Attention Deficit Hyperactivity Disorder

Imagine living in a fast-moving kaleidoscope, where sounds, images, and thoughts are constantly shifting. Feeling easily bored, yet helpless to keep your mind on tasks you need to complete. Distracted by unimportant sights and sounds, your mind drives you from one thought or activity to the next. Perhaps you are so wrapped up in a collage of thoughts and images that you don't notice when someone speaks to you.

For many people, this is what it's like to have Attention Deficit Hyperactivity Disorder, or ADHD. They may be unable to sit still, plan ahead, finish tasks, or be fully aware of what's going on around them. To their family, classmates or coworkers, they seem to exist in a whirlwind of disorganized or frenzied activity. Unexpectedly--on some days and in some situations--they seem fine, often leading others to think the person with ADHD can actually control these behaviors. As a result, the disorder can mar the person's relationships with others in addition to disrupting their daily life, consuming energy, and diminishing self-esteem.

ADHD, once called hyperkinesis or minimal brain dysfunction, is one of the most common mental disorders among children. It affects 3 to 5 percent of all children. Two to three times more boys than girls are affected. ADHD often continues into adolescence and adulthood, and can cause a lifetime of frustrated dreams and emotional pain.

But there is help...and hope. In the last decade, scientists have learned much about the course of the disorder and are now able to identify and treat children, adolescents, and adults who have it. A variety of medications, behavior-changing therapies, and educational options are already available to help people with ADHD focus their attention, build self-esteem, and function in new ways.

In addition, new avenues of research promise to further improve diagnosis and treatment. Within a few years it is possible that scientists will pinpoint the biological basis of ADHD and learn how to prevent or treat it even more effectively.

ADHD does not have clear physical signs that can be seen. ADHD can only be identified by looking for certain characteristic behaviors, and these behaviors vary from person to person. Scientists have not yet identified a single cause behind all the different patterns of behavior--and they may never find just one. Rather, someday scientists may find that ADHD is actually an umbrella term for several slightly different disorders.

At present, ADHD is a diagnosis applied to children and adults who consistently display certain characteristic behaviors over a period of time. The most common behaviors fall into three categories: inattention, hyperactivity, and impulsivity.

Inattention. People who are inattentive have a hard time keeping their mind on any one thing and may get bored with a task after only a few minutes. They may give effortless, automatic attention to activities and things they enjoy. But focusing deliberate, conscious attention to organizing and completing a task or learning something new is difficult.

Hyperactivity. People who are hyperactive always seem to be in motion. They can't sit still. They may dash around or talk incessantly. Sitting still through a lesson can be an impossible task. Hyperactive children squirm in their seat or roam around the room. Or they might wiggle their feet, touch everything, or noisily tap their pencil. Hyperactive teens and adults may feel intensely restless. They may be fidgety or, they may try to do several things at once, bouncing around from one activity to the next.

Impulsivity. People who are overly impulsive seem unable to curb their immediate reactions or think before they act. They may blurt out inappropriate comments. They may run into the street without looking. Their impulsivity may make it hard for them to wait for things they want or to take their turn in games. They may grab a toy from another child or hit when they're upset.

Not everyone who is overly hyperactive, inattentive, or impulsive has an attention disorder. Since most people sometimes blurt out things they didn't mean to say, bounce from one task to another, or become disorganized and forgetful, how can specialists tell if the problem is ADHD?

To assess whether a person has ADHD, specialists consider several critical questions: Are these behaviors excessive, long-term, and pervasive? That is, do they occur more often than in other people the same age? Are they a continuous problem, not just a response to a temporary situation? Do the behaviors occur in several settings or only in one specific place like the playground or the office? The person's pattern of behavior is compared against a set of criteria and characteristics of the disorder. These criteria appear in the DSM (short for the Diagnostic and Statistical Manual of Mental Disorders).

According to the DSM, there are three patterns of behavior that indicate ADHD. People with ADHD may show several signs of being consistently inattentive. They may have a pattern of being hyperactive and impulsive. Or they may show all three types of behavior.

According to the DSM,

Signs of inattention include:

• becoming easily distracted by irrelevant sights and sounds
• failing to pay attention to details and making careless mistakes
• rarely following instructions carefully and completely
• losing or forgetting things like toys, or pencils, books, and tools needed for a task

Some signs of hyperactivity and impulsivity are:

• feeling restless, often fidgeting with hands or feet, or squirming
• running, climbing, or leaving a seat, in situations where sitting or quiet behavior is expected
• blurting out answers before hearing the whole question
• having difficulty waiting in line or for a turn

Because everyone shows some of these behaviors at times, the DSM contains very specific guidelines for determining when they indicate ADHD. The behaviors must appear early in life, before age 7, and continue for at least 6 months. In children, they must be more frequent or severe than in others the same age. Above all, the behaviors must create a real handicap in at least two areas of a person's life, such as school, home, work, or social settings. So someone whose work or friendships are not impaired by these behaviors would not be diagnosed with ADHD. Nor would a child who seems overly active at school but functions well elsewhere.

The fact is, many things can produce these behaviors. Anything from chronic fear to mild seizures can make a child seem overactive, quarrelsome, impulsive, or inattentive. For example, a formerly cooperative child who becomes overactive and easily distracted after a parent's death is dealing with an emotional problem, not ADHD. A chronic middle ear infection can also make a child seem distracted and uncooperative. So can living with family members who are physically abusive or addicted to drugs or alcohol. Can you imagine a child trying to focus on a math lesson when his or her safety and well-being are in danger each day? Such children are showing the effects of other problems, not ADHD.

In other children, ADHD-like behaviors may be their response to a defeating classroom situation. Perhaps the child has a learning disability and is not developmentally ready to learn to read and write at the time these are taught. Or maybe the work is too hard or too easy, leaving the child frustrated or bored.

It's also important to realize that during certain stages of development, the majority of children that age tend to be inattentive, hyperactive, or impulsive--but do not have ADHD. Preschoolers have lots of energy and run everywhere they go, but this doesn't mean they are hyperactive. And many teenagers go through a phase when they are messy, disorganized, and reject authority. It doesn't mean they will have a lifelong problem controlling their impulses.

ADHD is a serious diagnosis that may require long-term treatment with counseling and medication. So it's important that a doctor first look for and treat any other causes for these behaviors.

What Can Look Like ADHD?

• Underachievement at school due to a learning disability
• Attention lapses caused by petit mal seizures
• A middle ear infection that causes an intermittent hearing problem
• Disruptive or unresponsive behavior due to anxiety or depression

One of the difficulties in diagnosing ADHD is that it is often accompanied by other problems. For example, many children with ADHD also have a specific learning disability (LD), which means they have trouble mastering language or certain academic skills, typically reading and math. ADHD is not in itself a specific learning disability. But because it can interfere with concentration and attention, ADHD can make it doubly hard for a child with LD to do well in school.

A very small proportion of people with ADHD have a rare disorder called Tourette's syndrome. People with Tourette's have tics and other movements like eye blinks or facial twitches that they cannot control. Others may grimace, shrug, sniff, or bark out words. Fortunately, these behaviors can be controlled with medication. Researchers currenlty are involved in evaluating the safety and effectiveness of treatment for people who have both Tourette's syndrome and ADHD.

More serious, nearly half of all children with ADHD--mostly boys--tend to have another condition, called oppositional defiant disorder. These children may overreact or lash out when they feel bad about themselves. They may be stubborn, have outbursts of temper, or act belligerent or defiant. Sometimes this progresses to more serious conduct disorders. Children with this combination of problems are at risk of getting in trouble at school, and even with the police. They may take unsafe risks and break laws--they may steal, set fires, destroy property, and drive recklessly. It's important that children with these conditions receive help before the behaviors lead to more serious problems.

At some point, many children with ADHD--mostly younger children and boys--experience other emotional disorders. About one-fourth feel anxious. They feel tremendous worry, tension, or uneasiness, even when there's nothing to fear. Because the feelings are scarier, stronger, and more frequent than normal fears, they can affect the child's thinking and behavior. Others experience depression. Depression goes beyond ordinary sadness--people may feel so "down" that they feel hopeless and unable to deal with everyday tasks. Depression can disrupt sleep, appetite, and the ability to think.

Because emotional disorders and attention disorders so often go hand in hand, every child who has ADHD should be checked for accompanying anxiety and depression. Anxiety and depression can be treated, and helping children handle such strong, painful feelings will help them cope with and overcome the effects of ADHD.

Of course, not all children with ADHD have an additional disorder. Nor do all people with learning disabilities, Tourette's syndrome, oppositional defiant disorder, conduct disorder, anxiety, or depression have ADHD. But when they do occur together, the combination of problems can seriously complicate a person's life. For this reason, it's important to watch for other disorders in children who have ADHD.

Health professionals stress that since no one knows what causes ADHD, it doesn't help parents to look backward to search for possible reasons. There are too many possibilities to pin down the cause with certainty. It is far more important for the family to move forward in finding ways to get the right help.

Scientists, however, do need to study causes in an effort to identify better ways to treat, and perhaps some day, prevent ADHD. They are finding more and more evidence that ADHD does not stem from home environment, but from biological causes. When you think about it, there is no clear relationship between home life and ADHD. Not all children from unstable or dysfunctional homes have ADHD. And not all children with ADHD come from dysfunctional families. Knowing this can remove a huge burden of guilt from parents who might blame themselves for their child's behavior.

Over the last decades, scientists have come up with possible theories about what causes ADHD. Some of these theories have led to dead ends, some to exciting new avenues of investigation.

One disappointing theory was that all attention disorders and learning disabilities were caused by minor head injuries or undetectable damage to the brain, perhaps from early infection or complications at birth. Based on this theory, for many years both disorders were called "minimal brain damage" or "minimal brain dysfunction." Although certain types of head injury can explain some cases of attention disorder, the theory was rejected because it could explain only a very small number of cases. Not everyone with ADHD or LD has a history of head trauma or birth complications.

Another theory was that refined sugar and food additives make children hyperactive and inattentive. As a result, parents were encouraged to stop serving children foods containing artificial flavorings, preservatives, and sugars. However, this theory, too, came under question. In 1982, the National Institutes of Health (NIH), USA, held a major scientific conference to discuss the issue. After studying the data, the scientists concluded that the restricted diet only seemed to help about 5 percent of children with ADHD, mostly either young children or children with food allergies.

ADHD Is Not Usually Caused by:

• too much TV
• food allergies
• excess sugar
• poor home life
• poor schools

In recent years, as new tools and techniques for studying the brain have been developed, scientists have been able to test more theories about what causes ADHD.

Using one such technique, scientists demonstrated a link between a person's ability to pay continued attention and the level of activity in the brain. Adult subjects were asked to learn a list of words. As they did, scientists used a PET (positron emission tomography) scanner to observe the brain at work. The researchers measured the level of glucose used by the areas of the brain that inhibit impulses and control attention. Glucose is the brain's main source of energy, so measuring how much is used is a good indicator of the brain's activity level. The investigators found important differences between people who have ADHD and those who don't. In people with ADHD, the brain areas that control attention used less glucose, indicating that they were less active. It appears from this research that a lower level of activity in some parts of the brain may cause inattention.

The next step will be to research WHY there is less activity in these areas of the brain. Scientists hope to compare the use of glucose and the activity level in mild and severe cases of ADHD. They will also try to discover why some medications used to treat ADHD work better than others, and if the more effective medications increase activity in certain parts of the brain.

Researchers are also searching for other differences between those who have and do not have ADHD. Research on how the brain normally develops in the fetus offers some clues about what may disrupt the process. Throughout pregnancy and continuing into the first year of life, the brain is constantly developing. It begins its growth from a few all-purpose cells and evolves into a complex organ made of billions of specialized, interconnected nerve cells. By studying brain development in animals and humans, scientists are gaining a better understanding of how the brain works when the nerve cells are connected correctly and incorrectly. Scientists are tracking clues to determine what might prevent nerve cells from forming the proper connections. Some of the factors they are studying include drug use during pregnancy, toxins, and genetics.

Research shows that a mother's use of cigarettes, alcohol, or other drugs during pregnancy may have damaging effects on the unborn child. These substances may be dangerous to the fetus's developing brain. It appears that alcohol and the nicotine in cigarettes may distort developing nerve cells. For example, heavy alcohol use during pregnancy has been linked to fetal alcohol syndrome (FAS), a condition that can lead to low birth weight, intellectual impairment, and certain physical defects. Many children born with FAS show much the same hyperactivity, inattention, and impulsivity as children with ADHD.

Drugs such as cocaine--including the smokable form known as crack--seem to affect the normal development of brain receptors. These brain cell parts help to transmit incoming signals from our skin, eyes, and ears, and help control our responses to the environment. Current research suggests that drug abuse may harm these receptors. Some scientists believe that such damage may lead to ADHD.

Toxins in the environment may also disrupt brain development or brain processes, which may lead to ADHD. Lead is one such possible toxin. It is found in dust, soil, and flaking paint in areas where leaded gasoline and paint were once used. It is also present in some water pipes. Some animal studies suggest that children exposed to lead may develop symptoms associated with ADHD, but only a few cases have actually been found.

Other research shows that attention disorders tend to run in families, so there are likely to be genetic influences. Children who have ADHD usually have at least one close relative who also has ADHD. And at least one-third of all fathers who had ADHD in their youth bear children who have ADHD. Even more convincing: the majority of identical twins share the trait. Researchers are also on the trail of a gene that may be involved in transmitting ADHD in a small number of families with a genetic thyroid disorder.

Many parents see signs of an attention deficit in toddlers long before the child enters school. For example, a child may be unable to focus long enough to play a simple game. Or, 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, 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 who are quiet and cooperative.

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.

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.

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 , and pemoline . 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 suggests that these medicines may also help children with an accompanying conduct disorder to control their impulsive, destructive behaviors.

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.

Stimulant drugs, such as methylphenidate (Ritalin), dextroamphetamine , and pemoline, 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. Pemoline is available in one form, which naturally lasts 5 to 10 hours. Ritalin and Dextroamphetamine 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 studying for an important exam. 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.

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.

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.

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.

While Ritalin is clearly effective in treating attention-deficit disorder (ADD) in the short term, a recent meta-analysis of clinical trials argues that the drug's long-term effectiveness has not been demonstrated. Researchers at the Children's Hospital of Eastern Ontario in Ottawa examined 62 studies involving 2,897 participants with ADD, with or without hyperactivity. They found that the quality of the research was poor (in particular, few studies compared Ritalin with a placebo) and that a publication bias may have suppressed studies questioning the drug's effectiveness. Only nine of the studies lasted more than four weeks, leaving some doubt about Ritalin's effectiveness and safety when given to children over longer periods of time. ADD without hyperactivity, such as the inattentive type, which is more common among girls, was poorly represented, so that the findings could not be generalized to girls. The current study's authors contend that a large trial lasting more than 14 months is required to demonstrate Ritalin's long-term effectiveness and safety. Until then, they recommend that clinicians carefully review the drug's benefits and side-effects prior to treatment, and carefully monitor their clients during treatment.

Canadian Medical Association Journal, November 27, 2001, v. 165(11): 1475 - 1488. Howard M. Schachter et al, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario.

The criteria for Attention-Deficit/Hyperactivity Disorder focus on behaviors that adults find frustrating and disruptive. Conflicts between children and adults are redefined as diseases or disorders within the children. Treatment with stimulant drugs such as methylphenidate (Ritalin) will produce greater docility in any child (or animal) without actually improving conduct or academic performance. Parents are not informed that they are trading behavioral control for toxic drug effects. The label ADHD is attached to children who are in reality deprived of appropriate adult attention These children require improved adult attention to their basic needs.

Myths About Stimulant Medication

Myth:

Stimulants can lead to drug addiction later in life.

Fact:

Stimulants help many children focus and be more successful at school, home, and play. Avoiding negative experiences now may actually help prevent addictions and other emotional problems later.

Myth:

Responding well to a stimulant drug proves a person has ADHD.

Fact:

Stimulants allow many people to focus and pay better attention, whether or not they have ADHD. The improvement is just more noticeable in people with ADHD.

Myth:

Medication should be stopped when the child reaches adolescence.

Fact:

Not so! About 80 percent of those who needed medication as children still need it as teenagers. Fifty percent need medication as adults.

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 to learn to think through tasks and organize the 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 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. 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.

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.

Even though most people don't outgrow ADHD, people do learn to adapt and live fulfilling lives--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. They may find that by structuring tasks and controlling their environment, they can achieve personal goals. They may learn to channel their excess energy into sports and other high energy activities. And 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.

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.

The U.S. Department of Education is cosponsoring a large national study since 1999--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.

Other scientists 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 research are 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 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.

Excerpt: The ADHD children who had not had any ADHD medications showed the same significantly smaller total brain and cerebellar volumes, but also showed a striking 10.7% smaller total white matter volume than controls.

Excerpt: The most feared side effect, movement difficulties (i.e. stiffness, known as extrapyramidal symptoms) occurred in 13% of the Risperidone group compared with 5% of the placebo group.

Title: Slow release stimulant drug SLI381 highly effective for after school and evening ADHD and problem behaviours

Excerpt: The children receiving the drug showed a significant five-fold improvement in their behaviour rated by teachers and 2.5 fold improvement rated by parents at the end of the three weeks, compared to the children on placebo.

Excerpt: The degree of prematurity was directly linked with the reduction in cognitive/IQ scores - the less premature, the less reduction.

Source: JAMA Date: August 2002 .

Title: ADHD up to 10 times more common in young adults than previously thought

Excerpt: The researchers concluded that previous studies of the frequency of ADHD which only used self-report methods may greatly underestimate the true prevalence of the condition in adult life.

Excerpt: None of the children had severe movement problems but 19 of them had significant minor movement problems (fine motor problems, clumsiness etc) and were classified as ADHD-MD.

Excerpt: They also found that the biggest increase in antidepressant use was by primary care doctors such as general practitioners/ family doctors, rather than by specialist psychiatrists or paediatricians.

Title: Sleep problems in early childhood linked to later ADHD

Excerpt: By the time the children were six years of age, seven (26%) of the children who had had severe sleep disorder as an infant, had ADHD (true ADHD by strict criteria) whereas none of the comparative (control) children had ADHD.

Excerpt: 85% of the definites were on medication, compared to 40% of the probables and 6% of the questionables.

Excerpt: The researchers calculated whether having soft signs could be used by doctors to predict the presence of low IQ, learning problems, behaviour problems and conditions such as ADHD.

Excerpt: The authors recruited 282 children with ADHD aged between six and 12 years. They randomly allocated them to three groups to receive either standard ritalin three times per day or OROS MPH once per day or an identical placebo.

Excerpt: They screened 250 patients on the telephone and recruited 63 6-12 year old children with ADHD (all of them already on stimulant drugs) to take either DHA (345mg per day) or an identical placebo for four months.

Excerpt: They found that 60% had improvements in their symptoms of both ADHD and depression.

Excerpt: Almost no side-effects were noted in all patients except one who stopped the drug because of excessive insomnia and night tremors.

Excerpt: 60% had a very poor outcome which included living on a pension, being convicted of a crime or having a drug or alcohol disorder

Excerpt: The researchers used a new 'expert consensus methodology' to attempt to get a panel of around 40 national experts to agree on a scientific policy for the drug treatment of ADHD.

Excerpt: The authors studied the brains of adults with ADHD using SPECT (single photon emission tomography), a scanning technique that allows us to integrate brain structure with function.