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AUTHOR Fowler, Mary TITLE Attention-Deficit/Hyperactivity Disorder. NICHCY Briefing Paper. 3rd Edition. INSTITUTION National Information Center for Children and Youth with Disabilities, Washington, DC. SPONS AGENCY Academy. for Educational Development, Washington, DC.; Special Education Programs (ED/OSERS), Washington, DC. REPORT NO NICHCY-BP-FS14 PUB DATE 2002-00-00 NOTE 25p.; See ED 351 830 for earlier (1991) edition. CONTRACT H326N980002 AVAILABLE.FROM National Information Center for Children and Youth with Disabilities, P.O. Box 1492, Washington, DC 20013. For full text: http://www.nichy.org. PUB TYPE Guides Non-Classroom (055) EDRS PRICE EDRS Price MF01/PCO2 Plus Postage. DESCRIPTORS * Etiology; *Academic Accommodations (Disabilities); Access to Education; *Attention Deficit Disorders; Behavior Modification; Clinical Diagnosis; Definitions; Drug Therapy; Educational Policy; Elementary Secondary Education; Eligibility; Hyperactivity; Special Education; *Student Characteristics; *Student Evaluation; *Teaching Methods

ABSTRACT This briefing paper uses a question-and-answer format to provide basic information about children and adolescents with attention deficit/hyperactivity disorder (AD/HD). It is intended to help parents, teachers, and others interested in AD/HD know what to look for, what to do, and how to get help. Questions address the following concerns: nature and incidence of ADD; causes of ADD; signs of ADD (inattention, hyperactivity, impulsivity, hyperactivity, .disorganization, and disinhibition); the diagnostic AD/HD assessment; how to get one's child evaluated for AD/HD; treatment of AD/HD (education about the disorder, behavior management, medication, and appropriate educational programming); determining if special education will help a child with AD/HD; determining the eligibility of,a child for special education services; the child's legal rights for special education; what teachers can do to help a child with AD/HD (includes tips for adapting curriculum and instruction, providing supports to promote executive function, using memory boosters, and using attention getters and keepers), and locating a support group. Four inserts list disorders that co-occur with AD/HD, discuss early intervention services, list ways to improve life in general, and list teaching strategies. A selected bibliography lists 12 references,4 relevant organizations, and 27 books and videos. (CR)

Reproductions supplied by EDRSare the best that can be made from the original document. F514, 3rd Edition, April 2002

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A publication of the National Information Center for Children and Youth with Disabilities

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C:21 U.S. DEPARTMENT OF EDUCATION Office of Educational Research and Improvement EDUCATIONAL RESOURCES INFORMATION CENTER (ERIC) This document has been reproduced as received from the person or organization glary Trowler originating it. Minor changes have been made to improve reproduction quality.

Points of view or opinions stated in this document do not necessarily represent official OERI position or policy.

Every year the ADD, throughout this paper the National Information disorder is called by its medically Center for Children. correct name of AD/HD. and Youth with Disabili- ties (NICHCY) receives thousands of requests for information about the educa- tion and special needs of children Table of Contents and youth with attention-deficit/ I Understanding & hyperactivity disorder (AD/HD). If Diagnosing AD/HD 2 your child or teen has AD/HD, or if you suspect that to be the ,case, you II. Treatment might be overwhelmed by the Recommendations 10 available information. A lot of that information is based on good III.School Issues & scientific research. However, some Interventions 15 of it is not scientifically accurate. IV. Meeting the 20 This NICHCY Briefing Paper is Challenge written to help parents, teachers, V. References 21 and others interested in AD/HD know what to look for, what to do, VI.Resources 21 and how to get help. Although 23 many people refer to attention- VII. Publishers deficit/hyperactivity disorder as

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What is AD/HD? Thus; there are three subtypes of ganglia, and the cerebellum AD/HD: (Castellanos & Swanson, in press). AD/HD is one of the most These areas are known to help us commonly diagnosed behavioral A. Predominantly Inattentive inhibit behavior, sustain attention, disorders of childhood. The Type and control mood. disorder is estimated to affect between .3 to 7 out of every 100 B. Predominantly Hyperactive- There is also strong evidence to school-aged children [American Impulsive Type suggest that certain chemicals in Psychiatric Association (APA), C. Combined Type (inattention,the braincalled neurotransmit- 2000]. This makes AD/HD a major hyperactivity-impulsivity) tersplay a large role in AD/HD- health concern. The disorder does type behaviors. Neurotransmitters not affect only children. In many Of course, from time to time, help brain cells communicate with cases, problems continue through practically every person can be a each other. The neurotransmitter adolescence and adulthood. bit absent-minded, restless, fidg- that seems to be most involved ety, or impulsive. So why are thesewith AD/HD is called dopamine. The core symptoms of AD/HD same patterns of behavior consid- Dopamine is widely used through- are developmentally inappropriate ered normal for some people and out the brain. Scientists have levels of inattention, hyperactivity, symptoms of a disorder in others? discovered a genetic basis for part and impulsivity. These problems It's partly a matter of degree. With of the dopamine problem that are persistent and usually cause AD/HD, these behaviors occur far exists in some individuals with difficulties in one or more major more than occasionally. They are AD/HD. Scientists also think that life areas: home, school, work, or the rule and not the exception. the neurotransmitter called social relationships. Clinicians norepinephrine is involved to base their diagnosis on the pres- some extent. Other neurotransmit- ence of the core characteristics and What Causes Ab/Hb? ters are being studied as well the problems they cause. AD/HD is a very complex, (Castellanos & Swanson, in press). Not all children and youth haveneurobiochemical disorder. Re- When neurotransmitters don't the same type of AD/HD. Because searchers do not know AD/HD's work the way they are supposed the disorder varies among indi- exact causes, as is the case with to, brain systems function ineffi- viduals, children with AD/HD many mental and physical health ciently. Problems result. With won't all have the same problems. conditions. Where AD/HD is AD/HD, these are manifested to Some may be hyperactive. Others concerned, there are a few indi- the world as inattention, hyperac- may be under, active. Some may viduals who do not believe AD/ tivity,impulsivity, and related have great problems with atten- HD really exists. As researchers behaviors. tion. Others may be mildly inat- continue to learn more about AD/ HD, this controversy will be put to tentive but overly impulsive. Still Children with AD/HD are often others may have significant prob- rest. Meanwhile, scientists are making great strides in unlocking blamed for their behavior. How- lems in all three.areas (attention, ever, it's not a matter of their hyperactivity, and impulsivity). the mysteries of the brain. Recent technological advances in brain choosing not to behave. It's a study are providing strong clues asmatter of "can't behave without the to both the presence of AD/HD right help." AD/HD interferes with and its causes. In people with the a person's ability to behave appro- disorder, these studies show that priately. certain brain areas have less activity And speaking of blame and blood flow and that certain parents and teachers do not cause brain structures are slightly smaller.AD/HD. Still, there are many These differences in brain activity things that both parents and and structure are mainly evident inteachers can do to help a child or the prefrontal cortex, the basal teen manage his or her AD/HD-

N1CHCY: 1-800-695-0285 2 3 AD/HD Briefing Paper (3rd Ed.) related difficulties. Before we lookInattention These attention difficulties at what needs to be done, how- result in incomplete assignments, ever, let us look at what AD/HD is Attention is a process. When wecareless errors, and messy work. and how it is diagnosed. pay attention: Children with AD/HD often tune we initiate (direct our attention out activities that are dull, uninter- How is AD /HD Diagnosed? to where it is needed or desired esting, or unstimulating. Their at the moment); performance is inconsistent both AD/HD is considered a mental at home and in school. Social health disorder. Only a licensed we sustain (pay attention for as situations are affected by frequent professional, such as a pediatri- long as needed); shifts or losing track of conversa- cian, psychologist, neurologist, tions, not listening to others, and psychiatrist, or clinical social we inhibit (avoid focusing on not following directions to games worker, can make the diagnosis something that removes our or rules (APA, 2000). that a child, teen, or adult has AD/ attention from where it needs HD. These professionals use the to be); and finally Symptoms of inattention, as listed in the DSM-IV-TR', are: Diagnostic and Statistical Manual of we shift (move our attention to Mental Disorders, Fourth Edition, Text other things as needed). Revised (DSM-IV-TR) as a guide (a) often fails to give close (APA, 2000). attention to details or makes careless mistakes in schoolwork,. Over the last 10 years, public ...the main features work, or other activities; awareness about AD/HD has led to more children and adults of the disability [are]: (b) often has difficulty sustain- being diagnosed with the disor- inattention, hyperactivity, ing attention in tasks or play der. Some people have expressed and impulsivity. activities; concern that the condition is (c) often does not seem to being overdiagnosed. The Ameri- listen when spoken to directly; can Medical Association (AMA) Children with AD/HD can pay (d) often does not follow took a serious look into these attention. Their problems have to claims. According to AMA's Special through on instructions and fails do with what they are paying to finish schoolwork, chores, or Council Report, however, there is attention to, for how long, and little evidence of widespread duties in the workplace (not due under what circumstances. It's not overdiagnosis of AD/HD or over- to oppositional behavior or failure enough to say that a child has a prescription of medication for the to understand instructions); problem paying attention. We disorder (Goldman et al., 1998). need to know where the process is (e) often has difficulty organiz- In order to be diagnosed with breaking down for the child so ing tasks and activities; AD/HD, children and youth must that appropriate individualized meet the specific diagnostic criteriaremedies can be created. (f) often avoids, dislikes, or is set forth in the DSM-IV-TR. These reluctant to engage in tasks that With AD/HD, we see three criteria are primarily associated require sustained mental effort common areas of inattention with the main features of the (such as schoolwork or home- problems: disability: inattention, hyperactiv- work); ity, and impulsivity. Let's take a sustaining attention long (g) often loses things necessary closer look at the specific types of enough, especially to boring, for tasks or activities (e.g., toys, behavior that must be evident in tedious, or repetitious tasks; school assignments, pencils, order for a diagnosis of AD/HD to books, or tools); be made. resisting distractions, especially to things that are more interest- (h) is often easily distracted by * Reprinted with permission from the ing or that fill in the gaps when extraneous stimuli; Diagnostic and Statistical Manual of sustained attention quits; and Mental Disorders, Fourth Edition, Text (i) is often forgetful in daily Revision. Copyright 2000 American not paying sufficient attention, activities. (APA, 2000, p. 92') Psychiatric Association. especially to details and organi- zation.

AD/HD Briefing Paper (3rd Ed.) 3 NICHCY: 1-800-695-0285 Hyperactivity (d) often has (h) often has difficulty difficulty playing or awaiting turn; Excessive activity is the most engaging in leisure visible sign of AD/HD. Studies activities quietly; (i) often interrupts show that these children are more or intrudes on others active, than those without the (e) is often "on the (e.g., butts into conversa- disorder, even during sleep. The go" or often acts as if tions or games). greatest differences are usually "driven by a motor;" seen in school settings (Barkley, For a diagnosis of predominantly 2000): Many parents find their (f) often talks excessively. (APA, inattentive type of AD/HD, six or toddlers and preschoolers quite 2000, p. 92') more of the inattention symptoms must be present (see list on page active. Care nriust be given before Impulsivity labeling a young one as hyperac- 3). For a diagnosis of hyperactive/ tive. At this developmental 'stage, a Children and youth with AD/ impulsive type, six or more of the comparison should be made HD often act without fully consid-hyperactivity or impulsivity symp- between the child and his or. her ering the circumstances or the toms must be present (see lists on same-age peers without AD/HD. consequences.. Actually, thinking this page). For a diagnosis of In young children, usually the about the potential outcomes of combined type, six or more symp- hyperactivity of AD/HD will come their actions before the fact often toms of inattention, plus six or more symptoms of hyperactivity or across as "always' on the go".or does not even cross their minds. "motor driven." You may see Their neurobiologically caused impulsivity, must be present. behaviors such as darting out of problem with impulsivity makes it The word often appears before the house or into, the street, hard to delay gratification. Waitingeach symptom of inattention, excessive climbing, and less time even a little while is too much for hyperactivity, and impulsivity in spent with any one toy. In elemen-their biological drive to have it now.the DSM-IV-TR. In order to be tary years, children with AD/HD The impulsivity leads these considered a symptom of AD/HD, will be more fidgety and squirmy a behavior can't be "a once in a than their same-age peers who do children to speak out of turn, interrupt others, and engage in while" problem. Nor can it be a not have the disorder. They also problem that pops up all of a are up and out of their seats more.what looks like risk-taking behav- ior. The child may run across the sudden. According to the DSM-IV- Adolescents and adults feel more TR, the following must be true: restless and bothered by quiet street without looking or climb to activities. At all ages, excessive and the top of very tall trees. Although There must be dear evidence of loud talking may be apparent. such behavior is risky, the child is significant difficulty in two or (APA, 2000) not so much a risk-taker as a child more settings (e.g., at home, in who has great difficulty controlling school, with peers, or at work). Symptoms of hyperactivity, as impulse and anticipating conse- listed in the DSM-IV-TR', are:. quences. Often, the child is sur- Symptoms of inattention, prised to discover that he or she hyperactivity, or impulsivity (a) often fidgets with hands or has gotten into a dangerous must be present at least six feet or squirms in seat; situation and has no idea of how months. (b) often leaves seat in class- to get out of it. Some studies shoW that these children are more Some of these symptoms have room or in other situations in to cause problems before age 7. which remaining seated is ex- accident prone,"particularly those pected; youth who are somewhat stub- The symptoms have to be born or defiant (Barkley, 2000). developmentally inappropriate. (c) often runs about or climbs excessively in situations in which it Symptoms of impulsivity, as "Developmentally inappropri- is inappropriate (in adolescents or listed in the DSM-IV-TR (APA, ate" is an important point. If you adults, may be limited to subjec- 2000, p. 92'), are: look again at the symptom list for the three main features of AD/HD, tive feelings of restlessness); (g) often blurts out answers you will notice that some of these before questions have been com- behaviors may be fairly normal at pleted; certain ages. For instance, no one

NICHCY 1-800-695-0285 4 AD/HD Briefing Paper (3rd Ed.) expects a two year old to keep essence, our brain has a capable With AD/HD, the very brain track of toys or to stay seated for executive or boss. areas responsible for executive very long. So, losing things or not function and inhibition are im- being able to stay in a chair for Of course, none of us is born paired. Children with AD/HD can long would not be considered being our own executive. We be considered hypenesponsiye, symptoms of AD/HD at that age. acquire these skills as our brains because they behave too much. These same behaviors in a ten yeardevelop and mature. Until we are They are more likely to respond to old, however, would be develop- able to monitor and. regulate our events that others usually over- mentally inappropriate. We don't own activities and lives, we rely onlook (Barkley, 2000). Their charac expect a ten year old to constantlypeople and things outside of teristic disinhibition often causes lose things. We do expect a ten ourselves to guide and direct us. others to find them annoying, year old to be able to stay seated Puberty marks the time when we irritating, or exasperating. during a half-hour of class or a become increasingly "brain-able" family dinner. to be our own boss. AD/HD is determined by the Our executive number of symptoms present and abilities also help us to Research is showing us the extent of the difficulty these concentrate longer and that AD/HD impairs the brain's to keep track of our cause. Also, the number of symp- executive function ability... toms and the problems they cause thoughts, especially may change across the life span. Inthose we need later. [which allows us to] think, plan, a small number of cases, AD/HD We are less distracted organize, direct, and monitor our by our own thoughts does go away in adolescence or thoughts and activities. adult years. However, in most and find it much easier cases, the problems shift. A hyper-to return to work after active-impulsive fourteen year old we've been distracted. Obviously, executive function may be able to stay seated longer The brain's executive abilities difficulties can create distress and than he or she could at age nine. also help us inhibit, or control, problems with daily functioning, While problems caused by hyper- behavior. Inhibition is the ability including emotional control. In activity-impulsivity seem to lessen to delay or pause before acting or addition to symptoms of inatten- with age, other AD/HD-related doing. It allows us to regulate our tion, impulsivity, and hyperactiv- symptoms usually become more thoughts, actions, and feelings. ity, you may also see these types of problematic. For instance, de- This self-regulation or self-control executive function problems: mands for longer periods of helps us manage or limit behavior. weak problem solving, sustained attention increase with We learn to say "not now" or "not age. So, for example, even though a good idea" to impulse. We learn poor sense of time and timing, a fourteen year old may sit still to control our activity levels to during a lengthy reading assign- meet situational demands. For inconsistency, ment, he or she may be bothered example, to yell at a ball game is difficulty resisting distraction, by an inability to concentrate. fine (unless we are shouting in someone's ear). Yelling in a class- difficulty delaying gratification, What Are Other room is usually not okay. Signs of Ab/Hb? problems working toward long- Thanks to our brain's executive term goals, Research is showing us that AD/abilities, we become driven more HD impairs the brain's executive by intention than impulse. That low "boiling point" for frustra- function ability. It's as if the brain means we pause and reflect before tion, has too many workers but no bosswe act. For instance, we are able to to direct or guide them. When the emotional over-reactivity, consider the demands of a situa-, brain's executive function abilities tion along with the rules. We can changeable mood, and operate appropriately, we think, delay an immediate reward in plan, organize, direct, and monitororder to hold out for a later poor judgment. our thoughts and activities. In reward that's more meaningful.

AD/HD Briefing Paper (3rd Ed.) 5 6 NICHCY: 1-800-695-0285 It's important to remember that How Do I Know For Sure What is the Recommended the self-control and self-regulation That My Son or Daughter Diagnostic Procedure? problems seen in people with AD/ Has AD/HD? The American Academy of HD are not a matter of deliberate Pediatrics (2000) recommends that choice. These problems are caused At present, no laboratory test clinicians collect the following by neurological events or condi- exists to determine if your child information when evalu- tions. People with AD/HD know has this disorder. You can't diag- ating a child for AD/HD: how to behave. They generally nose AD/HD with a urinalysis, blood test, CAT scan, MRI, EEG, know what is expected in a given 1. A thorough medical situation. But they run into PET or SPECT scan, although some of these technologies are used for and family history. trouble at the point of perfor- mancethat moment in time research purposes. 2. A medical examina- when they must inhibit behavior Diagnosing AD/HD is compli- tion for general health to meet situational demands. Theircated and much like putting and neurologic status. troubles may show up in how they together a puzzle. You, as a parent, 3. A comprehensive interview act in the outside world, or in may think your child has AD/HD, with the parents, teachers, and their internal selves. They charac- but an accurate diagnosis requires child. teristically have inconsistent an assessment conducted by a performance. This inconsistency is well-trained licensed professional 4. Standardized behavior rating often mistaken for a lack of regard (usually a developmental pediatri- scales, including AD/HD-specific or respect, or as a lack of effort. cian, child psychologist, child ones completed by parents, psychiatrist, pediatric neurologist, teacher(s), and the child when Because of inhibition problems, appropriate. (Know that people the disorder also makes it hard foror clinical social worker). This with AD/HD typically are not great the young person to follow the person must know a lot about at accurately reporting symptoms rules, especially if the rules are notAD/HD and all other disorders of the disorder, because it causes crystal clear. Children with AD/HDthat can have symptoms similar to them to have poor insight into usually need a lot of incentive to those found in AD/HD. Until the their own behavior.) follow the rules, too. That doesn'tpractitioner has collected and evaluated all the necessary infor- mean that they are intentionally 5. Observation of the child. bratty or demanding. When a mation, he or shelike you, the child's executive and inhibition parentcan only assume that the 6. A variety of psychological mechanisms are not functioning child might have AD/HD. tests to measure IQ and social and fully or normally, then we need to The AD/HD diagnosis is made emotional adjustment. These tests provide external incentives to on the basis of the observable also help to determine the pres- pump up the child's ability to behavioral symptoms listed on ence of specific learning disabili- inhibit thoughts, feelings, and pages 3 and 4. The symptoms of ties, which can co-occur with AD/ actions. AD/HD must occur in more than HD. Performance usually improves one setting. The person doing the Once the practitioner completes when external guides, rewards, andevaluation must use multiple the evaluation, he or she makes incentives are provided. These sources of information. Since symp- one of three determinations: toms of AD/HD can also be might include step-by-step ap- 1. The child does or does not proaches, extra praise and encour- associated with many other condi- have AD/HD. agement, and the tions, be wary of any practitioner chance to earn specialwho makes a snap diagnosis either because you've said you think 2. The child does not have AD/ privileges for better HD, but either has another performance. More your child has AD/HD or because he or she has observed the child disorder(s) or other factors that will be said about have created the difficulties. these approaches in once. Children with AD/HD Section II of this commonly behave well on the first 3. The child has AD/HD and meeting. Furthermore, personal Briefing Paper. another disorder (called a co- observation is only one source of existing condition). information.

NICHCY: 1-800-695-0285 6 AD/HD Briefing Paper (3rd Ed.) To make the first determina- so such events do not automati- anxiety. A list of disorders that tionthat the child has or does cally rule out the existence of AD/ commonly co-occur with AD/HD not have AD/HDthe clinician HD. is provided in the box below. considers his or her findings in relation to the criteria of the DSM- To make the third determina- The fact is: Other mental health IV-TR mentioned earlier. tionthat the child has AD/HD conditions such as those listed in and a co-existing conditionthe the box below can be the result of To make the second determina- assessor must first be aware that AD/HD, in addition to AD/HD, or tionthat the child's difficulties AD/HD can and often does co- mistaken for AD/HD. That is why are caused by another disorder or occur with other difficulties, evaluations need to be conducted other factorsthe professional particularly learning disabilities, by a professional who is trained in first considers the disorders that oppositional defiant disorder, and a wide variety of child and adoles- have symptoms similar to AD/HD. You should be aware that some mental health disorders have their Disorders That Commonly Co-Occur With AD/HD onset after puberty, but early warning signs, which are very For more information about the following disorders that frequently similar to AD/HD symptoms, may occur with AD/HD, see the resource list on page 21. be present. Thus, it is possible for a diagnosis to change as the child Oppositional Defiant Disorder (ODD)A pattern of negative, hostile, develops and other disorders and defiant behavior. Symptoms include frequent loss of temper, become more apparent. It is also arguing (especially with adults), refusal to obey rules, intentionally possible for a child or youth to annoying others, blaming others. The person is angry, resentful, have more than one disorder, or possibly spiteful, and touchy. (Many of these symptoms disappear co-occuring disorders. with AD/HD treatments.) Generally, the DSM-IV-TR Conduct Disorder (CD)A pattern of behavior that persistently requires clinicians to rule out AD/ violates the basic rights of others or society's rules. Behaviors may HD if they see Pervasive Develop- include aggression toward people and animals, destruction of mental Disorder (PDD), schizo- property, deceitfulness or theft, or serious rule violations. phrenia, other psychotic disorders, AnxietyExcessive worry that occurs frequently and is difficult to or if the symptoms are better control. Symptoms indude feeling restless or on edge, easily fa- explained by another disorder. For tigued, difficulty concentrating, irritability, muscle tension, and sleep instance, although not very com- disturbances. mon, Bipolar Disorder (BPD) can be mistaken for AD/HD in early DepressionA condition marked by trouble concentrating, sleeping, years. and feelings of dejection and guilt. There are many types of depres- sion. With AD/HD you might commonly see dysthymia, which It is also true that major stress- consists of a depressed mood for many days, over or under eating, ful life events can result in tempo- sleeping too much or too little, low energy, low self-esteem, poor rary symptoms that look like AD/ concentration, and feeling hopeless. Other forms of depression may HD. Such events could indude also be present. parental divorce, child abuse, death of a loved one, a move, or a Learning DisabilitiesProblems with reading, writing, or mathemat- sudden traumatic experience. ics. When given standardized tests, the student's ability or intelli- Under these circumstances, AD/ gence is substantially higher than his or her achievement. Under- HD-like symptoms may arise achievement is generally considered age-inappropriate. [Note: suddenly and, therefore, would Children with AD/HD frequently have problems with reading have no long-term history. Re- fluency and mathematical calculations. AD/HD learning problems member, AD/HD symptoms must have to do with attention, memory and executive function difficul- exist for at least six months and ties rather than dyslexia, dysgraphia, or dyscalculia, which are learn- cause some difficulty before the ing disabilities. The point here is not to overlook either. Depending age of seven. Of course, a child can on how learning disabilities are defined, between 10-90% of youth have AD/HD and a stressful event, with AD/HD also have a learning disability (Robin, 1998).]

AD/HD Briefing Paper (3rd Ed.) 7 NICHCY: 1-800-695-0285 cent disorders. Thorough and child's pediatrician, a community Thus, if you suspect that your correct diagnosis is an essential mental health center, a university child has an attentional or hyper- first step to better treatments. mental health clinic, or a hospital activity problem, or know for child evaluation unit. certain that your child has AD/HD, and his or her educational perfor- How Do I Have My Child It is important for you to Evaluated for AD /HD? mance appears to be adversely realize, however, that the schools affected, you should first request When your child is experiencinghave an affirmative obligation to that the school system evaluate difficulties that suggest that he or evaluate a child (aged 3 through your child. Be sure to put your she may have AD/HD, you as a 21) if school personnel suspect request in writing. Your letter parent can take one of two basic that the child might have AD/HD should include the date, your paths to evaluation. You can seek or any other disability that is name, your child's name, and the the services of an outside profes- adversely affecting educational reason(s) you are requesting an sional or clinic, or you can requestperformance. (That means the evaluation. The letter should state that your local school district child must be having difficulties inthe type of educational difficulties conduct an evaluation. school. Those difficulties include your child is experiencing. Keep a social, emotional, and behavioral copy of the letter in your file. In pursuing a private evaluationproblems, not just academic or in selecting a professional to troubles.) (See the box below if Preschoolers (children aged 3 perform an assessment for AD/ your child is under three years through 5) may be eligible for HD; you should consider the old.) This evaluation is provided services under Part B of the Indi- clinician's training and experience free of charge to families and viduals with Disabilities Education with the disorder, as well as his or must, by law, involve more than Act (IDEA). If your child is a her availability to coordinate the one standard- preschooler, you may wish to various treatment approaches. ized test or contact the State Department of Most AD/HD parent support procedure. Education or local school district, groups know clinicians trained to ask your pediatrician, or talk with evaluate and treat children with local day care providers about how AD/HD. You may also ask your to have your child assessed through your school district's special education department. But My Child is a Toddler... Also, under Head Start regula- If your child is under three years old, and you suspect that AD/HD tions, AD/HD is considered a may be affecting his or her development, you may want to investi- chronic or acute health impair- gate what early intervention services are available in your state ment entitling the child to special through the Part C program of the Individuals with Disabilities education services when the child's Education Act (IDEA). inattention, hyperactivity, and Since AD/HD is a developmental disorder, diagnosing young impulsivity are developmentally inappropriate, chronic; and dis- children requires some special consideration. For instance, toddlers don't pay attention for long periods of time, so a dinician played in multiple settings, and wouldn't necessarily find inattention in a toddler a symptom of when the AD/HD severely affects performance in normal develop- AD/HD. Also, toddlers are more easily frustrated and do shift mental tasks (for example, in activities a lot. It's important that the person doing the diagnosis planning and completing activities be very familiar with normal child development in order to deter- or following simple directions). mine what behaviors would be inappropriate for that age. You can find out about the availability of early intervention ser- If your child is school-aged (six vices in your state by contacting the state agency responsible for or older), and you suspect that administering early intervention services (which is listed on AD/HD may be adversely affecting his or her educational perfor- NICHCY's State Resource Sheet), by asking your pediatrician, or by contacting the nursery or child care department in your local mance, you can ask your local hospital.

NICHCY 1-800-695-0285 8 AD/HD Briefing Paper (3rd Ed.) school district to conduct an evaluation. With the exception of IbEA's Definition of "Other Health Impairment" the physical examination, the assessment can be conducted by In order to be eligible for special education, a student must meet the school personnel as long as a definition criteria for at least 1 of 13 disability categories listed in the member of the evaluation group is federal regulations. Some students may meet more than one definition. knowledgeable about assessing Many students with AD/HD now may qualify for special education services AD/HD. If not, the district may under the "Other Health Impairment" category within the Individuals with need to use an outside profes- Disabilities Education Act (IDEA). IDEA defines "other health impairment" sional consultant trained in AD/ as... HD assessment. This person must "...having limited strength, vitality or alertness, including a height- know what to look for during ened alertness to environmental stimuli, that results in limited child observation, be competent alertness with respect to the educational environment, that is due to to conduct structured interviews chronic or acute health problems such as asthma, attention deficit with parents, teacher(s), and child, disorder or attention deficit hyperactivity disorder, diabetes, epi- and know how to administer and lepsy, a heart condition, hemophilia, lead poisoning, leukemia, interpret behavior rating scales. nephritis, rheumatic fever, and sickle cell anemia; and adversely Identifying where to go and affects a child's educational performance." whom to contact in order to 34 Code of Federal Regulations §300.7(c)(9): request an evaluation is just the first step. Unfortunately, many parents experience difficulty in the next stepgetting the school However, if the school district cases offer direct assistance. You system to agree to evaluate their does not believe that your child's may also use a special education child. In the past, some schools educational performance is being attorney. adversely affected, it may refuse to have not understood their obliga- For children who are evaluated tions to serve children who, evaluate your child. In this case, there are a number of actions you by the school system, eligibility for because of their AD/HD, are in special education and related need of special education and can take, including pursuing a private evaluation. It is also impor-services will be based upon evalua- related services. In 1999, AD/HD tion results and the specific poli- was specifically listed in the federaltant to persist with the school, enlisting the assistance of an cies of the state: Many parents regulations of IDEA under the have found this to be a problem- disability category of "other healthadvocate, if necessary. You can generally find this type of assis- atic area as well. Therefore, eligibil- impairment" (see definition in the ity for special education services box above). The indusion of AD/ tance by contacting the Parent Training and Information (PTI) and the services themselveswill HD in this disability category be discussed in greater detail in should help to clarify the school's center for your state, the Protec- tion and Advocacy (P&A) agency, Section III of this Briefing Paper obligation to evaluate children (see page 15). who are suspected of having AD/ or a local parent group. (Contact HD that is adversely affecting NICHCY to get a State Resource For the moment, however, let educational performance. Sheet, which lists your state's PTI us look at what we know about and P&A.) A school district's managing AD/HD and the specific refusal to evaluate a child sus- difficulties associated with the pected of having AD/HD involves disorder. issues that must be addressed on an individual basis. Your state's PTI, P&A, or a local parent group will typically be able to provide information on a parent's legal rights, give specific suggestions on how to proceed, and in many

AD/HD Briefing Paper (3rd Ed.) 910 NICHCY 1-800-695-0285 How is Ab/Hb Treated? 1Parent, Child, and Teacher 2Medication Education about the Disorder Like many medical conditions, The MTA study found medica- AD/HD is managed, not cured. Often, the first treatment step tion to be very effective in the There's no "quick fix" that resolvesbegins with learning what AD/HD management of AD/HD symp- the symptoms of the disorder. Yet is and what to do about it. This toms. Since AD/HD is a neuro- a lot can be done to help. Throughknowledge will help you under- biochemically-based problem, it effective management, some of thestand that the way stands to reason that medication secondary problems that often your child thinks, that gets to the core of the prob- arise out of untreated AD/HD mayacts, and feels has lem would be effective. The medi- be avoided. In the majority of a lot to do with cation most often used is stimu- cases, AD/HD management will be circumstances lant medication, especially meth- a life-long endeavor. It may be outside his or her ylphenidate. Most people know helpful to think of AD/HD as a control. When we this medication as the drug Rita lin. challenge that can be met. understand the There are other stimulant medica- nature of the tionsConcerta, Metadate, Recently, the National Institute challenge, we are Dexedrine, Cylert, and Adderall, an of Mental Health (NIMH), in better equipped amphetamine compound. combination with the U.S. Depart-to meet the ment of Education's Office of challenge. These medications are believed Special Education Programs to work by stimulating the action (OSEP), completed a long-term, Understanding AD/HD also of the brain's neurotransmitters, multi-site study to determine changes the way in which a child's especially dopamine. With the which treatments had the greatest behavior is viewed. When we brain's systems working more positive effect on reducing AD/HDknow more about AD/HD, we efficiently, attention, memory, and symptoms. This study is known as come to understand that the child executive functions, including the MTA study (The MTA Coopera- has troubles and is not the cause of inhibition, are improved. The tive Group, 1999). MTA stands for those troubles. result is better concentration, multi-modal treatment study of increased working memory capac- children with AD/HD. There are accommodations that ity, greater recall, less hyperactivity, can help your son or daughter and more impulse control. Stimu- The recommended multi-modaladapt reasonably well. It is critical lant medications do not tend to treatment approach consists of to learn what these accommoda- help with symptoms of anxiety or four core interventions: tions are and to work to see that depression (Barkley, Du Paul, & they are put in place across differ- O'Connor, 1999). 1. patient, parent, and teacher ent environmentsschool, home, education about the disorder; community. Children with AD/HD The decision to place a child on 2. medication (usually from the need strong advocates. They also medication may not be an easy class of drugs called stimulants); need to be taught self-advocacy one, especially given the contro- skills if they are to successfully versy that surrounds the stimu- 3. behavioral therapy; and manage their symptoms through- lants, specifically Rita lin. There out life. Self-advocacy should have been many reports that 4. other environmental sup- begin early in life. Help your child medication is overprescribed for ports, including an appropriate understand and identify his or her treatment of AD/HD. However, school program. difficulties. Teach him or her how according to the American Medical Each of these core interventions to ask for help and accommoda- Association's Council on Scientific is described in more detail below. tions. Affairs (Goldman et al., 1998), These approaches are your tool "There is no widespread over- chest. prescription of methylphenidate by physicians" (p. 1100). By fol- 11 NICHCY: 1-800-695-0285 10 AD/HD Briefing Paper (3rd Ed.) lowing good diagnostic information for any parent or procedures, the chances of Often, the first treatment step teacher of a child with AD/ overprescribing this medica- HD. tion are significantly reduced. begins with learning what Some children cannot take AD/HD is and what to do Researchers have identified effective strategies that stimulant medications. In about it. When we understand these cases, the physician parents can use. The follow- knows what other medica- the nature of the challenge, ing brief explanation gives tions can be helpful in reliev- you an idea of the types of we are better equipped help your son or daughter ing AD/HD symptoms. to meet the challenge. Medication may not be the needs, along with some right approach for every child. examples. You can find a lot more help through reading, Always discuss any medication Some parents are reluctant to talking to other parents, and treatment thoroughly with your place their child on medication for working with a clinician. child's physician. He or she shouldfear that doing so may lead to later explain the benefits and the substance abuse. Researchers have You must consider the age of drawbacks of medication to you looked into this concern quite your child, and his or her ability and also to your child, if appropri- seriously. A recent study supports before using any strategy. A good ate. When medication is first previous findings that stimulant rule of thumb is to provide inter- prescribed, the physician should medication treatment may actually ventions until your son or daugh- start with a low dose and then prevent later substance abuse ter demonstrates that these are no gradually raise it until the symp- (Zametkin & Ernst, 1999). As with longer needed. If you withdraw toms improve. You will need to any medication, though, parents interventions and problems re- dispense the medication as pre- must carefully monitor its use to occur, put the interventions back scribed and closely monitor its be sure that the medication is in place. effects, including any side effects. taken as prescribed. With stimulants, most side effects 3Behavioral Therapy are quite mild and go away over Behavior Intervention A time. Since your child spends a As parents and teachers know, Be an executive 4.4: large portion of his or her day at AD/HD can cause significant Provide structure,. routines,. school, you will also need to be in inappropriate behavior. Frequent assistive devices, .eXternal.. contact with your child's teachers complaints include failure to supports, and guides:- to determine positive effects and follow rules, listen to commands, side effects. Communicate with thecomplete tasks, delay gratification, Think of the executive as the physician often, especially when or control impulse. In addition, boss who creates a work environ- medication is started. Call immedi-some youth may be aggressive or ment in which all the workers ately with any problems or ques- anxious. These symptoms lead to know what they have to do to do tions. their own set of problems, such as their jobs appropriately. The boss Also be aware that during fighting or avoiding tasks. It is very easy for everyone involvedthe also provides the necessary struc- adolescence many teens actively ture for them to do so. Perfor- resist taking medication. If this child, the parents, and the teacher(s)to be worn down into mance expectations and company happens, it's wise to discuss the rules are clear. The executive super- a pattern of negative, and some- situation with your child's doctor. vises and directs but does not times hostile, interactions. This While medication cannot be forced overmanage or micro-manage. cycle, however, can be broken, and on an unwilling patient, the doctor Children who have difficulty with may have some ideas of how to different, more positive interac- tions and behavior patterns can be planning, thinking, organizing, work with your son or daughter concentrating, and self-monitoring about any resistance to taking the developed. Knowing more about behavior and how to support need to have systems in place to medication. guide and direct them. Parents and behavior that is positive and teachers need to be the executives appropriate is extremely useful in the child's life.

AD/HD Briefing Paper (3rd Ed.) NICHCY: 1-800-695-0285 11 12 Examples: Behavior Intervention B- not happen. You change what 4' Develop behavior happens before the behaviorhead Make your expectations dear. it off at the pass, so to speak. For Say, "I expect you to..." management strategies + Use positive attention, rules instance, if your child constantly Try to do things at the same and consequences, and formal forgets things for school, design a time every dayhomework, systems such as contracts and system for where to put things so playtime, recreation, bedtime. charts. they get picked up on the way out Post the schedule on the fridge. the door. When making schedule changes, The main goal of all behavior Your son or daughter needs to give advance warning as much management strategies is to in- know ahead of time what behavior as possible. crease the child's appropriate is expected. He or she also needs behavior and decrease inappropri- to know what the consequences Have simple systems for organi- ate behavior. The best way to will be for behaving (following the zationwhere to keep posses- influence any behavior is to pay rules) or misbehaving (breaking sions and needed items such as attention to it. Thus, the best way the rules). Consequences are given backpacks, gym clothes, pens, to increase a desirable behavior is as soon as possible. Give far more and so on. to catch the child being good. positive consequences and rewards than punishment. Children who Use homework organizers, Children with AD/HD receive a hear too much negative feedback notebook organizers, day tremendous amount of negative often become oppositional or planners, weekly planners, feedback. Parents and teachers depressed. Managing behavior computers, or even laptops need to learn to give much more thoughtfully, without a lot of when called for. positive attention and feedback. reaction, especially undue punish- That means you have to pick your ment or criticism, helps to prevent Do backpack cleaning and battles carefully and let a lot of notebook organization once a unwanted side effects of poorly nonessential stuff slide. Otherwise, managed AD/HD. week. increased conflict and arguments Understand that you and your between you and your child can Some families need to use child's teachers will need. to provide result. formal behavior management systems. These include charts or much more direct supervision than How do you make the bulk of seems necessary for the chronological contracts. The difference between your interactions positive and yet the two is simple. age. Remember, AD/HD is a devel- still provide discipline? With opmental disability, so these youththought and planning. Effective Generally, contracts are used usually fall short of age expecta- parents (and teachers) know aheadduring early to mid-adolescence. In tions. of time what behavior is acceptablea contract, the involved parties and not acceptable. They know (usually the parents and child, or what issues they are willing to teacher and student) talk about negotiate and which ones, like certain chores or obligations that safety, are non-negotiable. In a the youth will fulfill. They draw up nutshell: Don't sweat the small an agreement. The youth receives stuff, and don't ignore the good certain agreed-upon privileges or stuff no matter how small. rewards for meeting the terms of the contract. Much of behavior management is about changing what you do. Charts are usually used for Your house rules (or the classroomchildren ages 11 or younger. A chart rules) need to be carefully de- lists behaviors that the child must signed. First, you want to structuredisplay. Points are given or taken them so that your child or teen away depending on the child's will be able to meet the expecta- behavior. Accumulated points may tions. In other words, you don't be traded for rewards. wait for a behavior to happen or

N1CHCY: 1-800-695-0285 12 13 AD/HD Briefing Paper (3rd Ed.) If you decide to make a behav- fact way. Your child needs to be Very often, people spend a lot ior modification chart, you may taught to .replace inappropriate of time solving the wrong prob- wish to follow these three simple with appropriate behavior. lem. It's important to analyze steps. problem areas. Pay attention to About time-out: When your child the facts and not the emotions of Make a list of problematic is misbehaving or out of control, the situation. Brainstorm to find behaviors or ones that need time-out can be an effective way topossible solutions. Put down all improving. manage the problem. Time-out ideas that come to mind. Evaluate means that your child is sent for a them. Pick the one that seems Select three to five short period of time to a previ- behaviors from the most likely to work. Go back to ously agreed-upon placeusually the drawing board if it doesn't. list. Review the list out of the main hub, like a special and, with input This approach helps to stop chair or area of a room. In general, conflict from escalating. from your child, he or she stays in time-out and select the behaviors must be quiet for three to five For example: Suppose your to work on. Pick behaviors that minutes. The time-out place child argues when you ask him or occur on a daily or frequent should not be a traumatic place, her to do a chore. While it appears basis, such as doing homework, such as a closet or dark basement. as if arguing is the problem, actu- going to bed on time, being The purpose of time-out is to ally that behavior might be the respectful to all family mem- provide a cooling off place where result of some problem with the bers, or doing chores. your child can regain control. request to do chores. Instead of Create a reward system. Assign a focusing on the arguing, direct Time-out works best with pre- your attention to the chore and point value to each listed adolescent kids. You can also use behavior. Throughout the day, what that problem is. For instance, time-out with teens. Usually that do you have a regular chore sched- give points for appropriate means asking your teen to go to behavior. At the end of the day ule? Are expectations clear? Does his or her room until he or she the child understand all the task or week, your child can "cash calms down. in" points for rewards or privi- expectations? Is there a definite leges that have been agreed time line? To some children, upon in advance. Behavior Intervention C picking up the room means mov- ing a couple of things out of the In order for rewards to work, Use problem solving + Develop skills in the art of way. they must have value to the child. Since children with AD/HD tend negotiation, give and take, and Once you clearly define the to become disinterested in the conflict resolution through problem, then you can brainstorm same thing over time, the rewards peaceful means. for a workable solution. Let's say usually need to be changed fre- your child understands all aspects quently to have value. (For more Problem solving helps take the of the chore, but it still doesn't get detailed information on how to reaction out of parenting. It is done without your nagging or design and use charts and con- results-oriented. If your child is threatening. Come up with a plan tracts, see the suggested reading listmature enough, involve him or herwhere the child knows exactly starting on page 21.) in this process. Good problem what to do by when. Decide if solving has three parts: reminders will be given. Give a About punishment: Children and reward for on-time chore comple- teens with AD/HD respond best to accurately defining the problem,tion. Give a bonus if the chore is motivation and positive reinforce- coming up with workable done ahead of time. Penalize the ment. It is best to avoid punish- solutions, and child if the chore is not done on ment. When punishment is neces- time, but don't nag. Take action. sary, use it sparingly and with evaluating results and trying Don't react. Make not doing the sensitivity. It is important that you something else, if necessary. chore the child's problem and not and your child's teachers respond yours. to the inappropriate behavior without anger and in a matter-of-

1 4 AD/HD Briefing Paper (3rd Ed.) 13 NICHCY: 1-800-695-0285 Behavior Intervention D eliminate putdowns, most attention, may actually be by-products of the school environ- + Use good express our agreement, and ment and AD/HD. These usually communication skills + occur when tasks are too long, too Say what you mean in a firm, use praise. hard, or lack interest. Many behav- loving way. Practice listening Problem solving and good ior problems can be avoided or without judgment and discus- communication help to eliminate lessened by adapting the school sion without attack. Recognize some of the oppositional and setting to fit the needs of the that your child with AD/HD has hostile encounters that often student. trouble listening. Be brief and to accompany the disorder of AD/ the point. HD. In the school arena, AD/HD is an educational performance problem. Screaming, yelling, speaking 4Educational When little or nothing is done to through clenched teeth, stamping Interventions help children with AD/HD im- prove their performance, over time feet, throwing things, finger point- One of the most critical areas in ing, and making threats are violent they will show academic achieve- which to offer support is in ment problems. This under- forms of communication. These the school arena. This escalate problems, as do put- achievement is not the result of an is where most chil- inability to learn. It is caused by downs, sarcasm, lecturing, preach- dren with AD/HD ing, and name calling. When we are the cumulative effects of missing experience the important blocks of information using good communication skills, greatest difficulty. we: and skill development that build That is because schools require from lesson to lesson and from let the speaker finish, great skill in the areas where one school year to the next. (It students with AD/HD are the concentrate on what is being weakest: attention, executive said, function, and memory. Although AD/HD does not interfere with show interest, the ability to learn, it does wreak avoid judgment, havoc on performance.Behavior problems, which usually get the

Ways to Improve Life in General Become Proactive. Knowledge is power. Gain knowledge about AD/HD so you under- stand why and how this disability affects your son or daughter at home, in school, in social situations, and how it affects your entire family. Change Your Belief System. Before your son or daughter can change his or her self- concept, the adults in the child's life have to change the way they view him or her. Separate the child from the behavior, and then separate the child from the disability. We don't have "AD/HD children." We have children who have AD/HD. De-stress. Find positive ways to soothe yourself. For example, exercise, meditate, take long walks. Less stress means better self-control. Look for the humor in things, and enjoy a good laugh. Act, Don't React. Emotional responses such as blame and anger lessen when you stop, look, listen, and then respond. Thoughtful parenting is needed here. Catch the Child Being Good. The home atmosphere and the child's sense of self-worth change when the air fills with words of praise and encouragement. Pay plenty of posi- tive attention to your son or daughter. Reward and show appreciation when he or she does what is expected. 15 NICHCY: 1-800-695-0285 14 AD/HD Briefing Paper (3rd Ed.) should be noted that a number of Those teaching or designing child would need guidance to students with AD/HD also have programs for students with AD/ follow all the directions. The third learning disabilities, and these do HD need to pinpoint where each child would need help in making interfere with the ability to learn.) student's difficulties occur. Other- transitions from one activity to wise, valuable intervention re- another. Generally, AD/HD will affect thesources may be spent in areas student in one or more of the where they are not critical. The sooner educational inter- following performance areas: ventions begin, the better. They For example, one child with should be started when educa- starting tasks, AD/HD may have difficulty start- tional performance problems staying on task, ing a task because the directions become evident and should not be are not clear. Another student may delayed because the child is still completing tasks, fully understand the directions butholding his or her own on achieve- forget to follow all of them. An- ment tests. Specific suggestions for making transitions, other may have difficulty making educational interventions are interacting with others, transitions and, as a result, get presented in Section III of this stuck in the space where one task Briefing Paper. Other school issues, following through on direc- ends and another begins. With theincluding special educa- tions, first child, intervention needs to tion, are discussed focus upon making directions clearthere as well. producing work at consistently and in helping the child to under- normal levels, and/or stand those directions. The second organizing multi-step tasks.

In the elementary years, AD/HDand self-directed. They receive less retrievalbeing able to locate on usually causes these problems: supervision. Demands for concen- demand information that has tration and more sophisticated been learned and stored in off -task behavior, thinking and problem solving memory. incomplete or lost assignments, increase. AD/HD makes it hard to meet those demands. Many students also show disorganization, problems in: Given the additional problems sloppy work or messy that seem to arise in middle school time management, handwriting, and beyond, it's not unusual to prioritizing work, see a student who's gotten by in not following directions, earlier grades dive bomb academi- reading comprehension, cally around puberty. errors in accuracy, note taking, inconsistent performance, The thinking difficulties associ- ated with AD/HD do not have to study skills, and disruptive behavior or spacey, do with intellectual ability. Instead, completing multi-step tasks. daydreaming behavior, and/or they arise out of problems with concentration, memory, and Clearly, a student with AD/HD social interaction difficulties. cognitive organization. Typically, can have difficulty in any number Around middle school and intoAD/HD-related memory problems of academic areas and with critical high school and beyond, most of arise in two areas: academic skills. Thus, it is ex- these problems continue. How- tremely important that the school working memorywhich helps and parents work together to ever, additional ones arise. That is the student keep one thing in because adolescents are expected design an appropriate educational mind while working on another, to be much more independent program for the student. This and

AD/HD Briefing Paper (3rd Ed.) 15 16 NICHCY: 1-800-695-0285 program needs to include the Presently, the IDEA lists 13 accommodations, modifications, categories of disability under and other services necessary to which a child may be found support the student academically eligible for special education. AD/ and promote successful learning HD is specifically mentioned in the and appropriate behavior. IDEA as part of its definition of "Other Health Impairment." The Will Special Education definition of this disability is Help My Child? provided on page 9. Special education is instruction How Is My Child Found Certain steps typically need to that is specially designed (at no Eligible for Special be taken in order for the child with cost to parents) to meet the Education? AD/HD to be found eligible for unique needs of a child with a The process by which a child is special education services. These disability. "Specially designed" found eligible for special educa- steps are: means adapting the content, tion services is described within 1. The child must be experienc- methodology, or delivery of in- the federal law known as the ing educational performance struction (as appropriate) to the Individuals with Disabilities problems. needs of the child, in order to: Education Act, or IDEA. The IDEA is the federal law under which 2. When such problems become address the unique needs of the schools: evident, the parent, teacher, or child that result from his or her other school staff person must disability, and evaluate children for the pres- request that the child be evaluated ence of a disability and their ensure the child's access to the for the presence of a disability. need for special services, and general curriculum (the same 3. The child is evaluated to curriculum as for students provide special education and determine if he or she does indeed without disabilities) .so that he related services to students whohave a disability and to determine or she can meet the educational meet eligibility requirements. the nature and extent of the child's standards that apply to all need for special education and children within the school Eligibility decisions about a related services. district or jurisdiction. child's need for special education and related services are made on a 4. A group of individuals, Because special education is case-by-case basis. School districts including the parents, meets to specially designed instruction, it may not arbitrarily refuse to either review the evaluation results and may be very helpful to your child. evaluate or offer services to stu- determine if the child meets However, not all children with AD/dents with AD/HD. eligibility criteria set forth in state HD need, or are eligible for, special and federal law. If so, the child is education services. Conversely, In order for your child to be eligible, he or she must have a found eligible for special educa- many would not be able to receive tion and related services. an appropriate education without disability according to the criteria special education services. set forth in the IDEA or under If your child is found eligible state law (state law is based on the for special education, you will then IDEA). The disability must ad- collaborate with school personnel versely affect his or her educationalto develop what is known as an performance. Thus, a medical Individualized Education Program diagnosis of AD/HD alone is not (IEP). Your child's IEP is a written enough to make your child eligibledocument that spells out, among for services. Educational perfor- other things, how your child's mance, which consists of social, specific problems and unique emotional, behavioral, or academiclearning needs will be addressed. performance, must be adversely The IEP considers strengths as well. affected.

I 7 NICHCY: 1-800-695-0285 16 AD/HD Briefing Paper (3rd Ed.) If a child's behavior impedes Read the informa- learning (including the learning oftion the school system others), the parents and school gives you. Make sure it Whether your child receives must consider, if appropriate, includes information services under IDEA, Section 504, strategies to address that behavior. about how to challenge or another program designed to This indudes positive behavioral the eligibility decision. interventions, strategies, and If that information is help students with special needs, supports. This proactive approach not in the materials theit is important that :the intervention to addressing behavior problems isschool gives you, ask be tailored to meet your intended to help individual stu- the school for it. dents minimize discipline prob- child's individual needs. lems that may arise as a result of Also get in touch the disability. If your child has with your State's Parent behavior problems, you will want Training and Information (PTI) What Can Teachers bo To to make sure that these are ad- center. The PTI can tell you what Help a Child with AD /HD? dressed in his or her IEP. steps to take next. Your PTI is listed on NICHCY's State Resource Whether your child receives After specifying the nature of Sheet for your state. services under IDEA, Section 504, your child's special needs, the IEP or another program designed to team (which includes you) deter- It is also helpful to know that help students with special needs, it mines what types of services are students with AD/HD may be is important that the intervention appropriate for addressing those eligible for services under a differ- be tailored to meet your child's needs. The IEP team also decides ent lawSection 504 of the Reha- individual needs. One size does not where your child will receive these bilitation Act of 1973. Section 504 fit all. Work with the school to servicesfor example, the regular is a civil rights law prohibiting identify the nature of your child's education classroom, a resource discrimination on the basis of a special needs and to design an room, or a separate classroom. disability. Any school district that educational program suited to receives federal funds must follow those needs. The IEP is a very important this law. Under Section 504, a document in the lives of students person with a disability means any In addition to the core interven- with disabilities. There is a lot to person with an impairment that tions described in the previous know about how it is developed, "substantially limits one or more section, there are a number of what type of information it con- major life activities." Since learningother educational interventions tains, and what part you, as a is considered a major life activity, that can potentially help students parent, play in writing it. More many students with AD/HD with AD/HD. This section looks at detailed information about the IEPqualify as a "person with a disabil- some of the more common inter- process is available from NICHCY, ity" under Section 504. Schools areventions, modifications, and either by contacting us directly then required to provide them adaptations. (at 1-800-695-0285) or by visiting with a "free appropriate public our Web site (www.nichcy.org). education," which can include Select a Supportive Teacher regular or special education ser- Try to place the student with What bo I Do If My Child vices, depending upon each teachers who are positive, Is Not Eligible for Services?student's specific needs. upbeat, flexible, and highly Under IDEA, the school system Therefore, if your child is found organized problem-solvers. must tell you in writing why your ineligible for services under IDEA, Teachers who praise liberally child was found "not eligible." It ask to have your child evaluated and who are willing to "go the must also give you information under the criteria of Section 504. extra mile" to help students about what you can do if you Many children are not eligible for succeed can be enormously disagree with this decision. There services under IDEA but are eligible beneficial to students with AD/ are legal actions and remedies under Section 504. HD. available. Each state has specific procedures required by the IDEA that must be followed.

AD/HD Briefing Paper (3rd Ed.) 17 18 NICHCY: 1-800-695-0285 Adapt Curriculum and Have the student create a Instruction master notebooka 3-ring binder where the student Provide more direct instruction organizes (rather than stuffs) and as much one-on-one papers instruction as possible Limit number of folders Use guided instruction used; have the student use Teach and practice organization hole-punched paper and and study skills in every subject clearly label all binders on Schedule difficult subjects at the spines; monitor notebooks area student's most productive time Lecture less Have daily and weekly orga- Use mentoring and peer tutor- nization and clean up rou- Design lessons so that students ing tines have to actively respondget Provide frequent and regularly Provide frequent checks of up, move around, go to the scheduled breaks board, move in their seats work and systems for organi- Set timers for specific tasks zation Design highly motivating and enriching curriculum with ample Call attention to schedule To improve follow through: opportunity for hands-on changes Create work completion activities and movement Maintain frequent communica- routines Eliminate repetition from tasks tion between home and school Provide opportunities for or use more novel ways to self-correction practice Do daily/weekly progress reports Accept late work Design tasks of low to moderate frustration levels Teach conflict resolution and Give partial credit for work peer mediation skills partially completed Use computers in instruction Provide Supports to Promote To improve self-control: Challenge but don't overwhelm Executive Function Prepare the student for Change evaluation methods to To support planning: transitions suit the child's learning styles and strengths Teach the student to use Display rules assignment pads, day plan- Provide Supports to Promote On- ners or time schedules, task Give behavior prompts Task Behavior organizers and outlines Have clear consequences Pair the student with a study Teach study skills and prac- buddy or learning partner who tice them frequently and in Provide the student with is an exemplary student all subjects time to de-stress Provide frequent feedback To increase organization: Allow doodling or other appropriate, Structure tasks Allow time during school day mindless motor for locker and backpack movement Monitor independent work organization Use activity as Allow time for student to a reward organize materials and assignments for homework Provide more supervision

1 9 N1CHCY: 1-800-695-0285 18 AD/HD Briefing Paper (3rd Ed.) Memory Boosters To assist with memory retrieval: Teach the student keyword underlining skills To assist with working memory: Teach the student memory strategies (grouping, Summarize key information Focus on one concept at a chunking, mnemonic de- time vices) Give visual cues List all steps Practice sorting main ideas Have the class start together Write all work down and details For problems sticking with and finishing tasks: Use reading guides and plot Teach information and summaries organization skills Add interest and activity to tasks Teach note-taking skillslet Make necessary test accom- the student use a study modations (allow open book Divide larger tasks into easily buddy or teacher-prepared tests; use word banks; use completed segments notes to fill in gaps other memory cues; test in preferred modalitye.g., Shorten overall tasks List all key points on board orally, fill in blank; give frequent quizzes instead of Allow the student choice in Provide summaries, study lengthy tests) tasks guides, outlines, and lists Attention Getters and Keepers Limit lecture time Let the student use the computer For problems beginning tasks: Call on the student often Repeat directions Increase task structure Highlight or color code directions and other impor- tant parts

About the Author...

Mary Fowler is an author, advocate, educator, and AD/HD coach, as well as an internationally recognized expert on AD/HD. Her best-selling book, Maybe You Know My Kid: A Parent's Guide to Attention Deficit Hyperactivity Disorder, is published in several languages. Her newest book, Maybe You Know My Teen: A Parent's Guide for Adolescents with ADHD (2001), is published by Broad- way Books. Mary also serves as a consultant to NICHCY on several writing projects, including this Briefing Paper. Mary has testified before Congress on educational issues and presented numerous workshops for parents and educators both in the United States and abroad. Mary's workshops offer the most current information on brain-based learning, AD/HD, and behavior, as well as the practical applications of this information. Visit her Web site at: www.maryfowler.com

AD/HD Briefing Paper (3rd Ed.) 19 20 NICHCY: 1-800-695-0285 There is no question that AD/ Most often that someone was a children with AD/HD can turn HD creates plenty of opportunity parent. Still, other caring adults some of their liabilities into assets, to overcome adversity. Why are such as coaches, teachers, and and they can minimize the others. some children and families better spouses, also filled them with able to meet the challenges AD/ hope and a belief in self. Meanwhile, there is help and HD presents? The answer can be hope available. Parent support glimpsed in the research that's To help your son or daughter groups exist in every state. Some, been done on resilience. develop a sense of well-being, like CHADD and National ADDA, think about the above list of are AD/HD-specific. Others like Resilience does not mean protective factors. Which ones can the Learning Disabilities Associa- avoiding adversity or sailing off you help your child develop? tion and Parent's Anonymous may into the sunset. To be resilient is to also be useful, depending on your adapt despite challenges and Remember, AD/HD is not a individual circumstances. Visit the threatening circumstances. matter of can't or won't. It's a Web sites of these groups (see matter of can and willwith the "Resources" on page 21), where AD/HD places children and right recognition and help. you'll find information on activi- youth at risk for a number of life ties and contact numbers of similar problems. Research shows that Where can I find support? groups in your area. certain protective factors help at- risk children and youth to mini- For parents, teachers, and mize the possibility of negative children challenged by this disor- affects. Among these helpful der, AD/HD can be a truly unique protective factors are: experience. While some days the struggles seem insurmountable, it's ordinary parents, important to realize that when AD/HD is properly managed connection to competent and caring adults,

self-efficacy (the power or 10 Ways to Teach Your Children Well ability to produce a desired outcome), 10. Help your child identify his or her areas of strength. intellectual ability, 9.Help him or her to identify areas of weakness and ways to pleasing personality, work around them. talents valued by society, and 8.Teach self-advocacy skills. being able to control one's 7.Be your child's strongest advocate. selfone's attention, emotion, 6.Create opportunities for successno matter how large or arousal, and behavior. (Masten, small, like special chores. 1999) 5.Play or do activities with him or her. When researchers Weiss and Hechtman (1993) did follow-up 4.Encourage your child's special interests. studies on adults with AD/HD 3.Enroll him or her in extra-curricular activities. who managed to successfully meet their challenges, the adults over- 2.Help your child find a niche. whelmingly identified one main reason for their success: Someone 1.Be your child's biggest fan. believed in them.

NICHCY: 1-800-695-0285 20 21 AD/HD Briefing Paper (3rd Ed.) 10.

American Academy of Pediatrics. (2000, May). Clinical (Journal of the American Medical Association), 279(14), 1100- practice guideline: Diagnosis and evaluation of the child 1107. [Abstract of this article is available on-line at: http:// with attention-deficit/hyperactivity disorder. Pediatrics, jama.ama-assn.org/issues/v279n14/toc.html] 105(5), 1158-1170. Masten, A.S. (1999). Resilience in children at risk: American Psychiatric Association. (2000). Diagnostic and Implications for interventions. In the American Association statistical manual of mental disorders (4th ed., text revision). of Children's Residential Centers (AACRC), Contributions to Washington, DC: Author. residential treatments 2000 conference. Washington, DC: AACRC. Barkley, R.A. (2000). Taking charge of ADHD: The complete, authoritative guide for parents (Rev. ed.). New York: MTA Cooperative Group. (1999, December). A 14- Guilford. month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Archives of General Barkley, RA., DuPaul, G., & O'Connor, D. (1999). Psychiatry, 56(12), 1073-1086. [Abstract of this article is Stimulants. In J.S. Werry & M.G. Aman (Eds.), Practitioner's available on-line at: http://archpsyc.ama-assn.org/issues/ guide to psychoactive drugs for children and adolescents (2nd v56n12/toc.html] ed.). New York: Plenum. Robin, A. (1998). ADHD in adolescents: Diagnosis and Castellanos, EX., & Swanson, I.M. (in press). Biological treatment. New York: Guilford. underpinnings of ADHD. In S. Sandberg (Ed.), Hyperactivity and attention disorders of childhood. Cambridge, England: Weiss, G., & Hechtman, L.T. (1993). Hyperactive children Cambridge University Press. grown up: ADHD in children, adolescents, and adults (2nd ed.). New York: Guilford. Code of Federal Regulations (CFR): Title 34, Part 300 (2001). (These are the federal regulations for the IDEA.) Zametkin, A.J., & Ernst, M. (1999). Current concepts: Problems in the management of attention-deficit/ Goldman, L.S., Genel, M., Bezman, R., & Slanetz, P.J. hyperactivity disorder. New England Journal of Medicine, (1998). Diagnosis and treatment of attention-deficit/ 340(1), 40-46. hyperactivity disorder in children and adolescents. JAMA

Organizations Books and Videos on Ab/H1) CHADD (Children and Adults with Attention-Deficit/ Barkley, R. (1997). ADHD and the nature of self-control. Hyperactivity Disorder), 8181 Professional Place, Suite 201, New York: Guilford. Landover, MD 20785. Telephone: (800) 233-4050; (301) 306- 7070. E-mail: national@ chadd.org Web: www.chadd.org Barkley, R. (2000). A new look at ADHD: Inhibition, time, and self-control [video]. New York: Guilford. Learning Disabilities Association (LDA), 4156 Library Road, Pittsburgh, PA 15234-1349. Telephone: (412) 341-1515. Barkley, R. (2000). Taking charge of AD/HD: The E-mail: [email protected]. Web: www.ldanatl.org complete, authoritative guide for parents (Rev. ed.). New York: Guilford. National Attention Deficit Disorder Association (ADDA), 1788 Obtaining Resources of Interest Barkley, R, & Benton, C. (1998). Second Street, Suite 200, Highland Your defiant child: Eight steps to better Park, IL 60035. Telephone: (847) 432- The names and addresses of the publishers behavior. New York: Guilford. 2332 (to leave a message). (e.g., Guilford) of these materials are Brooks, R., & Goldstein, S. (2001). E-mail: [email protected] provided on page 23. Raising resilient children. New York: Web: www.add.org NTC/Contemporary. Parents Anonymous, 675 W. Foothill Blvd., Suite 220, Dendy, S.A.Z. (1995). Teenagers with ADD: A parents' Claremont, CA 91711. Telephone: (909) 621-6184. guide. Bethesda, MD: Woodbine House. E-mail: [email protected] Web: www.parentsanonymous.org Dendy, S.A.Z. (2000). Teaching teens with ADD and ADHD: A reference guide for teachers and parents. Bethesda, MD: Woodbine House. Fowler, M. (1999). Maybe you know my kid: A parent's See listing of additional organizations guide to identifying, understanding, and helping your child in the box on the next page. with ADHD (3rd ed.). Kensington, NY: Citadel.

AD/HD Briefing Paper (3rd Ed.) 21 2.2 NICHCY: 1-800-695-0285 Fowler, M. (2001). Maybe you know my teen: A parent's Resources on Conditions That Can Co-Occur guide to helping your adolescent with attention deficit with AD/HD hyperactivity disorder. New York: Broadway Books. Barkley, R.A. (1997). Managing the defiant child: A guide Greenbaum, J., & Markel, G.P. (2001). Helping adolescents to parent training [video, with companion manual]. New with ADHD & learning disabilities: Ready-to-use tips, York: Guilford. techniques, and checklists for school success. West Nyack, NY: Center for Applied Research in Education. Dacey, J.S., Fiore, L.B., & Ladd, G.T. (2000). Your anxious child: How parents and teachers can relieve anxiety in children. Hallowell, E.M., & Ratey, J.J. (1995). Driven to distraction: San Francisco: Jossey-Bass. Recognizing and coping with Attention Deficit Disorder from childhood through adulthood. New York: Simon & Schuster. Green, R. (1999). The explosive child: A new approach for understanding and parenting easily frustrated, 'chronically National Institute of Mental Health. (2000). NIMH inflexible' children. New York: HarperCollins. research on treatment for attention deficit hyperactivity disorder: The Multimodal Reatment StudyQuestions and Koplewicz, H.S. (1997). It's nobody's fault: New hope and answers [On-line]. Available: www.nimh.nih.gov/events/ help for difficult children and their parents. New York: Times mtaqa.cfm Books. National Institutes of Health. (1998). Diagnosis and Manassis, K. (1996). Keys to parenting your anxious child. treatment of attention deficit hyperactivity disorder. NI H Hauppauge, NY: Barrons Educational Series. Consensus Statement, 16(2), 1-37 [On-line]. Available: Papolos, D.F., & Papolos, J. (2000). The bipolar child: The odp.od.nih.gov/consensus/cons/110/110_statement.htm definitive and reassuring guide to childhood's most Power, T.J., Karustis, J.L., & Habboushe, D.F. (2001). misunderstood disorder. New York: Broadway Books. Homework success for children with ADHD: A family-school Rapee, R.M., Spence, S., Cobham, V., & Wignall, A. intervention program. New York: Guilford. (2000). Helping your anxious child: A step-by-step guide for Weingartner, P.L. (1999). ADHD handbook for families: A parents. Oakland, CA: New Harbinger. guide to communicating with professionals. Washington, DC: Riley, D.A. (1997). The defiant child: A parent's guide to Child Welfare League of America. oppositional defiant disorder. Dallas, TX: Taylor. Wilens, T. (1998). Straight talk about psychiatric Riley, D.A. (2001). The depressed child: A parent's guide for medications for kids. New York: Guilford. rescuing kids. Dallas, TX: Taylor. Wodrich, D.L. (2000). Attention deficit hyperactivity disorder: What every parent wants to know (2nd ed.). Baltimore, MD: Paul H. Brookes. Zentall, S., & Goldstein, S. (1999). Seven steps to homework success. Plantation, FL: Speciality Press.

Free Information! For free information about a variety of disorders, including AD/HD, anxiety, conduct disorders, bipolar disorder, oppositional defiant disorder, and depression, visit these Web sites or contact the organizations directly: Center for the Advancement of Children's Mental Health, National Institute on Mental Health (NIMH), Public Division of Child and Adolescent Psychiatry Columbia Inquiries, 6001 Executive Boulevard, Room 8184, MSC University, 1051 Riverside Drive, New York, NY 10032. 9663, Bethesda, MD 20892-9663. Telephone: (301) Telephone: (212) 543-5334. 443-4513; (301) 443-8431 (TIY). E-mail: infoOkidsmentalhealth.org E-mail: [email protected] Web: www.kidsmentalhealth.org Web: www.nimh.nih.gov/publicat/index.cfm Center for Mental Health Services (CMHS), Knowledge National Mental Health Association Resource Center, Exchange Network (KEN), P.O. Box 42490, Washington, 1021 Prince Street, Alexandria, VA 22314-2971. DC 20015. Telephone: 1-800-789-2647; Telephone: 1-800-969-6642; 1-800-433-5959 (TIY). 1-866-889-2647 (TIY). E-mail: [email protected] E-mail: [email protected] Web: www.nmha.org Web: www.mentalhealth.org National Alliance for the Mentally Ill (NAMI), Colonial Place Three, 2107 Wilson Blvd., Suite 300, Arlington, VA 22201. Telephone: 1-800-950-6264. E-mail: [email protected] Web: www.nami.org

NICHCY: 1-800-695-0285 22 23 AD/HD Briefing Paper (3rd Ed.) American Association of Children's Residential Centers New Harbinger Publications, 5674 Shattuck Avenue, (AACRC), 51 Monroe Place, Suite 1603, Rockville, MD Oakland, CA 94609. Telephone: (510) 652-0215, 20850. Telephone: (301) 738-6460. Web: www.newharbinger.com / E-mail: [email protected] Web: www.aacrc-dc.org NTC/Contemporary Books, contact Resilience Partners, American Psychiatric Publishing, 1400 K Street, N.W., 230 South 500 East, Suite 100, Salt Lake City, UT 84102. Washington, DC 20005. Telephone: 1-800-368-5777; (202) Telephone: (801) 532-1484. 682-6262. Web: www.appi.org Web: www.raisingresilientkids.com/index.html Barrons Educational Series, Inc., 250 Wireless Boulevard, Parents Press, contact Childswork/Childsplay, 135 Dupont Hauppauge, NY 11788. Telephone: 1-800-645-3476. Street, Plainview, NY 11803. Telephone: (516) 349-5520. Web: barronseduc.com/ Web: www.childswork.com. Broadway Books: The resources that list "Broadway" as Paul H. Brookes Publishing Company, P.O. Box 10624, publisher are available through your local booksellers or Baltimore, MD 21285-0624. Telephone: 1-800-638-3775. booksellers on-line such as amazon.com. To help readers E-mail: [email protected] identify either a local or on-line bookseller, Broadway Books Web: www.brookespublishing.com (through Random House) provides this address: www.randomhouse.com/backyard/order.html Plenum Publishing, contact Kluwer Academic Publishers, Order Department, P.O. Box 358, Accord Station, Hingham, Cambridge University Press, The Edinburgh Building, MA 02018-0358. Telephone: (781) 871-6600. Shaftesbury Road, Cambridge England CB2 2RU. E-mail: [email protected] E-mail: [email protected] Web: www.wkap.nl/kaphtml.htm/HOMEPAGE Web: www.uk.cambridge.org Simon & Schuster, 100 Front Street, Riverside, NJ 08075. Center for Applied Research in Education, contact Telephone: 1-800-223-2336. Web: www.simonsays.com Pearson Education, P.O. Box 11071, Des Moines, IA 50336. Telephone: 1-800-947-7700. Web: www.phdirect.com Speciality Press (now ADD Warehouse), 300 N.W. 70th Avenue, Suite 102, Plantation, FL 33317. Child Welfare League of America, 440 First Street NW Telephone: 1-800-233-9273. Web: www.addwarehouse.com Third Floor, Washington, DC 20001-2085. Telephone: (202) 638-2952. Web: www.cw1a.org/pubs/ Taylor Publishing Company: The resources that list "Taylor" as publisher are available through your local Citadel Books, contact Kensington Publishing Corporation, booksellers or booksellers on-line such as amazon.com. Dept. CO, 850 Third Avenue, New York, NY 10022. Telephone: 1-888-345-2665. Times Books, see Broadway Books. E-mail: [email protected] Woodbine House, 6510 Bells Mill Road, Bethesda, MD Web: www.kensingtonbooks.com 20817. Telephone: 1-800-843-7323; (301) 897-3570. Guilford Press, 72 Spring Street, New York, NY 10012. Web: www.woodbinehouse.com Telephone: 1-800-365-7006. E-mail: [email protected] Web: www.guilford.com HarperCollins, 1000 Keystone Industrial Park, Scranton, PA 18512. Telephone: 1-800-331-3761; (212) 207-7000. Web: www.harpercollins.com Jossey-Bass, 989 Market Street, San Francisco, CA 94103- 1741. Telephone: 1-800-956-7739; (415) 433-1740. Web: www.josseybass.com/

AD/HD Briefing Paper (3rd Ed.) 23 2 4 NICHCY: 1-800-695-0285 NICHCY Briefing Papers are published in response to questions from individuals and organizations that contact us. NICHCY also disseminates other materials and can respond to individual requests for infor- mation. For further information or assistance, or to receive a NICHCY Publications Catalog, contact NICHCY, P.O. Box 1492, Washington, DC 20013. Telephone: 1-800-695-0285 (Voice /TTY) and (202) 884- 8200 (Voice /TTY). You may also e-mail us ([email protected]) or visit our Web site (www.nichcy.org), where you will find all of our publications. NICHCY thanks our Project Officer, Dr. Peggy Cvach, at the Office of Special Education Programs, U.S. Department of Education. We would also like to thank Dr. Peter Jensen, Director of the Center for Ad- vance of Children's Mental Health, New York, New York, for his thoughtful and timely reviewof this publication. And, finally, we extend our deep appreciation to Mary Fowler for her longstanding commit- ment to the well-being of children with AD/HD, their parents, and their teachers, and for generously sharing her expertise with all of us.

Director Suzanne Ripley Assistant Director Donna Waghom Editor Lisa Kiipper Author Mary Fowler

This information is copyright free. Readers are encouraged to copy and share it, but please credit the Na- tional Information Center for Children and Youth with Disabilities (NICHCY). Please share your ideas and feedback with our staff by writing to the Editor.

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