Improve Listening Skills in ADHD Children

The ADHD Success Formula

The ADHD Success Formula

This is an audio and guide that will help you battle through ADHD and Accomplish Twice As Much In Half The Time. Learn more by download your very own copy today.

Get My Free Ebook


Focus Pocus 100 Ways To Help Your Child Pay Attention

Focus Pocus includes hints on how to pay attention in the classroom. It lists ways kids can focus on homework. There are strategies, techniques and little tricks that will help your child pay attention whether or not they are on medication, whether or not they are labeled Adhd. Hints Like These: paying attention hint To make vocabulary words easier to learn, divide them up into small groups, and study each in a different room. how to pay attention To give a multi-sensory whammy to math, have your child talk through math problems out loud. how to focus To help students copy homework assignments correctly, write them on the board in different or alternating colors. how to pay attention in class To keep kids from zoning out through verbal reminders to pay attention, flash the lights or ring a bell. pay attention To help your child sit still through a boring class, teach them appropriate ways to fidget.

Focus Pocus 100 Ways To Help Your Child Pay Attention Summary

Rating:

4.6 stars out of 11 votes

Contents: Ebook
Author: Kayla Fay
Price: $15.00

My Focus Pocus 100 Ways To Help Your Child Pay Attention Review

Highly Recommended

I started using this ebook straight away after buying it. This is a guide like no other; it is friendly, direct and full of proven practical tips to develop your skills.

When compared to other e-books and paper publications I have read, I consider this to be the bible for this topic. Get this and you will never regret the decision.

Download Now

Stimulant Medications for Adults with ADHD

For many decades, most of the studies of stimulant medications for ADHD assessed only children. More recently, studies have also tested the effectiveness of medications for treating ADHD in adults. Stephen Faraone and colleagues (2004) published a meta-analysis of the efficacy of MPH for treatment of ADHD in adults. Across studies he found strong evidence that this medication is as effective in alleviating ADHD in adults as it is in helping children and adolescents with the disorder.

Training for Parenting Children with ADHD

Most parents need some help to learn how to design and effectively implement behavioral programs. Useful strategies for all children have been described by Thomas Phelan (2003) in his book 1-2-3 Magic. Russell Barkley (2000), in his Taking Charge of ADHD, also offers ways for parents to deal with many behavioral problems associated with ADHD. And systematic training programs to help parents learn how to apply behavioral treatment strategies to children with ADHD have been described by Arthur Anastop-oulos and colleagues (1998) and Charles Cunningham (1998). programs work. For example, Edmund Sonuga-Barke and colleagues (2002) reported a study of preschool children with ADHD and their mothers in which the children of mothers who themselves had relatively high levels of ADHD symptoms showed the least improvement after their mothers had received parent training. This suggests that the benefits a child receives from behavioral treatment at home are strongly influenced by the ability of...

Additional Disorders That May Cause or Complicate ADHD

There are many reasons that a child or adolescent may be unsuccessful at school or in social relationships, just as there are many reasons that adults may be unsuccessful in education, work, social relationships, or family life. ADHD is one possible reason, but not the only one. For this reason, any evaluation for possible ADHD should include screening for environmental problems and for other learning or psychiatric disorders that may be causing or complicating the symptoms presented as possible ADHD. The Brown ADD Diagnostic Form in versions for children, adolescents, and adults all include guidelines to assist clinicians in checking for pos sible additional disorders. The implications of these additional disorders for understanding ADHD are discussed in Chapter 8.

Executive Networks Differ in Those with ADHD

One of the earliest studies of differences in brain functioning of persons with ADHD was provided in 1990 by Alan Zametkin and colleagues. They used imaging to compare levels of chemical activity in the brains of adults with and without a history of hyperactivity since childhood. Results indicated that when adults with ADHD did a task that required sustained concentration, they demonstrated a lower rate of chemical activity, both globally and in specific regions of the brain, than did normal controls. Brains of those with ADHD were less turned on while doing the concentration task than were the matched controls. Monique Ernst and others (1999) did an imaging study that compared brains of children with ADHD to normal controls. These images showed that children with ADHD had an abnormality in the processing of dopamine in their midbrain regions. Sarah Durston (2003) used a different imaging method to study self-control systems in children with ADHD compared to normal children. While in...

The Severity of ADHD Symptoms and Accurate Diagnosis

DSM-IV field study selected cutoff scores that included the 7 percent who were most impaired by ADHD symptoms, thus establishing that the remaining 93 percent of children would not be considered impaired enough to warrant diagnosis. But why should that be the cutoff for diagnosis rather than 3 percent, 10 percent, or 15 percent One way to address this question is to determine the percentage of individuals in the general population who typically meet diagnostic criteria for ADHD as defined by DSM-IV. The prevalence rate cited for ADHD in DSM-IV-TR is 3 to 7 percent of school-aged children. But this estimate has not been well documented in epidemiological studies. In 2001, Andrew Rowland and colleagues reported an epidemiological study that used parent and teacher reports about a population-based sample of children in North Carolina. This study found that 16 percent of the children in their sample were significantly impaired by ADHD symptoms, an incidence rate much higher than the...

Future Directions In Genetic Studies Of Adhd 61 Endophenotypes for ADHD

Evidence is emerging in support of endophenotypes or ADHD subtypes in which genes may exert a larger effect than in the categorical diagnosis. Recent studies have examined whether specific genetic risk factors for ADHD correlate with measures of hyperactivity in population samples. Their hypothesis is that if ADHD were a continuous trait, investigation of association between genes (quantitative trait loci QTL ) and continuous measures of the phenotype would be a more appropriate strategy in the identification of susceptibility variants. To date, there have been few QTL association studies in ADHD and findings have been mixed. In an epidemiological sample, Curran et al. (117) selected children on the basis of high and low scores on the five ADHD items of the Strengths and Difficulties Questionnaire and found a significant relationship between the DRD4 7-repeat allele and high-scoring children. However, Mill et al. (118) did not replicate this finding. Similarly, Todd et al. (119)...

Behavior Problems Are Not Necessarily a Part of ADHD

Some researchers continue to claim that the primary problems in ADHD are impairments in the control of behavior. In 1997 Russell Barkley introduced a new theory of ADHD that in many ways is similar to my model of ADD syndrome. He noted that problems in ADHD lie not simply in the individual's ability to pay attention or in excessive hyperactivity, but rather in the executive functions of the brain. Functions included in his model of executive functions are virtually identical to those in the model of execu Yet Barkley's model differs from my model in two important ways. First, Barkley claims that his model applies only to the combined type of ADHD, not to the predominantly inattentive subtype. He has argued that the predominantly inattentive subtype of ADHD may be a disorder entirely distinct from the combined type of ADHD (Barkley 1997 Barkley 2001b). In contrast, my model of ADD syndrome is intended to describe all subtypes of ADHD, not just the combined or predominantly inattentive....

Conflicting Findings In Genetic Studies Of Adhd

Despite compelling evidence for a genetic basis to ADHD and findings of association replicated across several studies, the findings in ADHD are, to date, not definitive. If, as hypothesized, ADHD is a complex genetic disorder, with many susceptibility genes each of small effect (114-116), the pattern of results seen to date is to be expected. Other factors that might account for conflicting results include power limitations secondary to small sample size, differences between the populations of origin of the samples, differences in measuring and defining the phenotype, and clinical heterogeneity with different distributions of the subtypes between samples.

Behavioral Treatments for ADHD

Although there is a vast body of evidence that certain medications alleviate many symptoms of ADHD, medicine alone is not sufficient treatment for some with ADHD, especially those children and adolescents whose behavior is seriously disruptive in school, with peers, and or at home with their families. Many of these children need systematic help to develop more adaptive patterns of behavior. Also, current medications are not effective for all individuals with ADHD as mentioned earlier, 20 to 30 percent of all patients diagnosed have no significant response to medication. In these situations, behavioral treatments may be helpful. Children and adolescents with disruptive behavioral problems are the ones who primarily benefit from behavioral treatments, which are of limited use for improving cognitive functions such as working memory, processing speed, and sustaining alertness. Behavioral strategies may also help to reduce the common tendency of parents, teachers, and others unwittingly...

Many with ADHD Are Not Hyper

For decades the primary marker used to identify individuals with ADHD impairments was hyperactivity. Children who were very obviously hyperactive were considered candidates for evaluation for ADHD, especially if they were being disruptive or making trouble for their teachers. ADHD diagnosis was not even considered for those who were not hyperactive and not disruptive in school. An elementary-school janitor described this as he came seeking evaluation for his ten-year-old daughter Many clinicians and educators still identify ADHD as the janitor described. As a result, many with ADHD, especially girls, are overlooked. Joseph Biederman (2002) studied the role of gender in diagnosis of ADHD. He found that although girls and boys with ADHD have similar patterns of severity with the problem, ten boys are referred to clinics for treatment of ADHD for every one girl referred. Community samples show a different gender ratio three boys have ADHD for every one girl who has the disorder. In...

ADHD Symptoms Are Not Always Obvious during Childhood

The criteria set out in DSM-IV stipulate that at least some of the impairing ADHD symptoms must have been present before age seven. But this requirement has no basis in empirical research it was arbitrarily stipulated by the committee that wrote the diagnostic criteria for DSM-IV. Presumably the rationale was to establish that ADHD does not appear de novo later in life. Such a view makes no sense when ADHD is seen as a developmental impairment of executive functions, an impairment that in some persons may not become apparent until such functions are challenged by the demands of elementary or secondary school, or perhaps even later, when the individual experiences the trials of adulthood. Russell Barkley and Joseph Biederman published an article in 1997 cautioning clinicians to avoid use of the age seven cutoff as a requirement for diagnosis of ADHD. They emphasized the lack of research to support it and argued that this age of onset requirement deserves to be abandoned or very...

Are the Symptoms Truly Caused by ADHD

In other situations, there may be little question about the presence of the symptoms, but considerable uncertainty about their causes. The parents, child, and the child's teachers may all agree that the child has some symptoms of ADHD, yet factors other than ADHD are likely to blame. For example, the family may be suffering from severe financial hardship with both parents unemployed. One parent may be seriously addicted to alcohol, causing disruption or abuse at home. An older sibling may be severely defiant toward the parents and intimidating to the patient. A beloved grandparent may be dying of cancer. Or a child's favorite teacher Such stressors, especially when more than one is present, may be the primary cause of the child's apparent ADHD impairments, or they may simply be exacerbating ADHD impairments that have been present since birth. The incidence of unemployment, marital conflict, substance abuse, and frequent changes of residence is elevated among individuals with ADHD. The...

Evidence For Monoaminergic Contribution To Adhdgenetic Studies

Ten years after Hechtman's review (76), studies are only starting to get under way to test her argument that genetic influences on NE will inform on ADHD. Genetic studies of features important to NE transmission and relevant to the ADHD condition have been few. They have concentrated on the a-2a site for which NE has high affinity (where increased binding has been related to stress and frontal lobe cognition 77,78 ) and the reuptake site, which if blocked (like the a-2a site) will lead to a decrease of neuronal firing (79). Metabolic enzymes (DBH, Catechol-0-methyl transferase COMT , and MAO Fig. 1) have also received some attention. MAO activity, relevant for the breakdown of all the monoamines, has been inversely related to the expression of personality features thought to be relevant for groups or subgroups of ADHD subjects (e.g., impulsiveness, aggression, and sensation-seeking see discussion in 80). A study using a so-called line-item approach to the a-2a receptor (approximately...

Adults with ADHD May Have Fewer Symptoms

According to the DSM-IV, a diagnosis of ADHD should be made only if an individual has at least six of the nine inattention symptoms or at least six of the nine symptoms of hyperactivity impulsivity. And it is true that this disorder involves concurrent impairments in a wide variety of functions it is a syndrome. But there is a big problem in this symptom count system when older adolescents or adults are being evaluated. The DSM-IV diagnostic criteria for ADHD are based on research data that included only children four to seventeen years old. Kevin Murphy and Russell Barkley (1996) did a study to see how many adults in a community sample met DSM-IV diagnostic criteria for ADHD. They reported that although the six of nine symptoms rule from DSM-IV picks up the most severely impaired 7 percent of children with ADHD impairments, when used for diagnosis of adults, this rule picks up only the most impaired 1 percent of adults who should be eligible for diagnosis. Murphy and Barkley found...

Strategies for Parenting Adolescents with ADHD

Arthur Robin (1998) has written guiding principles for parenting adolescents with ADHD and has provided explanations and multiple examples of how these can be implemented Other books that may be helpful to parents of adolescents with ADHD include Marlene Snyder's 2001 book on problematic issues that often arise as adolescents with ADHD begin driving motor vehicles and Chris Dendy's practical guidebooks on parenting adolescents with ADHD (1995) and teaching adolescents with ADHD (2000).

Evidence For Monoamine Contributions To Adhdne And 5ht Activity

Does the metabolism of NE and 5-HT differ between children with ADHD and those without a psychiatric or medical diagnosis The question is based on the following assumptions 2. Transmitter metabolism underlies the expression of the behavioral and cognitive measures typical of ADHD. Analyses of CSF, blood compartments, and urine (Table 1) indicate that in the ADHD condition MHPG levels (NE metabolite) are usually lower than normal less clearly, NE levels may be increased. Overall this suggests a decreased turnover. There is a hint that other catabolic pathways may be differentially affected (NMN levels). The severity of the core symptoms do not influence the results (161,162). But, over the 4-5 yr from pre- to post-puberty when a number of symptoms regress, MHPG levels have been noted to increase or normalize (163). Further, some studies that deliberately contrasted subgroups find that several comorbidities (independent of their nature) appear to counteract the metabolic decrease e.g.,...

Parental Polarization in Raising Children with ADHD

When parents chronically disagree about how to deal with a problematic child, the entire family, even extended family members such as grandparents, may become involved in complex alliances. One parent may take on the role of defender of the ADHD child, spending a lot of time talking sympathetically with and about that child, often making excuses for wrongdoing or failures. The defending parent may even conspire with the ADHD child to keep secret from the other parent negative reports from the school or complaints from other siblings. Meanwhile, the other parent may become so consumed with frustration and anger that he or she gives up trying interact with the spouse or the ADHD child, aligning instead with another son or daughter. Such alliances may be skewed by a parent's earlier life experiences with their own siblings, or by unrecognized wishes to be more firm or sympathetic, or less uptight or intrusive, than their own parents seemed to be. Not every family that has a member with...

Biological Studies And Theories Of Addadhd 91 Quay and Gray

Quay (92) speculates that ADHD, CD, and anxiety withdrawal (AW) disorder can be differentiated in terms of Gray's (124) theory of two important control systems a behavioral inhibition system (BIS) and a behavioral reward system (REW). In Gray's theory, increases in responding brought about by positive reinforcement (hope) and by both active avoidance and escape paradigms (reward is escape from punishment, or relief) are under the control Stimulant drugs enhance the activity of both REW and BIS. Quay speculates that there is a relatively greater enhancement of BIS than of REW in ADHD children given stimulant medication, thus bringing the two systems into balance. He concludes that ADHD children have a deficiency in the BIS system, noting that antianxiety medications tend to affect them adversely. Again and again, deficiencies in inhibition are emphasized, beginning with the early papers of Luria (7). Because amphetamine improves passive avoidance but does not improve CD, and because...

Neurobiological Theories Of Adhd

The overall pattern of neuropsychological, neuroimaging, and neurotransmitter-related findings in ADHD is consistent with the hypothesis that ADHD is associated with dysfunction in the frontosubcortical pathways mediated by catecholamine neurotransmission, which control attention and motor behavior. Dopaminergic, serotonergic, and noradrenergic systems have come under close scrutiny and each has contributed candidate genes for genetic analysis. 3.1. Dopaminergic Theories of ADHD Evidence to support dopaminergic dysfunction in ADHD derives from the neuropharma-cology of stimulant medication, the behavior and biochemistry of animal models, and neu-roimaging studies. The mainstay of treatment for ADHD is methylphenidate and other psychostimulant medications (dextroamphetamine, pemoline), which are known to inhibit the dopamine transporter (13), thus increasing the availability of dopamine in the synaptic cleft. Knowledge of the mechanism of action for methylphenidate and its possible...

Very Intelligent People with ADHD Are Often Overlooked

Sometimes persons with a higher overall IQ who suffer from ADHD are at greater risk of having their impairments overlooked. At Yale, Donald Quinlan and I studied adults who sought evaluation for chronic atten-tional problems, all of whom had a tested IQ in the superior range in terms of intelligence, they were in the top 1 to 9 percent of the general population. Despite their very high IQ scores, 42 percent of these men and women had dropped out of their postsecondary schooling at least once, not because they were not smart enough to understand the work, but because they were not able to organize, focus, and sustain their efforts to deal with academic requirements. Some eventually returned to complete their education and achieved success in business or professions others experienced continuing frustration and failure. Even today many educators and clinicians do not realize that those executive functions crucial to effective performance as a student can be severely impaired even in...

Nonstimulant Medications for ADHD

Although stimulant medications are effective in alleviating ADHD symptoms in most children, adolescents, and adults who suffer from the disorder, about 20 to 30 percent do not respond well to stimulants. For these individuals, nonstimulant medications may be effective. Even among those who do experience significant relief from their symptoms when taking stimulants, there are many who experience significant difficulties with mood, anxiety, tics, or other problems that may be exacerbated, or at least not helped much, by stimulants. For these individuals, too, treatment with nonstimulant medications may be preferable. This chapter does not provide an exhaustive review of all nonstimulant medications used for treatments of ADHD only those prescribed most often are listed here. At present only one nonstimulant medication, Atomoxetine (ATX), has been approved by the FDA specifically for treatment of ADHD. (Nonstimulant medications approved for other uses are often used for ADHD treat ment...

Tailoring Treatments for Individuals and Families with ADHD

Some clinicians claim that every patient with ADHD should receive multimodal treatment. This fancy phrase simply means that medication alone is often not enough to fully treat ADHD. Typically, behavioral treatments and education are added to the list of treatment modalities that should be provided for every patient. But although it is true that educating the patient and family about the nature of ADHD and its treatment is an essential component of any adequate treatment plan, it is not true that every patient diagnosed with ADHD needs or will benefit from behavioral treatments, psychotherapy, cognitive behavioral treatment, or accommodations in school or the workplace. In particular, behavioral treatments may be quite helpful for some children with ADHD, particularly those with significant behavioral problems they are less likely to be appropriate or useful for adolescents or adults with ADHD. And cognitive behavioral treatment or counseling might be beneficial for some persons with...

More Moderate Criticisms about ADHD

A somewhat less ideological criticism of the ADHD diagnosis and its treatment has occurred in some media, including a variety of books like Thomas Armstrong's The Myth of the ADD Child (1995). Armstrong ar As alternatives to medication for ADHD, Armstrong advises that parents provide a balanced breakfast, find out what interests your child, enroll your child in a martial arts program, use background music to focus and calm, provide a variety of stimulating learning activities, provide positive role models, and employ a variety of other strategies to give the child more attention, flexible but supportive structure, and positively toned discipline. Most of the strategies recommended by Armstrong would be helpful for any child, including those with ADD syndrome, but in themselves they are not likely to alleviate the persisting problems of those children whose impairments are sufficient to warrant the diagnosis of ADHD. Arguments from critics like Armstrong and others such as Lawrence...

Radical Attacks against ADHD

The most aggressive attacks against recognition of ADHD as a legitimate disorder have come from groups such as the Citizens Commission on Human Rights (CCHR), which advocates against using psychiatric or psy-chotropic medicines in any situation. This well-funded group and certain individuals associated with it have circulated allegations that ADHD is a fictitious disorder. One of their publications, Psychiatry Betraying Families The Hoax of ADD ADHD and Other Learning Disabilities, argues, These are made up disorders along with others including severe emotional disorder . . . and dyslexia. ADHD is a total, 100 fraud. Some individuals espousing such views have even persuaded legislators in a few states to pass laws impeding access to such medications or forbidding school staff from talking with parents about ADHD. Radical advocates for this viewpoint have also organized letter-writing or media campaigns to challenge school boards or to attack the credibility of physicians,...

Genetic Epidemiology Of Adhd

Evidence reviewed in the preceeding chapter suggests that ADHD is a heterogeneous condition that has many causes, and is considered as a final common pathway for a variety of complex brain developmental processes (1). The exact etiology of ADHD is unknown, but a substantial genetic element has been implicated from family, twin, and adoption studies. 2.1. Family Studies in ADHD Family studies investigate the degree of familial clustering of a disorder. Thapar and Scourfield (2) summarize family, twin, and adoption studies in ADHD. Family studies have shown an increased risk of ADHD in the families of children with ADHD (whether defined using the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition (DSM-III) or DSM-III-R diagnostic criteria) with reported relative risks (A) of between 4 and 5.4 for first-degree relatives (3,4). 2.2. Twin Studies in ADHD From Attention Deficit Hyperactivity Disorder From Genes to Patients Edited by D. Gozal and D. L. Molfese Humana Press...

ADHD Rating Scales

Regardless of the age of the patient being evaluated, detailed ADHD symptom rating scales should be used. These scales are typically listings of cognitive, emotional, and behavioral problems often experienced by individuals with ADHD. Standardized scales have been administered to selected samples of individuals within a particular age group who have been carefully diagnosed with ADHD and to a sample of individuals matched for age and socioeconomic variables who are in the general population, not identified as having ADHD. Scores of a person being evaluated can then be compared with those in the general population to ascertain whether the levels of impairment are consistent with an ADHD diagnosis. Keith Conners (1997), Conners and colleagues (1999) and I (1996c, 2001c) have published ADHD rating scales standardized for all ages from early childhood to adulthood. The Conners' Rating Scales-Revised (long form) and the Brown ADD Scales both include multiple items that assess symptoms of...

Etiology Possible Causes And Modifiers

Some of the presumed causes of ADHD are no longer discussed, and the remaining chapters of the book will bring the readers up to date on important new developments. Conclusions from myriad studies suggest the following 3. Sugars desserts, and candy bars appear to have little or no effect in exaggerating ADHD symptoms (177,200,201). 5. Parental conflict, common in families with ADHD children does not cause ADHD but can certainly exaggerate the severity of symptoms (204-213). 6. Genetic factors appear to be more important than all others as a cause of both ADHD and LD. Of the many studies in this area, among the best are those by John DeFries, Bruce Pennington, and colleagues at the University of Colorado and those of Jim Stevenson and associates in England. Gillis et al. (214) used a sophisticated regression model developed by DeFries and Fulker (215,216) to estimate the heritability of ADHD. Subjects were 37 pairs of monozygotic (MZ) and 37 pairs of dizygotic (DZ) twins. At least one...

Research Diagnostic Criteria

Swanson et al. (112) add further restrictions to the definition, increasing the homogeneity of children satisfying the aforementioned restrictive criteria. It is important to remember that this is for the stated purpose of obtaining a homogenous group of ADD ADHD subjects. These are as follows 1) If the ADD ADHD symptoms have an early onset and are expressed (perhaps in different but age expected forms) across developmental periods before another disorder is manifested, we recommend that the ADHD symptoms be considered primary. 2) If the symptoms of the other disorder appear first, or if the presence of ADD ADHD symptoms varies with the waxing and waning of the other disorder or specified environmental conditions, we recommend that the ADD ADHD symptoms be considered secondary. 3) We propose that a diagnosis of ADD ADHD be made only on the basis of primary symptoms. Swanson et al. were concerned, as we have been, with the overlap of ADHD and LD. The California studies (191) indicate...

Ascending Dsms And Related Research On Diagnosis

ADD in various versions of the American Psychiatric Association diagnostic manuals (16,17,25,176) has gradually changed. In DSM-II, the hyperkinetic definition was restricted to youths with maladaptive levels of inattention, impulsiveness (IMP), and motor restlessness. DSM-III took a categorical approach with diagnosis based on the number of items entered on three separate lists of items, measuring inattention, IMP, and motoric activity. DSM-III was much more specific than DSM-II in definitions of ADD, and placed a greater emphasis on inattention and IMP than on HYP. It also described a subtype referred to as ADD WO (inattention without hyperactivity). DSM-III-R took a dimensional approach in which 8 of 14 symptoms had to be present (some of the items were composites of inattention and hyperactivity). DSM-III-R did not include items enabling one to make a reliable diagnosis of the inattentive, non-HY child, and this manual substituted ADHD for the ADD of earlier versions. To date, the...

Interactions Between Monoamines

Many of the central effects of 5-HT arise via modulation of activity in DA paths. Often the levels of DA and 5-HT metabolites in samples of cerebrospinal fluid (CSF) drawn from healthy subjects are highly intercorrelated (29). Indeed, in ADHD children high levels of 5-HIAA and HVA decreased together in those reponding to psychostimulant treatment (30). Thus it is not surprising to learn that increases of amphetamine-induced locomotion (31) and the associated induced release of DA (32) are modulated by 5-HT at 5-HT2a receptors both effects are suppressed by 5-HT2a antagonists. Other ADHD-like features modeled in animals show DA 5-HT interactions. Shifts of attention and stimulus-reward learning, facilitated by methylphenidate, are impaired by reduced 5-HT synthesis (33). A separate psychostimulant action on reinforcement the amphetamine-induced enhancement of response for conditioned reward is suppressed by 5-HT stimulation (at mesolimbic 5-HT1b sites 34). Reverse influences of DA on...

Nucleus Accumbens Shell

In support of a deficit in the nucleus accumbens shell, giving rise to ADHD behavior in SHRs, Papa et al. (26,27) found decreased calcium calmodulin-dependent protein kinase II and reduced c-Fos expression only in the nucleus accumbens shell of SHRs and not the core subdivision when compared to WKYs. The mesolimbic dopamine projection to the shell subdivision of the nucleus accumbens is responsible for motivation it determines the amount of effort an animal is prepared to exert in order to achieve a reward. Hypofunction of the mesolimbic dopamine system will impair the function of the mesocortical and nigrostriatal dopamine systems, by influencing dopamine release and the cortico-striato-thalamo-cortical circuits that dopamine modulates. This could impair learning and expression of goal-directed behavior, thereby contributing to the ADHD symptoms displayed by SHRs.

Second Messenger Systems

The hyperactivity observed in ADHD children has been suggested to be because of increased cAMP levels in the prefrontal cortex and striatum (60). Increased expression of Gia genes has been demonstrated in very young SHRs at 2 wk of age (8). Inactivation of Gia proteins by intraperitoneal injection of pertussis toxin into 2-wk-old SHRs delayed the development of hypertension (61). These results suggest that the increased expression of genes for Gi proteins, with a consequent decrease in cAMP levels and impaired regulation of cellular function, precedes the elevation of blood pressure and may contribute to the development of hypertension and ADHD symptoms in SHRs. If striatal Gia proteins are also increased, then activation of D2 receptors may give rise to enhanced D2 receptor-mediated inhibition of dopamine release from SHR nucleus accumbens and caudate-putamen slices (20-22).

Glutamatergic Systems

The tonic dopamine concentration in the extracellular fluid appears to be regulated by glutamate, which is present in micromolar concentrations in the extracellular space outside the synaptic cleft (46-50). Glutamate inhibits dopamine release by activation of group II metabotropic receptors (mGluR2 3) and stimulates dopamine release by activation of group I receptors (mGluR5) on dopamine terminals in rat striatum (46,51). Dopamine release is also increased by activation of AMPA receptors in rat striatum and stimulation of ventral tegmental dopamine neurons (52-56). As suggested by Seeman and Madras (57), the common defect in ADHD could be decreased extracellular dopamine levels. This deficiency could result from increased expression of DAT, impaired dopamine synthesis or release, or any other cause, including the possibility that regulation of extracellular dopamine by glutamate afferents

Ventral Tegmental Area Dopamine Neurons

Glutamate plays an important role in stimulating catecholamine release at the somatic level. Disturbances at the level of the dopamine cell body may occur at a very early stage of development, giving rise to subsequent impaired dopamine neuron function in terminal areas such as the nucleus accumbens. The development of ADHD symptoms could be analogous to the process of drug addiction. Children who have been exposed prenatally to drugs of abuse exhibit ADHD-like behavior (66). Exposure to drugs of abuse increases the extracellular dopamine concentration, which activates D1- and D2-like receptors in the ventral tegmental area of the midbrain, which in turn increases glutamate-driven activity in dopamine-containing neurons (67). The mechanism is suggested to involve increased AMPA receptor-mediated excitatory transmission in ventral tegmental area dopamine neurons (67,68). Increased activation by glutamate initially causes sensitization of ventral tegmental dopamine neurons with...

Important Early Work Of Others

In 1981, Barkley and others began to question the concept of attention deficit as the defining characteristic for ADD ADHD (73-75). It was recognized that children in many psychiatric diagnostic categories were overactive and inattentive, and it was noted that the excessive activity and inattention of the children who were labeled ADD tended to be situational in nature and did not occur in all conditions (11,76). This, of course, was what we were struggling with in our paper on intention. As more rigorous and technical studies of attention in ADHD children appeared in the 1980s, an increasing number failed to find evidence of problems with sustained attention under some experimental conditions while observing them under others (62,74,75,84-87). These findings, coupled with the realization that both instructional and motivational factors played a strong role in determining the presence of ADHD symptoms, led some investigators to hypothesize that motivation may be a better model for...

Dopamine Hypofunction Hypothesis

Because the most effective treatment of ADHD involves the use of psychostimulant drugs, such as methylphenidate and d-amphetamine, which inhibit the dopamine transporter (DAT) and thereby increase the extracellular concentration of dopamine, ADHD symptoms have been suggested to result from hypoactivity of dopamine systems in the brain (13). Results obtained with SHRs support this hypothesis. Low doses of d-amphetamine and methylphenidate reduced the hyperactivity of SHR and a stroke-prone substrain of SHRs (14,15). In fixed-interval schedules of reinforcement of bar-presses by water, the psychomotor stimulants were shown to weaken control by immediate reinforcers and strengthen control by delayed reinforcers, thereby improving sustained attention (4). Impaired function of the mesolimbic dopamine system was suggested to produce a shorter and steeper delay gradient in both SHRs and children with ADHD, giving rise to hyperactivity, motor impulsivity, and impaired sustained attention...

The Mbd And Early Add Period

Greatly influenced by a number of writers the pioneering work of Strauss and Lehtinen (27), who enumerated the characteristics of children with known brain damage the study of Bradley (28) showing that Benzedrine reduced hyperactivity the published work on perinatal risk factors (e.g., bleeding in pregnancy, low birth weight) in causing behavior and learning problems and a variety of other papers suggesting that neurological impairment results in behavioral and emotional symptomatology (6,29-34). The MBD term as used by Clements and Peters designated children who were HY, LD, or both. It included one or more of the following signs specific learning deficits, perceptual-motor deficits, general coordination deficits, hyperkinesis (extreme overactivity), impulsivity, emotional lability, short attention span and or distractibility, equivocal neurological signs, and borderline abnormal or abnormal electroencephalogram (EEG). Clements and Peters gave a description of MBD that could be used...

Dopamine Functions

DA is a slow-acting neurotransmitter utilized in the mammalian central nervous system. DA functions include regulation of blood pressure, movements, goal-directed behavior, cognition, attention, and reward. Dysregulation of DA systems has been associated to several neuropsy-chiatric disorders such as Parkinson's disease (PD), which is caused by a selective degeneration of mesostriatal (MS) DA neurons, and schizophrenia and ADHD, which are both associated with a dysfunction of mesocorticolimbic (MCL) neurons. In fact, most antipsychotic drugs used in schizophrenia act as DA receptor (DAR) antagonists, whereas ADHD symptoms are generally alleviated by drugs that regulate Dopaminergic (DAergic) transmission. From Attention Deficit Hyperactivity Disorder From Genes to Patients Edited by D. Gozal and D. L. Molfese Humana Press Inc., Totowa, NJ

Epidemiology

In the introduction to their book, Shaywitz and Shaywitz (193) say that ADD is now recognized as the most common neurobehavioral disorder of children. It affects children from earliest infancy through school and into adult life. According to this article, estimates for ADD with or without HYP range from 10 to 20 (194). DSM-IV estimates the prevalence of ADHD to be much lower (3-5 in school-age children). Shekim et al. (195) report that symptoms of ADD ADHD persist into adulthood in one-third to one half of subjects who receive this diagnosis in childhood, and that the overwhelming majority of adult subjects have other co-occurring diagnoses. A problem that Barkley (184) pointed out in discussing the limitations of DSM-IV was that of diagnosing ADD ADHD reliably in the preschool years. However, Palfrey et al. (196) had earlier evaluated children at eight checkpoints between birth and age four, and the writers report that 13 of the children met criteria for possible ADD ADHD at one or...

Conclusion

In conclusion, SHR provide a good model for ADHD symptoms. Disturbances that have been identified in the central nervous system of SHR have provided insight into the possible neurogenesis of the behavioral disturbances of ADHD. Evidence suggests that the most frequently prescribed psychostimulants, D-amphetamine and methylphenidate, alleviate ADHD symptoms by blocking dopamine reuptake, which increases dopamine availability at postsy-naptic and extrasynaptic receptors not only following impulse-triggered release of dopamine from mesolimbic, mesocortical, and nigrostriatal dopamine nerve terminals, but also following glutamate-stimulated release of dopamine from mesolimbic terminals in the nucleus accumbens shell. The nucleus accumbens shell plays an important role in the integration of afferent signals from limbic areas of the brain, particularly the amygdala, hippocampal formation, prefrontal cortex, and cingulate cortex. Transmission of these signals to motor areas of the brain is...

Dopamine Transporter

The dopamine transporter (DAT) is a membrane transporter that clears DA from the synaptic cleft. This is also the main mechanism for clearance of released DA (50,51). DAT represents the major target for amphetamine and methylphenidate, the main pharmacological treatments for ADHD (52). DAT is expressed on presynaptic DA terminals, and can be used as specific marker for DA fibers. An association between ADHD and polymorphisms in the DAT gene has been reported (53-55). The DAT KO displays hyperactivity (56), which is likely to be owing to higher levels of brain DA, because of the absence of the clearance of DA from the synaptic cleft. Moreover, DAT KO mice reduce hyperactivity after treatment with psychostimulants, although they lack the DAergic target of psychostimulants. This suggest that psychostimulants, such as methylphenidate, could improve ADHD symptoms acting on non-DA sites, such as the serotonin (5 HT) system. It is still highly controversial whether ADHD is characterized by a...

General Issues

Early proposals that NE could have a causal role in ADHD, and hyperkinetic behavior in particular (228), were based on the effect of amphetamine to reduce NE activity during arousal. Now there is a widespread belief that children with ADHD are under- rather than overaroused, yet there is an increasing consensus that NE function has something to do with the symptoms (205). Evidence in this chapter shows that NE activity undoubtedly modulates attentional mechanisms both directly (tuning signal-to-noise ratios) and indirectly (via the control of mesocorticolimbic DA release). NE may influence other relevant behaviors depending on their dependence on cognitive mechanisms (e.g., environmental stimulation facilitating hyperkinesis) and the nature of the mechanisms underlying comorbid conditions. Crucial mechanisms include the control of catecholamine availability in the cortex (via the transporter) and phasic firing modes in the LC. Both of these should be targets for treatment. Common to a...

Animal Models

The strength of the lesion model lies in the reliable stimulation of increased locomotion. However there is an overriding weakness. Although the lesion renders the system hypofunc-tional in one sense, DA receptors become supersensitive to DA stimulation to produce the activity. This form of DA hyperactivity is not the basis for motor hyperactivity in ADHD subjects where there is much evidence for a (relatively) hypo-DA function. Nonetheless, as both psychostimulants and agents acting on other monoaminergic systems can calm ADHD patients (see Section 10), it is important that not only methylphenidate antagonizes hyperlocomotion in lesioned rats, but antagonists of 5-HT and NETs also reduce the locomotion elicited from lesioned rats (110). Indeed, the 5-HT modulation is not limited to the transporter and DA D2 mechanisms. 5-HT2 antagonists (e.g., ritanserin) also prevent D1 stimulation of hyperlocomotion arising from a lesion-induced supersensitive neostriatum (111). Clearly this most...

Dopaminergic Systems

Changes that have been identified in the central nervous system of SHRs have provided insight into possible neural disturbances of ADHD. In vitro stimulation-evoked release (electrical and or exposure to high K+ concentration) of dopamine from terminals of mesocortical, mesolimbic, and nigrostriatal dopamine neurons of SHR is significantly less than WKY (16-22). Dopamine D2 receptor-mediated inhibition of dopamine release was greater in SHR caudate-putamen and nucleus accumbens than WKY, whereas dopamine D2 receptor function was unchanged in the prefrontal cortex of SHR (19,20). Increased efficacy of endogenous dopamine activation of D2 autoreceptors was suggested to account for the decreased release of dopamine in SHR striatum (19,20). This downregulation of dopamine transmission was suggested to have occurred as a compensatory reaction to abnormally elevated dopamine levels at an early stage of development, perhaps as a result of exposure to stress or a genetic defect (19)....

Methods

Invasive methods for measuring transmitter activity in the CNS in vivo are available in animals (e.g., dialysis probes, electrochemistry) and adult humans (e.g., position emission tomography studies of ligand binding) but are not justified from an ethical standpoint in children. Measures must be conducted peripherally. There are three possible points of access along the route of elimination of excess monoamines and their metabolic products. These are the CSF, blood (including plasma and platelets), and urine. Opinions differ widely on the extent to which these peripheral measures can reflect CNS function. Somatic sources of 5-HT are particularly high. As there is no reason to suspect that in otherwise somatically healthy ADHD children central systems are differentially impaired with respect to peripheral systems, crude indicators may be sought in the comparison of baseline measures between groups. The effects of challenges with monoaminergic drugs or environmental conditions on...

Da Receptors

D4R distribution differs markedly from that of D2 and D3. It appears to have a high affinity for clozapine, which has made its study exciting from the clinical point of view, because of clinical applications of clozapine in schizophrenic patients. The D4R has polymorphic forms in the human population, with certain polymorphisms being more represented in ADHD patients. It is interesting to note that although D1Rs, D2Rs and D3Rs have been described in the rat cerebellum, no DA fibers have been detected in the same region (although a DA projection to the cerebellum has been suggested in humans). However, the cerebellum receives an important norepinephrine innervation (similarly to the cerebral cortex, see Subheading 7.1.1.). Moreover, alterations in cerebellar development have been suggested in ADHD children (65). The DA D4R has recently received much attention because of reports that specific tandem repeat polymorphisms of the human D4R gene correlate with higher than average...

Biochemistry

From Attention Deficit Hyperactivity Disorder From Genes to Patients Edited by D. Gozal and D. L. Molfese Humana Press Inc., Totowa, NJ For NE synthesis, phenylalanine is hydroxylated to tyrosine prior to the rate-limiting hydroxylation to L-3, 4-dehydroxy-phenylalanine (Fig. 1). Decarboxylation then produces DA, which can be dehydroxylated to NE. Many studies examining the effects of enhancing or depleting NE make use of the crucial role of tyrosine hydroxylase (TOH) and dopamine -hydroxylase (DBH). Studies of 5-HT depletion often use diets free of tryptophan for examining the effect of reducing 5-HT activity. Thus it is not surprising that dietary effects on the availablity of factors needed for transmitter synthesis have been part of the agenda in some ADHD studies.

Fact Add looks very much like a willpower problem but it isnt Its essentially a chemical problem in the management

Most individuals who suffer chronically from an impaired ability to pay attention are able to focus their attention very well on activities that interest them. So why can't they pay attention during other activities that they recognize as important To answer this riddle, we have to look more carefully at the many aspects of attention, recognizing that processes of attention in the human brain are more complex and subtle than we might have imagined. One way to understand the complexity of attention is to listen carefully to patients with ADHD as they describe their struggles with inattention. Meet a patient of mine, a teenaged hockey player whom I'll call Larry

ADD Syndrome and Impaired Executive Functions

For decades the syndrome now known as ADHD was seen simply as a childhood behavior disorder characterized by chronic restlessness, excessive impulsivity, and an inability to sit still. Late in the 1970s it was recognized that these hyperactive children also had significant and chronic problems paying attention to tasks or listening to their teachers. This discovery paved the way for changing the name of the disorder in 1980 from hyperkinetic disorder to attention deficit disorder and to recognizing that some children suffer from chronic problems of inattention without any significant hyperactivity. That change from an exclusive focus on hyper-activity and impulsive behavior to a primary focus on inattention as the principal problem of the disorder was the first major paradigm shift in understanding this syndrome. In recent years another major shift in understanding ADHD has been developing. Increasingly researchers are recognizing that the syndrome of ADHD symptoms overlaps with...

Clinical Features of Tourette Syndrome

Tourette syndrome (TS) is characterized by chronic waxing and waning motor and vocal tics and usually begins between the ages of twelve and fifteen years and affects boys more frequently than girls. About half of the patients start with simple motor tics such as frequent eye blinking, facial grimacing, head jerking, shoulder shrugging, or with simple vocal tics such as throat clearing, sniffing, grunting, snorting, hissing, barking, and other noises. Most patients then develop more complex tics and mannerisms such as squatting, hopping, skipping, hand shaking, compulsive touching of things, people, or self, and other stereotypical movements. The tics may change from one form to another. Although described as a lifelong condition, up to one third of patients eventually achieve spontaneous remission during adulthood. Coprolalia, echolalia, and echopraxia are the most dramatic symptoms of TS, but are present in a minority of patients. In addition to the motor and vocal tics described...

Relevance Of The Chroniclowdose Mptp Monkey Model To Other Disorders

While the deficits in chronic-low-dose MPTP-treated monkeys described earlier in this chapter are strikingly similar in nature to those described in early Parkinson's disease patients, the frontal attentional executive function deficits observed in these animals have significant overlap with, and clinical relevance for, other disorders such as attention deficit hyperactivity disorder (ADHD) and schizophrenia in which frontostriatal dysfunction has been implicated. A number of similarities between the cognitive deficits of chronic-low-dose (CLD) MPTP-treated monkeys and children with attention deficit disorder have been noted and attributed to frontostriatal dysfunction secondary to deficits in dopamin-ergic and noradrenergic neurotransmission 40 . Recent studies of children and adolescents with attention deficit hyperactivity disorder (ADHD) indicate that, in addition to inattention and distractibility, a number of executive functioning deficits have also been documented 41-43 ....

Intermittent schedules of reinforcement

Attention deficit hyperactivity disorder (ADHD) was associated with increased response rates on FI performance in 7- to 12-year-old boys, as well as a bursting pattern of response produced by a run of closely spaced responses separated by a short pause 25 . This pattern was also observed in 3-year-old monkeys exposed to lead from birth (Figure 6.1) 18 . Children with ADHD also responded more in the extinction (TO) portion of the schedule, as did lead-exposed monkeys. FI performance predicted poorer performance on a test of impulsivity in normal children 26, 27 children with high response rates and shorter post-reinforcement pause times

Cluster 4 Managing Frustration and Modulating Emotions

The diagnostic criteria for attention-deficit hyperactivity disorder in the DSM-IV do not include any items referring to emotions. Yet many clinicians report that patients with ADHD struggle with managing their emotions. Paul Wender (1987, 1995) described how individuals with ADHD have affective lability and frequently demonstrate a bored or demoralized mood, irritable complaining, angry outbursts, or insufficiently controlled excitability. Wender also noted that individuals with ADHD appear to have a low tolerance for frustration and often find it difficult to persevere through the many stresses of daily life they readily experience feeling overwhelmed or stressed out. My own clinical research with children, adolescents, and adults has led to similar conclusions. ADD symptom rating scales I have developed from studying each of these age groups include a cluster of symptoms related to managing frustration and modulating emotions (Brown 1996a, 1996b, 1996c, 2001a, 2001b, 2001c). In...

Fact Add affects persons at all levels of intelligence And although everyone sometimes has symptoms of ADD only those

Most people who hear about the symptoms of ADD syndrome respond by commenting, Oh, I have those problems too. Doesn't everybody This reaction is understandable because symptoms in this syndrome occur from time to time in all children, adolescents, and adults, especially when they are overtired or stressed. The difference between persons legitimately diagnosed as having ADHD and those who do not warrant this diagnosis is essentially one of degree. How severely are these problems interfering with their lives And are they impaired just briefly once in a while or consistently over an extended time There is no single measure, no blood test or brain scan, no rating scale or computer task that can make or rule out an ADHD diagnosis. The most effective instrument for assessing ADHD is an intensive interview conducted by a clinician who understands what ADHD looks like, and who can differentiate ADHD from other disorders that may cause similar problems. In this chapter I explain some things I...

Thousands of Medication Studies

In the decades since stimulant medications were first introduced, several thousand scientific studies have assessed the effectiveness of these medications for alleviating ADHD symptoms. C. Keith Conners (2002) published a comprehensive review of research that covered hundreds of studies involving over ten thousand individuals. He reported that evidence from many hundreds of researchers, who assessed many thousands of children with ADHD in a wide range of diverse settings, powerfully demonstrates that stimulant medications significantly improve symptoms of ADHD for most of those who are treated.

Critical Questions of the Evaluation

Once all elements of the evaluation are completed, a process that usually requires at least two hours, sometimes considerably more, I weigh the available data and make a determination Does this patient meet the diagnostic criteria for ADHD I find the answer not by simply adding up scores on rating scales or counting symptoms that the patient or family say are present. To make an adequate diagnosis, I need to use informed judgment to answer two critical questions (1) Does this patient currently suffer from symptoms of ADHD in ways that impair his or her functioning in daily life to a degree that treatment may be warranted and (2) Are these symptoms substantially caused by developmental impairments of ADHD rather than by other circumstances or disorders for which ADHD treatment would be inappropriate

Symptoms of Depression or Anxiety

Some individuals well past childhood have repeatedly sought help for their difficulties from psychologists, psychiatrists, or other mental health professionals who did not recognize their ADHD impairments. In years past, and even today, many professionals in these fields have received no adequate professional training to help them understand and recognize impairments of ADHD. They are, however, usually trained to recognize depression, anxiety, and personality disorders. Consequently, many doctors are quick to identify symptoms of these more familiar disorders in individuals seeking help. They may also assume that conventional psychotherapy or antidepressant medications will alleviate ADD impairments. Unfortunately, these misguided therapies have caused a large number of older adolescents and adults with ADHD to struggle unsuccessfully, and often for many years, to overcome their ADHD symptoms. In 1992 John Ratey and others published a study that described sixty patients with ADHD who...

Substance Use Disorders

Among individuals diagnosed with ADHD, there is a markedly elevated incidence and severity of abuse and dependence on alcohol and other drugs over the lifetime. This difference does not become clear in group data until after mid-adolescence, however, when many of those with ADHD tend to become caught up in escalating problems with substance abuse. Joseph Biederman and Timothy Wilens (1997) published data comparing ADHD boys' and normal controls' use of drugs and alcohol at baseline and four years later. They found no difference between the ADHD adolescents and controls in rates of substance use disorders up to age fifteen years. Yet an earlier study of adults indicated that 52 percent of those diagnosed with ADHD had qualified for diagnosis of substance abuse or dependence at some point in their lives, while only half that percentage (27 percent) of adults without ADHD met the diagnostic criteria for substance use disorder. According to data presented by Wilens and others (1998, 2000)...

Websites with a National Focus

The following websites are sponsored by ADHD education and advocacy organizations in various countries. Some are much better established and provide much more reliable information than others. Many list addresses for local groups within their country. Usually the material is presented in the dominant language of the country listed. http www.adhd.dk Estonia http www.adhd-liitto.fi France http www.obis.is adhd Ireland http www.adhd.nl New Zealand http www.adhd.org.nz http www.adhd-foreningen.no Romania

Traumatic Brain Injury

Joan Gerring and colleagues (1998) studied boys and girls aged four to nineteen years diagnosed with severe to moderate closed head injuries (CHI). Most had been injured as pedestrians or as drivers or passengers in a motor vehicle many had been in a coma for about ten days. Gerring found that 20 percent of the children with CHI had ADHD prior to their head injury. This elevated incidence is consistent with the expectation that children with ADHD are more likely to behave in impulsive or careless ways that put them at risk of such injuries. During the year following their CHI, an additional 19 percent of children and adolescents in this sample developed sufficient ADHD symptoms to warrant diagnosis. This development suggests that impairments of ADHD may be acquired by certain kinds of physical damage to the brain. Similar results were obtained in studies by Jeffrey Max and others (1998).

Nontricyclic Antidepressants

The other nonstimulant medication recommended by the American Academy of Pediatrics (2001) as a second-line treatment for ADHD is bupro-prion (BUP). Marketed under the brand names Wellbutrin and Zyban, buproprion is classified as an antidepressant, but its chemical structure is quite different from that of most other medications in this class. BUP acts on the noradrenergic system and indirectly on the dopaminergic system. Controlled studies have found BUP to be effective for treating ADHD in children (two trials) and adults (two trials). One open-label study found BUP useful for treating patients with ADHD and comorbid bipolar disorder. Wilens and colleagues (2002) suggested that treatment with BUP for ADHD patients should be initiated at 37.5 mg and increased every three or four days up to a maximum of 300 mg daily in younger children and 450 mg daily in older children or adults. Adverse effects may include excessive activation, irritability, insomnia, and (rarely) seizures.

Educating the Patient

Once I have completed the clinical interview, scored the ADD rating scales, administered standardized measures, and screened for additional disorders, I ask the patient what information they have about ADHD. Some who come seeking evaluation for themselves or their children are very sophisticated in their understanding of ADHD. They have learned much about the diagnosis and treatment of this disorder from reading, taking courses, or talking with others who are well informed. Others come to the initial evaluation with very limited information about ADHD, and with many misconceptions. Once I ascertain what is already known, I try to provide information about ADHD at an appropriate level. I believe that teaching the patient and family about ADHD is a very important part of the initial evaluation. I provide a concise description of the primary symptoms of ADHD impairment using clear examples to illustrate each one. Usually I do this in a format something like the description of symptom...

Helpful Standardized Measures

Although self-reporting is a central component of evaluation for ADHD, and though there is no single test that is definitive for making an ADHD diagnosis, I have found that some standardized measures can provide useful information. One of these is a test of short-term auditory memory. Donald Quinlan and I (2003) reported a study in which we administered short-term verbal memory tests to adults diagnosed with ADHD by DSM-IV criteria. We used two stories, each twenty-five word units long, from the Wechsler Memory Scale. We found that 66 percent of the adults with ADHD in our sample had a large discrepancy (one standard deviation or more) between their verbal IQ and their story memory in the general public only 16 percent of adults show such a wide difference. Children with ADHD show a similar problem with listening and remembering. In 2001c I reported on use of a similar story-memory test administered to several age groups of children. Among those with ADHD, 57 to 73 percent showed...

Fears Due to Inadequate Understanding

Moreover, these mistaken assumptions are deeply entrenched in the public consciousness. Educating the public about ADHD is thus no simple matter. In explaining ADD to most people, we are trying to counter strongly held misunderstandings with more accurate, scientifically based information about the disorder and its treatment, but often people see no need for a different explanation. Many believe that they clearly understand this disorder when they truly do not. Yet helping people develop a scientifically accurate understanding of ADD syndrome is vitally important, because common misunderstandings of ADD syndrome perpetuate the suffering of children, adolescents, and adults afflicted with this disorder. Parents and professionals who believe ADHD is an insignificant and transient problem of childhood or just Unrealistic fears of the diagnosis and treatment are also a problem for many, and those who do not understand that ADHD is a complicated and significantly impairing problem are not...

Impairment by What Measure

One important factor in determining impairment is the basis for comparison. To whom should an individual be compared in order to make a diagnosis of ADHD The DSM-IV (2001) states that the ADHD symptoms must be maladaptive and inconsistent with developmental level (p. 92). For children, developmental level might be taken as referring simply to age groups. One could argue that a five-year-old is not impaired in her ability to pay attention if she can pay attention as well as most other five-year-olds. The DSM-IV does not, however, spell out the full range of meanings for developmental level, which could also be taken to refer to level of intelligence. At the lower boundary, this reinterpretation would mean that one would not make the diagnosis of ADHD for an eight-year-old developmentally disabled child with an IQ of 60 by comparing his ability to sustain attention with that of other eight-year-olds with normal IQ. This is generally accepted.

Behavioral Interventions at School

Behavioral strategies have also been developed to support and improve the functioning of children with ADHD and related problems in school. Details about approaches for schools are not reviewed in this book, but are readily available elsewhere. George DuPaul and Gary Stoner (2003), for example, have described in detail a variety of ways that children with ADHD can be supported in school. And Sandra Rief (2005) has written a book offering practical suggestions for teachers who want to adapt their classroom to maximize learning opportunities for their students with ADHD. Behavioral strategies need to be adapted carefully to each context and to the developmental level of each child. Some approaches that work well at school for many younger children with ADHD do not work as effectively for older children or adolescents, who usually interact with five to seven teachers daily. Getting accurate, up-to-date information about how an adolescent is performing in school whether their homework is...

Interviewing Adolescents and Adults

Sometimes clinicians become too cautious about making a diagnosis of ADHD in adults because the data are essentially self-reported. They feel that some hard evidence must be provided, such as old report cards with some teacher comments about learning or behavior problems, or direct testimony from a parent or childhood friend. They feel that self-reporting is too subjective. It is certainly possible for the self-report to be biased or deceptive, but most skilled clinicians are able to sort this out in a comprehensive clinical interview. Diagnostic decisions in many other fields of medicine are made based primarily on self-reporting. For example, there is no laboratory test or diagnostic instrument that can measure pain, so self-reported information about the location, intensity, and timing of pain may be crucial for diagnostic decision-making in medicine, especially when there are few other clues on which to base a diagnostic or treatment decision. Indeed, self-reported information...

Resolving Conflicting Views

Sometimes a teacher feels strongly that a child has ADHD impairments while neither parent sees such problems. Or parents may see ADHD impairments in their child's efforts to do homework, household routines, and social relationships while the child's teacher reports no evidence of any such difficulties at school. Studies comparing data from parents and teachers usually find low rates of agreement in their assessments of any given child. Victor Mota and Russell Schachar (2000) compared ADHD symptom ratings of children by their parents and teachers. Their methods allowed them to identify which of the DSM-IV symptoms of ADHD were most important to parents and which were most important to teachers when a child's performance was being assessed for evidence of ADHD. others. Using a sample of children ages seven to twelve referred for possible ADHD, they obtained ratings from parents and a teacher for each child. Using a sophisticated statistical analysis, they created a subset of symptoms...

Learning Memory Attention and Related Cognitive Disorders

There is a wide variety of cognitive conditions that deleteriously affect learning, memory, and attention but that do not involve other psychopathology. For example, Attentional Deficit Disorder with and without hyperactivity (ADHD and ADD), senile dementia, and Alzheimer's disease are familiar to the public. Each of these conditions can have profound negative effects on daily living and quality of life. Psychopharmacologic treatment for these conditions is an active, current topic of interest with modest success to date. For example, ADHD is treated with stimulants (including dextroamphetamine, methylphenidate Ritalin , and pemoline), antidepressants (including imipra-mine, desipramine, and nortriptyline), and clonidine. Memory deficit-related conditions are an area of great interest and experimental investigations are examining various medications, including drugs that act as do-paminergic agonists, a-2 adrenergic agonists, cholin-ergic agonists, general cerebral metabolic...

ADD Syndrome Impairs Written Expression

Skills of written expression, the ability to put thoughts into sentences and paragraphs that others will be able to read and understand, are also problematic for many children with ADHD. Written expression is a more demanding task than is talking, reading, or doing basic math computations. To write one's thoughts places much heavier demands on learned skills and executive functions. Virginia Berninger and Todd Richards (2002) described some of these demands Relatively few studies have assessed impairments of written expression in individuals with ADHD. Susan Mayes and colleagues (2000) studied children with ADHD in comparison to children who had other emotional or behavioral problems without ADHD all of these children were eight to sixteen years old and had been referred to a child psychiatric treatment clinic. Each child was given individually administered tests for IQ and academic achievement. Of the children with ADHD, 65 percent had a score for written expression that was...

How Much Do the Symptoms Interfere with Daily Life

To evaluate someone for ADHD, I need to gain a realistic appreciation of how much difficulty the various symptoms are causing for that person in meeting the challenges of their current life situation. This requires knowing something about the individual's tasks of daily life and the circumstances under which those tasks must be performed. It also requires an appreciation ofhow much trouble any given symptom of ADHD is consistently causing this particular individual relative to most others of the comparison group. Sometimes one or two symptoms may be severely impairing, comparable to a deep valley and a high mountain on the hiking path. In other persons the weight of ADHD impairment may be significant not from any one or two severely impairing symptoms, but from difficulties caused by an overwhelming combination of many less severe symptoms, none of which might be considered so problematic in isolation.

Diagnosis Combined Type Inattentive Type

It should be emphasized that the percentages in this table are lifetime rates. For example, a forty-seven-year-old businessman with combined-type ADHD who had smoked marijuana heavily for a year during college and then had abstained from any marijuana use for the following quarter-century would be included in the 69 percent with a history of substance abuse or dependence. To grasp the significance of comorbidity in adults with ADHD, a comparison with baseline rates in the general population is needed. The 2004 replication of the National Comorbidity Survey sampled the entire U.S. population in the fifteen- to forty-four-year age range. From this study Ronald Kessler (2004) reported that 88 percent of adults with ADHD had at least one additional psychiatric disorder sometime in their lifetime. This was sixfold the prevalence in the general population of adults. Here are the findings for the U.S. sample

Interviewing Children

In the evaluation of children, parents play a crucial role in providing relevant information, but the child's input is also essential. Since many executive functions impaired in ADHD involve cognitive processes not noticed by others, it is crucial that I interview the patient. Even young children can provide important information about their experience to a clinician skilled at asking relevant questions and listening carefully to responses. For children whose schooling is mostly in a classroom with one teacher, information from that teacher may be very helpful. Such teachers usually can describe the child's responses to different types of tasks, and can compare the child's performance to that of many other children of the same age. Often elementary schoolteachers can also furnish valuable information about how the child gets along with classmates and how the child interacts with teachers and other adults on the school staff. Yet teachers alone cannot and should not make or deny a...

ADD Syndrome Can Cause Tragic Sustained Suffering

When I met Joel at age fifteen, he was a handsome, well-developed, appealing boy in a wheelchair. He was unable to walk and could move his arms and fingers only in contorted ways. He was unable to speak, but he could smile and was able to understand much of what was said to him. His ADHD had not been diagnosed or treated until he was twelve years old, and even then the treatment had been insufficient. Joel had continued to struggle with severe ADHD impairments that were extremely disruptive at school and at home. Joel was eventually resuscitated, but only after parts of his brain had been permanently damaged by lack of sufficient oxygen. Since that time he has remained bound to a wheelchair, completely dependent on assistance for even the most basic tasks of eating and self-care. His mother commented to the newspaper reporter, I think that there are a lot of children and adults out there who have taken their own lives because of this disorder ADHD . . . but so many times another...

Accommodations at School or Work

Some individuals with ADHD continue to be quite impaired despite treatment. Moreover, some individuals are not able to acquire or sustain appropriate treatment for ADHD. In such situations, some changes, or accommodations, in the requirements and procedures at school or work may provide a fairer chance for the individual with ADHD. In the United States, federal regulations stipulate that children and adolescents with certain impairments, including ADHD and specific learning disabilities, must be allowed special accommodations in school in accordance with the results of a professional evaluation and extensive documentation about which accommodations are needed. Requirements for these processes in the United States have been summarized by George DuPaul and Thomas Power (2000). Many other nations have not yet set up such protections for impaired students.

Failure or Success Is Not a Good Measure

An attorney once came seeking evaluation and treatment for ADHD after partners of his law firm decided that he would not himself become partner, a promotion he very much wanted and felt that he deserved. Here is his explanation I've decided that I have ADHD. I am a bright guy and I work hard and I earned very good grades in law school, but I'm not getting the success I should have by now. Each year the senior partners promote a couple of attorneys from our firm to junior partner. That's a signal that they really like you and your work and that they want you to stay in the firm. If you don't get picked after a while you need to start looking somewhere else or just accept that you are going to stay stuck in associate status without a very promising future. There has to be some reason that I'm not getting moved up. I read an article about ADHD and how it can cause even very bright people to underachieve and not reach their potential. I looked at the list of symptoms difficulty staying...

Managing Work While Nurturing Relationships

The challenges of adult life do not all come in the earliest adult years. Some with ADD syndrome report that they encounter problems from their executive-function impairments later, in unexpected ways. One thirty-three-year-old woman with ADD syndrome sought treatment after working successfully for ten years as an intensive care nurse in a large hospital. She had been diagnosed with ADHD during high school and had benefited from medication treatment for this throughout high school and college. My ADHD is kicking up again. With the medicine I was taking for it during high school and college I did very well. I stopped taking it after I graduated and got into full-time nursing. I didn't seem to need it anymore. The excitement of working in the ICU kept me plenty focused. I'm good at my work and I love the challenge of caring for these really sick patients. Now things are getting bad again for me. I'm having that same frustration and feeling of helplessness and stupidity that I had for so...

More Specialized Treatments

As mentioned earlier, some persons with ADD syndrome also suffer from severe learning disorders such as reading disorder, math disorder, or disorder of written expression. During the school years, they are likely to need special education services in addition to treatment for ADD impairments. Others with ADD syndrome are actively caught up in abuse or dependence on alcohol, marijuana, or other drugs for them, effective treatment of their substance abuse will be required before their ADD impairments can adequately be alleviated. Still others with ADD syndrome may have chronic and severe problems with panic attacks or OCD. And severe social impairments on the Asperger's autistic spectrum or severe problems with mood regulation, depression, or bipolar disorder can also complicate the patient's struggles with ADD syndrome. Detailed information about treatment options for ADHD in combination with these various comorbid disorders is the primary focus of my edited textbook Attention Deficit...

Working for Money and Driving a

Evaluation indicated that this young cook had solidly average intelligence, but fully met diagnostic criteria for ADHD. He had been frustrated throughout his schooling by chronic difficulties in sustaining attention to assignments requiring reading and writing. Although he was very competent at organizing his work in the kitchen and in sustaining attention to For adolescents and young adults who suffer from ADD syndrome, driving a car presents not only the same challenges and satisfactions as for anyone else of the same age, but also additional obstacles. In a series of studies of driving in young adults with ADHD, Russell Barkley (1993) and colleagues (1996, 2002) found that those with ADHD demonstrated numerous problems in operating a motor vehicle. In a study comparing adolescents and young adults with ADHD to matched controls, all of whom had comparable years of experience in driving, Barkley found that those in his ADHD sample did not differ significantly in their driving skills...

The Clinical Interview The Most Sensitive Assessment Tool

The most sensitive instrument for making a diagnosis of ADHD is a well-conducted interview in which a skilled clinician asks about the history and nature of the patient's current functioning and life situation as well as the patient's earlier life experiences, noting the presence or absence of patterns of impairment in school, work, family life, and social relationships. tional aspirations and work experiences, and their past and present use or abuse of alcohol and other drugs. Detailed formats to help clinicians in structuring clinical interviews for evaluation of ADHD in children and adults have been published by Barkley and Murphy (1998) and by me (1996a, 1996b, 1996c, 2001a, 2001b, 2001c).

Disorderadult sample Odds ratio

The numbers listed under odds ratio show how much the ADHD sample exceeded the general population sample. An odds ratio of 1.0 means that the ADHD sample had the same percentage as was found in the larger population, whereas an odds ratio of 3.0 indicates that the disorder occurred three times as often in the ADHD population. These estimates do not include any learning or language disorders, but they do highlight the markedly elevated incidence of psychiatric disorders reported by adults with ADHD. Figure 7 Executive-function impairments characterize most diagnoses. These three groupings, clustered according to important common elements, include a variety of learning and psychiatric disorders that often occur with ADHD. All of these disorders involve impairments in executive functions as well as other malfunctions specific to that disorder. Figure 7 Executive-function impairments characterize most diagnoses. These three groupings, clustered according to important common elements,...

Disorders of Learning and Language

Dennis Cantwell and Lorian Baker (1991) studied the overlap between language disorders and ADHD in preschoolers referred to a clinic for speech or language problems. Almost all had serious problems relative to others of their age in being able to understand what was said to them or in being able to use verbal language to express themselves. Nineteen percent of these children with speech or language impairments also met diagnostic criteria for ADD, almost fourfold the baseline incidence of ADD reported at that time in the general population. Joseph Beitchman and others (1996) did a longer-term study of preschool children with language disorders. In that sample, too, ADHD was found to be the most common psychiatric disorder, occurring in 30 percent of the preschoolers who had speech or language disorders. Findings from Beitchman's long-term study showed that children with impaired language function at age five were much more likely than others to have a psychiatric disorder at age...

Discussing the Diagnosis with the Patient

Within this patient square, I then draw one or several overlapping circles to represent each appropriate diagnosis, which perhaps includes ADHD, explaining in understandable terms what each diagnostic term represents. These circles can be drawn as in the Venn diagram in Figure 6, each sized to represent the current importance of the problem to the patient, and overlapping to represent interacting effects. The purpose of the overlapping circles in squares is to provide a clear and manageable description of the nature of the patient's current difficulties in the context of important personal strengths and environmental stressors. As part of this collaborative process, it is essential also to consider a wide range of other disorders that often occur with ADHD.

Multiple Routes to Impaired Executive Functions

These studies show that many impairments of executive function seen in ADD syndrome can occur in persons who did not have ADHD in their earlier years. For some, head injuries, the hormonal changes of menopause, or cognitive changes of old age create a cluster of impairments that looks very much like ADD without the lifespan history of symptoms. It seems likely that severe chronic substance abuse and a variety of other psychiatric or medical disorders may have similar damaging effects on executive functions. It also seems likely that external challenges like these would cause some individuals who have a lifelong history of ADD syndrome to experience a worsening of their ADD symptoms. I am suggesting that impairments of executive functions are a larger aspect of many psychiatric and learning disorders than has thus far been recognized. If accurate, this interpretation may have important implications for treatment of persons with other disorders. Perhaps some treatments demonstrated...

Clinical and Selected Special Purpose Clusters

Broad Attention is a special clinical cluster that provides a global measure of attention. Frequently, attention and concentration difficulties are measured using external behavior observation measures. However, more recent ADHD research points to the importance of examining cognitive indicators in addition to traditional behavior indicators (Barkley, 1996). The four tests that comprise the Broad Attention cluster Auditory Working Memory, Numbers Reversed, Auditory Attention, and Pair Cancellation each measure a qualitatively different aspect of attention (see neuropsychological applications section later in this chapter for more information). The Working Memory cluster provides additional information about a person's ability to hold information in immediate awareness while performing operations on it. The two tests comprising the Working Memory cluster (Auditory Working Memory, Numbers Reversed) require divided attention and the management of the limited capacity of short-term memory.

Finding the Most Effective Dose

Some medications are prescribed best according to the patient's age, weight, or severity of symptoms. But stimulant medications do not reliably follow such guidelines. Nora Volkow and James Swanson (2003) described individual differences that affect one's response to stimulant medications. Mark Rapport and Colin Denney (2000) demonstrated that body mass fails to predict optimal dose for ADHD patients. Some very young and small children need quite large and frequent doses of stimulant to get a positive effect whereas other children, adolescents, and adults may benefit from very small doses of stimulant and may have adverse effects to larger doses. In short, more medication is not always better. And since it is not possible to predict the optimal dose from age, weight, or symptom severity, the usual approach is to begin with a very small dose of one or another of the stimulant medications and then increase the dose gradually, allowing about three to seven days on a dose before trying a...

Learning to Read and Write

In the field studies used to develop the DSM-IV diagnostic criteria for ADHD, one survey item was Seems unmotivated to do schoolwork or homework. This descriptor fit many children with ADHD, but it was not Stephen Faraone and others (1996) compared children aged six to seventeen years diagnosed with ADHD to normal controls. Results indicated that at some point in their schooling, 56 percent of the ADHD children had needed academic tutoring, 30 percent had repeated a grade, and 35 percent had been placed in a special class. Comparable numbers for normal controls were much lower 25 percent had received academic tutoring, 13 percent had repeated a grade, and 2 percent had been placed in a special class.

The Bias against Treating a Presumed Lack of Willpower

Many who understand this biologically based view of ADHD remain reluctant to see medication used as the primary treatment. They tend to think of cognitive problems in ADD syndrome as a special category of impairment, very different from malfunctions of the pancreas, heart, eyes, or other bodily organs. For malfunctions of virtually every other organ sys It is ironic that many who strongly resist the notion that prescription medications may be needed to alleviate ADHD have no problem with using everyday stimulants to aid their own cognitive functioning. Richard Rudgley (1993) has described the longstanding and widespread use of stimulants such as coffee, tea, cola, tobacco, and betel nut throughout the world to improve alertness and concentration in daily life. Because one or another of these substances is usually readily available and socially sanctioned, many do not recognize that they are providing on a more transient, erratic, and somewhat less potent basis stimulation to cognitive...

Sexual Feelings and Relationships

As she spent more time with her older boyfriend and his friends, the girl also joined in the beer drinking and marijuana smoking that often occurred at their weekend parties. Joseph Biederman, Timothy Wilens, and others (1998) have shown that individuals with ADHD not only have a twofold increased lifetime risk of substance use disorders than those without ADHD, but also tend to begin substance abuse earlier and continue it longer. Elizabeth Disney and colleagues (1999) found that girls with ADHD often begin substance abuse earlier than boys with ADHD, possibly because they tend to associate with older boys whose patterns of substance abuse may be more fully developed. This girl's early adolescent coital experience and premarital pregnancy are consistent with a pattern reported from the Milwaukee longitudinal study of hyperactive children by Russell Barkley (1998). His group followed 158 hyperactive children and 81 matched controls for more than fourteen years. During this period the...

Medication for More Than Just School or Work

Recognition of the pervasiveness of impairments from ADD syndrome has led many clinicians to prescribe stimulant medications to cover not only school or workdays, but every day of the week. In practice, the use of stimulant medications by persons with ADHD varies as does the use of eyeglasses. Just as some individuals wear their eyeglasses all day, every day, because the help they provide is needed for virtually everything they do, so do many with ADD syndrome maintain their stimulant medication coverage throughout virtually every day. Others, like those who need their eyeglasses only for reading or for watching TV, will plan with their physician to use their medication only when they need it for specific types of activities like schoolwork or employment.

Medication Alone May Not Be Enough

Dren, including many with ADHD, to refrain from being disruptive in classrooms and at home. But it is difficult to see how even the best behavioral treatment program can modify an individual's impairments of ADD syndrome as they affect working memory or hamper one's ability to sustain attention enough to understand what one is reading, to write an essay, or to drive a car. And it is very difficult to imagine how such approaches could be used effectively for adolescents or adults with ADD syndrome who struggle to function as students in high school or university, or as working adults, or parents situations where no one is available to monitor their complex behaviors or manage their reinforcements.

Brain Imaging Studies Show Stimulants in Action

Although the positive results of medication treatment for ADHD symptoms have been widely recognized for many years, it is only in the past four or five years that newly developed imaging techniques have made it possible for researchers to begin to understand the mechanisms by which these medications benefit patients. Nora Volkow and colleagues (2002) developed a technology for using positron emission tomography (PET) to observe directly the effects of stimulant medications in the brain.

Principles of Behavioral Treatment

Although behavioral treatment for ADHD can be summarized in a few simple principles, for example, You catch more flies with honey than you do with vinegar and Don't feed what you don't want to grow, the design and implementation of effective behavioral treatments for a particular child can require as much clinical skill and individualized tailoring as the design of an effective medication regimen. Some think of behavioral treatment as just putting a checklist on the refrigerator door and then pasting on stars when the child is being good. It's not that simple. or to follow established routines for getting up, dressed, and ready for school in time for the bus pickup. Often parents have a long list of changes they want to see in the behavior of their child with ADHD. A clinician may need to assist the parents (and child) in selecting the most important and then stating each goal in a clear and positive way. For example, Show a positive attitude is too general. Use polite language...

The Many Costs of ADD Syndrome

And how does one assess the costs to an individual who receives appropriate treatment, but only late in his schooling One high school senior came into my office for a follow-up session three months after his ADHD had been diagnosed and treated for the first time. Throughout junior high and high school this student had been chided repeatedly by his parents and teachers. They had reminded him about his very superior abilities demonstrated in standardized tests. They had confronted him about how he had been placed in classes for gifted students throughout elementary school and then removed from such classes in junior high because he was too inconsistent about studying and completing homework assignments. They had warned him that despite his strong abilities and high ambitions, he would be unable to gain admission to a good university unless he improved his grades.

Disorders of Social Emotional Regulation

My daughter has ADHD, but she also has a lot of social problems that most kids with ADHD just don't have. She has never been able to catch on to how kids get along with other people, especially with other kids. Stuff that most kids just pick up by listening and watching other people, she doesn't absorb even when we try to explain it to her. She just doesn't get it That's why all the other kids pick on her and call her weird. They won't have anything to do with her. It's been this way since about sec This girl's impairment in understanding and managing social interactions is qualitatively different from that of most other children with ADHD. Her problems affect the various executive functions that comprise ADD syndrome, but she is also impaired in more fundamental ways that have to do with the ability to read and understand emotions communicated by others in implicit, nonverbal ways. She has Asperger's disorder as well as ADHD.

Neurobiology Of Tourette Syndrome

Neurobiology Tourette Syndrome

Terns, these patterns are not stereotyped and differ from tics. More work is needed in these areas to distinguish what features of the cortical and subcortical circuits give rise specifically to tic-like involuntary movements that can be modeled and examined more closely in the laboratory setting. In addition, further anatomical explanation of OCD and ADHD are required for the development of animal models.

How Can Medications Help

In assessing effectiveness of treatments for ADD syndrome, it is important to ask What is the desired outcome Some studies answer this question by analyzing how stimulant medications affect a patient's performance not on combined DSM-IV symptoms of ADHD, but on specific tasks orchestrated by executive functions. Seven of these studies are briefly described here. Virginia Douglas (1999) demonstrated an even broader effect of meth-ylphenidate (MPH) on self-regulation in children with ADHD. When provided MPH, boys with ADHD appropriately speeded up for more automatic, faster-paced tasks and slowed down as needed for complicated tasks that required more concentration and effort. Persons with ADHD often complain of being too easily distracted. Caryn Carlson and colleagues (1991) found that while on medication boys with ADHD were better able to ignore distractions and to sustain focus and maintain speed and accuracy on their primary task. Some parents and teachers believe that tangible...

Cluster 5 Utilizing Working Memory and Accessing Recall

There has not been much research on students who have problems with written expression, but preliminary studies indicate that persons with ADHD demonstrate a disproportionately high incidence of impairment in this respect. For reasons explained in Chapters 4 and 8, it is likely that working memory impairments of ADD syndrome play a significant role in creating difficulties with written expression among ADHD students.

Sometimes One Stimulant Works Better Than Another

This difference between the two primary stimulant medications may explain why some individuals with ADHD respond to one medication better than another. Eugene Arnold (2000) reviewed studies that compared patients with ADHD on consecutive trials of both MPH and AMP. Of these patients, more than 66 percent responded well to AMP and over 56 percent responded well to MPH most responded equally well to both. The overall response rate to one or another of these stimulants was 85 percent.

Using Integrated Information for Diagnosis

This chapter asks how one can recognize those children, adolescents, and adults whose problems with executive functions warrant diagnosis and treatment for ADHD. My answer is that a comprehensive clinical evaluation is the most adequate way to differentiate those individuals who meet diagnostic criteria for ADHD from those who do not. As described earlier, this evaluation should include a careful clinical interview that focuses on the patient's past and present functioning and, if possible, includes information from others who know the patient well. The evaluation should also include use of a standardized, age-appropriate ADD rating scale such as the Conners or Brown scales and some standardized measures like the verbal memory test described earlier. For students of any age, a comparison of IQ index scores from the WISC or WAIS IQ tests may also be helpful. Yet when all of these data are gathered, a question remains How severe does impairment from ADD symptoms have to be in order to...