Article 71

Counseling Children with ADHD:

Three Focus Areas for Professional Counselors

Nancy J. Hamilton and Randall L. Astramovich

Hamilton, Nancy J., is an Assistant Professor in the Department of Counseling,

Adult, & Rehabilitation Education at the University of Arkansas at Little Rock.
Her research examines self-regulatory mechanisms in educational contexts.
Those contexts include reading relevance instructions and Attention Deficit
Hyperactivity Disorder.
Astramovich, Randall L., is an Associate Professor of Counselor Education at the
University of Nevada, Las Vegas. He has published numerous articles and a book
on the topic of counseling program evaluation. His current research interests
focus on counseling in schools, client self-advocacy, and evaluation methods in
counseling.
Correspondence regarding this article should be addressed to Nancy J. Hamilton,
Department of Counseling, Adult, & Rehabilitation Education, University of
Arkansas at Little Rock. E-mail: njhamilton@ualr.edu
Abstract
Attention Deficit Hyperactivity Disorder (ADHD) affects millions of children in
the U.S. every year. Symptoms of ADHD may negatively affect a child’s school,
home, and social environments and cause challenges well into adulthood.
Professional counselors may play a central role in helping children with ADHD
successfully manage this disorder through focusing on three areas of concern
including conflict resolution, motivation and self-efficacy, and self-esteem.
Keywords: attention deficit hyperactivity disorder, counseling interventions

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
Ideas and Research You Can Use: VISTAS 2014

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

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providers to develop a collaborative and active treatment plan which is critical to ensure
success (Herr, 2009).

Conflict Resolution
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

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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.

Self-Esteem
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

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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 self-
esteem 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 child-
centered 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).

Conclusion

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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Note: This paper is part of the annual VISTAS project sponsored by the American Counseling Association.
Find more information on the project at: http://www.counseling.org/knowledge-center/vistas