by Karen Durbin
Attention Deficit Hyperactivity Disorder (ADHD) has been defined as a collection of symptoms, all of which lead to disruptive behavior and are therefore expected to be seen in various combinations in most ADHD children.

The characteristic symptoms of ADHD are not abnormal in themselves. In fact, they are present in all children at one time or another, and only when excessive do they become disruptive behavioral problems. Three distinctions to keep in mind when examining the eight principal ADHD characteristics discussed here are their intensity, persistence, and patterning (Wender 1987). But also note that not all of these characteristics are present in every ADHD child.

1. Inattentiveness and Distractibility
ADHD children are nearly always easily distracted and have short attention spans. At home, these children don't listen to what their parents say to them; they don't mind; and they forget things. Their homework is never finished. When getting dressed, they may leave buttons unbuttoned and zippers unzipped, and even put shoes on the wrong feet. At school, their teachers notice that they have difficulty listening to and following directions, have trouble completing assignments, and often are off-task and out of their seats.

It is important to remember that inattentiveness and distractibility need not be present at all times. Many teachers report that these children do well when given one-to-one attention, and physicians and psychiatrists note good attention spans during brief office visits.

The paradox of ADHD children being attentive under specialized conditions, but unable to pay attention and complete tasks under normal conditions, is confusing to parents and teachers, especially when they see that these children are able to sit and watch television for long periods of time. But, as Pugliese (1992) has observed, television programming reinforces the way ADHD children think by switching rapidly from idea to idea and scene to scene, with numerous commercial interruptions. There is constant movement both on the screen and in the minds of the affected children.

2. Impulsiveness
ADHD children tend to speak and act first, and think later (Garber et al. 1990). They talk out in class and interrupt others. They rush across streets, oblivious to traffic, and have more than their share of accidents.

These children are often unable to tolerate delays, and become upset when people or things fail to respond as they wish. This may result in broken toys, as well as attacks on siblings and classmates (Wender 1987).

3. Hyperactivity
Hyperactivity, which involves such attributes as restlessness, excessive talking, difficulty awaiting turns in games, and shifting from one uncompleted activity to another (Garber et al. 1990), is not always exhibited by ADHD children. They may appear to be normally, or even less than normally, active until they have an important task to complete. It is then that these children, distracted by things that would barely be noticed by anyone else, display the classic symptoms of hyperactivity -- constant motion, fidgeting, drumming fingers, and shuffling feet. In the classroom, hyperactive children talk constantly, jostle and annoy others, do a lot of clowning, and are generally disruptive.

4. Attention-Demanding Behavior
All children want and need adult attention, and ADHD children are no exception. The difference is in their insatiable desire for such attention. They have to have center stage, be the clown, monopolize the conversation, and show off. Wender (1987) explains the adult reaction to such behavior:

The demand of attention can be distressing, confusing, and irritating to parents. Since the child demands so much, they feel they have not given him what he needs. Since they cannot understand how to satisfy him, they feel deficient. Finally, because the child may cling and poke simultaneously and endlessly, they feel angry.

5. Learning Difficulties
While ADHD is in no way related to mental retardation, some ADHD children do have similar problems. Their intellectual development may be uneven -- advanced in some areas and behind in others. For example, a child may be able to do fifth-grade mathematics, but only second-grade reading.

Problems in perception are more difficult to define and are more complex than simple vision or hearing limitations. ADHD children may be unable to distinguish between similar sights or sounds, or to connect sensations in a meaningful way.

Such difficulties in children of normal intelligence are called specific developmental disorders (SDDs), a term that is replacing "learning disabilities." While the most common SDDs are in reading and arithmetic, not all ADHD children have these disorders. Nevertheless, because most ADHD children have learning difficulties, they are often viewed as underachievers.

6. Coordination Difficulties
About half of all ADHD children have problems with various types of coordination. For example, trouble with fine muscle control may result in difficulties in coloring, writing, tying shoelaces, and buttoning. For many of these children, handwriting is perceived as an awesome chore, and the results are often illegible. They may also have difficulty learning to ride a bike and throwing and catching a ball. Such difficulties are especially detrimental for boys because these abilities help win social acceptance, and their importance as building blocks for self-esteem should not be taken lightly.

7. Unacceptable Social Behavior
Probably the most disturbing feature of ADHD, and the one most likely to be the initial cause of referral, is the difficulty that ADHD children have in complying with adult requests and prohibitions. While some may appear to forget what they are told, others may obstinately refuse to comply. Parents often describe their ADHD children as obstinate, disobedient, stubborn, bossy, sassy, and uncaring (Wender 1987).

While these children are often very adept at making initial friendships, they are unable to maintain them because they have to be the leaders, the first ones in line, the ones that make the rules. Unable to see the connection between how they treat others and the way others respond to them, they wonder why they have no friends.

8. Immaturity
It is important to remember that while all of these characteristics can be seen in all children from time to time, in ADHD children they appear to reflect the behavior of children four or five years younger. It may be helpful to consider the actions of a ten-year-old ADHD child as being much like those of a normal five-year-old (Wender 1987).

Diagnosis and Implications
The first step parents should take for a child suspected of having ADHD is a medical examination to rule out physicial problems that may show similar symptoms. The second step is for a qualified physician or psychologist to diagnose the child's condition, based in part on a parent questionnaire and teacher assessments.

What are the implications of an ADHD diagnosis on a child's relationships with family and peers? This is an important area, minimized in the past, that may continue to hinder the development of self-esteem even after most or all ADHD symptoms have disappeared.

Because managing these children requires such energy, parents are likely to give more direct orders, feel they need to supervise more, and not allow the kinds of freedoms that other children of the same age would be able to handle. Parents may also demonstrate unresolved anger toward their ADHD children. If self-esteem is formed on the basis of how others respond to us, it is easy to see why ADHD children often form low opinions of themselves (Wender 1987).

Peer Relationships
This attack on self-esteem occurs not only within the family, but in the ADHD child's relationships with peers. Because these children lack social skills, they often find themselves without friends. They are not invited to parties; in choosing up sides for games, they are chosen last -- or not al all; and they are often teased because they react highly to teasing (Wender 1987). The area of peer relationships is one that continues to be troubling for ADHD children even when most or all of their symptoms respond to treatment. While the attitudes and reactions of adults may improve, studies have shown that peers continued to reject ADHD children even after they have successfully learned social skills.

Treating ADHD: Medication
The most common treatment for ADHD children is stimulant medication, and the three most widely used stimulants are Dexedrine, Ritalin, and Cylert. All have been highly effective in improving attention span, impulse control, restlessness, and compliance with requests from parents and teachers (Anastopoulos and Barkley 1990). Also, by being less bossy, more obedient, and better students, these children are more readily accepted by the people around them at home and in school. They feel better about themselves and about their lives in general.

While treatment with stimulant medication alone makes ADHD children more manageable and attentive in the short term, it is not clear if it will have a long-term beneficial effect on learning. Studies have shown that this type of treatment is not always a panacea (Klein and Abikoff 1989).

Treating ADHD: Therapy
Other treatments that have shown some effectiveness in reducing ADHD symptoms are behavior therapy, cognitive therapy, and combinations of these, with and without medicaton.

At the Attention-Deficit Hyperactivity Disorder Clinic of the University of Massachusetts Medical Center, two of the most commonly recommended treatment services are parent training and parent counseling (Anastopoulos and Barkely 1990). Even when medication is used, parents must possess the knowledge and skills to manage their ADHD children on evenings and weekends, when medication is usually not taken, and medication-improved behavior may not be maintained.

Parents must also be aware that ADHD children often exhibit forms of psychosocial behavior that cannot be helped through medication, such as aggression, diminished self-esteem, depression, and lack of appropriate social skills (Anastopoulos and Barkley 1990).

Behavior Management
The use of behavior management principles is one way parents can minimize ADHD symptoms and establish positive new behaviors. Behavior therapy is based on the assumption that ADHD children need clear, consistent, and immediate consequences for their behavior (Gordon et al. 1990).

One approach for parents is the use of negative consequences. For example, simply ignoring an attention-seeking behavior is one effective way to eliminate it, particularly with younger children. There are a number of other effective behavior modification techniques, but of paramount importance is the coordination of such efforts between parents and educators.

How Educators Can Help
Because the problems of ADHD children spill over into school, effective classroom intervention is needed. Teachers should know and be able to use the same behavior modification principles used by parents. In addition, however, teachers can benefit from classroom management suggestions like these:

Maintain a structured program for ADHD children.
Have them practice positive behaviors repeatedly until they internalize them.
Give them work paced to fit their capabilities.
Keep a daily checklist to help them stay focused on their behavior. (Pugliese 1992)
The success of school interventions is dependent not only on the range of cognitive strategies used, but on a high level of communication and cooperation between parents and educators. The main goal is to instill self-control and reflective problem-solving skills in ADHD children.

However, behavior and cognitive therapies also have some limitations. Research has found, for example, that treatment focused on one academic or social skill does not tend to transfer to another area. It appears that behavior therapy needs to be instituted in each specific setting, and that the success of cognitive therapy is highly dependent on the ability of an adult to provide the needed learning cues and encouragement.
Because successful treatment of ADHD by medication and/or therapy has thus far been elusive, we are left with the realization that affected children need individualized, broadly based, and long-term intervention, and that those who help these children must sustain a high level of optimism, enthusiasm, and energy throughout their involvement (Pfiffner and Barkley 1990).

Is ADHD Curable?
There is no one-shot cure for ADHD. One theory is that treatment intervention is required until the brain matures and is able to produce adequate amounts of required chemicals (Wender 1987). Another theory is that ADHD is a lifestyle rather than an acute disorder and therefore cannot be completely eliminated (Whalen and Henker 1991).

Even though symptoms may diminish or disappear in over half of all ADHD children as they move into adolescence and adulthood, many of them will continue to have symptoms well into their adult years. Psychiatrists recognize an adult form of ADHD as Attention Deficit Disorder, Residual Type (ADD/RT).

For the present, research indicates that ADHD children will derive the greatest benefit from multimodal treatment strategies that combine various therapeutic approaches. But such treatment requires a long-term, consistent effort by both parents and educators.

References
Anastopoulos, A.D., and Barkley, R.A. "Counseling and Training Parents." In R.A. Barkley (ed.), Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment, New York: Guilford Press, 1990.
Garber, S.W.; Garber, M.D.; and Spizman, R.F. If Your Child Is Hyperactive, Inattentive, Impulsive, Distractible: Helping the ADD (Attention Deficit Disorder)/Hyperactive Child. New York: Villard Books, 1990.
Gordon, M.; Thomason, D.; Cooper, S.; and Ivers, C.L. "Nonmedical Treatment of ADHD/Hyperactivity: The Attention Training System." Journal of School Psychology 29 (Summer 1991): 151-152.
Klein, R.G.; and Abikoff, H. "The Role of Psychostimulants and Psychosocial Treatments in Hyperkinesis." In T. Sagvolden and T. Archer (eds.), Attention Deficit Disorder: Clinical and Basic Research. New York: Lawrence Erlbaum Associates, 1989.
Pfiffner, L.J.; and Barkley, R.A. "Educational Placement and Classroom Management." In R.A. Barkley (ed.), Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. New York: Guilford Press, 1990.
Pugliese, Frank. Lecture notes by author, March 10, 1992.
Wender, P.H. The Hyperactive Child, Adolescent, and Adult: Attention Deficit Disorder through the Lifespan. New York: Oxford University Press, 1987.
Whalen, C.K.; and Henker, B. "Therapies for Hyperactive Children: Comparisons, Combinations, and Compromises." Journal of Consulting and Clinical Psychology 59:1 (February 1991): 126-135.
Whalen, C.K.; and Henker, B. "Social Impact of Stimulant Treatment for Hyperactive Children." Journal of Learning Disabilities 24:4 (April 1991): 231.
Karen Durbin, a teacher at Southwest Elementary School in Belton, Texas, is working toward a master's degree in educational counseling at the University of Mary Hardin Baylor in Belton.
Reprinted by permission. National Association of Elementry School Principals, Streamlined Seminar, Vol. 11, No. 4, February 1993.