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Attention Deficit Hyperactivity Disorder

the role of occupational therapy practitioners

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Attention Deficit Hyperactivity Disorder

  1. 1. Attention Deficit Hyperactivity Disorder (ADHD) • Introduction • What is Occupational therapy • When does child need Occupational therapy • What is attention deficit hyperactivity disorder? • What are the symptoms of ADHD in children? • What Causes ADHD? • How is ADHD diagnosed/scales? • Occupational therapy method of treating ADHD? • Medications • Psychotherapy • What conditions can coexist with ADHD? • How can I work with my child’s school? • Do teens with ADHD have special needs? • Can adults have ADHD? • What efforts are under way to improve treatment? • Citations • For more information on attention deficit hyperactivity disorder Introduction: Occupational therapist addresses co-existing physical or sensory integration concerns, such as motor planning, balance and coordination problems and hand writing difficulties, Occupational therapy practitioners consider the effect that learning and attention problems have on children’s ability to perform valued activities, OT’s provide support to parents around behavior management and develop strategies to help parents help their children, using occupation as the vehicle to promote health and is one of the few disciplines that combine knowledge of psychological aspect of behavior and learning with sensory motor aspects. What is occupational therapy? Occupational Therapy is the assessment and treatment of physical and psychiatric conditions using specific, purposeful activity to prevent disability and promote independent function in all aspects of daily life. When does a child need occupational therapy?. Occupational therapy is provided when there is a disruption in function in one or more of the following the areas:
  2. 2. • Gross Motor Skills : movement of the large muscles in the arms, and legs. Abilities like rolling, crawling, walking, running, jumping, hopping, skipping etc • Fine Motor Skills : movement and dexterity of the small muscles in the hands and fingers. Abilities like in-hand manipulation, reaching, carrying, shifting small objects etc. • Cognitive Perceptual Skills: Abilities like attention, concentration, memory, comprehending information, thinking, reasoning, problem solving, understanding concept of shape, size and colors etc. • Sensory Integration : ability to take in, sort out, and respond to the input received from the world. Sensory processing abilities like vestibular, proprioceptive, tactile, visual, auditory, gustatory and olfactory skills. • Visual Motor Skills : a child's movement based on the perception of visual information. Abilities like copying. • Motor Planning Skills : ability to plan, implement, and sequence motor tasks. • Oral Motor Skills : movement of muscles in the mouth, lips, tongue, and jaw, including sucking, biting, chewing, blowing and licking. • Play skills : to develop age appropriate, purposeful play skills • Socio-emotional skills : ability to interact with peers and others. • Activities of daily living: Self-care skills like daily dressing, feeding, grooming and toilet tasks. Also environment manipulation like handling switches, door knobs, phones, TV remote etc. • Occupational therapists in schools collaborate with teachers, special educators, other school personnel, and parents to develop and implement individual or group programs, provide counseling, and support classroom activities. • Occupational therapists design and develop equipment or techniques for improving existing mode of functioning. What is attention deficit hyperactivity disorder? Attention deficit hyperactivity disorder (ADHD) is one of the most common childhood disorders and can continue through adolescence and adulthood. Symptoms include difficulty staying focused and paying attention, difficulty controlling behavior, and hyperactivity (over-activity). ADHD has three subtypes:1 • Predominantly hyperactive-impulsive o Most symptoms (six or more) are in the hyperactivity-impulsivity categories. o Fewer than six symptoms of inattention are present, although inattention may still be present to some degree. • Predominantly inattentive
  3. 3. o The majority of symptoms (six or more) are in the inattention category and fewer than six symptoms of hyperactivity-impulsivity are present, although hyperactivity-impulsivity may still be present to some degree. o o Children with this subtype are less likely to act out or have difficulties getting along with other children. They may sit quietly, but they are not paying attention to what they are doing. Therefore, the child may be overlooked, and parents and teachers may not notice that he or she has ADHD. • Combined hyperactive-impulsive and inattentive o Six or more symptoms of inattention and six or more symptoms of hyperactivity-impulsivity are present. o Most children have the combined type of ADHD. Treatments can relieve many of the disorder's symptoms, but there is no cure. With treatment, most people with ADHD can be successful in school and lead productive lives. Researchers are developing more effective treatments and interventions, and using new tools such as brain imaging, to better understand ADHD and to find more effective ways to treat and prevent it. What are the symptoms of ADHD in children? Inattention, hyperactivity, and impulsivity are the key behaviors of ADHD. It is normal for all children to be inattentive, hyperactive, or impulsive sometimes, but for children with ADHD, these behaviors are more severe and occur more often. To be diagnosed with the disorder, a child must have symptoms for 6 or more months and to a degree that is greater than other children of the same age. Children who have symptoms of inattention may: • Be easily distracted, miss details, forget things, and frequently switch from one activity to another • Have difficulty focusing on one thing • Become bored with a task after only a few minutes, unless they are doing something enjoyable • Have difficulty focusing attention on organizing and completing a task or learning something new • Have trouble completing or turning in homework assignments, often losing things (e.g., pencils, toys, assignments) needed to complete tasks or activities • Not seem to listen when spoken to • Daydream, become easily confused, and move slowly • Have difficulty processing information as quickly and accurately as others • Struggle to follow instructions.
  4. 4. Children who have symptoms of hyperactivity may: • Fidget and squirm in their seats • Talk nonstop • Dash around, touching or playing with anything and everything in sight • Have trouble sitting still during dinner, school, and story time • Be constantly in motion • Have difficulty doing quiet tasks or activities. Children who have symptoms of impulsivity may: • Be very impatient • Blurt out inappropriate comments, show their emotions without restraint, and act without regard for consequences • Have difficulty waiting for things they want or waiting their turns in games • Often interrupt conversations or others' activities. ADHD Can Be Mistaken for Other Problems Parents and teachers can miss the fact that children with symptoms of inattention have the disorder because they are often quiet and less likely to act out. They may sit quietly, seeming to work, but they are often not paying attention to what they are doing. They may get along well with other children, compared with those with the other subtypes, who tend to have social problems. But children with the inattentive kind of ADHD are not the only ones whose disorders can be missed. For example, adults may think that children with the hyperactive and impulsive subtypes just have emotional or disciplinary problems. What Causes ADHD? Scientists are not sure what causes ADHD, although many studies suggest that genes play a large role. Like many other illnesses, ADHD probably results from a combination of factors. In addition to genetics, researchers are looking at possible environmental factors, and are studying how brain injuries, nutrition, and the social environment might contribute to ADHD. Genes. Inherited from our parents, genes are the "blueprints" for who we are. Results from several international studies of twins show that ADHD often runs in families. Researchers are looking at several genes that may make people more likely to develop the disorder.2,3 Knowing the genes involved may one day help researchers prevent the disorder before symptoms develop. Learning about specific genes could also lead to better treatments. Children with ADHD who carry a particular version of a certain gene have thinner brain tissue in the areas of the brain associated with attention. This NIMH research showed that the difference was not permanent, however, and as children with this gene grew up, the brain developed to a normal level of thickness. Their ADHD symptoms also improved.4
  5. 5. Environmental factors. Studies suggest a potential link between cigarette smoking and alcohol use during pregnancy and ADHD in children.5,6 In addition, preschoolers who are exposed to high levels of lead, which can sometimes be found in plumbing fixtures or paint in old buildings, may have a higher risk of developing ADHD.7 Brain injuries. Children who have suffered a brain injury may show some behaviors similar to those of ADHD. However, only a small percentage of children with ADHD have suffered a traumatic brain injury. Sugar. The idea that refined sugar causes ADHD or makes symptoms worse is popular, but more research discounts this theory than supports it. In one study, researchers gave children foods containing either sugar or a sugar substitute every other day. The children who received sugar showed no different behavior or learning capabilities than those who received the sugar substitute.8 Another study in which children were given higher than average amounts of sugar or sugar substitutes showed similar results.9 In another study, children who were considered sugar-sensitive by their mothers were given the sugar substitute aspartame, also known as Nutrasweet. Although all the children got aspartame, half their mothers were told their children were given sugar, and the other half were told their children were given aspartame. The mothers who thought their children had gotten sugar rated them as more hyperactive than the other children and were more critical of their behavior, compared to mothers who thought their children received aspartame.10 Food additives. Recent British research indicates a possible link between consumption of certain food additives like artificial colors or preservatives, and an increase in activity.11 Research is under way to confirm the findings and to learn more about how food additives may affect hyperactivity. How is ADHD diagnosed/scales? ATTENTION- DEFICIT / HYPERACTIVITY DISORDER Alternative Diagnoses Symptoms ADHS Sensory Learning- Nutritio Normal (DSM-IV) Integration Related n Child Dysfunction Visual Allergies Under (Ayres) Problems (Rapp, 7 (Kavner) Crook (Gesell)
  6. 6. & Smith) Inattention (At least 6 necessary) Often fails to give close attention to x x x x details or makes careless mistakes Often has difficulty sustaining attention in x x x x x tasks or play activities Often does not listen when x x x x spoken to directly Often does not follow through on x x x x x instructions or fails to finish work Often has difficulty organizing x x x x x tasks and activities Often avoids, dislikes or is reluctant to engage x x x x x in tasks requiring sustained mental effort Often loses x x x x x things
  7. 7. Often distracted by x x x x x extraneous stimuli Often forgetful in x x x x daily activities Hyperactivity and Impulsivity (At least 6 necessary) Often fidgets with hands x x x x x or feet or squirms in seat Often has difficulty remaining seated x x x x x when required to do so Often runs or climbs x x x x excessively Often has difficulty x x x playing quietly Often "on x x x x the go" Often talks x x x x excessively Often blurts out answers to questions x x x x before they have been completed Often has x x x x x difficulty
  8. 8. awaiting turn Often interrupts x x x x x or intrudes on others Physicians often recommend that ADHD or AD/HD be treated asymptomatically with stimulant medication, special education and counseling. Although these approaches sometimes yield positive benefits, they may mask the problems rather than get to their underlying causes. In addition, many common drugs for ADD (such as ritalin, methylphenidate, cylert), which have the same Class 2 classification as cocaine and morphine, can have some negative side effects that relate to appetite, sleep and growth. Placing a normal student who has difficulty paying attention in a special class and counseling could undermine rather than boost his self esteem. A sensible, multi-disciplinary, developmental approach treats underlying causes rather than the symptoms which are secondary. VISION THERAPY improves visual skills that allow a person to pay attention. These skill areas include visual tracking, fixation, focus change, binocular fusion and visualization. When all of these are well developed, children and adults can sustain attention, read and write without careless errors, give meaning to what they hear and see, and rely less on movement to stay alert. OCCUPATIONAL THERAPY for children with sensory integration dysfunction enhances their ability to process lower level senses related to alertness, body movement and position, and touch. This allows them to pay more attention to the higher level senses of hearing and vision. Common scales use:- Conners' Rating Scales– Brown Attention-Deficit Disorder Scales Brown Attention-Deficit Disorder Scales for Children
  9. 9. Attention-Deficit/Hyperactivity Disorder Test (ADHDT) Spadafore ADHD Rating Scale (S-ADHD-RS) ADHD Symptoms Rating Scale (ADHD-SRS) Vanderbilt ADHD Diagnostic Teacher Rating Scale INSTRUCTIONS AND SCORING Behaviors are counted if they are scored 2 (often) or 3 (very often). Inattention Requires six or more counted behaviors from questions 1–9 for indication of the predominantly inattentive subtype. Hyperactivity/ Requires six or more counted behaviors from questions 10–18 impulsivity for indication of the predominantly hyperactive/impulsive subtype. Combined Requires six or more counted behaviors each on both the subtype inattention and hyperactivity/impulsivity dimensions. Oppositional Requires three or more counted behaviors from questions 19–28. defiant and conduct disorders Anxiety or Requires three or more counted behaviors from questions 29–35. depression symptoms
  10. 10. The performance section is scored as indicating some impairment if a child scores 1 or 2 on at least one item. FOR PROFESSIONALS Vanderbilt ADHD Diagnostic Teacher Rating Scale Name: Grade: ____________________ Date of Birth: ______________ Teacher:__________________________________ School: __________________________________ Each rating should be considered in the context of what is appropriate for the age of the children you are rating. Frequency Code: 0 = Never; 1 = Occasionally; 2 = Often; 3 = Very Often 1. Fails to give attention to details or makes careless mistakes in schoolwork 0 1 2 3 2. Has difficulty sustaining attention to tasks or activities 0 1 2 3 3. Does not seem to listen when spoken to directly 0 1 2 3 4. Does not follow through on instruction and fails to finish schoolwork 0 1 2 3 (not due to oppositional behavior or failure to understand) 5. Has difficulty organizing tasks and activities 0 1 2 3 6. Avoids, dislikes, or is reluctant to engage in tasks that require 0 1 2 3 sustaining mental effort 7. Loses things necessary for tasks or activities (school assignments, pencils, 0 1 2 3 or books) 8. Is easily distracted by extraneous stimuli 0 1 2 3 9. Is forgetful in daily activities 0 1 2 3 10. Fidgets with hands or feet or squirms in seat 0 1 2 3 11. Leaves seat in classroom or in other situations in which remaining 0 1 2 3 seated is expected 12. Runs about or climbs excessively in situations in which remaining 0 1 2 3 seated is expected 13. Has difficulty playing or engaging in leisure activities quietly 0123 14. Is “on the go” or often acts as if “driven by a motor” 0 1 2 3 15. Talks excessively 0 1 2 3
  11. 11. 16. Blurts out answers before questions have been completed 0123 17. Has difficulty waiting in line 0 1 2 3 18. Interrupts or intrudes on others (e.g., butts into conversations or games) 0 1 2 3 19. Loses temper 0 1 2 3 BRIGHT FUTURES TOOL FOR PROFESSIONALS 20. Actively defies or refuses to comply with adults’ requests or rules 0 1 2 3 21. Is angry or resentful 0 1 2 3 22. Is spiteful and vindictive 0 1 2 3 23. Bullies, threatens, or intimidates others 0 1 2 3 24. Initiates physical fights 0 1 2 3 25. Lies to obtain goods for favors or to avoid obligations (i.e., “cons” others) 0 1 2 3 26. Is physically cruel to people 0 1 2 3 27. Has stolen items of nontrivial value 0 1 2 3 28. Deliberately destroys others’ property 0 1 2 3 29. Is fearful, anxious, or worried 0 1 2 3 30. Is self-conscious or easily embarrassed 0 1 2 3 31. Is afraid to try new things for fear of making mistakes 0 1 2 3 32. Feels worthless or inferior 0 1 2 3 33. Blames self for problems, feels guilty 0 1 2 3 34. Feels lonely, unwanted, or unloved; complains that “no one loves him/her” 0 1 2 3 35. Is sad, unhappy, or depressed 0 1 2 3 PERFORMANCE Problematic Average Above Average Academic Performance 1. Reading 1 2 3 4 5 2. Mathematics 1 2 3 4 5 3. Written expression 1 2 3 4 5 Classroom Behavioral Performance 1. Relationships with peers 1 2 3 4 5 2. Following directions/rules 1 2 3 4 5 3. Disrupting class 1 2 3 4 5 4. Assignment completion 1 2 3 4 5
  12. 12. 5. Organizational skills 1 2 3 4 5 56 Vanderbilt ADHD Diagnostic Teacher Rating Scale (continued) Frequency Code: 0 = Never; 1 = Occasionally; 2 = Often; 3 = Very Often Occupational therapy method of treating ADHD? Sensory integration/Activity Occupational and speech therapy catalogs offer a wide array of cool tools and toys, many of them carrying pricetags more appropriate for a school district budget than a family's pocketbook. Improvise with some homemade items that may give you a preview of how your child will respond to more expensive items, or keep you from having to buy them altogether. Fidget Toys You can get sets of nifty fidget toys, of all kinds and sizes and shapes, from many occupational therapy catalogs, but you can also assemble a good batch of them yourself, from easy-to-find items. Try, for starters: • A balloon filled with sand and knotted securely • A smooth stone • A palm-size sea shell • An old set of keys • A combination lock Weighted Items Weighted blankets and vests can exert a calming influence on your child, but seeing the prices some companies charge for them can have the opposite effect on you. Whether you're wanting to see whether weights work before coughing up all that dough; want to get a jump-start on weight benefits while you're waiting for a professional version to be delivered; or just can't bear the expense and want to do-it-yourself, here are five ways to improvise weighted items for your child.
  13. 13. • Weighted blanket: Take a heavy afghan and and fold it into quarters to concentrate the weight. Put it on your child at night and see if it stops rocking, rolling, and sleeplessness. • Weighted vest: Take an old vest or shirt and fill up the pockets and hems with curtain weights. Have your child wear it during stressful times, but not constantly -- it will lose its effect with overuse. Consult with an occupational therapist trained in sensory-integration techniques to determine the appropriate amount of weight for your child. • Pencil weight: Got a big box of loose nuts and bolts in the garage? Rummage through to find some nuts that will fit on the end of a pencil, then glue two or three of them around the barrel. • Weighted stuffed animal: Take an old favorite stuffed animal -- but one not so favorite that your child will mind you slashing it open -- and cut open paws and tummy to insert more curtain weights, nuts and bolts, or other heavy items. Sew the critter back up securely and let him sit on your child's lap during homework. • Body weights: Catalogs sell weights for wrists, arms, even shoes. Improvise by putting some books in a backpack or weights in a fanny pack and having your child wear them when jumpy. Oral Motor Items Strengthening the muscles in your child's mouth can increase speech production and decrease drooling. Anything that gives the mouth a strong sensory jolt can also improve sensory integration and make your child less likely to finger-suck or mouth objects. Try these around-the-house items to do a little impromptu oral-motor therapy. • Straw: Have your child suck something thick -- pudding or yogurt are good choices -- through a regular or twisty straw. • Whistle: Speech and occupational therapy catalogs sell a variety of fancy whistles, but your child can get some benefit from a plain whistle, a plastic flute, a kazoo, or one of those mini-trombone-type whistles where you pull the end of it and the sound goes up and down. • Bubbles: Blowing bubbles is good exercise for your child's mouth. Make sure he or she actually blows rather than just waving the wand around. • Cotton balls: Hold races to see who can blow a cotton ball across a table the fastest. Have your child do it with just his mouth, and then with a straw. • Plastic necklace: Inexpensive aquarium tubing from a pet store makes a nice chewable necklace for kids who need to gnaw. Try knotting some beads in the tube for extra oomph, or putting it in the fridge for a cool bite. Tactile Experiences
  14. 14. Textured toys and putties and squeezies fill the pages of sensory integration catalogs, but you have plenty of good tactile tools in your own pantry, closets, and medicine chests. • Rice: Fill a bin with rice and let your child plunge hands deep into it. Hide some toys and measuring cups for added fun. Dried beans are another good choice. • Bubbles: Blowing bubbles is good, and trying to catch bubbles is good, too. Kids who don't like to touch stickly slimy substances may be less threatened when the stuff is bubbling through the air. • Shaving Cream: Spray some on a shower or bathtub wall and let your child fingerpaint with it. • Sand: A sandbox can be a full-body experience for a child with tactile cravings. Let your child get down and dirty with it. • Ball pits: You can buy a big inflatable pit and the balls to fill it for big bucks, but many kids' restaurants will let your child play in theirs for as long as you want for the price of a slice or a soda. Bring a book and enjoy it while your child hits the pit and has a great therapeutic experience. Educational Interventions & Other Behavioral Techniques for Attention- Deficit/Hyperactivity Disorder (ADHD) Environmental Supports for Children with ADHD: ADHD and the School Environment • The ideal classroom for a child with ADHD is one in which classroom rules and expectations are clearly defined; the environment is organized; and routines are structured. • A child with ADHD should not be isolated in the classroom but seating should be preferential with the child located front and center near the teacher. Fellow students who would present as good behavioral role models should be seated close by. •
  15. 15. A study area with reduced stimuli and traffic should be placed in the room and available for use by all the students, not just the child with ADHD. • Close attention to schedules and routines should be given so that the fluctuation in energy presented by the child can be accommodated. For instance, it would be unwise to spend too much time in low energy activities. A mixture of low and high-energy activities would be more desirable. • Activities, though, should generally be stimulating, interesting and meaningful and involve a lot of hands-on projects vs. seat and board work or lecture. ADHD and the Home Environment The home environment can also be structured to provide optimum support to the child with ADHD. Family and household rules should be clear and well defined as well as consistently applied. Predictable routines often help structure time for the child with ADHD. A quiet, organized study area, free of distractions, should be present. Set times and routines should be established for study and review of work by the parent. The child's family responsibilities should also be well defined and it may be necessary to break chores or tasks into very small sequential steps. Plans should be reviewed with the child and they should be prepared for any out of the ordinary changes to routine. Instructional Strategies for ADHD : 1. Giving Directions: Directions need to be given clearly, concisely and through multiple channels. For instance, the teacher should clearly state the directions as well as have written directions or a pictorial list of directions available. Complex directions need to be simplified. Teachers should patiently repeat directions if this is necessary. Make sure the student understands the directions before proceeding to the task. Ask them to repeat the directions back. 2. Assistance:
  16. 16. The teacher can help the child with ADHD feel comfortable asking for assistance. One way to do so it to institute a classroom wide method that all students can use rather than singling out the child with ADHD. Develop and discuss with the student private cues that can be used when the student gets off task. For instance, the teacher can quietly touch the student's arm to remind him/her to refocus on the task. 3. Assignments: Make sure that the student is writing down assignments correctly each day. If a student is too young or is not capable, the teacher should assist in providing a record of assignments to go home with the student. Assignments may need broken into smaller segments or steps to complete vs. an entire project. Make sure that the assignment is actually one that the student has the capacity to perform. Some assignments may need further modified or adapted for the student. 4. Test Taking: Students with ADHD may need extended time to complete tests. Once more, be sure that test directions are understood and that the child is capable of what is being asked of him/her. Some children may need modifications in the way a test is delivered. For instance, the test perhaps should be given orally or perhaps the student can respond orally instead of in writing. Unique and individual needs should be considered at all times. [] Teaching Self-Monitoring: Students with ADHD can often participate in planning for improvements in their own behavior, thus allowing them to hopefully experience more ownership for change and also pride in accomplishing improvements. First students need to be aware of the problem behaviors and the control they can exhibit to improve the situation. To begin assisting a student with self-monitoring, teachers need to select a behavior and precisely explain to the student the nature of the problem and what exactly would consistute improvement. The teacher can then assist the student by developing a rating scale to rate behavior and document improvement. The student will need to learn how to use the rating scale and the scale should be age appropriate. Teachers can demonstrate how they would rate the behavior and verbalize aloud their process of decision-making. Learning to use the rating tool with some
  17. 17. reliable accuracy will be a precursor to implement the self-monitoring program. Make decisions on the time interval by which the child will record their "data" or rating of the target behavior. However, be careful to insure that whatever time interval is set that the child is capable of being successful. An example used in one resource gave the example of a child using sarcastic remarks. If the child is known to use sarcastic remarks about once every 20 minutes, the teacher would want to set the time interval for 15 minutes, thus enhancing a child's chance of experiencing successful control. Self-monitoring can be gradually faded out for the behavior as progress is noted. However, in some cases formal self-monitoring may be desirable for some time to come. [ Positive Behavioral Intervention and Support: Positive Behavioral Support is different than traditional "behavior modification". One key reason for the difference is that with Positive Behavioral Support we ask the question, "why?" Why is the child's work so sloppy? Why is the child seemingly never in his seat? Why is this child having problems making friends? The adults in the situation observe the behaviors and observe the child in numerous settings in order to develop ideas on the function that the behavior is serving for the child. Positive Behavioral Support has a focus on changing the environment and responses in order to enhance a child's experience of feeling successful and teaching important skills that reduce the function of the problem behavior. Positive Behavioral Support is not one approach focused solely on reducing a problem behavior, rather, it garners a collective team vision and collaboration, creating a multifaceted approach to improve the circumstances for the child, their school and community. Positive Behavioral Support was initially developed as an alternative to aversive procedures for those with the most severe and extreme behavioral challenges. However, more recently, it has been used successfully with a wide range of students and contexts and has been extended to apply to entire school environments, not just individuals. According to the Beach Center for Children, the following are general key steps to implementing Positive Behavioral Supports: 1. Ensuring a fit with your values: This is not a one-size-fits-all, simplistic plan. There is no "recipe" or quick fix.
  18. 18. 2. Putting together a collaborative team: No one person alone can create a solution but many ideas and perspectives can lend themselves toward creating better futures. 3. Creating a vision: This involves imagining what an ideal life and positive future would look like for the focus individual. Such a vision should incorporate the individuals personal preferences, talents, gifts, abilities and relationships. 4. Completing a functional assessment: This is a structured method of gathering and testing information about the function that the behavior may have in the individuals' life. 5. Developing strategies: A. Teaching new skills B. Appreciating positive behavior C. Changing systems According to the O.S.E.P. Technical Assistance Center on Positive Behavioral Interventions and Supports: "Positive behavioral support is not a new intervention package, nor a new theory of behavior. Instead, it is an application of a behaviorally-based systems approach to enhance the capacity of schools, families, and communities to design effective environments that improve the fit or link between research- validated practices and the environments in which teaching and learning occurs." "Attention is focused on creating and sustaining school environments that improve lifestyle results (personal, health, social, family, work, recreation, etc.) for all children and youth by making problem behavior less effective, efficient, and relevant, and desired behavior more functional. In addition, the use of culturally appropriate interventions is emphasized." Haring and De Vault (1996) indicate that PBS is comprised of: a. "Interventions that consider the contexts within which the behavior occurs" b. "Interventions that address the functionality of the problem behavior" c. "Interventions that can be justified by the outcomes" d. "Outcomes that are acceptable to the individual, the family, and the supportive community" (p. 116). It goes beyond one approach - reducing challenging or impeding behavior - to multiple approaches: changing systems, altering environments, teaching skills and focusing on positive behavior." The information above is designed to provide solely an overview of Positive Behavioral Support (PBS). Those interested should study the topic in much more detail, as the philosophy and practice can be quite complex. Some initial internet references are listed at the end of this section. [
  19. 19. Movement Therapies: Many children with ADHD will benefit from opportunities throughout their day to be involved in movement activities. The environment should support appropriate movement. For instance, in classrooms students can be given physical chores. Teachers can assign active projects that allow a student to change seating frequently. Hands-on, constructional projects and manipulatives can be used. More specific movement "therapies" include the following: • The "Brain Gym" Program: Brain Gym is a patented, trademarked program providing movement intervention in order to enhance brain development. Brain Gym's five-step process is based on kinesiology, the science of body movement and its relationship to brain function. Well-established and coordinated physical movements assist in brain development and in establishing neural connections. According to Dr. Paul E. Dennison, one of the developers of Brain Gym: "Educational Kinesiology (Edu-K) is an innovative approach that uses movement as a means to enhance learning. In Edu-K, the mind and body are integrated through a variety of simple activities that expand the learner's perceptual awareness while providing access to the innate abilities needed for information processing." The Brain Gym program focuses on various "dimensions": T Laterality: the relationship between the two sides of the brain, described as essential for coordinated and planned movement and learning. c Focus: the relationship between the front and back of the brain allowing old information to be integrated with new learning. t Centering: the connections between the top and bottom structures of the brain, proported to connect emotion with thought and create balance. The Importance of Emotional Support for Children with ADHD:
  20. 20. Children with ADHD will also need emotional and social support. Because they can be "challenging" to both adults and other children, their self-esteem may be affected and children with ADHD may lack positive experiences with accomplishment and friendships. Some ideas for providing emotional support include: • Identify the child's strengths and talents: Caring adults need to help the child focus on and develop talents and strengths vs. always focusing on the child's shortcomings or irritating behavior. Many people with ADHD are quite creative and talented and these qualities should be nurtured in all settings. Understanding the concept of multiple intelligences may help the child and adults focus on their positive qualities • Offer sincere praise for accomplishments • Help the student envision a positive future and a career in which their talents and abilities will be needed and desired. • Encourage participation and cooperative groupings instead of a focus on winning or losing. • Help the child to understand their learning differences and the affect of ADHD on their lives. Sometimes children assume that the reason they have difficulty is that they are "dumb" or "stupid" or "bad". They need adults to help them understand so that they need not blame themselves or think less of themselves as people. • Arrange for formal counseling as needed by individual children. • Insure a coordinated "team effort" of support by all adults in the child's life, including parents, educators, medical personnel and other key people. Medications.
  21. 21. The most common type of medication used for treating ADHD is called a "stimulant." Although it may seem unusual to treat ADHD with a medication considered a stimulant, it actually has a calming effect on children with ADHD. A list of medications and the approved age for use follows. Trade Name Generic Name Approved Age Adderall amphetamine 3 and older Adderall XR amphetamine (extended release) 6 and older Concerta methylphenidate (long acting) 6 and older Daytrana methylphenidate patch 6 and older Desoxyn methamphetamine hydrochloride 6 and older Dexedrine dextroamphetamine 3 and older Dextrostat dextroamphetamine 3 and older Focalin dexmethylphenidate 6 and older Focalin XR dexmethylphenidate (extended release) 6 and older Metadate ER methylphenidate (extended release) 6 and older Metadate CDmethylphenidate (extended release) 6 and older Methylin methylphenidate (oral solution and chewable tablets)6 and older Ritalin methylphenidate 6 and older Ritalin SR methylphenidate (extended release) 6 and older Ritalin LA methylphenidate (long acting) 6 and older Strattera atomoxetine 6 and older Vyvanse lisdexamfetamine dimesylate 6 and older *Not all ADHD medications are approved for use in adults. NOTE: "extended release" means the medication is released gradually so that a controlled amount enters the body over a period of time. "Long acting" means the medication stays in the body for a long time. Over time, this list will grow, as researchers continue to develop new medications for ADHD. Medication guides for each of these medications are available from the U.S. Food and Drug Administration (FDA). What are the side effects of stimulant medications? The most commonly reported side effects are decreased appetite, sleep problems, anxiety, and irritability. Some children also report mild stomachaches or headaches. Most side effects are minor and disappear over time or if the dosage level is lowered. • Decreased appetite. Be sure your child eats healthy meals. If this side effect does not go away, talk to your child's doctor. Also talk to the doctor if you have concerns about your child's growth or weight gain while he or she is taking this medication. •
  22. 22. • Sleep problems. If a child cannot fall asleep, the doctor may prescribe a lower dose of the medication or a shorter-acting form. The doctor might also suggest giving the medication earlier in the day, or stopping the afternoon or evening dose. Adding a prescription for a low dose of an antidepressant or a blood pressure medication called clonidine sometimes helps with sleep problems. A consistent sleep routine that includes relaxing elements like warm milk, soft music, or quiet activities in dim light, may also help. • • Less common side effects. A few children develop sudden, repetitive movements or sounds called tics. These tics may or may not be noticeable. Changing the medication dosage may make tics go away. Some children also may have a personality change, such as appearing "flat" or without emotion. Talk with your child's doctor if you see any of these side effects. Are stimulant medications safe? Under medical supervision, stimulant medications are considered safe. Stimulants do not make children with ADHD feel high, although some kids report feeling slightly different or "funny." Although some parents worry that stimulant medications may lead to substance abuse or dependence, there is little evidence of this. Psychotherapy Different types of psychotherapy are used for ADHD. Behavioral therapy aims to help a child change his or her behavior. It might involve practical assistance, such as help organizing tasks or completing schoolwork, or working through emotionally difficult events. Behavioral therapy also teaches a child how to monitor his or her own behavior. Learning to give oneself praise or rewards for acting in a desired way, such as controlling anger or thinking before acting, is another goal of behavioral therapy. Parents and teachers also can give positive or negative feedback for certain behaviors. In addition, clear rules, chore lists, and other structured routines can help a child control his or her behavior. Therapists may teach children social skills, such as how to wait their turn, share toys, ask for help, or respond to teasing. Learning to read facial expressions and the tone of voice in others, and how to respond appropriately can also be part of social skills training. How can parents help? Tips to Help Kids Stay Organized and Follow Directions • Make time and space for your child to play, and reward good play behaviors often.
  23. 23. ADD/ADHD parenting tip 1: Stay positive and healthy yourself As a parent, you set the stage for your child’s emotional and physical health. You have control over many of the factors that can positively influence the symptoms of your child’s disorder. The power of a positive attitude Your best assets for helping your child meet the challenges of ADD/ADHD are your positive attitude and common sense. When you are calm and focused, you are more likely to be able to connect with your child, helping him or her to be calm and focused as well. • Keep things in perspective. Remember that your child’s behavior is related to a disorder. Most of the time it is not intentional. Hold on to your sense of humor. What’s embarrassing today may be a funny family story ten years from now. • Don’t sweat the small stuff and be willing to make some compromises. One chore left undone isn’t a big deal when your child has completed two others plus the day’s homework. If you are a perfectionist, you will not only be constantly dissatisfied but also create impossible expectations for your ADD/ADHD child. • Believe in your child. Think about or make a written list of everything that is positive, valuable, and unique about your child. Trust that your child can learn, change, mature, and succeed. Make thinking about this trust a daily task as you brush your teeth or make your coffee. When you take care of yourself, you’re better able to take care of your child As your child’s role model and most important source of strength, it is vital that you live healthfully. If you are overtired or have simply run out of patience, you risk losing sight of the structure and support you have so carefully set up for your child with attention deficit disorder.
  24. 24. • Take care of yourself. Eat right, exercise, and find ways to reduce stress, whether it means taking a nightly bath or practicing morning meditation. If you do get sick, acknowledge it and get help. • Seek support. One of the most important things to remember in rearing a child with ADD/ADHD is that you don’t have to do it alone. Talk to your child’s doctors, therapists, and teachers. Join an organized support group for parents of children with ADHD. These groups offer a forum for giving and receiving advice, and provide a safe place to vent feelings and share experiences. • Take breaks. Friends and family can be wonderful about offering to babysit, but you may feel guilty about leaving your child, or leaving the volunteer with a child with ADD/ADHD. Next time, accept their offer and discuss honestly how best to handle your child. ADD/ADHD parenting tip 2: Establish structure and stick to it Children with ADHD are more likely to succeed in completing tasks when the tasks occur in predictable patterns and in predictable places. Your job is to create and sustain structure in your home, so that your child knows what to expect and what they are expected to do. Tip for helping your child with ADD/ADHD stay focused and organized • Follow a routine. It is important to set a time and a place for everything to help the child with ADD/ADHD understand and meet expectations. Establish simple and predictable rituals for meals, homework, play, and bed. Have your child lay out clothes for the next morning before going to bed, and make sure whatever he or she needs to take to school is in a special place, ready to grab. • Use clocks and timers. Consider placing clocks throughout the house, with a big one in your child’s bedroom. Allow enough time for what your child needs to do, such as homework or getting ready in the morning. Use a timer for homework or transitional times, such between finishing up play and getting ready for bed.
  25. 25. • Simplify your child’s schedule. It is good to avoid idle time, but a child with ADHD may become more distracted and “wound up” if there are many after- school activities. You may need to make adjustments to the child’s after-school commitments based on the individual child’s abilities and the demands of particular activities. • Create a quiet place. Make sure your child has a quiet, private space of his or her own. A porch or bedroom can work well too, as long as it’s not the same place as the child goes for a time-out. • Do your best to be neat and organized. Set up your home in an organized way. Make sure your child knows that everything has its place. Role model neatness and organization as much as possible. Avoid problems by keeping kids with attention deficit disorder busy! For kids with ADD/ADHD, idle time may exacerbate their symptoms and create chaos in your home. It is important to keep a child with ADD/ADHD busy without piling on so many that the child becomes overwhelmed. Sign your child up for a sport, art class, or music. At home, organize simple activities that fill up your child’s time. These can be tasks like helping you cook, playing a board game with a sibling, or drawing a picture. Try not to use the television or computer/video games as time-fillers. Unfortunately, TV and video games are increasingly violent in nature and may only increase your child’s symptoms of ADD/ADHD. ADD/ADHD parenting tip 3: Set clear expectations and rules Children with ADHD need consistent rules that they can understand and follow. Make the rules of behavior for the family simple and clear. Write down the rules and hang them up in a place where your child can easily read them. Children with ADD/ADHD respond particularly well to organized systems of rewards and consequences. It's important to explain what will happen when the rules are obeyed and when they are broken. Finally, stick to your system: follow through each and every time with a reward or a consequence. Don’t forget praise and positive reinforcement As you establish these consistent structures, keep in mind that children with ADHD often receive criticism. Be on the lookout for good behavior—and praise it. Praise is especially important for children who have ADD/ADHD because they typically get so little of it. These children receive correction, remediation, and complaints about their behavior—but little positive reinforcement.
  26. 26. A smile, positive comment, or other reward from you can improve the attention, concentration and impulse control of your child with ADD/ADHD. Do your best to focus on giving positive praise for appropriate behavior and task completion, while giving as few negative responses as possible to inappropriate behavior or poor task performance. Reward your child for small achievements that you might take for granted in another child. Kids with ADD/ADHD: Using Rewards and Consequences Rewards Consequences • Reward your child with privileges, • Consequences should be spelled praise, or activities, rather than out in advance and occur with food or toys. immediately after your child has • Change rewards frequently. Kids misbehaved. with ADD/ADHD get bored if the • Try time-outs and the removal of reward is always the same. privileges as consequences for • Make a chart with points or stars misbehavior. awarded for good behavior, so • Remove your child from situations your child has a visual reminder of and environments that trigger his or her successes inappropriate behavior. • Immediate rewards work better • When your child misbehaves, ask than the promise of a future what he or she could have done reward, but small rewards leading instead. Then have your child to a big one can also work. demonstrate it. • Always follow through with a • Always follow through with a reward. consequence. ADD/ADHD parenting tip 4: Encourage movement and sleep Physical activity can help your child with ADD/ADHD Children with ADD/ADHD often have energy to burn. Organized sports and other physical activities can help them get their energy out in healthy ways and focus their attention on specific movements and skills. The benefits of physical activity are endless: it improves concentration, decreases depression and anxiety, and promotes brain growth. Most importantly for children with attention deficits, however, is the fact that exercise leads to better sleep, which in turn can also reduce the symptoms of ADD/ADHD. Find a sport that your child will enjoy and that suits his or her strengths. For example, sports such as softball that involve a lot of “down time” are not the best fit for children with attention problems. Individual or team sports like basketball and hockey that require constant motion are better options. Children with ADD/ADHD may also benefit from
  27. 27. martial arts training, tae kwon do, or yoga, which enhance mental control as they work out the body. Better sleep can help your child with ADD/ADHD Insufficient sleep can make anyone less attentive, but it can be highly detrimental for children with attention deficit disorder. Kids with ADD/ADHD n eed at least as much sleep as their unaffected peers, but tend not to get what they need. Their attention problems can lead to overstimulation and trouble falling asleep. A consistent, early bedtime is the most helpful strategy to combat this problem, but it may not completely solve it. Help your child get better rest by trying out one or more of the following strategies: • Decrease television time and increase your child's activities and exercise levels during the day. • Eliminate caffeine from your child’s diet. Cola drinks and chocolate have significant caffeine. • Create a buffer time to lower down the activity level for an hour or so before bedtime. Find quieter activities such as coloring, reading or playing quietly. • Spend ten minutes cuddling with your child. This will build a sense of love and security as well as provide a time to calm down. • Use lavender or other aromas in your child's room. The scent may help to calm your child. • Use relaxation tapes as background noise for your child when falling asleep. There are many varieties available including nature sounds and calming music. Children with ADHD often find "white noise" to be calming. You can create white noise by putting a radio on static or running an electric fan. The benefits of “green time” in kids with attention deficit disorder Research shows that children with ADD/ADHD benefit from spending time in nature. Kids experience a greater reduction of symptoms of ADD/ADHD when they play in a park full of grass and trees than on a concrete playground. Take note of this promising and simple approach to managing ADD/ADHD. Even in cities, most families have access
  28. 28. to parks and other natural settings. Join your children in this “green time”—you’ll also get a much-deserved breath of fresh air for yourself. ADD/ADHD parenting tip 5: Help your child eat right Diet is not a direct cause of ADHD, but food can and does affect your child's mental state, which in turn seems to affect behavior. Monitoring and modifying what, when, and how much your child eats can help decrease the symptoms of ADD/ADHD. All children benefit from fresh foods, regular meal times, and staying away from junk food. These tenets are especially true for children with ADD/ADHD, whose impulsiveness and distractedness can lead to missed meals, disordered eating, and overeating. Eating small meals more often may help your child’s ADD/ADHD Children with ADD/ADHD are notorious for not eating regularly. Without parental guidance, these children might not eat for hours and then binge on whatever is around. The result of this pattern can be devastating to the child’s physical and emotional health. Prevent this pattern by scheduling regular healthy meals or snacks for your child no more than three hours apart. Physically, the child with ADD/ADHD needs a regular intake of healthy food; mentally, meal times are a necessary break and a scheduled rhythm to the day. • Get rid of the junk foods in your home. • Put fatty and sugary foods off-limits when eating out. • Turn off television shows riddled with junk-food ads. • Give your child a daily vitamin-and-mineral supplement. Nutrition Basics for Kids Whether or not your child has ADD/ADHD, he or she will benefit from eating a nutritious diet. Most children eat far too many unhealthy foods—from burgers and fries to ice cream and soft drinks. Few get the vitamins, minerals, and fiber, they need. It is important to your child’s current and future health to eat a healthful diet, and that may mean that you need to improve your own diet to set a good example.
  29. 29. ADD/ADHD parenting tip 6: Teach your child how to make friends Children with attention deficit disorder often have difficulty with simple social interactions. They may struggle with reading social cues, talk too much, interrupt frequently, or come off as aggressive or “too intense.” Their relative emotional immaturity can make them stand out among children their own age, and make them targets for unfriendly teasing. Keep in mind that many kids with ADHD are exceptionally intelligent and creative and will eventually figure out for themselves how to get along with others and spot people who aren’t appropriate as friends. Moreover, personality traits that might exasperate parents and teachers may come across to some people as quirky and charming. Helping a child with attention deficit disorder improve social skills It's hard for children with ADHD to learn social skills and social rules. You can help your child with ADD/ADHD become a better listener, learn to read people’s faces and body language, and interact more smoothly in groups. • Speak gently but honestly with your child about his or her challenges and how to make changes. • Role-play various social scenarios with your child. Trade roles often and try to make it fun. • Be careful to select playmates for your child with similar language and physical skills. • Invite only one or two friends at a time at first. Watch them closely while they play. • Have a zero tolerance policy for hitting, pushing and yelling in your house or yard. Schedule. Keep the same routine every day, from wake-up time to bedtime. Include time for homework, outdoor play, and indoor activities. Keep the schedule on the refrigerator or on a bulletin board in the kitchen. Write changes on the schedule as far in advance as possible. Organize everyday items. Have a place for everything, and keep everything in its place. This includes clothing, backpacks, and toys. Use homework and notebook organizers. Use organizers for school material and supplies. Stress to your child the importance of writing down assignments and bringing home the necessary books.
  30. 30. Be clear and consistent. Children with ADHD need consistent rules they can understand and follow. Give praise or rewards when rules are followed. Children with ADHD often receive and expect criticism. Look for good behavior, and praise it. What conditions can coexist with ADHD? Some children with ADHD also have other illnesses or conditions. For example, they may have one or more of the following: • A learning disability. A child in preschool with a learning disability may have difficulty understanding certain sounds or words or have problems expressing himself or herself in words. A school-aged child may struggle with reading, spelling, writing, and math. • • Oppositional defiant disorder. Kids with this condition, in which a child is overly stubborn or rebellious, often argue with adults and refuse to obey rules. • • Conduct disorder. This condition includes behaviors in which the child may lie, steal, fight, or bully others. He or she may destroy property, break into homes, or carry or use weapons. These children or teens are also at a higher risk of using illegal substances. Kids with conduct disorder are at risk of getting into trouble at school or with the police. • • Anxiety and depression. Treating ADHD may help to decrease anxiety or some forms of depression. • • Bipolar disorder. Some children with ADHD may also have this condition in which extreme mood swings go from mania (an extremely high elevated mood) to depression in short periods of time. • • Tourette syndrome. Very few children have this brain disorder, but among those who do, many also have ADHD. Some people with Tourette syndrome have nervous tics and repetitive mannerisms, such as eye blinks, facial twitches, or grimacing. Others clear their throats, snort, or sniff frequently, or bark out words inappropriately. These behaviors can be controlled with medication. ADHD also may coexist with a sleep disorder, bed-wetting, substance abuse, or other disorders or illnesses.
  31. 31. Recognizing ADHD symptoms and seeking help early will lead to better outcomes for both affected children and their families. How can I work with my child’s school? If you think your child has ADHD, or a teacher raises concerns, you may be able to request that the school conduct an evaluation to determine whether he or she qualifies for special education services. Start by speaking with your child's teacher, school counselor, or the school's student support team, to begin an evaluation. Also, each state has a Parent Training and Information Center and a Protection and Advocacy Agency that can help you get an evaluation. A team of professionals conducts the evaluation using a variety of tools and measures. It will look at all areas related to the child's disability. Once your child has been evaluated, he or she has several options, depending on the specific needs. If special education services are needed and your child is eligible under the Individuals with Disabilities Education Act, the school district must develop an "individualized education program" specifically for your child within 30 days. If your child is considered not eligible for special education services—and not all children with ADHD are eligible—he or she still can get "free appropriate public education," available to all public-school children with disabilities under Section 504 of the Rehabilitation Act of 1973, regardless of the nature or severity of the disability. Transitions can be difficult. Each school year brings a new teacher and new schoolwork, a change that can be especially hard for a child with ADHD who needs routine and structure. Consider telling the teachers that your child has ADHD when he or she starts school or moves to a new class. Additional support will help your child deal with the transition. Do teens with ADHD have special needs? Most children with ADHD continue to have symptoms as they enter adolescence. Some children, however, are not diagnosed with ADHD until they reach adolescence. This is more common among children with predominantly inattentive symptoms because they are not necessarily disruptive at home or in school. In these children, the disorder becomes more apparent as academic demands increase and responsibilities mount. For all teens, these years are challenging. But for teens with ADHD, these years may be especially difficult. Although hyperactivity tends to decrease as a child ages, teens who continue to be hyperactive may feel restless and try to do too many things at once. They may choose tasks or activities that have a quick payoff, rather than those that take more effort, but
  32. 32. provide bigger, delayed rewards. Teens with primarily attention deficits struggle with school and other activities in which they are expected to be more self-reliant. Teens also become more responsible for their own health decisions. When a child with ADHD is young, parents are more likely to be responsible for ensuring that their child maintains treatment. But when the child reaches adolescence, parents have less control, and those with ADHD may have difficulty sticking with treatment. To help them stay healthy and provide needed structure, teens with ADHD should be given rules that are clear and easy to understand. Helping them stay focused and organized—such as posting a chart listing household chores and responsibilities with spaces to check off completed items—also may help. Teens with or without ADHD want to be independent and try new things, and sometimes they will break rules. If your teen breaks rules, your response should be as calm and matter-of-fact as possible. Punishment should be used only rarely. Teens with ADHD often have trouble controlling their impulsivity and tempers can flare. Sometimes, a short time-out can be calming. If your teen asks for later curfews and use of the car, listen to the request, give reasons for your opinions, and listen to your child's opinion. Rules should be clear once they are set, but communication, negotiation, and compromise are helpful along the way. Maintaining treatments, such as medication and behavioral or family therapy, also can help with managing your teenager's ADHD. What about teens and driving? Although many teens engage in risky behaviors, those with ADHD, especially untreated ADHD, are more likely to take more risks. In fact, in their first few years of driving, teens with ADHD are involved in nearly four times as many car accidents as those who do not have ADHD. They are also more likely to cause injury in accidents, and they get three times as many speeding tickets as their peers.13 Most states now use a graduated licensing system, in which young drivers, both with and without ADHD, learn about progressively more challenging driving situations.14 The licensing system consists of three stages—learner's permit, during which a licensed adult must always be in the car with the driving teen; intermediate (provisional) license; and full licensure. Parents should make sure that their teens, especially those with ADHD, understand and follow the rules of the road. Repeated driving practice under adult supervision is especially important for teens with ADHD. Can adults have ADHD? Some children with ADHD continue to have it as adults. And many adults who have the disorder don't know it. They may feel that it is impossible to get organized, stick to a job, or remember and keep appointments. Daily tasks such as getting up in the morning,
  33. 33. preparing to leave the house for work, arriving at work on time, and being productive on the job can be especially challenging for adults with ADHD. These adults may have a history of failure at school, problems at work, or difficult or failed relationships. Many have had multiple traffic accidents. Like teens, adults with ADHD may seem restless and may try to do several things at once, most of them unsuccessfully. They also tend to prefer "quick fixes," rather than taking the steps needed to achieve greater rewards. How is ADHD diagnosed in adults? Like children, adults who suspect they have ADHD should be evaluated by a licensed mental health professional. But the professional may need to consider a wider range of symptoms when assessing adults for ADHD because their symptoms tend to be more varied and possibly not as clear cut as symptoms seen in children. To be diagnosed with the condition, an adult must have ADHD symptoms that began in childhood and continued throughout adulthood.15 Health professionals use certain rating scales to determine if an adult meets the diagnostic criteria for ADHD. The mental health professional also will look at the person's history of childhood behavior and school experiences, and will interview spouses or partners, parents, close friends, and other associates. The person will also undergo a physical exam and various psychological tests. For some adults, a diagnosis of ADHD can bring a sense of relief. Adults who have had the disorder since childhood, but who have not been diagnosed, may have developed negative feelings about themselves over the years. Receiving a diagnosis allows them to understand the reasons for their problems, and treatment will allow them to deal with their problems more effectively. How is ADHD treated in adults? Much like children with the disorder, adults with ADHD are treated with medication, psychotherapy, or a combination of treatments. Medications. ADHD medications, including extended-release forms, often are prescribed for adults with ADHD, but not all of these medications are approved for adults.16 However, those not approved for adults still may be prescribed by a doctor on an "off- label" basis. Although not FDA-approved specifically for the treatment of ADHD, antidepressants are sometimes used to treat adults with ADHD. Older antidepressants, called tricyclics, sometimes are used because they, like stimulants, affect the brain chemicals norepinephrine and dopamine. A newer antidepressant, venlafaxine (Effexor), also may be prescribed for its effect on the brain chemical norepinephrine. And in recent clinical trials, the antidepressant bupropion (Wellbutrin), which affects the brain chemical dopamine, showed benefits for adults with ADHD.17
  34. 34. Adult prescriptions for stimulants and other medications require special considerations. For example, adults often require other medications for physical problems, such as diabetes or high blood pressure, or for anxiety and depression. Some of these medications may interact badly with stimulants. An adult with ADHD should discuss potential medication options with his or her doctor. These and other issues must be taken into account when a medication is prescribed. Education and psychotherapy. A professional counselor or therapist can help an adult with ADHD learn how to organize his or her life with tools such as a large calendar or date book, lists, reminder notes, and by assigning a special place for keys, bills, and paperwork. Large tasks can be broken down into more manageable, smaller steps so that completing each part of the task provides a sense of accomplishment. Psychotherapy, including cognitive behavioral therapy, also can help change one's poor self-image by examining the experiences that produced it. The therapist encourages the adult with ADHD to adjust to the life changes that come with treatment, such as thinking before acting, or resisting the urge to take unnecessary risks. What efforts are under way to improve treatment? This is an exciting time in ADHD research. The expansion of knowledge in genetics, brain imaging, and behavioral research is leading to a better understanding of the causes of the disorder, how to prevent it, and how to develop more effective treatments for all age groups. NIMH has studied ADHD treatments for school-aged children in a large-scale, long-term study called the Multimodal Treatment Study of Children with ADHD (MTA study). NIMH also funded the Preschoolers with ADHD Treatment Study (PATS), which involved more than 300 preschoolers who had been diagnosed with ADHD. The study found that low doses of the stimulant methylphenidate are safe and effective for preschoolers, but the children are more sensitive to the side effects of the medication, including slower than average growth rates.18 Therefore, preschoolers should be closely monitored while taking ADHD medications.19,20 PATS is also looking at the genes of the preschoolers, to see if specific genes affected how the children responded to methylphenidate. Future results may help scientists link variations in genes to differences in how people respond to ADHD medications. For now, the study provides valuable insights into ADHD.21 Other NIMH-sponsored clinical trials on children and adults with ADHD are under way. In addition, NIMH-sponsored scientists continue to look for the biological basis of ADHD, and how differences in genes and brain structure and function may combine with life experiences to produce the disorder.
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  36. 36. 12 The MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for attention-deficit hyperactivity disorder. Archives of General Psychiatry, 1999; 56:1073-1086. 13 Cox DJ, Merkel RL, Moore M, Thorndike F, Muller C, Kovatchev B. Relative benefits of stimulant therapy with OROS methylphenidate versus mixed amphetamine salts extended release in improving the driving performance of adolescent drivers with attention-deficit/hyperactivity disorder. Pediatrics, 2006 Sept; 118(3):e704-e710. 14 U.S. Department of Transportation, National Highway Traffic Safety Administration, Legislative Fact Sheets. Traffic Safety Facts, Laws. Graduated Driver Licensing System. January 2006. 15 Wilens TE, Biederman J, Spencer TJ. Attention deficit/hyperactivity disorder across the lifespan. Annual Review of Medicine, 2002; 53:113-131. 16 Coghill D, Seth S. Osmotic, controlled-release methylphenidate for the treatment of attention-deficit/hyperactivity disorder. Expert Opinions in Pharmacotherapy, 2006 Oct; 7(15):2119-2138. 17 Wilens TE, Haight BR, Horrigan JP, Hudziak JJ, Rosenthal NE, Connor DF, Hampton KD, Richard NE, Modell JG. Bupropion XL in adults with attention-deficit/hyperactivity disorder: a randomized, placebo-controlled study. Biological Psychiatry, 2005 Apr 1; 57(7):793-801. 18 Swanson J, Greenhill L, Wigal T, Kollins S, Stehli A, Davies M, Chuang S, Vitiello B, Skroballa A, Posner K, Abikoff H, Oatis M, McCracken J, McGough J, Riddle M, Ghouman J, Cunningham C, Wigal S. Stimulant-related reductions in growth rates in the PATS. Journal of the Academy of Child and Adolescent Psychiatry, 2006 Nov; 45(11):1304-1313. 19 Greenhill L, Kollins S, Abikoff H, McCracken J, Riddle M, Swanson J, McGough J, Wigal S, Wigal T, Vitiello B, Skroballa A, Posner K, Ghuman J, Cunningham C, Davies M, Chuang S, Cooper T. Efficacy and safety of immediate-release methylphenidate treatment for preschoolers with attention-deficit/hyperactivity disorder. Journal of the Academy of Child and Adolescent Psychiatry, 2006 Nov; 45(11):1284-1293. 20 Wigal T, Greenhill L, Chuang S, McGough J, Vitiello B, Skrobala A, Swanson J, Wigal S, Abikoff H, Kollins S, McCracken J, Riddle M, Posner K, Ghuman J, Davies M, Thorp B, Stehli A. Safety and tolerability of methylphenidate in preschool children with attention-deficit/hyperactivity disorder. Journal of the Academy of Child and Adolescent Psychiatry, 2006 Nov; 45(11):1294-1303. 21 McGough J, McCracken J, Swanson J, Riddle M, Greenhill L, Kollins S, Greenhill L, Abikoff H, Davies M, Chuang S, Wigal T, Wigal S, Posner K, Skroballa A, Kastelic E, Ghouman J, Cunningham C, Shigawa S, Moyzis R, Vitiello B. Pharmacogenetics of
  37. 37. methylphenidate response in preschoolers with attention-deficit/hyperactivity disorder. Journal of the Academy of Child and Adolescent Psychiatry, 2006 Nov; 45(11):1314-1322. For more information on attention deficit hyperactivity disorder Visit the National Library of Medicine's MedlinePlus and En Español For information on clinical trials: NIMH supported clinical trials National Library of Medicine Clinical Trials Database Information from NIMH is available in multiple formats. You can browse online, download documents in PDF, and order paper brochures through the mail. If you would like to have NIMH publications, you can order them online at If you do not have Internet access and wish to have information that supplements this publication, please contact the NIMH Information Center at the numbers listed below. National Institute of Mental Health Science Writing, Press & Dissemination Branch 6001 Executive Boulevard Room 8184, MSC 9663 Bethesda, MD 20892-9663 Phone: 301-443-4513 or 1-866-615-NIMH (6464) toll-free TTY: 301-443-8431 TTY: 866-415-8051 FAX: 301-443-4279 E-mail: Web site: Reprints NIMH publications are in the public domain and may be reproduced or copied without the permission from the National Institute of Mental Health (NIMH). NIMH encourages you to reproduce them and use them in your efforts to improve public health. Citation of the National Institute of Mental Health as a source is appreciated. However, using government materials inappropriately can raise legal or ethical concerns, so we ask you to use these guidelines: • NIMH does not endorse or recommend any commercial products, processes, or services, and publications may not be used for advertising or endorsement purposes.
  38. 38. • NIMH does not provide specific medical advice or treatment recommendations or referrals; these materials may not be used in a manner that has the appearance of such information. • NIMH requests that non-Federal organizations not alter publications in a way that will jeopardize the integrity and "brand" when using publications. • Addition of Non-Federal Government logos and website links may not have the appearance of NIMH endorsement of any specific commercial products or services or medical treatments or services. If you have questions regarding these guidelines and use of NIMH publications, please contact the NIMH Information Center at 1-866-615-6464 or at The photos in this publication are of models and are used for illustrative purposes only. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health NIH Publication No. 08-3572 Revised 2008 Ingersoll, B., & Goldstein, S. (1993). Attention Deficit Disorder and Learning Disabilities: Realities, Myths, and Controversial Treatments. New York: Doubleday Publishing Group. Kratochvil, C.J., Heiligenstein, J.H., Dittmann, R., et al. Atomoxetine and methyphenidate treatment in children wtih ADHD. A prospective, randomized, open-label trial. J. Am. Acad Child Adolesc Psychiatry 2002, 41, 776-84. MTA Cooperative Group. (1999). A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder: Multimodal Treatment Study of Children with ADHD. Archives of General Psychiatry, 56 (12), 1073-1086. O’Leary, K.D., & Becker, W.C. (1967). Behavior modification of an adjustment class: A token reinforcement program. Exceptional Children, 33, 637-642. Pelham, W.E., Greiner, A.R., & Gnagy, E.M. (1997). Children’s summer treatment program manual. Buffalo, NY: Comprehensive Treatment for Attention Deficit Disorder. Pelham, W. E. (2002) Psychosocial Interventions for ADHD. In P.S. Jensen & J.R. Cooper (Ed.), Attention Deficit Hyperactivity Disorder: State of the science • best practices (pp 12-1-12-24) New Jersey: Civic Research Institute, Inc. Rabiner, D. (1999). ADHD Monitoring System: A systematic guide to monitoring school progress for children with ADHD. Florida: Specialty Press, Inc. Recommended Reading Barkley, R. A. (2000) Taking charge of ADHD: The complete authoritative guide for parents. New York: Guilford Press. Barkley, R. A. (1998). Your defiant child. New York: Guilford Press.
  39. 39. Dendy, C.A. (1995). Teenagers with ADD: A parents' guide. Maryland: Woodbine House. Goldstein, S. & Goldstein, M. (1998). Managing attention deficit hyperactivity disorder in children: a guide for practitioners (2nd ed.). New York, NY: John Wiley. Parker, H. (1992). Put yourself in their shoes. Understanding teenagers with attention deficit hyperactivity disorder. Plantation, FL: Specialty Press, Inc. Phelan, T. (1995). 1-2-3 Magic. Illinois: Child Management. Wilens, T. E. (1999). Straight talk about psychiatric medications for kids. New York: Guilford Press. Ingersoll, B., & Goldstein, M. (1993). Attention deficit disorder and learning disabilities: Realities, myths, and controversial treatments. New York: Doubleday. Teaching Children with ADHD, The Council for Exceptional Children, 1989 ADHD - Building Academic Success, Appalachia Educational Laboratory Armstrong, Thomas. To Empower! - Not Control! A Holistic Approach to ADHD. Reaching Today's Youth, Winter, 1998 Brain Gym & the Educational Kinesiology Foundation, Ventura, CA. Dana Nicholls OTR/L and Peggy Syvertson M.A. Sensory Integration, Attention, and Learning. New Horizons for Learning. Sensory Integration International. 1514 Cabrillo Avenue, Torrance, CA. 90501-2817. ADD Tips: Activities and Strategies. Indiana University - Center for Adolescent Studies. 1996. Rinholm, Joanne. Classroom Behaviour Strategies. OBE News Warger , Cynthia . Positive Behavior Support and Functional Assessment . ERIC/ OSEP Digest #E580. September 1999. Applying Positive Behavior Support and Functional Behavioral Assessment in Schools. OSEP Technical Assistance Center on Positive Behavioral Interventions and Supports.