ADD and ADHD: An Overview for School Counselors.
by Pledge, Deanna S.
School counselors are often consultants for parents and teachers on
problems that children and adolescents face. Attention deficit is one such
problem. It is frequently misunderstood, presenting a challenge for parents
and teachers alike. The counselor is a resource for initial identification
and interventions at home and in the classroom. The counselor must have
at least a working knowledge of typical symptoms and likely responses to
environmental demands in order to be an effective resource on attention
Attention Deficit Disorder without Hyperactivity (ADD) or with Hyperactivity
(ADHD) continues to be a misunderstood diagnosis by many. Some parents
and teachers still hold a perception that the label simply provides an
excuse for disruptive behavior; however, studies continue to support a
biochemical or organic basis to the disorder.
Presentation of symptoms can be affected by family interactions, school
expectations, and other demands placed on the individual child. Part of
the reason that attention deficit is usually diagnosed in school age children
(e.g., first to third grade) is attributable to the demands placed on the
child when beginning school (American Psychiatric Association [APA], 2000).
The structure at school differs from that in the home or preschool environment.
Typical predisposing factors within the individual, as well as in the
family history, are being identified in the literature (Chi and Hinshaw,
2002). For example, a history of alcoholism, smoking, or depression in
parents can be predisposing factors (Mick, Biederman, Faroane, Sayer, and
Kleinman, 2002). Certain physiological markers, such as frequent early
ear infections (Combs, 2002), have also been associated with the presentation
of attention deficit. Physical complications can be a factor in the development
of language and reading disabilities that are associated with attention
deficit for between 45% and 60% of those diagnosed (Lloyd, Hallahan, Kauffman,
and Keller, 1998).
Attention Deficit Disorder presents in a slightly different way for
each individual, partially due to the factors noted above. Although there
is a cluster of symptoms usually associated with the disorder, the individual
presentation can be just as varied as the predisposing factors.
SYMPTOMS AND DIAGNOSIS
Diagnosis in children and adults is usually made by history, self- report,
and observation from significant others in the person's life. Central to
diagnosis in children are the symptoms in the general areas of inattention,
impulsivity, and hyperactivity (APA, 2000). In adults, the most prominent
symptom is inattention (Stern, Garg, and Stern, 2002).
Symptoms of attention deficit can be mimicked by emotional disorders,
e.g., reaction to abuse, depression or anxiety (APA, 2000). If therapy
is not successful in addressing underlying emotional concerns, medication
may be used with positive results just as in the case of more classic symptoms
of ADHD. In those cases where early abuse or neglect has been instrumental
in affecting the neurology of the individual, the actual outcome, and thus
treatment, may not differ significantly from other cases of ADHD. Difficulty
sleeping is often seen with attention deficit, particularly for those with
hyperactivity (Stein, Pat-Horenczyk, Blank, Dagan, Barak, and Gumpel, 2002).
Sleep problems can also be exacerbated by medication use.
Other disorders may co-occur with Attention Deficit Disorder. Those
commonly observed include: Tourette's, Obsessive-Compulsive Disorder, Depression,
Autism, Oppositional Defiant Disorder (ODD), or Conduct Disorder (CD) (Burns
and Walsh, 2002). The relationship between ADHD, ODD, and CD is often presented
on a continuum or as a progressive relationship. Symptoms of ADHD often
present initially, followed by ODD, and ultimately CD for a small percentage
of those with initial attention problems. Individual characteristics, family
factors, and life experiences all interact to push some individuals through
this continuum to more serious behavioral concerns. The comorbidity of
other disorders or symptoms often makes successful treatment more difficult.
Other features of ADHD include differences in level of executive functioning
between those who present with hyperactivity and those who do not (Klorman,
Hazel-Fernandez, Shaywitz, Fletcher, Marchione, Holahan, Stuebing, and
Shaywitz, 1999). Deficits in executive functioning are associated with
greater hyperactivity and impulsivity. These differences in executive functioning
include an inability to self-monitor and self-control.
Prevalence estimates for ADHD and ADD are between 3 to 7% of school
age children (American Psychiatric Association, 2000).
Effective treatment usually combines medication and therapy, including
behavioral interventions aimed at increasing structure at home and school.
Parents and teachers are active participants in successful treatment efforts.
Stimulants are the most commonly used medications, with some use of anti-depressants,
for co-morbid conditions of depression and anxiety (Shatin and Drinkard,
2002). Other interventions include parent training and family therapy,
individual therapy, support groups, and social skills training. Providing
structure for these individuals, and helping children learn to provide
structure for themselves, are at the core of successful interventions (Shapiro,
DuPaul and Bradley-Klug, 1998).
Although medication is often part of a successful treatment approach,
school personnel are usually not directly involved in recommending a prescription.
Diagnoses and prescriptions can only be provided by the family physician,
pediatrician, or psychiatrist. Even the process of referral can expose
a school to liability for financial responsibility, so the counselor needs
to be aware of the manner in which any conversation about medication or
referral takes place.
INTERVENTIONS: COUNSELING, CONSULTATION, AND SUPPORT
The counselor's role in enhancing the academic performance of students
with ADD or ADHD often involves consultation with teachers around classroom
interventions, as well as providing support and education to parents. In
addition to basic behavioral interventions, coping skills, social skills,
and self-monitoring skills are important tools that can be reviewed through
various modalities, including individual counseling, group sessions, or
classroom guidance modules. Providing workshops in the evening with separate
sessions for parents and children can be a resource welcomed by parents.
Such efforts may be jointly offered with community support groups.
Parents often need information about appropriate expectations for behavior
and school work, positive parenting techniques, and support groups at the
school or in the community, such as CHADD (a support group for children
and adults with attention deficit disorder). For example, a counseling
newsletter to parents can provide descriptions of ADD, such as the fact
that disruptive behaviors observed at school may not be observed at home,
or that behavior can be inconsistent - at times under the child's control,
and impulsive at others. Information and support can help parents in making
the decision to seek an evaluation.
Typical challenges for students with ADD or ADHD include: 1) organizational
problems; 2) problems with transitions; 3) acting as if rules don't apply
to them; 4) adopting a negative attitude out of frustration in academic
tasks, social interactions, or as a defense against low self esteem; 5)
experiencing isolation or exclusion from peers; 6) poor grades as a result
of rushing through assignments, incomplete work, or distractibility in
class; 7) impulsive behavior; 8) difficulty sustaining attention; 9) different
learning styles; or 10) disruption of sleep or appetite, as a result of
ADD or medication. These students often describe feeling bored at school,
and may appear oppositional (APA, 2000). Motivation around academic tasks
or conforming to rules can be a challenge for these students.
A simple intervention that has proven successful includes "chunking"
or organizing assignments into smaller sections. This makes successful
completion a more likely outcome, and if applied to in-class assignments,
allows the student a legitimate reason to get up and walk to the teacher's
desk. Even such a small amount of movement can help discharge energy that
is so critical for these students. It is for this reason that a common
consequence for not completing homework (i.e., losing recess) is actually
counter-productive with overactive children.
It is also important to remember the lack of self-monitoring ability
as being central for many of these individuals. Teachers and parents can
help children and adolescents develop this skill. Mechanisms to increase
self-awareness include external monitoring systems such as checklists in
the classroom. Additionally, the teacher can provide verbal cues such as
asking the class to, "Stop and check - where is your mind?" Or the teacher
can use physical monitoring cues for particular students, e.g., a simple
tap on the shoulder to help them self-monitor. These cues are general enough
to ensure that students don't feel ostracized by their use.
Symptoms of attention deficit continue throughout adulthood, although
symptoms of hyperactivity generally do not. Recent estimates as high as
50% have been made regarding the continuation of symptoms into adulthood
(Stern, Garg and Stern, 2002). It is noted that the gender ratio in adulthood
(approximately twice as frequent for males) is more equal than in childhood
(estimates ranging from 6 to 10 males for every 1 to 3 females; APA, 2000).
Children and Adults with Attention Deficit Disorder (CHADD) CHADD website:
http://www.chadd.org/ CHADD National Call Center 1-800-233-4050
Attention Deficit Disorder Association Website: http://www.add.org
American Academy of Child & Adolescent Psychiatry Website: http://www.aacap.org/
American Psychiatric Association (APA), 2000. Diagnostic and Statistical
Manual of Mental Disorders (4th ed.), Text Revision. Washington, D.C.:
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symptoms on the development of oppositional defiant disorder symptoms in
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Marchione, K.E.; Holahan, J.M.; Stuebing, K.K.; & Shaywitz, B.A. (1999).
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