Adults with ADHD and safeguarding children

The following characteristics of ADHD provide the justification for an increased interest in child protection issues.

Forensic issues and domestic violence

The high prevalence of childhood (50%)^{Reference Young, Gudjonsson, Wells, Asherson, Theobald and Oliver25} and ongoing adult (21.7%)^{Reference Retz, Retz-Junginger, Hengesch, Schneider, Thome and Pajonk26} ADHD in prison populations, taken together with greater recidivism and violent behaviour in offenders who have ADHD,^{Reference Satterfield and Schell27} might suggest a causal link between ADHD and criminality – perhaps because of high impulsivity. However, the association between childhood ADHD and later criminality is thought to be entirely dependent on the presence of comorbid childhood conduct disorder.^{Reference Satterfield, Faller, Crinella, Schell, Swanson and Homer28,Reference Mannuzza, Klein, Konig and Giampino29} Despite this, it remains important to carefully consider past criminal and conduct problems in adults with ADHD.

There may be a higher rate of ADHD in perpetrators of domestic violence, but there is insufficient evidence to suggest that ADHD is responsible for this – other factors may confound.^{Reference Mandell30} Parents who have been either the perpetrators or recipients of violence may struggle to meet the needs of their children, and childhood exposure to domestic violence is associated with high risks for ‘developing emotional and behavioural problems’.²¹

Impact of ADHD on parenting capacity

By its nature, ADHD makes it difficult for parents to be organised, consistent and to maintain attention when supervising their children.^{Reference Weiss, Hechtman and Weiss31} In women, ADHD is associated with having more sexual partners and experiencing a pregnancy at a younger age.^{Reference Barkley and Barkley32} In general, adults with ADHD are more likely to experience divorce and separation,^{Reference Biederman, Faraone, Spencer, Wilens, Norman and Lapey18} as well as multiple marriages,^{Reference Murphy and Barkley7} and therefore their children will be exposed to greater instability in family structure. Such adults are also likely to have poorer academic qualifications, a greater likelihood of being an unskilled worker, have more unstable work records with more frequent changes in job, poorer occupational performance and a greater likelihood of impulsively leaving a job or being sacked.^{Reference Murphy and Barkley7,Reference McGough, Smalley, McCracken, Yang, Del'Homme and Lynn19} These social impairments are relevant because maternal youth, poverty, poor maternal education, poor marital quality, parental conflict, low paternal involvement, single parent status and low self-esteem have all been associated with neglectful parenting.^{Reference Brown, Cohan, Johnson and Salzinger33}

The challenges to parenting from adult ADHD are present even before giving birth, with expectant mothers more likely to be unmarried, their pregnancy to be unplanned and their attendance at prenatal check-ups to be poorer.^{Reference Ninowski, Mash and Benzies34} Given that ‘even prior to any contact with their infant, women with ADHD symptoms have maladaptive cognitions regarding their expectations of motherhood and parenting abilities’ (p. 54),^{Reference Ninowski, Mash and Benzies34} it is hardly surprising that they develop ‘lower parenting self-esteem, a more external parenting locus of control, and less effective disciplinary styles’ (p. 28).^{Reference Banks, Ninowski, Mash and Semple35}

Even adults without ADHD find being a parent of a child with ADHD very challenging. In general, parents of children with significant aggressive-hyperactive-impulsive-inattentive behaviours are likely to feel less satisfied, more stressed and less efficacious in their parental role than parents of children who do not have ADHD,^{Reference Shelton, Barkley, Crosswait, Moorehouse, Fletcher and Barret36} and report a lower quality of life than the general population.^{Reference Xiang, Luk and Lai37} Owing to the high heritability of the condition, parents with ADHD commonly have children with the condition, and this can be particularly challenging for families. In general, self-reported inattention in the parents of children with ADHD may be associated with lax parenting.^{Reference Harvey, Danforth, McKee, Ulaszek and Friedman38}

There is evidence that mothers and fathers with ADHD interact with their children who also have ADHD in different ways.^{Reference Harvey, Danforth, McKee, Ulaszek and Friedman38–Reference Psychogiou, Daley, Thompson and Sonuga-Barke40} Mothers with ADHD tend to monitor their children with ADHD less, are less consistent in their parenting,^{Reference Murray and Johnson39} and show less ‘positive and involved’ parenting styles.^{Reference Psychogiou, Daley, Thompson and Sonuga-Barke40} There is some evidence, though, that ‘high levels of ADHD symptoms in mothers [ameliorate] the negative effects of child ADHD on parenting’, perhaps from having more ‘empathy or tolerance’ towards their child.^{Reference Psychogiou, Daley, Thompson and Sonuga-Barke40} However, it has been suggested that this empathy and tolerance might disguise a parenting style that lacks ‘consistent discipline’ and ‘clear boundaries’.^{Reference Psychogiou, Daley, Thompson and Sonuga-Barke40} Conversely, impulsive fathers may argue more with their children who have ADHD,^{Reference Harvey, Danforth, McKee, Ulaszek and Friedman38} and high levels of ADHD symptoms tend to have a more ‘negative’ effect on their parenting of children with serious ADHD.^{Reference Psychogiou, Daley, Thompson and Sonuga-Barke40} This could relate, as Psychogiou et al suggest,^{Reference Psychogiou, Daley, Thompson and Sonuga-Barke40} to fathers feeling ‘annoyed and/or overwhelmed’ by the combination of their children's ADHD and their own. Most children whose parents have ADHD are well cared for. However, a combination of the functional impairments of the disorder, as well as the commonly associated social impairments are considered by Mulsow et al ^{Reference Mulsow, O'Neal and Murry41} to be potential risk factors for child maltreatment.

How can we help protect children and support parents?

Table 1 attempts to collate and summarise a number of important reports from UK governmental and non-governmental agencies, relevant to child welfare, which may not be widely known to adult psychiatry services. The Royal College of Psychiatrists’ report Patients as Parents,²¹ and its successor Parents as Patients,²² highlight the responsibilities of mental health staff in safeguarding children. Although both reports emphasise that most parents with mental illness do not abuse their children, a high importance is placed on staff being aware of the needs of children, proactively considering their safety, and understanding the correct procedures to follow when concerns arise. This theme of asking adult mental health services to accept their responsibilities in this area is repeated in a number of other reports. Professionals working with adults are instructed to assess and document the parental responsibilities and key child safeguarding risk factors in relation to their patients. In addition, they are asked to share information with other agencies, acting appropriately and efficiently to ensure children are protected when safeguarding issues are suspected.

TABLE 1 Summary of relevant published guidance on child safeguarding in the UK

Risk assessment

Parents as Patients states that ‘All psychiatrists and members of multidisciplinary teams should be familiar with legal and policy frameworks in their jurisdiction in relation to safeguarding children’ (p. 8).²² Establishing whether the service user ‘is likely to have or resume contact with their own child or other children’ (p. 8)²² is important, and professionals should be prompted to consider this in all formal documentation processes, including assessments and care programme approach reviews. This is supported by the NPSA and other organisations (Table 1), which strongly recommend that professionals record the full details of any children in close contact with adult patients, and assess the ‘potential or actual impact of mental health on parenting, the parent/child relationship and the child, as well as the impact of parenting on the adult's mental health’ (p. 8).²² Care programme approach and other local documentation forms should encourage professionals to do this.⁵²

Although Parents as Patients particularly highlights parents with personality disorders, substance use disorders and intellectual disability, it also specifically mentions ADHD. The original Patients as Parents report²¹ discussed ‘the serious risks posed to children by parents with impulsivity, high levels of aggression and unstable relationships’ (p. 27). We suggest that recognition of ADHD in parents should prompt a careful risk assessment, with a particular focus on comorbid personality disorders, neurodevelopmental disorders, substance misuse and forensic problems.

Concluding comments

Most parents with ADHD are devoted to their children and able to look after them very well. For some adults, ADHD may have a positive impact on their parenting style, for example in terms of ‘enthusiasm, boundless energy, and playfulness’.^{Reference Weiss, Hechtman and Weiss31} The aim of our article is to make patients feel confident and competent in their parental role, through identifying their needs and signposting them to appropriate support. Even where there are parenting problems, these will often lead to relatively mild disadvantages. However, professionals working with parents who have ADHD need to remain alert to the small number of children who could be at significant risk. Further research is needed into the impact of specific symptoms on parental capacity and to investigate the efficacy of treatment strategies in improving the parenting skills of adults with ADHD.