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Counseling Children with ADHD: Three Focus Areas for Professional Counselors
Attention Deficit Hyperactivity Disorder (ADHD) is one of the most frequent childhood behavioral disorders, affecting several million children and their families in the U.S. every year (National Institute of Mental Health [NIMH], 2012). The current Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013) identifies the incidence of ADHD at 5% of children, although recent surveys from the Centers for Disease Control and Prevention (CDC, 2014) suggest the prevalence maybe as high as 11%. Because the symptoms may last into adulthood in up to 33% of those diagnosed with the disorder, ADHD is considered a chronic health condition (Visser et al., 2014) and a life-span issue (Erk, 2000). Historically, much research on ADHD focused on the educational impact of symptoms and the effectiveness of psychopharmacological treatments in symptom reduction (APA, 2013; Shillingford-Butler & Theodore, 2013). Today, psychostimulant medication for ADHD remains a central component of symptom management (Sinacola & Peters-Strickland, 2011). However, helping children with ADHD has been addressed by professional counselors for several decades (e.g., Bowley & Walther, 1992; Schwiebert, Sealander, & Tollerud, 1995) and more recent success seen by combining behavioral interventions along with medication in the treatment of ADHD (e.g., Hoffman, 2009; Schottelkorb & Ray, 2009) suggests that professional counselors in schools and mental health settings may have much to offer children and their families coping with this disorder.
Characteristics of ADHD
The primary characteristics of ADHD include a pervasive pattern of inattention and hyperactivity which persists for 6 months or longer and is developmentally inappropriate for the child’s age level (APA, 2013). Symptoms must interfere with functioning in multiple environments and be present before age 12. The disorder is classified into two predominant types, inattentive and hyperactive/impulsive, with a combined type when a child exhibits both inattention and hyperactivity concurrently. Inattentive ADHD is characterized by being off task, lacking sustained focus, and being disorganized. Hyperactive ADHD is characterized by excessive gross or fine motor activity such as talkativeness, fidgeting, and tapping of hands and/or feet, while impulsivity is characterized as an inability to control impulses that may result in highly harmful situations (APA, 2013).The signs and symptoms of ADHD often begin between ages 3 and 6; however, many children may not be diagnosed until they enter school and teachers notice the behavior patterns associated with the disorder. Diagnosis of ADHD is primarily conducted through observation and behavioral assessments completed by parents, teachers, physicians, and mental health professionals (NIMH, 2012).
Three Focus Areas for Counseling Children with ADHD
Professional counselors in community agency and school settings may help child clients with ADHD and their families through a variety of interventions. Although academic impairment is often addressed directly by teachers, professional counselors may specifically help children learn to cope with social impairments that occur with ADHD in order to treat the full spectrum of symptoms (Herr, 2009; McConaughy, Volpe, Antshel, Gordon, & Eiraldi, 2011). Research on counseling children with ADHD suggests that action-oriented approaches are vital and that play therapy may be effective when working with young children coping with ADHD symptoms (Portrie-Bethke, Hill, & Bethke, 2009; Schottelkorb & Ray, 2009). Group counseling for children with ADHD has also been suggested (Webb & Myrick, 2003) along with adopting a systemic intervention approach incorporating regular parent and teacher consultations (Shillingford, Lambie, & Walter, 2007). Regardless of the particular setting or counseling approach, three areas of focus are of importance when counseling children with ADHD. These three areas, including conflict resolution, motivation and self-efficacy, and self-esteem, may help counselors organize and structure their interventions. Furthermore, these focus areas can help counselors when consulting with parents, caregivers, teachers, and other healthcare providers to develop a collaborative and active treatment plan which is critical to ensure success (Herr, 2009).
Children with ADHD often experience interpersonal conflict and rejection in their home, school and other social environments as a result of not paying attention, being off task, and difficulty controlling talking or other impulses (Deater-Deckard, 2001). Teachers redirecting students back to individual work, parents repeating instructions, and peers expressing different ideas may be exceptionally challenging for a child with ADHD and lead to conflict and potentially aggressive behavior. Therefore, helping children with ADHD develop conflict resolutions skills and strategies may help reduce the interpersonal difficulties that they often experience. Peer mediation programs in school settings have shown a high degree of effectiveness in helping children resolve conflicts with peers, teachers, and parents. Elementary and secondary children who do not receive training in peer mediation programs frequently fail to resolve interpersonal conflicts and further strain their social relationships. However, after peer mediation training, children learn to successfully utilize negotiation and mediation skills and have more productive outcomes in their relationships with others (Johnson & Johnson, 1996). Likewise, helping children with ADHD and their parents learn skills to resolve disputes in the home setting can be especially important to reinforce conflict resolution skills in multiple environments. Given the proclivity to interpersonal conflict among children with ADHD, professional counselors should continually assess the ability of the child with ADHD to manage and resolve conflict in a constructive manner. With young children, bibliotherapy and narrative-based interventions (Kamali & Looyeh, 2013) may provide an effective avenue for introducing skills in conflict resolution. Numerous age-appropriate conflict resolution books for children are available in print and electronic formats. Older children and adolescents may benefit from therapeutic adventure-based interventions designed to help facilitate stronger interpersonal relationships and reframing negative behaviors into potential strengths (Portrie-Bethke et al., 2009). Professional counselors can also help parents of children with ADHD understand the biological and environmental factors that may lead to conflict and develop skills for facilitating parent-child interactions (Ghanizadeh, 2007). Ultimately, helping children with ADHD develop conflict resolution skills helps minimize social alienation and improves their self-esteem and a sense of self efficacy.
Motivation and Self-Efficacy
Motivation is a particularly challenging aspect in treating ADHD because it is difficult to differentiate the general psychological effects of motivation from symptoms of the disorder itself (Ormrod, 2011). Motivation issues affect children with ADHD in a variety of environments. In school, children with ADHD often do not finish assignments, submit messy assignments, or submit incomplete assignments, which adults may interpret as being due to low motivation. Children with ADHD also frequently struggle to complete activities such as schoolwork or homework that require sustained mental focus and attention and they may avoid them altogether (APA, 2013). In the home environment, motivational challenges for children with ADHD include following through on household chores, finishing games or other activities, and frequently losing things (NIMH, 2012). Children who have had successful experiences at school and at home are less likely to struggle with motivation. However, children with ADHD often have accumulated a series of negative experiences in multiple settings that decreases their willingness to engage in new behaviors. In addition, issues with rejection and motivation can be particularly challenging for minority youth struggling with ADHD and their families due to numerous systemic and institutionalized barriers when seeking help (Tucker & Dixon, 2009). Self-efficacy is considered a central component of successful living and is closely related to motivation. Bandura (1977) found that if a child does not expect to be successful in a particular activity, he or she will be less likely to put forth the effort to successfully engage in the activity. Children with ADHD often struggle with self-efficacy concerns that may result from repeated experiences of failure and rejection in school and at home. Although motivation is considered part of the initial energy directed towards an activity, it is the child’s feelings of potential success (i.e., self-efficacy) that determines how long he or she will continue to exert energy on the activity (i.e., motivation.). Professional counselors can address motivation and self-efficacy by helping children with ADHD to identify and promote strategies to engage in, and successfully complete, activities both at school and at home. In particular, helping children develop intrinsic motivation through the counseling process is critical to help children gain confidence in their abilities and desire to try new behaviors. For older children and adolescents, cognitive-behavioral interventions may be of use in helping assess self-talk and negative self-statements that may contribute to low motivation (Shillingford et al., 2007). A child who impulsively moves from one activity to another might be challenged to examine thoughts that precede the desire to switch activities and come up with new self-statements that will encourage completion of the initial task. The professional counselor also may utilize reflective statements that emphasize intrinsic motivations of the child (Watts, Cashwell, & Schweiger, 2004). For example, the counselor can use reflections that help the child make decisions rather than relying on the counselor, such as “You are working hard to figure out what to do next.” Additionally, the counselor should refrain from using praising statements that foster an external locus of control such as “Good job!” or “Excellent work!” Instead, the counselor can reflect on the child’s internal efforts and motivation by using statements such as “You are feeling proud of your success,” or “You are keeping yourself focused right now.” These strategies for fostering intrinsic motivation can help alleviate some of the struggles with motivation and self-efficacy experienced by children with ADHD.
In the school setting, students and teachers alike perceive children with ADHD to be more socially rejected than students without ADHD (Barkley, DuPaul & McMurray, 1990; Johnston, Pelham & Murphy, 1985; Pope, Bierman & Mumma, 1989). Because of frequent experiences of rejection, self-esteem may be a significant concern for children coping with ADHD. Maslow (1943) originally developed a theory of human motivation emphasizing the need for individuals to value themselves and to believe that others value them. In Maslow’s theory, self-esteem is a deficiency need and therefore must be met before a child can focus on learning, which is considered a growth need. Low self-esteem among children with ADHD may be a consequence of perceived incompetence and continual social rejection that ultimately impedes learning and may lead to feelings of isolation. Professional counselors working with children with ADHD need to assess for low self-esteem and challenge clients’ patterns of thinking and behavior that lead to negative feelings about the self. McKay and Fanning (2000) created a cognitive approach to improving self-esteem that may be readily applied to working with children with ADHD. Their model emphasizes the role of the “internal critic” in the development of low selfesteem and helps clients learn to minimize negative self-statements and learn to assess strengths and weaknesses more accurately. Honos-Webb (2010) also highlighted the need for children and adolescents with ADHD to develop a stronger self-esteem by learning to focus on personal strengths and recognize they do not have to base their self-esteem on weaknesses. In addition, the development of a strong therapeutic alliance in childcentered play therapy has been suggested as an effective counseling intervention to help improve self-esteem in young children (Schottelkorb & Ray, 2009). Finally, providing children with ADHD opportunities to experience leadership roles during therapeutic group activities can help improve their confidence and self-esteem (Portrie-Bethke et al., 2009).
The number of children diagnosed with ADHD has risen in the past decade (CDC, 2014) and many of today’s professional counselors working with children will work with a client affected by the disorder. Although psychostimulant medication has been the primary intervention in the past, the inclusion of counseling in combination with medication is becoming more commonplace (Hoffman, 2009; Portrie-Bethke et al., 2009). Numerous strategies are available to professional counselors when working with children coping with ADHD and their families. By focusing on the three areas of conflict resolution, motivation and self-efficacy, and self-esteem, professional counselors can help provide comprehensive behavioral support to ensure the lifelong success of children with ADHD.
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Nancy J. Hamilton and Randall L. Astramovich