Tag Archives: Children & Adolescents

Behind the Book: Solution-Focused Counseling in Schools

By Bethany Bray November 2, 2015

One of the many reasons solution-focused counseling is a good fit for school settings is because it’s a client-directed approach, says John Murphy, a longtime school psychologist and author of Solution-Focused Counseling in Schools.

School counselors often find the bulk of their time consumed with noncounseling tasks. When they Branding-Box-Solutionare able to meet with a student, using a solution-focused approach provides a customizable way to forge a therapeutic bond with the young person in a short amount of time.

“The simple and practical premise of solution-focused counseling – find what works and do more of it – is one of its most appealing features for school practitioners,” Murphy writes in the book’s conclusion. “This does not mean, however, that it is easy to do. Solution-focused work requires careful attention to language, client feedback, relationship building and other therapeutic nuances and skills. Mastery of these skills requires patience and practice. If your experience is anything like mine, however, it is well worth the effort.”

Solution-Focused Counseling in Schools was originally released in 1997; the American Counseling Association published a third edition of Murphy’s book earlier this year.


Q+A: John Murphy on Solution-Focused Counseling in Schools

In the book’s introduction, you write “schools are not set up to accommodate counseling.” Can you elaborate on what you mean by that?

This is not a criticism, merely an observation that the main purpose of schools is to teach reading, writing, math and other important academic skills. Unlike mental health centers and private practice settings where counseling is the main focus and the physical setting reflects that focus, school settings present some unique challenges for counselors.

These challenges include working around students’ and teachers’ busy class schedules, safeguarding client confidentiality and conducting “counseling sessions” whenever and wherever you can — in the lunchroom, on the playground, talking with a parent by phone or walking alongside a student or teacher in the hallway. This requires a lot of flexibility on the part of school practitioners.

But let’s not forget that there are advantages to school-based counseling as well. In addition to offering instant access to students and teachers, schools provide a natural and familiar setting for students and parents who might otherwise have to leave their community and travel long distances to receive services. For these reasons, and the fact that we know more than we ever have about helping people change, I ended the new edition of Solution-Focused Counseling in Schools by stating that there has never been a better time to be a school-based counselor.


From your perspective, what makes a solution-focused approach effective in helping elementary through high school students? How is it a “good fit”?

For starters, solution-focused counseling (SFC) is a clear and practical approach that makes sense to students, caregivers and counselors. Research tells us that people are more likely to benefit from counseling approaches that make sense to them, that respect their input and goals, and that customize counseling to them rather than requiring them to conform to the counselor’s preferred methods. SFC meets all of these criteria, which explains why it is effective with students of all ages.

Although solution-focused counselors validate problem-related experiences and struggles, they gently invite students to take action instead of spending a lot of time analyzing the problem. The “less talk, more action” nature of SFC seems to appeal to students as well as school counselors, who have very little time to do counseling in the first place.

Another reason SFC works with students is because it grabs their attention as “something different” rather than more of the same. Most students with school problems are well accustomed to problem-focused conversations with adults. These well-intentioned conversations emphasize what is wrong with students, with little or no attention to what they are doing well, which may include coping with a problem or preventing it from getting worse. In contrast, solution-focused conversations seek out students’ strengths and resources and explore how these assets could be applied toward solutions. In my experience, conversations that recognize and build on what is right and working with students engage their participation more effectively than “more of the same,” problem-saturated discussions.

The solution-focused approach fits with school counselors as well. In teaching classes and workshops throughout the U.S. and overseas, counselors often tell me that the solution-focused emphasis on “doing what works” as quickly as possible is more practical than cumbersome, time-consuming approaches that don’t fit well for schools and school problems. Building on students’ strengths also appeals to counselors’ desire to empower, energize and encourage people. The fact that solution-focused counseling accommodates a variety of cultural backgrounds and life experiences is another important feature in today’s increasingly diverse world. Most people, including myself, signed up for this business to lift people up, and SFC fits nicely with this goal.


What prompted you to do a third edition of this book? What’s new and different in this edition?

Though many of the basic ideas and techniques of SFC have been carried over from previous editions, several aspects of my approach to SFC have changed since the previously published second edition in 2008. Research continues to clarify specific elements of effective counseling, all of which are incorporated into the new edition of Solution-Focused Counseling in Schools. These elements include the importance of building a strong counselor-client alliance and of collecting ongoing client feedback.

The third edition has new chapters on topics such as the restrictive influence of problems and practical strategies for developing “goals that matter,” as well as additional practice exercises at the end of each chapter and a widely expanded chapter on innovative ways to use solution-focused strategies in group counseling, classroom teaching, peer helping programs, parent education, consultation with parents and teachers, systems-level change and referral forms. I also included new appendices with examples of solution-focused checklists and referral forms, therapeutic letters to students of all ages, scripts for introducing client feedback tools and handy crib sheets for conducting SFC sessions.


What is a main takeaway you want counselors of all types, including nonschool counselors, to know about the importance of solution-focused counseling in school settings?

The main takeaway is that the ideas and techniques in this book are “value added.” A value-added technique adds value and impact to whatever it is combined with, making everything else you do with clients more effective. Examples of value-added techniques include obtaining client feedback, giving compliments, validating students’ experiences and exploring exceptions to the problem.

The beauty of these techniques is that there are no risks or downsides to using them. The worst thing that can happen is that the person does not respond and nothing changes, at which point you simply move on to something else. Even then, value-added techniques can enhance the alliance by conveying respect for people’s input, wisdom and capability. The bottom line is this: You can use the techniques in this book regardless of your theoretical orientation and regardless of whether or not you consider yourself a solution-focused practitioner.


You were a public school teacher and school psychologist for many years. How have you seen the role of school counselor/psychologist change since then?

I haven’t seen much of a change in the roles of most school counselors or school psychologists, especially when it comes to the small amount of time they spend in intervention-related activities such as individual and group counseling, parent/teacher consultation and schoolwide prevention/intervention programs. I am not criticizing the professionals who fill these roles, many of whom would like to spend more time on such activities. School counselors and psychologists often tell me that they are pulled in so many different directions and saddled with certain responsibilities that leave little time for counseling and other intervention-related services. Unfortunately, the situation will not change in a big way if schools continue to rely exclusively on outside professionals and agencies to provide the bulk of school-based counseling and intervention services.


What advice would you give to a new professional who is starting a career as a school counselor?

Find ways to stay active, involved and hopeful about your profession and the people you serve. Effective practitioners are continually engaged in professional learning and development. They also find ways to sustain their hope in the midst of the ongoing problems and challenges they face on a daily basis. I would also advise them to make sure that their job description and role includes sufficient time for counseling and intervention activities.


Besides your book, what resources would you recommend for school counselors who would like to learn more about solution-focused counseling?

There are many more resources on solution-focused counseling with young people and schools than there were when I wrote the book’s first edition almost 25 years ago. An Internet search of “solution-focused counseling in schools” will yield various articles and chapters. The Solution-Focused Brief Therapy Association’s website (sfbta.org) contains general information about SFBT. I also maintain a website on solution-focused and strengths-based practices in schools that has a variety of links and additional information about solution-focused practice in schools, workshop offerings on the topic and other related topics (drjohnmurphy.com).





Solution-Focused Counseling in Schools is available from the American Counseling Association bookstore at counseling.org/publications/bookstore or by calling 800-422-2648 x 222


For more insights from Murphy, see these downloadable VISTAS articles from ACA:

Solution-Focused Counseling in Schools

Building School Solutions From Students Natural Resources

Student-Driven Interviewing Practical Strategies for Involving Students in School Solutions


Also, see ACA’s podcast with Murphy on solution-focused school counseling: bit.ly/1OSO26v





About the author

John J. Murphy is a licensed psychologist and professor of psychology and counseling at the University of Central Arkansas. Previously, he was a public school teacher and school psychologist.




Bethany Bray is a staff writer for Counseling Today. Contact her at bbray@counseling.org


Follow Counseling Today on Twitter @ACA_CTonline and on Facebook: facebook.com/CounselingToday



Stuck in the middle

By Ann M. Ordway and Ruth O. Moore October 21, 2015

Licensed professional counselors are increasingly becoming involved in court proceedings relative to their work with families involved in high-conflict divorce, separation and custody litigation. Counseling professionals can serve in a variety of roles when working with families embroiled in divorce litigation. For example, a counselor might develop a therapeutic relationship with an individual family member, a couple or the entire family unit. These roles are typically kept distinctly separate. However, when working with high-conflict families, such roles can become easily blurred. Thus, Child-Custody_brandingcounselors can be unexpectedly swept into litigation because of misinformation, hidden agendas, the expansion of what started as a fairly simple role or even a lack of knowledge about court terminology and procedures (such as not recognizing when counselors are required to release information to the court and when they are not).

Counselors must be proactive and engage in cautious practice when interacting with high-conflict families and with court professionals. We offer counselors 10 simple guidelines to follow.

1) Be aware of ulterior motives. There is no question that individuals going through separation or divorce appropriately turn to counselors for support and guidance to get through one of life’s most challenging psychosocial events. But the possibility also exists that attorneys will refer clients to counseling for other reasons. For example, if a couple is involved in custody litigation, an attorney might refer a client to a counselor to document the client’s version of events or to set the stage for later seeking an opinion from the counselor about the client’s mental health status or ability to function as a parent. There may also be times when attorneys direct clients to bring their children to counseling in hopes of later soliciting a supporting opinion from the counselor regarding the individual’s abilities as a parent.

A counselor needs to be clear at the onset of the therapeutic relationship about why the client is there, what the client expects, what the counselor can and cannot do and whether the referral is from the client’s attorney for a specific reason. It is critical for the counselor to also know who the identified client is.

Counselors can certainly work with clients to enhance their coping skills and to effect change. If a client has a history of substance abuse, for example, proactive and voluntary involvement in counseling can demonstrate that client’s interest in and willingness to tackle a problem before being ordered to do so by a judge. Participation in counseling can also indicate effort and bolster a court’s impression that the client’s problem is under control.

However, it is important that counselors not be used to perpetuate a false impression for court purposes. Counselors cannot control the sincerity of a client’s motive, but we do not want to be complacent in a ruse to gain an advantage in court.

2) Know your role and avoid dual relationships/multiple roles. A counselor in a therapeutic role provides support for clients and empowers them to build on their existing strengths and make positive changes. In contrast, an evaluator gathers information from multiple angles and sources for the express purpose of rendering a report and recommendations to the court.

Counselors can certainly opine about the condition and progress of the client. However, counselors should not opine about the condition, progress or functionality of individuals they have not met or for whom they have limited information.

Sometimes the client, or an attorney, will ask the treating counselor to offer an opinion about specific issues such as parental fitness, abuse or domestic violence. The counselor must offer recommendations and opinions that are consistent with the counselor’s role and competency. For example, it might be fine to say that the client presents with symptoms consistent with someone who has been a victim of domestic violence. But if the counselor’s information is limited only to what the client has told the counselor, it would not be prudent to comment on the propensity of the client’s partner toward violence. Similarly, it would not be prudent to repeat the client’s statements as fact if the counselor was not present for the described events.

3) Be familiar with ethical codes, legal statutes and best practices. The 2014 ACA Code of Ethics specifically addresses issues such as informed consent and confidentiality, dual relationships, multiple roles and identifying the client. When in doubt about a situation, counselors need to always consult the ACA Code of Ethics and avail themselves of the ethical consultations made available through the American Counseling Association (call 800.347.6647 ext. 314 or email ethics@counseling.org).

It is also in the best interest of counselors to be familiar with their state laws and regulations. Some state laws include nuances that more clearly define when confidentiality must be broken, such as in cases of child abuse and neglect.

Counselors must also refrain from offering legal advice to clients, while at the same time remaining aware of laws in their jurisdictions so they can avoid guiding clients down the wrong path. Counselors should refer clients to attorneys when legal advice is needed and in the client’s best interest. One counselor encountered serious legal problems and a licensing board complaint when she suggested that a client, whom the counselor believed to be a victim of domestic violence, take the children and relocate to another country where the client’s family lived. States have specific laws regarding the removal of children from the jurisdiction. Removal of children without the permission of the court or consent from the other parent can result in criminal charges against the removing parent and a loss of custody.

4) Obtain consent and document all contact. Counselors should obtain copies of any documentation regarding custody and visitation when a separation or divorce is involved. Counselors need to ask for the most current copy of the court order and document that the copy is represented to be the most current copy. A counselor’s informed consent document should outline the expectation that all modified and updated court orders will be provided as they occur.

When there is no official documentation, counselors must keep detailed records about what they were told and by whom. Counselors working with children in divorce situations should seek consent and input from both parents whenever possible. When this is not possible, the reasons should be documented. Sometimes a court order will grant one parent sole custody of the children or sole decision-making authority. Other times one parent may state that the other parent isn’t involved because of estrangement or death. Client records need to reflect what the presenting parent has told the counselor so that the counselor will have a reasonable basis for proceeding if another parent surfaces and objects.

5) Offer support, not re-entrenchment. From a humanistic perspective, the therapeutic alliance is built upon support and unconditional positive regard for the client. However, in cases of high-conflict separation or divorce, there can be a fine line between the position that the client is 100 percent right and the estranged spouse is 100 percent wrong.

It can be difficult for two people to settle the economic and custody-based differences in their legal case when one person is cemented into a faulty belief system of entitlement or stuck in a position rooted in principle. Settlements result from the art of compromise, and positions based on principles can be expensive. In other words, clients are sometimes so concerned with winning a point that they lose sight of the big picture and end up jeopardizing more important elements of the case. Counselors sometimes do their clients a disservice by being so supportive of the client’s position that the client cannot move forward realistically through a legal system that is often more concrete in the application of the law.

6) Maintain neutrality where appropriate. This guideline pertains mostly to counselors working with children. It is easy to become invested in the parent whom the counselor sees or talks to most frequently. Hearing only one side of the story can absolutely affect the counselor’s view of the child’s experience, especially when the child has limited verbal or cognitive abilities, is not emotionally insightful or is not detail oriented.

Counselors should start with the understanding that children generally fare much better in divorce situations when they are not caught in the middle. Counselors serve the child well by supporting his or her relationship with both parents, unless there is a clear risk of harm to the child. Counselors can refer family members in need of support to other professionals to avoid conflicts of interest.

7) Do not offer an opinion of someone you have never met. It isn’t uncommon for a lawyer to ask a child’s counselor to render an opinion and recommendations regarding custody of the child or for a client’s counselor to opine regarding parental fitness and ability. However, the counselor should stick exclusively to what the counselor knows.

It is OK to speak about the counselor’s own client — with the client’s permission — to include what that client has reported, the consistency of words and affect, and impressions regarding that client. It is not wise, however, to offer comment on a parent whom the counselor has never met. Such comments would be based exclusively on what the parent who is a client has reported to the counselor. It is acceptable to state, “The client reported that her husband hit her,” but it is not advisable for the counselor to state, “Mr. Jones is an abusive man who is violent in his relationships. He should not be trusted to have custody of his son.”

8) Do not assume you can avoid court involvement. Some counselors think they can avoid court involvement by adding one or two phrases to their informed consent documents stating that they refuse to participate in court proceedings. Although there might be an argument that the client agreed to waive any right to call the counselor as a witness, a subpoena can trump that agreement. In other words, if an attorney subpoenas a counselor, the counselor will likely have to appear for a deposition or for a hearing.

The counselor can seek to have the subpoena quashed and should not release any clinical information until it is determined that the subpoena is valid and will be upheld. Best practices suggest that the counselor obtain consent from the counselor’s own client or an authorization to release information. However, even without that consent or waiver, the counselor may have to provide records or even testify.

Avoiding court begins the moment the client walks in the door. Informed consent and documentation are essential. Counselors should be trained in courtroom dynamics, testimony and legal and ethical issues even when it is the counselor’s preference to not go to court. Such measures, including ongoing communication with the client, can decrease the likelihood of having to participate in court proceedings.

9) Consult with your state licensing board, malpractice insurance carrier or attorney when necessary. If subpoenaed, consulting with an attorney before releasing records or providing testimony is wise. It is helpful for any counselor whose practice involves working with high-conflict families to have an attorney available for prompt consultation if necessary.

An attorney can review documents and guide the counselor regarding the process for balancing ethical responsibility and court involvement. Sometimes subpoenas can be quashed or suppressed. Some counselors make the mistake of responding to a threatening letter from legal counsel suggesting that the counselor must immediately make all records available. An attorney will know if the request or demand is valid in the counselor’s jurisdiction and can guide the counselor away from any ethical pitfalls associated with an incorrect response or the premature release of confidential records. Under no circumstance, however, should a subpoena simply be ignored.

10) Choose your words carefully. Wording can be everything. When asked for a report or an opinion, the counselor should confine his or her response to that which the counselor knows. Counselors should avoid supposition and assumption. It is acceptable to say, “My client stated …,” but it is not acceptable to respond as if the counselor was present or witnessed the event unless that is the case.

Simple wording can make a difference in how the counselor’s opinions or recommendations are received. When asked a question by an attorney, the counselor should listen to the question, think about it and then offer an answer that is responsive without providing more information than was requested.

Credibility is critical, and it is the counselor’s reputation (as well as the best interests of the client) on the line when the counselor renders an opinion or makes recommendations. The counselor must be able to support recommendations and opinions with facts, best practices and empirical evidence.


Counseling high-conflict families going through separation or divorce can present a slippery slope. The work is extremely important for the family unit and its individual members because they are dealing with an extremely challenging life event. However, cases involving the courts are stressful in even the simplest of cases. Many counselors prefer to maintain a supportive role and do not wish to do forensic (court-related) work. However, they can easily be maneuvered into the role of witness regardless of their efforts to avoid that position.

The guidelines provided in this article do not represent an exhaustive list of the professional and ethical responsibilities of counselors involved with high-conflict divorce cases. However, following these guidelines can help counselors maintain credibility, be more mindful of potential legal and ethical obligations and provide the client or family with needed emotional support. The guidelines should also remind counselors of the importance of receiving training for work with this population.




Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Ann M. Ordway has been an attorney for 25 years and practiced in family court for many years before entering the counseling profession. She is completing her doctorate in counselor education and supervision through Walden University. She is a distance clinical professor in the Department of Counseling and Special Populations at Lamar University in Beaumont, Texas. Contact her at aordway@lamar.edu.

Ruth O. Moore is a licensed professional counselor and national certified counselor who is a distance clinical professor at Lamar University. She has extensive experience in expert witness testimony and has published and presented widely on court process in child abuse and child custody cases. Contact her at rmoore@lamar.edu.

Letters to the editorct@counseling.org


Where’s Waldo? A creative tool to introduce CBT skills

By Brandon Ballantyne October 13, 2015

Regardless of how old I get, there are certain childhood activities, toys and outlets that continue to bring me positive memories and feelings. One of my fondest activities from childhood involved Where’s Waldo?

The Where’s Waldo? series was created by Martin Handford. In the books, the reader is invited to scramble and search through pages and pages of chaos and busy illustration in attempt to locate and find the main character, Waldo. Waldo is typically dressed in a red-and-white-striped hat and

"Where's Waldo" image via Flickr creative commons http://bit.ly/1NBXHy9

“Where’s Waldo” image via Flickr creative commons http://bit.ly/1NBXHy9

shirt. However, there are many lookalikes on each page, so attention to detail is very important for the reader.

As a licensed professional counselor who works with adolescents, I find it important to incorporate a certain level of creativity into the process of helping clients build coping skills. I have been strongly trained in the area of cognitive behavior therapy (CBT), so I commonly introduce interventions and skills associated with thought logs and coping thoughts.

With adolescents, I find that providing a basic understanding of CBT is effective in most cases. I typically introduce the theory of CBT as a relationship between thoughts and feelings. I provide education on the way in which thoughts directly influence feelings and establish a foundation of awareness that we can achieve more desirable feelings if we can find ways to change thoughts.

With this basic description of CBT in mind, the intervention of a thought log can be very effective in helping adolescents to practice “catching” negative thoughts, identifying the immediate emotions and then “inserting” coping thoughts to challenge the negative self-talk, thus leading to more desirable emotions and more effective problem-solving of the situation at hand.

I introduce a thought log to my adolescent clients as a type of journal. They can use it to sit down for a given period of time or while in the presence of an external event to actively practice recording negative self-talk/thoughts and any associated emotions that arise as a result of those thoughts. Next the client will identify and record an associated coping thought/positive affirmation to counter the negative self-talk and associated emotions.

It is important to ask clients to rank the intensity of their thoughts and emotions because some coping thoughts may create new emotions, while others may simply decrease the intensity of the negative self-talk. This helps clients form a personal conceptualization and understanding of which coping thoughts are more effective on the basis of the emotions that they want to achieve or decrease the intensity of.


The Where’s Waldo? connection

At this point, you may find yourself wondering how this CBT intervention relates to Where’s Waldo? In my professional opinion, the chaos and busy illustration featured on each page of Where’s Waldo? simulates the day-to-day chaos and conflict that clients may experience within their system of stressors: school, family, relationships, peers, jobs, etc.

In the Where’s Waldo? activity, finding Waldo is the goal. For many adolescents, personal goals and ambitions are often discouraged or lost among the chaos and conflict of their day-to-day stressors. This is because that ongoing chaos and conflict can create a stream of negative thought that adolescents often find too difficult to challenge.

In my work with clients, I ask them to practice completing a thought log while engaged in the Where’s Waldo? activity. I invite them to sit with a piece of paper while they search for Waldo and record any negative thoughts that they experience. Examples of negative thoughts while trying to locate Waldo: “I can’t do this”; “This is too hard”; “I want to give up”; “I do not succeed at anything.”

I also ask my clients to record emotions created by these thoughts — for example, frustration, anger, hopelessness and anxiety. It is important to sit with clients as they engage in this activity because the thought log is an active, ever-changing intervention and skill. The counselor not only educates clients on how to perform the thought log but also serves as a support, encouraging clients to counter their negative thoughts with coping thoughts that will help them resist the urge to give up on finding Waldo.

This activity provides clients with an outlet to practice emotional distress tolerance and implement CBT skills in the context of a simulated activity. It also offers them encouragement to apply those same skills to actual day-to-day stressors. To conclude the activity, counselors can invite clients to compare and contrast the negative thoughts and emotions they experienced during the activity with what arises when they encounter the presence of the day-to-day chaos of real life.

Processing the activity creates an opportunity for clients to access personal growth and insight. It also provides them with the confidence to take the thought log home and implement it with some of the specific stressors that may have brought them into treatment. I believe that change occurs when clients are able to apply what is learned in therapy to real-life dilemmas.

By simulating chaos and conflict through creative, nonintimidating outlets such as this Where’s Waldo? activity, we can help clients to acquire the tools and confidence to effectively apply those coping skills to the personal dilemmas that initially led them to treatment.

Remember, as overwhelming as the chaos may seem on each page of Where’s Waldo?, the truth is that Waldo really does appear on every page. This can help to reinforce the idea to clients that at times in real life, it is necessary to tolerate the distress that is present. Because for every moment that distress is tolerated, the opportunity to reach the goal increases.



Brandon S. Ballantyne is a licensed professional counselor, national certified counselor and certified clinical mental health counselor with Reading Health System in Reading, Pennsylvania. Contact him at ballantynebrandon@yahoo.com.

Diagnosing ADHD in toddlers

By Donna M. MacDonald August 27, 2015

In 2000, Dr. Steven Hyman, then director of the National Institute of Mental Health (NIMH), made a statement for the record and publicly recognized that preschoolers can have the mental health condition of attention-deficit/hyperactivity disorder (ADHD). He made this statement even though this belief was not widely accepted at the time. He further stated that preschoolers with ADHD were _toddlersunable to interact happily and healthily with friends and family members, significantly impairing their self-esteem and the stress level of the family unit. Therefore, Hyman urged a push for more studies to be conducted on medication for children as young as age 3. (It’s important to note that Hyman is not “for” or “against” medication; he is for what is right for each individual case). He was hopeful that more studies and results would give parents of young children legitimately suffering from this disorder more treatment options.

In 2011, the American Academy of Pediatrics adjusted its guidelines for the diagnosis and treatment of ADHD to include younger children. Previously, it had “allowed” ADHD to be diagnosed in children only 6 and older, but since the push from NIMH in 2000, more research studies had in fact been conducted, and those results warranted the change to include the diagnosis and treatment of preschoolers.

Some public school preschools enroll their students at age 3 (even though most children start a bit later because of where their birthdays fall on the calendar). An ADHD diagnosis requires that the symptoms be consistently intense and frequent for a period of six months, which means that most preschoolers who legitimately have the disorder are receiving the diagnosis at the end of age 3 or the beginning of age 4. According to Dr. Demitri Papolos, a recipient of an NIMH Physician/Scientist Award whose research findings have been widely published, the latest research suggests that the age of onset for ADHD is usually prior to age 4 and can occur as early as infancy. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) reports that ADHD symptoms will have an onset prior to age 12 and that the observation of excessive motor activity during toddlerhood is likely. However, the DSM-5 states that these young cases of ADHD can be hard to distinguish from normative behaviors.

‘Within normal limits’

Given this information, what should counselors watch for in terms of identifying possible ADHD symptoms in these very young children? It can be challenging to discern between the typical hyperactivity, impulsivity, inattention, irritability and aggression that toddlers will inevitably display and the symptoms that are actually clinically significant and indicative of the neurodevelopmental disorder of ADHD in 1- to 5-year-olds. This is because in toddlers, as the DSM-5 states, behavior and emotional expression that is considered “within normal limits” spans a very wide range. Consider, for instance, the following scenarios:

  • What if a 1-year-old bites her sister?
  • What if a 2-year-old throws a tantrum in the store when he doesn’t get the toy he wants?
  • What if a 3-year-old runs around the minivan and won’t stay in her car seat?
  • What if a 4-year-old constantly says “NO!” and won’t follow directions?
  • What if a 5-year-old can’t sit still at the dinner table?

All of these scenarios can be associated with ADHD, but they are not necessarily indicative of the child actually having ADHD because each of the examples can fall within normal limits for the age range. This does not mean that these behaviors are always acceptable, however. Therefore, some of these behaviors will need modification.

On the other hand, in some instances, parents really do need to lower their expectations of what a toddler can and should be able to do. After all, toddlers are not meant to be mini-adults or even mini-children. Therefore, it is important to remember that it’s normal for a toddler to say “no” because it means he is trying to gain a sense of independence. It’s normal for a toddler to throw a tantrum when she doesn’t get her way because of the need for immediate gratification, which is associated with an immature frontal lobe of the brain. It’s normal for a toddler to want to run, jump and climb because movement actually helps the brain develop properly and helps the toddler to feel well emotionally. Toddlers don’t have long attention spans, so sitting still should be difficult for them.

According to staff members who specialize in early intervention with children ages birth to 36 months at the U.S. Department of Health and Human Services, a child who is 12 to 15 months old should be able to hold attention to an activity for one minute. A child who is 16 to 19 months old should be able to hold attention for two to three minutes. Nearing age 2, a child should be able to attend for three to six minutes. By age 3, this attention span should increase to five to eight minutes, and by age 4, the child should be able to hold attention to one activity for eight to 10 minutes. This does not mean, however, that the child will necessarily be able to remain still while attending to the activity. It is important that clinicians and physicians have a thorough understanding of what is within normal range so that they do not misdiagnose ADHD.

As the child ages, the range of behaviors that is considered within normal limits diminishes significantly. For instance, if a 7-year-old engages in any of the scenarios listed above, such as biting another child or running around the minivan while the parent is driving, especially if this happens on a regular basis and the child is not responsive to consistent behavior modification techniques, it provides much more reason for concern for an actual mental health condition.

Indicators of ADHD in toddlers

So, what are the signs of actual ADHD in a toddler? For actual ADHD, the toddler’s behavior must showcase a pattern of chronicity, meaning demonstrating the behavior frequently and consistently for a period of at least six consecutive months and without responding to consistent behavior modification techniques. In addition, the behavior of a toddler with ADHD must be intense in nature — much more intense than a typical toddler who might showcase these symptoms occasionally.

There will also be a rule-out procedure for ADHD to ensure that the toddler’s behavior is not due to normal temperament, a medical issue or sleep disorder, the externalization of daily stressors or another mental health condition. If all these causes for the toddler’s behavior are ruled out, the following may serve as signs of ADHD in the toddler:

  • Putting self in danger on a regular basis. This action is due to the presence of novelty-seeking behaviors, sensory-seeking behaviors or impulsive behaviors. Examples include hanging over a second-story banister, jumping down an entire flight of stairs, climbing the bookcase or the drapes, or darting into the street.
  • Putting others in danger by impulsively becoming physically aggressive, such as ripping toys out of others’ hands or pushing another child off of a swing. These actions are the result of a strong need for immediate gratification.
  • Struggling to make friends and difficulty following social norms, such as taking turns while talking, sharing toys or waiting in line. Parents of young children with ADHD may notice that other parents routinely cancel play dates with them or are not heard from again after having one play date with their child.
  • Falling behind in preschool despite interventions in the classroom to help the child succeed.
  • Engaging in tantrums for extended periods of time (15-30 minutes) on a daily basis or, sometimes, several times per day. During these tantrums, the child loses all rational thought. These tantrums display cognitive, behavioral and emotional impulsivity. Many of these instances are triggered by events that are considered “minor.” Most typical toddlers would not react in this extreme manner to these events, so this type of reaction is considered “disproportionate to the event.”
  • Overreacting in a positive manner to minor events. An example is jumping from one piece of furniture to another out of excitement, yelling loudly and throwing his or her hands in the air because of getting to go to the park, even when visiting the park is an almost daily occurrence. This overreaction makes it especially difficult for the child to transition into actual participation in the desired activity because he or she struggles to calm down.

Behaviors must be measured not only in terms of developmental norms but also in proportion to the event. If an 18-month-old goes to the library for the first time, she may run, yell loudly and touch every book she can out of excitement. However, if the child is now 4 years old, has been to the library regularly and still struggles to use “quiet feet” or cannot maintain herself for the five minutes of story time, that is cause for concern. If a 3-year-old throws a tantrum for 20 minutes because the big trip to Legoland — a place the child has never been before — has been canceled, that’s more “normal” than if a 4-year-old engages in a tantrum for 20 minutes because it’s raining and he can’t go to the local pool that he visits almost every day. That reaction would be considered disproportionate to the event.

Children younger than 6 or 7 cannot process traditional talk therapy because of its abstract nature. Therefore, it is important to get the young child with ADHD involved in another form of interpersonal behavior therapy to work on self-awareness, self-management, social skills and decision-making skills. Play therapy, dance/movement therapy, art therapy, music therapy and animal-assisted therapy are examples of nontraditional therapy forms that may be especially appropriate for young children, as long as clinicians are incorporating all of the self-regulation skills necessary for a child to use age-appropriate behavior.




Donna M. MacDonald is a licensed clinical professional counselor who has worked professionally with ADHD for 15 years as a teacher, YMCA director and, currently, licensed clinical therapist in a therapeutic day school. She is also the mother of 6-year-old twins who were diagnosed with ADHD at age 3. She is the author of the book Toddlers & ADHD under the pen name Donna Mac. Contact her through her website at toddlersandadhd.com.

Letters to the editor: ct@counseling.org


Related reading: See MacDonald’s Counseling Today article from earlier this year: The connection between ADHD, speech delays, motor skill delays, sensory processing disorders and sleep issues




Emotion, personified: What “Inside Out” gets right about mental health

By Erin Shifflett June 25, 2015

A person’s mind is a mysterious labyrinth of thoughts, feelings, memories, ideas and compulsions; the mind of a young girl is likely even more complex. Disney-Pixar’s latest animated offering, Inside Out, bravely delves into that intricate world in a way that effectively captures the nuances of the way people feel and think—and maybe helps them understand why they act the way they do sometimes.

Developed with the guidance of University of California, Berkeley psychologist Dacher Keltner, the film tells the tale of Riley, an 11-year old whose family relocates from Minnesota to San Francisco. Through the move, Riley loses her friends and beloved hockey team and is forced to transition to a place where pizza is served with broccoli as a topping and the cool girls in school wear eye shadow, much to Riley’s surprise. Guiding Riley on a consistent basis are the five emotions operating at Headquarters (Riley’s brain): Joy, Sadness, Disgust, Fear and Anger. Each is displayed with a

Image via Wikimedia Commons

Image via Wikimedia Commons

corresponding color (Anger is a fiery red, for example). The emotions take turns ensuring that Riley reacts appropriately to everything that occurs in her life. This is where the viewer can begin to see how this film might resonate with those in the counseling profession—and their clients.

The dominant emotion in Riley’s life is Joy; she’s the “IT” girl, always front and center and determined to ensure that she has a big presence in Riley’s day-to-day activities and any memories that are formed. The other emotions are supportive of this because, well, they want Riley to be happy, and Joy is certainly the best one to make that happen. A shift occurs, though, when Riley finds herself trying to adapt to her new surroundings. Suddenly, Sadness starts to forcibly interject herself into Riley’s day. When the other emotions become frustrated and ask her why she’s behaving in such a manner, Sadness states simply, “I don’t know what’s wrong with me—I can’t help it.” This translates to Riley crying on her first day in her new school, and the other emotions become alarmed and concerned. This scene is a prime example of what this film “gets right” about mental health and also provides an opportunity for working with clients who feel “not themselves” or find that they’re behaving in an unusual manner after a trauma or sudden change in their lives.

People can’t expect to feel Joy all the time, and though we often attempt to push Sadness aside, it’s a normal emotion and it has a place in our lives as well. This scene might be particularly useful when working with young children as it provides a tangible, visual representation of something they might not have the ability to verbalize—being able to see Sadness in all of her gloomy, blue splendor will likely allow a child to better understand that particular feeling.

The importance of Sadness and, indeed, the other less pleasant emotions such as Fear, Disgust and Anger, is highlighted multiple times throughout the film when their roles and functions are explained. Disgust’s job description includes keeping Riley safe by ensuring that she avoids things that could harm her (poison, for example). Fear allows Riley to pause and consider a situation before acting. Anger makes it possible for Riley to express her frustrations and defend herself. These three-dimensional representations of normal, healthy emotions that are often regarded as negative or harmful open the door to conversations about feelings which might otherwise be difficult to address.

One of the characters in the film that will likely spark conversations between parents and children and, perhaps, counselors of children is Bing-Bong, Riley’s imaginary friend. There are some truly poignant scenes revolving around Bing-Bong’s dawning realization that Riley no longer needs him and has in fact begun to forget about him. One scene in particular takes place in “Pre-School Land,” which has a landscape littered with the usual artifacts of early childhood: building blocks, primary colors, dolls, etc. When Bing-Bong arrives on the scene, he witnesses a demolition team tearing down all of these items in order to make room for the other stages in Riley’s life. This scene presents a prime opportunity to talk with children about how they feel about the changes that are occurring in their lives as they make similar transitions from preschool to elementary school to middle school and beyond.

Lest anyone think that children are the only ones likely to benefit from the lessons learned in this film, it is worth noting that Inside Out is frequently touted as an adult movie made for kids. It offers multiple images and scenes that are likely to spark a note of reflection in even the most cynical and hardened adult hearts while the children in the audience are marveling at the bright colors and playful characters.

A primary example lies in the imagery of Riley’s “Islands of Personality.” These concepts— presented as literal islands tethered to Riley’s brain—are named after the most important qualities that make Riley who she is at this point in her life. There’s Family Island, Friendship Island, Goofball Island, Hockey Island and Honesty Island. In a particularly effective approach, when something interferes with the essential quality of these notions, the tethers to one or more of the islands are destroyed and the islands themselves crumble and disappear. The first to go is Goofball Island—it represents Riley at her most silly, playful self. There are images of her running around after a bath as a toddler, making monkey faces with her parents, etc. As she begins to evolve emotionally, Riley no longer displays that particular side of her personality and, as a result, Goofball Island goes dark and falls into nonexistence. Other islands follow suit, and it is likely that adults watching this film will feel pangs of nostalgia as they recall—perhaps for the first time in years—which parts of their personalities have been lost along the way due to factors such as age, environment, obligation, etc. It is conceivable that counselors working with those who feel as if they’ve lost a clear idea of their identities and purpose may be able to reference this idea (Islands of Personality) as a way of identifying what has been surrendered and abandoned along the way, what the effects have been and whether or not it’s possible, necessary or appropriate to reconstruct some of them.

Inside Out marks the first animated foray into the world of emotions and mental health and presents everything in a way that is, above all, accessible. It is a certainty that those who filed into a cool, dark theater hoping for some escapism and an opportunity to be amused for ninety minutes came away with something much more significant—an opportunity to reflect on how emotions impact all of us and the importance of giving each feeling its due.



Avid movie buff Erin T. Shifflett is director of the American Counseling Association’s Ethics and Professional Standards department.


Related reading: See “Counseling goes to the movies,” Counseling Today‘s list of counselor’s favorite movies:  http://bit.ly/1AWKDcq


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