13

Anthony Rostain, MD, MA, on the years of transition to adulthood

interview by Susan Buningh, MRE

PARENTS ARE OFTEN PERPLEXED ABOUT THEIR ROLE DURING THE SOMETIMES DIFFICULT YEARS when their children with ADHD are transitioning to adulthood. For guidance, Attention turned to Anthony L. Rostain, MD, MA, director of the Adult ADHD Treatment and Research Program at the University of Pennsylvania. He is professor of psychiatry and pediatrics at PENN’s School of Medicine. As director of education for the department of psychiatry, he is responsible for overseeing medical student education and resident training. Triple boarded in pediatrics, adult psychiatry, and child and adolescent psychiatry, he treats patients of all ages at the University of Pennsylvania Health System and at the Children's Hospital of Philadelphia, where he also directs the developmental neuropsychiatry program.

Dr. Rostain's clinical focus is in lifespan developmental neuropsychiatry. His research has focused on improving clinical outcomes for patients with ADHD and other neurodevelopmental disorders, and in creating effective service systems for high-risk children, youth, and families. Among his numerous publications is the book he coauthored with J. Russell Ramsay, Cognitive Behavioral Therapy for Adult ADHD: An Integrative Psychosocial and Medical Approach (New York: Routledge, 2008).


What is the role of parents when their children with ADHD become young adults? It may be clearer for those whose offspring become college students, but what about when they don't go away to college?

Under the best of circumstances, a parent’s role in the life of the young-adult child with ADHD should be one of consultant and collaborator rather than director and manager. This can be seen as a goal toward which parent and child are both striving, rather than an expectation, because ADHD imposes certain constraints on adult development.

When ADHD is present, the young adult’s executive functioning is likely to be underdeveloped, leading to problems with time management, organization, self-regulation, judgment, decision-making, and impulse control, to name but a few. Hence, the first step in determining an appropriate parental role is to make an assessment of the young adult’s overall readiness to manage life on his or her own. Areas of strength and competence should be identified, as these can serve as reminders that the young adult has achieved the capacity to function in an age-appropriate manner. Areas of relative weakness should be identified and targeted for discussion, as these will likely lead to predictable difficulties for the young adult and the rest of the family.

The discussion should focus on specifying what role the parent is expected to play. For example, if the young adult is having trouble with time management, such as waking up and getting going in an efficient fashion in the morning, it would be advisable to identify this issue as a problem area requiring joint problem solving. It is critical that the young adult “own” both the problem and the solution and that the parent be invited by the young adult to assist in whatever ways are mutually acceptable. In some families, this means helping to find a good alarm system; in others, it means knocking on the bedroom door to ascertain that the young adult is actually awake and starting his or her morning routines.

The most important thing for parents to remember is that the young adult with ADHD must be continuously encouraged in taking more and more control of his or her life, even if this process is slower than everyone would like. It helps to have a good sense of humor and keep an eye on the long view. It is vital that parents do whatever they can to avoid “role strain” and burnout, as this often leads to demoralization as well as chronic conflicts in the home. If this unfortunate situation already characterizes your family life, it is time to seek family counseling.

A mother of two young adults with ADHD writes, “How do I get them to listen? I know it is wise to choose my battles, but how do I get the best results when I absolutely have to comment or make a suggestion about the way they are living?”

Parents of young adults with ADHD often find it very frustrating to see their children acting in ways that are unwise, unproductive, or unhealthy. The decision to comment on these negative habits or poor choices should be made in a reflective and proactive fashion, with sensitivity to how the message will be received. If you feel you must comment on a behavior that is particularly concerning to you, it is best to do so in the context of a dialogue. Unsolicited criticism, nagging, badgering, yelling, threatening, or other highly charged comments are likely to be ignored or to provoke an angry confrontation, which does not achieve the desired end of promoting communication and collaborative problem solving.

A preferred approach—borrowed from the Collaborative Problem Solving method developed by Ross Greene—is to pick battles when the issue is serious enough to warrant it. Unacceptable behaviors (such as excessive drinking, substance abuse, reckless driving, violence, or physical abuse) must be confronted and challenged with a clear message: “Either cease this behavior or you may have to live elsewhere.” This can be considered the bottom line for allowing young adults to continue residing in the family home. Less-than-optimal behaviors (such as excessive computer game playing, maladaptive procrastination, overeating, poor hygiene, or lack of consideration for others) should become the topics of negotiation sessions where a clear contract is drawn up with rights and responsibilities of the young adult and the parents.

Ideally, a positive reinforcement schedule can be created whereby the young adult agrees to work on behavior change (with measurable outcomes) in exchange for continued room and board, laundry, and so forth. Progress toward these identified goals should be reinforced by granting desired privileges or material rewards. But the basic point to keep in mind is that people change their behaviors when they see that it benefits them to change, and not because people around them don’t approve of their behaviors.

When can parents expect that young adults who have ADHD will understand money and budgets?

Many young adults with ADHD have trouble understanding concepts of budgeting and personal finances. It is important to determine whether this represents a skill deficit (they just don’t grasp the basic concepts) or a performance deficit (they understand the principles of personal finances but they don’t exercise any real restraints on their spending activities).

Skill deficits can be addressed with a basic course in how to create and live within a budget. Unless the young adult has a math disability, it should be easy for him or her to grasp these principles and start applying them to his or her own life. A great deal of practice may be needed before these skills are honed enough to be performed without supervision. Performance deficits require behavioral reinforcements (such as reminder systems, practice sessions, externally imposed spending limits, consequences for overspending, rewards for executing budgetary discipline) that should be written up in the form of an explicit contract.

One common mistake of young adults with ADHD is inappropriate use of credit cards. As most Americans have come to realize, we cannot borrow endlessly in order to support an unrealistic lifestyle, which implies belt-tightening and spending cuts. Young adults with ADHD should demonstrate appropriate spending practices with ATM cards before being given limited capacity credit cards (with a maximum of $500, for example) that can help them practice how to spend responsibly. Managing money takes repeated effort and is very hard to pull off for many of today’s youth, so parents should expect a “gradual” learning curve. It is also advisable to ask the young adult who is earning an income to contribute to the household expenses.

What are the options when a young adult with ADHD lives at home—and it's just not working out? The parents don't believe he or she can live on his or her own.

Current research on young adult development suggests that there is a changing pattern in the life trajectory of people in their early twenties. Instead of starting their own families and careers and moving out on their own, a substantial percentage of youth are staying at home and living with their families. This can cause stress on everyone if the arrangements are not clear, especially if expectations about rules, responsibilities, and privileges are not explicitly discussed.

So the first step is to clarify what people are expecting from this living situation, and what each family member is expected to contribute to the household. The next step is to examine precisely where areas of conflict are emerging, and why this is occurring. For instance, is the young adult keeping a schedule that is “out of sync” with the family? Is he or she staying up all night long on the computer and then sleeping all day long? This is a set-up for chronic conflict. There may be resentment on the part of parents who feel the young adult is being lazy and is avoiding adult responsibilities. The young adult may feel that the parents are being too old-fashioned or too intrusive. If this leads to unresolved power struggles, it is time to seek professional help.

Family therapy can be a productive method for reducing conflicts and improving communication among family members. If things are not working out because the young adult is simply not interested in cooperating with the rest of the family and is acting in an entitled or antisocial fashion (for example, when rule breaking becomes law breaking), then a firm, tough-love approach is needed. It might be necessary to tell the young adult that if he or she can’t live within the reasonable rules of the family, he or she will have to find another place to live. This should not be done in an emotional or threatening fashion. Rather, a calm and practical discussion about living elsewhere (perhaps with other relatives or with friends) should be initiated. If the young adult expresses the desire to live on his or her own but doesn’t possess basic skills to do so, then a group home, halfway house or residential treatment facility may be required as an intermediate step to provide the individual with the skills to learn to live independently.

How can a parent tell the difference between being supportive and helpful versus enabling or creating dependence?

It is often difficult for parents to assess whether their efforts to be helpful are instead creating an over-dependency situation that may actually inhibit a young adult from assuming more responsibility for himself or herself. The first question that needs to be answered is whether the young adult is exhibiting a skill deficit or a performance deficit. In the first instance, the individual does not yet have the ability to carry out a task independently (or does so only with great difficulty). In the second instance, the young adult has the ability but is not consistently performing the job.

Parental assistance is more appropriate in the first situation because the individual actually needs assistance to get things done. Examples of this include managing money, keeping track of time, staying on-task and minimizing distractions. These tasks require a high degree of executive functioning, which can be underpowered in people with ADHD. Skill deficits can be addressed via direct instruction or skill-building therapy (such as meta-cognitive therapy), or via coaching, accommodation, or direct assistance.

Performance deficits (not getting up on time, failing to carry out chores, staying up too late playing video games) should be addressed via behavior-management strategies, with incentives for carrying out targeted tasks and consequences for failing to do so. When parents find themselves providing support to a young adult who is not carrying out tasks that he or she is capable of performing, this is an example of parental overfunctioning and should be addressed in a straightforward manner.

What can parents do when their young adult is struggling to get his or her life together? How can a parent convince the young adult to get therapy or coaching?

There is no secret formula for convincing a young adult to seek therapy or counseling when he or she is having a hard time. Parents need to address two questions: “Why is the young adult struggling?” and “What is my role in helping my child overcome his/her problems?”

If the young adult is having a hard time due to inadequately treated ADHD symptoms, a strong case should be made for pursuing medical treatment since this can make a huge difference. If the young adult is exhibiting executive functioning problems, the services of a life-skills coach can be very helpful. Resistance to this type of assistance may be based in a sense of shame or failure. It would be important to address this situation with an upbeat attitude and comments like: “Athletes and singers use coaches to help them perform at their best. Why not give it a try?”

If a young adult is showing signs of demoralization, apathy, anxiety, or depression, it is vital that parents express their concern and emphasize that they see it as their role to find a suitable counselor or therapist for him or her to start working with. If the resistance to this suggestion appears to come from a sense of shame or failure, a nonjudgmental endorsement of therapy is the best strategy. If the resistance is rooted in depression and an accompanying sense of helplessness/hopelessness, it should be reframed as a sign of a “treatable disorder” that can get better with the proper treatment. More than anything else, it is important to voice confidence that the young adult can reach his or her goals and find greater fulfillment in life with the assistance of these helpers. If parents are struggling to manage their feelings about the young person’s struggles, professional counseling aimed at helping them deal with this situation can also be very helpful.

What should parents do if their young-adult child is still seeking financial support from them as parents—but the young adult is also raising his or her own young children?

There is no easy way to determine what is “right” regarding the level of financial support that parents should provide their young adult children. Each family has to look at the realities of their finances and come up with a best-possible solution to the thorny issue of money. Once parents determine how much they have in the way of funds to support their child and grandchildren, it’s important to sit down with the young adult and review his or her finances and budget. It might be helpful for parents to take on a specific expense (babysitting, daycare, tuition for postsecondary education for the young adult) that could facilitate more earning power on the part of their child. If more money is being requested than parents feel is justified, a loan rather than a gift should be negotiated.

The process for discussing these options should be as calm and reflective as possible, avoiding power struggles or control battles over the minute details of household finances. It is important that the young adult learn how to manage a budget and live within his or her means, but this is a trial-and-error process for many young people (and older adults, too). Parents can be most helpful if they act as “coaches” rather than “money managers” in these discussions.

Many emerging adults, particularly those affected by ADHD, struggle with finding and holding a job. What is the best way for parents to help? At times, some young people neither attend school nor work. How can parents jumpstart the young adult’s ambition if they sense inertia is part of the problem? And finally, when the young adult finds a job, how closely should parents monitor how things are going?

It would be important to figure out what is interfering with the young adult’s success in finding and holding a job, and to identify someone who could serve as a job coach. In general, it is best for parents to avoid being job coaches themselves since this creates inevitable tensions and frustrations on both sides. However, parents should always be encouraging of the search for an appropriate job and should function as consultants if and when the young adult wants advice.

One important function of a professional job coach is to teach the young adult with ADHD the skills of job searching (including finding appropriate open positions, contacting employers, filling out applications, interviewing and following up). Another function is to prepare the young adult for success at work. This includes identifying prior difficulties in the workplace and constructing a plan for avoiding those problems with their next job. Issues such as motivation, punctuality, attentiveness, consistency of job performance, and social skills can also be addressed by a job coach.

If there is too much inertia and lack of motivation to pursue a job search, it can be helpful for parents to sit down with the young adult and work out a contract that stipulates what the young adult’s responsibilities and privileges are. In exchange for being given a place to live, food, clothing, and so forth, it is reasonable for parents to insist that the young person give back to the family in some concrete fashion, either by finding paid work and contributing to the household finances, or by taking on housekeeping functions (such as cooking, cleaning, laundry, or food shopping). The more specific you make the list of chores and the daily hours to be devoted to them, the better. If there is no paid work for the young adult to pursue, volunteer work can be considered a form of giving back to the community, and might be exchanged for hours of household chores.

How should parents handle outbursts of anger from a young adult? The dynamics of such household disruptions differ from dealing with younger children.

Anger outbursts can be extremely difficult for parents to live with, especially if these are directed against family members. It can be helpful to begin with a “diagnosis” of the outbursts.

Are they short-lived, triggered by frustration, mostly verbal, and generally attention-seeking in nature? If so, these can be addressed via individual and family counseling with the goal of reducing the behavior by identifying the triggers of the outbursts, tracking the consequences, and applying different contingencies when the behavior appears. For example, if the behavior serves the function of getting the young adult out of doing chores or of having to be accountable for his or her behavior, it would make sense to “uncouple” the behavior from these undesired consequences. Enforcing rules, expecting the young adult to be responsible, rewarding self-control and anger management efforts, and ignoring the outbursts themselves can serve to reduce the intensity and frequency of anger episodes.

If, on the other hand, the outbursts seem to be a sign of an untreated mood disorder, then evaluation and treatment by a mental-health provider is certainly indicated. Finally, if the outbursts are severe enough to cause physical damage to property or to others, it is best to accompany the young adult to crisis-intervention services.

Let’s look at two very real situations parents have shared with us. A twenty-one-year-old has a co-occurring anxiety condition and has never held a job. He doesn’t want to identify himself as having ADHD in order to access college services, vocational rehabilitation, or disability benefits. How can his parents get him to accept these forms of assistance?

One of the hardest things for parents to accept is the limits of their influence on a child’s attitudes and behaviors. It may be clear as day to them that their son needs assistance and that he is limiting his potential for success by refusing help. At the same time, he is not ready to acknowledge this fact, let alone act upon its implications

If the parents have reached an impasse in discussing this issue with their son, it might be helpful for them to seek professional assistance from a counselor or therapist. The parents can explain to their son that they are seeking help for themselves because they feel “stuck” and are unsure of how to be helpful to him. The therapist can help them identify strategies for dealing with their son’s resistance. For example, sometimes “less is more.” By leaving the topic alone for a while, their son might begin to think about it for himself. The parents can leave around some literature on college services for students with ADHD for the young man to notice, or they can go to a website that lists resources and leave it “on” the home computer.

It also may be helpful to talk with other parents who have faced similar challenges, which is one of the great values of organizations like CHADD. The bottom line here is the truth of the old adage: “You can lead a horse to water but you can’t make him drink.” After a while, if the horse is thirsty enough, he will drink. Hopefully, the young man will eventually want to do more than sit around the house while other people his age are moving ahead in life. And at that point, he will start to look at the situation he is in differently.

In another not-uncommon situation, a nineteen-year-old with ADHD is attending community college because “there’s nothing else to do.” Her mother ends up nagging her to make appointments and register for classes. She thinks she can just show up on the first day of college and take any class. The mother wonders whether she should just let her fall on her face. Do you have any suggestions about how the mother could motivate her daughter to understand the consequences of inaction?

The law of natural consequences suggests that people learn best when they face the consequences of their actions. In this situation, I would let the chips fall where they may. Once the daughter realizes that her procrastination has led to her having fewer options than she expected, she will “get with the program” and start planning ahead. It may take her being excluded from certain classes or even from being able to enroll at all for her to learn this valuable lesson. And while it may be painful for this mother to see her daughter “fall on her face,” the truth is that she is likely to pick herself up and learn from the experience so that it doesn’t happen again.

Once she gets started in college, it is important to remind her that she is responsible for keeping up with her schoolwork and organizing her time for studying accordingly. If she is having trouble doing that, there are likely to be learning resource centers on her campus that specialize in helping students get adjusted to the realities of college life. There are also courses (e.g., Freshman 101) that are specifically designed to teach these skills. The bottom line is that the more the parent can stay out of the picture, the more the young adult will seek out the parent’s advice and help. And at that point, instead of nagging her (and feeling frustrated), the parent will be helping her make good choices to find the right path toward her goals.


Anthony L. Rostain, MD, MA, is director of the Adult ADHD Treatment and Research Program at the University of Pennsylvania and professor of psychiatry and pediatrics at PENN’s School of Medicine. Triple boarded in pediatrics, adult psychiatry, and child and adolescent psychiatry, he treats patients of all ages at the University of Pennsylvania Health System and at the Children's Hospital of Philadelphia, where he also directs the developmental neuropsychiatry program.
Susan Buningh, MRE, is executive editor of Attention magazine.
This article originally appeared in the October 2010 issue of Attention magazine. Copyright © 2010 by Children and Adults with Attention Deficit Hyperactivity Disorder (CHADD). All rights reserved. No portion of this article may be reproduced without written permission from CHADD.