Tag Archives: ADHD

Taming impulses

By Lindsey Phillips August 5, 2019

About five years ago, a young client walked reluctantly into Jennifer Skinner’s office. In addition to impulse-control issues, the 10-year-old had been diagnosed with attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD), struggled with issues around being adopted, and had medical concerns. This long list meant the boy was often being told what to do and felt powerless.

Shortly after the boy’s parents dropped him off, he walked out of Skinner’s office and headed toward his house a few blocks away. Skinner, a licensed professional counselor (LPC) at Kettle Moraine Counseling in Wisconsin, quickly followed. She told him she wasn’t going to stop him from going home, but she was going to make sure he got there safely. Hearing this, the boy circled back to Skinner’s office and locked her out. Skinner stayed calm, and eventually he let her back in.

According to prevalence data cited by Psych Central, 10.5% of Americans have an impulse-control disorder. Even so, Skinner, a licensed professional school counselor who works with students with self-esteem, impulse-control and other social-emotional issues, says that impulsiveness is often poorly understood or is not on people’s radar. She rarely has clients present and tell her they are impulsive.

Similarly, Laura Galinis, an LPC in private practice in Georgia, affirms that when she uses the term impulsivity to describe her work with clients, she is frequently met with blank stares.

Impulsiveness comes from an internal place in which individuals either react without thought or can’t stop themselves from doing the impulsive behavior, says Skinner, a member of the American Counseling Association. Sometimes, if these individuals don’t yell or lash out, they will be left feeling unsatisfied, she adds.

Edward F. Hudspeth, an associate dean of counseling at Southern New Hampshire University, acknowledges that “some impulsivity is just a natural part of growing up [and] learning from situations.” It becomes a problem, however, when repeated consequences and societal pressures have no impact on the person’s impulsive behavior. “Basically,” adds Hudspeth, a member of ACA, “you’re saying that everyone around you and even consequences are of no value to change [your] behavior. It’s just, ‘I’m going to be impulsive,’ and nothing seems to stop this.”

According to Galinis, impulsivity is an inclusive term that describes the ways that people disconnect from themselves, their relationships and their reality. The majority of her clients come in because they are having relationship problems or because someone suggested they seek help. She finds that “the deeper root is not really feeling present when you make decisions.” To her, this means that impulsive behavior can take several forms, including sleeping with lots of people indiscriminately or drinking or spending more than one wants to.

Because impulsivity can be broadly defined, Galinis recommends asking clients what they mean when they say they struggle with impulsivity. She also suggests questions that will help counselors determine whether a client’s impulsivity has gone too far:

  • Has the client been unsuccessful in attempts to fix the impulsive behavior?
  • What consequences is the client facing because of impulse-control issues?
  • Is the client’s impulsive behavior causing problems in relationships, with finances or with work?
  • Does the client’s impulsivity stem from not setting parameters, or is the client disassociated and being prompted to engage in behaviors he or she may not want to do?
  • Is there a pattern with the client’s impulsivity? Does it show up in just one relationship or across the board?

Impulsivity across the life span

Impulse-control disorders are often first diagnosed in childhood, but as Hudspeth points out, they can occur across the life span.

Children with impulse-control issues will often act on impulsive desires because their prefrontal cortex, which regulates impulse control, has yet to fully develop, explains Hudspeth, who is both an LPC and a registered pharmacist. In adults, he finds that impulsive behavior shifts in terms of its intensity. For example, impulsive behaviors that showed as verbal outbursts and some physical aggression as a child would develop into something more disruptive and destructive as an adult, he says.

Galinis, whose specialty areas include impulsivity and trauma, agrees that some people remain impulsive into adulthood unless treated. Impulse-control issues just look different across age ranges, she says. Often, adults can hide or delay the consequences of impulsive behavior because they are more independent, typically coordinating their own schedules, funding their own lifestyles and so on, she says. Teenagers, on the other hand, may be referred to counseling because they are spending too much time on their phones in school. But with adults, the impulsivity progresses beyond simple phone addiction to behaviors that cause relationship issues, such as an impulse to watch pornography or to spend money online.

Shifting societal norms for young adults have created a different developmental stage, known as emerging adulthood, for people ages 18-26, says Hudspeth, co-author of a chapter on impulse-control disorders and interventions for college students in the book College Student Mental Health Counseling: A Developmental Approach. He explains that members of this age group aren’t at the same level of brain development that they would have been 30 years ago. That’s in part because they no longer feel pressured to instantly get a job in their early 20s and start a family, he says. Instead, they often have a period of exploration before emerging as adults.

“Add that to impulsivity, and you get a lot of chaos and a lot of strange behaviors,” Hudspeth continues. “They’re adults. They have adult rights. They can consent to things. They can do things without the approval of someone else, so it presents the opportunity for a lot more riskiness and impulsivity.” For example, it’s not uncommon for these young adults to engage in impulsive behaviors such as taking a last-minute vacation while trying to hold down a job.

Hudspeth, president-elect of the Association for Creativity in Counseling, a division of ACA, points out that impulse-control disorders have morphed over the past three versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM), so diagnosing and treating impulsivity can be challenging. In 2013, the DSM-5 published a new chapter on “Disruptive, Impulse-Control and Conduct Disorders.” Intermittent explosive disorder, pyromania, kleptomania, conduct disorders and ODD were included under that heading. At the same time, disorders such as gambling, sexual addiction and trichotillomania were moved out of the impulsive category. 

The new DSM-5 chapter attempts to limit the misconception that impulsivity is only a childhood issue by bringing in the developmental perspective and detailing that these disorders can also show up in different forms in adolescence and adulthood, Hudspeth says. In fact, while doing research for a book chapter in Treating Disruptive Disorders: A Guide to Psychological, Pharmacological and Combined Therapies, Hudspeth found that intermittent explosive disorder is often underdiagnosed and misdiagnosed because it was previously included in a chapter on childhood disorders in the DSM.

Counseling professionals need to be aware that impulse-control disorders can occur across the life span and not just during a particular developmental phase, he says.

Symptom or disorder?

For counselors, the challenge is not necessarily determining whether a client is impulsive but rather figuring out if impulsivity is the main presenting issue or a symptom of other issues such as substance use, ADHD or trauma, Hudspeth says. For this reason, the initial intake and assessment are crucial with regard to impulsivity. Hudspeth advises counselors to look beyond clients’ observable impulsive behaviors to try to figure out what is initiating those behaviors. Why and in what situations are clients being impulsive?

Skinner says it is common to see dual diagnosis with impulse issues. For example, ODD, conduct disorders, eating disorders, addiction and ADHD all have impulse control as a symptom.

Galinis finds that trauma is often an underlying cause of impulsivity. In fact, she says she has yet to see a client struggling with impulsivity who doesn’t also have some trauma attached to it.

Hudspeth concurs: “Trauma and abuse will make a person very hypervigilant and impulsive, and if it’s just treated as an impulse-control disorder, you’re never getting to the core issue.” He advises counselors to ask clients whether a history of trauma, abuse or neglect is connected to their impulsive behavior, either directly or indirectly. If there is, then counselors should approach impulsivity from a different perspective than they would if it were just part of ODD, ADHD or another disorder.

In addition, Hudspeth suggests asking clients the following questions: What is their developmental history? What was their temperament as a child (e.g., easy to soothe, difficulty eating or sleeping)? Where does the impulsive behavior occur (e.g., at school, at home, in the community, everywhere)? Is the person generally well-controlled but then suddenly explode? Does the person make spur-of-the-moment decisions such as taking a weeklong vacation at the drop of a hat?

Because inadequate sleep can make it more difficult to manage impulses, counselors should also ask clients about their sleeping habits, Skinner adds.

It also can be beneficial, if given consent by the client, to speak with others who are around the client on a regular basis, Hudspeth says. All of these situational factors can help counselors determine how best to treat the impulsive behavior, he explains.

Contextual factors such as culture, gender and socioeconomic status also can play a role. Hudspeth points out that every culture perceives and deals with impulsivity differently, so counselors need to consider these factors too. For example, are clients being impulsive because they feel they may never have that experience again or because they’ve never had that experience before and thus don’t have a tool in their toolbox to deal with it? “If it’s an experience that you don’t have on a regular basis and your brain hasn’t collected enough evidence on how to deal with it, then you [may be] impulsive,” Hudspeth observes.

Some recent studies suggest that living in poverty can lead people to opt for short-term rather than long-term rewards. For example, the well-known marshmallow experiment (in which a child’s ability to delay gratification of eating a marshmallow predicted better life outcomes) has recently been challenged by Tyler Watts, Greg Duncan and Haonan Quan’s 2018 study that aligns one’s social and economic background with the ability to delay gratification.

Factors such as trauma, depression and poverty can all affect people’s abilities to regulate their impulses and can make it difficult for them to see the world outside of themselves, Skinner adds.

Thus, to get a better sense of clients’ skills for handing their impulses, counselors should ask how they respond in new or unfamiliar situations, Hudspeth says.

Hudspeth also warns counselors not to latch on to the initial report or diagnosis too quickly when it comes to impulse-control issues. “There’s a lot more behind it than just the symptoms that somebody has reported,” he explains. “It takes a thorough comprehensive intake with assessment and then the willingness to more or less change as you know more.” He advises counselors to consider the first 90 days with the client as a continual period of assessment in which the diagnosis could change as the counselor learns more.

The shame of impulsivity

With impulse-control disorders, the client’s distress can adversely affect the well-being and safety of others and even violate others’ rights (through aggression or destruction of property, for example).

Impulse control “is one of those disorders that could be considered to be both internal and external,” Hudspeth says. “Internally, you’re not stopping yourself from doing something that’s impulsive. Externally, you’re affecting others. You’re in their space. You may be disruptive. You may be yelling. The origins are internal, but how it displays and who it affects is the individual and everybody around them.”

People who struggle with impulsivity often act without thinking and frequently lament their actions almost immediately afterward, which means their lives might be filled with regret, Skinner says. That consistent presence of regret can turn into shame, she adds.

In fact, one huge warning sign that clients’ impulsivity is getting out of hand is when they try to keep their impulsive behaviors a secret, Galinis points out. Even clients with whom she is familiar will sometimes mention impulsive behaviors they have been hiding from her, especially if they involve vulnerable topics such as sexual behavior or addiction. This secrecy results from the sense of shame these clients feel over their behavior and lack of impulse control, she says.

When clients mention being anxious or having uncomfortable emotions, counselors should check in to see how they are handling those emotions, Galinis advises. Asking how clients are coping often opens a door into the unhealthy and impulsive ways they are attempting to manage those feelings, she adds.

With her younger clients who have trouble identifying and communicating their feelings, Skinner likes to read books such as Bryan Smith’s What Were You Thinking? Learning to Control Your Impulses, about a boy whose impulsivity often gets him in trouble. Eventually, the boy learns to control his impulses by thinking about the possible consequences of his actions.

“Reading stories with clients, especially with children, takes the focus off of them, helps them realize they’re not the only person who is struggling with [impulsivity], and shows them possible solutions,” she says.

Engaging emotions and the senses

Impulse control “is not often based in logic,” Galinis says. “It is an emotional experience that drives the behavior, so we need to be able to incorporate the emotions into it because logic is going to fall short every time.” Counselors can’t simply tell people to stop being impulsive. Instead, she explains, they have to help clients understand their emotions and connect them to their behaviors.

“Sometimes we will act on an emotion before we even realize that we are having that emotion,” Skinner notes. For instance, a child might instinctively yell when a teacher enforces limits on the child. Children don’t necessarily know how to handle their feelings when someone makes them mad, so they just react, Skinner explains.

Thus, a large part of her work with clients involves helping them understand their emotions. “Just being able to name your emotions takes … the reactive part of the brain offline and allows your executive functioning to come into play more, and as soon as your executive functioning is coming into play, you’re going to have a better response to the situation,” Skinner says.

She often uses the Disney-Pixar movie Inside Out to explain to younger clients how each emotion has a purpose. “Emotions don’t just happen out of the blue,” she says. “They happen because we have a need that needs to be met.”

To help clients develop a habitual awareness of their emotions, Galinis has clients pick a number on the clock in her office. Then, she tells them that every time they see that number anywhere throughout the course of their day, they should check in on how they are feeling in the moment.

Skinner also gets creative to help clients better understand and name their emotions. For instance, she asks clients to play feelings charades (in which they name and act out all of the feelings they can think of). She also has clients look through magazines and find different emotions on people’s faces. Sometimes, she has clients make up stories about why the person in the magazine feels that way. “That [exercise] helps develop empathy and perspective taking, and both of those things are really important in treating impulse-control disorders,” she says.

Skinner also advises parents and caregivers to continue these exercises at home by pausing when reading stories or watching television to discuss characters’ emotions. She recommends asking questions such as “What do you think this person is feeling right now?” and “Why is the person feeling this way?”

She explains that guiding clients to develop a broad, robust vocabulary about their emotions will help them learn over time to act, not just react, when they are feeling impulsive.

Slowing the process down

Because impulsivity is a quick response, Galinis’ goal is to help clients slow down. She wants clients to connect to their feelings without flooding their emotions, she says. To help clients achieve this balance, she often uses somatic experiencing, which aims to regulate or reset the nervous system by releasing the energy accumulated during stressful events.

For example, if a client is talking about an event that was triggering during the week, Galinis may stop the client upon noticing that he or she is getting agitated and ask what the client is feeling in the body. If the client responds, “My hands are clenched,” she will direct the client to hold that feeling and then ask what the clients wants to do. The client may say, “I want to punch something.” Then, with Galinis’ help, the client will follow through with the punch in slow motion. According to Galinis, this technique helps clients get “unstuck” so they can fully process their impulse and the emotions in their body.

Galinis also has clients create a timeline of feelings and actions surrounding an impulsive behavior. For example, she may have clients walk her through what they noticed from the moment they woke up until the moment they impulsively started watching pornography, even though they hadn’t planned to or didn’t want to. As they talk through this event, she will ask what they notice in their body. Is their heart rate elevated? Does their stomach feel swirly?

If clients notice a change in their body, Galinis tells them to hold on to the uncomfortable feeling for a minute rather than immediately trying to get rid of it or run away from it. This process helps clients build up distress tolerance so that when they’re feeling uncomfortable, they are less likely to feel the need to escape and act impulsively, she explains.

Like Galinis, Skinner uses behavioral sequencing to help clients connect their thoughts, feelings and actions. She asks clients: What is the problem? What happened before you acted out? What happened and what were you feeling during the impulsive behavior? What was the outcome? “Through that process, we try to figure out offramps from that one trajectory that they are on,” she says.

Skinner also finds mindfulness useful with impulse-control disorders because it helps clients understand what is happening in the body. She recommends the 5-4-3-2-1 grounding technique, which engages the senses to help clients get back to the present. With this technique, counselors tell clients to take a deep breath and name five things they see, four things they feel, three things they hear, two things they smell and one thing they taste.

Skinner says meditation is one of her favorite tools for addressing impulsivity because it calms the nervous system down, which allows clients to make better choices instead of just reacting.

Galinis keeps tactile sensory objects such as stress balls, stuffed animals and a cozy blanket in the counseling room to make clients feel more comfortable and to help them calm their body down. Sometimes she even lets clients take a calming stone or an essential oil home with them because it serves as a tangible reminder of what they are working toward and aids them in finding that sense of calm they experienced in her office.

Learning control through play

Impulsive behaviors can frequently impede on the rights and safety of others. This means that many clients who enter counseling for impulsivity might not be there of their own accord. In fact, Skinner says that 95% of the time, her child and adolescent clients are seeing her at someone else’s suggestion.

Understanding that these clients may be reluctant participants in counseling, she uses creative counseling techniques such as games and role-playing. Any activity “where kids have to really stop and think about what their body is doing and pay attention to their surroundings is really helpful and fun” for them, she says. Games also help take the focus off of the client and their “problem,” she adds.

Skinner particularly likes to use the therapeutic board game Stop, Relax & Think with clients who struggle with impulse control. The objective of the game is to help impulsive children think before they act. Players move through the Feelings, Stop, Relax and Think stations on the board, collecting chips along the way.

With the feeling cards, clients name how they would feel in different situations. For example, if the card says, “Your brother hits you,” the client might respond, “I would be angry and want to hit him back.” The cards support clients in better understanding not only their own feelings but also the other players’ feelings, which helps them develop perspective taking, Skinner says.

When players land on a stop sign space, they have to perform an action such as patting their head and rubbing their stomach — which, as Skinner points out, requires a lot of concentration — until another player says, “Stop.” If the player stops immediately, then he or she gets a chip.

Skinner loves that clients can judge counselors when landing on this space. Children, especially ones with ODD, often feel powerless, she points out, and this stopping activity allows them to feel empowered in a safe, healthy way. Sometimes Skinner will purposely fail to stop in time. She wants clients to know that she’s not perfect and doesn’t expect them to be either. It also allows her to model appropriate behavior when someone is frustrated or makes a mistake. 

The relax spaces on the board help clients learn how to calm their bodies. The space may instruct them to take three slow breaths, think about white clouds, or say “I am calm” three times. With the think cards, players come up with ways to handle different scenarios (such as a friend breaking their favorite toy) and earn a token if it is a good plan.

Skinner also uses games such as Uno and Parcheesi to help clients learn how to wait their turn and practice impulse control. In addition, she recommends basic childhood games such as Mother May I; Red Light, Green Light; Simon Says; and Follow the Leader. She says counselors can even stage relay races in which children have to walk carefully while balancing a marshmallow on a spoon. These types of games also work well for group counseling sessions, she adds.

Hudspeth, editor of the International Journal of Play Therapy and The Journal of Counselor Preparation and Supervision, agrees that games are a great way to help child and adolescent clients learn to focus and grasp that there is a sequence of events they must follow to get what they want. Take darts, for example. “Just throwing the dart at the wall is not going to get you points,” he says. “Taking time to aim at the place that’s going to get you the most points is more likely to get you to the place of winning the game.” 

When sessions become impulsive

Sometime clients’ impulsive behaviors spill into the counseling session. When this happens, Skinner reminds counselors to be calm, ignore the bad behavior and reward the positive behavior.

When Skinner worked as a clinical intern at an outpatient clinic with youth who experienced trauma, she had clients whose impulsive and aggressive behavior resulted in overturned chairs and tables and smashed lamps in the office. When this happened in group settings, she would get the other kids out of the room and then make sure the child having the impulsive reaction stayed safe. Other than that, she would show no reaction to the outburst and praised the child when he or she calmed down and regained control.

Control is a big part of impulsivity, Hudspeth points out. For this reason, he uses play therapy, which provides clients with a sense of control but allows counselors to set limits and model appropriate behavior in a safe, trusting environment. For example, with children with impulsive behaviors, Hudspeth would tell them they were allowed to do anything in the playroom as long as they didn’t hurt themselves. This statement might not have been one hundred percent true, he says, but it helped the children feel a sense of control. Then, if a child picked up a Nerf gun and shot darts at him, he would respond, “I am not for shooting, and if you choose to shoot me, you choose not to play with that toy.” After setting this limit, he would offer the client an alternative (and more appropriate) behavior such as shooting the wall.

Skinner and Hudspeth both point out that counselors might also have to train parents to use this method at home to help their children make progress with the impulsive behavior. Often, people assume that children understand what is happening during the impulsive moment, so they may yell or remove children from the situation without giving them a reason, Hudspeth says. “By setting the limit and giving them the alternative and then telling them what the consequence is, you’ve spelled it all out,” he explains. “There’s nothing left to wonder about as a child.”

One realization Skinner had was that clients with impulse-control issues, and especially those with ODD and conduct disorder, could trigger her own impulsive and angry reactions. She acknowledges that sometimes it is difficult as a counselor to hear what certain clients are doing to other people or how they are reacting. In fact, she admits once making a snarky comment to an adult client who was rolling his eyes and being defiant throughout a session. Skinner says she instantly felt terrible and knew that her comment wasn’t helpful to the counseling process.

The experience taught Skinner that she has to temper her own impulses and focus on giving clients what they need in session. She says she also learned that she needs to take a moment between sessions to calm down and prepare for the next one. Even if all she has available is 30 seconds, she closes her door, takes a deep breath and centers herself.

It’s quite possible that counselors will face challenging moments with clients who struggle with impulse control. Five years later, Skinner is still working with the client who stormed out of the counseling session determined to walk home, only to turn around and lock her out of her own office. Thankfully, he has come a long way since that first meeting

Challenging sessions still occur in which the client comes in and won’t say a word. Skinner simply responds, “That’s OK. I guess this is going to be a quiet one. Let me know if you want to do anything.” Sometimes, the client will say that he wants to play a game.

“But within that space, he has learned how to control himself a little bit,” she says. “He has learned that he has some control over his life. He has found his voice … and he’s been able to assert himself with adults in a calmer and more appropriate way.”

 

 

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist living in Northern Virginia. Contact her at hello@lindseynphillips.com or through her website at lindseynphillips.com.

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Parent-child interaction therapy for ADHD and anxiety disorders

By Donna Mac March 6, 2019

When one hears the term “parent-child interaction therapy” (PCIT), it might be assumed the therapy’s purpose is solely for that specific use — i.e., for parents to use with their children. However, this couldn’t be further from the truth. In fact, PCIT can be used in therapy sessions, then the therapist can teach the child’s teacher how to use PCIT in the school environment and, of course, the therapist can teach parents how to use these skills at home and in community settings, all in an effort to coordinate and synchronize treatment across settings.

Sheila M. Eyberg developed PCIT in the 1970s out of the University of Florida. It was built from multiple theories of child development, including attachment, parenting styles and social learning. In the past, PCIT was intended mostly for children 2 to 7 years old with disruptive emotional disorders and behavior disorders such as attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder. The purpose of PCIT was to work on rapport building and to enhance the relationship between the child and parent, for the child to develop more intrinsic motivation to comply and for the parent to develop more positive feelings toward the child — a cycle that can then be positively repetitive.

In addition to disruptive disorders, PCIT also seems to help children with anxiety disorders. In particular, there is research demonstrating its efficacy with the anxiety disorder of selective mutism. Therefore, clinicians have also begun using it for social anxiety disorder, social phobia, school phobia and agoraphobia. In school and community settings, PCIT is used as an antecedent intervention that helps shape the environment to create an emotionally safe space for these types of anxiety disorders to be more effectively managed. (It should also be noted that PCIT can be used to treat ADHD and anxiety beyond age 7 with simple modifications.)

The goal of this therapy is to produce more prosocial behaviors, regardless of the diagnosis. For example, with anxiety disorders that specifically manifest as a fear of being around people or communicating with others, the goal is for the child to be less inhibited and avoidant. The child’s symptoms might include struggling to leave the home, averting eye contact, displaying a shrinking body posture and having frozen reactions, both in terms of a lack of verbal response and a lack of body movement (think of a “deer in the headlights” appearance). The goal in such cases is to help these children manage their symptoms so they can present in a socially expected manner.

On the other hand, children with ADHD can present as too disinhibited, demonstrating hyperactive, impulsive, incessant and intrusive behaviors, so the goal is to adjust those behaviors to be more inhibited.

Subsequently, the PCIT goal for both of these populations is to produce more desired social behaviors, which will lead to better social outcomes, thus perpetuating the cycle in a positive manner. When children receive positive social feedback, they are likely to keep using these skills in an effort to continue engaging in positive interactions.

Addressing self-esteem

PCIT is a relationship-enhancing therapeutic technique. The concepts from this therapy that I use with children who have either ADHD or avoidant anxiety disorders revolve around Eyberg’s child-directed interaction (CDI) and PRIDE skills. CDI and PRIDE go hand in hand and, when combined, have been shown to build rapport with the other person and build confidence and self-esteem within the child (in an effort to manage both disruptive and anxious-avoidant behaviors). If a child feels comfortable with a certain relationship, that child may feel more valued, worthy and confident and have stronger self-esteem. As a result, the child will be less anxious, better able to manage disruptive impulses and more likely to use expected social skills.

Children with ADHD often struggle with their self-esteem because of the amount of negative feedback they tend to receive on a daily (or more frequent) basis: “Don’t touch everything in this store.” “Stop asking me if we can go to the pool.” “Leave your sister alone.” “Why can’t you just behave?” Yet if a child receives positive feedback versus corrective feedback in an approximate ratio of 4-to-1, the child will be more likely to comply with the directive to “stop asking that question,” to “leave your sister alone,” etc.

Children with the avoidant types of anxiety disorders also struggle with self-esteem because of the negative judgments they assume and perceive that others are making about them. When these children receive praise, it helps them feel less anxious. In turn, when their brains are stabilized, they are more able to use their actual abstract counseling strategies (such as cognitive behavior therapy, or CBT) on themselves to manage their anxiety and actually “leave the house,” “maintain eye contact,” “use complete sentences” (rather than one-word answers), etc.

In therapy, PCIT can be used as a stand-alone treatment, but I recommend combining it with other therapeutic treatments such as operant conditioning, exposure therapy and CBT. Of course, the use of CBT will depend on the age of the child and whether his or her brain is developed enough to process abstract counseling strategies. Children don’t usually possess this ability until age 7 or 8. It should be noted that use of these treatment techniques (alone or in combination) does not guarantee success or an absence of symptoms.

Implementing PCIT with CDI and PRIDE

Some professionals refer to CDI as “child chooses.” Regardless of the terminology, during this portion of PCIT, no directives are to be given to the child and no questions are to be asked until CDI has been used for at least three minutes. This allows the child to feel positive about himself or herself because nobody is giving directions to correct something that the child was “doing wrong” upon entering a room or during a new transition.

When children feel positively about themselves, they are more likely to comply later down the line. Therefore, it should be noted that CDI is not a time to criticize. CDI means that the child will choose something to do without any adult direction. The adult (whether that is the counselor, the parent or the teacher) is to observe what the child does and give the child physical space if the adult’s presence seems to agitate or increase anxiety in the child. After at least three minutes of CDI, the adult uses PRIDE skills (verbal interaction from the adult) when the child seems more emotionally regulated. PRIDE is an acronym that directs the adult to offer the child labeled praise, reflection, imitation, description and excitement/enjoyment (in the adult’s voice).

As a real-life example, let’s say that “Alison” is in homeroom at school first thing in the morning. At the therapeutic school in which I work, this is where the students meet in the mornings to get any homework lists, eat healthy food, use coping skills, check in with their teachers and therapists, and practice socializing with peers appropriately. CDI is used immediately upon students’ arrival.

In this case, Alison puts her backpack on the floor upon entering the room, then goes to sit at her desk (her backpack is not where it is supposed to be, plus it is open, with its contents falling out). When Alison enters the classroom for the first time, it is time for CDI, so the teacher is not to direct her to move the backpack, at least for a few more minutes. (If your first interaction involved someone telling you to correct something, think about how you would feel.)

At her desk, Alison eats an apple, and then a peer asks Alison for a piece of paper. Alison silently gives her peer the paper, without offering any eye contact, and then gets up to throw away the apple she just finished eating. She then remembers to get her assignment notebook out of her desk. Even though Alison’s backpack is open on the floor with papers, food and more disorganized contents spilling out, the teacher doesn’t direct her to do anything until after offering Alison the full array of PRIDE skills:

  • Praise: Praise appropriate behavior. This should be specific labeled praise about what is positive. In this case, it could be any number of things: “Alison, thanks for sharing your paper with Sarah. You are so helpful” or “Thanks for throwing away that apple in the garbage. You are very responsible” or “You remembered to get out your assignment notebook. You have a great memory!” This labeled praise includes helpers to build confidence in Alison related to both her IQ and her EQ (emotional intelligence), therefore lessening her anxiety and helping her manage her impulsivity.
  • Reflect: Reflect appropriate talk. This means the adult reflects back what the child says to them. For example, when Alison is done with her assignment notebook, she asks the teacher, “When is the fire drill?” The teacher is to reflect the main concept of the question. In this case, the teacher might say, “I am glad you want to know when the fire drill is so you can be prepared. That is very responsible of you. It is at 9.” Reflection is key to letting children know you are really listening to them. And if someone is listening to them, then they feel valued, understood, worthy and accepted, lessening their anxiety and raising their self-esteem. In this case, the teacher also offered more labeled praise about Alison being prepared and responsible.
  • Imitate: Imitate appropriate social behaviors. If Alison takes out paper and colored pencils to draw as a “quiet coping” skill during the appropriate time, the teacher takes note of how to imitate this same concept down the line. “Your drawing just reminded me of something, Alison. When all of the homeroom students have arrived, we can all play that drawing game we played a few weeks ago. Would you be willing to lead the game since you really understood it last time and are such a talented artist?” This lets Alison perceive that she is worthy because she was doing something that the teacher also wants to do (artwork). This serves to lessen Alison’s anxiety. It also helps her realize that she can in fact be a leader herself, increasing her self-confidence.
  • Describe: This is the time to give behavioral descriptions. Simply describe what the child is doing, which shows the child that someone is both attending to them and giving approval of their actions. This serves to increase the child’s confidence and decrease anxiety. For example, the teacher might tell Alison, “You’re drawing a sports car with a mountain in the distance. That looks fast and powerful yet peaceful at the same time. That’s pretty impressive and creative that you’re able to capture all of that in one picture.” This description also includes more labeled praise pointing out that Alison is creative.
  • Excitement/enjoyment: Demonstrate excitement in your voice, which is key to attending skills. This strengthens the relationship with the child and allows the child to experience many positive feelings. This also increases the chances the child will comply when you give a corrective direction.

It should be noted that some people with anxiety fear receiving positive praise in front of other people. If this is the case, adjustments can be made to the treatment technique.

In Alison’s case, all of the PRIDE letters were used, and she received even more than the allotted three minutes of CDI time. Alison’s CDI time included getting to choose to eat her apple, asking her fire drill question and taking out paper to draw a picture. Once CDI and PRIDE have been used, the teacher can move to adult-directed interaction, in which the teacher can finally:

  • Ask questions: “Alison, do you have your math assignment from last night?”
  • Direct some peer interaction (such as getting the students together for the drawing game referenced earlier).
  • Give instructions (such as addressing that backpack issue): “Alison, it would help us out if you could close your backpack and put it in your locker. I would hate for anything of yours to get lost or for someone to get hurt tripping on it.” When Alison complies with that direction, the teacher can follow up with more labeled praise: “Thanks for following directions.” One caveat: Never say, “Thanks for listening.” There is a big difference between someone “listening” and someone “following directions.”

Other considerations

The CDI/PRIDE skills/adult-directed interaction combination should be used in the child’s home continuously, at play dates in others’ homes, at school and community activities and, of course, in the therapy office. PRIDE continues to be a way of communication, so it doesn’t stop when the conversation gets going.

In the therapy office, once emotional regulation has been established with the combination of CDI/PRIDE/adult-directed interaction, the counselor can move to reminding the child of the operant conditioning plan, then work on CBT skills or exposure skills to continue building strategies to manage impulsivity or anxiety.

If children’s ADHD symptoms are impairing their social and educational functioning with significant intensity, frequency and chronicity, it is also likely that a psychiatrist will prescribe a stimulant medication. ADHD is a genetically based, neurobiological disorder that affects many parts of the brain. Medication can touch parts of this, especially when it comes to dopamine and norepinephrine disruptions, but it can’t adjust everything. Even for the parts of the brain that can be medicated, medication doesn’t guarantee an absence of symptoms. That is why it is crucial to continue using therapeutic techniques as antecedent management and counseling strategies to help children function in their different environments.

In terms of anxiety, for those suffering impairment in their social and educational settings on an intense, frequent and chronic level, the first line of medication will likely be a selective serotonin reuptake inhibitor (SSRI). This is because the main area of the brain affected is serotonin (in addition to anxiety affecting norepinephrine, glutamate and the limbic system structures of the hippocampus, hypothalamus and amygdala). Again, however, an SSRI will not guarantee an absence of symptoms, which is why therapeutic techniques, exposures and counseling strategies remain key.

 

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For more examples of how the attending skills of CDI, PRIDE and others related to PCIT can be used in school settings, home situations and community/recreation settings, please reference my two books: Toddlers & ADHD and Suffering in Silence: Breaking Through Selective Mutism.

 

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Donna Mac is a licensed clinical professional counselor in her 12th year working for AMITA Health in one of its therapeutic day school locations. Previously, she was a teacher in both regular and special education settings. She has three daughters, including identical 9-year-old twins diagnosed with ADHD hyperactive/impulsive presentation and selective mutism anxiety. Contact her at donnamac0211@gmail.com or through her websites: toddlersandadhd.com and breakingthroughselectivemutism.com.

 

Letters to the editor: ct@counseling.org

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Working memory: A review for children’s mental health providers

By Jerrod Brown and Tracy Packiam Alloway October 1, 2018

Working memory is an essential cognitive skill that allows an individual to learn through the processing and manipulation of information. In other words, working memory is the process through which information is manipulated and then linked to other existing memories.

A wealth of research has investigated the capacity of working memory in children. Working memory is different from short-term memory, which simply stores pieces of information for a limited period of time. Working memory allows an individual to maintain information for use in intricate tasks such as higher-order thought, organization and planning, and language comprehension. Working memory also enables children to perform several important functions, including learning new information, comparing and contrasting different concepts, and making informed decisions.

Working memory is composed of three important tasks:

1) Maintaining new pieces of information for subsequent use

2) Filtering out information that is not relevant to the task at hand

3) Manipulating the relevant information to perform the given task (e.g., navigating to a destination)

Working memory capacity is dependent upon a number of abilities, including attention, behavioral control and cognitive flexibility. Attention is an individual’s ability to focus on a given task while blocking out distractions and other irrelevant information. Behavioral control is the ability to manage one’s impulses and emotions. Cognitive flexibility is the capacity to adapt to feedback and evolving needs.

Children affected by working memory deficits may experience a host of academic, behavioral and emotional issues. The deleterious impact of working memory deficits on academic achievement is apparent in students, from those entering preschool to young adults in college. These impairments may be even more pronounced among children who are affected by various problems related to mental health.

Deficits associated with working memory can negatively impact how a child navigates all areas of life, from academic performance to social interactions. As such, children’s mental health professionals should become familiar with working memory deficits and their impact on day-to-day functioning. Increased awareness and understanding of these problems will help professionals maximize the effectiveness of services provided to these children.

To that end, this article reviews multiple considerations related to working memory that all children’s mental health clinicians need to know.

 

Academic performance: In children, working memory has been linked to everything from academic performance to the symptoms of neurological, developmental and psychological disorders. Working memory is also important from kindergarten to the tertiary level, and is an excellent predictor of academic success, longitudinally.

Assessment: Working memory can be assessed in a reliable and valid manner in children as young as 3. Early identification of working memory deficits that are supported by appropriate interventions can lead to positive outcomes throughout the individual’s life span. A study of more than 3,000 students found that approximately 10 percent had working memory problems that led to learning difficulties in the classroom (see ncbi.nlm.nih.gov/pubmed/19467014). As such, early identification and intervention are key to long-term success.

Attention, behavioral and social problems: Several theories of cognitive processing posit that working memory plays an essential function in attention. In addition, deficits associated with working memory can sometimes contribute to problematic behaviors resulting in school-related and social consequences. This is especially the case when the child has not been properly assessed, treated and supported. One of the most consistent findings in research studies is that students with attention-deficit/hyperactivity disorder have poor working memory, particularly when they have to remember visual information, such as graphs or images.

Classroom difficulties: Working memory impairments often contribute to difficulties in the classroom. For example, students with working memory impairments may have trouble remembering instructions, completing complicated tasks, and comprehending and abiding by directions to solving a math problem or writing a sentence.

Creativity: Although relatively few studies have investigated the role of working memory in creativity, Larry Vandervert and colleagues have posited that working memory is one of the building blocks of creativity (see tandfonline.com/doi/abs/10.1080/10400410709336873). Their rationale hinges on the assumption that working memory serves as the “blackboard of the mind,” enabling an individual to manipulate and combine a variety of pieces of information and ideas in different ways. A study with college students reported that working memory was associated with one particular aspect of creativity — flexibility, which relates to breadth of thinking.

Environmental considerations: An important consideration for children with working memory deficits is limiting their exposure to environments and influences that could exacerbate such issues. These issues may include exposure to caregivers who abuse substances, neglect and maltreatment, and environments filled with chaos and chronic stress.

Importance of early identification: Working memory deficits in preschool may predict the likelihood of dropping out of high school. However, some research offers hope for the development of early interventions that strengthen working memory and the reduction of risk for dropping out of high school.

Information overload: Deficits in working memory can result in children experiencing information overload during learning-based activities. As a result, these children may act out behaviorally or withdraw socially. When misidentified or undertreated, these issues can negatively affect children’s emotional and behavioral health.

Intervention: Interventions that improve working memory hold the potential to positively benefit children’s classroom performance across a range of subjects (see ncbi.nlm.nih.gov/pubmed/20018296). These gains were maintained eight months later (see sciencedirect.com/science/article/pii/S0747563212003032). As such, children’s mental health providers play a vital role in the identification and treatment of working memory deficits.

Learning performance: Problems meeting the learning requirements of school may be attributed to deficits in working memory. Working memory predicts reading and math performance among students with learning disabilities. These associations remain even when controlling for the student’s intelligence and knowledge of language and math. These issues can persist across the child’s life span when such deficits have not been identified, treated and supported.

Learning styles: A prevalent argument in the education research community is that learning styles have a significant influence on how well students will do in school. The learning styles theory argues that individuals learn best in different ways. A popular framework for learning styles is one that separates Verbalizers from Visualizers, and Holistic thinkers from Analytical ones. A study with high schoolers found that students with good working memory excelled at all subjects, regardless of their learning style preference. One explanation is that although students may have a certain preference for acquiring knowledge, those with good working memory won’t be held back if information is not presented in their preferred learning style because they can adapt their learning style to different learning situations.

Note taking: The inability to remember several manageable pieces of information while performing another task such as taking notes on a lecture is an example of a working memory deficit. This can present challenges in group treatment settings in which participants are required to take notes while listening to a live lecture.

Problem-solving: Enhanced working memory capacity can result in improvements in the ability to learn and to solve problems. When working memory is impaired, decision-making and problem-solving abilities can be negatively affected. Treatment providers should consider screening clients for working memory impairments when decision-making and problem-solving abilities are impaired.

Theory of Mind: Theory of Mind (ToM) is the skill to appreciate that the conduct of others is motivated by their opinions, wishes and other mental states. The maturation of ToM has been linked to the cognitive development of both behavioral control and working memory. Working memory has also been linked to false belief and verbal deception in 6- and 7-year-olds.

Thought suppression: Research suggests that working memory could play an important role in the suppression of unwanted or obsessive thoughts. As such, helping children strengthen their working memory capacity should be considered when providing supports and services to individuals struggling to cope with such thoughts.

Trauma: Working memory deficits have been observed in individuals suffering from posttraumatic stress disorder (PTSD). In particular, common PTSD symptoms such as hypervigilance, reliving trauma memories and avoidance of reminders of trauma may interfere with working memory processes.

Underidentification: Despite the previously mentioned consequences, working memory deficits often go unrecognized and untreated in children’s mental health settings. In some instances, professionals may misinterpret working memory impairments as issues with behavior, impulse control and attention. In a survey of classroom teachers, most knew what working memory was but were able to correctly identify only one or two classroom behaviors associated with working memory deficits.

Understand: Professionals should strive to understand the potential consequences associated with working memory deficits in children. Exploration of how working memory deficits may affect academic, emotional, social and interpersonal capacities is of significant importance. Children’s mental health treatment providers should consider incorporating working memory screening and intervention strategies into their clinical programming.

 

Conclusion

Deficits associated with working memory can have profound and diverse impacts on children. Mental health providers are likely to encounter children on a regular basis who are affected by working memory deficits. To minimize the consequences of working memory deficits, clinicians should become more familiar with the implications these problems have on screening and assessment, treatment and educational outcomes, and social functioning abilities. We highly recommend advanced training in working memory for professionals who provide children’s mental health services.

 

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Jerrod Brown is an assistant professor and director of the master’s degree program in human services with an emphasis in forensic behavioral health at Concordia University in Minnesota. He has also been employed with Pathways Counseling Center in St. Paul for the past 15 years. He is the founder and CEO of the American Institute for the Advancement of Forensic Studies and editor-in-chief of Forensic Scholars Today and the Journal of Special Populations. For a complete list of references used in this article, contact him at Jerrod01234Brown@live.com.

 

Tracy Packiam Alloway is a TEDx speaker and an award-winning psychologist. Her research has contributed to scientific understanding of working memory, specifically in relation to education and learning needs. Her research has been featured on or by Good Morning America, Today, Forbes, Bloomberg, The Washington Post, Newsweek and others.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Understanding adult ADHD

By Donna Mac November 20, 2017

Many people ask, “Isn’t ADHD something that kids grow out of?” When people think of attention-deficit/hyperactivity disorder (ADHD), they usually picture a child “bouncing off the walls” and then being unable to follow directions to stop that behavior.

In mainstream society, we don’t see adults bouncing off the walls, so it makes sense that people wonder if ADHD is something that is “grown out of.” In addition, ADHD usually isn’t diagnosed for the very first time during adulthood. Because the onset of ADHD typically is prior to age 4, it is usually first diagnosed in childhood. Therefore, people don’t tend to think of ADHD as an “adult condition.” Rather, they might assume that it’s isolated as a childhood condition.

It is important to remember that ADHD is actually a genetic condition. It affects the brain’s neurotransmitter system of dopamine and norepinephrine, brain waves and connections, and the actual structure of the brain, specifically the frontal lobe and prefrontal cortex, cerebral volume, caudate nucleus and gray matter/white matter. In addition, certain environmental factors can further exacerbate a person’s symptomology. Regardless, ADHD is actually a “brain condition,” which means that it can also affect adults.

Going back to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, there was a chapter that included mental health diagnoses that were all first diagnosed in “infancy, childhood or adolescence.” ADHD was one of the diagnoses included in that chapter. Therefore, some people figured those disorders were not likely found in adults. However, the chapter’s title didn’t specify that those disorders weren’t found in adults; rather, it indicated that they were typically first noticed in childhood.

When the fifth edition of the DSM (DSM-5) was written, the task force offered more clarification for those disorders, so that the entire chapter was actually eliminated and the diagnoses in that chapter displaced. Due to the revision, ADHD was moved to the new “Neurodevelopmental Disorders” chapter, to more accurately reflect that the disorder is related to the biology of the brain.

In writing the DSM-5’s revisions for ADHD, there was also a symptom threshold change for the adult qualifiers. The purpose of the change was to reflect the substantial evidence of clinically significant ADHD impairment in adults within social, occupational and educational settings, in addition to difficulties with maintaining daily living responsibilities. To qualify for an ADHD diagnosis according to the DSM-5, an adult needs to meet only five symptoms, instead of the six required for children, in either of the two presentations (hyperactive/impulsive and inattentive/disorganized).

 

Growing out of ADHD?

At this point, it has been well-established that adults can have ADHD, so the question now becomes: Is it possible for a child with ADHD to experience symptom reduction (or elimination) as he or she transitions to adulthood? The answer is tertiary: yes, no and sometimes!

As children with ADHD grow into adolescence, research does show that up to two-thirds will experience a noticeable reduction in motoric restlessness or hyperactivity. Because of the manner in which the brain develops during this period, there can be an opportunity for rewiring in which the neurons proliferate and then are pruned back to complete the development of the frontal lobes.

With this particular symptomology of hyperactivity and motoric restlessness being reduced or eliminated, however, it is still possible that the person’s other ADHD symptoms may remain. The remaining symptoms are likely the ADHD core symptoms of impulsivity, impaired attention and lack of intrinsic motivation. Research shows that these symptoms will likely continue to some degree — possibly still to a clinically significant degree — but they might also be less impairing than they were for the person during childhood.

So, to answer the question of whether adults can experience ADHD symptom reduction or elimination, here is a recap:

  • Some symptoms in adults will dissipate completely.
  • Some symptoms will lessen.
  • Some symptoms will remain the same.
  • Some symptoms will change by being expressed differently than they were in childhood.
  • Sometimes, the symptoms will remain, but they will appear less impairing because the adult has developed strategies to manage the symptoms.

As we examine how adult ADHD symptoms can be expressed, think about ADHD as a brain disorder stemming from an inability to self-regulate and executive functioning deficits. These functions allow us to plan, change flexibly from one course of action to another, inhibit actions (impulse control) and modulate affect. Executive functioning also includes organizational skills, emotional control, working memory and short-term memory, time estimation and time management, focus and attention, problem-solving, verbal reasoning, intrinsic motivation, task initiation and shifting gears. If a deficit is present in any of these areas, think about how much more difficult an already stressful job would be, in addition to how one might struggle with maintaining relationships, raising a family, completing daily living responsibilities and remaining connected in the community.

 

Childhood vs. adulthood scenarios

With all of the possible ADHD deficits stemming from its different presentations and with different degrees of impairment, these symptoms can be expressed in adults in a variety of ways. The scenarios below showcase how ADHD symptoms might remain similar in adulthood as in childhood, or how the symptoms’ expressions can also change over time.

  • Think about a child with ADHD constantly getting out of her seat at school. That can be the same adult tapping her pen or shaking her leg at her desk at work.
  • Think about a child with ADHD constantly talking to her “neighbor” in school while the teacher is talking. That might be the same adult unintentionally getting her co-workers off-task during a meeting.
  • Think about a child with ADHD impulsively pulling a toy out of another kid’s hand, struggling to take turns and share. That sounds like the same adult struggling to “take turns” while he is talking and expressing ideas with his co-workers.
  • Think about a child with ADHD refusing to shut off her video game. That might be the same adult finding it difficult to get off of her social media accounts.
  • Think about a child with ADHD unwilling to compromise with friends, always wanting his own way instead. That sounds like the same adult insisting his wife watch “his show” or listen to “his radio station.”
  • Think about a child with ADHD carelessly rushing through her trumpet scales (a dreaded, nonpreferred task) in an attempt to get to the preferred part of her trumpet practice sooner, which is playing the actual song. That could be the same adult at work, carelessly rushing through writing a report, to more quickly get to the things she actually enjoys doing at her job.
  • Think about a child with ADHD always trying to get away with doing less at school (maybe by not “showing” his required math work). That might be the same adult also trying to get away with doing less at his job.
  • Think about a child with ADHD being dragged out of bed and taking “forever” to get dressed, eat breakfast and groom herself. That may be the same adult constantly being late for work or other appointments.
  • Think about the bedroom of a child with ADHD looking like a tornado hit it. That could be the same adult whose wife is nagging him because his dirty laundry is all over the bedroom floor, or whose boss is upset with him because he presents poorly at work with a disorganized, messy desk.
  • Think about a child with ADHD incessantly begging her parents for something to obtain immediate gratification for herself: “Take me to the pool. Take me to the pool! Puh-Lease!” That sounds like the same adult refusing to take “no” for an answer in other social relationships.
  • Think about a child with ADHD disregarding minor details with his schoolwork. That could be the same adult overlooking “minor details” in other areas of life, such as neglecting to wear his identification badge at work, forgetting to check the “change oil on this date” sticker in his car or, worse, forgetting to check the gas tank.
  • Think about a child with ADHD struggling to get started with her chores at home. That can be the same adult struggling to initiate, sustain or complete daily living responsibilities at home. For example, she may buy groceries, get them home and put the items away in the kitchen. However, the items needing to be placed elsewhere in the house (shampoo, body wash, etc.) remain in the grocery bags on the kitchen counter. After her husband nags her for a day to put the rest of the items away, she eventually moves the grocery bags upstairs to the bathroom and places the bags on the bathroom counter. After her husband nags her another day, she eventually takes the items out of the bag and puts them under the bathroom cabinet.
  • Think about a child with ADHD climbing the drapes in a banquet hall at a wedding. That could be the same adult craving a dopamine rush as she is darting in and out of traffic at high rates of speed. Remember, when it comes to dopamine, people with ADHD either don’t produce enough, retain enough or transport it efficiently. Dopamine is a “feel good” neurotransmitter (in addition to being the main “focus” neurotransmitter), so when individuals are recklessly impulsive, they are likely feeling understimulated and attempting to stimulate their dopamine level to “feel good.”

However, people with ADHD can be notoriously impatient. In the driving scenario above, it may not be about stimulation; it might be about her impatience. In a third scenario, this person could also be darting in and out of traffic because she is late for something because people with ADHD can also be notoriously late.

  • Think about a child with ADHD hyperfocusing on something — likely a preferred activity that seems irrelevant to others. Many times, this is because of norepinephrine. We require this neurotransmitter to help us pay attention to things that are either boring or challenging. When this neurotransmitter is not produced enough, retained enough or transported efficiently, as in people with ADHD, it can be a struggle to pay attention in boring and challenging situations. However, when people with ADHD really enjoy something, norepinephrine can actually be stimulated, and then they can hyperfocus.

Now think of the adult hyperfocusing at home on something that appears irrelevant. This person also then has a propensity toward becoming overwhelmed with all of the other dreaded, nonpreferred tasks on her “list of things to do.” She may use the hyperfocus ability with something that she enjoys as a misguided coping strategy to avoid the nonpreferred tasks. This further perpetuates her feelings of being overwhelmed with everything that she’s supposed to be doing and not getting accomplished.

  • Think about a child with ADHD struggling to pay attention to his teacher. That sounds like the same adult struggling to remain focused as he and his wife have a conversation at the dinner table. Then, the next morning, when he doesn’t get out of bed when he’s supposed to, she wonders why he didn’t get up early to take the dog to the vet. It’s possible that he wasn’t focusing on their conversation the previous night, so he didn’t actually know he was responsible for this. Or, he did know, but he struggled with time management. Or, he struggled with intrinsic motivation to get out of bed to get things accomplished for the day. Or, he was paying attention to the conversation, remembered it and was actually motivated to take the dog to the vet, but he forgot to set his alarm clock.

With this type of situation, it can be unclear why he didn’t get up that morning because it could have been from any number of ADHD symptoms — or a combination of some of them.

 

Other experiences

According to the Centers for Disease Control and Prevention, people with ADHD also experience other situations that I didn’t necessarily address specifically in the scenarios above. People with ADHD can experience:

  • More unplanned pregnancies and sexually transmitted diseases
  • Higher arrest rates and propensity for repeating offenses
  • More aggressive behavior (This does not mean that all adults with ADHD are aggressive. In fact, most are not. But the rates of aggression among those with ADHD are higher when compared with those in the general population.)
  • More speeding tickets
  • More shoplifting convictions
  • More money management issues, impulsive spending habits and credit card debt
  • More substance abuse (higher in unmedicated ADHD patients than in the general population)
  • More risk-taking behaviors
  • Higher rates of smoking (in unmedicated ADHD patients)
  • Higher rates of depression (especially among males) and anxiety
  • Comorbid diagnoses (more than half of those with ADHD have a dual diagnosis)
  • Low self-esteem due to perceived failures at school or work and due to struggles in relationships

In looking at all of the different issues and scenarios related to ADHD and presented in this article, it is important to note that all adults will be late to an appointment once in awhile, lose something important, become overwhelmed with their “list of things to do,” interrupt during a conversation or even get a speeding ticket. These situations are all within normal limits as human beings. It becomes clinically significant only when a variety of these instances occur chronically and intensely and also interfere with the person’s functioning.

Adults with noticeable ADHD symptoms can sometimes manage these symptoms. This can be done in a number of ways:

  • An ADHD medication regimen
  • Psychotherapy to learn strategies to self-regulate
  • Neurofeedback to help strengthen connections in the brain
  • Holistic practices of consuming nutrients that promote proper brain functioning, including zinc, vitamin C, omega 3 fatty acids and protein
  • Exercise to increase blood flow in the brain, specifically in the neocortex where it’s needed to increase focus and decrease impulsivity

A combination of treatment modalities may be most effective so that adults with ADHD can continue to function well in their respective environments.

Because of the multifaceted origin of this disorder and the external variables each person experiences, ADHD symptoms can come across differently, so each person with ADHD (child or adult) will not present the same, even among the same presentation. Some individuals will have overtly noticeable symptoms. In the case of other individuals, outsiders may not even notice their symptomology, especially if they have learned to cope with their ADHD and self-regulate.

 

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Donna Mac is a licensed clinical professional counselor treating adolescents in psychotherapy who are transitioning to adulthood. She is also the author of the book Toddlers & ADHD, which can actually be applied across the life span. Find out more via her website, toddlersandadhd.com or email donnamac0211@gmail.com.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Reconsidering ADHD

By Laurie Meyers July 20, 2016

The stereotypical image of attention-deficit/hyperactivity disorder (ADHD) is the raucous little boy who can’t sit still in the classroom and is a discipline problem at home. But counselors who commonly work with ADHD know that it can also manifest as a young girl who is seemingly always in her own world or an adult who just can’t seem to get things done and frequently misses deadlines. Even after moving beyond the stereotypes, however, ADHD isn’t necessarily Branding-Images_ADHDeasy to spot, especially because the disorder can mimic the symptoms of mental health conditions such as depression, anxiety and schizophrenia.

Once viewed strictly as a behavioral problem, ADHD is now considered by many experts to also be a neurological and cognitive disorder that starts in childhood and presents lifelong challenges for those who have it. Although much remains to be discovered about ADHD, researchers believe that the problem lies with an impairment in the brain’s executive function that causes inattention, hyperactivity and impulsivity. In the past, ADHD was divided into two types, but the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders delineates three types of ADHD: inattentive type, hyperactive/impulsive type and combined type (a mix of symptoms from both the inattentive and the hyperactive/impulsive types). Although typically diagnosed in childhood, ADHD can go undetected until a person reaches adulthood. The difficulties adults with ADHD confront may look different than the difficulties children with the disorder face. For example, instead of failing to complete homework, adults may have problems with missing deadlines at work or forgetting appointments. Regardless, the root cause of those challenges and many of the strategies that are used to adapt and cope are the same for children and adults, according to counselors who work with ADHD.

The professional counselors interviewed for this article say that a number of interventions, including time-management strategies, cognitive behavior therapy and, if needed, prescription medications, can be helpful for those with ADHD. But they also emphasize that one of the most important things practitioners can do is to explain to clients why they experience the difficulties they do. Before showing up in a counselor’s office, many of these clients have come to believe (or have been told by others) that they are dumb, lazy or even mentally unstable.

Childhood challenges

Those who read the comic strip The Family Circus are likely familiar with the character of Billy, the family’s 7-year-old son, and his “trails,” which are often featured in the larger Sunday comic. The dashed lines in the comic trace Billy’s wanderings as he performs seemingly simple tasks such as going to the mailbox. One of Billy’s typical trails might lead to every room in the house, on and off the furniture and perhaps even around the neighborhood as he stops to investigate everything that draws his attention along the way to the mailbox.

Clay Martin, a national certified counselor who was diagnosed with ADHD as a child, says that Billy and his trails are the perfect example of a child with ADHD. It might take Billy forever to get the mail, but it’s not because he’s misbehaving, Martin says. It’s because he has a faulty filter for sensory input. Children and adults with ADHD may, in essence, have trouble distinguishing the signal from the noise, being unable to focus on one thing in a sea of sensory output, explains Martin, a member of the American Counseling Association.

Unfortunately, Martin adds, the adults in the life of a child with ADHD don’t typically understand this, or at least not initially. Instead, parents often think that their child is being disrespectful, willfully disobedient or just plain defiant, but that is usually not the case, he says. Martin explains that when children with ADHD get in trouble, they often are not even sure of what they have done wrong. That’s because they don’t usually possess a strong sense of time, may have trouble processing information and likely intended to listen to the instructions they were given but were ultimately unable to focus on what the parent, teacher or other adult said, according to Martin. He calls this circumstance “blinking” and acknowledges that it sometimes remains a challenge for him even as an adult. Even though he is intent on listening to a conversation, his mind will suddenly be seized by something else.

When providing counseling, Martin does a number of things to help ensure that he stays focused on his clients. He maintains what he calls a “spartan” work environment with few distractions. He silences his mobile phone and locks it in a cabinet until lunchtime and then again until the end of the workday. He maintains eye contact with clients through the entire session and summarizes their statements immediately rather than letting them “pile up.”

Beth Ann Dague, a licensed professional counselor in Wheeling, West Virginia, says the biggest challenge she faces when working with children with ADHD is often helping parents and teachers better understand the nature of the disorder. “I try to educate them about problems that occur with the prefrontal cortex and that [ADHD] is more than a short attention span and distractibility,” she says. In fact, children (and adults) with ADHD can also struggle with lack of perseverance, impulse control, hyperactivity, chronic lateness, poor time management, disorganization, procrastination, poor judgment, trouble learning from experience, short-term memory problems, and social and test anxiety, notes Dague, a member of ACA who has done advanced training in ADHD work.

When children are grappling with several of those issues simultaneously, academic problems are inevitable unless classroom accommodations are made, Dague asserts. She encourages parents to become their child’s best advocate, ensuring that the child gets all the services that those with ADHD are entitled to under federal law because the disorder is classified as a disability. Parents should push especially hard for an Individualized Education Program (IEP) for their child, she says. Under an IEP, a student with ADHD is given accommodations such as the ability to take tests separately, individual lessons with a teacher or tutor to go over problem material and other classroom modifications. Dague says that ADHD is in many ways a disorder of motivation. For that reason, parents may have to be motivated for their children with ADHD, encouraging them to keep trying and assisting them with homework, she adds.

Martin formerly worked with adolescents as an in-home counselor in Georgia and now counsels the same age group in a substance abuse program as part of the clinical work for his doctoral program at the College of William & Mary in Williamsburg, Virginia. He cautions that parents whose children have ADHD should always consult with the child and consider his or her input. Children with ADHD benefit from having structured schedules, Martin says. So parents might decide that, each day, the child will be allowed to play video games or play outside for an hour after school, but then homework must be completed, the family will eat dinner, the parents will check the child’s work and then the child will get to choose whatever he or she wants to do in the time remaining before bed. Rather than the parents always determining the schedule, Martin encourages what he calls “therapeutic negotiation,” in which the parents agree to try a different schedule arrangement based on the child’s desires. For example, the child might propose doing homework for an hour first, followed by video games for two hours. Before agreeing, the parents and child would reach an understanding that if schoolwork is neglected under the new schedule, the child will resume the original schedule.

Both Martin and Dague say it is important to encourage children with ADHD to find and pursue their passions, and both counselors highly recommend extracurricular activities for these children. These outside interests are significant not just as an outlet for excess energy, but as a place where young people with ADHD can excel and experience success, especially if academics prove challenging to them. Dague talks to parents and children about trying out various sports and other activities at school and also informs them about low-cost programs such as a fine arts institute and music programs in the local area. She urges parents not to let their child simply “give up,” which is common among those with ADHD, Dague says. Instead, parents can encourage their child to try a different activity or to stay in a current program or activity a little while longer in hopes that it will spark the child’s interest.

Extracurricular activities can also teach valuable life skills, Martin notes. He credits participating in drama club in high school with helping him learn social skills, how to communicate with others and how to make friends. It was also a place where he was surrounded by individuals who accepted and supported him.

Dague is particularly in favor of sports or other physical activities for children with ADHD because she believes that movement is helpful for activating their brains. She notes that movement increases blood flow, oxygen and neurotransmitters such as serotonin, norepinephrine and dopamine.

But Dague also likes to teach yoga and diaphragmatic breathing for relaxation to child clients with ADHD. Martin finds meditation personally helpful for focus and stress relief and often suggests that clients with ADHD try it too.

Dague encourages parents to look for cognitive training resources to work on with their children. Among those she mentions are Nintendo’s Brain Age and workbooks that include exercises for increasing attention and focus. She also engages in exercises with clients in her office that are meant to enhance their attention levels. For example, she might play Simon Says, Jenga or checkers with them. Dague says that checkers is particularly difficult for children with ADHD because they are thinking too fast to strategize. In her sessions with these clients, she slows things down and helps them think about what moves they could make to beat her. She also encourages older children with ADHD to try out cooking under parental supervision. She believes that following a recipe step by step can help to increase their focus.

In cases of children with ADHD who are acting out, Dague talks with the child and parents about setting up a behavior plan. For example, the family might pick a week and say that if the child can go consecutive evenings without yelling, stomping, refusing to do homework or engaging in other disruptive behavior, he or she can earn some type of reward. Dague also teaches children with ADHD and behavior issues to visualize a stop sign or stoplight every time they feel themselves getting angry or feel the urge to grab or touch things they aren’t supposed to.

Martin and Dague stress that amid all of the possible tips and techniques for managing a child’s behavior, it is important for counselors to remember that ADHD still carries a stigma and that the struggles these children face can leave a mark.

Dague and those she supervises have used multiple methods in school or in the counseling office to help children with ADHD work on their self-esteem. She says it is common for these children to struggle to identify their positive personal aspects, so counselors in school might use worksheets and ask the children to mark their “good traits” or to write down good things that others have said to them. Dague also likes to have children make a “self-esteem box.” The shoebox, personalized with pictures or drawings on the outside, is used as a place to store positive comments from teachers, parents or peers.

Martin is also familiar with the self-esteem issues that those with ADHD often face. When he sought counseling for himself as an adult, it wasn’t to learn time-management or relaxation techniques. It was to learn self-acceptance. Beginning when Martin was a child, he had wondered why he was so different from everyone else. Over time, with the help of a counselor, he learned that he wasn’t inferior to those who didn’t face the same challenges that he faced. Eventually, he even came to appreciate his differences and, in fact, no longer considers ADHD a disorder but rather a different way of seeing the world. He encourages counselors to let their clients know that ADHD is neither an indictment nor a life sentence. Instead, their unique perspectives and passions might lead them to feats of creativity and accomplishment that many others may only dream of, Martin concludes.

College bound

The transition from high school to college can prove challenging for any adolescent, but that can hold especially true for students with ADHD. Some of these students may have grown reliant in high school on receiving assistance from their parents with remembering deadlines, organizing their assignments and managing their time, says Deborah Ebener, an associate professor and coordinator of counselor education at Florida State University (FSU) in Tallahassee. These students most likely also had an IEP in high school that guaranteed them specific accommodations that may not be available to them in college.

“In addition, [students with ADHD] must deal with changes in how disability services are delivered,” continues Ebener, a certified rehabilitation counselor, national certified counselor and licensed psychologist. “College may be the first time the student is solely responsible for requesting and managing [his or her] own academic accommodations.”

The stakes are high. Research has shown that college students with ADHD generally have poorer academic results and are less likely to graduate than their peers who do not have ADHD. Those who do graduate are likely to take longer than their peers to finish college, says Ebener, a member of ACA. College students with ADHD also tend to have poorer psychosocial and emotional outcomes, higher levels of psychological distress and higher rates of depressive symptoms, says Ebener, noting that the research is borne out by what she has seen in her private practice.

“The existing services that are available to college students with ADHD may not be adequate to help them meet the rigorous academic and psychosocial demands that come with going to college,” says Susan Smedema, who collaborated with Ebener to create a group counseling program for students with ADHD at FSU. “For example, academic support services provided by campus-based disability centers provide students with specific course-related assistance, such as extended testing time, but typically don’t address psychosocial concerns, such as helping them to make friends or navigate the dating scene.”

“Individual counseling addresses psychosocial issues and skill development, but it may be difficult to find a counselor with ADHD expertise, and counseling is often expensive and time-limited,” Smedema continues. “Individual ADHD coaching helps students develop skills and self-confidence, but it is also expensive and does not provide emotional support or address a student’s specific problems. Group counseling, however, is a cost-effective way to help students with ADHD cope more effectively with college life.”

FSU’s student disability resource center asked Ebener to develop group counseling services for college students with disabilities. She created the Coping With ADHD project and, with Smedema, developed it into a service, teaching and research project. Ebener describes the group program as a combination of cognitive behavioral and individual coaching interventions.

“We utilize a psychoeducational approach to coaching the students in such areas as time management, organizational skills, test preparation, problem-solving and goal setting,” she says. “In addition, cognitive behavioral interventions are used to address psychosocial issues related to adaption to their ADHD and other life areas. This psychosocial adaptation to disability component is what makes this intervention unique.”

The group curriculum that Ebener and Smedema created consists of eight 90-minute sessions co-led by two advanced graduate students. Topics include understanding and coping with ADHD symptoms, medication issues (such as dealing with side effects), stress reduction, self-advocacy (including how to ask for accommodations from professors), social skills (dating, in particular, is a very popular topic, Smedema says), goal setting, time management and memory strategies.

“The ultimate goals are to help students minimize their functional limitations, reduce psychological distress, gain social support, develop self-advocacy skills and effectively adjust to college,” says Smedema, who has since left FSU to become an assistant professor of rehabilitation psychology and special education at the University of Wisconsin-Madison. She continues to be a co-investigator with Ebener on the research aspects of what is now called the Disability Counseling Project.

Smedema, a member of ACA, says that each session generally consists of 10 minutes of group member check-in, a 15-minute presentation of content related to the day’s topic, 15 minutes of member response to the presentation, a 10-minute break and 40 minutes of general group process.

The eight sessions are:

1) About my disability: Self-assessment and understanding resources

2) Coping with my disability: Self-monitoring and stress management

3) Career decision-making and exploration: Obtaining and maintaining employment; reducing commitment anxiety and external conflict

4) Awareness of self and environment and learning to work well with others: Self-advocacy and social skills; students with disabilities’ rights and responsibilities

5) Learning to manage myself: Aggressive vs. assertive responses; developing memory skills and effective work habits

6) Who’s in control: Time management; solution-focused/forward thinking

7) How do I remember all of this: Memory strategies (e.g. calendars)

8) Wrapup: Debriefing

The group facilitators use psychoeducation to cover topics such as time management. But for other topics, such as stress reduction, they demonstrate effective techniques (for example, diaphragmatic breathing or progressive muscle relations) and lead the group in performing the exercises.

In the reaction portion of the sessions, students talk about their responses to the presentation topic or the technique being demonstrated. For example, they might discuss questions such as how particular relaxation strategies made them feel, how they might be able to implement the techniques in their lives, what barriers they might encounter in using a particular strategy or technique and what impact they think a particular strategy or technique might have on them overall.

The general group process portion of the sessions allows members to absorb what they’ve learned together while providing one another with emotional support, Smedema says.

“According to our research, students who participate in the group demonstrate significant increases in quality of life and college self-efficacy and significant decreases in psychological distress,” Smedema notes. “These results show incredible promise for the efficacy of this type of intervention in college students with ADHD.”

Recognizing ADHD in adults

Stacey Chadwick Brown, a licensed mental health counselor and private practitioner in Fort Myers, Florida, recently started working with an adult client who had formerly been diagnosed with depression. She told Brown that her anxiety and depression weren’t improving. Some of the woman’s current symptoms, such as trouble focusing and a lack of motivation, resembled depression, but as Brown listened to her story over several sessions, she noticed that the client reported long-term attention problems.

When discussing the client’s lack of motivation, Brown discovered that the woman actually was motivated, but only to do things that she found enjoyable. The client also reported feeling anxiety, which Brown definitely sensed. But Brown still didn’t feel that she was getting the full picture of the client, so she did something that she likes to do with all of her cases (with clients’ permission) — get the perspective of at least one other person in the client’s life.

“I had her roommate come in,” recounts Brown, a member of ACA, “and she said, ‘Did she tell you about how she won’t pay bills on time, gets stuck [pulled in] if she walks by the TV and has trouble getting up in the morning?’”

The client had also tried various exercises for depression and anxiety in the past but never kept up with them. Brown considered the lack of follow-up a red flag that possibly indicated the presence of ADHD.

Brown had also asked the woman to journal (another technique that Brown likes to use with most of her clients). The client showed up at the next session proudly displaying her brand-new journal, complete with an intricate self-portrait but no writing or observations. She had also neglected to complete some homework that Brown had assigned.

When Brown delved into the client’s history, the woman reported that teachers used to tell her parents that they couldn’t get through to her and that she wasn’t listening. She also remembered not liking to do her school assignments. In fact, the client told Brown that sometimes her mother had done her homework for her to keep her out of trouble.

Brown finally talked to the client about the symptoms of ADHD and asked her to think about whether she recognized any of those symptoms in herself. Brown believes that educating adult clients about the possible presence of ADHD is very important. She has asked certain clients to watch TED talks and short videos on ADHD and has also recommended that clients read You Mean I’m Not Lazy, Stupid or Crazy?! a self-help book for adults with ADHD by Kate Kelly and Peggy Ramundo. She also gives certain clients ADHD symptom scales to fill out. “It’s all about education and getting [certain clients] to see if [they] think it applies,” Brown says.

When presenting any client with an ADHD diagnosis, Brown tries to ensure that the person leaves her office understanding that the disorder is neurological, not an implied behavioral or character defect. To help in this understanding, she typically draws a picture of a brain, explaining the importance of dopamine for executive function and how those with ADHD have a shortage of this important neurotransmitter. Brown tells clients that executive function is akin to an administrative assistant who keeps the CEO (the brain) organized. When someone has untreated ADHD, it’s like the administrative assistant is on vacation, making it more difficult for the CEO to function efficiently. Brown also tells her clients that medication can sometimes help with executive function. If they are interested in exploring prescription treatment, she gives them the name of a psychiatrist who specializes in ADHD.

Brown says that providing psychoeducation is particularly important because clients grappling with ADHD often internalize a significant amount of shame. She recalls a recent client who constantly beat herself up and had a distorted self-image because of her struggles with ADHD. “She called herself fat, lazy, unmotivated, and kept comparing herself to her ‘successful’ brother,” Brown says. “She hadn’t noticed what she was doing. I kept count in one session, and she called herself lazy 12 times.”

Brown focused on making the client more aware of her negative self-talk and how to use cognitive reframing to challenge it. She had the woman take note of when she was feeling guilty or blaming herself and then fill out a spreadsheet with three columns: the activating event, its consequence and the resulting behavior. For example, an activating event might be that the client failed to pay her power bill on time. The consequence was that she felt guilty. Brown explained to the client that not paying the power bill was not an event that automatically triggered guilt on its own; instead, there was a negative self-narrative of blame that caused the guilt. And that guilt (the consequence) caused the client to overeat, stay in bed and give up on the rest of the day (resultant behavior).

Brown encourages clients struggling with ADHD to think about how they can change that cycle. For instance, instead of engaging in self-blame, this client could say to herself, “I’m human. I forgot. Next time I will put a reminder on my phone, or maybe not keep the bill by the bedside but on the fridge, or maybe try electronic billing. I’m not a terrible person because I did this,” Brown says.

Reframing can pull clients out of the shame cycle and simultaneously encourage them to become more action oriented by coming up with possible solutions, Brown says. One of her clients is a manager who is accustomed to meeting daily deadlines, but outside of the structure that work provides, she struggles to function efficiently. Brown and the client have discussed how the client functions better when kept to a tight schedule, so they are working together to develop a schedule for all the tasks the client needs to complete in her daily life and assign regular deadlines to those tasks. Brown has also encouraged the client to maintain to-do lists and reward herself in some way for every task she crosses off.

Brown has also suggested ways that the client might strategize to avoid scheduling pitfalls. For example, the client acknowledges getting pulled in to television wherever she is, even if she is out somewhere. She turns it on first thing in the morning and often ends up sidetracked instead of getting things accomplished. Brown has encouraged
her to turn on the radio instead, especially when she knows that she has tasks to complete.

Another area Brown and the client are working on is organization. The client often misplaces things, including in the kitchen, so they have talked about organizing in a simple, systematic way — cereal goes with cereal, soup goes with soup, vegetables go with vegetables and so on.

As she does with any client showing signs of a mental health disorder, Brown has also asked this client to visit her doctor and have bloodwork done to rule out thyroid problems, a hormonal imbalance or other possible medical issues that might be causing or exacerbating the problems she is experiencing.

Like Martin, Brown doesn’t think of ADHD in purely negative terms. Those with ADHD have problems with attention in general, but when they are interested in something, they tend to focus tightly on it and even develop a passion for it that can propel them to greater mastery and success, say Brown and Martin. Both counselors believe that there is joy to be gained from these passions and from the unique way that those with ADHD see the world. Martin says that at times, this alternate worldview can even lead to creative problem-solving that might not be possible without the frame of ADHD.

 

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To contact the people interviewed for this article, email:

 

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Additional resources

For those who would like to learn more about the topics addressed in this article, the American Counseling Association offers the following resources:

Books and therapeutic games (counseling.org/bookstore)

  • ADHD Game (therapeutic card set to be used with Dinosaur Game Board, sold separately), Bradley Erford
  • Group Work and Outreach Plans for College Counselors, edited by Trey Fitch & Jennifer L. Marshall

Webinars (counseling.org/continuing-education/webinars)

  • “Adult ADHD: Help Your Clients to Thrive if They Have ADHD (or Think They Might), Tim Bilkey

Practice Briefs (counseling.org/knowledge-center/practice-briefs)

  • “Attention Deficit Hyperactivity Disorder (ADHD): Treating Adults,” John S. Wadsworth & Laura Gallo

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor: ct@counseling.org