Parents, teachers, daycare workers, pediatricians, camp counselors, scout leaders, coaches, playground monitors, and anyone who has any regular interaction with children are all acutely aware of the growing prevalence in our culture of Attention Deficit Disorder (ADD), and Attention Deficit/Hyperactivity Disorder (ADHD). Certainly the recognition of ADD and ADHD as real psycho-biological disorders has positively impacted those children and parents who were suffering helplessly with highly disruptive behavior and symptoms that hampered learning, damaged relationships, and stressed families to their breaking points. Through the implementation of medication therapy, supportive counseling and behavior management, these families are having some success at overcoming the problems associated with these disorders. At the same time, as often happens with "public advertising," the diagnoses of ADD and ADHD have become the catch all for a myriad of child related problems, particular for those children who are in the school system.

There are a number of reasons why this has occurred. Part of it has to do with the increasing tendency in our culture to overburden the educational system with a whole host of tasks that go far beyond academic instruction. Teachers, guidance counselors and principals find themselves intervening in social and family problems, dealing with difficult disciplinary challenges, and often standing in for parents as the source of emotional guidance and support. Conversely, no one can ignore the tremendous stress endured by parents who are struggling to meet the basic economic needs of the family while also providing the proper amount of nurturing and care for their children. Very often and especially in the wake of high rates of divorce and single parenthood, these responsibilities are overwhelming and create insurmountable obstacles that ultimately take their toll everyone. On a larger societal basis we can see yet another factor, which is a culture that feeds on high degrees of stimulation whether it comes from entertainment, media, or general activity. We find ourselves racing from one thing to another in our work, our play, and even unfortunately often in our relationships. It isn't really so strange that we would see an increase in hyperactive children in a culture that seems to define itself in hyperactive terms. What all of this means is that when we begin to examine the problem of attention deficits and hyperactivity, we see that the explanation, diagnosis, and solutions to such problems are quite complex. We must carefully consider each individual separately in terms of all the possible factors that could be contributing to the problem before deciding a course of treatment or intervention.

Since the problem is rather complex, I would like to discuss it over several articles beginning in this writing with an explanation of the emotional factors that influence attention. For continued discussion read the articles entitled "Attention Deficit Disorder" and "Understanding ADHD."

ORGINS OF ATTENTION

The ability to attend is initiated very early in life during the first several months after birth. As the new infant emerges from the safety and warmth of the womb, he is initially assaulted with a variety of sensory experiences as the rude light of reality descends upon him in the labor room. In the hours, days and weeks that follow, these sensory experiences begin to take a regular shape in the sound of mommy's soothing voice, the warmth of her smiling gaze, or the security of being tucked in her arms and rocked. As she makes little faces at him, lovingly cups his feet, or coos at him, the baby is beginning to organize his senses to take in experiences and respond to them emotionally.

Baby's sensory experiences, particularly those involving mommy (or his primary caretaker) become both a means of stimulation and excitement, as well as mechanisms for self-soothing and reaching a state of calm (Greenspan, 1999, p. 24). Mommy's voice is very exciting when she is making high-pitched sounds accompanied by funny faces, and is in turn very soothing when she speaks to baby in soft, low-pitched tones while stroking or holding him. It is this regular and predictable interaction between mother and baby characterized by warmth and protectiveness that supplies the infant with the first means for attending to and harnessing the senses in ways that provide the opportunity for learning while regulating and calming oneself. In fact, "baby's ability to hear and respond to" mommy's voice "is one of the primary ways in which he learns how to take a deep breath, calm down, and pay attention to you and the world," (p. 30). It is in the convergence and experience of all the senses at once during the loving interactions with mommy that baby's basic ability to attend and regulate the emotions are established. Moreover, the basic sense of trust and security that is built during these first few months provides the background from which attention is derived and steadied.

Greenspan points out that this stage in a baby's development is crucial. The absence of loving caregivers "to help babies become interested and engaged in the world around them" (p. 25) can prevent the achievement of this basic sense of security, and at its worst, result in infants that are "self-absorbed" and who lose interest in the their surroundings. In speaking of cases of severe emotional neglect, Greenspan reports that these infants can become so self-absorbed that they lose muscle tone, sometimes resulting in an inability to even move their heads (p. 25). This underscores the very important link between emotional security and the ability to attend.

THE ELEMENTS OF ATTENTION

Attention is usually thought of as the ability to focus mentally in a singular direction for a specified length of time during which other objects of interest or focus can be put aside or kept on the periphery. What usually is not included in the definition is the dynamic quality of attention. It is an interactive process in which the person attending interacts with the object of attention in such a way that there is a reciprocal interchange. Using baby as the example, if baby attends to mommy's face, her expressions, gaze, movements, and so forth communicate something back to him. If mommy smiles and winks, a feeling of warmth and receptivity is communicated which is felt by him in the process of attending. In turn, there is a reaction communicated back to mommy either in terms of expression, a felt emotional response, or perhaps a return smile, squeal, or giggle. Even with inanimate objects such as a toy or a book, the process of attending is a dynamic one in which the words or pictures communicate something to the child as he or she looks at the book. Or perhaps the color and shape of the toy communicate some sense of excitement or interest as the child picks it up, handles it, looks at it, and so forth. Attention, then, requires a certain degree of interest coupled with enough interactive reciprocity so that interest and focus are maintained over time. Although the act of focusing the mind can be considered to be a mental skill, it is the elements of interest, interaction, and involvement that are the emotional elements of the process without which attention could not be sustained.

Based on this dynamic interpretation, we can make the following assertions about attention:

• The capacity to attend is initiated during the first three months of life as a result of the nurturing relationship between the infant and primary caretaker in which the sensory system is alternately stimulated and soothed.
  
• Paying attention is an interactive, dynamic process that engages and focuses the mind in a singular direction.
  
• It requires an emotional investment based on interest and motivation.
  
• It is enhanced in children by a steady sense of emotional security and trust.
  
• It requires the ability to calm and regulate the emotions.
  
• It is best when the reciprocal feedback from the act of attending is positive.
  
• It is easily interrupted by stress, emotional problems, and overstimulation.

Let's examine the following scenario to see how these assertions play out. Sara is a 9-year-old fourth grader who has a good relationship with her parents, feels comfortable in her family life, and has no particular learning disabilities. She likes puzzles and problem-solving sorts of games, and is particularly good at math. When asked to do a timed math quiz at school involving multiplication, she easily attends to the task at hand, finishes before the time is up, and relishes having her answers checked because she feels confident she will have done well. She gets most or all of the answers correct, her teacher gives her a big smile and tells her "good job," and she goes about the rest of her day with a sense of accomplishment and contentedness. David, also a 9-year-old fourth grader, lives with his mother (Dad left the home last year). His mother works two jobs, is highly stressed, and David spends a good deal of time with other caretakers along with his younger brother. He misses his Dad, but sees him only occasionally. David also historically has not done well with math and he has felt humiliated a number of times when other children made fun of him during class math games. Under the same quiz circumstances, he becomes highly anxious, fidgets in his chair, is unable to focus on the problems, daydreams, and doesn't finish the quiz in the allotted time. Worse yet, he gets many or most of the problems wrong. He doesn't get the teacher's smile, his mother isn't happy with his performance, and he is left feeling incompetent and discontented as he moves on to his other daily activities.

Sara's circumstances contain all of the necessary ingredients for being able to attend well in the above scenario. She has had and continues to have ongoing emotional nurturing from her parents. She lives in a family and environmental situation that is not overburdened with stress and conflict. She has attained the capacity to focus and calm herself when the need arises, and in this particular situation, she is involved in an activity that is easy for her, she excels at, and from which she receives reinforcement in terms of her competence and self worth. She has both interest in the math games and an emotional investment in the results she will attain from doing well. David, on the other hand, is somewhat emotionally neglected in view of his father's absence and his mother's inability to both support the family and adequately attend to his needs. In fact, the fallout from the recent marital separation is sapping both his and his mother's energy. His ability to calm and regulate his emotions has diminished as the stress of the separation spills over into his daily living. Math is not his best subject and he has already learned that his inability to perform well in this area has resulted in negative reactions from others. For him, there is no real interest in the subject, it isn't easy, and he is not emotionally invested in participating as he suspects the outcome will bring negative responses and ultimately further emotional despair. It's not surprising that David has great difficulty in attending to the task at hand.

WHAT PARENTS CAN DO

Extracting from David's and Sara's situations above, it would seem that there are certain key elements that need to be in place for a child to be able to attend well.

• Beginning at birth and continuing throughout childhood and adolescence, children need a warm, loving relationship with their parents (or parent if only one is available). This relationship begins in the first three months as described above, and must by nurtured continually. This means spending time with children, trying to understand their distinctive dispositions and needs, and confirming them as valuable family members as well as individuals. Children who are neglected emotionally are particularly at risk for attention problems.
  
• Keep stress, overstimulation and conflict to a minimum. Family conflicts, particularly marital problems, are highly stressful to children even if they appear not to be directly effected. What happens is that their emotions become tied up with the stress they are experiencing so that they are unable to use their energy in other pursuits such as learning. Other types of overstimulation include abuse, yelling, too much nudity in the home, chaotic living patterns, etc.
  
• Build on strengths instead of focusing primarily on weaknesses. You want to give equal if not more time to supporting your child's talents and abilities. If you have a good reader, show your support by getting a library card, making up stories together, and sharing your pleasure in your child's interest.
  
• Don't ignore deficits, but assist your child in learning how to work through and around them. If there seems to be a problem with any particular area of learning, get a thorough evaluation done to see if there are some specific learning problems that need additional educational assistance. Keep in mind that very often children who have attention problems do not have them across the board, but only in relation to certain kinds of situations.
  
• Finally, set reasonable limits on behavior, and follow through consistently with them. Children who have permissive parents can have attention problems simply because they have not internalized the self-discipline that goes hand in hand with parental limits.

________________________________________________________________________

Greenspan, Stanley I. Building Healthy Minds. Cambridge, Massachusetts: Perseus Books, 1999.

by Barbara Frazier, M.S.W.

Attention Deficit Disorder has become a household word over the last decade garnering the attention of parents, educators, physicians, and child care workers not to mention talk show hosts, TV programs, magazines, newspapers, and other such venues of public discussion. Is it new? Not really. Most researchers agree that Attention Deficit Disorder (ADD) has always been around, but not necessarily diagnosed, or perhaps was recognized as some other syndrome. Whether it is occurring more or not is hard to say. Certainly the population is increasing allowing for greater hereditary transmission of the problem. What is on the rise is a growing body of research into the causes, management, and treatment of ADD that is now available to families struggling with these problems. Likewise, there is a fair amount of misinformation as well as contradictory information that is available. What I propose to do here is to outline the basic symptoms and characteristics, causes, methods for evaluation, and strategies for the management of ADD. Since there are two major categories of ADD, I'm going to address what is known as the Inattentive Type in this article. See Understanding ADHD for a discussion of the specific concerns related to the Combined Type (more commonly called ADHD) that include not only problems related to inattention, but also hyperactivity and impulsivity.

WHAT ADD LOOKS LIKE

The primary problem that characterizes the Inattentive Type of ADD is the inability to focus one's attention. Children with this type of ADD are unable to sustain their attention over prolonged periods of time and find themselves easily distracted by the smallest of stimuli in the environment. People talking, the sound of a car coming up the street, rain falling on the roof, a dog moving quickly in the periphery of one's vision, a stiff crease in one's pants - all of these are keenly felt by the child with ADD, and efforts to suppress them are unsuccessful. It is as though all of the sights, sounds, odors, and somatic (physical) sensations flood their sensory apparatus involuntarily without the capacity to modulate their intensity. In normal circumstances, we may be aware of a number of stimuli in our immediate surroundings, but we have some control on how much attention we wish to direct toward each of them. We can keep some things in low relief while maintaining our primary object of focus in high relief. The ADD person simply cannot do this.

Common complaints about ADD children are that they are dreamy, spaced out, forgetful, careless, unable to concentrate, disorganized and distracted. If they manage to get their homework done and in the backpack, they can't seem to turn it in when they get to school. If you send them to clean their rooms, you may come in hours later and find them sitting in the middle of the floor occupied in some activity with little to no progress made in the task at hand. If you ask what they've been doing all this time, they may not be able to tell you exactly. Perhaps they picked up one toy, placed it on the bedside table, saw something that interested them for the moment, and forgot what they were there to do. Parents of these children become extremely frustrated with their disorganization and forgetfulness, and often peg these kids as simply lazy. To make things more confusing, there seem to be certain situations in which ADD children can be attentive. This occurs when there is the element of novelty (something new like the first week of school), a high interest value (Nintendo), an atmosphere of intimidation (mom and dad are really mad now), or participating in a one-on-one situation with an adult (seeing the therapist, eating out with dad). Parents often say things like, "he can sit in front of his Nintendo for hours" or "she seems to be able to listen to music, and knows all the words to her favorite songs," and so forth. At the same time, they do poorly in school and complain about hating the work. Verbal instructions seem to go in one ear and out the other. They lose things, don't finish work, make careless mistakes, complain about the simplest distractions such as a shirt that is too scratchy against their skin.

Socially, these kids are not a behavior problem. They are cooperative and don't have particular difficulties with other children. If anything they are more often overlooked and recede into the background. They may have less interest in interacting with others and appear to hang out on the periphery, very unlike the ADHD kids that are more "in your face" and demanding of attention. Teachers like them and often their problems are not detected until later in the upper elementary years or even middle school when their difficulties with organization and forgetfulness become very noticeable.

WHAT CAUSES ADD?

There is some controversy around this question, but most research points to heredity as the most common factor. ADD children very often have a parent who has similar problems. Conversations with these families usually will reveal this pattern, although it is likely that the parent's problems were never diagnosed or treated. The largest controversy has to do with whether poor parenting can cause ADD. In the case of true ADD, it cannot. Poor parenting can greatly aggravate the problems and prevent the development of good coping mechanisms for dealing with the symptoms. In fact, one of the difficulties in making the correct diagnosis comes from our knowledge that the effects of poor parenting, dysfunctional environmental conditions, and lack of proper nurturing can create symptoms in children that mimic ADD. This is especially true in regard to the behavioral components of hyperactivity, impulsivity, and poor self-control that are the hallmark of ADHD. This is why the evaluation process is so important. We must determine the source of the problems by taking a full history and then carefully evaluating the symptoms and history against the diagnostic criteria for ADD.

EVALUATION AND DIAGNOSIS

Diagnosis and evaluation is difficult because there is not a specific test for ADD. Moreover, ADD children usually do not display their symptoms at the doctor's or therapist's office, especially during the first several appointments as these situations have the quality of being novel or sometimes even intimidating. Instead, the process requires the collection of a great deal of detailed information from parents, the school, the child, and perhaps physicians or others involved in the child's life. Certain kinds of testing are also helpful. I recommend starting with an extensive interview of the parents over several appointments. At a minimum, the interview should include a developmental history, history of symptoms related to attentiveness, history of behavior and social interactions, and equally important, a history of the parents' school performance and difficulties with attentiveness if they exist. Interviews with school teachers are quite helpful as well as reviewing school records, report cards, behavior histories, and so forth. Psychological testing can provide a baseline of information about IQ, basic developmental capacities, and tendencies toward other psychological problems, but these do not necessarily contribute much to the assessment of ADD. There are a number of what's called "rating scales" that can be helpful. A short list would include the Achenback Child Behavior Checklist (CBCL), Behavior Assessment System for Children (BASC), Conners Rating Scales-Revised (CRS-R), ADD-H Comprehensive Teacher/Parent Rating Scales (ACTeRS) and the Attention Deficit Disorder Evaluation Scale (ADDES) series. For evaluators, Russell Barkley's Home and School Situations Questionnaires are good devices for gathering pertinent information from parents and teachers. These use a rating scale to be applied to a series of questions that target ADD symptoms.

The bottom line in making a diagnosis of ADD is to carefully collect and review all of the information listed above, as well as spend adequate time with the family and child for observation and discussion. It is necessary to rule out other possibilities such as specific learning disabilities and processing problems, depression and anxiety disorders, or reactions to social stress either at home or school. All of these may be present along with ADD and their careful evaluation is necessary. ADD children can develop depression and anxiety over time, especially as their self-esteem is challenged due to their inability to perform and the negative reactions of others in this regard. Treatment for these problems often accompanies the treatment for ADD.

INTERVENTION STRATEGIES

Once the diagnosis of ADD has been made, it is then necessary to develop a comprehensive plan for treatment and monitoring. The plan should include the following four elements: education and counseling, behavior management, medication evaluation, and monitoring. Let's take them one at a time.

Education and Counseling - Children and parents both will be able to deal with the symptoms of ADD more effectively if they know as much as they can about the disorder, how it manifests, and especially how it effects both the individual and the family. A counselor is very important in this part of the process, and can serve as the person that oversees the process of education as well as monitors how the family is dealing with problems as they go along. The specific issues the counselor can address are helping the parents to devise an effective behavior management plan, repairing negative perceptions about the child, treatment of depression and anxiety symptoms that may have developed among any or all of the family members, and monitoring progress. Counseling may also be necessary to deal with marital distress that has arisen in trying to cope with an ADD child. This is especially true for children diagnosed with the Combined Type of ADD where behavior problems related to hyperactivity and impulsivity are more prevalent.

Behavior Management - The diagnosis of ADD does not mean that irresponsible behavior is to be excused. Rather it assists the child and family with understanding that different kinds of strategies may be necessary to help the ADD child function well. For example, ADD children often do much better with written instructions, timed chores, extra positive reinforcement, more one-on-one interaction, and structured activity. They may also need some training in self-cueing to help them deal with forgetfulness. Another good technique is to break tasks into smaller components such as listing out each step of a single chore. A counselor can help parents and children (especially teens) devise the various strategies that will work, as well as monitor their effectiveness in order to revise them as necessary. At the same time, limit setting is necessary and needs to be reinforced as usual, but with the understanding of the child's capacities. ADD children need to get the message that they can learn to successfully cope with their problems by identifying and understanding what they are, and then learning how to compensate for them.

Medication Evaluation - The most common and popular treatment strategy is the use of stimulant medication. Stimulant medications (Ritalin, Dexedrine, Adderall) can be quite helpful in increasing the ability to focus, but it is very important to have a full picture of the exact nature of the problems and their sources before plunging into this avenue of intervention. It is not advisable to put children on stimulant medication unless we are sure of the diagnosis, and sometimes depending on the types of problems that are prominent, other types of medications are indicated. In particular, children who are having greater problems with anxiety and depression along with ADD symptoms may do well on a regimen of what are known as the tricyclic antidepressants (Tofranil, Norpramin, Pamelor). Sometimes both stimulants and antidepressants are taken at the same time so that the symptoms of anxiety and depression are alleviated while the ability to focus is also enhanced.

Why Stimulants Work - ADD seems to correlate with problems in the prefrontal areas of the brain. The prefrontal cortex is associated with the ability to focus and attend as well as self-regulate behavior and impulses. This area of the brain is underactive in people with ADD, and has a low level of dopamine functioning. Stimulants enhance dopamine functioning which in turn enhances the ability to focus and regulate behavior. Stimulants are particularly effective with the Combined Type of ADD, and often quite effective with Inattentive Type. They can be contraindicated when anxiety and a tendency toward over-focusing are present. In these cases SSRI antidepressants (Prozac) can be helpful. A word of caution is to be sure that a thorough evaluation as described above has been completed if medication is to be considered. Prescribing medication on the basis of a 15 to 30 minute assessment by a physician without all of the other information is not advisable. Nor is medication treatment without counseling and education a good strategy. Learning to cope with and compensate for the problems associated with ADD has equal if not more importance than simply the alleviation of attention related problems.

Is Medication Necessary? No, not always. Behavior management programs that are constructed to cater to the specific problems related to ADD can greatly improve the functioning of these children, often without medication. The decision to use medication depends on the severity of the problems, the effectiveness of other intervention strategies, and a clear understanding of other problems that may be contributing to the child's overall functioning. Sometimes the treatment of anxiety and depression along with the development of an effective behavioral program is enough to increase the ADD child's experience of success enough so that attention related problems can adequately be compensated for without medication. For others, medication is necessary for even the mundane day to day activities such as getting dressed, brushing one's teeth, or getting to school. Each child needs to be evaluated from the perspective of his or her own individual characteristics and needs, family situation, and best overall strategies for creating successes.

Monitoring - Monitoring should take place throughout the process of evaluation and treatment. Regular appointments with the counselor, school personnel, and physician prescribing medication are necessary. In addition, regular feedback between the parents with each other, and the parents and child are also helpful in staying on top of problems as they occur. Keep in mind that regular, positive interaction with the ADD child is very important to enhance and preserve the parent-child relationship, and should always outweigh time spent in dealing with problems.

by John P. Frazier, M.S.W. and Barbara Frazier, M.S.W.

In our article entitled "Attention Deficit Disorder," we began our discussion of ADD by covering the symptoms, causes, and treatment of the Inattentive Type. We emphasized that the primary problem encountered by children with this type of ADD is the inability to focus and sustain the attention. Often described as distracted, day-dreamy, spacey, and sometimes even lazy, we also noted that these children are for the most part cooperative, quiet, and well liked by teachers. For this reason their problems are often not detected until well into their school years when the problems with inattention become very noticeable. ADHD (Attention Deficit/Hyperactivity Disorder) children, on the other hand, are noticed early in childhood, often in the preschool years and certainly by the time they reach kindergarten and first grade. Why is this? Because the inability to control one's impulses and the accompanying disruptive behavior that are the hallmark of ADHD surface loudly and early in these children's activities and interactions with others. Not only do they have difficulties sustaining attention over time as do ADD children, they have the added problems of hyperactivity and impulsivity. Let's begin by taking a look at the three major components of ADHD which are inattention, hyperactivity and impulsivity, and then go on to see how these affect thought processes and behavior.

INATTENTION

Like the ADD child whose basic problem is the incapacity to focus and sustain attention, the ADHD child has all of the same problems in attending to schoolwork, becoming distracted, and following instructions. In terms of school work, these children often make careless mistakes, do not follow through on instructions, may get homework finished (with prodding) but then not turn it in the next day, have difficulty organizing and keeping track of school supplies, and simply forget what they have been told. They lose things, have difficulty listening when spoken to, and tend to avoid tasks that require sustained mental effort. It's not so much that they are unable to pay attention or even to understand what they are told, it's more a problem with being able to sustain their attention long enough to translate instructions into action. They can't seem to keep themselves from wandering mentally toward something that is of greater interest than the task at hand.

Russell Barkley points out most importantly that ADHD children do not have problems with filtering information (1995, p. 30). In other words, they can extract the important information from the irrelevant in a communication. This means that there is not a problem with understanding what is said. The problem is more one of distractibility, particularly when the task at hand is lengthy, boring, repetitious, or uninteresting. Schoolwork almost always falls into the "uninteresting and boring" category, as do lectures from adults, instructions that are complicated and have a number of parts, and tedious activities that offer no immediate rewards. ADHD children attend best when activity is interesting, novel, fun, and generates a good deal of energy. In fact, we might go so far as to say that ADHD children are "energy junkies." They gravitate toward highly stimulating activities that produce sensations of excitement and emotionality. These are usually those activities that are more action oriented and offer immediate rewards. Also, the greater the sensory and emotional stimulation the better. Loud music, colorful toys, big motion outside activities, action packed video games, and so forth, offer the right stimulation.

The last part of the inattention problem has to do with the capacity to delay gratification. As was mentioned above, ADHD children go for tasks and activities that offer immediate rewards. They need something to look forward to on almost a momentary basis. If they have to choose between picking up three toys off the floor rewarded with five minutes of video game time, and doing a number of jobs to earn the money to buy a new favorite video game (at a later time), they will almost always opt for the former. They would rather have the immediate reward even though it has far less value both monetarily and in terms of the pleasure it can offer over time.

HYPERACTIVITY

Inattention is certainly a problem that is noticed in school, but more often hyperactive behavior is what brings the note home from the teacher asking the parents to come in for a conference. This is because the disruptive quality of this behavior and the difficulty in managing it requires an intensive and collaborative effort by teachers and parents together. The hyperactivity displayed by these children has two components worth mentioning here. The first one I would call an overall "restlessness" that is supercharged with energy. These kids can't stay seated in class and sometimes leave the room without permission. They talk excessively and loudly, squirm in their chairs, make unnecessary noises liking humming or tapping their pencils, and so on. These are the kids you see running through the grocery store with their mothers chasing after them in despair as others look on with that "can't you keep your child under control" look. Other descriptions often used are things like "being driven by a motor", "bouncing off the walls," "always on the go," "can't sit still," and sometimes simply "hyper." Normal attempts to restrict this kind of behavior often don't work. You might hear a teacher complain that she's moved the child to every possible seat in the classroom, including a seat isolated from the other students, but the child still talks to everyone and regularly disrupts the class.

The second component has to do with being overly responsive to situations. Barkley describes this as "behaving too much" or being "hyperresponsive," (1995, p. 37). What he means is that these children are quick to respond, often with a sort of high intensity knee-jerk reaction that doesn't take into account the context of the situation, possible rules that might apply, or consideration of the consequences. These responses are highly emotional and forcefully acted out without the benefit of first thinking through the situation. Another way of understanding it is that ADHD children are very easily emotionally aroused, and they react automatically to their heightened feelings without first filtering them through a process of analysis. I'll explain more about this further on in the article, but for now lets move on to "impulsivity."

IMPULSIVITY

We've actually already alluded to the problems with controlling impulses above. Because of the high emotional response factor, ADHD children don't make decisions based on objectively thinking through a situation, but rather base decisions on their moment to moment feelings and desires. For example, they might blurt out an answer to a question before the question has been fully stated, or they might interrupt others' conversations, sometimes repeatedly even though they've been told to wait their turn. They act quickly on ideas without considering the consequences, especially if the situation appeals to their need for stimulation and excitement. They seem almost incapable of waiting, and as such are quite demanding and excessive in their drive to act. Parents complain of these children that once they have decided they want something, they will badger them unceasingly to get it now. If a movie is planned for the weekend, they will do their best to get a parent to take them during the week. They will ask repeatedly, offer a number of reasons why they need to go now, try and manipulate the situation, coerce the parent, use guilt if necessary, or if all else fails, whine, cry and/or throw tantrums. The intensity and longevity of the attempts to sway parents is what is so difficult to endure, and often wears them down until they give in.

Impulsivity also plays a negative role in social development. In playing with other children, ADHD children seem unable to share, take turns, give equal time to other children's ideas and desires, and generally be considerate of others. They are likely to grab things out of another child's hands, blurt out something rude or hurtful, or disrupt activities that require delaying a response such as playing a board game. They badger their friends in the same way they badger their parents, and quite often are seen as selfish and annoying. Unfortunately, most of these children want to have friends and participate as part of the group, but they form negative relationships with other children as a result of their pushy, disruptive behavior.

BARKLEY'S "NEW THEORY ABOUT ADHD"

Russell Barkley offers a unique view of ADHD that is very helpful in understanding the mechanisms that underlie the problems of inattention, hyperactivity and impulsivity. He believes that the real root problem is an impairment of "behavioral inhibition," (1995, p. 43). In other words, ADHD children do not seem to be able to inhibit their urges to "act" in the same way as other children of a similar age can. The way this plays out is that when the child needs to focus on or attend to something, he is unable to inhibit his urges to shift his attention to something that is more interesting or rewarding. It's not so much that he has a short attention span, but he has a "short interest span," (p. 43). Likewise, hyperactive behavior and the tendency to impulsively act out an emotional response are again the result of not being able to inhibit the urge to respond or gain immediate gratification. Barkley points out that as children mature, they naturally develop the ability to delay responses and impulses, and to focus on instructions and activities that have low interest value. The ADHD child does not mature in the same way and is in fact much more like the normal younger child. Parents of ADHD children often complain that their child seems unable to carry out the basic age appropriate tasks that their younger children have already mastered. If you follow these kids all the way through school and into college, the same pattern of lagging behind developmentally seems to hold.

Dr. Barkley expands his theory of ADHD by borrowing from Dr. Jacob Bronowski who has a lot to tell us about how our methods of communication are different from those of other animals, especially the primates. In fact, a distinguishing factor between humans and primates is the ability to "impose a delay between a signal, a message, or an event that we experience and our reaction or response to it," (1995, p. 45). We can take in a message, impose a period of waiting while we process it, and inhibit our response until we have deliberately decided what our response should be. Further, this capacity to inhibit the urge to respond allows us to process the message in four ways: (1) we can split the experience or message into both the emotional and informational components, (2) place the experience within time by connecting it to past experiences and thereby creating a sense of the future; (3) talk to ourselves as a means of facilitating the process and controlling our responses; and (4) break the information down into parts so that we can then put it back together in a new and synthesized message with which we respond (p. 45). In short, humans are able to stand back from an experience, analyze it, compare it to previous experiences, foresee the consequences of different responses, and then synthesize all of this to produce an outgoing message or response. Moreover, it is the ability to delay and inhibit behavior that is the starting point of the entire process. Let's look at how each of these manifests in the behavior of ADHD children.

Separating Emotions from Information

What's implied here is the ability to break an experience into both its subjective and objective components. What is the personal meaning versus the facts of the situation? Is what we are feeling actually in response to the reality of the situation, or are we overreacting or incorrectly assessing what is really going on? By imposing a delay, we create some emotional space that allows our thinking capacity to emerge and help us calmly and objectively analyze the experience in order to formulate a proper response. Those with ADHD very often are not able to create that space because they cannot delay or inhibit their response. They are instead hyperresponsive to their own emotions and tend to act (or act out) without any analysis.

Gaining a Sense of Past and Future

The ability to delay a response slows time down in such a way that a situation or experience can be kept actively alive in the mind long after the event has passed (1995, p. 46). This allows us to study and evaluate the experience, compare it to past experiences, and place it within the context of our personal history. More importantly, it enables us learn from our past experiences as well as hypothetically consider our future actions. The "now" is placed in the larger picture of personal time. People with ADHD have difficulty in building this larger historical view. Without the capacity to adequately delay responses, past and future get lost in the emotional "now" driven by the need for stimulation. It's no wonder that the same mistakes are made repeatedly, or that the payoffs that come from long-term pursuits allude these folks. The inability to orient oneself to the future coupled with the need for immediate gratification can have dire results, particularly if the avenues of stimulation and gratification become self-destructive as in the case of school failure, substance abuse, careless driving, and so forth.

Talking to Ourselves to Control Behavior

When we are able to delay responses, we allow ourselves time to talk ourselves through the experience and examine possible responses. This kind of self directed speech is called "internalized speech," (1995, p. 49). Dr. Bronowski explains that internalized speech is different from social speech or speech used to communicate something to someone else. Talking to ourselves, or internalized speech, is an "instrument of reflection and exploration" (p. 49) to hypothetically construct verbal responses. We practice how we are going to respond by verbalizing the possibilities to ourselves before we act on them. It has been found that ADHD children have very little self-directed speech. In fact there are a number of treatment programs that have focused on teaching these children how to develop and make use of internalized speech.

Synthesizing Information

The last skill related to the ability to delay and inhibit behavior has to do with the capacity to break incoming messages into smaller components so that we can thoroughly analyze them and then recombine them into a response that incorporates all of the aspects of our experience. This may sound somewhat complicated, but most of us do it automatically. We hear something, analyze it from a number of perspectives that incorporate both the subjective and objective elements, and through a process of synthesis we formulate a response that hits the mark so to speak. The response takes into considerations past experience and future possibilities, as well as the information imparted in the present. The more successful we become at this whole process, the better we are at problem solving. Again, all of this is dependent on the ability to delay responses, inhibit behavior, and impose a waiting period for processing.

THE BRAIN CONNECTION

The ability to inhibit behavior, which is as we have determined the root problem for those with ADHD, is facilitated in the frontal region of the brain in an area called the orbital-frontal cortex. This is the area of the brain that is directly linked to the capacity to sustain attention, inhibit behavior, plan for the future, and control impulses. It is also the area of the brain that is far more developed in humans as compared to primates. There are a number of studies that have linked underactivity in this area of the brain among children with ADHD as compared to non-ADHD children. This is why stimulant medications help. They speed up the processes in this area of the brain, and the results are a greater ability to focus and attend, delay responses, and control behavior. The slower brain activity might also explain why ADHD children have such a high need for stimulation. These children sometimes are much better able to do homework with a radio on, or to sleep for that matter, because the stimulation from the music actually has the effect of speeding up the functions performed in the orbital-frontal cortex, and hence serves to calm and focus the mind. All of this has implications for finding ways to best help these children harness their intensity and drive toward productive activities as well as methods to compensate for deficits. I've discussed this more thoroughly in the article entitled "Managing Your ADHD Child." For now, it's good to keep in mind that "stimulation" is a key component to both understanding and assisting children with ADHD. Any effective behavioral program will necessarily need to incorporate the need for stimulation as a key component in developing strategies that will work.
________________________________________________________________________

Barkley, Russell A. Taking Charge of ADHD: The Complete, Authoritative Guide for Parents. New York: The Guilford Press, 1995.

by Barbara Frazier, M.S.W.

To successfully manage ADHD children, it is important to keep in mind what you have learned about their overall strengths and weaknesses. Specifically, we know that they have difficulties in inhibiting their responses to events and experiences, and that their responses are often emotionally based and without the benefit of analysis. Secondly, they have a lot of difficulty in placing themselves and their behavioral choices in the future, or conversely in comparing a current situation to a past situation that is similar. This means they don't learn easily from previous mistakes. On the good side, they have high energy and intensity which channeled constructively can be used to assist them in managing their behavior as well as in performing in socially acceptable activities such as art, music, sports, and so forth.

Keeping all of this in mind, it is necessary to develop and implement a behavioral plan that will provide a lot of structure, uses clearly defined rules and consequences, and offers regular incentives and rewards that appeal to the ADHD child's need for immediate gratification and emotional stimulation. Most important, it is also necessary to work daily on a positive parent-child relationship that maintains the child's sense of being loved and cared for in spite of problems that arise. This is the cornerstone of effectively dealing with all children, ADHD or otherwise.

Below we have summarized some general guidelines for effectively managing the ADHD child. Parents of non-ADHD children should also find these guidelines to be helpful in establishing good behavior.

STOP THE EXPLANATIONS!

In trying to get ADHD children to perform tasks (even simple ones), parents may develop the habit of offering reasonable explanations of why things need to be done. "You have to get dressed now because you're going to be late for school!" "You need to brush your teeth because you'll get cavities if you don't!" This seems reasonable and for most children it works fine. It is helpful to know why some things need to be done. For the ADHD child, however, these sorts of explanations and energized warnings do not increase compliance, and in fact over time make things worse. The negative energy that usually emerges from the parent as these admonitions and explanations are offered actually offer the ADHD child a reward for his poor behavior, because the attention given feeds the need for stimulation. So it is important to omit explanations, lectures, verbal attempts to cajole, or even warnings about what will happen if the child does not comply. Save the explanations for another time when you are not in the process of enforcing a rule or request.

DON'T BE PULLED INTO ARGUMENTS AND DEBATES

When you give a command or make a request, there should be no further conversation. If you have gotten into the habit of allowing your child to challenge your requests and pulling you into debates, this will be a hard habit to break. You simply make the request in a direct way such as "Pick up your toys now." Don't answer questions such as "why", or as stated above fall prey to providing explanations when your child challenges you. Simply give the request and apply consequences you have established previously if the request is not followed. If you are in the habit of allowing arguments and debates, you will need to demonstrate to your child that you will not be pulled into arguments before trying consequences. A good technique is to simply look at the child without reacting as he goes through his bag of tricks to cajole you into an argument. Other techniques are to shrug your shoulders, or walk away. Eventually when he understands you won't play his game, he'll stop automatically.

USE INCENTIVES AND REWARD

Remember that ADHD children need more rewards and incentives than other children. One of the best incentives you can offer is verbal, positive feedback for rules followed or chores accomplished. The feedback should be very detailed and descriptive such as "I appreciate your picking up your toys and putting them in the toy box. Good job!" Saying just "good job" is not enough as it doesn't reinforce specifically what has been done, or offer the needed attention. You can also offer physical affection, written notes, and genuine looks of appreciation. Sometime rewards are necessary, especially in working with problem behaviors. Rewards include things such as extra privileges, or if using a home token or credit system, giving points for good behavior that can be spent on privileges. A powerful reward is your time such as playing a game together, throwing the ball outside, etc. When giving positive feedback or rewards, be sure to give credit for even partially correct behavior. If you ask your child to put her clothes in the clothes hamper, and she gets only some of them in before getting distracted, then you can say something like "I see that you heard me say to put the clothes in the hamper. I appreciate that you got started." You can then request that she finish.

BREAK TASKS DOWN INTO THEIR PARTS

In the above example, you could break the task down into smaller parts, and then time them while offering feedback all along the way. For example, if there are ten pieces of clothing on the floor, request that the child pick up five of them and set a kitchen timer for two minutes. As soon as she makes a move to begin picking up the clothes, let her know you see that she has started. As she gets the second or third piece of clothing in the hamper, comment that she's halfway done and cheer her on. If she gets done before the timer goes off, you can praise her for beating the clock. If she doesn't finish before the ringer goes off, praise her for whatever portion she's completed, and then have her finish the task. The idea is to break tasks down to the smallest component necessary to make it possible for the child to comply, and then use reinforcement along the way as she complies. You are training her to focus and concentrate. Eventually, you will need to offer much less feedback while still getting good results.

ESTABLISH CLEAR CONSEQUENCES

Although incentives are the primary method of establishing good behavior habits, sometimes they are not enough. In these cases you need to apply consequences. Natural and logical consequences work very well for most children, however, the ADHD child does best if the consequences are simplified and the same for most situations. I recommend sticking with time-out as the primary consequence, especially if you set up a home token or credit system. Sticking with time-out provides the repetition these children need to reinforce and remember the rules. It is effective in interrupting unwanted behavior patterns while being short enough to maintain the necessary potency for children with short-attention spans. It also can be applied the same way every time, making the need for consistency easy to enact. The key is to always apply consequences firmly, but in a neutral manner without any added negative emotion or commentary. This leaves the child in the position of having no alternative but to turn his attention to his own behavior (as opposed to yours). The only other consequences recommended are those that involve the need for reparation. If the infraction involves causing harm to someone else, or destroying property, then in addition to time-out you should have the child take the needed steps to repair the situation. If he throws a baseball through the neighbor's window, then he needs to earn the money to replace it.

ACT FIRST, TALK LATER

Once you have established the rules, system of incentives, and consequences, then enforce them directly and quickly. Don't use warnings, give second chances, or stop to explain or debate. Act swiftly and decisively to carry out the plan you have established. Negotiating rules and privileges is a productive strategy, but should be confined to family meetings or strategy sessions when behavior is not in question. Never negotiate a rule while offering a consequence.

BE CONSISTENT

Be consistent with every facet of your behavior management program. This means a consistent system of rewards and privileges, consistent consequences, consistent effort in implementing the plan especially in the beginning, and consistent responses to misbehavior. Set up your plan and don't deviate, even when setbacks occur. Above all, if there are two parents, they must be in agreement about the plan and both use the same methods in its implementation.

AVOID PERSONALIZING YOUR CHILD'S BEHAVIOR

It is very important, particularly with difficult children, not to interpret your child's behavior problems as a reflection of your worth as a parent. This means not taking your child's behavior toward you personally, and not internalizing other adults' negative evaluations of your parenting skills. ADHD children have specific problems that are not related to parental abilities. Others, although well intentioned, often don't understand or buy such explanations and can actually make things worse even as they are trying to give support. Getting professional help can help ease this situation as well as assist you in carrying out your plan.

SPECIAL TIME

Spending "special time" with children is one of the most powerful tools parents have to enhance the parent-child relationship and establish a base from which to manage behavior. Without such a base, no behavioral plan will work. Children must feel connected to you through love, caring and nurturing in order to have the basic incentive to comply with your wishes. Spending free time that is not task-oriented or focused on discipline is necessary to foster this connection. With children who are difficult to manage, this is even more important due to the daily assault on the parent-child connection by negative behavior patterns.

IDENTIFY AND ENCOURAGE STRENGTHS

It is important to recognize and keep in mind that having ADHD is not a lifetime curse. In fact, people with ADHD have certain strengths that not only serve them well as they develop, but are assets that are to be appreciated. Their drive and intensity is a resource that can have very productive results when coupled with strong interest. It allows them to pursue a desired direction with sustained energy over time. Their emotionality and hyperresponsiveness are assets in activities that require more direct response and less analysis such as artistic pursuits, athletic activities, salesmanship, inspirational speaking, and so forth. Parents should mentally review their ADHD child's strengths daily. A good exercise is to make a list of everything you like about your child including his or her potential strengths, and place the list in place where you see it every day. Better yet, review it at the end of the day to help balance out the day's struggles. Take note of any small improvements. This will assist you in keeping a big picture view and avoid getting mired down in negative thought patterns about deficits. Enjoy your "spirited child!"

FINAL NOTE

If you have a child that seems particularly defiant, non-compliant, and/or is prone to becoming explosive at seemingly benign situations, then the ideas offered in this article will not work well. These children, who are usually diagnosed with "Oppositional Defiant Disorder," may also have ADHD, but the problems associated with their explosiveness require different strategies for management. I would suggest reading The Explosve Child by Ross W.Greene for an excellent explanation of the problems associated with these children as well as strategies for handling them.