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A Group Counseling Intervention for Children with Attention Deficit Hyperactivity Disorder

By: Linda D. Webb and Robert. D Myrick

A theoretical framework is presented to increase school counselor understanding of students with attention deficit hyperactivity disorder (ADHD) and support a counselor intervention. This article outlines a six-session group counseling intervention to help students with ADHD understand its effects on their classroom performance and to learn and practice a repertoire of school success skills. The unit is based on the theme of a journey with ADHD students who learn they are different travelers in the world of education and often take alternate routes to their destinations (academic, personal-social, and career goals). Fourteen elementary school counselors received training, delivered the intervention, and completed a post-intervention survey. Student and teacher reports of school success behaviors from the intervention pilot are also reported.

Attention deficit hyperactivity disorder (ADHD)is a diagnostic label used to describe people who have developmentally inappropriate levels of inattention, hyperactivity, and impulsivity. They find it difficult to complete routine tasks or concentrate for an extended period of time. They frequently fidget and have difficulty inhibiting behaviors that can distract others. An estimated 3% to 5% of the school age population has ADHD (American Psychiatric Association, 1994) with boys outnumbering girls (Kauffman, 1993; Barkley, 1990). It is one of the most commonly diagnosed and studied disorders among children, and it is receiving increased attention by school administrators, teachers, and counselors (Barkley, 1998; Shaywitz & Shaywitz, 1992).

ADHD students often have problems in school where rules and procedures require them to sit still, be attentive, and stay focused on academic tasks and classroom discussions. They may receive some assistance from special education teachers who typically have smaller classes and who rely on the use of behavioral techniques in managing students. However, between 85% and 90% of ADHD students are still served in general education classrooms for all or part of the day (Montague & Wagner, 1997). The regular classroom teacher works with a larger number of students at one time and usually lacks the training related to working with learning disorders. Some special education strategies may seem too impractical or time consuming, and many teachers are unsure of what to do and need support.

School counselors and ADHD students

School counselors, as behavioral and relationship specialists, can provide support for ADHD students and their teachers. The American School Counselor Association published a position statement that strongly encourages the involvement of school counselors in the multidimensional treatment of these students (ASCA, 1994). Others in the field (Erk, 1995; Lavin, 1997; Schweibert, Sealander & Tollerud, 1995) have also addressed the need.

Myrick (2002) described a developmental school guidance and counseling program with the goal of helping all students learn more effectively and efficiently. Counselors provide such interventions as individual counseling, small group counseling, large group guidance, peer facilitator training, and consultation with parents, teachers, and administrators. Sometimes certain student populations such as those with ADHD are targeted for special attention and one or more counselor interventions.

Braswell and Bloomquist (1991) recommend group counseling more often than individual counseling for most ADHD children. Group sessions closely approximate real-life peer relationship situations; group members can help each other acquire skills and make generalizations. Group counseling activities that elicit the behaviors and feelings associated with academic and social problems enable counselors to intervene and assist children who are low performers in school and have difficulties with their peers. Interventions applied consistently within the school setting seem to be the most effective.

Understanding ADHD in a learning environment

During the past decade, researchers linked the causes of ADHD to neurological and genetic factors. It appears that these factors may play a more important role than social or environmental ones, making the disorder a treatable but not necessarily curable one (Barkley, 1998; Teeter & Semrud-Clikeman, 1995). This also suggests that the disorder might be managed but it is not likely to disappear. Barkley identified impulsivity as a hallmark of the disorder. Impulsive behavior is also frequently seen in cases in which students are referred to school administrators for discipline. The greatest number of classroom problems and referrals associated with ADHD are related to behaviors that often cause conflicts with teachers and other students (Zentall, 1995). Counselors want to help ADHD students gain the most from school by helping them manage their behavior and adjust to rules and procedures.

Although the onset of ADHD for most children is prior to age 4, it is most often diagnosed when a child is in elementary school (McKinney, Montague, & Hocutt, 1993). This is when children are introduced to the structure and demands of the educational system. How students learn to manage themselves and the learning environment during their first few years of school often determines how successful they will be in later years.

As many as 56% of ADHD students may require academic tutoring, up to 30% may repeat a grade, and 30% to 40% may be placed in special education programs. As many as 46% of ADHD students may be suspended from school with up to 35% dropping out completely and not finishing high school (Barkley, DuPaul, & McMurray, 1990; Barkley, Fischer, Edelbrock, & Smallish, 1990; Weiss & Hechtman, 1993). In addition, without assistance students may develop emotional problems laden with anger, aggression, depression, and anxiety (McKinney et al., 1993; Reeve, 1990). These can lead to oppositional defiant and conduct disorders (Biederman, Faraone, & Lapey, 1992) and result in troublesome conflicts.

Learning skills such as listening, attending, following directions, and exhibiting social competence have a strong correlation with successful social and academic achievement in school (Cartledge & Milburn, 1978; Eisenberg et al., 1997; Masten & Coatworth, 1998). Because ADHD students cannot sustain their attention and are easily distracted, they have difficulty doing academic tasks, completing homework, and acting appropriately with peers and teachers. Lack of success and repeated confrontations can lower self-esteem. Increased anxiety and frustration follow. Inconsistent performance in school, low test scores, disorganized desks and backpacks, and disruptive behavior are additional problems (DuPaul & Stoner, 1994; Reeve, 1990; Zentall, 1993) that draw counselors' attention.

ADHD intervention

The most common treatment for ADHD is medication (Epstein, Singh, Luebke, & Stout, 1991). Sixty percent to 90% of children diagnosed with the disorder receive stimulant medication for prolonged periods during their school careers (Whalen & Henker, 1991). Short-term enhancements in behavioral functioning have been found in about 75% of those being treated with stimulant medication (DuPaul & Rapport, 1993; Kavale, 1992; Whalen & Henker). Even though the medication has no effect on academic attainment per se, productivity in school may improve as a result of controlling behaviors that interfere with learning and classroom performance (Montague & Wagner, 1997).

The metaphor of a journey provided opportunities to construct group activities that were fun and enabled participants to reflect on personal management skills.

Stimulant medication does not teach appropriate behaviors, but it does increase the probability of a child displaying appropriate behaviors that are already in their repertoire. According to Barkley (1998), the difficulty for ADHD students is not knowing what to do, but doing what they know. In addition, it has been shown that there is a difference between possessing a skill and using it effectively (Stein, Szumowski, Blondis, & Roizen, 1995). An intervention that targets school success behaviors, including practice and application, increases the chances of improved behavior for students who take stimulant medication. Researchers Weiss & Hechtman, (1993) found the long-term prognosis for ADHD children treated with stimulant medication alone was the same as those receiving no treatment.

A recent study sponsored by the National Institute of Mental Health (MTA Cooperative Group, 1999) reported that a carefully managed protocol of stimulant medication and behavioral intervention was effective in treating ADHD symptoms. The combination resulted in improved social skills, parent-child relations, and academic achievement. It was also reported that in some circumstances, behavioral/psychosocial interventions alone produced these same results. While school counselors often help to identify behaviors symptomatic of ADHD, diagnosing and medically treating ADHD are not school counselor functions. However, helping students understand and manage their behavior and their relationships with others to maximize their learning potential is an important school counselor function.

The widespread use of stimulant medication and the emphasis on behavioral modification by teachers and parents raises another question. Should ADHD students feel less responsibility for the outcomes of their behavior? They may falsely conclude that what happens during the school day is the result of their medication and teachers' efforts, rather than their own choices and actions. This external locus of control can lead students to disclaim personal responsibility for what they do and lay a foundation for making excuses when problems or difficulties arise. Research findings (Linn & Hodge, 1982) support this external locus-of-control finding for ADHD students along with the need for explicit external cues.

However, Barkley (1998) suggests that ADHD is not an excuse or a reason to dismiss the consequences of one's actions, but rather an explanation as to why it is necessary for those with the disorder to increase awareness of life's behavioral contingencies. Helping students understand how their disorder affects school performance may be one way for ADHD students to begin to see themselves as having the capacity to manage themselves in their environment (Goldstein & Goldstein, 1998). ADHD students need additional counselor intervention strategies that (a) help them understand ADHD, (b) provide a repertoire of skills to enhance learning, and (c) help them understand the importance of external cues. Cognitive behavioral methods promote a shift from caregivers (teachers and parents) to the ADHD students themselves. The student is in the best position to recognize signs of problems before they occur and to take actions that help manage their lives.

Between 85% and 90% of ADHD students are served in general education classrooms for all or part of the day.

A Basic Counseling Theory

Rational Emotive Behavior Therapy (REBT; Ellis & MacLaren, 1998) provides a theory for developing a group guidance unit that helps students learn how ADHD affects learning behaviors and classroom performance. It offers a rationale for increasing student awareness and the value of practicing school success skills. The theory assumes that an ADHD student cannot exhibit a behavior that has not been learned.

REBT emphasizes behavioral change and self-regulation along with the examination and possible modification of thoughts, beliefs, feelings, and expectations. It is an approach that supports recent treatment interventions for children with ADHD (Ellis & Wilde, 2002; Schweibert et al., 1995). It is assumed that, while the primary symptoms of the disorder are difficult to ameliorate, it may be possible to help children develop competencies that lower the risk of serious secondary difficulties (Braswell, 1993). According to Myrick (2002), this approach also lends itself to brief counseling that is so often used in schools.

The journey: a group counseling intervention

What follows is a description of a small group counseling intervention that has been used with ADHD students. The intervention focuses on increased understanding of the disorder and how it impacts school performance. It was assumed that students needed to face their disorders and recognize that it is part of who they are. Further, the disorder by itself will not keep them from their personal, academic, or career goals. To the contrary, many individuals who have ADHD have made valuable and significant contributions to society. The secret to success is being able to manage one's thoughts, feelings, and behaviors.

Fourteen elementary school counselors from one school district delivered the intervention consisting of six small group sessions designed for about six students per group. Each session had a specific objective related to thoughts, behaviors, and skills that focused on school and personal achievement and began with a review of the previous session and a check on application of skills. Sessions ended with tasks for practice and an encouraging summary statement. The unit culminated with snacks, juice, and talk about the group experience as well as a review of plans for utilizing strategies.

The sessions were based on the theme of a journey that students might imagine they were taking. Of course, the journey required preparation and the ability to recognize certain road signs and to manage the vehicle in such a way that the students would arrive safely at their final destination. Because the students had ADHD, they would be a different kind of traveler and, at times, take a different route than others, although they would eventually arrive at the same destination. The metaphor of a journey provided opportunities to construct group activities that were fun and enabled participants to reflect on goals and goal setting, the influence of personal characteristics on achieving goals, and personal management skills. As they considered skills needed to move them along on their imaginary journey, they also thought about how the skills were related to the academic, personal, social, and career goals shared by all students their age.

Preparing for the journey

The counselor begins the unit by telling students that they have been selected for the group because they have been identified as different kind of learners: They have ADHD. They are asked, "What do you know about ADHD?"

Discussion and clarification help the students identify ADHD symptoms and how the symptoms are manifested in school, which often makes them learn in different ways than others. They are, in one sense, a different traveler in the education world. It is explained that sometimes they take the same road as others while learning things and then, at other times, they will go another way, perhaps taking some detours, even though everyone is trying to get to the same place. The counselor leads the participants through a series of structured learning activities. Special efforts are made to focus on what students experience (their feelings) and how those feelings are related to behaviors (their actions). Students discuss what they believe to be true about themselves and others, and how they can manage their thoughts, feelings, and behaviors. Once introductory activities are completed, the journey begins.

The Journey: Group Counseling Intervention for ADHD Students

Title & Number of Session Objectives
1. Our Journey
Activity: Map Quest
  1. Students will gain increased knowledge of ADHD.
  2. Students will identify behaviors associated with ADHD and the effect of these behaviors on school success.
  3. Students will be given an opportunity to discuss their own ADHD diagnosis and express associated feelings.
2. Pack It Up
Activity: Messy Bag
  1. Students will learn and practice strategies to support the need for Activity: Messy Bag better organization as related to school success.
3. Stop Lights & Traffic Cops
Activity: The Signs Around Us
  1. Students will learn and practice behaviors associated with attending.
  2. Students will identify school situations in which attending is important.
  3. Students will identify school situations in which attending is difficult.
4. Using Road Signs As a Guide
Activity: Reading Classroom Cues
  1. Students will learn to recognize, create, and use external cues in the classroom.
  2. Students will gain awareness of the need for strategies to support school success.
5. Road Holes and Detours
Activity: When Things Don't Go Right
  1. Students will identify school situations that are particularly difficult.
  2. Students will identify ways to improve school situations that are difficult.
6. Roadside Assistance & Being Your Own Mechanic
Activity: Increasing Control Of Our Success
  1. Students will identify sources of support at school.
  2. Students will be given the opportunity to experience the feelings of "being in control."
  3. Students will associate increased practice of a skill with improvement of that skill.
  4. Students will gain increased knowledge of the use of medication in treating some ADHD cases.


Session One:

Our Journey. Participants begin their journey as they explore a variety of paths to reach a single destination in Map Quest; they talk about goals and places to go. As they discover the link between an objective and school success, students realize that not all students must take the same journey through school; however, they can each achieve success and arrive at the same destination. Summary statements include: "Having ADHD doesn't mean you can't be successful as a student; however, it does mean that you might have to find some ways to get there (success) that will be a little different than the routes others take. You will need to learn to be a different kind of traveler and do some things to help yourself become successful. If you do, you will have more control over where you are going and how you will get there."

Session Two:

Pack It Up. Students experience the "messy bag.' The counselor begins the session by rummaging through a bag or backpack, throwing things left and right and creating havoc. It is a demonstration of the chaos that comes from being cluttered and disorganized. Students explore their own bags and the need for organization. Being orderly will probably remain a difficult task to learn, but students may have more insight as to why others are continually trying to organize them. Organizational skills are introduced, demonstrated, and practiced. The session closes with a brief summary statement: "Keeping things organized is important. It is one way for you to help yourself on your journey to school success.

Session Three:

Stop Lights and Traffic Cops. Students embark on an imaginary "car ride' to heighten their awareness of the need to attend and pay attention to the signs around them. As they pretend to drive a car, signs are flashed in front of them, and they have to navigate obstacles in the room. They then play the "paying attention' game. A participant wins the game by keeping his or her eyes focused on an object, a book, or perhaps a person who is walking around the room such as a teacher might do for various time intervals. Time intervals are increased from a few seconds until a one-minute interval is reached. The counselor summarizes by saying, "Having ADHD makes paying attention and listening more difficult, but it can be done. Learning and remembering strategies like we practiced today help us notice important things along the way and let us take control during our journey."

Many individuals who have ADHD have made valuable and significant contributions to society.

Session Four:

Using Road Signs as a Guide. Students identify familiar road signs (cards) that cue behavior on the road before they identify signs in their classroom that may help to cue behavior or remember something. Students each develop their own cue to support increased success in the classroom. Summarizing remarks include, "Students with ADHD can be successful in school and get things done — using cues and reminders in your classroom and making up your own are ways to do it."

Session Five:

Road Holes and Detours. Students imagine things that could go wrong on a road trip, including obstacles to getting to their destination (construction, detours, holes in the road, etc). Students generate school situations (many times generated by their own behavior) that create obstacles to success in school. The counselor teaches and demonstrates selected cognitive behavioral strategies before giving students an opportunity for practice. The counselor closes with, "We know there will be holes in the road for ADHD students. There are holes in the road for all students, but your map is marked and you can expect them. You are learning ways to get around obstacles and difficult situations at school and go on with your journey."

Session Six:

Roadside Help and Being Your Own Mechanic. Students explore the idea of breaking down on the road and becoming their own mechanic. Previously learned skills and attitudes are reviewed as tools they will need to get back on the road. Sometimes one has to ask for assistance from someone else when necessary tools are not in the toolbox. However, most of the time, students will have the tools they need to stay or get back on track. Knowing that they can fix things and be their own mechanic is an empowering experience. They are more responsible for managing their own vehicle. The topic of medication is introduced. Doctors and parents usually determine if medication is an appropriate intervention. If students have been prescribed medication, they are encouraged to help themselves by taking the medication, as if it were a tool, and working on the self-management strategies.

The final session summary includes, "We know that all students can be successful in school and that not everyone must be the same kind of traveler or learner. During our sessions we have learned about ADHD and some of the skills and attitudes that will help us in our travels as we journey through school. We have talked about the value of being organized, using cues and strategies to help us remember things, paying attention, and thinking before we act. We also practiced some skills and tried using them in school and at home. With the right kind of attitudes and skills, we can reach our destination—school success."

Support for the group counseling intervention

School Counselor Survey

School counselors completed a survey at the conclusion of the intervention implementation. The survey contained 11 items that were answered on a 5-point Likert-type scale. All 14 surveys were returned. Counselors (100%) supported the appropriateness of unit content, sessions, and outline, and would recommend the unit to other counselors. All counselors (100%) also agreed that the unit contributed to their own understanding of ADHD students and was an effective strategy for this population. Most counselors reported increased confidence with regard to teacher consultation (93%) and changed counselor perceptions (71%). A large majority (93%) of counselors also believed that students participating in the unit changed their views of themselves as students. The results of the counselor reports are shown in Table 1.

Table 1. Counselor Survey Results

Percentage of Counselors Choosing Each Response

Question Strongly Agree Agree Uncertain Strongly Disagree Disagree
Q1. Unit content was appropriate for ADHD students. 79% 21% 0% 0% 0%
Q2. The session activities were fun and informative. 64% 36% 0% 0% 0%
Q3. The session outlines were easy to follow. 86% 14% 0% 0% 0%
Q4. The sessions reflected increased student awareness of ADHD. 50% 50% 0% 0% 0%
Q5. The unit improved the way ADHD students saw themselves as successful students. 57% 36% 7% 0% 0%
Q6. Delivery of the intervention contributed to my knowledge and insight of ADHD students. 86% 14% 0% 0% 0%
Q7. The unit increased my own confidence in working with teachers of ADHD students. 50% 43% 7% 0% 0%
Q8. The unit helped change my perception of ADHD students. 21% 50% 14% 7% 7%
Q9. This unit is effective for use with ADHD students. 50% 50% 0% 0% 0%
Q10. I would recommend the small group unit to other counselors. 71% 29% 0% 0% 0%
Q11. I plan to use the unit again. 79% 14% 7% 0% 0%


School Success Inventory

Students participating in the group intervention were asked to rate their own school success behaviors, pre- and post-intervention, using the School Success Inventory-Student Form (SSI-SF; Cuthbert, 1987). The SSI-SF is a paper-pencil measure containing 12 items that represent each of the six classroom behaviors of attending, listening, volunteering,using self control, interacting, and assessing oneself. This instrument uses a Likert-type scale to score students' self-report of their ability to demonstrate these school success behaviors; lower scores indicate a greater report that school success skills are being used.

At the end of the 6-week intervention, the student ratings on the SSI-SF were not significantly different from a control group of ADHD students (Webb, 1999). However, in a previous pilot intervention that lasted an additional 6 weeks, when the group counseling intervention was implemented in conjunction with teacher direction for practice and feedback of school success behaviors learned in the group, mean ratings of these skills improved significantly (Webb, 1998). Outcomes for the pilot's multi-treatment approach were also measured by having students complete the SSI-SF pre- and post-intervention. In addition, teachers completed a teacher form (SSI-TF) pre- and post-intervention. The teacher's form of this instrument is based on observation of the student's exhibited behavior. Mean student ratings improved by 12.33 points, and teacher ratings improved by an average of 13.55 points. Dependent t tests found both improvements to be significant (. =.05); Tables 2 and 3 provide more statistical information. It was noted that while the duration of the counseling intervention was also 6 weeks during the pilot, teachers continued to practice and provide feedback to students over a 12-week period prior to post-test completion. Providing direction to teachers about practice and feedback of school success behaviors that students learned in the group—along with an extended period for practice—appear to have played a significant role.

Table 2. School Success Skills Student Form—Dependent t Results

Statistic Value
No. of pairs of scores 9
Sum of D -111
Mean of D's -12.33
Sum of D2 2061
t value -3.98
Degrees of freedom 8
α .05
Table value of t 2.306
Note: Significant mean difference of teacher reports (3.98 >= 2.306).



Table 3. School Success Skills Teacher Form—Dependent t Results

Statistic Value
No. of pairs of scores 9
Sum of D -122
Mean of D's -13.55
Sum of D2 2080
t value -5.58
Degrees of freedom 8
α .05
Table value of t 2.306
Note: Significant mean difference of teacher reports (5.58 >= 2.306).


Conclusions

Research and theory were provided to increase school counselor understanding and to support a 6- week group counseling intervention for ADHD students as part of a multi-treatment approach to help improve the students' success in school. Counselors enjoyed delivering this intervention to students with ADHD. The intervention provided the teachers some direction, was helpful in their work, and was perceived as impacting student awareness and perception of self with regard to ADHD. A longer, 12- week intervention that combined teachers' reinforcement in the classroom of success skills learned in the group yielded significant improvement in student and teacher ratings of school success behaviors. Perhaps examining the effectiveness of the unit delivered in conjunction with teacher intervention aimed at providing practice and feedback of targeted skills on classroom behavior and academic performance after a longer period of time would yield the most relevant outcomes. With a nation of teachers, parents, and counselors turning their eyes to the needs of ADHD students and wondering how to help them gain the most from school, a small group counseling intervention as part of the treatment is appealing. It can be fun and give students a language of self-help that enables them to be more responsible for their actions and to manage themselves in the school environment.

References

References

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Linda D. Webb and Robert. D Myrick (2006)