Counseling Youth With  Attention-Deficit/Hyperactivity Disorder (ADHD)

Published May 2017

Nicole A. Stargell, The University of North Carolina at Pembroke
Luke A. Barker, Youngstown State University
Victoria E. Kress, Youngstown State University
M. Lisa Bullock, The University of North Carolina at Pembroke

Attention-Deficit/Hyperactivity Disorder (ADHD) is a neurological processing disorder in which youth, in most cases before the age of seven years, show difficulty in the areas of attention, impulsivity, and/or hyperactivity (APA, 2013). Youth experience these difficulties in more than one setting, including the home, school, and interpersonal contexts. Youth who seek or are brought to counseling for ADHD usually demonstrate fidgeting, difficulty sitting still, or playing quietly. Additional symptoms include struggles with short-term memory, trouble following directions, difficulty completing assigned tasks, rapidly shifting attention from one activity to another before completion, and/or difficulty shifting attention when the focus is on something the youth enjoys (APA, 2013; Kendall & Comer, 2010).

Three types of ADHD that can be diagnosed. With attention-deficit/hyperactivity disorder predominately inattentive type, youth show inattention to details, make careless mistakes, lack organization, and show signs of not listening and/or following directions incorrectly.

Youth with attention-deficit/hyperactivity disorder—predominately hyperactive/impulsive type are usually seen as being very fidgety with their hands and feet, lacking patience while waiting, can’t seem to sit still, and are possibly disruptive. With attention-deficit/hyperactivity disordercombined type, youth show a combination of inattentive and hyperactive/impulsive symptoms.

Attention-deficit/hyperactivity disorder symptoms, contrary to popular belief, are experienced beyond childhood and adolescence and are traditionally experienced for the duration of life if left unaddressed (Centers for Disease Control and Prevention, 2015). Around 5% of all school-age youth in the United States are diagnosed with ADHD (APA, 2013). The main reason males are diagnosed with ADHD twice as often as females is likely because females tend to show fewer signs of disruption and attention-seeking behaviors (APA, 2013).

IDENTIFICATION/ASSESSMENT STRATEGIES
When assessing youth for ADHD, it is important to obtain information from parents, school teachers, and any school or mental health professionals who have worked with the child in the past. It is also important to note that symptoms resulting from ADHD (e.g., difficulty following directions, excessive talkativeness) may contribute to conflict and negative interactions between youth with ADHD and family members or peers (Barkley, 2013). Additionally, instances of ADHD are elevated in first-degree relatives (e.g., parents, full siblings, or children), and similar difficult symptoms might be present in family members who are active in the treatment process (APA, 2013).

The Child Behavior Checklist (CBCL)
The CBCL is a 124-item, parent-rated measure for youth who fall between the ages of six and eighteen. The CBCL measures maladaptive and prosocial behaviors, with the added potential for assessing progress during treatment. This measure can be used by counselors to assess relationships, academic performance, and other school-related constructs while also assessing anxiety, oppositional defiance, and other problematic behaviors (Achenbach & Rescorla, 2001).
Resources:
To purchase this instrument or for more information, visit: http://www.aseba.org or http://www.aseba. org/schoolage.html

Conners, 3rd Edition (Conners 3)

The Connors 3 comes in two forms, a full form and a short form, for assessing children and adolescents from ages six to eighteen years of age (teacher and parent forms) and eight to eighteen years of age (self-report form). This measure is a behavioral rating scale available to counselors to identify and diagnose ADHD, specifically for children and adolescents. The Conners 3 can also be used to assess other comorbid disorders and problematic areas associated with ADHD, such as depression (Conners, 2008).
Resources:
To view a sample report from this instrument, visit: https://www.acer.org/documents/sample_reports/ conners3-self-report.pdf To purchase this instrument or for more information, visit: http://www.mhs.com/product.aspx?gr=edu&id=overview&prod=conners3

ADHD Rating Scales-5
The ADHD Rating Scales-5 can be used by counselors to assess youth between the ages of five and seventeen years of age for ADHD. The ADHD Rating Scales-5 is an 18-item measure rated by parents and teachers that are organized to assess the diagnostic criteria associated with inattention and hyperactivity-impulsivity. The ADHD Rating Scales-5 provides frequency of symptoms depending on where the youth is located (i.e., home or school). This measure may simultaneously be used to assess progress during the counseling treatment process as well (DuPaul, Power, Anatopoulos, & Reid, 2016).
Resources:
For more information, visit: http://www.guilford.com/books/ADHD-Rating-Scale-5-for-Children-andAdolescents/DuPaul-Power-Anastopoulos-Reid/9781462524877/summary For technical information, visit: http://www.guilford.com/books/ADHD-Rating-Scale-5-for-Childrenand-Adolescents/DuPaul-Power-Anastopoulos-Reid/9781462524877/technical-information To purchase this instrument, visit: http://www.guilford.com/ordering-information

NICHQ Vanderbilt Assessment Scales, 2nd Edition
The NICHQ Vanderbilt Assessment Scales (2nd ed.) can be used by counselors to measure the manifestation of symptoms, performance in an academic setting, past mental health treatments and diagnoses, and comorbid conditions. The NICHQ is a measure completed by parents and teachers to assess youth between the ages of five and seventeen years of age. . This measure organizes ADHD symptoms into four categories: predominantly inattentive; predominantly hyperactive; ADHD combined inattentive/hyperactive; and oppositional-defiant/conduct disorder (American Academy of Pediatrics, 2011b). The NICHQ may also be utilized as a follow-up measure to evaluate treatment gains.
Resources:
For more information or to download a free version of the NICHQ, visit: http://www.nichq.org/childrens-health/adhd/resources/vanderbilt-assessment-scales For scoring information, visit: https://www.aap.org/en-us/Documents/sodbp_vanderbilt_scoringinstructions.pdf

The Test of Variables of Attention (T.O.V.A.)

The T.O.V.A. assesses attention and impulsivity in anyone over the age of four. Being completely computerized, the T.O.V.A. can be used by counselors to conduct two types of examinations: visual processing and auditory processing. The intention of this measure is to be used alongside interviews, checklists, and other behavioral measures. The T.O.V.A. measures response times and consistency of those response times, how quickly performance worsens, errors, and guessing responses (Leark, Greenberg, Kindschi, Dupuy, & Hughes, 2007).
Resources:
For more information, visit: http://www.tovatest.com/


INTERVENTION STRATEGIES
When counseling youth with ADHD, it is vital to incorporate a holistic treatment approach that includes the help of parents, teachers, physicians, and any other individuals who may be able to support the youth. Successful treatment of youth with ADHD stems from both the effective use of counseling strategies in the youth’s multiple contexts (i.e., home, school, community) and the utilization of all the people present in their lives (e.g., family, teachers, past and present health and mental health professionals; Erk, 2008). It is important to keep the counseling process creative, adaptive, and multifunctional in terms of approaches and settings. Also, the use of pharmacological agents, including stimulant or non-stimulant medication, can be successfully incorporated with proper client education and coordinated counseling interventions.

Counseling
Youth with ADHD can experience significant reduced symptomology by engaging in cognitive behavioral therapy (CBT), often in conjunction with proper medication (Döpfner et al., 2015). Some younger youth may not have the cognitive development needed to fully benefit from CBT strategies, and, therefore, behavioral interventions and development of practical skills should be highlighted (Fabiano et al., 2009). The overall focus of CBT or behavior therapy includes the following: increase organizational and planning skills, reduce distractibility, enhance problem-solving, challenge negative thought processes, reduce procrastination, improve overall communication, and implement stress-reduction and anger management techniques. A variety of fun, creative interventions can be used to operationalize these goals. For example, youth might be given a color-coded folder for each school subject, and youth can be rewarded with points or trinkets each time the folders are used.

Counselors must take a supportive, yet firm, approach while using CBT to help the child focus on their goals and to help reduce symptomology as best as possible. Overall, a CBT approach, being directive and highly structured, can assist youth in changing thoughts, feelings, and behaviors. Throughout the process of dealing with ADHD, a child may develop low self-esteem and diminished belief in their personal capabilities. With the use of CBT, counselors can help youth change everyday perspectives and give them the ability to see alternative ways of thinking. From this perspective, their newly-acquired beliefs about themselves and the world around them can positively impact specific thoughts, leading to desirable behaviors. It is vital to assist youth in switching their focus to view problems and struggles from a strengths-based approach in which resources and exceptions are highlighted.

Parent Education
It is in the best interest of the child or adolescent to also include parent education during the treatment process. Counselors can explain the risk factors and prognosis associated with ADHD to parents, emphasizing that while ADHD symptoms may be reduced by applying consistent parenting techniques, biology is considered the main source of unhelpful behaviors. Counselors can assist parents in a number of approaches that may benefit their parenting styles as well as help reduce problematic symptoms of ADHD. Working with parents can help reduce any underlying feelings of guilt or frustration while focusing on a comprehensive approach to treatment. Goals of parent education may include, but are not limited to: set daily goals, plan daily routines, highlight strengths, provide appropriate rewards, communicate/collaborate with other key stakeholders, and/or enhance diet to help regulate sleep patterns. Parents play a vital role in the successful treatment of ADHD in youth.
Resources:
For more information and support resources, visit: https://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd/index.shtml http://www.chadd.org/ https://www.nimh.nih.gov/health/publications/attention-deficit-hyperactivity-disorder-adhd-the-basics/index.shtml

Medication
Stimulant medication (e.g., Adderall, Ritalin, Focalin), along with proper management and education, can help reduce symptoms of ADHD in youth. Especially pertaining to youth, it is important to include education on common side effects (e.g., headaches, abdominal pains, loss of appetite, sleep disturbances) that might result from taking ADHD medication (American Academy of Pediatrics, 2011a). Youth who attend school may consider extended release stimulants to simplify medication administration during long school hours. Stimulant medications, along with some common side effects, can be addictive and should be extensively reviewed with the youth’s prescribing physician.

If a child is not able to function properly because of harsh side effects, non-stimulant medication (e.g., Strattera, Intuniv, Kapvay) has been considered effective in treating symptoms of ADHD in youth (American Academy of Pediatrics, 2011a). Although non-stimulant medication has not been approved for pre-school age children, it has been useful for improving attention span, working memory, and impulsivity. All medication should be provided in conjunction with counseling services.
Resources:
http://www.webmd.com/add-adhd/guide/adhd-medication-chart#1 http://kidshealth.org/en/teens/ritalin.html
Children and Adults with Attention Deficit/Hyperactivity Disorder: http://www.chadd.org/ National Institute of Mental Health: https://www.nimh.nih.gov/health/publications/attention-deficit-hyperactivity-disorder-adhd-the-basics/index.shtml
National Resource Center on ADHD: http://www.help4adhd.org/

REFERENCES

Achenbach, T. M., & Rescorla, L.A. (2001). Manual for the ASEBA school-age forms & profiles. Burlington, VT: University of Vermont, Research Center for Children, Youth, & Families.

American Academy of Pediatrics. (2011a). ADHD: Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics, 128, 1007–1022. doi:10.1542/peds.2011-2654

American Academy of Pediatrics. (2011b). Caring for children with ADHD: A resource toolkit for Clinicians. Elk Grove Village, IL: Author.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Barkley, R. A. (2013). Taking charge of ADHD: The complete, authoritative guide for parents (3rd ed.). New York, NY: Guilford.

Centers for Disease Control and Prevention (CDC). (2015). Attention-deficit/hyperactivity disorder (ADHD). Retrieved from: http://www.cdc.gov/ncbddd/adhd/facts.html Conners, C. K. (2008).

Conners 3rd edition manual. North Tonawanda, NY: Multi-Health Systems.

Döpfner, M., Ise, E., Metternich-Kaizman, T. W., Schürmann, S., Rademacher, C., & Breuer, D. (2015). Adaptive multimodal treatment for children with attention-deficit/hyperactivity disorder: An 18-month follow-up. Child Psychiatry & Human Development, 46, 44–56. doi:10.1007/s10578-014-0452-8

DuPaul, G. J., Power, T. J., Anatopoulos, A. D., & Reid, R. (2016). ADHD rating scales—5 for children and adolescents: Checklist, norms, and clinical interpretations. New York, NY: Guilford.

Erk, R. R. (2008). Attention-deficit/hyperactivity disorder in children and adolescents. In R. R. Erk (Ed.), Counseling treatment for children and adolescents with DSM-IV-TR disorders (2nd ed., pp. 114–162). Upper Saddle River NJ: Pearson.

Fabiano, G. A., Pelham, W. E., Coles, E. K., Gnagy, E. M., Chronis-Tuscano, A., & O’Connor, B. C. (2009). A meta-analysis of behavioral treatments for attention-deficit/hyperactivity disorder. Clinical Psychology Review, 29, 129–140. doi:10.1016/j.cpr.2008.11.001

Kendall, P. C., & Comer, J. S. (2010). Childhood disorders (2nd ed.). New York, NY: Psychology Press.

Leark, R. A., Greenberg, L. K., Kindschi, C. L., Dupuy, T. R., & Hughes, S. J. (2007). Test of variables of attention: Clinical manual. Los Alamitos, CA: The TOVA Company.