Attention Deficit Hyperactivity Disorder

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How Is ADHD Identified and Diagnosed?

Many parents see signs of an attention deficit in toddlers long before the child enters school. For example, as a 3-year-old, Henry's son already displayed some signs of hyperactivity. He seemed to lose interest and dart off even during his favorite TV shows or while playing games. Once, during a game of "catch," he left the game before the ball even reached him!

Like Henry's son, a child may be unable to focus long enough to play a simple game. Or, like Mark, the child may be tearing around out of control. But because children mature at different rates, and are very different in personality, temperament, and energy level, it's useful to get an expert's opinion of whether the behaviors are appropriate for the child's age. Parents can ask their pediatrician, or a child psychologist or psychiatrist to assess whether their toddler has an attention disorder or is just immature, has hyperactivity or is just exuberant.

Seeing a child as "a chip off the old block" or "just like his dad" can blind parents to the need for help. Parents may find it hard to see their child's behavior as a problem when it so closely resembles their own. In fact, like Henry, many parents first recognize their own disorder only when their children are diagnosed.

In many cases, the teacher is the first to recognize that a child is hyperactive or inattentive and may consult with the school psychologist. Because teachers work with many children, they come to know how "average" children behave in learning situations that require attention and self control. However, teachers sometimes fail to notice the needs of children like Lisa who are quiet and cooperative.

Types of Professionals Who Make the Diagnosis

School-age and preschool children are often evaluated by a school psychologist or a team made up of the school psychologist and other specialists. But if the school doesn't believe the student has a problem, or if the family wants another opinion, a family may need to see a specialist in private practice. In such cases, who can the family turn to? What kinds of specialists do they need?

The family can start by talking with the child's pediatrician or their family doctor. Some pediatricians may do the assessment themselves, but more often they refer the family to an appropriate specialist they know and trust. In addition, state and local agencies that serve families and children, as well as some of the volunteer organizations listed in the back of this booklet, can help identify an appropriate specialist.

Knowing the differences in qualifications and services can help the family choose someone who can best meet their needs. Besides school psychologists, there are several types of specialists qualified to diagnose and treat ADHD. Child psychiatrists are doctors who specialize in diagnosing and treating childhood mental and behavioral disorders. A psychiatrist can provide therapy and prescribe any needed medications. Child psychologists are also qualified to diagnose and treat ADHD. They can provide therapy for the child and help the family develop ways to deal with the disorder. But psychologists are not medical doctors and must rely on the child's physician to do medical exams and prescribe medication. Neurologists, doctors who work with disorders of the brain and nervous system, can also diagnose ADHD and prescribe medicines. But unlike psychiatrists and psychologists, neurologists usually do not provide therapy for the emotional aspects of the disorder. Adults who think they may have ADHD can also seek a psychologist, psychiatrist, or neurologist. But at present, not all specialists are skilled in identifying or treating ADHD in adults.

Within each specialty, individual doctors and mental health professionals differ in their experience with ADHD. So in selecting a specialist, it's important to find someone with specific training and experience in diagnosing and treating the disorder.

Steps In Making a Diagnosis

Whatever the specialist's expertise, his or her first task is to gather information that will rule out other possible reasons for the child's behavior. In ruling out other causes, the specialist checks the child's school and medical records. The specialist tries to sense whether the home and classroom environments are stressful or chaotic, and how the child's parents and teachers deal with the child. They may have a doctor look for such problems as emotional disorders, undetectable (petit mal) seizures, and poor vision or hearing. Most schools automatically screen for vision and hearing, so this information is often already on record. A doctor may also look for allergies or nutrition problems like chronic "caffeine highs" that might make the child seem overly active.

Next the specialist gathers information on the child's ongoing behavior in order to compare these behaviors to the symptoms and diagnostic criteria listed in the DSM ("Diagnostic and Statistical Manual of Mental Disorders"). This involves talking with the child and if possible, observing the child in class and in other settings.

The child's teachers, past and present, are asked to rate their observations of the child's behavior on standardized evaluation forms to compare the child's behaviors to those of other children the same age. Of course, rating scales are subjective--they only capture the teacher's personal perception of the child. Even so, because teachers get to know so many children, their judgment of how a child compares to others is usually accurate.

The specialist interviews the child's teachers, parents, and other people who know the child well, such as school staff and baby-sitters. Parents are asked to describe their child's behavior in a variety of situations. They may also fill out a rating scale to indicate how severe and frequent the behaviors seem to be.

In some cases, the child may be checked for social adjustment and mental health. Tests of intelligence and learning achievement may be given to see if the child has a learning disability and whether the disabilities are in all or only certain parts of the school curriculum.

In looking at the data, the specialist pays special attention to the child's behavior during noisy or unstructured situations, like parties, or during tasks that require sustained attention, like reading, working math problems, or playing a board game. Behavior during free play or while getting individual attention is given less importance in the evaluation. In such situations, most children with ADHD are able to control their behavior and perform well.

The specialist then pieces together a profile of the child's behavior. Which ADHD-like behaviors listed in the DSM does the child show? How often? In what situations? How long has the child been doing them? How old was the child when the problem started? Are the behaviors seriously interfering with the child's friendships, school activities, or home life? Does the child have any other related problems? The answers to these questions help identify whether the child's hyperactivity, impulsivity, and inattention are significant and long-standing. If so, the child may be diagnosed with ADHD.

Adults are diagnosed for ADHD based on their performance at home and at work. When possible, their parents are asked to rate the person's behavior as a child. A spouse or roommate can help rate and evaluate current behaviors. But for the most part, adults are asked to describe their own experiences. One symptom is a sense of frustration. Since people with ADHD are often bright and creative, they often report feeling frustrated that they're not living up to their potential. Many also feel restless and are easily bored. Some say they need to seek novelty and excitement to help channel the whirlwind in their minds. Although it may be impossible to document when these behaviors first started, most adults with ADHD can give examples of being inattentive, impulsive, overly active, impatient, and disorganized most of their lives.

Until recent years, adults were not thought to have ADHD, so many adults with ongoing symptoms have never been diagnosed. People like Henry go for decades knowing that something is wrong, but not knowing what it is. Psychotherapy and medication for anxiety, depression, or manic-depression fail to help much, simply because the ADHD itself is not being addressed. Yet half the children with ADHD continue to have symptoms through adulthood. The recent awareness of adult ADHD means that many people can finally be correctly diagnosed and treated.

A correct diagnosis lets people move forward in their lives. Once the disorder is known, they can begin to receive whatever combination of educational, medical, and emotional help they need.

An effective treatment plan helps people with ADHD and their families at many levels. For adults with ADHD, the treatment plan may include medication, along with practical and emotional support. For children and adolescents, it may include providing an appropriate classroom setting, the right medication, and helping parents to manage their child's behavior.

What Are the Educational Options?

Children with ADHD have a variety of needs. Some children are too hyperactive or inattentive to function in a regular classroom, even with medication and a behavior management plan. Such children may be placed in a special education class for all or part of the day. In some schools, the special education teacher teams with the classroom teacher to meet each child's unique needs. However, most children are able to stay in the regular classroom. Whenever possible, educators prefer to not to segregate children, but to let them learn along with their peers.

Children with ADHD often need some special accommodations to help them learn. For example, the teacher may seat the child in an area with few distractions, provide an area where the child can move around and release excess energy, or establish a clearly posted system of rules and reward appropriate behavior. Sometimes just keeping a card or a picture on the desk can serve as a visual reminder to use the right school behavior, like raising a hand instead of shouting out, or staying in a seat instead of wandering around the room. Giving a child like Lisa extra time on tests can make the difference between passing and failing, and gives her a fairer chance to show what she's learned. Reviewing instructions or writing assignments on the board, and even listing the books and materials they will need for the task, may make it possible for disorganized, inattentive children to complete the work.

Many of the strategies of special education are simply good teaching methods. Telling students in advance what they will learn, providing visual aids, and giving written as well as oral instructions are all ways to help students focus and remember the key parts of the lesson.

Students with ADHD often need to learn techniques for monitoring and controlling their own attention and behavior. For example, Mark's teacher taught him several alternatives for when he loses track of what he's supposed to do. He can look for instructions on the blackboard, raise his hand, wait to see if he remembers, or quietly ask another child. The process of finding alternatives to interrupting the teacher has made him more self-sufficient and cooperative. And because he now interrupts less, he is beginning to get more praise than reprimands.

In Lisa's class, the teacher frequently stops to ask students to notice whether they are paying attention to the lesson or if they are thinking about something else. The students record their answer on a chart. As students become more consciously aware of their attention, they begin to see progress and feel good about staying better focused. The process helped make Lisa aware of when she was drifting off, so she could return her attention to the lesson faster. As a result, she became more productive and the quality of her work improved.

Because schools demand that children sit still, wait for a turn, pay attention, and stick with a task, it's no surprise that many children with ADHD have problems in class. Their minds are fully capable of learning, but their hyperactivity and inattention make learning difficult. As a result, many students with ADHD repeat a grade or drop out of school early. Fortunately, with the right combination of appropriate educational practices, medication, and counseling, these outcomes can be avoided.

Right to a Free Public Education

Although parents have the option of taking their child to a private practitioner for evaluation and educational services, most children with ADHD qualify for free services within the public schools. Steps are taken to ensure that each child with ADHD receives an education that meets his or her unique needs. For example, the special education teacher, working with parents, the school psychologist, school administrators, and the classroom teacher, must assess the child's strengths and weaknesses and design an Individualized Educational Program (IEP). The IEP outlines the specific skills the child needs to develop as well as appropriate learning activities that build on the child's strengths. Parents play an important role in the process. They must be included in meetings and given an opportunity to review and approve their child's IEP.

Many children with ADHD or other disabilities are able to receive such special education services under the Individuals with Disabilities Education Act (IDEA). The Act guarantees appropriate services and a public education to children with disabilities from ages 3 to 21. Children who do not qualify for services under IDEA can receive help under an earlier law, the National Rehabilitation Act, Section 504, which defines disabilities more broadly. Qualifying for services under the National Rehabilitation Act is often called "504 eligibility."

Because ADHD is a disability that affects children's ability to learn and interact with others, it can certainly be a disabling condition. Under one law or another, most children can receive the services they need.

Some Coping Strategies for Teens and Adults With ADHD

(Adapted from: Weinstein, C. Cognitive Remediation Strategies. "Journal of Psychotherapy Practice and Research" 3(1):44-57, 1994):

• When necessary, ask the teacher or boss to repeat instructions, rather than guess.
  
  
• Break large assignments or job tasks into small, simple tasks. Set a deadline for each task and reward yourself as you complete each one.
  
  
• Each day, make a list of what you need to do. Plan the best order for doing each task. Then make a schedule for doing them. Use a calendar or daily planner to keep yourself on track.
  
  
• Work in a quiet area. Do one thing at a time. Give yourself short breaks.
  
  
• Write things you need to remember in a notebook with dividers. Write different kinds of information, like assignments, appointments, and phone numbers--in different sections. Keep the book with you all of the time.
  
  
• Post notes to yourself to help remind yourself of things you need to do. Tape notes on the bathroom mirror, on the refrigerator, in your school locker, or dashboard of your car--wherever you're likely to need the reminder.
  
  
• Store similar things together. For example, keep all your Nintendo disks in one place, and tape cassettes in another. Keep canceled checks in one place, and bills in another.
  
  
• Create a routine. Get yourself ready for school or work at the same time, in the same way, every day.
  
  
• Exercise, eat a balanced diet, and get enough sleep.

What Treatments Are Available?

For decades, medications have been used to treat the symptoms of ADHD. Three medications in the class of drugs known as stimulants seem to be the most effective in both children and adults. These are methylphenidate (Ritalin), dextroamphetamine (Dexedrine or Dextrostat), and pemoline (Cylert). For many people, these medicines dramatically reduce their hyperactivity and improve their ability to focus, work, and learn. The medications may also improve physical coordination, such as handwriting and ability in sports. Recent research by NIMH suggests that these medicines may also help children with an accompanying conduct disorder to control their impulsive, destructive behaviors.

Ritalin helped Henry focus on and complete tasks for the first time. Dexedrine helped Mark to sit quietly, focus his attention, and participate in class so he could learn. He also became less impulsive and aggressive. Along with these changes in his behavior, Mark began to make and keep friends.

Unfortunately, when people see such immediate improvement, they often think medication is all that's needed. But these medicines don't cure the disorder, they only temporarily control the symptoms. Although the drugs help people pay better attention and complete their work, they can't increase knowledge or improve academic skills. The drugs alone can't help people feel better about themselves or cope with problems. These require other kinds of treatment and support.

For lasting improvement, numerous clinicians recommend that medications should be used along with treatments that aid in these other areas. There are no quick cures. Many experts believe that the most significant, long-lasting gains appear when medication is combined with behavioral therapy, emotional counseling, and practical support. Some studies suggest that the combination of medicine and therapy may be more effective than drugs alone. NIMH is conducting a large study to check this.

Use of Stimulant Drugs

Stimulant drugs, such as Ritalin, Cylert, and Dexedrine, when used with medical supervision, are usually considered quite safe. Although they can be addictive to teenagers and adults if misused, these medications are not addictive in children. They seldom make children "high" or jittery. Nor do they sedate the child. Rather, the stimulants help children control their hyperactivity, inattention, and other behaviors.

Different doctors use the medications in slightly different ways. Cylert is available in one form, which naturally lasts 5 to 10 hours. Ritalin and Dexedrine come in short-term tablets that last about 3 hours, as well as longer-term preparations that last through the school day. The short-term dose is often more practical for children who need medication only during the school day or for special situations, like attending church or a prom, or studying for an important exam. The sustained-release dosage frees the child from the inconvenience or embarrassment of going to the office or school nurse every day for a pill. The doctor can help decide which preparation to use, and whether a child needs to take the medicine during school hours only or in the evenings and on weekends, too.

Nine out of 10 children improve on one of the three stimulant drugs. So if one doesn't help, the others should be tried. Usually a medication should be tried for a week to see if it helps. If necessary, however, the doctor will also try adjusting the dosage before switching to a different drug.

Other types of medication may be used if stimulants don't work or if the ADHD occurs with another disorder. Antidepressants and other medications may be used to help control accompanying depression or anxiety. In some cases, antihistamines may be tried. Clonidine, a drug normally used to treat hypertension, may be helpful in people with both ADHD and Tourette's syndrome. Although stimulants tend to be more effective, clonidine may be tried when stimulants don't work or can't be used. Clonidine can be administered either by pill or by skin patch and has different side effects than stimulants. The doctor works closely with each patient to find the most appropriate medication.

Sometimes, a child's ADHD symptoms seem to worsen, leading parents to wonder why. They can be assured that a drug that helps rarely stops working. However, they should work with the doctor to check that the child is getting the right dosage. Parents should also make sure that the child is actually getting the prescribed daily dosage at home or at school--it's easy to forget. They also need to know that new or exaggerated behaviors may also crop up when a child is under stress. The challenges that all children face, like changing schools or entering puberty, may be even more stressful for a child with ADHD.

Some doctors recommend that children be taken off a medication now and then to see if the child still needs it. They recommend temporarily stopping the drug during school breaks and summer vacations, when focused attention and calm behavior are usually not as crucial. These "drug holidays" work well if the child can still participate at camp or other activities without medication.

Children on medications should have regular checkups. Parents should also talk regularly with the child's teachers and doctor about how the child is doing. This is especially important when a medication is first started, re-started, or when the dosage is changed.

The Medication Debate

As useful as these drugs are, Ritalin and the other stimulants have sparked a great deal of controversy. Most doctors feel the potential side effects should be carefully weighed against the benefits before prescribing the drugs. While on these medications, some children may lose weight, have less appetite, and temporarily grow more slowly. Others may have problems falling asleep. Some doctors believe that stimulants may also make the symptoms of Tourette's syndrome worse, although recent research suggests this may not be true. Other doctors say if they carefully watch the child's height, weight, and overall development, the benefits of medication far outweigh the potential side effects. Side effects that do occur can often be handled by reducing the dosage.

It's natural for parents to be concerned about whether taking a medicine is in their child's best interests. Parents need to be clear about the benefits and potential risks of using these drugs. The child's pediatrician or psychiatrist can provide advice and answer questions.

Another debate is whether Ritalin and other stimulant drugs are prescribed unnecessarily for too many children. Remember that many things, including anxiety, depression, allergies, seizures, or problems with the home or school environment can make children seem overactive, impulsive, or inattentive. Critics argue that many children who do not have a true attention disorder are medicated as a way to control their disruptive behaviors.

Medication and Self-Esteem

When a child's schoolwork and behavior improve soon after starting medication, the child, parents, and teachers tend to applaud the drug for causing the sudden change. But these changes are actually the child's own strengths and natural abilities coming out from behind a cloud. Giving credit to the medication can make the child feel incompetent. The medication only makes these changes possible. The child must supply the effort and ability. To help children feel good about themselves, parents and teachers need to praise the child, not the drug.

It's also important to help children and teenagers feel comfortable about a medication they must take every day. They may feel that because they take medicine they are different from their classmates or that there is something seriously wrong with them. CH.A.D.D. (which stands for Children and Adults with Attention Deficit Disorders), a leading organization for people with attention disorders, suggests several ways that parents and teachers can help children view the medication in a positive way:

• Compare the pills to eyeglasses, braces, and allergy medications used by other children in their class. Explain that their medicine is simply a tool to help them focus and pay attention.
  
  
• Point out that they're lucky their problem can be helped. Encourage them to identify ways the medicine makes it easier to do things that are important to them, like make friends, succeed at school, and play.

Myths About Stimulant Medication

Treatments To Help People With ADHD and Their Families Learn To Cope

Life can be hard for children with ADHD. They're the ones who are so often in trouble at school, can't finish a game, and lose friends. They may spend agonizing hours each night struggling to keep their mind on their homework, then forget to bring it to school.

It's not easy coping with these frustrations day after day. Some children release their frustration by acting contrary, starting fights, or destroying property. Some turn the frustration into body ailments, like the child who gets a stomachache each day before school. Others hold their needs and fears inside, so that no one sees how badly they feel.

It's also difficult having a sister, brother, or classmate who gets angry, grabs your toys, and loses your things. Children who live with or share a classroom with a child who has ADHD get frustrated, too. They may feel neglected as their parents or teachers try to cope with the hyperactive child. They may resent their brother or sister never finishing chores, or being pushed around by a classmate. They want to love their sibling and get along with their classmate, but sometimes it's so hard!

It's especially hard being the parent of a child who is full of uncontrolled activity, leaves messes, throws tantrums, and doesn't listen or follow instructions. Parents often feel powerless and at a loss. The usual methods of discipline, like reasoning and scolding, don't work with this child, because the child doesn't really choose to act in these ways. It's just that their self-control comes and goes. Out of sheer frustration, parents sometimes find themselves spanking, ridiculing, or screaming at the child, even though they know it's not appropriate. Their response leaves everyone more upset than before. Then they blame themselves for not being better parents. Once children are diagnosed and receiving treatment, some of the emotional upset within the family may fade.

Medication can help to control some of the behavior problems that may have lead to family turmoil. But more often, there are other aspects of the problem that medication can't touch. Even though ADHD primarily affects a person's behavior, having the disorder has broad emotional repercussions. For some children, being scolded is the only attention they ever get. They have few experiences that build their sense of worth and competence. If they're hyperactive, they're often told they're bad and punished for being disruptive. If they are too disorganized and unfocused to complete tasks, others may call them lazy. If they impulsively grab toys, butt in, or shove classmates, they may lose friends. And if they have a related conduct disorder, they may get in trouble at school or with the law. Facing the daily frustrations that can come with having ADHD can make people fear that they are strange, abnormal, or stupid.

Often, the cycle of frustration, blame, and anger has gone on so long that it will take some time to undo. Both parents and their children may need special help to develop techniques for managing the patterns of behavior. In such cases, mental health professionals can counsel the child and the family, helping them to develop new skills, attitudes, and ways of relating to each other. In individual counseling, the therapist helps children or adults with ADHD learn to feel better about themselves. They learn to recognize that having a disability does not reflect who they are as a person. The therapist can also help people with ADHD identify and build on their strengths, cope with daily problems, and control their attention and aggression. In group counseling, people learn that they are not alone in their frustration and that others want to help. Sometimes only the individual with ADHD needs counseling support. But in many cases, because the problem affects the family as well as the person with ADHD, the entire family may need help. The therapist assists the family in finding better ways to handle the disruptive behaviors and promote change. If the child is young, most of the therapist's work is with the parents, teaching them techniques for coping with and improving their child's behavior.

Several intervention approaches are available and different therapists tend to prefer one approach or another. Knowing something about the various types of interventions makes it easier for families to choose a therapist that is right for their needs.

• Psychotherapy works to help people with ADHD to like and accept themselves despite their disorder. In psychotherapy, patients talk with the therapist about upsetting thoughts and feelings, explore self-defeating patterns of behavior, and learn alternative ways to handle their emotions. As they talk, the therapist tries to help them understand how they can change. However, people dealing with ADHD usually want to gain control of their symptomatic behaviors more directly. If so, more direct kinds of intervention are needed.

• Cognitive-behavioral therapy helps people work on immediate issues. Rather than helping people understand their feelings and actions, it supports them directly in changing their behavior. The support might be practical assistance, like helping Henry learn to think through tasks and organize his work. Or the support might be to encourage new behaviors by giving praise or rewards each time the person acts in the desired way. A cognitive-behavioral therapist might use such techniques to help a belligerent child like Mark learn to control his fighting, or an impulsive teenager like Lisa to think before she speaks.

• Social skills training can also help children learn new behaviors. In social skills training, the therapist discusses and models appropriate behaviors like waiting for a turn, sharing toys, asking for help, or responding to teasing, then gives children a chance to practice. For example, a child might learn to "read" other people's facial expression and tone of voice, in order to respond more appropriately. Social skills training helped Lisa learn to join in group activities, make appropriate comments, and ask for help. A child like Mark might learn to see how his behavior affects others and develop new ways to respond when angry or pushed.

• Support groups connect people who have common concerns. Many adults with ADHD and parents of children with ADHD find it useful to join a local or national support group. Many groups deal with issues of children's disorders, and even ADHD specifically. The national associations listed at the back of this booklet can explain how to contact a local chapter. Members of support groups share frustrations and successes, referrals to qualified specialists, and information about what works, as well as their hopes for themselves and their children. There is strength in numbers--and sharing experiences with others who have similar problems helps people know that they aren't alone.

• Parenting skills training, offered by therapists or in special classes, gives parents tools and techniques for managing their child's behavior. One such technique is the use of "time out" when the child becomes too unruly or out of control. During time outs, the child is removed from the agitating situation and sits alone quietly for a short time to calm down. Parents may also be taught to give the child "quality time" each day, in which they share a pleasurable or relaxed activity. During this time together, the parent looks for opportunities to notice and point out what the child does well, and praise his or her strengths and abilities.

An effective way to modify a child's behavior is through a system of rewards and penalties. The parents (or teacher) identify a few desirable behaviors that they want to encourage in the child--such as asking for a toy instead of grabbing it, or completing a simple task. The child is told exactly what is expected in order to earn the reward. The child receives the reward when he performs the desired behavior and a mild penalty when he doesn't. A reward can be small, perhaps a token that can be exchanged for special privileges, but it should be something the child wants and is eager to earn. The penalty might be removal of a token or a brief "time out." The goal, over time, is to help children learn to control their own behavior and to choose the more desired behavior. The technique works well with all children, although children with ADHD may need more frequent rewards.

In addition, parents may learn to structure situations in ways that will allow their child to succeed. This may include allowing only one or two playmates at a time, so that their child doesn't get overstimulated. Or if their child has trouble completing tasks, they may learn to help the child divide a large task into small steps, then praise the child as each step is completed.

Parents may also learn to use stress management methods, such as meditation, relaxation techniques, and exercise to increase their own tolerance for frustration, so that they can respond more calmly to their child's behavior.

Controversial Treatments

Understandably, parents who are eager to help their children want to explore every possible option. Many newly touted treatments sound reasonable. Many even come with glowing reports. A few are pure quackery. Some are even developed by reputable doctors or specialists--but when tested scientifically, cannot be proven to help.

Here are a few types of treatment that have not been scientifically shown to be effective in treating the majority of children or adults with ADHD:

• biofeedback
• restricted diets
• allergy treatments
• medicines to correct problems in the inner ear
• megavitamins
• chiropractic adjustment and bone re-alignment
• treatment for yeast infection
• eye training
• special colored glasses

A few success stories can't substitute for scientific evidence. Until sound, scientific testing shows a treatment to be effective, families risk spending time, money, and hope on fads and false promises.

Sustaining Hope

Mark

Lisa

Lisa is about to graduate from high school. She's better able to focus her attention and concentrate on her work, so that now her grades are quite good. Overcoming her depression and learning to like herself have also given her more confidence to develop friendships and try new things.

Lately, she has been working with the school guidance counselor to identify the right kind of job to look for after graduation. She hopes to find a career that will bypass her attention problems and make the best use of her assets and skills. She is more alert and focused and is considering trying college in a year or two. Her counselor reminds her that she's certainly smart enough.

Henry

These days, Henry is successful and happy in his job as a shoe salesman. The work allows him to move around throughout the day, and the appearance of new customers provides the variety he needs to help him stay focused. He recently completed a course in time management, and now keeps lists, organizes his work, and schedules his day. Now that he has harnessed his energy, his ability to think about several things at once allows him to be creative and productive.

He is proud that he and his wife have developed important parenting skills for working with their son, so that he, too, is doing better at home and at school. Henry is also pleased with his new ability to follow through on projects. In fact, he just finished making his son a beautiful wooden toy chest for his birthday.

Can ADHD Be Outgrown or Cured?

Even though most people don't outgrow ADHD, people do learn to adapt and live fulfilling lives. Mark, Lisa, and Henry are making good lives for themselves--not by being cured, but by developing their personal strengths. With effective combinations of medicine, new skills, and emotional support, people with ADHD can develop ways to control their attention and minimize their disruptive behaviors. Like Henry, they may find that by structuring tasks and controlling their environment, they can achieve personal goals. Like Mark, they may learn to channel their excess energy into sports and other high energy activities. And like Lisa, they can identify career options that build on their strengths and abilities.

As they grow up, with appropriate help from parents and clinicians, children with ADHD become better able to suppress their hyperactivity and to channel it into more socially acceptable behaviors, like physical exercise or fidgeting. And although we know that half of all children with ADHD will still show signs of the problem into adulthood, we also know that the medications and therapy that help children also work for adults.

All people with ADHD have natural talents and abilities that they can draw on to create fine lives and careers for themselves. In fact, many people with ADHD even feel that their patterns of behavior give them unique, often unrecognized, advantages. People with ADHD tend to be outgoing and ready for action. Because of their drive for excitement and stimulation, many become successful in business, sports, construction, and public speaking. Because of their ability to think about many things at once, many have won acclaim as artists and inventors. Many choose work that gives them freedom to move around and release excess energy. But some find ways to be effective in quieter, more sedentary careers. Sally, a computer programmer, found that she thinks best when she wears headphones to reduce distracting noises. Like Henry, some people strive to increase their organizational skills. Others who own their own business find it useful to hire support staff to provide day-to-day management.

What Hope Does Research Offer?

Although no immediate cure is in sight, a new understanding of ADHD may be just over the horizon. Using a variety of research tools and methods, scientists are beginning to uncover new information on the role of the brain in ADHD and effective treatments for the disorder Such research will ultimately result in improving the personal fulfillment and productivity of people with ADHD.

For example, the use of new techniques like brain imaging to observe how the brain actually works is already providing new insights into the causes of ADHD. Other research is seeking to identify conditions of pregnancy and early childhood that may cause or contribute to these differences in the brain. As the body of knowledge grows, scientists may someday learn how to prevent these differences or at least how to treat them.

NIMH and the U.S. Department of Education are cosponsoring a large national study--the first of its kind--to see which combinations of ADHD treatment work best for different types of children. During this 5-year study, scientists at research clinics across the country will work together in gathering data to answer such questions as: Is combining stimulant medication with behavior modification more effective than either alone? Do boys and girls respond differently to treatment? How do family stresses, income, and environment affect the severity of ADHD and long-term outcomes? How does needing medicine affect children's sense of competence, self-control, and self-esteem? As a result of such research, doctors and mental health specialists may someday know who benefits most from different types of treatment and be able to intervene more effectively.

NIMH grantees are also trying to determine if there are different varieties of attention deficit. With further study, researchers may find that ADHD actually covers a number of different disorders, each with its own cluster of symptoms and treatment requirements. For example, scientists are exploring whether there are any critical differences between children with ADHD who also have anxiety, depression, or conduct disorders and those who do not. Other researchers are studying slight physical differences that might distinguish one type of ADHD from another. If clusters of differences can be found, scientists can begin to distinguish the treatment each type needs.

Other NIMH-sponsored research is examining the long-term outcome of ADHD. How do children with ADHD turn out, compared to brothers and sisters without the disorder? As adults, how do they handle their own children? Still other studies seek to better understand ADHD in adults. Such studies give insights into what types of treatment or services make a difference in helping an ADHD child grow into a caring parent and a well-functioning adult.

Animal studies are also adding to our knowledge of ADHD in humans. Animal subjects make it possible to study some of the possible causes of ADHD in ways that can't be studied in people. In addition, animal research allows the safety and effectiveness of experimental new drugs to be tested long before they can be given to humans. One NIH-sponsored team of scientists is studying dogs to learn how new stimulant drugs that are similar to Ritalin act on the brain.

Piece by piece, through studies of humans and animals, scientists are beginning to understand the biological nature of attention disorders. New research is allowing us to better understand the inner workings of the brain as we continue to develop new medications and assess new forms of treatment.

As we learn more about what actually happens inside the brain, we approach a future where we can prevent certain brain and mental disorders, make valid diagnoses, and treat each effectively. This is the hope, mission, and vision of the National Institute of Mental Health.

What Are Sources of Information and Support?

Several publications, organizations, and support groups exist to help individuals, teachers, and families to understand and cope with attention disorders. The following resources provide a good starting point for gaining insight, practical solutions, and support. Other resources are outpatient clinics of children's hospitals, university medical centers, and community mental health centers. Additional printed information can be found at libraries and book stores.

Books for Children and Teens:

Galvin, M. "Otto Learns about his Medication." New York: Magination Press, 1988. (for young children)

Gehret, J. "Learning Disabilities and the Don't Give Up Kid." Fairport, New York: Verbal Images Press, 1990. (for classmates and children with learning disabilities and attention difficulties, ages 7-12)

Gordon, M. "Jumpin' Johnny, Get Back to Work! A Child's Guide to ADHD/Hyperactivity." DeWitt, New York: GSI Publications, 1991. (for ages 7-12)

Meyer, D.; Vadasy, P.; and Fewell, R. "Living with a Brother or Sister with Special Needs: A Book for Sibs." Seattle: University of Washington Press, 1985.

Moss, D. "Shelly the Hyperactive Turtle." Rockville, MD: Woodbine House, 1989. (for young children)

Nadeau, K., and Dixon, E. "Learning to Slow Down and Pay Attention." Annandale, VA: Chesapeake Psychological Publications, 1993.

Parker, R. "Making the Grade: An Adolescent's Struggle with ADD." Plantation, FL: Impact Publications, 1992.

Quinn, P., and Stern, J. "Putting on the Brakes: Young People's Guide to Understanding Attention Deficit Hyperactivity Disorder." New York: Magination Press, 1991. (for ages 8-12)

Thompson, M. "My Brother Matthew." Rockville, MD: Woodbine House, 1992.

Books for Adults With Attention Disorders:

Adelman, P., and Wren, C. "Learning Disabilities, Graduate School, and Careers: The Student's Perspective." Lake Forest, IL: Learning Opportunities Program, Barat College, 1990.

Hallowell, E., and Ratey, J. "Driven to Distraction." New York: Pantheon Books, 1994.

Hartmann, T. "Attention Deficit Disorder: A New Perception." Lancaster, PA: Underwood-Miller, 1993.

Kelly, K., and Ramundo, P. "You Mean I'm Not Lazy, Stupid, or Crazy?!" Cincinnati, OH: Tyrell and Jeremy Press, 1993.

Weiss, G., and Hechtman, L. (eds). "Hyperactive Children Grown Up." 2d ed. New York: Guilford Press, 1992.

Weiss, L. "Attention Deficit Disorder in Adults." Dallas, TX: Taylor Pub. Co., 1992.

Wender, P. "The Hyperactive Child, Adolescence, and Adult: Attention Deficit Disorder Through the Lifespan." New York: Oxford University Press, 1987.

Books for Parents:

Anderson, W.; Chitwood, S.; and Hayden, D. "Negotiating the Special Education Maze: A Guide for Parents and Teachers." 2d ed. Rockville, MD: Woodbine House, 1990.

Bain, L. "A Parent's Guide to Attention Deficit Disorders." New York: Dell Publishing, 1991.

Barkley, R. "Defiant Children." New York: Guilford Press, 1987.

Child Psychopharmacy Center, University of Wisconsin. "Stimulants and Hyperactive Children." Madison: 1990. (Order by calling (608) 263-6171.)

Copeland, E., and Love, V. "Attention, Please!: A Comprehensive Guide for Successfully Parenting Children with Attention Disorders and Hyperactivity." Atlanta, GA: SPI Press, 1991.

Fowler, M. "Maybe You Know My Kid: A Parent's Guide to Identifying, Understanding, and Helping your Child with ADHD." New York: Birch Lane Press, 1990.

Goldstein, S., and Goldstein, M. "Hyperactivity: Why Won't My Child Pay Attention?" New York: J. Wiley, 1992.

Greenberg, G.; Horn, S.; and Wade F. "Attention Deficit Hyperactivity Disorder: Questions & Answers for Parents." Champaign, IL: Research Press, 1991.

Ingersoll, B., and Goldstein, S. "Attention Deficit Disorder and Learning Disabilities: Realities, Myths, and Controversial Treatments." New York: Doubleday, 1993.

Kennedy, P.; Terdal, L.; and Fusetti, L. "The Hyperactive Child Book." New York: St. Martrin's Press, 1993.

Moss, R., and Dunlap, H. "Why Johnny Can't Concentrate: Coping with Attention Deficit Problems." New York: Bantam Books, 1990.

Silver, L. "Dr. Silver's Advice to Parents on Attention-Deficit Hyperactivity Disorder." Washington, DC: American Psychiatric Press, 1993.

Vail, P. "Smart Kids with School Problems." New York: EP Dutton, 1987.

Wilson, N. "Optimizing Special Education: How Parents Can Make a Difference." New York: Insight Books, 1992.

Windell, J. "Discipline: A Sourcebook of 50 Failsafe Techniques for Parents." New York: Collier Books, 1991.

Other Resources:

For individuals with a computer and modem, there are on-line bulletin boards where parents, adults with ADHD, and medical professionals share experiences, offer emotional support, and ask and respond to questions.

Two such on-line services include CompuServe [(800) 848-8990] and America Online [(800) 827-6364]. You may also wish to check with other national and local on-line communications companies to see if they offer similar services.

Resources for Teachers and Specialists:

Barkley, R. "Attention Deficit Hyperactivity Disorder" (four 40-minute videocassettes in VHS format). New York: Guilford Publications, 1990.

Copeland, E., and Love, V. "Attention Without Tension: A Teacher's Handbook on Attention Disorders." Atlanta, GA: 3 C's of Childhood, 1992.

Harris, K., and Graham, S. "Helping Young Writers Master the Craft." Cambridge, MA: Brookline Books, 1992.

Johnson, D. "I Can't Sit Still-Educating and Affirming Inattentive and Hyperactive Children: Suggestions for Parents, Teachers, and Other Care Providers of Children to Age 10. Santa Cruz, CA: ETR Associates, 1992.

Parker, H. "The ADD Hyperactivity Handbook for Schools." Plantation, FL: Impact Publications, 1992.

Related Materials Available from NIH:

Attention Deficit Disorder Information Packet and "Know Your Brain Fact Sheet." Both are available from NIH Neurological Institute, P.O. Box 5801; Bethesda, MD 20824 (800) 352-9424.

"Learning Disabilities" (NIH Pub. No. 93-3611) and "Plain Talk about Depression' (NIH Pub. No. 93-3561). These are available by contacting: NIMH, Room 7C-02, 5600 Fishers Lane, Rockville, MD 20857.

Support Groups and Organizations

Attention Deficit Information Network (Ad-IN)
475 Hillside Avenue
Needham, MA 02194
(617) 455-9895

Provides up-to-date information on current research, regional meetings. Offers aid in finding solutions to practical problems faced by adults and children with an attention disorder.

ADD Warehouse
300 NW 70th Avenue
Plantation, FL 33317
(800) 233-9273

Distributes books, tapes, videos, assessment on attention deficit hyperactivity disorders. A central location for ordering many of the books listed above. Call for catalog.

Center for Mental Health Services
Office of Consumer, Family, and Public Information
5600 Fishers Lane, Room 15-105
Rockville, MD 20857
(301) 443-2792

This national center, a component of the U.S. Public Health Service, provides a range of information on mental health, treatment, and support services.

Children and Adults with Attention Deficit Disorders (CH.A.D.D.)
499 NW 70th Avenue, Suite 109
Plantation, FL 33317
(305) 587-3700

A major advocate and key information source for people dealing with attention disorders. Sponsors support groups and publishes two newsletters concerning attention disorders for parents and professionals.

Council for Exceptional Children
11920 Association Drive
Reston, VA 22091
(703) 620-3660

Provides publications for educators. Can also provide referral to ERIC (Educational Resource Information Center) Clearinghouse for Handicapped and Gifted Children.

Federation of Families for Children's Mental Health
1021 Prince Street
Alexandria, VA 22314
(703) 684-7710

Provides information, support, and referrals through federation chapters throughout the country. This national parent-run organization focuses on the needs of children with broad mental health problems.

HEATH Resource Center
American Council on Education
1 Dupont Circle, Suite 800
Washington, DC 20036
(800) 544-3284

A national clearinghouse on post-high school education for people with disabilities.

Learning Disabilities Association of America
4156 Library Road
Pittsburgh, PA 15234
(412) 341-8077

Provides information and referral to state chapters, parent resources, and local support groups. Publishes news briefs and a professional journal.

National Association of Private Schools for Exceptional Children
1522 K Street, NW, Suite 1032
Washington, DC 20005
(202) 408-3338

Provides referrals to private special education programs.

National Center for Learning Disabilities
99 Park Avenue, 6th Floor
New York, NY 10016
(212) 687-7211

Provides referrals and resources. Publishes Their World magazine describing true stories on ways children and adults cope with LD.

National Clearinghouse for Alcohol and Drug Information
P.O. Box 2345
Rockville, MD 20847
(800) 729-6686

Provides information on the risks of alcohol during pregnancy, and fetal alcohol syndrome.

National Information Center for Children and Youth with Disabilities (NICHCY)
P.O. Box 1492
Washington, DC 20013
(800) 695-0285

Publishes free, fact-filled newsletters. Arranges workshops. Advises parents on the laws entitling children with disabilities to special education and other services.

Sibling Information Network
A.J. Pappanikou Center
1776 Ellington Road
South Windsor, CT 06074
(203) 648-1205

Publishes a newsletter for and about siblings of children with special needs.

Tourette Syndrome Association
42-40 Bell Boulevard
Bayside, NY 11361
(718) 224-2999

State and local chapters provide national information, advocacy, research, and support.

Message From The National Institute Of Mental Health

Research conducted and supported by the National Institute of Mental Health brings hope to millions of people who suffer from mental illness and to their families and friends. In many years of work with animal as well as human subjects, researchers have advanced our understanding of the brain and vastly expanded the capability of mental health professionals to diagnose, treat, and prevent mental and brain disorders.

Now, in the 1990s, which the President and Congress have declared the "Decade of the Brain," we stand at the threshold of a new era in brain and behavioral sciences. Through research, we will learn even more about mental and brain disorders such as depression, bipolar disorder, schizophrenia, panic disorder, obsessive-compulsive disorder, and attention deficit hyperactivity disorder. And we will be able to use this knowledge to develop new therapies that can help more people overcome mental illness.

The National Institute of Mental Health is part of the National Institutes of Health (NIH), the Federal Government's primary agency for biomedical and behavioral research. NIH is a component of the U.S. Department of Health and Human Services.

Credits

This booklet was written by Sharyn Neuwirth, M.Ed., an education writer and instructional designer in Silver Spring, MD. Scientific information and review was provided by NIMH staff members L. Eugene Arnold, M.D.; F. Xavier Castellanos, M.D.; and Alan J. Zametkin, M.D. Also providing review and assistance were Russell A. Barkley, Ph.D., University of Massachusetts Medical School; Eileen Weiner-Dwyer, Ph.D., and Kevin Dwyer, M.A., N.C.S.P., of the Montgomery County (Maryland) Schools; JoAnne Evans, R.N., Children and Adults with Attention Deficit Disorders; Jane Hauser, U.S. Department of Education; Reid Lyon, Ph.D., National Institute of Child Health and Human Development; Harvey C. Parker, Ph.D., A.D.D. Warehouse; Larry B. Silver, M.D., Georgetown University. Editorial direction was provided by Lynn J. Cave, NIMH.

U.S. Department of Health and Human Services
Public Health Service

National Institutes of Health
National Institute of Mental Health

NIH Publication No. 94-3572
Printed 1994

Bulk sales (Stock No. 017-024-01543-1) by the U.S. Government Printing Office, Superintendent of Documents, Mail Stop: SSOP, Washington, DC 20402-9328.

What Is the National Institute of Mental Health?

The National Institute of Mental Health (NIMH) is the U.S. Government agency that conducts and supports research on mental illness and mental health, including studies of the brain, behavior, and mental health services. NIMH is a component of the National Institutes of Health (NIH).

By mail:
National Institute of Mental Health
Information Resources and Inquiries Branch
5600 Fishers Lane, Room 7C-02
Rockville, MD 20857
General information and publications: (301) 443-4513
Mental disorders and their treatments : (301) 443-4513
Media/press office : (301) 443-4536