Article

The Family Journal: Counseling and

Therapy for Couples and Families
An Integrated Approach to Counseling 2018, Vol. 26(1) 105-109
ª The Author(s) 2018
Reprints and permission:
Children Diagnosed With ADHD, ODD, sagepub.com/journalsPermissions.nav
DOI: 10.1177/1066480718756594
and Chronic Stressors journals.sagepub.com/home/tfj

Joseph Rufus Wofford1 and Jonathan H. Ohrt1

Abstract
Families in rural, low socioeconomic status areas are often underserved related to mental health services. Additionally, attention
deficit hyperactive disorder (ADHD) and oppositional defiant disorder (ODD) are common comorbid concerns for children in
these areas. Further, chronic stressors are typically present in the lives of children in such a setting when a parent loses custody of
the child, and another family member takes on the parenting role. In this article, we (a) review information on the confluence of
ADHD, ODD, and chronic stressors; (b) present an assimilative integrated approach using behavioral therapy as the foundational
theory, supplemented by techniques from play therapy and structural family therapy; and (c) present a case example in which the
approach was utilized.

Keywords
ADHD, caregiver, child, play, stressors

In this article, we present an assimilative integrated counseling
approach and discuss application through a case example. In
our example, behavioral therapy is the primary theory, while
the ancillary techniques are implemented from structural fam-
ily therapy (SFT) and play therapy approaches. The supple-
mentary techniques are utilized for the purpose of symptom
remission and resource activation while taking into account the
child’s developmental level. The treatment occurred in the
context of managed care.
Bussing, Zima, and Bellin (1998) found that being female
and being a rural resident were among the factors that
decreased the likelihood of receiving help for ADHD. In their
study, rural living was also related to less access to mental
health specialists, which could result in challenges obtaining
treatment for children with attention deficit hyperactivity dis-
order (ADHD). Furthermore, consider that unremitting and
chaotic stressors associated with poverty can change a child’s
internal biology and brain activity (Thompson & Haskins,
2014). Researchers have suggested a greater prevalence “of
poverty, public coverage, and mental health impairment among
rural children explain their greater likelihood of a mental health
prescription and stimulant use” (Anderson, Neuwirth, Lenard-
son, & Hartley, 2013, p. 1). They also stated that among chil-
dren with the greatest mental health needs, those in rural areas
are more frequently given a diagnosis of ADHD when com-
pared to urban children. The researchers highlighted that such
children were less likely to receive a mental disorder diagnosis
beyond ADHD, had a reduced likelihood of receiving mental
health counseling, and their psychological difficulties could
remain unidentified until symptoms increase. Thus, a consid-
eration of the current context and literature may serve to iden-
tify steps to best practice in helping rural children with ADHD,
who are living in the chronic stressor that is poverty and an
upbringing away from a biological parent.
Although scholars have addressed the combination of
ADHD and oppositional defiant disorder (ODD; Danforth,
2007; Swanson et al., 2001), as well as grandparents as care-
givers (Lindblad-Goldberg & Igle, 2015) independently, there
is a gap in the literature regarding these presenting concerns as
a whole (i.e., ADHD comorbid with ODD with an elderly
family member as primary caregiver). Therefore, we propose
that using behavioral therapy, while assimilating techniques
from SFT and play therapy may be efficacious in a managed
care context with children diagnosed with ADHD comorbid
with ODD and chronic stressors while in the custody of an
elderly caregiver. In short, behavioral therapy informs the child
and elderly caregiver about coping strategies, SFT provides the
foundation for maintaining boundaries with other family mem-
bers, and play therapy provides the nurturing context. In the
counselor’s office, shared meaning and ideas are considered in
1
Department of Educational Studies, University of South Carolina, Columbia,
SC, USA
Corresponding Author:
Joseph Rufus Wofford, Department of Educational Studies, University of South
Carolina, Columbia, SC 29208, USA.
Email: wofforjr@email.sc.edu
106 The Family Journal: Counseling and Therapy for Couples and Families 26(1)
order to establish a bond, so that the child and caregiver con-
tinue to enjoy therapy as they experience preferred outcomes.
Symptoms and Stressors
Symptoms of ADHD
ADHD is characterized by symptoms of inattention, hyperac-
tive behavior, and/or impulsivity (American Psychiatric Asso-
ciation, 2013). In the United States, if symptoms manifest prior
to 12 years of age and so long as they are not attributable to
other mental disorders, persons can be diagnosed with ADHD
for having at least six symptoms of inattention alone, six symp-
toms hyperactivity/impulsivity alone, or a combination of at
least six symptoms for each subgroup.
Symptoms of ODD
ODD is characterized by active defiance, annoying others, and
being easily annoyed by others (American Psychiatric Associ-
ation, 2013), as opposed to mere impulsivity, distractibility,
and forgetfulness indicative of ADHD. The clinician must take
care to ensure the child is not being considered defiant due to
unreasonable parental or school demands (e.g., expected to
perform work beyond the child’s developmental capacity).
Barkley (1998) reported that 54–67% of youth with ADHD
will cross the diagnostic threshold for ODD as well. Further-
more, Perry and Szalavitz (2006/2008) noted that post-
traumatic stress disorder (PTSD) should be ruled out for
children presenting with ODD symptoms, indicating that a
triggered fight-or-flight response (i.e., symptoms of reexper-
iencing trauma due to a cue/reminder of the trauma, and an
exaggerated startle response) can appear to be merely defi-
ance and aggressive disruptive behavior to the uninformed
observer.
Chronic Stressors
Living in a low socioeconomic status bracket is related to a
number of complex stressors that may confound the therapeutic
process for the child if not attended to on a systemic level. As
mentioned previously, a recent policy brief indicates research-
ers have found that stressors of an unremitting and chaotic type
which are associated with poverty actually change a young
child’s internal biology in such a way that the child’s ability
is hampered when it comes to achieving gains in school and life
in general (Thompson & Haskins, 2014). Thompson and
Haskins asserted that unremitting stress inhibits multiple areas
of brain functioning. The researchers posit that “Young chil-
dren experiencing chronic stress also have poorer impulse con-
trol, more difficulty focusing their attention and thinking, and
more trouble controlling their emotions, consistent with the
effects of stress hormones on the prefrontal cortex and related
brain areas” (p. 3). One can readily see how this could appear to
be ADHD or exacerbate an underlying diagnosis of ADHD.
The authors also contend that in rural areas with higher poverty
rates, the lives of children may be more chaotic than those of
poor children in other settings.
Costello, Compton, Keeler, and Angold (2003) concluded
that some externalizing symptoms can be ameliorated through
social change (increased income), whereas internalizing symp-
toms may not change in such a case. Duncan (2014) indicates
that factors outside of therapy account for 86% of client change
and treatment effects account for the other 14%. With that in
mind, note that Thompson and Haskins (2014) suggest that
relational support from adults both inside and outside the fam-
ily can be effective at reducing the stress levels of children in
poverty. Therefore, help for such children should come from
outside as well as inside the therapy office. Additionally, the
authors infer that when children are in an environment of safety
and can predict with relative accuracy how things will go, it is
possible to strengthen their social skills and their ability to
regulate emotions.
Assimilative Approach
Assimilative Integrative Therapy
Messer (1992) describes the assimilative approach as,
contextualist in that it emphasizes, when incorporating elements of
other therapies into one’s own, that a procedure takes its meaning
not only from its point of origin, but even more so from the struc-
ture of the therapy into which it is imported. (p. 151)
Nonetheless, it is important to understand the theory one is
borrowing techniques from, even if not remaining true to the
theory of origin, so as not to confound the intervention process
with unintended consequences.
Although play therapy offers a number of advantages for
any therapist working with children, a primary reason for using
play therapy techniques in an auxiliary fashion is because of
service to a clientele insured primarily by managed care orga-
nizations. Play therapy has recently been granted evidence-
based status for only a limited number of childhood problems
(Substance Abuse and Mental Health Services Administration,
2016). For further background information on the potential
efficacy of play therapy, see Kottman (2011, pp. 262–263) and
see also Shapiro, Friedberg, and Bardenstein (2006, p. 419).
However, as noted by Shapiro et al. (2006),
instilling an element of fun in the child’s therapy experience may
be a necessary precondition for the goal-oriented treatment proce-
dures that occur in this context. (Medicaid regulations that require
a rigid, moment-to-moment focus on documented treatment goals
betray an unfortunate lack of understanding of the way child ther-
apy works.) (pp. 18–19)
SFT offers a number of benefits that are discussed later in
this article. However, as indicated by Shirk and Karver (2011),
outcomes in working with youth are dissimilar to outcomes in
working with adults in that there is no verdict that all therapies
perform about the same, that is, the “Dodo Bird verdict.”
Wofford and Ohrt
Indeed, Weiss and Weisz (1995) conducted a meta-analysis and
found behavioral therapy to be superior to other forms of child
therapy regardless of methodological quality of the studies
under review, at least in terms of statistical significance. On
the other hand, one issue they mentioned that merits further
consideration is that their meta-analysis did not explore clinical
significance.
Behavioral Therapy
Behavioral treatments are rooted in behaviorism (Feist &
Rosenberg, 2012). Behaviorism maintains that habitual human
behavior can be acquired, via conditioning, and it can also be
displaced (Feist & Rosenberg, 2012; Skinner, 1974). Shapiro
et al. (2006) stated that behavioral therapy started in research
facilities rather than treatment centers. The idea was to apply
what was known from science to the development of interven-
tions for psychiatric problems. Shapiro et al. indicated that this
approach typically involves outcome research, so that interven-
tions are either cast aside, altered, or maintained based on
results. Behavioral therapy is commonly used to treat children
struggling with anxiety, disruptive behavior, and/or inept social
skills (Shapiro et al., 2006).
Structural Family Therapy
Central to structural family therapy (SFT) is the premise that
individuals must be treated within their social contexts. Min-
uchin (1974/2003) indicated that problems ensue when bound-
aries between others in that context are too unyielding, that is,
“disengaged,” or too flexible, that is, “enmeshed” (p. 54). He
asserted that the establishment of clarified boundaries may be
brought about through direct intervention from the therapist
highlighting areas of familial disengagement or enmeshment
and calling for either greater clarity with the former or loosen-
ing up with the latter. Thus, counselors implementing SFT hold
that one’s psychological life is not simply an internal process
but rather a recursive process between the individual and the
inhabited context. Therefore, counselors using SFT seek to
change the family organizational structure, thus changing the
positions of the family members, which leads to altered experi-
ences for each member. SFT is used to treat systemic issues
such as boundary problems with irresponsible family members,
family member self-blame, and caregiver–child conflict (Min-
uchin, 1974/2003; Minuchin & Fishman, 1981).
Play Therapy
Play therapy is a form of counseling children through the uti-
lization of toys, art materials, games, and other forms of play to
work with clients (Kottman, 2011). Landreth and Bratton
(1999) specify that play is the language of children and toys
are their words. Kottman indicates that children under 12 years
of age lack a mature ability to state their thoughts and feelings
through verbal reasoning and therefore are unable to just sit in a
counselor’s office and process psychological concerns through
107
talking. But, they can enter an office and communicate these
concerns through the tools of play. Landreth (1991) promotes
the notion that play is actually the ideal way to develop a
relationship that will contribute to therapy with children.
Kottman (2011) elaborates that play therapy may serve as an
adjunct to other therapies when it comes to certain conditions
including ADHD.
Assimilative Proposal in Context
The approach proposed in this article is designed for situa-
tions involving elderly caregivers of children in a low socio-
economic status setting, seeking help in a managed care
context, when the children have inconsistent contact from a
noncustodial biological parent, a history of chronic stressors,
and a diagnosis of ADHD comorbid with ODD. The protocol
in managed care focuses on remission of symptoms. However,
growth is the means by which deficits are overcome, and
people grow from their strengths rather than from simply
identifying weaknesses (Duncan, 2014; Ivey & Ivey, 2007).
Therefore, even in a managed care setting, a counselor may
focus on growth.
The techniques utilized in this approach are drawn primarily
from behavioral therapy and secondarily from play therapy and
SFT. The techniques from behavioral therapy are grounded
in the principles of controlling stimuli and contingencies.
The techniques from play therapy are based around building
rapport and considering the meaning behind the child’s
play. One important caveat is that the counselor should
ensure a room is stocked with play therapy supplies. See
Landreth (1991) and Kottman (2011) for typical lists of
supplies for a play therapy office. The techniques from SFT
are based on implementing clearly defined boundaries with
a family member and with the child’s behavior relative to
caregiver expectations. The role of the counselor in this
approach is to work collaboratively with the child and care-
giver toward (a) the establishment and maintenance of a
therapeutic alliance, (b) adaptive functioning of the child
rather than oppositional defiance, (c) implementation of
adaptive boundaries within the family subsystems, and (d)
facilitation of the child’s developmental task of expressing
feelings through words.
An inherent aim of this approach is to address the individual
and family needs of the population rather than offering the
option of a procrustean bed. See Figure 1 for a pictorial illus-
tration of this approach. Using the analogy of the child as a
sapling, the main ideas are as follows: Through SFT, the care-
giver protects the welfare of the child (the knight) and clarifies
boundaries (the fences) to reduce the impact of chronic stres-
sors; play therapy allows the counselor to inhabit the child’s
world and approximate her position therein (the ladder); and
the gain in proximity allows for agreement to try recommended
behavioral techniques (the wires to temporarily help the sapling
remain rooted and pointing upward while growing) without
much direct pushback from the child, if any.
108 The Family Journal: Counseling and Therapy for Couples and Families 26(1)
Figure 1. Pictorial illustration of assimilative approach.
Case Illustration
The following is an example of my (first author) work with
Lauren, a 7-year-old White female residing with an elderly
caregiver with full custody, referred to me from a previous
counselor who had seen her for several sessions. Her medical
history included a number of health problems. She was residing
in a southern state in a rural, low socioeconomic status home,
which did not belong to her caregiver. Her mother was incar-
cerated at the time of the intake, and she was to be released
within a matter of months. Her caregiver informed me that
Lauren carried previous diagnoses of separation anxiety disor-
der, PTSD, and ADHD. However, I ruled out PTSD, as there
was no reported history of Lauren being exposed to actual or
threatened death or serious injury of herself or anyone else.
Lauren’s play revealed her naturally sociable nature as she
wanted her caregiver and me to join her in play. At her request,
she played with the ukulele I kept in my office, and we created
a song with simple lyrics. Early parts of our work together
consisted of playing and my observing and occasionally prob-
ing for meaning in her play. Through her play illustrating con-
flict, she revealed a rudimentary understanding of how strife
gets passed around and the results of reuniting after conflict has
occurred, yet she also exhibited no application of characters
saying sorry to one another after a conflict. Once, during a
puppet play session when Lauren introduced a parrot that could
fly away when it wanted, I noted the watery look in her eyes.
On the behavioral side, we worked on Lauren using a noise
of her choice rather than striking her caregiver when she was
upset. She used this to good effect. This intervention marked
the beginning of successive approximations of using words to
indicate strong feelings. We also began to work on more
sequential activities in session, and Lauren would insist on
cleaning up her own messes.
During the course of therapy, Lauren’s mother was released
from incarceration. However, Lauren found herself disap-
pointed as her mother did not follow through on her
commitment to frequent visits. Thus, Lauren’s condition
decompensated considerably. She eventually manifested symp-
toms consistent with ODD. After we discussed the matter, her
caregiver clarified boundaries with Lauren’s mother to allow
for times when the caregiver could prepare for the tantrums that
would ensue whether Lauren’s mother did not follow through
with contacting her. We also worked on how Lauren could
express herself to her mother and Lauren began to do so verb-
ally on the phone rather than attempting to inhibit her strong
emotions toward her mother.
Our time in play involved a number of fantasy tea parties
and meals in which Lauren was occasionally our waitress. The
power she had over our meal selections, that is, telling us what
was and what was not available, appeared to be a means for
Lauren to have a sense of control in her tumultuous world. One
notable feature of her play was an apparent drive to bring about
order in the midst of disorder, and her caregiver and I agreed
that she was able to show in her own way her discontent with
the disorder of her world.
Over the course of time, Lauren faced multiple changes in
her school setting and relocation to another town with her
caregiver. Lauren’s caregiver continued to bring her to see
me for counseling. Her caregiver’s boundaries with Lauren’s
biological mother paid off as evidenced by Lauren’s ability to
perform adequately in a school setting and her continued prac-
tice of verbalizing her feelings. Furthermore, Lauren told a
story in play therapy with a complete beginning, middle, and
end, which was no small task for her. She also shared about her
progress in school. When she got behind, she was able to get
nearly caught up over a break. While she still had trouble
following through with cleaning up after herself in the home,
she no longer struck her caregiver and was able to articulate her
frustrations as needed.
Limitations
According to the literature (Weiss & Weisz, 1995), behavioral
therapy is an effective intervention when working with chil-
dren. However, counselors reading this article may dispute the
claim that play therapy techniques being assimilated were only
an auxiliary part of treatment and contend that it was really out
of a play therapy framework that any of the other interventions
were successful. That is a reasonable limitation to consider
with regard to this approach. Another limitation exists with
regard to diversity, as this approach was used with a White
client from a low socioeconomic status background, thus the
client did not face some of the stressors that may be encoun-
tered by racial and ethnic minorities in the United States.
A common critique of behavioral therapy is that it may
oversimplify the complexities of human existence. Another
drawback to this particular case illustration is the issue of client
maturation over the course of therapy. Perhaps her behavior
would have changed without the interventions, through
Wofford and Ohrt
maturation along with the compassionate and responsive beha-
vior of her elderly caregiver. Nevertheless, the overall case
stands out as a success even with manifold factors having
influenced the outcomes.
Implications for Family Counselors
The overarching goal of increased adaptive functioning of child
clients can be served through a multipronged approach under-
girded by the consistent love of a concerned caregiver, regard-
less of the chaos in a client’s life, so long as the child is
protected from physical harm and exposure to violence or other
behavior inappropriate for children to witness. With regard to
shelter from harm, the child therapy office serves as a place for
insight and instruction to aid in this endeavor.
Although this case example sheds some light on the topic of
how child therapy can be of use to elderly caregivers and chil-
dren, much more research should be conducted in this area.
Areas for future research include (a) examining the potential
success of the approach with male children and racial/ethnic
minorities, (b) how the approach may differ with inconsistent
contact from a biological father, and (c) how to modify the
approach when a biological mother resides with another child
while the client remains in the custody of her or his elderly
caregiver.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
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