It's about Time: Promising Practices for Children and Adolescents with ADHD

Prepared by Harvey C. Parker, Ph.D.

What is ADHD?
ADHD is a neurologically-based disorder which affects one’s ability to regulate behavior and attention. People with ADHD often have problems sustaining attention, controlling activity, and managing impulses. Although we can easily regulate many things in our environment, regulating ourselves is not always so simple. Unfortunately, the process of self-regulation—purposefully controlling behavior—is rather complicated.

The brain is responsible for self-regulation-planning, organizing, and carrying out complex behavior. These are called “executive functions.” They develop from birth through childhood. During this time, we develop language to communicate with others and with ourselves, memory to recall events, a sense of time to comprehend the concept of past and future, visualization to keep things in mind, and other skills that enable us to regulate our behavior.

Executive functions are carried out in a part of the brain called the orbital-frontal cortex. This area of the brain may not be as active in people with ADHD. This area is richer in neurons (brain cells) which depend on dopamine to operate efficiently. Stimulant medications affect dopamine production and, therefore, lead to improved executive functioning.

How Common is ADHD?
Most experts agree that ADHD affects from 3 to 5 percent of the population. Children with ADHD have been identified in every country in which ADHD has been studied. For example, rates of ADHD in New Zealand ranged in several studies from 2 to 6 percent, in Germany 8.7 percent, in Japan 7.7 percent, and in China 8.9 percent. ADHD is more common in boys than girls. Girls are often older than boys by the time they are diagnosed and they are less likely to be referred for treatment. This is because the behavior of girls with ADHD is not usually disruptive or aggressive. Girls are typically less trouble to their parents and teachers.

What Causes ADHD?
ADHD has been extensively studied for more than fifty years. With recent advances in technology, which allow us to study brain structure and functioning, there has been a greater appreciation for the neurobiological basis of ADHD. However, the pathogenesis of ADHD varies. Studies involving molecular genetics have provided us with mounting evidence to support the theory that ADHD can be a genetic disorder for many individuals. It is not likely caused by one gene alone, but the result of multiple genes and their interaction with the social and physical environment of the individual. Not everyone who has ADHD inherited it. ADHD may also be caused by problems in development related to pregnancy and delivery, early childhood illness, head injury caused by trauma, or exposure to certain toxic substances.

How is ADHD Diagnosed?
A physician or mental health professional with appropriate training can diagnose those suspected of having ADHD. The Diagnostic and Statistical Manual of Mental Disorders (DSM IV), published by the American Psychiatric Association in 1994, provides health care professionals with the criteria that need to be met to diagnose a person with ADHD. To receive a diagnosis of ADHD a person must exhibit a certain number of behavioral characteristics reflecting either inattention or hyperactivity and impulsivity for at least six months to a degree that is “maladaptive and inconsistent with developmental level.” These behavioral characteristics must have begun prior to age seven, must be evident in two or more settings (home, school, work, community), and must not be due to any other mental disorder such as a mood disorder, anxiety, learning disability, etc. These eighteen characteristics are listed below:
Inattention Symptoms

1. often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
2. often has difficulty sustaining attention in tasks or play activities
3. often does not seem to listen when spoken to directly
4. often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
5. often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
6. often has difficulty organizing tasks and activities
7. often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
8. often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
9. is often easily distracted by extraneous stimuli
10. is often forgetful in daily activities

Hyperactive Symptoms

1. often fidgets with hands or feet or squirms in seat
2. often leaves seat in classroom or in other situations in which remaining seated is expected
3. often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
4. often has difficulty playing or engaging in leisure activities quietly
5. is often “on the go” or often acts as if “driven by a motor”
6. often talks excessively

Impulsive Symptoms

1. often blurts out answers before questions have been completed
2. often has difficulty awaiting his or her turn
3. often interrupts or intrudes on others (e.g., butts into conversations or games)

There are three types of ADHD. Some children with ADHD show symptoms of inattention and are not hyperactive or impulsive. Others only show symptoms of hyperactivity-impulsivity. Most, however, show symptoms of both inattention and hyperactivity-impulsivity.

• predominantly inattentive type
• predominantly hyperactive-impulsive type
• combined type

While the term ADHD is the technically correct term for either of the three types indicated above, in the past the term attention deficit disorder (ADD) was used, and still is by many. For the past ten years ADD and ADHD have been used synonymously in publications and in public policy.

Complete this ADHD Symptom Checklist
Below is a checklist containing 18 items which describe characteristics frequently found in people with ADHD. Items 1-9 describe characteristics of inattention. Items 10-15 describe characteristics of hyperactivity. Items 16-18 describe characteristics of impulsivity.
In the space before each statement put the number that best describes your child’s (your student’s) behavior (0=never or rarely; 1 = sometimes; 2 = often; 3 = very often).

___1. Fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
___2. Has difficulty sustaining attention in tasks or play activities.
___3. Does not seem to listen when spoken to directly.
___4. Does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).
___5. Has difficulty organizing tasks and activities.
___6. Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework).
___7. Loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools).
___8. Is easily distracted by extraneous stimuli.
___9. Is often forgetful in daily activities.
___10. Fidgets with hands or feet or squirms in seat.
___11. Leaves seat in classroom or in other situations in which remaining seated is expected.
___12. Runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness).
___13. Has difficulty playing or engaging in leisure activities quietly.
___14. Is “on the go” or often acts as if “driven by a motor.”
___15. Talks excessively.
___16. Blurts out answers before questions have been completed.
___17. Has difficulty awaiting his or her turn.
___18. Interrupts or intrudes on others (e.g., butts into conversations or games).

Count the number of items in each group (inattention items 1-9 and hyperactivity-impulsivity items 10-18) you marked “2” or “3.” If six or more items are marked “2” or “3” in each group this could indicate serious problems in the groups marked.

Associated Problems
Many people with ADHD have associated problems which doctors call, co-morbid conditions. Children with ADHD are likely to experience problems with learning, behavior, and mood. Learning disabilities affect as many as twenty-five percent of children with ADHD and cause problems in reading, written language, and mathematics. Many children and teens with ADHD have other behavioral problems-strong-willed, difficult to manage, temper outbursts, irritable mood, etc. They may be diagnosed as having oppositional defiant disorder, or in more severe cases, conduct disorder. Problems with low self-esteem, depression, and anxiety also affect a good number of people with ADHD from childhood through adulthood. Some have such extreme mood shifts, episodes of manic behavior, temper outbursts and may suffer from bipolar disorder. Treating these co-morbid problems is very important.

How is ADHD Treated?
Medication Treatments. Fortunately, we have made many advances in treating ADHD. Stimulants are the best studied medicines for ADHD. Commonly prescribed stimulants are Ritalin®, Adderall®, Methylin®, Dexedrine®, and Concerta®. With over 150 controlled double-blind studies of stimulant use in children with ADHD, the findings are well documented that these medicines improve attention span, self-control, behavior, fine motor control, and social functioning. Stimulants are quick-acting (within 30 minutes), but short lasting (4 to 6 hours). Newer preparations, such as Concerta® promise once-a-day dosing lasting up to 12 hours. Antidepressant medications (Imipramine® and Desipramine®, for example) and Welbutrin® have been less well studied than stimulants but have been shown to be effective agents for ADHD. Certain anti-hypertensive medications known as adrenergic agonists (Clonidine® and Tenex®) have been shown to be effective as well to manage hyperactivity, impulsivity, and aggression.

In the NIMH funded MTA study completed in 1999, nearly 600 children ages 7 to 9 were assigned to four treatment conditions (medication, behavior treatment at home and school, combination of medication and behavior treatment, and community treatment). During the 14 months of treatment, children were evaluated on ADHD symptoms by parents and teachers. Medication accounted for the largest improvement in ADHD symptoms. The addition of behavior treatments resulted in additional modest gains which normalized behavior.

Educational Interventions. Educators understand the importance of providing assistance to students with ADHD. Under existing federal laws (IDEA, ADA, Rehabilitation Act of 1973 [Section 504]) public schools are required to provide special education and related services to students with ADHD who need such assistance. Schools must meet the needs of those with ADHD who require accommodations in regular education classes. Such accommodations may “even the playing field” for those disabled by ADHD who must compete with other students in school.

Students with ADHD have a greater risk of having academic skill problems. These problems could be the result of different factors. For example, difficulty with attention and focus will obviously cause the student to miss important instruction. Insufficient practice and review of material taught in class will reduce the chance of strengthening skills. Deficits in speech and language or in perceptual processing (such as auditory or visual memory, association, or discrimination) may be more common in students with ADHD. Such deficits are often associated with problems in learning.

Reading is a fundamental skill that is learned and practiced both inside and outside the classroom. Parents play an important role in the development of reading and language skills. Parents should make sure that their child sees them read often and write letters, messages, and instructions. Encourage your child to read every day and read with young children when possible. The single most important step to overcome a reading problem is for the child to receive individualized tutoring in a phonics-based approach to reading.

Students with ADHD may have more difficulty with spelling. They may not pay attention to detail when writing or may be careless. This can cause spelling errors. Some students may have weaknesses in auditory or visual memory which can also contribute to problems with spelling. Teach a phonetic approach to word analysis. Although many words are not spelled as they sound, a good understanding of phonics can be a powerful aid to weak spellers.

Students with ADHD often have difficulty with fine-motor control. This can affect their handwriting. For some, written work becomes so laborious they avoid it. Writing assignments that may take other students a few minutes, may take the student with fine-motor problems hours to complete. Encourage the student to use a sharp pencil and have an eraser available. Teach appropriate posture and how to position the paper correctly. Experiment with pencil grip, special papers, etc. Allow student to use laminated handwriting cards, containing samples of properly formed letters.

Managing Behavior. Over half of children with ADHD present challenging behavior which must be managed by parents or teachers. Behavior modification principles involving systematic delivery of reinforcements and punishments work pretty well. Parents and teachers who are structured, consistent, provide close supervision and feedback about behavior to children and teens with ADHD get the best results. Instruction in such strategies can be obtained through parent training groups offered in school districts or community clinics or practices. The following suggestions apply to parents and teachers:

• Post house/school rules in a conspicuous place. Clearly communicated rules are helpful in maintaining proper behavior. Children with ADHD may need such rules to be reviewed daily. When possible, consequences for rule violations should be specified.
• Be alert to early warning signs of a problem. Anticipate trouble brewing. Intervene quickly before a situation becomes problematic.
• Provide concrete, visual examples of appropriate and inappropriate behavior. Use role-playing to illustrate these behaviors giving students clear guidelines as to teacher expectations.
• Establish routines for regular family or classroom activities (i.e. at home —cleaning room, doing homework, morning and bedtime tasks; at school—handing out and collecting papers in class, entering and leaving the room, taking attendance, answering questions, etc.)
• Use “proximity control” to manage problem behavior. Stay near the child who is acting out so you can provide immediate, frequent praise for appropriate behavior and quickly intervene when/if negative behavior occurs.
• Redirect the acting out child to more appropriate behavior when you notice inappropriate behavior (i.e., a student who is talking to another student could be redirected to get on task).
• Praise positive behavior often. Positive reinforcement is an effective way to motivate children to behave appropriately. Use of verbal praise can be extremely effective.
• Use response-cost to encourage behavior change. Response cost (loss of tokens or points, privileges, free time, etc.) should be implemented for student misbehavior. Behavior change is most effective when teachers praise or reward positive behavior and provide punishment (response costs) for inappropriate student behavior.

Seven Principles for Parents of AD/HD Children and Teens

1. Provide unconditional love and positive regard.
2. Spend enjoyable time with your child.
3. Become an AD/HD expert.
4. Model good values.
5. Provide structure at home with clear and consistent rules.
6. Monitor compliance with rules and check behavior regularly.
7. Inspire confidence as a parent-coach.

Summary
Parents need to become “ADHD experts.” Through their knowledge of ADHD and their familiarity with the needs of their child, they can coordinate treatment by health professionals, communicate with educators, and advocate for their child to ensure that the best possible programs are in place to help their child succeed. Knowing the basic facts about ADHD reviewed in this article will help parents and teachers understand ADHD. This can be an important first step in helping children and teens.

Books and Training Programs for Teachers and Parents
Barkley, R. A. (2000). Taking charge of ADHD: The complete authoritative guide for parents. New York: Guilford Press.
Christie, L. & Mitchell, S. (2000). Attention Deficits Update 2000. Florida: Professional Development Resources, Inc.
Dendy, C. A. (1995). Teenagers with ADD: A parents’ guide. Maryland: Woodbine House.
Hallowell, E. & Ratey, J. (1994). Driven to distraction. New York: Simon and Schuster.
Koplewicz, H. S. (1996). It’s nobody’s fault: New hope and help for difficult children and their parents. New York: Random House.
Latham P, & Latham, P. (1998). ADD and the law (2nd ed.). Washington, DC: JKL Communications.
Nadeau, K. G. & Biggs, S. H. (1995). School strategies for ADD teens. VA: Chesapeake Psychological Services.
Parker, H. C. (1999). Put yourself in their shoes: Understanding teenagers with attention deficit hyperactivity disorder. Plantation, FL: Specialty Press, Inc.
Parker, H. C. (1994). The ADD hyperactivity workbook for parents, teachers, and kids (2nd. ed). Plantation, FL: Specialty Press, Inc.
Parker, H. C. (1992). The ADD hyperactivity handbook for schools (2nd. ed.). Plantation, FL: Specialty Press, Inc.
Phelan, T. (1993). Surviving your adolescents. Glenn Elyn: IL: Child Management.
Rief, S. (1993). How to reach and teach ADD/ADHD children. West Nyack, NY: The Center for Applied Research in Education.
Zentall, S. S. & Goldstein, S. (1999). Seven steps to homework success: A family guide for solving common homework problems. Plantation, FL: Specialty Press, Inc.

Videos for Teachers and Parents
Barkley, R. A. (1992). ADHD—What do we know? New York: The Guilford Press.
Barkley, R. A. (1992). ADHD—What can we do? New York: The Guilford Press.
Phelan, T. 1-2-3 Magic! Training your preschooler and preteen to do what you want them to do! Glen Ellyn, IL: Child Management, Inc.
Robin, A. L. & Weiss, S. K. (1997). Managing oppositional youth. Effective, practical strategies for managing the behavior of hard to manage kids and teens! Plantation, FL: Specialty Press, Inc.

Books and Videos for Children and Adolescents
Bramer, J. S. (1996). Succeeding in college with attention deficit disorders: Issues and strategies for students, counselors, & educators. Plantation, FL: Specialty Press, Inc.
Corman, C. & Trevino, E. Eukee the jumpy jumpy elephant. Plantation, FL: Specialty Press, Inc. Davis, L., Sirotowitz, S. & Parker, H. (1996). Study strategies made easy: A practical plan for school success. Plantation, FL: Specialty Press, Inc.
Gordon, M. (1991). Jumpin’ Johnny get back to work: A child’s guide to ADHD/hyperactivity. DeWitt, NY: GSI Publications.
Nadeau, K. G. & Biggs, S. H. (1993). School strategies for ADD teens. Annandale, VA: Chesapeake Psychological Pub.
Parker, R. N. & Parker, H. C. (1995). Slam dunk: A young boy’s struggle with ADD. Plantation, FL: Specialty Press, Inc.
Parker, R. N. and Parker, H. C. (1992). Making the grade: An adolescent’s struggle with attention deficit disorders. Plantation, FL: Specialty Press, Inc.
Quinn, P. O. (1994). ADD and the college student. Washington, DC: Magination Press.
Quinn, P. O. & Stern, J. (1991). Putting on the brakes. New York: Magination Press.