001

Table of Contents
 
Title Page
Copyright Page
Preface
Dedication
The Authors
 
SECTION ONE - Basic Information on ADHD
 
1.1 ADD, ADHD, AD/HD: WHAT’S THE DIFFERENCE?
1.2 DEFINITIONS AND DESCRIPTIONS OF ADHD
1.3 RISK FACTORS ASSOCIATED WITH ADHD
1.4 BEHAVIORAL CHARACTERISTICS OF ADHD
1.5 ADHD AND THE EXECUTIVE FUNCTIONS
1.6 WHAT WE DO AND DO NOT YET KNOW ABOUT ADHD
1.7 ADHD AND COEXISTING CONDITIONS AND DISORDERS
1.8 POSSIBLE CAUSES OF ADHD
1.9 ADHD LOOK-ALIKES
1.10 GIRLS WITH ADHD
1.11 MAKING THE DIAGNOSIS: A COMPREHENSIVE EVALUATION FOR ADHD
1.12 MULTIMODAL TREATMENT FOR ADHD
1.13 MEDICATION TREATMENT FOR ADHD
1.14 BEHAVIORAL TREATMENT AND MANAGEMENT OF ADHD
1.15 WHAT TEACHERS AND PARENTS NEED TO KNOW ABOUT MEDICATION
1.16 THE IMPACT OF ADHD ON THE FAMILY
1.17 THE IMPACT OF ADHD ON SCHOOL SUCCESS
1.18 CRITICAL ELEMENTS FOR SCHOOL SUCCESS
1.19 POSITIVE TRAITS COMMON IN MANY CHILDREN AND ADULTS WITH ADHD
1.20 EDUCATIONAL RIGHTS FOR STUDENTS WITH ADHD
 
SECTION TWO - Checklists for Parents
 
2.1 WHAT CHILDREN AND TEENS WITH ADHD NEED FROM PARENTS
2.2 POSITIVE AND EFFECTIVE DISCIPLINE
2.3 PREVENTING BEHAVIOR PROBLEMS AT HOME
2.4 PREVENTING BEHAVIOR PROBLEMS OUTSIDE THE HOME
2.5 COPING AND DEALING WITH YOUR CHILD’S CHALLENGING BEHAVIORS
2.6 REWARDS AND POSITIVE REINFORCERS FOR HOME
2.7 FOLLOWING DIRECTIONS AND INCREASING COMPLIANCE: TIPS FOR PARENTS
2.8 ENVIRONMENTAL MODIFICATIONS AT HOME
2.9 WHAT PARENTS CAN DO TO HELP WITH ORGANIZATION
2.10 WHAT PARENTS CAN DO TO HELP WITH TIME MANAGEMENT
2.11 HOMEWORK TIPS FOR PARENTS
2.12 PARENTING YOUR CHILD WITH ADHD: RECOMMENDED DO’S AND DON’TS
2.13 SUPPORTS AND TRAINING PARENTS NEED
2.14 BUILDING A POSITIVE RELATIONSHIP WITH THE SCHOOL
2.15 ADVOCACY TIPS FOR PARENTS
2.16 PLANNING AHEAD FOR THE NEXT SCHOOL YEAR
2.17 PURSUING AN EVALUATION FOR ADHD: RECOMMENDATIONS FOR PARENTS
 
SECTION THREE - Checklists for Teachers
 
3.1 PROACTIVE CLASSROOM MANAGEMENT
3.2 PREVENTING BEHAVIOR PROBLEMS DURING TRANSITIONS AND CHALLENGING TIMES OF ...
3.3 TIPS FOR GIVING DIRECTIONS AND INCREASING STUDENT COMPLIANCE
3.4 MANAGING CHALLENGING BEHAVIOR
3.5 REWARDS AND POSITIVE REINFORCERS FOR SCHOOL
3.6 ENVIRONMENTAL SUPPORTS AND ACCOMMODATIONS IN THE CLASSROOM
3.7 GETTING AND FOCUSING STUDENTS’ ATTENTION
3.8 MAINTAINING STUDENTS’ ATTENTION AND PARTICIPATION
3.9 KEEPING STUDENTS ON TASK DURING SEAT WORK
3.10 STRATEGIES FOR INATTENTIVE, DISTRACTIBLE STUDENTS
3.11 COMMUNICATING WITH PARENTS: TIPS FOR TEACHERS
3.12 HOMEWORK TIPS FOR TEACHERS
3.13 WHAT TEACHERS CAN DO TO HELP WITH ORGANIZATION
3.14 WHAT TEACHERS CAN DO TO HELP WITH TIME MANAGEMENT
3.15 ADAPTATIONS AND MODIFICATIONS OF ASSIGNMENTS
3.16 ADAPTATIONS AND MODIFICATIONS OF MATERIALS
3.17 TESTING ADAPTATIONS AND SUPPORTS
3.18 IF YOU SUSPECT A STUDENT HAS ADHD
 
SECTION FOUR - Academic Strategies for Home and School
 
4.1 COMMON READING DIFFICULTIES
4.2 READING STRATEGIES AND INTERVENTIONS
4.3 MATH DIFFICULTIES RELATED TO ADHD AND LEARNING DISABILITIES
4.4 MATH STRATEGIES AND INTERVENTIONS
4.5 WHY WRITING IS A STRUGGLE
4.6 STRATEGIES TO HELP WITH PREWRITING: PLANNING AND ORGANIZING
4.7 STRATEGIES FOR COMPOSITION AND WRITTEN EXPRESSION
4.8 STRATEGIES FOR REVISING AND EDITING
4.9 MULTISENSORY SPELLING STRATEGIES
4.10 IMPROVING HANDWRITING AND THE LEGIBILITY OF WRITTEN WORK
4.11 STRATEGIES FOR BYPASSING AND ACCOMMODATING WRITING DIFFICULTIES
 
SECTION FIVE - Other Important Checklists for Parents and Teachers
 
5.1 THE TEAM APPROACH
5.2 MEMORY STRATEGIES AND ACCOMMODATIONS
5.3 RELAXATION STRATEGIES, VISUALIZATION, EXERCISE, AND MORE
5.4 ADHD AND SOCIAL SKILLS INTERVENTIONS
5.5 ADHD IN YOUNG CHILDREN
5.6 ADHD IN ADOLESCENTS
5.7 WEB RESOURCES TO UNDERSTAND AND SUPPORT CHILDREN WITH ADHD AND RELATED DISORDERS
5.8 BOOKS AND OTHER RESOURCES BY SANDRA RIEF
 
Index

001

Preface
Approximately 5 to 9 percent of school-age children in the United States have attention deficit disorders. Every classroom teacher most likely has at least one or two students with ADHD in his or her classroom each year, and these educators need to understand the nature of the disorder, as well as the most effective strategies for reaching and teaching these students.
To make well-informed decisions on how to best help their son or daughter, parents of children with ADHD must learn as much as they can about the disorder and research-validated treatments. They must also be equipped with the skills and strategies that help in managing their child’s ADHD symptoms and often challenging behaviors.
It is often not easy to live with or teach a child who has ADHD. The better we understand this disorder, the more tolerant, empathetic, and empowered we all will be to help.
The purpose of this book is to help parents and teachers gain insights into and better understanding of children and teenagers with ADHD, as well as the support and intervention that will help them succeed. Although the book is primarily written for parents and teachers, many others interested in children and teens with ADHD (physicians, mental health professionals, other school personnel, and relatives, for example) should find the information useful as well. Most of the book focuses on specific strategies, supports, and interventions that have been found to be effective in minimizing the typical problems associated with ADHD and helping these children and teens achieve their potential.
This new edition of my original ADD/ADHD Checklist, first published in 1998, has been completely updated with the most current information on the disorder. It is designed in a simple, concise, user-friendly format of checklists that address a number of topics. The checklists are divided into five sections.
Section One provides general information about the disorder, its likely causes, common coexisting conditions, and the diagnosis and treatment of ADHD—what most experts in the field believe about it, based on the scientific evidence available at this time. It also includes information about educational rights for students with ADHD.
Section Two is specifically for parents. It looks at topics that are relevant to managing ADHD behavior at home and in other settings, how to pursue an evaluation for ADHD, and strategies for homework, organization skills, and other areas for helping their children to be successful at school as well.
Section Three is geared toward teachers, with checklists on classroom strategies, supports, and accommodations (behavioral, instructional, and environmental). Teachers should note that the strategies suggested in this section are beneficial for all students, not just those with ADHD.
Section Four offers information about common academic difficulties in students with ADHD. It also provides a host of strategies, supports, and accommodations in the areas of reading, math, and written language that both teachers and parents can use to help strengthen their children’s skills and boost academic achievement.
Section Five contains other important information on ADHD, such as boosting memory, relaxation, exercise, and other self-regulation strategies, and social skill interventions. It also contains specific information and strategies related to ADHD in early childhood and in adolescence, as well as several recommended resources.
I learned a number of the strategies and recommendations in this book from my many wonderful students with ADHD, their families, and my colleagues in my twenty-three years of teaching. In addition, during my consulting in schools, speaking engagements, and training, I have had the extraordinary privilege of observing hundreds of classrooms and working with scores of educators and other practitioners across the United States and internationally. I am grateful to them all and awed by their dedication and commitment.
It is always preferable to be able to identify children with ADHD or any other special needs early, initiating interventions and supports at a young age in order to avoid some of the frustration, failure, and subsequent loss of self-esteem. However, it is never too late to help. Fortunately, we know a lot from the enormous amount of research about the interventions that are effective in managing ADHD. Also, in many cases, the kind of help that makes a difference does not take a huge effort. For example, awareness of and simple changes in structuring the environment or responding to the child’s behaviors can lead to significant improvements. If I am able to convey any message throughout this book, I wish for it to be one of hope and optimism. When we (parents, teachers and other school professionals, and clinicians) work together—providing intervention, appropriate strategies, encouragement, and support—every child can succeed.
Although I am maintaining the use of ADD/ADHD in the book’s title (as in the first edition), I have chosen throughout the rest of this book to refer to this disorder as just ADHD, which is the way it is currently best known. Checklist 1.1 explains the differences in terminology. Please be aware that all references to ADHD encompass all types of the disorder.
 
June 2008
San Diego, California
Sandra F. Rief

In memory of my beloved son, Benjamin, and to all of the children who face obstacles in their young lives each day with loving, trusting hearts, determination, and extraordinary courage
 
 
My deepest thanks and appreciation to
• My precious, loving family: Itzik, Ariel, Jackie, Jason, Daniella, Sharon, and Gil
• All of the wonderful educators, doctors, and families of children with ADHD who have shared their insights and ideas with me over the years and have been an inspiration
• The extraordinary parents (especially the wonderful volunteers in CHADD and other organizations worldwide) whose tireless efforts have raised awareness about ADHD and as a result have improved the care and education of our children
• My editor, Margie McAneny, and the great team at Jossey-Bass.

The Authors
Sandra Rief, M.A., is an internationally known speaker, teacher trainer, educational consultant, and author. Her areas of focus include effective strategies and interventions for helping students with learning, attention, and behavioral challenges. Sandra is a popular presenter at seminars and workshops for educators, and keynotes nationally and internationally on the topics of ADHD and learning disabilities.
Previously an award-winning teacher with over twenty-three years’ experience in the classroom, Sandra is the author of several popular books including How to Reach and Teach Children with ADD/ ADHD, Second Edition; The ADHD Book of Lists; How to Reach and Teach All Children in the Inclusive Classroom, Second Edition (coauthored with Julie A. Heimburge); and How to Reach and Teach All Children Through Balanced Literacy (coauthored with Julie A. Heimburge)
Sandra also developed and presented these acclaimed educational videos: ADHD & LD: Powerful Teaching Strategies and Accommodations; How to Help Your Child Succeed in School: Strategies and Guidance for Parents of Children with ADHD and/or Learning Disabilities; ADHD: Inclusive Instruction and Collaborative Practices, and together with Linda Fisher and Nancy Fetzer, the videos Successful Classrooms: Effective Teaching Strategies for Raising Achievement in Reading and Writing and Successful Schools: How to Raise Achievement & Support “At-Risk” Students.
Sandra is an instructor for continuing education courses offered through California State University, East Bay, and Seattle Pacific University. For more information, visit her Web site at www.sandrarief.com.

SECTION ONE
Basic Information on ADHD

1.1 ADD, ADHD, AD/HD: WHAT’S THE DIFFERENCE?

AD/HD stands for Attention Deficit/Hyperactivity Disorder. Sometimes it is written with the slash mark (AD/HD) and sometimes without (ADHD). This is the current and official term that is used when referring to this disorder, and it is the umbrella term for the three types of AD/HD: the Predominantly Inattentive type (AD/HD-I), the Predominantly Hyperactive and Impulsive type (AD/HD-HI), and the Combined type (AD/HD-C). Most people diagnosed with ADHD have the combined type of the disorder with significant symptoms in inattention, impulsivity, and hyperactivity.
ADD stands for Attention Deficit Disorder and has been a term associated with this disorder for many years. Many people use ADD interchangeably with ADHD when referring to all types of the disorder, and it is also the term of choice by many when referring to the Predominantly Inattentive type of ADHD, that is, individuals without hyperactivity.
• The federal special education law (Individuals with Disabilities Education Act, IDEA) regulations that govern educational rights of children with disabilities refer to both ADD and ADHD among the “other health impairments” that may qualify a student for special education and related services (if they meet all of the other eligibility criteria).
• It is likely that there will be changes in the name and abbreviation of this disorder (or among some types of the disorder) in the future.
• Throughout the remainder of this book, I just use ADHD (without the slash mark), which is inclusive of all three types.

1.2 DEFINITIONS AND DESCRIPTIONS OF ADHD

There are several descriptions or definitions of ADHD based on the research evidence and most widely held belief of the scientific community at this time, including the following from leading experts and researchers in the field:
• ADHD is a neurobiological behavioral disorder characterized by chronic and developmentally inappropriate degrees of inattention, impulsivity, and in some cases hyperactivity.
• ADHD is a chronic biochemical, neurodevelopmental disorder that interferes with a person’s capacity to regulate and inhibit behavior and sustain attention to tasks in developmentally appropriate ways.
• ADHD is a neurological inefficiency in the area of the brain that controls impulses and is the center of executive functions—the self-regulation and self-management functions of the brain.
• ADHD is a developmental delay or lag in inhibition, self-control, and self-management.
• ADHD is a brain-based disorder that arises out of differences in the central nervous system in both structural and neurochemical areas.
• ADHD is a pattern or constellation of behaviors that are so pervasive and persistent that they interfere with daily life.
• ADHD is a dimensional disorder of human behaviors that all people exhibit at times to certain degrees. Those with ADHD display the symptoms to a significant degree that is maladaptive and developmentally inappropriate compared to others that age.
• ADHD is a developmental disorder of self-control. It consists of problems with regulating attention, impulse control, and activity level.
• ADHD represents a condition that leads individuals to fall to the bottom of a normal distribution in their capacity to demonstrate and develop self-control and self-regulatory skills.
• ADHD is a disorder of inhibition (being able to wait, stop responding, and not respond to an event). Inhibition involves motor inhibition, delaying gratification, and turning off or resisting distractions in the environment while engaged in thinking.
• ADHD is a neurobiological behavioral disorder causing a high degree of variability and inconsistency in performance, output, and production.
• ADHD is a common although highly varied condition. One element of this heterogeneity is the frequent co-occurrence of other conditions.

1.3 RISK FACTORS ASSOCIATED WITH ADHD

ADHD places those who have this disorder at risk for a host of serious consequences. Numerous studies have shown the negative impact of this disorder without early identification, diagnosis, and proper treatment. Compared to their peers of the same age, youth with ADHD (those untreated for their disorder) experience:
• More serious accidents, hospitalizations, and significantly higher medical costs
• More school failure and dropout
• More delinquency and altercations with the law
• More engagement in antisocial activities
• More teen pregnancy and sexually transmitted diseases
• Earlier experimentation with and higher use of alcohol, tobacco, and illicit drugs
• More trouble socially and emotionally
• More rejection, ridicule, and punishment
• More underachievement and underperformance at school or work

Prevalence of ADHD

• Estimates of the prevalence in school-age children range from 3 percent to 12 percent. Most sources agree that somewhere between 5 and 9 percent of children are affected.
• Approximately 2 to 4 percent of adults are believed to have ADHD.
• The worldwide prevalence of ADHD in children is estimated at approximately 5 percent. The U.S. prevalence rate falls somewhere in the middle range of other reporting countries.
• Although this disorder can have serious negative outcomes affecting millions of people when untreated, it is estimated that at least half of the children with ADHD are not receiving treatment, and far more adults remain unidentified and untreated.

More Statistics Associated with ADHD

• Between 50 and 75 percent of individuals with ADHD have at least one other disorder or coexisting condition such as anxiety, depression, oppositional defiant disorder, learning disabilities, or speech and language impairments. See checklist 1.7.
• Barkley (2000), a leading researcher in the field, cites these statistics:
• Almost 35 percent of children with ADHD quit school before completion.
• Up to 58 percent have failed at least one grade in school.
• At least three times as many teens with ADHD as those without ADHD have failed a grade, been suspended, or been expelled from school.
• For at least half of the children with ADHD, social relationships are seriously impaired.
• Within their first two years of independent driving, adolescents with a diagnosis of ADHD have nearly four times as many auto accidents and three times as many citations for speeding as young drivers without ADHD (Barkley & Murphy, 1996).
• For more information, go to the Web sites of CHADD (Children and Adults with Attention Deficit/Hyperactivity; www.chadd.org), the National Resource Center on ADHD (www.help4adhd.org), and the National Institute of Mental Health (www.nimh.nih.gov/health/).
References
Barkley, R. A. (2000). Taking charge of ADHD (Rev. ed.). New York: Guilford Press.
Barkley, R. A., Murphy, K. R., & Kwasni, D. (1996). Motor vehicle driving competencies and risks in teens and young adults with ADHD. Pediatrics, 98(6 Pt. 1), 1089-1095.

1.4 BEHAVIORAL CHARACTERISTICS OF ADHD

The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and the text revised edition (DSM-IV-TR), published by the American Psychiatric Association, is the source of the official criteria for diagnosing ADHD. The DSM lists nine specific symptoms under the category of inattention and nine specific symptoms under the hyperactive/impulsive category. Part of the diagnostic criteria for ADHD is that the child or teen often displays at least six of the nine symptoms of either the inattentive or the hyperactive-impulsive categories or six of the nine symptoms in both categories.
The checklists that follow contain symptoms and characteristics common in children and teens with ADHD. The specific behaviors listed in the DSM-IV (1994) and DSM-IV-TR (2000) are italicized. Additional symptoms and characteristics associated with ADHD are also included; they are not italicized.

Predominantly Inattentive Type of ADHD

• This type of ADHD is what many prefer to call ADD because those diagnosed with it do not have the hyperactive symptoms. They may show some, but not a significant amount of symptoms in the hyperactive-impulsivity category.
• These children and teens often slip through the cracks and are not as easily identified or understood. Since they do not exhibit the disruptive behaviors that command attention, it is easy to overlook these students and misinterpret their behaviors and symptoms as “not trying” or “being lazy.”
• Most people display any of the following behaviors at times and in different situations to a certain degree. Those who truly have an attention deficit disorder have a history of frequently exhibiting many of these behaviors—far above the normal range developmentally. They are pervasive symptoms, exhibited in different settings and environments, and they cause impairment in functioning at school, at home, and in other settings.
• Many children with ADHD and significant difficulties with inattention are often able to be focused and sustain attention for long periods of time when they play video games or are engaged in other high-interest, stimulating, and rapidly changing activities.
 
CHARACTERISTICS AND SYMPTOMS OF INATTENTION
Easily distracted by extraneous stimuli (for example, sights, sounds, movement in the environment)
Does not seem to listen when spoken to directly
• Difficulty remembering and following directions
Difficulty sustaining attention in tasks and play activities
• Difficulty sustaining level of alertness to tasks that are tedious, perceived as boring, or not of one’s choosing
Forgetful in daily activities
Does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
• Tunes out; may appear “spacey”
• Daydreams (thoughts are elsewhere)
• Appears confused
• Easily overwhelmed
• Difficulty initiating or getting started on tasks
• Does not complete work, resulting in many incomplete assignments
Avoids, dislikes, or is reluctant to engage in tasks requiring sustained mental effort such as schoolwork or homework
• Difficulty working independently; needs a high degree of refocusing attention to task
• Gets bored easily
• Sluggish or lethargic (may fall asleep easily in class)
Fails to pay attention to details and makes many careless mistakes (for example, with math computation, spelling, and written mechanics such as capitalization and punctuation)
• Poor study skills
• Inconsistent performance; one day is able to perform a task and the next day cannot; the student is “consistently inconsistent”
Loses things necessary for tasks or activities (for example, toys, school assignments, pencils, books, or tools)
Difficulty organizing tasks and activities (for example, planning, scheduling, preparing)
 
ACADEMIC DIFFICULTIES RELATED TO INATTENTION
Reading
• Loses his or her place when reading
• Cannot stay focused on what he or she is reading (especially if the text is difficult, lengthy, boring, or not of his or her choice reading material), resulting in missing words, details, and spotty comprehension
 
Writing
• Off topic as a result of losing train of thought
• Poor spelling, use of capitalization and punctuation, and other mechanics and a poor ability to edit written work as a result of inattention to these details
 
Math
• Numerous computational errors because of inattention to operational signs (plus, minus, multiplication, division), decimal points, and so forth
• Poor problem solving due to inability to sustain the focus to complete all steps of the problem with accuracy

Predominantly Hyperactive-Impulsive Type of ADHD

• Individuals with this type of ADHD have a significant number of hyperactive-impulsive symptoms; they may have some but not a significant number of inattentive symptoms considered developmentally inappropriate. This type of ADHD is most commonly diagnosed in early childhood, and many of those receiving this diagnosis will be reclassified as having the combined type of ADHD when they get older and the inattentive symptoms become developmentally significant.
• Children and teens with ADHD may exhibit many of the characteristics in the lists that follow. Although each of these behaviors is normal in children at different ages to a certain degree, for those with ADHD, the behaviors far exceed that which is normal developmentally (in frequency, level, and intensity). Again, the behaviors written in italics are those listed in the DSM-IV and DSM-IV-TR.
• Most children, teens, and adults with ADHD have the combined type of the disorder. That means they have a significant number of inattention, impulsive, and hyperactive symptoms that are chronic and developmentally inappropriate, evident from an early age, and are impairing evident from an early age and are impairing their functioning in at least two environments (such as home and school).
 
CHARACTERISTICS AND SYMPTOMS OF HYPERACTIVITY
• “On the go” or acts as if “driven by a motor
Leaves seat in classroom or in other situations in which remaining seated is expected
• Cannot sit still (instead, jumps up and out of chair, falls out of chair, sits on knees, or stands by desk)
Talks excessively
• Highly energetic; almost nonstop motion
Runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
• A high degree of unnecessary movement (pacing, tapping feet, drumming fingers)
• Restlessness
• Seems to need something in hands; finds or reaches for nearby objects to play with or put in mouth
Fidgets with hands or feet or squirms in seat
• Is not where he or she is supposed to be (for example, roams around)
Difficulty playing or engaging in leisure activities quietly
• Intrudes in other people’s space; difficulty staying within own boundaries
• Difficulty settling down or calming self
• Overall difficulty regulating motor activity
 
CHARACTERISTICS AND SYMPTOMS OF IMPULSIVITY
• Much difficulty in situations requiring waiting patiently
• Difficulty with raising hand and waiting to be called on
Interrupts or intrudes on others (for example, butts into conversations or games)
Blurts out answers before questions have been completed
Has difficulty waiting for his or her turn in games and activities
• Cannot keep hands and feet to self
• Cannot wait or delay gratification; wants things immediately
• Knows the rules and consequences but repeatedly makes the same errors or infractions of rules
• Gets in trouble because he or she cannot stop and think before acting (responds first, thinks later)
• Difficulty standing in lines
• Makes inappropriate noises
• Does not think or worry about consequences, so tends to be fearless or gravitate to high-risk behavior
• Engages in physically dangerous activities without considering the consequences (for example, jumping from heights, riding bike into the street without looking); hence, a high frequency of injuries
• Accident prone and breaks things
• Difficulty inhibiting what he or she says, making tactless comments; says whatever pops into his or her head and talks back to authority figures
• Begins tasks without waiting for directions (before listening to the full direction or taking the time to read written directions)
• Hurries through tasks, particularly boring ones, to get finished, and consequently makes numerous careless errors
• Gets easily bored and impatient
• Does not take time to correct or edit work
• Disrupts, bothers others
• Constantly drawn to something more interesting or stimulating in the environment
• Hits when upset or grabs things away from others (not inhibiting responses or thinking of consequences)
 
OTHER COMMON CHARACTERISTICS IN CHILDREN AND TEENS WITH ADHD
• Disorganized, frequently misplaces or loses belongings; desks, backpacks, lockers, and rooms extremely messy and chaotic
• Little or no awareness of time; often underestimates length of time a task will require to complete
• Procrastinates
• A high degree of emotionality (for example, temper outbursts, quick to anger, gets upset, irritable, moody)
• Easily frustrated
• Overly reactive
• Difficulty with transitions and changes in routine or activity
• Displays aggressive behavior
• Difficult to discipline
• Cannot work for long-term goals or payoffs
• Low self-esteem
• Poor handwriting, fine motor skills, written expression, and output—getting their ideas down on paper and amount of work produced
• Overly sensitive to sounds and other stimuli in the environment
• Motivational difficulties
• Receives a lot of negative attention and interaction from peers and adults
• Learning and school performance difficulties; not achieving or performing to level that is expected given his or her apparent ability
 
References
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders—IV-TR (4th ed., text rev.). Washington, DC: Author.

1.5 ADHD AND THE EXECUTIVE FUNCTIONS

• Many of the difficulties associated with ADHD center on the ability to employ the executive functions of the brain. It is now understood that ADHD is more than a disorder of the three core symptoms of inattention, impulsivity, and hyperactivity; it affects the executive functions of the brain as well. Much of what we have learned since the 1990s about the developmental delay in executive functioning and the significant impact it has on the academic performance of students with ADHD comes from the work of leading ADHD researchers and authorities (particularly Dr. Russell Barkley, Dr. Martha Denckla, and Dr. Thomas E. Brown).
• Executive functions are:
• The management functions (“overseers”) of the brain
• The self-directed actions individuals use to help maintain control of themselves and accomplish goal-directed behavior
• The range of central control processes in the brain that activate, organize, focus, integrate, and manage other brain functions
• Brain functions that have to do with self-regulation of behavior
• The higher-order cognitive processes involved in the regulation of behavior, inhibition of impulses, planning, and organizing
• For all people, the executive functions are the last part of the brain to develop fully. Research shows that children and teens with ADHD lag in their development of executive functioning skills. This developmental delay is estimated to be approximately 30 percent compared to other children their age. In other words, a fifteen-year-old with ADHD is developmentally more like a ten-year-old and a ten-year-old is more like a seven-year-old in their behaviors related to executive functioning and self-management. It is important that teachers and parents understand that children with ADHD are immature in their self-regulation and self-management abilities in spite of how intelligent they may be. They will need more adult supports, monitoring, and supervision than other children or teens their age will require.
• It has not yet been determined exactly what constitutes all of the executive functions of the brain. However, some of these functions are believed to involve:
• Working memory (holding information in your head long enough to act on it)
• Organization of thoughts, time, and space
• Planning and prioritizing
• Arousal and activation
• Sustaining alertness and effort
• Self-regulation
• Emotional self-control
• Internalization of speech and language (using inner speech to guide behavior)
• Inhibiting verbal and nonverbal responding
• Quick retrieval and analysis of information
• Developing and following through on a plan of action
• Strategy monitoring and revising
• Children whose executive functions are immature and not working efficiently face a number of challenges, particularly with regard to schoolwork and homework. For example, weaknesses in executive functioning often cause difficulties to varying degrees with:
• Time awareness and time management
• Organization and study skills
• Perseverance on tasks and work production
• Delaying immediate gratification for long-term gain
• Decision making based on thoughtful weighing of consequences
• Planning for and completing long-term projects
• Forgetfulness and holding information in mind
• Moderating their emotions
• Using their metacognitive skills
• Ability to resist distractions
• Complex problem solving
• Executive functioning weaknesses commonly cause academic challenges to some degree (mild to severe), regardless of how intelligent, gifted, and capable the person may be. Consequently most children and teens with ADHD need some supportive strategies or accommodations, or both, to compensate for their deficit in executive functioning whether they are part of a written plan or not.

1.6 WHAT WE DO AND DO NOT YET KNOW ABOUT ADHD

What We Know

• ADHD has been the focus of a tremendous amount of research. Literally thousands of studies and scientific articles have been published (nationally and internationally) on ADHD.
• There is no quick fix or cure for ADHD, but it is treatable.
• Proper diagnosis and treatment can substantially decrease ADHD symptoms and impairment in functioning.
• The evidence from an overwhelming amount of worldwide research indicates that ADHD is a neurobiological, brain-based disorder.
• ADHD exists across all populations, regardless of race, ethnicity, gender, nationality, or socioeconomic level.
• ADHD symptoms range from mild to severe.
• There are different types of ADHD with a variety of characteristics. No one has all of the symptoms or displays the disorder in the exact same way.
• A very high percentage (approximately 50 to 75 percent) of children, teens, and adults with ADHD have additional coexisting disorders or conditions. See checklist 1.7.
• Many children and teens with ADHD slip through the cracks without being identified or receiving the intervention and treatment they need. This is particularly true of racial and ethnic minorities and girls.
• Although ADHD is diagnosed more frequently in boys than girls, research is showing that many more girls actually have ADHD but are not being diagnosed because they often do not have the disruptive behaviors associated with hyperactivity and impulsivity. See checklist 1.4.
• The challenging behaviors that children with ADHD exhibit stem from their physiological, neurobiological disorder. Rarely are these behaviors willful or deliberate. Children with ADHD are often not even aware of their behaviors and their impact on others.
• Children with ADHD are more likely than their peers to be suspended or expelled from school; retained a grade or drop out of school; have trouble socially and emotionally; and experience rejection, ridicule, and punishment. See checklist 1.3.
• ADHD is typically a lifelong disorder. The majority of children with ADHD (about 70 to 80 percent) continue to have substantial symptoms into adolescence, and many continue to exhibit symptoms into adulthood. In the past, ADHD was believed to be a childhood disorder. We now know that this is not the case.
• Although ADHD is most commonly diagnosed in school-age children, it can be and is diagnosed in younger children and adults as well.
• The prognosis for ADHD can be alarming if it is not treated. Without interventions, those with this disorder are at risk for serious problems in many domains: social, emotional, behavioral, academic, health, safety, employment, and others. See checklist 1.3.
• The prognosis for ADHD when treated is positive and hopeful. Most children who are diagnosed and provided with the help they need are able to manage the disorder. Parents should be optimistic because ADHD does not limit their child’s potential. Countless highly successful adults in every profession and walk of life have ADHD.
• ADHD has been recognized by clinical science and documented in the literature since 1902 (having been renamed several times). Some of the previous names for the disorder were Minimal Brain Dysfunction, Hyperactive Child Syndrome, and ADD with or without Hyperactivity.
• Children with ADHD can usually be taught effectively in general education classrooms with proper management strategies, supports, and accommodations, and engaging, motivating instruction.
• ADHD is not the result of poor parenting or lack of caring, effort, and discipline.
• ADHD is not laziness, willful misbehavior, or a character flaw.
• Medication therapy and behavioral therapy are effective treatments for ADHD. See checklists 1.12, 1.13, and 1.14.
• Stimulant medications are proven to work effectively for reducing the symptoms and impairment in 70 to 95 percent of children diagnosed with ADHD. They are effective in adults as well. See checklists 1.12, 1.13, and 1.15.
• The use of behavioral programs, such as a token economy or a daily report card system between home and school, are beneficial for students with ADHD. See checklist 1.14.
• A number of other conditions, disorders, or factors (for example, learning, medical and health, social, emotional) may cause symptoms that look like but are not ADHD. See checklist 1.9.
• ADHD causes problems with performance and work production.
• A number of factors can intensify the problems of someone with ADHD or lead to significant improvement, such as the structure in the environment, support systems, or level of stress.
• ADHD can be managed best by a multimodal treatment and a team approach. We know that it takes a team effort of parents, school personnel, and health and mental health professionals to be most effective in helping children and teens with ADHD. See checklists 1.12 and 5.1.
• No single intervention will be effective for treating and managing ADHD. It takes vigilance, ongoing treatment and intervention plans, as well as revision of plans.
• The teaching techniques and strategies that are necessary for the success of children with ADHD are good teaching practices and helpful to all students.
• There are many resources available for children, teens, and adults with ADHD, as well as those living with and working with individuals with ADHD. See checklists 5.7 and 5.8.
• There is need for better diagnosis, education, and treatment of this disorder that affects so many lives.
• We are learning more and more each day due to the efforts of the many researchers, practitioners (educators, mental health professionals, physicians), and others committed to improving the lives of individuals with ADHD.
• Fortunately, we know a great deal about:
• Which behavior management techniques and discipline strategies are effective in the home and school for children with ADHD. See checklists 1.14, 2.2-2.5, and 3.1-3.4.
• The classroom interventions, accommodations, and teaching strategies most helpful for students with ADHD. See checklists 3.6-3.10, and 3.13-3.17.
• Specific parenting strategies that are most effective with children who have ADHD. See checklists 2.1-2.12.
• Research-validated treatments that have been proven effective in reducing the symptoms and improving functioning of individuals with ADHD. See checklists 1.12, 1.13, 1.14, and 5.4.
• Many additional strategies that help those with ADHD build skills and compensate for their weaknesses (for example, with self-regulation, academics, study skills, and interpersonal relationships). See checklists 4.2, 4.4, 4.6, 4.7, 4.8, 4.9, 4.10, 4.11, 5.2, 5.3, and 5.4.

What We Do Not Yet Know

• A lot about ADHD is still unknown, and there is much that we do not know enough about at this time. Among other things, research is needed to learn more about the following:
• The causes
• How to prevent ADHD or minimize the risk factors and negative effects
• The inattentive type of ADHD
• The disorder in certain populations (early childhood; adults; females; racial and ethnic minorities)
• More conclusive tests for diagnosing ADHD
• Long-term treatment effects
• What may prove to be the best, most effective treatments and strategies for helping individuals with ADHD

1.7 ADHD AND COEXISTING CONDITIONS AND DISORDERS

ADHD is often accompanied by one or more other conditions or disorders: psychiatric, psychological, developmental, or medical. Because symptoms of these various disorders commonly overlap, diagnosis and treatment can be complex in many individuals. The word comorbidity is the medical term for having coexisting disorders.
• At least half, and as high as two-thirds, of children and teens with ADHD have at least one other coexisting disorder, such as learning disabilities, oppositional defiant disorder, Tourette syndrome, anxiety disorder, or depression.
• Coexisting disorders can cause significant impairment above and beyond the problems caused by ADHD.
• Coexisting conditions make diagnosis, intervention, and management more complicated.
• In order to effectively treat the child or teen, an accurate diagnosis must first be made. That is why it is so important for the clinician making the diagnosis to be skilled and very knowledgeable about ADHD and coexisting conditions. It will be important to tease out what is ADHD and what may be something else—such as a different condition with similar symptoms or additional disorders or conditions that accompany or coexist with the ADHD. See checklist 1.9.
• Determining the proper diagnosis requires that the evaluator takes the time and is thorough in obtaining information and data about the child from multiple sources and perspectives and carefully reviewing the history and behaviors. It also can take time for all of the pieces of the puzzle to come together, and parents, teachers, and clinicians need to monitor the child’s development and any emerging concerns.

Common Coexisting Conditions and Disorders

• The prevalence of specific coexisting conditions and disorders accompanying ADHD varies depending on the source. Most sources indicate the following ranges:
• Oppositional defiant disorder—approximately 40 to 65 percent
• Anxiety disorder—approximately 25 to 30 percent of children and 25 to 40 percent of adults
• Conduct disorder—approximately 10 to 25 percent of children, 25 to 50 percent of adolescents, and 20 to 25 percent of adults
• Bipolar—approximately 1 to 20 percent
• Depression—approximately 10 to 30 percent in children and 10 to 47 percent in adolescents and adults
• Tics, Tourette syndrome—about 7 percent of those with ADHD have tics or Tourette syndrome, but 60 percent of Tourette syndrome patients also have ADHD
• Learning disabilities—a range from 20 to 60 percent, with most sources estimating that between one-quarter and one-half of children with ADHD have a coexisting learning disability
• Sleep problems—approximately 40 to 50 percent
• Secondary behavioral complications—up to 65 percent of children with ADHD may display secondary behavioral complications such as noncompliance, argumentativeness, temper outbursts, lying, blaming others, and being easily angered
• Go to the Web site of the National Resource Center on AD/HD (www.help4adhd.org) for the most up-to-date and reliable information about coexisting disorders with ADHD and recommended treatment.

Consequences of Comorbidities

• Most children with ADHD have school-related achievement, performance, or social problems.
• Because such a high percentage of children with ADHD also have learning disabilities, a psychoeducational evaluation by the school team is very important when a possible learning disability is suspected. See checklists 1.20, 2.17, and 3.1.
• Parents, educators, and medical and mental health care providers should be alert to signs of other disorders and issues that may exist or emerge, often in the adolescent years, especially when current strategies and treatments being used with the ADHD child or teen are no longer working effectively. For example, children with the combined type of ADHD are at a much higher risk than the average child of developing a more serious disruptive behavior disorder (oppositional defiant disorder or conduct disorder). There is also a high rate of coexisting depression and anxiety disorder in teenage girls with ADHD that can easily be overlooked.
• It is important to recognize the risks, identify coexisting conditions, and provide the necessary treatment and support to address the problems that stem from ADHD and any other disorders or conditions that exist.
• Early identification of ADHD and implementing appropriate interventions can help significantly in all respects, reducing the risk for future problems developing and increasing overall successful outcomes.

1.8 POSSIBLE CAUSES OF ADHD

ADHD has been researched extensively in the United States and a number of other countries throughout the world. Hundreds of well-designed and controlled scientific studies have tried to determine the causes and most effective treatments for those with ADHD. Sophisticated brain-imaging technologies and recent genetic research have provided a lot of information and hold promise of much more to come. To date, however, the causes of ADHD are not fully known or understood and there are a number of theories. Nevertheless, based on the enormous amount of research so far, there is a lot of consensus in the scientific community about most probable causes.

Heredity

• Based on the evidence, heredity is the most common cause of ADHD: believed to account for about 80 percent of children with ADHD.
• ADHD is known to run in families, as found by numerous studies (for example, twin studies with identical and fraternal twins, adopted children, family studies, and molecular genetic studies).
• It is believed that a genetic predisposition to the disorder is inherited. Children with ADHD frequently have a parent, sibling, grandparent, or other close relative with ADHD or whose history indicates they had similar problems and symptoms during childhood.
• Molecular genetic studies and candidate-gene studies have identified certain genes linked to ADHD. Since ADHD is a complex disorder with multiple traits, future research will likely identify multiple genes involved in ADHD.
• It is hypothesized that the child may inherit a biochemical condition in the brain that influences the expression of ADHD symptoms. An abnormality in one or more genes associated with ADHD may be inherited, such as one of the genes that regulates dopamine activity in the brain. Others suggest that what is inherited is a tendency toward problems in the development of the brain region associated with executive functioning and self-regulation.

Diminished Activity and Lower Metabolism in Certain Brain Regions

• Numerous studies measuring electrical activity, blood flow, and brain activity have found differences between those with ADHD and control groups (those without ADHD), including:
• Decreased activity level in certain regions of the brain (mainly the frontal region and basal ganglia). These regions that are underactivated are known to be responsible for controlling activity level, impulsivity, attention, and executive functions.
• Lower metabolism of glucose (the brain’s energy source) in the frontal region.
• Decreased blood flow to certain brain regions associated with ADHD.
• Less electrical activity in these key areas of the brain.
• These differences have been identified using brain activity and imaging tests and scans—for example, functional magnetic resonance imaging (MRI), single photon emission computed tomography (SPECT), positron emission tomography (PET), and electroencephalograms (EEGs).
• Although imaging and other brain tests are used in researching ADHD, they are not used in diagnosing it.

Chemical Imbalance or Deficiency in Neurotransmitters

• There is strong scientific evidence that those with ADHD have a deficiency, imbalance, or inefficiency in brain chemicals (neurotransmitters) that affect certain brain regions associated with ADHD—particularly the prefrontal cortex. The two main neurotransmitters involved in ADHD are dopamine and norepinephrine, and their levels in those affected brain regions are believed to influence attention, inhibition, motivation, and motor activity.
• The neurotransmitters are the chemical messengers of the brain. The neurons in the brain are not connected. They have a “synapse” or gap between them. The neurotransmitters help carry messages between two neurons by releasing into the synapse and then being recycled or taken back to the first neuron once the message gets across. It is believed that with ADHD, those brain chemicals (dopamine and norepinephrine) may not be efficiently releasing and staying long enough in the synapse in order to do their job in that region and circuits of the brain effectively.
• Stimulant medications for ADHD are believed to work by normalizing the brain chemistry of the neurotransmitters and increasing the availability of the dopamine and norepinephrine in underactivated regions of the brain. See checklist 1.13.

Prenatal Exposure to Certain Toxins

There has been found to be an association between prenatal exposure to some environmental toxins and ADHD. Certain substances the pregnant mother consumes or exposes the developing fetus to are believed to increase risk factors and may be a contributing cause for ADHD in some children. This includes fetal exposure to alcohol, nicotine from cigarettes, and high levels of lead.

Birth Complications, Illnesses, and Brain Injury

• For a very small percentage of children with ADHD, some causes may be related to:
• Birth complications, such as toxemia or significantly premature birth and low birthweight
• Trauma or head injury to the frontal part of the brain
• Certain illnesses that affect the brain, such as encephalitis

Structural Brain Differences and Delays in Brain Development