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 easy 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:

• Stacey Chadwick Brown at stacey@staceybrowncounseling.com
• Beth Ann Dague at bdague1@comcast.net
• Deborah Ebener at debener@fsu.edu
• Clay Martin at cmartin51277@gmail.com
• Susan Smedema at ssmedema@wisc.edu

 

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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