the body's response to stress and emergencies. The corticoids- adrenaline, epinephrine, and norepinephrine - shut down some essential bodily functions as part of the short term emergency response. These include digestion, reproduction, growth, tissue repair, and maintenance of the immune system. Although these are critical to our physical health, we can spare them for short periods of time, as long as it's necessary for survival.

5. When the brain determines that the emergency is over, it gives the "all clear" signal and about 3 minutes later the body calms down and ceases the "fight or flight" reaction. Heart rate, breathing, blood pressure return to normal- if you survived the situation. The same system that revved the body up calms it down. The calming down is called the "relaxation" response. Research has shown that we can exert some control over the relaxation response by using certain psychological techniques.

Long term effects of stress: What doesn't kill you may not make you stronger.

Sometimes people are stuck in high pressure situations where they stay stressed and never fully rebound from the "fight or flight state." What are some situations that might prolong the stress response so that your system never quite returns to the calm state?

Your company announces that there will be layoffs in 3 months, that each worker will be evaluated for productivity until then, and only those with the the top 5 productivity levels will keep their jobs.

You go through a messy, combative divorce requiring you to move, to change jobs, and to pay large legal fees.

You find out that you or someone you love has a life-threatening illness and that intensive medical treatment will be required for at least 6 months if there is to be hope of survival.

When circumstances demand a constant and prolonged stress response, it is called chronic stress. Chronic stress can also happen when there are a number of distressful events that occur in a sequence, so that an individual doesn't have time to recover from one crisis before having to deal with the next. For example if a woman's mother dies in April, her 15 year old son is arrested in early May for shoplifting, and her husband loses his job in June, then she may develop some physical and/or mental affliction because of the accumulated stress. What happens when you undergo chronic stress? Remember what the coriticoids do during the emergency response. They shut down digestion, reproduction, growth, tissue repair, and maintenance of the immune system. That's O.K. for a 3 minute, 10 minute, or even a 1 hour emergency, but it can be unhealthy for extended periods of time. Some people in ongoing high pressure situations never completely shut off the emergency response, and, therefore, have some essential bodily functions compromised indefinitely. Over the past 50 years, researchers have discovered some interesting links between chronic stress and disease.

Continued stress can damage almost every system in your body. When chronic stress indirectly suppresses the reproduction system, it can cause amenorrhea (cessation of menstruation), ovulation failure in women, impotency in men, and loss of libido in both. Stress can also increase the symptoms of asthma, bronchitis, and other respiratory conditions. Some studies indicate that loss of insulin during chronic stress responses may be a factor in the onset of adult diabetes. Stress can suppress bodily tissue repair which in turn causes decalcification of the bones, osteoporosis, and susceptibility to fractures. Inhibition of immune and inflammatory systems makes you more susceptible to colds and flu and can make other chronic illnesses, such as arthritis, chronic pain, and diabetes, worse. There is also evidence that continued release and depletion of norepinephrine during a state of chronic stress can contribute to depression. There are studies suggesting that stress can accelerate the aging process. Given all of these possible consequences from sustained stress, you should keep in mind that what doesn't kill you may not make you stronger and may actually impair your health and quality of life.

Stress and parents of AD/HD children

Is it possible that having AD/HD children in a family can be stressful? Does the sun rise in the east? Do ducks take to water? Of course caring for AD/HD children can be stressful, but have you ever thought about what the consequences of that stress could be? A year or so ago I conducted a study (see Letters to the Editor, ADDAG Newsbriefs, Spring 1995, p.20) to find out how much control ADHD parents feel that they have in their parenting role. The results indicated that ADHD parents feel that they have much less control than parents of non- ADHD children. Feeling that you have little or no control can be stressful in itself, but it can also lead to depression, hopelessness, and an apathetic approach to dealing with problems- not a good style to use with AD/HD issues. Some studies have shown that families of AD/HD children are three times more likely to experience separation and/or divorce (of the biological parents) than families of other children (Barkley, 1990). Remember what chronic stress can do to your mental and physical health. Unless you take steps to manage the stress AD/HD brings to you and your family, you could be putting your health at risk.

If you are the martyr type who is willing to make any sacrifice and undergo any distress for your AD/HD child and your family, please reconsider. In the long run you may actually undermine your own goal of being there for your child. By failing to manage stress effectively you put yourself on the disabled list of the team- the AD/HD Multimodal Treatment Team of which you are the key player. The team consists of the pediatrician or psychiatrist who may prescribe medication; the teacher or principal who deals with your AD/HD child at school; the counselor; social-worker, and/or psychologist who may provide psychotherapy; your other family members, your AD/HD child, and yourself. The player that holds the team together is the parent. The parent cares for and advocates for the AD/HD child; the parent works with the teacher to meet the child's educational needs; the parent listens to the counselor/psychotherapist and tries to carry out treatment recommendations; the parent gets the child to the pediatrician/psychiatrist and keeps prescriptions filled; and the parent serves as the arbitrator and referee between the child and his/her siblings. If the parent gets sidelined or hampered because of illness due to stress, then the whole team falls apart and the AD/HD child does not get the support he or she needs. So if you really want to be there for your child, then take care of yourself.

Awareness = Potential for Change = Control = Stress Relief

How do you protect yourself against the stress that comes with being an AD/HD parent? The first step is to become aware of how AD/HD impacts you and your family. If you are not aware of how you are affected specifically, then it is harder to plan changes that can give you more control and reduce stress. Recall the 4 sources of stress- the environment, social demands, physical states, and thoughts and beliefs. Think about how AD/HD issues impact you through those 4 sources.

For the parents of AD/HD children, the environment may be a bit noisier than most other households, especially if their children are hyperactive. Because AD/HD children are attracted to highly stimulating activities, the radio, television, or SEGA/NINTENDO may get cranked up to thunderous levels. AD/HD children often need help in staying organized. Their rooms and the rest of the house may get pretty messy at times and walking to the front door may seem like passing through an obstacle course. Some wear and tear on furniture is expected with all children but ADHD children often devise new and interesting destructive methods. Some AD/HD children have difficulty in mastering social skills. This can lead to more quarrels between siblings or neighborhood children. After you have determined how AD/HD affects your environment, you can evaluate how you would like to change things to make your surroundings more manageable. For example, to isolate the noise and destruction in your environment you can designate a room in the house or a place in the yard for rough and loud activities.

Being the parent of an AD/HD child can imply certain physical consequences. Keeping up with a hyperactive child can drain your energy. Attending appointments with teachers, sessions with counselors, keeping contact with the pediatrician regarding medications, and maintaining peace at home can cause physical and mental fatigue. Trying to meet the needs of your AD/HD child and the rest of your family may leave you little time to get the exercise and recreation that you need to stay healthy. Once you evaluate how your health is affected by having an AD/HD child you can plan changes to ensure your wellness. If you spend your recreational time chasing after a hyperactive child, then you might take a walk in the park or around the block while your little tornado works off his/her energy riding circles around you on a bicycle.

Having an AD/HD child involves a variety of social stressors. The most immediate social stressor is your own relationship with your AD/HD child. Are there certain things he or she does that you cannot tolerate, such as turning up the TV or stereo too loud? Do you have habits that drive your AD/HD child up the walls such as asking for the 50th time if she/he has any homework? Consider other types of stress that AD/HD brings to the family. Your other children struggle to understand why your AD/HD child gets so much of your time and attention when they are behaving themselves so well and causing so little trouble. Your partner wonders if you really are adhering to the same rules and discipline that you've discussed so many times. Your relatives and friends suggest hundreds of parenting articles, books, and videotapes for you to study. You continually struggle to referee your children, negotiate with your partner, and educate your parents and your relatives about what AD/HD means. How do these social interactions affect you? What changes can you affect to make them positive experiences? If your children usually fight during games because your AD/HD child cannot wait his/her turn, then you may need to sit in and help him/her learn to wait.

Being an advocate for your child at school and in the community creates another area of stressful social experiences. Think of all the times that you've explained to a teacher that your child does the homework but loses it or forgets to turn it in. Teachers who have not worked extensively with AD/HD children may file your explanation under the same category as, "My dog ate my homework," or "Aliens abducted me before I could get my math assignment done." Such school situations produce stress and anxiety and often leave you feeling frustrated and discouraged. Review how such encounters have gone in the past and recall how things could have been explained better. Should you prepare a folder full of AD/HD information to share with teachers and other school personnel? Look to the past to prepare for future encounters.

This brings us to another, and perhaps the most important, source of stress: thoughts and beliefs. As mentioned earlier, it is often how you respond to stress that determines the impact it will have on your life. If you are confident in your ability to deal with challenges, then you can face problems with a greater sense of control and perhaps make better decisions in a crisis. People who believe that they can make positive changes in their lives look for solutions to problems instead of helplessly accepting their lot. If you believe that you are not competent enough to deal with difficulties, then you may give up in crisis without trying to deal with it effectively. If you believe that there is no hope in dealing with the problems that the AD/HD condition presents, then you may fail to recognize ideas or solutions that can help your situation.

Sometimes people develop a particular thought in a crisis that they replay again and again, especially when a similar event takes place. Remember the earlier example of receiving a note from the teacher? Think of the thoughts and feelings that you have experienced in a similar situation. Remember the first time you had a meeting with a teacher or principal regarding your child's behavior or performance?

During these situations parents often think to themselves: "I'm not doing enough to discipline my child," or "I'm a bad parent because I can't get my child to do better," or "Maybe my child really is lazy, stupid, or mean and it's hopeless to try to make things better." Years later, even after parents have educated themselves about AD/HD and learned what is best for their child, these same nagging thoughts recur when they get a note or phone call from the teacher or principal.

How do you challenge these thoughts and combat the stress and anxiety that they can invoke? A psychologist, Albert Ellis, developed a system for refuting irrational thoughts and beliefs and for replacing them with more rational and healthier thoughts (Ellis,1975). His system involves the same equation: awareness = potential for change = control = relief from stress. However, Ellis provided a structured, step-by-step method to deal with irrational thoughts that we replay in our minds and that produce unnecessary stress. Ellis suggests that you use an event that causes you to feel anxious, stressed, apprehensive, etc. to evaluate your response and find better ways to deal with such situations. Here's how it goes:

1. A stressful event occurs.

Example: You get a phone call from your AD/HD child's teacher requesting a conference.

2. Record both the rational ideas and irrational ideas that arise surrounding the event and examine the consequences of those thoughts.

Continuing with the example:

A. Rational thoughts:

Something has happened with my child that the teacher needs to discuss. This is not unusual since my child has AD/HD and needs help in managing the symptoms.

B. Irrational thoughts:

I have failed as a parent. If I were a good parent, then I would not get phone calls from teachers. It is hopeless for my child. If he/she was smart enough... nice enough... mature enough..., then I wouldn't get these phone calls. I have tried everything and it's useless to try anymore.

C. Consequences of the irrational thoughts:

I feel like a failure. I feel depressed. I feel disappointed in my child. I feel angry at my child and the teacher. I feel like I deserve any criticism that others make of me.

3. Challenge the irrational ideas:

A. Choose one irrational idea:

If I were a good parent, then I would not get phone calls from teachers.

B. Evaluate if there is rational support for this idea:

No. Good and bad parents get calls from teachers.

C. Look at evidence against the idea:

Many AD/HD parents get calls frequently even though they are doing all that can be done for their children.

4. Create and substitute alternative thoughts and feelings:

A. Alternative thoughts:

I have learned as much as I can about AD/HD and I'm applying it to help my child. If there is something else that needs to be done, then I am ready and willing to do it. If the teacher does not understand my child and my child's needs, then I am ready to advocate and educate to change the situation.

B. Alternative feelings:

I feel that my child and I deserve respect whatever the problem. I feel proud that I am ready to deal with the situation responsibly and constructively. I feel confident that my child is doing his/her best.

In addition to these strategies for reducing AD/HD related stress, there are a number of methods for general stress reduction. In the library or in book stores you can find books, audio-tapes, and video-tapes on relaxation exercises and techniques that you can use at home and at work. Try them. You'll be surprised at how much calmer and rested you can feel in just a few minutes. Another important stress reducer that has been briefly mentioned is recreation and exercise. By engaging in a vigorous activity you can release endorphins (your body's natural tranquilizers) and improve your fitness and health. You don't have to run marathons, pump tons of iron, or risk collapsing in aerobics class. Choose something moderate to begin with and something that you can enjoy and go from there. Take some time off for yourself. You don't have to travel to Jamaica, just go to the park for an hour or take in a movie. Hire a babysitter or get a relative to sit with the kids for a short break. Good parents are allowed to take time off from their families.

Schedule relaxation and recreation like you would schedule a meal. Review the ideas described above and create your own strategies to deal with your unique family and situation. Use them! If you don't manage the stress, no one else will. Take care of yourself. We need you!

REFERENCES

Barkley, Russell A. 1990. Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment, 2nd. ed. New York: The Guilford Press.

Ellis, A. 1975. A New Guide to Rational Living. North Hollywood, California: Wilshire Books.

About the author:

Since 1980 Edward Cable, Psy.D., has worked with children, adolescents, and families in a number of settings including a psychiatric hospital, group homes, public schools, a community mental health center, a pediatric clinic, and in private practice. He received his masters degree in clinical psychology from Appalachian State University in North Carolina in 1986 and his doctoral degree in clinical psychology from the University of Denver earlier this year. He has worked with AD/HD children, adolescents, and adults since 1987. With the supervision of Dr. George Dorry, he helped to establish continuing psychotherapeutic groups for AD/HD children and their parents at the Professional Psychology Clinic, part of D.U.'s Graduate School of Professional Psychology. After completing his psychology internship at Denver's Children's Hospital, he joined the Attention & Behavior Center in September where he worked for two years.   He now maintains his own private practice and provides psychological assessment and treatment for children, adolescents and adults.  His specialties include assessment and treatment for AD/HD; assessment and treatment for neurobehavioral disorders; treatment for depression; stress and anxiety management; behavioral problems in children; parenting skills; and learning disabilities.

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