Tag Archives: Children & Adolescents

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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Handle with care: Addressing child trauma in West Virginia

By Bethany Bray May 5, 2015

“Their normal is chaos, and we have to bring calm.”

For public school students in West Virginia, the calm therapist Felicia Bush is referring to comes in the form of an innovative, multidisciplinary program that aims to identify and treat trauma in real time.

Bush, a provisionally licensed social worker with a master’s degree in counseling, provides trauma-focused therapy for youth in the public schools through the Defending Childhood Initiative (DCI). The program brings together law enforcement, public school staff and mental health professionals to create a HandleWithCaresafety net for youngsters, bridging the gap between what happens at home and the hours they spend at school.

For example, a child might witness police responding to a domestic violence incident that occurs in the home in the wee hours of the morning. Through DCI, police officers are trained to note whether a child was present during such incidents. Officers then find out what school the child attends and file a “handle with care” notice with the school. The one-page form doesn’t provide details about what happened but simply lets the school know that the student may need extra attention.

“The child sometimes discloses what happened but not always,” Bush says. “You don’t have to know what happened. You just have to know that something happened that potentially can affect the child’s ability to learn.”

In other cases, a parent or caregiver might alert the school that something is going on at home, such as a parent’s impending military deployment or the death of an extended family member.

After being alerted, DCI’s network clicks into place to provide whatever extra care the child may need at school — from a space to shower, nap and change clothes to a chance to retake a test to recurring sessions with a trauma-focused therapist.

Law enforcement personnel and entire school staffs — from principals to the cooks in the cafeteria — complete DCI training to help them identify and be sensitive to child trauma. The initiative is designed to stem both the short-term and long-term effects of trauma, especially its impact on children’s ability to learn.

“Trauma is a public health issue, not just a counseling issue,” says Carol Smith, a licensed professional counselor (LPC) and member of the DCI advisory board in West Virginia. “[Addressing this] is a huge paradigm shift, and it’s going to take all of us.” That includes medical and mental health professionals, educators, law enforcement personnel, religious leaders and others in the community, she says.


Getting started

The DCI in West Virginia is a localized version of a program first introduced by U.S. Attorney General Eric Holder. He launched DCI in 2010, prompted by the plentiful research showing that trauma affects a child’s ability to learn and is associated with long-term physical and mental harm.

In West Virginia, U.S. Attorney Booth Goodwin has overseen the launch of a DCI program tailored to local needs, including creation of the “handle with care” form used by law enforcement.

A group from the Child Witness to Violence Project, a successful multidisciplinary trauma-focused program in Brockton, Massachusetts, came to West Virginia in 2011 to train DCI participants before the program launched in pilot schools, according to Tracy Chapman, the victim witness coordinator in the U.S. Attorney’s Office for the Southern District of West Virginia.

“We looked at what works, and we looked at the needs of West Virginia — the needs that are impacting our children, our classrooms,” she says.

The first pilot schools in West Virginia adopted the program in 2013. In less than two years, law enforcement personnel have recorded 414 incidents involving 768 children through DCI, according to Charleston Police Lt. Chad Napier, a coordinator for the program.

Now, after its success in five different pilot schools at the elementary, middle and high schools levels, the stage is being set to roll the DCI program out statewide.

This spring, it was announced that the DCI program will now be headquartered in the newly created West Virginia Center for Children’s Justice, located at a state police facility in Dunbar. This change will allow DCI to be more easily implemented statewide while adhering to a consistent model, Chapman says.

“We can no longer work in our silos focused on one piece of a child’s life puzzle. We must work together to make systemic improvements that can truly change the trajectory of a child’s path,” Goodwin said at the center’s unveiling. “… This [Center for Children’s Justice] will improve communication and collaboration between law enforcement, prosecutors, schools, advocates and mental health providers, and help connect families, schools and communities to mental health services.”

Goodwin has been the driving force between DCI in West Virginia, making it a personal priority, Chapman says. “As a federal prosecutor, we can’t arrest our way out of crime and the types of problems that are affecting our communities,” she says. “We have to provide the resources to children and to communities and to schools to actually change and break the cycle. We have to intervene early, and we have to intervene effectively with kids to help keep them on the right track. That’s his [Goodman’s] message.”


Creating a safety net

Through DCI, school staffs work to provide as much specialized care as possible for trauma-affected children, such as partnering them with a mentor or ensuring that they can make up missed homework. The school counselor plays an integral role in these efforts, from readying a schoolwide traumatic crisis response plan to identifying children and families who could benefit from extra mental health support, says Smith, a member of the American Counseling Association and president of the West Virginia Counseling Association.

When children affected by trauma need extra help beyond what the school can provide, they are referred to mental health practitioners who provide in-school therapy as part of DCI. All of these practitioners are specially trained to treat trauma. One of DCI’s pilot schools, an elementary school in Charleston, has established a permanent mental health clinic in the school.

“[DCI] gives services to the child immediately upon the experience of a potentially traumatic event. If it’s needed, the service is there, and there’s no stigma to it,” says Bush, executive director of Harmony Mental Health, a nonprofit mental health and social services agency based in Parkersburg.

Prior to the launch of DCI, Bush says, school staff members had to guess when something had happened in a child’s life outside of school, clued in by sudden behavior changes or when Child Protective Services personnel came to the school — often weeks later — to ask the child questions. Now the initiative is allowing professionals to help students deal with trauma in its immediate aftermath.

Professionals involved in DCI agree that the program is helping to reach students who might have previously fallen through the cracks and not been identified as needing help. “A lot of these kids were never on anyone’s radar unless they were a direct victim,” Chapman says.


A culture of safety

In addition to providing extra help for individual children, the DCI program trains educators to introduce schoolwide initiatives that focus on mental health.

In one example, the school principal and other staff members greet students coming off the bus each morning. The students are asked to give a thumbs up or thumbs down, depending on how they are feeling that day. The principal uses this to gauge the school population’s overall climate for the day and tailors the school day accordingly. On “thumbs down” days, this could include having a therapy dog visit the school, postponing testing or introducing extra small group counseling sessions with a school counselor.

A similar initiative is introduced for classrooms. Upon arriving, students are asked to take a marble and place it in a bowl. They select a green marble if they are feeling OK and a red marble if they are feeling bad. The teacher can gauge the classroom’s needs by checking the bowl, adding extra wellness initiatives to the day such as breathing exercises or playing soothing music in the classroom (see sidebar, below).

The program also requires a provider of trauma-focused cognitive behavior therapy to be available at each school, Chapman says.

Individual children who are referred to mental health practitioners through DCI are given an initial screening to see whether they need general counseling or trauma-focused counseling, Bush says. If the case does involve trauma, the therapist will go over a treatment plan with the child’s parent or caretaker.

In addition to trauma-focused cognitive behavior therapy, the mental health practitioners provide lots of psychoeducation, Bush explains. DCI therapists work to help the children understand what trauma is and guide them in learning coping mechanisms, including the management of behavior, anger and emotions.

“Some of [these children] have no ability to identify or control their emotions,” says Bush, who has worked with victims of domestic violence and trauma for more than a decade. “The goal is to help them identify the trauma they’ve experienced, put it into a narrative and begin to express it so it doesn’t affect them for their whole lives.”

Because the therapy is conducted in the schools, mental health practitioners are able to collaborate with school staff, check in often with the children’s teachers and see the students “in context,” Bush says. The mental health practitioners often visit a child’s classroom, the lunchroom or a gym class just to observe the child in a group setting. “We do a lot of listening,” Bush says.

By being so ingrained in the schools, the therapists are also able to schedule therapy around field trips and other events the child would not want to miss, Bush says. Teachers have been very willing to work with Bush and her therapist colleagues, she says, even participating in department and individualized education plan (IEP) meetings when asked.

One of the most helpful aspects of the DCI program is that the children “realize they’re important to us [the adults], to the school and to all the people who have put in extra effort to make this available for them,” Bush says.


It takes a village

The DCI program brings together professions that were not always good about communicating with one another, Chapman notes. “Unfortunately, for far too long we’ve all worked in our individual silos. Children do not live in silos. They live in all of our worlds,” Chapman says. “… For far too long we haven’t communicated and collaborated and broken out of our silos to make sure that we’re comprehensively addressing the needs of the child. For far too long these kids have fallen through the cracks.”

Chapman and Bush both use the metaphor of putting pieces of a puzzle together to describe the program’s multidisciplinary approach.

“We all have a little piece of the puzzle, a little piece of a child’s life,” says Bush, adding that anytime those puzzle pieces are connected, it benefits the child. “We’re blurring the lines for the benefit of the child. Not the lines of confidentiality or procedure, but making the community safer by providing a safety net for children so they’re not the next generation of perpetrators or the next generation of adult victims.”

Treating the effects of trauma in young children “is the only place we can truly change the cycle of violence in our community,” she says.

DCI stakeholders — including law enforcement personnel, public school representatives, mental health providers and community partners such as social service agencies — meet often to review and evaluate the work being done.

In some ways, the program’s training has also ushered in a cultural shift, Chapman says, in part by introducing a level of care and follow-up that didn’t often exist previously in the state’s law enforcement. New protocols guide police to avoid making arrests or interviewing witnesses in the

Blackwater Falls State Park, West Virginia

Blackwater Falls State Park, West Virginia

presence of children whenever possible and to make regular, noncrisis visits to local schools.

“There’s a whole new culture and mindset in the police department that they need to recognize when kids are present [during an incident] and the potential impact that could have on the child,” Chapman says.


In your neighborhood

DCI was launched in some of the neediest schools in West Virginia. At the program’s first pilot school, an elementary school in Charleston, 93 percent of the students are from low-income families. But those involved in the initiative agree that DCI’s multidisciplinary approach is needed everywhere as well.

All communities have children and households that are affected by trauma, Chapman notes. “We all have to think differently. … If we continue to do the same things we’ve always been doing, we’ll continue to get the same results. That goes for schools, mental health [practitioners] and law enforcement,” Chapman says. “Counselors play a vital role in this process as well. … I would encourage mental health providers to think outside of the box [and] understand the limitations that some families have with coming to their offices [outside of the school day].”

“People don’t exist in a vacuum of 50 minutes” — the length of a typical in-office counseling session, agrees Bush. “You want to send them out into as much support as you can possibly garner on their behalf. If you want [clients] to be successful, it’s a no-brainer. Make yourself familiar with all the [support] systems that are available.”

The collaborative work being done in programs such as DCI involves going the extra mile, but it’s well worth it, Bush says. “Step out of your comfort zone and you will have a richness of experience that you can’t imagine,” she says, her voice breaking with emotion. “Open up your world to experiences, people and situations that you wouldn’t normally experience. It’s just such a growth experience for everyone.”

DCI also models what adults regularly try to teach children: to be cooperative. “[Students] see adults working together not in a negative way, but in a healing way,” Bush says.

Both Chapman and Bush stress that communities interested in DCI should adopt the program as a whole. It doesn’t do any good to have law enforcement record and refer children involved in traumatic incidents unless a trauma-sensitive network is set up in the community’s schools, Chapman asserts.

“It takes all these components working together to get this initiative to succeed,” Bush agrees. “It’s important that [communities] don’t piecemeal it.”


Meeting a need

Through her involvement in DCI, Smith has decided to devote the remainder of her career to focusing on trauma. At Marshall University, where she is an associate professor of counseling, Smith is involved in the launch of a graduate certificate program in violence, loss and trauma counseling. In addition, several Marshall University counseling interns have been involved in DCI under Bush, Smith says.

“When your eyes are opened to trauma, you realize it’s everywhere. Everyone who walks through your door has it, and if you don’t handle it correctly, you can restigmatize or cause harm,” Smith says. “Counselors can become change agents in the community. … The field is waking up and becoming savvy to the issues that are swirling around us. Yes, it’s exhausting, but it’s worth it.”




Learn more about DCI in West Virginia: handlewithcarewv.org


Much of DCI’s schoolwide trauma training is adapted from the book Helping Traumatized Children Learn, a publication of the Massachusetts-based Trauma and Learning Policy Initiative. Find out more, and download the book for free, at traumasensitiveschools.org.





Classroom initiatives for “thumbs down” days

What should happen on days when the majority of students indicate that they’re not OK? The possibilities are limitless, says Carol Smith, a licensed professional counselor, member of West Virginia’s Defending Childhood Initiative advisory board and president of the West Virginia Counseling Association.

Examples of activities to calm and refocus students include:

  • Doodle-quilts: Each child is asked to take out a 4-by-4-inch piece of paper (already cut and available for such a time as this) and to spend five minutes quietly doodling on it in whatever colors the child chooses. Students then pass the pieces of paper to the front of the room. The teacher tapes the pieces together and posts the “quilt” of doodles on a bulletin board, observing that the doodles show the students’ “processing” of whatever caused the heated (unhappy/stressed) temperature.
  • Round robins: Children sit or stand in a circle, facing each other. With the process explained and structured by the teacher, each child, in order, identifies one thing that is on his or her mind. The teacher summarizes, validates, encourages and then redirects the children to the work at hand.
  • Stand up and stretch: The teacher validates the students’ collective temperature and provides structure: “We are going to breathe a few breaths and do a few stretches to process our feelings, and then we’ll get to today’s lesson.” The teacher takes students through a couple of deep breaths and a short series of stretches to allow students to “reboot.” The verbal validation, structuring and limited activity work to restore equilibrium and allow students to get back to business.
  • An agreed-to, brief regrounding ritual that has been previously co-constructed by the teacher with the children, typically at the beginning of the school year.

Source: Carol Smith, associate professor of counseling, Marshall University




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


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Assessing ‘ideal’ versus ‘real’ family characteristics with adolescents

By Brandon S. Ballantyne April 13, 2015

When working with adolescents in a group setting, it is important to provide opportunities to explore, evaluate and process the dynamics that occur within their homes. After all, eventually they will be faced with the dilemma of figuring out how to apply what they have learned in therapy to situations at home.

I have formulated a creative, psychoeducational task that allows adolescents to assess and explore the similarities and differences between their “ideals” and what really occurs within their unique and, at times, chaotic family relationships. I have broken this down into three simple categories. I ask the housedrawing_1adolescents to draw an illustration of a house. Inside the house are to be three distinct rooms with boundaries, because boundaries are healthy no matter how you slice that pie. The adolescents usually laugh at that analogy. Utilizing that humor, I then invite them to talk more about the boundaries at home.

I next ask them to label each of the three distinct rooms in the house. One section is labeled “Think,” another section is labeled “Do” and the last section is labeled “Say.”

I ask them to title their paper “Family Shoulds.” As a group, we discuss what the word “should” refers to. Typically, one group member will mention his or her impression of the word “should” as a reflection of a demand, expectation or wish. All of those definitions are acceptable for this task.

The idea is to have each group member write a list of three items for each category inside the house: three things they believe a family “should think,” three things they believe a family “should do” and three things they believe a family “should say.”

I have found that when I simplify group tasks in terms of “threes,” that the group flows more smoothly. For example, three rooms in the house and a list of three items for each of the three categories. I think this provides the task a sense of organization and predictability, thus increasing the group members’ level of trust and safety. This creates a less intimidating environment for each group member to talk about his or her family issues or other issues that may come up.

It is important to invite each group member to ask questions about the assignment. For example, I usually receive questions such as “What do you mean by things a family should say?” You might encourage the adolescents to write down specific things they believe a family should say to one another and then apply this to the other categories as well. For example, you might encourage the adolescents to write down three things they believe a family “should do together.” Or encourage them to write down a list of three things they believe a family “should think about one another.”

In the second component to this task, you instruct each group member to draw another outline of a house with the same three categories: think, say and do. Except this time, you ask the adolescents to write down their beliefs about their “Family Reals.” It is important to have a discussion about what you mean by the term “reals.” Usually, one group member will suggest that “reals” refers to facts or reality.

As the counselor, you can then take the focus of the group and place it on sharing ideas of “what actually goes on” from day to day in their families. Discuss how this is similar to or different from their beliefs about what a family “should” be doing, thinking, or saying.

This invites conversation about specific issues within their families that the adolescents want to address. You can also have a discussion about what “shoulds” are healthy versus what “should” are unhealthy. Finally, you can discuss which “shoulds” are realistic to address, identifying achievable, measurable steps to work toward at home.

As the adolescents listen to the other group members speaking about their family issues, they beginhousedrawing_2 to feel a sense of validation and belongingness. They cultivate a belief that “I am not alone.” As anyone who has studied Irvin Yalom likely knows, these three components are critical to the progress of individuals in group settings.

This task can also be used as a tool in family therapy sessions, serving as a less intimidating way to open the door to communication. It can be used to explore and address each family member’s expectations for others in the family unit.

It can be emotionally difficult for adolescents to talk directly about family issues. But as a counselor, I believe that if you can access adolescents’ creativity and provide a level of predictability, organization and safety, it will open the door to communication between you and your client. This can then be transferred to work with the family as a whole.

I believe this task creates opportunities for individual growth within the therapeutic relationship and opportunities for growth within the family system by reinforcing the difference between realistic and unrealistic expectations, discussion of problem-solving and implementation of communication skills.



Brandon S. Ballantyne is a licensed professional counselor, national certified counselor and certified clinical mental health counselor. Contact him at ballantynebrandon@yahoo.com.



Empowering youth victimized by cyberbullying

By Janet Froeschle Hicks February 25, 2015

JF_HicksTechnology has changed the way adolescents bully one another. What once happened during an eight-hour school day now happens online within the home environment. This form of bullying is inescapable and occurs at all hours of the day and night. For victims, the consequences of being targeted by this behavior can range from lowered academic achievement to mental health issues such as anxiety, depression and even suicide. When assisting victims of cyberbullying, I find a combination of principles from Rudolf Dreikurs’ mistaken goals, Betty Lou Bettner and Amy Lew’s Crucial C’s, Alfred Adler’s social interest and Steve de Shazer’s solution-focused brief therapy to be helpful.

Dreikurs contended that children mistakenly seek out attention, power, revenge and inadequacy in lieu of healthy personal goals. This might explain some of the behavior associated with cyberbullying. For example, adolescents might bully one another to gain attention or power from others. The victim may then choose to perpetuate the behavior by seeking revenge or choosing a stance of inadequacy and hopelessness.

Fortunately, Bettner and Lew describe four Crucial C’s that I find helpful to positively displace a youth’s mistaken goals. These Crucial C’s consist of feeling connected, feeling courageous, feeling capable and feeling that you count (or are important). In my opinion, shifting the focus from Dreikurs’ mistaken goals of revenge, power, attention and inadequacy to those of courage, capability, connectedness and importance may change the outcome of cyberbullying from victimization to empowerment. This change of focus could alter the cycle of cyberbullying so that victims do not choose revenge and therefore avoid becoming perpetrators themselves. Additionally, victims become focused on improving internal characteristics and, in turn, enhance mental health.

Adler’s social interest may be used to further reinforce these Crucial C’s. Victimized youth who become involved in helping others demonstrate courage as part of initial engagement and experience connectedness as a result of their community involvement. Furthermore, I believe they experience a sense of counting or importance as a result of their contributions, as well as self-evidenced proof of their capabilities. As youth victimized by cyberbullying experience these Crucial C’s firsthand, they become empowered and feel more in control of their feelings and reactions. Self-efficacy and self-esteem begin to replace anxiety, depression and hopelessness.

The theoretical principles mentioned above become even more productive when combined with de Shazer’s solution-focused brief therapy techniques to assist victims of cyberbullying. Complimenting youth when they avoid mistaken goals and demonstrate positive attributes and behaviors builds a foundation on which courage can thrive. Instead of exhibiting retaliatory behaviors, the victim of cyberbullying may exhibit developmentally appropriate coping skills. According to de Shazer, complimenting involves pointing out a person’s strengths so that self-efficacy is instilled and recognized. Exception questions allow victimized youth to uncover times when they responded to difficult times without negative behaviors or emotions. This encourages a focus on what works rather than replicating self-defeating mistaken goals and behaviors. Solution-focused brief therapy feedback allows the counselor to reinforce the client’s strengths at the end of a session, connect ideas by agreeing with the client’s stance and suggest a task for the client to undertake.

In short, a synthesis of Dreikurs’ mistaken goals, Bettner and Lew’s Crucial C’s and Adler’s social interest with de Shazer’s solution-focused brief therapy techniques may empower victims of cyberbullying and improve their mental health. The case of “Elizabeth” that follows illustrates how I specifically combine these elements within a counseling session.

Case study

Elizabeth is a 14-year-old high school freshman. Her teacher referred her to the school counselor because her grades are falling and she is skipping classes. Not surprisingly, Elizabeth reveals that she is spending most of her nonschool time communicating with others through social media. It doesn’t take long for the counselor to discover that another girl is cyberbullying Elizabeth. Elizabeth indicates that her self-esteem has fallen, and she thinks about the social fallout constantly.

Because Elizabeth’s self-esteem and grades have declined, she needs to believe that she is capable of succeeding and that she has value (or that she counts). At the same time, she requires the courage to overcome feelings of inadequacy, thoughts of revenge and a desire for power and attention. The connectedness she already possesses with friends and family may help Elizabeth overcome some of the negative feelings associated with being cyberbullied.

To accomplish this in the counseling session, I use a five-step model:

1) Build rapport

2) Identify and express emotions

3) Integrate feelings and experiences

4) Develop coping strategies

5) Administer feedback

The initial use of solution-focused brief therapy may be effective in building rapport with Elizabeth and changing the overall tone of the session from a focus on the negative to a more positive position. Elizabeth needs to be genuinely complimented so that she minimizes feelings of inadequacy and refocuses on her personal strengths. Asking Elizabeth exception questions helps her to focus on instances when she has been successful. When followed by solution-focused complimenting, this also helps her to reframe the situation and begin to feel empowered.

Next, Elizabeth must identify and express the emotions she feels at home, at school and online. To accomplish this, I ask Elizabeth to describe how she feels in each setting and to associate a color with each feeling. Next, I have her draw a line using a different colored marker for each emotion on three separate pages (school, home and online). Each colored mark is labeled and discussed as a representation of an emotion she feels within that particular setting. I then use solution-focused brief therapy complimenting and exception questioning techniques to demonstrate ways in which Elizabeth is positively handling these emotions. Pointing out times when Elizabeth has handled similar emotions adequately ensures a focus on her strengths and a repetition of the Crucial C’s as demonstrated in her response behaviors.

To integrate feelings and experiences and to expand on ways that Elizabeth is demonstrating the Crucial C’s, I find it helpful to assist her with associating mistaken goals and the Crucial C’s. When shown separate index cards, each containing a written mistaken goal, Elizabeth reads the word and describes a time when she experienced each feeling. For example, Elizabeth might read the word inadequacy and say, “I feel inadequate every time that girl posts something about me.” Or Elizabeth might say, “The word revenge reminds me of the time I got even with her by telling lies about her to others.”

After Elizabeth elaborates and finishes the story, I ask her to tell me which of the Crucial C’s she needed to improve the situation. She then retells the story using the selected Crucial C. For example, Elizabeth might retell the story about revenge with a new focus on courage and connectedness. For instance, “That girl said I was ugly, but instead of making up lies about her, I logged off and texted my best friend. We talked about other things until I forgot all about it. It took courage not to get even, but because I have other friends, I was able to do it.”

Finally, I ask Elizabeth to generate short-term and long-term coping mechanisms. Exception questions help Elizabeth recognize and generate this list of ways she has previously coped in similar situations. These strategies may include creating art, journaling, playing video games, playing with pets, exercising or participating in sports, playing or listening to music, doing guided imagery, visiting with friends, talking to parents and numerous other ideas. To strengthen her long-term coping strategies, I ask Elizabeth to find a social interest activity. Suggested activities include mentoring younger children affected by cyberbullying, creating safety tips for children who surf the Internet, reading empowerment stories to younger children, reading to or visiting elderly adults, volunteering to work in community agencies and countless other possibilities. I then ask Elizabeth to contemplate these ideas, generate a list of both short-term and long-term coping strategies to use during the next week and return to the next session with social interest ideas.

At the end of the session, I incorporate de Shazer’s solution-focused brief therapy feedback technique. I compliment Elizabeth once again so her strengths are evident to her as she leaves the session. For example, I might say, “I recognize the courage it took to share all of this with me this week. I think that shows you have strengths to help you get through this.” Then I might add, “I agree that you need to feel better about yourself. Over the next week, I suggest using the short- and long-term coping strategies you listed as well as finding a project to help others while helping yourself.” To conclude, I ask Elizabeth to report on her success at the next session.

Subsequent sessions focus on self-reported improvement and implementing social interest activities. There is also continued focus on implementing the Crucial C’s in lieu of mistaken goals. Solution-focused brief therapy techniques, including complimenting, exception questions and feedback, are used throughout all sessions to continue reinforcing Elizabeth’s strengths. Finally, I incorporate Internet and online safety and social media trainings for Elizabeth and educate her parents on what Elizabeth is experiencing all day, every day online.

Why include parents?

Parents are included in future sessions for several reasons. First, upon hearing about cyberbullying, many parents fear the Internet and insist that their children avoid all technology. Although this may be an effective short-term solution, I do not believe it helps long term. Eventually, youth find themselves required or tempted to use the Internet for employment, homework or socialization.

As a result, I teach Internet and online safety skills both to parents and youth. These safety tips provide education about privacy and restraint when posting online, decrease fear and allow youth to continue using the Internet provided that their parents are involved in Internet communications. Youth and parents must understand the importance of keeping specific personal information private as it relates to the long-term and worldwide reach of the Internet. Once parents understand how to use social media appropriately, they have an opportunity to become role models for the proper use of technology. Learning strategies to avoid harm while using the Internet may be an important mechanism for personal empowerment for both victims of cyberbullying and their parents.

Another reason counselors should involve parents is related to the mistaken goals discussed earlier. Initially, parents often respond to their child’s victimization with inappropriate feelings of attention, Branding-Box-Cyberbullyrevenge, inadequacy and power. These feelings could result in parental behaviors that perpetuate bullying rather than improving the situation. For example, some parents initially respond to knowledge that their child is being cyberbullied with feelings of revenge. These parents may confront the bully or the bully’s parents and unknowingly increase, rather than decrease, their child’s victimization.

I teach parents to first empathize and communicate with their child. It is important that any parental response to bullying first be discussed with the child. If nurtured, the bond between parent and child may become the greatest protective element for youth who have been cyberbullied.


As Elizabeth experiences the Crucial C’s firsthand through social interest, feels secure in the bond with her parents and focuses on her strengths, she begins to feel empowered rather than victimized. Internet safety tips that illustrate the importance of privacy and restraint when posting online further demonstrate to Elizabeth that she possesses courage and has control over life events. Eventually, Elizabeth is able to focus on her own value rather than on the unhealthy stigma perpetuated by others.


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

Janet Froeschle Hicks is an associate professor of counselor education and chair of the Educational Psychology & Leadership Department at Texas Tech University. She is both a licensed professional counselor and a certified school counselor in Texas. Contact her at janet.froeschle@ttu.edu.

Charles R. Crews, associate professor of counselor education at Texas Tech University, also contributed to this article.

Letters to the editor: ct@counseling.org