Archives: Consumer Topics

by Dr. Robert Myers, Child Psychologist

Imagine that you are living inside of a video game, where everything is coming at you at once and every sight, sound and sensation is a distraction. For a child with ADHD, getting through a typical day is something like that-and it explains a great deal about how they experience the world. Children with ADHD typically have impairment of functions such as concentration, memory, impulse control, processing speed and an inability to follow directions. If you're a parent of a child with ADD or ADHD, this most likely sounds all too familiar. Over the years, you've probably struggled through homework sessions with your child, tried (and failed) to get them to complete certain tasks like cleaning their room or finishing yard work, and on more than one occasion, you've probably felt completely drained by their high energy and seeming inability to focus.

The good news is, there is something you can do to help your ADHD child improve their concentration skills. For years it was thought that each of us was born with a generous supply of brain cells, but that we were unable to produce additional cells or make changes in how they function. Fairly recently, neuroscientists discovered the presence of something called "neuroplasticity" which enables the brain to actually grow additional cells or modify the function of existing cells. Amazingly, cognitive exercises have been found to produce desired changes in not only how the brain works, but how it looks. What this means for parents is that you now have the ability to work with your child to help improve their ADHD symptoms.

As a child psychologist and the father of a son with ADHD, I developed a host of exercises that help ADHD kids improve their concentration. The key is presenting them as games that are actually fun for parents and children to do together.

Here are a few simple suggestions to get you started:

1. The Coin Game: This is one of the games that we use in the Total Focus Program. Parents like it because it improves memory and sequencing as well as attention and concentration, and kids enjoy it because it's fast-paced and fun. First, you will need a small pile of assorted coins, a cardboard sheet to cover them, and a stopwatch (or a regular watch with a second hand.) Choose five of the coins from the pile (for this example, we'll say three pennies and two nickels) and put them into a sequence. Now, tell your child to "Look carefully at the coins arranged on the table." Then, cover the coins with the cardboard. Start the stopwatch, and then ask them to make the same pattern using the coins from the pile. When they are finished, mark the time with the stopwatch and remove the cardboard cover. Write down the time it took them to complete the pattern and whether or not they were correct. If they didn't complete it correctly, have them keep trying until they can do it. You can increase the difficulty of the patterns as you go, and include pennies, nickels, dimes, quarters, and half dollars. You'll see your child's concentration and sequencing improve the more they play, which is a great reward for both of you.

2. Relaxation and Positive Imagery: Combining simple relaxation techniques such as deep breathing with positive visual imagery helps the brain to improve or learn new skills. For instance, research shows that if a person mentally practices their golf swing, the brain actually records the imaginary trials the same as if they were real trials which leads to improvement on the golf course. So ADHD kids can "imagine" that they're paying attention in class or able to handle teasing, and this can in turn change their behavior at school. You and your child can use your own creativity and give this a try.

3. Mind - Body Integration: An example of this technique would be to have your child attempt to sit in a chair without moving. The parent times how long the child is able to accomplish this. Repeated practice over several weeks will show improvement. Through this activity, the neural connections between the brain and body are strengthened, providing improved self-control.

4. Crossword Puzzles and Picture Puzzles: It sounds simple, but these are great tools for kids with ADHD. Crossword puzzles actually improve attention for words and sequencing ability, while picture puzzles-in which your younger child has to look for things that are "wrong" in the picture or look for hard-to-find objects-also improve attention and concentration.

5. Memory and Concentration Games: Children's games such as Memory or Simon are great ideas for improving memory and concentration. They are quick and fun. Memory motivates the child to remember the location of picture squares and Simon helps them memorize sequences of visual and auditory stimuli. Through repeated playing, brain circuits are "exercised" and challenged, which strengthens connections and thus improves function. Also, there are some free computer games on the internet that also improve concentration or memory: Memory, Mosquito Killer and Memorizer. For older children and adolescents, check out the cognitive exercises provided by Lumosity.

As you do all of these "brain exercises," you should work together with your child serving as his or her "coach." Provide them with encouragement and track their progress as they improve. This is a win/win solution, because it also strengthens the relationship you have with your child.

Go ahead. Have some fun. Do the exercises along with your child, and who knows, you may find your brain will work a little faster and smarter, too!

These suggestions are provided as activities to supplement medical and/or psychological treatment provided under the guidance of a physician or psychologist. They will enhance the benefits of the treatment but will not on their own resolve serious symptoms for a child who has been accurately diagnosed with ADHD.

5 Simple Concentration Building Techniques for Kids with ADHD reprinted with permission from Empowering Parents. For more information, visit www.EmpoweringParents.com

Author: Dr Robert Myers is a child psychologist with over 25 years of experience working with children and adolescents with Attention Deficit Hyperactivity Disorder and learning disabilities and is the creator of the Total Focus Program www.trytotalfocus.com. Dr Myers is Associate Clinical Professor of Psychiatry and Human Behavior at UC Irvine School of Medicine. "Dr Bob" has provided practical information for parents as a radio talk show host and as editor of Child Development Institute's website, 4parenting.com which reaches 3 million parents each year. Dr. Myers earned his PhD from the University of Southern California.

Page last modified or reviewed on January 23, 2014

With all the things that you have to do each day, finding the time and motivation to get moving can be challenging. Here are some suggestions for ways to get started:

• If you do not have 30 minutes in one stretch to set aside for moderate physical activities, try being active in three 10-minute periods throughout the day.
• Join a sports team. For example, you may work for a company that has a baseball team that you could join.
• Join a hiking or running club.
• Use stairs instead of the elevator.
• Walk or bike to work or to the store.
• Be physically active at lunch with co-workers, family, or friends.
• Take a break at work to stretch or take a quick walk.
• Go dancing with your partner or friends.
• Plan active vacations rather than only driving trips.
• Wear a pedometer (a small tool worn on your belt that counts the number of steps you take). Try to walk 10,000 steps each day.
• While watching TV, use a stationary bicycle or treadmill. Another idea is to work out with hand weights.
• Spend time in active play with your kids. While you're at it, you could also teach your kids about the health benefits of physical activity. Children and adolescents should be engaging in at least 60 minutes of moderate-intensity physical activity on most, and prefer-ably all, days of the week.l If you are having trouble finding the time or motivation to be physically active, figure out what is holding you back and then brainstorm with family and friends about ways to overcome these barriers.

Perhaps the most important tip, though, is to find physical activities that you enjoy. You are more likely to keep physically active if you are having fun.

SAFETY TIPS While you are being physically active, be sure to keep safety in mind. We have already mentioned some safety tips, such as starting slow if you have not been physically active for a long time. Below are a few more safety tips: Use safety equipment. For example, wear a helmet for bike riding or the right shoes for walking or jogging. Drink plenty of fluids when you are physically active, even if you are not thirsty. Always bend forward from the hips, not the waist. If you keep your back straight, you're probably bending the right way. If your back "humps," that's probably wrong.

Source: Adapted from The Healthy Woman: A Complete Guide for All Ages
U.S. Department of Health and Human Services, Office on Women's Health - 2008

Reviewed by athealth on February 6, 2014.

What is Acute Stress Disorder (ASD)?

Acute Stress Disorder, or ASD, is a psychiatric diagnosis that was introduced into the DSM-IV in 1994. The current diagnostic criteria for ASD are similar to the criteria for PTSD, although the criteria for ASD contain a greater emphasis on dissociative symptoms and the diagnosis can only be given within the first month after a traumatic event. The inclusion of ASD in the DSM-IV was not accompanied by extensive research, and some debate exists regarding whether the diagnostic criteria accurately reflect pathological reactions to trauma that occur within the first month after a trauma ¹ . However, even though debate exists about the empirical basis of the diagnosis, it has been found to be highly predictive of subsequent PTSD.

How Common Is ASD?

Because ASD is a relatively new diagnosis, research on the disorder is in the early stages. Studies of ASD have utilized a variety of measurement tools with varying degrees of reliability and validity. The following rates should be interpreted with some caution, and it is possible that rates will change as measures for ASD become more uniform among researchers.

Studies of motor vehicle accident (MVA) survivors have found rates of ASD ranging from approximately 13%^{2, 3} to 21%⁴ . A study of survivors of a typhoon revealed an ASD rate of 7% ⁵ while a study of survivors of an industrial accident revealed a rate of 6%.⁶ A rate of 19% was found in survivors of violent assault ⁷ while a rate of 13% was found in a mixed group consisting of survivors of assaults, burns, and industrial accidents.⁸ A recent study of victims of robbery and assault found that 25% met criteria for ASD⁹ while a study of victims of a mass shooting found that 33% met criteria.¹⁰

A study that used PTSD criteria and evaluated rape survivors within the first month of a trauma revealed a rate of 94%.¹¹ This last study evaluated PTSD diagnostic criteria related to the first month of a trauma. Therefore, it did not assess for the presence of dissociative symptoms that are specific to the diagnosis of ASD (but not PTSD). However, the Rothbaum et al.¹¹ study is included here to give the reader a sense of the level of posttraumatic sequelae that may be expected after sexual assault.

Who is at risk for ASD resulting from trauma?

While many studies have examined factors that place individuals at risk for developing PTSD, only a handful of studies have examined risk factors for the development of ASD. One retrospective study¹² found that individuals with exposure to prior trauma, individuals with prior PTSD, and individuals with more psychiatric dysfunction were all more likely to develop ASD when confronted with a new traumatic stressor. Bryant and Harvey¹ report that in their sample of MVA survivors without head injuries, depression score, history of psychiatric treatment, history of PTSD, and prior motor vehicle accidents were strong predictors of ASD severity (accounting for 61% of the variance). There is also some evidence that individuals prone to experiencing dissociation in the face of traumatic stressors may be more likely to develop ASD.¹³

How do PTSD and ASD differ?

ASD and PTSD differ in two fundamental ways. The first difference is that the diagnosis of ASD can be given only within the first month following a traumatic event. If posttraumatic symptoms were to persist beyond a month, the clinician would assess for the presence of PTSD. The ASD diagnosis would no longer apply. ASD also differs from PTSD in that it includes a greater emphasis on dissociative symptoms. An ASD diagnosis requires that a person experience three symptoms of dissociation (e.g., numbing, reduced awareness, depersonalization, derealization, or amnesia) while the PTSD diagnosis does not include a dissociative symptom cluster. (Please see Bryant and Harvey's comprehensive text on ASD¹ for a thorough discussion of the differences between ASD and PTSD.)

How predictive of PTSD is ASD?

A diagnosis of ASD, in the absence of treatment, appears to be an accurate predictor of subsequent PTSD. Harvey and Bryant³ found that 78% of MVA survivors who initially met criteria for ASD met criteria for PTSD 6 months posttrauma. In a similar study of MVA survivors with mild traumatic brain injury, 82% of those initially diagnosed with ASD met criteria for PTSD 6 months posttrauma¹⁴ . Brewin et al.⁷ found that 83% of assault victims who initially met criteria for ASD met criteria for PTSD at a 6-month follow-up.

Bryant and Harvey¹ note that while ASD is highly predictive of subsequent PTSD, subthreshold ASD (which is typically ASD without the dissociative symptoms) is also a good predictor of PTSD. This suggests that the ASD criteria do not adequately capture all individuals who are at risk for developing full-blown PTSD. The reason for this appears to be that some individuals at risk for PTSD do not develop acute dissociative symptoms and therefore do not ever meet criteria for ASD. Research is currently underway regarding the different trajectories that individuals follow in the development of PTSD.

How is ASD diagnosed?

Because ASD is a relatively new diagnosis, there are few well-established and empirically validated measures to assess it. Although a comprehensive review of assessment measures is beyond the scope of this fact sheet, the tools with the strongest psychometric properties are described below:

• The Acute Stress Disorder Interview (ASDI)¹⁵ is the only structured clinical interview that has been validated against DSM-IV criteria for ASD. It appears to meet standard criteria for internal consistency, test-retest reliability, and construct validity. The interview was validated by comparing it with independent diagnostic decisions made by clinicians with experience in diagnosing both ASD and PTSD.
• The Acute Stress Disorder Scale (ASDS)¹⁶ is a self-report measure of ASD symptoms that correlates highly with symptom clusters on the ASDI. It has good internal consistency, test-retest reliability, and construct validity.

Both scales may be found in Bryant and Harvey's text on ASD.¹

Are there effective treatments for ASD?

Cognitive-behavioral interventions

At present, cognitive-behavioral interventions during the acute aftermath of trauma exposure have yielded the most consistently positive results in terms of preventing subsequent posttraumatic psychopathology. Four out of five randomized clinical trials (RCTs) related to early cognitive-behavioral interventions during the acute aftermath of trauma^{17, 18, 19, 20} found that the Cognitive-Behavioral Therapy (CBT) group experienced a greater reduction of PTSD symptoms than comparison groups. One of the RCTs²¹ did not find this to be true. The study by Brom et al.²¹ found that all three active conditions (desensitization, hypnotherapy, and psychodynamic therapy) yielded equal improvement relative to the waitlist control group. However, the Brom et al.²¹ study lacked a treatment adherence measure so it is unclear whether the CBT intervention was implemented in a standardized manner relative to other studies of CBT.

A different controlled (but not randomized) comparison of a CBT versus an assessment-only course of action in the acute phase posttrauma found fewer PTSD symptoms in the CBT group at a 5 1/2 -month follow-up.²²

Bryant and colleagues^{15, 19} have conducted the only studies that specifically assessed and treated ASD. They have shown that a brief cognitive-behavioral treatment may not only ameliorate ASD, but it may also prevent the subsequent development of PTSD. Approximately 10 days after exposure to an MVA, industrial accident, or nonsexual assault, Bryant and colleagues randomly assigned those with ASD to five individual, 11/2-hour sessions of either a cognitive-behavioral treatment or a supportive counseling control condition. They found that fewer CBT subjects met criteria for PTSD posttreatment and 6 months later. In the 1999 study, Bryant and colleagues compared two different individual CBT approaches (prolonged exposure plus anxiety management and prolonged exposure alone) to a supportive counseling intervention. They found that both CBT groups showed significantly greater reductions in PTSD symptom severity compared to the supportive counseling group. (Please see Bryant and Harvey's text¹ for a detailed description of their cognitive-behavioral intervention for ASD.)

Psychological debriefing?

Psychological debriefing is an early intervention that was originally developed for rescue workers that has been more widely applied in the acute aftermath of potentially traumatic events. However, RCTs of debriefing have yielded inconsistent findings in terms of its efficacy. A review of the literature on debriefing RCTs²³ concluded that there is little evidence to support the continued use of debriefing with acutely traumatized individuals. Mitchell and Everly²⁴ , the originators of the debriefing model, have made the cogent argument that most of the debriefing RCTs to date have studied only one component (debriefing) of the longer-term and more comprehensive Critical Incident Stress Management model. It is possible that this more comprehensive intervention would prove efficacious, but to date no RCTs have been conducted using the full intervention.

Recommended Readings

Please see Bryant and Harvey's comprehensive text, Acute Stress Disorder: A Handbook of Theory, Assessment, and Treatment¹, published by the American Psychological Association. This contains an overview of relevant research as well as theoretical and treatment considerations.

References

1. Bryant, R.A., & Harvey, A.G. (2000). Acute Stress Disorder: A handbook of theory, assessment, and treatment. Washington, D.C.: American Psychological Association.

2. Harvey, A.G., & Bryant, R.A. (1998a) Acute Stress Disorder following mild traumatic brain injury. Journal of Nervous and Mental Disease, 186, 333-337.

3. Harvey, A.G., & Bryant, R.A. (1998b). The relationship between Acute Stress Disorder and Posttraumatic Stress Disorder: A prospective evaluation of motor vehicle accident survivors. Journal of Consulting and Clinical Psychology, 66, 507-512.

4. Holeva, V., Tarrier, N., & Wells, A. (2001). Prevalence and predictors of Acute Stress Disorder and PTSD following road traffic accidents: Thought control strategies and social support. Behavior Therapy, 32, 65-83.

5. Stabb, J.P., Grieger, T.A., Fullerton, C.S., & Ursano, R.J. (1996). Acute Stress Disorder, subsequent Posttraumatic Stress Disorder and depression after a series of typhoons. Anxiety, 2, 219-225.

6. Creamer, M., & Manning, C. (1998). Acute Stress Disorder following an industrial accident. Australian Psychologist, 33, 125-129.

7. Brewin, C.R., Andrews, B., Rose, S., & Kirk, M. (1999). Acute Stress Disorder and Posttraumatic Stress Disorder in victims of violent crime. American Journal of Psychiatry, 156, 360-366.

8. Harvey, A.G., & Bryant, R.A. (1999). Acute Stress Disorder across trauma populations. Journal of Nervous and Mental Disease, 187, 443-446.

9. Elklit, A. (2002). Acute Stress Disorder in victims of robbery and victims of assault. Journal of Interpersonal Violence, 17, 872-887.

10. Classen, C., Koopman, C., Hales, R., & Spiegel, D. (1998). Acute Stress Disorder as a predictor of posttraumatic stress symptoms. American Journal of Psychiatry, 155, 620-624.

11. Rothbaum, B.O., Foa, E.B., Riggs, D.S., Murdock, T., & Walsh, W. (1992). A prospective examination of Post-traumatic Stress Disorder in rape victims. Journal of Traumatic Stress, 5, 455-475.

12. Barton, K.A., Blanchard, E.B., & Hickling, E.J. (1996). Antecedents and consequences of Acute Stress Disorder among motor vehicle accident victims. Behaviour Research and Therapy, 34, 805-813.

13. Bryant, R.A., Guthrie, R.M., & Moulds, M.L. (2001). Hypnotizability in Acute Stress Disorder. American Journal of Psychiatry, 158, 600-604.

14. Bryant, R.A., & Harvey, A.G. (1998). The relationship between Acute Stress Disorder and Posttraumatic Stress Disorder following mild traumatic brain injury. American Journal of Psychiatry, 155, 625-629.

15. Bryant, R.A., Harvey, A.G., Dang, S., & Sackville, T. (1998). Assessing Acute Stress Disorder: Psychometric properties of a structured clinical interview. Psychological Assessment, 10, 215-220.

16. Bryant, R.A., Moulds, M., Guthrie, R. (2000). Acute Stress Disorder scale: A self-report measure of Acute Stress Disorder. Psychological Assessment, 12, 61-68.

17. Gidron, Y., Gal, R., Freedman, S.A., Twiser, I., Lauden, A., Snir, Y., & Benjamin, J. (2001). Translating research findings to PTSD prevention: Results of a randomized-controlled pilot study. Journal of Traumatic Stress, 14(4), 773-780.

18. Bryant, R. A., Harvey, A. G., Dang, S. T., Sackville, T., & Basten, C. (1998). Treatment of Acute Stress Disorder: A comparison of cognitive-behavioral therapy and supportive counseling. Journal of Consulting and Clinical Psychology, 66, 862-866.

19. Bryant, R.A., Sackville, T., Dang, S.T., Moulds, M., & Guthrie, R. (1999). Treating Acute Stress Disorder: An evaluation of cognitive behavior therapy and counseling techniques. American Journal of Psychiatry, 156, 1780-1786.

20. Echeburua, E., deCorral, P., Sarasua, B., & Zubizarreta, I. (1996). Treatment of acute Posttraumatic Stress Disorder in rape victims: An experimental study. Journal of Anxiety Disorders, 10, 185-199.

21. Brom, D., Kleber, R.J., & Hofman, M.C. (1993). Victims of traffic accidents: Incidence and prevention of Post-traumatic Stress Disorder. Journal of Clinical Psychology, 49, 131-140.

22. Foa, E. B., Hearst-Ikeda, D., & Perry, K. J. (1995). Evaluation of a brief cognitive-behavioral program for the prevention of chronic PTSD in recent assault victims. Journal of Consulting and Clinical Psychology, 63, 948-955.

23. Litz, B.T., Gray, M.J., Bryant, R.A., Adler, A.B. (2002). Early intervention for trauma: Current status and future directions. Clinical Psychology-Science & Practice, 9, 112-134.

24. Mitchell, J.T., & Everly, G.S. (2000). Critical Incident Stress Management and Critical Incident Stress Debriefings: Evolutions, effects and outcomes. In B. Raphael & J.P. Wilson (Eds.), Psychological debriefing: Theory, practice and evidence (pp.71-90). New York, New York: Cambridge University Press.

Source: National Center for PTSD
Author: Laura E. Gibson, PhD, University of Vermont
Updated: May 22, 2007

Page last modified or reviewed on January 27, 2014

What is attention deficit hyperactivity disorder?

Attention deficit hyperactivity disorder (ADHD) is one of the most common childhood disorders and can continue through adolescence and adulthood. Symptoms include difficulty staying focused and paying attention, difficulty controlling behavior, and hyperactivity (over-activity). ADHD has three subtypes:¹

• Predominantly hyperactive-impulsive
  • Most symptoms (six or more) are in the hyperactivity-impulsivity categories.
  • Fewer than six symptoms of inattention are present, although inattention may still be present to some degree.
• Predominantly inattentive
  • The majority of symptoms (six or more) are in the inattention category and fewer than six symptoms of hyperactivity-impulsivity are present, although hyperactivity-impulsivity may still be present to some degree.
  • Children with this subtype are less likely to act out or have difficulties getting along with other children. They may sit quietly, but they are not paying attention to what they are doing. Therefore, the child may be overlooked, and parents and teachers may not notice that he or she has ADHD.
• Combined hyperactive-impulsive and inattentive
  • Six or more symptoms of inattention and six or more symptoms of hyperactivity-impulsivity are present.
  • Most children have the combined type of ADHD.

Treatments can relieve many of the disorder's symptoms, but there is no cure. With treatment, most people with ADHD can be successful in school and lead productive lives. Researchers are developing more effective treatments and interventions, and using new tools such as brain imaging, to better understand ADHD and to find more effective ways to treat and prevent it.

What are the symptoms of ADHD in children?

Inattention, hyperactivity, and impulsivity are the key behaviors of ADHD. It is normal for all children to be inattentive, hyperactive, or impulsive sometimes, but for children with ADHD, these behaviors are more severe and occur more often. To be diagnosed with the disorder, a child must have symptoms for 6 or more months and to a degree that is greater than other children of the same age. Children who have symptoms of inattention may:

• Be easily distracted, miss details, forget things, and frequently switch from one activity to another
• Have difficulty focusing on one thing
• Become bored with a task after only a few minutes, unless they are doing something enjoyable
• Have difficulty focusing attention on organizing and completing a task or learning something new
• Have trouble completing or turning in homework assignments, often losing things (e.g., pencils, toys, assignments) needed to complete tasks or activities
• Not seem to listen when spoken to
• Daydream, become easily confused, and move slowly
• Have difficulty processing information as quickly and accurately as others
• Struggle to follow instructions.

Children who have symptoms of hyperactivity may:

• Fidget and squirm in their seats
• Talk nonstop
• Dash around, touching or playing with anything and everything in sight
• Have trouble sitting still during dinner, school, and story time
• Be constantly in motion
• Have difficulty doing quiet tasks or activities.

Children who have symptoms of impulsivity may:

• Be very impatient
• Blurt out inappropriate comments, show their emotions without restraint, and act without regard for consequences
• Have difficulty waiting for things they want or waiting their turns in games
• Often interrupt conversations or others' activities.

ADHD Can Be Mistaken for Other Problems.

Parents and teachers can miss the fact that children with symptoms of inattention have the disorder because they are often quiet and less likely to act out. They may sit quietly, seeming to work, but they are often not paying attention to what they are doing. They may get along well with other children, compared with those with the other subtypes, who tend to have social problems. But children with the inattentive kind of ADHD are not the only ones whose disorders can be missed. For example, adults may think that children with the hyperactive and impulsive subtypes just have emotional or disciplinary problems.

What Causes ADHD?

Scientists are not sure what causes ADHD, although many studies suggest that genes play a large role. Like many other illnesses, ADHD probably results from a combination of factors. In addition to genetics, researchers are looking at possible environmental factors, and are studying how brain injuries, nutrition, and the social environment might contribute to ADHD.

Genes. Inherited from our parents, genes are the "blueprints" for who we are. Results from several international studies of twins show that ADHD often runs in families. Researchers are looking at several genes that may make people more likely to develop the disorder.^2,3 Knowing the genes involved may one day help researchers prevent the disorder before symptoms develop. Learning about specific genes could also lead to better treatments. Children with ADHD who carry a particular version of a certain gene have thinner brain tissue in the areas of the brain associated with attention. This NIMH research showed that the difference was not permanent, however, and as children with this gene grew up, the brain developed to a normal level of thickness. Their ADHD symptoms also improved.⁴

Environmental factors. Studies suggest a potential link between cigarette smoking and alcohol use during pregnancy and ADHD in children.^5,6 In addition, preschoolers who are exposed to high levels of lead, which can sometimes be found in plumbing fixtures or paint in old buildings, may have a higher risk of developing ADHD.⁷

Brain injuries. Children who have suffered a brain injury may show some behaviors similar to those of ADHD. However, only a small percentage of children with ADHD have suffered a traumatic brain injury.

Sugar. The idea that refined sugar causes ADHD or makes symptoms worse is popular, but more research discounts this theory than supports it. In one study, researchers gave children foods containing either sugar or a sugar substitute every other day. The children who received sugar showed no different behavior or learning capabilities than those who received the sugar substitute.⁸ Another study in which children were given higher than average amounts of sugar or sugar substitutes showed similar results.⁹ In another study, children who were considered sugar-sensitive by their mothers were given the sugar substitute aspartame, also known as Nutrasweet. Although all the children got aspartame, half their mothers were told their children were given sugar, and the other half were told their children were given aspartame. The mothers who thought their children had gotten sugar rated them as more hyperactive than the other children and were more critical of their behavior, compared to mothers who thought their children received aspartame.¹⁰

Food additives. Recent British research indicates a possible link between consumption of certain food additives like artificial colors or preservatives, and an increase in activity.¹¹ Research is under way to confirm the findings and to learn more about how food additives may affect hyperactivity.

How is ADHD diagnosed?

Children mature at different rates and have different personalities, temperaments, and energy levels. Most children get distracted, act impulsively, and struggle to concentrate at one time or another. Sometimes, these normal factors may be mistaken for ADHD. ADHD symptoms usually appear early in life, often between the ages of 3 and 6, and because symptoms vary from person to person, the disorder can be hard to diagnose. Parents may first notice that their child loses interest in things sooner than other children, or seems constantly "out of control." Often, teachers notice the symptoms first, when a child has trouble following rules, or frequently "spaces out" in the classroom or on the playground. No single test can diagnose a child as having ADHD. Instead, a licensed health professional needs to gather information about the child, and his or her behavior and environment. A family may want to first talk with the child's pediatrician. Some pediatricians can assess the child themselves, but many will refer the family to a mental health specialist with experience in childhood mental disorders such as ADHD. The pediatrician or mental health specialist will first try to rule out other possibilities for the symptoms. For example, certain situations, events, or health conditions may cause temporary behaviors in a child that seem like ADHD.

Between them, the referring pediatrician and specialist will determine if a child:

• Is experiencing undetected seizures that could be associated with other medical conditions
• Has a middle ear infection that is causing hearing problems
• Has any undetected hearing or vision problems
• Has any medical problems that affect thinking and behavior
• Has any learning disabilities
• Has anxiety or depression, or other psychiatric problems that might cause ADHD-like symptoms
• Has been affected by a significant and sudden change, such as the death of a family member, a divorce, or parent's job loss.

A specialist will also check school and medical records for clues, to see if the child's home or school settings appear unusually stressful or disrupted, and gather information from the child's parents and teachers. Coaches, babysitters, and other adults who know the child well also may be consulted. The specialist also will ask:

• Are the behaviors excessive and long-term, and do they affect all aspects of the child's life?
• Do they happen more often in this child compared with the child's peers?
• Are the behaviors a continuous problem or a response to a temporary situation?
• Do the behaviors occur in several settings or only in one place, such as the playground, classroom, or home?

The specialist pays close attention to the child's behavior during different situations. Some situations are highly structured, some have less structure. Others would require the child to keep paying attention. Most children with ADHD are better able to control their behaviors in situations where they are getting individual attention and when they are free to focus on enjoyable activities. These types of situations are less important in the assessment. A child also may be evaluated to see how he or she acts in social situations, and may be given tests of intellectual ability and academic achievement to see if he or she has a learning disability. Finally, if after gathering all this information the child meets the criteria for ADHD, he or she will be diagnosed with the disorder.

How is ADHD treated?

Currently available treatments focus on reducing the symptoms of ADHD and improving functioning. Treatments include medication, various types of psychotherapy, education or training, or a combination of treatments.

Medications: The most common type of medication used for treating ADHD is called a "stimulant." Although it may seem unusual to treat ADHD with a medication considered a stimulant, it actually has a calming effect on children with ADHD. Many types of stimulant medications are available. A few other ADHD medications are non-stimulants and work differently than stimulants. For many children, ADHD medications reduce hyperactivity and impulsivity and improve their ability to focus, work, and learn. Medication also may improve physical coordination.

However, a one-size-fits-all approach does not apply for all children with ADHD. What works for one child might not work for another. One child might have side effects with a certain medication, while another child may not. Sometimes several different medications or dosages must be tried before finding one that works for a particular child. Any child taking medications must be monitored closely and carefully by caregivers and doctors.

Stimulant medications come in different forms, such as a pill, capsule, liquid, or skin patch. Some medications also come in short-acting, long-acting, or extended release varieties. In each of these varieties, the active ingredient is the same, but it is released differently in the body. Long-acting or extended release forms often allow a child to take the medication just once a day before school, so they don't have to make a daily trip to the school nurse for another dose. Parents and doctors should decide together which medication is best for the child and whether the child needs medication only for school hours or for evenings and weekends, too.

A list of medications and the approved age for use follows. ADHD can be diagnosed and medications prescribed by MDs (usually a psychiatrist) and in some states also by clinical psychologists, psychiatric nurse practitioners, and advanced psychiatric nurse specialists. Check with your state's licensing agency for specifics. Trade NameGeneric NameApproved Age

Adderall	amphetamine	3 and older
Adderall XR	amphetamine (extended release)	6 and older
Concerta	methylphenidate (long acting)	6 and older
Daytrana	methylphenidate patch	6 and older
Desoxyn	methamphetamine hydrochloride	6 and older
Dexedrine	dextroamphetamine	3 and older
Dextrostat	dextroamphetamine	3 and older
Focalin	dexmethylphenidate	6 and older
Focalin XR	dexmethylphenidate (extended release)	6 and older
Metadate ER	methylphenidate (extended release)	6 and older
Metadate CD	methylphenidate (extended release)	6 and older
Methylin	methylphenidate (oral solution and chewable tablets)	6 and older
Ritalin	methylphenidate	6 and older
Ritalin SR	methylphenidate (extended release)	6 and older
Ritalin LA	methylphenidate (long acting)	6 and older
Strattera	atomoxetine	6 and older
Vyvanse	lisdexamfetamine dimesylate	6 and older

*Not all ADHD medications are approved for use in adults.

NOTE: "extended release" means the medication is released gradually so that a controlled amount enters the body over a period of time. "Long acting" means the medication stays in the body for a long time.

Over time, this list will grow, as researchers continue to develop new medications for ADHD. Medication guides for each of these medications are available from the U.S. Food and Drug Administration (FDA).

What are the side effects of stimulant medications?

The most commonly reported side effects are decreased appetite, sleep problems, anxiety, and irritability. Some children also report mild stomachaches or headaches. Most side effects are minor and disappear over time or if the dosage level is lowered.

• Decreased appetite. Be sure your child eats healthy meals. If this side effect does not go away, talk to your child's doctor. Also talk to the doctor if you have concerns about your child's growth or weight gain while he or she is taking this medication.
• Sleep problems. If a child cannot fall asleep, the doctor may prescribe a lower dose of the medication or a shorter-acting form. The doctor might also suggest giving the medication earlier in the day, or stopping the afternoon or evening dose. Adding a prescription for a low dose of an antidepressant or a blood pressure medication called clonidine sometimes helps with sleep problems. A consistent sleep routine that includes relaxing elements like warm milk, soft music, or quiet activities in dim light, may also help.
• Less common side effects. A few children develop sudden, repetitive movements or sounds called tics. These tics may or may not be noticeable. Changing the medication dosage may make tics go away. Some children also may have a personality change, such as appearing "flat" or without emotion. Talk with your child's doctor if you see any of these side effects.

Are stimulant medications safe?

Under medical supervision, stimulant medications are considered safe. Stimulants do not make children with ADHD feel high, although some kids report feeling slightly different or "funny." Although some parents worry that stimulant medications may lead to substance abuse or dependence, there is little evidence of this.

FDA warning on possible rare side effects. In 2007, the FDA required that all makers of ADHD medications develop Patient Medication Guides that contain information about the risks associated with the medications. The guides must alert patients that the medications may lead to possible cardiovascular (heart and blood) or psychiatric problems. The agency undertook this precaution when a review of data found that ADHD patients with existing heart conditions had a slightly higher risk of strokes, heart attacks, and/or sudden death when taking the medications.

The review also found a slight increased risk, about 1 in 1,000, for medication-related psychiatric problems, such as hearing voices, having hallucinations, becoming suspicious for no reason, or becoming manic (an overly high mood), even in patients without a history of psychiatric problems. The FDA recommends that any treatment plan for ADHD include an initial health history, including family history, and examination for existing cardiovascular and psychiatric problems.

One ADHD medication, the non-stimulant atomoxetine (Strattera), carries another warning. Studies show that children and teenagers who take atomoxetine are more likely to have suicidal thoughts than children and teenagers with ADHD who do not take it. If your child is taking atomoxetine, watch his or her behavior carefully. A child may develop serious symptoms suddenly, so it is important to pay attention to your child's behavior every day. Ask other people who spend a lot of time with your child to tell you if they notice changes in your child's behavior. Call a doctor right away if your child shows any unusual behavior. While taking atomoxetine, your child should see a doctor often, especially at the beginning of treatment, and be sure that your child keeps all appointments with his or her doctor.

Do medications cure ADHD?

Current medications do not cure ADHD. Rather, they control the symptoms for as long as they are taken. Medications can help a child pay attention and complete schoolwork. It is not clear, however, whether medications can help children learn or improve their academic skills. Adding behavioral therapy, counseling, and practical support can help children with ADHD and their families to better cope with everyday problems. Research funded by the National Institute of Mental Health (NIMH) has shown that medication works best when treatment is regularly monitored by the prescribing doctor and the dose is adjusted based on the child's needs.¹²

Psychotherapy:

Different types of psychotherapy are used for ADHD. Behavioral therapy aims to help a child change his or her behavior. It might involve practical assistance, such as help organizing tasks or completing schoolwork, or working through emotionally difficult events. Behavioral therapy also teaches a child how to monitor his or her own behavior. Learning to give oneself praise or rewards for acting in a desired way, such as controlling anger or thinking before acting, is another goal of behavioral therapy. Parents and teachers also can give positive or negative feedback for certain behaviors. In addition, clear rules, chore lists, and other structured routines can help a child control his or her behavior. Therapists may teach children social skills, such as how to wait their turn, share toys, ask for help, or respond to teasing. Learning to read facial expressions and the tone of voice in others, and how to respond appropriately can also be part of social skills training.

How can parents help?

Children with ADHD need guidance and understanding from their parents and teachers to reach their full potential and to succeed in school. Before a child is diagnosed, frustration, blame, and anger may have built up within a family. Parents and children may need special help to overcome bad feelings. Mental health professionals can educate parents about ADHD and how it impacts a family. They also will help the child and his or her parents develop new skills, attitudes, and ways of relating to each other. Parenting skills training helps parents learn how to use a system of rewards and consequences to change a child's behavior.

Parents are taught to give immediate and positive feedback for behaviors they want to encourage, and ignore or redirect behaviors they want to discourage. In some cases, the use of "time-outs" may be used when the child's behavior gets out of control. In a time-out, the child is removed from the upsetting situation and sits alone for a short time to calm down.

Parents are also encouraged to share a pleasant or relaxing activity with the child, to notice and point out what the child does well, and to praise the child's strengths and abilities. They may also learn to structure situations in more positive ways. For example, they may restrict the number of playmates to one or two, so that their child does not become overstimulated. Or, if the child has trouble completing tasks, parents can help their child divide large tasks into smaller, more manageable steps. Also, parents may benefit from learning stress-management techniques to increase their own ability to deal with frustration, so that they can respond calmly to their child's behavior.

Sometimes, the whole family may need therapy. Therapists can help family members find better ways to handle disruptive behaviors and to encourage behavior changes. Finally, support groups help parents and families connect with others who have similar problems and concerns. Groups often meet regularly to share frustrations and successes, to exchange information about recommended specialists and strategies, and to talk with experts.

Tips to Help Kids Stay Organized and Follow Directions

• Schedule. Keep the same routine every day, from wake-up time to bedtime. Include time for homework, outdoor play, and indoor activities. Keep the schedule on the refrigerator or on a bulletin board in the kitchen. Write changes on the schedule as far in advance as possible.
• Organize everyday items. Have a place for everything, and keep everything in its place. This includes clothing, backpacks, and toys.
• Use homework and notebook organizers. Use organizers for school material and supplies. Stress to your child the importance of writing down assignments and bringing home the necessary books.
• Be clear and consistent. Children with ADHD need consistent rules they can understand and follow.
• Give praise or rewards when rules are followed. Children with ADHD often receive and expect criticism. Look for good behavior, and praise it.

What conditions can coexist with ADHD?

Some children with ADHD also have other illnesses or conditions. For example, they may have one or more of the following:

• A learning disability. A child in preschool with a learning disability may have difficulty understanding certain sounds or words or have problems expressing himself or herself in words. A school-aged child may struggle with reading, spelling, writing, and math.
• Oppositional defiant disorder. Kids with this condition, in which a child is overly stubborn or rebellious, often argue with adults and refuse to obey rules.
• Conduct disorder. This condition includes behaviors in which the child may lie, steal, fight, or bully others. He or she may destroy property, break into homes, or carry or use weapons. These children or teens are also at a higher risk of using illegal substances. Kids with conduct disorder are at risk of getting into trouble at school or with the police.
• Anxiety and depression. Treating ADHD may help to decrease anxiety or some forms of depression.
• Bipolar disorder. Some children with ADHD may also have this condition in which extreme mood swings go from mania (an extremely high elevated mood) to depression in short periods of time.
• Tourette syndrome. Very few children have this brain disorder, but among those who do, many also have ADHD. Some people with Tourette syndrome have nervous tics and repetitive mannerisms, such as eye blinks, facial twitches, or grimacing. Others clear their throats, snort, or sniff frequently, or bark out words inappropriately. These behaviors can be controlled with medication.

ADHD also may coexist with a sleep disorder, bed-wetting, substance abuse, or other disorders or illnesses. For more information on these disorders, visit the NIMH website. Recognizing ADHD symptoms and seeking help early will lead to better outcomes for both affected children and their families.

How can I work with my child's school?

If you think your child has ADHD, or a teacher raises concerns, you may be able to request that the school conduct an evaluation to determine whether he or she qualifies for special education services.

Start by speaking with your child's teacher, school counselor, or the school's student support team, to begin an evaluation. Also, each state has a Parent Training and Information Center and a Protection and Advocacy Agency that can help you get an evaluation. A team of professionals conducts the evaluation using a variety of tools and measures. It will look at all areas related to the child's disability.

Once your child has been evaluated, he or she has several options, depending on the specific needs. If special education services are needed and your child is eligible under the Individuals with Disabilities Education Act, the school district must develop an "individualized education program" specifically for your child within 30 days.

If your child is considered not eligible for special education services - and not all children with ADHD are eligible - he or she still can get "free appropriate public education," available to all public-school children with disabilities under Section 504 of the Rehabilitation Act of 1973, regardless of the nature or severity of the disability.

For more information on Section 504 visit the U.S. Department of Education's Office for Civil Rights which enforces Section 504 in programs and activities that receive Federal education funds.

Visit the Department of Education programs for more information about children with disabilities.

Transitions can be difficult. Each school year brings a new teacher and new schoolwork, a change that can be especially hard for a child with ADHD who needs routine and structure. Consider telling the teachers that your child has ADHD when he or she starts school or moves to a new class. Additional support will help your child deal with the transition.

Do teens with ADHD have special needs?

Most children with ADHD continue to have symptoms as they enter adolescence. Some children, however, are not diagnosed with ADHD until they reach adolescence. This is more common among children with predominantly inattentive symptoms because they are not necessarily disruptive at home or in school. In these children, the disorder becomes more apparent as academic demands increase and responsibilities mount. For all teens, these years are challenging. But for teens with ADHD, these years may be especially difficult.

Although hyperactivity tends to decrease as a child ages, teens who continue to be hyperactive may feel restless and try to do too many things at once. They may choose tasks or activities that have a quick payoff, rather than those that take more effort, but provide bigger, delayed rewards. Teens with primarily attention deficits struggle with school and other activities in which they are expected to be more self-reliant.

Teens also become more responsible for their own health decisions. When a child with ADHD is young, parents are more likely to be responsible for ensuring that their child maintains treatment. But when the child reaches adolescence, parents have less control, and those with ADHD may have difficulty sticking with treatment.

To help them stay healthy and provide needed structure, teens with ADHD should be given rules that are clear and easy to understand. Helping them stay focused and organized - such as posting a chart listing household chores and responsibilities with spaces to check off completed items - also may help.

Teens with or without ADHD want to be independent and try new things, and sometimes they will break rules. If your teen breaks rules, your response should be as calm and matter-of-fact as possible. Punishment should be used only rarely. Teens with ADHD often have trouble controlling their impulsivity and tempers can flare. Sometimes, a short time-out can be calming.

If your teen asks for later curfews and use of the car, listen to the request, give reasons for your opinions, and listen to your child's opinion. Rules should be clear once they are set, but communication, negotiation, and compromise are helpful along the way. Maintaining treatments, such as medication and behavioral or family therapy, also can help with managing your teenager's ADHD.

What about teens and driving?

Although many teens engage in risky behaviors, those with ADHD, especially untreated ADHD, are more likely to take more risks. In fact, in their first few years of driving, teens with ADHD are involved in nearly four times as many car accidents as those who do not have ADHD. They are also more likely to cause injury in accidents, and they get three times as many speeding tickets as their peers.¹³

Most states now use a graduated licensing system, in which young drivers, both with and without ADHD, learn about progressively more challenging driving situations.¹⁴ The licensing system consists of three stages - learner's permit, during which a licensed adult must always be in the car with the driving teen; intermediate (provisional) license; and full licensure. Parents should make sure that their teens, especially those with ADHD, understand and follow the rules of the road. Repeated driving practice under adult supervision is especially important for teens with ADHD.

Can adults have ADHD?

Some children with ADHD continue to have it as adults. And many adults who have the disorder don't know it. They may feel that it is impossible to get organized, stick to a job, or remember and keep appointments. Daily tasks such as getting up in the morning, preparing to leave the house for work, arriving at work on time, and being productive on the job can be especially challenging for adults with ADHD.

These adults may have a history of failure at school, problems at work, or difficult or failed relationships. Many have had multiple traffic accidents. Like teens, adults with ADHD may seem restless and may try to do several things at once, most of them unsuccessfully. They also tend to prefer "quick fixes," rather than taking the steps needed to achieve greater rewards.

How is ADHD diagnosed in adults?

Like children, adults who suspect they have ADHD should be evaluated by a licensed mental health professional. But the professional may need to consider a wider range of symptoms when assessing adults for ADHD because their symptoms tend to be more varied and possibly not as clear cut as symptoms seen in children.

To be diagnosed with the condition, an adult must have ADHD symptoms that began in childhood and continued throughout adulthood.¹⁵ Health professionals use certain rating scales to determine if an adult meets the diagnostic criteria for ADHD. The mental health professional also will look at the person's history of childhood behavior and school experiences, and will interview spouses or partners, parents, close friends, and other associates. The person will also undergo a physical exam and various psychological tests.

For some adults, a diagnosis of ADHD can bring a sense of relief. Adults who have had the disorder since childhood, but who have not been diagnosed, may have developed negative feelings about themselves over the years. Receiving a diagnosis allows them to understand the reasons for their problems, and treatment will allow them to deal with their problems more effectively.

How is ADHD treated in adults?

Much like children with the disorder, adults with ADHD are treated with medication, psychotherapy, or a combination of treatments.

Medications. ADHD medications, including extended-release forms, often are prescribed for adults with ADHD, but not all of these medications are approved for adults.¹⁶ However, those not approved for adults still may be prescribed by a doctor on an "off-label" basis.

Although not FDA-approved specifically for the treatment of ADHD, antidepressants are sometimes used to treat adults with ADHD. Older antidepressants, called tricyclics, sometimes are used because they, like stimulants, affect the brain chemicals norepinephrine and dopamine. A newer antidepressant, venlafaxine (Effexor), also may be prescribed for its effect on the brain chemical norepinephrine. And in recent clinical trials, the antidepressant bupropion (Wellbutrin), which affects the brain chemical dopamine, showed benefits for adults with ADHD.¹⁷

Adult prescriptions for stimulants and other medications require special considerations. For example, adults often require other medications for physical problems, such as diabetes or high blood pressure, or for anxiety and depression. Some of these medications may interact badly with stimulants. An adult with ADHD should discuss potential medication options with his or her doctor. These and other issues must be taken into account when a medication is prescribed.

Education and psychotherapy. A professional counselor or therapist can help an adult with ADHD learn how to organize his or her life with tools such as a large calendar or date book, lists, reminder notes, and by assigning a special place for keys, bills, and paperwork. Large tasks can be broken down into more manageable, smaller steps so that completing each part of the task provides a sense of accomplishment.

Psychotherapy, including cognitive behavioral therapy, also can help change one's poor self-image by examining the experiences that produced it. The therapist encourages the adult with ADHD to adjust to the life changes that come with treatment, such as thinking before acting, or resisting the urge to take unnecessary risks.

What efforts are under way to improve treatment?

This is an exciting time in ADHD research. The expansion of knowledge in genetics, brain imaging, and behavioral research is leading to a better understanding of the causes of the disorder, how to prevent it, and how to develop more effective treatments for all age groups.

NIMH has studied ADHD treatments for school-aged children in a large-scale, long-term study called the Multimodal Treatment Study of Children with ADHD (MTA study). NIMH also funded the Preschoolers with ADHD Treatment Study (PATS), which involved more than 300 preschoolers who had been diagnosed with ADHD. The study found that low doses of the stimulant methylphenidate are safe and effective for preschoolers, but the children are more sensitive to the side effects of the medication, including slower than average growth rates.¹⁸ Therefore, preschoolers should be closely monitored while taking ADHD medications.^19,20

PATS is also looking at the genes of the preschoolers, to see if specific genes affected how the children responded to methylphenidate. Future results may help scientists link variations in genes to differences in how people respond to ADHD medications. For now, the study provides valuable insights into ADHD.²¹

Other NIMH-sponsored clinical trials on children and adults with ADHD are under way. In addition, NIMH-sponsored scientists continue to look for the biological basis of ADHD, and how differences in genes and brain structure and function may combine with life experiences to produce the disorder.

Citations

1 DSM-IV-TR workgroup. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association.

2 Faraone SV, Perlis RH, Doyle AE, Smoller JW, Goralnick JJ, Holmgren MA, Sklar P. Molecular genetics of attention-deficit/hyperactivity disorder. Biological Psychiatry, 2005; 57:1313-1323.

3 Khan SA, Faraone SV. The genetics of attention-deficit/hyperactivity disorder: A literature review of 2005. Current Psychiatry Reports, 2006 Oct; 8:393-397.

4 Shaw P, Gornick M, Lerch J, Addington A, Seal J, Greenstein D, Sharp W, Evans A, Giedd JN, Castellanos FX, Rapoport JL. Polymorphisms of the dopamine D4 receptor, clinical outcome and cortical structure in attention-deficit/hyperactivity disorder. Archives of General Psychiatry, 2007 Aug; 64(8):921-931.

5 Linnet KM, Dalsgaard S, Obel C, Wisborg K, Henriksen TB, Rodriguez A, Kotimaa A, Moilanen I, Thomsen PH, Olsen J, Jarvelin MR. Maternal lifestyle factors in pregnancy risk of attention-deficit/hyperactivity disorder and associated behaviors: review of the current evidence. American Journal of Psychiatry, 2003 Jun; 160(6):1028-1040.

6 Mick E, Biederman J, Faraone SV, Sayer J, Kleinman S. Case-control study of attention-deficit hyperactivity disorder and maternal smoking, alcohol use, and drug use during pregnancy. Journal of the American Academy of Child and Adolescent Psychiatry, 2002 Apr; 41(4):378-385.

7 Braun J, Kahn RS, Froehlich T, Auinger P, Lanphear BP. Exposures to environmental toxicants and attention-deficit/hyperactivity disorder in U.S. children. Environmental Health Perspectives, 2006 Dec; 114(12):1904-1909.

8 Wolraich M, Milich R, Stumbo P, Schultz F. The effects of sucrose ingestion on the behavior of hyperactive boys. Pediatrics, 1985 Apr; 106(4):657-682.

9 Wolraich ML, Lindgren SD, Stumbo PJ, Stegink LD, Appelbaum MI, Kiritsy MC. Effects of diets high in sucrose or aspartame on the behavior and cognitive performance of children. New England Journal of Medicine, 1994 Feb 3; 330(5):301-307.

10 Hoover DW, Milich R. Effects of sugar ingestion expectancies on mother-child interaction. Journal of Abnormal Child Psychology, 1994; 22:501-515.

11 McCann D, Barrett A, Cooper A, Crumpler D, Dalen L, Grimshaw K, Kitchin E, Lok E, Porteous L, Prince E, Sonuga-Barke E, Warner JO. Stevenson J. Food additives and hyperactive behaviour in 3-year-old and 8/9-year-old children in the community: a randomised, double-blinded, placebo-controlled trial. Lancet, 2007 Nov 3; 370(9598):1560-1567.

12 The MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for attention-deficit hyperactivity disorder. Archives of General Psychiatry, 1999; 56:1073-1086.

13 Cox DJ, Merkel RL, Moore M, Thorndike F, Muller C, Kovatchev B. Relative benefits of stimulant therapy with OROS methylphenidate versus mixed amphetamine salts extended release in improving the driving performance of adolescent drivers with attention-deficit/hyperactivity disorder. Pediatrics, 2006 Sept; 118(3):e704-e710.

14 U.S. Department of Transportation, National Highway Traffic Safety Administration, Legislative Fact Sheets. Traffic Safety Facts, Laws. Graduated Driver Licensing System. January 2006.

15 Wilens TE, Biederman J, Spencer TJ. Attention deficit/hyperactivity disorder across the lifespan. Annual Review of Medicine, 2002; 53:113-131.

16 Coghill D, Seth S. Osmotic, controlled-release methylphenidate for the treatment of attention-deficit/hyperactivity disorder. Expert Opinions in Pharmacotherapy, 2006 Oct; 7(15):2119-2138.

17 Wilens TE, Haight BR, Horrigan JP, Hudziak JJ, Rosenthal NE, Connor DF, Hampton KD, Richard NE, Modell JG. Bupropion XL in adults with attention-deficit/hyperactivity disorder: a randomized, placebo-controlled study. Biological Psychiatry, 2005 Apr 1; 57(7):793-801.

18 Swanson J, Greenhill L, Wigal T, Kollins S, Stehli A, Davies M, Chuang S, Vitiello B, Skroballa A, Posner K, Abikoff H, Oatis M, McCracken J, McGough J, Riddle M, Ghouman J, Cunningham C, Wigal S. Stimulant-related reductions in growth rates in the PATS. Journal of the Academy of Child and Adolescent Psychiatry, 2006 Nov; 45(11):1304-1313.

19 Greenhill L, Kollins S, Abikoff H, McCracken J, Riddle M, Swanson J, McGough J, Wigal S, Wigal T, Vitiello B, Skroballa A, Posner K, Ghuman J, Cunningham C, Davies M, Chuang S, Cooper T. Efficacy and safety of immediate-release methylphenidate treatment for preschoolers with attention-deficit/hyperactivity disorder. Journal of the Academy of Child and Adolescent Psychiatry, 2006 Nov; 45(11):1284-1293.

20 Wigal T, Greenhill L, Chuang S, McGough J, Vitiello B, Skrobala A, Swanson J, Wigal S, Abikoff H, Kollins S, McCracken J, Riddle M, Posner K, Ghuman J, Davies M, Thorp B, Stehli A. Safety and tolerability of methylphenidate in preschool children with attention-deficit/hyperactivity disorder. Journal of the Academy of Child and Adolescent Psychiatry, 2006 Nov; 45(11):1294-1303.

21 McGough J, McCracken J, Swanson J, Riddle M, Greenhill L, Kollins S, Greenhill L, Abikoff H, Davies M, Chuang S, Wigal T, Wigal S, Posner K, Skroballa A, Kastelic E, Ghouman J, Cunningham C, Shigawa S, Moyzis R, Vitiello B. Pharmacogenetics of methylphenidate response in preschoolers with attention-deficit/hyperactivity disorder. Journal of the Academy of Child and Adolescent Psychiatry, 2006 Nov; 45(11):1314-1322.

National Institutes of Health NIH

Publication No. 08-3572

Page last reviewed by athealth on January 27, 2014

What is attention-deficit/hyperactive disorder - ADHD?

Attention-deficit/hyperactive disorder, ADHD, is highlighted by the persistent inability of a person to pay attention to what is considered important. There may be the additional characteristics of hyperactive motor movements and/or impulsivity.

What characteristics are associated with attention-deficit/hyperactive disorder?

Children normally have a lesser ability to pay attention than do adults, and therefore, we do not expect children to exhibit the same kinds of behaviors as we do adults. The person who is suspected of having ADHD must have a much lower attention span than others when compared to peers of a similar age.

People with ADHD are usually quite impulsive, quite active, or hyperactive. A diagnosis of ADHD means that the symptoms of inattention and/or hyperactivity have to manifest themselves in at least two environments. For example, the symptoms must be present at school or at work and at home. To be considered to be ADHD, the lack of attention has to cause problems for the individual in the academic or occupational setting.

Are there genetic factors associated with ADHD?

Attention-deficit/hyperactive disorder tends to run in families. The disorder appears more often in children whose parents suffer from ADHD, alcohol dependence, and/or mood disorders.

Does attention-deficit/hyperactive disorder affect males, females, or both?

ADHD is much more common in males than in females. There are studies which report that males with ADHD outnumber females by at least 4 to1.

At what age does attention-deficit/hyperactive disorder begin?

The diagnosis of ADHD is often not made before the child enters school. Although ADHD may be present earlier, it is the school setting which usually highlights a child's inattention or hyperactivity. The child's lack of attention compared with the attention of other children is frequently noted by the teacher and reported to the parents. Children may be diagnosed with ADHD throughout their school years.

Adults may also suffer from the disorder.

How often is attention-deficit/hyperactive disorder seen in our society?

Probably, between two percent (2%) and five percent (5%) of all school-age children have some form of attention-deficit/hyperactive disorder. One quarter of those with ADHD may have a learning disorder. See learning disorders.

How is attention-deficit/hyperactive disorder diagnosed?

A pediatrician or mental health professional arrives at the diagnosis of attention-deficit/hyperactive disorder by taking a very careful personal history. The diagnosis of ADHD in the school age child should be made with the help of both parents and teachers. Some psychological tests can be helpful in confirming the diagnosis. Although there are no laboratory tests necessary to confirm the presence of attention-deficit/hyperactive disorder nor any physical conditions that must be met, it is very important not to overlook a physical illness that might mimic or contribute to ADHD. If there is any doubt about a medical problem, the mental health professional should refer to a physician, who would perform a complete physical examination and request any necessary laboratory tests.

How is attention-deficit/hyperactive disorder treated?

Behavior therapy and the use of medications have been shown to be effective treatments for ADHD. The use of medications such as Adderall, Concerta, Ritalin, Strattera, and Vyvanse have become the treatment of choice throughout much of the country.

If the person with ADHD is a child, behavior therapy involving the child and his/her parents is frequently helpful. Behavior therapy can be conducted alone or can be combined with medication therapy. The therapist's consultation with the child's teacher(s) is a very important element of the treatment.

What happens to someone with attention-deficit/hyperactive disorder?

Children with ADHD often continue to show symptoms of inattention and impulsivity into their adolescence and early adulthood. Children and adolescents with ADHD frequently struggle with low self-esteem.

What can people do if they need help?

If you, a friend, or a family member would like more information and you have a therapist or a physician, please discuss your concerns with that person.

Page last modified/reviewed by athealth on January 29, 2014

Mario's Story
Mario is 10 years old. When he was 7, his family learned he had AD/HD. At the time, he was driving everyone crazy. At school, he couldn't stay in his seat or keep quiet. At home, he didn't finish his homework or his chores. He did scary things, too, like climb out of his window onto the roof and run across the street without looking.Things are much better now. Mario was tested by a trained professional to find out what he does well and what gives him trouble. His parents and teachers came up with ways to help him at school. Mario has trouble sitting still, so now he does some of his work standing up. He's also the student who tidies up the room and washes the chalkboard. His teachers break down his lessons into several parts. Then they have him do each part one at a time. This helps Mario keep his attention on his work.

At home, things have changed, too. Now his parents know why he's so active. They are careful to praise him when he does something well. They even have a reward program to encourage good behavior. He earns "good job points" which they post on a wall chart. After earning 10 points he gets to choose something fun he'd like to do. Having a child with AD/HD is still a challenge, but things are looking better.

What is ADHD?

Attention-Deficit/Hyperactivity Disorder (ADHD) is a condition that can make it hard for a person to sit still, control behavior, and pay attention. These difficulties usually begin before the person is 7 years old. However, these behaviors may not be noticed until the child is older.

Doctors do not know just what causes ADHD. However, researchers who study the brain are coming closer to understanding what may cause ADHD. They believe that some people with AD/HD do not have enough of certain chemicals (called neurotransmitters) in their brain. These chemicals help the brain control behavior.

Parents and teachers do not cause ADHD. Still, there are many things that both parents and teachers can do to help a child with ADHD.

How Common is ADHD?

As many as 5 out of every 100 children in school may have ADHD. Boys are three times more likely than girls to have ADHD.

What Are the Signs of ADHD?

There are three main signs, or symptoms, of ADHD. These are:

• problems with paying attention,
• being very active (called hyperactivity), and
• acting before thinking (called impulsivity).

More information about these symptoms is listed in a book called the Diagnostic and Statistical Manual of Mental Disorders (DSM), which is published by the American Psychiatric Association (1994).

Based on these symptoms, three types of ADHD have been found:

• inattentive type, where the person can't seem to get focused or stay focused on a task or activity;
• hyperactive-impulsive type, where the person is very active and often acts without thinking; and
• combined type, where the person is inattentive, impulsive, and too active.

1. Inattentive type.

Many children with ADHD have problems paying attention. Children with the inattentive type of ADHD often:

• do not pay close attention to details;
• can't stay focused on play or school work;
• don't follow through on instructions or finish school work or chores;
• can't seem to organize tasks and activities;
• get distracted easily; and
• lose things such as toys, school work, and books. (APA, 1994, pp. 83-84)

2. Hyperactive-impulsive type.

Being too active is probably the most visible sign of ADHD. The hyperactive child is "always on the go." (As he or she gets older, the level of activity may go down.) These children also act before thinking (called impulsivity). For example, they may run across the road without looking or climb to the top of very tall trees. They may be surprised to find themselves in a dangerous situation. They may have no idea of how to get out of the situation.

Hyperactivity and impulsivity tend to go together. Children with the hyperactive-impulsive type of ADHD often may:

• fidget and squirm;
• get out of their chairs when they're not supposed to;
• run around or climb constantly;
• have trouble playing quietly;
• talk too much;
• blurt out answers before questions have been completed;
• have trouble waiting their turn;
• interrupt others when they're talking; and
• butt in on the games others are playing. (APA, 1994, p. 84)

3. Combined type.

Children with the combined type of ADHD have symptoms of both of the types described above. They have problems with paying attention, with hyperactivity, and with controlling their impulses.

Of course, from time to time, all children are inattentive, impulsive, and too active. With children who have ADHD, these behaviors are the rule, not the exception.

These behaviors can cause a child to have real problems at home, at school, and with friends. As a result, many children with ADHD will feel anxious, unsure of themselves, and depressed. These feelings are not symptoms of ADHD. They come from having problems again and again at home and in school.

How Do You Know if a Child Has ADHD?

When a child shows signs of ADHD, he or she needs to be evaluated by a trained professional. This person may work for the school system or may be a professional in private practice. A complete evaluation is the only way to know for sure if the child has AD/HD. It is also important to:

• rule out other reasons for the child's behavior, and
• find out if the child has other disabilities along with AD/HD.

What About Treatment?

There is no quick treatment for ADHD. However, the symptoms of ADHD can be managed. It's important that the child's family and teachers:

• find out more about ADHD;
• learn how to help the child manage his or her behavior;
• create an educational program that fits the child's individual needs; and
• provide medication, if parents and the doctor feel this would help the child.

Tips for Parents

• Learn about ADHD. The more you know, the more you can help yourself and your child. See the list of resources and organizations at the end of this publication.
• Praise your child when he or she does well. Build your child's abilities. Talk about and encourage his or her strengths and talents.
• Be clear, be consistent, be positive. Set clear rules for your child. Tell your child what he or she should do, not just what he shouldn't do. Be clear about what will happen if your child does not follow the rules. Have a reward program for good behavior. Praise your child when he or she shows the behaviors you like.
• Learn about strategies for managing your child's behavior. These include valuable techniques such as: charting, having a reward program, ignoring behaviors, natural consequences, logical consequences, and time-out. Using these strategies will lead to more positive behaviors and cut down on problem behaviors. You can read about these techniques in many books. See "Resources" at the end of this publication.
• Talk with your doctor about whether medication will help your child.
• Pay attention to your child's mental health (and your own!). Be open to counseling. It can help you deal with the challenges of raising a child with ADHD. It can help your child deal with frustration, feel better about himself or herself, and learn more about social skills.
• Talk to other parents whose children have ADHD. Parents can share practical advice and emotional support. Call NICHCY to find out how to find parent groups near you.
• Meet with the school and develop an educational plan to address your child's needs. Both you and your child's teachers should get a written copy of this plan.
• Keep in touch with your child's teacher. Tell the teacher how your child is doing at home. Ask how your child is doing in school. Offer support.

Tips for Teachers

• Learn more about ADHD. The resources and organizations at the end of this publication will help you identify behavior support strategies and effective ways to support the student educationally. We've listed some strategies below.
• Figure out what specific things are hard for the student. For example, one student with ADHD may have trouble starting a task, while another may have trouble ending one task and starting the next. Each student needs different help.
• Post rules, schedules, and assignments. Clear rules and routines will help a student with ADHD. Have set times for specific tasks. Call attention to changes in the schedule.
• Show the student how to use an assignment book and a daily schedule. Also teach study skills and learning strategies, and reinforce these regularly.
• Help the student channel his or her physical activity (e.g., let the student do some work standing up or at the board). Provide regularly scheduled breaks.
• Make sure directions are given step by step, and that the student is following the directions. Give directions both verbally and in writing. Many students with ADHD also benefit from doing the steps as separate tasks.
• Let the student do work on a computer.
• Work together with the student's parents to create and implement an educational plan tailored to meet the student's needs. Regularly share information about how the student is doing at home and at school.
• Have high expectations for the student, but be willing to try new ways of doing things. Be patient. Maximize the student's chances for success.

What About School?

School can be hard for children with ADHD. Success in school often means being able to pay attention and control behavior and impulse. These are the areas where children with ADHD have trouble.

There are many ways the school can help students with ADHD. Some students may be eligible to receive special education services under the Individuals with Disabilities Education Act (IDEA). Under the newest amendments to IDEA, passed in 1997, AD/HD is specifically mentioned under the category of "Other Health Impairment" (OHI). We've included the IDEA's definition of OHI below. Other students will not be eligible for services under IDEA. However, they may be eligible for services under a different law, Section 504 of the Rehabilitation Act of 1973. In both cases, the school and the child's parents need to meet and talk about what special help the student needs.

Most students with ADHD are helped by supports or changes in the classroom (called adaptations). Some common changes that help students with ADHD are listed under "Tips for Teachers" above. More information about helpful strategies can be found in NICHCY's publication called Attention-Deficit/Hyperactivity Disorder. The resources listed below will also help families and teachers learn more about ways to help children with AD/HD.

IDEA's Definition of "Other Health Impairment"

Many students with ADHD now may qualify for special education services under the "Other Health Impairment" category within the Individuals with Disabilities Education Act (IDEA). IDEA defines "other health impairment" as...

"...having limited strength, vitality or alertness, including a heightened alertness to environmental stimuli, that results in limited alertness with respect to the educational environment, that is due to chronic or acute health problems such as asthma, attention deficit disorder or attention deficit hyperactivity disorder, diabetes, epilepsy, a heart condition, hemophilia, lead poisoning, leukemia, nephritis, rheumatic fever, and sickle cell anemia; and adversely affects a child's educational performance."

34 Code of Federal Regulations §300.7(c)(9)

Resources

Alexander-Roberts, C. (1994). ADHD parenting handbook: Practical advice for parents from parents: Proven techniques for raising a hyperactive child without losing your temper. Dallas, TX: Taylor Publishing. [Telephone: 1-800-677-2800.]

Barkley, R. (1995). Taking charge of AD/HD. New York: Guilford Press. [Telephone: 1-800-365-7006.]

Dendy, S.A. Z. (1995). Teenagers with ADD: A parents’ guide. Bethesda, MD: Woodbine House. [Telephone: 1-800-843-7323.]

Fowler, M. (1994). Attention-deficit/hyperactivity disorder. NICHCY Briefing Paper, 1-16. [Telephone: 1-800-695-0285. Also available on NICHCY’s Web site: www.nichcy.org]

Fowler, M. (1999). Maybe you know my kid: A parent’s guide to identifying, understanding, and helping your child with ADHD (3rd ed.). New York: Birch Lane Press. [Telephone: 1-800-447-2665.]

Fowler, M. (1992). CH.A.D.D. educators manual: An in-depth look at attention deficit disorders from an educational perspective. Plantation, FL: CH.A.D.D. [Telephone: 1-800-233-4050.]

Wodrich, D.L. (1994). Attention deficit hyperactivity disorder: What every parent wants to know. Baltimore, MD: Paul H. Brookes. [Telephone: 1-800-638-3775.]

Source:

National Information Center for Children and Youth with Disabilities
Update: August 1999

Reviewed by athealth on January 14, 2014

Athealth.com: Athealth.com is pleased to welcome Kathleen Nadeau, PhD, who shares her expertise on the diagnosis and treatment of ADHD, particularly as it relates to the treatment of girls.

Dr. Nadeau, an internationally recognized expert on ADHD, is a member of the CHADD professional advisory board. A clinical psychologist, she has been in practice for more than 30 years.

She is the co-director of Chesapeake Psychological Services of Maryland. Dr. Nadeau is the author, co-author, and/or editor of numerous books on the topic of ADHD, the co-editor of ADDvance, a magazine for women with ADHD, and the co-publisher of Advantage Books, a specialty press that publishes books related to the topic of ADHD.

Athealth.com: What have been the most important developments in the area of treating Attention Deficit/Hyperactivity Disorder in recent years?

Dr. Nadeau: One of the most critical developments is the recognition of ADHD as a lifespan disorder that significantly affects many adults.

Athealth.com: The media seem to portray ADHD as a catchall diagnosis for children (especially boys) with conduct issues. In your opinion, is the diagnosis frequently misapplied to boys and not applied enough to girls?

Dr. Nadeau: ADHD may be over-diagnosed among boys in certain circumstances - there are anecdotal stories of classrooms in which nearly half of the boys are diagnosed with ADHD and prescribed Ritalin. It is important to keep this in perspective. A statewide study in Maryland, for example, found that, if anything, ADHD continues to be under-diagnosed - even among boys. Under 3% of children in Maryland are diagnosed with ADHD, while common estimates suggest that at least 5% of the population has ADHD.

Girls are undoubtedly under-diagnosed and misunderstood. Diagnostic criteria that are currently used were developed to identify boys and are largely inappropriate in identifying girls.

Athealth.com: Also, the diagnosis is now being applied to adults when it was typically considered a disorder of childhood. Can you comment on this?

Dr. Nadeau: In the past five years we have come to recognize that ADHD is NOT a childhood disorder, but a lifelong disorder. Because many women self-refer for assessment for ADHD, we are beginning to gather convincing evidence of its frequency among females.

Athealth.com: Establishing a therapeutic alliance with a child, adolescent, or adult suffering from Attention Deficit/Hyperactivity Disorder can be clinically challenging. Are there differences in how you approach a child, adolescent, or adult?

Dr. Nadeau: Therapeutic alliances are usually easy to establish with adults. They recognize their difficulties and refer themselves for treatment. At this point they have already accepted that they need help.

Perhaps the most difficult population to work with is the teen with ADHD. Often teenagers resent the nagging and supervision that they need, and they feel infantilized at the same time. It is essential that the teen get to the point of wanting to develop life management skills for his/her own sake and for the sake of the teen's future. Therapy will never work until the young person buys into the process. And, this may not happen until he/she has experienced some pretty distressing failures.

Children with ADHD need help in understanding what their challenges are. Many kids think in simple terms like "I can't pay attention in class." Often they are quite receptive to tips and suggestions, especially when they learn that homework can be completed more quickly and rewards can be earned more frequently once they work to establish better habits and routines. Behavioral programs are often quite helpful with children with ADHD.

For teens, parents and therapists must be very careful to set up incentive programs that don't seem childish or too controlling.

Athealth.com: Are there differences in how you approach treatment with a girl and a boy?

Dr. Nadeau: One very important area of growing interest is the better identification and treatment of girls with ADHD. Girls are less likely to be referred because they tend to cause fewer problems in the classroom. Their behavior may be misunderstood as immaturity or lack of academic ability rather than as ADHD. Let me give you an example.

Marie (not her real name) had the good fortune of having a mother who was a trained educator and who recognized that ADHD might be a possibility when Marie began to have difficulty in completing class work and homework in the third grade. Her daughter was evaluated by a well-known neuropsychologist who diagnosed her with "mild" ADHD. Her mother was reluctant to try stimulant medication, but worked with her daughter to become more focused on homework in the evenings.

Marie worked hard, but complained of how difficult school remained for her. Even though her mother was aware of the ADHD, they frequently found themselves in arguments if Marie lost her house keys or forgot her jacket at school.

Finally, as Marie's grades took a downturn in her sophomore year in high school, her mother reluctantly decided upon a trial of stimulant medication. Marie's academics took a rapid and marked turnaround. She became a solid, A/B student whereas before she had made Bs and Cs.

Marie's mother regretted that over the years she had denied her daughter access to the full range of treatment. Today, Marie is a successful college student whose creative talents find their expression in her college major of design.

Athealth.com: There seems to be a growing interest in evidence based clinical practice. Is the field of ADHD research and treatment working to maximize positive clinical outcomes?

Dr. Nadeau: Unfortunately, the majority of funded research is conducted by physicians in medically oriented clinic settings or by educators in classroom settings. To date, there is almost no evidence-based research on treatment outcomes except those focusing on medication. We have yet to truly study the types of psychotherapeutic interventions that are most effective.

Athealth.com: Does this work account for gender bias in diagnosis and treatment?

Dr. Nadeau: Gender bias is built into research as long as we are reliant upon DSM-IV diagnostic criteria - which have been developed almost exclusively through the study of boys and of those "outlying' girls whose behavior closely resembles boys with ADHD. There is widespread and growing consensus that there is a need for more gender-sensitive norms.

Athealth.com: Are there gender differences in how ADHD is presented?

Dr. Nadeau: Girls are more likely to be "primarily inattentive" - a category that has been repeatedly shown to be difficult to recognize both by educators and professionals. They are less aggressive, less likely to show conduct disorders, and less likely to show symptoms in early childhood. In fact, at puberty, just as boys' hyperactivity is lessening, many girls show the first marked signs of ADHD.

Athealth.com: What do you recommend that clinicians do to prevent girls and women from being overlooked diagnostically?

Dr. Nadeau: I have worked with other professionals to develop a self-report questionnaire for girls. The questionnaire is available on our website at ADHD Self-Rating Scale for Girls.

Parents and teachers complete most AD/HD questionnaires. It is important for girls to be allowed to self-report because many of their experiences are difficult to observe externally, but still have a profound impact on them. Any girl who is struggling academically should routinely be given such a self-report form.

Athealth.com: Overall, do you see any positive trends in the area of treatment outcomes, prevention, and intervention? Is this disorder curable?

Dr. Nadeau: The disorder isn't curable, but it's highly treatable. I see positive developments in many areas. Medications are continuing to be developed that are longer lasting and have fewer side effects. The field of ADD coaching is becoming widely accepted and can be very effective in supporting the individual with ADHD in developing better coping skills. The more the general public is educated regarding this very common disorder, the greater the chance that children can grow up feeling supported rather than criticized and blamed.

Athealth.com: Are there simple assessment tools you would recommend for use by therapists who are not ADHD specialists?

Dr. Nadeau: There are simple screening instruments that can be used, but if ADHD is suspected, the child or adult should be referred to an expert for a complete assessment.

Athealth.com: Do you have any tips to offer that might help clinicians for whom ADHD is not an area of clinical specialty?

Dr. Nadeau: Yes, beware of dismissing ADHD symptoms as the result of anxiety and/or depression. Depression often accompanies ADHD, but if there is a lifelong history of disorganization and a family history of disorganization - then ADHD is a strong likelihood along with co-existing conditions.

Athealth.com: Do you have any resources to recommend?

Dr. Nadeau: There are a range of ADHD websites, but typically I recommend the CHADD site. Parents can be sure to receive accurate information there.

Parents and professionals should be advised that there is a predominance of negative and inaccurate information regarding stimulant medication on the Internet. They should be careful to get their information from qualified sources such as NIMH and CHADD.

I can also recommend the following books.

• A Comprehensive Guide to ADD in Adults
• ADD in the Workplace
• Survival Guide for College Students with ADHD or LD

Athealth.com: Thank you, Dr. Nadeau, for sharing your expertise with us.

Copyright © 2001 - At Health, Inc.
Page last modified or reviewed on January 27, 2014

The idea that children can cause stress in parents is an often-exploited scenario in cartoon pages. "Dennis the Menace" has tormented his parents and other adults for decades, and Calvin, the little boy in the cartoon series "Calvin and Hobbes," kept a record on his calendar of how often he drove his mother crazy. Similarly, in the noncartoon world, the question of whether children cause stress yields numerous raised hands in any group of parents. Indeed, a considerable number of publications in the psychological literature support the argument that children are a major source of stress for their parents (Crnic and Acevedo 1995).

Not surprisingly, parents of children with behavior problems-particularly children with attention deficit hyperactivity disorder (ADHD)-experience highly elevated levels of daily child-rearing stresses (Abidin 1990; Mash and Johnston 1990). Children with ADHD disregard parental requests, commands, and rules; fight with siblings; disturb neighbors; and have frequent negative encounters with schoolteachers and principals.

Although many investigations have dealt with parenting stress caused by disruptive children, only a handful of studies have addressed the question of how parents cope with this stress. For example, if stress in general can precipitate alcohol consumption, it would not be surprising to discover that some parents might attempt to cope with their parenting stress and distress by drinking. This article first reviews the relationship between childhood behavior problems and subsequent adult drinking behavior, and then explores the effects of child behavior on parental drinking. The discussion includes a review of a series of studies assessing parental distress and alcohol consumption among parents of normal children and ADHD children after the parents interacted with either normal- or deviant-behaving children.

Childhood Behavior Disorders and Adult Alcohol Consumption

Children with ADHD have problems paying attention, controlling impulses, and modulating their activity level. Two other disruptive behavior disorders-oppositional defiant disorder (ODD) and conduct disorder (CD)-overlap considerably with ADHD. Children with ODD are irritable and actively defiant toward parents and teachers, whereas children with CD exhibit norm-violating behavior, including aggression, stealing, and property destruction. Substantial comorbidity occurs among these disorders, ranging from 50 to 75 percent. A large body of research has demonstrated many connections between alcohol problems in adults and these three disruptive behavior disorders (Pelham and Lang 1993):

• Children with externalizing disorders are at increased risk for developing alcohol or other drug (AOD) abuse and related problems as adolescents and as adults (Molina and Pelham 1999).
• Adult alcoholics more commonly have a history of ADHD symptomatology compared with non-alcoholics (e.g., Alterman et al. 1982).
• The prevalence of alcohol problems is higher among fathers of boys with ADHD and/or CD/ODD than among fathers of boys without these disorders (e.g., Biederman et al. 1990).
• Similarities exist between the behavioral, temperamental, and cognitive characteristics of many children of alcoholics and such characteristics of children with ADHD and related disruptive disorders (Pihl et al. 1990).

In summary, these findings indicate that childhood externalizing behavior disorders are associated with an increased risk of familial alcohol problems, as well as subsequent adult alcohol problems. Furthermore, parental alcohol problems may contribute to a child's current and future psychopathology. Conversely, a child's behavior problems may intensify parental drinking, which in turn may exacerbate the child's pathology. This vicious cycle may result in ever more serious problems for the entire family.

Effects of Childhood Behavior Problems on Parental Drinking

As described in the previous section, in families with children with behavior disorders and/or parental alcoholism, both the parents and children appear to have an elevated risk for alcohol-related problems. Researchers have only recently begun, however, to explore the causal mechanisms operating in these relationships. In addition, the research has focused primarily on the effects that parental drinking has on the children and their behavior. Some recent studies, however, have begun to examine the possible effects of deviant child behavior on parental alcohol problems.

Researchers and clinicians widely believe that children with behavior problems, particularly those with such externalizing disorders as ADHD, can adversely affect their parents' mental health (Mash and Johnston 1990). Childhood externalizing problems frequently result in stressful family environments and life events affecting all family members, including parents. For example, numerous investigators have reported higher rates of current depression in mothers of children who were referred to a clinic because of behavioral problems than in mothers of healthy children (e.g., Fergusson et al. 1993). In addition, a significant correlation exists between daily parenting hassles (e.g., experiencing difficulty finding a baby sitter, having to talk to a child's teacher, or coping with fighting among siblings) and child behavior problems. Thus, studies investigating the distressing effects of deviant child behavior on the immediate reactions and long-term functioning of parents have shown that exposure to difficult children is associated with dysfunctional parental responses, such as maladaptive discipline practices (Crnic and Acevedo 1995; Chamberlain and Patterson 1995).

Despite the evidence that children with behavior problems cause substantial stress and other dysfunctional responses in their parents, almost no research has investigated whether these parental responses include elevated alcohol consumption and/or alcohol problems. This lack of research is particularly surprising given the well-documented association between adult alcohol problems and childhood externalizing disorders. Several relationships may exist among deviant child behavior, parental stress, and two broad types of dysfunctional responses in parents-emotional problems, such as anxiety and depression (i.e., negative affect), and problem drinking. These hypothesized relation-ships are shown in the model in Figure 1. The relationships among parental affect, drinking, and child behavior problems are believed to be transactional, with each variable influencing the other over time. In addition, various parental and child characteristics may influence these relationships. We have hypothesized that child behavior problems increase parental distress, which in turn influences drinking and parental affect. Drinking and negative affect result in maladaptive parenting behaviors, which exacerbate child behavior problems.

Studies of the Influences of Child Behavior on Parental Drinking

Between 1985 and 1995, researchers at the University of Pittsburgh and Florida State University conducted a series of studies examining the relationships described above. Although some of those analyses have examined the influences of parental alcohol consumption on child behavior (Lang et al. 1999), most of the investigations have focused on the influences exerted by child behavior on parental behavior. Thus, these studies have manipulated child behavior and measured the resulting levels and changes in parental alcohol consumption. In order to determine the direction of effect in the documented associations between child behavior problems and parental drinking problems, the studies were conducted as experimental laboratory analogues, rather than as correlational studies in the natural environment.

Thus, all the studies described in this section have employed a similar design and similar measures. The participants, of whom most were parents and all were social drinkers (i.e., none were alcohol abstainers and none were self-reported problem drinkers), were recruited for what they believed were studies designed to investigate the effects of alcohol consumption on the way they interacted with children. The participants were told that they would have a baseline interaction with a child, followed by a period in which they could consume as much of their favored alcoholic beverage as they wanted (i.e., an ad lib drinking period), followed by another interaction with the same child. Each interaction period consisted of three phases:

• a cooperative task in which the child and adult had to cooperate to solve a maze on an Etch-a-Sketch,
• a parallel task during which the child worked on homework while the adult balanced a checkbook, and
• a free-play and clean-up period.

In all three settings, the adult was responsible for ensuring that the child stuck to the required task but also was directed to refrain from providing the child with too much assistance.

The adult participants were led to believe that the aim of the study was to compare their interactions with the children before and after drinking in order to learn about alcohol's effects on adult-child interactions. The adults also were told that the child with whom they would interact might be a normal child from a local school or an ADHD child who was receiving treatment in a clinic. In fact, however, all of the children were normal children who had been hired and trained to enact carefully scripted roles that reflected either ADHD, non-compliant, or oppositional behavior (referred to as "deviant children") or normal child behavior (referred to as "normal children"). The true goal of the study was to evaluate each adult's emotional, physiological, and drinking behavior in response to his or her first interaction with a particular child and while anticipating a second interaction with the same child.

Studies Involving Undergraduate Students

Using undergraduate students as subjects, the first study of the series was designed to evaluate the validity of the concept that interactions with deviant children could induce both stress and stress-related alcohol consumption in adults (i.e., a proof-of-concept study) (Lang et al. 1989). In that study, both male and female subjects who interacted with deviant children reported consider-ably elevated levels of subjective distress and consumed significantly more alcohol compared with subjects who interacted with normal children. No significant differences in subjective distress or alcohol consumption existed between male and female subjects interacting with the deviant children. Thus, the study demonstrated that interactions with a deviant child could produce stress-induced drinking in young adults.

Intriguing as these results were, however, they could not be generalized to parents of children with behavior disorders, because the subjects were single undergraduate students who were not parents. The results did illustrate, however, that child behavior could be used to manipulate adult drinking behavior and that interactions with deviant children were potentially stressful, at least in young adults without parenting experience.

Studies Involving Parents of Normal Children

Using the same study design, Pelham and colleagues (1997) replicated these results with a sample of parents of normal children (i.e., children with no prior or current behavior problems or psychopathology). The subjects included married mothers and fathers as well as single mothers. The study found that both mothers and fathers were substantially distressed by interacting with deviant children and showed increases in negative affect and self-ratings of how unpleasant the interaction was overall, how unsuccessful they were in the interaction, and how ineffective they were in dealing with the child (See Figure 2). More-over, parents from all three groups who interacted with a deviant child consumed more alcohol than did parents who interacted with a normal child. Interestingly, for both reported subjective distress and drinking behavior, the differences between subjects interacting with deviant and normal children were considerably larger among parents of normal children than among college students in the investigation by Lang and colleagues (1989). These findings indicate that when parents are presented with a stress-inducing factor (i.e., an ecologically valid stressor) relevant to their normal life, such as child misbehavior that induces considerable subjective distress, they may engage in increased alcohol consumption (i.e., stress-induced drinking).

It is notable that these effects were obtained in a sample of parents of non-deviant children. Thus, the results are consistent with other studies showing that parenting hassles can cause distress even in normal families (Crnic and Acevedo 1995; Bugental and Cortez 1988). Furthermore, because the effects were obtained in both mothers and fathers, the study demonstrated that problematic child behavior can influence drinking behavior regardless of parent gender. Among the mothers studied, interactions with deviant children had the largest impact on single mothers, who have also been shown to be particularly vulnerable to numerous stressors, including parenting difficulties (Weinraub and Wolf 1983) and drinking problems (Wilsnack and Wilsnack 1993).

Studies Involving Parents of ADHD Children

To explore the link between alcohol problems and deviant child behavior in parents of children with ADHD, Pelham and colleagues (1998) employed the same study design with a sample of parents who had children with an externalizing disorder. Again, the study included single mothers as well as married mothers and fathers to allow analysis of potential differences in drinking behavior as a function of gender and marital status. In addition, after the initial data analysis, the investigators conducted an unplanned analysis using the Michigan Alcoholism Screening Test to determine problematic drinking behavior of the subjects' parents and associated familial risk for drinking problems. This analysis was prompted by considerable research indicating that familial history of alcohol problems may be associated with the effects of stress and alcohol on a person's behavior (Cloninger 1987).

As in the studies by Lang and colleagues (1989) and Pelham and colleagues (1997), parents of ADHD children responded with self-ratings of increased distress and negative affect after interactions with the deviant children. The magnitude of the elevations in parent distress was as great as that seen in parents of normal children. Because parents of children with disruptive behavior disorders are exposed to such deviant child behavior on a daily basis, these observations suggest that those parents experience chronic interpersonal stressors. Other studies have indicated that such chronic interpersonal stressors have a greater impact in causing negative mood states (e.g., depression) in adults than do one-time (i.e., acute) and/or non-interpersonal stressors (Crnic and Acevedo 1995). Consequently, these findings illustrate the importance of child behavior on parental stress and mood levels.

Despite the increased distress levels, however, parents of ADHD children as a group did not display the stress-induced drinking shown by college students or parents of normal children. Deviant child behavior resulted in elevated drinking levels only when the investigators conducted the subgroup analyses based on family history of alcohol problems. Thus, parents with a positive family history of alcohol problems exhibited higher drinking levels after interacting with deviant children than after interacting with normal children. Conversely, parents without a family history of alcohol problems showed lower drinking levels after interacting with deviant children than after interacting with normal children.

This finding was somewhat surprising, because the investigators had strongly expected parents of ADHD children as a group to exhibit elevated drinking in response to deviant child behavior. The study results suggest, however, that some parents of ADHD children (i.e., parents without a family history of alcohol problems) may have developed coping techniques other than drinking (e.g., reducing their alcohol consumption or establishing problem-solving strategies) to cope with the stressors associated with raising a child with deviant behavior. Consequently, it is important to measure additional differences among individuals in order to fully explain responses to various types of child behavior.

Notably, the effect of a family history of alcohol problems on drinking levels was comparable for mothers and fathers. Most previous studies had demonstrated an association between a positive family history and alcohol problems in men, whereas the evidence for such an association in women was less convincing (Gomberg 1993). Furthermore, two distinct subgroups of parents, differentiated by their family history of alcoholism, appeared to exist, and they exhibited different coping techniques. Thus, parents with a family history of alcohol problems more commonly used maladaptive, emotion-focused coping techniques (i.e., drinking), whereas parents without such a history more commonly used adaptive, problem focused coping techniques (i.e., not drinking). Accordingly, the researchers continued to explore whether these sub-groups also existed among mothers of ADHD children.

To facilitate data interpretation, the investigators modified the study design in several ways, as follows:

• They determined the subjects' family histories of alcohol problems, defined as having a father with alcohol problems, prior to the study and used this information as a criterion for subject selection.
• They quantified stress-induced drinking for each subject using a within-subject design rather than the between-subject design employed in previous investigations. Thus, rather than comparing subjects who had interacted with a deviant child with subjects who had interacted with a normal child, the investigators had each subject participate in two laboratory sessions 1 week apart. In one session, the subject interacted with a deviant child and in the other session she interacted with a normal child.
• They measured the subjects' heart rate and blood pressure during their interactions with the children in order to obtain physiological information about subjects' stress levels.
• They administered numerous tests in order to identify dispositional characteristics, such as psychopathology, personality, coping, attributional style, alcohol expectancies, life events, family functioning, and drinking history, which might influence the subjects' response in addition to the family history of alcohol problems.

The results of the study confirmed the previous findings on the effects of child behavior on parental stress levels that were obtained from college students and parents of normal children. After interacting with the deviant children, the mothers of ADHD children showed greater physiological distress (i.e., significantly increased heart rate and blood pressure) than after interacting with the normal children. These mothers also showed greater subjective distress (i.e., increased negative affect; decreased positive affect; and increased self-ratings of unpleasantness, unsuccessfulness, and ineffectiveness). Furthermore, the mothers consumed approximately 20 percent more alcohol after interacting with the deviant children than after interacting with the normal children (Pelham et al. 1996a).

These findings clearly demonstrate that interactions with ADHD children engender large stress responses from their mothers in multiple domains. Furthermore, the mothers in this study as a group coped with this distress by drinking more alcohol. Contrary to the family history analysis in the previous study (Pelham et al. 1998), however, the subject's paternal history of alcohol problems (selected in advance) did not affect alcohol consumption in this larger sample.

To further clarify the results of the study among mothers of ADHD children, the researchers also evaluated the mothers' dispositional characteristics before their interactions with the children to identify potential associations with their stress-induced drinking (Pelham et al. 1996b). The investigators correlated these measures with the amount of alcohol the mothers consumed after interacting with a deviant child (i.e., stress-induced drinking), controlling for the amount of alcohol consumed after the interaction with the normal child. These analyses identified numerous factors associated with higher levels of stress-induced drinking, including the following:

• Higher levels of routine drinking (i.e., a greater number of drinks per drinking occasion)
• More negative consequences of drinking
• Higher levels of drinking problems
• A denser family history of alcohol problems (i.e., alcoholic relatives in addition to the father)
• Maternal history of drinking problems
• Higher self-ratings of using maladaptive coping strategies, feeling depressed, and experiencing more daily life stressors

Although many mothers of ADHD children showed elevated drinking levels in response to interacting with a deviant child, a substantial number of mothers decreased their alcohol consumption after such interactions. This pattern of divergent responses is comparable to the one observed among mothers of ADHD children in the earlier study by Pelham and colleagues (1998) and points to the need for more fine-grained analysis.

The individual differences in coping with deviant child behavior noted in both studies suggest that alcohol consumption in mothers of ADHD children is a complex phenomenon. Clearly, some mothers resort to maladaptive coping mechanisms (i.e., drinking) in response to the stress of dealing with their child. Such a dysfunctional coping response often can be predicted by the mothers' general coping styles. Other mothers, however, cope in a problem-solving fashion by decreasing their alcohol consumption when anticipating another interaction with the deviant child, apparently believing that drinking would decrease their effectiveness in interacting with that child.

Whereas a paternal history of alcohol problems did not predict stress-induced drinking in the mothers of ADHD children, a maternal history of alcohol problems and the frequency of alcohol problems in other first-degree relatives did predict stress-induced drinking. These findings suggest that in addition to, or instead of, paternal alcohol problems, researchers should consider maternal drinking history and family density of drinking when assessing the influence of family history on female drinking behavior.

The study on the mothers of ADHD children, as well as all the other studies in this series, was conducted in an "artificial" laboratory setting. The fact that subjects' self-reported drinking levels (i.e., number of drinks per occasion) and self-reported alcohol problems correlated highly with stress-induced drinking measured in this setting confirms that this type of investigation can generate information that reflects real-life behavior.¹ Thus, the laboratory findings provide strong support for the hypothesis that among mothers of ADHD children, routine drinking and drinking problems are at least in part a response to the daily stress of coping with their children.
¹ Some of the subjects reported alcohol problems even though the sample only included women classified as

Conclusions

A recent review of the relationship between AOD abuse and parenting concluded that huge gaps exist in under-standing the association between parental alcohol abuse and parent-child relationships (Mayes 1995). For example, more information is needed regarding the effects of alcohol on parenting behaviors (e.g., overly punitive discipline) that are known to affect child development. Lang and colleagues (1999) recently demonstrated in a laboratory setting that alcohol negatively influences parenting behaviors (e.g., lax monitoring) that mediate the development of conduct problems in children (Chamberlain and Patterson 1995). This finding confirms the parent-to-child influence on the relationship between parental alcohol problems and externalizing behavior problems in children. Conversely, the studies described in this article strongly support the assumption that the deviant child behaviors that represent major chronic interpersonal stressors for parents of ADHD children (Crnic and Acevedo 1995) are associated with increased parental alcohol consumption, thereby confirming a child-to-parent influence on the same relationship.

Childhood externalizing disorders affect approximately 7.5 to 10 percent of all children, with a considerably higher incidence among boys. The association between childhood behavior disorders and parental alcohol problems means that many adults with drinking problems are parents of children with behavior problems. Moreover, the study by Pelham and colleagues (1997) involving parents of normal children has demonstrated that parenting hassles may result in increased alcohol consumption even in normal families. Together, the results described in this article indicate that the stress associated with parenting and its influence on parental alcohol consumption should occupy a salient position among the variables that are examined in the study of stress and alcohol problems.

References

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ALTERMAN, A.I.; PETRARULO, E.; TARTER, R.E.; AND MCGOWAN, J.R. Hyperactivity and alcoholism: Familial and behavioral correlates. Addictive Behaviors 7:413-421, 1982.

BIEDERMAN, J.; FARAONE, S.V.; KEENAN, K.; KNEE, D.; AND TSUANG, M.T. Family-genetic and psychosocial risk factors in DSM-III attention deficit disorder. Journal of the American Academy of Child and Adolescent Psychiatry 29:526-533, 1990.

BUGENTAL, D., AND CORTEZ, V. Physiological reactivity to responsive and unresponsive children as moderated by perceived control. Child Development 59:686-693, 1988.

CHAMBERLAIN, P., AND PATTERSON, G.R. Discipline and child compliance in parenting. In: Bornstein, M.H., ed. Handbook of Parenting. Vol. 4. Mahwah, NJ: Lawrence Erlbaum Associates, 1995. pp. 205-225.

CLONINGER, C.R. A systematic method for clinical description and classification of personality variants. Archives of General Psychiatry 44:573-588, 1987.

CRNIC, K., AND ACEVEDO, M. Everyday stresses and parenting. In: Bornstein, M.H., ed. Handbook of Parenting. Vol. 4. Mahwah, NJ: Lawrence Erlbaum Associates, 1995. pp. 277-298.

FERGUSSON, D.M.; LYNSKEY, M.T.; AND HORWOOD, L.J. The effect of maternal depression on maternal ratings of child behavior. Journal of Abnormal Child Psychology 21:245-269, 1993.

GOMBERG, E.L. Women and alcohol: Use and abuse. The Journal of Nervous and Mental Disease 181:211-219, 1993.

LANG, A.R.; PELHAM, W.E.; JOHNSTON, C.; AND GELERNTER, S. Levels of adult alcohol consumption induced by interactions with child confederates exhibiting normal versus externalizing behaviors. Journal of Abnormal Psychology 98:294-299, 1989.

LANG, A.R.; PELHAM W.E.; ATKESON, B.M.; AND MURPHY, D.A. Effects of alcohol intoxication on parenting behavior in interactions with child confederates exhibiting normal or deviant behaviors. Journal of Abnormal Child Psychology 27:177-178, 1999.

MASH, E.J., AND JOHNSTON, C. Determinants of parenting stress: Illustrations from families of hyperactive children and families of physically abused children. Journal of Clinical Child Psychology 19:313-328, 1990.

MAYES, L.C. Substance abuse and parenting. In: Bornstein, M.H., ed. Handbook of Parenting. Vol. 4. Mahwah, NJ: Lawrence Erlbaum Associates, 1995. pp. 101-125.

MOLINA, B., AND PELHAM, W.E. "Explaining ADHD Risk for Adolescent Substance Use and Abuse: Exploring the Intrapersonal Domain of Personality, Attitudes, and Beliefs." Paper presented at the Biennial Meeting of the International Society for Research in Child and Adolescent Psychopathology in Barcelona, Spain, June 1999.

PELHAM, W.E., AND LANG, A.R. Parental alcohol consumption and deviant child behavior: Laboratory studies of reciprocal effects. Clinical Psychology Reviews 13:763-784, 1993.

PELHAM, W.E.; LANG, A.R.; JACOB, R.G.; JENNINGS, J.R.; BLUMENTHAL, J.D.; BAUMANN, B.L.; SCHOLLE, R.E.; AND MEISINGER, K.D. "Child Effects on Distress and Alcohol Consumption in Mothers of ADHD Boys." Poster presented at the annual meeting of the Research Society on Alcoholism and the International Society for Biomedical Research on Alcoholism in Washington, D.C., June 1996a.

PELHAM, W.E.; LANG, A.R.; JACOB, R.G.; JENNINGS, J.R.; BLUMENTHAL, J.D.; BAUMANN, B.L.; HAWK, L.W.; SCHOLLE, R.E.; AND MEISINGER, K.D. "Individual Risk Factors and Stress-Induced Drinking in Mothers of ADHD Boys." Poster presented at the annual meeting of the Research Society on Alcoholism and the International Society for Biomedical Research on Alcoholism in Washington, D.C., June, 1996b.

PELHAM, W.E.; LANG, A.R.; ATKESON, B.; MURPHY, D.A.; GNAGY, E.M.; GREINER, A.R.; VODDE-HAMILTON, M.; AND GREENSLADE, K.E. Effects of deviant child behavior on parental distress and alcohol consumption in laboratory interactions. Journal of Abnormal Child Psychology 25:413-422, 1997.

PELHAM, W.E.; LANG, A.R.; ATKESON, B.; MURPHY, D.A.; GNAGY, E.M.; GREINER, A.R.; VODDE-HAMILTON, M.; AND GREENSLADE, K.E. Effects of deviant child behavior on parental alcohol consumption: Stress-induced drinking in parents of ADHD children. American Journal on Addictions 7:103-114, 1998.

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WEINRAUB, M., AND WOLF, B.M. Effects of stress and social supports on mother-child interactions in single- and two-parent families. Child Development 54:1297-1311, 1983.

WILSNACK, S.C., AND WILSNACK, R.W. Epidemiological research on women's drinking: Recent progress and directions for the 1990s. In: Gomberg, E.S.L., and Nirenberg, T.D., eds. Women and Substance Abuse. Norwood, NJ: Ablex, 1993. pp. 62-99.

Source: National Institute on Alcohol Abuse and Alcoholism
Alcohol Research & Health Vol. 23, No. 4
By William E. Pelham, Jr., PhD, and Alan R. Lang, PhD

Page last modified/reviewed by athealth on January 28, 2014

by Dr. Robert Myers, Child Psychologist

The word "disorder" conjures up images of illness, disease and serious disabilities. All parents want to see their child as the smartest, most capable and best liked boy or girl on the block. So why would they want to have a label attached to them that often coveys just the opposite--such as slow learner, under-achiever or Attention Deficit Hyperactivity Disorder?

What a difference one word can make. Suppose we changed the last D in ADHD from "disorder" to "difference." We could then say that a child with ADHD has some significant differences in his cognitive ability, emotional sensitivity and activity level when compared to other children. This difference is probably inherited. His "skill set" is different from 95% of the children in his class.

I believe that, as a society, we have created a monster with ADHD, and it has fueled our perception that medicating our children can solve all their problems - and ours.

Unfortunately, the environment in which he spends most of his time is geared toward the other 95%. However, we then could look at helping him to adapt successfully to this environment, using his own set of strengths rather than helping him to cope with this environment due to his weaknesses. We then might say that this child may need psychostimulants and/or psychological intervention to enable him to concentrate on boring tasks and control spontaneity in a highly regimented environment.

The above in some ways reflects the ongoing debate about whether ADHD is a valid mental health condition that requires appropriate medical and psychological intervention OR that ADHD is a mythical disease state, manufactured by the medical community in order to make huge profits and is promoted by educational bureaucrats and abusive parents desiring to tranquilize unruly kids. I believe that, as a society, we have created a monster with ADHD. We perceive it as a diagnosis that will forever change or even taint the course of our child's life. And we are no longer surprised by the number of school-age children who are now diagnosed with ADHD. In fact, we have come to regard it as a norm, and it has fueled our perception that medicating our children can solve all their problems-and ours.

The facts, as in most debates, point to the truth being somewhere in the middle of these perceptions. ADHD is a condition worthy of future study to provide answers to scientific questions that will result in more accurate diagnosis and more effective methods of treatment. In the meantime, ADHD left untreated leads to a higher likelihood of depression, suicide and substance abuse later in life. ADHD appropriately treated leads to a higher likelihood of success in life because it can help the child properly channel his increased sensitivity, creativity and high energy.

On a more personal level, as a parent of a son who was diagnosed with ADHD at the age of five, I can identify with parents who may lean toward either the denial or victim mentality. When my wife and I were concerned about our son's behavior and emotional well-being, the last thing I thought of was that he had ADHD. Sometimes, I was probably a bit on the overprotective side. But on the whole, once our whole family accepted that he was a child with an attention deficit hyperactivity difference who needed medication, along with psychological support (provided by us at home), the situation turned around completely. He responded well to the medication, and the crisis of emotional turmoil was over. Over the years, we continued to provide consistent structure (as best we could) and encouragement as well as teaching him how to relax, learn necessary social skills and how to "stop and think." It all paid off. He has been off medication since middle school. He graduated with honors from a highly regarded university and is now pursuing a successful career in TV and film. He has a great sense of humor and lots of friends.

I encourage parents not to be afraid of the diagnosis, give it undue weight and importance, or use the label as a crutch for your child. Instead, I believe we need to accept it as the first step in turning a difficult situation around to a positive direction. Helping a child with ADHD succeed requires a team approach that often needs to continue over many years. That team includes the family, health professionals, teachers, and, of course, the child. Children may need medication, but treatment guidelines indicate that psychological interventions are also important. In some cases, psychological interventions may be sufficient to bring about desired results. In other cases, they address symptoms medication alone does not help and may also actually reduce the dosage of medication necessary to achieve desired results.

Effective psychological interventions include parent education, behavior modification, home-school contracts, cognitive behavioral therapy, social skills training, relaxation training and mental exercises to improve cognitive functioning. Recent research indicates that many or all of these interventions may be most effective when implemented at home with the parents and the child working as a team. Not only does this approach appear to improve the short-term effectiveness of the interventions, it also results in positive parenting techniques and an open and supportive parent/child relationship that becomes a way of life that is consistent and enduring over time.

So, ADHD can be perceived as a label to be dreaded, used as an excuse to avoid difficult situations, or it can be perceived as the identification of the problem underlying a child's difficulties at home and at school which can be successfully addressed. On the one hand, it is a curse. On the other, it is an opportunity to make things better. The basic tenet of cognitive behavioral therapy is that how we think determines how we feel, which then determines how we behave. If we want to change how we feel and how we behave as the result of those feelings, we need to change how we think. ADHD: Think of it as an opportunity.

ADHD-Disorder or Difference? reprinted with permission from Empowering Parents.

Author: Dr. Robert Myers is a clinical psychologist with 25 years of experience working with children and adolescents with Attention Deficit Hyperactivity Disorder and learning disabilities, and is the creator of The Total Focus Program. Dr. Bob has been a talk show host on KIEV and KORG in Southern California and has also appeared as a guest on many radio and television talk shows nationally and as a regular columnist for Parents and Kids Magazine. Dr. Myers earned his PhD from the University of Southern California.

Page last modified or reviewed by athealth on January 28, 2014

by James Lehman, MSW

I've worked with a lot of children and teens with behavior problems over the years—and believe me, very few of their parents liked their friends. It's like the national anthem of parents: "It's not my child; it's those kids he hangs out with!" When I hear that, I always say, "Maybe that's so, but the reason he hangs out with that group is because he's similar to them. And just like you're saying, 'It's those other kids he hangs out with,' those other kids' parents are saying it's yourkid who's the problem."

The old axiom is true, birds of a feather do flock together—and that's especially accurate in adolescence. In fact, one of the main needs of their particular developmental level is to belong to a group and be accepted. That's why teenagers are always so worried about how they look and act. And once they find a mode of dress, a type of music and a group of kids who accept them, it's very hard for parents to break through.

The first thing you have to realize is that you can't pick your child's friends. In fact, if you criticize their friends, you will see them react very strongly. That's because they're developmentally bound to defend their chosen peer group. When kids enter adolescence, they employ a way of looking at the world in which their friends are more important than anybody else. You'll often hear them say, "You just don't understand." And another part of that mindset is, "Nobody understands me but my friends." So if you criticize or attack their friends, you're really just making the relationship stronger. And no matter how you feel about your child's friends, I don't believe this direct kind of attack is effective. In fact, there are kids who like the fact that their parents don't approve of their friends; it adds to the flavor of the relationship. Understand that while your goal as a parent is to keep your child protected and safe, your child's goal is to be with people who like him.

When You Don't Like Your Child's Friends: 6 Ways to Deal with the "Wrong Crowd"

Try to Avoid Repeated Criticisms of Their Friends 

I personally don't think repeatedly criticizing your child's friends or pointing out that they're bad is going to be a successful strategy. Again, adolescents are developmentally at a place in their life where they're defending their friends. And so it's very difficult for a parent to turn around and say, "Your friends are no good," and expect to have a conversation. Your child's natural urge is going to be to protect his or her friends, whether or not they know you're right. Realize that criticizing your child's friends is like criticizing an aspect of your child. It's going to meet with the same resistance and hostility—even if what you're saying is true. And all it will do is further alienate your child from you.

Make Clear Statements about Behavior

I think if you don't like your kid's friends, the most effective thing to do is state: "I don't like the way they behave." That's the first thing you can say. "I don't like you hanging out with kids who get in trouble, because you get in trouble with them." Can you say this every day? No. But you can say it once in awhile. Be sure to simply state the facts. State what you don't like about their friends' behavior. You're not judging them. As a parent, I think you want to be a little smooth about that. You could say, "Look, I'm sure your friends are great to you. But they all smoke pot and they all get into trouble. If you hang out with them, you're going to get into the same trouble."

Remember, when we're having conversations like this with our kids we want to keep our observations on a level we can see. By that I mean talk about things that are recognizable: "I don't like that Jackie got arrested for shoplifting. I don't want you to get arrested for it, too. I don't like that your buddies all use drugs because I don't want you using drugs. I don't think it's good for you." Make those observations and keep it simple and direct.

Use Structure

I think that structure can be very helpful when dealing with your child's friends. In other words, if you don't like the kids he's hanging out with, then don't let him go out on school nights. Try to have more control over where he goes and what he does. If he says he's going to the football game and then you catch him down at the mall with those friends, that's his choice. He chose to go some place which you didn't know about and there should be consequences.

Set Limits

If you know your child's friends are engaging in behavior that isn't in line with your values, then I think you should set limits on how much time they spend with those kids—or whether or not your child can see them at all. If his friends are breaking the law or doing things that are unhealthy, you can say, "Maybe they're your friends, but I'm not going to let you hang out with them." With a lot of adolescents, defiance becomes a big problem. Many of the kids I dealt with would climb out their windows when told they couldn't go out. But again, you set the standard as the parent; you set the expectation. If your child doesn't meet it, at least he knew there were standards and expectations to begin with, and now he will have to face the consequences and be held accountable for his actions.

Going Out on Friday Night is Not a "Right"

All of a sudden, kids hit a certain age when they think they have the right to go out. Well, I don't think so. I think kids have to behave responsibly in order to earn the right to go out. And you can say, "I'll let you go out if you show me that you're trustworthy." Behaving responsibly does not include hanging out with kids who use drugs and drink—that's all there is to it. I also think going out on Friday or Saturday night is not a right; it has to be something that is discussed every week. My son used to come to me and say, "Listen, Saturday night we're all going up to the lake. Is it okay if I go?" Saturday night was not his automatic night out. Instead, that was negotiated each week, and the answer wasn't always "Sure." As a parent, I think you should be saying, "What are your plans this weekend?" Your child should know that they have to have their plans Okayed by you first, and that they have to behave responsibly in order to earn the privilege of going out.

Talk to Them about Mean Friends

What if your child is hanging out with kids who treat him badly? Know that he's hanging out with them for a reason. He's probably afraid of them so he's trying to become one of them. When kids are afraid of bullies and other kids, one of the options they have is to join the group and become a bully. Because even though these kids are mean to him, there is a sense of safety there. The deal they make is, "I'll let you be mean to me and tease me, but you won't abuse me or beat me up or take my lunch money any more."

But I think if your kid's friends are mean to him, the kind of questions you want to ask are, "What are you trying to accomplish by letting people treat you this way? What are you getting out of that?"

Try to have an adult conversation with your child. You can say, "Listen, you have choices; you don't have to hang out with these kids. You don't have to be a victim. I can get you help with this."

When Your Child Hangs Out with Kids Who Use Drugs

As we've said, there are several reasons why people gravitate toward different groups. If you have a kid with behavior problems, you will often find that they are attracted to friends who also have behavior problems. If you have a child who doesn't do his homework and fails in school and is resistant and mouthy, he's going to gravitate toward friends who won't hold him accountable for that kind of behavior. Instead, his chosen peer group will reward and reinforce what he's doing. In order to belong, he just has to do what the other kids are doing. That might be any number of things, including shoplifting, defacing property, using drugs or drinking.

It's a simple fact that kids who use drugs hang out with other kids who use drugs. These kids are not likely to ask, "Did you get an A in science?" If these are your child's friends, realize that he is almost certainly engaging in the same type of risky behavior—even if he says he's not. Let me be clear: there is no other reason for your child to pal around with kids who do drugs. If he says, "Well, they do it, but they don't do it around me," that's a lot of nonsense. It's just something kids tell you to throw you off track; and sadly, it's often a far cry from the truth.

Some parents say things to their kids like, "Well, you shouldn't smoke pot, but everybody experiments with it." Don't give your child that cop-out line.

Make it very clear: "No matter what you see your friends or other kids doing, there is no using drugs. That's our expectation of you."

We were really clear on that with our son. I personally feel parents cop out when they say, "You shouldn't do it, but everybody else does it." Your kid is not equipped to make decisions about drugs. Drugs get you high, drugs take away stress, drugs take away feelings of panic or crisis, and that means something. Once kids start using drugs, it's easy for teens to become dependent on them because adolescents always feel stress. Drugs can become a dangerous way for them to get relief from all their fears and anxieties. Make no bones about it, drug rehabs today are filled with teenagers whose parents said, "They're only experimenting" when their kids first started using.

There are important problem-solving tasks adolescents have to work through in order to prepare for adult living. Also, there is knowledge about the world that teenagers have to learn in order to make healthy choices and keep themselves safe. The use of drugs and alcohol in adolescence inhibits the possibility of these milestones being reached. So I don't think parents should turn a blind eye or make excuses. Many times, parents are afraid to feel powerless, so they'll make those kinds of statements instead of just telling their child "no." But you need to hold your child accountable and tell them right from wrong; that's simply the way it has to be. You have to be very clear and take a stand: "No drinking. No drugs."

When Your Child's Behavior Changes

If your child starts changing as a result of the kids he hangs out with, use a structured parenting routine: set limits and manage their time. I also think you should expect that they're going to change during adolescence. They're going to find a group with whom they're going to identify. When you see an adolescent, believe me, he's probably rebelling against adult authority in a lot of little ways. And while your child may go to school and be fairly responsible, you'll find that through music, through clothes, through a myriad of different things, it's a rebellious time in his life.

I think it's important for parents to understand that rebelliousness has a developmental function. Teenagers are individuating from their parents; what I mean by that is they're becoming individuals and separating from their parents. This feels as natural to adolescents as water feels to a duck. Saying that, it's often a very hard thing for parents to accept and manage.

Here's the bottom line: kids are going to make mistakes and they're going to make bad choices. The best we can do is guide them, set limits, project our view of what's right and wrong in the world and hold them accountable

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Does Your Child Have "Toxic" Friends? 6 Ways to Deal with the Wrong Crowd reprinted with permission from Empowering Parents. For more information, visit www.EmpoweringParents.com

Author: James Lehman is a behavioral therapist and the creator of The Total Transformation Program for parents. He has worked with troubled teens and children for three decades. James holds a Masters Degree in Social Work from Boston University.

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Page last modified or reviewed by athealth.com on February 3, 2014