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.