Archives: Consumer Topics

Heavy Drinking

An estimated 5.3 million women in the United States drink in a way that threatens their health, safety, and general well-being. A strong case can be made that heavy drinking is more risky for women than men:

• Heavy drinking increases a woman's risk of becoming a victim of violence and sexual assault.
• Drinking over the long term is more likely to damage a woman's health than a man's, even if the woman has been drinking less alcohol or for a shorter length of time than the man.

The health effects of alcohol abuse and alcoholism are serious. Some specific health problems include:

• Alcoholic liver disease: Women are more likely than men to develop alcoholic hepatitis (liver inflammation) and to die from cirrhosis.
• Brain disease: Most alcoholics have some loss of mental function, reduced brain size, and changes in the function of brain cells. Research suggests that women are more vulnerable than men to alcohol-induced brain damage.
• Cancer: Many studies report that heavy drinking increases the risk of breast cancer. Alcohol also is linked to cancers of the digestive track and of the head and neck (the risk is especially high in smokers who also drink heavily).
• Heart disease: Chronic heavy drinking is a leading cause of cardiovascular disease. Among heavy drinkers, women are more susceptible to alcohol-related heart disease, even though women drink less alcohol over a lifetime than men.

Finally, many alcoholics smoke; smoking in itself can cause serious long-term health consequences.

Alcohol in Women's Lives: Safe Drinking Over a Lifetime

The pressures to drink more than what is safe—and the consequences—change as the roles that mark a woman's life span change. Knowing the signs that drinking may be a problem instead of a pleasure can help women who choose to drink do so without harm to themselves or others.

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Source: NIH Publication No. 08–4956
Revised 2008

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

Moderate Drinking: Benefits and Risks

Moderate drinking can have short- and long-term health effects, both positive and negative:

Benefits

Heart disease: Once thought of as a threat mainly to men, heart disease also is the leading killer of women in the United States. Drinking moderately may lower the risk for coronary heart disease, mainly among women over age 55. However, there are other factors that reduce the risk of heart disease, including a healthy diet, exercise, not smoking, and keeping a healthy weight. Moderate drinking provides little, if any, net health benefit for younger people. (Heavy drinking can actually damage the heart.)

Risks

Drinking and driving: It doesn't take much alcohol to impair a person's ability to drive. The chances of being killed in a single-vehicle crash are increased at a blood alcohol level that a 140-lb. woman would reach after having one drink on an empty stomach.

Medication interactions: Alcohol can interact with a wide variety of medicines, both prescription and over-the-counter. Alcohol can reduce the effectiveness of some medications, and it can combine with other medications to cause or increase side effects. Alcohol can interact with medicines used to treat conditions as varied as heart and blood vessel disease, digestive problems, and diabetes. In particular, alcohol can increase the sedative effects of any medication that causes drowsiness, including cough and cold medicines and drugs for anxiety and depression. When taking any medication, read package labels and warnings carefully.

Breast cancer: Research suggests that as little as one drink per day can slightly raise the risk of breast cancer in some women, especially those who are postmenopausal or have a family history of breast cancer. It is not possible, however, to predict how alcohol will affect the risk for breast cancer in any one woman.

Fetal Alcohol Syndrome: Drinking by a pregnant woman can harm her unborn baby, and may result in a set of birth defects called fetal alcohol syndrome (FAS).

Fetal Alcohol Syndrome

Fetal alcohol syndrome (FAS) is the most common known preventable cause of mental impairment. Babies with FAS have distinctive changes in their facial features and they may be born small. The brain damage that occurs with FAS can result in lifelong problems with learning, memory, attention, and problem solving. These alcohol-related changes in the brain may be present even in babies whose appearance and growth are not affected. It is not known if there is any safe drinking level during pregnancy; nor is there any stage of pregnancy in which drinking—at any level—is known to be risk free. If a woman is pregnant, or wants to become pregnant, she should not drink alcohol. Even if she is pregnant and already has consumed alcohol, it is important to stop drinking for the rest of her pregnancy. Stopping can reduce the chances that her child might be harmed by alcohol.

Another risk of drinking is that a woman may at some point abuse alcohol or become alcoholic (alcohol dependent). Drinking four or more drinks on any given day OR drinking eight or more drinks in a typical week increases a woman's risk of developing alcohol abuse or dependence.

The ability to drink a man—or anyone—under the table is not a plus: it is a red flag. Research has shown that drinkers who are able to handle a lot of alcohol all at once are at higher—not lower—risk of developing problems, such as dependence on alcohol.

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Source: NIH Publication No. 08–4956
Revised 2008

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

ADHD: Treatment Options

What Are the Treatment Options?

Although at present no cure for ADHD exists, there are a number of treatment options that have proven to be effective for some children. Effective strategies include behavioral, pharmacological, and multimodal methods.

Behavioral Approaches

Behavioral approaches represent a broad set of specific interventions that have the common goal of modifying the physical and social environment to alter or change behavior (AAP, 2001). They are used in the treatment of ADHD to provide structure for the child and to reinforce appropriate behavior. Those who typically implement behavioral approaches include parents as well as a wide range of professionals, such as psychologists, school personnel, community mental health therapists, and primary care physicians. Types of behavioral approaches include behavioral training for parents and teachers (in which the parent and/or teacher is taught child management skills), a systematic program of contingency management (e.g. positive reinforcement, "time outs," response cost, and token economy), clinical behavioral therapy (training in problem-solving and social skills), and cognitive-behavioral treatment (e.g., self-monitoring, verbal self-instruction, development of problem-solving strategies, self-reinforcement) (AAP, 2001; Barkley, 1998b; Pelham, Wheeler, & Chronis, 1998). In general, these approaches are designed to use direct teaching and reinforcement strategies for positive behaviors and direct consequences for inappropriate behavior. Of these options, systematic programs of intensive contingency management conducted in specialized classrooms and summer camps with the setting controlled by highly trained individuals have been found to be highly effective (Abramowitz, et al., 1992; Carlson, et al., 1992; Pelham & Hoza, 1996). A later study conducted by Pelham, Wheeler, and Chronis (1998) indicates that two approaches-parent training in behavior therapy and classroom behavior interventions-also are successful in changing the behavior of children with ADHD. In addition, home-school interactions that support a consistent approach are important to the success of behavioral approaches.

The research results on the effectiveness of behavioral techniques are mixed. While studies that compare the behavior of children during periods on and off behavior therapy demonstrate the effectiveness of behavior therapy (Pelham & Fabiano, 2001), it is difficult to isolate its effectiveness. The multiplicity of interventions and outcome measures makes careful analysis of the effects of behavior therapy alone, or in association with medications, very difficult (AAP, 2001). A review conducted by McInerney, Reeve, and Kane (1995) confirms that the effective education of children with ADHD requires modifications to academic instruction, behavior management, and classroom environment. Although some research suggests that behavioral methods offer the opportunity for children to work on their strengths and learn self-management, other research indicates that behavioral interventions are effective but to a lower degree than treatment with psychostimulants (Jadad, Boyle, & Cunningham, 1999; Pelham, et al., 1998).

Behavior therapy has been found to be effective only when it is implemented and maintained (AAP, 2001). Indeed, behavioral strategies can be difficult to implement consistently across all of the settings necessary for it to be maximally effective. Although behavioral management programs have been shown to enhance the academic performance and behavior of children with ADHD, followup and maintenance of the treatment is often lacking (Rapport, Stoner, & Jones, 1986).

In fact, some research has shown that behavioral techniques may fail to reduce ADHD's core characteristics of hyperactivity, impulsivity, and inattention (AAP, 2001; U.S. Department of Health and Human Services [DHHS], 1999). Conversely, one must consider that the problems of children with ADHD are seldom limited to the core symptoms themselves (Barkley, 1990a). Children frequently demonstrate other types of psychosocial difficulties, such as aggression, oppositional defiant behavior, academic underachievement, and depression (Barkley, 1990a). Because many of these other difficulties cannot be managed through psychostimulants, behavioral interventions may be useful in addressing ADHD and other problems a child may be exhibiting.

Pharmacological Approaches

Pharmacological treatment remains one of the most common, yet most controversial, forms of ADHD treatment. It is important to note that the decision to prescribe any medicine is the responsibility of medical-not educational-professionals, after consultation with the family and agreement on the most appropriate treatment plan. Pharmacological treatment includes the use of psychostimulants, antidepressants, anti-anxiety medications, antipsychotics, and mood stabilizers (NIMH, 2000). Stimulants predominate in clinical use and have been found to be effective with 75 to 90 percent of children with ADHD (DHHS, 1999). Stimulants include Methylphenidate (Ritalin), Dextroamphetamine (Dexedrine), and Pemoline (Cylert). Other types of medication (antidepressants, anti-anxiety medications, antipsychotics, and mood stabilizers) are used primarily for those who do not respond to stimulants, or those who have coexisting disorders. The results of the Multimodal Treatment Study (MTA), which are discussed in further detail in the next section, confirm research findings on the use of pharmacological treatment for patients with ADHD. Specifically, the study found that the use of medication was almost as effective as the multimodal treatment of medication and behavioral interventions (Edwards, 2002).

Researchers believe that psychostimulants affect the portion of the brain that is responsible for producing neurotransmitters. Neurotransmitters are chemical agents at nerve endings that help electrical impulses travel among nerve cells. Neurotransmitters are responsible for helping people attend to important aspects of their environment. The appropriate medication stimulates these underfunctioning chemicals to produce extra neurotransmitters, thus increasing the child's capacity to pay attention, control impulses, and reduce hyperactivity. Medication necessary to achieve this typically requires multiple doses throughout the day, as an individual dose of the medication lasts for a short time (1 to 4 hours). However, slow- or timed-release forms of the medication (for example, Concerta) may allow a child with ADHD to continue to benefit from medication over a longer period of time. Doctors, teachers, and parents should communicate openly about the child's behavior and disposition in order to get the dosage and schedule to a point where the child can perform optimally in both academic and social settings, while keeping side effects to a minimum. If it is determined that the child should receive medication during the school day, it is important to develop a plan to ensure that medication is administered in accordance with the plan. Such a plan would be an appropriate component of the child's IEP. In addition, schools must ensure that the child's and parent's rights to medical confidentiality are maintained.

Although the positive effects of the stimulant medication are immediate, all medications have side effects. Adjusting the dosage of the medicine can diminish some of these side effects. Some of the more common side effects include insomnia, nervousness, headaches, and weight loss. In fewer cases, subjects have reported slowed growth, tic disorders, and problems with thinking or with social interaction (Gadow, Sverd, Sprafkin, Nolan, & Ezor, 1995). Medication also can be expensive, depending upon the medicine prescribed, the frequency of administration, and the subsequent frequency of refills. Stimulant medicines do not "normalize" the entire range of behavior problems, and children under treatment may still manifest higher levels of behavioral problems than their peers (DHHS, 1999). Nonetheless, the American Academy of Pediatrics (AAP) finds that at least 80 percent of children will respond to one of the stimulants if they are administered in a systematic way. Under medical care, children who fail to show positive effects or who experience intolerable side effects on one type of medication may find another medication helpful. The AAP reports that children who do not respond to one medication may have a positive response to an alternative medication, and concludes that stimulants may be a safe and effective way to treat ADHD in children (AAP, 2001).

In January 2003, a new type of nonstimulant medication for the treatment of children and adults with ADHD was approved by the FDA. Atomoxetine, also known as Straterra, may be prescribed by physicians in some cases.

Multimodal Approaches

Research indicates that for many children the best way to mitigate symptoms of ADHD is the use of a combined approach. A recent study by the NIMH-the Multimodal Treatment Study of Children with ADHD (MTA)-is the longest and most thorough study of the effects of ADHD interventions (MTA Cooperative Group, 1999a, 1999b). The study followed 579 children between the ages of 7 and 10 at six sites nationwide and in Canada. The researchers compared the effects of four interventions: medication provided by the researchers, behavioral intervention, a combination of medication and behavioral intervention, and no-intervention community care (i.e., typical medical care provided in the community).

Of the four interventions investigated, the researchers found that the combined medication/behavior treatment and the medication treatment work significantly better than behavioral therapy alone or community care alone at reducing the symptoms of ADHD. Multimodal treatments were especially effective in improving social skills for students coming from high-stress environments and children with ADHD in combination with symptoms of anxiety or depression. The study revealed that a lower medication dosage is effective in multimodal treatments, whereas higher doses were needed to achieve similar results in the medication-only treatment.

Researchers found improvement in the following areas after using a multimodal intervention: child anxiety, academic performance, oppositional behavior, and parent-child interaction. Positive results also were found in school-related behavior when multimodal treatment is coupled with improved parenting skills, including more effective disciplinary responses, and appropriate reinforcements (Hinshaw, et al., 2000). These findings were replicated across all six research sites, despite substantial differences among sites in their samples' sociodemographic characteristics. The study's overall results appear to apply to a wide range of children and families identified as in need of treatment services for ADHD (NIMH, 2000). Other studies demonstrate that multimodal treatments hold value for those children for whom treatment with medication alone is not sufficient (Klein, Abikoff, Klass, Ganeles, Seese, & Pollack, 1997).

In October 2001, the AAP released evidence-based recommendations for the treatment of children diagnosed with ADHD. Their guidelines state that:

• Primary care clinicians should establish a treatment program that recognizes ADHD as a chronic condition;
• The treating clinician, parents, and the child, in collaboration with school personnel, should specify appropriate target outcomes to guide management;
• The clinician should recommend stimulant mediation and/or behavioral therapy as appropriate to improve target outcomes in children with ADHD;
• When the selected management for a child with ADHD has not met target outcomes, clinicians should evaluate the original diagnosis, use of all appropriate treatments, adherence to the treatment plan, and the presence of coexisting conditions; and
• The clinician should periodically provide a systematic followup for the child with ADHD. Monitoring should be directed to target outcomes and adverse effects, with information gathered from parents, teachers, and the child.

The AAP report stressed that the treatment of ADHD (whether behavioral, pharmacological, or multimodal) requires the development of child-specific treatment plans that describe not only the methods and goals of treatment, but also include means of monitoring over time and specific plans for followup. The process of developing target outcomes requires careful input from parents, children, and teachers as well as other school personnel where available and appropriate. The AAP concluded that parents, children, and educators should agree on at least three to six key targets and desired changes as requisites for constructing the treatment plan. The goals should be realistic, attainable, and measurable. The AAP report found that, for most children, stimulant medication is highly effective in the management of the core symptoms of ADHD. For many children, behavioral interventions are valuable as primary treatment or as an adjunct in the management of ADHD, based on the nature of coexisting conditions, specific target outcomes, and family circumstances (AAP, 2001).

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Source: Adapted from U.S. Department of Education, Office of Special Education and Rehabilitative Services, Office of Special Education Programs, Identifying and Treating Attention Deficit Hyperactivity Disorder: A Resource for School and Home, Washington, D.C., 2008.

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

ADHD: Educational and Medical Evaluation

ADHD Educational Evaluation

An educational evaluation assesses the extent to which a child's symptoms of ADHD impair his or her academic performance at school. The evaluation involves direct observations of the child in the classroom as well as a review of his or her academic productivity.

Classroom observations are used to record how often the child exhibits various ADHD symptoms in the classroom. The frequency with which the child with ADHD exhibits these and other target behaviors are compared to norms for other children of the same age and gender. It is also important to compare the behavior of the child with ADHD to the behaviors of other children in his or her classroom.

It is best to collect this information during two or three different observations across several days. Each observation typically lasts about 20 to 30 minutes.

In order to receive special education and related services under Part B of IDEA, a child must be evaluated to determine (1) whether he or she has a disability and (2) whether he or she, because of the disability, needs special education and related services. The initial evaluation must be a full and individual evaluation that assesses the child in all areas related to the suspected disability and uses a variety of assessment tools and strategies. As discussed in the section on Legal Requirements (above), a child who has ADHD may be eligible for special education and related services because he or she also meets the criteria for at least one of the disability categories, such as specific learning disability or emotional disturbance. It is important to note that the assessment instruments and procedures used by educational personnel to evaluate other disabilities-such as learning disabilities-may not be appropriate for the evaluation of ADHD. A variety of assessment tools and strategies must be used to gather relevant functional and developmental information about the child.

An educational evaluation also includes an assessment of the child's productivity in completing classwork and other academic assignments. It is important to collect information about both the percentage of work completed as well as the accuracy of the work. The productivity of the child with ADHD can be compared to the productivity of other children in the class.

Once the observations and testing are complete, a group of qualified professionals and the parents of the child will review the results and determine if the child has a disability and whether the child needs special education and related services. Using this information, the child's IEP team, which includes the child's parents, will develop an individualized educational program that directly addresses the child's learning and behavior. If the child is recommended for evaluation and determined by the child's IEP team not to meet the eligibility requirements under IDEA, the child may be appropriate for evaluation under Section 504.

ADHD Medical Evaluation

Part B of IDEA does not necessarily require a school district to conduct a medical evaluation for the purpose of determining whether a child has ADHD. If a public agency believes that a medical evaluation by a licensed physician is needed as part of the evaluation to determine whether a child suspected of having ADHD meets the eligibility criteria of the OHI category, or any other disability category under Part B, the school district must ensure that this evaluation is conducted at no cost to the parents (OSEP Letter to Michel Williams, March 14, 1994, 21 IDELR 73).

In May 2000, the American Academy of Pediatrics (AAP) published a clinical practice guideline that provides recommendations for the assessment and diagnosis of school-aged children with ADHD. The guideline, developed by a committee comprised of pediatricians and experts in the fields of neurology, psychology, child psychiatry, child development, and education, as well as experts in epidemiology and pediatrics, is intended for use by primary care clinicians who are involved in the identification and evaluation process. The recommendations are designed to provide a framework for diagnostic decision making and include the following:

• Medical evaluation for ADHD should be initiated by the primary care clinician. Questioning parents regarding school and behavioral issues, either directly or through a pre-visit questionnaire, may help alert physicians to possible ADHD.
• In diagnosing ADHD, physicians should use DSM-IV criteria.
• The assessment of ADHD should include information obtained directly from parents or caregivers, as well as a classroom teacher or other school professional, regarding the core symptoms of ADHD in various settings, the age of onset, duration of symptoms, and degree of functional impairment.

Evaluation of a child with ADHD should also include assessment of co-existing conditions such as learning and language problems, aggression, disruptive behavior, depression, or anxiety.

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Source: Adapted from U.S. Department of Education, Office of Special Education and Rehabilitative Services, Office of Special Education Programs, Identifying and Treating Attention Deficit Hyperactivity Disorder: A Resource for School and Home, Washington, D.C., 2008.

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

Legal Requirements for Identification of and Educational Services for Children with ADHD

Two important federal mandates protect the rights of eligible children with ADHD-the Individuals with Disabilities Education Act (IDEA) and Section 504 of the Rehabilitation Act of 1973 (Section 504). The regulations implementing these laws are 34 CFR sections 300 and 104, respectively, which require school districts to provide a "free appropriate public education" to students who meet their eligibility criteria. Although a child with ADHD may not be eligible for services under IDEA, he or she may meet the requirements of Section 504.

The requirements and qualifications for IDEA are more stringent than those of Section 504.IDEA provides funds to state education agencies for the purpose of providing special education and related services to children evaluated in accordance with IDEA and found to have at least one of the 13 specific categories of disabilities, and who thus need special education and related services. Attention Deficit Hyperactivity Disorder may be considered under the specific category of "Other Health Impairment" (OHI), if the disability results in limited strength, vitality, or alertness, including a heightened alertness to environmental stimuli that results in limited alertness with respect to the educational environment and that is due to chronic or acute health problems.

Under IDEA, each public agency-that is, each school district-shall ensure that a full and individual evaluation is conducted for each child being considered for special education and related services. The child's individualized education program (IEP) team uses the results of the evaluation to determine the educational needs of the child. The results of a medical doctor's, psychologist's, or other qualified professional's assessment indicating a diagnosis of ADHD may be an important evaluation result, but the diagnosis does not automatically mean that a child is eligible for special education and related services. A group of qualified professionals and the parent of the child determine whether the child is an eligible child with a disability according to IDEA. Children with ADHD also may be eligible for services under the "Specific Learning Disability," "Emotional Disturbance," or other relevant disability categories of IDEA if they have those disabilities in addition to ADHD.

After it has been determined that a child is eligible for special education and related services under IDEA, an IEP is developed that includes a statement of measurable annual goals, including benchmarks or short-term objectives that reflect the student's needs. The IEP goals are determined with input from the parents and cannot be changed without the parents' knowledge. Although children who are eligible under IDEA must have an IEP, students eligible under Section 504 are not required to have an IEP but must be provided regular or special education and related aids or services that are designed to meet their individual educational needs as adequately as the needs of non-disabled students are met.

Section 504 was established to ensure a free appropriate education for all children who have an impairment-physical or mental-that substantially limits one or more major life activities. If it can be demonstrated that a child's ADHD adversely affects his or her learning-a major life activity in the life of a child-the student may qualify for services under Section 504. To be considered eligible for Section 504, a student must be evaluated to ensure that the disability requires special education or related services or supplementary aids and services. Therefore, a child whose ADHD does not interfere with his or her learning process may not be eligible for special education and related services under IDEA or supplementary aids and services under Section 504.

IDEA and Section 504 require schools to provide special education or to make modifications or adaptations for students whose ADHD adversely affects their educational performance. Such adaptations may include curriculum adjustments, alternative classroom organization and management, specialized teaching techniques and study skills, use of behavior management, and increased parent/ teacher collaboration. Eligible children with ADHD must be placed in regular education classrooms, to the maximum extent appropriate to their educational needs, with the use of supplementary aids and services if necessary. Of course, the needs of some children with ADHD cannot be met solely within the confines of a regular education classroom, and they may need special education or related aids or services provided in other settings.

Components of a Comprehensive Evaluation

• Behavioral
• Educational
• Medical

A diagnosis of ADHD is multifaceted and includes behavioral, medical, and educational data gathering. One component of the diagnosis includes an examination of the child's history through comprehensive interviews with parents, teachers, and health care professionals. Interviewing these individuals determines the child's specific behavior characteristics, when the behavior began, duration of symptoms, whether the child displays the behavior in various settings, and coexisting conditions. The American Academy of Pediatrics (AAP) stresses that since a variety of psychological and developmental disorders frequently coexist in children who are being evaluated for ADHD, a thorough examination for any such coexisting condition should be an integral part of any evaluation (AAP, 2000).

Behavioral Evaluation

Specific questionnaires and rating scales are used to review and quantify the behavioral characteristics of ADHD. The AAP has developed clinical practice guidelines for the diagnosis and evaluation of children with ADHD, and finds that such behavioral rating scales accurately distinguish between children with and without ADHD (AAP, 2000). Conversely, AAP recommends not using broadband rating scales or teacher global questionnaires in the diagnosis of children with ADHD. They suggest using ADHD-Specific rating scales including:

CPRS-R:L-ADHD Index
(Conners Parent Rating Scale-1997
Revised Version: Long Form, ADHD Index Scale)

CTRS-R:L-ADHD Index
(Conners Teacher Rating Scale-1997
Revised Version: Long Form, ADHD Index Scale)

CPRS-R:L-DSM-IV Symptoms
(Conners Parent Rating Scale-1997
Revised Version: Long Form, DSM-IV Symptoms Scale)

CTRS-R:L-DSM-IV Symptoms
(Conners Teacher Rating Scale-1997
Revised Version: Long Form, DSM-IV Symptoms Scale)

SSQ-O-1
(Barkley's School Situations Questionnaire-Original Version, Number of Problem Settings Scale)

SSQ-O-II
(Barkley's School Situations Questionnaire-Original Version, Mean Severity Scale)

(Taken from Green, Wong, Atkins, et al. (1999). Diagnosis of Attention Deficit/Hyperactivity Disorder. Technical Review 3. Rockville, MD: U.S. Department of Health and Human Services, Agency for Health Care Policy and Research, as cited in AAP, 2000).

As with all psychological tests, child-rating scales have a range of measurement error. Appropriate scales have satisfactory norms for the child's chronological age and ability levels.

Collecting information about the child's ADHD symptoms from several different sources helps ensure that the information is accurate. Appropriate sources of information include the child's parents, teachers, other diagnosticians such as psychologists, occupational therapists, speech therapists, social workers, and physicians. It is also important to review both the child's previous medical history as well as his or her school records.

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Source: Adapted from U.S. Department of Education, Office of Special Education and Rehabilitative Services, Office of Special Education Programs, Identifying and Treating Attention Deficit Hyperactivity Disorder: A Resource for School and Home, Washington, D.C., 2008.

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

How Do We Identify ADHD?

Although toddlers and preschoolers, on occasion, may show characteristics of ADHD, some of these behaviors may be normal for their age or developmental stage. These behaviors must be exhibited to an abnormal degree to warrant identification as ADHD. Even with older children, other factors (including environmental influences) can produce behaviors resembling ADHD.

The criteria set forth by the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) are used as the standardized clinical definition to determine the presence of ADHD (see DSM-IV Criteria for ADHD). A person must exhibit several characteristics to be clinically diagnosed as having ADHD:

• Severity: The behavior in question must occur more frequently in the child than in other children at the same developmental stage.
• Early onset: At least some of the symptoms must have been present prior to age 7.
• Duration: The symptoms must also have been present for at least 6 months prior to the evaluation.
• Impact: The symptoms must have a negative impact on the child's academic or social life.
• Settings: The symptoms must be present in multiple settings.

The specific DSM-IV criteria are set forth in the following chart.

What Causes ADHD?

ADHD has traditionally been viewed as a problem related to attention, stemming from an inability of the brain to filter competing sensory inputs such as sight and sound. Recent research, however, has shown that children with ADHD do not have difficulty in that area. Instead, researchers now believe that children with ADHD are unable to inhibit their impulsive motor responses to such input (Barkley, 1997; 1998a).

It is still unclear what the direct and immediate causes of ADHD are, although scientific and technological advances in the field of neurological imaging techniques and genetics promise to clarify this issue in the near future. Most researchers suspect that the cause of ADHD is genetic or biological, although they acknowledge that the child's environment helps determine specific behaviors.

Imaging studies conducted during the past decade have indicated which brain regions may malfunction in patients with ADHD, and thus account for symptoms of the condition (Barkley, 1998a). A 1996 study conducted at the National Institutes for Mental Health (NIMH) found that the right prefrontal cortex (part of the cerebellum) and at least two of the clusters of nerve cells known collectively as the basal ganglia are significantly smaller in children with ADHD (as cited in Barkley, 1998a). It appears that these areas of the brain relate to the regulation of attention. Why these areas of the brain are smaller for some children is yet unknown, but researchers have suggested mutations in several genes that are active in the prefrontal cortex and basal ganglia may play a significant role (Barkley, 1998a). In addition, some nongenetic factors have been linked to ADHD including premature birth, maternal alcohol and tobacco use, high levels of exposure to lead, and prenatal neurological damage. Although some people claim that food additives, sugar, yeast, or poor child rearing methods lead to ADHD, there is no conclusive evidence to support these beliefs (Barkley, 1998a; Neuwirth, 1994; NIMH, 1999).

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Adapted from U.S. Department of Education, Office of Special Education and Rehabilitative Services, Office of Special Education Programs, Identifying and Treating Attention Deficit Hyperactivity Disorder: A Resource for School and Home, Washington, D.C., 2008.

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

There is a great concern about the incidence of violent behavior among children and adolescents. This complex and troubling issue needs to be carefully understood by parents, teachers, and other adults.

Children as young as preschoolers can show violent behavior. Parents and other adults who witness the behavior may be concerned, however, they often hope that the young child will "grow out of it." Violent behavior in a child at any age always needs to be taken seriously. It should not be quickly dismissed as "just a phase they're going through!"

Range of Violent Behavior

Violent behavior in children and adolescents can include a wide range of behaviors: explosive temper tantrums, physical aggression, fighting, threats or attempts to hurt others (including homicidal thoughts), use of weapons, cruelty toward animals, fire setting, intentional destruction of property and vandalism.

Factors Which Increase Risk of Violent Behavior

Numerous research studies have concluded that a complex interaction or combination of factors leads to an increased risk of violent behavior in children and adolescents.

These factors include:

• Previous aggressive or violent behavior
• Being the victim of physical abuse and/or sexual abuse
• Exposure to violence in the home and/or community
• Genetic (family heredity) factors
• Exposure to violence in media (TV, movies, etc.)
• Use of drugs and/or alcohol • Presence of firearms in home
• Combination of stressful family socioeconomic factors (poverty, severe deprivation, marital breakup, single parenting, unemployment, loss of support from extended family)
• Brain damage from head injury

What are the "warning signs" for violent behavior in children?

Children who have several risk factors and show the following behaviors should be carefully evaluated:

• Intense anger
• Frequent loss of temper or blow-ups
• Extreme irritability
• Extreme impulsiveness
• Becoming easily frustrated

Parents and teachers should be careful not to minimize these behaviors in children.

What can be done if a child shows violent behavior?

Whenever a parent or other adult is concerned, they should immediately arrange for a comprehensive evaluation by a qualified mental health professional. Early treatment by a professional can often help. The goals of treatment typically focus on helping the child to: learn how to control his/her anger; express anger and frustrations in appropriate ways; be responsible for his/her actions; and accept consequences.

In addition, family conflicts, school problems, and community issues must be addressed.

Can anything prevent violent behavior in children?

Research studies have shown that much violent behavior can be decreased or even prevented if the above risk factors are significantly reduced or eliminated. Most importantly, efforts should be directed at dramatically decreasing the exposure of children and adolescents to violence in the home, community, and through the media. Clearly, violence leads to violence.

In addition, the following strategies can lessen or prevent violent behavior:

• Prevention of child abuse (use of programs such as parent training, family support programs, etc.)
• Sex education and parenting programs for adolescents
• Early intervention programs for violent youngsters
• Monitoring child's viewing of violence on TV/videos/movies

If you find Facts for Families© helpful and would like to make good mental health a reality, consider donating to the Campaign for America’s Kids. Your support will help us continue to produce and distribute Facts for Families, as well as other vital mental health information, free of charge.

American Academy of Child and Adolescent Psychiatry -  2012 Reviewed January 23, 2014

Reviewed January 23, 2014

Traditionally, stress has been defined in terms of its source (e.g., internal and external) (Marion, 2003). Internal sources of stress include hunger; pain; sensitivity to noise, temperature change, and crowding (social density); fatigue; and over- or under-stimulation from one's immediate physical environment. External stressors include separation from family, change in family composition, exposure to arguing and interpersonal conflict, exposure to violence, experiencing the aggression of others (bullying), loss of important personal property or a pet, exposure to excessive expectations for accomplishment, "hurrying," and disorganization in one's daily life events (Bullock, 2002). Although the research literature tends to focus on the impact of single-variable stressors on children's development, in real-life situations, children experience stress from multiple sources. Researchers note that multiple stressors interact with one another and can have cumulative effects (Stansbury & Harris, 2000). This digest discusses how children experience and adapt to stress, and offers suggestions to teachers and parents on preventing and reducing children's stress.

How Vulnerable Are Young Children to Stress?

Stress is experienced in many forms and varies by the individual, the child's developmental level, and the child's previous life experience. Adapting or managing stress appears to be highly dependent on a child's developmental capabilities and coping-skill inventory. Researchers suggest that children under the age of 6 are developmentally less capable of

• thinking about an event in its entirety;
• selecting from a menu of possible behaviors in response to any new, interesting, or anxiety-inducing event;
• comprehending an event separate from their own feelings; and
• modifying their physical reactions in response to change in stimuli (Allen & Marotz, 2003).

Stress can have positive as well as negative influences. The younger the child, the greater the impact of new events, and the more powerful and potentially negative stress becomes. Some stress is a normal part of a child's everyday life and can have positive influences. However, excessive stress can have both immediate and far-reaching effects on children's adaptability to new situations, even events that are seemingly unrelated to the specific stressful event.

Research indicates that the negative impact of stress is more profound on children who are younger than age 10, have a genetic temperament that is "slow-to-warm-up" or "difficult," were born premature, are male, have limited cognitive capacity, or have experienced prenatal stress (Monk et al., 2000). Children who live in poverty, who live in violent communities, or who are bullied in school settings are also subject to more external stress (McLoyd, 1998) than other children. Children who have lower thresholds for external and internal stimuli will find a wider variety of events and conditions to be negatively stressful (Stansbury & Harris, 2000).

How Do Children Experience Stress?

Specialists have identified two categories of stressful experiences. Acute stress is defined as a sudden, intense onset (e.g., short-term parental illness) and then the subsidence of stressful stimuli. Chronic stress (e.g., loss through death or prolonged separation of a significant person in the child's life--grandparent, caregiver, sibling) is, on the other hand, ongoing and has the most significant and detrimental effects on children, including changing brain chemistry and function, and lowering resistance to disease (Gunnar & Barr, 1998; Lombroso & Sapolsky, 1998).

Zegans (1982) theorizes that stress is experienced in four somewhat distinct stages:

• alarm and physical reaction;
• appraisal, as a child attempts to make meaning from the event;
• searching for adaptation and coping strategies; and finally
• implementation of a strategy or strategies.

This implementation stage may be a one-time action or may be extended over hours or days. Children's appraisal of stressful events and their choices of viable coping strategies are different from those used by adults (e.g., leaving a favorite toy at child care overnight may have a negative impact on children who cannot "find" a way to "wait" until they are reunited; this reaction and fear of its recurrence may last for several days). In addition, experts have observed that children's physical responses to stress are also different from adult responses in that they may be more intense and involve the whole body (Zegans, 1982).

How Does Stress Manifest Itself in Children?

Stress is most often seen as an overt physical reaction: crying, sweating palms, running away, aggressive or defensive outbursts, rocking and self-comforting behaviors, headaches and stomachaches, nervous fine motor behaviors (e.g., hair twirling or pulling, chewing and sucking, biting of skin and fingernails), toileting accidents, and sleep disturbances (Stansbury & Harris, 2000; Fallin, Wallinga, & Coleman, 2001; Marion, 2003). Experts suggest that children may react globally through depression and avoidance; excessive shyness; hyper-vigilance; excessive worrying; "freezing up" in social situations; seemingly obsessive interest in objects, routines, food, and persistent concern about "what comes next"; and excessive clinging (Dacey & Fiore, 2000).

How Do Children Adapt to Stress?

Theorists believe that these behaviors represent children's struggles to manage and react to stressful events. They believe that children generally distance themselves emotionally from stressful situations by behaving in ways to diminish the stress (e.g., crying and being upset in order to show feelings of abandonment when parents go to work) or acting in ways to cover or conceal feelings of vulnerability (e.g., acting out and being aggressive or disruptive when it's time for toys to be put away or play to stop). With age, children increasingly use cognitive problem-solving strategies to cope with negative stress by asking questions about events, circumstances, and expectations for what will happen and clarification of what has happened (Kochenderfer-Ladd & Skinner, 2002).

Prolonged exposure to stress and a child's continued use of coping strategies may result in behavior patterns that are difficult to change if the child perceives the strategy as being effective (Kochenderfer-Ladd & Skinner, 2002; Stansbury & Harris, 2000).

How Can Adults Respond to Children's Stress?

Assisting children in understanding and using effective adaptation and coping strategies must be based on the child's developmental level and understanding of the nature of the stress-inducing event. Teachers and parents can prevent and reduce stress for children in many ways:

• Help the child anticipate stressful events, such as a first haircut or the birth of a sibling. Adults can prepare children by increasing their understanding of the upcoming event and reducing its stressful impact (Marion, 2003). Over-preparing children for upcoming stressful events, however, can prove even more stressful than the event itself (Donate-Bartfield & Passman, 2000). Adults can judge the optimal level of preparation by encouraging the child to ask questions if he or she wants to know more.
• Provide supportive environments where children can play out or use art materials to express their concerns (Gross & Clemens, 2002).
• Help children identify a variety of coping strategies (e.g., "ask for help if someone is teasing you"; "tell them you don't like it"; "walk away"). Coping strategies help children feel more effective in stressful situations (Fallin, Wallinga, & Coleman, 2001).
• Help children recognize, name, accept, and express their feelings appropriately.
• Teach children relaxation techniques. Consider suggesting to a child such things as "take three deep breaths"; "count backwards"; "tense and release your muscles"; "play with play dough"; "dance"; "imagine a favorite place to be and visit that place in your mind" (use creative imagery) (O'Neill, 1993).
• Practice positive self-talk skills (e.g., "I'll try. I think I can do this.") to help in promoting stress management (O'Neill, 1993).

Other basic strategies include implementing sound positive discipline strategies, following consistent routines, enhancing cooperation, and providing time for children to safely disclose their concerns and stresses privately and in groups.

Conclusion

Our increasing knowledge about the importance and impact of stress on young children should be put to good use in reducing stress factors for young children and in assisting children to increase coping strategies and healthy responses to the unavoidable stresses in their lives.

For More Information

1. Allen, K. E., & Marotz, L. R. (2003). Developmental profiles (4th ed.). Albany, NY: Delmar.
2. Bullock, J. (2002). Bullying. Childhood Education, 78(3), 130-133.
3. Dacey, J. S., & Fiore, L. B. (2000). Your anxious child. San Francisco: Jossey-Bass.
5. Donate-Bartfield, E., & Passman, R. H. (2000). Establishing rapport with preschool-age children: Implications for practitioners. Children's Health Care, 29(3), 179-188.
6. Elkind, D. (1988). The hurried child (Rev. ed.). Menlo Park, CA: Addison-Wesley.
7. Fallin, K., Wallinga, C., & Coleman, M. (2001). Helping children cope with stress in the classroom setting. Childhood Education, 78(1), 17-24.
8. Greenman, J. (2001). What happened to the world? St. Paul, MN: Redleaf Press.
9. Gross, T., & Clemens, S. G. (2002). Painting a tragedy: Young children process the events of September 11. Young Children, 57(3), 44-51.
10. Gunnar, M R., & Barr, R. G. (1998). Stress, early brain development, and behavior. Infants and Young Children, 11(1), 1-14.
11. Kochenderfer-Ladd, B., & Skinner, K. (2002). Children's coping strategies: Moderators of the effects of peer victimization? Developmental Psychology, 38(2), 267-278.
12. Lombroso, P. J., & Sapolsky, R. (1998). Development of the cerebral cortex: XII. Stress and brain development: I. Journal of the American Academy of Child and Adolescent Psychiatry, 37(12), 1337-1339.
13. Marion, M. (2003). Guidance of young children (6th ed.). Upper Saddle River, NJ: Prentice Hall.
14. McLoyd, V. C. (1998). Socioeconomic disadvantage and child development. American Psychologist, 53(2), 185-204.
15. Monk, C. F., Fifer, W. P., Myers, M. M., Sloan, R. P., Trien, L., & Hurtado, A. (2000). Maternal stress responses and anxiety during pregnancy: Effects on fetal heart rate. Developmental Psychology, 36(1), 67-77.
16. O'Neill, C. (1993). Relax. Auburn, ME: Child's Play International.
17. Stansbury, K., & Harris, M. L. (2000). Individual differences in stress reactions during a peer entry episode: Effects of age, temperament, approach behavior, and self-perceived peer competence. Journal of Experimental Child Psychology, 76(1), 50-63.
18. Zegans, L. (1982). Stress and the development of somatic disorders. In L. Goldberger & S. Breznitz (Eds.), Handbook of stress: Theoretical and clinical aspects (pp. 134-152). New York: Free Press.

Source: ERIC/EECE Digests
by Jan Jewett and Karen Peterson
December 2002

Reviewed by athealth on February 8, 2014.

What are some of the most common causes of stress?

Stress can arise for a variety of reasons. Stress can be brought about by a traumatic accident, death, or emergency situation. Stress can also be a side effect of a serious illness or disease. There is also stress associated with daily life, the workplace, and family responsibilities. It's hard to stay calm and relaxed in our hectic lives. As women, we have many roles: spouse, mother, caregiver, friend, and/or worker. With all we have going on in our lives, it seems almost impossible to find ways to de-stress. But it's important to find those ways. Your health depends on it.

What are some early signs of stress?

Stress can take on many different forms, and can contribute to symptoms of illness. Common symptoms include headache, sleep disorders, difficulty concentrating, short-temper, upset stomach, job dissatisfaction, low morale, depression, and anxiety.

How do women tend to react to stress?

We all deal with stressful things like traffic, arguments with spouses, and job problems. Some researchers think that women handle stress in a unique way: we tend and befriend.

• Tend: Women protect and care for their children
• Befriend: Women seek out and receive social support

During stress, women tend to care for their children and find support from their female friends. Women's bodies make chemicals that are believed to promote these responses. One of these chemicals is oxytocin (ahk-see-toe-sin), which has a calming effect during stress. This is the same chemical released during childbirth and found at higher levels in breastfeeding mothers, who are believed to be calmer and more social than women who don't breastfeed. Women also have the hormone estrogen, which boosts the effects of oxytocin. Men, however, have high levels of testosterone during stress, which blocks the calming effects of oxytocin and causes hostility, withdrawal, and anger.

How does stress affect my body and my health?

Everyone has stress. We have short-term stress, like getting lost while driving or missing the bus. Even everyday events, such as planning a meal or making time for errands, can be stressful. This kind of stress can make us feel worried or anxious.

Other times, we face long-term stress, such as racial discrimination, a life-threatening illness, or divorce. These stressful events also affect your health on many levels. Long-term stress is real and can increase your risk for some health problems, like depression.

Both short and long-term stress can have effects on your body. Research is starting to show the serious effects of stress on our bodies. Stress triggers changes in our bodies and makes us more likely to get sick. It can also make problems we already have worse. It can play a part in these problems:

• Trouble sleeping
• Headaches
• Constipation
• Diarrhea
• Irritability
• Lack of energy
• Lack of concentration
• Eating too much or not at all
• Anger
• Sadness
• Higher risk of asthma and arthritis flare-ups
• Tension
• Stomach cramping
• Stomach bloating
• Skin problems, like hives
• Depression
• Anxiety
• Weight gain or loss
• Heart problems
• High blood pressure
• Irritable bowel syndrome
• Diabetes
• Neck and/or back pain
• Less sexual desire
• Harder to get pregnant

What are some of the most stressful life events?

Any change in our lives can be stressful - even some of the happiest ones like having a baby or taking a new job. Here are some of life's most stressful events.

• Death of a spouse
• Divorce
• Marital separation
• Spending time in jail
• Death of a close family member
• Personal illness or injury
• Marriage
• Pregnancy
• Retirement

From the Holmes and Rahe Scale of Life Events (1967)

What is post-traumatic stress disorder (PTSD)?

Post-traumatic stress disorder (PTSD) can be a debilitating condition that can occur after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened. Traumatic events that can trigger PTSD include violent personal assaults such as rape or mugging, natural or human-caused disasters, accidents, or military combat.

Many people with PTSD repeatedly re-experience the ordeal in the form of flashback episodes, memories, nightmares, or frightening thoughts, especially when they are exposed to events or objects that remind them of the trauma. Anniversaries of the event can also trigger symptoms. People with PTSD also can have emotional numbness, sleep disturbances, depression, anxiety, irritability, or outbursts of anger. Feelings of intense guilt (called survivor guilt) are also common, particularly if others did not survive the traumatic event.

Most people who are exposed to a traumatic, stressful event have some symptoms of PTSD in the days and weeks following the event, but the symptoms generally disappear. But about 8% of men and 20% of women go on to develop PTSD, and roughly 30% of these people develop a chronic, or long-lasting, form that persists throughout their lives.

How can I help handle my stress?

Don't let stress make you sick. As women, we tend to carry a higher burden of stress than we should. Often we aren't even aware of our stress levels. Listen to your body, so that you know when stress is affecting your health. Here are ways to help you handle your stress.

• Relax. It's important to unwind. Each person has her own way to relax. Some ways include deep breathing, yoga, meditation, and massage therapy. If you can't do these things, take a few minutes to sit, listen to soothing music, or read a book.
• Make time for yourself. It's important to care for yourself. Think of this as an order from your doctor, so you don't feel guilty! No matter how busy you are, you can try to set aside at least 15 minutes each day in your schedule to do something for yourself, like taking a bubble bath, going for a walk, or calling a friend.
• Sleep. Sleeping is a great way to help both your body and mind. Your stress could get worse if you don't get enough sleep. You also can't fight off sickness as well when you sleep poorly. With enough sleep, you can tackle your problems better and lower your risk for illness. Try to get seven to nine hours of sleep every night.
• Eat right. Try to fuel up with fruits, vegetables, and proteins. Good sources of protein can be peanut butter, chicken, or tuna salad. Eat whole-grains, such as wheat breads and wheat crackers. Don't be fooled by the jolt you get from caffeine or sugar. Your energy will wear off.
• Get moving. Believe it or not, getting physical activity not only helps relieve your tense muscles, but helps your mood too! Your body makes certain chemicals, called endorphins, before and after you work out. They relieve stress and improve your mood.
• Talk to friends. Talk to your friends to help you work through your stress. Friends are good listeners. Finding someone who will let you talk freely about your problems and feelings without judging you does a world of good. It also helps to hear a different point of view. Friends will remind you that you're not alone.
• Get help from a professional if you need it. Talk to a therapist. A therapist can help you work through stress and find better ways to deal with problems. For more serious stress related disorders, like PTSD, therapy can be helpful. There also are medications that can help ease symptoms of depression and anxiety and help promote sleep.
• Compromise. Sometimes, it's not always worth the stress to argue. Give in once in awhile.
• Write down your thoughts. Have you ever typed an email to a friend about your lousy day and felt better afterward? Why not grab a pen and paper and write down what's going on in your life! Keeping a journal can be a great way to get things off your chest and work through issues. Later, you can go back and read through your journal and see how you've made progress!
• Help others. Helping someone else can help you. Help your neighbor, or volunteer in your community.
• Get a hobby. Find something you enjoy. Make sure to give yourself time to explore your interests.
• Set limits. When it comes to things like work and family, figure out what you can really do. There are only so many hours in the day. Set limits with yourself and others. Don't be afraid to say NO to requests for your time and energy.
• Plan your time. Think ahead about how you're going to spend your time. Write a to-do list. Figure out what's most important to do.
• Don't deal with stress in unhealthy ways. This includes drinking too much alcohol, using drugs, smoking, or overeating

I heard deep breathing could help my stress. How do I do it?

Deep breathing is a good way to relax. Try it a couple of times every day. Here's how to do it.

• Lie down or sit in a chair.
• Rest your hands on your stomach.
• Slowly count to four and inhale through your nose. Feel your stomach rise. Hold it for a second.
• Slowly count to four while you exhale through your mouth. To control how fast you exhale, purse your lips like you're going to whistle. Your stomach will slowly fall.
• Repeat five to 10 times.

Does stress cause ulcers?

Doctors used to think that ulcers were caused by stress and spicy foods. Now, we know that stress doesn't cause ulcers - it just irritates them. Ulcers are actually caused by a bacterium (germ) called H. pylori. Researchers don't yet know for sure how people get it. They think people might get it through food or water. It's treated with a combination of antibiotics and other drugs.

Source: Office on Women's Health in the Department of Health and Human Services
August 2004

Reviewed by athealth on February 8, 2014.