Ariel Botta, LICSW, works with the Group Therapy Team in the Outpatient Psychiatry Service at Boston Children’s Hospital. Here she shares why social skills training is a particularly important aspect of treatment for children and adolescents diagnosed with ADHD.


Why do group work?
Most of them have come from individual therapy but haven’t made the progress they would like. They have been referred to group to really work on impulse control, emotion management, and building their self-esteem. There are some kids that are nervous about going group. Usually I have a prescreening with them and talk to them about the purpose of group, the goals of group, and answer any questions. Most kids are excited about it because it really is a safe place for them to work on their goals.


Working with parents
I spend a lot of time sharing the successes of their kids with parents. Parents with kids of ADHD don’t hear a lot of success stories, and a lot of them are really apprehensive when an adult says “I’d like to talk with you” because they think their child is in trouble or has done something wrong. I think that in and of itself is a therapeutic thing to be able to share these positive experiences with them and to give them permission and to encourage them to talk to their child about his experiences.


Feel better about themselves
One thing that happens in my ADHD boys’ groups is that there is such a high level of empathy. These kids are so capable of having really close intimate relationships when provided with the opportunity to do that and the tools to develop those skills. Part of it is behavioral modification giving kids skills that they can actually use and put in their toolbox. Another part of it is relational work, teaching them the skills necessary to build trusting relationships, which helps them with their parents, with their siblings, with their peers, with their teachers, and enhances their lives in general. At the end of group parents will say to me, “My child feels so much better about himself” and children will say the same thing because they feel like they have mastered the important things in their lives.


Working in the moment
I think that group therapy is a very powerful form of treatment for kids with ADHD because the very things they are struggling with will be happening in the room so that you can actually work on it in the moment. When you are in individual therapy with a child with ADHD often you won’t actually see the behaviors. You talk about it in theory but that is not always helpful to kids, it doesn’t resonate with them. But when you alter behaviors in the moment I think that is internalized much more, and becomes part of long term memory.


Working on things in group
If I were to walk into a room and say “Today I am going to change all these things that you are doing,” most children would not be open to that. Part of the group process is helping kids identify things that are getting in the way of helping them build relationships or succeeding in life– in their words, not in my words. When there’s a conflict or someone hurts someone else’s feelings because they said something impulsively we can say, “Wow, what just happened here?” The group can process it, and everyone can give feedback. Usually the child feels safe enough that they can say, “This happens to me all the time. I always say things that I don’t mean because they always come out of my mouth before I have time to think about them.” So then the child has identified that impulsivity does in fact make him uncomfortable because it makes people angry and it makes him feel bad about himself. So now we have a goal to work on and now we can say to that child and all of his peers, “Can we all work on this together and help you figure out ways to be more in control in the things that you say and you do? It sounds like it would make your life feel better.” Then they are committed to that goal.


A safe place to work on things
In group we spend a lot of time processing interactions and trying to understand what the driving force is behind behaviors. I always say in group, “In here when a rule is broken you are not going to get punished, you’re not going to get in trouble, you’re not going to get kicked out of group. We expect that rules will be broken because that’s why you are here: to learn how to work on certain things. We are going to all figure out together how to not keep breaking rules the same way.” So that each time a rule is broken it will be a learning experience, for each person who broke it and for everyone else in the group and it won’t be punitive. What this does is it invites kids to be accountable because kids with ADHD are often in trouble. They are always getting in trouble in the classroom and they are often in trouble at home. They really aggravate and irritate people. Their behaviors and the things they struggle with make most adults really angry, but they also make lots of kids really angry. What’s hard is that these kids are not doing these impulsive things on purpose; they really can’t control it until they have skills to be able to.


Seeing improvement
Incredible improvement, incredible! I see kids with ADHD who used to lie about their behaviors and had emotion regulation problems because they are so angry about always getting in trouble or they are so sad about always getting in trouble. They are really more in touch with the way their brain works and why they do certain things. I see them much more accountable for their actions and being able to say, “Mom, I’m sorry I did that to my brother, I really didn’t mean to and I’m working on it.” I’ve seen them apologize for their actions, often not because they are forced to. I’ve seen kids with ADHD who really gain control of their impulses and really start to recognize physical indicators that could show that they are having a rough time so that they could be more proactive.


Transferring skills outside of group
That is the biggest challenge of all group work and of psychotherapy with children is helping them transfer their skills from one environment to another. Often what happens is they do a fantastic job in group, but because they go back to their real lives where everyone responds to them the same way they always have they fall back into a negative pattern of behavior, so it’s trying to help them become change agents in their own lives. Part of that work with young children is absolutely working with parents: giving them the same language, helping parents reinforce the same things, helping them create a similar culture that happens at group at home. Like letting kids develop house rules, that’s what we do in group they develop the rules in group. Somehow when you develop your own rules you are more likely to follow them, rather then being told what you are supposed to do, what you are not allowed to do. Lots of parents have let their kids come up with house rules and let them lead the family in this process it’s just been amazing.