Within the healthcare professions, there has been a movement towards the use of evidenced based or scientifically validated treatments. This movement is reflected in mental health care as well.
However, the first wave of empirically supported treatment research has focused rather narrowly on efforts at relieving the specific symptoms used to define diagnosed conditions. While this is certainly a valid means of assessing treatment effectiveness, there are other benefits to be derived from treatment, particularly for individuals with chronic neurologic or medical conditions.
For example, we would not argue that someone with a terminal medical condition could not be helped to cope with their final days simply because the “counseling” did not cure the condition. In this month’s article, I will provide a brief overview of the history of counseling for ADHD and offer a rationale for considering individual, cognitively based counseling for children with ADHD based on an increasing body of research focusing on empirically supported therapy relationships.
In our 1998 second edition textbook, Managing Attention Deficit Hyperactivity Disorder in Children, Dr. Michael Goldstein and I wrote that the intuitive appeal of helping children with ADHD through a counseling approach develop internal strategies to allow them to act as their own change agent and thus reduce impairment, adversity and perhaps symptoms of ADHD had led to a seductive quest for researchers and clinicians over forty year period. In the very same textbook, Dr. Lauren Braswell succinctly summarized the available research literature pointing out that a variety of cognitively based therapies on both individual group bases over a six to twelve month period had not demonstrated effectiveness in improving the behavior and functioning of children with ADHD. Dr. Braswell suggested that medication and behavior management approaches should be viewed as first order treatments for ADHD but that “cognitive behavioral methods can serve as useful adjuncts in tailoring treatment plans to meet the needs for a particular child, family and school staff.”
Since the publication of our 1998 text, there has been insufficient published research to significantly modify those opinions. Although the preponderance of the data still argues strongly that cognitive interventions, particularly in the form of individual counseling, do not directly impact ADHD symptoms, there has been an increasing volume of literature suggesting that counseling, particularly cognitive counseling can be effective in dealing with self-esteem and related problems that develop in children and adults as the result of living with ADHD, by building motivation through changing perception and attitudes. In fact, a chart review study by the Harvard group treating adults with ADHD found reason to suggest that cognitive behavioral therapy may not only be effective in facilitating improved mental health but also in enhancing self-control and reducing severity of ADHD symptoms.
In 1998 we suggested that on even a basic level, increasing parents’ and teachers’ ability to understand, anticipate and see the world through the eyes of children with ADHD, could not help but lead to a more motivated adult participant and ultimately a more effective change agent. Further, the recent work of among others, Drs. Bill Pelham and Myrna Shure, give reason to believe that if sufficient time for training and generalization is planned, children with ADHD can and do demonstrate improvements in behavior and reduction in severity of ADHD symptoms.
In a special issue of the clinical journal, Psychotherapy, guest edited by psychologist, John Norcross, presented an increasing body of research indicating that the “person” of the psychotherapist was significantly tied to the outcome of psychotherapy. In fact, a number of researchers have concluded that there are large positive therapist effects beyond the type of therapy being offered and that these effects may in fact exceed the benefits derived from a specific kind of therapy. Recently the American Psychological Association Division of Psychotherapy presidential task force sought to identify and disseminate information on empirically supported therapy relationships. They reviewed a large body of research and drew a number of interesting conclusions that support a place for psychotherapy in the treatment of ADHD across all ages.
- A strong alliance created by the therapist through good communication, empathy, openness and efforts to avoid angry or hostile interactions with clients independent of condition or treatment type led to improved functioning.
- A strong causal link between therapist empathy and positive outcome was demonstrated, suggesting that empathy served a positive relationship function and can be powerfully impacting in client’s lives
- Warm acceptance unconditionally, particularly when therapists ensure that their positive feelings are communicated to clients made a positive difference.
- The therapist’s capacity to communicate and be congruent in what is said and done led to positive outcome.
- Providing feedback, problem solving and emotional support led to positive outcome.
- For individuals similar to those with ADHD who manifested impairment in two or more areas of life (family, social, occupational, school, etc.) greater benefit was derived from lengthier, more intensive treatment supplemented by psychoactive medication.
So what does this have to do with ADHD?
ADHD is a neurobiological disorder that is clearly not the result of bad parenting or other environmental adversities. Engage your common sense. Each of us has had an experience of feeling inadequate at one time or another. Each of us has had an experience of repeated failure despite effort. Think of how you coped and responded then think of dealing with those kinds of experiences on a routine, often daily basis in multiple settings. How would this affect your mindset and mental health?
The problems of children with ADHD result not only from an interaction of their neurology and the environment but also as the result of the coping strategies they develop, which as my colleague Dr. Robert Brooks points out, arise from their effort to cope with these adversities. The majority of children with ADHD experience repeated failure. This places them at greater risk to develop an external locus of control, feelings of helplessness and an inability to understand why they experience so much difficulty meeting the expectations of their world.
Is Counseling an Option for Children?
For these reasons, I believe that all children with ADHD at the time of diagnosis should be placed in short term counseling to assist them in developing an understanding of the manner in which they are coping with their environment and the reasons for their difficulties. Counseling can afford the opportunity to reduce feelings of helplessness, foster optimism, increase motivation and improve coping skills. Counseling can help children and adults with ADHD address issues about themselves and family members. Most importantly, forming a counseling alliance with a therapist capable of developing an empirically supported therapy relationship provides another layer of protection facilitating resilience and allowing an agreed upon means for dealing with problems whether current or future. Thus, in the case of ADHD, while therapy may not take place on a regularly scheduled basis, a therapist is likely to see a child or adult for that matter, repeatedly over many years.
In the absence of significant comorbid problems, the majority of children with ADHD do not exhibit difficulties requiring intensive psychotherapy. However, given the significant co-morbidity of depression and anxiety with ADHD a significant minority will require directed treatment for these conditions. In these circumstances, treatment modifications must be made, taking into account the impact executive functioning deficits will have upon a child, or for that matter adult, in their ability to benefit from empirically proven treatments for depression or anxiety.
Is Counseling an Option for Adults?
For adults with ADHD, therapists can not only provide emotional support but assist in helping these individuals develop time management, organizational skills, problem solving ability and anger management. As Dr. Robert Brooks pointed out in his chapter in my co-edited text with Ann Teeter Ellison, A Clinician’s Guide to Adult ADHD (2002), a therapist can help individuals with ADHD recognize that they have control over their lives, that success is not based on chance, that failure is not an indication of inadequacy and that they may have much to offer the world. As Dr. Brooks points out, each of these issues when addressed in psychotherapy can and will improve the daily lives of adults with ADHD. Finally, as Dr. Kathleen Nadeau points out in the very same text, since ADHD is primarily a neurobiological condition that effects behavior and emotions, psychotherapy must employ a cognitive rehabilitation model helping individuals gain skills, develop compensatory abilities and restructure their lives.
Cognitively based psychotherapy will not cure ADHD. I believe and suggest there is sufficient scientific evidence to strongly offer the opinion that psychotherapy can and does help individuals with ADHD – human beings suffering with a chronically impairing condition – cope and feel better, ultimately improving the quality of their lives. Though insurance companies increasingly refuse to compensate psychologists for their psychotherapy work with individuals suffering from ADHD, I strongly urge my professional readers to continue advocating for the important role of including psychotherapy in the treatment of ADHD across the life span.
Author: Sam Goldstein, Ph.D., University of Utah, School of Medicine