Overview :   ADD/ADHD

Attention-Deficit/Hyperactivity Disorder (ADHD) is a medical condition that affects the parts of the brain that control attention and activity.   People with ADHD have greater difficulty than others in their ability to concentrate, sit still, and control impulsive behaviors.  Some people with ADHD also have high activity levels, acting restless or even agitated.

 While most children have trouble paying attention or controlling their behavior at one time or another, children with ADHD struggle more with these things.  Symptoms such as hyperactivity typically decrease over time, but for over half of individuals with ADHD, problems with attention and organization will remain.  Sometimes symptoms can appear to worsen in adolescence, as demands increase in middle school.   ADHD may cause issues at school, home, and in friendships.   A child with ADHD might: 

• have difficulty listening
• struggle to pay attention, even in fun activities
• be distracted or “daydream” often
• make careless mistakes
• lose or forget things
• interrupt others’ words or actions
• fidget or squirm
• talk constantly, even when not appropriate
• have trouble waiting to take turns      
• find organizing tasks difficult
• jump from one activity to another
• blurt out answers to teachers’ questions      

In the past, ADHD was sometimes called ADD (attention deficit disorder) when hyperactivity was not present.  Now, people with ADHD are described in three categories:

ADHD, Predominantly Inattentive Type:  the category formerly referred to as ADD.  This type makes it hard for the person to finish a task, organize, listen to instructions and follow conversations, and pay attention to details.  Easily distractible and forgetful. 

ADHD, Predominantly Hyperactive-Impulsive Type:  This type is usually diagnosed when the person’s greatest difficulties are sitting still and completing tasks.  He or she may fidget and talk constantly.  Children with this type may be especially active, feeling a frequent need to run, jump, or climb.  Because the person with this type of ADHD often acts quickly without thinking first, they may have a hard time waiting their turn and following directions.  Reckless behavior in these individuals can also lead to more injuries and accidents, including automobile accidents.  They may interrupt others often, speak when not appropriate, or grab things from other people. 

ADHD, Combined Type:  This type is diagnosed when symptoms from the two categories above are both present in equal amounts – the most common type. 

ADHD is usually discovered in childhood, although sometimes it’s not noticed until the teenage years or even adulthood.  Even if it isn’t diagnosed until later in life, ADHD is something a person has at birth.  It is not caused, as some used to believe, by eating too much sugar, watching too much television, or lack of proper parenting.  

Scientists are, however, studying possible risk factors for ADHD.  The exact causes are still unknown, but current research points to a genetic link and also to potential risk factors including:

• Brain injury
• Premature delivery
• Alcohol and tobacco use during pregnancy
• Low birth weight
• Environmental exposures (such as lead)       

Doctors have found differences in brain chemicals called neurotransmitters (nur-ō-tranz-mit-ers) among people with ADHD.  These are chemicals that take messages between brain cells.  One example is dopamine (dō-puh-meen).  This chemical stimulates the brain’s attention centers, and low amounts of it in a person’s brain may appear as ADHD symptoms. 

Diagnosis 

There is no one test that can detect ADHD.  Instead, a diagnosis is reached after a complete evaluation that takes many other possible explanations into consideration.  Primary care doctors (Pediatrician or Family care doctors) may be responsible for determining and treating ADHD.  Otherwise, specialist doctors like a psychiatrist, psychologist, or neurologist, may be needed to evaluate the person suspected of having ADHD.  

Requirements for diagnosis of ADHD - 

Behaviors must:

• fit one of the ADHD types and appear before the age of 7
• be present for at least 6 months
• be present for at least 6 months
• cause difficulties in at least two areas of a child’s life (such as home, school, friendships, or day-care settings)
• be more severe than the same behaviors seen in other kids the of the same age   •   

Doctors also must rule out other causes for adhd-like behavior, like major life stressors (divorce of parents, a move, change of school, or other major life events) and other possible diagnoses (depression, learning disability, anxiety, Tourette syndrome, etc.).  The evaluation may include:

• a medical history and physical exam, including current medications, allergies, etc.
• hearing and vision check
• emotional well-being check
• parent questionnaire and/or interview, to determine parents’ concerns
• educational evaluation
• IQ and achievement tests       

As of today, ADHD cannot be cured, but it can be successfully managed with the help of your doctor.  For information on treatments, interventions, and helpful hints, please see the Current Practices section of this informational packet.  

Learning about ADHD can be confusing.  

Don’t be afraid to ask questions of your doctors, other families who have gone through it too, and our staff here at the Missouri Developmental Disability Resource Center.  We’re here to help.

 Works Cited 

Centers for Disease Control and Prevention. (2009, October 7). Retrieved March 1, 2010, from http://www.cdc.gov/ncbddd/adhd/facts.html 

National Institute of Mental Health. (2008, July 21). Retrieved March 1, 2010, from http://www.nimh.nih.gov/science-news/2008/age-related-decline-of-adhd-symptoms-disrupted-by-middle-school

Current Practices :   ADD/ADHD

Support Through Medication

Medication can be a support for people with ADHD. Although most parents and teachers of children with ADHD find medication helpful, it cannot take away all the symptoms of ADHD. Medication may help children to be less hyperactive, more attentive, and better organized than they would be without medication, but it is unlikely to enable them to function on the social and organizational levels of children without ADHD. Neither do stimulants help the central auditory processing deficits common among children with ADHD (Tillery, Katz & Keller, 2000).

Some parents are afraid to give their children stimulants because they have heard that stimulants are like street drugs. Although stimulants are sometimes abused, the therapeutic use of stimulants differs from the street use of stimulants. “Getting high” requires large dose increases of stimulants, or it requires quick absorption of stimulants through intravenous or nasal routes. When taken orally at prescribed doses, methylphenidate does not cause a “high” because it takes too long to reach the brain. In order to be used as a street drug, it would have to be crushed and snorted or injected (Gottlieb, 2001). When used therapeutically, stimulants are not a risk factor for substance abuse (Castellanos, 1997).

Although outward signs of hyperactivity often decrease as children enter adolescence, inner restlessness is likely to persist. Disorganization and inattention to detail follow many people with ADHD throughout life. Some adults with ADHD find medication useful as they interact with a world full of organized, punctual, and detail oriented people.

Types of Medication

Stimulants decrease hyperactivity in about 80-90% of children with ADHD. Stimulants are currently the treatment of choice for both adults and children with ADHD unless they have a condition that makes treatment with stimulants unwise.

Methylphenidate (Ritalin) is the stimulant most commonly prescribed for ADHD. It is available in tablets that last about four hours each, in sustained release tablets that last 6-8 hours, and in a new form called Concerta that lasts 10-12 hours.

Other stimulants commonly used for ADHD include Adderall, Dexedrine, Dexedrine SR.. Adderall lasts about the same amount of time as sustained release methylphenidate, and it is thought by some doctors to have a smoother and steadier effect.

A medicine that is neither a stimulant nor an antidepressant was released in early 2003 after short-term studies with 4000 people. The brand name for this medicine is Strattera. Its formulation is known as atomoxetine [formerly known as tomoxetine]. It is being promoted as benefiting people with ADHD who do not do well on stimulants. So far, tests have indicated that Strattera is moderately effective in reducing symptoms of ADHD while improving sociability. Strattera has some of the same side effects as stimulants prescribed for ADHD (including decreased appetite). In addition, some people claim they have irritability and mood swings as an unpleasant side effect. Strattera does not appear to increase insomnia – in fact, some people report being sleepy as a side effect of Strattera. Long term studies have not yet been published.

Psychological Supports

Although medication alone has been shown to be more effective than psychological interventions alone (Treatment of Attention-Deficit/Hyperactivity Disorder, 1999), most clinicians feel that psychological interventions should accompany medication. These interventions often involve behavior management, cognitive-behavior strategies, or attention-training techniques.

Behavior techniques can sometimes help children stay on task and can improve their organizational skills. Behavioral techniques commonly used for children with ADHD include systems of rewards (such as point systems), contingent attention, time out, functional analysis, and positive behavior supports. (For more information see Fast Facts on Developmental Disabilities: Challenging Behavior online at http://www.MODDRC.com or call 800- 444-0821.)

Behavior techniques applied by parents and teachers are helpful. However, behavior techniques probably are most effective when applied in specialized summer camps or other controlled settings by highly trained people (U.S. Department of Health and Human Services, 1999). Some behavior treatments may be able to target areas in the brain and affect brain function (Castellanos, 1997).

Cognitive-behavior interventions teach children to observe their own behavior and to use problem-solving approaches to alter it.

Attention-training techniques originally evolved as a treatment for people with head injuries. It was later found that similar techniques were useful for children with ADHD.

Other psychological interventions include social skills training, interventions to build self-esteem, or interventions that address coexisting issues such as anxiety or depression.

Alternative Interventions

Dietary:
Various herbs, vitamin/mineral/fatty acid supplements, and special diets eliminating certain foods (wheat, gluten, sugar, food additives) have been suggested as treatments for ADHD. The National Institutes of Health Consensus Development Conference Statement on ADHD states that “some of the dietary elimination strategies showed intriguing results suggesting the need for future research” (2000, p. 184).

Neurofeedback is an alternative treatment that involves learning to alter the rhythm of brain activity with the help of an EEG machine. Supporters claim that it is as effective as stimulant medication, and that results are sustained over time. However, most studies to date have been small and have not included controls (Sterman, 2000).

Other treatments:

Other alternative treatments include biofeedback, chiropractic skull manipulation, and Attention Restoration Theory. The latter states that people are able to focus their attention better after contact with nature. Supporters say that ADHD symptoms are alleviated after children have played outside in natural “green” settings, and that the more time they spend in “green” settings, the less severe attention deficit is (Taylor, 2001).

Large scale, independent, and well-controlled studies are not available for alternative therapies. Some of these treatments may help specific people with symptoms of hyperactivity or inattention, but they have not yet been shown to be effective for the general population of people with ADHD.

Educational Supports

504 Accommodation Plans and Individual Educational Plans:

Sometimes it is difficult to obtain special educational services for children with ADHD. The Individuals with Disabilities Act (IDEA) was written before much clinical information on ADHD was available, so ADHD was not addressed specifically in the law. Because of this confusion, the U. S. Department of Education issued memoranda clarifying state and local responsibilities in this area.

A memorandum issued in 1991 stated that children with ADHD should be classified as eligible for services under the “other health-impaired” category of the IDEA when “ADD is a chronic or acute health problem that results in limited alertness, which adversely affects educational performance.” (U.S. Department of Education, 1991, p.3). However, children with ADHD are not eligible to receive special education services simply because they have been diagnosed with ADHD. In order to receive special education, educational performance must be adversely affected by ADHD.

Students may also receive services and accommodations under Section 504 of the Rehabilitation Act of 1973. This law prohibits discrimination on the basis of disability. Schools are required to provide students with disabilities “free appropriate education.” A 504 Plan may include classroom or homework accommodations. It may also include special study or social skill classes.

If the child is found eligible for a 504 Plan or for an Individual Educational Plan, the parents and school personnel work together to form a plan that meets the child’s needs. (See Fast Facts on Developmental Disabilities: Individual Educational Plans. It is available from the Missouri Developmental Disabilities Resource Center www.MODDRC.com or call 800-444-0821.)

If the child is found ineligible, the following are options:
Ask whether the child has been evaluated under Section 504 criteria. (Some children not eligible under IDEA are eligible under Section 504 criteria).
Contact the state Parent Training and Information Center. (The Parent Training and Information centers in Missouri and Kansas are listed in this article under the heading “Resources.”)
Become involved in a local ADHD support group and learn how others in the area have navigated their way through the system.
Contact the state Protection and Advocacy Agency (Missouri Protection and Advocacy is listed in this article under “Resources.”)

Tips for Parents

When assigning tasks or giving instructions, remember that children with ADHD have trouble processing and remembering instructions given orally. They may need simple one step instructions repeated several times. Older children may benefit from written instructions they can refer to step by step.

Children with ADHD live in the present. They reflect little on the past, and are not interested in consequences. Warnings about what may happen if they persist in their present actions hold little meaning for most children with ADHD. They usually do not care about rewards or punishments in the (perhaps unimaginable) future. They respond to instant feedback and tangible rewards in the present.

Children with ADHD seek immediate gratification. Some are able to use a point system most profitably with tangible tokens (play money or other items they can touch and hoard.) It also helps to have reward items prominently displayed.

Homework often becomes a struggle for parents and their children with ADHD. If possible, encourage children to complete the regular assigned homework. Some students enjoy estimating how long an assignment will take, setting the timer, and then racing against the timer. Others prefer small rewards or rest breaks when each assignment is completed. If homework becomes too much of a challenge, it may become necessary to request smaller assignments or other accommodations.

Many children with ADHD are unusually creative. Sometimes the special abilities of children with ADHD who are gifted go unnoticed, because the focus is on their needs. This is particularly true when children have learning disabilities or behavior disorders along with ADHD.

Children with ADHD should be encouraged to pursue individual interests. However, children should not be pressured to meet unrealistic goals. Some children with ADHD feel the need to avoid stress and complexity in their lives. They may be happier to have fewer organized activities and responsibilities, and more “down time” when they can just relax and unwind.

Children with ADHD may need help with self-esteem, and may need extra encouragement, praise, and affection. They are often out of step with the rest of the world, resulting in many reprimands and disappointments. It helps them to feel that their parents accept them even when they make mistakes and experience failure. Parents who decide to enjoy their children as they are can gradually encourage more of the traits they value.

Support :   ADD/ADHD

Sharing Our Strengths (SOS) Peer Support Network

2200 Holmes
Kansas City, MO 64108
Phone: 800-773-8652
Web: http://www.sharingourstrengths.com/

SOS is a statewide support network of parents, family members, people with developmental disabilities and professionals who are matched with peer mentors to share experiences, offer emotional support and to network with others. You can request an individual parent to parent or peer support match with another parent or individual who has experienced similar circumstances.

CH.A.D.D. Children and Adults with Attention Deficit Disorder

8181 Professional Place, Suite 201
Landover, MD  20785
Work Phone: (301) 306-7070
Alternative Phone: (800) 233-4050
Fax: (301) 306-7090 Email: national@chadd.org
Web: http://www.chadd.org/
In spanish too

Personal Perspectives :   ADD/ADHD

Reaching Her Personal Best: Jordan's Story

By Shelly H., mother of four, including one child with ADHD

My daughter Jordan is the oldest of four children in our family. She is now 12 years old and in the 6th grade. Jordan was diagnosed with ADHD, Inattentive Type when she was eight years old and in the 3rd grade.

In the beginning, it was difficult to notice her symptoms, since she was the firstborn. I was somewhat concerned in first and second grade, when Jordan brought home her seat work incomplete. Even though her work was explained in class and she was given ample time to complete it, Jordan needed me to explain again and assist her in completing it.

At a parent teacher conference, Jordan’s teacher indicated that Jordan “just wasn’t getting it”. I began to think Jordan might have a learning problem. There wasn’t one particular area that stood out, but she struggled in all areas of school.

In 3rd grade, both her teacher and I felt Jordan must have a learning disability. She was having trouble keeping up with her classmates on daily work. Math stood out as a particular area of concern. Anything involving several steps was too complicated for her. She needed a lot of assistance in class and at home, but Jordan continued to be very well behaved and continued to be a hard worker.

At home and outside of school, she seemed to learn a lot from her surroundings. She was eager to learn and loved to read. She was always calm and content. Jordan had beautiful handwriting and artistic ability. I think it was easier for her to learn at home, one on one with her father and me.

At school she became lost in the shuffle. She was in a big group of students with many distractions. Jordan had loads of homework each night. I could tell at the time that she was a little discouraged. Many of her classmates were able to get their work done at school. Jordan was beginning to feel she wasn’t smart. She oftentimes didn’t raise her hand in class, for fear of being wrong.

Jordan’s 3rd grade teacher and I agreed that she needed to be evaluated. We weren’t sure what the answer was to her struggles, but we felt now was the time to determine this. I especially didn’t want to wait until she was in the 4th grade and really struggling.

Jordan attended a parochial school where there weren’t opportunities for extra learning support. Jordan’s teachers were wonderful, but as at many parochial schools, our school didn’t have a school psychologist or a special education program. In this situation, when teachers see a student with special needs, they work with the public school district. The teacher has to document all the things they have tried to help the student. Then they have to prove that these interventions are not helping the student to be successful. It often takes months for a student to get evaluated.

I knew that I did not want to wait for Jordan to be evaluated, so my husband and I decided to have her evaluated outside the school district at the our University Medical Center. Jordan was given an achievement test and I.Q. test to determine whether a specific learning disability was present. She was also given a test to determine if she had an attention problem. Other tests were conducted to measure her level of anxiety and if depression was present. I had to fill out behavior rating scales, giving the psychiatrists my view on Jordan. I had an interview in person, explaining my concerns. Her teacher filled out forms as well, to show what she saw in the classroom.

It was determined that Jordan did not have a learning disability, at least not shown on paper. There was not a big enough gap between her achievement and I.Q. scores. The medical staff diagnosed her as having ADHD, Inattentive Type, because Jordan did not show signs of hyperactivity.

When I heard this diagnosis, I was a bit taken aback. At first, I thought my child couldn’t have an attention problem. Then I realized she really did. Even though she appeared to be taking everything in around her, she wasn’t focused on what was happening. I see now that her struggles in 3rd grade were a result of everything she missed in 1st and 2nd grade, maybe even Kindergarten. She was behind in her knowledge of basic skills. As the work load increased, she felt completely lost.

Jordan’s psychiatrist recommended that she start taking a stimulant medication. When Jordan’s third grade teacher and I did not notice improvement in her learning, the psychiatrist decided to try a different stimulant. After that, third grade continued to be a lot of work for Jordan, but she showed a marked improvement in her learning. She still had a lot of catching up to do. She gradually began to feel more confident within herself.

Jordan started off 4th grade pretty well. As the workload increased, we noticed her falling behind. It was hard for her to keep up once again. Jordan’s 4th grade teacher and I agreed she needed some interventions and modifications to help her be successful.

We worked together with the public school elementary special education teachers and school psychologist. They helped us come up with a plan to help Jordan in math computation and problem solving skills, as well as higher level reading skills. They even helped us come up with a strategy to help Jordan with her difficulty ordering her lunch and drink in the morning at school.

My husband and I were careful how we explained her diagnosis to Jordan. I explained that it had nothing to do with intelligence. She was smart and we would get through this. I told Jordan that she shouldn’t be ashamed of having ADHD. This was how God built her brain, and I knew it would make her a stronger person.

Jordan maintained B’s and C’s through her strong work ethic. She still had a lot of homework, but her teacher was willing to modify math assignments. She also had a daily math journal with examples of how to do her problems.

My husband and I decided that the public schools in our area might be a better choice for our family, especially Jordan. I met with the school counselor and psychologist. They explained all the support Jordan could receive, even though she wasn’t a special education student. She could receive a 504 Plan, which would recognize ADHD, giving her teachers a plan to follow.

Jordan is now in 6th Grade. She is in a lower level Math class, which moves at a much slower pace. She still learns the same concepts as students in the higher level class. Jordan also has a supplemental Math class, which pre-teaches skills she will learn in her regular math class. The confidence she has gained from this is amazing. Jordan is actually helping other students in her math classes, who are struggling. Her Math teacher allows her to write on the white board, because her handwriting is so beautiful. Math will always be hard for Jordan, but she is feeling proud of her success.

Her middle school has taught her organizational skills, which Jordan thrives on. Jordan needs structure and direction. Her new school has provided this for her. Jordan made the A/B honor roll, and has been recognized twice by her teachers as “Student of the Week”.

Jordan is also a dancer. Her success in school and the added effects of her medicine have also helped her improve her dance ability. She loves dance. Jordan learns her dances a lot quicker now, because she is able to concentrate!

Living in a house of four children can be very distracting. Jordan has her own desk and space to complete her homework. She needs that special area to concentrate. She also has a wipe-off board where she lists things she needs to get done. Jordan likes feeling organized and able to work on her own. She also knows she can come to me or her father for help when she needs it. Children with ADHD especially need this security.

My husband and I are blessed with a child who cares so much about doing her personal best. This good attitude was definitely on her side. Had we not stayed on top of things, communicating with her teachers, finding out what was best for her, and evaluating her learning progress, she wouldn’t be where she is today.

Each year of school for Jordan is like starting over. I will always meet with her new teachers at the beginning of the year, giving them a little insight on what Jordan is all about. Of course, I have to believe in their professional knowledge and opinions, and trust in what they feel is good for her. I still know I will speak up when something isn’t right. I am Jordan’s best advocate. Parents are the keys to their child’s success.

I want to leave you with some thoughts from my daughter Jordan. Here is what she has felt in the past and is feeling now. I am so proud of her!

In Jordan’s words:

Before I knew I had ADHD, I felt stressed in school. I was confused and didn’t know what was wrong with me. When I found out that I had ADHD I was really upset. I said, “Why do I have to have this?”

Now I feel better because I take medication to help me concentrate. It really helps me to do a lot better in school. I also felt better because my mom explained to me that I was still Jordan, no matter what. I didn’t have to be different than the other kids. It was also my private business, which I didn’t have to share with anyone. I could still be who I wanted to be and do well in school. ________________________________________________________

Resources :   ADD/ADHD

Online Resources:

NICHCY (National Information Center for Children and Youth with Disabilities)

Detailed information about ADD/ADHD (PDF document)

NICHCY (National Information on Children and Youth with Disabilities)

Facts sheet about ADD/ADHD

National Resource Center on ADD/ADHD

Questions parents often ask about ADD/ADHD

ONE ADD PLACE

Myths and misconceptions about ADD/ADHD

Schwab Learning Foundation for Learning Disabilities and ADD/ADHD

An essential guide to ADD/ADHD for parents (PDF document)

Healthline

Information about ADD/ADHD symptoms, causes, and treatments.