ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD):
RECOMMENDATIONS

I.  ABILITY RECOMMENDATIONS

1. Interventions among children presenting with ADD / ADHD tend to focus on enhancing “conductor” functions with an emphasis on inhibition (“Just Stop” in pediatricneurology.com/anger.htm) including behavior, motor responses and arousal levels.  Individuals with similar ADD / ADHD presentations generally do not fail due to a limitation in their verbal or perceptual-motor abilities, but in a failure to adequately access those abilities.  As a result, interventions must necessarily focus on establishing the conditions for learning (rather than learning).  Specific interventions that are identified as standards of practice include: (a) have child sit in the front of the class, (b) establish good eye contact, (c) tap on the desk (or use other code) to bring the child back into focus, (d) alert child’s attention with phrases such as “This is important.”, (e) break down longer directions or instructions into simpler chunks, (f) check for comprehension (i.e., “What did I say?”), (g) underline the key words of direction and encourage strategies that limit stimuli or choices (i.e., mark  incorrect multiple-choice answers with an “x” first and, (i) provide physical outlets (i.e., out of their seats to hand out papers, use of a squeeze ball, etc.).
   
   
2. Compensatory strategies among children with ADD/ADHD tend to focus on enhancing “frontal lobe” contributions including: (a) maximization of external organization (i.e., keep desk clear of extraneous stimuli, arrange materials before beginning, organize desk, backpack, dresser, etc.) and (b) maximization of temporal organization including establishment of a well-defined schedule of activities (i.e., daily schedule, planner, etc.), expected time frames and a means of determining whether the schedule was accurate.

II. SKILL RECOMMENDATIONS

1. Children presenting with ADD / ADHD tend to experience lags in academic skills, not due to deficits in processing components, but rather due to chronic inattention with resulting gaps in knowledge. This knowledge gap tends to be most prominently expressed in “pyramid” subjects including math and history.  Interventions to address knowledge gaps often include provision of resource classes during which class materials for the day may be reviewed, parental or teacher reviews of class notes, requiring the child to re-write their notes from the day and requiring the child to write to study for a quiz/test.
   
   
2. Interventions among children with ADD / ADHD profiles tend to focus on utilization of “frontal lobe” strategies to compensate for weak areas.  Specific “frontal lobe” interventions within the school tend to focus on: (a) maximization of structure by using lined or grid paper to arrange columns, (b) maximization of temporal organization including establishment of a well-defined schedule of activities (i.e., homework time), expected time frames (i.e., child estimations of how long an assignment will take) and a means of determining whether the schedule was accurate (i.e., comparing child estimate with reality), (c) provision of clear and specific feedback regarding outcomes including marking all incorrect items with a different colored pencil, providing a second “clean” sheet (no writing on it) to redo failed items and requiring that the child check their work product against the answer sheet and (d) use of assignment books at school .  Development of a strategy to insure that the books and assignments are actually taken home is critical to any program.  The initial school to home program may need to be rather extensive with multiple safeguards.  The goal of the program is to reduce or fade any existing intervention so that the child will eventually assume responsibility for assignments.
   
   
3. A review of recommendations for children with ADD / ADHD may be found in the ADHD e-Book at pediatricneurology.com/schoolrx.htm.  In addition, “101 Tips for Teachers” may be found at allnaturalworld.biz/adhdtips.html.  This site represents the compilation of recommendations based on a multi-disciplinary study group.

III. COPING RESOURCE RECOMMENDATIONS

1. Children with ADD / ADHD presentations tend to react impulsively (live life as though it is 4 seconds long) based on emotions and hunches.  Interventions to address this impulsive style tend to include cognitive-behavioral therapy (CBT) strategies.  Specific cognitive-behavioral approach strategies include: (a) increasing self-observer functions by labeling emotions (i.e.., “it looks like you are feeling…”) (to assist in articulation of negative emotions), (b) providing cues/assistance in identification of antecedents or triggers for negative emotions (i.e., “when did you begin to feel that way?  where were you?, etc.) (to assist in identification of trigger zones or antecedents), (c) learning to identify that behaviors are choices (i.e., “what did you choose to do with those negative emotions?”) (to enhance higher level executive contributions to behavior), (d) assistance in identification of outcomes (i.e., “how did that work out for you?”) (to facilitate self-observation and utilization of feedback) and (e) assistance in recognition of the extent to which outcomes influenced triggers (“did those outcomes change the triggers?”) (to avoid vicious cycles in which behaviors have no impact on the triggers). 

IV. MEDICAL CONSIDERATIONS

1. Children with ADD / ADHD profiles tend to show benefits to psychostimulant medications (Adderall, Metadate, Concerta, etc.).  Recent studies have shown that the long-acting class of medications tends to be associated with significant benefits to attention/concentration while avoiding the roller coaster of blood levels associated with shorter-acting medications.  Families are encouraged to collect information on costs-benefits of medical interventions and to discuss treatment options with the child’s attending physician.
   
   
2. Children with ADHD or hyperactivity profiles often show some benefits to medications that “turn down the volume” of distress levels and associated activation. Use of alpha-adrenergic agonists (i.e., clonidine) have been found to be effective in the management of children with disinhibition syndromes.  Families are encouraged to collect information on costs-benefits of medical interventions and to discuss treatment options with the child’s attending physician.