Attention Deficit Disorder and Learning Disorders

David Johnson, M.D.

Attention Deficit Hyperactivity Disorder


Attention and learning disorders in children are very common

A persistent (more than 6 months) cluster of behaviors characterized by inattention, hyperactivity, and impulsivity with the following features: Behaviors are more frequent and more severe than occurs in most children at a comparable developmental level Behaviors began before 7 years of age Behaviors are manifested in two or more settings (eg, school and at home) Behaviors cause clinically significant dysfunction in social, academic, occupational, or family function

problems. Primary care pediatricians should be the ones to make the diagnosis and do the treatment in the majority of children. You do not need a specialist in developmental/behavioral pediatrics to treat most kids or diagnose most kids with ADHD.

Attention Deficit Hyperactivity Disorder:

ADHD and the new DSM IV criteria. ADHD is defined as a persistent,

DSM IV Criteria
1. Inattention: Six or more of the following. often flails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities. often has difficulty sustaining attention in tasks or play activities. often does not seem to listen when spoken to directly. often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not because of oppositional behavior or inability to understand directions). often has difficulties organizing tasks and activities. often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework). often loses things necessary for tasks and activities (eg, school assignments, pencils, books, tools). is often distracted by extraneous stimuli. is often forgetful in daily activities.

that is more than 6 month cluster of behaviors. It's a behavioral cluster that has to have been going on for awhile - it can't just have started last week or last month. The behaviors are more frequent and more severe than most children at a comparable developmental level. This is very subjective, and part of the whole problem with diagnosing ADHD is there is no one way to make the diagnosis. There is no specific test. It is defined as behavior that is just more frequent and more severe than most children at a comparable level. It has to begin before seven years of age. It is not something that begins later on.

Most importantly, it has to be manifested in two or more settings: school or work and home. If you just have these behaviors occurring in one setting only, that is not ADHD. If it is only at home and not at school, it is not ADHD. If it is only at school and not at home, that is not ADHD. You should be thinking of other parts of your differential diagnosis. So, ADHD has to occur in at least two or more settings.

Finally to make the diagnosis, it has to cause clinically significant dysfunction in the social, academic, occupational, or family setting. There are some kids you'll see, that you will say to yourself, "this kid has ADHD. He's wild." But, he's doing great. He has friends. He's doing well in school. The school has adapted to him. The family has adapted to him. You might not make the diagnosis in that child because there is not a clinically significant dysfunction. With the same child in another setting who has a lot of problems in school and at home, you might make the diagnosis. So the diagnosis of ADHD is tough because there are these subjective features. And even among experts, so-called experts, people will disagree with the diagnosis.

The DSM IV criteria. For inattention, you have to have six or more of the following. One fails to give close attention to details or makes careless mistakes in school work, work outside the home, or in other activities. They often have difficulty sustaining attention in tasks or play activities. What is important is sustaining attention when it is not easy to sustain attention, when it takes a little more effort, that is when ADHD shows up. The parents say, "He can play Nintendo for two hours." and therefore he doesn't have ADHD. But that is not true. Because think of the kind of attention that it takes to play Nintendo. Whereas you have to pay attention to what's going on it is always changing. You are not sitting laboriously studying one thing or looking at a number of things as you do in school. Does not seem to listen when spoken to directly.

Often does not follow through on instructions and fails to finish schoolwork, chores or duties in the workplace (not because of oppositional behavior or inability to understand directions). He just

2. Hyperactivity - Impulsivity: 6 or more of the following. Hyperactivity often fidgets with hands or feet or squirms in seat. often leaves seat in classroom (or in other situations where remaining in seat is expected). often runs about or climbs excessively in situations where it is inappropriate (in adolescents or adults, feature may be limited to subjective feelings of restlessness). often has difficulties playing or engaging in leisure activities quietly. is often on the go or often acts as is driven by a motor. often talks excessively.

can't get things done. Keeps trying a million projects, none of which get completed on time, if they get completed at all. Often has difficulties organizing tasks and activities. And often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort, such as schoolwork, homework.

Again inattention, six or more of these. Often loses things necessary for tasks and activities, like school assignments, pencils, or books. Is often distracted by extraneous stimuli. These are the kind of kids who are in your office and they hear someone crying next door and they are already over there looking to see what is happening. Something is going on in the waiting room and they are looking over there. They are extremely distractible. Their attention cannot stay focused unless it is a quiet environment with very little else going on. And finally, is often forgetful in daily activities. Many people are diagnosing themselves with ADHD. Because it's on a continuum and all of us have, to a greater or lesser degree, some of these issues. The question is, is it causing dysfunction in our lives, and that is really a key question in making a diagnosis.

Impulsivity often blurts out answers before questions have been completed. often has difficulty awaiting turn. often interrupts or intrudes on others (eg, butts into conversations or games).

The second aspect of ADHD, after inattention, is hyperactivity. As you know, you can have inattention without hyperactivity. So, six or more of the following. Often fidgets with hands or feet or squirms in seat. ADHD kids didn't move more than non-ADHD kids. It was that it was non-directional, non-purposeful movements that happened more--squirming, fidgeting all the time. When sitting in their seats, their foot is always racing. They are always squirming, fidgeting around. When watching television, they are in one position, then another position, then they're on the floor and so on.

Often leaves seat in classroom or in other situations where remaining in seat is expected. Often runs about or climbs excessively in situations where it is inappropriate. Sometimes they have no sense of fear. They are fearless at climbing and running around. In adolescents or adults this may be manifested in more subjective feelings of restlessness. The child feel restless and squirmy. The hyperactivity may go away, and often usually does go away in older children and adults, but the internal sensation of feeling restlessness persists. Often has difficulties playing or engaging in leisure activities quietly. These are boisterous kids. They are often "on the go" or act as if "driven by a motor". They are talkative kids who talk excessively all the time. That is the second part of the triad of ADHD, inattention and hyperactivity.

Thirdly, there is impulsivity. Often blurts out answers before questions have been completed. Often has difficulty awaiting turn. Often interrupts or intrudes on others, like butting into conversations or games. It's almost as if there is no inhibition. There is no sensor

DSM IV: Types of ADHD Patients

1. 2. 3. ADHD, Combined type (if criteria for both inattention and hyperactivity are met) ADHD, predominantly inattentive type ADHD, predominately hyperactive impulsive type

between the thought and the action. Most of us have thoughts. We want to do things, but we have the ability to pull in or rein in the impulses. But for some kids, the thought is the action--there is nothing in between. It is a disinhibition that causes them their impulsivity. Some people view ADHD as a disorder of disinhibition, inability to inhibit action in activity, inability to inhibit wandering attention and inability to inhibit impulsivity.

The DSM IV then describes three types of ADHD. The combined type, if the criteria for inattention as well as hyperactivity or impulsivity are met. ADHD, predominantly inattentive type. These are kids who are usually not diagnosed until they are school-age because they are not hyperactive, but have a very difficult time in school paying attention and achieving their potential in school because of attentional problems. Some people feel that the incidence of males and females for the inattentive type is about the same, although it is much higher for the hyperactive type in males than females. And then primarily hyperactive-impulsive type, which is much less common.

Differential Diagnosis of ADHD

        
Differential diagnosis. The first part of any differential diagnosis is

Active, normal child Acute or chronic stress Post-traumatic Stress Disorder Anxiety disorder Depression Under stimulation Oppositional behavior or conduct disorder Learning Disorder Early mood disorder

always, "This is an active, normal child. This is a very active child but not a hyperactive child. And that is a very difficult decision to make. I would stress that it is probably based more on the issue of dysfunction in the child's life than an absolute level of activity or inattention. The child is able to do well, has friends and so on - you may just say this is a very active child. The same child though who is not doing well in school or socially, you might say has ADHD.

Acute or chronic stress. Some kids will respond in a way that is very ADHD-like to stress in their lives. Stress of any sort. Again as primary care physicians, you are in the best position to know if it is stress that is engendering these behaviors in kids. Post traumatic stress disorder (PTSD) occurs in children who witness a lot of violence. Children who have been traumatized themselves can look very much like ADHD. And again, you need to know what the environmental context of these behaviors are before you reach the conclusion that this is an endogenous problem in the child that has ADHD. Anxiety disorders, depression, the child is understimulated, oppositional behaviors, conduct disorders, learning disabilities, and early mood disorders. It is very interesting when people go back and look at adults who have bipolar disorder, manic depressive disorder, serious depression, they were often diagnosed in childhood as having ADHD. Again, this is one of the things that is going to be hard to know unless there is a positive family history. But it looks like some children, who will eventually have significant psychiatric mood disorders as young adults or adults, will for look like they had ADHD when they were young children.

Important Coexisting Features of ADHD, Not in DSM Criteria

emotional lability / immaturity resistance to reinforcement aggressiveness academic problems poor social skills poor peer relations Poor Self-esteem
Kids with ADHD tend to have emotional lability and immaturity. Other kids see them as babies. They cry a lot, they laugh a lot. They're up, they're down. They seem to be really immature. It's almost as if their emotions are as labile and hyperactive as everything else about them. They seem to be resistant to reinforcement. When we talk to parents, and say, "Try this. Try 'time out'." They say, "I tried it. I tried it and nothing works." In fact, that is one of the hardest parts of dealing with hyperactive kids is that they are more relatively resistant to reinforcement than other children, positive or negative reinforcement. They just can't seem to inhibit themselves no matter much how reinforcement you use.

They may be aggressive. If there is one red flag about long term outcome in children with ADHD, it is the aggressive child of ADHD. When we look at long term studies, it is the ones who were really aggressive in early childhood who are the most worrisome for a bad long term outcome. And that should be a major red flag. If it is a very aggressive child with ADHD, then that child definitely needs counseling among the other modalities that you will use for the child. So, aggressiveness is very important to ask about in terms of long term prognosis. Academic problems clearly go along with ADHD, as well as learning disabilities. Poor social skills and poor peer relations should be sought.

One way to differentiate the very active child from an ADHD child is that generally the very active child is accepted by his peers, and I say "his" because males outnumber females 6:1. Very active children are accepted by the peers, full of energy, very active, and other kids like him. ADHD kids are not so much fun. They butt in, they are babies, they can't inhibit themselves, they don't play the games correctly, they may miss social cues. Often, other kids don't like them. After treating their ADHD, these children may for the first time be asked to play by other children. Social dysfunction as part of ADHD. Other kids don't like them.

The bottom line, and I think in some ways the most pernicious aspect of ADHD in the long run, is poor self-esteem. You put all these things together, the child is having trouble with his parents, not doing well in school, none of the kids like him. He really gets a sense of himself that he's just not worth very much, and that sense of himself may dog him all his days, long after perhaps he learns to cope with his ADHD symptoms. One of the most important things that you can do is emphasize to parents the importance of selfesteem. Try to help the child to find islands of confidence in feeling good about himself because in the long run that may be the most important therapy of all.

Prevalence of ADHD
4-6% of elementary school children Male to female ratio is 6:1 ? on the rise or more diagnostic sensitivity or overdiagnosed? much higher incidence in first and second degree relatives

The prevalence of ADHD is up to 25%, and these kids are on Ritalin. In other communities 0%. I think it is the most overdiagnosed and most underdiagnosed condition in childhood. So, it kind of depends on where you live and who you see. The best estimates I would say are 4-6% of elementary school children may have ADHD. So if you see a lot higher, you know something is up. There is a higher incidence in first and second degree relatives. So, family history is helpful in this.

Etiology of ADHD
We believe that ADHD is endogenous, not environmentally medi-

The etiology is unknown believed to have a neurological basis (underactivity of frontal lobes on PET scan; decreased dopamine metabolites in CSF)

ated in any way. It is believed to have a neurological basis. There have been studies showing the underactivity of frontal and prefrontal lobes on PET scans. Decreased dopamine metabolites in CSF. It's been associated with maternal smoking, prematurity. At this point we really don't know.

Clinical Diagnosis of ADHD


In making the diagnosis, you have to seek corroboration, via ques-

Corroboration. A questionnaire or interview of most or all of the child's significant caregivers should assess the presence and severity of symptoms. Clinical judgment is essential.

tionnaires or interview, of the symptoms from most or all of the child's significant caregivers. You never should make the diagnosis just because you think it's true and the parent thinks it's true. That is not enough because some kids can keep it together in the office very well in a short visit. I have the luxury now of sometimes hour and half evaluations in an academic setting and it isn't until an hour into the evaluation the kid is beginning to show his true colors. The clinicians perception of ADHD in the office does not necessarily correlate. The child may be very anxious in the office and look like he has ADHD when he doesn't, or conversely, be very quiet in the office but if he stuck with it longer you'd see the symptoms.

History

           

Symptoms are evaluated. Complicating home or social stressors is assessed. Cognitive and academic performance is documented. The impact of symptoms on the rest of the family, including the parent, is evaluated. Child and sibling relationships are evaluated. Treatments tried in the past are sought.

Physical exam Most useful to assess child's response to a structured situation Neurological exam (e.g., clumsiness, "soft signs" not helpful; hearing, tics) Minor congenital or anomalies Skin for neurocutaneous stigmata Laboratory evaluation should include lead levels, anemia, ?hyperthyroidism.
In making the diagnosis it has to be in more than one setting. If the parents give you a good history that's great. But you have to seek corroboration in other important aspects of the child's life. If it's daycare, if it's school, if it's Head Start, if it's grandparents, if it's the babysitter. You need to hear from them too because to make the diagnosis they have to have the symptoms across settings. If the babysitter says, "No, he's great. I have no problems at all." then you really need to question whether this is ADHD or not.

Aside from history of symptoms, which you'll ask about, you'll certainly want to know about complicating home and social stressors. Looking at the environmental context. How the child is doing cognitively and academically.

Physical exam I think is generally not that helpful. You need to do it, but there are almost no medical problems that you are going to be ruling out. I think the physical exam is most useful to assess the child's response to a structured situation and whether the child acts like a kid with ADHD when you are examining him or her, as opposed to looking for any special physical finding or medical finding.

Minor congenital anomalies. There is increased ADHD in children with minor congenital anomalies. But again it is not going to help you so much with diagnosis. Looking for neurocutaneous stigmata, just to make sure you're not missing something like neurofibromatosis or tubular sclerosis. Lead, anemia, hyperthyroidism should also be excluded.

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Diagnostic testing in ADHD

The use of the diagnostic test will be basically based on a history

Testing is indicated only as indicated by the history and physical examination. Computer vigilance tests are not clinically useful. The value of educational/neuropsychological testing is questionable because of the 40% co-occurrence of learning disabilities.

and physical exam. Computer vigilance tests are not that helpful currently. There are too many false positives and false negatives for it to be useful. If the child is doing well in school, I hold off on the learning disabilities evaluation, if I think it is purely ADHD. On the other hand, if the child is doing poorly at school, you may want to try medication. If the medication works and the child continues to do poorly in school, you should get a learning disabilities evaluation, or you may want to do the learning disabilities evaluation initially.

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Learning Disorders
Learning disabilities. Learning disabilities are characterized by a

Learning disorder is a generic term referring to a heterogeneous group of disorders manifested by significant difficulties in the acquisition and use of reading (dyslexia), writing (dysgraphia) and/or mathematical abilities (dyscalculia). These disorders are intrinsic to the individual and presumed to occur secondary to central nervous system dysfunction.

substantial discrepancy between ability as measured in an IQ test, as much as that measures ability, and academic performance. The kind of kid who is smart, but is just not doing well in school--should be doing a lot better but isn't. You need that discrepancy. Difficulties with neurodevelopmental functions such as language, memory, visual-spatial ordering, temporal-sequential ordering. Different kinds of ways of processing information seem to have problems. These will come out best with neurodevelopmental testing. These children also have difficulties with what people are now calling executive functions. These are higher order mental processes, such as concept acquisition, reasoning, problem-solving skills, critical thinking and social cognition.

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Learning Disorder
characterized by a substantial discrepancy between ability (as measured on IQ tests) and actual academic performance. difficulties with neurodevelopmental functions such as language, memory, visual-spatial ordering, temporal-sequential ordering. difficulties with executive functions such as concept acquisition, reasoning, problem-solving skills, critical thinking, social cognition

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Prevalence of Learning Disorder

About 5% of American schoolchildren are identified as having

5% of American schoolchildren are identified as having a learning disorder. Some estimates as high as 15%. male to female ratio is 4:1.

learning disabilities. Some people think it is a lot more, again. The gradation between a learning disability and non-learning disability is tough. All of us have strengths and weaknesses in our functioning. Some estimates are as high as 15%. Again, males get the short end of the stick, 4:1 as usual.

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Etiology of Learning Disorder

The etiology is unclear. There is often a strong family history.

The etiology is unknown There is often a strong family history Dyslexia is now believed to be caused by dysfunction in phonemic awareness.

Dyslexia. People used to talk about dyslexia as reading letters backwards, writing letters backwards. It is now felt that dyslexia has nothing to do with that. It doesn't matter if you write your letters backwards or not. It is that dyslexia is a dysfunction in phonemic awareness. That the children cannot process phonemes, the fundamental building block sounds, of language. They can't differentiate "da" from "pa" very well. And because they can't differentiate these phonemes they can't then begin to understand the words. They can't differentiate one from the other when it comes to reading. They are unable to do that. So, if they take the word "cat", they cannot decode the word "cat" and therefore can't identify the word. In effect, their ability to read specifically those words, even though they know what a cat is.

 

20 % of all boys and girls may be dyslexic. The belief that letter reversal is indicative of dyslexia is a Myth.

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Consequences of Learning Disorder

  
Concomitants to learning disabilities. The high school drop-out rate

The school drop-out rate is 40%. Trouble keeping a job and problems with peer relations are frequent. 10-25% coexist with conduct disorder, oppositional defiant disorder, depression, or ADHD

is 40%. Many kids who drop out of school have learning disabilities, trouble keeping a job, problems with peer relations, and again, the co-occurrence with conduct disorders, oppositional defiant disorder, depression or ADHD.

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Office assessment of Learning Disorder

 
Physical examination and laboratory tests are rarely useful. Clinical Evaluation of Learning Disorder:

      

academic achievement classroom behavior attendance previous special testing and services at school medical/perinatal history developmental/behavioral history family / social history

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Assessment of Learning Disorder

If you want an assessment done too, you can start with the school

Initial assessment should start with the school (a mandate under Public Law 94-142). Parents have the right to an independent, second opinion. A multi-disciplinary is recommended, but an assessment by a psychologist is best if only one professional is allowed.

and mandate under Public Law 94-142 that the school do an evaluation for learning disabilities. The parents then have a right for an independent second opinion if they don't agree with what the school has said. Multidisciplinary evaluations are usually best, but I would say if you were going to pick one, pick a psychologist or a neuropsychologist to do the evaluation.

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Treatment of Learning Disorder

Treatment of learning disabilities. Bypass strategies are used, so that

bypass strategies (e.g., decrease rate, volume, complexity of task, go to auditory or visual mode, play to interests, use a computer) skill remediation

decreasing the rate or volume or complexity of the task, even in small chunks, to work on at a time going in just the auditory or visual mode. If you have trouble with auditory processing, you have to learn visually. If you can hear things and remember things well aurally but not visually, then you need to hear things and not so much see them to do better in school. Computers seem to be very helpful in teaching learning disabled kids. I think there is wonderful potential in that area to learn at their own rate in the modality that works best for them, whether it is visual or auditory.

developmental therapies (OT, speech, physical therapy) curriculum modification enhance strengths

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Management of ADHD

Goals

  

ADHD is really is a family problem. Kids with ADHD aren't fun. But I think our role in the management of ADHD is critical in trying to help the children. Especially by looking at enhancing social functioning, academic functioning and emphasizing the importance of self-esteem. The second thing we can do though is use medications. There is no question that the best treatment for a child who truly has ADHD are medications. They are effective in about 70% of the cases but they are not a cure. They improve symptomatology, but the symptoms, although they will change over time, will probably last a lifetime. The long term efficacy of medications is still not entirely clear. It's clear in the short term, it works, but in the long run, we think it works, but the studies are not there to confirm it. Ritalin is not a diagnostic test. If the child pays attention better it doesn't matter. You would pay attention better if you took Ritalin. In fact, I remember that people at school used it to study for finals sometimes, illicitly. Ritalin improves attention for everybody, in all kids. So the fact that a child does have a positive response doesn't mean that they have ADHD.

Enhance social functioning Enhance academic functioning Improve self-esteem

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Medical Management of ADHD

I think that you should be very comfortable in using at least Ritalin

Medications are effective in 70% of cases medications are not a cure-all; long term efficacy data remains inconclusive not a diagnostic test!

and Dexedrine. We usually mention pemoline, or Cylert. You may have read the cautions about liver disease in Cylert, so I would relegate it to a second line, although I still think you should be comfortable with it. I use psychostimulants first. There are a few rules to remember. One is that in the clinical trial, the decisions are reversible. Just because you start it doesn't mean you can't stop it. And you should present it to the parents as such. "We don't know if it is going to work. Maybe it will work. If you like the idea, we can try it. If you don't like it, we'll stop it. You need to do frequent follow-up, at least until the child stabilizes. It is not the only treatment. It is best used as part of a multi-modal treatment, including educational, behavioral and counseling, if needed.

Ritalin is great and it helps, but the children may need help at school. They may need counseling. The long term studies show that the kids who do best are the ones who get multi-modal treatment.

You need to obtain ongoing efficacy and feedback from the same caretakers who provided the history. If you asked the daycare provider if the child had ADHD through questionnaires or calling them on the phone. If one medication doesn't work, try another. It is pretty clear that some kids respond better to Dexedrine than they do to Ritalin or to Ritalin than to Dexedrine or to pemoline or any of the others. So, that it is worth it to go through all three. You might think about whether they want to try some of the second line drugs, like clonidine or tricyclic antidepressants.

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Drug Therapy of ADHD

Rule 1: Drug use is a clinical trial and decisions should be reversible. Rule 2: Frequent follow-up is necessary until stabilized. Rule 3: Drug therapy is best used as a part of multi-modal treatment, including education, behavioral therapy, and counseling. Rule 4: Obtain ongoing efficacy feedback from the caretakers who provided the initial history. Adjust medications accordingly. Rule 5: If one medication doesn't work, try another.

Stimulants are the drug of choice. The good news is there is very high efficacy and low morbidity to Ritalin and Dexedrine in children. They have been extensively studied and they are very safe when used correctly and you should feel comfortable about using those. Many people start with Ritalin or Dexedrine.

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Stimulants Are Drugs of Choice

High efficacy/low morbidity Stimulants may increase the number of adrenergic receptors in brain that stimulate attention and inhibitory centers. Physicians should pick one or two agents and become comfortable with their use.

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Methylphenidate and Dextroamphetamine

Start with about 0.3 mg/kg/dose of methylphenidate (MPD) or 0.15 mg/kg/dose of dextroamphetamine (DA). Increase every few days up to maximum of 1.0 mg/kg/dose (80 mg/day max) for MPD (1/2 dose to DA). Onset 30 minutes; peak 2 hours; quite variable. Frequency depends on target symptoms and setting.

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Short or Long-acting Stimulant?

Short-acting or long-acting. Remember the problem with long-

Calculate daily dose of short-acting and convert to long-acting Balance convenience vs erratic absorption Consider effects on appetite

acting is erratic absorption, so that the sustained release may last longer but you never know when you are going to get the effect. It is perfectly legitimate to titrate short-acting and long-acting.

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Side Effects of Stimulants

Side effects include appetite suppression, sleep disturbances, re-

Appetite suppression Sleep disturbance Rebound hyperactivity vs. paradoxical effect Emotional dysphoria ("zombie") Questionable growth retardation Tics

bound hyperactivity, paradoxical effects., emotional dysphoria or "zombie"-like kids is really something to watch for especially in younger kids. Growth retardation, which probably doesn't exist and if it does, it is no more than 2%, the studies have shown. It is generally not a real concern. And finally, tics. Tics will occur frequently and nobody really feels that stimulants caused the tics, but we may uncover tics in the child who has a pre-existing tic disorder, like Tourette's, which may not show up beforehand. On the other hand, in any child who has tics, I probably would not use any of the stimulants, and clonidine is probably the drug of choice.

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Second line drugs

There is a second line now, you may or may not use. I am getting

Clonidine Desipramine ?SSRIs (Prozac)

comfortable now using clonidine. I still am not comfortable using the tricyclics, desipramine, and I refer those out if the child is also depressed, especially if he has ADHD. People are now beginning to use the serotonin, reuptake inhibitors, like Prozac. It is not clear how well they will work.

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Parent Counseling
Provide information; demystify; take onus off child Explain there is no cure, only coping Emphasize importance of enhancing self-esteem

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Parent Training
Finding something positive for that child to do that plays into their

Positive reinforcement; minimize punishment; differential attention ("time-in") Make positive prophecies; avoid negative character attributions Discriminate necessary versus unnecessary limit-setting Provide environments that are free of restraint

strengths and not their weaknesses helps with self-esteem. Looking at the environments. These kids need to be able to run and have a good time and not be fenced in. Looking at the environment and the quality of the environment. In letting the child have opportunities to run and play and be free because that's what his nature tells him he needs to do. Talk to parents about positive reinforcement, differential attention ("time-out") and so on. Making positive prophecies for the child. "It's going to be good." as opposed to "It's going to be bad." Discriminating necessary and unnecessary limits. These are all common behavioral interventions you'll use in other areas.

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Classroom Therapy
The classroom should be involved too and this needs to be consistent with the home program with immediate and frequent conse-

Consistent with home program Immediate and frequent consequences for misbehavior Concrete rules Hierarchy of rewards and punishments Extra supervision and training Allow time for uninhibited play

quences for misbehavior and positive behavior. Concrete rules. A hierarchy of rewards and punishments and some time for uninhibited play are important interventions.

And then for the kids counseling and psychotherapy. If the child's self-esteem is really low, if they are aggressive, if they are having a really hard time, I think that counseling is helpful. Not to stop him from having ADHD, but in dealing with the emotional consequences of ADHD and/or a learning disability. Find successful activities and awareness.

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Prognosis of ADHD
Symptoms persist in the majority, but change in nature (eg, hyperactivity replaced by feelings of restlessness). Most studies show a higher incidence of problems: Anti-social behavior, violating the law (20-25%), substance abuse (16%), other DSM diagnosis (33%) Some have poorer work performance; adaptive problems; poor interpersonal skills. On the other hand, the majority become normal (especially if not aggressive, high IQ, high socioeconomic scale, multi-modal treatment)

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References
Dworkin P. School failure. in: Parker S and Zuckerman B: Behavioral and developmental Pediatrics: A handbook for primary care. Boston, MA:Little, Brown and Co. 1995, pp 256-260. Levine M. Neurodevelopmental variation and dysfunction among school-aged children. In Levine M, Carey W, Crocker A: Developmental-behavioral pediatrics. Philadelphia: Saunders, 1992, pp 477-494. Sprague R, Sleator E. Methylphenidate in hyperkinetic children: Differences in dose-effects on learning and social behavior. Science 198:1274, 1977. Manhuzza S, et al. Adult outcome of hyperactive boys. Arch Gen Psychiatry 50:565,1993.

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