ADHD and psychotherapy

Children suffering from ADHD exhibit behavioural problems like the fidget spinner in the picture books of the 19th century Frankfurt doctor Heinrich Hofmann. Today, the symptoms of inattention, hyperactivity and lack of action control (impulsivity) are core features of the ADHD diagnosis. If these symptoms occur in two or more areas of life (e.g. school, family) over a six-month period, they impair social and academic development.

The appearance of AHDS can lead to stress for the child and carers at any age. At pre-school and school age, these children often show aimless activity, play little and have learning difficulties. In most cases, they also have problems with their peers, which interfere with the child's self-esteem development. In adolescence, the restlessness decreases, while attention problems, emotional stress and problems with social behaviour persist.

The core symptoms of ADHD are frequent forgetting, difficulty concentrating for long periods of time, outbursts of anger or rash behaviour and are in contrast to school and social demands. Supporting a child with ADHD can place high demands on the family and teachers.

If the family is already under pressure or teachers are unable to provide this support, this has a negative impact on the symptoms. This is why training parents and teachers in dealing with ADHD in children is one of the main pillars of treatment.

Multimodal treatment

The multimodal treatment of ADHD in children includes psychotherapy and, depending on the symptoms, drug treatment with stimulants. And it includes:

• Parent-centred (educator-centred) training
• School-centred training
• Child-centred training

Psychotherapy aims to overcome psychological disorders by means of psychological procedures. This includes the analysis of underlying conflicts (clarification), information about the factors maintaining the disorder and about treatment options (psychoeducation), the development of common goals (goal orientation) and the practice of behaviours (action orientation) to achieve the goal. Emotional experiences, thoughts and physical symptoms are also taken into account. Psychotherapy takes place in an individual or group setting and includes work with parents and the social environment.

This is what the practice looks like

The assessment of the symptoms (diagnosis) and their categorisation into diagnostic categories (DSM-5 or ICD-10) form the basis of psychotherapeutic treatment. Psychotherapy for ADHD has a practising character and takes place on an outpatient basis. Only in cases of severe symptoms and lack of success is partial or inpatient treatment recommended.

Psychotherapy for ADHD includes

• Recording the disorder pattern and maintaining factors (when are the symptoms particularly pronounced, when do they improve?
• analysing the role of parents and teachers (clarification),
• informing the child, parents and teachers about the disorder and psychotherapeutic treatment (psychoeducation),
• the joint development of goals (goal-orientation),
• Practising the behaviour to achieve the goal and transferring it to everyday life (action orientation).

Specifically: 9-year-old Alex has moderately pronounced problems such as forgetting, lack of concentration, interrupting and fighting. He is of average ability but finds it difficult to follow the school curriculum. The relationship between him and his parents is good, but there are often arguments and tears when the parents do tasks with him or look for his gym bag.

Alex is ashamed, feels bad and says that this is why he argues more than others. In psychotherapy, Alex learns to recognise the limits of his attention and helps himself with lists on his smartphone. He practises saying openly that he has forgotten something and works out ways to «make up» for forgotten things or outbursts of anger. This is done in consultation with the parents, who themselves agree to give Alex the opportunity to practise directing his attention in everyday life (cooking, games).

The aim is to take responsibility for dealing with strengths and weaknesses.

The teacher will be involved and will signal to Alex at the end of the lesson during the first four weeks that he should now write down the homework in his exercise book. Later, 30 minutes before the end of the lesson, he will indicate to the teacher that he remembers the exercise book. Alex is rewarded for his efforts and he in turn rewards his parents for their efforts to be more patient.

Children with ADHD often suffer from other psychological problems such as anxiety and depressive mood. Failure to achieve school or social goals (inclusion in peer groups) has an unfavourable effect on self-esteem and progression. This «vicious circle» must be broken if children are to learn to do what they find difficult in the long term. If it is not possible to improve the child's condition sufficiently during ADHD treatment, additional therapy will be necessary later on.

The role of parents and teachers

Mental disorders in childhood and adolescence invite people to look for «simple» explanations for complex interactions, such as blaming parents or teachers. This is unjustified and harmful for the child. Approaching the child's problems together contributes to effective treatment.

In parent training, problems are identified, the communication of requirements is practised and adapted and appropriate consequences are agreed for undesirable behaviour and rewards for positive behaviour. Due to their core symptoms, children with ADHD are dependent on a caring and limit-setting attitude.

Children can learn to deal responsibly with their weaknesses and strengths. In psychotherapy with the child, the focus is on conveying positive experiences. The child moves towards the goal (e.g. reliably completing tasks, suppressing unfavourable behaviour) in small steps, whereby improvements may initially only be noticeable to the child and their parents. Psychotherapy alone for ADHD is effective in mild and moderate cases.

Psychotherapy does not make ADHD «disappear».

In cases of severe ADHD symptoms or insufficient effectiveness, a combination of psychotropic drugs (usually stimulants) and thus multimodal treatment is initiated for successful treatment.

What does «successful treatment» mean in everyday life? Progress can be seen in the reduction in the frequency or severity of symptoms: the children forget less, learn to guide themselves, know what is good for them, what exacerbates problems and develop confidence.

Parents and teachers report more positive experiences, more efforts to overcome problems, less shame and anger in arguments. Psychotherapy does not make ADHD «disappear».

The aim is therefore not to cure the disorder, but to help the child develop a self-responsible way of dealing with weaknesses and strengths with the help of the family and school. Psychotherapy for ADHD is aimed at building positive reciprocity between the child and the family and school. In this way, the child learns not to doubt his or her competences, but to use strategies to deal with problems appropriately. Parents and teachers are the children's most important coaches!