Frequently Asked Questions
			Reflections and Strategies for Parents
			Resources

As a parent, loved one, or caregiver of a child or young adult, you may wonder just how much is known about ADHD, how most experts differentiate it from the normally rambunctious and impulsive behavior of a youngster, and why stimulants are often used to treat it. You may also have questions about the swirling controversy over ADHD and the outspoken critics who insist that it is all a fraud.

This guide presents some of the most frequently asked questions about ADHD and points readers to online resources and interviews with experts from various backgrounds that address these questions. This guide also contains a list of off-line and online resources, as well as links to federal organizations, that can help one to navigate the many issues surrounding ADHD. It is designed as a starting point for gathering some of this information and is not comprehensive or definitive.

This guide was developed by Simone Bloom Nathan, Ed.M. and Anne Kaplan, M.A., Media Education Consultants; and written by Roselle Kovitz McCleery, M.P.A., with input from Jessica Smith of FRONTLINE and the "Medicating Kids" viewers' guide advisory panel. Advisors include Lynne Yancy Christian, associate director of outreach for KCET, Los Angeles; Dr. Suzan Nolan, elementary school counselor; Jonathan Simmons, Ph.D., clinical psychologist; Suzanna V. Zimmet, M.D., child & adolescent psychiatrist. Special thanks to Suzanna V. Zimmet, M.D.

Q: What is ADHD and what do we know about it?

A: Most medical professionals classify ADHD as a neurodevelopmental or neurobehavioral disorder that emerges in childhood and may persist into adulthood. Symptoms that may indicate ADHD include high levels of activity, impulsivity and a short attention span in an excessive and developmentally inappropriate form that interferes with function.

Scientists have yet to pinpoint a cause for ADHD. Studies of families, twins and adopted children with ADHD suggest that there is a strong genetic component to the disorder, with various environment factors, such as in-utero exposure to cocaine, alcohol, cigarettes or other drugs, or early childhood exposure to lead or heavy metals also associated.

Read a summary of the National Institutes of Health Consensus Statement on ADHD.

Q: How is ADHD diagnosed?

A: As with many mental health and psychiatric disorders, there is no definitive biological test for ADHD--such as a blood test or a brain scan. This makes diagnosing the disorder difficult. For example, a child made extremely anxious by a traumatic or stressful situation may exhibit behaviors that could be mistaken for ADHD. In addition, ADHD is often found in children with other psychiatric disorders--including depression or a learning disorder--further complicating diagnosis.

A thorough diagnosis for ADHD should involve a team of professionals including a healthcare practitioner, speech therapist and occupational therapist, as well as input from parents and teachers. The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) provides diagnostic standards for ADHD.

View the diagnostic criteria for ADHD from DSM-IV.

Read "Steps in Making a Diagnosis" from the National Institute of Mental Health.

Q: Is ADHD over-diagnosed? Under-diagnosed?

A: ADHD diagnoses have increased dramatically in the 1990s. Critics argue that the steep increase in prescriptions for Ritalin and similar medications over the last decade indicate overuse, as well as a troubling trend to medicate children having difficulties in school. In addition, media attention over the rise in diagnosis and stimulant use may also have contributed to concerns of over-diagnosis.

Others attribute this rise to several factors, including heightened awareness of ADHD and improved diagnostic criteria, as well as changes to the Individuals with Disabilities Education Act (IDEA). Under IDEA, which officially recognized ADHD as a disorder in 1991, children with ADHD are entitled to extra time on tests, tutoring and less homework, all at the school's expense. Some argue that this change in educational law caused parents to more readily seek out services for their children, resulting in the steep increase in the diagnosis of ADHD and the prescription of stimulants to treat it.

Read expert opinions from FRONTLINE's interviews about the Ritalin explosion.

Q: Who is affected by ADHD?

A: According to the National Institutes of Mental Health (NIMH), 3 to 5 percent of school-age children have ADHD, with three times more boys than girls treated for the disorder [2]. ADHD often co-occurs with other problems, such as depressive and anxiety disorders, conduct disorder, drug abuse, or antisocial behavior. [3]

ADHD often continues into adolescence and adulthood. [4]

Q: Why are more boys diagnosed with ADHD than girls?

A: Neurodevelopmental disorders in general (such as mental retardation, autism, and language difficulties) are more prevalent in young boys. Boys with ADHD may be referred more often for treatment partially because they tend to present more frequently with disruptive behaviors such as hyperactivity and impulsivity. Girls with a predominantly inattentive type of ADHD may be under-diagnosed and dismissed as "daydreamers."

Q: How is ADHD Treated?

A: Opinions vary on the best way to treat ADHD. Treatment most often includes behavioral therapy and/or medications including Ritalin, Adderall, Concerta and Dexedrine.

In 1999, the National Institute of Mental Health published a study called the Multi-modal Treatment Study of ADHD (MTA), comparing the efficacy of four treatment programs: 1) medication management alone; 2) behavioral treatment alone; 3) a combination of both; and 4) routine community care. Study results revealed that on average, carefully monitored medication management with input from teachers was more effective than behavioral treatment. Further, "the combination of medication management and intensive behavioral treatments was also significantly superior to psychosocial treatment alone ... and families and teachers reported somewhat higher levels of consumer satisfaction for those treatments that included the behavioral therapy components. [5]"

A multimodal approach requires a team of caregivers and involves a variety of interventions including:

• parent training in diagnosis, treatment, and behavior management techniques, such as developing a clear and effective discipline system that rewards appropriate behaviors and uses specific strategies for misbehavior,

• an educational program for the child or young adult,

• counseling for the child and family, and

• medication, as appropriate.

Read a summary of the MTA.

Q: Why are stimulants used to treat ADHD and why are they controversial?

A: Use of stimulants may seem to be a counterintuitive approach to treating ADHD. Why, one might ask, doesn't this aggravate the symptoms of children with hyperactivity?

While scientists don't know exactly how stimulants work to control the effects of ADHD, evidence suggests that areas of the brain that manage levels of attention, impulse control, and activity are disregulated in those with symptoms associated with ADHD. Stimulants may help to regulate the neurochemistry in these areas of the brain, thereby increasing a child's ability to control or modulate their behavior.

The fact that stimulants don't cure ADHD, the lack of research on the long-term effect of stimulants, and the fear that these medications may lead to experimentation with addictive drugs such as cocaine, fuel concerns among critics of ADHD. They would argue that medicating children is potentially dangerous and sacrifices a child's natural personality and vitality for an easy fix to disciplinary problems.

Proponents argue that Ritalin and related prescriptions are among the most extensively studied medications and are quite safe when combined with close expert supervision to monitor possible side effects. They maintain that a failure to properly treat ADHD may exacerbate a problematic situation by delaying developmental progress and increasing the likelihood of depression, low self-esteem and social and educational problems. In addition, they argue that evidence suggests that proper treatment of ADHD, including the use of medication, can protect against or lower the risk of later substance abuse.

Read more about the stimulants used to treat ADHD in "What is Known About These Drugs?"

Q: Will medication change or suppress a child's personality?

A: With careful monitoring, many experts say that children who take stimulants to treat their ADHD should gain control of impulsive and/or inattentive behaviors and increase their focus without significant detriment to their natural vitality, spontaneity or personality. Infrequently, patients treated with stimulants become overly subdued. This and other more common side effects--including loss of appetite and difficulty sleeping--are usually corrected by adjusting the dosage and disappear altogether when medication is stopped.

Read this list of brand-name stimulants commonly used to treat ADHD, along with their generic names and manufacturers.

Q: What is the Individuals with Disabilities Education Act (IDEA)?

A: IDEA provides school districts with federal funding to support special education and related services to children who meet the eligibility criteria. To be eligible for evaluation at the school's expense, children suspected of suffering from ADHD, but not yet diagnosed, must also exhibit difficulty with schoolwork and behavior. The National Information Center for Children and Youth with Disabilities (NICHCY) offers State Resource Sheets with information about accessing disability-related resources in your area.

Read more about the federal laws and state policies regarding special accommodations available for students diagnosed with ADHD.

Q: Can the school force my child to take medication?

A: Before you decide whether to place your child on medication, it is crucial to have a comprehensive evaluation of your child completed by a team of qualified professionals. While teachers and other school officials may suggest that your child take medication, they cannot prescribe it or force you to place your child on it. Strict laws govern the prescription of stimulants. Some school systems also have guidelines for the appropriate level of school involvement, as well as privacy policies. Contact your state board of education or state mental health agency for more specific information in your area.

Q: What professionals can help evaluate a child suspected of having ADHD?

A: It is very important that a child thought to have ADHD be given a thorough and comprehensive evaluation that takes into account a full range of environmental and biological factors including family situation, educational setting, environmental stressors and medical history. A thorough assessment should be as multi-disciplinary as possible, including evaluation and input from parents, teachers, therapists and counselors, the family doctor, a speech and language specialist, an occupational therapist, a neuropsychologist and a learning disabilities specialist.

The following qualified professionals can serve as an entry-point to a thorough evaluation.

Child or adult psychiatrist

Diagnoses and treats mental and behavioral disorders

May diagnose, prescribe medication, and offer counseling and/or training

Pediatric or adult neurologist

Diagnoses and treats brain and nervous system disorders

May diagnose and prescribe medication

Pediatrician

Specializes in treating children

May diagnose and prescribe medication

Child or adult psychologist

Diagnoses behavioral disorders; provides counseling for children with mental and behavioral disorders

May diagnose, offer counseling and/or training

Licensed clinical social worker

Provides counseling for mental and behavioral disorders

May diagnose, offer counseling and/or training

School psychologists, social workers, or nurses

Evaluates children referred by teachers

May help parents find appropriate referrals for diagnosis and treatment

School counselors

Evaluates children referred by teachers

May help parents find appropriate referrals for diagnosis and treatment and provides support through skills training for families and support groups

Parents and caregivers often feel overwhelmed when it comes to deciding whether to give medication to their child for mental health reasons. The following questions are designed help you sort out what is best for your child within the context of what is known about ADHD and its treatment.

Some of these questions can be answered without consulting a medical expert. Others will require you to consult with professionals involved with your child, such as a teacher, counselor or physician.

• What behaviors am I concerned about?
• Are these behaviors manageable? At home? At school?
• Do these behaviors interfere with my child's functioning? At home? At school? Among friends?
• Am I concerned about my child's safety?
• What approaches or treatments are my child, my family and I comfortable with?
• What are the risks of medication?
• What are the risks of not treating my child?
• How do my child, my family and I feel about my child taking medication?

• Work with the team of professionals treating your child to develop a plan you can follow that is individualized to address your child's particular condition.
• Educate and involve the entire family about your child's ADHD. Make it clear that ADHD is a family issue.
• Provide clear, simple one-step instructions or directions for your child.
• Make eye contact when communicating with your child (if culturally appropriate), or otherwise be sure to gain their attention before speaking to them.
• Provide frequent prompts, reminders, rewards, praise, and corrections, while being sensitive to the balance of attention within the whole family.
• Help your child avoid, manage, and calm down from over-stimulating situations, perhaps by providing a more appropriate and focused stimulus.
• Encourage your child to engage in physical exercise to help channel some of his or her energy productively.
• Build your child's self-esteem by identifying and promoting your child's strengths.
• Help your child develop problem-solving skills by breaking down difficult tasks or situations into smaller, more manageable hurdles.
• Help your child develop social skills.
• Some children with ADHD may be the target or perpetrator of teasing or bullying. Check with your child's school to determine if the teachers and administrators support a zero-tolerance policy toward bullying. If not, advocate for one. (For tips on dealing with bullying, check out www.accesseric.org:81/resources/parent/bullying.html or www.pta.org/programs/sycsch.htm#Helping.)

The following books, organizations and web sites are provided to help you learn more about ADHD and the many services available to families and professionals coping with a diagnosis of ADHD. FRONTLINE does not endorse the views of any person or organization included on this list.

Arnold, L. Eugene, M.Ed., M.D.
Contemporary Diagnosis and Management of Attention-Deficit/Hyperactivity Disorder
Newtown, PA: Handbooks in Healthcare Co., 2000
Arnold offers an in-depth look at psychostimulant treatment for those affected by ADHD.

Barkley, Russell A., Ph.D.
Attention Deficit Hyperactivity Disorders: A Handbook for Diagnosis and Treatment
New York: Guilford, 2000
Barkley, a psychologist, provides readers with scientific, historical, and practical information about the disorder as well as advice and resources for dealing with it.

Diller, Lawrence H., M.D.
Running on Ritalin: A Physician Reflects on Children, Society, and Performance in a Pill
New York: Bantam Books, 1998
A pediatrician and family therapist, Diller takes a critical look at the research, trends, and practices surrounding the diagnosis and treatment of children with ADHD, particularly the use of Ritalin.

Fowler, Mary Cahill
Maybe You Know My Kid: A Parents' Guide to Identifying, Understanding and Helping Your Child with Attention-deficit Hyperactivity Disorder
New York: Birch Lane Press, 1999 (3rd Edition)
Written from a parent's perspective, Fowler lets readers in on her own journey with ADHD as well as providing historical and scientific background information and guidelines for dealing with the disorder.

Hallowell, Edward M., M.D. and John J. Ratey, M.D.
Driven to Distraction: Recognizing and Coping with Attention Deficit Disorder from Childhood through Adulthood
New York: Simon & Schuster, 1995
Written by two medical professionals who have ADD themselves, this book looks at ADD as both problematic and advantageous, provides a background information on the disorder as well as tips for dealing with those affected by ADHD.

Wilens, Timothy E., M.D.
Straight Talk about Psychiatric Medications for Kids
New York: Guilford Press, 1998
This book provides information on the types of medications that may be prescribed for children, why they are prescribed, and their impact on children's health, emotions and school performance.

Mental Health Organizations

Center for Mental Health Services (CMHS)
P.O. Box 42490
Washington, DC 2001
(800) 789-CMHS
www.mentalhealth.org

Part of the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services, CMHS helps states with treatment, rehabilitation and support services for people with mental illness, their families and communities.

CMHS's Knowledge Exchange Network (KEN), offers resources for consumers, professionals, children, providers, policy makers and the media, including information on federal, state, and local organizations dedicated to treating and preventing mental illness. KEN also has information on federal grants, conferences and other events.

National Institute of Mental Health (NIMH)
6001 Executive Boulevard, Rm. 8184, MSC 9663
Bethesda, MD 20892-9663
Voice (301) 443-4513
Fax (301) 443-4279
www.nimh.nih.gov

While primarily a research organization, the National Institute of Mental Health (NIMH) offers information about the symptoms, diagnosis and treatment of mental illnesses. Included are brochures and information sheets, reports, press releases, fact sheets, and other educational materials about ADHD and other mental illnesses, all of which are available online.

Disability and Special Education Resources

The National Information Center for Children and Youth with Disabilities (NICHCY)
P.O. Box 1492
Washington, DC 20013
(800) 695-0285
www.nichcy.org

NICHCY is the national information and referral center that provides information on disabilities and disability-related issues for families, educators, and other professionals focusing on children and youth, from birth to age 22. NICHCY publishes free, fact-filled newsletters, arranges workshops, and advises parents on the laws entitling children with disabilities to special education and other services. State resource sheets--also available online--will help you locate organizations and agencies within your state that address disability-related issues.

Federal Resource Center for Special Education (FRC)
Academy for Educational Development
1825 Connecticut Avenue NW
Washington, DC 20009
(202) 884-8215
(202) 884-8200 TTY
www.dssc.org/frc/index.htm

The FRC is a five-year contract between the Academy for Educational Development (AED), its partner, the National Association of State Directors of Special Education (NASDSE), and the U.S. Department of Education, Office of Special Education Programs (OSEP).

The FRC supports a nationwide technical assistance network to respond to the needs of students with disabilities, especially students from under-represented populations. The six Regional Resource Centers (RRCs) are specifically funded to assist state education agencies in the systemic improvement of education programs, practices and policies that affect children and youth with disabilities.

The Council for Exceptional Children (CEC)
1110 North Glebe Road, Suite 300, Arlington, VA 22201-5704
(888) CEC-SPED
TTY: (703) 264-9446
FAX: (703) 264-9494
www.cec.sped.org

The Council for Exceptional Children (CEC) is the largest international professional organization dedicated to improving educational outcomes for individuals with exceptionalities, students with disabilities and/or gifted students. CEC advocates for appropriate governmental policies, sets professional standards, provides continual professional development, advocates for under-served individuals with exceptionalities, and helps professionals obtain conditions and resources necessary for effective professional practice.

Advocacy and Support Groups

Children and Adults with Attention Deficit Disorders (CHADD)
8181 Professional Place Suite 201
Landover MD, 20785
1-800-233-4050
www.chadd.org

Formed in 1987 to improve the lives of individuals with ADHD and those who care for them, CHADD provides family support and advocacy, public and professional education and encouragement of scientific research on ADHD. Information on the location of local CHADD chapters is available on the web.

National Attention Deficit Disorder Association
(National A.D.D.A.)
1788 Second Street, Suite 200
Highland Park, IL 60035
(847) 432-ADDA
www.add.org

National A.D.D.A., founded in 1989, provides education, research and public advocacy on ADHD. It is especially focused on the needs of adults and young adults with ADD, such as work and career issues, legal issues, college and higher education and relationship issues. Information on the location of local ADDA chapters is available on the web.

Online Communities and Resources

www.adhd.com

This online community for families with ADHD includes resource directories, chat rooms, active message forums, news alerts, an e-mail newsletter, and more.

www.addhelpline.org

This nonprofit organization provides a chat room, newsletter, motivational and parenting tips, and columns by coaches who specialize in ADHD. Resources also include a weekly online support meeting. The group is neutral but informative about all approaches to managing and treating ADHD.

www.add.about.com

Run by a professional "guide," the ADD subject area covers just about everything, including fundamental FAQs as well as specific information on diverse ADD subjects--from attorneys and alternative medicines to SSI benefits and romance.

[1] "Attention Deficit Hyperactivity Disorder (ADHD): Questions and Answers," fact sheet, National Institute of Mental Health, March 2000.

[2] "Attention Deficit Hyperactivity Disorder (ADHD): Questions and Answers," fact sheet, National Institute of Mental Health, March 2000.

[3] "Science on our Minds 2001," National Institute of Mental Health, January 2001.

[4] "Attention Deficit Hyperactivity Disorder," National Institute of Health, publication number 96-3572, 1996.

[5] "Collaborative Study Finds Effective Treatment for Attention Deficit Hyperactivity Disorder," press release, National Institute of Mental Health, December 14, 1999.