NOT ALL CHILDREN ARE CREATED EQUAL

As much as you try to be equal in what you give and expect from each child, children are different and the Attention Deficit Hyperactivity Disorder (ADHD) child is more different than most. Start from that honest acknowledgement and you have taken the first step toward understanding and improving the level of sibling rivalry in your family. You can be fair to all, but not always equal, because the ADHD child has different needs. Let's look at those differences and how they affect the family with an ADHD child.

Imagine a mobile sculpture with each member of your family a doll suspended by wires that hold the sculpture together. Now imagine the ADHD child's doll with a motorized helicopter blade on top. Yes, you get the picture. The high speed, random motion of the ADHD child tends to throw the entire system into chaos. Everyone is affected! Everyone is involved in the process of trying to balance the system. While the adults in the family may have an understanding of what is happening, siblings generally do not, unless Mum and Dad know about and explain ADHD and how it is affecting the ADHD child and the entire family system.

THE FAMILY CIRCUS

No tightrope walker has ever had as difficult a job as a parent trying to balance the attention given to an ADHD child with that given his or her siblings. It is easier to watch the child who sticks close to Mum or Dad than the ADHD child who can instantly disappear into the street, the toy store at the mall, or the attic crawl space. A pre-school ADHD child needs more supervision than one parent can give without a lion tamer's chair and whip (and we don't recommend that.) Tag-team supervision, with at least two people frequently trading off the task, may seem like ganging up on the child, but it works. Do not feel as though you are not a good parent if you ask for help in "taming" an ADHD youngster.

"But why do I have to watch him again ... you always make me do it?!?" Older siblings usually do not mind an occasional request to baby sit, however they are often caught in the double bind of responsibility without authority. Remember how difficult it is for you to keep your ADHD child under control and out of trouble? It is even more difficult for the older sibling who does not have the natural parental authority to be ringmaster for the family circus. Limit how long and how often you have the older sibling in charge of your ADHD child. It is often better to pay an adult or child-care center to care for the ADHD child than to push the limits of brotherly or sisterly love.

ATTENTION!!

All children are "black holes" for attention, sucking up as much as any parent will provide, but ADHD children do demand more attention than their siblings. That demand can cause the siblings to be resentful or to imagine that the parent loves the ADHD child more. The sibling who usually does what is asked the first time may be angry at the ADHD child who is easily distracted from getting dressed and holds up the entire family. Be aware of that possibility, and plan to start the ADHD child earlier so everyone is ready to go at the same time.

When impulsivity personified, in the form of an ADHD child, bursts into every conversation with whatever happens to be on his or her mind, even the most patient siblings will start looking through the Yellow Pages for the number of the used child market to see what they can get on a trade-in. Parents who wish to avoid coming home to find that an older brother got a great deal swapping their ADHD child for a neighbor's dog are well advised to enforce clear limits on the ADHD child's behavior. Listen to the concerns and complaints of siblings with an open mind because they are communicating their distress. If they feel you are not hearing that distress, they may act out their anger towards the ADHD child.

LET THE GAMES BEGIN ...

If you are not careful, siblings can chose sides for the Super Bowl between two teams; the Saints and the SINNERS. Siblings who are age-appropriately "good" can appear and sometimes intentionally act better, exaggerating the contrast with the ADHD child's less appropriate behavior. Unless you like striped shirts and whistles, and enjoy the role of referee, it would be better to stop that form of scape-goating . You do not have to discourage a child who is applying for a sainthood, unless it is at the expense of another.

When it is, praise the improvement in the saint-to-be's behavior, but then clearly describe that scape-goating will have a predefined negative consequence. For example, "If you tease Johnny about how much better you can do that, then you will lose the benefit you normally receive for doing it." Encourage all children to excel on their own merits, not through trying to look better by knocking down someone else. Siblings sometimes regress or step out of their usual roles to imitate the behavior of the ADHD child. "Well ... if he gets so much attention from Mum and Dad for doing that - maybe I can too." While this is probably close to the top of your list of THE LAST THING I NEEDED TO HAVE HAPPEN, it can be a catalyst for discussion at a full family meeting (NOTE; NOT to be held at mealtime.) Clear GAME RULES, which are explained to all children at reasonable intervals, are at the core of improving any child's behavior.

THE AMERICAN (FAMILY) REVOLUTION-THE STRUGGLE FOR INDEPENDENCE

Gradually, over the years between diapers and diplomas, each child must learn to be responsible and self-sufficient. Parents sometimes fall into the protective fallacy of doing for children what they are able to do for themselves. That keeps children dependent as opposed to encouraging independence. It gives children the false impression that they can manipulate the world to get what they want without effort on their part. A household works best when everyone does his or her share of the chores. You will also have fewer rebellions with which to contend. ADHD children are hurt by being excused from their chores, and helped by your insistence that, even if they march to the beat of a different drummer, they still have to do their share. What ever the task, it can be "chunked" into do-able parts so that the child can accomplish it. "First take the milk and butter off the table and put them in the refrigerator ... O.K. you did a good job doing that, now put the place mats aside and wipe the table." It is easy to forget to praise or to set aside the special moments each day for every one of the troops. Maybe it is only when you tuck them up in bed at night, but be sure to affirm their importance as a person, your love for them as they are, and to acknowledge, beyond that, the improvements that every child can accomplish. These are important moments for you to. Without that affirmation on at least a daily basis, you forget the essential distinction between the child you love and the behaviors that you do or do not like. Keeping the distinction in mind will help you to promote independence and growth in your child.

SHARING

ADHD children can be less socially and emotionally mature than we would expect for their age. When the young ADHD child grabs a sibling's toy with a "I want what I want and I want it now" attitude, it is not surprising that the sibling does not want to play any more. Separating them until the issue subsides is more likely to be effective than insisting they share at that time. There is a very different aspect to sharing that goes beyond the sibling's understanding of ADHD. A parent may learn about ADHD through a local support group. This information can then be shared with extended family members, family friends, and teachers. Support groups offer many other reading materials to pass along to others.

LAST, BUT NOT LEAST

On a personal and hopeful note, my family went through many difficult times when I was a classic ADHD boy. When asked why I ended up working with ADHD families, I claim it was my Mother's curse; "When you grow up, I hope you have to deal with kids like you!" So, to my parents, whose patience was sorely tried, and to my sisters who, at best, tolerated an outrageous brother, I offer sincere thanks. Not long after my sisters and I passed the trials, tribulations, and raging hormones of adolescence, we gradually outgrew the struggles of childhood. We have successfully settled into a truly caring relationship. Despite the many conflicts we went through and the incessant teasing which still persists, we actually love each other dearly. Although it may seem impossible in the midst of your day to day experiences, in the long run the passage through can strengthen us all.

Copyright George W. Dorry, Ph. D.
Dr Dorry is a psychologist in private practice who specializes in the assessment and treatment of childhood and adult ADD. He is the founder and director of The Attention and Behavior center in Denver, Colorado. He is a member of the ADDAG Board of Directors and served as their first Chairman of the Board from the organisation's inception in March 1988 until January of 1995.

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Ideas For Home Management

We've all done it. Tried to muffle a snicker when our 'specialist' asks us to make a 'star chart.' This supposedly will encourage our child to work towards rewards and learn that they will get no attention, positive or otherwise, from bad behavior. Does this strategy work? Does it cocoa!

Unfortunately, many techniques which work with 'normal' kids just do not with ours. What these practitioners just don't understand is that the mechanism which remembers the reward and gives that good feeling when one is given, is dulled in our children.

What does work then? Well, there aren't any management strategies that work every time, with all kids. What I have found is that something which works on one particular day, may not work the next day. The kids are just too inconsistent, and don't learn from experience. Therefore, it is better to take each occurrence as it comes and don't rely too much on experience. Take it an hour at a time!

Try these tips:

1. If yours is the kind of kid who won't get up in the morning, try offering an incentive. One parent told me that before, his son just wouldn't rise on being called each morning. But he changed his call from "Johnny, get up. It's breakfast time," to "Captain 'Crusader's' starting." Because the kid was going to get to see his favorite cartoon NOW, he was soon downstairs, sitting, eating his breakfast ... in front of the cartoon of course, but hey who cares, he was up! This has continued and now the problem has been solved - for now.

2. One way to ease the pressure is to ACCEPT. Learn about ADHD and what behavior you can expect. The more I learned, the more I started to see that some of the baffling things that George does, are just part of his make-up. I also stopped beating my head up against a wall to make him comply with things which weren't that important. Like putting clothes on the right way. If he's happy wearing clothes inside out and back to front, it's OK with me! Well, most of the time.

3. If you are going through a particularly bad patch, where everything but everything seems to be going wrong, your child seems to be going backwards, and he is picking up so many strange habits and bad behaviors that you don't know where to start, try focusing on one or two of the WORST misdemeanors and forget the rest for the time being.

4. It is important to distinguish "inability" from "non-compliance." I know this is difficult, but when you start to learn what the child can and can't control, you have a better idea of when to punish and when not to.
   
   Easier said than done, I hear you say. It is difficult, but by learning as much as you can about ADHD and devouring all the information you can about what to expect, the emotional rollercoaster you are on will subside.
   
   I used to beat my brains out about George's inability (or was it refusal) to get ready for school in the morning. It was one long week-in, week-out battle after another. Then one day I just said "forget it." In the space of 8 or 10 minutes I could have him washed, dressed, hair brushed and ready...if I did it for him. Some parents would be unhappy about this, but I decided to make life easier for ME.

5. Now, although George is eleven, I wash him, brush his teeth and comb his hair every day. Dressing, he more or less, he does for himself now, but only if I lay things out for him the night before. I do, however, often have to turn his clothes the right way as he still has a penchant for wearing things back-to-front. It's ten minutes more work for me, but the aggravation factor has decreased a hundred fold in the mornings! I have accepted that motivation is not George's strong point!

6. Look for the good things and see the whole picture. Although things can be really bad at times for us, and George goes through periods when he is the devil himself, we do accept that things are much better than they were two years ago. He has caught up with his school work and is starting to shine in certain things. Handwriting has improved, swearing has decreased, hyperactivity has decreased. When things look really bad, I think of the all round improvements. There's no magic formula-just a stubbornness to get through this and a hope that things will turn out okay in the end.

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A talk by Roger Yeager, PhD, M. Ellen Gellerstedt, MD, and Dan DeMarle, M.S.

Dr. Yeager was up to bat first, and he noted that our audience was made up of people who have been dealing with the subject of ADHD for a long, long . . . long time, while others were quite new. He gave a brief introduction to the topic so we were all starting on the same foundation for the presentation. He explained that the term ADD was and would be used although the technically correct term is now ADHD. The speakers were going to use these terms interchangeably tonight.

ADD is a biologically based difference in how some areas of the brain function. That means a couple of things: it is not caused by bad parenting, and it's not just a willful child and, believe it or not, it isn't caused by sugar. ADD is around for the long haul; it doesn't go away so it is necessary to look at it from that perspective. In addition to the usual list of characteristics, Dr. Yeager noted resilience, imagination, creativity, boundless energy, and risk-taking as examples of the exciting aspects of ADD.

"ADD can be thought of as a skill deficit problem", he noted. It was frequently a question of degree and frequency. Tonight's talk, although directed at parents, would be of value to adults with ADD if they reflected on their younger years.

Every child and family has unique strengths and needs. Parenting challenging kids requires that you become a chef, not just rely on a cookbook recipe. When using a cookbook approach, you have to follow a recipe exactly and if you're missing some of the ingredients, or don't like the results, you're stuck. But if you're a chef, you know how to substitute or what to improvise. You know what's possible and when and how to use the possibilities.

"Tonight, we'll give you some recipes but also show you how to become a chef in the field of behavior." Just as the techniques and strategies must be tailored to the individual situation, often a team of people have to work together to execute the treatment. Prepare a custom developed plan to enhance the strengths of a family and teach skills to compensate for the deficits. Treatment is not a "One size fits all" proposition. There are four areas the team would address tonight.

What is the goal of treatment? To get a good fit of children's skills/deficits and those of the parents. Find a coach, one who will help keep the "big picture" in mind, and monitor progress over time.

Educate yourself, your family and others about ADD as a skill deficit and how it manifests itself in your situation i.e. know that a lack of organization in a child is a skill deficit, not stupidity. Parenting difficulty is a lack of special skills, not incompetence. Part of the education process is to learn what does and what doesn't work.

Mental Health Interventions include behavior management. There are caveats to this which include: positive reward systems help; use consequences rather than reasoning; don't yell or hit; expect performance; don't blame, don't shame or humiliate; avoid inconsistency; affirmations are important; and avoid the "how comes".

Individual Therapy - Why is it needed? Where is it not needed?

Family Therapy - Remember that ADD may exist in only one member of a family, but it affects the whole family.

Social Skills Training is also an important area to be aware of.

Dr. Yeager then turned the microphone over to Dan DeMarle who addressed educational interventions.

Dan noted that an analogy would be helpful for his portion of the talk. Imagine yourself as a terrible gymnast, which isn't too much of a stretch for some of us?! Although strong in other areas, you just hate gymnastics. But you know that for the next 12 years, you'll be judged on your gymnastic ability. Either you'll pass or fail. Then you're told that the way you perform may well affect your future children's quality of life. This is very much the way children feel as they're going through school.

ADD kids are at risk for difficulty in school. "Children with ADD are fragile learners, power learners, active learners and at risk for problems with self-esteem. ADD kids need to be involved, both mentally and physically, in what they're being taught. For children with ADD, we must learn that if it's important, make it novel. If you can't make it novel, make it active", Dan said. Using the right instructional techniques for these children enables the child to turn their natural activity level from a negative into a positive.

In school there are strategies for both environmental modifications and interventions to change behavior. There are ways we can teach children to do better on homework. Don't become the "homework monster", though, when there's trouble in this area. More important than turning a particular assignment in the next morning is that the child needs to know you are a loving, caring parent they can turn to when they need you the next time. One solution may be to split up the homework between parents. Another way may be to involve a tutor.

Schools can and should be an invaluable asset to you as a parent working with your child. Unfortunately, in many cases the parent and school can be at opposite ends of a tug of war with the children caught in the middle! What we want to happen is to have parents and school staffs working together for the benefit of the child's future! The two most important aspects of the parent/teacher relationship are effective communication, and having a joint understanding of the child's strengths and needs both at school and at home. Again, a coach (particularly at school) can be an invaluable asset.

As parents, it is important to be "informed consumers" so we can help the schools make appropriate decisions about education. It's important to find the treatment tools that work and that we find new ones when the old ones don't work as well, and help the schools do the same.

As a closing thought, recall the analogy of gymnastics. As a society, we make children go to school. Yet as members of our society, if we make these fragile learners go to school every day, then we as parents and child advocates must help to insure that going to school is a useful and productive activity for these fragile children.

Ellen Gellerstedt then addressed us.

Let's put some things in perspective i.e. get the big picture. We may have all these thoughts and this information flying around in our heads, but it is important to realize every child, every parent, and every family is unique. You don't need 100 strategies or interventions in action at once. We have to know that what the child needs in 1st grade may have nothing to do with their needs in the 5th grade. You don't have to know it all. There's a lot of expertise in our community - - Use them!

A physician can do a number of things: diagnosis, medication, help monitor progress over time, monitor what's going on with new treatments. "All that's hyper is NOT hyperactivity." Some causes of symptoms similar to those of ADD include Anxiety, Depression, Learning Disabilities, Obsessive Compulsive Disorder, Tourette's Syndrome, Oppositional and Defiant Behavior, Thyroid Condition, Manic-Depressive Illness, Lead Poisoning, Processing Problems, Seizures, Family Disruptions and a Chaotic Environment.

When should we think about medication? Medication doesn't cure ADD but it can, temporarily, alleviate some of the symptoms that are causing children so much trouble.

The long term goals of ALL treatments are: Confidence, Self Awareness, and Independence. We need to have them learn the skills they need so they can make their mark in the world.

Learn and understand what medication can do as well as what it cannot do. Medications used for ADD CAN'T cure ADD, CAN'T motivate someone, CAN'T give them skills, CAN'T make them either smarter or dumber, and CAN'T eliminate oppositional or defiant behavior. Medication CAN be extremely important, but it can't be the only treatment. Dosage and schedule must be individualized. Talk to your doctor often. Physicians can also help with networking or getting a team to work together.

In summary, there is no generic ADD. The hallmark of Multi-Modal Intervention is to enhance the strengths and teach the skills that are deficient. ADD is a biologic entity; the characteristics of it may be life-long. Many of the traits are blessings while some are true disabilities. The needs for the child and family change over time, and members of the team may change over time. The goals of treatment are to maximize the development of the child's cognitive, social and academic abilities and to maximize the growth of the family and the unit. There are no magic cures, but the situation is far from hopeless.

Roger Yeager, PhD - Psychologist, M. Ellen Gellerstedt, MD - Pediatrician, and Dan DeMarle, MS - Educator are with the Behavior Pediatrics Program at the Rochester General Hospital.

This article appeared in the Winter '94 GRADDA Newsletter. The Greater Rochester Attention Deficit Disorder Association. PO Box 23565, Rochester, New York 14692-3565. e-mail us at gradda@net2.netacc.net

Thanks to Dick Smith of GRADDA and the authors for permission to reproduce this article.

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Human beings are rarely created in perfect form, so the great majority of us arrive in this world with unique differences. Some differences are blessings; others are handicaps. Poor vision, for example, is a common handicapping condition that affects millions of people throughout the world. I consider poor vision a condition of "human-ness." People can also have other conditions such as diabetes, asthma, thyroid conditions, ADHD, etc.--all well recognized differences that can impair the pursuit of a normal life if not dealt with in some manner.

ADHD is characterized by a prolonged history of inattention, impulsiveness, and variable amounts of hyperactivity. It is important to emphasize that all of these symptoms are normal human characteristics. All of us are forgetful and inattentive at times. We all at times become nervous and fidgety, and we certainly are impulsive to some degree. It's part of our "human-ness." ADHD, then, is not diagnosed by the mere presence of these normal and characteristic human behaviors, but from the DEGREE to which we manifest these symptoms. ADHD people have an overabundance of these normal human characteristics.

WHO SHOULD TAKE MEDICATION, AND WHY?

Returning to the vision analogy, there are a number of options open to an individual who has bad eyesight. One option is to attempt to correct the problem. This could involve wearing glasses to correct the visual deficiency. Perhaps glasses can totally correct the problem, or perhaps they can only partially help. After the glasses are in place, we are in a position to assess what further problems are interfering with success. Then we can address these issues as well.

ADHD is a medical condition. Dr. Alan Zametkin has clearly demonstrated that there is something uniquely different about the metabolism of the brain affected by ADHD. If a person meets the criteria for a diagnosis of ADHD and is not succeeding academically or socially up to expectations, medication should be a PRIMARY OPTION of therapeutic intervention. The opportunity to eliminate the symptoms- toms of a medical condition partially or completely should be available to all. Many children benefit enormously from the use of medication. Many families who understand ADHD and its clinical manifestations prefer to try medication as a PART of their treatment plan. As many as 80% of individuals will show a positive response to one of the medical treatments.

Since it is impossible to determine who will respond favorably to medication, I always offer a trial of medication to each diagnosed patient. If medication will help alleviate the symptoms and does not elicit any unfavorable effects, then the patient may choose to utilize medication as one part of therapy for ADHD.

WHAT IMPROVEMENT SHOULD BE SEEN?

In the early 1930's, Dr. Charles Bradley noted some dramatic effects of stimulant medications on patients with behavior and learning disorders. He found that the use of stimulants "normalized" many of the systems that we use for successful living. People on medication IMPROVED their attention span, concentration, memory, motor coordination, mood, and on-task behavior. At the same time they DECREASED daydreaming, hyper- activity, anger, immature behavior, defiance, oppositional behavior. It was evident that medical treatment allowed intellectual capabilities that were already present to function more appropriately. When medication is used appropriately, patients notice a significant
improvement in control. Objective observers should notice better control of focus, concentration, attending skills, and task completion. Many children are able to cope with stress more appropriately, with fewer temper outbursts, less anger, and better compliance. They relate and interact better with siblings and friends. Less restlessness, motor activity and impulsiveness are noted.

It is very important to remember what medicine does and does not do. Using medication is like putting on glasses. It enables the system to function more appropriately. Glasses do not make you behave, write a term paper, or even get up in the morning. They allow your eyes to function more normally IF YOU CHOOSE to open them. YOU are still in charge of your vision. Whether you open your eyes or not, and what you choose to look at, are controlled by you. Medication allows your nervous system to send its chemical messages more efficiently, and thus allows your skills and knowledge to function more normally. Medication does not provide skills or motivation to perform. ADHD individuals often complain of forgotten appointments, incomplete homework, miscopied assignments, frequent arguments with siblings and parents, excessive activity, and impulsive behaviors. With medication, many of these problems dramatically improve. Patients successfully treated with medication typically can go to bed at night and find that most of the day went the way they had planned.

WHO SHOULD PRESCRIBE MEDICATIONS?

Medications can be prescribed by a licensed physician only. This person may serve as a coordinator to assist with the multiple therapies often needed, such as educational advocacy, counseling, parent training, and social skill assistance. Parents and adults should look for a physician who has a special interest and knowledge in dealing with ADHD individuals.

MEDICAL TRIALS

It is necessary to establish a team for an appropriate evaluation of the medication trial. I gather information from sources who spend time with my patients. This might include parents, teachers, spouses, friends, co-workers, grandparents, tutors, piano teachers, coaches, etc. As gradually increasing dosages are administered, input is gathered from these observers. Various rating scales are available to assist in gathering factual data. However, the true assessment is whether the ADHD patient's quality of success in life has improved. For this information, I find no scale takes the place of conversations with observers.

When evaluating patients during a trial of medication, I will treat them throughout the day, seven days a week. Treating them only at school or only at work is totally inadequate. I need all involved observers, assisting in the evaluation process. Furthermore, I want to know if treatment has an effect on non- academic issues. After the trial of medication, if positive results are evident, then the family and/or the patient can make informed decisions as to when the medication is helpful. Many patients find the medication is helpful throughout all waking hours. Others may need it only during certain times of the day.

WHAT IS THE CORRECT MEDICATION?

At the present stage of medical knowledge, there is not a method of predicting which medication will be most helpful for any individual. At best, physicians can make educated decisions based on information about success rates with individual medications. In general, a large percentage of patients will respond favorably to Ritalin or Dexedrine, and one of these is usually my first choice. If one stimulant does not work effectively, the others should be tried, for experience has proven that individuals may respond quite differently to each one. Many patients respond remarkably well to imipramine or desipramine, and some physicians feel this group of medications is under used. Each family and physician must be willing to try different medications in order to determine the best and most effective therapy. This is the only way to find the appropriate treatment modality. In some patients who have multiple diagnoses such as ADHD and depression, or ADHD and oppositional-defiant disorder, or ADHD and Tourette Syndrome, combinations of drugs are being successfully utilized for treatment.

WHAT IS THE CORRECT DOSE?

If medications work, there is a best dose for each individual. Unfortunately, medical knowledge is not at a point where it can predict what the correct dose will be. This is not an unusual circumstance in medicine, however. For a person with diabetes, we must try different forms and amounts of insulin to achieve the best control of blood sugar levels. For people with high blood pressure, there are many medications that can be effective, and often a trial of multiple medications and dosages is needed to determine the best treatment. For ADHD medications, there is no magic formula. The dose cannot be determined by age, body weight, or severity of symptoms.

In fact, it appears that the correct dose is extremely individual and is not really predictable. Again, similar to people who need glasses, the kind of prescription and the thickness of the lenses is not dependent on any measurable parameter other than what you say enables you to see well. The dose of medication is determined solely by what ADHD patients need to improve their symptoms. You must be willing to experiment with carefully observed dosage changes to determine your child's correct dosage. Once the correct dosage is determined, it does not seem to change significantly with age or growth. Medication continues to work effectively through the teenage years and into adulthood if needed.

SUMMARY

Individuals with ADHD will present with a variety of well-defined symptoms and behaviors. Medication may be extremely helpful in alleviating some of these symptoms and will make the other forms of accompanying therapies much more meaningful and effective. Families must be willing to work closely with their physician to identify the correct medications and establish the best dosage levels.

MEDICATIONS: OVERVIEW

RITALIN TABLETS (methylphenidate)

Form: Short acting tablets administered by mouth. Ritalin 5 mg, 10 mg, 20 mg Dosage: Very individual. Average 5 mg - 20 mg every 4 hours. I prescribe 5 mg to start and raise by 5 mg every 4-5 days with close observation until correct dose is achieved. Duration of Action: Rapid acting Ritalin starts to work in 15-20 minutes, which is extremely helpful for the child who has trouble starting his day, Some children will need medication 20 minutes BEFORE time to get up. It will last about 3'/24 hours, and so the effective dosage will need to be repeated every 31/2-4 hours to maintain positive effects during the waking hours. By virtue of its short action, Ritalin is discontinued every night and must be restarted each morning. Effects: Ritalin is one of the best and most dependable medications for treatment of ADHD symptoms. It specifically improves concentration, memory, and control of frustration and anger. Possible Side Effects: Moderate appetite suppression, mild sleep disturbances, transient weight loss, irritability, motor ties may occur if dose is too high (will disappear on lower dose). (Patients with Tourette Syndrome -- if Ritalin makes ties worse, discontinue. In some Tourette patients, ties decrease on stimulants.) Overdose effects with stimulants: depression, lethargy, "loss of spark." If this occurs, lower the dose. Pros: Excellent safety record. Very easy to use and evaluate. Very specific control of medication timing. Most dramatic improvement for many individuals. May be used with most other commonly used medications. Cons: Must be administered frequently during the day. Inconvenient to use at school. May experience moderate rebound reaction -- anger, frustration, temper when medication wears off. Possible roller coaster effect during the day as medication level fluctuates.

RITALIN SR 20 (methylphenidate sustained release)

Form: Long acting tablets administered by mouth. Ritalin SR 20. Dosage: Very individual. Two to three tablets may be needed. I use it primarily in conjunction with regular Ritalin to smooth out peaks and valleys and prevent rebound. I give 1/2-1 tablet of Ritalin SR 20 with each dose of regular Ritalin. Duration of Action: Long acting, about 6-8 hours. BE AWARE -- although called SR20 it actually appears to release only 5-7 mg of medication (not 20 mg) over 6-8 hours. Effects: Same as Ritalin tablets. Possible Side Effects: Same as Ritalin. Pros: Excellent safety record. May be most effective when used in conjunction with regular Ritalin. Tends to smooth out the peaks and valleys of regular tablets. Given with regular Ritalin 15-20 minutes before the child gets out of bed in the morning, it will prolong the positive effect of regular Ritalin to five hours (the lunch hour). Cons: Does not always work in a predictable fashion, and sometimes not at all.

DEXEDRINE SPANSULES (dextroamphetamine)

Form: Long acting, administered by mouth, Dexedrine Spansules 5, 10, 15 mg. Dosage: Very individual: Average is 5-20 mg. Duration of Action: Very individual. May take 1-2 hours to be effective. Usually lasts 6-8 hours. In some it may be effective all day. In others it may only last four hours. Effects: Same as Ritalin. Possible Side Effects: Same as Ritalin. Pros: Excellent safety record. May be the best drug for some individuals: longer acting, smoother course of action. May avoid lunch time dose at school. Cons: Slow onset of action. Remember, it takes 1-2 hours to work and may require a short-acting dose at first in the AM to start the day.

DEXEDRINE TABLETS (dextroamphetamine)

Form: Short-acting tablets administered by mouth. Dexedrine tablets 5 mg. Dosage: Very individual: Average 1-3 tablets each dose. Duration of Action: Rapid onset of action 20-30 minutes. Lasts 4 hours. Effects: Same as Ritalin. Possible Side Effects: Same as Ritalin Pros: Excellent safety record. Rapid acting. Some patients who do well on Dexedrine prefer the tablets over the Spansules. The more rapid rate of onset is apparently more effective for these individuals. Cons: Same as Ritalin.

CYLERT (pemoline)

Form: Long-acting tablets administered by mouth. Cylert 37.5, 75 mg. Dosage: Very individual. Duration of Action: Slow onset of action, thought to be a medication that will last all day, but in most cases lasts 6-8 hours. Effects: Same as Ritalin Possible Side Effects: Same as Ritalin. However, has been known to cause mild liver damage. Pros: Long acting, may eliminate lunch dose. Cons: Not as safe as the other stimulants. Would only use if other stimulants are not effective. Should NEVER be first drug of choice. Has caused hepatitis and death. Must do liver function blood test every six months.

TOFRANIL and NORPRAMINE (imipramine and desipramine)

Form: Tablets administered by mouth. 10, 25, 50, and 100 mg tablets. Dosage: Very individual. I start with a low dose 10-25 mg, and raise slowly as needed. Duration of Action: Variable. Often has a 24-hour effect, and therefore can be administered at night. Some patients prefer to split the dose and take every 12 hours. Effects: Often relatively low doses can improve ADHD symptoms within a few days, but may take 1-3 weeks for full effect. Higher doses may improve depression symptoms and mood swings, which are often seen in ADHD individuals. Possible Side Effects: Nervousness, sleep problems, tiredness, and upset stomach, dizziness, dry mouth, unusually fast heart rate. May affect conduction time of the heart, leading to irregular heart rate. May affect blood count (rare). Pros: Often works when stimulant medications are not helpful, and may be the drug of choice for many individuals. Prolonged duration eliminates school dose. Smoother course of action. Often helps with mood swings and depression. May be used in conjunction with stimulant medications. Cons: Can affect the heart conduction rate, therefore requires an EKG prior to the medication trial and after treatment level has been established. Can affect the blood count, therefore requires a complete blood count with all illnesses. Need to be careful when taking other medications. Consult doctor for list of medications to avoid. Medication needs to be increased and decreased gradually. Should not start and stop abruptly.

CLONIDINE (catapres)

Form: Patches applied to back of shoulder. Catapres TTS-1, TTS-2, TTS-3 (expensive). Tablets administered by mouth. Catapres tablets--1 mg., 2 mg., 3 mg. (low price) Duration of Action: Patches will last 5-6 days. Tablets are short acting, last 4-6 hours. Effects: Often will improve ADHD symptoms, although not always as dramatically as Ritalin. Decreases facial and vocal ties in Tourette Syndrome. Often has a dramatic positive effect on oppositional defiant behavior and anger management. Possible Side Effects: Major side effect is tiredness, particularly if raised too quickly. Will normally disappear with time. Some patients may notice dizziness, dry mouth. Some will notice increased activity, irritability, conduct disorder and should discontinue the medication. Pros: Excellent delivery system if patch is used. No pills required. Frequent positive effect on oppositional defiant behavior, and obsessive compulsive behavior. Does not effect sleep or appetite. Positive effect on tic behavior. Cons: Does not usually work as well as Ritalin for ADHD symptoms. Patch causes skin irritation in many and cannot be tolerated.

ADDERALL (four amphetamine salts)

Form: Long-acting tablets: 10 mg and 20 mg Dosage: Very individual, usually between 5 mg and 20 mg, once or twice a day Duration of Action: Usually last 6-12 hours. May be given once or twice a day, depending on length of therapeutic effect. Duration of effect varies from person to person. Effects: Same as Ritalin Possible Side Effects: Less affect on sleep, appetite, growth and rebound. No roller coaster effect. Pros: Only needs to be given once or twice a day, often fewer side effects. Very nice medication when effective. Cons: Does not work well for everybody. Relatively new on the market and not much clinical experience at this time.

WELLBUTRIN (bupropion hcl)

Form: 75 mg (yellow-gold) 100 mg (red) Dosage: 75-300 mg daily (average) in three divided doses Duration of Action: Long acting medication (half-life of 24 hours) Effects: A few studies suggest improvement in ADHD. In general, not as good as stimulants. Very helpful in conjunction with stimulants for depression. Possible Side Effects: Can cause seizures (1/4000) if dose STARTED too rapidly. Raise dose slowly. Cannot use if seizure disorder is present. May cause dry mouth, anorexia, rash, sweating, tremors, tinnitus Pros: Very good medication to use for treatment of depression Cons: Very little evidence that it is helpful for ADHD. Studies are still in progress.

WELLBUTRIN SR (bupropion hcl long-acting)

Form: 100 mg (blue) 150 mg (purple) Dosage: 100-150 mg twice a day Duration of Action: Effective for over 24 hours Effects, Possible Side Effect, Pros, Cons: Same as Wellbutrin

Dr. Mandelkorn trained in pediatrics and adolescent medicine and was a mental health fellow under Dr. Michael Rothenberg. An adult with ADHD who has a son with ADHD, Dr. Mandelkorn specializes in the diagnosis and treatment of ADHD in children and adolescents. He maintains a private practice in Mercer Island, Washington. His ADHD clinic presently follows over 600 children with ADHD. Dr. Mandelkorn lectures nationwide about management.

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The treatment of Attention Deficit Disorder (ADD) begins with hope. Most people who discover they have ADD, whether they be children or adults, have suffered a great deal of pain. The emotional experience of ADD is filled with embarrassment, humiliation, and self castigation. By the time the diagnosis is made, many people with ADD have lost confidence in themselves. Many have been misunderstood repeatedly. Many have consulted with numerous specialists, only to find no real help. As a result, many have lost hope.

The most important step at the beginning of treatment is to instill hope once again. Individuals with ADD may have forgotten what is good about themselves. They may have lost, long ago, any sense of the possibility of things working out. They are often locked in a kind of tenacious holding pattern, bringing all theory, considerable resiliency, and ingenuity just to keeping their heads above water. It is a tragic loss, the giving up on life too soon. But many people with ADD have seen no other way than repeated failures. To hope, for them, is only to risk getting knocked down once more.

And yet, their capacity to hope and to dream is immense. More than most people, individuals with ADD have visionary imaginations. They think big thoughts and dream big dreams. They can take the smallest opportunity and imagine turning it into a major break. They can take a chance encounter and turn it into a grand evening out. They thrive on dreams, and they need organizing methods to make sense of things and keep them on track.

But like most dreamers, they go limp when the dream collapses. Usually, by the time the diagnosis of ADD has been made, this collapse has happened often enough to leave them wary of hoping again. The little child would rather stay silent than risk being taunted once again. The adult would rather keep his mouth shut than risk flubbing things up once more. The treatment, then, must begin with hope. We break down the treatment of ADD into five basis areas:

1. Diagnosis
2. Education
3. Structure, support, and coaching
4. Various forms of psychotherapy
5. Medication

In this article we will outline some general principles that apply both to children and adults concerning the non-medication aspects of the treatment of ADD. One way to organize the non-medication treatment of ADD is through practical suggestions.

50 TIPS INSIGHT AND EDUCATION:

1. Be sure of the diagnosis. Make sure you're working with a professional who really understands ADD and has excluded related or similar conditions such as anxiety states, agitated depression, hyperthyroidism, manic depressive illness, or obsessive compulsive disorder.
   
   
2. Educate yourself. Perhaps the single most powerful treatment for ADD is understanding ADD in the first place. Read books. Talk with professionals. Talk with other adults who have ADD. You'll be able to design your own treatment to your own version of ADD.
   
   
3. Coaching. It is useful for you to have a coach, for some person near to you to keep after you in a supportive way. Your coach can help you get organized, stay on task, give you encouragement, or remind you to get back to work. Friend, colleague, or therapist (it is possible, but risky for your coach to be your spouse), a coach is someone to stay on you to get things done, exhort you as coaches do, keep tabs on you, and in general be in your corner, on your side. A coach can be tremendously helpful in treating ADD.
   
   
4. Encouragement. ADD adults need lots of encouragement. This is in part due to their having many self-doubts that have accumulated over the years. But it goes beyond that. More than the average person, the ADD adult withers without encouragement and positively thrives when given it. The ADD adult will often work for another person in a way he won't work for himself. This is not "bad," it just is. It should be recognized and taken advantage of.
   
   
5. Realize what ADD is NOT, i.e., conflict with mother, etc.
   
   
6. Educate and involve others. Just as it is key for you to understand ADD, it is equally, if not more important, for those around you to understand it--family, friends, people at work or at school. Once they get the concept they will be able to understand you much better and to help you out as well. It is particularly helpful if your boss can be aware of the kinds of structures that help people with ADD.
   
   
7. Give up guilt over high-stimulus seeking behavior. Understand that you are drawn to high stimuli. Try to choose them wisely, rather than brooding over the "bad" ones.
   
   
8. Listen to feedback from trusted others. Adults (and children, too) with ADD are notoriously poor self observers. They use a lot of what can appear to be denial.
   
   
9. Consider joining or starting a support group. Much of the most useful information about ADD has not yet found its way into books but remains stored in the minds of the people who have ADD. In groups this information can come out. Plus, groups are really helpful in giving the kind of support that is so badly needed.
   
   
10. Try to get rid of the negativity that may have infested your system if you have lived for years without knowing what you had was ADD. A good psychotherapist may help in this regard. Learn to break the tapes of negativity that can play relentlessly in the ADD mind.
    
    
11. Don't feel chained to conventional careers or conventional ways of coping. Give yourself permission to be yourself. Give up trying to be the person you always thought you should be -- the model student or the organized executive, for example--and let yourself be who you are.
    
    
12. Remember that what you have is a neurological condition. It is genetically transmitted. It is caused by biology, by how your brain is wired. It is NOT a disease of the will, nor a moral failing. It is NOT caused by a weakness in character, nor by a failure to mature. It's cure is not to be found in the power of the will, nor in punishment, nor in sacrifice, nor in pain. ALWAYS REMEMBER THIS. Try as they might, many people with ADD have great trouble accepting the syndrome as being rooted in biology rather than weakness of character.
    
    
13. Try to help others with ADD. You'll learn a lot about the condition in the process, as well as feel good to boot.

Performance Management

1. External structure. Structure is the hallmark of the non-pharmacological treatment of the ADD child. It can be like the walls of the bobsled slide, keeping the speedball sled from careening off the track. Make frequent use of:
   1) notes to self - 2) color coding - 3) rituals - 4) lists - 5) reminders - 6) files

2. Color coding. Mentioned above, color coding deserves emphasis. Many people with ADD are visually oriented. Take advantage of this by making things memorable with color: files, memoranda, texts, schedules, etc. Virtually anything in the black and white of type can be made more memorable, arresting, and therefore attention-getting with color.

3. Use pizzazz. In keeping with #15, try to make your environment as peppy as you want it to be without letting it boil over.

4. Set up your environment to reward rather than deflate. To understand what a deflating environment is, all most adult ADDers need do is think back to school. Now that you have the freedom of adulthood, try to set things up so that you will not constantly be reminded of your limitations.

5. Acknowledge and anticipate the inevitable collapse of x% of projects undertaken, relationships entered into obligations incurred.

6. Embrace challenges. ADD people thrive with many challenges. As long as you know they won't all pan out, as long as you don't get too perfectionistic and fussy, you'll get a lot done and stay out of trouble.

7. Make deadlines. Think of deadlines as motivational devices rather than echoes of doom. If it helps, call them lifelines, instead of deadlines. In any case, make them and stick to them.

8. Break down large tasks into small ones. Attach deadlines to the small parts. Then, like magic, the large task will get done. This is one of the simplest and most powerful of all structuring devices. Often a large task will feel overwhelming to the person with ADD. The mere thought of trying to perform the task makes one turn away. On the other hand, if the large task is broken down into small parts, each component may feel quite manageable.

9. Prioritize. Avoid procrastination. When things get busy, the adult ADD person loses perspective: paying an unpaid parking ticket can feel as pressing as putting out the fire that just got started in the wastebasket. Prioritize. Take a deep breath. Put first things first. Procrastination is one of the hallmarks of adult ADD. You have to really discipline yourself to watch out for it and avoid it.

10. Accept fear of things going too well, accept edginess when things are too easy, when there's no conflict. Don't gum things up, just to make them more stimulating.

11. Notice how and where you work best: in a noisy room, on the train, wrapped in three blankets, listening to music, whatever. Children and adults with ADD can do their best under rather odd conditions. Let yourself work under whatever conditions are best for you.

12. Know that it is O.K. to do two things at once: carry on a conversation and knit, or take a shower and do your best thinking, or jog and plan a business meeting. Often people with ADD need to be doing several things at once in order to get anything done at all.

13. Do what you're good at. Again, if it seems easy, that is O.K. There is no rule that says you can only do what you're bad at. Do what you're good at. Again, if it seems easy, that is O.K. There is no rule that says you can only do what you're bad at.

14. Leave time between engagements to gather your thoughts. Transitions are difficult for ADDers, and mini-breaks can help ease the transition.

15. Keep a notepad in your car, by your bed, and in your pocketbook or jacket. You never know when a good idea will hit you, or you'll want to remember something else.

16. Read with a pen in hand, not only for marginal notes or underlining, but for the inevitable cascade of "other" thoughts that will occur to you.

Mood Management:

1. Have structured "blow-out" time. Set aside some time in every week for just letting go. Whatever you like to do -- blasting yourself with loud music, taking a trip to the race track, having a feast -- pick some kind of activity from time to time where you can let loose in a safe way.

2. Recharge your batteries. Related to #30 most adults with ADD need feeling guilty about it. One guilt-free way to conceptualize it is to call it time to recharge your batteries. Take a nap, watch TV, meditate. Some-thing calm, restful, at ease.

3. Choose "good," helpful addictions such as exercise. Many adults with ADD have an addictive or compulsive personality such that they are always hooked on something. Try to make this something positive.

4. Understand mood changes and ways to manage these. Know that your moods will change willy-nilly, independent of what's going on in the external world. Don't waste your time ferreting out the reason why or looking for someone to blame. Focus rather on learning to tolerate a bad mood, knowing that it will pass, and learning strategies to make it pass sooner. Changing sets, i.e. getting involved with some new activity (preferably interactive) such as a conversation with a friend or a tennis game or reading a book will often help.

5. Related to #33, recognize the following cycle which is very common among adults with ADD: Something "startles" your psychological system, a change or transition, a disappointment or even a success. The precipitant may be quite trivia. b. This "startle" is followed by a mini-panic with a sudden loss of perspective, the world being set topsy-turvy. c. You try to deal with this panic by falling into a mode of obsessing and ruminating over one or another aspect of the situation. This can last for hours, days, even months.

6. Plan scenarios to deal with the inevitable blahs. Have a list of friends to call. Have a few videos that always engross you and get your mind off things. Have ready access to exercise. Have a punching bag or pillow handy if there's extra angry energy. Rehearse a few pep talks you can give yourself, like, ''You've been here before. These are the ADD blues. They will soon pass. You are OK."

7. Expect depression after success. People with ADD commonly complain of feeling depressed, paradoxically, after a big success. This is because the high stimulus of the chase or the challenge or the preparation is over. The deed is done. Win or lose, the adult with ADD misses the conflict, the high stimulus, and feels depressed.

8. Learn symbols, slogans, sayings as shorthand ways of labeling and quickly putting into perspective slip ups, mistakes, or mood swings. When you turn left instead of right and take your family on a 20-minute detour, it is better to be able to say, "There goes my ADD again," than to have a 6-hour fight over your unconscious desire to sabotage the whole trip. These are not excuses. You still have to take responsibility for your actions. It is just good to know where your actions are coming from and where they're not.

9. Use "time-outs" as with children. When you are upset or over stimulated, take a time-out. Go away. Calm down.

10. Learn how to advocate for yourself. Adults with ADD are so used to being criticized, they are often unnecessarily defensive in putting their own case forward. Learn to get off the defensive.

11. Avoid premature closure of a project, a conflict, a deal, or a conversation. Don't "cut to the chase'' too soon, even though you're itching to.

12. Try to let the successful moment last and be remembered, become sustaining over time. You'll have to consciously and deliberately train yourself to do this because you'll just as soon forget.

13. Remember that ADD usually includes a tendency to over focus or hyper focus at times. This hyper focusing can be used constructively or destructively. Be aware of its destructive use: a tendency to obsess or ruminate over some imagined problem without being able to let it go.

14. Exercise vigorously and regularly. You should schedule this into Your life and stick with it. Exercise is positively one of the best treatments for ADD. It helps work off excess energy and aggression in a positive way, it allows for noise-reduction within the mind, it stimulates the hormonal and neurochemical system in a most therapeutic way, and it soothes and calms the body. When you add all that to the well-known health bene- fits of exercise, you can see how important exercise is. Make it something fun so you can stick with it over the long haul, i.e. the rest of you life.

Interpersonal Life

1. Make a good choice in a significant other. Obviously this is good advice for anyone. But it is striking how the adult with ADD can thrive or flounder depending on the choice of mate.

2. Learn to joke with yourself and others about your various symptoms, from forgetfulness, to getting lost all the time, to being tactless or impulsive, whatever. If you can be relaxed about it all to have a sense of humor, others will forgive you much more.

3. Schedule activities with friends. Adhere to these schedules faithfully. It is crucial for you to keep connected to other people.

4. Find and join groups where you are liked, appreciated, understood, enjoyed. People with ADD take great strength from group support.

5. Reverse of #47. Don't stay too long where you aren't understood or appreciated. Just as people with ADD gain a great deal from supportive groups, they are particularly drained and by negative groups.

6. Pay compliments. Notice other people. In general, get social training, as from your coach.

7. Set social deadlines. Without deadlines and dates your social life can atrophy. Just as you will be helped by structuring your business week, so too you will benefit from keeping your social calendar organized. This will help you stay in touch with friends and get the kind of social support you need.

This educational material is made available, courtesy of the author and a non-profit organization based in Tacoma, WA. whose purpose is to educate adults, and the professionals who treat them, about Attention Deficit Disorder. We have numerous materials as well as a quarterly newsletter for sale. Our address is: ASW, PO Box 7804, Tacoma, WA. 98407-0804. Msg. Tel. 253-759-5085, email: addult@addult.org and web site: www.ADDult.org."

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come on now, smile :)

Every once and awhile, it's helpful to laugh at the situation you are in. After all, it's not your child's, or your fault. It just is.

You know you are the parent of an ADHD child when:

• You wake up in the morning and your heart sinks when you realize "this is not a bad dream."
• No less than 86% of your hair is completely gray...and you are only 27 years old.
• Everything in your house is either broke, or at least on it's last legs.
• You look ten years older than you actually are...through sheer exhaustion.
• You feel apprehensive eare nagging to stop at every McDonalds, garage, and sweet shop you pass. Incessantly, the chvery time you get in your car. The children are trying to climb out of the doors while the car is moving, the children keep trying to pull the handbrake on while you are driving, the childrenildren are crying again because you won't allow them to take the front dashboard off the car.
• When it gets to three p.m. - school time is over, you feel like your life has ended again for that day.
• You are often to be heard saying, "He must have picked it up in the playground," as your child demonstrates his knowledge of the latest swearword, very loudly in the middle of the shopping center.
• You know every crack in the ceiling and pattern on the walls of your child's headteacher's office because you have spent so long in there over the years.
• You know the ADHD diagnostic criteria by heart, and can recite it...backwards!

You know you are an ADD/ADHD sufferer when:

• You've lost your keys again, and that's the fifth time today!

• This is the third time this month that you've set the stove on fire because you keep forgetting you've started to cook.

• You have just read the same paragraph of the book you are reading seventeen times...and you still haven't got the gist of the story.

• You go into the other room to get something. "Now what was it ?!?!?"

• You have a cigarette in one hand and a double brandy in the other...often.

• Your TV remote handset is completely worn out from too much channel hopping.

• Waiting in this queue is driving you completely insane.

• You have just sent off your resume for a new job. The tenth new job in six months!

• You have just forgotten what you were going to say, a split second before you were going to say it.

• Your spouse tells you off again for distracting them from the telly with your finger- drumming or toe-waggling.

• You wish the person you are talking to would JUST GET TO THE POINT.

• Your darling husband asks "Was that OK for you?" and you reply "Was what OK?"

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from notes taken at a presentation by Dr. Ned Hallowell

"What's it like to have ADD? Some people say the so-called syndrome doesn't even exist, but believe me it does. Many metaphors come to mind to describe it. It's like driving in the rain with bad windshield wipers. Everything is smudged and blurred and you're speeding along, and it's frustrating and frightening not to be able to see what you're zooming past at sixty m.p.h. In other ways, it's like being supercharged all the time. You get one idea and you have to act on it, and then, what do you know, but you've got another idea before you've finished up with the first one, and so you go for that one, but of course a third idea intercepts the second, and you just have to follow that one, and pretty soon people are calling you disorganized and impulsive and all sons of impolite words that miss the point completely. Because you're trying really hard. It's just that children with ADD have all these invisible vectors pulling this way and that, which makes it really hard to stay on task."

"What is it like to have ADD? In ADD, time collapses. Someone once said, 'Time is the thinking that keeps everything from happening all at once.' Time parcels moments out into separate bits so that we can do one thing at a time. In ADD, this does not happen. Time becomes a black hole. To the person with ADD it feels as if everything is happening all at once. This creates a sense of inner turmoil or even panic. The child loses perspective and the ability to prioritize. He or she is always on the go, trying to keep the world from caving in on top."

"There is a very positive side to all this. Usually the positive doesn't get mentioned when people speak about ADD because there is a natural tendency to focus on what goes wrong or at least what has to somehow be controlled. But often once ADD has been diagnosed, and the child, with the help of teachers, parents, coaches, and even friends, has learned to cope with it, an untapped realm of the brain swims into view.

Suddenly the windshield is clear. And the child, who has been such a problem, such a general pain in the neck to himself and everybody else, that person starts doing things he'd never been able to do before. He surprises everyone around him, and he surprises himself" Dr. Hallowell uses the male pronoun, but it could just as easily be she.

Dr. Hallowell says "ADD people are highly imaginative and intuitive. They have a "feel" for things, a way of seeing right to the heart of matters while others have to reason their way along methodically. This is the child who can't explain how he thought of the solution, or where the idea for the story came from, or why suddenly he produced a painting, or how he knew the short cut to the answer, but all he can say is, he just knew it, he could feel it. This is the man or woman who makes million dollar deals in catnip and pulls them off the next day. This is the child who, having been reprimanded for blurting something out, is then praised for having blurted out something brilliant. These are the children who learn and know what to do and go by touch and feel."

"These people can feel a lot. In places where most of us are blind, they can, if not see the light, at least feel the light, and they can produce answers apparently out of the dark. It is important for others to be sensitive to this 'sixth sense' many ADD people have, and to nurture it. If the environment insists on rational, linear thinking and good behavior from these kids all the time, then they may never develop their intuitive style to the point where they can use it profitably. It can be exasperating to listen to these children talk. They can sound so vague and rambling. But if you take them seriously and grope along with them, often you will find they are on the brink of startling conclusions or surprising solutions."

"Their cognitive style is qualitatively different from most people's and what at first may seem impaired, with patience and encouragement may become gifted."

"The thing to remember is that if the diagnosis can be made, then most of the bad stuff associated with ADD can be avoided or contained. The diagnosis can be liberating, particularly for people (children) who have been stuck with labels like. 'lazy, stubborn, willful, disruptive, impossible, tyrannical, a spaceshot, stupid, or just plain bad.' Making the diagnosis of ADD can take the case from the court of moral judgment to the clinic of neuropsychiatric treatment."

"What is the treatment all about? Anything that turns down the noise. Just making the diagnosis helps turn down the noise of guilt and self-recrimination. Building certain kinds of structure into one's life can help a lot. Working in small spurts rather than long hauls; Breaking down tasks into smaller tasks; Getting extra help. Medication can help too, but it is far from the whole solution."

Hallowell spoke about ADD children having the ability to "hyper-focus" and actually be able to excel at tasks much of the time with the help of a patient person on their side. He spoke about growing up in Chatham on the Cape [Cod] with a special elementary school teacher, in the early 60's. "She took me by her side and kept my attention by being a 'good coach.' She gave me encouragement at every wrong turn." Hallowell has gone on to be on the staff at Harvard Medical School and he has a successful medical practice in Cambridge. MA.

Dr. Hallowell concluded with this thought: "We need your help and understanding. We make mess-piles wherever we go, but with your help, those mess-piles can be turned into realms of reason and art. So, if you know someone like me who's acting up and daydreaming and forgetting this or that and just not getting with the program, consider ADD before he starts believing all the bad things people are saying about him and it's too late."

Ed Note: This is a summary of a talk given by Ned Hallowell, M.D. of Harvard Medical School to a local chapter of CH.A.D.D (Children and Adults with ADD) in February of 1993. Many thanks to Carson Graves for preparing this transcription and permitting its distribution. This summary is taken from the newsletter of the Concord Special Education Parent Advisory Council which encourages readers to share its contents with others. Address: P.O. Box 274 Cocord, MA 01742

This article appeared in the Spring '97 GRADDA Newsletter. The Greater Rochester Attention Deficit Disorder Association. PO Box 23565, Rochester, New York 14692-3565. e-mail us at gradda@net2.netacc.net

Thanks to Dick Smith of GRADDA and the authors for permission to reproduce this article.

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We:

• Are highly motivated, persistent, and stimulated by many of the intellectual challenges, which are beyond the average person.

• Can be spontaneous, imaginative, creative, a little eccentric and able to express ourselves in the most unique ways.

• Make great scientists, artists, actors and entrepreneurs.

• Are often bursting with high energy and able to meet and beat challenges with zeal.

• Become stimulated by intrigue and inspired by the novelty involved in change.

• Can be keen observers, with an ability to find quick solutions to situations many mere mortals find complicated.

• Are very resourceful, and can devise ingenious means of accomplishing things.

• Think laterally and solve problems in very distinctive ways.

• Can juggle many balls in the air at once, and think about lots of different things at the same time.

• Are humorous, often with a keen wit and an ability or talent to make others laugh too.

• Can be extremely diligent with a never-say-die approach to life's problems.

• Are not afraid to take risks, often seeing risk-taking as a form of stimulation.

And our children, can be kind, thoughtful and often enjoy doing things for other people.

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It is generally believed now that there is a strong genetic connection of ADD and ADHD in families. Therefore, if one or more children are diagnosed in a family, then there is a good chance that at least one of the parents will exhibit symptoms also. With this connection in evidence it is inevitable that many adults (with ADD or ADHD) will find themselves raising a child who also suffers. Many of these ADD parents raising ADD kids were themselves brought up by one or more ADD parents! These grandparents and parents would more than likely have been undiagnosed and therefore treated.

Awareness of ADD and ADHD is only in the early stages, so for many children in Britain today, getting help and/or treatment is still a lottery. Unfortunately for us, because of the way ADD is perceived, many of our professionals are not yet taking on board that the cycle goes in both directions. It has been shown that ADD families have higher divorce rates, many ADD and ADHD children have been adopted, rates for domestic violence are higher, many of these children are taken into care for either abuse or perceived abuse and so on, so considering this long line of untreated ADD running through families, is it any wonder that many parents have difficulties?

So what can we do to improve things? First of all realize how our ADD affects our way of parenting. We know that these children do best in a structured environment .... which is totally the opposite to the way many of us live! This lack of structure does nothing to help the child who needs to know what he is supposed to be doing at all times. What an ADD adult may well regard as spontaneity, an ADD child may interpret as uncertainty or unpredictability. What about our impulsive natures? Do we often over react just like our children? Think about it. Perhaps your child may feel that he or she cannot depend on you for firm boundaries and consistent support.

Our ADD kids needs structure, structure and more structure, masses of support and a stable environment. Without these, they are being set up to fail, regardless of any medication they might be taking. The unfortunate thing is, that ADD adults often have difficulty providing this type of environment. How can we therefore parent these children in a more effective way? Well, for a start it is important to remember that the parent is the parent and the child is the child. As the adult in the relationship the responsibility must be with us at all times. We must keep control of situations, have the confidence to make (and enforce) rules and have the final say in discussion. Difficult I know - my son would argue the hind legs off a donkey. What often confuses issues is the fact that many situations which cause us difficulty as parents, are brought about by the child's reaction to something we have done and this unfortunately can turn some issues into chicken and egg situations which can escalate and escalate into total chaos and anarchy if the brakes aren't applied somewhere. This has to be our job, bearing in mind an understanding of our own possible ADD.

It often helps to reflect on what has worked and what hasn't in the past. Does shouting and screaming at an already wound up ADHD child really work? It is true, we may yell because we were yelled at as children, or we may have been driven to near distraction by the child's antics on a particular day, or because it is in our temperamental make up too. But if it has little or no effect on the child why continue to yell?

Sometimes, adding humor to a situation helps. I am confident enough by now, through knowing all about ADHD and by being able to understand how my son ticks, to turn difficult situations into jokes. Yes it is frustrating when your 12 year old sprinkles talcum all over YOUR bedroom floor, but getting him to vacuum it up (even after extended tantrumming) saying "This will stand you in good stead for when you get your own place son" wink, wink will make you feel better and also make him feel not as bad about his behavior.

So, simply put, often all that is needed is the belief in your own methods and the confidence to carry things out. This can be very difficult, especially if your parenting skills have been brought into question at any time, and your personality is such that you behave rather as your child does at times! But remember, parents of ADD and ADHD children do a more than excellent job under extremely difficult circumstances. Added to this may be the knock-on effects of their own ADD.

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Often parents have a difficult time getting an answer as to what is causing their children's inexplicable behavior. Over time, they may visit pediatricians, psychiatrists, clinical and educational psychologists and general practitioners. In many cases, parents find out through their own research, as I did, what is ailing their children. This is not the end of the road, however. Often it is the start of a new one. After all that, parents then have the difficult task of getting a firm diagnosis for their children.

Children who have displayed challenging behavior from a very young age could be suffering from Attention Deficit Hyperactivity Disorder (ADHD). On the other hand, it's important to keep in mind, your child may have a different disorder, for example, Asperger Syndrome, Conduct Disorder or Dyslexia. In any case, in order for these children to get the most appropriate medical, educational and managerial accommodations possible, they need some sort of diagnosis.

Here though, highlights the issue of whether or not to 'label' children who suffer from this range of childhood conditions. During my time manning the ADHD support group telephone helpline, I repeatedly encountered the frustration of parents whose children were left in diagnostic limbo, so to speak. Here in Britain, this was evident on a large scale.

Many was the time a parent would say to me that their specialist didn't want to 'put a label' on what was ailing their child (ren). Although one can see that labeling could bring into effect self-fulfilling prophesy in some cases, surely children who are obviously ill or disordered NEED a label (or diagnosis) to give a framework to the outside world of what would be expected of them.

Personally, I have had to fight tooth and nail to get 'labels' for my child. To have my child diagnosed the first time, I had to travel outside my community. However after coming back under the same authority recently, I have again had to cause waves to get in writing that my son also has Asperger syndrome (high-functioning autism). My specialists, in turn, have gotten frustrated with me because I HAVE to know what is the matter with my son, but I say this:

• Without a proper 'reason' for a child's difficulties, a parent cannot go through the necessary grieving process enabling them to come to terms and go forward.
• Diagnosed children get far more educational, medical and social accommodations that they are entitled to, than the child who does not have this so-called 'label'.
• Children without diagnoses, or with wrong ones, simply do not have their educational or medical assistance tailored exactly to their needs. What use is it for a child with Aspergers, whose most profound difficulty may be in comprehending everyday social situations, to have a statement of special needs which focuses mainly on his handwriting difficulties, when the help which is available would be much better utilized addressing the most acute presenting problems.
• A parent needs to KNOW, in order to move on. In simple terms, once a diagnosis has been made the parent can then educate him or herself all about the condition in question and how best to deal with situations which arise.

British professionals must somehow be made to see how this 'label' moves a situation on. In many other countries parents don't have this difficulty. Here parents often wait many, many years for such a label, which never comes. These are the parents whose children are excluded from school, who have dropped out of school because of underachievement, who are depressed, maybe unemployed, possibly abusing alcohol or substances...or even dead. So please, all you British professionals out there, never be afraid to label a child. You might just save their life.

So, what should a parent do if they are having difficulty getting a firm diagnosis? Well here are a few suggestions which might just help when you next see a specialist:

1. Go along and make it quite clear that you feel your child is suffering from ADD or ADHD. Try to get documentary evidence from school, in the form of report cards, behavior tick charts or letters, etc. If you have school reports outlining the particular difficulties, all the better.

2. If possible try to fill in a diagnostic criteria before you attend the appointment, otherwise you are wasting time. (Time your child hasn't got to waste). If you have any books or information leaflets referring to the behaviors your child shows, highlight them with a felt pen, and be insistent.

3. Make sure your specialist knows about these kinds of disorders. You need to be seeing a pediatrician or possibly a psychiatrist for initial diagnosis. It is no good if you have to wait months for your appointment if your child is going to be assessed by a drama therapist or practice nurse! (It does happen!) Before you agree to an appointment with this person find out what experience they have in ADD or ADHD. Ask which diagnostic tools they will be using.

4. If the secretary, or even the practitioner hasn't a clue what you are talking about, ask to be referred to someone who does. Be insistent. Also ask whether they are prepared to prescribe appropriate stimulant (or other appropriate) medication. Again, if not, ask to be referred to an experienced pediatrician who will. If they do not know of anyone to refer you to, ring your local Support Group who will be able to tell you the name of your nearest ADHD specialist.

5. Then, tell who you would have been seeing that you will be writing a letter to the health trust (or local medical board) voicing your concern about their lack of knowledge in dealing with the problem of ADD.

6. If you do get to see someone who does know a bit about ADD and ADHD, but who is reluctant to diagnose either way, ask IN WRITING why they think your child DOES NOT fulfill the criteria for ADD/ADHD.

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