NICHCY Briefing Paper

NICHCY
BRIEFING
PAPER
By Mary Fowler

(Attention Deficit Disorder - 1991)
National Information Center for Children and Youth with Disabilities
P.O. Box 1492 Washington, DC. 20013-1492

"Maybe you know my kid. He's the one who says the first thing that comes to mind. He's the youngster who can't remember a simple request. When he scrapes his knee, he screams so loud and long that the neighbors think I'm beating him. He's the kid in school with ands in his pants who could do the work if he really tried. Or so his parents have been told over and over again."

(Drawn from Mary Fowler's (1990) Maybe you know my kid:
A parent's guide to identifying, understanding, and helping your child with ADHD)

The Every year the National Information Center for Children and Youth with Disabilities (NICHCY) receives hundreds of requests for information about the education and special needs of children and youth with Attention Deficit Disorder (ADD) or Attention Deficit Hyperactivity Disorder (ADHD). Over the past three years, ADD and ADHD have become a subject of increased attention from parents, professionals, and policy makers across the country.

In response to the growing concern and interest in this disability, this NICHCY Briefing Paper was developed. It is disigned to answer some of the commonly asked questions regarding ADD and ADHD and to provide concerned individuals with other resources for information and support.

What is Attention Deficit Disorder?

Attention Deficit Disorder (ADD), also called Attention Deficit Hyperactivity Disorder (ADHD), is a developmental disability estimated to affect between 3-5% of all children (Barkley, 1990). The disorder is characterized by three predominant features: inattentiveness, impulsivity, and in many but not all cases, restlessness or hyperactivity. The disorder is most prevalent in children and is generally thought of as a childhood disorder. Recent studies, however, show that ADD can and still does continue throughout the adult years. Current estimates suggest that approximately 50 to 65% of the children with ADD will have symptoms of the disorder as adolescents and adults (Barkley, 1990, p. 124).

What Causes ADD?

Scientists and medical experts do not know precisely what causes ADD. Scientific evidence suggests that the disorder is genetically transmitted in many cases, and is caused by a chemical imbalance or deficiency in certain neurotransmitters (chemicals that regulate the efficiency with which the brain controls behavior). Results from a landmark study conducted by Alan Zametkin, MD., and his colleagues at the National Institute of Mental Health showed that the rate at which the brain uses glucose, its main energy source, is lower in subjects with ADD than in subjects without ADD (Zametkin et al., 1990). Even though the exact cause of ADD remains unknown, we do know that ADD is a neurologically-based medical problem and is not caused by poor parenting or diet.

What Are The Signs of ADD?

Inattention. A child with ADD is usually described as having a short attention span and as being distractible. The child will have difficulty concentrating (particularly on tasks that are routing or boring), listening, beginning or finishing tasks, and following direction (especially when three or more steps are given at one time). The child may appear to hear but not listen. Parents and teachers find that they often have to repeat directions and redirect the child to tasks such as getting ready for school, putting away toys or materials, completing worksheets, or finishing meals. Some children with ADD wander about, while others appear to daydream.

Attention is a skill that can be applied or directed in a variety of ways. The inattentativeness of a child with ADD,then, can take several forms. The child may have difficulty with selective attention (figuring out where his/her attention needs to be), focusing attention (the child knows where attention needs to be, but has difficulty zeroing in on the relevant task), sustaining attention (difficulty in maintaining attention through distractions),and/or dividing attention (difficulty doing two or more tasks at the same time). The child can have difficulty with one or all of these attention skills.

Impulsivity. A child with ADD often acts without thinking, and has great difficulty waiting for his or her turn. The child may rush through assignments, shift excessively from one task to another, or frequently call our or ask irrelevant questions in class. This child will often interrupt others and have outbursts of imappropriate responses such as silliness or anger. When this child gets a case of "the giggles" or flies into a temper tantrum, s/he has great difficulty regaining emotional control.

Impulsivity often leads the child into physical danger and disapproval. He or she may engage in what looks like risk taking behavior, such as running across a street without looking, climbing on or jumping from roof tops or tall trees, shooting a rubber band at a classmate, and so on. This child is not really a risk taker but, rather, a child who has great difficulty controlling impulse. Often, the child is surprized to discover that s/he has gotten into a dangerous situation and has no idea how the situation developed or why.

Hyperactivity (Poor Motor Control). Many (but not all) children with ADD are hyperactive. A hyperactive child is often described as "always on the move" or "motor driven." This child runs or climbs excessively, has difficulty sitting still, fidgets, and engages in physical activity not related to the task, such as frequent pencil sharpening, falling out of his/her chair, finger tapping, or fiddling with objects. The child may also make excessive vocalizations, noises, or talk in a loud voice. It is important to realize, however, that some children are more hyperactive than others, and that a hyperactive child may have periods of calm as well.

In contrast to children who have ADD with hyperactivity, some children with ADD are underactive and often called "lazy" or "spacey." Children with ADD - those with hyperactivity and those without are often "accident prone."

Disorganization. Inattentiveness and impulsivity often cause the child with ADD to be very disorganized. This child frequently forgets needed materials or assignments, loses his/her place, and has difficulty following sequences, such as directions with three or more steps. When given multiple worksheets or directions, the child often does not know where to begin or overlooks part of the assignment.

Social Skill Deficits. The childwith ADD is often described as immature, lacking in self-awareness and sensitivity, and demanding of attention. The child may frustrate easily and be inconsiderate, overly sensitive, or emotionally overactive. S/he may have difficulty expressing feelings, accepting responsibility for behavior, or get into frequent fights or arguments. This child often reacts to a social situation without first determining whatbehavior is desirable; for example, s/he may interupt a game in progress or crack a "joke" diring a serious moment. Though this child has social problems, it is important to understand that the social skills deficits stem from the disorder. This child wants to be liked and accepted, but usually goes about it with an inappropriate style.

Don't All Children Show These Signs Occasionally?

From time to time all children will be inattentive, impulsive, exhibit high energy levels. But, in the case of ADD, these behaviors are the rule, not the exception. This child is often described as experiencing difficulty "getting with the program" at home, in school, or with peers. Keep in mind, however, that the degree of difficulty varies with each child.

Many parents spend years wondering why their child is difficult to manage. They may blame themselves, thinking they are "bad" parents or feeling guilty and ashamed of the way they respond to the child. As the child grows older, the "out of step" behavior is often misunderstood as a deliberate choice to be non-compliant, and the child is blamed. When the child enters school and experiences difficulty in that environment, teachers with knowledge of this disability may recognize the behaviors as possible indicators of ADD. Teachers without knowledge of ADD may blame the child, the parents or both.

How Do I Know For Sure If My Child Has ADD?

There is a big difference between suspecting your child has ADD and knowing for certain. Parents are cautioned against diagnosing this disorder by themselves. ADD is a disability that, without proper identification and treatment, can have serious and long-term complications.

Unfortunately, there is no simple test, such as a blood test or urinalysis, which will determine if a child has this disorder. Diagnosing ADD is complicated and much like putting together a puzzle. An accurate diagnosis requires an assessment conducted by a well-trained professional, usually a developemental pediatrician, child psychologist, child psychiatrist, or pediatric neurologist.

What Does an ADD Assessment Involve?

The evaluation for diagnosing ADD usually includes the following elements:

A thorough medical and family history

A physical examination

Interview with the parents, child, and child's teacher

Behavior rating scales

Observation of the child

Psychological tests which measure I.Q., social and emotional adjustment, as well as screen for learning disabilities.

Sophisticated medical tests such as EEG's (to measure the brain's electrical activity) or MRI's (an X-Ray that gives a picture of the brain's anatomy) are NOT part of the routine assesment. Such tests are usually given only when the diagnostician suspects another problem, and those cases are rare. Positron emission tomography (PET Scan) has recently been used for research purposes but is not part of the diagnostic evaluation.

The professional evaluating your child will look at all the information collected and decide whether or not your child has ADD. This professional will base this decision in part upon whether your child exhibits at least eight of the behaviors (called criteria) listed in the American Psychiatric Association's (APA)Diagnostic and Statistical Manual (DSM). These criteria are presented in the table below:

Diagnostic Criteria for ADHD, as Listed in the DSM-III-R

A. At least eight of the following behaviors must be present, for at least six months:

often fidgets with hands and feet, or squirms in seat (in adolescents, may be limited to subjective feelings of restlessness)

has difficulty remaining seated when required to do so.

is easily distracted by axtraneous stimuli

has difficulty awaiting turn in games or group situations

often blurts out answers to questions before they have been completed

Has difficulty following through on instructions from others (not due to oppositional behavior or failure to comprehend directions), e.g., fails to complete chores

has difficulty sustaining attention in tasks or play activities

often shifts from one uncompleted activity to another

has difficulty playing quietly

often talks excessively

often interrupts or intrudes on others, e.g., butts into other childrens games

Often does not seem to listen to what is being said to him/her

often loses things necessary for tasks or activities at school or at home (e.g., toys, pencils, books, assignments)

often engages inphysically dangerous activities without considering possible consequenses (not for the purpose of thrill-seeking), e.g., runs into street without looking

B. These behaviors begin before the age of seven.

* Drawn from the American Psyciatric Association's (1987), Diagnostic and Statistical Manual of Mental Disorders (3rd edition-revised), pp. 52-53.

It is useful to know that in recent years the description of ADD in the DSM has been revised as a result of research and the opinions of experts in the field. While prior editions of the DSM refered to the disorder as "ADD with hyperactivity" and "ADD without hyperactivity," the latest edition (called the DSM-III-R) uses the acronym ADHD, which stands for Attention Deficit Hyperactivity Disorder. This change in terminology shows the predominance of hyperactivity as one characteristic of the disability. Yet, many children with attention dificit disorders are not hyperactive. The DSM-III-R acknowledges this fact by stating that "signs of impulsiveness and hyperactivity are not present in Undifferentiated Attention-deficit Disorder" (p.52). Thus, while professionals may assess a child according to the criteria listed in the DSM-III-R, they will take into consideration that hyperactive or impulsive behavior may not necessarily be present in all children with ADD.

In general, then, for a child to be diagnosed as having ADD, the behavioral signs listed in the table above must be evident in early childhood (prior to age seven), inappropriate for the child's age, and present for at least six months.

All children with ADD do not have the disorder to the same degree or intensity. ADD can be mild with the child exhibiting few symptoms in perhaps only the home or school environment. Other children may have moderate to severe degrees of ADD and experience difficulty in all areas of their lives.

How Do I Get My Child Evaluated For ADD?

If your child is an infant or toddler, and you suspect an attention or hyperactivity problem, you may want to investigate what early intervention services are available in your state through the Part H program of the Individuals with Disabilities Education Act (IDEA). You can find out about the availability of these services in your state by contacting the State Department of Education, contacting your local education agency, asking your pediatrician, or contacting the nursery or child care department in your local hospital.

While your state may not specifically list ADD as a disability to be addressed through the Part H program, most states have a category such as "atypical" children or "other" under which an ADD assessment might be made.

Preschoolers (children aged 3-5) may be eligible for services under Part B of the Individuals with Disabilities Education Act. If your child is a preschooler, you may wish to contact the State Department of Education, local education agency, ask your pediatrician, or talk with local day care providers about how to access services under Part B in order to have your child assessed.

If your child is school-aged, and you suspect that ADD may be adversely affecting his/her educational performance, you can ask your local school district to conduct an evaluation. With the exception of the physical examination, the assessment can be conducted by the child study team, provided they have been trained in the assessment of ADD. If not, the district may need to utilize an outside professional consultant trained in teh assessment of ADD. This person must know what to look for during child observation, be competent to conduct structured interviews with the parent, teacher, and child, be able to interpret the review results, and know how to administer and interpret behavior rating scales.

Parents may also choose to have their child assessed privately. In selecting a professional to perform an assessment for ADD, parents should consider the chinician's training and experience with the disorder, and his/her availability to coordinate the various treatment approaches. Parent can consult their child's pediatrician, community mental health center, university mental health clinics, or hospital child evaluation units. Most ADD parent support groups have a list of clinicians trained to evaluate and treat children with ADD.

How Is ADD Treated?

There is no cure or "quick fix" when treating ADD. Widely publicized "cures" such as special diets have, for the most part, proven ineffective.

Effective treatment of ADD generally requires these basic components:

Education about the disorder	Training in the use of behavior management
Medication when indicated	An oppropriate educational program

References:

Barkley, R. (1990) Attention Deficit Hyperactivity Disorder, a handbook for diagnosis and
    treatment. New York: Guilford Press
American Psychiatric Association (1987) Diagnostic and statistical manual of mental
    disorders (3rd Edition-revised). Washington DC.: Author.
Fowler, MC. (1990) Maybe you know my kid: A parent's guide to identifying, understanding,
    and helping your child with ADHD. New York: Birch Lane Press.
Zametkin, A., Mordahl, T.E., Gross, M., KingA.C., Semple, W.E., Rumsey, J., Hamburger, S., &
    Cohen, R.M. (1990). Cerebral glucose metabolism in adults with hyperactivity of childhood
    onset. New England Journal of Medicine, 323(2), 1361-1366.

This document was devoloped by interstate Research Associates, Inc. pursuant to Cooperative Agreement #H030A0002 with the Office of Special Education Programs of the U.S. Department of Education. The contents of this document do not necessarily reflect the views or policies of the Department of Education, nor does mention of Trade names, commercial products, or organization imply endorsement by the U.S. Goverment.

This information is in the public domain unless otherwise indicated. Readers are encouraged to copy and share it, but please credit the National Information Center for Children and Youth with Disabilities. Your comments and suggestions for briefing papers are welcomed. Please share your ideas and feedback by writing the Editor.

BIBLIOGRAPHY

Print Materials

Clark, L. (1989) SOS: Help for Parents
            Parents Press
            P.O. Box 2180
            Bowling Green, KY.
            42102-2180

Copeland, E.D. (1989) Understanding Attention Disorder
Atlanta: 3 C's of Childhood

Fowler, M.C. (1990) Maybe you know my kid: A parent's guide to identifying, understanding, and helping your child with ADHD.    Available at:
            Birch Lane Press.
            120 Enterprise Avenue
            Seacaucus, NJ    07094
            (Tel: 800-447-BOOK)

Goldstein, M. & Goldstein, S. (1990) Managing attention disorders in children: A guide for prctitioners. New York: Wiley Interscience Press. Book available from:
            John Wiley & Sons, Inc.
            Eastern Distribution Center
            1 Wiley Drive
            Somerset, NJ.   08873

Gorden, M (1990)   ADHD/Hyperactivity: A consumer's guide. DeWitt, NY: GSI Publications. Book available from:
            GSI Publications
            P.O.Box 746
            DeWitt, N.Y.   13214

Ingersoll, B. (1988)   Your hyperactive child. New York: Doubleday. Book Available from:
            Bantam-Doubleday-Dell
            Fulfillment Department
            2451 S. Wolf Road
            Des Plains, IL.   60018

LeVine, M.D. (1990)   Keeping ahead in school. Cambridge, MA: Educators Publishing Service. Book available from:
            Educator's Publishing Service
            75 Multon Street
            Cambridge, MA.   02138

Maxey, DW. (1989) How to own and operate an attention deficit kid. Roanoke and Charlottesville, VA.: HADD. Book available from:
            HADD
            Colonial Avenue
            SW, Building E - Suite 6
            Roanoke, VA   24018

Moss, D. (1989) Shelly the hyperactive Turtle. Rockville, MD: Woodbine House. Available from:
            Woodbine House
            5615 Fishers Lane
            Rockville, MD.   20852

Ripley, S. & Cvach, P.A. (1989 July)   Choosing a doctor for your child with learning disabilities or attention deficit disorders. McClean, VA: Interstate Research Associates, Learning Disabilities Project. Available from:
            Learning Disabilities Project
            Interstate Research Associates
            7926 Jones Branch Drive
            Suite 1100
            McLean, VA   22102

Parker, H.C. (1988)   The ADD hyperactivity workbook for parents, teachers, and kids. Plantation, FL: Impact Publications. Available from:
            Impact Publications
            300 NW 70th Avenue
            Plantation, FL.   33317

Wender, P.M. (1987)   The hyperactive child, adolescent, and adult. New York: Oxford University Press. Available from:
            Oxford University Press
            Order department
            2001 Evans Road
            Cary, NC   27513

Organizations

Attention Deficit Disorder Association (ADDA)References:

Print Materials

Clark, L. (1989) SOS: Help for Parents
            Parents Press
            P.O. Box 2180
            Bowling Green, KY.
            42102-2180

Copeland, E.D. (1989) Understanding Attention Disorder
Atlanta: 3 C's of Childhood

Goldstein, M. & Goldstein, S. (1990)References:

Organizations

Attention Deficit Disorder Association (ADDA)
            80913 Ireland Way
            Aurora, CO   80016
    Tel:   (313) 690-7548

Attention Deficit Information Network (AD-IN)
            P.O.Box 790
            Plymouth, MA.   02360
    Tel:   (508) 747-5180

A.D.D. Warehouse
            300 NW 70th Avenue
            Plantation, FL   33317
    Tel:   (800)   233-9273

Center for Hyperactive Children Information, Inc. (CHCI)
            P.O. Box 66272
            Washington, DC.   20035
    Tel:   (703)   415-1090

Children with Attention Deficit Disorders (CH.A.D.D.)
            499 NW 70th Avenue
            Suite 308
            Plantation, FL   33317
    Tel:   (305)   587-3700

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