Background:

• Treating ADD requires medical, psychological and educational intervention, and behavior management techniques. It requires the coordinated efforts of a team of health care professionals, educators and parents. Parents often play the critical role of coordinating the array of services and programs.
• A multi-modal treatment approach includes:
  • appropriate educational program (see "Attention Deficit Disorder in the Classroom")
  • individual and family counseling when needed
  • medication when required

Medication:

• Psychostimulants are the most widely used medication for the management of ADD related symptoms. 70-80% of children with ADD respond positively to psychostimulants. These medications decrease impulsivity and hyperactivity, increase attention and, in some children, decrease aggression.
• Psychostimulants used in the treatment of ADD include Ritalin (methylphenidate) -- the most widely prescribed medication -- Dexedrine (dextroamphetamine), and Cylert (pemoline).
• The specific dose of medicine must be determined for each child. To ensure proper dosage, regular monitoring at different levels of medication is required. Periodic trials off medication are conducted to determine continued need.
• The most common side effects of psychostimulants are reduction in appetite, loss of weight, and problems in falling asleep. These side effects are usually managed effectively by changing the dose of the medication.
• Contrary to popular perception, psychostimulants can also be effective with adolescents and adults with ADD.
• Antidepressants, used less frequently for ADD, have been shown to be effective with some children. They are used when contraindications to psychostimulants exist, or when psychostimulants have been ineffective or have resulted in unacceptable side effects.

Changing behavior:

• Parent training, behavior management techniques, specially designed educational interventions -- all are designed to help the child with ADD adapt to his or her disability and succeed in the school and home and with peers. Once the child, parents and teachers understand that the child has a neurobiologically based disability, frustration with poor performance lessens. The focus becomes adaptation and the goal becomes increasing performance.
• Behavior management is an important intervention with children who have ADD. The most important technique is positive reinforcement, in which the child is provided a rewarding response after a particular desired behavior is demonstrated. See the parent training discussion under "Parenting a Child with Attention Deficit Disorder" for implementation of behavior management.
• Parents, teachers and therapists work to create an environment that maximizes the child's probability of success.
• Classroom success may require a range of interventions. Most children can be taught in the regular classroom with either minor adjustments to the classroom setting, the addition of support personnel, and/or "pull-out" programs that provide special services outside of the classroom. The most severely affected may require self-contained classrooms. .

Federal law requires that children with ADD be provided a free and appropriate public education. As it has only recently been clarified that these children are eligible for special educational services and given the lack of understanding in some quarters regarding ADD, many children with ADD may not be receiving required educational services.

Background:

• Both Public Law 94-142, Part B of the Individuals with Disabilities Education Act or IDEA, and Section 504 of the Rehabilitation Act of 1973 require that school systems make a "free and appropriate public education" available to eligible and qualified children with disabilities. Special education and related services must be made available to any child with a qualifying disability when the disability impairs the child's educational performance.
• On September 16, 1991, the U.S. Department of Education issued a Policy Clarification Memorandum expressly recognizing children with ADD as eligible for special education and related services under Part B of the IDEA and Section 504. The Department concluded that children who present only with ADD are eligible for services under Part B of the IDEA as they fall within the law's "Other Health Impaired" category.
• The Department's action responded to the fact that many children with ADD were not receiving a free and appropriate public education, while many others appeared to be receiving assistance unrelated to their specific ADD needs.
• Part B of the IDEA not only requires that public schools provide a free education to children with disabilities, the law also sets parameters for determining an appropriate education. Such education must include special education and related services specifically designed to meet each child's unique needs through an individualized education plan (IEP). The IEP must reflect the nature and severity of each disability present and specify aids and services to be provided to meet the child's unique needs created by each disability. Part B further requires public schools to meet a disabled child's needs to the maximum extent appropriate in a regular classroom with non-disabled peers. If this is not possible, the schools must consider a range of options including but not limited to a mix of regular and special education classroom services; full-time special education classes in a regular public school; a private school; and home instruction.
• Part B of the IDEA requires public schools to identify and promptly evaluate, using a multidisciplinary team, children having or suspected of having a disability to determine the child's need for special education and related services at no charge to parents.
• Section 504 of the Rehabilitation Act prohibits discrimination against otherwise qualified persons with disabilities in federally assisted programs and activities solely on the basis of their disabilities. All public schools that receive federal funds must comply with Section 504 by addressing the needs of children with disabilities as adequately as the needs of non-disabled children. Section 504 sets similar parameters to Part B of the IDEA for determining an appropriate education.
• Section 504 protections extend further than the IDEA because 504 does not consider a need for special education as an eligibility requirement, as is the case under Part B of the IDEA. Rather, Section 504 applies to any person who has a "physical or mental impairment which substantially limits a major life activity."
• The Americans with Disabilities Act (ADA), enacted in 1990, provides another legal means of requiring all educational institutions, other than those operated by religious organizations, to meet the needs of children with ADD. Title II of the Act, applicable to all public schools, prohibits the denial of educational services, programs or activities to all students with disabilities and the discrimination against all such students once enrolled. Title III of the Act applies these same requirements to non- sectarian private schools.
• In considering the ADA's applicability to children with ADD in public schools, it is quite likely that courts will look to the U.S. Department of Education's policy guidance on Part B of the IDEA and Section 504 of the Rehabilitation Act as they relate to ADD.

• Parents often find that approaches to parenting that work well with children who do not have ADD, do not work as well -- or at all -- with children who have ADD.
• Parents often feel helpless, frustrated and exhausted. Too often, family members become angry and withdraw from each other. If untreated, the situation only worsens.
• Children with ADD often need their parents to identify their areas of strength. By focusing on these areas, children can develop the confidence and skills to tackle other, difficult situations.
• Parents of children who have ADD must work on the task of not overreacting to their children's mistakes.

Parent Training:

• Parent training can be one of the most important and effective interventions for a child with ADD. Effective training will teach parents how to apply strategies to manage their child's behavior and improve their relationship with their child.
• Without consistent structure and clearly defined expectations and limits, children with ADD can become quite confused about the behaviors that are expected of them.
• A technique called "charting" is often the first step in any behavior modification program. It requires that parents specifically define the behavior they are concerned about so that it can be observed and counted. Charting makes parents more aware of their own behavior and children more aware of a problem behavior.
• Parents are encouraged to designate 10 to 15 minutes of each day as "very special time." Parents use this time to focus on being with the child, attending to what he is doing, listening to the child, and providing occasional positive feedback.
• Parents are taught how to effectively use positive reinforcement by attending to their child's positive behavior while ignoring, as much as possible, negative behavior.
• Parents are also taught how to decrease inappropriate behavior through a series of progressively more active responses -- ignoring behavior; natural consequences, such as not replacing a toy left out in the rain; logical consequences, such as loss of television time if the child leaves the room without turning the television off; and time-out. Time-out involves having the child sit quietly in a designated place for a specific time after he has misbehaved.
• Parents learn to give commands and directions that can be understood and attended to by the child with ADD.

Peer Relations:

• Making and keeping friends is a difficult task for children with ADD. A variety of behavioral excesses and deficits common to these children get in the way of friendships. They may talk too much, dominate activities, intrude in others' games, or quit a game before its done. They may be unable to pay attention to what another child is saying, not respond when someone else tries to initiate an activity, or exhibit inappropriate behavior.
• Parents of a child with ADD need to be concerned about their child's peer relations. Problems in this area can lead to loneliness, low self-esteem, depressed mood, and increased risk for anti-social behavior.
• Parents can help provide opportunities for their child to have positive interactions with peers. There are a number of concrete steps parents can take:
  • setting up a home reward program that focuses on one or two important social behaviors
  • observing the child in peer interactions to discover good behaviors and poor, or absent, behaviors
  • directly coaching, modeling and role-playing important behaviors
  • "catching the child" at good behavior so as to provide praise and rewards
• Other strategies include structuring initial activities for the child and a friend that are not highly interactive, such as trips to the library or playground; using short breaks from peer interactions when the arousal level becomes high; and working to reduce aggressive behavior in the home.