A GROUP COUNSELING INTERVENTION
FOR CHILDREN WITH
ATTENTION-DEFICIT HYPERACTIVITY DISORDER
LINDA DEJONG WEBB
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
UNIVERSITY OF FLORIDA
11II I1111111111111 11111 I 11111 11111
3 1262 08555 1645
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
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
ACKNOWLEDGMENTS ............................................. ii
ABSTRACT .......................................................... v
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
Sampling Procedure ............
Resultant Sample ..............
Research Design ...............
School Counselor Training .......
Treatment Description ..........
Assessment Techniques .........
Data Analysis .................
Research Procedures ............
. . 3 5
. . 3 7
. .. 3 8
.................... ............. 40
. .4 1
. .4 3
. .4 6
.......................... ....... 52
.......................... ....... 52
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
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
Linda DeJong Webb
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.
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.
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,
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,
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
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
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
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.
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
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.
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
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:
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
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:
(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
(e) is often "on the go" or often acts as if "driven by a motor"
(f) often talks excessively
(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)
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
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
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.
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
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.
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
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.
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
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.
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-
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
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
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
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-
It has also been suggested (Searcy & Hawkins-Searcy, 1979) that those with an
internal locus of control are better adjusted. Adalbjamardottir (1995) has demonstrated
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.
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.
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.
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
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.
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.
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
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.
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
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.
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.
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%
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
Demographic Characteristics of Sample by Sex and Race
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%
Demographic Characteristics of Sample by Age, Medication, and ESE Status
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.
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).
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
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.
Levels of Experience and Education of Participating Counselors by School
Certified School Counselor Highest Degree Experience
B M Sp. Doc. Years
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
C. Extent of the problem in schools
D. Interventions (including medication)
E. Meeting ADHD student needs in Developmental Guidance
III. Research Procedures
A. Overview of Design
C. Informed consent
D. Collecting pre- and posttest data
IV. Delivery of the Counseling Intervention
V. Return of Materials
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.
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
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
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.
Session # Title of Session Content Objectives
Session #1 Our Journey 1. Students will gain increased knowledge of
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
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
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.
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.
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.
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
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
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'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
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
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
The following hypotheses will be evaluated at the .05 level of significance in this
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.
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
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
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.
Mixed Effects ANCOVA Model
Y (X X)= p + a + Y7 + ay, + 2 +
post covariate = grand mean + treatment + school + school by treatment + age +
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.
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
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.
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
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
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
Four hypotheses were investigated using three targeted dependent variables. The
means and standard deviations for all pre- and postmeasures can be found in
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.
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
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
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.
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
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
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
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, =
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
Series 1 = Males; Series 2 = Females
Treatment by Sex Interaction CNSIE
Series 1 = Students not on medication; Series 2 = Students on medication
Treatment by Medication Interaction--CNSIE
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
Adjusted Post-Test Means of CNSIE
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
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
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
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
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
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
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.
Counselor Survey Results (Number of Counselors Responding to Each Choice)
Strongly Agree Uncertain Disagree Strongly
Question 1 11 3 0 0 0
(Unit content appropriate)
Question 2 9 5 0 0 0
Question 3 12 2 0 0 0
(Outlines easy to follow)
Question 4 7 7 0 0 0
awareness of ADHD)
Question 5 8 5 1 0 0
Question 6 12 2 0 0 0
Question 7 7 6 1 0 0
Question 8 3 7 2 1 1
perceptions of ADHD)
Question 9 7 7 0 0 0
Question 10 10 4 0 0 0
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.
SUMMARY, CONCLUSIONS, DISCUSSION, LIMITATIONS,
IMPLICATIONS, AND RECOMMENDATIONS
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
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
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.
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
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
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
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.
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
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
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
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
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.
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
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 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.
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
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.
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
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.
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
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
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
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
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
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
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
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.
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
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:
1. Workshop participation by school
2. Random selection of students for
participation in study.
3. Parent permission letters sent.
4. Random assignment to treatment and
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
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
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.