Attention deficit hyperactivity disorder: overview and characteristics

ADHD, or attention deficit hyperactivity disorder, is a common childhood problem affecting as much as 3-5% of the school-age population. The core symptoms of ADHD are inattention, hyperactivity and impulsivity. Children with ADHD exhibit functional impairment across multiple settings and engage in disruptive behaviors, thus inviting criticism from adults and peer rejection. Psycho stimulant medication has been shown to be reasonably successful, but may produce significant side effects in a school-age child. A multi-component model of intervention consisting of pharmacological treatment in consonance with contingency management and cognitive behavior modification techniques seems to be the answer for this very baffling problem. For practitioners to have confidence in the expected outcomes, specific procedures to implement behavioral management in school classrooms must be scientifically replicated.

Chapter 1

Introduction

What is ADHD?

Impact of ADHD

Diagnostic Standards

Related Disorders and Comorbidity

Chapter 2

Review of literature

Multi-component Intervention

Comorbidity

Pharmacological Intervention

Chapter 3

Methodology

Chapter 4

Findings and results

Chapter 5

Conclusions and summary

Overview of ADHD

Introduction

What is ADHD? ADHD, or attention deficit hyperactivity disorder, is a common childhood problem. It is estimated that ADHD affects 3-5% of the school-age population, which means that as many as 3.5 million children could be affected nationwide.

ADHD is not a defined biological entity, but a collection of related symptoms and behaviors that interfere with an individual's capacity to regulate activity level (hyperactivity), inhibit behavior (impulsivity), and attend to tasks (inattention) in ways that are developmentally appropriate. The core symptoms of ADHD include a proneness to being easily distracted, an inability to sustain attention and concentration, inappropriate levels of activity, and impulsivity.

Children with ADHD often fail to pay close attention to details or make careless mistakes in schoolwork. They are unable to follow through on instructions and fail to complete tasks on time, do not seem to listen when spoken to directly, and have difficulty organizing tasks and activities. They often avoid tasks that require sustained mental effort. Further, a child with ADHD often loses things needed for home or school, is easily distracted, and is often forgetful. Hyperactive behavior includes inability to sit still, and thereby fidgeting or squirming when sitting, talking out of turn, and the like. Thus, children having ADHD

Overview of ADHD exhibit functional impairment across multiple settings, which include the home, the school, and peer relationships.

According to Barkley (1997), behavioral inhibition is the main underlying component of ADHD. This impairment negatively influences nonverbal working memory, internalization of speech, self-regulation of affect/motivation / arousal, and analysis-synthesis processes.

Impact of ADHD. Besides long-term adverse effects on academic and vocational performance, ADHD has been observed to negatively impact social-emotional development. The academic and social difficulties experienced by individuals with ADHD have far-reaching consequences. Interestingly, the core symptoms of ADHD such as inattention, hyperactivity and impulsivity are traits also seen in children unaffected by ADHD. Such a study can however be meaningful only when comparison is made between children at the same developmental level. For example, while it is perfectly normal for an active three-year to be impulsive or to interrupt others, similar behavior by an eight-year-old would be a cause for concern.

Diagnostic standards. The Diagnostic and Statistical Manual of Mental Disorders, fourth edition; DSM-IV (1997), American Psychological Association, lists the essential steps in diagnosing ADHD. The diagnosis of ADHD must be based on a number of observations

Overview of ADHD since no validated diagnostic text exists to confirm the clinical diagnosis of the disorder. Typically, parents and teachers complete questionnaires, children are observed at home and at school, psychological tests are administered, and a clinical interview of the child and the family is conducted.

The Conners Teacher's Rating Scale (CTRS), developed in 1969, is a behavioral rating scale that has been used extensively as an assessment tool in the identification of ADHD.

ADHD is also exhibited in forms where all the components of attention-deficit or hyperactive behavior may not be present. In the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III; American Psychological Association, 1980), two distinct diagnostic categories were used to distinguish inattentive behavior that occurred on its own (Attention Deficit Disorder without Hyperactivity; ADD/WO) from such behavior that occurred with overactivity (Attention Deficit Disorder with Hyperactivity; ADD/H).

The distinction between the two disorders was dropped in next revision of the manual, the DSM-III-R (APA, 1987), in which all three symptoms were subsumed into one category of Attention Deficit Hyperactivity Disorder (ADHD). A residual category, Undifferentiated Attention Deficit Disorder (UADD), was included in the DSM-III-R for children who exhibit pure inattentive behavior.

Overview of ADHD

The DSM-IV (APA, 1994) differentiates three subtypes within ADHD. The first subtype encompasses inattention, overactivity, and impulsiveness (ADHD-COM, combined subtype). The second subtype is characterized by the presence of inattentive behavior without hyperactivity or impulsiveness (ADHD-I; predominantly inattentive subtype). The third subtype is distinguished by symptoms of hyperactivity and impulsivity in the context of appropriate attentive behaviors (ADHD-HI, predominantly hyperactive-impulsive subtype).

Related Disorders and Comorbidity. There has been increasing awareness that children and adults having AD/HD often experience other difficulties and may meet criteria for one or more other psychiatric diagnoses. Comorbidity means having two or more diagnosable conditions at the same time.

Other psychiatric disorders comorbid with ADHD may mask or complicate the process of diagnosis and treatment. Disorders of depression, anxiety, learning disability, substance abuse, aggression and behavior disorders, and sleep disorders, have all been reported to occur in persons with ADD. Close biological relatives of children with ADHD are far more likely to have ADHD and other comorbid disorders mentioned above, than relatives of children without ADHD, a clear sign of the heritable nature of the disorder.

Conditions that commonly co-exist with AD/HD are:

Overview of ADHD

Anxiety

Depression

Sleep Problems

Oppositional Defiant Disorder (and Conduct Disorder)

Learning and communication differences

Obsessive-Compulsive Disorder

Enuresis

Drug abuse

Bipolar Disorder

Tourette's Disorder

Many forms of physical illness (such as asthma)

Comorbidity may also arise from the stresses and strains of having to live with ADHD. Many people with ADHD experience intense frustration in their efforts to learn, to work, and to get along with other people from their early years. They suffer ongoing criticism from teachers, parents, and peers. Years of such chronic sustained frustration may produce disorders that are comorbid to the ADHD. Other disorders may similarly develop reactively.

Review of Articles.

The present study is a review of 35 Primary Peer Reviewed Ulrich's referenced journal articles written within the last 5 years. Some of the articles reviewed relate to the question of the efficacy of a multi-component program in the treatment of ADHD; a few of the articles

Overview of ADHD examine the exclusive use of medication as a way to treat children with symptoms of ADHD, and raise the question of the ethics of subjecting school-age and preschool-age children to medication; disorders comorbid to ADHD, their diagnoses and treatment are also covered in some of the articles.

Multi-component intervention. In a study on the effectiveness of a multi-component intervention program for the children with ADHD (Miranda, Jesus & Soriano, 2002), the objective was to evaluate the efficacy of such an intervention program for treating ADHD.

Fifty children with ADHD participated in the study. The program was conducted by teachers in natural settings without disruption of the ongoing class routine. The teachers of 29 of the 50 students were trained in the use of behavior modification techniques, cognitive behavior strategies, and instructional management strategies. The other 21 students formed the control group. After the implementation of the program, parents observed that there were significant improvements in attention-related difficulties as also in behavioral problems. The results also showed increased academic scores, and enhanced classroom behaviors. The parents of the control group also perceived improvement on some internalizing problems, such as somatic problems and psychopathological disorders.

Overview of ADHD

Importantly, teachers perceived a reduction in hyperactive / impulsive behaviors and a significant increase in self-control. Considerable reduction in the disruptive behavior of these students in the classroom was also observed. The program increased the academic performance in mathematics and natural sciences of students in the experimental group, and was also effective in increasing the teachers' knowledge about how to respond to the educational needs of children with ADHD.

In a similar approach, the author (Reis, 2002), of an article entitled Attention Deficit Hyperactivity Disorder: Implications for the Classroom Teacher, has outlined several strategies for teachers to adopt towards students with ADHD. The strategies are based on the lines of contingency management and cognitive behavior management techniques, and can serve as a set of tools to help children with ADHD achieve better classroom performance.

Positive reinforcement. A student with ADHD is given to indulging in distracting behavior in the classroom, such as the clicking of a pen or the bending of a paper clip, as also to talking out of turn. The common approach of teachers is to meet such behavior with sternness or recrimination. When it was suggested that they try a new approach using positive verbal reinforcement (such as "Sensational effort, keep up the good work!"), teachers put this into practice and were amazed at the results. Students not only showed improved ability to complete tasks on time, they also exhibited reduced negative behavior. When students recognize that they can succeed at school-related tasks, they develop a better sense of self-

Overview of ADHD worth, feel reassured and are motivated to do better. Such a technique of positive reinforcement could be used to develop positive outcomes.

Bridging from previously taught concepts to new concepts. Students with ADHD, burdened with learning disabilities, need help with processing the material that is being taught. "By providing opportunities for students to look for connections between what they have learned and what they are now studying, students are better able to expand on the ideas that they are learning (Howell, Fox, & Morehead, 1993)."

Providing opportunities for students to apply new concepts to the reality of their daily lives. Students with ADHD tend to be very egocentric and are often unaware of important day-to-day events that are taking place in the world around them. When classroom teachers employed the technique of using focus journals to help them apply concepts that they studied, to the reality of their daily lives, results were very encouraging. Students could express their opinions on diverse topics, integrating what they learnt with their experiences.

Using cueing systems. Students with ADHD have difficulty sustaining attention on what is taught in the classroom. Teachers used the technique of visual cueing - through the use of ordinal words like first, second etc. - and also used overhead transparencies to reinforce the presentation of ideas with graphics. This strategy helped involve students beyond listening and reading, to the actual articulation of ideas based on the material that was being presented.

Overview of ADHD

The transparencies serve as a visual organizer that the student can refer to at a later point, to complete some assignment based on this learning.

Using contingency-based self-management techniques. This strategy usually involves a reward system that encourages students to keep track of their own behavior. In the contingency-based self-management system, the student evaluates his own behavior on a 5-point scale (0=unacceptable to 5=excellent) at the end of an agreed time period, and the points earned could be used for privileges, leading to positive behavioral changes.

Self-monitoring of attention to increase on-task behavior. Students with ADHD have difficulty in remaining on-task for extended periods of time. To overcome this, students are helped to use self-monitoring techniques in which they ask themselves questions like: "Was I paying attention?" And recording a "Yes" or a "No" on a score sheet every time they hear a tone on a tape recorder, to begin with. They begin to understand what triggers their off task behavior and thus learn to return to on task behaviors.

In an article titled: Are Students with ADHD More Stressful to Teach? The authors (Greene, Beszterczey, Katzenstein, Park, & Goring, 2002), research the question of whether students with ADHD contribute to increased levels of stress in teachers.

Overview of ADHD

Using the Index of Teaching Stress (ITS) as an instrument to assess a teacher's subjective level of stress and frustration (in response to teaching and interacting with a particular student), it was found that elementary school teachers rated students with ADHD as significantly more stressful to teach than their classmates without ADHD. Students with ADHD who also exhibited oppositional or aggressive behavior, were rated as significantly more stressful to teach than students with ADHD.

The article provides insights into the problems facing teachers as well as parents when having to deal with children having ADHD.

A review of twenty six experimental articles on interventions for treating and managing preschool children with ADHD is presented the article: Early Intervention for Preschool-Age Children with ADHD: A Literature Review (McGoey, Eckert & Dupaul, 2002).

Children with ADHD often are described as careless, disorganized, carefree, and non-reflective, even as preschoolers. They are frequently disruptive, non-compliant and defiant in response to commands and authority figures. Thus, even at preschool-age, children with ADHD are often at-risk for expulsion. Removal from preschool will mean a denial of opportunities to practice and develop pre-academic and social skills, and to be exposed to the structured setting of the classroom. In this review, the authors emphasize the need to take initiatives for early intervention in the case of children with ADHD. Failure to take

Overview of ADHD cognizance of this need with the urgency it deserves, could put children at risk in terms of escalation of the problems as they grow older.

The authors also suggest that practitioners should tailor the intervention to match the needs of the child. For example, while psychostimulant medication has been shown to be successful, it may produce significant side effects in a preschool-age child. School practitioners therefore should take an active role in monitoring the effects of medication. Also, systems should be in place, whereby immediate and consistent feedback is given, supplemented by age-appropriate rewards and procedures. Parents must be enabled to provide support and guidance to affected children, and need appropriate training. A well designed program incorporating the efforts of all concerned, could result in a potentially successful treatment approach.

The AAP Guideline on Treatment of Children with ADHD (Chatfield, 2002) reviews the clinical practice guideline for the treatment of school-aged children with ADHD issued by The Committee on Quality Improvement and the Subcommittee on Attention Deficit Hyperactivity Disorder of the American Academy of Pediatrics (AAP).

The guideline is intended for primary care physicians who have accurately established the diagnosis of ADHD, and focuses on the treatment of children with ADHD without major comorbidity.

Overview of ADHD

The following are the complete recommendations from the guideline:

1. Primary care physicians should foster a partnership with the family, the child having ADHD, teachers, psychologists and counselors. They should also provide resources and coordinate health and other services together with the development of child-specific treatment plans and goals, including plans for follow-up.

2. Development of three to six specific outcomes are recommended, such as improvements in relationships, self-esteem, and school performance, and a decrease in disruptive behaviors before developing a treatment plan. Because the core symptoms of ADHD (inattention, impulsivity, hyperactivity) impact the child's performance in many areas, the main focus of treatment should be to maximize function.

3. The physician should recommend stimulant medication Short-term efficacy in improving the core symptoms of ADHD and social and classroom behaviors, has been demonstrated. Stimulants comprise the first-line treatment and include methylphenidate or dextroamphetamine. Second-line treatment includes antidepressants (imipramine, desipramine) and bupropion.

If one stimulant does not work for a child at the highest feasible dose, the physician should recommend another.

Overview of ADHD

4. Physicians should evaluate the original diagnosis, use of all appropriate treatments, adherence to the treatment plan, and presence of coexisting conditions, when the selected management has not met target outcomes for a child with ADHD.

5. The physician should periodically provide a systematic follow-up for the child with ADHD. Monitoring should be directed to target outcomes and adverse effects by obtaining specific information from parents, teachers, and the child.

In addition to a system of follow-up office visits, the AAP recommends that primary care physicians be in continued communication with others involved, like parents, teachers and counselors). Behavior report cards and checklists are two methods of obtaining ongoing information.

Child-specific treatment plans, increased treatment options, and long-term efficacy are areas in which the AAP recommends further research.

In an article titled Tailored Psychosocial Treatments for ADHD: The Search for a Good Fit (Abikoff, 2001), the author advocates the need for drawing up a treatment plan that meets the needs of individual patients. Such a plan still remains elusive, given the complex design and needs assessment methodologies that are involved.

Overview of ADHD

Goal attainment scaling (GAS) to identify and evaluate outcome measures, hybrid efficacy-effectiveness designs to assess the impact of treatment preference on outcome, are two suggested techniques.

Goal attainment scaling recognizes that a focus on individualized target behaviors is a central theme of behavioral treatment, and provides for the identification, prioritization, and measurement of change in behaviors, domains, or both that are specifically relevant and important to the individual patient as well as to significant others. In effect, GAS is similar to some aspects of clinical practice wherein the clinician, in concert with the patient, integrates the problems and treatment goals into a treatment plan. These goals are periodically evaluated and changed as needed.

Treatment Preference is another tailoring strategy, which is especially relevant in the treatment of ADHD, where parents often have strong attitudes and beliefs regarding the use of medication as well as psychosocial treatments (MTA Cooperative Group, 1999a).

Hybrid study designs, in which parallel efficacy and effectiveness studies would be conducted concurrently, can be used to evaluate the impact of treatment preference on outcome (Abikoff, 1998, in press). The findings from hybrid designs can be especially relevant to clinical practice.

Overview of ADHD

The article: Teacher perceptions of the incidence and management of ADHD (Glass & Wegar, 2000), examines perceptions of 225 teachers on the incidence of ADHD among their students. It lists their views on the causes of the disorder and the most desirable and effective means of intervention. The research also shows that perceived incidence of ADHD greatly exceeds the accepted average level and may be related to environmental factors such as classroom size. There is found to be a tendency among teachers to ignore other possible methods of intervention, such as changes in classroom size and alternative teaching methods.

The author asserts that our society should not be too hasty to label children with a disorder which may lead to stigmatization and social exclusion, when in fact the undesirable behaviors may be lessened or eliminated given a change in environmental factors. In some cases, the problem may lie within the educational system, not within the child. Teachers who find they believe a large proportion of their students suffers from ADHD should evaluate their teaching methods and look for more flexible styles of instruction. There is also the issue of classroom size. As classroom size increases, the opportunity for behavior problems to appear within the classroom also increases. A reduction in classroom size will, again, benefit not only those who display behavior characteristic of ADHD, but also unaffected children.

Overview of ADHD

In the article: Parent-, Teacher-, and Self-Rated Motivational Styles in ADHD Subtypes, (Carlson, Booth, Misung, & Canu, 2002), motivational styles of children with different subtypes of ADHD were compared. In all, there are three ADHD diagnostic subtypes: ADHD, combined type (ADHD/C; both hyperactivity/impulsivity and inattention present to a significant extent); ADHD, predominantly inattentive type ADHD/IA; inattention significantly present, with sub-threshold hyperactivity/impulsivity); and ADHD, predominantly hyperactive/impulsive type (ADHD/HI; hyperactivity/impulsivity present, with sub-threshold inattention). Both ADHD/C and ADHD/IA subtypes have been found to show learning problems and motivational deficits. However, the two subtypes could have different patterns of motivational style.

The motivational styles of 25 children with attention deficit hyperactivity disorder, combined type (ADHD/C), 13 children with ADHD, inattentive type (ADHD/IA), and 25 non-diagnosed controls (NC) were compared using parent, teacher, and self-ratings. Both ADHD subtypes demonstrated motivational impairment characterized by a preference for easy work, less enjoyment of learning, less persistence, and a greater reliance on external than on internal standards to judge their performance relative to NC. Some motivational style differences between ADHD subtypes were also revealed, with the ADHD/C group more motivated by competitiveness and a desire to be perceived as superior to others and the ADHD/IA group less uncooperative and possibly more passive in their learning styles. When IQ was statistically controlled, these results were generally unchanged.

Overview of ADHD

In a study on boys with reading disabilities and/or ADHD: distinctions in early childhood, four groups of boys with reading disabilities only (RD only; n = 46), reading disabilities and ADHD (RD/ADHD; n = 16), ADHD only (n = 20), and a comparison group (n = 281) were observed. Differences on receptive and expressive language and temperament were investigated for ages 3 and 5.

Boys from the RD-only group performed worse on measures of receptive and expressive language. The results also indicated that boys from the RD/ADHD groups consistently performed worse on measures of receptive language and exhibited more behaviors indicative of an under-controlled temperament. Children with reading disabilities and ADHD experienced the most significant receptive language impairment. The authors therefore suggest that reading disabilities and ADHD frequently co-occur and are characterized by distinct developmental pathways.

Comorbidity. Among disorders comorbid with ADHD, sleep disturbance is one that is frequently encountered. In a study on sleep disturbances in adolescents exhibiting ADHD (Stein, Pat-Horenczyk, Blank, Dagan, Barak, & Gumpel 2002), 32 nonmedicated male adolescents diagnosed ADHD in childhood, 35 male adolescents similarly diagnosed who were receiving methylphenidate (MPH), and 77 control boys were evaluated. Non-medicated participants and controls did not differ in the severity of sleep disturbance. In contrast, the medicated participants demonstrated a significantly greater severity of sleep disturbance,

Overview of ADHD

Compared with the non-medicated participants and reported elevated levels of symptoms of ADHD, anxiety, and depression. Specific analyses showed that depressive symptoms contributed significantly to the degree of sleep disturbance when controlling for ADHD diagnosis and MPH treatment. The authors conclude that among adolescents with ADHD symptoms, the severity of symptoms of depression may contribute to the degree of sleep disturbance in addition to the effect of their primary disorder and MPH treatment.

In a study on EEG analysis of children with ADHD and comorbid reading disabilities, (Clarke, Barry, McCarthy, & Selikowitz, 2002),the study investigated electroencephalographic differences between two groups of children with attention deficit hyperactivity disorder, combined type, with reading disabilities (ADHD + RD) or without (ADHD) and typical control participants. Twenty participants were included in each group. All participants were between the ages of 8 and 12 years, and groups were matched on age and gender.

The electroencephalographic (EEG) was recorded during an eyes-closed resting condition from 21 monopolar derivations, which were clustered into nine regions for analysis. The EEGs were Fourier-transformed to provide absolute and relative power estimates for the delta, theta, alpha, and beta bands. Ratio coefficients were also calculated for the theta/alpha and theta/beta ratios. Compared with controls, the clinical groups demonstrated the increased slow-wave and reduced fast-wave activity commonly reported in the ADHD literature. The Overview of ADHD

ADHD + RD group had more relative theta, less relative alpha, and a higher theta/alpha ratio than the ADHD group. A number of hemispheric differences were also found in the delta and alpha bands. These results suggested that some of the EEG divergences found in the ADHD + RD group represent an electrophysiological component associated with the reading disability that is independent of the EEG divergences found in ADHD.

A study on seizure occurrence in children with ADHD (Williams, Schulz, & Griebel, 2001), examined the relationship between occurrence and risk for epilepsy in children diagnosed with ADHD.

Children with ADHD have an increased risk for oppositional behavioral disorders, learning disabilities, emotional disorders, and problems with social interaction, while children with epilepsy have higher rates of cognitive dysfunction, underachievement, and psychiatric disturbance than in the general population.

ADHD affects 3% to 5% of school-age children. Epilepsy affects 1% of the pediatric population and is the most common neurologic disorder in children, and febrile seizures occur in 2% to 5% of children. Childhood disorders that are highly associated with epilepsy include mental retardation (9-31%), autism (11-35%), and cerebral palsy (18-35%).(n7) In individuals with both mental retardation and cerebral palsy, epilepsy is present in 41% to Overview of ADHD

94% of the patients.(n8) Children with epilepsy also have a higher risk of being diagnosed with ADHD.

Results from the clinical sample suggested that the vast majority (93%) of children diagnosed with ADHD did not experience provoked or unprovoked seizures. Although the occurrence rate for epilepsy following the diagnosis of ADHD was slightly higher than expected, comorbid conditions could account for this difference. In the sample of children with ADHD, no children who were otherwise normal neurodevelopmentally, had epilepsy. In this study, ADHD did not appear to predispose a child to epilepsy in the initial 4 years following diagnosis and treatment. The temporal relationship of these two disorders, particularly the risk of ADHD being diagnosed in children with preexisting seizures, needs to be researched further.

Pharmacological intervention. The titration trial of the Multimodal Treatment Study of children with ADHD (MTA) is the largest placebo-controlled study to have been conducted on the efficacy of methylphenidate in the treatment of children with ADHD. In this controlled trial, 289 children aged 7-9 years received methylphenidate at 3 different dosages and placebo in a 4-week crossover study. Methylphenidate was found to be superior to placebo on all measures of behavior in school and at home. The data indicated that most children with ADHD improve on methylphenidate in the short-term and maintain their

Overview of ADHD improvement without intolerable adverse events for at least 13 months. Likewise, amphetamine, which is similar to methylphenidate in therapeutic activity, was found to have long-term efficacy in a placebo-controlled discontinuation trial Thus, the efficacy of methylphenidate in decreasing the symptoms of ADHD is well documented.

History. ADHD is not new, though our understanding of the disorder is still developing. Children were first noticed exhibiting inattentiveness, impulsivity, and hyperactivity in 1902. Since that time, the disorder has been given different names, including Minimal Brain Dysfunction or Minimal Brain Damage, and Hyperkinesis, The Hyperkinetic Reaction of Childhood or Hyperactivity. In 1980, the diagnosis of Attention Deficit Disorder was formally recognized in the Diagnostic and Statistical Manual, 3rd edition (DSM III), the official diagnostic manual of the American Psychiatric Association (APA).

In the early 1970's, ADHD has assumed many names over time from hyperkinesis to hyperactivity In the 1980s, the syndrome was labeled Attention Deficit Disorder, or ADD, which could exist with or without hyperactivity. This definition underlined the importance of the inattentiveness or attention deficit that is often, but not always, accompanied by hyperactivity. In the revised edition DSM-III-R, published in 1987, this disorder was officially named ADHD. DSM-IV recognizes various subtypes within ADHD, which include symptoms of both inattention and hyperactivity-impulsivity, signifying that there are some individuals in whom one or another pattern is predominant.

Overview of ADHD

There is no concrete medical test to diagnose ADHD, which often makes the diagnosis of ADHD subjective. It is therefore imperative that the diagnosis is done properly and by an appropriate and qualified person. The Diagnostic Statistical Manual (1997), lists six essential steps in diagnosing ADHD.

The first step is the parent interview. This should include presenting problems, developmental history, and family history.

The next step is interviewing the child about home, school, and social functioning.

Then behavior-rating scales describing home and school functioning are completed.

The fourth step is to obtain data from school. The data should include grades, achievement test scores, current placement, and other pertinent information.

Step five is the psychological testing for IQ and screening for a Learning Disability. This step may have been previously completed.

The final step is physical and/or neurological exams.

These are only suggested steps and are not universally followed. Professionals who can diagnose include psychiatrists, psychologists, pediatricians or physicians, and neurologists. Parents, teachers, and professionals may provide important information to help in the diagnosis.

Overview of ADHD

Methodology

1. In a study on Audio-visual hyperactivity disorder (AVHD), most of the clinical features of ADHD were observed in physicians during academic rounds when they chose to use PowerPoint (PP) presentations rather than simple slide shows (SSS). AVHD is a new behavioral disorder seen in people attempting to excel in presentations by projecting Word with PowerPoint.

Baseline data was collected by observing each presenter "at rest," before his or her presentation. Recovery time from visible dysfunction following the presentation (an ordeal), was continued to be observed. Overt operator physical signs (OOPS) of autonomic dysfunction (increased facial color, sweating, tremors, ticks, in-coordination, raised vocal volume and descent into infantile or foul language), were the measures observed.A Likert scale was used to rate the severity of the signs (0 = normal or nil, 5 = abnormal or extreme).

The findings were as follows: 99% of the presenters in the SSS group were 30 years and older, whereas in the PPP group, younger individuals outnumbered the older presenters more than 2:1.Thus, age was significantly associated with choice of presentation format. In the PPP group, the mean severity scores for the OOPS signs were much higher in the older group than in the younger group.

Overview of ADHD

In the PPP group, large numbers of the audience exhibited bizarre group behavior when there was laptop-projector incompatibility, hopeless resolution, calling up of wrong files and computer crashes. In 12% of the PPP presentations, more than 10 people were around the podium actively troubleshooting problems or counseling the presenter or both. In the SSS group, peer response was rare, but there was visible age and sex bias.

2.In the study on effectiveness of a School-Based Multi-component Program for the Treatment of Children with ADHD, the experimental group was composed of 29 students with ADHD, 26 boys (89.7%) and 3 girls (10.3%) ranging in age from 8 years 2 months to 9 years 1 month (M = 8 years 6 months). The control group was composed of 21 children with ADHD, 5 girls (23.8%) and 16 boys (76.2%) ranging in age from 8 years 5 months to 9 years months (M = 8 years 1 month). Most of the children were from families with a low socioeconomic status. There were an average of 25 students per class. They were third -- and fourth-grade students in primary education from 17 different state schools in Valencia (Spain).