the role of occupational therapy practitioners

1. Attention Deficit Hyperactivity Disorder
(ADHD)
• Introduction
• What is Occupational therapy
• When does child need Occupational therapy
• What is attention deficit hyperactivity disorder?
• What are the symptoms of ADHD in children?
• What Causes ADHD?
• How is ADHD diagnosed/scales?
• Occupational therapy method of treating ADHD?
• Medications
• Psychotherapy
• What conditions can coexist with ADHD?
• How can I work with my child’s school?
• Do teens with ADHD have special needs?
• Can adults have ADHD?
• What efforts are under way to improve treatment?
• Citations
• For more information on attention deficit hyperactivity disorder
Introduction:
Occupational therapist addresses co-existing physical or sensory integration
concerns, such as motor planning, balance and coordination problems and
hand writing difficulties, Occupational therapy practitioners consider the
effect that learning and attention problems have on children’s ability to
perform valued activities, OT’s provide support to parents around behavior
management and develop strategies to help parents help their children, using
occupation as the vehicle to promote health and is one of the few disciplines
that combine knowledge of psychological aspect of behavior and learning
with sensory motor aspects.
What is occupational therapy?
Occupational Therapy is the assessment and treatment of physical and psychiatric
conditions using specific, purposeful activity to prevent disability and promote
independent function in all aspects of daily life.
When does a child need occupational therapy?.
Occupational therapy is provided when there is a disruption in function in one or more
of the following the areas:

2. • Gross Motor Skills : movement of the large muscles in the arms, and legs.
Abilities like rolling, crawling, walking, running, jumping, hopping, skipping etc
• Fine Motor Skills : movement and dexterity of the small muscles in the hands and
fingers. Abilities like in-hand manipulation, reaching, carrying, shifting small
objects etc.
• Cognitive Perceptual Skills: Abilities like attention, concentration, memory,
comprehending information, thinking, reasoning, problem solving, understanding
concept of shape, size and colors etc.
• Sensory Integration : ability to take in, sort out, and respond to the input received
from the world. Sensory processing abilities like vestibular, proprioceptive,
tactile, visual, auditory, gustatory and olfactory skills.
• Visual Motor Skills : a child's movement based on the perception of visual
information. Abilities like copying.
• Motor Planning Skills : ability to plan, implement, and sequence motor tasks.
• Oral Motor Skills : movement of muscles in the mouth, lips, tongue, and jaw,
including sucking, biting, chewing, blowing and licking.
• Play skills : to develop age appropriate, purposeful play skills
• Socio-emotional skills : ability to interact with peers and others.
• Activities of daily living: Self-care skills like daily dressing, feeding, grooming
and toilet tasks. Also environment manipulation like handling switches, door
knobs, phones, TV remote etc.
• Occupational therapists in schools collaborate with teachers, special educators,
other school personnel, and parents to develop and implement individual or group
programs, provide counseling, and support classroom activities.
• Occupational therapists design and develop equipment or techniques for
improving existing mode of functioning.
What is attention deficit hyperactivity disorder?
Attention deficit hyperactivity disorder (ADHD) is one of the most common childhood
disorders and can continue through adolescence and adulthood. Symptoms include
difficulty staying focused and paying attention, difficulty controlling behavior, and
hyperactivity (over-activity).
ADHD has three subtypes:1
• Predominantly hyperactive-impulsive
o Most symptoms (six or more) are in the hyperactivity-impulsivity
categories.
o Fewer than six symptoms of inattention are present, although inattention
may still be present to some degree.
• Predominantly inattentive

3. o The majority of symptoms (six or more) are in the inattention category and
fewer than six symptoms of hyperactivity-impulsivity are present,
although hyperactivity-impulsivity may still be present to some degree.
o
o Children with this subtype are less likely to act out or have difficulties
getting along with other children. They may sit quietly, but they are not
paying attention to what they are doing. Therefore, the child may be
overlooked, and parents and teachers may not notice that he or she has
ADHD.
• Combined hyperactive-impulsive and inattentive
o Six or more symptoms of inattention and six or more symptoms of
hyperactivity-impulsivity are present.
o Most children have the combined type of ADHD.
Treatments can relieve many of the disorder's symptoms, but there is no cure. With
treatment, most people with ADHD can be successful in school and lead productive lives.
Researchers are developing more effective treatments and interventions, and using new
tools such as brain imaging, to better understand ADHD and to find more effective ways
to treat and prevent it.
What are the symptoms of ADHD in children?
Inattention, hyperactivity, and impulsivity are the key behaviors of ADHD. It is normal
for all children to be inattentive, hyperactive, or impulsive sometimes, but for children
with ADHD, these behaviors are more severe and occur more often. To be diagnosed
with the disorder, a child must have symptoms for 6 or more months and to a degree that
is greater than other children of the same age.
Children who have symptoms of inattention may:
• Be easily distracted, miss details, forget things, and frequently switch from one
activity to another
• Have difficulty focusing on one thing
• Become bored with a task after only a few minutes, unless they are doing
something enjoyable
• Have difficulty focusing attention on organizing and completing a task or learning
something new
• Have trouble completing or turning in homework assignments, often losing things
(e.g., pencils, toys, assignments) needed to complete tasks or activities
• Not seem to listen when spoken to
• Daydream, become easily confused, and move slowly
• Have difficulty processing information as quickly and accurately as others
• Struggle to follow instructions.

4. Children who have symptoms of hyperactivity may:
• Fidget and squirm in their seats
• Talk nonstop
• Dash around, touching or playing with anything and everything in sight
• Have trouble sitting still during dinner, school, and story time
• Be constantly in motion
• Have difficulty doing quiet tasks or activities.
Children who have symptoms of impulsivity may:
• Be very impatient
• Blurt out inappropriate comments, show their emotions without restraint, and act
without regard for consequences
• Have difficulty waiting for things they want or waiting their turns in games
• Often interrupt conversations or others' activities.
ADHD Can Be Mistaken for Other Problems
Parents and teachers can miss the fact that children with symptoms of inattention have the
disorder because they are often quiet and less likely to act out. They may sit quietly,
seeming to work, but they are often not paying attention to what they are doing. They
may get along well with other children, compared with those with the other subtypes,
who tend to have social problems. But children with the inattentive kind of ADHD are
not the only ones whose disorders can be missed. For example, adults may think that
children with the hyperactive and impulsive subtypes just have emotional or disciplinary
problems.
What Causes ADHD?
Scientists are not sure what causes ADHD, although many studies suggest that genes play
a large role. Like many other illnesses, ADHD probably results from a combination of
factors. In addition to genetics, researchers are looking at possible environmental factors,
and are studying how brain injuries, nutrition, and the social environment might
contribute to ADHD.
Genes. Inherited from our parents, genes are the "blueprints" for who we are. Results
from several international studies of twins show that ADHD often runs in families.
Researchers are looking at several genes that may make people more likely to develop the
disorder.2,3 Knowing the genes involved may one day help researchers prevent the
disorder before symptoms develop. Learning about specific genes could also lead to
better treatments.
Children with ADHD who carry a particular version of a certain gene have thinner brain
tissue in the areas of the brain associated with attention. This NIMH research showed that
the difference was not permanent, however, and as children with this gene grew up, the
brain developed to a normal level of thickness. Their ADHD symptoms also improved.4

5. Environmental factors. Studies suggest a potential link between cigarette smoking and
alcohol use during pregnancy and ADHD in children.5,6 In addition, preschoolers who are
exposed to high levels of lead, which can sometimes be found in plumbing fixtures or
paint in old buildings, may have a higher risk of developing ADHD.7
Brain injuries. Children who have suffered a brain injury may show some behaviors
similar to those of ADHD. However, only a small percentage of children with ADHD
have suffered a traumatic brain injury.
Sugar. The idea that refined sugar causes ADHD or makes symptoms worse is popular,
but more research discounts this theory than supports it. In one study, researchers gave
children foods containing either sugar or a sugar substitute every other day. The children
who received sugar showed no different behavior or learning capabilities than those who
received the sugar substitute.8 Another study in which children were given higher than
average amounts of sugar or sugar substitutes showed similar results.9
In another study, children who were considered sugar-sensitive by their mothers were
given the sugar substitute aspartame, also known as Nutrasweet. Although all the
children got aspartame, half their mothers were told their children were given sugar, and
the other half were told their children were given aspartame. The mothers who thought
their children had gotten sugar rated them as more hyperactive than the other children and
were more critical of their behavior, compared to mothers who thought their children
received aspartame.10
Food additives. Recent British research indicates a possible link between consumption of
certain food additives like artificial colors or preservatives, and an increase in activity.11
Research is under way to confirm the findings and to learn more about how food
additives may affect hyperactivity.
How is ADHD diagnosed/scales?
ATTENTION- DEFICIT / HYPERACTIVITY
DISORDER
Alternative Diagnoses
Symptoms ADHS Sensory Learning- Nutritio Normal
(DSM-IV) Integration Related n Child
Dysfunction Visual Allergies Under
(Ayres) Problems (Rapp, 7
(Kavner) Crook (Gesell)

6. & Smith)
Inattention (At least 6 necessary)
Often fails
to give
close
attention to x x x x
details or
makes
careless
mistakes
Often has
difficulty
sustaining
attention in x x x x x
tasks or
play
activities
Often does
not listen
when x x x x
spoken to
directly
Often does
not follow
through on
x x x x x
instructions
or fails to
finish work
Often has
difficulty
organizing x x x x x
tasks and
activities
Often
avoids,
dislikes or
is reluctant
to engage
x x x x x
in tasks
requiring
sustained
mental
effort
Often loses
x x x x x
things

7. Often
distracted
by x x x x x
extraneous
stimuli
Often
forgetful in
x x x x
daily
activities
Hyperactivity and Impulsivity
(At least 6 necessary)
Often
fidgets
with hands x x x x x
or feet or
squirms in
seat
Often has
difficulty
remaining
seated x x x x x
when
required to
do so
Often runs
or climbs x x x x
excessively
Often has
difficulty
x x x
playing
quietly
Often "on
x x x x
the go"
Often talks
x x x x
excessively
Often
blurts out
answers to
questions x x x x
before they
have been
completed
Often has x x x x x
difficulty

8. awaiting
turn
Often
interrupts
x x x x x
or intrudes
on others
Physicians often recommend that ADHD or AD/HD be treated asymptomatically with
stimulant medication, special education and counseling. Although these approaches
sometimes yield positive benefits, they may mask the problems rather than get to their
underlying causes.
In addition, many common drugs for ADD (such as ritalin, methylphenidate, cylert),
which have the same Class 2 classification as cocaine and morphine, can have some
negative side effects that relate to appetite, sleep and growth. Placing a normal student
who has difficulty paying attention in a special class and counseling could
undermine rather than boost his self esteem.
A sensible, multi-disciplinary, developmental approach treats underlying
causes rather than the symptoms which are secondary.
VISION THERAPY improves visual skills that allow a person to pay attention. These
skill areas include visual tracking, fixation, focus change, binocular fusion and
visualization. When all of these are well developed, children and adults can sustain
attention, read and write without careless errors, give meaning to what they hear and see,
and rely less on movement to stay alert.
OCCUPATIONAL THERAPY for children with sensory integration dysfunction
enhances their ability to process lower level senses related to alertness, body movement
and position, and touch. This allows them to pay more attention to the higher level senses
of hearing and vision.
Common scales use:-
Conners' Rating Scales–
Brown Attention-Deficit Disorder Scales
Brown Attention-Deficit Disorder Scales for Children

9. Attention-Deficit/Hyperactivity Disorder Test (ADHDT)
Spadafore ADHD Rating Scale (S-ADHD-RS)
ADHD Symptoms Rating Scale (ADHD-SRS)
Vanderbilt ADHD Diagnostic Teacher Rating
Scale
INSTRUCTIONS AND SCORING
Behaviors are counted if they are scored 2 (often) or
3 (very often).
Inattention Requires six or more counted behaviors from
questions 1–9 for
indication of the predominantly inattentive subtype.
Hyperactivity/ Requires six or more counted behaviors
from questions 10–18
impulsivity for indication of the predominantly
hyperactive/impulsive
subtype.
Combined Requires six or more counted behaviors each
on both the
subtype inattention and hyperactivity/impulsivity
dimensions.
Oppositional Requires three or more counted behaviors
from questions 19–28.
defiant and
conduct disorders
Anxiety or Requires three or more counted behaviors
from questions 29–35.
depression
symptoms

10. The performance section is scored as indicating some
impairment if a child scores 1 or 2 on at
least one item.
FOR PROFESSIONALS
Vanderbilt ADHD Diagnostic Teacher Rating
Scale
Name: Grade: ____________________
Date of Birth: ______________
Teacher:__________________________________ School:
__________________________________
Each rating should be considered in the context of what is
appropriate for the age of the children you are rating.
Frequency Code: 0 = Never; 1 = Occasionally; 2 = Often; 3 = Very Often
1. Fails to give attention to details or makes careless mistakes
in schoolwork 0 1 2 3
2. Has difficulty sustaining attention to tasks or activities 0 1 2 3
3. Does not seem to listen when spoken to directly 0 1 2 3
4. Does not follow through on instruction and fails to finish
schoolwork 0 1 2 3
(not due to oppositional behavior or failure to understand)
5. Has difficulty organizing tasks and activities 0 1 2 3
6. Avoids, dislikes, or is reluctant to engage in tasks that
require 0 1 2 3
sustaining mental effort
7. Loses things necessary for tasks or activities (school
assignments, pencils, 0 1 2 3
or books)
8. Is easily distracted by extraneous stimuli 0 1 2 3
9. Is forgetful in daily activities 0 1 2 3
10. Fidgets with hands or feet or squirms in seat 0 1 2 3
11. Leaves seat in classroom or in other situations in which
remaining 0 1 2 3
seated is expected
12. Runs about or climbs excessively in situations in which
remaining 0 1 2 3
seated is expected
13. Has difficulty playing or engaging in leisure activities quietly
0123
14. Is “on the go” or often acts as if “driven by a motor” 0 1 2
3
15. Talks excessively 0 1 2 3

11. 16. Blurts out answers before questions have been completed
0123
17. Has difficulty waiting in line 0 1 2 3
18. Interrupts or intrudes on others (e.g., butts into
conversations or games) 0 1 2 3
19. Loses temper 0 1 2 3
BRIGHT FUTURES TOOL FOR PROFESSIONALS
20. Actively defies or refuses to comply with adults’ requests
or rules 0 1 2 3
21. Is angry or resentful 0 1 2 3
22. Is spiteful and vindictive 0 1 2 3
23. Bullies, threatens, or intimidates others 0 1 2 3
24. Initiates physical fights 0 1 2 3
25. Lies to obtain goods for favors or to avoid obligations (i.e.,
“cons” others) 0 1 2 3
26. Is physically cruel to people 0 1 2 3
27. Has stolen items of nontrivial value 0 1 2 3
28. Deliberately destroys others’ property 0 1 2 3
29. Is fearful, anxious, or worried 0 1 2 3
30. Is self-conscious or easily embarrassed 0 1 2 3
31. Is afraid to try new things for fear of making mistakes 0 1 2
3
32. Feels worthless or inferior 0 1 2 3
33. Blames self for problems, feels guilty 0 1 2 3
34. Feels lonely, unwanted, or unloved; complains that “no one
loves him/her” 0 1 2 3
35. Is sad, unhappy, or depressed 0 1 2 3
PERFORMANCE
Problematic Average Above Average
Academic Performance
1. Reading 1 2 3 4 5
2. Mathematics 1 2 3 4 5
3. Written expression 1 2 3 4 5
Classroom Behavioral Performance
1. Relationships with peers 1 2 3 4 5
2. Following directions/rules 1 2 3 4 5
3. Disrupting class 1 2 3 4 5
4. Assignment completion 1 2 3 4 5

12. 5. Organizational skills 1 2 3 4 5
56
Vanderbilt ADHD Diagnostic Teacher Rating Scale (continued)
www.brightfutures.org
Frequency Code: 0 = Never; 1 = Occasionally; 2 = Often; 3 = Very Often
Occupational therapy method of treating ADHD?
Sensory integration/Activity
Occupational and speech therapy catalogs offer a wide array of cool tools and toys, many
of them carrying pricetags more appropriate for a school district budget than a family's
pocketbook. Improvise with some homemade items that may give you a preview of how
your child will respond to more expensive items, or keep you from having to buy them
altogether.
Fidget Toys
You can get sets of nifty fidget toys, of all kinds and sizes and shapes, from many
occupational therapy catalogs, but you can also assemble a good batch of them yourself,
from easy-to-find items. Try, for starters:
• A balloon filled with sand and knotted securely
• A smooth stone
• A palm-size sea shell
• An old set of keys
• A combination lock
Weighted Items
Weighted blankets and vests can exert a calming influence on your child, but seeing the
prices some companies charge for them can have the opposite effect on you. Whether
you're wanting to see whether weights work before coughing up all that dough; want to
get a jump-start on weight benefits while you're waiting for a professional version to be
delivered; or just can't bear the expense and want to do-it-yourself, here are five ways to
improvise weighted items for your child.

13. • Weighted blanket: Take a heavy afghan and and fold it into quarters to
concentrate the weight. Put it on your child at night and see if it stops rocking,
rolling, and sleeplessness.
• Weighted vest: Take an old vest or shirt and fill up the pockets and hems with
curtain weights. Have your child wear it during stressful times, but not constantly
-- it will lose its effect with overuse. Consult with an occupational therapist
trained in sensory-integration techniques to determine the appropriate amount of
weight for your child.
• Pencil weight: Got a big box of loose nuts and bolts in the garage? Rummage
through to find some nuts that will fit on the end of a pencil, then glue two or
three of them around the barrel.
• Weighted stuffed animal: Take an old favorite stuffed animal -- but one not so
favorite that your child will mind you slashing it open -- and cut open paws and
tummy to insert more curtain weights, nuts and bolts, or other heavy items. Sew
the critter back up securely and let him sit on your child's lap during homework.
• Body weights: Catalogs sell weights for wrists, arms, even shoes. Improvise by
putting some books in a backpack or weights in a fanny pack and having your
child wear them when jumpy.
Oral Motor Items
Strengthening the muscles in your child's mouth can increase speech production and
decrease drooling. Anything that gives the mouth a strong sensory jolt can also improve
sensory integration and make your child less likely to finger-suck or mouth objects. Try
these around-the-house items to do a little impromptu oral-motor therapy.
• Straw: Have your child suck something thick -- pudding or yogurt are good
choices -- through a regular or twisty straw.
• Whistle: Speech and occupational therapy catalogs sell a variety of fancy
whistles, but your child can get some benefit from a plain whistle, a plastic flute, a
kazoo, or one of those mini-trombone-type whistles where you pull the end of it
and the sound goes up and down.
• Bubbles: Blowing bubbles is good exercise for your child's mouth. Make sure he
or she actually blows rather than just waving the wand around.
• Cotton balls: Hold races to see who can blow a cotton ball across a table the
fastest. Have your child do it with just his mouth, and then with a straw.
• Plastic necklace: Inexpensive aquarium tubing from a pet store makes a nice
chewable necklace for kids who need to gnaw. Try knotting some beads in the
tube for extra oomph, or putting it in the fridge for a cool bite.
Tactile Experiences

14. Textured toys and putties and squeezies fill the pages of sensory integration catalogs, but
you have plenty of good tactile tools in your own pantry, closets, and medicine chests.
• Rice: Fill a bin with rice and let your child plunge hands deep into it. Hide some
toys and measuring cups for added fun. Dried beans are another good choice.
• Bubbles: Blowing bubbles is good, and trying to catch bubbles is good, too. Kids
who don't like to touch stickly slimy substances may be less threatened when the
stuff is bubbling through the air.
• Shaving Cream: Spray some on a shower or bathtub wall and let your child
fingerpaint with it.
• Sand: A sandbox can be a full-body experience for a child with tactile
cravings. Let your child get down and dirty with it.
• Ball pits: You can buy a big inflatable pit and the balls to fill it for big bucks, but
many kids' restaurants will let your child play in theirs for as long as you want for
the price of a slice or a soda. Bring a book and enjoy it while your child hits the
pit and has a great therapeutic experience.
Educational Interventions & Other Behavioral Techniques for Attention-
Deficit/Hyperactivity Disorder (ADHD)
Environmental Supports for Children with ADHD:
ADHD and the School Environment
•
The ideal classroom for a child with ADHD is one in which classroom rules
and expectations are clearly defined; the environment is organized; and
routines are structured.
•
A child with ADHD should not be isolated in the classroom but seating
should be preferential with the child located front and center near the
teacher. Fellow students who would present as good behavioral role
models should be seated close by.
•

15. A study area with reduced stimuli and traffic should be placed in the room
and available for use by all the students, not just the child with ADHD.
•
Close attention to schedules and routines should be given so that the
fluctuation in energy presented by the child can be accommodated. For
instance, it would be unwise to spend too much time in low energy
activities. A mixture of low and high-energy activities would be more
desirable.
•
Activities, though, should generally be stimulating, interesting and
meaningful and involve a lot of hands-on projects vs. seat and board work
or lecture.
ADHD and the Home Environment
The home environment can also be structured to provide optimum support to the
child with ADHD. Family and household rules should be clear and well defined as
well as consistently applied. Predictable routines often help structure time for the
child with ADHD. A quiet, organized study area, free of distractions, should be
present.
Set times and routines should be established for study and review of work by the
parent. The child's family responsibilities should also be well defined and it may
be necessary to break chores or tasks into very small sequential steps. Plans
should be reviewed with the child and they should be prepared for any out of the
ordinary changes to routine.
Instructional Strategies for ADHD :
1. Giving Directions:
Directions need to be given clearly, concisely and through multiple
channels. For instance, the teacher should clearly state the directions as
well as have written directions or a pictorial list of directions available.
Complex directions need to be simplified. Teachers should patiently
repeat directions if this is necessary. Make sure the student understands
the directions before proceeding to the task. Ask them to repeat the
directions back.
2. Assistance:

16. The teacher can help the child with ADHD feel comfortable asking for
assistance. One way to do so it to institute a classroom wide method that
all students can use rather than singling out the child with ADHD. Develop
and discuss with the student private cues that can be used when the
student gets off task. For instance, the teacher can quietly touch the
student's arm to remind him/her to refocus on the task.
3. Assignments:
Make sure that the student is writing down assignments correctly each
day. If a student is too young or is not capable, the teacher should assist
in providing a record of assignments to go home with the student.
Assignments may need broken into smaller segments or steps to
complete vs. an entire project. Make sure that the assignment is actually
one that the student has the capacity to perform. Some assignments may
need further modified or adapted for the student.
4. Test Taking:
Students with ADHD may need extended time to complete tests. Once
more, be sure that test directions are understood and that the child is
capable of what is being asked of him/her. Some children may need
modifications in the way a test is delivered. For instance, the test perhaps
should be given orally or perhaps the student can respond orally instead
of in writing. Unique and individual needs should be considered at all
times.
[]
Teaching Self-Monitoring:
Students with ADHD can often participate in planning for improvements in their
own behavior, thus allowing them to hopefully experience more ownership for
change and also pride in accomplishing improvements. First students need to be
aware of the problem behaviors and the control they can exhibit to improve the
situation.
To begin assisting a student with self-monitoring, teachers need to select a
behavior and precisely explain to the student the nature of the problem and what
exactly would consistute improvement. The teacher can then assist the student
by developing a rating scale to rate behavior and document improvement. The
student will need to learn how to use the rating scale and the scale should be
age appropriate.
Teachers can demonstrate how they would rate the behavior and verbalize aloud
their process of decision-making. Learning to use the rating tool with some

17. reliable accuracy will be a precursor to implement the self-monitoring program.
Make decisions on the time interval by which the child will record their "data" or
rating of the target behavior. However, be careful to insure that whatever time
interval is set that the child is capable of being successful.
An example used in one resource gave the example of a child using sarcastic
remarks. If the child is known to use sarcastic remarks about once every 20
minutes, the teacher would want to set the time interval for 15 minutes, thus
enhancing a child's chance of experiencing successful control. Self-monitoring
can be gradually faded out for the behavior as progress is noted. However, in
some cases formal self-monitoring may be desirable for some time to come.
[
Positive Behavioral Intervention and Support:
Positive Behavioral Support is different than traditional "behavior modification".
One key reason for the difference is that with Positive Behavioral Support we ask
the question, "why?" Why is the child's work so sloppy? Why is the child
seemingly never in his seat? Why is this child having problems making friends?
The adults in the situation observe the behaviors and observe the child in
numerous settings in order to develop ideas on the function that the behavior is
serving for the child.
Positive Behavioral Support has a focus on changing the environment and
responses in order to enhance a child's experience of feeling successful and
teaching important skills that reduce the function of the problem behavior.
Positive Behavioral Support is not one approach focused solely on reducing a
problem behavior, rather, it garners a collective team vision and collaboration,
creating a multifaceted approach to improve the circumstances for the child, their
school and community.
Positive Behavioral Support was initially developed as an alternative to aversive
procedures for those with the most severe and extreme behavioral challenges.
However, more recently, it has been used successfully with a wide range of
students and contexts and has been extended to apply to entire school
environments, not just individuals.
According to the Beach Center for Children, the following are general key steps
to implementing Positive Behavioral Supports:
1. Ensuring a fit with your values:
This is not a one-size-fits-all, simplistic plan. There is no "recipe" or quick
fix.

18. 2. Putting together a collaborative team:
No one person alone can create a solution but many ideas and
perspectives can lend themselves toward creating better futures.
3. Creating a vision:
This involves imagining what an ideal life and positive future would look
like for the focus individual. Such a vision should incorporate the
individuals personal preferences, talents, gifts, abilities and relationships.
4. Completing a functional assessment:
This is a structured method of gathering and testing information about the
function that the behavior may have in the individuals' life.
5. Developing strategies:
A. Teaching new skills
B. Appreciating positive behavior
C. Changing systems
According to the O.S.E.P. Technical Assistance Center on Positive Behavioral
Interventions and Supports:
"Positive behavioral support is not a new intervention package, nor a new theory
of behavior. Instead, it is an application of a behaviorally-based systems
approach to enhance the capacity of schools, families, and communities to
design effective environments that improve the fit or link between research-
validated practices and the environments in which teaching and learning occurs."
"Attention is focused on creating and sustaining school environments that
improve lifestyle results (personal, health, social, family, work, recreation, etc.)
for all children and youth by making problem behavior less effective, efficient,
and relevant, and desired behavior more functional. In addition, the use of
culturally appropriate interventions is emphasized."
Haring and De Vault (1996) indicate that PBS is comprised of:
a. "Interventions that consider the contexts within which the behavior occurs"
b. "Interventions that address the functionality of the problem behavior"
c. "Interventions that can be justified by the outcomes"
d. "Outcomes that are acceptable to the individual, the family, and the
supportive community" (p. 116). It goes beyond one approach - reducing
challenging or impeding behavior - to multiple approaches: changing
systems, altering environments, teaching skills and focusing on positive
behavior."
The information above is designed to provide solely an overview of Positive
Behavioral Support (PBS). Those interested should study the topic in much more
detail, as the philosophy and practice can be quite complex. Some initial internet
references are listed at the end of this section.
[

19. Movement Therapies:
Many children with ADHD will benefit from opportunities throughout their day to
be involved in movement activities. The environment should support appropriate
movement. For instance, in classrooms students can be given physical chores.
Teachers can assign active projects that allow a student to change seating
frequently. Hands-on, constructional projects and manipulatives can be used.
More specific movement "therapies" include the following:
•
The "Brain Gym" Program:
Brain Gym is a patented, trademarked program providing movement intervention
in order to enhance brain development. Brain Gym's five-step process is based
on kinesiology, the science of body movement and its relationship to brain
function. Well-established and coordinated physical movements assist in brain
development and in establishing neural connections.
According to Dr. Paul E. Dennison, one of the developers of Brain Gym:
"Educational Kinesiology (Edu-K) is an innovative approach that uses movement
as a means to enhance learning. In Edu-K, the mind and body are integrated
through a variety of simple activities that expand the learner's perceptual
awareness while providing access to the innate abilities needed for information
processing."
The Brain Gym program focuses on various "dimensions":
T Laterality:
the relationship between the two sides of the brain, described as essential for
coordinated and planned movement and learning.
c Focus:
the relationship between the front and back of the brain allowing old information
to be integrated with new learning.
t Centering:
the connections between the top and bottom structures of the brain, proported to
connect emotion with thought and create balance.
The Importance of Emotional Support for Children with ADHD:

20. Children with ADHD will also need emotional and social support. Because they
can be "challenging" to both adults and other children, their self-esteem may be
affected and children with ADHD may lack positive experiences with
accomplishment and friendships. Some ideas for providing emotional support
include:
•
Identify the child's strengths and talents: Caring adults need to help the
child focus on and develop talents and strengths vs. always focusing on
the child's shortcomings or irritating behavior. Many people with ADHD are
quite creative and talented and these qualities should be nurtured in all
settings. Understanding the concept of multiple intelligences may help the
child and adults focus on their positive qualities
•
Offer sincere praise for accomplishments
•
Help the student envision a positive future and a career in which their
talents and abilities will be needed and desired.
•
Encourage participation and cooperative groupings instead of a focus on
winning or losing.
•
Help the child to understand their learning differences and the affect of
ADHD on their lives. Sometimes children assume that the reason they
have difficulty is that they are "dumb" or "stupid" or "bad". They need
adults to help them understand so that they need not blame themselves or
think less of themselves as people.
•
Arrange for formal counseling as needed by individual children.
•
Insure a coordinated "team effort" of support by all adults in the child's life,
including parents, educators, medical personnel and other key people.
Medications.

21. The most common type of medication used for treating ADHD is called a "stimulant."
Although it may seem unusual to treat ADHD with a medication considered a stimulant,
it actually has a calming effect on children with ADHD.
A list of medications and the approved age for use follows.
Trade Name Generic Name Approved Age
Adderall amphetamine 3 and older
Adderall XR amphetamine (extended release) 6 and older
Concerta methylphenidate (long acting) 6 and older
Daytrana methylphenidate patch 6 and older
Desoxyn methamphetamine hydrochloride 6 and older
Dexedrine dextroamphetamine 3 and older
Dextrostat dextroamphetamine 3 and older
Focalin dexmethylphenidate 6 and older
Focalin XR dexmethylphenidate (extended release) 6 and older
Metadate ER methylphenidate (extended release) 6 and older
Metadate CDmethylphenidate (extended release) 6 and older
Methylin methylphenidate (oral solution and chewable tablets)6 and older
Ritalin methylphenidate 6 and older
Ritalin SR methylphenidate (extended release) 6 and older
Ritalin LA methylphenidate (long acting) 6 and older
Strattera atomoxetine 6 and older
Vyvanse lisdexamfetamine dimesylate 6 and older
*Not all ADHD medications are approved for use in adults.
NOTE: "extended release" means the medication is released gradually so that a
controlled amount enters the body
over a period of time. "Long acting" means the medication stays in the body for a long
time.
Over time, this list will grow, as researchers continue to develop new medications for
ADHD. Medication guides for each of these medications are available from the U.S.
Food and Drug Administration (FDA).
What are the side effects of stimulant medications?
The most commonly reported side effects are decreased appetite, sleep problems, anxiety,
and irritability. Some children also report mild stomachaches or headaches. Most side
effects are minor and disappear over time or if the dosage level is lowered.
• Decreased appetite. Be sure your child eats healthy meals. If this side effect does
not go away, talk to your child's doctor. Also talk to the doctor if you have
concerns about your child's growth or weight gain while he or she is taking this
medication.
•

22. • Sleep problems. If a child cannot fall asleep, the doctor may prescribe a lower
dose of the medication or a shorter-acting form. The doctor might also suggest
giving the medication earlier in the day, or stopping the afternoon or evening
dose. Adding a prescription for a low dose of an antidepressant or a blood
pressure medication called clonidine sometimes helps with sleep problems. A
consistent sleep routine that includes relaxing elements like warm milk, soft
music, or quiet activities in dim light, may also help.
•
• Less common side effects. A few children develop sudden, repetitive movements
or sounds called tics. These tics may or may not be noticeable. Changing the
medication dosage may make tics go away. Some children also may have a
personality change, such as appearing "flat" or without emotion. Talk with your
child's doctor if you see any of these side effects.
Are stimulant medications safe?
Under medical supervision, stimulant medications are considered safe. Stimulants do not
make children with ADHD feel high, although some kids report feeling slightly different
or "funny." Although some parents worry that stimulant medications may lead to
substance abuse or dependence, there is little evidence of this.
Psychotherapy
Different types of psychotherapy are used for ADHD. Behavioral therapy aims to help a
child change his or her behavior. It might involve practical assistance, such as help
organizing tasks or completing schoolwork, or working through emotionally difficult
events. Behavioral therapy also teaches a child how to monitor his or her own behavior.
Learning to give oneself praise or rewards for acting in a desired way, such as controlling
anger or thinking before acting, is another goal of behavioral therapy. Parents and
teachers also can give positive or negative feedback for certain behaviors. In addition,
clear rules, chore lists, and other structured routines can help a child control his or her
behavior.
Therapists may teach children social skills, such as how to wait their turn, share toys, ask
for help, or respond to teasing. Learning to read facial expressions and the tone of voice
in others, and how to respond appropriately can also be part of social skills training.
How can parents help?
Tips to Help Kids Stay Organized and Follow Directions
• Make time and space for your child to play, and reward good play behaviors
often.

23. ADD/ADHD parenting tip 1: Stay positive and healthy
yourself
As a parent, you set the stage for your child’s emotional and physical health. You have
control over many of the factors that can positively influence the symptoms of your
child’s disorder.
The power of a positive attitude
Your best assets for helping your child meet the challenges of ADD/ADHD are your
positive attitude and common sense. When you are calm and focused, you are more likely
to be able to connect with your child, helping him or her to be calm and focused as well.
• Keep things in perspective. Remember that your child’s behavior is related to a
disorder. Most of the time it is not intentional. Hold on to your sense of humor.
What’s embarrassing today may be a funny family story ten years from now.
• Don’t sweat the small stuff and be willing to make some compromises. One
chore left undone isn’t a big deal when your child has completed two others plus
the day’s homework. If you are a perfectionist, you will not only be constantly
dissatisfied but also create impossible expectations for your ADD/ADHD child.
• Believe in your child. Think about or make a written list of everything that is
positive, valuable, and unique about your child. Trust that your child can learn,
change, mature, and succeed. Make thinking about this trust a daily task as you
brush your teeth or make your coffee.
When you take care of yourself, you’re better able to take care of your
child
As your child’s role model and most
important source of strength, it is vital that you live healthfully. If you are overtired or
have simply run out of patience, you risk losing sight of the structure and support you
have so carefully set up for your child with attention deficit disorder.

24. • Take care of yourself. Eat right, exercise, and find ways to reduce stress,
whether it means taking a nightly bath or practicing morning meditation. If you do
get sick, acknowledge it and get help.
• Seek support. One of the most important things to remember in rearing a child
with ADD/ADHD is that you don’t have to do it alone. Talk to your child’s
doctors, therapists, and teachers. Join an organized support group for parents of
children with ADHD. These groups offer a forum for giving and receiving advice,
and provide a safe place to vent feelings and share experiences.
• Take breaks. Friends and family can be wonderful about offering to babysit, but
you may feel guilty about leaving your child, or leaving the volunteer with a child
with ADD/ADHD. Next time, accept their offer and discuss honestly how best to
handle your child.
ADD/ADHD parenting tip 2: Establish structure and
stick to it
Children with ADHD are more likely to succeed in completing tasks when the tasks
occur in predictable patterns and in predictable places. Your job is to create and sustain
structure in your home, so that your child knows what to expect and what they are
expected to do.
Tip for helping your child with ADD/ADHD stay focused and organized
• Follow a routine. It is important to set a time and a place for everything to help
the child with ADD/ADHD understand and meet expectations. Establish simple
and predictable rituals for meals, homework, play, and bed. Have your child lay
out clothes for the next morning before going to bed, and make sure whatever he
or she needs to take to school is in a special place, ready to grab.
• Use clocks and timers. Consider placing clocks throughout the house, with a big
one in your child’s bedroom. Allow enough time for what your child needs to do,
such as homework or getting ready in the morning. Use a timer for homework or
transitional times, such between finishing up play and getting ready for bed.

25. • Simplify your child’s schedule. It is good to avoid idle time, but a child with
ADHD may become more distracted and “wound up” if there are many after-
school activities. You may need to make adjustments to the child’s after-school
commitments based on the individual child’s abilities and the demands of
particular activities.
• Create a quiet place. Make sure your child has a quiet, private space of his or her
own. A porch or bedroom can work well too, as long as it’s not the same place as
the child goes for a time-out.
• Do your best to be neat and organized. Set up your home in an organized way.
Make sure your child knows that everything has its place. Role model neatness
and organization as much as possible.
Avoid problems by keeping kids with attention deficit disorder busy!
For kids with ADD/ADHD, idle time may exacerbate their symptoms and create chaos in
your home. It is important to keep a child with ADD/ADHD busy without piling on so
many that the child becomes overwhelmed. Sign your child up for a sport, art class, or
music. At home, organize simple activities that fill up your child’s time.
These can be tasks like helping you cook, playing a board game with a
sibling, or drawing a picture. Try not to use the television or
computer/video games as time-fillers. Unfortunately, TV and video
games are increasingly violent in nature and may only increase your
child’s symptoms of ADD/ADHD.
ADD/ADHD parenting tip 3: Set clear
expectations and rules
Children with ADHD need consistent rules that they can understand and follow. Make
the rules of behavior for the family simple and clear. Write down the rules and hang them
up in a place where your child can easily read them.
Children with ADD/ADHD respond particularly well to organized systems of rewards
and consequences. It's important to explain what will happen when the rules are obeyed
and when they are broken. Finally, stick to your system: follow through each and every
time with a reward or a consequence.
Don’t forget praise and positive reinforcement
As you establish these consistent structures, keep in mind that children with ADHD often
receive criticism. Be on the lookout for good behavior—and praise it. Praise is especially
important for children who have ADD/ADHD because they typically get so little of it.
These children receive correction, remediation, and complaints about their behavior—but
little positive reinforcement.

26. A smile, positive comment, or other reward from you can improve the attention,
concentration and impulse control of your child with ADD/ADHD. Do your best to focus
on giving positive praise for appropriate behavior and task completion, while giving as
few negative responses as possible to inappropriate behavior or poor task
performance. Reward your child for small achievements that you might take for granted
in another child.
Kids with ADD/ADHD: Using Rewards and Consequences
Rewards Consequences
• Reward your child with privileges, • Consequences should be spelled
praise, or activities, rather than out in advance and occur
with food or toys. immediately after your child has
• Change rewards frequently. Kids misbehaved.
with ADD/ADHD get bored if the • Try time-outs and the removal of
reward is always the same. privileges as consequences for
• Make a chart with points or stars misbehavior.
awarded for good behavior, so • Remove your child from situations
your child has a visual reminder of and environments that trigger
his or her successes inappropriate behavior.
• Immediate rewards work better • When your child misbehaves, ask
than the promise of a future what he or she could have done
reward, but small rewards leading instead. Then have your child
to a big one can also work. demonstrate it.
• Always follow through with a • Always follow through with a
reward. consequence.
ADD/ADHD parenting tip 4: Encourage movement and
sleep
Physical activity can help your child with ADD/ADHD
Children with ADD/ADHD often have energy to burn. Organized sports and other
physical activities can help them get their energy out in healthy ways and focus their
attention on specific movements and skills.
The benefits of physical activity are endless: it improves concentration, decreases
depression and anxiety, and promotes brain growth. Most importantly for children with
attention deficits, however, is the fact that exercise leads to better sleep, which in turn can
also reduce the symptoms of ADD/ADHD.
Find a sport that your child will enjoy and that suits his or her strengths. For example,
sports such as softball that involve a lot of “down time” are not the best fit for children
with attention problems. Individual or team sports like basketball and hockey that require
constant motion are better options. Children with ADD/ADHD may also benefit from

27. martial arts training, tae kwon do, or yoga, which enhance mental control as they work
out the body.
Better sleep can help your child with ADD/ADHD
Insufficient sleep can make anyone less attentive, but it can
be highly detrimental for children with attention deficit disorder. Kids with ADD/ADHD
n eed at least as much sleep as their unaffected peers, but tend not to get what they need.
Their attention problems can lead to overstimulation and trouble falling asleep. A
consistent, early bedtime is the most helpful strategy to combat this problem, but it may
not completely solve it.
Help your child get better rest by trying out one or more of the following strategies:
• Decrease television time and increase your child's activities and exercise levels
during the day.
• Eliminate caffeine from your child’s diet. Cola drinks and chocolate have
significant caffeine.
• Create a buffer time to lower down the activity level for an hour or so before
bedtime. Find quieter activities such as coloring, reading or playing quietly.
• Spend ten minutes cuddling with your child. This will build a sense of love and
security as well as provide a time to calm down.
• Use lavender or other aromas in your child's room. The scent may help to
calm your child.
• Use relaxation tapes as background noise for your child when falling asleep.
There are many varieties available including nature sounds and calming music.
Children with ADHD often find "white noise" to be calming. You can create
white noise by putting a radio on static or running an electric fan.
The benefits of “green time” in kids with attention deficit disorder
Research shows that children with ADD/ADHD benefit from spending time in nature.
Kids experience a greater reduction of symptoms of ADD/ADHD when they play in a
park full of grass and trees than on a concrete playground. Take note of this promising
and simple approach to managing ADD/ADHD. Even in cities, most families have access

28. to parks and other natural settings. Join your children in this “green time”—you’ll also
get a much-deserved breath of fresh air for yourself.
ADD/ADHD parenting tip 5: Help your child eat right
Diet is not a direct cause of ADHD, but food can and does affect your child's mental
state, which in turn seems to affect behavior. Monitoring and modifying what, when, and
how much your child eats can help decrease the symptoms of ADD/ADHD.
All children benefit from fresh foods, regular meal times, and staying away from junk
food. These tenets are especially true for children with ADD/ADHD, whose
impulsiveness and distractedness can lead to missed meals, disordered eating, and
overeating.
Eating small meals more often may help your child’s ADD/ADHD
Children with ADD/ADHD are notorious for not eating regularly. Without parental
guidance, these children might not eat for hours and then binge on whatever is around.
The result of this pattern can be devastating to the child’s physical and emotional health.
Prevent this pattern by scheduling regular healthy meals or snacks for your child no
more than three hours apart. Physically, the child with ADD/ADHD needs a regular
intake of healthy food; mentally, meal times are a necessary break and a scheduled
rhythm to the day.
• Get rid of the junk foods in your home.
• Put fatty and sugary foods off-limits when eating out.
• Turn off television shows riddled with junk-food ads.
• Give your child a daily vitamin-and-mineral supplement.
Nutrition Basics for Kids
Whether or not your child has ADD/ADHD, he or she will benefit from eating a
nutritious diet. Most children eat far too many unhealthy foods—from burgers and fries
to ice cream and soft drinks. Few get the vitamins, minerals, and fiber, they need. It is
important to your child’s current and future health to eat a healthful diet, and that may
mean that you need to improve your own diet to set a good example.

29. ADD/ADHD parenting tip 6: Teach your child how to
make friends
Children with attention deficit disorder often have difficulty with simple social
interactions. They may struggle with reading social cues, talk too much, interrupt
frequently, or come off as aggressive or “too intense.” Their relative emotional
immaturity can make them stand out among children their own age, and make them
targets for unfriendly teasing.
Keep in mind that many kids with ADHD are exceptionally intelligent and creative and
will eventually figure out for themselves how to get along with others and spot people
who aren’t appropriate as friends. Moreover, personality traits that might exasperate
parents and teachers may come across to some people as quirky and charming.
Helping a child with attention deficit disorder improve social skills
It's hard for children with ADHD to learn social skills and social rules. You can help your
child with ADD/ADHD become a better listener, learn to read people’s faces and body
language, and interact more smoothly in groups.
• Speak gently but honestly with your child about his or her challenges and how to
make changes.
• Role-play various social scenarios with your child. Trade roles often and try to
make it fun.
• Be careful to select playmates for your child with similar language and physical
skills.
• Invite only one or two friends at a time at first. Watch them closely while they
play.
• Have a zero tolerance policy for hitting, pushing and yelling in your house or
yard.
Schedule. Keep the same routine every day, from wake-up time to bedtime. Include time
for homework, outdoor play, and indoor activities. Keep the schedule on the refrigerator
or on a bulletin board in the kitchen. Write changes on the schedule as far in advance as
possible.
Organize everyday items. Have a place for everything, and keep everything in its place.
This includes clothing, backpacks, and toys.
Use homework and notebook organizers. Use organizers for school material and
supplies. Stress to your child the importance of writing down assignments and bringing
home the necessary books.

30. Be clear and consistent. Children with ADHD need consistent rules they can understand
and follow.
Give praise or rewards when rules are followed. Children with ADHD often receive
and expect criticism. Look for good behavior, and praise it.
What conditions can coexist with ADHD?
Some children with ADHD also have other illnesses or conditions. For example, they
may have one or more of the following:
• A learning disability. A child in preschool with a learning disability may have
difficulty understanding certain sounds or words or have problems expressing
himself or herself in words. A school-aged child may struggle with reading,
spelling, writing, and math.
•
• Oppositional defiant disorder. Kids with this condition, in which a child is
overly stubborn or rebellious, often argue with adults and refuse to obey rules.
•
• Conduct disorder. This condition includes behaviors in which the child may lie,
steal, fight, or bully others. He or she may destroy property, break into homes, or
carry or use weapons. These children or teens are also at a higher risk of using
illegal substances. Kids with conduct disorder are at risk of getting into trouble at
school or with the police.
•
• Anxiety and depression. Treating ADHD may help to decrease anxiety or some
forms of depression.
•
• Bipolar disorder. Some children with ADHD may also have this condition in
which extreme mood swings go from mania (an extremely high elevated mood) to
depression in short periods of time.
•
• Tourette syndrome. Very few children have this brain disorder, but among those
who do, many also have ADHD. Some people with Tourette syndrome have
nervous tics and repetitive mannerisms, such as eye blinks, facial twitches, or
grimacing. Others clear their throats, snort, or sniff frequently, or bark out words
inappropriately. These behaviors can be controlled with medication.
ADHD also may coexist with a sleep disorder, bed-wetting, substance abuse, or other
disorders or illnesses.

31. Recognizing ADHD symptoms and seeking help early will lead to better outcomes for
both affected children and their families.
How can I work with my child’s school?
If you think your child has ADHD, or a teacher raises concerns, you may be able to
request that the school conduct an evaluation to determine whether he or she qualifies for
special education services.
Start by speaking with your child's teacher, school counselor, or the school's student
support team, to begin an evaluation. Also, each state has a Parent Training and
Information Center and a Protection and Advocacy Agency that can help you get an
evaluation. A team of professionals conducts the evaluation using a variety of tools and
measures. It will look at all areas related to the child's disability.
Once your child has been evaluated, he or she has several options, depending on the
specific needs. If special education services are needed and your child is eligible under
the Individuals with Disabilities Education Act, the school district must develop an
"individualized education program" specifically for your child within 30 days.
If your child is considered not eligible for special education services—and not all
children with ADHD are eligible—he or she still can get "free appropriate public
education," available to all public-school children with disabilities under Section 504 of
the Rehabilitation Act of 1973, regardless of the nature or severity of the disability.
Transitions can be difficult. Each school year brings a new teacher and new schoolwork,
a change that can be especially hard for a child with ADHD who needs routine and
structure. Consider telling the teachers that your child has ADHD when he or she starts
school or moves to a new class. Additional support will help your child deal with the
transition.
Do teens with ADHD have special needs?
Most children with ADHD continue to have symptoms as they enter adolescence. Some
children, however, are not diagnosed with ADHD until they reach adolescence. This is
more common among children with predominantly inattentive symptoms because they
are not necessarily disruptive at home or in school. In these children, the disorder
becomes more apparent as academic demands increase and responsibilities mount. For all
teens, these years are challenging. But for teens with ADHD, these years may be
especially difficult.
Although hyperactivity tends to decrease as a child ages, teens who continue to be
hyperactive may feel restless and try to do too many things at once. They may choose
tasks or activities that have a quick payoff, rather than those that take more effort, but

32. provide bigger, delayed rewards. Teens with primarily attention deficits struggle with
school and other activities in which they are expected to be more self-reliant.
Teens also become more responsible for their own health decisions. When a child with
ADHD is young, parents are more likely to be responsible for ensuring that their child
maintains treatment. But when the child reaches adolescence, parents have less control,
and those with ADHD may have difficulty sticking with treatment.
To help them stay healthy and provide needed structure, teens with ADHD should be
given rules that are clear and easy to understand. Helping them stay focused and
organized—such as posting a chart listing household chores and responsibilities with
spaces to check off completed items—also may help.
Teens with or without ADHD want to be independent and try new things, and sometimes
they will break rules. If your teen breaks rules, your response should be as calm and
matter-of-fact as possible. Punishment should be used only rarely. Teens with ADHD
often have trouble controlling their impulsivity and tempers can flare. Sometimes, a short
time-out can be calming.
If your teen asks for later curfews and use of the car, listen to the request, give reasons for
your opinions, and listen to your child's opinion. Rules should be clear once they are set,
but communication, negotiation, and compromise are helpful along the way. Maintaining
treatments, such as medication and behavioral or family therapy, also can help with
managing your teenager's ADHD.
What about teens and driving?
Although many teens engage in risky behaviors, those with ADHD, especially untreated
ADHD, are more likely to take more risks. In fact, in their first few years of driving,
teens with ADHD are involved in nearly four times as many car accidents as those who
do not have ADHD. They are also more likely to cause injury in accidents, and they get
three times as many speeding tickets as their peers.13
Most states now use a graduated licensing system, in which young drivers, both with and
without ADHD, learn about progressively more challenging driving situations.14 The
licensing system consists of three stages—learner's permit, during which a licensed adult
must always be in the car with the driving teen; intermediate (provisional) license; and
full licensure. Parents should make sure that their teens, especially those with ADHD,
understand and follow the rules of the road. Repeated driving practice under adult
supervision is especially important for teens with ADHD.
Can adults have ADHD?
Some children with ADHD continue to have it as adults. And many adults who have the
disorder don't know it. They may feel that it is impossible to get organized, stick to a job,
or remember and keep appointments. Daily tasks such as getting up in the morning,

33. preparing to leave the house for work, arriving at work on time, and being productive on
the job can be especially challenging for adults with ADHD.
These adults may have a history of failure at school, problems at work, or difficult or
failed relationships. Many have had multiple traffic accidents. Like teens, adults with
ADHD may seem restless and may try to do several things at once, most of them
unsuccessfully. They also tend to prefer "quick fixes," rather than taking the steps needed
to achieve greater rewards.
How is ADHD diagnosed in adults?
Like children, adults who suspect they have ADHD should be evaluated by a licensed
mental health professional. But the professional may need to consider a wider range of
symptoms when assessing adults for ADHD because their symptoms tend to be more
varied and possibly not as clear cut as symptoms seen in children.
To be diagnosed with the condition, an adult must have ADHD symptoms that began in
childhood and continued throughout adulthood.15 Health professionals use certain rating
scales to determine if an adult meets the diagnostic criteria for ADHD. The mental health
professional also will look at the person's history of childhood behavior and school
experiences, and will interview spouses or partners, parents, close friends, and other
associates. The person will also undergo a physical exam and various psychological tests.
For some adults, a diagnosis of ADHD can bring a sense of relief. Adults who have had
the disorder since childhood, but who have not been diagnosed, may have developed
negative feelings about themselves over the years. Receiving a diagnosis allows them to
understand the reasons for their problems, and treatment will allow them to deal with
their problems more effectively.
How is ADHD treated in adults?
Much like children with the disorder, adults with ADHD are treated with medication,
psychotherapy, or a combination of treatments.
Medications. ADHD medications, including extended-release forms, often are prescribed
for adults with ADHD, but not all of these medications are approved for adults.16
However, those not approved for adults still may be prescribed by a doctor on an "off-
label" basis.
Although not FDA-approved specifically for the treatment of ADHD, antidepressants are
sometimes used to treat adults with ADHD. Older antidepressants, called tricyclics,
sometimes are used because they, like stimulants, affect the brain chemicals
norepinephrine and dopamine. A newer antidepressant, venlafaxine (Effexor), also may
be prescribed for its effect on the brain chemical norepinephrine. And in recent clinical
trials, the antidepressant bupropion (Wellbutrin), which affects the brain chemical
dopamine, showed benefits for adults with ADHD.17

34. Adult prescriptions for stimulants and other medications require special considerations.
For example, adults often require other medications for physical problems, such as
diabetes or high blood pressure, or for anxiety and depression. Some of these medications
may interact badly with stimulants. An adult with ADHD should discuss potential
medication options with his or her doctor. These and other issues must be taken into
account when a medication is prescribed.
Education and psychotherapy. A professional counselor or therapist can help an adult
with ADHD learn how to organize his or her life with tools such as a large calendar or
date book, lists, reminder notes, and by assigning a special place for keys, bills, and
paperwork. Large tasks can be broken down into more manageable, smaller steps so that
completing each part of the task provides a sense of accomplishment.
Psychotherapy, including cognitive behavioral therapy, also can help change one's poor
self-image by examining the experiences that produced it. The therapist encourages the
adult with ADHD to adjust to the life changes that come with treatment, such as thinking
before acting, or resisting the urge to take unnecessary risks.
What efforts are under way to improve treatment?
This is an exciting time in ADHD research. The expansion of knowledge in genetics,
brain imaging, and behavioral research is leading to a better understanding of the causes
of the disorder, how to prevent it, and how to develop more effective treatments for all
age groups.
NIMH has studied ADHD treatments for school-aged children in a large-scale, long-term
study called the Multimodal Treatment Study of Children with ADHD (MTA study).
NIMH also funded the Preschoolers with ADHD Treatment Study (PATS), which
involved more than 300 preschoolers who had been diagnosed with ADHD. The study
found that low doses of the stimulant methylphenidate are safe and effective for
preschoolers, but the children are more sensitive to the side effects of the medication,
including slower than average growth rates.18 Therefore, preschoolers should be closely
monitored while taking ADHD medications.19,20
PATS is also looking at the genes of the preschoolers, to see if specific genes affected
how the children responded to methylphenidate. Future results may help scientists link
variations in genes to differences in how people respond to ADHD medications. For now,
the study provides valuable insights into ADHD.21
Other NIMH-sponsored clinical trials on children and adults with ADHD are under way.
In addition, NIMH-sponsored scientists continue to look for the biological basis of
ADHD, and how differences in genes and brain structure and function may combine with
life experiences to produce the disorder.

35. Citations
1
DSM-IV-TR workgroup. The Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association.
2
Faraone SV, Perlis RH, Doyle AE, Smoller JW, Goralnick JJ, Holmgren MA, Sklar P.
Molecular genetics of attention-deficit/hyperactivity disorder. Biological Psychiatry,
2005; 57:1313-1323.
3
Khan SA, Faraone SV. The genetics of attention-deficit/hyperactivity disorder: A
literature review of 2005. Current Psychiatry Reports, 2006 Oct; 8:393-397.
4
Shaw P, Gornick M, Lerch J, Addington A, Seal J, Greenstein D, Sharp W, Evans A,
Giedd JN, Castellanos FX, Rapoport JL. Polymorphisms of the dopamine D4 receptor,
clinical outcome and cortical structure in attention-deficit/hyperactivity disorder.
Archives of General Psychiatry, 2007 Aug; 64(8):921-931.
5
Linnet KM, Dalsgaard S, Obel C, Wisborg K, Henriksen TB, Rodriguez A, Kotimaa A,
Moilanen I, Thomsen PH, Olsen J, Jarvelin MR. Maternal lifestyle factors in pregnancy
risk of attention-deficit/hyperactivity disorder and associated behaviors: review of the
current evidence. American Journal of Psychiatry, 2003 Jun; 160(6):1028-1040.
6
Mick E, Biederman J, Faraone SV, Sayer J, Kleinman S. Case-control study of
attention-deficit hyperactivity disorder and maternal smoking, alcohol use, and drug use
during pregnancy. Journal of the American Academy of Child and Adolescent Psychiatry,
2002 Apr; 41(4):378-385.
7
Braun J, Kahn RS, Froehlich T, Auinger P, Lanphear BP. Exposures to environmental
toxicants and attention-deficit/hyperactivity disorder in U.S. children. Environmental
Health Perspectives, 2006 Dec; 114(12):1904-1909.
8
Wolraich M, Milich R, Stumbo P, Schultz F. The effects of sucrose ingestion on the
behavior of hyperactive boys. Pediatrics, 1985 Apr; 106(4):657-682.
9
Wolraich ML, Lindgren SD, Stumbo PJ, Stegink LD, Appelbaum MI, Kiritsy MC.
Effects of diets high in sucrose or aspartame on the behavior and cognitive performance
of children. New England Journal of Medicine, 1994 Feb 3; 330(5):301-307.
10
Hoover DW, Milich R. Effects of sugar ingestion expectancies on mother-child
interaction. Journal of Abnormal Child Psychology, 1994; 22:501-515.
11
McCann D, Barrett A, Cooper A, Crumpler D, Dalen L, Grimshaw K, Kitchin E, Lok
E, Porteous L, Prince E, Sonuga-Barke E, Warner JO. Stevenson J. Food additives and
hyperactive behaviour in 3-year-old and 8/9-year-old children in the community: a
randomised, double-blinded, placebo-controlled trial. Lancet, 2007 Nov 3;
370(9598):1560-1567.

36. 12
The MTA Cooperative Group. A 14-month randomized clinical trial of treatment
strategies for attention-deficit hyperactivity disorder. Archives of General Psychiatry,
1999; 56:1073-1086.
13
Cox DJ, Merkel RL, Moore M, Thorndike F, Muller C, Kovatchev B. Relative benefits
of stimulant therapy with OROS methylphenidate versus mixed amphetamine salts
extended release in improving the driving performance of adolescent drivers with
attention-deficit/hyperactivity disorder. Pediatrics, 2006 Sept; 118(3):e704-e710.
14
U.S. Department of Transportation, National Highway Traffic Safety Administration,
Legislative Fact Sheets. Traffic Safety Facts, Laws. Graduated Driver Licensing System.
January 2006.
15
Wilens TE, Biederman J, Spencer TJ. Attention deficit/hyperactivity disorder across
the lifespan. Annual Review of Medicine, 2002; 53:113-131.
16
Coghill D, Seth S. Osmotic, controlled-release methylphenidate for the treatment of
attention-deficit/hyperactivity disorder. Expert Opinions in Pharmacotherapy, 2006 Oct;
7(15):2119-2138.
17
Wilens TE, Haight BR, Horrigan JP, Hudziak JJ, Rosenthal NE, Connor DF, Hampton
KD, Richard NE, Modell JG. Bupropion XL in adults with attention-deficit/hyperactivity
disorder: a randomized, placebo-controlled study. Biological Psychiatry, 2005 Apr 1;
57(7):793-801.
18
Swanson J, Greenhill L, Wigal T, Kollins S, Stehli A, Davies M, Chuang S, Vitiello B,
Skroballa A, Posner K, Abikoff H, Oatis M, McCracken J, McGough J, Riddle M,
Ghouman J, Cunningham C, Wigal S. Stimulant-related reductions in growth rates in the
PATS. Journal of the Academy of Child and Adolescent Psychiatry, 2006 Nov;
45(11):1304-1313.
19
Greenhill L, Kollins S, Abikoff H, McCracken J, Riddle M, Swanson J, McGough J,
Wigal S, Wigal T, Vitiello B, Skroballa A, Posner K, Ghuman J, Cunningham C, Davies
M, Chuang S, Cooper T. Efficacy and safety of immediate-release methylphenidate
treatment for preschoolers with attention-deficit/hyperactivity disorder. Journal of the
Academy of Child and Adolescent Psychiatry, 2006 Nov; 45(11):1284-1293.
20
Wigal T, Greenhill L, Chuang S, McGough J, Vitiello B, Skrobala A, Swanson J,
Wigal S, Abikoff H, Kollins S, McCracken J, Riddle M, Posner K, Ghuman J, Davies M,
Thorp B, Stehli A. Safety and tolerability of methylphenidate in preschool children with
attention-deficit/hyperactivity disorder. Journal of the Academy of Child and Adolescent
Psychiatry, 2006 Nov; 45(11):1294-1303.
21
McGough J, McCracken J, Swanson J, Riddle M, Greenhill L, Kollins S, Greenhill L,
Abikoff H, Davies M, Chuang S, Wigal T, Wigal S, Posner K, Skroballa A, Kastelic E,
Ghouman J, Cunningham C, Shigawa S, Moyzis R, Vitiello B. Pharmacogenetics of

37. methylphenidate response in preschoolers with attention-deficit/hyperactivity disorder.
Journal of the Academy of Child and Adolescent Psychiatry, 2006 Nov;
45(11):1314-1322.
For more information on attention deficit hyperactivity
disorder
Visit the National Library of Medicine's MedlinePlus and En Español
For information on clinical trials:
NIMH supported clinical trials
National Library of Medicine Clinical Trials Database
Information from NIMH is available in multiple formats. You can browse online,
download documents in PDF, and order paper brochures through the mail. If you would
like to have NIMH publications, you can order them online at www.nimh.nih.gov.
If you do not have Internet access and wish to have information that supplements this
publication, please contact the NIMH Information Center at the numbers listed below.
National Institute of Mental Health
Science Writing, Press & Dissemination Branch
6001 Executive Boulevard
Room 8184, MSC 9663
Bethesda, MD 20892-9663
Phone: 301-443-4513 or
1-866-615-NIMH (6464) toll-free
TTY: 301-443-8431
TTY: 866-415-8051
FAX: 301-443-4279
E-mail: nimhinfo@nih.gov
Web site: http://www.nimh.nih.gov
Reprints
NIMH publications are in the public domain and may be reproduced or copied without
the permission from the National Institute of Mental Health (NIMH). NIMH encourages
you to reproduce them and use them in your efforts to improve public health. Citation of
the National Institute of Mental Health as a source is appreciated. However, using
government materials inappropriately can raise legal or ethical concerns, so we ask you to
use these guidelines:
• NIMH does not endorse or recommend any commercial products, processes, or
services, and publications may not be used for advertising or endorsement
purposes.

38. • NIMH does not provide specific medical advice or treatment recommendations or
referrals; these materials may not be used in a manner that has the appearance of
such information.
• NIMH requests that non-Federal organizations not alter publications in a way that
will jeopardize the integrity and "brand" when using publications.
• Addition of Non-Federal Government logos and website links may not have the
appearance of NIMH endorsement of any specific commercial products or
services or medical treatments or services.
If you have questions regarding these guidelines and use of NIMH publications, please
contact the NIMH Information Center at 1-866-615-6464 or at nimhinfo@nih.gov.
The photos in this publication are of models and are used for illustrative purposes only.
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
National Institutes of Health
NIH Publication No. 08-3572
Revised 2008
Ingersoll, B., & Goldstein, S. (1993). Attention Deficit Disorder and Learning Disabilities:
Realities, Myths, and Controversial Treatments. New York: Doubleday Publishing Group.
Kratochvil, C.J., Heiligenstein, J.H., Dittmann, R., et al. Atomoxetine and methyphenidate
treatment in children wtih ADHD. A prospective, randomized, open-label trial. J. Am. Acad Child
Adolesc Psychiatry 2002, 41, 776-84.
MTA Cooperative Group. (1999). A 14-month randomized clinical trial of treatment strategies for
attention-deficit/hyperactivity disorder: Multimodal Treatment Study of Children with ADHD.
Archives of General Psychiatry, 56 (12), 1073-1086.
O’Leary, K.D., & Becker, W.C. (1967). Behavior modification of an adjustment class: A token
reinforcement program. Exceptional Children, 33, 637-642.
Pelham, W.E., Greiner, A.R., & Gnagy, E.M. (1997). Children’s summer treatment program
manual. Buffalo, NY: Comprehensive Treatment for Attention Deficit Disorder.
Pelham, W. E. (2002) Psychosocial Interventions for ADHD. In P.S. Jensen & J.R. Cooper (Ed.),
Attention Deficit Hyperactivity Disorder: State of the science • best practices (pp 12-1-12-24) New
Jersey: Civic Research Institute, Inc.
Rabiner, D. (1999). ADHD Monitoring System: A systematic guide to monitoring school progress
for children with ADHD. Florida: Specialty Press, Inc.
Recommended Reading
Barkley, R. A. (2000) Taking charge of ADHD: The complete authoritative guide for parents. New
York: Guilford Press.
Barkley, R. A. (1998). Your defiant child. New York: Guilford Press.

39. Dendy, C.A. (1995). Teenagers with ADD: A parents' guide. Maryland: Woodbine House.
Goldstein, S. & Goldstein, M. (1998). Managing attention deficit hyperactivity disorder in children:
a guide for practitioners (2nd ed.). New York, NY: John Wiley.
Parker, H. (1992). Put yourself in their shoes. Understanding teenagers with attention deficit
hyperactivity disorder. Plantation, FL: Specialty Press, Inc.
Phelan, T. (1995). 1-2-3 Magic. Illinois: Child Management.
Wilens, T. E. (1999). Straight talk about psychiatric medications for kids. New York: Guilford
Press.
Ingersoll, B., & Goldstein, M. (1993). Attention deficit disorder and learning disabilities: Realities,
myths, and controversial treatments. New York: Doubleday.
Teaching Children with ADHD, The Council for Exceptional Children, 1989
ADHD - Building Academic Success, Appalachia Educational Laboratory
Armstrong, Thomas. To Empower! - Not Control! A Holistic Approach to ADHD.
Reaching Today's Youth, Winter, 1998
Brain Gym & the Educational Kinesiology Foundation, Ventura, CA.
Dana Nicholls OTR/L and Peggy Syvertson M.A. Sensory Integration, Attention,
and Learning. New Horizons for Learning.
Sensory Integration International. 1514 Cabrillo Avenue, Torrance, CA.
90501-2817.
ADD Tips: Activities and Strategies. Indiana University - Center for Adolescent
Studies. 1996.
Rinholm, Joanne. Classroom Behaviour Strategies. OBE News
Warger , Cynthia . Positive Behavior Support and Functional Assessment . ERIC/
OSEP Digest #E580. September 1999.
Applying Positive Behavior Support and Functional Behavioral Assessment in
Schools. OSEP Technical Assistance Center on Positive Behavioral
Interventions and Supports.