Behavior management techniques, educational strategies, and medication can help the 3 to 6 percent of American children affected by attention deficit disorder.
Jason’s parents have come to dread the phone calls from his teachers. Although Jason is only 6 years old, the first-grader is already viewed as a disciplinary problem. When Jason was 3 years old, his preschool teacher informed Jason’s parents that Jason’s pushy behavior interfered with the play of other children in the class. In the teacher’s judgment, Jason was an undisciplined child. When Jason was age 4, his prekindergarten teacher said that other children complained about Jason’s aggressiveness. Disciplining him did not work. The following school year, Jason’s kindergarten teacher described him as a wild boy who ran about the classroom knocking toys off shelves and interrupting other children. His classmates did not want to play with him because he was so aggressive.
Jason’s first-grade teacher compares him to a tornado. When Jason enters a room, he changes the tone from peaceful quiet to total pandemonium. Jason’s parents acknowledge that he behaves the same way at home. His distraught parents are reluctant to take him anywhere because of his sudden tantrums. He has never been invited to a birthday party, and he has no playmates.
Jason’s parents finally seek help from their pediatrician, who refers them to a pediatric neurologist (a doctor who specializes in diseases and disorders of the brain and nervous system). The doctor diagnoses Jason’s condition as attention deficit disorder (ADD), one of the most common neurological disorders of childhood. After the diagnosis, Jason’s parents feel guilty and apprehensive. They wonder if their parenting caused Jason to develop ADD and worry that the condition will prevent him from leading a normal, productive life.
Advances in understanding the cause and treatment of ADD have helped ease the concerns of parents with children like Jason. Doctors and other professionals who work with children believe that ADD is the result of chemical, not environmental, factors. Assessment procedures, behavior management techniques, medications, and family counseling methods help children who, in past decades, may have been labeled “lazy” or “troublemakers” overcome difficulties associated with ADD. Also, laws mandate equal educational opportunities and school accommodations for children with ADD.
What is ADD and what causes it?
Although its causes are not fully understood, experts generally believe that ADD is a bioneurological problem brought on by a chemical imbalance in the brain. Research suggests that ADD is genetic, which means that the condition is inherited. Doctors estimate that at least 3 to 6 percent of American children are affected by the disorder. Studies show that as many girls as boys have ADD. However, boys are four times more likely to be diagnosed with it, probably because girls tend to show less physical aggression and loss of control than boys do.
The name of the disorder can cause confusion, because different terms are used by the various professional groups who treat people with the condition. The American Psychiatric Association uses the term attention-deficit/hyperactivity disorder (ADHD), while the U.S. Department of Education has used both ADD and ADD/ADHD. In practice, the terms ADD and ADHD refer to the same disability and are used interchangeably.
People with ADD are characterized by three main traits—inattention, impulsiveness, and hyperactivity—though not all people with ADD have all three traits. These characteristics often prevent people with ADD from behaving appropriately at home, at school, and in social situations. Inattention makes it difficult for a child to complete a task or activity. Impulsiveness can cause a child to constantly interrupt others or to act without considering the consequences of the action. Hyperactivity causes a child to be in constant motion.
ADD symptoms change with age
The symptoms of ADD change over time, and distinctive behaviors resulting from ADD appear at different stages of an individual’s life. Preschool children (ages 2 to 6) with ADD often engage in excessive gross motor activity (the use of large muscle groups), such as continual running or climbing. They cannot sit still for most activities for more than a few minutes at a time. Parents find it difficult to take these children to stores, restaurants, or other public places. Because many children with ADD sleep very little and need constant supervision, parents do not get adequate rest, which may contribute to the stressful situation caused by the child’s behavior.
Elementary-school-age children (ages 7 to 11) with ADD tend to be restless, fidgety, and poorly organized. Teachers may complain that the child talks too much in class, hurts other children’s feelings, or intrudes on other children’s games. The child’s inability to concentrate interferes with school learning, particularly learning to read.
Adolescence (ages 12 to 18) may be turbulent in and of itself. The poor attention skills, impulsive behavior, and hyperactivity of youth with ADD may add to the turmoil. During adolescence, as academic workloads increase, deficiencies in skills such as organization and listening intensify the pressure on children with ADD. Although adolescents with ADD may appear less hyperactive than they were at a younger age, they often develop other symptoms—such as disorganized thought processes—that they cannot control. Often they have difficulty making and keeping friends. The academic and social problems of adolescence can lead to lowered self-esteem, depression, and, in some cases, conduct disorder, which includes such behaviors as bullying, stealing, and destroying property.
Social implications of ADD
At one time, ADD was considered a childhood problem that the individual outgrew. However, experts now believe that many people continue to have ADD into adulthood. The high energy levels that accompany ADD can result in creativity and persistence, which may help some adults with ADD lead very successful lives. For others, however, the disorder causes disorganization, impulsiveness, and social problems that disrupt careers and personal relationships.
About 65 percent of people with ADD have other conditions as well, such as learning disabilities or emotional and behavioral problems. Children with learning disabilities have the ability to learn but fail to acquire basic academic skills. They find school learning to be difficult, especially in the areas of language, reading, writing, and arithmetic. Researchers estimate that 25 to 40 percent of children with ADD also have learning disabilities.
About 40 to 60 percent of children with ADD have coexisting emotional and behavioral problems. These children have conduct or oppositional defiant disorders and may be aggressive, delinquent, destructive, or depressed.
Since hyperactive children tend to be aggressive, they are often rejected by their peers. In addition, many people with ADD are socially imperceptive and unable to establish satisfying social relationships. They cannot “read” the body language of others and thus may commit such social blunders as making hurtful remarks without realizing it, intruding on private conversations without recognizing that their presence is unwanted, or insisting on a particular way of doing things without taking others’ wishes into account.
How is ADD diagnosed?
When parents or school officials suspect that a child has ADD, the first step toward getting treatment is to have the child assessed by a qualified professional, such as a psychiatrist, clinical or school psychologist, neurologist, or pediatrician. The examiner collects information about the child to identify the problem, to diagnose the extent of the problem, and to develop an effective treatment program.
The assessment process usually begins with a detailed physical examination to ensure that an undetected medical condition is not the cause of the problem. The child will also undergo vision tests, hearing tests, and tests that check mental and emotional development.
After physical causes for the problem have been ruled out, a variety of techniques are used to determine if a child has ADD. For example, interviews are conducted with parents, teachers, and the child. Interviews with parents reveal information about the child’s background, development, health, and the child’s relationships with family members and peers. Parents may describe episodes that show that the child had symptoms of ADD very early in his or her life.
Interviews with teachers are useful in obtaining information about the student’s school achievement, learning strengths and weaknesses, and social skills. Interviews with the child or adolescent who may have ADD reveal the individual’s feelings and views about the problem. In addition, school staff members, such as a special education teacher or a guidance counselor, observe the child at play, in class, or at home to see how the child behaves in various situations.
Other Tests tools of ADD
The child is usually given psychological tests (intelligence tests), which can be useful in judging the child’s ability to concentrate. The widely used Wechsler Intelligence Scale for Children-III, for example, consists of 20 subtests. By combining certain subtest scores, a specialist can evaluate the child’s concentration skills over a period of time. Assessing ADD with the Wechsler Scale alone is not conclusive, because test scores can be influenced by such factors as fatigue, anxiety, and cultural and language differences. But psychological tests can help gauge a child’s strengths and weaknesses in areas such as verbal reasoning, hand-eye coordination, and attention to detail.
A child’s educational performance is a critical part of any evaluation of ADD. For many children, the traits of ADD lead to difficulty in school learning. Academic assessment, such as standardized tests and informal measures, evaluates the child’s achievement in subjects such as language, reading, writing, spelling, and mathematics.
Another tool in the assessment process that is sometimes used is a Continuous Performance Test (CPT). The CPT is a device with a display screen on which letters or numbers are rapidly projected. The child watches the screen and presses a button when certain letters or numbers appear on the screen. By comparing the number of times the child pressed the button with the number of times the designated letter or number was actually projected, the CPT can measure the child’s ability to concentrate over a period of time.
After all of the test results are in, many professionals use the guidelines listed in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), published by the American Psychiatric Association in 1994, to determine whether a particular child has ADD. According to DSM-IV, an individual with ADD has exhibited some symptoms by age 7, has demonstrated these symptoms for at least six months, and has experienced problems that result from the symptoms in at least two environments (such as home or school). For the child to be diagnosed with ADD, the symptoms cannot be caused by another disorder.
Types of ADD
The DSM-IV lists three types of ADD: Primarily Inattentive Subtype, Primarily Hyperactive-Impulsive Subtype, and Combined Subtype. People diagnosed with Primarily Inattentive Subtype have poor attention, but they are not hyperactive. To be diagnosed with Primarily Inattentive Subtype, a person must display at least six of the following nine symptoms:
- is inattentive to details or makes careless mistakes in schoolwork, work, or other activities;
- has difficulty keeping attention on tasks or play activities;
- does not seem to listen when spoken to directly;
- does not follow instructions and fails to finish schoolwork or chores (but not because of anger or failure to understand the directions);
- has difficulty organizing tasks and activities;
- avoids or dislikes tasks that require sustained mental effort;
- loses things needed to perform tasks or activities;
- is easily distracted;
- is forgetful.
People diagnosed with Primarily Hyperactive-Impulsive Subtype are attentive; however, they are also hyperactive or impulsive. The diagnosis of this subtype requires that a person display at least six of the following nine symptoms:
- fidgets with hands or feet or squirms in seat;
- leaves seat in classroom or other situation where remaining seated is expected;
- runs or climbs excessively in inappropriate situations, or continually feels restless;
- has difficulty engaging in leisure activities quietly;
- is often “on the go” or acts as if “driven by a motor”;
- talks excessively;
- blurts out answers before questions have been completed;
- has trouble waiting turn;
- interrupts or intrudes on others during conversations or games.
People with Combined Subtype display six or more symptoms of both Primarily Inattentive and Hyperactive-Impulsive Subtypes. Combined Subtype is the most common diagnosis for children and adolescents with ADD.
Medications used to treat ADD
For many individuals with ADD, medication forms the cornerstone of the treatment process because it can provide rapid improvement of several symptoms. The most effective types of medication are psychostimulants (drugs that increase activity in the brain). Research suggests that psychostimulants help many people with ADD by increasing the availability of certain chemicals that transmit nerve impulses in the brain. According to some studies, people with ADD do not produce enough of the brain chemicals that control attention and impulsiveness.
Psychostimulant medications such as methylphenidate (Ritalin), dextroamphetamine (Dexedrine), and pemoline (Cylert) are thought to prevent the brain from rapidly using up the chemicals needed to concentrate. Research and clinical experience show that children with ADD who take psychostimulants are more attentive, more likely to complete their schoolwork and other projects, and better behaved at school and at home. About 70 percent of children with ADD show improvement in their symptoms after they begin taking one of the three major psychostimulant medications.
In choosing the type of medication to prescribe, a doctor considers such factors as side effects and how the medication will be administered. For example, short-acting Ritalin, which is the most frequently prescribed psychostimulant, lasts for only about four hours. If the child takes the medication at home in the morning, a second dose is needed during the school day, requiring the school to be responsible for giving the medication. Doctors prefer the short-acting form because it is more effective than longer-acting Ritalin.
Concerns about Ritalin
By the mid-1990’s, so many children in the United States were taking Ritalin for ADD that many parents and professionals became concerned. They wondered whether the disorder was being overdiagnosed and the medication overprescribed. However, a study led by Linda B. Bresolin of the American Medical Association’s Council on Scientific Affairs reported in April 1998 that neither overdiagnosis nor overprescription were taking place. According to the report—which reviewed studies on the diagnosis and treatment of people with ADD from 1975 through 1997—the number of children being treated with Ritalin for ADD was actually quite small compared to the number of children estimated to have the disorder.
For some people, Ritalin controls ADD symptoms more effectively when combined with other medications, such as the psychostimulants Dexedrine and Cylert. Although Cylert is longer acting, it is not as safe as the other psychostimulants. Cylert may damage the liver, so people taking the drug must have a liver function blood test every six months.
In 1996, a new, longer-acting psychostimulant called Adderall was introduced. Adderall contains a combination of dextroamphetamine and amphetamine. Studies showed that Adderall is effective in controlling ADD symptoms. Because it is a longer-acting medication, it can be more convenient for children on a school schedule.
If psychostimulant medications do not improve an individual’s attention and reduce hyperactivity, or if they cause additional symptoms, the doctor may prescribe antidepressants such as desipramine (Norpramin), imipramine (Tofranil), and amitryptyline (Elavil). Other people with ADD—particularly those who are very hyperactive or aggressive—may benefit from clonidine (Catapres), a drug normally used to treat hypertension (high blood pressure) in adults.
Other ways of treating ADD
Doctors and other professionals have found that the most effective way to treat ADD is through a combination of methods. These include medication, along with behavioral management, educational strategies, classroom procedure adjustments, family counseling, and parent training. Teachers, parents, and other family members can use a variety of techniques to help modify a child’s behavior at school or at home.
One behavioral technique, contingent reinforcement, uses the immediate consequences of a behavior to either strengthen or weaken the behavior. Doctors believe that rewards are more effective in changing behavior than punishments. For example, rewards such as praise or favorite activities are more likely to encourage children to complete an assignment than punishments such as losing television time. However, it is important to find rewards that the child desires.
When a child behaves inappropriately, the teacher or parent may try a disciplinary method called “time-out” to encourage better behavior. Time-outs involve placing the child in an isolated area for a short period. The technique works best when the parent or teacher warns the child only once about the misbehavior, restates the broken rule, does not talk or make eye contact with the child during the time-out, encourages the child to join in activities after the time-out is over, and praises the child when he or she behaves appropriately.
Help at school and at home
Modifications in the school curriculum or adjustments in classroom procedures can significantly help children with ADD. Teachers can seat the child in the least distracting location, such as in the front of the class and away from windows. They can break assignments into small parts, reduce the amount of homework, and allow the use of learning aids, such as calculators and tape recorders. Teachers can also give students with ADD more opportunities to move about, such as having them run errands or collect papers.
Parents can help children with ADD by establishing a schedule at home, with regular times of waking, eating, doing homework, playing, and sleeping. Since many children with ADD find adjusting to change difficult, parents can avoid unnecessary changes in routine or discuss changes before they occur. Parents can also help students organize their schoolwork by making lists on which the child checks off each item as it is completed.
Counseling may be needed for members of a family that includes an individual with ADD. While trying to help the affected child, parents often disagree about how to manage the youngster and can become too permissive or too strict. Brothers and sisters may resent the fact that so much attention is focused on one child or may be embarrassed by the child’s behavior in public. Learning about ADD and approaches to consistent and appropriate behavior management can make life easier for the whole family. Many parents also benefit from joining a support group. Sharing their experiences with other parents of children with ADD helps to reduce stress, and in their group they may find practical solutions that have worked for others.
Legislation that helps people with ADD
Legislation has also helped individuals with ADD cope with the disorder. Children and adolescents may be covered by the Individuals with Disabilities Education Act (IDEA), first passed by Congress in 1975. Amendments to IDEA have affirmed that children with ADD may be eligible for special education services if the disorder is a chronic health problem that results in limited alertness, adversely affecting education performance. Students with ADD may also be eligible for special education services under IDEA if they have additional learning disabilities or emotional problems.
Children with ADD may be eligible for services under Section 504 of the Rehabilitation Act, even if they do not qualify under IDEA. Section 504 requires institutions that receive federal funds to make reasonable accommodations for individuals with disabilities. First passed in 1973, Section 504 was originally used to ensure such accommodations as “curb cuts” and wider bathroom doors for people in wheelchairs and interpreters for the hearing impaired. Since 1997, the law has allowed children who have ADD to receive such classroom accommodations as untimed tests, access to a teacher’s or another student’s notes, or exemption in such curriculum requirements as foreign language study.
The Americans with Disabilities Act (ADA), passed by Congress in 1990, can benefit adults with ADD. This law mandates reasonable accommodations for people with ADD at their place of work.
The road for children with ADD is filled with obstacles, but there is reason for hope. In the past, people displaying symptoms of ADD were often ignored, misdiagnosed, or mistreated. Too often parents were blamed for a child’s behavior, and children were lost in school systems unable to deal effectively with the disorder. By 1998, doctors, psychologists, and educators had realized that ADD is a treatable condition and that children with the disorder—and their families—can learn how to cope with ADD.
For further reading:
Boyles, Nancy S., and Contadino, Darlene. Parenting a Child with Attention Deficit/Hyperactivity Disorder. Lowell House, 1996.
Dendy, Chris A. Zeigler. Teenagers with ADD: A Parents Guide. Woodbine House, 1995.
Lerner, Janet W., Lowenthal, Barbara, and Lerner, Sue R. Attention Deficit Disorders: Assessment and Teaching. Brooks/Cole Pub. Co., 1995.
Quinn, Patricia O. Attention Deficit Disorder: Diagnosis and Treatment from Infancy to Adulthood. Brunner, 1997.
Parent support groups:
Children and Adults with Attention Deficit Disorder (CH.A.D.D.)
499 NW 70th Ave. Suite 308. Plantation, FL 33317
Web URL: http://www.chadd.org/
National Attention Deficit Disorder Association (NADDA)
PO Box 972. Mentor, OH 44061
Phone 313-709-6690, 800-487-2282
Web URL: http://www.add.org/