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Attention-Deficit Hyperactivity Disorder (ADHD) tends to be one of the most serious disorders that children and their parents have to face nowadays. The analysis and description of this disorder may turn out to be rather difficult as certain percentage of the symptoms that children with ADHD have are present only at some particular time and thus, they can be easily left unnoticed. Attention-Deficit Hyperactivity Disorder (ADHD) is known as a very serious developmental disorder that can be defined with the help of such symptoms as certain problems with attention and hyperactivity.

It is believed that ADHD is one of the most common behavioral disorders nowadays and according to the recent statistics, it affects approximately 10% of school-age children. Besides, there are certain gender peculiarities concerning this issue as boys are three times more likely to suffer from such disorder as compared with girls. The most widespread symptoms also include trouble focusing as children with ADHD understand and perfectly perceive information, however, they are unable to properly respond and perform the required and expected actions.

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Prior to the twentieth century, children's behavioral and attentional problems were described in nonbiological terms. Impulsive or distractible children were thought to have moral or religious defects. This thinking about the cause of children's behavior problems influenced the kind of problem-solving approaches people took. Solutions were located in communities, religious institutions, and families. However, as modern science gradually replaced religion at the center of the emerging American society, these same behavioral problems of childhood became medicalized.

History and Definition of Terms

This linking of children's behavior problems to biological causes received a boost during a major epidemic of encephalitis in 1917 and 1918. Physicians noted that children with the disease often developed postencephalitic symptoms that included hyperactivity, impulsive behavior, and impaired attention—the same three symptoms that now define as ADHD. By the 1930s this collection of behavior problems was referred to as “organic drivenness” and was believed to result from some kind of brain injury. The 1930s also saw the first use of stimulant medication to control hyperactivity when Charles Bradley prescribed Benzedrine for that purpose.

In the 1950s the term minimal brain dysfunction (MBD) was used to describe “excessive restlessness”, “aimless wandering,” and “poor ability to sustain interest in activities”. MBD served as an umbrella term for the effects of brain injury on mentally retarded children. Research, however, failed to show evidence of a biological cause. In addition, physicians felt that MBD was too inclusive term and not useful in prescribing treatment. Thus MBD fell out of favor.

During the 1960s, researchers continued to look for a biological cause of hyperactivity in children. New terms were used to describe overactivity, for example, hyperactive child syndrome and hyperkinetic reaction of a childhood. This decade also saw the first use of Ritalin in the treatment of hyperactivity. The cause of the hyperactivity was believed to be related to brain mechanisms but not necessarily brain damage. In summary, ADHD has a rich and storied life in this century, including several name changes. Yet two features remain constant: (1) the trio of symptoms— inattention, impulsivity, and hyperactivity and (2) the biological cause and necessity of medical treatment. ADHD has become as popular as other twentieth-century diseases such as diabetes, polio, and AIDS. Yet, unlike the aforementioned diseases, ADHD has not been proven to have a biological cause.

The idea that ADHD is a biological disease predominates among medical researchers and faculty. The leading proponent of this view is Russell Barkley of the University of Massachusetts Medical School, who states that Ritalin is the primary treatment for ADHD. In his book, Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosing and Treatment, Barkley states that talk therapies are not helpful and may not be necessary at all. He recommends a lifelong treatment using Ritalin for some ADHD patients. Barkley also reassures physicians that they should not feel guilty if their treatment plan does not include psychosocial elements because ADHD is a biological condition and is not caused or (by his logic) treated by psychosocial interventions (Merrell, 1999). Physicians, the media, and patients widely accept the explanation that ADHD is a biological disease. Physicians and managed care organizations have been particularly influenced by the idea because medicating children with Ritalin is more cost-effective and quicker than other forms of treatment. As a result, children diagnosed with ADHD in HMOs are more likely to receive Ritalin as the primary component of their treatment plan than privately insured children.

The Influence of ADHD on the Child and Family

One of the most effective and highly recommended approaches in order to treat ADHD is the SMART approach that is mainly influenced by postmodern therapies. Once the problem of ADHD is named, the SMART therapist works with the family to develop an understanding of the myriad effects of the problem on the child and on the family's life as this is one of the most serious consequences of this disorder. This process is called “mapping the influence of the problem”; it invites the child and family to make a detailed account of the often tyrannizing influence of ADHD in their lives.

SMART therapists are guided by certain attitudes or ethical postures in their work with children. These attitudes help them ask the kinds of questions that create possibilities and open space for new stories, thus providing the groundwork and context for SMART therapy.


As opposed to traditional therapists who operate from a position of expertise and certainty, SMART therapists take a stance of curiosity. This means that they privilege children's and their families' expertise about problems and solutions. SMART therapists can tolerate ambiguity and move tentatively in defining the problem. The SMART approach encourages clinicians to avoid the assumption that they understand children's experiences. Instead, therapists remain genuinely inquisitive about their clients' knowledge and understanding. The greatest tool of SMART therapists is questions that are neither designed to diagnose children nor to confirm what therapists already think they know. Rather, the questions are designed to discover the unique struggles, strengths, and abilities of children.


The SMART therapist has a deep respect for children labeled ADHD. It is imperative to believe that children have hidden resources that have been overlooked or ignored. Often they have not been encouraged to access their own problem-solving abilities because the deficit language of ADHD has subjugated their knowledge; they become convinced, and everyone around them is convinced that ADHD is in charge. The SMART approach works to resurrect this knowledge and value it over “expert” ideas about ADHD.

SMART therapists do not assume that they know what is best for children or their families. This way of working requires clinicians to be ever vigilant about imposing their own biases; they must frequently check in with the child and family to make sure they are privileged and respected. Thus, the therapy becomes a collaborative endeavor that helps to flatten the hierarchy that exists between client and therapist.


SMART therapists value curiosity and respect; they remain vigilant about imposing their biases on children and families. However, one bias that SMART therapists persistently introduce into therapy is hope. SMART therapy operates from a place of “tempered optimism”. The diagnosis of ADHD can invite therapists to feel discouraged about the therapeutic prognosis. The traditional ADHD belief that the child will have a biological condition for life forces therapists as well as children and families into resignation. SMART therapists do not get recruited into this despair. Using language of hope and possibility, SMART clinicians believe that change is possible and that children have the abilities and resources to solve their own problems.

The SMART Assessment

With attitudes such as curiosity, respect, and hope, SMART therapists take a unique approach to the assessment phase of treatment. In today's managed care era, most therapists have only one session authorized to develop a diagnosis and treatment plan. They must not only conduct an assessment session in a time-efficient manner but develop treatment goals and plans with children by the end of the first session.

The SMART assessment format consists of five areas of therapeutic inquiry and collaboration: (1) the meanings the family makes of ADHD, (2) the environmental checklist, (3) the SMART rating scale, (4) collaborative goal setting, and (5) the medication option. Each of these areas will be discussed in detail.

Many therapists encourage clients to examine their problems. In traditional therapies, however, problems are typically seen as belonging to the client and representing some kind of deficit or character flaw. To a certain extent, the client must admit ownership of the problem in order to begin the healing process. Clients who fail to admit their ownership are considered to be in denial.

In contrast, SMART therapy places the problem outside the client. In SMART therapy, the problem is often referred to as an independent, mischievous entity with designs on the child and family's happiness. From this externalized position, the child and family are free to account for the devastating influence of the problem without viewing themselves from a deficit-saturated position.

Mapping the influence of the problem is a critical step in SMART therapy because it allows the therapist to enter the world of the child and family and to learn the specific ways ADHD may be wreaking havoc. SMART therapists do not rely solely on the DSM-IV to understand what ADHD can do to a child (Kail, 2005). SMART therapists do not assume they know all of ADHD's plans and tactics for ruining a family's life. Instead, we trust our expert guides, the clients, to instruct us regarding ADHD's particular strategies.

Exploring the problematic effects of ADHD with the family is a crucial step in SMART therapy. In this process, the child's and family's meanings are privileged over expert meanings. The child is able to give a very precise and vivid account of ADHD's effects on him/her and others around him/her. SMART therapists ask two kinds of questions to map the influence of the problem: (1) “effects” questions and (2) “deconstruction” questions. Effects questions are derived from Michael White's (1989) ideas about relative influence questioning.

Thus, effects questions enrich and amplify the externalizing process. Deconstruction questions assist people in unpacking their ideas about ADHD and viewing them from different perspectives. These questions induce families to locate the problem of ADHD in a wider historical and cultural context.

By way of illustration, a SMART therapist would attempt to help every child and his/her caregiver account for many and various supports for ADHD-like behavior that do not derive solely from child's biology. The therapist might ask the child and his/her caregiver to consider the effects of race, class, and social context on the family's and community's expectations of him/her. Further, the therapist might challenge them to consider whether alcohol misuse, physical abuse or some other influence imposed by someone, have an impact on child's developing ideas about the world and his/her place in it. The SMART therapist explores how the culture may contribute and give support to the problem of ADHD.

Instead of being preoccupied with the etiology of ADHD, it is important to understand what ADHD means to the child and the family through a collaborative inquiry, family stories about ADHD and medication. Often parents have found the diagnosis as well as dominant ideas about ADHD helpful; ADHD relieves their sense of guilt.

Separating the Problem of ADHD from the Child

The ADHD label is a powerful example of an internalizing description. Children, who exhibit ADHD symptoms in one context, are often referred to as ADHD as if they have had the disorder. Evidence of the child's ability to defeat the problem in other contexts is often ignored. Furthermore, people begin to filter all of their experiences with the child through the lens of ADHD. All behaviors, regular and irregular, are attributed to the disorder, often at the expense of the child's creativity and ability to cope.

To counter the negative effects of internalizing labels, White and Epston developed a therapeutic practice called externalizing the problem, a term that refers to the therapeutic practice of naming the problem and linguistically separating it from the child. This practice of separating the problem from the child is the first step in the SMART therapy approach.

Narrative therapists view these externalizing conversations as powerful tools to help children realize that they are more than the sum of their ADHD symptoms. Externalizing conversations create distance between the child's identity and the problem, making space for the child to consider who he would like to be by identifying skills, resources, and preferences.

Some critics have referred to these conversations as a means of encouragement or as a way to minimize the effects of problems in children's lives. But White, Epston, and their colleagues look at it as philosophical and political practice designed to reverse the ever-increasing trend toward pathologizing and objectifying persons according to dominant cultural specifications. White and Epston (1990) state that the externalizing process is helpful because it reduces unproductive conflict over who is accountable for the problem. In addition, externalizing the problem helps people cooperate and work against the problem rather than each other. And last, separating the problem allows people to take a more playful and less serious approach to solving problems.

 • It decreases conflict over those who are responsible for the problem.

 • It reduces the sense of failure that people have in response to not having solved the problem.

 •  It unites people against the problem rather than against each other.

 •  It opens the way for people to reclaim their lives from problems.

 •   It liberates people to view the problem in new ways.

Externalizing conversations develop fluid descriptions of clients, their lives, and their problems. In externalizing conversations, we pay attention to how the client's relationship with the problem evolved over time. This takes the pressure off the therapist to come up with succinct and tidy externalization that will remain static and constant throughout the therapy. Instead, this more fluid description acknowledges that conversations, like problems and solutions have their twists and turns. In addition, externalizing conversations acknowledge that clients are often influenced by simultaneous and multiple problems that become entangled. Some other effective and modern therapies include Narrative Therapy, Expressive Arts Therapy, and Solution-Focused Therapy.

Narrative Therapy

Narrative therapists believe that human beings live their lives according to stories that reflect the meanings people make of the events they experience. Stories both describe and shape people's lives. According to White and Epston (1990), families and individuals often become bogged down in dominant stories that disqualify, limit, or disempower them. For example, a child who has been labeled ADHD can develop a deficit-based story of himself/herself. The ADHD story becomes dominant and totalizing; the child's past, present, and future are seen through ADHD lens. As a consequence, parents and teachers may fail to notice events or behaviors in a child's life that contradict the ADHD story. The deficit story frequently becomes internalized so that the name ADHD and the client become one and the same. Narrative therapists attempt to challenge dominant, problem-saturated stories by engaging clients in externalizing conversations that separate the problem from the person. By discussing the problem itself as the problem rather than the child's biology or disorder, narrative therapists begin to distinguish between the child's preferred ways of being and the problem's effects on the child. Externalizing conversations make room for the child's abilities, skills, and talents that exist alongside the problem story. These abilities, which may have been previously overlooked or impeded by the problem story, are now fertile ground for developing problem-solving strategies. Externalizing conversations encourage therapists and clients to align with each other and against the problem. Consequently, far from inviting hopelessness or resignation, externalizing conversations promote the child's and the family's agency to fight against the problem and its effects.

Once the problem is separated from the person, space is opened for the therapist and the client to attend to experiences or events that challenge the problem story. These events are referred to as unique outcomes or sparkling moments, times when the problem (or the problem story) is not in charge of the client. Questioning and other clinical practices such as letter writing explore the client's understanding of these victories over the problem, thereby thickening the story of the client's success.

Solution-Focused Therapy

The solution-focused therapy (SFT) model has become increasingly popular in the last decade, particularly with managed care health plans, due to its emphasis on brief, measurable, and long-lasting change (Babb & Laws, 1997). Many therapists have learned the model in order to become more cost-effective, goal-directed, and efficient in therapy.

SFT is a user-friendly and practical therapy. Therapists who use this approach ask clients to define their complaint and then search for instances when this complaint is less present in their lives. These instances are referred to as exceptions. The therapist then uses these exceptions to construct a solution by asking carefully crafted questions. One of the best-known techniques is to ask the miracle question: If there was a miracle one night while you were sleeping and the problem was gone when you woke up, how would you know? By imagining the outcome of the miracle in some detail, clients can be more hopeful about the future. SFT is useful in the work with ADHD children because it helps focus on exceptions to problems. In addition, SFT techniques enable one to set specific, clear goals with children and families; positive therapeutic outcomes become more possible by setting measurable, achievable goals.

As a conclusion it should be said that Attention-Deficit Hyperactivity Disorder (ADHD) is one of the most serious disorders that children have to face these days, and thus there should be urgent measures taken. Luckily, the range of the available therapies and medications is rather diverse and every family can choose personal approach in order to get rid of ADHD or help the child cope with this disorder with less serious consequences.

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