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Facts About Attention Deficit Disorder
Harvey C. Parker, Ph.D.
Clinical Psychologist

Author of The ADD Hyperactivity Workbook for Parents, Teachers, and Kids, The ADD Handbook for Schools, and Problem Solver Guide for Students with ADHD.

Current interest in Attention Deficit Hyperactivity Disorder (ADHD) is soaring. Magazine articles, newspaper reports, network newscasts, and television talk show hosts have found this to be a timely topic. Scientific journals report thousands upon thousands of studies of ADHD children and youth and ADHD support groups continue to grow at an astounding rate as parents seek to learn more about this disorder in an effort to help their youngsters succeed at home and at school.

While some of this interest in ADHD arose from the controversies surrounding this condition, the growing recognition that ADHD can be a seriously debilitating disorder with lifelong effects has caused tremendous concern. Controversy about ADHD revolves around disagreements as to the cause of the disorder as well as differing opinions regarding treatment. Apprehension with respect to the dispensing of medication to ADHD children had captured media attention in the mid to late 1990s. Disagreement as to the educational needs of ADHD children and whether they should be eligible to receive special education services when their disorder severely impacts upon their academic performance has been a hotly debated issue.

A Harris Interactive survey done in 2000 polled parents and grandparents of children with ADHD as well as adults with the condition. One in three (34%) parents and grandparents said they did not know where to go for information when their child was diagnosed. The majority of parents and grandparents said confusing media reports (91%) and lack of reliable information (94%) prevent children from getting the treatment they need for ADHD. The purpose of this article is to briefly summarize some of the facts we know about ADHD related to characteristics, prevalence, cause, identification, treatment and outcome. Other articles contained on the addwarehouse.com site provide additional information about the disorder.

Characteristics of ADHD

The Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV), published by the American Psychiatric Association, defined three types of attention deficit hyperactivity disorder: ADHD, predominantly hyperactive-impulsive type; ADHD, predominantly inattentive type; and ADHD, combined type. ADHD is characterized by symptoms of inattention, impulsivity or hyperactivity which have an onset before age seven, which persist for at least six months, and which are not due primarily to other psychiatric disorders or environmental circumstances, such as reaction to family stresses, etc. ADHD, predominantly inattentive type refers to disturbances in which the primary characteristic is significant inattentiveness without signs of hyperactivity. ADHD, predominantly hyperactive-impulsive type refers to disturbances in which the primary characteristics are hyperactivity and impulsivity, without inattention. Recent study of ADHD children who are the inattentive type indicates that this group of children tend to show more signs of anxiety and learning problems, qualitatively different inattention, and may have different outcomes than the hyperactive group who show more externalizing behavior problems associated with the oppositional and conduct disorders.

Prevalence of ADHD

Prevalence reports of ADHD have varied over the past several years and range from 3 to 9 percent of the population of children and adolescents, with boy significantly out numbering girls. The number of children and adolescents affected by ADHD in the United States is probably well over 2 million. Adults can also be affected as it is estimated that from 30 to 70 percent of children with the disorder will continue to have symptoms throughout adulthood.

Cause of ADHD

There are still many unanswered questions as to the cause of the disorder. Over the years the presence of ADHD has been weakly associated with a variety of conditions including: prenatal and/or perinatal trauma, maturational delay, environmentally caused toxicity such as fetal alcohol syndrome or lead toxicity, and food allergies. History of such conditions may be found in some individuals with ADHD, however, in most cases there is no history of any of the above.

Researchers have turned their attention to altered brain biochemistry and brain anatomy as possible causes of ADHD. Presumed differences in brain chemistry or structure may be the cause of poor regulation of attention, impulsivity and motor activity. A great deal more research has to be done to reach more definitive answers. However, we do know that there is no evidence that ADHD is caused by poor parenting, food allergies, excess sugar, or exposure to television. Other disorders may cause similar symptoms, which is why it is important to get a comprehensive diagnosis from a specialist.

Identification of ADHD

The identification and diagnosis of children with ADHD requires a combination of clinical judgement and objective assessment. Since there is a high rate of coexistence of ADHD with other psychiatric disorders of childhood and adolescence any comprehensive assessment should include an evaluation of the individual's medical, psychological, educational and behavioral functioning. The more domains assessed the greater certainty there can be of a comprehensive, valid, and reliable diagnosis. The taking of a detailed history including medical, family, psychological, developmental, social and educational factors is essential in order to establish a pattern of chronicity and pervasiveness of symptoms. Augmenting the history are the use of standardized parent and teacher behavioral rating scales which are essential to quantifiably assess the normality of the individual with respect to adaptive functioning in a variety of settings such as home and school. Psychoeducational assessment investigating intellectual functioning and cognitive processes including reasoning skills, use of language, perception, attention, memory, and visual-motor functioning as well as academic achievement should be performed.

Treatment of ADHD

Most experts agree that a multi-modality approach to treatment of the disorder aimed at assisting the child medically, psychologically, educationally and behaviorally is often needed. This requires the coordinated efforts of a team of health care professionals, educators and parents who work together to identify treatment goals, design and implement interventions, and evaluate the results of their efforts.

Medications used to treat ADHD primarily include psychostimulants such as: Ritalin, Focalyn, Dexedrine, Adderall and Adderall XR, Metadate CD, and Concerta which have been shown to have dramatically positive effects on attention, over activity, visual motor skills, and even aggression in 70% or more ADHD children. The tricyclic antidepressant medications, Tofranil, Desipramine, Elavil, and others have been studied and used clinically to treat the disorder. Other types of antidepressants (i.e., Prozac, Paxil, etc.) called selective serotinin reuptake inhibitors are used less frequently because they have little impact on attention and hyperactivity or impulsivity. However, they do help regulate mood. Catapres and Tenex, antihypertensive agents, and Tegretol, an anti-convulsant, have been shown to be effective for some children as well.

Ideally, treatment should also include consideration of the individual's psychological adjustment targeting problems involving self-esteem, anxiety, and difficulties with family and peer interaction. Frequently family therapy is useful along with behavioral and cognitive interventions to improve behavior, attention span, and social skills.

Educational interventions such as accommodations made within the regular education classroom, compensatory educational instruction, or placement in special education may be required depending upon the particular child's needs. A 1999 study by the NIMH (the MTA study) concluded that medication treatment was very effective in helping children with ADHD and that psychosocial treatments provided additional benefit.

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Assessment of Attention Deficit Disorders: A Team Approach
Harvey C. Parker, Ph.D.
Clinical Psychologist
Author of The ADD Hyperactivity Workbook for Parents, Teachers, and Kids.

The primary characteristics of Attention Deficit Hyperactivity Disorder (ADHD/ADD) are not difficult to spot in a classroom. However, not all children who are inattentive, impulsive, or overactive have ADD. These same symptoms can be a result of other factors such as: frustration with difficult schoolwork, lack of motivation, emotional concerns, or other medical conditions. A comprehensive assessment by a team of professionals working in conjunction with the parents and the child can usually determine whether problems are the result of ADD or other factors. Members of this assessment team usually include physicians, psychologists, social workers, and school personnel such as teachers, guidance counselors, or learning specialists.

The Physicians Role

Routine Physical examinations of children with ADD are often normal, but they are needed to rule out the unlikely possibility of there being a medical condition which could cause ADD-like symptoms. Tests such as chromosome studies, electroencephalograms (EEGs), magnetic resonance imaging (MRI), or computerized axial tomograms (CT scans) are not used routinely for evaluation of ADD. Child and adolescent psychiatrists and pediatric neurologists may play an important part in identifying this condition as well as other possible related conditions such as learning disabilities, Tourette syndrome, pervasive development disorder, obsessive compulsive disorder, anxiety disorder, depression or bipolar disorder.

The Psychologist's Role

Clinical or school psychologists administer and interpret psychological and educational tests of cognition, perception, and language development (such as intelligence, attention span, visual-motor skills, memory, impulsivity) as well as tests of achievement and social/emotional adjustment. Psychologists and other mental health professionals often interpret data collected from parents and teachers who complete behavior rating scales about the child in question. Results of such tests can provide important clues as to whether a child's difficulties are related to having ADD and/or other problems with learning, behavior, or emotional adjustment. Such scales offer quantifiable, descriptive information about the child, thus providing a means by which to compare the child's behavior to that of others of the same sex and age. Some of the more popular rating scales used in the assessment of ADD are: Conners Teacher Rating Scale (CTRS) and Conners Parent Rating Scale (CPRS), ADD-H: Comprehensive Teacher Rating Scale (ACTeRS), ADHD Rating Scale, Child Attention Profile, Child Behavior Checklist (CBCL), Home Situations Questionnaire, School Situations Questionnaire, and Academic Performance Rating Scale (APRS).

The School's Role

Assessments for ADD should always include information about the student's current and past classroom performance, academic skills strengths and weaknesses, attention span, and other social, emotional, or behavioral characteristics. Such information can be gathered through teacher interviews, review of cumulative records, analysis of test scores, and direct observation of the student in class. The student's adjustment in class should relate to aspects of the instructional environment, namely: the curriculum in which the student is working; teacher expectations for the class and for the individual student; methods of instruction employed by the teacher; incentives for work completion; methods of teacher feedback to students; and comparative performance of other students in the class.

The Parent's Role

Having witnessed the child in a variety of situations over a number of years, parents have the unique perspective on their child's previous development and current adjustment. Information from parents is usually acquired by interview or through questionnaires completed by parents. The focus is usually on obtaining overall family history, current family structure and functioning, and to document important events from the child's medical, developmental, social, and academic history relevant to the assessment of ADD.

The Child's Role

An interview with the child offers the clinician the opportunity to observe the child's behavior and can yield valuable information as to the child's social and emotional adjustment, feelings about themselves and others, attitudes about school and other aspects of their life. However, even children with ADD often behave well during such interviews. Therefore, observations of a child's behavior, level of activity, attentiveness, or other compliance made during the interview sessions should not be taken as true of the child in other settings. Normal behavior in a one-on-one setting does not diminish the likelihood of the child having ADD.

The Team's Role after the Assessment

Ideally, after all the data has been collected, members of the assessment team should collaborate to discuss their findings. This should lead to a thorough understanding of the child's strengths and areas of need physically, academically, behaviorally, and emotionally. If a diagnosis of attention deficit disorder (and/or other conditions) is established, treatment planning should be done in all areas where interventions are recommended. The physician may discuss appropriate medical interventions with the child and parents. The psychologist or other mental health professional may discuss counseling, behavior modification, or social and organizational skills training options. The school may set up classroom interventions to accommodate the child's areas of need in school or may provide special education or related services. Once the initial assessment is completed and appropriate treatment is instituted, there should be routine follow-up by members of the assessment and treatment team to determine how the child is progressing. ADD, being a chronic condition, will often require long-term care and monitoring on a regular basis. Obviously, parents play a key role in encouraging members of the assessment and treatment team to maintain close collaboration and to work together consistently for the best interests of the child. Coordination of all this, whether it be by a parent or a professional, is no easy task, but the outcome is usually well worth the effort.

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Avoiding the Back to School Homework Blues
Sam Goldstein, Ph.D. and Sydney Zentall, Ph.D.

  Your home has been a homework-free zone, but summer is over. Although going back to school may free-up time during your day the thought of homework is an experience each year that is often met with uncomfortable expectation. If you are like most parents, you feel a mixture of emotions about homework. Some of them positive, but many of them unpleasant. Frustration, annoyance, boredom, confusion, and even anger are among the many negative emotions parents, as well as their children, express when it comes to homework. Face it, most of us did not like doing homework when we were kids and we probably do not like it any better as parents.

Homework, you are reminded constantly by your child's teachers, is an important component of the school experience. You are told that completing homework successfully makes for successful students. Homework continues to be an institution in our educational system. Even in well functioning families under ideal circumstances, homework can be one of the hottest parent-child crisis buttons. Parents are unsure as to the best time, place, routine, or system their child should use to complete homework. Many children rebel and parents feel overwhelmed by the pressure of meeting their children's school demands. It is not surprising that parents complain about homework almost as much as their children do.

Most children during their school career forget some assignments, lose homework, require assistance, or make mistakes. Some children have difficulty learning essential skills that enable them to complete homework independently. Some have trouble obtaining assignments. Some may be confused, overwhelmed with long-term projects, or rush through assignments. For children experiencing school problems, the challenges of homework are added to existing classroom difficulties. It is not uncommon for these children to bring incomplete class work home as well as homework. For them, and for you, there is the prospect of hours and hours of schoolwork at home, often with minimal long-term benefit.

Your child's ability to be successful with homework begins with the value you place upon homework. Success also requires helping your child develop essential homework skills, creating a working alliance with your child and teachers as well as learning to deal with common homework problems. In this article, we provide answers to five of the most common homework problems parents face.

  1. When your child won't do homework without you. Asking about homework and helping out is an important part of your guiding role as a parent, especially for elementary aged children experiencing difficulty completing homework independently. Try to establish a working relationship with your child. This will create a homework alliance in which you have an agreed upon time, place and system for completing and monitoring homework each day. Keep in mind, however, excessive involvement in your child's homework, may stifle the ability to learn to do homework independently. Be available for assistance and feedback. Do not jump in too quickly to correct homework, nor wait until the 11th hour when, out of frustration, you end up completing their homework.
  2. When your child repeatedly makes excuses to avoid doing homework. By staying involved with your children's education, you will be familiar enough with their ability and homework habits to know when they are really struggling with homework or when they are using excuses to avoid homework. Sometimes "it's too hard" or "I don't understand it" are honest statements. Other times they reflect strategies your child may use to avoid working independently. Children who make excuses for not completing homework, even though they possess the understanding, the skill, and the opportunity to complete it successfully, should be held responsible for their behavior. Follow these steps:
    1. Encourage your child to take responsibility for homework and don't allow yourself to get trapped in lengthy discussion or arguments.
    2. Set up homework rules that you and your child can agree to follow.
    3. Help your child make short-term homework goals that can gradually be extended. Keep in mind that some children are overwhelmed with the thought of too much homework.
    4. Reinforce and praise appropriate homework behavior and avoid a negative pattern of scolding, nagging, or threatening.
  3. When your child waits until the last minute to start homework assignments. Everyone procrastinates to some extent. Avoiding an unpleasant task in exchange for doing something more pleasurable is common for all of us. Some children, however, get stuck in a procrastination holding pattern. They don't get started on daily homework assignments until late in the day or evening, put off working on long-term projects and fail to study for tests in advance. You can help you child avoid the procrastination habit.
    1. Choose a pleasant, consistent place to complete homework.
    2. Create an agreed upon schedule and routine for homework.
    3. Have your child learn to make checklists of what needs to be completed.
    4. Provide appropriate supervision.
    5. Create incentives including pleasurable activities that can be accessed when homework is partially or fully completed.Set goals and use a clock or timer to help your child to develop a sense of timeliness for required tasks.
  4. When your child rushes through homework and makes careless errors. Some children rush through their homework but do it thoroughly and correctly. In general this is not a problem. However, many others rush to complete homework just to get it done. They make numerous careless errors, hand in sloppy work or fail to pay attention to directions. These children need to work at a slower pace and check their assignments for accuracy. They need to learn that inaccurately completed work is unacceptable. If your child sacrifices accuracy for speed, try the following.
    1. Review homework assignments nightly, checking for thoroughness, neatness and accuracy. Encourage, but do not demand that mistakes are corrected.
    2. Have your child underline or highlight important words or phrases in directions of an assignment as a means of cueing what needs to be done.
    3. Emphasize that you want your child to do their best work, not their fastest work.
    4. Help your child self-monitor by checking for errors in spelling, punctuation, neatness, calculations, correct headings, etc.
  5. Withhold privileges until you are satisfied that your child has put forth the best effort possible and has completed homework accurately. Be aware, however, that if you suspect errors are due to poor understanding rather than hasty completion, provide needed assistance. Some children have difficulty with written homework due to visual motor problems. This makes it difficult for them to write neatly. Asking them to re-do homework to be neater is often frustrating and fruitless. If the goal of the task is creativity and ideas, offer assistance. If the goal of the task is to develop neat handwriting, then additional practice for some children may be warranted.

With patience, planning, insight, and empathy you can avoid singing the back to school homework blues this year and help your children experience homework success.

Guidelines for Successfully Parenting ADHD Children
Sam Goldstein, Ph.D.

To effectively parent a child with ADHD you must be an effective manager. You are managing someone with poor self-regulation. Your interactions with your ADHD child must be consistent, predictable and most importantly, understanding of the chronic difficulties this child likely will experience. The following guidelines are essential:

  1. Education. You must become an educated consumer. You must thoroughly understand this disorder, including developmental, scholastic, behavioral and emotional issues.
  2. Incompetence vs. Non-compliance. You must develop an understanding of incompetence (non-purposeful problems that result from the child's inconsistent application of skills leading to performance and behavioral deficits) and non-compliance (purposeful problems which occur when children do not wish to do as they are asked or directed). ADHD is principally a disorder of incompetence. However, since at least 50% of children with ADHD also experience other disruptive, non-compliant problems. Parents must develop a system to differentiate between these two issues and have a set of interventions for both.
  3. Positive Directions. (telling children what to do rather than what not to do or giving them a start rather than a stop direction). That provides the most effective type of commands for the ADHD population.
  4. Rewards. Remember that children with ADHD need more frequent, predictable and consistent rewards. Both social rewards (praise) and tangible rewards (toys, treats, privileges) must be provided at a higher rate when the ADHD child is compliant or succeeds. Remember, it is likely that the ADHD child receives less positive reinforcement than siblings. Make an effort to keep the scales balanced.
  5. Timing. Consequences (both rewards and punishment) must be provided quickly and consistently.
  6. Response Cost. A modified response cost program (you can lose what you earn) must be utilized with this child at home. This system can provide the child with all the reinforcers starting the day and the child must work to keep them or can start the child with a blank slate, allowing the child to earn at least three to five times the amount of rewards for good behavior versus what is lost for negative behavior (earn five chips for doing something right, lose one chip for doing something wrong).
  7. Planning. Understanding the forces that affect your ADHD child, as well as the child's limits should be used in a proactive way. Avoid placing the child in situations in which there is an increased likelihood the child's temperamental problems will result in difficulty.
  8. Take Care of Yourself. Families with one or more children experiencing ADHD are likely to experience a greater stress, more marital disharmony, potentially more severe emotional problems in parents and often rise and fall based upon this child's behavior. It is important to understand the impact this child may have upon a family and deal with these problems in a positive, preventative way rather than a frustrated, angry and negative way after you have reached your tolerance.
  9. Take Care of Your Child. Remember that your relationship with this child is likely to be strained. It is important to take extra time to balance the scales and maintain a positive relationship. Find an enjoyable activity and engage in this activity with your child as often as possible, at least a number of times per week.

Sam Goldstein, Ph.D. Dr. Goldstein is a member of the faculty at the University of Utah and in practice at the Neurology, Learning and Behavior Center. He has authored twelve texts, book chapters, articles and training videos dealing with a range of child development topics.

Correspondence to Dr. Goldstein can be addressed c/o the Neurology, Learning and Behavior Center, 230 South 500 East, Suite 100, Salt Lake City, Utah 84102, (801) 532-1484, FAX (801) 532-1486, e-mail: info@samgoldstein.com, or visit his website at www.samgoldstein.com

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Resources for Parents and Teachers Working with Children Experiencing Attention Problems

Videos

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Lonely, Sad and Angry: How to Know if Your Child is Depressed and What To Do
Sam Goldstein, Ph.D.
Barbara Ingersoll, Ph.D.

Three year old Joshua was a happy, outgoing youngster who enjoyed a great deal of attention from a large, loving family. He became increasingly withdrawn, irritable, and unhappy following a three-week hospitalization for an acute physical illness.

Despite a history of mild learning disabilities and Attention Deficit Disorder, eight year old Lee appeared to be doing well at home and in school. When his best friend moved away he became morose and moody. He lost interest in his school work, his appetite diminished, and he spent long hours sleeping or watching television.

At age twelve, Elizabeth appeared helpless and unhappy. She seemed unable to handle the ups and downs of daily life at home or in school and, when faced with stress, often cried, "I hate my life" and "I wish I were dead."

What's wrong with these children?

According to recent public health studies, emotional disorders are widespread in our population. Although poets and artists often portray childhood as a happy, carefree time of life; many children -- like adults -- actually suffer from emotional disorders. Depression is one of the most common of these disorders.

What is depression?

Depressive illnesses, which are also called "mood disorders," can range in severity from mild unhappiness in response to life's stresses to profound unhappiness and suicidal thoughts and actions. Typical symptoms of depression include sadness or irritability, low self-esteem, and loss of interest in previously pleasurable activities.

Depression has been aptly described as a "whole-body illness" because it involves not only changes in mood but in almost every other area of a child's life, as well. Depressed youngsters may suffer from problems with sleep, appetite, and general health. They frequently complain of vague physical symptoms, such as headaches and stomachaches, for which no medical cause can be found. Depression affects the ability to think, concentrate, and remember; so the depressed child's school performance deteriorates and grades begin to drop. Friendships dissolve as depressed children become increasingly withdrawn or, in some cases, irritable and argumentative. The family suffers, too, from the child's moodiness, emotional outbursts, and constant whining and complaining.

We see, then, that depression affects the way a child looks, feels, thinks and behaves. Depressed children often look distinctly unhappy: bright smiles and cheerful grins give way to a glum, mask-like facial appearance. If the predominant mood symptom is irritability, an angry, sullen expression seems permanently fixed on the child's face. Self-esteem plummets and the child feels guilty, inadequate, and unloved. Loss of energy is common and depressed children often become "couch potatoes" who do little but watch TV or play video games. A previously agreeable child might become increasingly uncooperative and defiant, refusing to abide by rules at home or in school. When this happens, parents often attribute the difficult behavior to willfulness and resort to disciplinary tactics, while the child's underlying problems go undiagnosed and untreated.

In teenagers, symptoms of depression such as moodiness, poor self-esteem, and school failure are often chalked up as "typical teenage behavior." If -- as is so often the case with depressed adolescents -- the teenager also falls in with a bad crowd, abuses drugs or alcohol, and runs afoul of family and societal rules, it is even more likely that the real source of the problem will be overlooked. The result? Problems that might otherwise be corrected with treatment may escalate out of control.

Depression is a common problem.

For a condition whose existence was not even recognized until quite recently, the statistics now emerging about childhood depression are somewhat alarming. Studies suggest that, during a year's time, eight to nine percent of children between the ages of ten and thirteen suffer from an episode of depression.

As startling as these figures are, it is likely that they reflect only the tip of the iceberg, since the incidence of depression in young people appears to be on the rise in our society. When we divide the population of this country into two groups -- those under forty years of age and those over forty -- we find that those under forty are three times more likely to suffer from a depressive illness than those over forty. If we examine the under-forty group more closely, the trend is clear: as age goes down, the risk of having a depressive illness goes up. This means that the risk is greatest for those born most recently -- our children.

Depression has many causes.

After years of neglect, childhood depression has become the subject of considerable research efforts. Behavioral scientists who have explored the causes of depressive illness now believe that depression results from problems with neurotransmitters,the chemical messengers within the brain which enable brain cells to communicate with each other. The roots of this malfunction appear to lie in a complex combination of genetic vulnerability and stressful life events.

Like diabetes and high blood pressure, depression has a tendency to "run in the family" and many depressed youngsters come from a long line of family members who have also suffered from mood disorders. We know, for example, that children of depressed parents are three times more likely than other children to suffer from depression at some point in their development.

The relationship is far from perfect, however: many children with a family history of depression never become ill; while others, lacking such a family history, succumb to a depressive illness. This indicates that life experiences also contribute to the development of a mood disorder. Children who have a family history of the illness and are also exposed to many negative life events are obviously at a much greater risk to develop a depressive illness.

Don't be afraid to act.

If you have noticed symptoms of depression in your child or adolescent, don't ignore your concerns in the hope that the problem will simply go away with time. These symptoms often signal a serious problem which, if left untreated, can cause enormous pain and suffering to both the child and the family.

Discuss the problem with your child's pediatrician, school guidance counselor, and other professionals who know your child. Obtain a consultation with a mental health specialist, such as a social worker, child psychologist or psychiatrist, since these professionals have particular expertise in diagnosing and treating depression in young people.

Be prepared to put some time into the process of obtaining a diagnosis. Unfortunately, there are no simple laboratory tests available for the diagnosis of depression. Instead, a professional makes the diagnosis only after careful consideration of the family history as well as the child's history and current difficulties. An interview with the child is essential, since children often report problems of which their parents know nothing, such as suicidal thoughts or plans. A thorough evaluation also includes information about family functioning, the child's interests and skills, his academic performance, social activities, and the like. A careful professional will also look for problems with attention and distractibility, as well as patterns of unusual fears and phobias,since such problems often precede or co-exist with mood disorders.

What can be done?

Although treatment of childhood depression is itself an infant field, information about effective treatment methods is accumulating rapidly and there is good cause for optimism. Although the anti-depressant medications which have helped so many depressed adults have produced rather disappointing results when used with children, there is good reason to believe that some of the newer anti-depressants may prove much more beneficial in alleviating symptoms of depression.

Behavioral scientists have also developed promising treatment techniques and programs to help young people overcome depression. Although many people equate the term "psychotherapy" with a bearded analyst and a patient lying on a couch complaining about his parents, the field of psychotherapy is actually much broader in scope. It encompasses a wide array of tactics and strategies designed to help people deal effectively with anxiety, depression, and other conditions which interfere with the ability to function well and enjoy life to the fullest.

Among the strategies which have proven most beneficial to youngsters suffering from depression are those which focus on helping depressed youngsters change the way in which they think about themselves and their world. Other effective tactics involve close collaboration with parents, helping parents to encourage their children's involvement in social activities, hobbies, and school work. Professional intervention can help, too, to keep open lines of communication among family members so that parents and children work through trying times together, instead of as adversaries.

If you would like to learn more about childhood depression, Dr. Goldstein's two hour video, Why Isn't My Child Happy? offers frank, honest information concerning the causes of depression, warning signs, the process of diagnosis, proven and unproven treatments and guidelines to assist parents, educators and professionals. This video includes interviews with men and women on the street, families, depressed youth and a round table discussion. This video along with the companion text, Lonely, Sad and Angry: The Parent's Guide to Childhood Depression co-authored with Barbara Ingersoll, Ph.D., as well as other materials by Dr. Goldstein are available from the Neurology, Learning and Behavior Center, 230 South 500East, Suite 100, Salt Lake City, Utah 84102, (801) 532-1484, FAX (801) 532-1486, e-mail: info@samgoldstein.com or website: www.samgoldstein.com

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Overcoming Underachieving:  Understanding Children's School Problems
Sam Goldstein, Ph.D.

School problems of children usually cannot be resolved quickly or cured with a magic potion. Instead they are often chronic and require regular management. To be effective, however, parents and teachers must first understand how children learn. What skills are required for school success? How do strengths or weaknesses in particular skills affect a child's mastery of particular subjects? Often the reasons a child struggles at school may be very different from the reasons another child struggles. It is important, however, to take the time to understand the underlying factors that contribute to these struggles rather than hastily shifting focus to grades or achievement levels. Over many years of working with children, my colleague, Dr. Nancy Mather at the University of Tucson, and I have developed a framework for understanding why children experience problems in learning. We call this framework the "building blocks of leaning."

There are ten blocks of learning, each of which contains a set of related learning skills. The blocks can be divided into three distinct groups which then stack together to form a pyramid. At the ground level of the pyramid are the four foundational blocks: attention/impulse control, emotions and behavior, self-esteem and the learning environment. The middle level contains the three processing blocks: visual, auditory and motor. The top level contains the three thinking blocks: language and images, and completing the pyramid strategies. As you will read, some of these blocks are more important than others for certain types of learning.

The Foundational Blocks

We refer to these as the foundational blocks because they provide the support system for all learning. Just as the foundation of a building must be strong enough to support the entire structure erected upon it, these four blocks must be strong enough to provide support for further learning to occur. The ability to pay attention is basic to all learning. Skills in the block of attention/impulse control allow children to focus on the relevant requirements of a learning task. The blocks of emotions and self-esteem contribute to how a child feels about himself or herself as well as to a willingness to stick to tasks until they are completed successfully. The environmental block concerns providing the child with a safe, supportive, appropriate climate for learning at home and in school. To succeed in learning a child requires efficient attention and impulse control, healthy emotions, a positive attitude towards self and learning and a loving, consistent, supportive environment.

Strengths in the foundational blocks help children learn to compensate for lesser abilities and to persist in the face of difficulties. Strong foundational block skills, however, do not guarantee that children will avoid all school difficulties. Weaknesses within the processing or thinking blocks also affect school performance.

The Processing Blocks

On the second level of the building blocks of learning are those involved with the processing of information through sight, hearing and touch. These are what educators refer to as the visual, auditory and motor skills. These skills facilitate learning and enable children to perform tasks that tend to be secretarial in nature, such as hearing and writing down assignments, taking notes or recognizing words. The skills in the processing blocks allow children to take in information, to discern it's various pieces, to memorize and to perform tasks involving symbolic learning such as the concept that a digit stands for a number of objects. Once children master these processing skills, they usually do not have to spend very much time during learning tasks concentrating upon these. For example, after learning to recognize a word in print, a child will usually recognize it automatically when it is encountered in the future.

Children struggling with learning in the early elementary grades often experience difficulty in one or more of these processing blocks. In fact, weaknesses in the auditory block account for the majority of children experiencing problems learning phonics. Yet other children may experience problems with visual tasks, such as those involved in remembering what a word looks like. Another may struggle to place letter sounds in correct order to spell a word. Still another may do poorly with the motor aspects of learning such as cutting, forming letters with a pencil or drawing. As with the foundational blocks, a child with adequate processing skills will be able to perform various tasks but these skills alone do not guarantee school success. They do, however, guarantee that children will often master basic academic skills well in the early grades.

The Thinking Blocks

At the top of the pyramid the thinking blocks include skills related to language,images and strategies. Thinking with language involves understanding spoken and written language, expressing ideas in reading and writing and learning vocabulary. Thinking with images involves reproducing complex patterns, understanding and judging visual relationships and reasoning with mathematics. Finally, thinking with strategies involves the ability to think about your thinking. This includes the abilities to plan, organize, monitor and evaluate on an on going basis. The skills in the thinking blocks help children understand meanings, comprehend relationships and apply previously gained knowledge as they perform school tasks. For example, these skills help children read to learn. Before writing a story or a report, a child must brainstorm and organize relevant information. To solve a word problem in mathematics a child must read the problem, sort the relevant information,decide what is being asked and perform the correct calculation.

All tasks leading to school success depend upon the ability to sit still and concentrate and the motivation to keep trying. Certain types of tasks are highly related to the thinking blocks; other are more closely aligned with the processing blocks. Children who experience difficulties within the skills of the processing blocks experience different types of learning problems than children whose difficulties are with skills within the thinking blocks. Problems in both of these areas may be made worse by weaknesses in the foundational blocks. These variations occur because the foundational, processing and thinking skills play different roles in children's abilities to learn efficiently.

With this model in mind, consider these two examples:

The building blocks of learning model provides a framework to evaluate, understand and, most importantly, efficiently utilize educational strategies to help every child overcome underachieving and experience school success.

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It's about Time: Promising Practices for Children and Adolescents with ADHD
Prepared by Harvey C. Parker, Ph.D.
What is ADHD?

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

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

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

How Common is ADHD?

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

What Causes ADHD?

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

How is ADHD Diagnosed?

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

Inattention Symptoms

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

Hyperactive Symptoms

Impulsive Symptoms

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

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

Complete this ADHD Symptom Checklist

Below is a checklist containing 18 items which describe characteristics frequently found in people with ADHD. Items 1-9 describe characteristics of inattention. Items 10-15 describe characteristics of hyperactivity. Items 16-18 describe characteristics of impulsivity.

In the space before each statement put the number that best describes your child's (your student's) behavior (0=never or rarely; 1 = sometimes; 2 = often; 3 = very often).

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

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

Associated Problems

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

How is ADHD Treated?

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

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

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

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

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

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

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

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

Seven Principles for Parents of AD/HD Children and Teens

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

Summary

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

Books and Training Programs for Teachers and Parents

Barkley, R. A. (2000). Taking charge of ADHD: The complete authoritative guide for parents. New York: Guilford Press.

Christie, L. & Mitchell, S. (2000). Attention Deficits Update 2000. Florida: Professional Development Resources, Inc.

Dendy, C. A. (1995). Teenagers with ADD: A parents' guide. Maryland: Woodbine House.

Hallowell, E. & Ratey, J. (1994). Driven to distraction. New York: Simon and Schuster.

Koplewicz, H. S. (1996). It's nobody's fault: New hope and help for difficult children and their parents. New York: Random House.

Latham P, & Latham, P. (1998). ADD and the law (2nd ed.). Washington, DC: JKL Communications.

Nadeau, K. G. & Biggs, S. H. (1995). School strategies for ADD teens. VA: Chesapeake Psychological Services.

Parker, H. C. (1999). Put yourself in their shoes: Understanding teenagers with attention deficit hyperactivity disorder. Plantation, FL: Specialty Press, Inc.

Parker, H. C. (1994). The ADD hyperactivity workbook for parents, teachers, and kids (2nd. ed). Plantation, FL: Specialty Press, Inc.

Parker, H. C. (1992). The ADD hyperactivity handbook for schools (2nd. ed.). Plantation, FL: Specialty Press, Inc.

Phelan, T. (1993). Surviving your adolescents. Glenn Elyn: IL: Child Management.

Rief, S. (1993). How to reach and teach ADD/ADHD children. West Nyack, NY: The Center for Applied Research in Education.

Zentall, S. S. & Goldstein, S. (1999). Seven steps to homework success: A family guide for solving common homework problems. Plantation, FL: Specialty Press, Inc.

Videos for Teachers and Parents

Barkley, R. A. (1992). ADHD—What do we know? New York: The Guilford Press.

Barkley, R. A. (1992). ADHD—What can we do? New York: The Guilford Press.

Phelan, T. 1-2-3 Magic! Training your preschooler and preteen to do what you want them to do! Glen Ellyn, IL: Child Management, Inc.

Robin, A. L. & Weiss, S. K. (1997). Managing oppositional youth. Effective, practical strategies for managing the behavior of hard to manage kids and teens! Plantation, FL: Specialty Press, Inc.

Books and Videos for Children and Adolescents

Bramer, J. S. (1996). Succeeding in college with attention deficit disorders: Issues and strategies for students, counselors, & educators. Plantation, FL: Specialty Press, Inc.

Corman, C. & Trevino, E. Eukee the jumpy jumpy elephant. Plantation, FL: Specialty Press, Inc. Davis, L., Sirotowitz, S. & Parker, H. (1996). Study strategies made easy: A practical plan for school success. Plantation, FL: Specialty Press, Inc.

Gordon, M. (1991). Jumpin' Johnny get back to work: A child's guide to ADHD/hyperactivity. DeWitt, NY: GSI Publications.

Nadeau, K. G. & Biggs, S. H. (1993). School strategies for ADD teens. Annandale, VA: Chesapeake Psychological Pub.

Parker, R. N. & Parker, H. C. (1995). Slam dunk: A young boy's struggle with ADD. Plantation, FL: Specialty Press, Inc.

Parker, R. N. and Parker, H. C. (1992). Making the grade: An adolescent's struggle with attention deficit disorders. Plantation, FL: Specialty Press, Inc.

Quinn, P. O. (1994). ADD and the college student. Washington, DC: Magination Press.

Quinn, P. O. & Stern, J. (1991). Putting on the brakes. New York: Magination Press.

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