***Caution***This page attempts to simplify a very complex condition.  While providing an overview, it lacks detail and depth.  The reader is advised to investigate the topic in a more precise and in-depth manner.
 

    School is often the first place where characteristics of ADD are noted or viewed as problematic.  Often it is in that school setting that youngsters are first asked to stay seated for long periods of time, maintain extended attention to a live individual, persist on a task, or wait one's turn.  Youngsters with ADD experience difficulties in the areas necessary for academic success: starting work assignments, completing tasks, interacting cooperatively with others, following directions, making smooth transitions, and managing multi-step tasks.  Excessive activity levels, talkativeness, interrupting, fidgeting, active and out of seat behavior, and underdeveloped social skills may also be evident.  A number of factors effect performance including time of day, amount of rest or fatigue, adequacy of supervision, adequacy of medication, and so forth.

    Since Dr. George Still first described "moral turpitude" (lack of moral self control) in 1902, the fields of education and mental health have tried to devise more appropriate names, better categorization systems, more accurate assessment procedures, and more effective teaching strategies.  It is one of the areas of greatest contention in the field of special needs.  Should these youngsters be labeled as "special ed"?  How many kids have these conditions?  Do these conditions really exist or are they simply excuses for poor parenting?  It all depends on who you listen to.  Below is a synopsis of the literature.
 

Diagnosis
    There is no definitive test for for ADD/ADHD.  Diagnosis is made by a physician after referral by parents and/or educators.  It usually takes 2-3 office visits before the diagnosis is final.  The physician should consider the impressions of the parents and teachers (perhaps written on a survey form).  Diagnosis should be made based on the criteria established in the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-4, 1994)   In the DSM-4 manual, the overall condition is known as "Attention Deficit Hyperactivity Disorder" (ADD and ADHD are not separated...even though most people tend to separate ADD and ADHD).  Under this condition are three different types of ADHD: (1) "ADHD combined type" (the most common type) in which there is found in the youngster six or more symptoms of inattention (from a list of nine symptoms) and six or more symptoms of hyperactivity/impulsivity (from a list of nine symptoms).  The symptoms must be observed in two or more settings (i.e., home and one class at school, two different classes at school); (2) "ADHD, Predominantly inattentive type" in which six or more symptoms of inattention are observed, but fewer than six symptoms of hyperactivity-impulsivity are seen; and (3) "ADHD, Predominantly hyperactive-impulsive type" with fewer than six signs of inattention, but six or more signs of hyperactivity-impulsivity.  Be aware that most professionals also recognize a fourth category "ADHD with aggression"

One caution: Many physicians use their own criteria.  Be sure to ask them if the diagnosis was based on DSM-4.   At present (late 2000), studies involving chemicals and electroencephalograms are underway.  In one study, chemicals that travel to and set into a part of the brain that is smaller in ADD individuals are used and then the brain is "scanned".  It is expected that these procedures will be available to diagnose ADD sometime between 2003 and 2005.
 

Click here to view the DSM-IV criteria for labeling a youngster as ADD/ADHD

ADD Symptoms
 The main symptoms associated with Attention Deficit Disorder are:

-Distractibility: The inability to filter out unnecessary sensory stimuli (sometimes compared to
    having many people talking to you at once, or using the scan button on the radio that
    skips stations every few seconds)

-Inattentiveness: Problems selecting the correct stimuli or maintaining focus on it.  Appearing
    to daydream or fail to listen

-Disorganization

-Deficiencies are often reported in social skills either as (1) a failure to pick up on social
    cues, body language, voice tones, or facial expressions of others, or (2) the display of
    behaviors that are inappropriate to the situation.

-Problems are often reported in the area of motor control and coordination

-Tourettes syndrome also seems to be over-represented in this population
 

ADHD Symptoms
    Youngsters with ADHD (about 70% of those who have ADD) display the symptoms mentioned above AND hyperactivity and impulsivity.  Hyperactivity presents itself as continual motion or fidgeting (e.g., fingers/feet tapping, body squirming/wiggling, legs swinging, difficulty staying seated) in a variety of situations.  Impulsivity involves acting or speaking one's thoughts without consideration of the possible consequences.  These students may have a low tolerance for frustration and often become angry, yell, throw things, hit others, or say inappropriate things without pausing to reflect.  About 40-60% of ADHD students also have a co-existing conditions called Oppositional Defiant Disorder (ODD), which involves a pattern of negativity, hostility, and defiant behavior (e.g., temper tantrums, arguing, deliberately defying directions, annoying people on purpose, blaming others for mistakes, seeming to be spiteful and vindictive).

    Most professionals also recognize another variation on ADD/ADHD.  It is estimated that 20-40% of ADHD youngsters are also aggressive or cruel, a condition known as Attention Deficit Hyperactivity Disorder with aggression.  One should be aware that depression in children (see this web site's home page link titled "Depression in Children") can present itself in distractible or active behavior.  Depression should be ruled out previous to a diagnosis of ADD or ADHD.
 

How Many Kids Have These Conditions?
 When it comes to ADD and ADHD, the professional literature contains estimates of 1 to 20% of school aged youth.  The National Institute of Health estimates 5 to 10%.  The use of  DSM-IV (Diagnostic and Statistical Manual of the American Psychiatric Association, edition 4) criteria would result in about a 3 to 5% prevalence of the conditions.  The conditions are more frequently found in boys (3 or 4 times more often).  One study of 30,000 children in Virginia found that 17% of white boys, 9% of African American boys, 7% of white girls, and 4 of African American girls had ADD.  In early 2002, the Mayo Clinic estimated that 7.5% of kids could be ADHD.

    ADD/ADHD is the most common childhood neurobehavioral disorder and it is estimated that ½ to 2/3 of individuals will carry the condition into adolescence and adulthood, often being viewed by others as "talkative", "scatterbrained", and/or "forgetful".  They are also at greater risk for experiencing social ills (i.e., family problems, job difficulties).
 

What Causes ADD/ADHD?
 That answer depends on who you ask.  Just about any cause you can think of has it's adherents.  The following are some of the common views on what causes or contributes to the conditions.

-prenatal problems
-prenatal exposure to cigarettes

-prenatal exposure to alcohol

-premature birth
-brain development/minimal brain dysfunction
-inner ear problems
-chemical imbalance
-thyroid problems
-sex linked chromosome
-inherited behavioral traits
-pollution
-fluorescent lights
-fast paced media and video games
-vitamin deficiencies
-lack of calcium
-food allergies
-yeast
-food additives
-low blood sugar
-heart problems
-inconsistent or lax discipline at home
-boring lessons
-poor behavior management skills of the teacher
-misdiagnosis of anxiety or depression

    In "true" ADD and ADHD, biochemical reactions related to the brain's neurotransmitters, especially the dopamine and serotonin pathways are involved.  Frontal lobes (the brain's center for attention and impulsivity) of ADHD individuals have been found to use less glucose (resulting in less energy) and demonstrate less electrical activity.
 

Treatments for ADD/ADHD
    While you will find advocates for all sorts of interventions (e.g., megavitamin therapy, chiropractic treatment, play therapy, biofeedback, sensory integration training, diet changes), most are questionable at best.  Nearly all positions can supply personal testimonials on effectiveness.  However, only psychostimulant medications (and it's combination with behavior management strategies) have any scientific proof supporting their effectiveness.  There has been a dramatic increase in the use of these "psychotropic" medications.  Most teachers have heard about Ritalin, a medication used in the USA at a rate at least 5 times higher than the rest of the world.  Although "vitamin R" is the most common medication for these conditions, many others exist (e.g., Adderal, Cylert, Premoline, Dexadrine, and various anti-depressants like Tofranil, Norpramin, and Elavil).  The aforementioned medications will not be effective for one out of five ADD/ADHD pupils.
  For pre-adolescents, medications like Ritalin, despite being stimulants, work well (reports vary with 65-90% positive treatment ratings).  Known as the "reciprocal effect", it is not known exactly why a stimulant calms these youngsters and helps them to concentrate.  Some believe that hyperactive and distractible behavior is an attempt to stimulate an underperforming brain.  The stimulant is believed to "speed up" the brain, increasing the level of dopamine in the frontal lobe of the brain which regulates attention and impulsivity, so that it needs less stimulation.  In other words, the drugs calm the individual by making the brain work more efficiently.  Research indicates that medication does work better than behavior modification therapy, and a combination of the two interventions is NOT more effective than the medication alone (NY Times, page A8, 12/15/99).  However, among the 70% of these youngsters who also had depression or anxiety with their condition, the combination did yield significant benefits beyond medication alone.  Educational remediation and special education often accompany the medication, as do parent training, family counseling, youth counseling, or other intervention.

     Ritalin may be available in a time release form, or the youngster may need to receive the medication every three to four hours.  It takes about 30 minutes to take effect.  Cylert takes days to weeks to become effective, but thereafter is needed only once per day.  A new drug, Concerta (a new form of the drug Methlyphenidate, commonly known as Ritalin) is now available.  Unlike Ritalin, which requires two or three doses per day, Concerta lasts 12 hours, making in-school and after-school dosing unnecessary.  Concerta comes in tablet form and is taken in the morning before school.  Strattera, a non-stimulant medication from Lilly Pharmaceuticals was introduced around 2003.

Side effects often accompany the medications.  The most common are loss of appetite, weight loss, irritability when the medication wears off, stomach pains, dry mouth, and problems falling asleep.  Less common side effects are slowed growth, tic disorders, and problems with flexible thinking.  As a teacher who sees the youngster often, you should document any possible side effects and report them to the parents/physician.

Medication is not a substitute for therapy and training.  It helps kids to better respond to the help.  It is estimated that about 90% of youngsters with ADHD benefit from the administration of medication.
 

Should They, or Can They Be Labeled "Special Ed"? (United States Education Law)
     While the conditions are not listed as one of the special education categories, the youngsters often receive special education services by being labeled "learning disabled" (if ADD is the primary concern), "emotionally disturbed" (if ADHD is the main concern), or "Other health impaired" (if parents or school personnel dislike the other two labels).  Many ADD individuals will also have accompanying conditions such as a learning disability, emotional or behavior disorder, Tourette's Syndrome, etc.

     If symptoms do not meet the criteria of the Individuals with Disabilities Education Act (the special education law), or school personnel hinder IDEA identification, parents sometimes seek to have their child labeled under the less stringent conditions of Section 504 of the Rehabilitation Act of 1973 (as amended).  Under section 504, a civil rights act, disabled youngsters are guaranteed school services to meet their needs.  A person with a disability is defined as "any person who has a physical or mental impairment which substantially limits a major life activity."  Certainly schooling and socializing are major life activities.

    If the student qualifies for special services under Section 504, the school must make determine and meet the educational needs of that youngster.

There is no one test for identifying whether youngsters have ADD or ADHD.  While physicians are often involved in the identification procedure, the U.S. Office of Education does NOT require a medical evaluation.  However, some states have added the additional requirement of a physician's evaluation.

    The Professional Group for Attention and Related Disorders (PGARD) recommends a two-tier process of evaluation for identifying ADD and ADHD.  The first tier contains a clinical evaluation to determine whether the youngster's symptoms match the criteria listed in DSM-IV.  The second level is comprised of an educational evaluation to determine if the condition is having a substantial negative impact on academic and classroom performance.  All individuals familiar with this youngster should contribute to the process which attempts to identify when the behaviors began, how often and under what circumstances they appear, and the effect on the youngster's academics, psychological state, and social life.  It is hoped that this multi-source process will provide an accurate overall picture of the boy/girl, and help in identification and programming.
 

Click here for cartoons about ADD & ADHD
#1    Might there be a genetic component in ADD?
#2     Teachers and ADD
#3
#4
#5
 
 

Click here for impulsivity joke

 
 

3/4/04