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Strength-based mental health counseling for children with ADHD: an integrative model of adventure-based counseling and Adlerian play therapy.

The hyperactivity and impulsivity experienced by children who are diagnosed with attention deficit/hyperactivity disorder (ADHD) can pose challenges for families, teachers, and mental health counselors (Barkley, 2000). The authors present an integrative model of Adlerian play therapy and adventure-based counseling (ABC) that extends beyond traditional talk therapy, fosters a strength-based perspective, and is action-oriented and dynamic. Specific ABC treatment activities for working with children and families affected by ADHD are presented in the context of the four phases of treatment in Adlerian play therapy.

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The National Institute of Mental Health (NIMH, 2007) estimates that children with attention deficit/hyperactivity disorder (ADHD) account for 2%-5% of the population in the United States. As a result, some 2 million children exhibit symptoms of ADHD, which has become the most frequently diagnosed childhood neurobehavioral disorder (Furman, 2005). It has been estimated that more than half of children diagnosed with ADHD will retain the diagnosis into adulthood (Shelley-Tremblay & Rosen, 1996). The core symptoms of ADHD (American Psychiatric Association [APA], 2000) are elevated levels of inattention, hyperactivity, and impulsivity that impede functioning and occur persistently in multiple settings. These symptoms can require creative counseling approaches that are dynamic, action-oriented, and beyond the scope of traditional talk therapy (Hanna, Hanna, & Keys, 1999).

The increasing expectations and demands placed on children today are drastically affecting their ability to function in classrooms, family settings, and social activities with same-age peers (Landau, Milich, & Diener, 1998). To enhance children's success in dealing with social pressures, classroom expectations, and changing environmental expectations, this article integrates adventure-based counseling (ABC) and Adlerian play therapy to provide a strength-based approach for mental health counselors working with children diagnosed with ADHD. Integrating ABC and Adlerian play therapy can provide a strength-based perspective for children to grow and develop with limited demands and expectations. Mental health counselors with a wellness model of holistic health are empowered by the basic philosophies of the theory to advocate for children to achieve belonging, significance, and a perception of self-worth within their social construct.

The Association for Play Therapy (1997) defined play therapy as "the systematic use of a theoretical model to establish the interpersonal process in which ... the therapeutic powers of play in counseling help clients prevent or resolve psychosocial difficulties and achieve optimal growth and development" (p. 4). Using play has been reported to provide children with a natural environment to communicate feelings and insights about self, others, and the world. The demands of talk counseling for children between the ages of 3 and 10 may be considered to be too difficult, straining, and incompatible with their developmental readiness (O'Connor, 2000). Therefore, using play may be more effective in counseling because children's capacity for abstract reasoning, thinking, and making meaning through verbal articulation of their personal thoughts, feelings, and reactions may imply inappropriate expectations (Kottman & Warlick, 1989). The Adlerian emphasis on conceptualizing behaviors, private logic, and family dynamics provides a framework for mental health counselors to competently assess children's functioning (Sweeney, 1998); expectations that embrace children's hyperactivity and impulsivity may enhance children's therapeutic gains.

Adventure-based counseling (ABC) integrates group counseling, experiential learning, and outdoor education (Fletcher & Hinkle, 2002; Glass & Myers, 2001; Glass & Shoffner, 2001). ABC creates therapeutic encounters in which clients learn through a hands-on approach. Engaging children in ABC encourages their use of personal strengths while harnessing their need to exert energy. As a treatment modality, ABC reframes ADHD features from negative behaviors to adaptive strengths. High energy and attention-seeking, typically perceived as challenging and exasperating, can be channeled for successful interactions and completion of tasks within ABC activities. Furthermore, ABC activities typically function as a metaphor for everyday stressors, thereby providing an active and dynamic approach to addressing the needs and issues of children with ADHD (Fletcher & Hinkle; Glass & Myers).

Children's needs are explored by counselors and children through the collaborative approach of Adlerian play therapy. Through collaboration and ABC strategies, the mental health counselor may explore the client's mistaken goals, faulty assumptions, lifestyle, and ability to strive for significance (Kottman, 1999). Refraining expectations for children with ADHD by integrating activities to harness their impulsive movement and energy allows for a more strength-based developmental counseling perspective. Creating an atmosphere with play and ABC activities can offer children a less demanding environment, thus decreasing the pressure for them to perform verbally and increasing self-expression (Fletcher & Hinkle, 2002; Schoel, Prouty, & Radcliffe, 1988). In what follows, we describe how mental health counselors can integrate ABC into the four phases of Adlerian play therapy to embrace the challenges of helping children with ADHD deal with their struggles and feel empowered.

A PARADIGM SHIFT IN THE TREATMENT OF ADHD

Current research has provided evidence of the most beneficial treatments of ADHD. The most common treatment, drug therapy, consists of stimulant medications such as Ritalin (methylphenidate), Dexedrine (dextroamphetamine), and Cylert (pemoline) (Greydanus, 2005; Olfson, 2004). The Multimodal Treatment Study of Children with ADHD (MTA Cooperative Group, 1999) focused on discovering the most efficacious treatment for children diagnosed with ADHD (Edwards, 2002). The results indicated that a family-based, behavioral-oriented, multimodal, and multisystemic approach is more effective than behavioral treatment alone, medication alone, or a placebo (Edwards). The study suggested that children who received counseling services, parental and educational support, and medication had the most success in academic adjustment, increased parental management, and child management of behaviors. As a result of this study, many health professionals continue to rely on medication as the primary treatment. The ABC approach would nicely encompass a combination of the necessary components to more effectively treat ADHD.

Specifically, the integration of ABC with Adlerian play therapy provides opportunities to embrace children's needs, parental involvement, peer support, and counseling. This integrative approach would require a paradigm shift beyond standard drug therapy. Adlerian theory has been applied in educational settings, parent education, family counseling, and group work--all important areas of application for children diagnosed with ADHD (Kottman, 2003; Sweeney, 1998). ABC is an active and dynamic treatment approach that harnesses the inherent energy and builds on the strengths of children rather than treating symptoms with drug therapy. Adlerian play therapy consists of four phases: (a) building an egalitarian relationship with children, (b) exploring their lifestyles, (c) helping them gain insight into their lifestyles, and (d) reorienting and reeducating them (Ansbacher & Ansbacher, 1978; Kottman, 1995; Snow, Buckley, & Williams, 1999; Sweeney). Table 1 provides a synopsis of these phases, related counselor loci, relevant ABC issues, and potential ABC interventions.

ABC and the First Phase of Adlerian Play Therapy

The first phase of Adlerian play therapy concerns the most essential requirement for the counseling process, namely the development of the counseling relationship (Kottman, 2003; Kottman & Johnson, 1993; Manaster & Corsini, 1982; Sweeney, 1998). The cooperative relationship may be established by sequencing counseling activities to begin with the least challenging activities and progress to the more challenging, a critical component of ABC. This promotes an egalitarian counseling relationship with children through ABC activities and the use of such essential skills as tracking, restatement of content, and reflection of feelings (Fletcher & Hinkle, 2002; Schoel, Prouty, & Radcliffe, 1988). In this approach mental health counselors begin sessions by engaging children in activities that are considered "low demand" so that the clients experience a counseling relationship that is fun and enjoyable with minimal physical, emotional, and mental challenge. As counselors track behaviors and restate content, they are indicating to the children that their feelings, behaviors, and communication attempts are important (Kottman & Johnson, 1993). Reflecting children's feelings may increase their ability to become more self-aware and offer opportunities for them to clarify emotional reactions while connecting on an affective level with counselors.

Along with reflecting emotion, a signature aspect of Adlerian play therapy is to display encouragement throughout counseling (Kottman, 2003; Kottman & Johnson, 1993; Manaster & Corsini, 1982; Sweeney, 1998). Encouragement can increase children's understanding of their abilities and strengths by highlighting their feelings, reactions, and behaviors (Kottman & Johnson). This is especially crucial for children with ADHD, who typically experience feelings of inadequacy and rejection.

One ABC activity mental health counselors may utilize while developing relationships with children is named Circles of Comfort (Kottman, Holtz, & Ashby, 2008, p. 99). To facilitate Circles of Comfort counselors may use ropes, webbing, string, or yam to form a circle, inside which a smaller circle should be created. The facilitator begins by asking the participants to stand outside the large circle. The facilitator explains that the circles represent differing degrees of comfort: the inside of the small circle represents the "comfort zone," the space between the small circle and the large circle represents the "challenge zone," and the outside of the large circle represents the "chaos zone" (Kottman, Holtz, & Ashby). Facilitators then make topic statements that are pertinent to the needs of their participants, giving particular attention to ensuring an environment and topics that are safe for discussion. Participants are encouraged to move to the appropriate level of comfort based on the topic stated. Topic statements may include things such as reading in front of a group of people, singing solo, acting in a play, swimming in the ocean, or sharing ideas with others. The facilitator may then use processing statements to explore the level of comfort participants choose, asking about, e.g., what pressure was experienced when selecting where to stand, what struggles were experienced, what circle the participant stood in the most, what changes they might want to make about their comfort levels, and what they learned about themselves and others in the group (Kottman, Holtz, & Ashby). This activity begins the process of moving around, listening, and focusing energy. The facilitator's role is to observe the reactions and interactions of the participants. If the facilitator notices challenges or inappropriate interactions, limits will need to be set (Rohnke & Butler, 1995).

Setting limits is also an initial strategy in building relationships and establishing a sense of safety while engaging in ABC activities (Fletcher & Hinkle, 2002; Schoel, Prouty, & Radcliffe, 1988). Setting limits can increase childrens' success in counseling by instilling a clear understanding of the rules, defining the concept of confidentiality, excluding behavior that is harmful to self and others (such as destruction of property), and eliminating other destructive behaviors. It is important, however, that mental health counselors encourage the children's verbal expression of feelings. Encouraging freedom of expression can increase children's carefree self-expression throughout the activities. Counselors need to clearly establish that all ABC activities are created for the participants to be "challenged by choice" (Rohnke & Butler, 1995), which means that each participant is encouraged to choose the degree of participation and engagement with others in the activity. In this first phase of Adlerian play therapy, setting limits models appropriate ways to express feelings of hyperactivity and impulsivity, which is a critical skill for children with ADHD to develop (Barkley, 2000; Kottman, 2003).

ABC and the Second Phase of Adlerian Play Therapy

The second phase can begin when children and mental health counselors have developed and are building an egalitarian relationship (Kottman, 2003; Sweeney, 1998). Counselors may explore children's lifestyles by assessing their goals of behavior via family atmosphere, family constellation, and early recollections. As the children's behaviors are explored through their lifestyles, misbehaviors identified by parents or counselor are also addressed. Children diagnosed with ADHD often feel discouraged, inadequate, hopeless, and worthless (Barkley, 2000). They may be disruptive in the classroom in an effort to seek attention or power (Kottman & Warlick, 1989). A significant number of children are referred for mental health counseling due to power-seeking behaviors that result in disruptive interrupting, changing topics in conversations, struggles with turn-taking, and trying to out-perform others, all of which can adversely affect school success and home performance (Kottman & Warlick).

Adlerian play therapy focuses on the four goals of misbehavior: attention, power, revenge, and inadequacy (Dreikurs & Soltz, 1964). These are the most common forms of behavior children use in attempting to achieve meaning and identity. When children are unable to achieve significance or gain the attention they need, they manifest a belief of inadequacy, assume they are helpless, and believe they will never be able to succeed in life (Kottman & Johnson, 1993). Using these goals of misbehavior as a context for conceptualizing children's choices provides a foundation for treatment from an ABC perspective, and use of ABC activities can inform mental health counselors about specific goals of misbehavior and create an environment for children to learn how to effectively engage in behaviors that meet their needs (Fletcher & Hinkle, 2002).

One example would be to initiate an activity where the children perceive themselves as the leader of the activity, such as Obstacles of Empowerment. In this activity, the mental health counselor provides materials for an obstacle course, including equipment such as a jungle gym, balls, trees, swings, slides, and monkey bars (indoors chairs, toys blocking hallways, tunnels, balls, and tables to crawl under might be used). Participants determine among themselves who will be the first to create a course for each individual to navigate. Each can run through the course individually while the facilitator encourages other participants to provide peer support to improve focus and self-acceptance.

Once the participants have navigated the course, the facilitator will explore how they felt while doing so and encourage discussion of what participants perceived to be helpful, what was most challenging, and how they worked through the challenges. The participants can also discuss ways to complete the course in less time when given an opportunity to improve their time as a group. The counselor's role is to help children feel safe and supported, and to promote an experience that encourages socially acceptable leadership behaviors. When providing counseling to a single child, the child can similarly create a course and complete an initial run-through while being timed and then try to beat the initial time. The purpose of this activity is to offer the child a chance to be creative while having a sense of control and engaging in problem-solving strategies.

The second phase of Adlerian play therapy also involves actively exploring the family atmosphere, interactions, and constellation (Kottman, 2003; Sweeney, 1998). Information is gathered from children during play and ABC experiences and from the parents during a consultation. The mental health counselor should pay particular attention to the parents' personalities, structure of discipline, family values, and relationship with each other and with the children. The counselor assesses the family constellation during the parental consultation and throughout the play therapy process. The family atmosphere and the family constellation should also be explored from the children's perspectives and be given more weight in treatment planning than the family's views (Kottman & Warlick, 1989). Counselors may gather information from children by giving them an opportunity to play with figures representing family members and toy houses. This may provide children with an opportunity to demonstrate parenting methods, discipline, interactions among siblings, and the family's intentions and beliefs. Children might also be encouraged to construct their experiences using manipulative objects, such as marshmallows, tooth picks, and Play-Doh.

One ABC activity that provides insight into familial patterns and interactions is Crossing the Hot Chocolate River (Burg, 2002). This activity requires family members to cross a symbolic river created between two parallel tape strips in a large room. Crossing the River is a metaphor for navigating family issues and concerns. The ABC activity is initiated by the facilitator explaining that crossing the river is necessary to reach their goals as a family, but the important fact is that the participants cannot "touch" the chocolate in the fiver because it is too hot. Family members are allowed to use carpet squares or something similar as stepping stones across the "river."

The facilitator can modify the challenge level by determining how many stepping stones are available and deciding if there is a time limit (typically two to three minutes) for how long the stepping stones are to be in the river (Burg).The participants are allowed time to brainstorm and communicate strategies for completing the initiative. Examples of such strategies include the sequencing of who crosses and how to return the squares to the other side so that every family member can use them. This ABC activity can be especially useful in the second phase of Adlerian play therapy because counselors can gain insight into the family's communication, interaction, and coping mechanisms (Burg, 2002). The use of a metaphorical activity may create a less threatening environment for a family to display these patterns and process what worked well for the family and what did not.

ABC and the Third Phase of Adlerian Play Therapy

In the third phase, the mental health counselor and the children explore hypotheses about the children's thoughts, behaviors, attitudes, perceptions, and the counseling relationship. The goal is for children and their families to gain insight into their lifestyle that will lead to cognitive, behavioral, attitudinal, perceptual, and relational shifts during the final phase of Adlerian play therapy (Dinkmeyer & McKay, 1989; Kottman, 1995, 1999; Lew & Bettner, 1996, 1998). The counselor can construct tentative hypotheses about the family's life experiences and share them using the children's art work, metacommunication, metaphors, and bibliotherapy to increase awareness and create insight into their life experiences. Parents are also taught Adlerian parenting strategies, such as recognition of behavior goals, logical consequences, and encouragement (Dinkmeyer & McKay; Kottman, 1995, 1999; Lew & Bettner). Including the parents in the counseling process may increase the opportunity for change among all family members. Providing parents with skills for interpreting their children's behaviors may encourage the development of strategies for all family members to cope with ADHD impulsivity and hyperactivity.

Within the third phase of Adlerian play herapy, an activity like Crossing the Hot Chocolate River may also be used to highlight family patterns of interaction (Burg, 2002). As families project their experiences and relationships into the ABC activity, their roles, boundaries, and rules can be made explicit, thereby creating some change in the family's interactional patterns (Gass, 1993). The emphasis in this phase of counseling is on creating insight, so the processing of an activity like this one creates a method for increasing meaningful child and parent understanding.

Building more effective communication patterns enables parents to clearly express their needs and desires for their children. Clear expression of self and being understood is an imperative step toward engaging in the third phase of Adlerian play therapy. One activity to foster strengthening of communication is Building Communication. This activity allows parents to actually see how communication may be misleading, misunderstood, and complicated by abstract comments and statements. To begin Building Communication, instruct parents to sit back to back (so they cannot see each other) and choose which will be the listener and which the communicator (speaker). Once they have chosen their role, give them each an identical bag of Lego blocks. The communicator builds a structure with the blocks that is not visible to the listener, and once the structure has been built instructs the listener on how to build an identical structure. The listener is not allowed to ask questions and must follow instructions through active listening. Once the listener has followed all the instructions, have the parents compare their structures. Process with the parents what communication processes worked and what became a communication challenge. If children are present, have them watch for misleading communication during the activity, so they may be integrated into processing after the activity has been completed. Counselors may use this as an opportunity to highlight communication strengths and areas for potential growth in communicating.

As the third phase of Adlerian play therapy continues, the mental health counselor helps children and parents better understand their assets and behavioral goals (Kottman, 2003). Through this process children and parents achieve insight into how their behaviors affect their sense of belonging and significance (Kottman). In order for children to better understand their behaviors and how they affect their interpersonal relationships, counselors are encouraged to provide opportunities for parents to experience the world their children with ADHD endure.

One activity that may be effective for helping parents examine their children's experiences is the Distraction Field (adapted from Minefield, as described in Rohnke & Butler, 1995). The Distraction Field provides an opportunity for parents to briefly experience the environmental, interpersonal, and intrapersonal challenges facing their children. Before the parents arrive for the counseling session, the counselor can set up an area 20 feet by 20 feet for one parent dyad and double the size for a more effective experience for additional parents. In this space there should be numerous stimulus items (distractions) of interest for the children that could include visual distractions such as dolls, balls, trucks, transformers, beach balls, hula hoops, chairs, stuffed animals, and other items. Auditory distractions might included televisions, radios, and noise makers. As the parents arrive, ask them to stand on the outside of the Distraction Field and explain to them that their children with ADHD experience numerous distractions in every interaction and environment throughout their day. Explain that the Distraction Field has been designed to give them an opportunity to experience the overstimulation their children face. Ask one parent to stand on one side of the Distraction Field while the other stands on the opposite side. The most pivotal component of this activity is that one parent is blindfolded and must cross the field in silence following the verbal directions of the other parent and must not encounter any objects. If participants bump or step on an item, they must go back and begin crossing again until they have crossed without encountering objects.

After both parents have crossed the Distraction Field, process with them what communication process worked well with the auditory and visual distractions, how they processed the directions with the extra stimulation, and how the extra stimulation affected their connection with the other parent. It is be important to connect the parents' experiences with the impact of ADHD in their children's environment. Furthermore, it is imperative that counselors provide opportunities for parents to inspect their children's beliefs and interactions with others based on this experience and how their parenting strategies might be adapted to decrease their children's ineffective behavior patterns. Understanding children's strengths and the potential triggers for ineffective behaviors enables parents to adopt family dynamics that are congruent with their desired lifestyles and beliefs about a sense of belonging (Kottman, 2003).

While parents can better understand the effects of ADHD through this activity, children may gain insight and awareness of their own strengths by crossing the Distraction Field. Counselor and parents can work together with children to devise strategies for effectively crossing without giving in to the diversions. This can be done by allowing the children to specify the distractions that most impact their concentration and to put those distractions into the field for the child to navigate. As a result, both children and parents gain from practicing ways to communicate needs, block distractions, and Find ways to overcome such challenges.

ABC and the Fourth Phase of Adlerian Play Therapy

In the fourth phase counselors can help children and parents learn and practice new interactional patterns to consolidate changes in cognition, attitudes, and perceptions, and to generalize the changes into other situations and relationships (Kottman, 1999). This re-education process might involve the mental health counselor, child, parents, and teachers. The role of the counselor is to teach problem-solving, identify possible solutions, test the effectiveness of the solutions, and evaluate how decisions are made (Kottman & Warlick, 1989). Identifying when a problem has arisen and how to communicate needs when problem-solving is an effective communication tool to teach children and families.

Kottman and Warlick (1989) begin the problem-solving process by asking the child to directly state the problem. Once the child has defined the problem, counselors will explore with the child possible ways to solve the problem perceived. Children should be encouraged first to choose solutions they want to try or to explore options and then to explore if the solution they chose is working and how the process of deciding on a solution benefits them. Children with ADHD may benefit from the structure of the questions and the repetition of this process for multiple problems and in multiple environments.

Providing children with a natural environment for practicing problem-solving is effective for generalization of skills, but most counseling sessions do not occur in their homes. To address this issue, the skills need to be practiced through interactive play settings. One ABC activity that effectively promotes the practice of problem-solving skills is rock climbing. By using a community rock wall, children are presented with an opportunity to problem-solve and experience immediate results. Mental health counselors can facilitate this activity by discussing with the children how they will achieve their climbing goal. After goals have been set and all safety measures have been taken, the children are allowed to climb.

After the first climb, mental health counselors should facilitate discussion of the children's experiences. Facilitators are encouraged to explore the most challenging aspects of the climb and what was helpful to the children as they climbed. During this exercise, children may specify challenges with the height of the wall, their strength, and a general fear of falling. As they express these fears, the counselor's role is to facilitate discussion of what is in place to protect them, such as the ropes, harness, helmet, and floor pads. Counselors are encouraged to provide opportunities for children to make connections between the protection equipment and those people in their lives who support them when they are scared or challenged. For instance, counselors need to discuss with the children how the ropes provide a secure support to prevent failing, and then have the children describe the support they receive from others and relate this to how the ropes provide support.

Next, counselors can explore what the children would do differently to climb higher. The role of the counselor is to help the child connect each rock to a separate obstacle in their lives that they can overcome. To further help children gain meaning from this experience, counselors might encourage them to name the obstacle they will overcome as they climb higher. During this process, it is useful to facilitate discussion of the children's willingness to challenge themselves to overcome their obstacles and address how these problem-solving strategies could be applied in real life settings. In addition to experiencing problem-solving strategies in the present, the role of the counselor is to help children problem-solve ways to achieve success when faced with future challenges.

The mental health counselor's role during this fourth-phase activity is to facilitate the children's experience and perhaps also to belay (control the climbing rope while a person climbs) the children on the rock wall. The children's trust in the belayor might be addressed. Carefully processing each role with the children is important for building trust in the counseling relationship and highlighting what to expect from a potentially scary experience. As counselors explore how children perceive their role, they are demonstrating that their thoughts and experiences count. Children who challenge themselves to accomplish their goals both on the rock wall and in real-life settings may feel a sense of worth and accomplishment.

IMPLICATIONS FOR MENTAL HEALTH COUNSELORS

Mental health counselors consistently encounter challenges like impulsivity, distractibility, and hyperactivity in working with children who have been diagnosed with ADHD who may not benefit greatly from traditional talk therapy (Hanna, Hanna, & Keys., 1999). Integrating Adlerian play therapy and ABC is a possible way to harness the inherent energy of children diagnosed with ADHD while simultaneously reflecting on their strengths and developing their relationship-building skills. This integrative model offers strategies for counseling children and methods for consulting with and educating parents and teachers (Kottman, 2003; Kottman & Johnson, 1993; Manaster & Corsini, 1982; Sweeney, 1998). Mental health counselors from other theoretical perspectives could likewise find value in integrating ABC interventions into their clinical work with children with ADHD.

We have described how the four phases of Adlerian play therapy provide a framework in which to integrate ABC treatment activities. Because the focus of the first phase is on relationship-building, ABC activities that are fun, undemanding, and initiate interpersonal interaction may be most helpful (Schoel, Prouty, & Radcliffe, 1988; Sweeney, 1998). In the second phase of Adlerian play therapy, the counselor explores the child's family constellation and lifestyle. ABC activities that highlight interaction styles, interpersonal behaviors, and private logic are most helpful during this stage. The third phase focuses on raising the awareness of the child and the family about patterns and purposes of behaviors, and counselors process ABC activities with these goals in mind. The final phase requires a transfer of learning and the development of greater problem-solving skills (Kottman, 2003; Sweeney). ABC activities that provide challenges that can be translated into real-life metaphors are most helpful in this stage (Fletcher & Hinkle, 2002).

This integrative model of adventure-based counseling and Adlerian play therapy provides mental health counselors with a creative, strength-based, dynamic, and action-oriented treatment approach for children diagnosed with ADHD. Engaging in ABC activities from an Adlerian play therapy perspective enhances the role of counselors as they empower children to harness their impulsivity, hyperactivity, and excess energy and create opportunities for them to learn how to relate socially. Further, the group format of most ABC activities fosters interpersonal relationships among children, enhancing their social belongingness (Fletcher & Hinkle, 2002).

As mental health counselors engage with children, they can work to uncover ways to help them detect their self-defeating behaviors and gain insight into the purpose of these behaviors. Training children to maintain these skills may result in increased social counectedness and personal satisfaction. To enhance personal growth, counselors may use ABC methods to promote children's awareness of self-defeating behaviors while empowering them to gain immediate insight into how these behaviors are harmful to their social relationships (Kottman, 2003). As a result of this cooperative interaction, children and counselors can develop alternative methods for coping successfully with life (Kottman & Warlick, 1989).

POTENTIAL LIMITATIONS AND FUNCTIONS

Although ABC interventions have potential benefits for the counselor and participants, there are several limitations on integrating such activities into current counseling practice. Several of the activities described in this article require specialized training, supervision, and purchase of materials. In addition, mental health counselors who are reimbursed by private insurance, Medicare, and Medicaid, may need to provide outcome data to support ABC interventions, and such data are scarce. Reimbursement for counseling service based on location of service is an additional concern. Counselors providing services outside an agency may not receive insurance reimbursement because this may result in a liability for mental health agencies.

Despite its potential usefulness, there is no research that specifically explores the outcome benefits of integrating Adlerian play therapy and ABC with children diagnosed with ADHD. Further research is thus warranted; variables in the research could be self-esteem, impulse control, appropriate affective expression, effective coping with hyperactivity, problem-solving skills, feelings of belongingness, and self-efficacy. One example would be a quantitative study that focuses on a specific ABC intervention and assesses its impact on child and family in terms of the development of problem-solving skills. An outcome study specific to children with ADHD could compare clients experiencing an integrative treatment model of Adlerian play therapy and ABC with clients receiving other types of counseling from the perspective of change over sessions related to impulse control, self-efficacy, and behavior modification. Similarly, single-case experimental design may hold promise for demonstrating the effectiveness of the proposed model. Another potential research project would be to conduct a qualitative focus group with parents after various ABC activities or after a course of counseling using the integrated ABC and Adlerian play therapy model.

The findings from the Multimodal Treatment Study of Children with ADHD (MTA Cooperative Group, 1999) suggest that effective treatment for children diagnosed with ADHD requires a multidimensional approach that is family-based and behavioral oriented (Edwards, 2002). The integrative model provides a multisystemic perspective that actively integrates the family in counseling sessions. Involvement of the family is critical because the therapeutic benefits of counseling affect family members as well as children diagnosed with ADHD. The implementation of ABC interventions creates opportunities for both children and parents to receive feedback on communication, familial interactions, leadership, behavioral management, and impulse control. Such a multifaceted approach can facilitate a familial paradigm shift that has a multisystemic impact, which has been correlated with the most efficacious treatment for children with ADHD.

The integration of ABC and Adlerian play therapy provides a unique, strength-based, dynamic, and creative treatment model for children with ADHD. It requires a paradigm shift beyond standard treatment based primarily on psychotropic medication. This integrative model embraces the inherent energy of children with ADHD and actively involves the family in therapeutic processes (Fletcher & Hinkle, 2002; Kottman, 2003; Sweeney, 1998). Depending on their approach, mental health counselors can implement this model as an overarching philosophical approach or may integrate therapeutic strategies identified in this model.

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Torey L. Portrie-Bethke is affiliated with the University of North Texas. Nicole R. Hill and Jerid G. Bethke are affiliated with Idaho State University. Correspondence about this article should be addressed to Torey L. Portrie-Bethke, Department of Counseling and Higher Education, University of North Texas, P.O. Box 310829, Denton, TX 76203-0829. E-mail: Torey.Portrie-Bethke@unt.edu.
Table 1. Synopsis of the Integrative Model of Adlerian Play
Therapy and ABC

Adlerian Phases
of Counseling Counselor's Focus

1. Building an --Reflecting feelings
 egalitarian
 relationship --Tracking statements
 with child
 --Providing
 encouragement

 --Building rapport
 and joining

 --Setting limits

2. Exploring --Exploring goals of
 child's behaviorst
 lifestyle misbehavior, family
 atmosphere, family
 constellation, early
 recollections

 --Creating an
 atmosphere for
 child to gain a
 sense of control
 over environment

 --Investigating how
 child views self
 and others

 --Conceptualizing
 child's choices for
 ABC treatment
 perspective

3. Encouraging --Exploring child's
 the child to ideas about thoughts,
 gain insight behaviors, attitudes,
 into his or her perceptions, and the
 lifestyle counseling
 relationship

 --Constructing
 tentative hypotheses
 about child's
 experiences to create
 insight into life
 experiences

 --Providing parents
 with parenting skills,
 such as recognizing
 child's behavioral
 goals, logical
 consequences, and
 encouragement

 --Enhancing child's
 sense of belonging and
 interpersonal
 relationships

4. Reorienting --Educating parents
 and reeducating and child on new
 interactional patterns
 to enhance changes in
 cognition, attitudes,
 and perceptions

 --Teaching problem-
 solving, brainstorming
 possible solutions,
 identifying
 possibilities, testing
 solutions, and
 evaluating process of
 decision-making

Adlerian Phases
of Counseling ABC Issues

1. Building an --Sequencing to ensure
 egalitarian beginning activities
 relationship are nonthreatening
 with child and provide
 opportunities for
 success

 --Limiting challenges
 within ABC
 interventions

 --Focusing on fun and
 interaction so that
 the child will
 engage in an
 authentic manner

2. Exploring --Providing guidance
 child's to help child
 lifestyle develop appropriate
 control over
 situation and others

 --Supporting child's
 insight into
 creative
 problem-solving,
 metaphors, and
 teamwork

3. Encouraging --Increasing child and
 the child to parent understanding
 gain insight and insight into
 into his or her behaviors by
 lifestyle challenging the
 child and parents
 with ABC activities

 --Embracing impulsivity
 and hyperactivity with
 challenges that promote
 personal choice and
 responsibility

 --Processing
 experience with child
 and parents to
 highlight behavioral
 strengths and
 significance

4. Reorienting --Providing a natural
 and reeducating environment for
 practicing and
 rehearsing effective
 problem-solving and
 interpersonal skills

 --Guiding child and
 parents to identify
 connections in ABC
 experiences and real-
 life events

 --Transferring
 learning and insight
 into life
 relationships and
 experiences

Adlerian Phases Potential ABC
of Counseling Interventions

1. Building an --Introductory
 egalitarian interventions that
 relationship encourage the child
 with child to share experiences
 and personal
 qualities

 --Interventions that
 reduce inhibitions
 and encourage
 movement and fun

 --EXAMPLE: Circles of
 Comfort

2. Exploring --Initiating
 child's interventions that
 lifestyle enhance child's
 feelings of safety,
 support, and
 socially acceptable
 leadership
 behaviors

 --Sequencing ABC
 challenges to promote
 problem-solving and
 personal responsibility

 --EXAMPLES: Obstacles
 of Empowerment and
 Crossing the Hot
 Chocolate River

3. Encouraging --Encouraging parent-
 the child to child interaction
 gain insight
 into his or her --Enhancing
 lifestyle opportunities for
 demonstration of
 parenting skills and
 communication
 strengths

 --EXAMPLE: Distraction
 Field and Building
 Communication

4. Reorienting --Challenging child to
 and reeducating achieve goals and
 experience
 significance

 --Processing
 activities so that
 learning can be
 consolidated and
 transferred to real-
 world experiences

 --EXAMPLE: Rock Wall
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Title Annotation:PRACTICE
Author:Portrie-Bethke, Torey L.; Hill, Nicole R.; Bethke, Jerid G.
Publication:Journal of Mental Health Counseling
Date:Oct 1, 2009
Words:6646
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