ADHD and psychotherapy  

Children with ADHD display behavioural problems similar to those of «Fidgety Phil», the character in the picture books by the Frankfurt doctor Heinrich Hofmann from the 19th century. Today, the symptoms of inattention, hyperactivity and poor impulse control are key features of an ADHD diagnosis. If these symptoms occur for more than six months in two or more areas of life (e.g. school, family), they impair social and academic development.

The symptoms of ADHD can place a strain on both the child and their carers at any age. During the pre-school and school years, these children often display aimless behaviour, play very little and experience learning difficulties. This is usually accompanied by problems with peers, which can hinder the child's development of self-esteem. In adolescence, the restlessness subsides, whilst attention problems, emotional distress and difficulties with social behaviour persist.

The core symptoms of ADHD include frequent forgetfulness, difficulty concentrating for long periods, outbursts of anger or acting impulsively, and these symptoms often clash with academic and social expectations. Supporting a child with ADHD can place significant demands on the family and teachers.

If the family is already under strain or if teachers are unable to provide this support, this has a negative impact on the symptoms. That is why training parents and teachers in how to manage ADHD in children is one of the main pillars of treatment.

Multimodal treatment

The multimodal treatment of ADHD in children involves psychotherapy and, depending on the symptoms, medication with stimulants. It also includes:  

• parent-centred (caregiver-centred) training
• school-based training
• child-centred training

Psychotherapy aims to address mental health issues using psychological approaches. This involves analysing underlying conflicts (clarification), providing information about factors that perpetuate the condition and about treatment options (psychoeducation), establishing shared goals (goal-orientation) and practising behaviours (action-orientation) to achieve these goals. Emotional experiences, thoughts and physical symptoms are also taken into account. Psychotherapy takes place in individual or group settings and involves working with parents and the social environment.

This is how it works in practice

Assessing the clinical presentation (diagnosis) and classifying it into diagnostic categories (DSM-5 or ICD-10) form the basis of psychotherapeutic intervention. Psychotherapy for ADHD is practice-based and is provided on an outpatient basis. Inpatient or day-care treatment is recommended only in cases of severe symptoms and where outpatient treatment has proved unsuccessful.

Psychotherapy for ADHD involves:

• identifying the nature of the disorder and the factors that contribute to it (when are the symptoms particularly pronounced, and when do they improve?),
• an analysis of the roles of parents and teachers (clarification), 
• providing the child, parents and teachers with information about the disorder and the psychotherapeutic treatment (psychoeducation),
• the joint development of objectives (goal-orientation), 
• practising behaviours designed to achieve goals and applying them in everyday life (action-oriented approach).

To be specific: 9-year-old Alex exhibits moderately pronounced problems such as forgetfulness, lack of concentration, interrupting others and getting into scuffles. Although he is of average ability, he finds it difficult to keep up with the schoolwork. He has a good relationship with his parents, but there are often arguments and tears when his parents help him with his homework or look for his PE bag.

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

The aim is to learn to manage one's strengths and weaknesses independently.

The teacher is involved and, during the first four weeks, gives Alex a signal at the end of the lesson to remind him to write his homework down in his homework book. Later on, he will signal to the teacher 30 minutes before the end of the lesson to remind her that he has remembered his homework 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 additional mental health issues such as anxiety and low mood. Failure to achieve academic or social goals (integration into peer groups) has a negative impact on self-esteem and the course of the condition. This «vicious circle» must be broken if children are to learn, in the long term, to do the things they find difficult. If ADHD treatment fails to improve the child's well-being sufficiently, additional therapy will be required later on.

The role of parents and teachers

Mental health issues in childhood and adolescence can lead people to seek «simple» explanations for complex interactions, such as blaming parents or teachers. This is unjustified and harmful to the child. Addressing the child's difficulties together contributes to effective treatment.

During parent training, problems are identified, parents practise and adapt the way they communicate expectations, and appropriate consequences for undesirable behaviour or rewards for positive behaviour are agreed upon. Due to their core symptoms, children with ADHD rely on an approach that is attentive to their needs and sets clear boundaries.

Children can learn to deal responsibly with their weaknesses and strengths. In psychotherapy with children, the focus is on providing positive experiences. The child moves towards the goal in small steps (e.g. reliably carrying out duties, suppressing undesirable behaviours), with improvements perhaps initially only noticeable to the child and their parents. Psychotherapy alone is effective for ADHD in mild and moderate cases.  

  Psychotherapy does not make ADHD «disappear».

In cases of severe ADHD symptoms or insufficient response to treatment, a combination of psychotropic drugs (usually stimulants) is initiated to ensure successful treatment, thereby forming part of a multimodal treatment approach.

What does «successful treatment» mean in everyday life? Progress is evident in a reduction in the frequency or severity of symptoms: the children forget things less often, learn to manage their own behaviour, understand what is good for them and what makes their problems worse, and develop self-confidence.

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

The aim, therefore, is not to cure the condition, but to help the child develop a responsible approach to their strengths and weaknesses, with the support of their family and school. Psychotherapy for ADHD focuses on building positive relationships between the child, their family and their school. In this way, the child learns not to doubt their abilities, but to use strategies to cope with problems appropriately. Parents and teachers are the child's most important mentors in this process!