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PLUK News June/July 1999 Volume 13 Number 11/12
	PLUK News is published by Parents, Let's Unite for Kids, a private nonprofit organization founded in 1984 by a group of parents of children with disabilities and chronic health problems. Subscriptions are free, however, we ask that subscribers contribute $15/year toward PLUK activities. PLUK News is available in alternative formats. Editor: Katharin A. Kelker, Ed.D. Production: Roger Holt, ATP PLUK Office 516 N 32nd St Billings MT 59101-6003 800.222.7585 in MT; 406.255.0540 (voice/TT); 406.255.0523 (fax) E-mail: plukinfo@pluk.org
The contents of this newsletter were developed under a grant from the Department of Education. However, those contents do not necessarily represent the policy of the Department of Education and you should not assume endorsement by the Federal Government. Products and services described herein are not endorsed by PLUK, the U.S. Department of Education, or by the Federal Government.

Article Index

PLUK'S Annual Barn Raising Picnic Work Incentives Bill Disability Earnings Limit Increase News on IDEA Amendment ASK PLUK ??? Supreme Court Decides Olmstead GAO Suspends IDEA Report What's New in the TRIC/PLUK Library

BEST OF PLUK NEWS - Attention Deficit Disorder - 10 years How can it be detected Doctors do not overdiagnose Myths about Stimulant Drugs Ritalin to be on Time Diagnosis of ADD Reflections of a Mom Once There was a Child Management at School Stimulants have Positive Effects School Programs & IEP's Choosing a Teacher School Assessment Beyond the Myths Section 504 Plans ADD Not an Excuse ADHD in Adolescents Best Practices for Evaluation Ritalin Prescriptions Triple Ideal Teacher A Hero for Children Stimulants Overprescribed Coaching: An Approach How Not to Diagnose New Guidelines New Data on Stimulant Use Pros and Cons of Drug Holidays Is ADHD Overdiagnosed? Experts Agree ADD "Major" Problem ASK PLUK??? 10 Years of Questions on ADD

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PLUK'S Annual Barn Raising Picnic

Parents, Let's Unite for Kids (PLUK) is UPDATING our computer lab and needs a little help from its friends.

Parents, Let's Unite for Kids is holding our second annual Barn Raising and needs financial help with unbudgeted expenses for renovation of the new office and computer lab.

PLUK annually assists over 4,000 children with disabilities and their families. The organization was located at MSU-Billings since 1984 and moved into our new quarters last year. Badly needed items include; new computers, internet access, Intellikeys adaptations, and software. We are asking our friends to help in the tradition of an old-fashioned Barn Raising.

Friends of PLUK can support the renovations in two ways: by buying raffle tickets or by taking part in an old-fashioned Barn Raising Picnic on:

Sunday, August 29, 1999, from 3:00 to 6:00 p.m. at the Shiloh Barn, 2121 S. 48th St, Billings MT.

To lend PLUK a hand, come to an old-fashioned Barn Raising Picnic with Entertainment, a Silent Auction, Children's Games, and Picnic Dinner. Dinner tickets for the afternoon of fun are $5.00 per person or $10.00 for a family. Also, PLUK is raffling a handmade quilt, cedar log rocking chair, and beautiful original Montana photographs by a local artist. Raffle tickets are $5.00 apiece. This year's Silent Auction will feature guided hunting trips (deer, elk, or birds) and the use of a cabin at East Rosebud, plus many more country items and baskets.

Contributions to the Barn Raising are tax deductible. For raffle or dinner tickets, call PLUK at 255-0540 or 1-800-222-7585. You can also help by selling tickets and/or volunteering to serve on an event committee.

Good News on Work Incentives Bill

On June 16, 1999, by a vote of 99-0, the U.S. Senate passed the Work Incentives Improvement Act. This bill addresses the problem that many people with disabilities have: if they go to work full-time and earn enough money to support themselves, they lose their eligibility for medical benefits. The proposed legislation is intended to remove some of the most significant barriers to the employment of people with disabilities by:

• Providing adequate and affordable health insurance when a person on SSI or SSDI goes to work, or develops a significant disability while working. This includes expanding Medicaid options for States, continuing access to Medicare coverage under a ten-year trial program, providing grants to States to develop infrastructures to support working individuals with disabilities, and creating a time-limited demonstration program permitting States to extend Medicaid coverage to certain workers with disabilities;
• Offering a user-friendly, public-private approach to job training and placement assistance for individuals with disabilities who want to work by providing up to $23 million per year for grants to states or private organizations for outreach programs to provide accurate information on available programs to individuals with disabilities;
• Creating a new payment system for employment services to SSDI/SSI beneficiaries that rewards successful outcomes. Vocational rehabilitation, training and employment services providers would be reimbursed a portion of benefit payments saved when a beneficiary earns more than the current laws "substantial gainful activity" SGA standard. The individual with a disability would be able to choose between public or private employment service providers;
• Encouraging SSDI beneficiaries to return to work by providing assurances that cash benefits would remain available if employment proves unsuccessful. Further, using "employment" as a sole criteria for a "continuing disability review" (CDR) to determine a beneficiary's continuing eligibility to receive benefits would be prohibited. An expedited eligibility determination process would be established for individuals who lose their SSDI benefits due to work and need to return to benefit status; and
• Extending the Social Security Administration's demonstration authority, which expired in 1996 and requires SSA to conduct a demonstration that reduces SSDI benefits by $1 for every $2 earned above "Substantial Gainful Activity."

Although the bill had 77 cosponsors, Sen. Phil Gramm objected to its reliance on tax changes to pay for it. So the Senate put off finding a way to pay for the $800 million, five-year measure. Instead, it directs future negotiators to come up with unspecified spending cuts. The legislation also has considerable support in the House but is stalled over how to pay for it. It has cleared the Commerce Committee but still must move through the Ways and Means Committee, which sets tax and disability policy. Last year, the House passed similar legislation. Rep. Archer (R-TX), chairman of the Ways and Means Committee, said he was optimistic about the bill's chances in the House this year.

President Clinton referred to the Work Incentives Improvement Act in his State of the Union Address, urging Congress to make WIIA a top priority and fully fund it in the budget. The President challenged Congress to send the Work Incentives bill to him by July 26th so he could sign this legislation into law on the 9th anniversary of the enactment of the Americans with Disabilities Act (ADA).

Disability Earnings Limit Increase

People who work while receiving Social Security disability benefits are able starting July 1, 1999, to earn more. The amount of money indicating substantial gainful activity has been increased from $500 a month to $700 a month.

This increase may affect as many as 250,000 Social Security beneficiaries with disabilities.

Previous rules stated that to become eligible for Social Security Disability Insurance (DI) or Supplemental Security Income (SSI) benefits, an individual must be unable to engage in any substantial gainful activity (SGA) that exceeds $500 per month. In addition, SGA is used as a measure in determining ongoing entitlement for DI benefits. The SGA level is set by the Commissioner of Social Security through regulation.

SGA has been increased only once since 1980 and that increase occurred in 1990. The proposed increase would raise SGA to reflect the level of the growth in average wages since 1990.

Currently, less than on half of one percent of disability beneficiaries leave the rolls voluntarily and return to work. Each year since 1991, approximately 400,000 disability beneficiaries have remained on the rolls and have participated in the workforce. The higher SGA level is expected to prompt additional beneficiaries to venture into the workforce.

For more information on the change, visit Social Security Online at http://www.ssa.gov.

Not So Good News on IDEA Amendment

The U.S. Senate has passed an amendment to IDEA, the federal special education law, as part of the Juvenile Justice Bill. The IDEA amendment, introduced by Sen. Bill Frist, R-TN, permits public schools to suspend or expel a child with a disability who possesses a firearm at school or at a school function. The amendment offered jointly with Sen. John Ashcroft, R-MO, is intended to align disciplinary procedures covering children with disabilities with those for nondisabled students. The measure also would allow schools to stop educational services for expelled or suspended special education students&emdash;including FAPE guaranteed under IDEA&emdash;if relevant state law does not require regular education students to receive educational services following suspension or expulsion.

Advocates for students with special needs has long advocate against any cessation of special education services for two reasons: 1) there is a long history of school districts using disciplinary measures to "push out" students with disabilities and deny them access to education, and 2) special education students who may commit weapons violations are in even greater need of educational and behavioral interventions in order to correc their behavior and assist them in becoming productive citizens. Advocates also point out that the recent perpetrators of school violence (e.g., Columbine High School)were not special education students, and there is no evidence that special education students are more likely than other students to commit acts of violence at school.

By voice vote, Sen. Tom Harkin, D-IA, also successfully amended the Senate version of the Juvenile Justice Bill to ensure that immediate appropriate interventions and services, including mental health interventions and services, are provided a child removed from school for any act of violence. Harkin's amendment amends the measure proposed by Sen. John Ashcroft which allows districts to suspend or expel a student with a disability for up to one year and provide no special education services. In other words, Sen. Harkin's amendment requires that students who are suspended or expelled must receive services of some kind to help them with their behavior. Funds to pay for the costs of interventions and services would be appropriated through an allotment to states under the Elementary and Secondary Education Act.

The U.S. House of Representatives has its own version of the Juvenile Justice Bill (HB 1501 introduced by Rep. Bill McCollum, R-FL) which also includes amendments to IDEA. An amendment by Rep. Norwood to allow school personnel to discipline students with disabilities who carry or possess weapons in the same manner as those students without disabilities was adopted by the House by a vote of 300 to 128. Because the Norwood amendment is not identical to the Ashcroft/Frist amendment in the Senate version, a Conference Committee must reconcile the differences. The final version of H.R. 1501 will be voted on after all of the amendments are considered.

Rep. Rick Hill, Montana's only representative, had a cessation of services amendment of his own which did not pass the House, but he was a supporter of the Norwood amendment.

The Clinton Administration, meanwhile, has announced that it has a provision in its proposed reauthorization of the Elementary and Secondary Education Act (ESEA) that calls for no cessation of educational services for all children, special or regular education students. The President's version makes treatment of special and regular education students equal by providing all students, even those who have been suspended or expelled, with continuing educational services. Specifically, the summary of the legislation states in the case of students who are suspended or expelled, public schools must provide for "appropriate supervision, counseling, and educational services that will help those students continue to meet the State's challenging academic standards. President Clinton has said that he is offering this proposal because of the research evidence that shows truant and expelled youth who are without educational services or supervision commit a large portion of daytime burglaries.

Families wishing to comment on this series of legislative acts at the federal level may do so using the following avenues:

• Contact members of the Conference Committee by calling the Capitol Switchboard at 202-225-3121.
• Contact Rep. Hill at his office in Washington DC (202 225-3211), by fax: 202 225-5687, or by e-mail: Rick.Hill@mail.house.gov. If you send an e-mail message, be sure to include your mailing address. Congressman Hill only responds to e-mail via regular mail.
• Contact President Clinton via his comment line at 202-456-1414; visit the Whitehouse web site to send e-mail from the web at http://www.whitehouse.gov; or send an e-mail directly to president@whitehouse.gov.
• Contact U.S. Secretary of Education Riley at 202-401-3000 or send an e-mail to CustomerService@inet.ed.gov.

ASK PLUK???

The following questions are recent inquiries received by PLUK staff.

Q: My son will be a senior in high school next year. He is due for a three year evaluation, but the school district has already informed me that they don't have to do a comprehensive evaluation for a student who is graduating. My son needs the information from a recent evaluation in order to be eligble for accommodations at college for his learning disabilities. Is the school district correct that it is no longer requirement to do a three year re-evaluation?

A: The IDEA '97 amendments allow for some flexibility in re-evaluating students in special education. The IEP Team can decide what is necessary to do in order to assess a student properly. Since you are a member of the team, you can certainly make the case that you would like a comprehensive assessment to guide your son's education in his last year of school as well as provide documentation of his need for accommodations in public school and postsecondary education.

Also, it used to be the case that graduation per se was considered a "change in placement" and therefore it triggered the need for re-evaluation. IDEA '97 clarifies that re-evaluation is not required when a student is graduating. This provision does not apply in your son's case since he is due for a three-year re-evaluation anyway.

Q: Is a student with multiple chemical sensitivities eligible for special education under the other health impairment category?

A: A student with this diagnosis is not automatically eligible for special education, but he or she may be eligible if the student's condition affects educational performance and the student meets the eligibility criteria for OHI. OHI is the most likely category in which the student may be eligible, but the assessment should also consider whether other disabilities are present like learning disabilities.

Q: We think our son who has multiple disabilities should be eligible for an extended school year (ESY) program. But every year when we bring up the subject, school officials tell us that they do not think our son regresses significantly over the summer break. We have asked to see the data the district keeps on regression/recoupment, and none has ever been provided. How should we go about ensuring that ESY is a possibility for our son next summer? How can we make sure that data is collected and shared with us?

A: ESY services are a possibility for all students with disabilities who have current IEPs. Each special education student should be considered for ESY at least annually. Determining the need for ESY programming in excess of the normal school year must be made on an individual student basis. Eligibilty rests with the IEP Team which includes you as parents.

Eligibility should be based upon data and discussion of the IEP Team and not determined by a formula. Many regression/recoupment formulas have been invalidated because they were found to lack indivdiualziation. Each decision should occur either retrospectively (looking back on data collected) or prospectively (speculating on the likelihood that the student will regress if services are not provided). The primary elements to be used in determining the need for ESY should include:

• the likelihood of significant regression, and
• the rate of probable recoupment of skills.

The IEP Team must document that a delay or break in the services of special education and related services would result in substantial regression and slower than normal recoupment of previously gained skills as stated on the IEP. Recent court decisions also suggest that other elements can be used in determining the need for ESY:

• degrees of impairment;
• parents' ability to provide an educational structure at home;
• student's rate of progress;
• behavioral and physical problems;
• availability of alternative resources;
• student's ability to interact with non-disabled students;
• curriculum areas that need continued attention; and
• student's vocational needs.

When your son returns to school in the Fall, ask for an IEP Team meeting to revise your son's IEP to include the types of data to be collected to determine regression and recoupment. Have the IEP specify that data will be collected before and after school breaks. Indicate that you will be asking to see that data after each break. If no data is available after the first break, ask for another IEP meeting to discuss why data are not kept.

Also, keep records yourself of any other factors which may influence your son's need for ESY. His degree of impairment and his slower rate of skill acquisition may, for example, justify ESY in his individual case.

Q: Our son who is 16 has been diagnosed with dyslexia. Through special education, he has finally learned to read, but reading is still very difficult for him. He has an above average IQ but his lack of reading skills has really hampered him in all content areas. His high school grades are not great. What kind of postsecondary education is possible for him? Is there any chance he could go to college?

A: In order to pursue postsecondary education and be able to cope with the reading demands, your son may have to use some assistive technology. From your description, he can read but it is a labor intensive activity for him and a barrier to his achievement in all content areas. Fortunately for him, the technology now exists which may help him enough with reading so that he can get the content without having such a struggle with the reading process.

Screen reading software is now available fairly inexpensively. This software will read aloud text that is digitized or scanned into the computer. Most programs are set up so the software reads word by word or line by line. Some programs allow the user to click on unknown words and get the dictionary meaning read aloud.

Your son may find that using a screen reader makes printed material much more accessible to him. With this aid, he may be better able to handle the longer reading assignments in content areas and may be better prepared to pursue postsecondary education.

The time to try a screen reader is now while he is still in public school. Ask your school district to conduct an assistive technology assessment to determine if use of a screen reader would be beneficial for your son.

In terms of postsecondary options, reading skill need not be a barrier to a whole range of options including two year colleges, college or university, vocational training, or specialized schools. The real question is whether or not your son has the academic knowledge which will allow him to enter one of these options. Ask your son's high school guidance counselor to review your son's achievement testing to determine whether he is accumulating the background knowledge that will allow him to be successful in college. If vocational training seems more appropriate, you can ask, as part of your son's transition plan for special education, that your son be assessed for vocational aptitudes.

Postsecondary schools like colleges and universities have to provide the kinds of accommodations that allow students with disabilities to be successful. If your son can meet the basic entrance requirements for some type of postsecondary training, then he can expect to be accepted and provided with the accommodations like screen reading software that he needs.

For more information on this topic, call PLUK at 800-222-7585 and ask for a copy of our Transition Guide.

Q: Is Extended School Year (ESY) the same thing as summer school?

A: No. Extended School Year is an option that is available only to special education students. ESY is a program designed individually to provide training and support so the student is able to maintain skills learned during the regular school year.

Summer school, on the other hand, is an opportunity which may be offered to regular or special education students. It is not necessarily an opportunity for individualized instruction designed to meet the unique needs of a special education student.

School districts do not have to provide summer school, but they do not have to provide ESY for those special education students who require it in order to maintain skills.

Q: My son is a special education student with an ED label. He has been doing fairly well in school because of the supports provided to him by special education. However, he is being denied academic credits because of frequent absences. Most of these absences were excused and were related to his disabling condition. For example, he sees a therapist once per week and often these appointments have to be made during school hours because it is very difficult to get in to see this particular counselor. It does not seem right to me that my son's absences are officially excused, but he is still denied credits toward graduation because he has exceeded the number of allowable absences.

A: If you know in advance that your son is likely to miss a lot of school because of therapy sessions and medical treatment, you will need to ask for an IEP meeting and include in his IEP that your son is to be exempted from the school district absence poicy in regard to excused absences. If the school district is not willing to agree to this exception in his IEP, then you can of course take the matter to due process.

It is also possible for the IEP Team to agree that your son will achieve graduation by some other means than accumulating credits. He can be graduated, for example, on the basis of completing his IEP goals and objectives. This may be a more practical route for him to go.

In any case, if your son has done the academic work at a passing level, your son should not be penalized academically for absences related to treatment of his disability.

Supreme Court Decides Olmstead Case

On June 22 the Supreme rendered a decision in Olmstead, a case from Georgia concerning whether or not a state is obligated by the Americans with Disabilities Act to provide services to individuals with mental disabilities in the least restrictive environment. Montana had file an amicus brief in this case siding with the State of Georgia in saying that the ADA did not require that individuals placed in institutions to be moved out into the community.

The original Georgia case involved two women with mentally retardation who resided in the psychiatric unit of the Georgia Regional Hospital at Atlanta. Although their physicians had concluded that each of the women could be cared for appropriately in a community-based program, the women remained institutionalized at the hospital.

The women filed suit against the State of Georgia seeking placement in community care. They alleged that the State had violated Title II of ADA in failing to place them in a community-based program once their physicians determined that such a placement was appropriate.

The District Court granted partial summary judgment for the women, ordering their placement in an appropriate community-based treatment program. The court rejected the State's argument that inadequate funding, not discrimination against the women accounted for their retention in the institution. Under Title II, the court concluded, unnecessary institutional segregation constitutes discrimination per se, which cannot be justified by a lack of funding. The court also rejected the State's defense that requiring immediate transfers in such cases would fundamentally alter the State's programs.

The Eleventh Circuit Court affirmed the District Court's judgement, but remanded for reassessment of the State's cost-based defense. The District Court had left virtually no room for such a defense. The appeals court read the statute and regulations to allow the defense, but only in tightly limited circumstances. Accordingly, the Eleventh Circuit instructed the District Court to consider as a key factor whether the additional cost for treatment of the women in community-base d care would be unreasonable given the demands of the State's mental health budget.

In the Supreme Court's review of the case, the majority of the court affirmed that States are required to place persons with mental disabilities in community settings rather than institutions when the State's treatment professionals have determined that community placement is appropriate, the transfer from institutional care to a less restrictive setting is not opposed by the affected individual , and the placement can be reasonably accommodated, taking into account the resources available to the State and the needs of others with mental disabilities.

Justice Ginsburg, joined by Justice O'Connor, Justice Souter, and Justice Breyer, concluded that the State's responsibility, once it provides community-based treatment to qualified persons with disabilities, is not boundless. The majority of the Court agreed that States were obligated to provide a range of service options, which might include institutional care for some individuals who required that level of supervision. The Court said that the ADA does not compel States to phase out all institutions. Nor is it the ADA's mission to drive States to move institutionalized patients into an inappropriate setting, such as a homeless shelter. For some individuals, in fact, no placement outside of the institution may ever be appropriate. To maintain a range of facilities and to administer services with an even hand, the Court said the State must have some leeway setting up a continuum of services to meet a variety of needs. If, for example, the State were to demonstrate that it had a comprehensive, effectively working plan for placing qualified persons with mental disabilities in less restrictive settings, and a waiting list that moved at a reasonable pace not controlled by the State's endeavors to keep its institutions fully populated, the ADA standards would be met (e.g., reasonable accommodation). In such circumstances, a court would not have the power to order displacement of persons at the top of the community-based treatment waiting list by individuals lower down on the list who filed law suits.

President Clinton responded to the Supreme Court decision in this case in a positive way, saying that he was pleased that the Court decision upheld the purposes of the ADA by recognizing that unjustified isolation of institutionalized persons with disabilities is prohibited discrimination. Clinton pointed out that the decision should pave the way for increased access to home- and community-based long term care services and supports for persons with disabilities.

Clinton also commented that his administration is committed to finding affordable ways to enable people who need long term services and support to remain in the community if they choose to do so. President Clinton has asked Secretary Shalala and Attorney General Reno to work with all interested parties to carry out the Court's decision in a fair manner. He stressed the need for collaborative efforts to find cost-effective ways to provide more community-based services.

GAO Suspends IDEA Discipline Report Until Fall

The General Accounting Office (GAO) has postponed major work on a congressionally mandated IDEA discipline study until September or October.

The GAO study&emdash;requested by lawmakers in the fiscal year 1999 budget bill to investigate current federal special education discipline policies&emdash;requires information that the U.S. Department of Education is still in the process of collecting.

States are required to report information about both regular and special needs student's discipline problems to the Education Department by November 1st, and it is the same data the GAO needs to determine how frequently students with disabilities are disciplined in school.

The GAO, which was originally obligated to submit a preliminary report by March 1 and a final version by July 30, consulted both Congress and the Education Department before postponing the project until early fall.

Waiting to complete the report will allow the Education Department to collect more data. In addition, the GAO wants to give schools more time to implement and work with the discipline provisions of the recently released implementing regulations for the IDEA amendments of 1997.

What's New in the TRIC/PLUK Library??

The following are recent additions to the library ordered by subject area. If you are interested in checking out any materials, please call the librarian, Janice Sand at 1-800-222-7585. Materials will be mailed out anywhere in the state of Montana at no charge.

• Accommodations in higher education under the Americans with Disabilities Act (ADA); A no nonsense guide for clinicians, educators, administrators, and lawyers Gordon, Michael,, Ph.D., Editor; Keiser, Shelby, MS, Editor
• Recovery - Discovery of life beyond the pain Kraizer, Sherryll, Ph.D.
• Diagnosis and treatment of attention deficit hyperactivity disorder
• Voices from fatherhood - Fathers, sons, and ADHD Kilcarr, Patrick J., Ph.D.; Quinn, Patricia O., M.D.
• Attention deficit disorder - A different perception Hartmann, Thom
• Managing attention and learning disorders - A guide for adults McEwan Elaine K.
• Help is on the way - A child's book about ADD Nemiroff, Marc A., Ph.D.; Annunziata, Jane, PsyD
• Dr. Larry Silver's advice to parents on ADHD 2nd EDITION Silver, Larry B., M.D.
• Montana Office of Public Instruction Assessment Handbook Volume1
• Activity schedules for children with autism - Teaching independent behavior McClannahan, Lynn E., Ph.D.; Krantz, Patricia J., Ph.D.
• Asperger's syndrome - A guide for parents and professionals Attwood, Tony
• Your defiant child - 8 steps to better behavior Barkley, Russell A., Ph.D.; Benton, Christine M.
• Looking forward - A guide for parents of the child with cleft lip and palate Cox, Barbara G., M.A., ED.S.
• Lifetimes - The beautiful way to explain death to children Mellonie, Bryan; Ingpen, Robert
• We'll paint the octopus red Stuve-Bodeen, Stephanie
• Fine motor skills in children with Down syndrome - A guide for parents and professionals Bruni, Maryanne, BScOT(C)
• Creating a 21st century Head Start - Final report of the advisory committee on Head Start quality and expansion
• Dr. Weisinger's anger work out book - Step-by-step methods for greater productivity better relationships healthier life Weisinger, Hendrie, Ph.D.
• Epilepsy and the family - A new guide Lechtenberg, Richard, M.D.
• Special siblings - Growing up with someone with a disability McHugh, Mary
• BRAIN AWARE Magnetic resonance imaging (MRI)
• BRAIN AWARE Electroencephalogram (EEG)
• BRAIN AWARE Evoked response testing
• BRAIN AWARE Genetic aspects of neurodevelopmental disorders
• BRAIN AWARE Motor disabilities in children
• BRAIN AWARE Nutritional and sleep disorders in children with developmental disabilities
• BRAIN AWARE Cognitive development and neuropsychological testing
• BRAIN AWARE Speech, language, and communication disorders
• BRAIN AWARE Vision and hearing disabilities
• BRAIN AWARE Psychiatric disorders of childhood
• BRAIN AWARE Attention deficit/hyperactivity disorder
• BRAIN AWARE Personal and family issues
• BRAIN AWARE Prioritizing therapies for the multiply-disabled child
• BRAIN AWARE Financial resources
• BRAIN AWARE Long term planning for children with developmental disabilities
• Students with acquired brain injury - The school's response Glang, Ann, Ph.D.; Singer, George H.S., Ph.D.; Todis, Bonnie, Ph.D.
• Because we can change the world - A practical guide to building cooperative, inclusive classroom communities Sapon-Shevin, Mara
• Dressing for independence - Adapting clothing for kids with special needs Pompelli, Jean
• Self-care - Independent living skills manual
• Ghosts from the nursery - Tracing the roots of violence Karr-Morse, Robin; Wiley, Meredith
• Childhood feeding disorders - Biobehavioral assessment and intervention Kedesdy, Jurgen H., Ph.D.; Budd, Karen S., Ph.D.
• Start smart - Building brain power in the early years Schiller, Pam
• Best of Parent News - A sourcebook on parenting from the National Parent Information Network Robertson, Anne
• Juvenile justice: improving the quality of care Krisberg, Barry, Ph.D.
• Me, myself and I - How children build their sense of self 18 to 36 months Pruette, Kyle D., M.D.
• Many ways to learn - Young people's guide to learning disabilities Stern, Judith, M.A.; Ben-Ami, Uzi, Ph.D.
• How to do homework without throwing up Romain, Trevor
• Straight talk about psychiatric medications for kids Wilens, Timothy E., M.D.
• What to do when you are due - A comprehensive guide to prenatal care
• Helping the child who doesn't fit in
• Community recreation and people with disabilities - Strategies for inclusion Second Edition Schleien, Stuart J.; Ray, M. Tipton; Green, Frederick P.
• Consumer health and safety activities - Just for the HEALTH of it? Toner, Patricia Rizzo
• Making choices - Life skills for adolescents Halter, Mary; Lang, Barbara Fierro
• Challenge - For adolescents and young adults Kraizer, Sherryll, Ph.D.
• Entering adulthood: connecting health, communication and self-esteem A curriculum for grades 9-12 Laing, Susan J.; Bruess, Clint E.
• I can manage life - Learning to choose and grow Hooker, Dennis
• Effective communication skills - Essential tools for success in work, social, and personal situations Ludden, Marsha
• I am already successful - 80 activities on developing motivation and self-esteem Hooker, Dennis
• Moving out and making it - Interpersonal skills
• Into adolescence: enhancing self-esteem - A curriculum for grades 5-8 Zevin, Dale, MA
• Speak out - A curriculum for teaching communication skills: group leader's guide Ansell, Dorothy; Griffin, William V.
• 100 of the nation's most creative life skill activities Ansell, Dorothy; Morse, Joan M.
• Happiness, it's your choice - The skill development theory for successful change Applegate, Gary, Ph.D.
• The kid's guide to social action - How to solve the social problems you choose and turn creative thinking into positive action Lewis, Barbara A.
• Childhood disability under the social security administration supplemental security income program
• Childhood disability: a guide for school professionals
• Could this happen in your program Volume II - A collection of case studies provoking reflection, discussion, and action
• Assistive Technology Services For Students - What are these? Margolis, Leslie, Esq.; Goodman, Susan, Esq.
• Assistive technology for young children with disabilities - A guide to family-centered services Judge, Sharon Lesar; Parette, Howard P.
• Cursing brain - The histories of tourette syndrome Kushner, Howard I.
• Teens speak out - A survey of teens with chronic illness and disabilities in transition
• How to help your child succeed in school - Strategies and guidance for parents of children with ADHD and/or learning disabilities Rief, Sandra
• Learn and live Burness, Patty; Snider, William
• Asperger's syndrome - A guide for parents and professionals Attwood, Tony
• Broken Rhymes; Harm's Way; Head Spinal Cord Assembly
• Cumberland: the balanced approach
• Head injury -PBS
• Malpractice - PBS
• Mending of the mind
• Post acute rehabilitation services for people with acquired brain injury
• Problems and coping strategies of mothers, siblings and young adult males with traumatic brain injury
• Starting over: Life after a severe head injury
• TBI: effective diagnosis and treatment
• Unseen injury: Minor head trauma
• This year don't lose any friends
• Head injury in Montana
• Misconceptions of head injury
• Choices - The Craig W. Barke story
• You, me & community - Connecting the pieces
• Putting interrupted lives on a positive course
• Goals for success: Writing IEPs that work
• Decisions, decisions: What's a teenager to do?
• Grounded for life - Teenage pregnancy: afraid to say no
• Adolescents: at risk for HIV infection
• The power of choice, Program 1 Pritchard, Michael
• Acting on your values - The power of choice, program 2 Pritchard, Michael
• Self-esteem - The power of choice, program 3 Pritchard, Michael
• Drugs and alcohol - The power of choice Pritchard, Michael
• Friendship and dating - The power of choice, program 9 Pritchard, Michael
• Communicating with parents - The power of choice, program 11 Pritchard, Michael
• Raising your parents - The power of choice, program 12 Pritchard, Michael
• Identify your skills - A job search essential
• Preparing teens for the world of work - A school to work transition guide for counselors, teachers and career specialists Schilling, Dianne; Schwallie-Giffis, Pat; Giddis, W. James
• Getting the job you really want - A step-by-step guide 3rd Edition Farr, J. Michael
• More than a job - Securing satisfying careers for people with disabilities Wehman, Paul; Kregel, John

BEST OF PLUK NEWS - Attention Deficit Disorder - 10 years of articles

February 1989

Attention Deficit Disorder: how can it be detected?

How can you tell if your child's learning problems are caused by Attention Deficit Disorder? It is not easy to tell whether a child truly has ADD or is simply displaying normal distractibility and activity levels. Professionals point out that the typical symptoms of ADD apply now and then to the behavior of almost any child. Fluctuations in activity and attending levels are normal. The difference in true ADD is that symptoms of the disorder are persistent, lasting at least six months at a stretch, and they show up in different settings not just at school, for example.

The medical profession makes a distinction between two basic types of Attention Deficit Disorder: 1) ADD with hyperactivity, and 2) ADD without hyperactivity. In other words, a child can have ADD and not be hyperactive. Children with ADD who are not hyperactive have difficulty attending to some tasks and may display extreme disorganization and distractibility.

To decide whether or not a preschool child may have ADD look for such things as excessive running or climbing and frequent shifting among activities. In older children, the main signs are excessive fidgeting or restlessness, failure to complete tasks and careless work habits.

The revised third edition of the Diagnostic and Statistical Manual (DSM) the handbook used by professionals to diagnose the disorder says a child must display eight of fourteen symptoms, beginning before age 7, to be diagnosed as having the disorder.

In addition to the symptoms mentioned above, other possible symptoms include frequent interrupting or intruding, difficulty waiting turns or playing quietly, inability to stay seated when requested.

Remember however, that none of these symptoms are significant unless the child displays them much more often than his or her peers. Also, keep in mind that their developmental disorders or emotional problems, such as depression and anxiety, have similar symptoms.

Here is a simple checklist, designed by Dr Cyrus I Admads, President of the Kentucky Psychiatric Association, to detect children who may have Attention Deficit Disorder. Rate your child on the following symptoms, adding 3 points for an answer of very much, 2 points for often, 1 point for a little, and 0 for not at all.

1. Is excitable or impulsive.
2. Cries easily and often.
3. Is restless and fidgety.
4. Appears to be always on the go.
5. Is destructive.
6. Fails to finish tasks.
7. Has extreme mood changes.
8. Is easily frustrated.
9. Disturbs other children.

September 1989

Doctors do not overdiagnosis ADHD

Primary care physicians (pediatricians and family practice doctors) are not overdiagnosing Attention Deficit hyperactivity Disorder in children and, on the contrary, may be slightly underdiagnosing it, Scott Lindgren, Ph.D., said at a conference on Mental Health services for children and adolescents presented by the National Institute of Mental Health, Rockville, Maryland.

The underdiagnosing does not appear to be serious, according to Dr. Lindgren of the University of Iowa College of Medicine.

Of 457 children aged 6 to 12 years old seen by four pediatricians and eight family practice physicians, 4.8% were diagnosed as having Attention Deficit (AD) and or hyperactivity Disorder (HD). Using the Diagnostic Interview Schedule for Children (DISC), the prevalence of AD and/or HD was 12.8% based on parents reports of symptoms and 6.9% based on teacher ratings.

Physicians' diagnoses agreed more often with reports of parents than those of teachers. Of the 22 diagnosed hyperactive children in Lindgren's study, 15 were identified by parents, only eight by teachers.

In addition, oppositional and defiant behavior was apparent in one-half of the children with AD and/or HD symptoms, and anxiety disorders were present in one-third.

December 1989

Myths About Stimulant Drugs Debunked

Use of stimulant drugs like Ritalin has come under fire recently both from the media and from organized efforts to curb abuse of stimulants. In the debate over the use of stimulant medications, several myths have gained in popularity. Unfortunately, belief in these myths sometimes stands in the way of using stimulant medications in appropriate ways. Here are some common misconceptions that can be refuted by reference to medical research:

1. Stimulant medications are addicting. Although it is well-known that adults who abuse stimulant medications can become addicted- primarily because of the euphoric effect achieved at high doses- the smaller doses used in treatment of attention deficit hyperactivity disorder (ADHD) produce no euphoria and are not addictive.
2. Stimulant therapy will lead to substance abuse in the future. There is indeed a higher rate of alcoholism and drug abuse among adults who had ADHD as children. But this is perhaps "understandable" when viewed in the context of the core symptoms of ADHD; irritability, impulsivity, and emotional lability. These symptoms may be curbed by use of appropriate drugs and through counseling, but they do not always go away completely. It is more likely that the symptoms of ADHD itself may lead to drug abuse and/or alcoholism, rather than the use of stimulant drugs in treatment of the symptoms.
   According to Dr. Esther H Wender in a presentation to the American Academy of Pediatrics: "There is no evidence to support a link to Ritalin and drug abuse and delinquency, and there is evidence that treatment reduces the risk of these bad outcomes."
3. Children taking stimulant drugs will become "zombies." The calming effect of stimulant use in ADHD is not like that seen with tranquilizers. If the stimulant dosage is too high, however, children may withdraw from social activities and show signs of unresponsiveness. These effects are reversible by lowering the dosage.
4. Diets are better than drugs. Comprehensive studies done over the past 10-15 years have not been able to show an association between food additives and ADHD, nor have food additive-free diets been shown to be effective therapy. Any improvement seen after dietary manipulation is probably due to a placebo effect. Megadose vitamin therapy has not been shown to be effective either.
5. Treatment causes brain damage. There is absolutely no evidence in the medical literature to support this statement.
6. Treatment causes psychosis. A rare child will develop psychotic-like behavior while on stimulant medication, but in almost all cases, a look at the child's medical history will reveal some psychotic symptoms prior to the drug therapy.
7. Treatment leads to depression. By definition, no child with ADHD should have symptoms consistent with a major depressive disorder, but children with ADHD may have some depressive symptoms, particularly low self-esteem. A small number of children become more depressed while on medication, usually after a few months on therapy. Medication should be discontinued of depression occurs. The depressive effects are completely reversed when the drug is discontinued.
8. Taking stimulant medications lead to Tourette's Syndrome. About half of children with Tourettes syndrome had full-blown ADHD symptoms before Tourette's developed, making it difficult to determine in those children who develop Tourette's while on stimulant medication whether the syndrome should have developed any way or whether it developed as a result of the medication.

March 1992

Ritalin to be On Time

The Office of Civil Rights (OCR) has concluded that a California school district (San Ramon Valley Unified School District, 18 IDELR 465--OCR 1991) violated Section 504 regulations by failing to provide a student with his Ritalin medication at the prescribed times. A nine-year-old student with attention deficit hyperactivity disorder (ADHD) was supposed to receive his prescribed dosage of Ritalin during regular school hours. On 13 occasions, the student did not receive his Ritalin at school because he forgot to come to the principal's office to have the medication administered to him. OCR determined that Ritalin had been prescribed for the student in order to modify his ADHD synptoms. Thus, because the administration of medication is considered necessary to assist the child in benefitting from his educational program, the school district violated Reg. 104.33 by failing to make certain that the student received his Ritalin on the 13 days in question.

(Source: Special Educator, February 25, 1992, Vol. 7 (11), p. 189.)

October 1992

Diagnosis of ADD

The Office of Special Education Programs recently has ruled that if a local educational agency (LEA) believes that a medical evaluation by a licensed physician is necessary to determine whether a child suspected of having attention deficit disorder (ADD) meets the eligibility criteria under the "other health impaired" category, then the LEA must ensure that such an evaluation is conducted at no cost to the parents. On the other hand, if the LEA believes that other effective methods of measuring ADD are available, then qualified personnel other than licensed physicians may be used to conduct the evaluation, a long as the evaluation meets the requirements of federal special education regulations Other qualified personnel may include properly licensed and trained school psychologists. Recommendations for medication must, however, be made by medical, not educational , personnel (Parker, 18 IDELR 963 OSEP 1992).

October 1992

Reflections on the First Weeks of School

by a Montana Mom

He headed off to school with such high hopes--a new lunch box, a fresh haircut, new clothes, his favorite high tops. But I could tell he was scared. That last week before school started, he didn't sleep well. He was moody, touchy, easily frustrated--twice he had awakened in the middle of the night with nightmares. His fingernails he had bitten to the quick. What could be so frightening to an eight year-old about going back to school? Why was he so worried? What did he think would happen when he returned to his desk in third grade?

My son has ADHD (Attention Deficit Hyperactivity Disorder). Last spring the school district was planning to expel him. He was in constant trouble on the playground and totally distracted in the classroom. we finally took him to a doctor and got him started on medication. He took his pills twice a day for the months of April and May and there was a remarkable improvement in his behavior at school during that period of time. He got on better with his classmates and didn't get into so many fights. He paid more attention in class and got most of his work done. He didn't have to stay in from recesses. He even got a Good Citizens' Award in May. No child has ever been prouder of an accomplishment. His grandmother had his award framed, and it hangs in our kitchen over our dining table.

Over the summer we took him off the medication and he had a happy vacation doing what ranch kids like to do. Now he is back on medication and returning to school. Wouldn't everything be fine?

I watched him come home from school the first three days. He had dark circles under his eyes--he looked exhausted. He didn't want to play. Twice he fell asleep in front of the television set before he had his dinner. I became concerned. Then on Friday of the first week of school, he came rushing into the kitchen, still with dark circles under his eyes, but with a wide grin and a burst of enthusiasm.

"Mom," he said. "Guess what!"

"What is it?" I replied, giving his shoulders an affectionate squeeze.

"My teacher understands!"

"What do you mean, she understands?"

"She told me today that she has a boy with ADD who takes pills, too. She told me all about how her boy used to get in trouble at school and have to go to the principal's office every day."

I watched his face--full of animation and relief.

"My teacher says that we can work together to help me do my work. She promised that I won't ever have to stay in for recess--as long as I'm trying. And look what she gave me."

He reached into his jeans pocket and brought out a laminated ticket with his name on it. The pass said that he could go anywhere in the school any time.

I asked him what the pass was for. He said, "My teacher said that anytime I need someone to talk to or someone to help me with my temper, I can come and see her. I can even knock on the Teachers' Lounge door and she will come out to talk to me."

He started to put the ticket into his pocket and then paused. "Mom," he said. "Where should we keep my ticket? I don't want to forget it--ever."

We fixed a basket by the back door where the coats and hats are hung on hooks. When my son comes home from school, he puts his ticket in the basket. In the morning when he leaves for the school bus, he grabs his ticket and puts it in his pocket. He has no more precious possession.

That ticket and his relationship with his teacher have given my son back his confidence in himself. The medication he takes every day helps him to concentrate, and it has been a tremendous benefit for him. But his relationship with his teacher is even more important. Her empathy and concern have restored his sense of self worth. She is recognizing every little step my son takes toward greater self control and better organization of his school assignments. She is helping him to gain insight into his own behavior. What a gift this teacher is!

School has been in session for a month. My son's days in third grade are never easy or without challenges, but he is blossoming under the eye of a teacher who sees the good in him and who has helped him see the good in himself.

January 1993

Once There Was a Child

by Betty Selvig

February 1993

ADD: Management at School

Attention Deficit Disorder is a condition in children and adults which can cause an individual to have difficulty paying attention, staying on task, getting along with others, handling frustration, and controlling behavior. These difficulties can lead to school failure and strained relationships with family members and peers.

Since school is the place where ADD symptoms seem to cause children the most difficulty, school accommodations are probably the most important part of an intervention program. If children with ADD are going to be successful at all in school, they have to be treated differently. Their attending mechanisms are so fragile that they are not able to learn using the methodologies which are most common in classrooms. They cannot sit still as long, and they cannot learn by listening only. They have to be able to move, and they must have opportunities to learn by doing. As a general rule, the following types of accommodations are basic to helping children with attending problems do better in school&emdash;

Preferential Seating

ADD children do best when they are seated near the teacher or near the place where instruction is being given. It is best if they are facing the teacher when he or she is speaking and if the teacher uses their name or touches them in order to make sure they are attending.

Decrease Distractions

ADD children are more comfortable and productive when they are concentrating if unimportant stimuli are reduced or eliminated. This means they may need to be seated at the front of the row so they are not distracted by looking at all of the other children. They should be away from traffic areas and not close to the windows where they can look out. Some ADD children do better on seat work when they wear ear plugs. Others like to use study carrels with sides that cut off visual distractions and reduce noise. Some children with ADD like to have quiet background noise (e.g., music through earphones) to help them focus on fewer stimuli. Usually the children themselves are good at explaining what helps them to pay better attention. Their suggestions should, as much as possible, be honored.

Provide Feedback

ADD children need lots of information about how they are doing. They often do not have efficient learning strategies and may use trial and error methods, rather than some more productive system. Therefore, ADD children require lots of feedback about whether they are proceeding correctly. They also need to know how much time they have, how much time has elapsed, and how much time is still to go.

Children with ADD will stick to a task much longer if they are provided with periodic feedback. Often their attention must be re-directed, but then they will continue to do productive work for several minutes more until their attention lapses and they need to be re-directed again.

Help with Learning Disabilities

Many children with ADD also have learning disabilities in reading, mathematics, or language. These learning problems need to be addressed specifically so that the child can do a better job in school. Often the child will require one-on-one or small group tutoring to catch up on subject matter missed when the child was not paying attention.

Harnessing Interests

ADD children can attend for extended periods of time when they are doing something in which they are interested. Every effort should be made to teach them skills using topics or methodologies which interest them. ADD children will learn a great deal of information incidentally about a subject during the course of the time that they are working on something of interest. For example, when the class is studying Egypt, the ADD child may enjoy building a pyramid. This child may learn a lot about pyramids and why they were built at the same time that he or she is busy with the construction.

Physical Activity "Breaks"

Children with ADD definitely need frequent opportunities during the school day to get up and move for legitimate reasons (e.g., to run errands, to move from one work area to another, to pass out papers for the teacher). Short work periods broken up by periods of activity are much more productive for the ADD child than longer, sustained work periods.

Praise for Accomplishment

All children thrive on praise, but children with ADD especially need to know when they are doing something right. Even the smallest correct or compliant behavior should be recognized and encouraged.

Structure and Predictability

ADD children do not respond well to change. They do best in environments that are entirely predictable and structured around routines. They need warnings when a transition or change is about to occur. They need to understand the rules of the situation and the consequences for breaking the rules. Consequences must be applied consistently and without too much verbal elaboration.

Teacher Selection

Some teachers are better than others at working with children who have ADD. The ideal teacher for an ADD child is one who is warm and demonstrative, who provides structure but is not rigid, who uses a variety of teaching methods and accepts a variety of methods for responding, and who does not dwell too heavily on details. Whenever possible, teachers for ADD children should be "handpicked" and matched to the child's learning style. The difference in the ADD child is often dramatic when the teacher is able to respond appropriately to the child's needs.

August 1993

Stimulants Found to have Positive Effects

Stimulant medications like Ritalin have long been considered effective for the treatment of the hyperactivity associated with ADHD. New research on the use of stimulants in children suggests an even wider range of beneficial effects beyond the reduction of disruptive behavior.

For example, contrary to previous belief, the use of stimulants in reducing hyperactivity does not appear to impair a child's social functioning. Indeed, in one recent study hyperactive children treated with Ritalin showed increased positive social behavior compared with those on a placebo.

Other data suggest that Ritalin treatment results in improved interactions between hyperactive children and their mothers, teachers, and peers. Not only do children become more cooperative, but the behavior of others toward the child improves, too.

Also contrary to widespread belief, there is evidence that stimulants can improve academic performance. In two recent studies, children on Ritalin showed significant improvement on arithmetic and language tasks. This effect is thought to be due to reduced motor restlessness and impulsivity.

New research also points to long-term benefits from stimulant use in childhood. In a comparison of a group of 20 adults who had received at least 3 years of continuous Ritalin therapy during childhood and a similar group who had been hyperactive as children but had not received stimulants, the treated group led more independent lives, were more likely to be in school, and had had less psychiatric treatment and fewer car accidents. The members of the treated group were also seen as less aggressive, had better social skills, and rated themselves as having better self esteem than the untreated group. However, the untreated group had held their last job for a longer period of time and reported fewer concentration problems.

In another study, exposure to stimulants for 6 months or more during childhood was associated with better parent ratings, less police contact for alcohol and drug use, and less drunken driving in early adolescence.

In summary, it appears that taking stimulant medications may have a number of positive effects for individuals with attention deficit hyperactivity disorder, including (a) improved behavior, (b) better social relationships, (c) improved academic performance, and (d) less anti-social behavior as adults.

(Source: Tucker, M. (July 1993). Improved behavior might not be the only benefit of stimulant use. Pediatric News, p. 24.)

April 1993

School Programs & IEP's for children with ADD

Depending on their individual characteristics, children with attention deficit disorder may qualify for special education as other health impaired (OHI), learning disabled (LD), or emotionally disturbed (ED). Their Individualized Education Programs (IEPs) should include goals both for academics and behavior. In general, children with ADD require help with organizational tasks, completing assignments, and filling in the gaps in their knowledge which occur because they have not been able to pay attention.

Academics

The assessment of the child for special education provides information about the skills and concepts that the child is missing. These missing skills can then become goal areas for the IEP. For example, it may be that the child has not learned the concept of borrowing in subtraction, so the IEP can include a goal and objectives focusing on subtraction.

Classroom Modifications

A student with ADD may also require some modifications of regular classroom assignments and routines. For example, the child may benefit from having directions repeated or from having a chart of daily assignments taped on the desk. Some children with ADD do well with shortened assignments and more frequent praise for completing smaller chunks of their work. Many children with ADD benefit from legitimate opportunities throughout the school day to get up and move and to be physically involved in a learning task.

With children who have ADD, it is important that the IEP focus on a few skills that are essential for the child to learn. Other skills of lesser importance should be ignored for the time being, so that the child can concentrate on accomplishing a manageable number of tasks. For example, if a child is working on developing written language skills, then handwriting, and perhaps even spelling, may be of lesser importance. The child should feel a sense of accomplishment in generating complete sentences, even though the handwriting and spelling may be less than perfect. The focus in academics should be on achieving as much success as possible and on providing frequent praise and attention for small steps in the right direction.

Behavior

Behavior is another significant issue for the IEP. The ultimate goal for children with ADD is for them to learn to recognize their inappropriate behaviors and control them as much as possible. Again, the IEP should address working on a limited number of behaviors or habits, the ones that most need changing in order for the child to be successful in school. The goals should be set at reasonable levels and the new behaviors should be expected to develop over time, not on the first day the IEP is implemented.

It is critical that children with ADD have alternatives available to them so that they can express their emotions in acceptable ways when they are feeling frustrated, angry, or overexcited. Even children as young as first grade should be taught to recognize when their feelings are getting out of control and to remove themselves from the group in order to calm down.

Sometimes it is helpful for the teacher to signal the child with a hand gesture or a quiet word which indicates to the child it is time to "take a break." Acceptable time-outs might include leaving the classroom and walking up and down in the hall for a few minutes, taking a seat at a learning center in the back of the room, putting on earphones and listening to music, or even removal to the nurse's or principal's office. The important thing is that these time-out sessions not be viewed as a punishment, but as an acceptable time for the child to gain control and feel better again. Children who use time-out effectively should be lavishly praised because this behavior is difficult to learn and demonstrates a level of maturity and self control which is not easy for most children with ADD.

Preventative Measures

Many children with ADD run afoul of the discipline policies in regular education. Often these policies prescribe specific "punishments" for talking back to teachers, chewing gum, forgetting materials, fighting and so forth. Children with ADD are much more prone than other children to be disorganized or forgetful, or to behave impulsively. Consequently, they frequently engage in behaviors which violate school rules.

For the student with ADD, the behavior or discipline plan should be based on positive reinforcement, and for most students, should ignore negative behaviors which are not seriously disruptive (e.g. forgetting a pencil). To give the student the best chance of behaving appropriately, the following guidelines are usually helpful:

• Student should be seated away from distractions
• Student should be given frequent opportunities to get up and move
• Learning environment should be structured for success

The IEP should identify situations which are likely to cause frustration and make suggestions for eliminating these problems.

Rules Waived

If there are school rules and or policies which are not appropriate for the student with ADD, those policies can be specially waived in the discipline plan. For example, the plan may say that "this student is not subject to the school rule which requires automatic in school suspension for failing to bring materials to class three times."

Consequences

The IEP should also include a series of acceptable consequences for noncompliant behavior. The focus of these steps should be on their educational purpose. In other words, the important question is: What will the child learn from these consequences for behavior?

Agreement should be made in the IEP about when, if ever, parents will be called about discipline problems. Generally, it is wise for consequences for misbehavior which happens at school to be delivered at school. Parents should not be expected to "punish" the child additionally at home because the child will not associate the consequence with behavior at school.

Generally, the consequence of in-school or out-of-school suspension should be reserved only for extreme behaviors. Students receiving special education services may not be suspended for a period in excess of ten days for behavior related to the disability. The school and parents should agree on and specify in the IEP those behaviors that may result in out-of-school suspensions. A child should not be repeatedly suspended for the same behavior, unless those behaviors create an immediate and substantial danger to others, self, or school property.

In addition, in-school suspension, which is often used as an alternative, is suspect as a consequence because it can deprive a child of an appropriate education if it is used repeatedly.

For students with ADD, the IEP planning process can be a powerful method for determining ahead of time how behavior will be handled. If parents and school staff agree upon procedures which all find acceptable, they can work much more effectively as a team and can keep the focus on meeting the child's educational needs. When problems arise, the IEP provides a framework for resolving issues, particularly those pertaining to discipline.

February 1994

Choosing a Teacher for an ADD Child

Since children with ADD receive most or all of their education in the regular classroom setting, the teaching style of classroom teachers is an important factor in the success of the ADD child. Generally, principals make the decision about the placement of children in particular classrooms, but many principals are open to hearing parents' requests, especially when those requests are based on a student's needs. Parents of ADD children may wish to consult with the principal at the end of the school year concerning the placement of the child for the next year. During this meeting, the parents might want to discuss with the principal how their child reacts to various teaching techniques and styles. It is usually wise not to talk about specific teachers, but instead to focus on the child's needs and the types of teaching strategies that work best. This information should help the principal to decide which teacher on the staff would be the most appropriate choice. In rural schools, where the child may have the same teacher for several years, the principal or lead teacher can sometimes work with the teacher to assist him or her in adjusting teaching techniques to better meet the needs of the ADD student.

Children with ADD vary greatly so it is difficult to generalize about the type of teacher who works best with them. However, there are some common characteristics of teachers who tend to serve ADD children well, including the following:

• An ability to provide structure in the classroom without being rigid
• A willingness to ignore some irritating behaviors while concentrating on assisting a student with two or three necessary behavioral changes
• A sense of humor
• A tolerance for a wide range of abilities in the classroom
• An ability to use a variety of teaching strategies
• A belief in "second chances" or opportunities for students to redeem poor grades or earn additional credit
• An ability to teach learning and organizational strategies along with academic content
• A willingness to allow students several choices for how they respond to an assignment (e.g., tape record a speech, build a model, draw a diagram, invent a game)
• Generosity with praise and genuine interest in student accomplishment, however limited in scope
• Self confidence
• Firmness and consistency in discipline
• A low key approach to correction of behavior or classroom work.

On the other hand, students with ADD generally do not do well with teachers who have these characteristics:

• A commitment to invariably high standards for every activity in the classroom
• A belief that most learning tasks can be accomplished in only one way
• A habit of awarding of zeroes for work not completed or not turned in on time
• A tendency to change discipline approaches several times (e.g. go from a point system to student contracts and then to check marks on the board for misbehavior)
• A tendency to withhold recess as a punishment
• A tendency to react negatively to every infraction of classroom etiquette
• An unwillingness to repeat directions more than once
• A tendency to correct more often than to praise or validate
• A tendency to admonish students in front of the whole class
• A strong belief that attention deficit disorder is not a "real" disabling condition
• A strong preference for neatness
• A concern for total control in the classroom.

Not every teacher is going to be a perfect match for the child with ADD, but as much as possible, it is helpful to try to place the student with ADD in a classroom environment which provides both the structure and the flexibility that the child needs. Some advance planning with the principal is often the best way to assure that the classroom placement will be a success.

November 1994

School Assessment of Attention Deficit Disorder

Even though a student has been diagnosed outside of school as having Attention Deficit Disorder (ADD), the school district must also do its own evaluation to determine whether a student is eligible for school services.

As with all other disabling conditions, evaluation of students suspected of having ADD or ADHD should be a multistep, multi-disciplinary procedure. The school district may begin with a prereferral process in regular education. During this process, at least two regular education interventions may be tried. The results of these interventions will indicate whether or not the student's attention deficit disorder can be accommodated with simple academic or behavioral modifications which are common in the regular classroom.

If the results of prereferral interventions are not positive, then the assessment may continue on a more formal basis to determine if the ADD is adversely affecting educational performance and what types of educational services may be necessary to assist the student.

The identification of students with ADD requires a combination of clinical judgement, objective assessment, and for Other Health Impaired, a medical diagnosis. ADD must be diagnosed by a person qualified in the use of Diagnostic and Statistical Manual of Mental Disorders. Since there is a high rate of coexistence of ADD with other disabilities of childhood and adolescence any comprehensive assessments should include an evaluation of the individual's medical, psychological, educational and behavioral functioning. The more domains assessed the greater certainty there can be of a comprehensive, valid and reliable diagnosis. The taking of a detailed history, including medical, developmental, social and educational factors is essential in order to establish a pattern of chronicity (at least six months) and pervasiveness of symptoms. Augmenting the history are the standardized parent and teacher behavioral rating scales which are essential to quantifiably assess the individual with respect to adaptive functioning in a variety of settings such as home and school. Psychoeducational assessment investigating intellectual functioning, use of language, perception, attention, memory, and visual-motor functioning as well as academic achievement should often be performed.

Both the Individuals with Disabilities Education Act (IDEA) and Section 504 of the Rehabilitation Act of 1973 provide coverage for children with ADD/ADHD. Both regulations specify that a student is entitled to a comprehensive evaluation. When the disability adversely affects education performance, eligibility should be approached through the processes of IDEA. When the disability does not affect educational performance but does substantially limit one or more major life activities, eligibility should be approached through Section 504.

To be eligible for special education as Other Health Impaired the student must have a chronic or acute health problem which results in limited strength, vitality or alertness. Alertness is the ability to initiate and sustain attention on a given task. Many students with ADD have difficulty in the area of "alertness." If the student does have the limited strength, vitality or alertness, to be eligible for special education, there must be evidence that the health condition adversely affects the student's educational performance (e.g., school work or behavior) to the extent of requiring special education. Examples of significant interference with educational performance might be failing semester grades, two or more disciplinary referrals in a month associated with impulsive or overactive behavior, chronic failure to complete work, discrepancy between academic performance and potential. Evaluation of OHI must include assessment of social-emotional functioning whether or not an academic deficiency exist. Documentation may include: grades, test data, discipline records, attendance, and behavior scales.

If the student does not meet the criteria for OHI, he or she may qualify under Section 504. If the student's ADD impairs a major life activity such as learning or social development and the impairment is substantial (i.e. cannot be accommodated with informal classroom adaptations), then the student may be eligible to receive formal accommodations under Section 504.

October 1994

Attention Deficit Disorder: Beyond the Myths

MYTH: Attention Deficit Disorder (ADD) does not really exist. It is simply the latest excuse for parents who do not discipline their children.

FACT: Scientific research tells us ADD is a biologically-based disorder that includes distractibility, impulsiveness, and sometimes hyperactivity. While the causes of ADD are not fully understood, recent research suggests that ADD can be in inherited and may be due to an imbalance of neurotransmitters--chemicals used by the brain to control behavior or abnormal glucose metabolism in the central nervous system. Before a student is labeled ADD, other possible causes of his or her behavior are ruled out.

MYTH: Children with ADD are no different from their peers; all children have a hard time sitting still and paying attention.

FACT: Before children are considered to have ADD, they must show symptoms that demonstrate behavior greatly different from what is expected for children of their age and background. They start to show the behaviors characteristic of ADD between ages three and seven, including fidgeting; restlessness; difficulty remaining seated; being easily distracted; difficulty waiting their turn; blurting out answers; difficulty obeying instructions; difficulty paying attention; shifting from one uncompleted activity to another; difficulty playing quietly; talking excessively; interrupting; not listening; often losing things; and not considering the consequences of their actions.

These behaviors are persistent and occur in many different settings and situations. Furthermore, the behavior must be causing significant social, academic, or occupational impairment for the individual to be diagnosed educationally as having ADD.

MYTH: Only a few people really have ADD.

FACT: Estimates of who has ADD range from 3 to 5 percent of the school age population (between 1.46 and 2.44 million children.) While boys outnumber girls by 4:1 to 9:1, experts believe that many girls with ADD are never diagnosed.

MYTH: ADD can be prevented.

FACT: While scientists are not certain they understand the causes of ADD, they have ruled out most of the factors controlled by parents. A poor diet does not cause ADD; nor does sugar or food additives. Normal quantities of lead will not cause ADD. Since the causes of ADD are genetic and biological, the parents cannot cause ADD by being too strict or too lenient.

However, actions by the parents can influence the child's ability to control his or her ADD behavior. Recently, some studies suggest a few cases of ADD may be caused by the use of alcohol and drugs by the mother while pregnant.

MYTH: All children with ADD are hyperactive and have learning disabilities.

FACT: While a certain percentage of children with ADD also have learning disabilities, the two disorders cause different problems for children. ADD primarily affects the behavior of the child--causing inattention and impulsivity-- while learning disabilities primarily affect the child's ability to learn mainly in the area of processing information.

Not all students with ADD are hyperactive and constantly in motion; many are considered to have undifferentiated ADD (Attention Deficit Disorder without hyperactivity). Because these children do not behave in the same way as hyperactive ADD students, their disorder frequently is not recognized, and they are often considered unmotivated or lazy.

MYTH: Many children are incorrectly diagnosed as having ADD.

FACT: Educators can use screening instruments to identify children who may have ADD. Children suspected of having ADD can then be referred to a child specialist (e.g., school counselor, psychologist, pediatrician) for clinical evaluation. Observations and reports from parents and teachers are critical to proper diagnosis. Sometimes children are given intelligence, attention and achievement tests. Doctors may also administer neuropsychological tests and neurological examinations.

Most importantly, it is a team of professionals in education, medicine, and psychology who pool test and observation results and make a final determination. Since a child's hyperactivity, distractibility, and impulsive behavior may be due to other factors, such as emotional problems, poor nutrition, or learning problems, the specialists check for other causes of these behaviors before making a diagnosis of ADD.

MYTH: Medication can cure students with ADD.

FACT: Medicine cannot cure ADD but can sometimes temporarily moderate its effects. Stimulant medication such as Ritalin, Cylert, and Dexedrine is effective in 70 percent of the children who take it. In those cases, medication causes children to exhibit a clear and immediate short-term increase in attention, control, concentration, and goal-directed effort. Medication also reduces disruptive behaviors, aggression, and hyperactivity.

But medication alone has only limited short-term benefits on social adjustment and academic achievement. While medication can be incorporated into other treatment strategies, parents and teachers should not use mediation as the sole method of helping the child.

MYTH: The longer you wait to deal with ADD in students, the better the chances are that they will outgrow it.

FACT: ADD symptoms continue into adolescence for 50-80 percent of the children with ADD. Many of them, between 30-50 percent, still will have ADD as adults. These adolescents and adults frequently show poor academic performance, poor self-image, and problems with peer relationships.

MYTH: There is little parents and teachers can do to control the behavior of children with ADD.

FACT: Teachers and parents have successfully used positive reinforcement procedures to increase desirable behaviors. A behavioral modification plan can give the child more privileges and independence as the child's behavior improves. Parents or teachers can give tokens or points to a child exhibiting desired behavior such as remaining seated or being quiet and can further reward children for good school performance and for finishing homework.

Mild, short, immediate reprimands or allowing natural consequences to occur can counter and decrease negative and undesirable behaviors. Students with ADD can learn to follow classroom rules when there are pre-established consequences for misbehavior, rules are enforced consistently and immediately, and encouragement is given at home and in school.

MYTH: Students with ADD cannot learn in the regular classroom.

FACT: More than half of the children with ADD succeed in the mainstream classroom when teachers make appropriate adjustments. Most others require just a part-time support from the resource program. Teachers can help students learn by providing increased variety. Often, altering features of instructional activities or materials, such as paper color, prestation rate, and response activities, help teachers hold the attention of students with ADD. Active learning and motor activities also help. ADD students learn best when classroom organization is structured and predictable.

(Suggestions come from the Division of Innovation and Development, Office of Special Education Programs, Office of Special Education and Rehabilitative Services, U.S. Department of Education)

December 1994

Section 504 Plans for ADD

Many students with attention deficit disorder do not require special education, but need accommodations and modifications in the regular classroom. A Section 504 plan is a way that these accommodations and modifications can be spelled out clearly for all of the staff who work with the student.

Students with ADD are eligible for 504 plans if (a) they have been diagnosed by a properly licensed professional (e.g. physician, psychologist), and (b) they are in need of accommodations and modifications in order to have access to the curriculum.

To request a 504 Plan, a parent should contact the child's principal or guidance counselor and ask for a planning meeting that includes all of the teachers who work with the student. At the planning meeting, the team can develop a list of accommodations and modifications which assist the student with paying attention, managing impulsiveness, or developing organizational skills.

Here are some suggestions for possible modifications which may prove helpful:

• Position the student's desk between two students who are not ADD and close to the front of the room (near the board or the teacher).
• After giving directions, ask the student (or the whole class) if the instructions or directions are understood. If necessary, ask the student with ADD privately to repeat the directions. Observe the student to see if the assignment is being done correctly.
• Accompany oral directions with written directions (on blackboard or paper) for the student to use as a reference.
• Do not give more than one oral instruction at a time; the ADD student will not remember them.
• Mark correct and acceptable work, not mistakes. Recognizing correct work is important for restoring self-esteem.
• Do not return handwritten work to be copied over; the assignment is often not improved and this adds to frustration.
• Reversals and transpositions of letters and numbers should not be marked wrong, but pointed out for correction.
• Sloppy, messy writing occurs when a student is unmedicated. Do not criticize handwritten work at those times.
• Provide a variety of ways to respond to assignments, including using a computer with word processing, tape recording responses, or making products instead of written responses.
• Recognize and give credit for oral participation in class--again for self-esteem.
• Whenever possible, tests and quizzes should be given within 1 hour after a student takes stimulant medications. This is important because concentration and memory/recall are most enhanced at the time when the medication has become effective. If quizzes or tests are taken at other times, the student's grades may be lower than when the student is properly medicated. When low grades occur, the student should be given the opportunity for retest when he or she is properly medicated.
• Provide extra test time and assignment time (if needed) since memory/recall for students with ADD is a little slower than normal, especially when medications are wearing off.
• Make arrangements for homework assignments to reach home with clear concise directions. Assignments should be written on the board so that the student may copy them onto a homework sheet to go home. The student should be asked at the end of the day if he or she has all the books needed for homework because after the medication has worn off the student is likely to forget materials or fail to organize work to take home.
• Avoid placing the student under pressure of time or competition. Many students with ADD will be concerned about how much time they have and will not be able to perform the task or complete the test. Timed tests only encourage impulsive behavior.
• Accept homework papers or reports typed by the student or dictated and typed by someone else.
• Do not require lengthy outside reading assignments.
• Provide tutoring or one on one instruction when necessary.
• Consider matching the student's learning style with the teacher's teaching style. Some teachers definitely do better with ADD students than others.

March/April 1995

ADD is a Reason, Not an Excuse

When a child is diagnosed as having attention deficit disorder (ADD), it can be a great relief to the whole family. At last, there is a name for the child's condition and there is information available about how to handle the symptoms. For the children, too, there is a sense of relief in knowing that there is a reason why they cannot pay attention, get tasks completed, or keep their school work organized. The children learn that ADD is a neurological condition that they did not cause. No one can blame them for having ADD because it is part of their physical nature.

However, there is a danger in children with ADD believing that ADD can be an excuse for behaving inappropriately or not trying to do school work. When a child is diagnosed with ADD, it is important to lay out a plan for dealing with the symptoms which may include behavior modification, counseling, educational accommodations, and sometimes medication. A coordinated approach should relieve some of the child's anxieties and make it possible for the child to perform better in school and get along better with classmates and family members.

For treatment of ADD to be entirely successful, however, it takes more than behavior modification, counseling, accommodations, and medication. The children themselves must gradually learn how ADD affects their behavior and must acquire strategies for correcting annoying behaviors so that they can be more functional. Having ADD does not excuse a child from trying to be in control of behavior or learning to be better organized. Perhaps the most important thing for a child with ADD to learn is how to use alternative strategies to overcome the ADD symptoms and gain greater self control. When individuals learn to deal with attention deficit disorder, their sense of competence and self worth is greatly enhanced.

Here are some hints for helping children to take charge of their own ADD symptoms:

• Explain the child's condition in understandable terms. Answer his or her questions about ADD matter-of-factly.
• Ask the child for feedback about what strategies seem to help him or her stay organized (e.g., folders, Trapper notebook).
• Allow natural consequences to occur. For example, if the child loses a jacket, have him wear an old one while he is helping to earn money to pay for a new one.
• Encourage the child to indicate when he or she is feeling frustrated. Work out strategies for relieving frustration like leaving the room, finding a quiet place, listening to music tapes, going for a run.
• Help the child break down tasks into manageable parts. Provide positive feedback as each segment of the task is completed.
• Never humiliate the child if he or she has a bad day. Provide encouragement that the next day will go better.
• Encourage the child to take part in activities outside of school which are pleasurable and successful (e.g., collecting rocks, riding motorcycles, painting, hiking, fixing motors).
• Don't insist on improvement in all areas at once. Focus on just a few things at a time and let the rest go.
• Spend some time each day listening to the child explain how things are going. Help the child to understand how other people might be feeling.
• Don't allow the child to use ADD as an excuse. Make conquering or working around ADD symptoms a challenge which the child can meet.
• Let children with ADD know that they are loved as they are--that they have lovable characteristics which others enjoy.

September/October 1995

ADHD in Adolescents

Sometimes a child is not identified as having Attention Deficit Hyperactivity Disorder (ADHD) until adolescence. During the elementary school years, some children manage to curb their ADHD symptoms in the classroom and display relatively minor problems.

However, when adolescence beings , mild problems which were overlooked in a younger child may become more significant. Adolescents who fidget excessively, are clumsy, interrupt and intrude, fail to finish school work or sustain attention, laugh excessively, or overreact to teasing or normal peer interactions may indeed have ADHD and be in need of treatment.

Diagnosis hinges on a comprehensive history of the child's development. If no childhood inattentive or disruptive behaviors have occurred in the past, ADHD should be ruled out. Other causes for the ADHD-like symptoms in adolescence may be affective and anxiety disorders, abuse, and acute or chronic medical problems.

Fifty percent of ADHD-affected adolescents improve with medication, particularly if combined with counseling as well as educational accommodations.

February 1995

Best Practices for ADD Evaluation

The Montana Association of School Psychologists has developed set of "best practices" to guide school psychologists as they evaluate students suspected of having attention deficit disorder. According to these guidelines, ADD evaluations should be multistep, multidisciplinary procedures.

First, at least two regular education interventions must have been tried for a reasonable amount of time with documented results. If regular education interventions do not correct the problems the student is having with learning, then, the psychologist should pursue a complete psychoeducational evaluation. Further assessment should determine the degree to which the student's educational performance is adversely affected by ADD symptoms. This information will help determine what types of educational services are necessary to assist the student.

The identification of students with ADD requires a combination of clinical judgment and objective assessment. Since there is a high rate of coexistence of ADD with other disabilities of childhood and adolescence any comprehensive assessment should include an evaluation of the individual's medical, psychological, educational and behavioral functioning. The more domains assessed the greater certainty there can be of a comprehensive, valid, and reliable diagnosis.

The taking of a detailed history, including medical, developmental, social and educational factors is essential in order to establish a pattern of chronicity (at least six months) and pervasiveness of symptoms. In addition to the history, the evaluation should include the standardized parent and teacher behavioral rating scales which are essential to assessing the student's behavior in a variety of settings such as home and school. Psychoeducational assessment investigating intellectual functioning, use of language, perception, attention, memory, and visual-motor functioning as well as academic achievement should also be performed.

August 1995

Ritalin Prescriptions Triple in 4 Years

It does appear to be true that Attention Deficit Disorder (ADD) is being diagnosed more often and more children are being placed on stimulant medication. IMS America, a marketing research firm in Plymouth Meeting, Pennsylvania, has reported that the number of prescriptions written for the three main stimulant drugs used to treat attention-deficit hyperactivity disorder (ADHD) and their generic counterparts--Ritalin, Dexedrine, and Cylert--have tripled from 1990 to 1994.

Ritalin's increasing popularity led to a shortage of the drug last year. That prompted the Drug Enforcement Administration to increase the production quota for Ciba-Geigy, the manufacturer of Ritalin to more than four times the allotment four years ago.

The positive side of these reports of increases in ADD diagnoses is that millions of children and adults with ADHD are being accurately diagnosed and treated. The bad news is that ADHD has become a very seductive diagnosis that is perhaps sometimes confused with other conditions, including normal developmental differences.

April 1996

Ideal Teacher for ADD Students

Students with attention deficit disorder definitely do better with some types of teachers than with others. Certain teaching styles seem to allow ADD students to flourish without their behavior getting out-of-hand.

Here are some characteristics to look for (or to nurture) in teachers who will do well with ADD students:

• Knows about ADHD and accepts the legitimacy of the disorder
• Is tough as nails about a few necessary rules but always calm and positive
• Is ingenious about modifying teaching strategies and materials in order to match the student's learning style
• Tailors academic materials to suit the student's abilities and skills
• Creates assignments that require as much activity on the student's part as possible--Hates dittos and endless seatwork
• Mixes high and low interest tasks to match the student's needs
• Isn't into homework in a major way
• Knows to back off when a student's level of frustration begins to peak
• Knows to back off when the teacher's level of frustration begins to peak
• Speaks clearly in brief, understandable sentences
• Looks the student straight in the eye when communicating
• Runs a predictable and organized classroom
• Controls the classroom without being controlling
• Provides immediate and consistent feedback (consequences) regarding behavior
• Never uses humiliating forms of discipline
• Routinely provides students with opportunities to redeem themselves
• Develops a private signal system to notify students when they are off task or acting inappropriately
• Maintains close physical proximity without being intrusive
• Ignores minor disruptions--Knows how to choose battles
• When appropriate and necessary, has no problem acting as an "Auxiliary Organizer" --Makes sure the student is organized for homework, parents are notified about school events, and so forth
• Maintains interest in the student as a person with interests, fears, and joys-even after a trying day
• Is willing to communicate with parents frequently to keep in step with other efforts to help the student outside of school
• Has a well-developed sense of humor.

August/September 1996

A Hero for LD and ADHD Children

Though undiagnosed during his lifetime, Winston Churchill, the great wartime Prime Minister of England, undoubtedly had learning disabilities and attention deficit disorder. The irony is that Churchill, one of the greatest users of the English language, was unable to read and write until he received remedial instruction in high school.

In the first volume of Winston Churchill's autobiography My Early Life (New York: Charles Scribner's Sons, 1930), he describes the pain he endured in school, his accident-proneness, his impulsivity, his inability to "get it" in reading and arithmetic. Churchill made such a muddle of Latin, he actually was forbidden to take foreign languages .

Churchill was forced to take remedial English instruction in high school, where he began to comprehend sentences for the first time and finally came to understand what written language is. Without this special instruction, Churchill might never have become one of the greatest leaders, writers, orators, and historians of the twentieth century.

August/September 1996

Are Stimulants Overprescribed for Children with Behavioral Problems?

Parents who are considering whether to place their child on Ritalin to treat ADHD symptoms struggle with whether they are doing the right thing. Most parents in this position question whether giving the medication is safe, whether it will be effective, or whether it is simply the "easy way out." These are all legitimate concerns.

The amount of Ritalin that is produced in this country has increased by 500% in the last five years. Most is being used to treat symptoms of attention deficit hyperactivity disorder, and the vast majority is given to 5-12 year-old boys.

It is important to ask why young boys are being seen so frequently as behavior problems. One response is that the new diagnostic criteria for ADHD have been widely publicized and have greatly broadened the pool of children who might qualify for the attention-deficit hyperactivity disorder (ADHD) diagnosis.

Another explanation for why so many more children have been identified and treated for ADHD is that more is asked of children today with less social support for them and their parents. For example, 20 years ago three to four year-olds were not expected to sit still and pay attention for as long; and they were also not expected to know the alphabet and numbers.

At the same time that greater demands for attending were being placed on children, public school classroom size has increased, and there has been a change in the style of teaching. Now it emphasizes cooperative-interactive learning which is often hard for easily distractible children.

In addition, these children--some of whom may need individualized instruction rather than medication--are not getting the help they need because their disabilities are not significant enough to qualify them for special education under federal and state law.

Rise in Treatment Linked to More Identification

Many physicians who work with children with ADHD argue that the sharp rise in the use of Ritalin is simply treatment rates catching up to diagnosis rates.

ADHD is estimated to affect 10% of children and the treatment rate is only about 4-5%. Girls are often not diagnosed with ADHD because they are generally less hyperactive and less aggressive than boys. Children with milder forms of the disorder may also be excluded from this estimate.

Ritalin Is Popular Because It Works

Against this backdrop of high demands on children and overcrowded, overextended schools, Ritalin is being prescribed because it is effective in curbing symptoms of hyperactivity and allowing children to concentrate better. Hyperactive children get in less trouble and suffer less punishment when they are taking medication. When the medication works, it can make life at school much more pleasant and rewarding for the child.

Medication alone, however, does not teach skills. It is not a cure-all for learning problems or social ineptness. In fact long-term positive results with Ritalin alone as treatment for ADHD are disappointing. In the studies that followed children beyond five years of treatment, there is no indication of a difference between controls (children not taking medication) and Ritalin-treated groups.

Successful Treatment Is Complex

Studies show that the real key to successful treatment of ADHD is not medication alone but a four-pronged approach which includes: educational interventions, counseling, behavior management, and medical intervention, if necessary.

Unfortunately very few children get all four. They receive medication because seeing a physician and receiving medical help is something parents can manage to accomplish and pay for. Medication alone can help children to concentrate better, but medication is no substitute for teaching the child specific skills of how to be organized, how to study, how to get along socially, and how to read write and calculate. Coordinating the other components of effective intervention--school modifications and accommodations, counseling and behavior management-- is much more difficult for parents to achieve.

Both Pills and Skills Are Needed

The issue is not whether or not medication is appropriate in treatment of ADHD, but whether medication alone can do the job. The clear evidence is that ADHD is best treated through a combination of interventions. Psychosocial therapies alone do not work with ADHD, nor does medication alone produce satisfactory results.

As more research is being done, it appears that some children may require lifelong treatment for ADHD, including medication, in order to be functional adults. Not providing medication to these people is like saying that children who are nearsighted should be taught to squint instead of wearing glasses. Squinting is one approach to nearsightedness but not the best one. Similarly not teaching ADHD children skills is like providing nearsighted children with glasses and expecting them automatically to learn to read. They will need instruction in reading skills as well as the glasses in order to become proficient readers.

Children whose hyperactive, impulsive or inattentive behavior make them dysfunctional in school may need both pills and skills to become appropriately educated and socially adept. Over-prescription of medication is a concern, but a greater concern is "under-provision" of individualized instruction and supportive counseling to assist children with a complex medical and educational problem.

AMA To Study Over-Diagnosis of ADHD

The American Medical Association (AMA) plans to study the possible overdiagnosis of attention-deficit disorder and the resultant overprescribing of ADHD medications. Concern among doctors is that common conditions, such as conduct disorder and depression, may not be addressed because attention is focused solely on treating ADHD.

November/December 1996

Coaching: A Respected Action-Oriented Approach to ADD

Coaching is an alternative to traditional counseling methods for assisting individuals diagnosed with attention deficit disorder. Counseling is often recommended as a strategy for alleviating ADD symptoms, but the usual types of psychotherapy do not seem to be of much value. Traditional psychotherapy is primarily insight-oriented and involves a dialogue between client and therapist, which is entirely client-centered and controlled. Within this framework, the client is not provided with concrete and explicit instructions from the therapist on how to act or achieve goals.

Individuals with ADD complain that "talk therapy" does not really help them with their problems because they come away from sessions feeling just as disorganized and out of control as when they went in.

In contrast to traditional counseling, Hallowell and Ratey, physician authors of the book Driven to Distraction, recommend coaching as a more successful approach because it is much more directed and goal-oriented, with the therapist taking a more active role in guiding and coaching the client from the sidelines. Rather than being insight-oriented, coaching is mainly action-oriented.

"Coaching" as a therapy strategy relies on practices from special education, psychology and psychiatry, as well as some sports psychology theories. Coaching ties these different methods into a unified approach. The first step in the coaching process is to know whether a person's situation is appropriate for coaching. The coach must assess the client's issues as well as past history. This information is used to determine an initial strategy, which is mutually agreed upon set goals and behaviors. Upon agreement, the coach can then aid the client in achieving the goals.

The coaching process is facilitated by a method known as a "check-in." Here, the coach and client agree on specific contact times, during which the client briefs the coach on progress or frustrations in attaining goals. Check-in times provide the client with frequent and regular feedback, which enables the person to modify the approach. These check-ins can be done by telephone, e-mail, fax or in person.

Common frustrations expressed by people with ADD include: insufficient organizational skills, difficulty starting and completing projects, and problems staying focused on goals. During check-in, the coach chooses a strategy to aid the client and get him or her back on track.

The coach determines if the client is being hindered by a task that is too demanding in light of the disability, or if it is an emotional reaction to failures and frustrations. Once this hindrance is assessed, the coach can pick a strategy.

Ideally, the coaching relationship matures in time. Through constructive and appropriate feedback from the coach to the client and vice-versa, the client is better able to identify strengths and weaknesses. Consequently, the client becomes more independent and can apply this independence to new situations and tasks.

As the effectiveness of coaching has been recognized, its popularity has grown. It is a process no longer reserved for just people with ADD. Those with other disabilities, such as traumatic brain injury, chronic illnesses, and psychiatric disorders and addictions, also use professional coaches. The coaches themselves come from a variety of backgrounds, including occupational therapy, special education and rehabilitation counseling. Thus coaches can specialize in different areas, depending on their expertise.

November/December 1996

How Not to Diagnose ADHD

In a recent article in Contemporary Pediatrics (November 1996), a research psychologist warns that tests which purport to identify children with ADHD are not reliable diagnostic tools. There is a long history of attempts to use performance on psychological tests to assess behavior. These efforts are based on the assumption that children with behavioral characteristics of ADHD (inattention, overactivity, impulsivity) will manifest a unique pattern of abnormal test results. Many tests have been considered for this purpose: subtests of the WISC-R that require focused attention; specific cognitive tests that require reflection; and mechanical measures of activity levels. Research has shown that these tests are excellent for some purposes but have serious shortcomings when used alone to make a diagnosis of ADHD because children with other disorders may have the same or similar abnormal patterns of test performance.

A specific type of laboratory test called the continuous performance test (CPT) is now being used for the assessment of ADHD. Usually, letters or numbers (and sometimes symbolic figures) are presented on a screen at a rapid rate, such as one per second, for 10 to 30 minutes. The test-taker's task is to press a key when a "target" appears. The target may be a single number or letter or a particular sequence, such as AX.

False positives and false negatives are associated with these neuropyshcological tests for ADHD, as they are with any test. Another problem in interpreting performance deficits on a CPT is that non-ADHD groups show deficits in performance, too. The abnormalities manifested by these groups may be difficult to distinguish from the deficits manifested by a group with ADHD. Dr. Swanson advises extreme caution when using performance on a CPT to diagnose a behavioral-developmental disorder such as ADHD. The diagnosis of ADHD, like that of any behavioral disorder, has to be based on multiple pieces of information and multiple observations. The standard for the diagnosis of ADHD remains a history of behavior derived from the clinical interview, not test performance.

February/March 1997

New Guidelines for Medical Determination of ADHD

Using stimulants to treat children with ADHD is once again under attack, and many parents and doctors are confused about what is best for children with attention problems. According to Dr. Frank R. Brown, the Director of the Meyer Center for Developmental Pediatrics at Texas Children's Hospital, in the current debate about attention deficit hyperactivity disorder--whether it is underdiagnosed, overdiagnosed, or really exists at all--the loudest and most extreme voices seem to be the only ones that are heard. Some critics claim that ADHD is a made-up ailment, and that the psychotropic medication used to treat it is a form of mind control that should not be used on any child. At the same time, teachers and parents besiege doctors with requests to medicate children who seem to be uncontrollable in the classroom or at home.

Dr. Brown and his colleagues Robert Voigt and Nick Elksnin, suggest that the extremists on both sides of this argument are mistaken. According to them, ADHD is a real condition, and using medication to treat it is an acceptable medical practice. At the same time, the problems teachers and parents have with children who are inattentive, have poor impulse control, and cannot sit still can be the result of a broad array of conditions--only one of which is ADHD.

To help sort out what is ADHD and what is something else, Drs. Brown, Voigt and Elksnin have suggested that doctors ask the following set of diagnostic questions:

1. Are the symptoms of inattention, poor impulse control or hyperactivity significantly interfering with the child's functioning across settings?

_____YES

_____NO

-- No further intervention necessary

2. Can the symptoms of inattention, poor impulse control or hyperactivity be solely related to another underlying medical, neurodevelopmental, psychiatric, or psychosocial condition?

_____YES

_____NO

-- Treat true cause of symptoms

3. Are the symptoms of inattention, poor impulse control, or hyperactivity inappropriate for, or discrepant from, the child's overall level of developmental functioning?

_____YES

_____NO

-- Special education services for mental retardation, slower learning, learning disabilities, communication disorders

4. Are environmental demands and expectations (at school and at home) congruent with the child's developmental abilities?

_____YES

_____NO

-- Adjust environmental demands and expectations (special education, classroom accommodations, counseling and support for parents)

5. Are behavioral and educational interventions successful in remediating the symptoms?

_____YES

_____NO

-- No further intervention necessary

6. Is a trial of stimulant medication successful in resolving symptoms of inattention, poor impulse control, and hyperactivity?

_____YES

_____NO

-- No further intervention necessary (continue behavioral and educational interventions)

7. Are you sure that ADHD is the correct diagnosis and that the symptoms that persist are amenable to medication management?

_____YES

_____NO

-- Reevaluate child (return to 1); increase level of educational and behavioral intervention

8. Trial of secondary medication (clonidine, imipramine).

Source: Brown, F., Voigt, R., and Elksnin, N. (June 1996). AD/HD: A neurodevelopmental perspective. Contemporary Pediatrics, 25-44.

April 1997

New Data on Stimulant Use

Up-to-date statistics on the use of stimulant medication with children having ADHD/ADD are difficult to come by and have resulted in wildly different figures being reported in the media. An article just published in the journal, Pediatrics, provides the best prevalence data available and suggests that some media reports have vastly overestimated the use of Ritalin in the United States. The authors of this article--Safer, Zito, and Fine (Dec. 1996)--,were able to utilize two large population-based data sources, three pharmaceutical databases, and a physician audit from five regions of the United States to derive a best estimate for the use of methylphenidate (Ritalin) over the years 1990-1995.

Results indicated that during this time frame there has been a 2.5 fold increase in the usage of methylphenidate for children diagnosed with ADHD/ADD. By the middle of 1995, the prevalence of usage was 2.8 percent or approximately 1.5 million children, ages 5 to 18 years. The authors attributed the rise in medication use to a longer duration of treatment with medication, an increase in the number of girls being diagnosed and treated, an increase in the number of adolescents also being diagnosed and treated, and the consideration of children who are mainly inattentive (and not hyperactive) for medication treatment. An improved public image for medication treatment also was considered as a possible contributor to these trends.

Results of this study help to correct misleading information from some media stories that medication use rose six fold in this period of time. The findings also suggest that only 50-60% of children eligible for a diagnosis of ADHD (population prevalence estimated at 5 percent) are receiving methylphenidate treatment for their disorder, seriously questioning the perception that the U.S. is overmedicating children having ADHD. If the latter were the case, use of stimulant medication should exceed the expected numbers of children diagnosed with the disorder. The Safer, Zito, and Fine study indicates that, rather than exceeding predicted numbers, just over half of the expected number of diagnosed children are actually being treated with Ritalin.

Source: Safer, D., Zito, J., & Fine, E. (December 6, 1996). Increased methylphenidate usage for attention deficit disorder in the 1990s. Pediatrics, 98, 1084-1088.

June/July 1998

Pros and Cons of Drug Holidays

Some doctors recommend that their patients who take Ritalin or other stimulants for ADD stop taking the medication over the summer. Other physicians continue the medication because it seems to help some children to cope with social situations during the summer. Each of these points-of-view has some merit. Here are the pros and cons of "drug holidays."

Reasons to Take a Drug Holiday Over the Summer

• There is no evidence that medication improves sport skills or acquisition of sport skills. Benefit in attention deficit without hyperactivity is also difficult to prove.
• Evidence also is lacking that medication enhances social abilities. Medication does not solve all ADD children's problems. Medication can help with paying attention, but it cannot make children be "good."
• The need for medication is at least as likely to stigmatize a child as the behavior that results when he or she is off medication.
• There is no evidence that taking Ritalin decrease accidents, though this may occur.
• Hyperactivity can aggravate parents, bosses, and family friends. But having to pay more attention to the child when he or she is off medication may be beneficial.
• Some children need a drug holiday so that their normal appetites return, they eat more, and they have an opportunity to grow physically.

Reasons NOT to Take a Drug Holiday Over the Summer

• Continuing to take medication during the summer may help a child with ADD to be safe while participating in sports. If the medication assists with concentration, it may help a child to attend to directions and be better prepared to follow the "game plan."
• Medication reduces impulsivity and overactivity. The child who is "out of the social loop" because he or she is inattentive and distracted misses the interpersonal cues necessary for smooth interactions with peers and adults. With medication, the child may attend better to social cues and be better able to practice skills of making a friend.
• Anything can stigmatize a child who perceives himself or herself as different from peers. Ostracism by others can be lessened by giving medications when no one is around to observe, teaching the child about the disability, empowering the child to learn to compensate for this disorder.
• Paying more attention to children's needs and not relying on medication alone leads to a better outcome, but an impulsive, overactive, and overreactive child can frustrate the most well-intended efforts of parents.

So the decision about whether or not to give medication during the summer depends upon a number of factors: (a) how the child reacts to medication, (b) what other supports are in place to help the child manage ADD, (c) what the demands are in the child's summer environments; and (d) the parents' ability to help the child with behavior management and socialization.

October/November 1998

Is ADHD Overdiagnosed?

The diagnosis and treatment of attention deficit/hyperactivity disorder (ADHD) often receives criticism in the popular press. The charges are that physicians are giving in to pressure from teachers and parents who do not want to put up with normally rambunctious children, or that doctors are diagnosing a psychiatric disorder where none exists, and prescribing stimulant medications unnecessarily, in ever-increasing quantities. These are serious charges, but according to a literature search performed by the American Medical Association's Council on Scientific Affairs, there is very little evidence to support these allegations (JAMA 1998;279 <14>:1100).

Data for the report were drawn from a National Library of Medicine database for all English-language studies on ADHD published from 1975 through 1997. Analysis of these studies indicates that diagnostic criteria for ADHD are derived from extensive research and the disorder is not being overdiagnosed or overtreated. The percentage of US school children being treated for ADHD is, in fact, at the low end of the prevalence range of 3% to 6% shown in epidemiologic studies. The use of stimulant medication to treat ADHD has also been extensively studied, and the data show it generally provides significant short-term relief of symptoms and academic improvement.

According to Martin Baren, MD, a developmental pediatrician who treats many children with ADHD, the Council's assessment is accurate. Solid epidemiologic studies not only in the US but worldwide indicate that the disorder is not diagnosed more frequently than its incidence in the population. Nevertheless, some children are misdiagnosed and inappropriately medicated, Dr. Baren believes, because of "short, cursory medical encounters that rely solely on diagnostic checklists and treatment that is limited to medication alone."

Comprehensive diagnostic workups that include a complete history, physical, and neurological and neurodevelopmental evaluation, and therapeutic regimens that include behavioral and educational approaches as well as medication, are necessary, according to Baren, for proper treatment of children with ADHD.

October/November 1998

Experts Agree ADD "Major" Problem

A panel of medical experts convened by the National Institutes of Health (NIH) has determined that 3% to 5% of children in the United States have attention deficit hyperactivity disorder (ADHD), and at least 1.5 million take drugs such as Ritalin for symptoms such as: attention and concentration problems, overactivity, distractibility, or impulsivity.

Attention deficit hyperactivity disorder (ADHD), dismissed by critics as an overused label for unruly children, is a "major public health problem," according to the National Institutes of Health Panel.

But there is no standard way to diagnose it. Drug treatment, though effective at getting children to calm down and pay attention in school and at home, has not been proven to improve school work or offer any other long-term benefits.

Children with the ADHD diagnosis struggle with school, frustrate their parents, alienate peers, and are at risk for long-term academic and social problems. Related school services alone cost $3 billion in 1995.

The NIH report from 13 physicians, educators and advocates raises more questions than it answers, and it is unlikely to quiet a raging debate about whether too many children take Ritalin and other stimulant drugs for a problem that some consider more about discipline than medicine.

Though some panelists argued that Ritalin may be overprescribed, many stressed that the drug has well-documented short-term benefits for many children.

A 14-month study presented to the panel shows drug treatment works better than behavioral approaches alone. In addition, evidence suggests that stimulants work for anywhere from 75% to 95% of children with ADHD.

ASK PLUK??? 10 Years of Questions on ADD

August 1989

Q: My son has been diagnosed by a physician as having Attention Deficit Disorder. He has been tested at school because he is bright and his achievement scores are adequate. In spite of being on medication, he has great difficulty concentrating all day in school. He frequently gets in fights and has even been suspended for misbehavior (he is in the fourth grade). We think he needs special help for his behavior problems. Is there any way that we can get this help from the school.

A: It is possible, even though your son did not qualify for special education services, that he may qualify for some service under Section 504 of the Rehabilitation Act. If his Attention Deficit Disorder is not properly controlled with medicine and it limits his ability to learn and benefit from other parts of the education program, he may be a qualified handicapped person under Section 504.

Whether or not your son is eligible for special education under Public Law 94-142, the district is required by Section 504 to provide regular education and related aids and services designed to a meet your child's individualized educational needs. Under Section 504 definitions, your son's behavior problems may constitute a serious impediment to learning.

Make an appointment with your child's principal and explain your concerns about your son's behavior and his possible qualification for services under Section 504. Ask that he be re-evaluated by the district with particular emphasis on behavior.

November 1989

Q: Our son has been diagnosed as having ADHD. We have shared this information with the school district, but they won't do anything about it. Isn't our son entitled to special education?

A: Attention Deficit Hyperactivity Disorder (ADHD) in not one of the handicapping conditions recognized under P.L. 94-142, so your son is not entitled to special education unless he qualifies for some other reason like learning disabilities (LD) or serious emotional disturbance (SED). ADHD is actually medical terminology used to describe physical symptoms that lead a child to have difficulty controlling behavior and paying attention in school. In order for your son to receive special education help he would need to have a multi-disciplinary evaluation by the school district. If the evaluation shows that he qualifies as learning disabled or emotionally disturbed and needs special education, then he could receive services.

You can ask your child's principal to refer him for a special education evaluation. Also, under Section 504 of the Rehabilitation Act of 1973, your son is entitled to an evaluation to determine if his behavior at school is the result of a handicapping condition. Even though he may not be eligible for services under the special education law, ADHD is covered by Section 504 and would entitle him to an evaluation.

November 1992

Q: My husband and I recently had a meeting with our son's teachers and principal at which it was suggested that our son might have attention deficit disorder. The principal, in particular, suggested that we should take our son to a doctor to have him diagnosed and have medicine prescribed for his attention problems. We were very upset by this meeting. Are we under any obligation to take our son to the doctor? Do we have to give him medication because the school wants us to do that?

A: You are under no obligation to do as the principal has suggested. Apparently, your son must be having some problems in school related to paying attention in class. There are a number of options for dealing with this problem. You may want to try either of these steps first:

• New strategies can be tried with your son in the regular classroom to see if they help him to pay better attention.
• Your son could be tested by school personnel for special education. He may qualify for services as a student with learning disabilities.

If you would like to pursue the question of a medical diagnosis for attention deficit disorder, you could to do that as well. Since the school district suggested the medical evaluation in the first place, you can request that the school district pay for the medical evaluation.

If you do decide to have your son evaluated by a physician, the decision about whether or not your child has ADD is strictly up to the doctor's judgment. You and your doctor can make whatever decisions you wish about whether medical treatment is necessary. If medication is suggested, it is up to you whether or not you wish to use medication.

January 1993

Q: tell me one more time can the school determine whether or not a child has attention deficit disorder? my son's teacher has told me that my son has adhd and that he should be on medication. can teachers make this determination?

A: Attention deficit disorder (ADD) and attention deficit disorder with hyperactivity (ADHD) are terms which are used by the medical profession. ADD is not a category for special education, though children with ADD can sometimes be served in special education if they qualify under disabilities like specific learning disabilities, emotional disturbance, or other health impaired.

The determination of whether or not a child has ADD or ADHD must be made by a physician, and of course only a physician can determine whether or not medication may be appropriate for a particular child's condition.

Classroom teachers can provide important information about the child's behavior and academic performance. This information is useful to the physician in determining whether or not the child has ADD. Teachers, however, cannot and should not identify the child as having ADD. Teachers should be careful to describe the behaviors they see and convey this information to the parents who can then confer with a physician, if they think that is advisable.

In addition, if a child is having significant behavior or academic problems, the parent (or the teacher) should make a referral for a special education evaluation. The educational assessment which is done by school personnel can help to determine whether the child is eligible for special education or accommodations in the classroom. For a child who is experiencing problems, it is certainly advantageous to have both a school and an medical evaluation in order to pin down the exact nature of the problem.

August 1993

Q: We would like to have our son evaluated for attention deficit by the school. The principal told us that the school can't evaluate for attention deficit disorder because it is a medical condition. He suggested we see our doctor. We think our son's problems are related to school, not to A health problem. Do we need to see a doctor?

A: Attention Deficit Disorder is not a category for special education in school. The term ADD is actually a medical term, and some physicians (e.g., pediatricians, neurologists) specialize in the diagnosis and treatment of this medical condition. Particularly when medication is an appropriate treatment, a physician can be helpful with ADD.

You may want to have your child evaluated by a physician to rule out any medical problem that may be interfering with learning and to determine if any medical intervention is appropriate.

The school district can also evaluate your child for educational problems that may be related to ADD. These problems might include: lack of organizational skills, difficulties in attending to task, impulsivity in responding and so forth. You can certainly ask to have your child evaluated to see if there is evidence that ADD is interfering significantly with learning. The school district should consider whether or not your child is eligible for special education as learning disabled, other health impaired, or emotionally disturbed. If he is not eligible for special education, he may still be eligible for classroom modifications under Section 504. In any case, having a school evaluation may help to clarify the types of assistance which may be valuable for him.

January 1995

Q: Our son who has ADHD is now 14 and has been on stimulant medication since he was 8. I am becoming very concerned that taking drugs for such a long time is addictive or will lead to addiction to other types of drugs. Are my fears reasonable?

A: Nearly every parent whose child is taking medication for attention deficit disorder is concerned about whether or not the medications are addictive. The clear evidence is that Ritalin and the other commonly-used ADD medications are not addictive. These medications have been prescribed routinely in the United States for more than 20 years and there is no evidence that individuals using these medications become addicted to them.

There is, however, troubling evidence that adults with ADD have a greater tendency than the general population to have addictive disorders. Recent studies have consistently shown elevated rates of substance abuse in adults with ADD. More specifically, in a group of adults with ADD, approximately one third have had alcohol abuse or dependence histories, while approximately one fifth have had drug abuse or dependence histories. In addition, a recent unpublished study at Massachusetts General Hospital indicates that most of the adults with ADD and substance abuse (generally alcohol or marijuana) also had a mood, anxiety, or antisocial condition.

Long term studies of children with ADD have shown that 30 to 40 percent of these children do well as adults, 40 to 50 percent continue to have ADD symptoms, and 20 to 30 percent have problems with substance abuse. In addition, these studies have shown that the group with ADD and elevated rates of substance abuse also had a continuation of their ADD symptoms as well as demoralization and evidence of conduct disorder. Research on children at risk for substance abuse also indicates that ADD plus conduct disorder may be an important antecedent to the onset of substance abuse.

The good news is that research indicates that children with ADD who receive proper treatment for their condition, including medication when appropriate, are less likely to exhibit addictive behaviors as adults.

February 1995

Q: My son is a high school freshman who has been labeled LD/ADD. His IEP has two goals--one involves keeping up his grades and the other deals with turning in homework. The problem is that he is just expected to do these things on his own, and he is not being taught skills that help him to be better organized. Shouldn't he be taught study skills?

A: Your son's IEP should be explicit about the study skills that he needs to learn in order to better organized and more successful in school. If the IEP does not contain this kind of detail, ask for an IEP Team meeting and make sure that specific objectives are written which would lead to mastery of study skills and organizational procedures. Your son may also need to have some classroom accommodations written into his IEP. If you need help with suggestions, the PLUK Parent Resource Library has some great materials with specific IEP objectives for LD/ADD students.

Q: Whenever our fifth grade son with ADD acts up at school, the principal calls us and expects us to bring our son home. Our son has learned that all he has to do is misbehave and he'll get to go home--which is where he wants to be anyway. If I am not home when the school calls, the principal becomes very annoyed. I feel trapped in my home because I am trying to be available at all times in case I have to go pick up my son. Is this right?

A: Your son needs a Section 504 plan which addresses the steps to be taken at school to manage his behavior. If he is becoming out-of-control or unmanageable, he needs to be removed from the classroom. However, he could be removed to a time out room, the principal's office or some other quiet area in the school instead of sending him home. It appears that misbehavior is being rewarded now with a trip home. It is likely that if this reward is withdrawn, your son will be less disruptive.

You are certainly under no obligation to be "on call" all the time in case your son has a bad day at school. In the 504 plan, why not indicate that bringing your son home is an absolute last resort method. You will be glad to come and get him if he is sick. Otherwise, he should remain at school.

Q: My seventh grade son was diagnosed as having symptoms of attention deficit disorder by a private therapist. I provided this information to the school district but they are refusing to do anything about it. My son needs help in school. He is having both academic and behavior problems.

A: If your son has ADD, he can receive help either through special education or a Section 504 plan. In order to make sure that the school addresses his needs, ask for an educational evaluation to see if he is eligible for special education. You will have to give your written consent to have him tested. This testing is free.

If your son is not eligible for special education, he is likely to be eligible for a 504 plan. Whether he is in special education or has a 504 plan, you will be able to work with the school on developing an individualized plan for academic and behavioral supports.

It is possible that the reason the school staff have not accepted the information from your son's therapist as grounds for special programming is that the report from the therapist is not specific enough about the diagnosis. Often private therapists are not aware of the information that schools must have to determine eligibility for special programs.

May/June 1995

Q: My eight year-old son has been diagnosed with ADHD and is being treated medically with some success. On top of the ADHD, he also seems to have a serious reading disability. Does ADHD cause reading problems? I seem to see so many boys with both problems.

A: As you know, children with ADHD have extreme difficulty paying attention, tend to be impulsive and often have difficulty sticking with tasks for long periods of time. Researchers studying ADHD have found, as you have, that ADHD and reading disabilities often appear to be found in the same persons. However, research indicates that the two disorders are separate and distinct and one does not cause the other.

Because reading disabilities are often found together with ADHD, and because ADHD is more likely to occur in males, many more males than females are identified as having reading disabilities as a consequence of their having been diagnosed with ADHD. Because the ADHD symptoms are so obvious, the ADHD is diagnosed and while these children are under scrutiny it is sometimes also noticed that they are having difficulty learning to read. Boys with ADHD are more likely to come to the attention of parents and professionals and are therefore more likely to receive both diagnoses of ADHD and LD.

Both ADHD and LD may be inherited characteristics. Research on Tourette Syndrome and ADHD has shown family patterns of both, suggesting a genetic link. Other research suggests a genetic component to reading disabilities, with family studies showing that many individuals may inherit deficits in phonological awareness (e.g., ability to associate sounds with letters). Additional studies link reading disorders to a specific site on chromosome 6.

The importance of knowing that a child has ADHD and a reading problem is that both conditions be addressed so that the child is better able to cope with the academic and social demands of school.

August 1995

Q: Our son has always wanted to be in the military. Last fall he went to the local army recruiter to talk about signing up and entering the army when he graduates from high school in June of 1996. The recruiter said that he could not be considered for the military because he had taken Ritalin at one time. We were dumbfounded. Our son is on no medications now. He took Ritalin when he was in junior high, but no longer needed to take it after that. Why should a history of taking Ritalin exclude a well-qualified young man from entering the military?

A: We have received a number of inquiries lately about the military's policy on barring young people from the service who have taken Ritalin. We made inquiries with all branches of the military and learned the following:

• The military services have always had a policy of excluding recruits who must take medicine on a daily basis. For example, individuals with diabetes who take insulin cannot serve in the armed forces.
• The military does not have an official policy excluding recruits with a history of taking a particular medication.
• The Air Force appears to be "fussier" than the other services about admitting individuals who have taken medications for ADHD or depression.

There appears, however, to be an "unofficial" policy among some recruiters to "weed out" recruits who have taken medications associated with "mental illness," even if the individual no longer needs to take the medicine.

The military, however, does not have any policy which excludes otherwise qualified individuals from servicing simply because they have a history of taking a medication that alters behavior.

For students who have taken Ritalin who want to have a military career, the advice is not to mention any medication unless the recruit has to take it currently.

November 1995

Q: Recently when my son was diagnosed by a physician as having attention deficit disorder, this doctor also suggested that I might have ADD as well. Do adults have ADD? Are there tests for ADD in adults?

A: Adults certainly can have Attention Deficit Disorder, though their symptoms as adults may be different those displayed by children and adolescents. There are two rating scales that are available for determining whether or not an adult has symptoms of ADD. One was developed by Karen Wells and Keith Connors. It is really an adolescent rating scale called the ADHD Adolescent Self-Rating Scale, but it can be used for adults. Another checklist is the Wender Utah Research Instrument (WURI) in which individual respond to the questions as they are now and as they recall being in childhood. Wender has also developed a self-rating scale and a significant other rating scale to be used not as a diagnostic scale but as a method to manage therapy over time. Wender has a new book, which will be published shortly, on adult ADHD.

A group in Worcester, Massachusetts, headed by Russ Barkley, has developed an ADHD adult scale. This scale can be used by supervisors or fellow workers to rate an individual's symptoms on the job. The problem with this scale is that very few adults want their bosses or supervisors to know that they are being evaluated for ADD.

For more information, consult:

Barkley, R.A. (1990). Attention deficit and hyperactivity disorder: a handbook for diagnosis and treatment. New York: The Guilford Press.

Wender, P.H. Bupropion treatment of ADHD in adults. American Journal of Psychiatry, 147, 1018-1020.

Q: My 14 year-old with ADHD has no friends and is obviously miserable much of the time, especially during the school year. My heart aches for him. Is there anything I can do as a parent to help him live more happily with his condition?

A: Having attention deficit disorder is no fun, particularly because this disability affects so many aspects of a child's life. During the teen years, the social problems connected with ADD may become more obvious and cause the child more stress. Here are some general suggestions which may be of help to your son:

• Be sure that your son's school testing is up-to-date and that he is not experiencing a learning disability as well as ADHD. If he has a learning disability, he will need specially designed instruction to help him overcome his learning problems.
• Consider hiring a private tutor to work with your son on his homework and to communicate directly with his teachers. When a child is a teenager, it is often better for someone outside of the family to be the one to monitor homework.
• Whenever possible, try to ensure that your son is in school classes with low student-teacher ratios. Title I classes, for example, are sometimes small and instruction is more individualized.
• Look into the possibility of specific social skills training for your son. Your local Mental Health Center, YMCA or Boys and Girls Club may have an appropriate program that would benefit your son.
• Work with your son on using positive self-talk. Try to guide him away from making remarks in which he puts himself down.
• Consider having your son use a word processor or computer to do his school work. Word processing can be faster and easier to use than handwriting, especially if your son has any trouble with organization, grammar or spelling.
• Encourage your son to get involved in individualized, noncompetitive sports like bowling, walking, swimming, jogging, biking, karate. Unless your son is particularly athletic and enjoys team sports, team activities should probably be avoided.
• Encourage your son to get involved in social activities outside of school like scouts, church groups, or other youth organizations which help develop social skills and self-esteem.
• Don't be dismayed if your son wants to socialize with children who are younger than he is. Many ADD children have more in common with younger children. Your son can still develop valuable social skills from interaction with younger children.
• Encourage your son to volunteer to work with elderly people or with young children. Nursing homes and hospitals generally have well-run volunteer programs with good training for new volunteers.
• Look into interest groups in your area. Your son may benefit from joining a computer, ham radio, antique car or chess club, even if most of the members are adults. Your son might also enjoy some involvement with a political organization, theater group, or environmental club.
• Be sure to recognize and praise every positive social effort your son makes. Try to overlook messiness and lapses in responsibility if overall your son is making efforts to become a part of the larger community.

In general, your son will benefit from having as many positive social contacts as possible outside of school. In settings outside of school where there is less emphasis on attending and remaining completely quiet and still, your son is likely to shine. If he will not respond to suggestions that you make, enlist the help of a minister, adult friend, or youth leader who will personally invite your son to participate in an activity.

December 1995/January 1996

Q: Is a Medical evaluation required for a diagnosis of attention deficit disorder (ADD)?

A: In the school setting, if you are concerned about whether your child has ADD which is interfering with learning, it is not necessary to seek a medical evaluation to identify the ADD condition. Special education law does not require a school district to conduct a medical evaluation for the purpose of determining whether a child has Attention Deficit Disorder (ADD) unless the child is being considered for identification as having Other Health Impairment (OHI).

If a school district believes that a medical evaluation by a licensed physician is needed as part of the evaluation to determine whether a child suspected of having ADD meets the eligibility criteria of the other health impaired category or any other disability category in special education, the school district must ensure that this evaluation is conducted at no cost to the parents

If parents disagree with the district's decision not to seek a medical evaluation as part of the comprehensive assessment, the parent may seek a medical evaluation as an Independent Educational Evaluation (IEE). If the district refuses to pay for the medical evaluation, the parent may seek a reimbursement order from an impartial hearing officer by showing a medical evaluation was necessary and the evaluation the parent's acquired was appropriate.

Q: Do children outgrow ADHD?

A: It used to be assumed that children outgrew ADHD symptoms as they approached adolescence and became more physically mature, but recent research is finding that this assumption is incorrect. What appears to happen over time is that the symptoms of ADHD shift somewhat as the child matures, but the symptoms may continue to be present throughout adolescence and into adulthood.

In elementary age children, ADHD symptoms often consist of hyperactivity, impulsive or reckless play, and lack of attention except to highly interesting subjects or activities. As children enter adolescence, there may be less display of the physical hyperactivity. In the older child more evident symptoms may be restlessness, disorganization, distractibility, moodiness, and irritability. These symptoms may persist into adulthood.

It is becoming more and more common that when parents take their children to be evaluated for ADHD, they begin to recognize in themselves a history of childhood symptoms of ADD and some persistent symptoms that are characteristic of adults. The treatment of ADD in adults is a new area. In general, it appears that adults respond well to the stimulant medications that are used in children, but often adults require lower doses for successful management of symptoms.

February/March 1997

Q: Our third grade son has been identified as learning disabled in reading and is served by a resource teacher. The resource teacher recently suggested to me that our son might have attention deficit disorder. I was stunned. We had never noticed that our son was distractible, impulsive, or hyperactive at home. The teacher asked me to come in and observe my son so that I could see for myself. I spent a whole morning in his third grade class, and I could see that my son was noticeably agitated and nervous during reading class. He did seem to have trouble concentrating at that time. However, at other times during the morning, especially during oral discussion, he was quite attentive and participated well. Couldn't my son's distractibility during reading instruction be explained by his inability to read? His teacher is really pressing me to use medication and I am very reluctant to do so. Shouldn't his learning disabilities be addressed first before we turn to medication?

A: You have raised some good questions about your son's situation. If it is true that your son displays ADD-like symptoms only when he is confronted with reading tasks, it may well be the case that his learning disability is causing him to be anxious and distractible. He may fear being called on or he may be concerned about not being able to do his work.

At this point, it might be helpful for a neutral party like the principal or the school psychologist to do some observations, too. If their observations confirm that the ADD symptoms occur only during reading, then it may be wise to call an IEP meeting to take a look at why your son is so anxious during reading instruction. Perhaps he needs more classroom modifications or a different type of reading instruction.

If, on the other hand, neutral observers find that your son appears to be distractible throughout the school day and that this inattentiveness is interfering significantly with learning, then it might be worthwhile to have your son evaluated for attention deficit disorder.

It is not at all unusual for a child to have a specific learning disability and attention deficit disorder, but your instincts are correct. The learning disability should be addressed first. Often, when the learning disability is being handled well, the ADD symptoms subside and the child is better able to concentrate on all school subjects.

Medication for ADD symptoms is a last resort after many other things are tried first. Be cautious and proceed slowly to gather as much information as you can about your son's needs.

August/September 1997

Q: We have just been through a hellish summer with our 8 year old son who has ADHD. During the summer, our son's doctor likes to take him off Ritalin to allow him a drug holiday. Unfortunately when our son is off his medication, he immediately gets into trouble with peers and can't get along with his siblings. We tried sending our son to camp this summer and had to go and pick him up after one day because his behavior was so unmanageable. Our son was miserable and lonely because he could not seem to get along with others. Is there any way that our son could continue on medication in the summer? Are we expecting too much from medication?

A: When summer arrives and school ends, symptoms of attention deficit disorder don't disappear along with classes and homework assignments. Yet when the school year is over, physicians often suggest a "medication holiday" for children who take psychostimulants like Ritalin or Dexedrine. They believe the break allows for better appetites and reduces medication costs, or that the child deserves a chance to be "normal" after having to take medication during the school year.

Though there are good reasons to discontinue medication in the summer, your son obviously did not benefit from his drug holiday. For some children, medication may be necessary in order to help them function in some typical summer activities.

Here are some common activities when medication may have potential benefits in the summer:

Team Sports. Medication may help "spacy" children tune in and concentrate when involved in team sports. Staying on medication enables them to focus and learn new skills without undue humiliation. Also, players who stay alert and focused are less likely to be injured.

Camp. Attending camp is a demanding enterprise for a child who is impulsive and hyperactive. The unmedicated child may experience social disaster at camp. The close quarters and demanding routines of camp can be just as hard for kids with ADD to manage as school. Taking medication can help the child to concentrate on the schedule and respond appropriately to group activities. Sometimes the longer-release forms of medication are recommended for camp in order to minimize the number of treks to the camp infirmary each day.

Safety. Kids with ADD can be accident prone. Taking medication sometimes helps them to concentrate better and be more aware of safety precautions. Sports that entail at least a moderate degree of physical risk (horseback riding, water skiing, skateboarding, and skating) may be less dangerous when children with ADD use medication as well as appropriate safety gear.

New Drivers. The young ADD driver may still be inexperienced in defensive techniques. Wandering attention can lead to accidents and serious injuries. Using medication may reduce the likelihood of accidents caused by distractibility.

Summer Job. The summer job, possibly the first ever, can be a more successful experience when the worker listens, follows directions, and stays organized. Taking medication on work days can help the teenager with ADD to stay focused on job tasks.

Family Vacations. The family vacation is togetherness carried to the extreme. Restless, overactive and impulsive children may stretch parental reserves beyond limits. In addition, the inattentive and distractible child may miss sight-seeing highlights and other worthwhile activities. Continuing medication for these special times can help the child with ADD tolerate long car rides and days of sight-seeing so that the child and family can create good vacation memories.

Summer Visits. When the child of divorced parents spends vacation time with the noncustodial parent and stepfamilies, medication can be helpful. Often the noncustodial parent does not understand the need for medication and may resist its use. However, for the child's sake, it makes sense to use medication to avoid creating a summer of constant punishment and negativity from a parent who has limited visitation time with the child.

Social Activities. "Hanging out" and remaining in the social loop requires social savvy. Listening skills and being able to read interpersonal cues are parts of successful social communication and interaction. Medication can help the child who is having social interaction problems make and keep friends.

Summer Learning. Children who are receiving tutoring or attending summer school also may need medication. These learning pursuits require good concentration; when medication is used, concentration is easier and parents have to do less nagging.

Outings. Children with ADHD have trouble maneuvering in busy places, probably because of sensory overload and inadequate filtering abilities. Medication can be used before a day of shopping at the mall, a birthday party, or a trip to the zoo where there may be crowds and noisy surroundings.

Clearly, the demands of summer can be just as strenuous for children with ADD as the school year. Since your son has not done well without medication, explain the summer's events to your doctor and ask for assistance in planning medication use for times when it may be needed next summer.

June/July 1998

Q: Are there ways of treating attention deficit disorder that don't involve medication? I've been hearing a lot about homeopathic approaches, but I don't know if they are safe.

A: Medication is certainly not the only or even the preferred treatment for ADD. Almost every month some new method for treating attention deficits receives publicity. The difficulty from the parent's point-of-view is figuring out which methods are likely to be helpful and which are not useful or are actually harmful.

The first rule of thumb is to be highly skeptical of treatments that are supported exclusively by anecdotal evidence (e.g., success stories told by a few). For example, no hard data support the use of acupuncture for attention deficits. Biofeedback, homeopathic approaches, and hypnosis remain controversial and require further scientific scrutiny.

While further research may shed light on these strategies, it is very unlikely that any one form of treatment will benefit the very diverse group of children who have attentional difficulties. Future investigations need to examine subtypes of children with attention deficits to determine which are likely to benefit from a particular treatment. Children with academic problems and children with behavioral problems, may need different management, for example.

As a general rule, the strategies which are helpful in treating ADD without medication include individual and family counseling, behavior modification, and educational adjustments within the classroom.

End of the PLUK NEWS June/July 1999

Since August 21, 1999

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