A group counseling intervention for children with Attention-Deficit Hyperactivity Disorder

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A group counseling intervention for children with Attention-Deficit Hyperactivity Disorder
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Includes bibliographical references (leaves 124-134) Counselor Education thesis, Ph.D.

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m m














A GROUP COUNSELING INTERVENTION
FOR CHILDREN WITH
ATTENTION-DEFICIT HYPERACTIVITY DISORDER













By

LINDA DEJONG WEBB


I
A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

THE UNIVERSITY OF FLORIDA


1999




















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UNIVERSITY OF FLORIDA
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3 1262 08555 1645














ACKNOWLEDGMENTS

I would like to extend sincere thanks to Dr. Robert Myrick for serving as

chairman of my committee. His professional suggestions and personal encouragement

were invaluable to me and are greatly appreciated. I would also like to thank Dr. David

Miller for serving on my committee. His patient attention while providing support during

the statistical analysis of data and throughout the process was assuring. Thanks are also

extended to Dr. Harry Daniels and Dr. Edward Turner for serving on the committee.

Special thanks are in order for the Alachua County, Florida, elementary school

counselors who delivered the counseling intervention and patiently carried out the

research procedures. The completion of this study depended on them, and they did not let

me down.

I would also like to thank Dan and Michelle at Office Automation in Gainesville

for the willingness to make all my copying a priority with little notice. Thanks also to Liz

at the Institutional Review Board for her personal attention. Specials thanks to Stephanie

Wehery for her help with the statistical analysis.

Additional thanks are extended (a) to my husband, John, for his love and support

throughout the entire doctoral process; (b) to my daughters, Pam and Christa, for

understanding my need to become obsessive and "snappy" at crunch times; (c) to my

sister, Rene6, for her help with data entry; (d) to my late mother for her strong directive

that I not ever become a "fluffy" school counselor; (e) to my father for his continued

support of everything I do; and (f) to my mother-in law for her support and help with the

girls during the last two years.
















TABLE OF CONTENTS


page

ACKNOWLEDGMENTS ............................................. ii

ABSTRACT .......................................................... v

CHAPTERS

1 INTRODUCTION .................................................. 1

Theoretical Perspective ................................ ............. 3
Statement of the Problem ............................................ 7
Purpose of the Study ..................................... ........... 8
Research Q questions .................................................. 9
Definition of Terms ............................................... 9
Overview of the Remainder of the Study ................................ 10

2 REVIEW OF RELATED LITERATURE .............................. 12

Diagnostic Criteria for Attention-Deficit Hyperactivity Disorder ............. 12
The History ofADHD .............................................. 15
ADHD Students in Schools ......................................... 19
ADHD in the School Counseling Literature ..............................21
Small Group Counseling Interventions ................ ................ 25


Dependent Variables ............
Sum m ary .....................


. . 2 8
. . 3 3


3 METHODOLOGY .............................................. 35


Population ....................
Sampling Procedure ............
Resultant Sample ..............
Research Design ...............
School Counselor Training .......
Treatment Description ..........
Assessment Techniques .........
Hypotheses ...................
Data Analysis .................
Research Procedures ............


. . 3 5
. . 3 7
. .. 3 8
.................... ............. 40
. .4 1
. .4 3
. .4 6
.......................... ....... 52
.......................... ....... 52
................................. 54






4 R E SU LT S ........................................................ 56

Data Analysis .................................................... 57
Summary of Results ............................................... 67

5 SUMMARY, CONCLUSIONS, DISCUSSION, LIMITATIONS,
IMPLICATIONS, AND RECOMMENDATIONS ....................... 69

Summary ....................................................... 69
Conclusions .................................... ................ 71
Discussion .............................................. ......... 73
Limitations ...................................................... 76
Implications .................................... ................... 78
Recommendations ................. ............................... 80

APPENDICES


A CONSENT LETTERS FOR PARTICIPATION ........................83

B RESEARCH PROCEDURES ...................................... 90

C RESEARCH INSTRUMENTS ........................................96

D GROUP FACILITATOR'S MANUAL .............................. 103

E SUPPLEMENTAL STATISTICS ................................... 122

REFERENCES ...................................................... 124

BIOGRAPHICAL SKETCH ............................................ 135














Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

A GROUP COUNSELING INTERVENTION
FOR CHILDREN WITH
ATTENTION-DEFICIT HYPERACTIVITY DISORDER

By

Linda DeJong Webb

August 1999

Chairman: Dr. Robert Myrick
Major Department: Counselor Education

A group counseling intervention for children with attention-deficit hyperactivity

disorder (ADHD) was evaluated for its effects on classroom behavior (Teacher Report

Form, TRF), on students' perceptions of locus of control (Children's Nowicki-Strickland

Internal External Locus of Control Scale, CNSIE), and on students' perceptions of school

success behaviors (School Success Inventory, SSI-SF). The intervention was delivered

by 13 certified school counselors to ADHD students in grades 3, 4, and 5 in 12 public

elementary schools (n = 93).

A randomized prepost control group design was used to assess the effects of the

dependent variables. ADHD students in the treatment group participated in six small

group sessions that focused on increased awareness of the disorder as it relates to school

performance and on student perceptions of control related to school success. Control

group students maintained their regular school routine during the intervention period.






A mixed model analysis of covariance (ANCOVA) on locus of control scores

yielded significant treatment effects ( = .0021). Significant treatment interactions were

found between sex (p = .0047) and whether a student was taking medication during the

intervention period (p = .0019). In each of the above CNSIE analysis, the shift was

towards a more external locus of control for students participating in the counseling

intervention. No significant treatment or interaction effects were found during the

ANCOVA analysis of TRF or SSI-SF scores.

Results suggested that a brief group counseling intervention for ADHD students

has the potential to increase awareness of ADHD characteristics as they affect school

performance. However, this increased awareness can leave students feeling less in

control of daily occurrences. The brevity and independence of the intervention were

considered when discussing these results.

It was suggested that follow-up and teacher collaboration be used in conjunction

with the counseling intervention for ADHD students. This type of intervention may be an

important adjunct in preparing ADHD students to accept the need for support and

alternative strategies as they strive to become successful students.














CHAPTER 1
INTRODUCTION

Attention-deficit hyperactivity disorder (ADHD) is one of the most commonly

diagnosed and studied disorders among children (Barkley, 1998; Shaywitz & Shaywitz,

1992). An estimated 3% to 5% of the school age population has ADHD, defined as

persistent patterns of developmentally inappropriate inattention, impulsivity, and/or

hyperactivity (American Psychiatric Association, 1994) with boys outnumbering girls

(Kauffman, 1993; Barkley, 1990). Recent research (Barkley, 1998) is leaning towards

impulsivity as a hallmark of the disorder.

Although the onset of ADHD for most children is prior to age 4, it is most often

diagnosed when a child is in elementary school (McKinney, Montague, & Hocutt, 1993).

This is the time when children are introduced to the demands of the educational system.

Problems with impulsivity, inattention, or hyperactivity, often resulting in

underachievement, put these students at risk for a variety of problems related to school

performance. Zentall (1995) suggests that ADHD children likely exhibit their greatest

problems in the classroom. As many as 56% of ADHD students may require academic

tutoring, up to 30% may repeat a grade, and 30-40% may be placed in special education

programs. As many as 46% of ADHD students may be suspended from school with up to

35% dropping out completely and not finishing high school (Barkley, DuPaul, &

McMurry, 1990; Barkley, Fischer, Edelbrock, & Smallish, 1990; Brown & Borden, 1986;

Weiss & Hechtman, 1993). In addition, without assistance students may develop








emotional problems with anger, aggression, depression, and anxiety (McKinney,

Montague, & Hocutt, 1993; Reeve, 1990), which can lead to oppositional defiant and

conduct disorders (Biederman, Faraone, & Lapey, 1992).

Elementary school counselors, as behavior and relationship experts in their

schools (Myrick, 1997), are in a position to provide support and intervention for ADHD

students, their teachers and families. A position statement on ADHD, published by the

American School Counselor Association (ASCA) in 1994, strongly encourages the

involvement of school counselors in the multidimensional treatment of ADHD students.

This statement is supported by professionals in the field (Erk, 1995; Lavin, 1997;

Schweibert, Sealander, & Tollerud, 1995;) who see school counselor involvement with

ADHD children as an essential component in enhancing their school performance.

Myrick (1997) sees the role of the school counselor as helping all students to become

more effective and efficient learners. This would include ADHD students, suggesting

school counselors be aware of counselor interventions for ADHD students that could

contribute to the goal of effective learning.

One type of counselor intervention in schools involves small group counseling.

Braswell and Bloomquist (1991) suggest group counseling as opposed to individual

counseling for most ADHD children. Group sessions more closely approximate real life

peer relationship situations and have the potential to enhance skill acquisition and

generalization. For ADHD children, interventions applied consistently within the school

setting at the point of performance are the most effective in improving social and

academic performance. Providing counseling activities that will elicit the behaviors and








feelings that create difficulties with peers and school performance, allows the school

counselor to apply intervention at the point of performance.

This study examines the effects of a small group counseling intervention designed

to help ADHD students increase knowledge and control of their disorder, leading to

improved perceptions of self as a student, a more internal locus of control, and improved

classroom behavior. Cognitive behavioral strategies will be used.

Theoretical Perspective

Attention-deficit hyperactivity disorder is the most recent diagnostic label for

children displaying significant problems with attention, impulsiveness, and hyperactivity.

During this decade a shift has been underway to view the cause of ADHD as more

influenced by neurological and genetic factors than by social or environmental ones, and

as treatable but not curable (Barkley, 1998; Teeter & Semrud-Clikeman, 1995).

Problems typically presented by school children with ADHD include completing

academic work, acting-out behavior problems, low self-esteem, and inappropriate

interactions with peers, parents and teachers (Reeve, 1990; Zentall, 1993). These children

can not sustain concentration and are easily distracted. Additional difficulties noted by

DuPaul and Stoner (1994) include struggles with consistent school performance; low test

performance; disorganized desks, backpacks, and reports; and disruptions caused as

ADHD students call out or impulsively express anger and frustration.

The most common treatment for ADHD is medication (Epstein, Singh, Luebke, &

Stout, 1991). Sixty to ninety percent of children diagnosed with the disorder receive

stimulant medication for prolonged periods during their school careers (Whalen &

Henker, 1991). Short-term enhancements in behavioral functioning have been found in








about 75% of those being treated with stimulant medication (DuPaul & Rapport, 1993;

Kavale, 1982; Whalen & Henker, 1991). Even though stimulant medication has no effect

on academic performance, per se, productivity may improve as a result of controlling the

interfering behaviors (Montague & Warger, 1997). In addition, researchers (Weiss &

Hechtman, 1986) have found the long-term prognosis for ADHD children treated with

stimulant medication alone to be the same as those receiving no treatment. Therefore,

maximizing the effects of psychosocial and educational treatments may be the greatest

benefit. Stimulants do not teach appropriate behavior but do increase the probability of a

child displaying appropriate behaviors that are already in their repertoire (Barkley, 1998).

It helps children to show what they know but does not alter the child's knowledge of what

needs to be done (Werry, 1978). According to Barkley (1998) the difficulty for ADHD

students is not knowing what to do, but doing what they know. This then makes ADHD

more a disorder of performance than a disorder of skill and not a learning disability.

From this perspective it is clear that additional intervention strategies are needed

to help ADHD students understand their disorder, and learn and practice new behaviors

that can become part of the repertoire of skills that enhances their learning. However, for

ADHD students, there is a difference between possessing a skill and using it effectively

(Stein, Szumowski, Blondis, & Roizen, 1995). Cognitive behavioral therapy provides

one approach to support student need for understanding how ADHD effects school

performance and a vehicle for learning and practicing skills needed to be successful in the

classroom. Providing the opportunity to learn school success skills would be a

prerequisite to demonstrating those skills in the classroom even when other interventions

are in place. An ADHD student can not exhibit a behavior that has not been learned.








A cognitive behavioral approach to intervention emphasizes behavioral change

and self-regulation along with the examination and possible modification of thoughts,

beliefs, and/or expectations. It is a theoretical approach that supports recent treatment

interventions for children with ADHD (Schweibert, Sealander, & Tollerud, 1995). This

theory assumes that while the primary symptoms of the disorder are difficult to

ameliorate, it may be possible to help children develop competencies that lower the risk

for the emergence of serious secondary difficulties related to low self-esteem, poor peer

relations, or conduct problems (Braswell, 1993). According to Myrick (1997), this

approach also lends itself to brief counseling that is so often used in the schools.

What continues to be evaluated is whether cognitive behavioral methods can

promote a shift from caregivers (teachers and parents) taking total control of the learning

conditions for the ADHD student to the students themselves taking responsibility and

making changes that enhance learning. One way to evaluate who the student perceives is

in control of making things happen is to consider the locus of control construct.

The theoretical construct of locus of control has been used to describe whether

students believe that reinforcements such as grades or achievements, are due to their own

actions (i.e., internal locus of control) or due to factors beyond their control (i.e., external

locus of control (Bryan & Pearl, 1979). An internal locus of control indicates that

outcomes are perceived to be the result of one's own ability or effort, whereas an external

locus of control indicates that outcomes are perceived to be the result of luck, the

consequences of actions by others, or other factors beyond the individuals control (Rotter,

1990).








There is general agreement in the literature that successful students tend to have

more of an internal locus of control (Lewis & Lawerence-Patterson, 1989). Additionally,

Adalbjarardottir (1995) has demonstrated that children with an internal locus of control

are better problem solvers than those with an external tendency. Some researchers (Linn

& Hodge, 1982) also suggest that children with attention problems tend to have a more

external locus of control than do normal children. It is not surprising then, that ADHD

students tend to develop a more external locus of control.

How has the widespread use of stimulant medication and the emphasis on

modifications by teachers and parents effected the locus of control frame of reference of

ADHD children? Students who take stimulant medication and are the targets of

numerous interventions may not see themselves as responsible for the outcomes of their

behavior. From this perspective, what happens during the school day is the result of the

effectiveness of their medication and teachers' efforts, not their own choices. This would

reflect an external locus of control.- On the other hand, Barkley (1998) suggests that

ADHD is not an excuse or a reason to dismiss the consequences of one's actions but

rather an explanation as to why it is necessary for those with the disorder to increase

awareness of life's behavioral contingencies. Helping ADHD students understand how

their disorder effects school performance may be one way to enhance a more internal shift

in locus of control perceptions. As this shift takes place, ADHD students can begin to see

themselves as having the capacity to control their environment (Goldstein & Goldstein,

1998).

This study involves the development of a school counseling intervention. It is

based on cognitive behavioral theory, and aimed to help students better understand








ADHD, their own behaviors, and ways to increase control of tasks related to school

performance.

Statement of the Problem

In 1991, the U.S. Department of Education initially recognized that ADHD may

qualify a student for special assistance in general education under Section 504 of the

Rehabilitation Act of 1973 (Public Law 93-112). It also supported the consideration of

ADHD as a disabling condition under the Individuals with Disabilities Education Act,

also known as IDEA (Public Law 101-476), thereby facilitating eligibility for special

education services (Davila, William, & MacDonald, 1991) under the label of Other

Health Impaired. This has increased the number of ADHD students who are eligible for

special education services.

Special education teachers with training in the use of behavioral techniques and

small class sizes typically implement behavioral interventions with ADHD students.

However, between 85% and 90% percent of ADHD students will still be served in

general education classrooms for all or part of the school day (Montague & Warger,

1997). This means that ADHD students are probably in most schools and regular

education classrooms everyday.

The regular education teacher without specific training in the use of behavioral

interventions, with 30 or more students in a class, may view some strategies as

impractical and too time consuming. Teachers need support in their efforts to work with

ADHD students.

School counselors are in a position to provide support and are increasingly being

asked to intervene directly with ADHD students (Jordan, 1992). According to the ASCA








coordinator of Children with Attention Deficit Disorders Professional Interest Network,

Robert Erk (1995b), these functions are within the realm of typical guidance and

counseling programs and are part of the multidisciplinary treatment necessary to optimize

the learning outcomes of the ADHD student. Designing and providing direct counseling

services and programs for ADHD students are among the activities he encourages for

school counselors.

The question that remains is whether providing direct service through a small

group counseling intervention can improve ADHD student behavior in the classroom.

The school counseling literature has yielded few outcome studies to support such a claim

since 1988 (Sexton, 1996) so we remain unsure. The school counseling literature has

presented implications of clinical and school based investigations for school counselors

working with ADHD students (Bowley & Walther, 1992; Bramlet, Nelson, & Reeves,

1997; Burnley, 1993, Erk, 1995a, 1995b, 1998; Kottman, Robert, & Baker 1995; Lavin,

1991, 1997; Lucker, & Molloy, 1995; Schweibert, Sealander, & Bradshaw, 1998;

Schweibert, Sealander, & Tollerud, 1995). However, there has been no evidence of any

outcome study indicating the effectiveness of any school counselor intervention for

ADHD students in the last decade. There is a need to formally evaluate interventions

provided by the school counselor for ADHD students.

Purpose of the Study

The purpose of this study was to examine the effectiveness of a small group

counseling intervention with ADHD children. More specifically, ADHD students in

grades 3, 4, and 5 in public elementary schools participated in a set of group counseling

activities designed to increase awareness of ADHD and their sense of personal control








grades 3, 4, and 5 in public elementary schools participated in a set of group counseling

activities designed to increase awareness of ADHD and their sense of personal control

and responsibility for classroom behaviors related to school performance. An

experimental research design, featuring pre- and postmeasures was used to study the

outcomes and test hypotheses.

Research Questions

1. Will the ADHD students' classroom behavior change following the

completion of the small group counseling intervention?

2. Will the ADHD students' perception of locus of control change following

the completion of the counseling intervention?

3. Will ADHD students perceive their skills for school success differently?

4. Do students respond differently to treatment based on their sex, age, ESE

status, or being on or off medication for ADHD symptoms?

Definition of Terms

Attention deficit hyperactivity disorder (ADHD) incorporates all of the subtypes

of attention deficit disorders as listed in the Diagnostic and Statistical Manual of Mental

Disorders (4th ed., [DSM-IV,] American Psychiatric Association, 1994). These include

attention-deficit hyperactivity disorder, predominantly inattentive type; attention-deficit

hyperactivity disorder, predominantly hyperactive-impulsive type; and attention-deficit

hyperactivity disorder, combined type.

External locus of control refers to the perception that reinforcement is under the

control of others or subject to forces beyond one's control (Rotter, 1990).








Impulsivity is a deficiency in inhibiting behavior in response to situational

demands (Barkley, 1998).

Inattention refers to a difficulty with attention relative to normal children of the

same age and gender, specifically with reference to alertness, arousal, selectivity,

sustained attention, distractibility, or span of apprehension (Barkley, 1998).

Internal locus of control is the perception that reinforcements are contingent upon

effort, behavior, or personal characteristics such as ability (Rotter, 1990).

Locus of control is the degree to which one believes they are able to influence the

outcome of situation.

School success skills are classroom behaviors (i.e., skills) which help students

perform more effectively in school (Cuthbert, 1987).

Small group counseling in schools is a counselor-led educational experience in

which students can work together to explore their ideas, attitudes, feelings, and behaviors,

especially as related to personal development and progress in school (Myrick, 1997).

Special education services are for students who have been specifically identified

(Public Law 94-142; 1975) for services extending beyond the regular classroom, due to

one or more handicapping condition, as governed by an Individual Educational Plan.

These services have also been referred to as Exceptional Student Education services.

Overview of the Remainder of the Study

The remainder of the study is organized into four additional chapters. A review of

the related literature is presented in Chapter 2 focusing on the history, research, and

treatment of ADHD, ADHD students in the schools, research related to the dependent

variables, and the use of school counseling interventions. Chapter 3 contains the research






11

methodology, where procedures of the study are described. The results will be presented

in Chapter 4. Chapter 5 will include a summary, conclusions, discussion, limitations,

implications, and recommendations.














CHAPTER 2
REVIEW OF RELATED LITERATURE

Attention-deficit hyperactivity disorder (ADHD) has been observed in children

from all racial, cultural, and socioeconomic groups with slightly elevated rates of the

disorder among children with a low socio-economic status (SES). Barkley (1990)

speculates this observed difference among the low SES population could be the result of

different rates of prenatal and perinatal difficulties, family instability, and/or a downward

social shift of ADHD individuals. Nonetheless, ADHD is diagnosed, using a common

criterion, in children from all walks of life.

Diagnostic Criteria for Attention-Deficit Hyperactivity Disorder

Attention-deficit hyperactivity disorder is a prevalent and chronic disorder among

school-aged children. The Diagnostic and Statistical Manual of Mental Disorders-IV

(1994) describes the diagnostic criteria as seen in Table 2-1. This criterion includes

symptoms in the areas of inattention, hyperactivity, and impulsivity with at least some of

the symptoms causing impairment before age seven. At the time of diagnosis, the

impairment must be significant in social, academic, or occupational functioning and be

present in two or more settings.

The current terminology for the disorder is attention-deficit hyperactivity disorder.

However, if both the criteria for attention (Al) and hyperactivity/impulsivity (A2) are met

(see Table 2-1), a diagnosis of attention-deficit hyperactivity disorder, combined type is

made. If the criterion for attention (Al) is met but criterion for








Table 2-1
Diagnostic Criteria for ADHD (DSM-IV, 1994)


A. Either (1) or (2):
(1) six (or more) of the following symptoms of inattention have persisted
for at least 6 months to a degree that is maladaptive and inconsistent
with the developmental level:

Inattention
1. often fails to give close attention to details or makes careless
mistakes in schoolwork, work, or other activities
2. often has difficulty sustaining attention in tasks or play activities
3. often does not seem to listen when spoken to directly
4. often does not follow through on instructions and fails to finish
schoolwork, chores, or duties in the workplace (not due to
oppositional behavior or failure to understand instructions)
5. often has difficulty organizing tasks and activities
6. often avoids, dislikes, or is reluctant to engage in tasks that
require sustained mental effort (such as schoolwork or
homework)
7. often loses things necessary for tasks or activities (e.g., toys,
school assignments, pencils, books, or tools)
8. is often easily distracted by extraneous stimuli
9. is often forgetful in daily activities

(2) six or more of the following symptoms of hyperactivity-impulsivity
have persisted for at least 6 months to a degree that is maladaptive and
inconsistent with developmental level:

Hyperactivity
(a) often fidgets with hands or feet or squirms in seat
(b) often leaves seat in classroom or in other situations in which
remaining seated is expected
(c) often runs about or climbs excessively in situations in which it is
inappropriate (in adolescents or adults, may be limited to
subjective feelings of restlessness)
(d) often has difficulty playing or engaging in leisure activities
quietly
(e) is often "on the go" or often acts as if "driven by a motor"
(f) often talks excessively

Impulsivity
(g) often blurts out answers before questions have been completed
(h) often has difficulty awaiting turn
(i) often interrupts or intrudes on others (e.g., butts into
conversations or games)








Table 2-1--continued

B. Some hyperactive-impulsive or inattentive symptoms that caused
impairment were present before age 7 years.

C. Some impairment from the symptoms is present in two or more settings
(e.g., at school [or work] and at home).

D. There must be clear evidence of clinically significant impairment in social,
academic, or occupational functioning.

E. The symptoms do not occur exclusively during the course of a Pervasive
Developmental Disorder, Schizophrenia, or other Psychotic Disorder and
are not better accounted for by another mental disorder (e.g., Mood
Disorder, nxiety Disorder, Dissociative Disorder, or a Personality
Disorder) (pp. 83-85).


hyperactivity/impulsivity (A2) has not been met for the past six months, a diagnosis of

attention-deficit hyperactivity disorder, predominantly inattentive type is made. Finally,

if the criterion for attention (Al) has not been met for the past six months but is met for

hyperactivity/impulsivity (A2), a diagnosis of attention-deficit hyperactivity disorder,

predominantly hyperactive-impulsive type can be made (American Psychiatric

Association, 1994).

ADHD is increasingly being diagnosed among children in the schools. Students

who are unable to follow rules, who are often out of their seats, unable to complete class

work, and are frequently referred for discipline do not learn well and are a concern to

their teachers and parents. The presence of ADHD does not mean that students can not

learn. Rather, it is frequently related to inappropriate responses to a structured

environment that does not tolerate impulsive behavior. If ADHD students were less

troublesome and were able to increase the frequency of school success skills, they would

probably not be viewed as such a problem in school.








The History of ADHD

The recognition of ADHD as a disorder may stem back to the early 1900s. Still

(1902) in his published letters to the Royal College of Physicians described a disorder in

which children exhibited deficits of cognitive relation to the environment, moral

consciousness, and inhibitory volition. He noted that children who were punished for

behaviors were exhibiting the same behaviors within a matter of hours. A greater

proportion of Still's cases were males and in most cases the disorder appeared in early

childhood. Many of the cases involved children with a chaotic family life although others

involved children from households that provided adequate upbringing. Still hypothesized

that the disorder had a neurological basis stemming from early, mild, undetected damage

to the brain.

Tredgold (1908) and later Pasamanick, Rogers, and Lilienfeld (1956) would use

this theory to explain developmental behavior and learning deficiencies (Barkley, 1998)

with the term minimal brain dysfunction (MBD) eventually emerging in the 1950s.

However, there were other (Childers, in 1935) who raised questions about a diagnosis

involving brain damage when no history of any such damage existed. Even so, this

theory remained a well-accepted one for many years. Strauss and Lehtinen (1947)

addressed the education of these "brain damaged" children in a classic text. It included

placing students in smaller, more regulated classrooms while reducing distracting stimuli.

In this same era (1937-1941) there was significant research and dialog about the

use of medication therapy for behaviorally disordered children as the effects of its use

were revealed (Barkley, 1998). Laufer, Denhoff, and Solomons (1957), who found

positive drug responses in half or more hospitalized hyperactive children, would later






16

support use of medication. By the 1970s, stimulant medication was a common treatment

for children with characteristics of ADHD.

The 1960s and 1970s

By this time the perspective prevailed that hyperactivity was a brain-dysfunction

syndrome focusing on brain functions as opposed to brain damage (Ross & Ross, 1976).

Excessive activity level was considered its primary characteristic and treatments included

stimulant medication, psychotherapy, and minimum-stimulation classrooms.

More than 2,000 published studies on the disorder existed by the end of the 1970s

(Weiss & Hechtman, 1979). During this time, the characteristics of the disorder were

expanded to include impulsivity, short attention span, low frustration tolerance,

distractibility, and aggressiveness (Safer & Allen, 1976).

The use of stimulant medication with school-aged hyperactive children was

rapidly increasing (Barkley, 1990). Drug therapy studies also increased. Early studies,

led by Keith Connors, paved the way for more rigorous scientific methodology to be used

as over 120 studies involving this treatment approach were published by 1976 and more

than twice that by 1995 (Swanson, McBurnett, Christian, & Wigal, 1995).

Even with extensive research to support the proven efficacy of the use of

stimulant medication as a treatment strategy, public and professional concern began to

arise about its increasingly widespread use with children. This led to claims that

hyperactivity was a "myth" arising from intolerant teachers and parents and an inadequate

educational system (Conrad, 1975). There was a backlash against "drugging" school

children for behavior problems, and a growing belief that hyperactivity was the result of

environmental factors such as reactions to dyes or preservatives in foods (Feingold,








1975). This view gained so much support that a National Advisory Committee on

Hyperkinesis and Food Additives was convened in 1980. The evidence clearly refuted

these claims (Conners, 1980). Nevertheless, it remained popular for almost 10 years only

to be replaced by an equally unsupported hypothesis that sugar was more to blame than

food additives (Wolraich, Wilson, & White, 1995).

Other developments during the 1970s included the notion that an increasing

societal tempo and more rapid cultural change caused increased environmental

stimulation that would interact with a predisposition of some children for hyperactivity

(Block, 1977). Poor child rearing and lack of behavior management skills of parents was

also used to explain behaviors related to hyperactive children (Willis & Lovass, 1977).

As a result, parent training was increasingly recommended.

The passage of Public Law 94-142 in 1975 mandated special education services

for children with handicapping and behavioral disabilities in addition to those already

available for children with mental retardation (Henker & Whalen, 1980). At that time,

hyperactivity was not considered a disorder that met the criteria for special education

services. However, the law's reinterpretation in 1991 by the Department of Education,

allows ADHD children to receive special education services under the "Other Health

Impaired" category, if the disorder includes a chronic or acute impairment that

significantly effects educational performance (Davila, Williams, & MacDonald, 1991).

During this decade there was also an abundance of research on behavioral

strategies for treatment (Allyon, Layman, & Kandel, 1975). The efficacy of these

strategies was evident but they did not produce the same degree of improvement as

stimulant medication. However, the opinion of the time was that stimulant medication








should not be used alone but should be accompanied by behavioral interventions and

parent training (Barkley, 1998).

The Conners Rating Scale, developed in 1969, was used widely to identify

children with ADHD. This was also the time period that an adult sequel to ADHD was

considered (Morrison & Minkoff, 1975) although it was not until the 1990s that this view

began to receive widespread acceptance.

The 1980s

This was an era in which diagnostic criteria were carefully examined. The

DSM-III (American Psychiatric Association, 1980) was published and radically re-

conceptualized hyperkinetic reaction to childhood, now called attention-deficit disorder

(with or without hyperactivity) which placed a greater emphasis on impulsivity and

inattention as central features of the disorder. Later in the decade the DSM-III (APA,

1987) was revised resulting in the renaming of the disorder to attention-deficit

hyperactivity disorder.

Research during this period began to focus on the social effects of ADHD on

children, their parents (Barkley, 1989), teachers (Whalen, Henker, & Dotemoto, 1980),

siblings (Mash & Johnston, 1982), and peers (Henker & Whalen, 1980). Cognitive-

behavioral therapies (Kendall & Braswell, 1985) and social skills training programs for

ADHD children were also introduced. In addition, medication treatments for ADHD

were expanded beyond the use of stimulants during the 1980s.

The 1990s

Barkley (1998) refers to the decade of the 1990s as the decade of neuro-imaging,

genetics, and adult ADHD. Neuopsychological research has shown developmental delays








and reduced brain metabolic activity in the frontal lobes of those with the disorder

(Zametkin et al., 1990). There has also been further support for the genetic link with

studies (Biederman, Faraone, & Lapey, 1992; Pauls, 1991) showing between 10% and

35% of immediate family members of those with ADHD also having the disorder with

the risk to siblings being about 31%. This decade has also seen broadening acceptance of

ADHD as a disorder that persists into adulthood.

The DSM-IV (American Psychiatric Association, 1994) further specified that

ADHD characteristics must be pervasive across settings and create significant

impairments in life functioning to be diagnosed as a disorder. Behavioral disinhibition is

now seen as the most distinguishing characteristic from other disorders (Barkley, 1997).

However, whatever causes ADHD and no matter what we call it, those who

display its characteristics still sound very similar to those described by Still in 1902

almost a century ago. Since that time, ADHD has become one of the most well studied

childhood disorders of all time.

We continue to look for ways to support academic success for children with

ADHD in our schools. The nature of the disorder, creating academic, behavioral, and

social problems, requires planning and intervention if success is to be achieved. It

involves including ADHD children in their own treatment.

ADHD Students in Schools

School personnel need to be prepared to work with the needs of ADHD students

as they are at risk with respect to social and academic failure in school settings (Weiss &

Hechtman, 1993). Three to five percent of the school age population has ADHD, with

boys outnumbering girls almost 3 to 1 (Kauffman, 1993; Barkley, 1990). Although the








onset of ADHD for most children is prior to age 4, it is most often diagnosed when a

child is in elementary school (McKinney, Montague, & Hocutt, 1993) when problems

related to school performance surface. ADHD students are at significant risk when they

are unable to meet the demands of the classroom. Secondary behavioral and adjustment

problems develop in part as a response to frequent and repeated failures (Goldstein &

Goldstein, 1998). Teachers and parents become concerned with the resulting

underachievement and social difficulties. In addition, without assistance, students may

develop emotional problems with anger, aggression, depression, and anxiety (McKinney,

Montague, & Hocutt, 1993; Reeve, 1990), which can lead to oppositional defiant and

conduct disorders (Biederman, Faraone, & Lapey, 1992) which can become even more

problematic in schools.

Teachers, administrators, and school counselors can not expect medication, parent

training, or family therapy to ameliorate the academic and behavioral difficulties of the

ADHD student (Abramowitz & O'Leary, 1991). Therefore, effective strategies are

needed for managing behavior and enhancing the academic success of students with

ADHD. These strategies are more involved than for normal students. The disorder

increases the complexity of the teaching process because the attentional problems result

in gaps in learning and behaviors that interfere with school performance.

Multimodal treatment for ADHD includes classroom modifications and

interventions; parent training; pharmacotherapy when appropriate; and other strategies

such as counseling, social skills training, problem solving, or anger management training

as needed (Abramowitz & O'Leary, 1991). This would put school counselors in a key

role helping teachers design and implement classroom modifications and interventions,








providing parent training, and developing small group counseling interventions geared

towards teaching skills that enhance school performance.

ADHD in the School Counseling Literature

Working with ADHD students in our schools has been a significant long-term

problem that has received sparse attention by school counseling articles published in

recognized professional journals. However, attempts have been made over the last 10

years by those contributing to the school counseling literature to synthesize clinical

reviews of the history, causes, and treatments of ADHD students. Their goals have been

to provide knowledge and implications for the practicing school counselor.

Elementary School Guidance and Counseling

As the decade began, Gomez and Cole (1991) presented a review of treatment

alternatives for ADHD students which included discussion of stimulant medication,

antidepressant medication, behavioral, and cognitive-behavioral strategies. Implications

were for school counselors to gain increased knowledge of the appropriate use of

medication as one method of treatment and to provide a research base for the planning of

classroom and counseling strategies.

In 1992 (Bowley & Walther) the role of the elementary school counselor was

discussed implying that the knowledgeable school counselor could play a number of vital

roles for children with ADHD, their families, and their teachers. Robert Erk, Coordinator

of the Children with Attention-Deficit Disorders Professional Interest Network, wrote

about the evolution of attention-deficit terminology while others (Schweibert, Sealander,

Tollerud, 1995) provided a current overview of ADHD for school counselors.

Schweibert et al. (1995) also wrote about treatments that included medication, behavioral,








and cognitive-behavioral interventions. During this same period, Lucker and Malloy

(1995) made an extensive list of resources for working with ADHD children, their

teachers, and their families available.

The most recent article appearing in this journal (Bramlett, Nelson, & Reeves,

1997) involved the implications for school counselors of stimulant drug treatment for

elementary school counselors. This was an outcome based study attempting to determine

the percentage of elementary children in the United States who are receiving stimulant

medication at school and offer suggestions to school counselors as to ways to support

these students. This study of 246,707 school children across 46 states (53% return)

concluded that 2.7% of school children were receiving stimulant medication with boys

outnumbering girls four to one. Of all children receiving stimulant medication, 93%

received Ritalin. The article suggested that school counselors may be able to assist in

monitoring the effectiveness of medication as it is often difficult for parents and teachers

to offer objective evaluations.

The School Counselor

In the 1990s The School Counselor also gave attention to the need for counselor

intervention of ADHD students. Burnley (1993) presented a team approach to identifying

and treating children with ADHD using a four-step plan. He developed a plan for

identifying ADHD students in schools, a system to use for delivering instructional

strategies to teachers and information to parents, and a system for follow-up with both

teachers and parents.

Parental perspectives of the support being provided their ADHD children in the

schools was examined by Kottman, Tobert, & Baker (1995). While the sample of parents








returning the survey in this study was low (22% return rate) and those returning (94%

white with an average family income of $57,000) not being representative of the ADHD

population, the results were interesting. The parents in this study reported that their least

useful resource for their ADHD child was school system personnel. Even with the

external validity problems, this can not be ignored as it represents the population who did

return the surveys, and they do not see school personnel as helpful.

Erk (1995b) again looked unique opportunities for the school counselor after a

review of the causes and diagnosis of ADHD. His implications supported the

multidisciplinary approach to treating students with ADHD, while suggesting social skills

training, behavioral techniques, and cognitive behavioral strategies among others.

Paul Lavin (1997), provided indicators of the efficacy of using a daily classroom

checklist for communicating with parents of children with ADHD. This was based on

behavioral interventions as a proven treatment modality (Barkley, 1990; Gomez & Cole,

1991; Lavin, 1991).

Professional School Counseling

As a new journal, Professional School Counseling now serves the needs of all

levels of school counselors (neither Elementary School Guidance and Counseling or The

School Counselor will continued to be published). Immediate attention was given to

counseling children and adolescents with disabilities in the October, 1998 special issue.

This issue included articles that generally discussed the needs of all students with

disabilities. Of particular significance to the ADHD literature was the article by

Schweibert, Sealander, and Bradshaw (1998) involving the preparation of ADHD

students for the workplace. They recognized that some symptoms persist into adulthood,








along with the related problems that emerge during adolescence, and discussed

implications for vocational and post secondary entry.

Robert Erk continues to address the topic of ADHD in the most recent issue of the

Professional School Counselor (Erk, 1999). This time he examines the legal implications

for school counselors as related to the Individuals with Disabilities Education Act,

Section 504 of the Rehabilitation Act of 1973, and the Americans with Disabilities Act of

1990. These federal acts provide an outline of the rights belonging to children with

ADHD. Erk (1999) outlines interventions and services that can be provided by school

counselors to help meet the needs of ADHD as well as satisfying the requirements of the

law.

The Journal of Counseling and Development

The Journal of Counseling and Development published an article (Jackson &

Farrugia, 1997) addressing the diagnosis and treatment of adults with ADHD. This was

significant as it was the only article published this decade specifically addressing the

disorder. It discussed making the adult diagnosis, other associated disorders, and

counseling strategies to be considered.

Overview of the School Counseling Literature

The review of the related school counseling literature over the past 10 years

indicates that counseling professionals recognize the need to address the concerns of

ADHD students. School counselors are becoming knowledgeable about their role in the

identification and treatment of the disorder as well as the legal implications of federal

statues. This review also suggests that the implications of clinical research have been

reported fairly consistently in the school counseling literature over the past ten years.






25

These implications include supporting the use of stimulant medication when appropriate,

coordinating multidisciplinary interventions, consulting with parents and teachers with

regard to modifications and behavioral intervention, being advocates for ADHD students,

and providing direct counseling intervention. However, at this time, there has been a lack

of published research in the school counseling literature to support the efficacy of direct

school counselor intervention for ADHD students.

Other counseling related literature such as The Journal of Counseling Psychology

and School Psychology have also published articles recognizing the need for

identification and intervention of ADHD. The focus of these articles tends to be on

accurate identification of ADHD symptoms, measuring related problems and creating

profiles that can be used to guide treatment planning.

Small Group Counseling Interventions

Small groups are frequently used to address the special needs and problems of

children (Corey & Corey, 1997). It is a valid counselor intervention in the schools that

can meet the needs of many students (Bowman, 1987; Brown, 1994). It can be a more

efficient and effective method for working with ADHD students as more than one student

can be seen at one time, students can support each others efforts, learn from each other,

and practice behaviors in a less intense setting than meeting with the school counselor

one on one (Myrick, 1997). Others concur (Schweibert et al., 1995), suggesting that

opportunities to work with ADHD students in groups may assist students to work more

appropriately with peers while using the counselor's time more effectively. However,

Braswell and Bloomquist (1991) caution that with one leader, the groups should be

limited to four students as behaviors associated with ADHD require attention.








Behavioral strategies have been found to be highly effective in altering the

behavior of ADHD students, especially when used in conjunction with stimulant

medication (Barkley, 1998). Many of the behavioral strategies stem from the work of B.

F. Skinner, spanning over 60 years. His theory contends that children choose behavior

based on anticipated consequences and that it is the things that happen to children that

influence and change them. Children are born neutral with the potential for either good

or evil, developing as a product of their environment. Because human behavior is

learned, any or all behavior can be unlearned and new behavior learned to take its place

(Skinner, 1971).

This concept is particularly important in treatment planning for the ADHD child.

While stimulant medication can improve impulsiveness and inattention, it does not

provide the repertoire of new behaviors necessary for the child to function successfully at

school. Small group counseling can provide a relatively safe setting for the ADHD child

to practice new behaviors before acting them out in the classroom. These small groups

are also helpful in reinforcing children as they attempt new behaviors. Thompson and

Rudolph (1996) suggest a format of tell me, show me, let me try.

Present day behaviorists generally combine behavioral approaches with cognitive

ones to attend to the child's thoughts as well as their behaviors (Sharf, 1996). Helping

ADHD children understand their disorder and how it effects their performance would be a

cognitive compliment aimed at improving the child's perception of self as new behaviors

are learned and practiced. Accepting appropriate responsibility for behavior and

recognizing the need to make behavioral changes are also important cognitive concepts.








Yet, highly cognitive strategies have not consistently proven successful for the

ADHD child. While researchers have found some success (Abramowitz & O'Leary,

1991; Schweibert et al., 1995) with cognitive strategies with this population, other studies

(Abikoff, 1987; Abikoff& Gittelman, 1985; Brown, Wynne, & Medenis, 1985).

examining the effectiveness of cognitive-behavioral strategies have not produced

significant effects at a level that could be detected in parent or teacher ratings. Braswell

and Bloomquist (1991), in their review of cognitive-behavioral studies, found that

successful cognitive-behavioral interventions for this population are more behavioral than

cognitive. These strategies emphasize group training for behavioral skill practice with

peers and maintain a focus on specific skills as well as the problem-solving process.

Students with ADHD often have difficulty even recognizing when they are involved in a

problematic situation. After additional study and research, Braswell (1998) has

concluded that while cognitive behavioral approaches provide viable strategies for

intervening with coexisting problems like aggression or peer difficulties, they will not

alleviate primary symptoms of ADHD.

Braswell and Bloomciuist (1991) also note that when a cognitive component is

added to a behavioral treatment approach, the child should be at least third grade level or

8 years old. Children at this age are moving through a concrete operational stage of

cognitive development (Piaget, 1967) and are showing a greater capacity for logical

reasoning. They are making progress towards extending their thoughts from the actual to

the potential (Elkind, 1970) but the starting point must still be what is real and what has

been experienced. These concepts must underlie the use of cognitive components used to

supplement behavioral techniques for treating ADHD children.








Dependent Variables

Three dependent variables have been chosen for this study. They include

classroom behavior, locus of control, and school success skills. It is hypothesized that the

effects of a small group counseling intervention for ADHD students can be detected using

measures of these constructs. The intervention focuses on increased knowledge and

awareness of the disorder, coupled with the introduction and practice of specific

behavioral skills aimed at improving a student's perception of self and shifting the

student towards a more internal locus of control. While these outcomes are perceptions

of students, classroom behavior followed eventually by improved academic success, are

the real targets.

Due to the short duration of this study (6 weeks), academic gains that would

follow behavioral improvements would not necessarily be expected and, therefore, will

not be assessed. It should be noted that Myrick and Dixon (1985) found that teachers

rated their students more positively after intervention. However, there will be no

expectations for teachers during this study other than completing the pre and posttest

measures. Teacher's will have this task for both treatment and control group students and

will not be involved in the actual intervention for any students.

School Success Skills

Cartledge and Milburn (1978), after reviewing the literature on behavioral skills in

the classroom setting, found certain skills linked to academic success and to school

success. From these, Cuthbert (1987) identified six specific task oriented skills and

developed a six-week school counseling intervention designed to improve student self-

perception as related to school success. Among the school success skills targeted were








paying attention in school, listening to teachers and peers, volunteering appropriately in

school, using self-control, interacting with teachers and peers, and utilizing self-

assessment.

Classroom attending refers to orienting towards the teacher or to stimuli defined

by the teacher, under conditions specified by the teacher (Cartledge & Milburn, 1978).

Another definition involves attending as doing what is appropriate in an academic

situation such as looking at the teacher when they present material or writing responses to

questions. This definition was used by Cobb (1972) in a study of classroom behavior and

academic achievement in fourth graders. Results found attending to be the most powerful

of eight behavioral categories examined as related to achievement.

Listening is also an important skill linked to school success. McGinnis and

Goldstein (1984) pointed out the importance of teaching students how to show that they

are listening in the classroom. This included, looking at the person who is talking, sitting

quietly, thinking about what is being said, acknowledging ideas, and asking questions.

Others (Myrick & Bowman, 1991; Foster, 1983) have also recognized the link between

listening and school success.

Volunteering (e.g., participating in classroom discussions appropriately) has been

positively correlated with academic achievement (Hops & Cobb, 1973). Wittmer and

Myrick (1989) spoke about this relationship as they believed asking questions and

contributing answers was a reflection of listening and active processing of material just

presented.

Interacting with teachers and peers has also been reported to have positive

relationship with successful learning. Cartledge and Milburn (1978), in their review of








selected studies, found a growing recognition of the reciprocal nature of interactions

between teachers and students. Research has shown that changes in student behavior can

bring about changes in teacher behavior. Klein (1971) also found support for this idea in

her study finding positive student behavior influencing teachers to use positive behaviors.

Teachers and counselors have long been concerned with finding ways to help

reduce aggressive behavior by teaching self-control and self-assessment skills. Kaufman

and O'Leary found that self-evaluation was effective in maintaining a lower level of

disruptive behavior in students who were deficient in reading and showed high rates of

disruptive behavior. Cox and Gunn (1980) have noted that the social skills of students

within the school setting has direct impact on their academic performance. They further

point out that the lack of appropriate social skills may be the result of not knowing what

to do, not having the skills (physical or cognitive) to execute the known behavior, or not

being able to deal with the emotional response (such as anger or anxiety) which inhibits

the skill performance.

Using these skills as a guide, it is not hard to understand why ADHD children

have so much difficulty in school. These are the very skills that ADHD students have

difficulty accessing, even if they are in their repertoire of known behaviors. These are

classroom skills that must continue to be the target of planning and intervention for

ADHD children.

Locus of Control

The literature on locus of control repeatedly identifies contrasting characteristics

of internal and external locus of control. According to Rotter (1966), this distinction

depends on whether or not the person perceives a causal relationship between his or her






31

behavior and what happens to them. He saw this as a particularly important influence as

the growing child learns appropriate social and personal behavior.

Evidence of the importance of locus of control in achievement was reported by

Coleman et al. (1966) in a study, Equality of Educational Opportunity, which included

information on over 645,000 students. It was concluded that students who assumed they

could affect their environment were higher achievers than those who felt that luck, fate,

or other uncontrollable factors were responsible for what happened to them. These

researchers reported that students' locus of control orientations appeared to have a

stronger relationship to achievement than all school factors combined.

Nowicki and Duke (1983) went on to review several studies confirming that an

internal locus of control is related to greater achievement in academic settings. Theory

suggests that students with an internal locus of control are differentially sensitive to task

structure when compared to those with an external locus of control.

Sandler, Reese, Spencer, and Harpin (1983), in their review of person-by-

environment interaction research, suggest that students with an internal locus of control

adapt better in low than high controlling environments. They concluded that this was due

to their activity preferences, self-control skills, reactance against loss of freedom, and

effective use of situational clues. Students with an external locus of control, on the other

hand, adapt better in high controlling situations as a result of their activity preference,

need for explicit cues, low reactance to loss of personal freedom, and poor internal self-

regulation skills.

It has also been suggested (Searcy & Hawkins-Searcy, 1979) that those with an

internal locus of control are better adjusted. Adalbjamardottir (1995) has demonstrated






32

that children with a more internal locus of control are better problem solvers than children

with an external orientation.

According to Linn and Hodge (1982), ADHD students tend to have a more

external locus of control with poor internal self-regulation skills and the need for explicit

cues. Tarnowski and Nay (1989) administered the Nowicki-Strickland Locus of Control

Scale (Nowicki & Strickland, 1973) to a group of boys and found that those with no

diagnosed difficulties were measured to have the least external locus of control while

those boys with attention-deficit who were also learning disabled demonstrated the most

external locus of control.

Goldstein and Goldstein (1998) find it no surprise that given the nature of the

lives of ADHD children, they are at risk for developing an external locus of control.

Modifications are made by parents and teachers, medications is frequently given, and

children begin to see themselves as "recipients" of an intervention out of their control

One aim of the small group counseling intervention designed for this study was to shift a

presumably external locus of control in the direction of a more internal one. This was to

be done through increasing student knowledge and awareness of the disorder, helping

students to understand how the disorders effects their school performance, as well as

teaching skills the student could use to effect school outcomes.

Classroom Behavior

Teachers are usually involved in the assessment of children's behavior regarding

school-based interventions. Their reports are a prime source of baseline data with which

to compare outcomes (Achenbach, 1991). Other variables, including self-reports can be

used to augment outcomes as we develop better ways of helping children.






33

The Teacher Report Form (TRF) is a rating scale designed to capture descriptive

distinctions in classroom behavior without specialized training. Like other rating scales,

the intention is not to produce a diagnosis but to describe behavior in an organized,

statistical fashion. The TRF attempts to provide a profile of behavior as it is actually seen

by the classroom teacher. Profiles are provided in eight subscales and include: (1)

withdrawn; (2) somatic complaints; (3) anxious/depressed; (4) social problems; (5)

thought problems; (6) attention problems; (7) delinquent behavior; and (8) aggressive

behavior. Unlike the Connors Revised Teacher Rating Scale (Goyette, Conners, &

Ulrich, 1978) that was designed primarily for assessing hyperactivity, the TRF can obtain

a more differentiated picture of classroom behavior and the degree of deviance in each

area. This is important in assessing classroom behavior as the pupil may not really be

deviant in the area of the referral complaint, because terms like "hyperactivity" tend to

serve as euphemisms for a wide range of nuisance behaviors (Achenbach, 1991).

Since the TRF is not confined to any theoretical view or topic in its use, it can be

used as an outcome measure for a wide range of constructs. In this study, the TRF will be

used to detect changes in classroom behavior of ADHD students after an intervention

focusing on the constructs of locus of control and school success skills. This seems to be

an appropriate use.

Summary

A review of the related literature has (a) provided a historical context for

considering diagnosis and treatment of ADHD; (b) shown that characteristics of ADHD

interfere with school outcomes; (c) shown that frequent prevalence of the disorder in

schools necessitates school-based intervention; (d) demonstrated the effective use of








behavioral and cognitive methods; (e) supported the use of small group counseling as a

vehicle for intervention delivery; and (f) demonstrated that self-report and teachers

ratings of perceptions and behavior can be used to assess treatment.

There is abundant clinical ADHD literature and general agreement as to the nature

of the disorder. The literature is fairly consistent with its implications for intervention

with ADHD students. Many roles, including co-ordinator, consultant, and direct service

provider, have been identified for the school counselor all within the guidance and

counseling framework.

However, how effective are school counselors in these roles with regard to the

ADHD population? Can brief direct counseling services make a difference in classroom

behavior? What student variables effect the outcome of treatment? A void remains when

it comes to examining the efficacy of school counselor involvement with the school-aged

ADHD population. Such research becomes the focus of this study.














CHAPTER 3
METHODOLOGY

This study was designed to investigate the effectiveness of a small group

counseling intervention on the classroom behavior, locus of control, and school success

skills of third, fourth and fifth grade ADHD students in the Alachua County, Florida

Public Schools. The intervention focused on helping students decrease their problem

behaviors in school through increasing their sense of personal control and responsibility

for school success skills. Further, this intervention involved helping students identify,

learn, and practice using skills and external resources to supplement the internal resources

that are often ineffective in allowing ADHD children to control and sustain behavior.

Pre- and postmeasures of locus of control and school success skills were

completed by treatment and control group students. The teacher of each participating

student completed a pre- and postmeasure of classroom behavior.

Population

The population of interest was third, fourth, and fifth grade students previously

diagnosed as ADHD in the 23 public elementary schools in Alachua County, Florida.

This included ADHD students who ranged in ages from 8-12 from five north central

Florida communities.

In 1997, the population of Alachua County was 208,145 including 44,000

University of Florida students. In the academic year 1996-1997, the Florida Department

of Education (1997) reported the Alachua County Public Schools having approximately








12,792 students attending 23 elementary schools. The racial and ethnic make-up of the

elementary school students included 52% white, 40% black, 4% Hispanic, 3% Asian, and

1% American Indian/Alaskan native students. The gender breakdown was 49% male and

51% female. Free or reduced lunch was received by 56% of the elementary aged students

in Alachua County during this same period.

The demographic statistics for Alachua County are similar to those statewide with

the exception of the black and Hispanic populations. The state average for black students

in a district was 26% while the state average for Hispanic students in a district was 17 %.

The increased mean in Hispanic students could be due to the high concentration of

Hispanic students in some south Florida districts.

At the time of the study, 342 students were identified as ADHD in grades three,

four, and five in Alachua County. The list of ADHD students was generated from the

School Board of Alachua County (SBAC) data base and confirmed in each of the 19

schools volunteering participation in the study. Students diagnosed as ADHD per parent

report to school staff or who were taking medication at school for ADHD symptoms but

were not in the data base, were added to the identified data base population yielding a

total of 342 students. Omission from the SBAC data base was the result of the parent not

writing ADHD on the enrollment or data cards even though they had alerted school staff.

The demographic make-up of ADHD students in grades 3, 4, and 5 in Alachua

County included 68% white, 28% black, 2% Hispanic, 1% Asian, and 1% Indian/Alaskan

native students. In addition, 73% were male and 27% were female. Comparing the

demographics of race and sex of the ADHD population to those for the elementary school

population of Alachua County suggests that white students are more likely to be








identified ADHD than black or Hispanic students. It also suggests that males are more

likely than females to be diagnosed with the disorder at a rate of three to one, a finding

consistent with the ADHD literature.

Sampling Procedure

Upon approval of the University of Florida's Institutional Review Board,

permission to conduct the study was sought from the Alachua County, Florida Public

Schools' Department of Research and Evaluation. Next, the principals and counselors of

the 23 public elementary schools were informed of the nature of the study and invited to

volunteer their schools for participation. Each principal received a copy of the

Application for Research in Alachua County Public Schools form explaining the purpose

of the research, giving a brief summary of the research design, describing the population,

and delineating the amount of time involved to complete the study. An accompanying

letter (Appendix A) was sent to principals. Principals and counselors of schools decided

to volunteer the participation of their school. One of the non-participating schools was

not eligible for the study serving only students in grades K-2. A second non-participating

school did not have a school counselor at the time of the intervention.

Within each school choosing to participate, the names of all students in grades

three, four, and five who had been diagnosed and identified by school personnel as

ADHD were placed on a list. School counselors followed instructions for random

selection of students (Appendix B) and assigned numbers beginning with 00. Eight

names were chosen and recorded on a student information sheet using a table of random

numbers. Alternates were also selected using this method. In schools with eight or fewer

ADHD students identified, all ADHD students were selected. A letter (Appendix A) was






38

sent to the parents of the selected students about the research, the nature of the counseling

intervention, and asking permission to include their child in the study. From the list of

ADHD students whose parents gave permission, students were randomly assigned, again

using a table of random numbers, to either a treatment or a control group for the duration

of the study.

Resultant Sample

Of the 19 Alachua County, Florida school counselors agreeing to participate in the

study, 13 were able to complete the intervention and posttests within the time frame

necessary to be included in the study. The resultant sample was composed of 93 students

from 12 elementary schools. Demographics of the participating schools can be found in

tables 3-1 and 3-2. It should be noted that a large school with two certified counselors

ran two groups, resulting in 13 small groups.


Table 3-1
Total Enrollment and Lunch Status by Participating School

School # Enrollment % Free/Reduced Lunch
1 575 52%
3 521 75%
4 404 80%
5 574 54%
7 569 45%
10 657 79%
11 554 62%
12 661 26%
13 446 83%
16 255 72%
17 958 38%
18 471 87%








Table 3-2
Students by Race for Participating Schools

School # % of Students by Race
White Black Hispanic Asian Indian
1 69% 27% 3% 1%* 1%*
3 52% 45% 2% 0% 1%
4 48% 48% 3% 1% 0%
5 52% 44% 3% 1% 1%*
7 80% 17% 2% 1%* 1%*
10 30% 67% 2% 1% 0%
11 72% 24% 2% 1%* 1%*
12 70% 20% 7% 3% 1%*
13 22% 71% 2% 5% 0%
16 79% 19% 1% 1%* 1%*
17 68% 25% 4% 3% 1%*
18 15% 74% 4% 7% 1%*
Notes less than 1%

Ninety-six students were selected and agreed to participate in the study. Three

moved during the study resulting in 93 student participants. Of those students, 47 were

assigned to treatment and 46 to control groups. The size of each group varied from three

(42% of the groups) to four (58% of the groups) students. The demographic make-up of

the total sample as well as treatment and control groups can be found in Table 3-3 and

Table 3.4.


Table 3-3
Demographic Characteristics of Sample by Sex and Race

Demographics
Groupings Male Female W B H
Total Sample n = 93 74% 26% 82% 18% 1%*
Treatment n = 47 70% 30% 87% 13% 0%

Control n = 46 83% 17% 72% 23% 4%
*Notes less than 1%








Table 3-4
Demographic Characteristics of Sample by Age, Medication, and ESE Status

Demographics

Age Group On Medication* ESE Program**

Groupings 8-9 yrs. 10-12 yrs. Yes No Yes No

Total Sample, n = 93 44% 66% 86% 14% 51% 49%

Treatment, n = 47 48% 52% 87% 13% 54% 46%

Control, n = 46 40% 60% 85% 15% 47% 53%
*On Medication--refers to whether or not the participating ADHD student was on
medication for ADHD symptoms during the study.
**In ESE Program--refers to ADHD students who are in an Exceptional Student
Education program other than speech, language, or gifted.


Research Design

The research design used in this study was a prepost control group design as seen

in Table 3-5. Following random assignment of students to treatment and control groups,

students completed the Children's Nowicki-Strickland Internal-External Locus of Control

Scale (CNSIE) and the School Success Inventory-Student Form (SSI-SF) both found in

Appendix C. Teachers completed the Teacher Report Form (TRF) for students in

treatment and control groups. Following the small group counseling intervention for the

treatment group, all measures were administered again. The combination of random

assignment of subjects to groups and the presence of a pretest and control group served to

control for most sources of internal validity (Gay, 1996).

School counselors delivered the small group counseling intervention. An attempt

to make the treatment uniform and consistent was made through a workshop presented by

the researcher that included review of the Group Facilitator's Manual (Appendix D).








Table 3-5
Prepost Control Group Design

Conditions Pre Post
Treatment R O1 02 03 X 01 02 03
Control R 01 02 03 01 02 03

R = Random assignment of subjects to groups
X = Group counseling for ADHD students
01 = Teacher Report Form (TRF)
02 = Children's Nowicki-Strickland Internal-External Locus of Control
Scale (CNSIE)
03 = School Success Inventory--Student Form (SSI-SF)


School Counselor Training

The participating Alachua County, Florida Public School counselors were trained

by the researcher. All participating counselors were certified school counselors earning at

least a masters degree with 54% earning at least a specialists degree. Years of experience

ranged from 1-27 years with an average of 12 years as a school counselor. State

certification status, highest degree earned and years of experience are seen in

Table 3-6 for each participating counselor by school.

Each counselor took part in a workshop led by the researcher. A package of

materials was presented at the workshop that contained a brief description of the project,

research procedures, and timelines to be followed. The package also contained copies of

the dependent measures and instructions on how to present them. As the materials were

reviewed, information regarding experimental conditions was discussed in an attempt to

control for differences in delivery of the intervention or data gathering across schools.

The researcher was available to consult with any counselor who was unsure of the

research procedures. A workshop outline follows.








Table 3-6
Levels of Experience and Education of Participating Counselors by School

Counselor Demographics
Certified School Counselor Highest Degree Experience


School Number
1
3
4
5
7
10
11
12
13
16
17 (01-04)*
17 (05-08)*
18


Yes
X
X
X
X
X
X
X
X
X
X
X
X
X


B M Sp. Doc. Years
X 14
X 7
X 5
X 20
X 2
X 15
X 27
X 12
X 13
X 12
X 10
X 1
X 16


Note: Two groups were run by in school 17, each by a different counselor.


Counselor Workshop Outline

I. Nature of the Study

II. Attention-Deficit Hyperactivity Disorder
A. History
B. Characteristics
C. Extent of the problem in schools
D. Interventions (including medication)
E. Meeting ADHD student needs in Developmental Guidance
Programs

III. Research Procedures
A. Overview of Design
B. Randomization
C. Informed consent
D. Collecting pre- and posttest data

IV. Delivery of the Counseling Intervention

V. Return of Materials


VI. Questions








The researcher supervised the random selection of ADHD students and several

alternates for each school. This was done at the workshop, where the lists of ADHD

students at each school were available.

Upon completion of review and questions about research procedures, the

workshop focus shifted to ADHD and included the treatment intervention and its

delivery. Tasks included talking about problems facing ADHD children, reviewing

teacher concerns, and studying the Group Facilitator's Manual. The participants

examined session content and discussed the activities in terms of objectives and

procedures. Counselors were encouraged to follow the counseling manual so the

treatment would be relatively consistent across counselors and schools.

Brief notices were sent to all counselors at two-week intervals with reminders

about important procedures and clarification reflecting any questions that had been raised

by any of the counselors. This was also an attempt to increase the uniformity of the

intervention delivery. The researcher remained available by phone throughout the

duration of the study.

Treatment Description

A small group format was used to deliver the counseling intervention to third,

fourth, and fifth grade ADHD students. The six counseling sessions took place in

approximately once a week sessions for a period of six weeks during the spring semester.

Each session lasted approximately 30-40 minutes. Counselors followed the agreed upon

guidelines described in the manual and implemented group counseling activities

accordingly.








The intervention followed the theme of a journey. During the small group

counseling intervention, ADHD students were encouraged to continue to set their sights

on "school success" as a destination while recognizing the need to consider "alternate

paths, detours, or the need for roadside assistance" as strategies to keep them on their

way. These metaphors were linked to specific skills that were taught and practiced during

the intervention.

Initially, each school counselor helped group members get acquainted, clarified

their reasons for being in the group, and began building a climate of trust and acceptance

through involvement in introductory activities. Thereafter, each session featured

activities and discussions that focused on helping students learn more about their disorder

as reflected in school performance. ADHD students were given an opportunity to explore

their own diagnosis and express feelings associated with that knowledge. A brief

discussion of the use of medication for ADHD symptoms was included.

Students participated in tasks and activities allowing them to identify behaviors

that support school success. The group format provided a setting in which students were

able to practice new behaviors while among their peers. Among the behaviors targeted

for this intervention were: paying attention, listening, organizing materials, recognizing,

creating, and using external cues in the classroom, handling frustration and anger, and

using available supports in the classroom to increase success in school. Students were

encouraged to take responsibility for their actions by recognizing the need for

modification and intervention in their daily routine.

The counseling intervention ended with a summary of what had been done,

allowing students to talk about their experience and describe their next steps. A brief








overview of the content sessions is outlined in Table 3.7. The complete intervention can

be found in the Group Facilitator's Manual in Appendix D.


Small Groun


Table 3-7
Counseling Intervention


Session # Title of Session Content Objectives
Session #1 Our Journey 1. Students will gain increased knowledge of
ADHD.
2. Students will identify behaviors
associated with ADHD and how those
behaviors effect school success.
3. Students will be given an opportunity to
discuss their own ADHD diagnosis and
express associated feelings.
Session #2 Pack It Up 1. Students will learn and practice strategies
to support the need for better organization
as related to school success.
Session #3 Stop Lights & Traffic 1. Students will learn and practice behaviors
Cops associated with attending.
2. Students will identify school situations in
which attending is important.
3. Students will identify school situations in
which attending is difficult.
Session #4 Using Road Signs As a 1. Students will learn to recognize, create
Guide and use external cues in the classroom.
2. Students will gain increased awareness of
the need for strategies to support school
success.
Session #5 Road Holes and Detours 1. Students will identify school situations
that are particularly difficult.
2. Students will identify ways to improve
school situations that are difficult.
Session #6 Roadside Assistance & 1. Students will identify sources of support
Becoming Your Own at school.
Mechanic 2. Students will be given the opportunity to
experience the feelings of "being in
control."
3. Students will associate increased practice
of a skill with improvement of that skill.
4. Students will gain increased knowledge of
the use of medication in treating ADHD.


Counselng Inteventio






46

Students who participated in the groups were compared to ADHD students in the

control groups on the dependent measures. Students in the control group continued with

their regular school routine during this period. They responded to the measures of locus

of control and school success at the same eight-week interval as the treatment group.

Teachers also completed the classroom behavior measure for the control group students at

the designated intervals.

Assessment Techniques

In order to assess the effects of the treatment, the following measures will be used:

Teacher Report Form (TRF); Children's Nowicki-Strickland Internal External Locus of

Control Scale (CNSIE); and School Success Inventory--Student Form (SSI-SF).

Teacher Report Form (TRF)

The Teacher Report Form was designed in 1986 by Achenbach and Edelbrock to

provide standardized descriptions of social-emotional development for students, by

gender, ranging in age from 6-16. The effects of race and SES were examined but the

authors found that differences were too small to warrant separate norms (Achenbach &

Edelbrock, 1986). The scoring profiles were derived using factor analyses of TRF's

completed on 1,800 children referred to mental health services in the eastern United

States. According to Christenson, in her 1992 review of the TRF, the norming

procedures were "impeccable."

The TRF includes 118 items on a 3-step response scale (0 = Not True, 1 =

Somewhat or Sometimes True, and 2 = Very True or Often True). It is designed to be

completed by teachers who have known a student in a school setting for at least 2 months.






47

It is self-administered and requires no special training. Teachers can complete the scale

in about 20 minutes.

The TRF was designed to provide standardized descriptions of students' behavior.

It does so by identifying behaviors that occur together and refers to these groupings as

syndromes. The syndromes were derived from TRF items identified by teachers for

children who were referred for special services (Achenbach & Edelbrock, 1986). The

following eight syndromes are displayed in the 1991 TRF profile: withdrawn, somatic

complaints, anxious/depressed, social problems, thought problems, attention problems,

delinquent behavior, and aggressive behavior (Achenbach, 1991).

Internalizing and externalizing groupings of behavior were also identified for each

age/sex group (Achenbach, 1991). The internalizing grouping is the sum of scores on the

withdrawn, somatic complaints, and anxious/depressed scales. The externalizing

grouping is comprised of the items on the delinquent and aggressive behavior scales.

These scales are not mutually exclusive. According to Achenbach (1991), students who

score high on one grouping tend to have at least above average scores in the other area as

well. Worth special consideration are students who have a much higher score in one

grouping than the other. A total sum score (TSS) of the internalizing and externalizing

behaviors can be derived as a measure of classroom problems exhibited by the student.

The behavior problems scale is comprehensive and is conceptually consistent with

other problem-oriented behavior rating scales ( Elliott & Busse, 1992). Construct validity

data is derived from factor analysis and concurrent validity with the Conners Revised

Teacher Rating Scale (r = .85) which also looks at children's problem behaviors. In

addition, Achenbach and Edelbrock (1986) found for all ages and both sexes that referral






48

status consistently accounted for the largest percent of the variance in ratings on the TRF.

One example was students whose diagnosis was made independently of the TRF.

Researchers (Edelbrock, Costello, & Kessler, 1984) found that students with ADHD

scored higher on the inattentive scale than a control group of referred students having

other diagnosis.

Test-retest reliability was reported by Achenbach in 1991. The correlation of test-

retest reliability of the TRF was r = .92 over a 15 day interval for problem behavior

scores. Inter-rater agreement was similar for teachers seeing students under different

conditions (r = .54) and teachers seeing students under more similar conditions (r = .55)

with respect to problem behaviors.

The TRF lends itself to statistical analysis done on samples that include children

of both sexes and different age ranges (Achenbach and Edelbrock, 1986). T scores, as

opposed to raw scores, can be used for the respective sex/age groups. The T score reflects

each subject's deviation from the mean of his/her normative group. Therefore, while a

raw score of 29 is in the borderline clinical range for boys age 12-18, it is well above the

clinical range for girls 12-18 resulting in a lower T score for boys.

Several hundred references to the Child Behavior Checklist in the Eleventh

Mental Measurements Yearbook (Christenson,1992) suggest its widespread acceptance

and use. However, it is recognized that the TRF not be used in isolation but in

combination with other methodologies to identify behavioral difficulties in school-aged

children.








Children's Nowicki-Strickland Internal External Locus of Control Scale (CNSIE)

The Children's Nowicki-Strickland Internal External Locus of Control Scale

(Appendix C) is a pencil paper self-report measure developed in 1969 consisting of 40

questions that are answered either yes or no. It was constructed on the basis of Rotter's

(1966) definition of the internal-external control of reinforcement dimension as an

attempt to measure locus of control in children. The items describe a variety of

reinforcement situations across interpersonal and motivational areas such as affiliation,

achievement, and dependency (Nowicki & Strickland, 1973).

Scores were based on the number of responses that indicated an external locus of

control orientation to the statement; therefore, scores could range from 0-40. Higher

scores indicate a more external locus of control than lower scores.

Upon testing 1,017 students in grades three through 12 twelve, Nowicki and

Strickland (1973) reported test-retest reliabilities that ranged from .66 to .71 after a six-

week period. All socioeconomic groups were included in this sample and all subjects had

intelligence tests scores in the average range.

Estimates of internal consistency using the split half method, corrected by the

Spearman Brown formula, were correlated by grade levels (Nowicki & Strickland, 1973)

and range from .63 (for grades 3, 4, and 5) to .81 (for grade 12). Since the CNSIE scale is

additive and the test items are not arranged sequentially according to difficulty and are

not comparable, the split-half reliabilities may underestimate the internal-consistency of

the scale (Nowicki & Strickland, 1973).

Construct validity was established (Nowicki & Strickland, 1973) comparing the

CNSIE to other locus of control measures. Significant (p < .01) but not high correlations






50

were found when comparisons were made to the Intellectual Achievement Responsibility

scale (Crandall, Katkovsky, & Crandall, 1965) with correlations of .31 and .51 for black

third (N = 182) and seventh graders (N = 171). A correlation of .41 with the Bialer-

Cromwell (Bialer, 1961) was also significant (p < .05) for 26 white students ages 9-11.

Additionally, the relationship between the Rotter (1966) and the CNSIE adult scale was

significant (p < .01) in two studies with college students yielding correlations of .61 (N

76) and .38 (N = 46) (Nowicki-Strickland, 1973).

Correlations of the CNSIE with the Children's Social Desirability Scale (Crandall,

Crandall, & Katkowsky, 1965) were computed. For males and females within each

grade level, locus of control scores were not significantly related to social desirability.

The CNSIE has been used to compare internal-external locus of control with

ADHD and control groups (Linn & Hodge, 1982). The effects of cognitive strategies on

locus of control for learning disabled students (Morin, 1993) has also been measured

using this instrument.

School Success Inventory--Teacher Form (SSI-TF)

The School Success Inventory--Student Form (Appendix C) is a paper and pencil

measure containing 12 items, 2 items to represent each of the six classroom behaviors of

attending, listening, volunteering, using self-control, interacting, and assessing self. The

items comprise behaviors related to school success (Cuthbert, 1987).

The student marks each item in terms of perceived frequency of occurrence on a

5-point scale of very often, often, sometimes, seldom, and very seldom. Students

indicated their choices by marking with an X or a check mark. Each of these categories

was assigned a numerical score, with one indicating the "desired behavior and








corresponding to Very Often. The total score over the 12 items ranges from 12

(behaviors occurring very often) to 60 (very seldom). A total frequency score was

recorded for each student. A lower score was more indicative of self-perceived desired

behaviors than was a higher score.

Cuthbert (1987) measured test-retest reliability for the SSI-SF yielding a

coefficient of stability of .79 during a pilot study. In this pilot, the SSI-SF was

administered to 49 students in two third-grade classrooms. Two weeks later, the students

rated themselves again on the same instrument. Cuthbert (1987) used this scale to

measure the effectiveness of a classroom guidance intervention aimed at teaching skills

for school success.

Both the CNSIE and the SSI-SF were developed to be completed by school-aged

children. Each instrument has a third grade reading level making them appropriate for

self-reporting. The students in the current study were in grades three, four, and five.

However, due to the possibility of ADHD students having reading abilities below grade

three, the counselor read the items on the instruments as the student followed along and

marked responses.

School Counselor Survey

School counselors, postintervention, completed a survey. The survey contained

11 items with a five point Likert-type scale. School counselors were asked to respond to

each statement on the survey by marking either Strongly Agree, Agree, Uncertain,

Disagree, or Strongly Disagree. Items focused on the counselor's perceptions of the unit,

the experience of participating students, the counselor's own experience, and

recommendations.








Hypotheses

The following hypotheses will be evaluated at the .05 level of significance in this

study:

1. There will be no significant difference between the classroom behavior

adjusted means of students in the treatment and control group, as measured by

the Teacher Report Form (TRF).

2. There will be no significant difference between treatment and control group

students' locus of control adjusted means, as measured by the Children's

Nowicki-Strickland Internal External Locus of Control scale (CNSIE).

3. There will be no significant difference between treatment and control group

students' adjusted mean perception of school success skills, as measured by

the School Success Inventory--Student Form (SSI-SF).

4. There will be no significant interaction between treatment and age, sex, ESE

status, or being on medication as measured by the TRF, CNSIE, and SSI-SF.

Data Analysis

Pre- and posttreatment data were initially analyzed using a hierarchical linear

model. This analysis was appropriate since each group of students receiving treatment

belonged to an intact school group that volunteered participation in the study (Patterson &

Goldstein, 1991; Raudenbush, 1988). The intact school groups participating could

influence the scores on dependent measures as a result of interaction with a particular set

of individuals or occurrences. In this analysis, the effects due to group membership

(school) were separated from the within-group residual error term. However, pooling the

error term and using a mixed effects model analysis of covariance (ANCOVA) was






53

considered appropriate in this case, as there was not a significant between school variance

on any of the dependent variables. Mixed effects models are used when the classification

of variables are a mixture of random and fixed effects (Agresti & Finlay, 1997), as was

the case in this study.

ANCOVA assumptions were checked and provided support for use of the

ANCOVA model. Assumptions of normality, equal variances, and linearity were

checked by plotting the data. The equal slopes assumption was checked through

statistical analysis. Independence was considered prior to the study through random

assignment of students. Measures that were appropriately reliable for social science

research were used to satisfy the measurement error assumption.

The mixed model ANCOVA was then performed on all measures for treatment

and control groups. The purpose of the ANCOVA to is determine whether the observed

differences between means are due to chance or to systematic differences among

treatment populations (Shavelson, 1996). It does so by statistically removing predictable

individual differences from the dependent variable, thereby providing a more precise

estimate of experimental error and a more powerful test of the null hypothesis. The

pretest score served as the covariate to adjust posttest scores. Random assignment of

subjects to treatment and control groups increased the validity for using the ANCOVA

(Gay, 1996).

The mixed effects ANCOVA model (Table 3-5) examined five main effects and

four two-way interactions. The main effects included treatment, age, sex, ESE

placement, and whether the student was taking medication for ADHD symptoms. The

two-way interactions looked at how treatment interacted with each of the other variables








(age, sex, ESE, and medication). The two-way interactions were introduced into the

ANCOVA model one at a time while holding the model constant. School was treated as

a random effect while age, sex, medication, and ESE status were treated as fixed effects.


Table 3-8
Mixed Effects ANCOVA Model

Y (X X)= p + a + Y7 + ay, + 2 +
post covariate = grand mean + treatment + school + school by treatment + age +
test

3+ + Ys + +
sex + meds + ese + error
Note: This is the portion of the model that was held constant as the two-way interactions
were introduced one at a time.


The alpha level for all tests in this study was set at the .05 level. The .05 level of

significance is a reasonable probability level (Gay, 1996) as this study is exploring the

effectiveness of a counselor intervention strategy for ADHD students while producing

implications for further research.

Research Procedures

During the week preceding the intervention, pretreatment measures were

administered. All measures were to be coded by number to ensure confidentiality of

results. Corresponding school, gender, race, age, special education designation, and

whether or not the student was on medication for ADHD symptoms were provided to the

investigator for use in the analysis. The school counselor at each school involved in the

study administered the student assessments in their respective schools.

School counselors were trained in procedures for administration of the Children's

Nowicki-Strickland Internal External Locus of Control scale and the School Success








Inventory--Student Form. Counselors read all test items to students to help control for

differences in reading abilities. School counselors gave teachers the Teacher Report

during this same pretreatment week and recovered all forms before treatment began.

Counselors planned with teachers to arrange a weekly time for the small group counseling

intervention.

The six treatment sessions took place approximately once per week and took

about 30-40 minutes. At the end of the six-week intervention, the school counselor again

administered the CNSIE and the SSI-SF to students in the treatment and control groups.

The school counselor disseminated the TRF to classroom teachers of students in the

treatment and control groups.

School counselors completed a postintervention questionnaire concerning

counselor demographics and perceptions of the intervention experience (Appendix C).

All data was placed in large envelopes, and collected and analyzed by the investigator.














CHAPTER 4
RESULTS

This study examined the effectiveness of a small group counseling iritervention

for ADHD students. School counselors delivered the intervention to ADHD

students in grades three, four, and five. Counseling activities were designed to increase

the students awareness of ADHD and improve their sense of control for behaviors related

to school success.

To assess the effectiveness of the group counseling intervention, analysis was

performed on pre- and postdata obtained using a mixed effects ANCOVA model. Three

dependent measures were used to gather data related to the effects of the intervention.

These measures included (a) teachers' ratings of student classroom behavior as measured

by the Teacher Report Form, (b) students' perceptions of their locus of control orientation

as measured by the Children's Nowicki Strickland Locus of Control Scale, and (c)

students' perceptions of school success behaviors as measured by the School Success

Inventory-Student Form.

Data on the three dependent measures were collected from 93 students in grades

three, four, and five, attending 13 public elementary schools. An experimental research

design provided for random assignment of students to treatment and control groups for

the duration of the intervention, resulting in 47 treatment and 46 control group

assignments.








Pre- and posttreatment data were initially analyzed using a hierarchical linear

model as each group of students receiving treatment belonged to an intact school group

that volunteered participation in the study. Using this analysis, the effects due to group

membership (school) were separated from the within-group residual error term.

However, pooling the error term and using a mixed effects model analysis of covariance

(ANCOVA) was considered appropriate, as there was not a significant between school

variance on any of the dependent variables. Pretest scores were used as covariates in

computing the analysis of covariance to remove the influence of pre-intervention

variation on the scores for each measure.

Assumptions providing support for use of the ANCOVA as an appropriate

statistical analysis, were checked. Results of tests for between school variance and

assumptions may be found in Appendix E. The confidence level was set at .05 for all

statistical tests.

Data Analysis

Four hypotheses were investigated using three targeted dependent variables. The

means and standard deviations for all pre- and postmeasures can be found in

Appendix E.

Teacher Rating of Classroom Behavior

To investigate the effects of treatment on the classroom behavior of ADHD

students, results of the Teacher Report Form (TRF) were subjected to analysis. The TRF

measures problem behaviors in the classroom as observed by the teacher. Higher scores

indicate more problematic behavior than lower scores. These results were then used to

test the stated null hypothesis.






58

Two-way interactions. The effect of treatment by sex, age, medication, and ESE

status, as measured by the Teacher Report Form was examined. Each interaction was

introduced into the ANCOVA model one at a time. The following null hypothesis was

tested.

Ho4: There will be no significant interaction between treatment and age, sex,
ESE status, or being on medication as measured by the TRF, CNSIE, or
SSI-SF.

None of the variables, age, sex, ESE, or medication status of the ADHD student,

interacted significantly with scores on the TRF. In addition, there was not a significant

school by treatment interaction for this dependent measure. A more detailed statistical

report of the Teacher Report Form results can be found in Table 4-1.


Table 4-1
Statistical Results Mixed Effects Model ANCOVA Teacher Report Form


Source SS df MS F Pr > F

Sch' 676.80 12 56.41 1.56 .4010
Trt' 32.40 1 32.40 .68 .4257
Sch*Trt 582.72 1 48.56 1.78 .0717
Sex 64.61 1 64.61 2.37 .1290
Age 136.39 1 136.39 4.99 .0290*
Meds 2.75 1 2.75 .05 .8252
ESE 64.10 1 64.10 1.15 .2883
Error 3463.93 62 55.87

'Error terms are estimated for Sch and Trt.
For Sch, MS (Err) = 48.63 (df= 11.95)
For Trt, MS (Err) = 47.79 (df= 12.51)
*Significance at the p < .05 level






59

Main effects of treatment. No significant difference was found when comparing

TRF adjusted posttest means of treatment and control group students (Table 4-1);

therefore, Ho, was not rejected.

Ho : There will be no significant difference between the classroom behavior of
students in the treatment and control groups, as measured by the Teacher
Report Form.

It appears that classroom behavior of ADHD students was not impacted by the treatment

intervention as measured by the TRF. However, teachers rated students in both treatment

and control groups as having slightly improved behavior.

Additionally, age was found to have an effect on TRF scores (F (1,62) = 4.99, p =

.03). The adjusted posttest mean for 8-9-year-old students (M = 59.58), was lower than

that of 10, 11, and 12-year-old students (M = 62.36) participating in the study. Results

did not yield any treatment by age interaction. Age of student effected TRF scores

regardless of group assignment (Table 4-1).

Student Perceived Locus of Control

The effects of treatment on student perceived locus of control was investigated by

analyzing the results of the Children's Nowicki-Strickland Internal External Locus of

Control Scale (CNSIE). The range of possible scores was 0-40, with points assigned for

each response made corresponding to the external choice. The higher the score, the more

external the locus of control orientation.

Two-way interactions. Treatment effect by sex, age, medication, and ESE status

was also examined with the ANCOVA model using adjusted posttest means to test the

null hypothesis (Table 4-2). Each interaction was introduced into the ANCOVA model

one at a time. This hypothesis was previously rejected based on a TRF by age interaction.








Ho4: There will be no significant interaction between treatment and age, sex,
ESE status, or being on medication as measured by the TRF, CNSIE, or
SSI-SF.

A significant interaction was found between treatment, as measured by the

CNSIE, and the sex of students (F (1,60) = 8.64, p = .005). While both males and

females in the treatment group had higher adjusted posttest means than their counterparts

in the control groups, females scores were significantly higher (Figure 4-1). Males in the

control group had an adjusted posttest mean of 16.58 with adjusted means for males in

the treatment group being reported at 18.10. Females in the control group had an adjusted

posttest mean of 13.99 while adjusted means for females in the treatment group were

reported at 21.63. Females locus of control scores were, on average, almost seven and a

half points higher when receiving treatment, indicating a significantly higher external

locus of control orientation. This treatment by sex interaction would provide additional

support for the rejection of Ho4.

A second two-way interaction was found during the ANCOVA analysis of CNSIE

results (Figure 4-2). Whether or not a student was taking medication during the

intervention period, significantly interacted with treatment results (F (1,60) = 10.51, =

.002).

Students taking medication showed little difference in their adjusted posttest

means regardless of their control group (M = 17.63) or treatment group (M = 17.92)

assignment. However, students not taking medication during the intervention, had

adjusted mean scores that were significantly impacted by group assignment. Control

group students not taking medication had an adjusted mean score of 12.95 while

treatment group students not taking medication had a mean score of 21.81 (Table 4-3).










Treatment*Sex Interaction CNSIE


-*- Seriesl

---- Series2


2

Treatment


Series 1 = Males; Series 2 = Females

Figure 4-1
Treatment by Sex Interaction CNSIE


Treatment*Medication Interaction


---- Seriesl
--- Series2


Control


Treatment


Series 1 = Students not on medication; Series 2 = Students on medication

Figure 4-2
Treatment by Medication Interaction--CNSIE


25
20
15
10
5
0


1

Control


Lr-









Table 4-2
Statistical Results Mixed Effects Model ANCOVA- CNSIE


Source SS df MS F Pr >F

Sch' 194.76 12 16.23 1.06 .4597
Trt1 138.64 1 138.64 10.42 .0021*
Sch*Trt 184.08 12 15.34 1.24 .2787
Trt*Sex 106.97 1 106.97 8.64 .0047*
Trt*Age 13.41 1 13.41 1.08 .3022
Trt*Meds 130.17 1 130.17 10.51 .0019*
Trt*ESE .21 1 .21 .02 .8957
Error 742.80 60 12.38

'Error terms are estimated for Sch and Trt.
For Sch, MS (Err) = 15.31 (df 12.23).
For Trt, MS (Err) = 13.31 (df= 56.53).
*Significance at the p < .05 level


Table 4-3
Adjusted Post-Test Means of CNSIE


Source


Control Group
Treatment Group

Control Group Males
Treatment Group Males

Control Group Females
Treatment Group Females

Control Group Students on Meds
Treatment Group Students on Meds

Control Group Students Not on Meds
Treatment Group Students Not on Meds


Scores for Significant Variables

Adjusted Post-Test Means


15.29
19.87

16.58
18.10

13.99
21.63

17.63
17.92

12.95
21.81








Students who received the intervention but were not taking medication had the highest

locus of control scores, indicating a significantly higher external locus of control

orientation. Non-medicated treatment group students also showed the greatest variation

in score when compared to their control group counterparts by scoring, on the average,

nine points higher on the CNSIE. This treatment by medication interaction continues to

provide support for the rejection of Ho4.

The remaining variables, age and ESE status, did not interact significantly with

treatment as measured by the CNSIE. Additionally, there was not a significant school by

treatment interaction for this dependent measure.

Main effects of treatment. The following null hypothesis was tested using the

CNSIE results.

Ho2: There will be no significant difference between treatment and control
group students locus of control, as measured by the Children's Nowicki-
Strickland Internal External Locus of Control Scale.

Results of the ANCOVA revealed a significant difference in the CNSIE posttest scores

for treatment and control groups (F (1, 56) = 10.42, p = .002). Therefore, Ho2 was

rejected. Adjusted posttest means for the control group (M = 15.29) were significantly

lower than the adjusted means for the treatment group (M = 19.87). Students in the

control group rated themselves as having a more internal locus of control than the

students who received treatment (Table 4-2 and 4-3).

Students' Perceptions of School Success Behaviors

Students' perception of School Success Behaviors was measured using the School

Success Inventory--Student Form (SSI-SF). This 10-item Likert-type scale yielded scores








that ranged from 12 to 60. The closer the score was to 12, the more positive the

students' perception regarding their school success behaviors.

Two-way interactions. The effects of treatment by sex, age, medication, and ESE

status, as measured by the SSI-SF showed no interaction effect. The following null

hypothesis was previously rejected based on variable interaction with the TRF and the

CNSIE.

Ho4: There will be no significant interaction between treatment and age, sex,
ESE status, or being on medication as measured by the TRF, CNSIE, or
SSI-SF.

The analysis of the SSI-SF yields no main or two-way interaction effects. The

previous decision to reject Ho4, stands. In addition, there was not a significant school by

treatment interaction for this dependent measure. A statistical report of the SSI-SF can be

found in Table 4-4.

Main effects of treatment. The following null hypothesis was tested using this

dependent measure.

Ho3: There will be no significant difference between treatment and control
group students perception of school success skills, as measured by the
School Success Inventory--Student Form.

No significant difference was found when comparing SSI-SF adjusted posttest means of

treatment and control group students; therefore, Ho3 was not rejected. Students'

perceptions of their school success skills was not impacted by the treatment intervention

as measured by the SSI-SF. There was less than a one point change in scores for both

treatment and control groups following intervention.








School Counselor Survey

School counselors completed a survey at the conclusion of intervention

implementation. The survey contained 11 items that were answered on a five point

Likert-type scale. There were 14 surveys returned. All counselors (100%) supported the

appropriateness of unit content, sessions, and outline, and would recommend the unit to

other counselors. All counselors (100%) also agreed that the unit contributed to their

own understanding of ADHD students and was an effective strategy for this population.

Increased confidence with regard to teacher consultation (93%) and changed counselor


Table 4-4
Statistical Results Mixed Model ANCOVA--SSI-SF

Source SS df MS F Pr >F
Sch' 583.36 12 48.63 1.27 .3416
Trt1 6.26 1 6.26 .16 .6931
Sch*Trt 458.40 12 38.20 .68 .7605
Sex 1.05 1 1.05 .02 .8913
Age 114.49 1 114.49 2.05 .1573
Meds 2.75 1 2.75 .05 .8252
ESE 64.09 1 64.09 1.15 .2883
Error 3463.94 62 55.87

'Error terms are estimated for Sch and Trt.
For Sch, MS (Err) = 38.31 (df= 12.23)
For Trt, MS (Err) = 38.34 (df= 12.29)
Significance set at the p < .05 level


perceptions (71%) were reported by most counselors. A large majority (93%) of

counselors also believed that students participating in the unit changed their views of

themselves as students. Table 4-5 shows the results of this survey.








Table 4-5
Counselor Survey Results (Number of Counselors Responding to Each Choice)

Strongly Agree Uncertain Disagree Strongly
Agree Disagree
Question 1 11 3 0 0 0
(Unit content appropriate)

Question 2 9 5 0 0 0
(Fun, informative
activities)

Question 3 12 2 0 0 0
(Outlines easy to follow)

Question 4 7 7 0 0 0
(Increased student
awareness of ADHD)

Question 5 8 5 1 0 0
(Increased student's
self-perception)

Question 6 12 2 0 0 0
(Counselor knowledge
and insight)

Question 7 7 6 1 0 0
(Increased counselor
confidence)

Question 8 3 7 2 1 1
(Changed counselor
perceptions of ADHD)

Question 9 7 7 0 0 0
(Effective unit)

Question 10 10 4 0 0 0
(Recommend unit)

Question 11 11 2 1 0 0
(Plan to use again)








Summary of Results

A summary of the results of the mixed effects ANCOVAs for this study are

presented below. The results are organized by dependent variable.

Teacher's Perceptions of Students Classroom Behavior as Measured by the Teacher
Report Form (TRF)

1. There was no significant difference between treatment and control groups in

teachers' perceptions of classroom behavior following the intervention.

2. There was a significant difference between the way 8-9 year old students and 10,

11, 12 year old students were perceived by their teachers following the

intervention regardless of group assignment.


Students' Perception of Locus of Control Orientation as Measured by the Children's
Nowicki-Strickland Internal External Locus of Control Scale

1. There was a significant difference between the way treatment and control group

students rated their own locus of control orientation following the intervention.

2. There was a significant difference between the way males and females rated their

own locus of control orientation that was effected by group assignment.

3. There was a significant difference in the way students on and off medication rated

their own locus of control orientation that was effected by group assignment.

Students' Perceptions of School Success Behaviors as Measured by the School Success
Inventory--Student Form (SSI-SF)

1. There was no significant difference between the way treatment and control group

students rated their own school success behaviors following the intervention.









There were no significant interactions between treatment and age, sex,

medication, or ESE status.

School Counselor Perception as Measured by the School Counselor Survey

1. School counselors perceived the intervention as appropriate for ADHD students.

2. School counselors perceived the intervention as effective in improving students'

perceptions of themselves as students.

3. School counselors perceived increased confidence in working with ADHD

students and their teachers.

In the next chapter, conclusions will be drawn based on results presented in

Chapter 4. Methodological limitations as well as implications and recommendations for

further research will be discussed.














CHAPTER 5
SUMMARY, CONCLUSIONS, DISCUSSION, LIMITATIONS,
IMPLICATIONS, AND RECOMMENDATIONS

Summary

The purpose of this study was to determine the effectiveness of a small group

counseling intervention with ADHD students. More specifically, ADHD students

participated in a set of counseling activities designed to increase awareness of ADHD and

a personal sense of control and responsibility for classroom behaviors related to school

success. ADHD students from third, fourth, and fifth grade classrooms in 12 public

schools participated in the study (n = 93). Students were randomly assigned to treatment

and control groups using a table of random numbers. Group means (n = 13) were used in

the analysis.

Thirteen school counselors delivered the intervention to ADHD students.

Sessions featured activities and discussions that focused on helping students learn more

about their disorder as reflected in school performance. The group format provided a

setting in which students were able to learn and practice new behaviors while among their

peers. Targeted behaviors included paying attention, listening, organizing materials,

recognizing, creating, and using external cues in the classroom, handling frustration and

anger, and using available supports in the classroom to increase success in school.

Students who participated in the groups were compared to ADHD students in the

control groups on three dependent variables. The first dependent variable, classroom








behavior, was measured by the Teacher Report Form (TRF). This instrument asked

teachers to rate the classroom behavior of their students using a 0 (Not True), 1

(Sometimes True), and 2 (Very Often True) rating scale for 118 behaviors. Standardized

T scores are generated, normed for age and sex, with higher scores indicating more

problematic behavior than lower scores. Total scores were used in the mixed model

ANCOVA.

The second dependent variable, locus of control, was measured by the Children's

Nowicki-Strickland Internal External Locus of Control Scale (CNSIE). Students were

asked to respond to 40 statements by circling yes or no as each response was read by the

counselor. Scores were based on the number of responses that indicated an external locus

of control orientation to the statement; therefore, scores could range from 0 to 40. Higher

scores indicated a more external locus of control than lower scores. The raw number of

external responses was used in the mixed model ANCOVA analysis.

The third dependent variable, students' perceptions of school success behaviors,

was measured by the School Success Inventory Student Form (SSI SF) which asked

students to rate themselves on 12 items related to school success skills in terms of

frequency on a five point Likert-type scale. Scores ranged from 12 (best performance) to

60 (worst performance). Total scores were used in the mixed model ANCOVA.

Descriptive statistics were used to examine the results of a post-intervention

school counselor survey. The focus of the 11 item Likert-type survey was to assess

counselors' perceptions of appropriateness and effectiveness of the intervention as well as

to assess the impact of intervention delivery on the school counselors themselves.








Conclusions

The outcomes of the study were mixed. Results suggested that the small group

counseling activities were not effective in changing classroom behavior or the students'

perceptions of school success behaviors. However, there were changes in locus of control

orientation that were effected by participation in the group activities. The conclusions are

discussed with regard to each of the dependent variables.

Teachers' Ratings of Classroom Behavior

The mixed model ANCOVA showed no significant difference between the

classroom behavior of students in the treatment and control group. Therefore, it was

concluded that the small group counseling intervention did not significantly impact the

classroom behavior of students.

The only variable that significantly effected the TRF scores was the age of student

being rated, not group membership. Teacher ratings of ADHD students in the 8-9 year

old age group were significantly lower as a whole than students who were 10,11, and 12

years old. Teachers perceived younger ADHD students as less problematic than older

students. Their perception was not effected by the group counseling intervention.

Neither sex, being on medication during the study, nor ESE status significantly

impacted the effectiveness of the counseling intervention. Likewise, none of these

variables seemed to effect the way students were rated by teachers on the TRF.

Student Perceived Locus of Control

The mixed model ANCOVA revealed a significant difference between the

perceived locus of control for treatment and control group students. Students in the

treatment group rated themselves as having a more external locus of control than students








in the control group. It was concluded that the small group counseling intervention did

effect perceptions of locus of control for ADHD students by shifting their orientation

towards becoming more external.

Two sub-groups of ADHD students seemed to be most effected by this external

shift. Females and students not on medication during the study were most significantly

effected by inclusion in the counseling intervention.

While both males and females in treatment had a more external locus of control

than students in the control group did, females seemed to be more effected by the

counseling intervention. Females who participated in the small groups rated themselves

as feeling less in control of what happens to them than males, even though females in the

control group felt more in control than their male counterparts. It can be concluded that

the locus of control perception for females was significantly effected by the counseling

intervention and that it became more external with treatment.

A second characteristic that appeared to impact the way locus of control

orientation was effected by the counseling intervention, was whether or not the student

was taking medication for ADHD symptoms during the study. Students who were taking

medication appeared to have their locus of control perceptions unaffected by the

intervention. However, students who were not on medication showed significantly more

external perceptions following treatment even though their control group counterparts had

a more internal locus of control perception than control group students on medication. It

can be concluded that the counseling intervention significantly impacted the locus of

control orientation of students not taking medication for ADHD symptoms during the

study and that it became more external with treatment.









Students' Perceptions of School Success Behaviors

The ANCOVA performed on the students' perceptions of school success

behaviors showed no significant differences between treatment and control groups.

Additionally, scores on the School Success Inventory Student Form were not effected

by age, sex, medication, or ESE status; therefore, it was concluded that these variables

did not seem to effect the way students rated themselves with regard to school success

behaviors.

School Counselor Perceptions

Descriptive statistics were used to examine perceptions of schools counselors

delivering the small group counseling intervention. Based on returned surveys, it can be

concluded that school counselors felt the intervention was appropriate for ADHD

students, that it positively effected student perceptions and knowledge, and that it

improved their own knowledge base and confidence in working with ADHD students and

their teachers.

Discussion

Results of the current study suggest that school counselors consider the

implications of brief group counseling interventions for ADHD students. Results also

suggest a look at variables that may impact the results of treatment and outcome

measures.

The counseling intervention did not appear to significantly impact the classroom

behavior of ADHD students. While school success behaviors were introduced and

practiced in the group, the brevity of the intervention may not have allowed for the

integration of skills that would be evident in teacher ratings of classroom behavior.






74

The only variable that appeared to effect teacher ratings was age. The behavior of

younger students did not seem as problematic to teachers as the behavior of older students

participating in the study. Since TRF results are normed by age and sex of student, this

was not simply an expected developmental increase in problematic behaviors. These

results might suggest that as ADHD students get older, their behaviors become even more

problematic when compared to other students of the same sex and age. This would

support existing literature. This would also support the need for school based

intervention for ADHD students.

There was a significant treatment effect with regard to the locus of control

construct. Locus of control became more external for students receiving treatment. This

may be due to ADHD students increasing awareness of their disorder and how it impacts

their school performance. Students may have begun to understand how ADHD

characteristics can create difficulties for them in the classroom, while not having the

outside or continued support necessary to integrate thoughts and behaviors into the

classroom routine.

Females and students not taking medication were most effected by this external

locus of control shift. It might be noted that only three students in the study fell into both

of these categories, females not taking medication. Non-medicated female control group

students actually felt more in control than males and students on medication. However,

female and medicated treatment groups students felt less in control at the conclusion of

the intervention.

Female students with ADHD frequently exhibit less aggressive characteristics of

the disorder. For this reason, teachers and parents may have felt less urgency to address






75

the disorder with female students. It is not uncommon for teachers and parents to provide

intervention without student collaboration.

Students in treatment and control groups who were taking medication during the

study showed no response to treatment. It may be that if students are on medication that

there is already some level of awareness of the characteristics of ADHD as it impacts

school performance. This awareness would not be the result of the medication itself but

rather the result of another adult taking the time to explain the rationale for treatment. It

is also possible that the results of the medication intervention have previously produced

noticeable behavioral changes in the classroom. Students not taking medication for

ADHD symptoms may be in particular need for understanding how their disorder impacts

their school performance and for follow-up interventions.

There was no treatment or interaction effect found in the ANCOVA analysis of

SSI-SF results even though this was the instrument that was most sensitive to changes in

student perceptions during a previous intervention period. This overall lack of

significance may have been the result of lack of school counselor familiarity with the

instrument. The school success behaviors were directly matched to unit content. While a

workshop and group counseling manual were provided prior to the beginning of the

study, school counselors may not have been familiar enough with the school success

language of the SSI-SF. Additionally, the lack of systematic collaboration with teachers

about ways to follow-up on the group counseling activities may have resulted in

inadequate practice of skills that would support changes in perceptions.

It was interesting to note that none of the dependent measures were effected by

Exceptional Student Education status. While students in ESE programs generally have






76

more complex academic and/or behavioral difficulties, it was somewhat surprising to find

that ADHD students who also had an additional ESE diagnosis showed no significantly

difference response to treatment or to the dependent measures.

Supporting the idea that follow-up, collaboration with teachers, or an extended

intervention may have produced additional results, are the counselor surveys.

School counselors delivering the intervention perceived changes in levels of student

knowledge and awareness of the disorder. They rated the unit as appropriate and

effective for use with ADHD students. While all dependent variable measures may not

have been sensitive to these changes, it was the counselors' perceptions that changes were

taking place that would support ADHD students becoming more effective students.

Limitations

During the six-week intervention, ADHD students explored their diagnosis as it

impacted school performance and identified, learned, and practiced behaviors that are

associated with success in school. The brevity of the intervention may have been a

limitation. While meeting weekly for six-weeks is a common format for group

counseling in elementary schools, it may not be long enough for ADHD students to

practice and integrate new behaviors into their school routine.

An additional limitation involved the independent delivery of the group

counseling intervention. Collaboration with classroom teachers to provide more

structured follow-up in the classroom was not part of the study. Prior research would

suggest that multiple treatment interventions have improved chances of producing results

with ADHD students. Although, when there are several interventions, it becomes more

difficult to assess effective components when they are embedded. This researcher






77

previously delivered the group counseling intervention to ADHD students, however, there

was also collaboration for teacher follow-up, adjusted academic strategies, as well as

smaller class sizes. While there were significant results with regard to students'

perceptions of school success behaviors as well as teacher observed classroom behavior,

it was difficult to assess which intervention may have been responsible for the changes.

Anytime research takes place in school settings there are limitations with regard to

control of outside interventions. As previously mentioned, ADHD students are frequently

involved in multiple interventions. The two intervention strategies that were controlled

for in the current study were whether or not the student was taking medication for ADHD

symptoms and whether or not the student was in an Exceptional Student Education

Program aimed at academic or behavioral support. Other classroom or home based

interventions such as tutors, academic or behavioral modifications taking place in the

classroom, and parent involvement are other possible types of interventions not controlled

for. The current study used random assignment of students to treatment and control

groups as a way to minimize this control of outside intervention limitation.

School principal's volunteered their schools participation in the study. The lack

of random selection of schools presents a limitation in generalization of results as does

using a small number of schools from a single school district. In this study, the

population being studied was schools in a single district and those volunteering

participation were representative of the range of district demographics. However, there

can be no generalization beyond the population outlined in the current study.

Statistical limitations were realized with the assignment of small numbers of

students to each treatment and control group. Due to the nature of the intervention as








well as the nature of the disorder (ADHD), a maximum of four students were

recommended for inclusion in each. Most schools were able to assign four students to the

treatment group while attrition left some schools' groups with three students. While the

adjusted mean score for each small group was reported, the small, unequal numbers

within each group produced estimated error rates and estimated degrees of freedom.

In summary, there were several possible limitations. Limitations included brevity,

the issue of embedded intervention, non-random inclusion of schools in the study, small

and unequal numbers of students in groups, and difficulty in controlling outside

intervention. However, it was felt that most of these limitations were anticipated and that

steps were taken in the design of the research to minimize their effects on the results of

the study.

Implications

The results of this study contribute to the limited information available to school

counselors about the effectiveness of small group counseling as an intervention for

ADHD students. The results also contribute to the growing body of information

concerning ADHD students and locus of control orientation.

The findings suggest that brief group counseling interventions for ADHD students

can effect changes in perceptions. Because of tight scheduling and time restrictions at all

levels of schooling, it is important to identify interventions that can produce effects in

short periods of time. Brief group intervention can help increase awareness of ADHD as

it relates to school behaviors. However, it is also important to recognize that this type of

brief intervention alone may not be enough to produce a sense of control of daily

occurrences or behavioral changes that can be generalized to classroom settings.






79

Counselors are in a position in school settings to offer small group counseling to

ADHD students to increase awareness and knowledge of the disorder as it impacts school

success. This study suggests that this may not be enough. However, school counselors

are in the unique position of being able to collaborate, follow-up, and co-ordinate

treatment interventions that build upon concepts and skills introduced during the group

counseling intervention.

The results of this study also contribute to the already growing body of literature

concerning locus of control and ADHD students. It has been recognized that ADHD

children tend to grow more external in their locus of control orientation with age

(Borden, Brown, Jenkins, & Clingerman, 1987). It has also been suggested that students

with a more internal locus of control tend to do better in school and with peers.

Therefore, it becomes important to continue to explore the locus of control construct for

ADHD students in relation to school success. If increased awareness does in fact begin

an external shift in locus of control perceptions, it is possible that continued and

coordinated intervention for practice and eventual integration of skills may be next.

An additional implication is found in the results of the school counselor survey.

While counselors perceived student growth, it was important to realize that all

participating school counselors agreed that their own knowledge and understanding of

ADHD students was increased through delivery of the intervention. In addition, a large

majority felt reported increased confidence in their abilities to consult with teachers about

the needs of ADHD students. It may be that while professional in-service about ADHD

student need is important, that direct contact with ADHD students through intervention

may better prepare school counselors for collaboration and consultation.








Recommendations

Follow-up and extended intervention, to include collaboration with teachers to

support practice and reinforcement of skills introduced during the intervention, would be

a primary recommendation. This would help counselors gain a clearer picture of the

value of increased awareness and introduction of school success behaviors.

While this study suggests that awareness and introduction of school success

behaviors may produce a more external locus of control, it would be interesting to extend

the study. What would happen to locus of control scores for groups of students who had

participated in small group counseling prior to behavioral intervention strategies being

implemented in the classroom? This could be compared to students involved in the same

behavioral strategies who had not participated in group counseling.

It seems possible that while the shift in brief treatment is towards an external

locus of control, this shift may accompany the understanding needed for ADHD students

to fully embrace the need for alternative strategies to attain school success. The increased

awareness resulting from the counseling intervention may prove to be the catalyst for

accepting modified behavioral and academic intervention. This type of intervention may

be an important adjunct in preparing ADHD students to accept the need for support and

alternative strategies as they strive to become successful students.

An additional recommendation would be to provide a similar intervention to

middle school students with ADHD. The cognitive component of this cognitive-

behavioral strategy may be more easily integrated by older students. The age range of

students in the current study was 8-12 years. Research suggests that cognitive

interventions are most appropriate with students who are at least eight. As this is the







81

bottom of the age range, it is suggested that middle school students might be better able

to embrace awareness concepts and move towards accepting their own role as participants

in achieving school success during the brief intervention.

A final recommendation is to continue to support the need for school counselors

to be advocates for ADHD students. Many school personnel continue to struggle with

acceptance of ADHD as a disorder. School counselors are in a position to provide

awareness activities and behavioral intervention for ADHD students while helping their

teachers' balance the need for structure, alternatives, and acceptance.














APPENDIX A
CONSENT LETTERS FOR PARTICIPATION






Department of Counselor Education
PO Box 117046 University of Florida
Gainesville, Florida 32611


Dear Elementary School Principal;

My name is Linda Webb. I have been a school counselor in Alachua County since
1985 at High Springs Elementary, Wiles Elementary, and most recently the ANCHOR
Center. Currently, I am on leave with the School Board of Alachua County while
finishing my Ph.D. in Counselor Education at the University of Florida.

During my leave I have been working part time with Dr. John Ross and Dr. Ed
Turner and the Multidisciplinary Training Project (MDTP) at UF. The focus of my direct
intervention with students in the project has been the development of school counselor
interventions that provide support to students with attention-deficit hyperactivity disorder
(ADHD) and their teachers.

Attached, you will find a request for your school's voluntary participation in a
study that would allow me to share information and intervention strategies with your
school counselor and at the same time meet UF requirements for completion of my
degree.

The counselor in your school knows this request is coming. Because the attached
request is so brief, I felt the need to alert school counselors as to the nature of their
commitment if your school participates. Additionally, they would be asked to attend a 2
hour workshop that would provide current information about ADHD and its treatment.
We would examine the role of the school counselor with ADHD students and their
teachers. I would then focus on the nature of my own research and provide the specific
information needed to carryout the study.

I will be available to you or your school's counselor throughout the study.
I thank you for taking the time to consider the attached request and look forward to
working with those who choose to participate. If you have any questions, please call me
at 332-2022.

Sincerely,

Linda Webb
School Counselor








Department of Counselor Education
PO Box 117046 University of Florida
Gainesville, Florida 32611


Dear School Counselor;

My name is Linda Webb. I am a doctoral student at the University of Florida
under the supervision of Dr. Robert Myrick. I am conducting a study that involves
examining the effectiveness of a small group counseling intervention for ADHD students.
I am inviting you to participate. While there will be no compensation for your voluntary
participation, benefits would include increased knowledge and resources for working with
ADHD students. There are no known risks associated with your participation. You may
withdraw from the study at any time without consequence.

If you choose to participate, you will be asked to complete several tasks that
include attending a two hour workshop, coordinating the study in your school,
administering pre and post test instruments, and delivering the small group counseling
intervention. These activities would take place over an 8 week period with the small
group meeting weekly for a period of six weeks.

Results of the study will be reported in the form of group data only. Individual
data, including names of counselors and schools will be coded by number and kept
confidential to the extent provided by law.

If you have questions, please contact me (332-2022) or my supervisor, Dr. Myrick
(392-0731). Questions about research participants' rights may be directed to the UFIRB
office, University of Florida, Box 112250, Gainesville, FL 32611-2250; (352) 392-0433.





I have read the information above and voluntarily agree to participate in Linda
Webb's study. I have received a copy of this information.


Counselor's Signature Date








Department of Counselor Education
PO Box 117046 University of Florida
Gainesville, Florida 32611

Dear Parent/Guardian,

My name is Linda Webb. I am a graduate student in the Department of Counselor
Education at the University of Florida, under the supervision of Dr. Robert Myrick,
conducting research on the effectiveness of a small group counseling intervention for
students with Attention Deficit Hyperactivity Disorder (ADHD). The purpose of this
study is to compare the perceptions and behaviors of ADHD students who take part in a
small group counseling intervention, with ADHD students who do not participate in the
intervention. The results of the study may better help school counselors understand the
types of interventions that can help ADHD students become more effective learners in
their classrooms. The counselor at your child's school will lead the small group
counseling intervention.

Half of the ADHD students who participate will be randomly selected to
participate in the small group counseling intervention which will take place once each
week for six weeks. Each session will last about 30-40 minutes and will meet at a time
and place during the school day, as agreed upon by the counselor and teacher. The
sessions will feature activities and discussions that focus on helping students learn more
about ADHD as it is reflected in their school performance, and learning ways to improve
that performance. ADHD students not receiving the counseling intervention will
maintain their regular school routine, helping to determine the effectiveness of the group
counseling.

All ADHD students who participate, even if they are not selected for participation in the
counseling sessions, will be asked to complete two instruments about how they see
themselves, that will require about 20 minutes of their time prior to the beginning of the
intervention and again at the conclusion of the intervention about 8 weeks later. The
school counselor will read the instruments to students at a time he/she has arranged with
your child's teacher. The students will not have to mark any items they do not want to
answer. Additionally, the teacher will be asked to complete a behavior checklist before
and after the counseling intervention for all ADHD students participating. Although the
children will be asked to write their names on the checklists for matching purposes, their
identity will be kept confidential to the extent provided by law. We will replace their
names with code numbers. Results will only be reported in the form of group data and
will be available upon request in July. Participation or non-participation in this study will
not affect the children's grades or placement in any programs.

You and your child have the right to withdraw consent for your child's participation at
any time without consequence. If your child is not aware of his/her ADHD diagnosis,
there may be some risk of uncertainty or anxiety about this new knowledge. Your child's








school counselor if prepared to help your child handle these feelings. If you do not want
your child to have age appropriate information about ADHD as it effects his/her
performance at school, he/she should not participate. Knowledge of the disorder, its
effects on school performance, and improved perceptions and behaviors are potential
benefits for children participating in the study. No compensation is offered for
participation. If you have any questions about this research project please contact me at
332-2022, or my faculty supervisor, Dr. Myrick, at 392-0731. Questions or concerns
about research participants' rights may be directed to the UFIRB office, University of
Florida, Box 112250, Gainesville, FL 32611-2250; (352) 392-0433.




Cut on the dotted line and return this portion of the consent to your child's school

counselor by if you would like your child to participate.

I have read the procedure described above. I voluntarily give my consent for my child,
to participate in Linda Webb's study involving a small
group counseling intervention for ADHD students. I have received a copy of this
description.

Parent/Guardian Date


2nd Parent/Witness


Date









Assent Script for All ADHD Students
(grades 3, 4, & 5)

The following paragraph is to be read to the students by the school counselor prior to
completion of pre-post test instruments. The name of each school's counselor will go in
the blank.


Hello,

My name is I am the counselor at your school. I am
helping a University of Florida student, Linda Webb, gather information about the way
students your age see themselves. I would like to ask you to complete two checklists with
me today and two again at a later time. I will read them to you. Only myself and the
University of Florida student will see your individual answers.

If you choose to take part, you may stop at any time and you will not have to
answer any questions you do not want to.


Would you like to do this?









Assent Script for ADHD Students Randomly Selected for Small Group Counseling
Intervention (grades 3, 4, & 5)


The following paragraph is to be read by the school counselor to each student prior to
beginning the small group counseling intervention. The name of each school's counselor
will go in the blank.



Hello,

My name is I am the counselor at your school.
I am helping a University of Florida student, Linda Webb, try out some ways school
counselors can help children become better students. Once each week for the next six
weeks, I will be meeting with a group of students for discussions and activities that have
to do with being successful at school. You will have the opportunity to take part in these
groups if you would like to.


If you do choose to participate, you may stop at any time. Would you like to
participate?














APPENDIX B
RESEARCH PROCEDURES














Checklist of Procedures
For ADHD Group Counseling Study

Principal Investigator: Linda Webb (332-2022)

The purpose of this study is to determine the effectiveness of a small group
counseling intervention with ADHD children. It involves the following:

(Date Completed)
1. Workshop participation by school
counselor.

2. Random selection of students for
participation in study.

3. Parent permission letters sent.

4. Random assignment to treatment and
control groups.

5. Pre-testing of all students in both groups.

6. Group counseling intervention delivered
for treatment group.

7. Post-testing of students in both groups.

8. Materials returned.








Instructions for Randomization

Sample Selection

1. One the following page you will find the list of ADHD students in your school that
has been computer generated. Please add the names, grade, sex, and race of the other
students you have identified with ADHD in grades 3, 4, and 5.
2. Number the students on the list. The numbering has been started and you should
continue by assigning the next student on the list the next number.
3. Turn to the Table of Random Numbers.
4. Without looking, drop you pencil onto the page. This will be the number of the first
student selected for the study.
(1) If the number of students on your list is less than 10, only pay attention to the
last digit of the random number. For example, you have 9 students on your
list and you drop your pencil on to the number 78. This would mean the
student on your list who is number 08 would be selected to participate.
(2) If you are using both digits because your number of students is greater than 10,
lets say it's 22, and you drop your pencil on 78 you would continue to move
down the list until you come to a number between 00 and 22 and select that
student.
3. Once your first student is selected, continue down the list of random numbers until
the desired number of students has been selected (8 plus alternates).
4. Record these names on the top of page 4.
5. Send parent permission letters home with the first 8 students. If you have parents
who do not want their child to participate or you can't get the form back, go to the
first alternate on the list and continue until you have 8 students (4 minimum).
6. Write the names of the students who have parent consent on the bottom of page four.
Now we will need to randomly assign these students to treatment and control groups.

Random Assignment to Treatment and Control Groups

1. Look at your numbered list of names in the middle of page four.
2. Refer again to your Table of Random Numbers.
3. Drop your pencil (you will only need to use the last digit see 4a above).
4. The first student selected will be placed in the treatment group. Write their name on
the bottom of page 4.
5. Continue down the random numbers list, the next student selected will be placed in
the control group. Record their name and continue this process until all 8 students
have been placed in either the treatment or control group.
6. You are ready to go! Remember all students in both the treatment and control
groups are given pre and post measures.