Diagnosis and Treatment with Attention Deficit Hyperactive Youth: Mental Health Consultation with School Counselors.

Attention deficit hyperactivity disorder (ADHD) can cause behavioral and academic problems for youth and can lead to problems in school. Mental health counselors are not trained as school counselors, and school counselors are not trained as mental health counselors. Yet school counselors are routinely expected to provide mental health interventions, and school personnel logically look to mental health counselors for answers to school problems. Mental health counselors can confidently step forward as external consultants to school personnel to help ADHD youth. Clinical consulting competence requires current information on diagnosis and assessment in order to avoid false positive diagnosis of ADHD symptoms, to properly intervene to reduce their symptoms where ADHD does exist, and to improve treatment compliance in schools.

Mental health counselors can serve as consultants to parents and school personnel, including school counselors, teachers, and principals. Mental health counselors know that attention deficit hyperactivity disorder (ADHD) is a public health problem resulting in a degree of morbidity and disability of children, adolescents, and adults (Wilens, Biederman, Abrantes, & Spencer, 1996), and that ADHD symptoms result in stress to families, schools, and individuals.

MENTAL HEALTH COUNSELORS AS CONSULTANTS

Because mental health counselors are usually not in the schools, and because school counselors are usually not mental health experts, children and parents can benefit by professional teaming where the needs of their ADHD children are concerned. If mental health counselors and school counselors do not work together, much less good will result than would otherwise occur in the lives of these youth. Lavin (1997) writes of parents and schools cooperating to help children with ADHD, and documented that parents are under stress and that schools can provide feedback about their children's classroom performance and behavior. Mental health counselors can assist school counselors in their work with these parents to make up for the fact that school counselor training is not in the mental health field (Erk, 1995). This teaming approach can help ADHD youth improve their functioning, even when parents may not see the educational system as a positive force for the mental health needs of their children (Kottman, Robert, & Baker, 1995). Along with some mental health counselors, many school counselors do not know the treatments that work for youth with ADHD, and so both are of less help to parents than they could be if they were better informed. Scant literature exists specifically for mental health consultants working with school counselors who must help ADHD youth, in spite of the fact that diagnoses of ADHD are rising (James & Nims, 1996). Because of this rise in need for consultation, mental health counselors must know the pivotal role they can assume in providing indirect service to ADHD youth within the school setting.

Purpose

This brief literature review has two purposes: (1) to provide diagnosis and assessment information to mental health counselors which they need if they are to avoid misdiagnosis or over-diagnosis of ADHD; and (2) to encourage mental health counselors to increase their consultation services to school counselors and other school personnel in order to assist ADHD youth. This article is intended as an overview only. More specific diagnostic information, ideas for intervention, and effectiveness of specific treatments used to relieve ADHD symptoms are beyond the scope of this article.

To satisfy the curiosity of mental health counselors who wish to know the information base for the ideas presented in this article, we must define the domain of our inquiry on this topic. Specifically, we searched four journals and covered a span of the past 5 years, including the New England Journal of Medicine, the Professional Mental Health Counselor (The Mental Health Counselor), Journal of Clinical Psychiatry, and Journal of American Academy of Child and Adolescent Psychiatry. A computer search was also conducted, using key terms such as ADD, ADHD, youth, psychosocial interventions, and behavior modification.

Summary of review. Mental health counselors can help school counselors become familiar with psychosocial interventions in order to help ADHD youth improve their academic and behavior performance and to assist parents when they become overwhelmed by the number of treatment options available (Kottman et al., 1995). In spite of the increasing numbers of youth diagnosed with ADHD, academic, cognitive, and behavioral interventions are limited. For this reason, we hope to inform mental health counselors so that they can serve as consultants to school counselors, who in turn would serve as consultants to teachers, parents, and principals. The goal is to better assist ADHD youth and their families.

OVERVIEW OF ADHD ASSESSMENT AND DIAGNOSIS

Recently, the Diagnostic and Statistical Manual of Mental Disorders (4th ed.). (American Psychiatric Association, 1994) introduced three subtypes of ADHD: predominantly inattentive, predominantly hyperactive/impulsive, or combined. ADHD symptoms must be present in two or more locations (e.g., home and school) to rule out false positive diagnoses of ADHD (Spencer et al., 1996).

Prevalence and Gender

Prevalence. The DSM-IV (1994) estimates that 3% to 5% of school-age children are affected by ADHD, but this estimate varies according to the population being sampled and the diagnostic criteria and diagnostic instruments used. These estimates also do not include preschool children, adolescents, or adults. Recent estimates of prevalence range from 4% to 12% for school-age children. Clearly, this is a problem of growing national concern.

Gender. Earlier research showed different risk factors and characteristics for girls and boys with ADHD. Although some studies indicate few differences based on gender, and other studies report important gender differences, teachers continue to identify more boys than girls with ADHD symptoms. According to Cantwell (1996), ADHD is diagnosed more in boys than in girls with a 9 to 1 ratio in clinical samples and a 4 to 1 ratio in epidemiological samples. Some studies report that girls have more inattentive and cognitive problems and fewer aggressive/impulsive problems than boys, although there is a general lack of information about ADHD in females. We do know, however, that boys are four times more hyperactive than girls and twice as inattentive (Biederman, 1998). Because ADHD lasts beyond childhood, with as many as 65% of children carrying the symptoms into adulthood (Dulcan, Benson, et al., 1997), mental health counselors must help parents and school professionals provide early interventions and management strategies for boys and girls now, so that in their adult lives they can maintain their coping skills to reduce the disturbing aspects of this disorder. Note that ADHD cuts across socioeconomic status, race, ethnicity, level of intelligence, and ego status (Popper, 1997).

Etiology of ADHD

Possible causes of ADHD. The cause of ADHD is unknown, but studies suggest heredity plays a key role. Polygenetic factors interact with psychological and perinatal conditions to produce ADHD (Biederman, 1998; Popper, 1997; Cantwell, 1996). This confluence of events produces a brain chemistry disorder when neurological chemicals become imbalanced. ADHD is associated with the dopamine (reuptake) transporter gene and the dopamine D4 receptor gene, again underscoring the probability of hereditary transmission (Erk, 1995). In fact, family aggregate studies show that children with ADHD often have one or more family members who have ADHD. Adoption studies also support a genetic rather than environmental explanation (Cantwell, 1996). In short, siblings and parents of an ADHD child have a greater chance of having ADHD than in the general population (Dulcan, Benson, et al., 1997).

Noncauses of ADHD. ADHD is not caused by psychosocial factors such as parent-child relationships, family dysfunction, parent-child conflict in communication, and negative verbalizations. Studies are inconclusive as to whether or not ADHD may be caused by brain damage, birth trauma, alcohol, drugs, caffeine, or smoking during pregnancy (Erk, 1995). A complete medical examination is necessary in order to rule ADHD in or out as a cause of symptoms that can masquerade as ADHD.

Diagnosing ADHD

Subtypes. Early diagnosis and treatment are essential. A delay in diagnosis brings greater difficulty in reducing ADHD symptoms (Erk, 1995). Although no specific diagnostic test exists, mental health counselors typically collect data from parents, school personnel, and the child (Findling & Dogin, 1998). Diagnosis must include evidence for the symptoms listed below under the subtypes of inattentive and hyperactive-impulsive (DSM-IV, 1994; Schwiebert, Sealander, & Bradshaw, 1998).

Inattentive subtype. A predominantly inattentive subtype diagnosis includes six or more symptoms from the categories listed below, which must occur often, must have lasted at least 6 months, and must have a negative effect on the child's development:

* Cannot pay attention or makes careless mistakes

* Cannot maintain attention to tasks

* Does not listen when directly spoken to

* Does not follow instructions nor complete tasks

* Has problems getting organized

* Does not attempt activities that require long-term mental effort

* Loses things

* Is easily distracted

* Is forgetful (DSM-IV, 1994)

Hyperactive-impulsive subtype. A predominantly hyperactive-impulsive subtype diagnosis includes six or more of the following symptoms, which must occur often, must have lasted at least 6 months, and must have a negative effect on the child's development:

* Fidgets while seated

* Often leaves seat

* Inappropriate and excessive running and climbing

* Cannot quietly play

* Acts motor driven

* Continually talks

* Blurts out answers before question is finished

* Cannot wait for one's turn

* Interrupts (DSM-IV, 1994)

Additional symptoms. In addition, some of the symptoms identified above must have been present before the age of seven, the problems associated with these symptoms must occur in two or more locations, there must be major social or academic impairment, no other disorder can better account for the symptoms, and no other single disorder contains the symptoms. For example, if the symptoms occur in the presence of a pervasive developmental disorder, schizophrenia, or other psychotic disorder, or if they are better accounted for by another psychiatric disorder, then by definition the diagnosis of ADHD cannot be made (Dulcan, Dunne, et al., 1997). This distinction is important because 50% to 95% of children fitting ADHD criteria actually have a different psychiatric disorder and not ADHD. In short, ADHD is a diagnosis of exclusion (Popper, 1997); if it is not anything else, then it may be ADHD.

Assessing ADHD

Cantwell (1996) proposed the following proper diagnostic approach: interview all the important adults in the child's life to determine where and with whom the symptoms occur; interview the child to evaluate her awareness of symptoms and difficulties; screen for a more appropriate disorder; require a medical evaluation to determine health, sensory, neurological, or other competing explanations for the symptoms; assess cognitive and achievement profiles; gather parent and teacher ADHD-rating scales; and assess speech, language and motor function.

Rating scales. Most frequently used rating scales are these: the parent and teacher Child Behavior Checklist; the Connors Parent and Teacher Rating Scales; the ADD-H: Comprehensive Teacher Rating Scale (ACTeRS); and the Barkley Home Situations Questionnaire and School Situations Questionnaire (Dulcan, Dunne, et al., 1997). Although Cantwell (1996) suggests that tests such as the Continuous Performance Task, the Wisconsin Cart-Sorting Test, The Matching Familiar Figures Test, and subtests of the WISC-R should not be used when assessing ADHD, the first author disagrees, and instead suggests that tests such as these must be used because of the need to use multiple tests to confirm an hypothesis of ADHD. In short, quantitative (objective tests) and qualitative sources (interviews) must be utilized in concert if we are to reduce diagnostic error.

WISC-III subscales. Arithmetic, Coding, Information, and Digit Span (ACID) profiles can be used to screen for ADHD youth. A mean ACID composite score that is two thirds of a standard deviation below average would be expected in a child with ADHD. Specifically, if a child scores below average in three of the four ACID subtests, the hypothesis of an attention-deficit disorder should be considered, because low scores on these subtests indicate problems with attention, concentration, and memory (Beutler & Berren, 1995). However, ADHD cannot be ruled out when the ACID profile is absent because a majority of children with ADHD may not exhibit this profile (Wechsler, 1991). So, although a child without the profile may have ADHD, we can be fairly confident that a child with the profile may have ADHD. Again, multiple measures are necessary and helpful in diagnosis.

Comorbidity

Examples of comorbidity. Because AHDH is often found in combination with other disorders in as much as 40% to 70% of the clinical samples of youth with ADHD, comorbidity must be considered. In fact, a pure case of ADHD may not even exist because of the rarity of children without comorbid conduct, oppositional-defiant, mood, and anxiety disorders (Popper, 1997). For example, although research in the United States on child mental disorders is underway, we know from a New Zealand study and similar studies in Puerto Rico and Canada that as many s 47% of hyperactive children had a coexisting conduct or oppositional disorder, 26% had a coexisting anxiety or phobia disorder, and 18% had two or more comorbid conditions (Richters et al., 1995).

Comorbid symptoms must be treated. In addition to treating ADHD, comorbid disorders must also be treated (Cantwell, 1996). In 80% of children who perform below their academic ability and who have learning disabilities, ADHD also exists (Schwiebert et al., 1998). At higher risk for school failure, these children may need help with oral expression, listening comprehension, written expression, reading skills, social interaction, problem solving, and organizational skills. Because comorbidity causes additional problems, mental health counselors need to advise school counselors that because ADHD is only one of the problems that these youth have, the other problems need to be addressed as well, thus requiring multiple interventions.

SERVING AS CONSULTANTS TO SCHOOL PERSONNEL

ADHD behavior puts children at risk for completing their education and for substance abuse, poor vocational experience, peer rejection, oppositional behaviors, and delinquency (Schwiebert et al., 1998). Mental health counseling interventions, taught to school counselors and parents, can help ADHD children cope with classroom demands, social areas, family situations, and with life. The mental health counselor must inform school counselors of the DSM-IV (1994) diagnostic criteria for ADHD so that school counselors can identify ADHD children, make parental recommendations, and help teachers develop strategies and curriculum for the classroom (Burnley, 1993; Kottman et al, 1995). The mental health counselor can help by working as co-therapists with school counselors; by conducting groupwork with ADHD children and their peers, siblings, parents, and caregivers; by providing social and academic feedback to parents and teachers; and by acting as a consultant to members of the home and school community.

Treatment Issues in the Schools

Growing controversy regarding medication and ADHD youth. Mental health counselors need to know of the growing controversy regarding an exponential increase in medicating children with ADHD over the past four decades. School counselors need advice on what they can comfortably recommend to parents, doctors, teachers, and children regarding the use of medication. School counselors also need advice on mediating when misunderstandings between caregivers and school personnel arise regarding the use of medication (James & Nims, 1996; Kottman et al, 1995).

Cultural importance. We found no research regarding cultural variation in ADHD children and their families. At the very least, however, mental health counselors need to be sensitive to different cultural interpretations regarding ADHD diagnosis (Schwiebert et al., 1998).

Legal importance. According to Section 504 of the Rehabilitation Act of 1973, ADHD children qualify for special education if they have a comorbid condition. In such cases, services and accommodations in the regular classroom are appropriate and can be recommended to school personnel (Mann, 1996; Schwiebert et al., 1998).

Interventions and training. Mental health counselors can serve as consultants to school personnel to teach ADHD interventions to school counselors, principals, teachers, parents, and youth. These interventions include behavior techniques, parent training, social-skills training, and cognitive behavior modification.

Behavior techniques are evident in the use of a daily report card, token economies, class rules, time out, feedback of positive and negative behaviors, a homework notebook, and relaxation training to control anger (Dulcan, Dunne et al., 1997). Specifically, mental health counselors can teach school counselors to focus on academics, behavior, and peer relationships. For example, school counselors can be encouraged to ask teachers to seat an ADHD child in the front of a structured classroom so the child experiences less distraction and can better focus on relevant matters. In addition, school counselors can be encouraged to help teachers and parents develop well-organized schedules with clearly defined rules that are then enforced, so that the child has a more predictable life (Cantwell, 1996). For example, school counselors can be encouraged to arrange to have a daily note sent home providing feedback on the ADHD child's behavior, daily homework, or other necessary information (Lavin, 1997). The school counselor can be shown ways to aid the teacher in creating individually adapted checklists that address a child's specific needs (such as daily behavior and homework), which the teacher would sign each day for the child to take to caregivers. Parents can award tokens if the checklist is brought home or if the child demonstrated improved behavior in specific target areas. Daily notes can later be substituted with weekly checklists to encourage emerging autonomy and responsibility.

Mental health counselors can teach school counselors to conduct parent training sessions to help parents develop in their children successful skills for positive relationships with their peers and with the adults in their lives. Short-term positive results are likely when parents are taught to use clear instructions and positive reinforcement and punishment (Dulcan, Dunne, et al., 1997). School counselors can be taught to help parents learn contingency management techniques and can also learn to help parents gain cooperation with school personnel. By consulting with school counselors, mental health counselors are providing indirect counseling to parents in order to reduce the ADHD child's disruptive behavior at home, to decrease family stress, and to increase parental self-confidence in their competence as parents (Cantwell, 1996). Parents can be helped to lower sensory stimulation so that distractions are minimized. Quiet areas for play or study can be designated, and rooms can be equipped with simple furniture and subdued colors, with toys and work materials out of sight. In addition, caregivers can be encouraged to monitor children attending parties, allow only a few visiting friends at a time, and shop in smaller stores. Changes such as these can relieve homes of some of the stress associated with ADHD symptoms, but they will not generalize to other settings without specific additional interventions (Popper, 1997).

Mental health counselors need to inform school counselors about the conditions for successful social-skills training. For example, school counselors often work with individuals, and so they may not be aware of the fact that individual instruction in social skills is usually not successful because the behavior to be changed cannot be seen. Instead, these skills can be taught in groups to allow the behavior to be observed. Modeling, practice, and feedback can then change target behaviors (Dulcan, Dunne, et al., 1997). Parents also can be taught successful ways to help their children use social skills when ADHD children experience peer rejection (Frankel, Myatt, Cantwell, & Feinberg, 1997).

Cognitive behavior modification is a specialty area for mental health counselors but not necessarily for school counselors or other school personnel. Mental health counselors can teach school personnel to combine cognitive strategies (stepwise problem solving) with behavior modification (reinforcement) in order to provide the necessary structure to help youth control their impulsivity and to increase their problem-solving skills. Popper (1997) reports that cognitive behavioral interventions can successfully help ADHD children to learn strategies to slow down impulsive responses, to focus attention, to learn not to gloss over errors, to double check for correctness, to manage aggressiveness, to handle temper tantrums, to create a stable environment, and to enhance social skills.

DISCUSSION

Attention deficit hyperactivity disorder is a complicated disorder that cannot be easily treated. Much remains unknown--why ADHD exists, why individuals are affected differently, why ADHD is often comorbid with other disorders, and why there is an increase in ADHD diagnoses.

Do psychosocial interventions work for ADHD youth? For most, ADHD is a life-long disorder. As such, parents and teachers grow weary, which can result in treatment noncompliance.

Regarding interventions with ADHD youth, we currently have few studies, clinical models, or theory. In addition, the scant information available is mostly based on white male children. Nevertheless, we know more now than ever about ADHD, and so mental health counselors can confidently begin to work directly with school counselors to design interventions for use in the classroom and at home. Mental health counselors are the logical leaders in this area, because they are the professionals who initially diagnose ADHD. Not all ADHD youth cause problems, have poor self-esteem, or need help, but for those who do, school counselors, parents, and teachers look to mental health counselors for help. Thus, mental health counselors are in a unique position to advise and to serve as consultants to schools. Although ADHD symptoms do not go away, they can be managed if the proper conditions are established and if the proper skills are taught. Medication and psychosocial interventions will reduce the symptoms of ADHD, but children need the help of all the principal players in their lives to work together if the positive effects of interventions designed to relieve their symptoms are to be maintained.

REFERENCES

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

Biederman, J. (1998). Attention-deficit/hyperactivity disorder: A life-span perspective. Journal of Clinical Psychiatry, 59(suppl. 7), 4-16.

Beutler, L. E., & Berren, M. R. (1995). Integrative assessment of adult personality. New York: Guilford Press.

Burnley, G. D. (1993). A team approach for identification of an attention deficit hyperactivity disorder child. The Mental Health Counselor, 40, 228-230.

Cantwell, D. P. (1996). Attention deficit disorder: A review of the past 10 years. Journal of American Academy of Child and Adolescent Psychiatry, 35, 978-987.

Dulcan, M. K., Benson, R. S., Dunne, J. E., Arnold, V., Bernet, W., Bukstein, O., Kinlan, J., McClellan, Jo, & Sloan, L. E. (1997). Summary of the practice parameters for the assessment and treatment of children, adolescents, and adults with ADHD. Journal of American Academy of Child and Adolescent Psychiatry, 36, 1311-1317.

Dulcan, M., Dunne, J. E., Ayres, W., Arnold, V., Benson, R. S., Bernet, W., Bukstein, O., Kinlan, J., Leonard, H., Licamele, W., McClellan, J., Sloan, L. E., & Miles, C. M. (1997). Practice parameters for the assessment and treatment of children, adolescents, and adults with attention-deficit/hyperactivity disorder. Journal of American Academy of Child and Adolescent Psychiatry, 36 (Suppl. October), 85S-121S.

Erk, R. R. (1995). A diagnosis of attention deficit disorder: What does it mean for mental health counselors and school health counselors. The Mental Health Counselor, 42,292-299.

Findling, R. L., & Dogin, J. W. (1998). Psychopharmacology of ADHD: Youth. Journal of Clinical Psychiatry, 59(Suppl. 7). 42-49.

Frankel, E, Myatt, R., Cantwell, D., & Feinberg, D. (1997). Parent-assisted transfer of children's social skills training: Effects on children with and without attention-deficit hyperactivity disorder. Journal of American Academy of Child and Adolescent Psychiatry, 36, 1056-1064.

James, S. H., & Nims, D. R. (1996). A catalog of psychiatric medications used in the treatment of child and adolescent mental disorders. The Mental Health Counselor, 43,299-307.

Kottman, T., Robert, R., & Baker, D. (1995). Parental perspectives on attention-deficit hyperactivity disorder. The Mental Health Counselor, 43,142-150.

Lavin, P. (1997). A daily classroom checklist for communicating with parents of children with attention deficit hyperactivity disorder. The Mental Health Counselor, 44, 315-318.

Mann, S. (1996). The ADD strategies worksheet. The Mental Health Counselor, 44, 155-157.

Popper, C. W. (1997). Antidepressants in the treatment of attention-deficit/hyperactivity disorder. Journal of Clinical Psychiatry, 58(Suppl. 14), 14-29.

Richters, J. E., Arnold, L. E., Jensen, P. S., Abikoff, H., Conners, C. K., Greenhill, L. L., Hechtman, L., Hinshaw, S. P., Pelham, W. E., & Swanson, J. M. (1995). NIMH collaborative multimodal treatment study of children with ADHD: I. Background and rationale. Journal of American Academy of Child and Adolescent Psychiatry, 34, 987-1000.

Schwiebert, V. L., Sealander, K. A., & Bradshaw, M. L. (1998). Preparing youth with attention deficit disorders for entry into the workplace and postsecondary education. Professional School Counseling, 2(1), 26-32.

Spencer, T., Biederman, J., Wilens, T., Harding, M., O'Donnell, D., & Griffin, S. (1996). Pharmacotherapy of attention-deficit hyperactivity disorder across the life cycle. Journal of American Academy of Child and Adolescent Psychiatry, 35, 409-432.

Wechsler, D. (1991). WISC-III: Wechsler Intelligence Scale for Children - Third Edition Manual. San Antonio, TX: Psychological Corp.

Wilens, T. E., Biederman, J., Abrantes, A. M., & Spencer, T. J. (1996). A naturalistic assessment of protriptyline for attention deficit hyperactivity disorder. Journal of American Academy of Child and Adolescent Psychiatry, 35, 1485-1490.

Alex S. Hall, Ph.D., is an professor and counselor educator with The University of Iowa, Iowa City, IA. Email [e-mail]. Arlinn G. Gushee is a teacher at Urbandale Middle School, Urbandale, IA.