1. Short attention span; difficulty sustaining attention on a consistent basis.
2. Susceptibility to distraction by extraneous stimuli and internal thoughts.
3. Gives impression that he/she is not listening well.
4. Repeated failure to follow through on instructions or complete school assignments or chores in a timely manner.
5. Poor organizational skills as demonstrated by forgetfulness, inattention to details, and losing things necessary for tasks.
6. Hyperactivity as evidenced by a high energy level, restlessness, difficulty sitting still, or loud or excessive talking.
7. Impulsivity as evidenced by difficulty awaiting turn in group situations, blurting out answers to questions before the questions have been completed, and frequent intrusions into others' personal business.
8. Frequent disruptive, aggressive, or negative attention-seeking behaviors.
9. Tendency to engage in carelessness or potentially dangerous activities.
10. Difficulty accepting responsibility for actions, projecting blame for problems onto others, and failing to learn from experience.
11. Low self-esteem and poor social skills.
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1. Client and parents describe the nature of the ADHD including specific behaviors, triggers, and consequences. (1, 2, 3) |
1. Actively build the level of trust with the client and parents through consistent eye contact, active listening, unconditional positive regard, and warm acceptance to help increase his/her ability to identify and express feelings.
2. Thoroughly assess the various stimuli (e.g., situations, people, thoughts) that have triggered the client's ADHD behavior; the thoughts, feelings, and actions that have characterized his/her responses; and the consequences of the behavior (e.g., reinforcements, punishments) toward identifying target behaviors, antecedents, consequences, and the appropriate placement of interventions (e.g., school-based, home-based, peer-based).
3. Rule out alternative conditions/causes of inattention, hyperactivity, and impulsivity (e.g., other behavioral, physical, emotional problems, or normal developmental behavior). |
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2. Complete psychological testing to measure the nature and extent of ADHD and/or rule out other possible contributors. (4) |
4. Arrange for psychological testing and/or objectives measures to assess the features of ADHD (e.g., Disruptive Behavior Rating Scale; ADHD Rating Scale–IV) rule out emotional problems that may be contributing to the client's inattentiveness, impulsivity, and hyperactivity; and/or measure the behavior and stimuli associated with its appearance; give feedback to the client and his/her parents regarding the testing results. |
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3. Provide behavioral, emotional and attitudinal information toward an assessment of specifiers relevant to a DSM diagnosis, the efficacy of treatment, and the nature of the therapy relationship. (5, 6, 7, 8, 9) |
5. Assess the client's level of in-sight (syntonic versus dystonic) toward the “presenting problems” (e.g., demonstrates good insight into the problematic nature of the “described behavior,” agrees with others' concern, and is motivated to work on change; demonstrates ambivalence regarding the “problem described” and is reluctant to address the issue as a concern; or demonstrates resistance regarding acknowledgment of the “problem described,” is not concerned, and has no motivation to change).
6. Assess the client for evidence of research-based correlated disorders (e.g., oppositional defiant behavior with ADHD, depression secondary to an anxiety disorder) including vulnerability to suicide, if appropriate (e.g., increased suicide risk when comorbid depression is evident).
7. Assess for any issues of age, gender, or culture that could help explain the client's currently defined “problem behavior” and factors that could offer a better understanding of the client's behavior.
8. Assess for the severity of the level of impairment to the client's functioning to determine appropriate level of care (e.g., the behavior noted creates mild, moderate, severe, or very severe impairment in social, relational, vocational, or occupational endeavors); continuously assess this severity of impairment as well as the efficacy of treatment (e.g., the client no longer demonstrates severe impairment but the presenting problem now is causing mild or moderate impairment).
9. Assess the client's home, school, and community for pathogenic care (e.g., persistent disregard for the child's emotional needs or physical needs, repeated changes in primary caregivers, limited opportunities for stable attachments, persistent harsh punishment, or other grossly inept parenting). |
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4. Take prescribed medication as directed by the physician. (10, 11) |
10. Arrange for the client to have an evaluation by a physician to assess the appropriateness of prescribing ADHD medication.
11. Monitor the client for psychotropic medication prescription compliance, side effects, and effectiveness; consult with the prescribing physician at regular intervals (consider assigning “Evaluating Medication Effects” in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis). |
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5. Parents and the client demonstrate increased knowledge about ADHD and its treatment. (12, 13, 14, 15) |
12. Educate the client and/or client's parents about the signs and symptoms of ADHD.
13. Discuss with the client and/or parents the various treatment options for ADHD (e.g., behavioral parent training, classroom-based behavioral management programs, peer-based programs, medication), discussing risks and benefits to fully inform the parents' decision-making.
14. Assign the parents readings to increase their knowledge of ADHD (e.g., Taking Charge of ADHD by Barkley; Parenting Children With ADHD: 10 Lessons That Medicine Cannot Teach by Monastra; The Family ADHD Solution: A Scientific Approach to Maximizing Your Child's Attention and Minimizing Parental Stress by Bertin).
15. Assign the client readings to increase his/her knowledge about ADHD and ways to manage related behavior (e.g., The ADHD Workbook for Teens: Activities to Help You Gain Motivation and Confidence by Honos-Webb; Take Control of ADHD: The Ultimate Guide for Teens with ADHD by Spodak and Stephano; ADHD—A Teenager's Guide by Crist). |
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6. Parents learn and implement Parent Management Training to increase prosocial behavior and decrease disruptive behavior of their adolescent child/children. (16, 17, 18, 19, 20) |
16. Explain how parent and child behavioral interactions can reduce the frequency of impulsive, disruptive, and negative attention-seeking behaviors and increase desired prosocial behavior through prompting and reinforcing positive behaviors as well as use of clear instruction, time out, and other loss-of-privilege practices for problem behavior (recommend The Kazdin Method for Parenting the Defiant Child by Kazdin; Parents and Adolescents Living Together: Part 1, The Basics by Patterson and Forgatch).
17. Teach the parents how to specifically define and identify problem behaviors, identify their reactions to the behavior, determine whether the reaction encourages or discourages the behavior, and generate alternatives to the problem behavior (assign “Switching from Defense to Offense” in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis).
18. Teach parents about the possible functions of the ADHD behavior (e.g., avoidance, attention, to gain a desired object/activity, regulate sensory stimulation); how to test which function(s) is being served by the behavior, and how to use parent training methods to manage the behavior.
19. Assign the parents home exercises in which they implement and record results of reinforcing prosocial behavior (or assign “Clear Rules, Positive Reinforcement, Appropriate Consequences” in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis); review in session, providing corrective feedback toward improved, appropriate, and consistent use of skills.
20. Refer parents to a Parent Management Training Course. |
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7. Parents work with therapist and school to implement a behavioral classroom management program. (21, 22) |
21. Consult with the client's teachers to implement age-appropriate strategies to improve school performance, such as sitting in the front row during class, using a prearranged signal to redirect the client back to task, scheduling breaks from tasks, providing frequent feedback, calling on the client often, arranging for a listening buddy, and implementing a daily behavioral report card.
22. Consult with parents and pertinent school personnel to implement an age-appropriate Behavioral Classroom Management Intervention (see ADHD in the Schools by DuPaul and Stoner, or Homework Success for Children with ADHD: A Family-School Intervention Program by Power, Karustis, and Habboushe) that reinforces appropriate behavior at school and at home, uses time-out for undesirable behavior, and uses a daily behavioral report card to monitor progress. |
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8. Complete a peer-based treatment program focused on improving social interaction skills. (23) |
23. Conduct or refer the client to a Behavioral Peer Intervention (e.g., Summer Treatment Program or after-school/weekend version) that involves brief social skills training followed by coached group play in recreational activities guided by contingency management systems (e.g., point system, time-out) and utilizing objective observations, frequency counts, and adult ratings of social behaviors as outcome measures (see Children's Summer Treatment Program Manual for ADHD by Pelham, Greiner, and Gnagy). |
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9. Parents develop and utilize an organized system to keep track of the client's school assign-ments, chores, and household responsibilities. (24, 25) |
24. Assist the parents in developing and implementing an organizational system to increase the client's on-task behaviors and completion of school assignments, chores, or household responsibilities through the use of calendars, charts, notebooks, and class syllabi (see “Getting It Done” in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis).
25. Assist the parents in developing a routine schedule to increase the client's compliance with school, household, or work-related responsibilities. |
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10. Utilize effective study and test-taking skills on a regular basis to improve academic performance. (26, 27, 28) |
26. Teach the client more effective study skills (e.g., clearing away distractions, studying in quiet places, and scheduling breaks in studying).
27. Teach the client more effective test-taking strategies (e.g., reviewing material regularly, reading directions twice, and rechecking work).
28. Assign the client to read 13 Steps to Better Grades (Silverman) to improve organizational and study skills; process the material read and identify ways to implement new practices. |
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11. Increase frequency of completion of school assignments, chores, and household responsibilities. (29) |
29. Assist the parents in developing a routine schedule to increase the client's compliance with school, household, or work-related responsibilities (or employ the “Getting It Done” program in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis). |
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12. Delay instant gratification in favor of achieving meaningful long-term goals. (30, 31) |
30. Teach the client mediational and self-control strategies (e.g., “stop, look, listen, and think”) to delay the need for instant gratification and inhibit impulses to achieve more meaningful, longer-term goals (or assign “Action Minus Thought Equals Painful Consequences” in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis).
31. Assist the parents in increasing structure to help the client learn to delay gratification for longer-term goals (e.g., completing homework or chores before playing). |
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13. Learn and implement social skills to reduce anxiety and build confidence in social interactions. (32, 33) |
32. Use instruction, modeling, and role-playing to build the client's general and developmentally appropriate social and/or communication skills.
33. Assign the client to read about general social and/or communication skills in books or treatment manuals on building social skills (e.g., or assign the “Social Skills Exercise” in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis). |
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14. Identify and implement effective problem-solving strategies. (34, 35) |
34. Teach older clients effective problem-solving skills through identifying the problem, brainstorming alternative solution options, listing pros and cons of each solution option, selecting an option, implementing a course of action, and evaluating the outcome (or assign the “Problem-Solving Exercise” in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis).
35. Utilize role-playing and modeling to teach the older child how to implement effective problem-solving techniques in his/her daily life. |
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15. Increase the frequency of positive interactions with parents. (36, 37, 38) |
36. Explore for periods of time when the client demonstrated good impulse control and engaged in fewer disruptive behaviors; process his/her responses and reinforce positive coping mechanisms that he/she used to deter impulsive or disruptive behaviors.
37. Instruct the parents to observe and record three to five positive behaviors by the client in between therapy sessions; reinforce positive behaviors and encourage him/her to continue to exhibit these behaviors.
38. Encourage the parents to spend 10 to 15 minutes daily of one-on-one time with the client to create a closer parent-child bond. Allow the client to take the lead in selecting the activity or task. |
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16. Increase the frequency of socially appropriate behaviors with siblings and peers. (39, 40) |
39. Give homework assignments where the client identifies 5 to 10 strengths or interests; review the list in the following session and encourage him/her to utilize strengths or interests to establish friendships (consider assigning “Show Your Strengths” or “Recognizing Your Abilities, Traits, and Accomplishments” in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis).
40. Assign the client the task of showing empathy, kindness, or sensitivity to the needs of others (e.g., allowing sibling or peer to take first turn in a video game, helping with a school fundraiser). |
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17. Increase verbalizations of acceptance of responsibility for misbehavior. (41, 42) |
41. Firmly confront the client's impulsive behaviors, pointing out consequences for him/her and others.
42. Confront statements in which the client blames others for his/her annoying or impulsive behaviors and fails to accept responsibility for his/her actions. |
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18. Identify stressors or painful emotions that trigger an increase in hyperactivity and impulsivity. (43, 44, 45) |
43. Explore and identify stressful events or factors that contribute to an increase in impulsivity, hyperactivity, and distractibility.
44. Explore possible stressors, roadblocks, or hurdles that might cause impulsive and acting-out behaviors to increase in the future.
45. Identify coping strategies (e.g., “stop, look, listen, and think,” guided imagery, utilizing “I messages” to communicate needs) that the client and his/her family can use to cope with or overcome stressors, roadblocks, or hurdles. |
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19. Parents and the client regularly attend and actively participate in group therapy. (46) |
46. Encourage the client's parents to participate in an ADHD support group. |
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20. Complete a course of biofeedback to improve concentration and attention. (47) |
47. Conduct or refer the client to a trial of EEG biofeedback (neurotherapy) for ADHD. |
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21. Identify and list constructive ways to utilize energy. (48) |
48. Give a homework assignment where the client lists the positive and negative aspects of his/her high energy level; review the list in the following session and encourage him/her to channel energy into healthy physical outlets and positive social activities (or assign “Channel Your Energy in a Positive Direction” in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis). |
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22. Express feelings through artwork. (49) |
49. Instruct the client to draw a picture reflecting what it feels like to have ADHD; process content of the drawing with the therapist. |
| 314.01 |
F90.2 |
Attention-Deficit/Hyperactivity Disorder, Combined Presentation |
| 314.00 |
F90.0 |
Attention-Deficit/Hyperactivity Disorder, Predominately Inattentive Presentation |
| 314.01 |
F90.1 |
Attention-Deficit/Hyperactivity Disorder, Predominately Hyperactive /Impulsive Presentation |
| 314.01 |
F90.9 |
Unspecified Attention-Deficit/Hyperactivity Disorder |
| 314.01 |
F90.8 |
Other Specified Attention-Deficit/Hyperactivity Disorder |
| 312.81 |
F91.1 |
Conduct Disorder, Childhood-Onset Type |
| 312.82 |
F91.2 |
Conduct Disorder, Adolescent-Onset Type |
| 313.81 |
F91.3 |
Oppositional Defiant Disorder |
| 312.9 |
F91.9 |
Unspecified Disruptive, Impulse Control, and Conduct Disorder |
| 312.89 |
F91.8 |
Other Specified Disruptive, Impulse Control, and Conduct Disorder |
| 296.xx |
F31.xx |
Bipolar I Disorder |