Mothers’ reflections on the role of the educational psychologist in supporting their children with attention deficit hyperactivity disorder

The characteristically disruptive conduct exhibited both at school and home by children diagnosed with attention deficit hyperactivity disorder (ADHD) appears to be particularly emotionally difficult for the children’s mothers, who often turn to educational professionals for guidance. With a view to improving best practice in assistance to mothers and to promoting the tenets of inclusive education policy, the authors investigated the ways in which mothers experienced the support provided by educational psychologists. A qualitative interpretivist approach was adopted, with five purposefully selected mothers, whose children had previously been diagnosed with ADHD. Data was gathered from a focus group discussion and an individual interview. It emerged that mothers experienced parenting their children with ADHD as stressful, requiring continual reassurance and emotional support from educational psychologists. Having need of counselling for their families and academic help for their children, these mothers expected that educational psychologists should collaborate with educators and other role players, so as to enhance overall support to their children as learners. The findings pointed to the need for an effective inclusive school environment that forefront the role of educational psychologists in sharing knowledge and working collaboratively across the education system in South Africa.


Introduction
South Africa's membership as part of the Brazil, Russia, India, China, and South Africa (BRICS) economic coalition serves as a reliable indicator of its sound positioning as a leading emerging economy in Africa.Moreover, as noted by the Global Competitiveness Report (2012)(2013) (Schwab, 2012), the country's economy has remained stable in the face of global economic uncertainty.While such stability usually heralds improved resources for any country, the full benefits of dedicated resourcing have not been evident in South Africa's public education sector, which should serve as a crucially important driving force for further socio-economic development.On the contrary, attempts at macro-and micro-levels to reconfigure the country's educational landscape have continually been hamstrung by significant socio-economic disparities that have remained as residuals of past political inequalities (Dieltiens & Meny-Gibert, 2012).The diminution of resource gaps within urban schools may have given rise to an illusion of change for the better, but this is belied by the fracturing of education in large parts of the country through under-resourcing of teaching and learning environments (Sedibe, 2011).The critical role of adequate resources implies that any insufficiencies in this respect will inevitably exert an adverse effect on improving educational outcomes.Thus, the need for educational planning research into the role of supportive resourcing in educational reform within the South African education system appears mandatory.
Research into inclusive education specifically, may well be the focal point in the creation of a socially just society, in which all individuals feel that they have been able to fulfil their potential and attain a way of life that benefits both themselves and the wider society (Polat, 2011).In South Africa, the need for such research is underscored by social justice factors -particularly the development of quality education for all -and is found most of all in the requirement for informed decision-making by policy makers and the provision of solid foundations for best-practice approaches.
According to the guidelines proposed in Education White Paper 6, "all children and youth can learn and need support and learner's individual strengths need to be encouraged" (cited by Nel, Nel & Hugo, 2012:7).In South African classrooms and homes, educators and learners, as well as parents, wage a daily battle in attempting to surmount a multitude of barriers to learning.One such barrier is ADHD, which requires researchdriven information in order to understand the condition and to support those affected by it.Educational research focusing specifically on the way that ADHD intersects the home, classroom, and professional support from an educational psychologist, is essential in this regard.According to the South African Department of Education's policy on inclusive education (Department of Education, 2001), the two most effective approaches to overcoming barriers to learning are prevention, and support.Educators and educational psychologists play integral roles in this regard.Considered to be the most valuable source of information within the school environment on referral and diagnosis of barriers to learning, educators are expected to be well-informed about the identification, referral, and treatment of ADHD (Decaires-Wagner & Picton, 2009).Hence, the educational psychologist plays a valuable role in supporting educators as well as families in the school environment on aspects pertinent to ADHD.
The link between ADHD and learning difficulties is well substantiated (Barkley, Murphy & Fischer, 2008;Harrison & Sofronoff, 2002;Wicks-Nelson & Israel, 2009).As one of the key challenges that create barriers to learning, ADHD is characterised by developmentally inappropriate levels of inattention and/or impulsivity-hyperactivity (American Psychiatric Association, 2000Association, , 2013)).Between 30 and 70% of diagnosed children and adolescents continue to experience difficulties into adulthood (Mahomedy, Van der Westhuizen, Van der Linde & Coetsee, 2007).
Behaviours associated with ADHD result in significant challenges in school settings, with learners exhibiting academic underachievement, disruptive conduct, and poor peer relationships (Barkley, 2006;DuPaul, 2007).Attendant conditions like anxiety and depression can exacerbate such behaviours (Barkley, 2012(Barkley, , 2013)).A less direct consequence of ADHD includes difficulties in processing social cues (Seabi & Economou, 2012).Such problems, in association with the more commonly pronounced characteristic of impulsivity, namely the inability to inhibit inappropriate behaviour (Van der Westhuizen, 2010;Wicks-Nelson & Israel, 2009), can make social integration problematic.Often presenting as inhibited, withdrawn or distracted (considering that impulsivity is not to be equated with authentic extroversion), some children and adolescents with ADHD may be ignored by their peers (Wicks-Nelson & Israel, 2009), whereas others may experience humiliation and intense levels of stress, as the educational environment confronts them with various challenges.It is not uncommon for learners with ADHD to develop low academic self-concepts, owing to frequent experiences of emotional, scholastic, and social failures early on in their school careers (Seabi & Economou, 2012).
The nature of ADHD is such that it places increased demands on family functioning, and disrupts the processes of parenting and caregiving, while disempowering parents so that they feel incompetent, disillusioned, and distressed about their parenting skills (Finzi-Dottan, Triwitz & Golubchik, 2011;Swensen, Birnbaum, Secnik, Marynchenko, Greenberg & Claxton, 2003;Theule, Wiener, Rogers & Marton, 2011;Wicks-Nelson & Israel, 2009).Affected families experience the start of difficulties in family functioning and relationships when the child is young.These difficulties seem to intensify during the adolescent years (Cunningham, 2007;Johnston & Mash, 2001).
Although both parents are usually at risk for a breakdown in their relationship with their child with ADHD (Kazdin & Whitley, 2003), it seems that mother-child relations are more strained than are father-child interactions (McLaughlin & Harrison, 2006).This may affect the capability of the mother to use positive parenting practices to produce cooperative conduct in their child (Cunningham, 2007;Kazdin & Whitley, 2003).Recent family research recommends that nurturing roles should be shared, which has the advantage of relieving the pressure on the mother and emphasising the need for a more present fatherly role (in traditional family compositions) (Prithivirajh & Edwards, 2011).
Difficulties with parenting a child with ADHD are often a reason for parents to seek professional help from an educational psychologist.Although some research (Prithivirajh & Edwards, 2011) describes the distress that parents experience in parenting children with ADHD, there seems to be a gap in understanding of the ways in which the educational psychologist in a South African context can support parents in particular.Despite limited South African research on this topic, it has been shown that social support is a valuable resource in reducing the stress experienced by families of children with ADHD (Finzi-Dottan et al., 2011).Psycho-education and parent training have been found to be acceptable means of supporting parents of children with ADHD (Deault, 2009;Finzi-Dottan et al., 2011;Van de Wiel, Mattys, Cohen-Kettenis & Van Engeland, 2002).Such support may require assisting parents with the daily tasks involved in managing their child, such as implementing routine, effective discipline practices, and homework intervention strategies.Support could also include establishing mothers' sense of confidence in their parenting abilities and implementing coping strategies through, for example, support groups with other mothers experiencing similar difficulties.

Educational Psychology Support
Much of the research into ADHD management has focused on the child and improving the child's overall functioning (Gerdes, Haack & Schneider, 2012), with recent indications being that a multimodal treatment approach has the best outcomes (Montoya, Colom & Ferrin, 2011).This may involve medication, psychological and psychosocial therapies (Montoya et al., 2011), and stressmanagement training for parents (Prithivirajh & Edwards, 2011).
Whereas interventions for children and adolescents include psychotropic medication (primarily stimulants), it has been found that behaviour modification strategies (Barkley, 2006) and psycho-education implemented across home and school settings are equally effective (Gerdes et al., 2012).DuPaul, Eckert and Vilardo (2012) discovered that a variety of school-based interventions were associated with moderate to large improvements in academic and behavioural functioning of learners with ADHD, including psycho-education, development of skills, and client empowerment (Montoya et al., 2011).Indications are, furthermore, that parents with more knowledge about ADHD report greater confidence in their parenting abilities, and better control over their children's behaviour (Cunningham, 2007).Treatment strategies consequently need to extend beyond symptom reduction, in order to exert a positive effect on critical areas of functioning such as academic performance (Evans, DuPaul, Mautone, Owens & Power, 2012).Interventions at the individual, home, and school levels also appear to be more successful if they are introduced early (Evans et al., 2012).
Educational psychologists in South Africa are mainly responsible for assessing and supporting children with special educational needs (Farrell, 2004), and the scope of their duties is formally defined in the Health Professions Act (No. 54 of 1974) as inter alia "assessing, diagnosing, and intervening in order to optimise human functioning in the learning and development", and "applying psychological interventions to enhance, promote and facilitate optimal learning and development" (Department of Health, 2011:8).According to Geldenhuys and Wevers (2013), South African schools lack the capacity for the early identification of learners who experience barriers to learning, proper assessment of learner's strengths and weaknesses and limited collaboration and cooperation between microsystems.In this regard, Bojuwoye, Moletsane, Stofile, Moolla and Sylvester (2014) state that the provision of support for effective learning in schools ought to extend beyond the institution, and that the aim of providing support services is to serve as a capacity building strategy in addressing learning difficulties.South Africa is limited in empirical knowledge on the potentially supportive role of the educational psychology field within inclusive settings.This deficiency is especially evident in areas regarding the effects of collaboration with schools, allied healthcare practitioners, and parents to maximise the success of the child with ADHD (Finzi-Dottan et al., 2011;Seabi & Economou, 2012).It is therefore particularly essential in an emerging economy such as South Africa's that the field of educational psychology expand its focus from a unitary medical perspective to a constructivist, resource-based, and research-driven approach to assessment and intervention.

Goal of the Study and Research Questions
The primary goal of the study was to explore the ways in which mothers of children with ADHD experienced educational psychology support in order to improve best practice in assistance to such mothers, and to promote the tenets of inclusive education policy by contributing to the corpus of research used by policy makers.The following research questions guided this enquiry: 1) How do mothers of children with ADHD experience support from an educational psychologist?2) What are mothers' understandings of the role of the educational psychologist in supporting their children with ADHD?

Framing the Study
Guided by a systems theory perspective and an inclusive education framework, the authors' point of departure in this study was that collaboration across educational support systems influences learners' educational outcomes positively.Bronfenbrenner refers to proximal processes in the context of mediating environments such as the school, peer group and the family, in which the learner actively engages (Swart & Pettipher, 2011).Since effective functioning within learners' educational microsystems (school level) affects their achievement, long-term educational outcomes, and psychological well-being (Reschly & Christenson, 2012), educational psychologists have a pivotal function, to fulfil in a collaborative systems approach by constituting a central linkage in the web of significant players in the subsystems of the inclusive school community, the family, and the child with ADHD.
Furthermore, in South Africa the implementation of inclusive education policies is largely focused upon a socio-ecological and collaborative approach to learning support.Contextual influencing factors are considered important in how support is offered and received.As inclusive education practices are supported by the bio-ecological model of Bronfenbrenner, there abound a multitude of influences, interactions, and interrelationships between the learner and other systems (Swart & Pettipher, 2011).Thus, utilising a systemic approach to learning support within inclusive education requires that all the influences, interactions, and interrelationships are explored by role players in the relevant systems working together in collaborative partnerships (Engelbrecht, 2007;Swart & Pettipher, 2011).
Given that collaboration between home, school, and community is essential to support learners' learning and development (Epstein & Sanders, 2006;Gimpel Peacock & Collett, 2009), schools are becoming increasingly aware that they can no longer function effectively in isolation from the wider school community (Loreman, Deppeler & Harvey, 2010).Where collaboration in the school community is the norm, parents and learners are likely to feel comfortable (Gimpel Peacock & Collett, 2009) and educational psychologists working within an inclusive school environment have further opportunities to foster such collaborative relationships with the intention of optimising the learning and development of learners with ADHD (Engelbrecht & Green, 2001).

Research Methodology
A qualitative approach within an interpretivist paradigm allowed for a phenomenological perspective (Nieuwenhuis, 2007a) in terms of which the authors relied on participants' views, concentrating on their meaning and interpretations (Creswell, 2007;Henning, Van Rensburg & Smit, 2004;Nieuwenhuis, 2007a).Within the multiple case study design, data was generated by means of a focus group discussion including all participants, and a one-on-one interview with a purposively selected participant (Nieuwenhuis, 2007b).Purposive and convenience sampling procedures were applied for selecting the five participants for the focus group and individual interviews (Creswell, 2007;Henning et al., 2004), since this type of sampling itself to information-rich cases, highlighting the questions under study (Patton, 2002).Participants were selected as mothers of children attending either an independent main-stream school or an independent special-needs school in Gauteng Province, South Africa.Further basis for selection included having a child or children diagnosed with ADHD by an educational psychologist, and having had to consult with an educational psychologist previously.The authors were flexible in allowing one mother with adult children to participate in this study, as it was deemed that she possessed substantial experience and information that could contribute to the study.
The limited scope of this study did not allow for the inclusion of fathers.Ethical considerations, such as participants' right to anonymity, confidentiality and voluntary participation, were respected.Furthermore, participants were provided with an opportunity to enquire about the research processes prior to signing the letter of informed consent.The appropriate ethical clearance was obtained from the University of Pretoria, and all other required guidelines were adhered to.Open-ended questions allowed mothers to reflect on their experiences.Interviews were recorded and member-checking for quality assurance was conducted.In order to establish the trustworthiness of the study, the authors ensured that the results were dependable, credible, confirmable, transferable and authentic.A systematic approach to content analysis was employed to identify and summarise message content (Creswell, 2007).The relevant details of participants and their children are reflected in Table 1.

Findings
Thematic data analysis of mothers' perceptions (referred to as "reflections") on the role of educational psychologists in supporting their children with ADHD revealed their need for in-depth explanations, additional emotional support, and collaborative professional management of their children's difficulties.The results are presented in terms of emergent themes, with supporting quotations from interview transcriptions.

Reflections on the Role of an Educational Psychologist as a Source of Support
The mothers generally appeared to experience parenting their children with ADHD as stressful, reporting high levels of frustration and increased tension at home.All five participants agreed that substantial and different levels of support from an educational psychologist might alleviate their stress, but their insight into the overall tasks of the educational psychologist and expected forms of support, varied between being unsure, and being fairly well-informed.One participant showed particular insight into the general role of the educational psychologist, and the benefits of a systemic approach to collaboration in providing a deeper level of support to parents and educators, but noted that such support was not being provided sufficiently in reality:

It is quite a broad role, [including] testing, play therapy, diagnosis of different learning areas and learning problems and [the] ADHD aspect. A lot of parents maybe feel that an educational psychologist is only used for identifying problems, especially ADHD, and I think [this] is something [the] school need[s] to work on.
[…] they could offer so much more to the staff and parents; but I don't think that role is fulfilled at the moment (Participant 5, interview).
Another participant, in commenting on the educational psychologist's scope of practice, thought it unethical for the psychologist to simply make a diagnosis of ADHD without following up with the parents or making further recommendations to them: This participant was of the opinion that it ought to be parents who decided whether they required ongoing assistance, thereby sharing the decisionmaking responsibilities with the educational psychologist.She also considered it necessary for educational psychologists to be clear about the respective roles and responsibilities of parents and children.Participant four expressed her need for indepth explanations as she was: going in there [sic] as a parent for the first time, you don't know this (Participant 4, focus group).
It became clear that all the participants had some form of expectation of emotional support for the family, from the educational psychologist: 'Maybe some follow-up phone calls or appointments to find out how it is going with the family [can be recommended], [ascertaining] where we need help and what challenges we are facing, […] I think I would really find that useful' (Participant 5,interview).With varying degrees of understanding and expectation of the role of the educational psychologist being apparent among the mothers, it was also evident that they looked to the educational psychologist for clarification of the roles and responsibilities of all concerned at the outset of the consultative process.

Reflections on Educational Psychology Processes
All mothers in this study had consulted with an educational psychologist for an in-depth educational psychology assessment for their children.Usually, an educational psychology assessment process consists of an initial intake interview with the parents, followed by a battery of cognitive, scholastic, and emotional assessments tailored to the child's needs and the reasons for the assessment.The parents are then invited to a feedback session, at which the educational psychologist reports on the findings of the assessment.
Regarding participants' perceptions of the assessment and therapeutic processes, they found these processes to be a positive experience, and considered the support provided during the assessment process to be adequate.The assessment findings generally guide the recommendations made to the parents.A participant related that, '[her and her husband] found the support during the whole assessment process very good and [agreed with] all the information [in] the report […]' (Participant 5,interview).
Another participant also expressed her positive experience with the assessment and feedback processes: The assessment for me was incredibly useful.She [educational psychologist] was amazing.The assessment was good; she gave the report back at her office, lots of things to recommend (Participant 3, focus group).
In this study, it was found that only one of the participants had been given recommendations regarding recourse to additional therapeutic processes (e.g.neurological tests or occupational therapy) for her child after the diagnosis of ADHD had been made.The other mothers felt that educational psychologists had had little to offer, aside from the initial diagnosis of ADHD, accompanied by a recommendation to start with a medication regimen.
Some participants indicated that their children were engaged in therapy with the educational psychologist after the diagnosis of ADHD had been made, and one mother even reported that her child loved therapy, especially since the educational psychologist seemed to be assisting in elevating the child's self-esteem.Supportive collaboration among professionals in the school system may include the educators, the institutional-level and district-based support teams, as well as various healthcare practitioners, such as occupational therapists, speech and language therapists, optometrists, and neurologists.Some mothers felt that such a collaborative relationship and sharing of knowledge among professionals could improve understanding of their children's difficulties, and cause the children to feel more supported during interventions that would reflect a greater measure of inclusivity.

Reflections on Educational Psychology Support for the Child and for the Parent
In view of the children's academic difficulties and the resultant constant failures that they faced, the mothers believed that their children developed anxiety and poor self-images.Although some of the children had received individual therapy from educational psychologists in order to address their emotional needs after the diagnosis of ADHD, several participants were of the opinion that therapeutic support -if provided -could have been of a better quality.For example, three participants noted that little else was offered beyond a bare diagnosis.
See [sic], she had no recommendations for L, other than: 'okay [sic], well he's ADD ' and 'get on with it' [sic].'Yeah and get your child medicated' [sic] (Participant 2, focus group).My experience has been a diagnostic one.She's diagnosed him and that was it [sic] (Participant 4, focus group).'This is the diagnosis'.There wasn't much followup at all (Participant 3, focus group).
Aside from insufficient and inadequate support for some children, participants also felt that the support that they themselves received was limited, with at least four of them feeling that they had been left to their own devices.The types of support that they felt they needed from educational psychologists could be described as follows: a) providing reassurance and emotional support in terms of allaying their fears, in other words, they wanted to hear that what they were feeling and experiencing was normal: sometimes I feel so alone and would like to chat to others about how they handle it all, it can all be so hard.I think that would also be helpful to hear […] from the other parents as well (Participant 5, interview); b) providing information and guidance about what to expect as parents of children with ADHD: I would appreciate maybe right from the beginning, when the diagnosis was made and the report was given back, maybe some assistance with regard to some websites to look at, information booklets or books we could read as a couple (Participant 5, interview); c) facilitating support groups for mothers of children with ADHD in order for them to benefit from sharing experience, thus gaining new knowledge and obtaining additional emotional support as is clear in the following extract: I think it would just make a huge difference, even just support in that form [parent support group]

Reflections on Knowledge Sharing and Interaction between Professionals
If intraschool-level liaison could be considered as being at micro level, four out of the five mothers gave indication that they were aware of advantages to be derived from liaison at what could be called macro level.They felt that it would benefit the educational psychologist to work in collaboration with other professionals within all systems of the school community, for example the educators, the institutional-level and district-based support teams, as well as the various health care practitioners such as occupational therapists, speech and language therapists, and even neurologists to provide support for parents and learners in dealing with ADHD.During the focus group, participant three indicated that: it was a pity that schools like our school, does not have the support, to be able to have somebody who can really interact with the teachers because I feel like as much as our teachers are supporting, they don't really get it.
Another participant noticed that, there's not enough interaction between them, I would have liked the educational psychologist maybe to come and meet the teacher (Participant 2, focus group).

Discussion
Given that ADHD places strain on family functioning (Cunningham, 2007), the participants in this study reported high levels of stress associated with parenting their children with ADHD.Hence, participants expressed the need for the educational psychologist to adopt a more supportive role for them as a family, since the resultant reduction of stress levels would in their view lead to a better ability to cope.This finding is consistent with the view of Finzi-Dottan et al. ( 2011) that support is a valuable resource in reducing stress experienced by families of children with ADHD.
In this study, participants also indicated their need for the educational psychologist to establish or facilitate support groups for individual work with families.Parents in particular needed to acquire knowledge about ADHD and, as part of the educational psychologist's scope of responsibility, it is therefore vital that psycho-education on the disorder should be provided to them.Montoya et al. (2011) claim that knowledge about ADHD, its treatment, and consequential stressors need to be discussed with parents.
This study further support researchers who state that parents with in-depth knowledge about ADHD have been shown to have a greater sense of competency and satisfaction in their parenting abilities, as well as better control over their child's behaviour (Cunningham, 2007).Corroboration was also found in the current study for investigations revealing that parent stress management programmes improve family cohesion, the ability to think in a different and more constructive manner about problems, and a sense of control, personal growth, and changes in negative behaviour in parents themselves (Prithivirajh & Edwards, 2011).
The participants in the current study indicated that the educational psychologist should be interacting with other professionals in order to support them and their children better.Additionally, participants voiced their frustration at educators' lack of understanding and knowledge of ADHD.This finding is consistent with the results of a study conducted in the Western Cape Province of South Africa on primary school educators' knowledge and misconceptions of ADHD (Perold et al., 2010).It was reported that educators had a substantial lack of knowledge, in particular, when it came to key areas of ADHD.
According to Swart and Pettipher (2000), as well as Bothma, Gravett and Swart (2000), South African educators have not been trained to cope with the increasing diversity of learners entering mainstream classrooms, and such learners consequently lack support.Thus, to fill the gap, educational psychologists could provide training for educators who may feel that they lack knowledge of ADHD and, in particular, could guide educators in communicating effectively with parents (Rogers, Weiner, Marton & Tannock, 2009).The literature suggests that the role of the educational psychologist should extend to all learners experiencing barriers to learning, their parents, the school-based support team, medical practitioners, and the wider community in order to create an inclusive school environment (Bradley, King-Sears & Tessier-Switlick, 1997).If the interconnectedness of the various components of the educational-cum-community system is viewed through an ecosystemic lens, it becomes apparent that the school could play a significant role in lessening the emotional impact of parenting children with ADHD.
The needs of the emergent South African economy dictate that research-driven policy decisions and best-practice approaches in the field of inclusive education ought to be paramount in order to sustain the momentum of reform.This paper established the need to listen to the voices of key participants in the inclusive process, as evidence for the need to reflect on, revise, and rethink the manner in which educational psychologists practice their profession.

Limitations of this Study
The primary limitation was the small sample size, where, because of the restricted scope of the study in which only five participants were interviewed.Therefore, the authors needed to be cautious in making generalisations and oversimplifying participants' experiences.

Conclusion
The authors reported on mothers' perceptions of educational psychology support and the challenges facing mothers while parenting their children with ADHD.Greater levels of support for these families can be achieved if educational psychologists provide assistance through their individual involvement with families as well as with parent support groups.This could subsequently nurture parent interactions and constructive parent involvement in the child's learning.They could also advise parents on the benefits of increased involvement in their child's education and school life.Moreover, the educational psychologist could play a pivotal role in breaking down the barriers between the school, the parents, and the other professionals involved in the child's life (Rogers et al., 2009).The findings suggest the need for collaborative relationships to be forged between the different learning communities, such that they come to share knowledge and to focus on support.The role of the educational psychologist in forging these collaborative associations is clear.Furthermore, not only do educational psychologists as individuals have a pivotal role to play in facilitating the successful development of inclusive education practices in South Africa, it is also essential that the entire South African field of educational psychology align itself with the international leaning towards family-centred and transdisciplinary intervention.The findings of this study reinforce the need for supportive resourcing in educational reform within the South African education system.

Table 1
Participants' details an educational psychologist, to just diagnose and then to leave you alone… I think they need to recommend and suggest, and talk and say 'okay, let's have a session, and this is what I think, what the options are' [sic].Then you make a decision, you [can decide whether you] want that support.She should be saying, 'this is what I can offer; this is the kind of thing that we do, that are within our scope' (Participant 2, focus group).