ADHD

Dr. Bernstein specializes in helping children, teens and adults with ADHD. He also advises parents, teachers and others who are responsible for the health and development of young people with ADHD.

Treatments/Issues

Psychological Issues Often Seen in ADHD Children & Adolescents.

Low self-esteem is a common complication. This may result from chronic academic underachievement/failure, social difficulties, or behavioral problems. Affected children/adolescents report:

• lower expectations
• Anxiety or depression due to a feeling of "not fitting in"
• School absenteeism, an unwillingness to attempt new tasks, or resignation may be evident
• Loss of motivation/chronic failure and criticism may result in "learned helplessness" or in maladaptive, face-saving tactics.
• Alcohol and drug use along with disruptive behavior can also occur in time, particularly in the midst of longstanding academic and family problems.

Treatment Goals for Children & Adolescents with ADHD.

1. To enhance child's insight and parents' understanding of attention deficits and related problems.
2. To target most maladaptive behavioral traits for special insight and specific management.
3. To set reasonable and realistic expectations and goals.
4. To identify associated processing problems or learning disabilities that compromise school performance.
5. To identify complications and secondary effects such as social or emotional problems and family dysfunction.
6. To improve interactions with parents, teachers, and peers.
7. To strengthen communication between home and school.
8. To mobilize child/adolescent's strengths and resources.

ADHD Impairments

Cognitive

Mild deficits in intelligence (approximately 7-10 points).
Deficient achievement skills (range of 10-30 standard score points).
Learning disabilities: reading (8-39%), spelling (12-26%), math (12-33%), and handwriting (common but unstudied).
Poor sense of time inaccurate time estimation and reproduction.
Decreased nonverbal and verbal working memory and impaired planning ability.
Reduced sensitivity to errors.
Impairment in goal-directed behavioral creativity.

Language

Delayed onset of language (up to 35% but not consistent).
Speech impairments (10-54%).
Excessive conversational speech (commonplace), reduced speech to confrontation.
Poor organization and inefficient expression of ideas.
Impaired verbal problem solving.
Coexistence of central auditory processing disorder (minority but still uncertain).
Poor rule-governed behavior.
Delayed internalization of speech (up to 30% delay).
Diminished development of moral reasoning.

Adaptive functioning:

10-30 standard score points behind normal.
Motor development
Delayed motor coordination (up to 52%).
More neurological "soft" signs related to motor coordination and overflow movements.
Sluggish gross motor movements.


Emotion

Poor self regulation of emotion.
Greater problems with frustration tolerance.
Under active arousal system.

School Performance

Disruptive behavior (commonplace).
Underperforming in school relative to ability (commonplace).
Academic tutoring (up to 56%), Repeat a grade (30% or more).
Placed in one or more special education programs (30-40%).
School suspensions (up to 46%) expulsions (10-20%).
Failure to graduate high school (10-35%).

Task Performance

Poor persistence of effort/motivation.
Greater variability in responding.
Decreased performance/productivity under delayed rewards.
Greater problems when delays are imposed within the task and as they increase in duration.
Decline in performance as reinforcement changes from being continuous to intermittent.
Greater disruption when noncontingent consequences occur during the task.

Medical/Health risks

Greater proneness to accidental injuries (up to 57%).
Possible delay in growth during childhood.
Difficulties surrounding sleeping (up to 30-60%).
Greater driving risks: vehicular crashes and speeding tickets.

*From: Russell Barkley (1998), Attention Deficit Hyperactivity Disorder, A Handbook for Diagnosis and Treatment.

ADHD Interventions

*Note: The following list of strategies is representative and not meant to be exhaustive. Medical, Mental Health, and Educational professionals should be involved when such interventions are implemented for individuals with ADHD.

Children/Adolescents at School

• Ensure ongoing parent and school communication (get and stay involved).
• Break down large tasks into small tasks.
• Provide EMPATHY, EMPATHY, EMPATHY.
• Provide extra time for exams and projects.
• Pay attention to the emotions involved in the learning process.
• Repeat directions. Write down directions. Speak clear directions.
• Seat the ADHD child near the teacher's desk or wherever you are most of the time.
• Set limits and boundaries but not in a punitive way.
• Go for quality rather than quantity of homework.
• Outline, underline.
• Simplify instructions, choices, and scheduling.
• Make expectations explicit and emphasize success.
• Pay attention to "connectedness."
• Assist with drug therapies (staff supervised).
• Encourage student-mediated conflict resolution programs.

Children/Adolescents at Home

• Use reinforcement programs (not as bribery but for increased motivation).
• Provide EMPATHY, EMPATHY, EMPATHY.
• Consider drug therapies.
• Increase structure at home to help child/teen complete school work.
• Eliminate shaming and blaming, e.g. comparisons to non-ADHD siblings and peers.
• Develop clear expectations but also be willing to re-evaluate them in the face
• of changing situations or circumstances.

Treatment Strategies for Adults

• Seek individual counseling (for coexisting problems of depression, anxiety, low-self
• esteem, interpersonal problems, and disorganization).
• Seek family/marriage counseling (useful for resolving difficulties that affect
• relationships family members, spouses and partners). Non-ADHD spouses often report
• feeling confused, angry, and frustrated. Both patients and spouses need EMPATHY.
• Consider vocational counseling (to address impulsivity, inattention, careless.
• mistakes, disorganization, poor time management, and inconsistency that can interfere
• in job performance).
• Consider drug therapies.

Drug Treatments

An Overview of Drug Treatments Used for Individuals with ADHD.

Note: Medications do not teach individuals with ADHD anything. They merely increase the probabilities of these individuals displaying helpful behaviors already in their repertoire.

Stimulants

While not a panacea, stimulants are the treatment modality to date that most normalize inattentive, impulsive, and overactive behavior in children, adolescents and adults with ADHD. The five most commonly employed stimulants are Ritalin, Concerta, Dexedrine, Cylert, and Adderall (a combination of amphetamine and dextroamphetamine). Benefits of these medications are improved attention, impulse control, task-irrelevant activity, academic productivity and accuracy, handwriting, play, social conduct, and/or compliance to commands or rules. Side effects can include insomnia, decrease appetite, anxiety, sadness, tics or nervous movements, and dizziness.

Antidepressants

Antidepressants also play an important role as a treatment for individuals with ADHD, particularly for those who do not respond to stimulants. Tricyclic antidepressants are the most established non-stimulant agents used in the treatment of ADHD. These include Norpramin, Pamelor, and Tofranil. Selective Seritonon Reuptake Inhibitors are also used such as Prozac and Zoloft. It is important to note that in addition to addressing the core ADHD symptoms, antidepressants are also helpful in addressing comorbid symptoms (depression, anxiety, aggression, obsessive-compulsiveness) that may accompany ADHD. Antidepressants can be used along with stimulant medications in some cases.

Other Medication for the Treatment of ADHD

Other medications may provide hope for some ADHD patients who do not respond to more conventional therapies. These include antihypertensive agents such as Clonidine and Guanfacine (both of which may help to reduce aggression and impulsivity). For children with comorbid Tourette Syndrome or tic disorder, antipsychotic medications (e.g., Thioridazine, haloperidol) may help.

Medications Not Found Useful in the Treatment of ADHD

Fenfluramine, antihistamines, benzodiazepines, lithium, caffeine.

*Adapted From: Russell Barkley (1998), Attention Deficit Hyperactivity Disorder, A Handbook for Diagnosis and Treatment.

ADHD Research Findings

A National Perspective on Treatment Services for ADHD

What have been the important trends during the past decade in the type of care that children with ADHD typically receive in community settings? As you can imagine, this is a difficult and complicated question to address. The answer to this question is enormously important, however, for it will inform us about critical gaps in the provision of appropriate care that parents need to be aware of and that professionals and policy makers need to address.

A recent article from the Journal of the American Academy of Child and Adolescent Psychiatry (JAACP) provides the most comprehensive information yet available on this issue (Hoagwood, K. et al., (2000). Treatment services for children with ADHD: A national perspective. JAACP, 39, 198-206). There is a tremendous amount of interesting data presented in this paper, and I will try to highlight what seem to be the key findings below.

Data for this study come from two large national data bases that were established in the 1980s and updated annually since then. These data bases include representative samples of pediatricians, family physicians, and psychiatrists who provide records of patient visits, diagnoses, and services provided at each visit. (All information that could potentially identify any patient is removed so that records remain anonymous.) By comparing the kinds of services provided to children who had been identified as having a diagnosis of ADHD, and noting the types of services that these children received, trends in service provision over the recent past can be identified. This is because these data are based on thousands of community physicians who treated thousands of children and teens for ADHD. Even though the exact same physicians did not provide data in different years, the sample is large enough, and representative enough, to provide a good picture of what is actually going on.

Results

The results of this study are fascinating. Here are some of the key findings:

* ADHD is being identified at a greater rate

The percentage of visits where ADHD was identified has risen from .74% in 1989 to 1.9% in 1996. In addition, for physician visits where a mental health problem was identified as the primary reason for the visit, the percentage of children identified as having important attentional problems increased from 41% to 60% during this same period.

Note: Although these data indicate that ADHD is being identified at an increased rate, 2 points are important to keep in mind. First, these data tells us nothing about the accuracy of the diagnoses being made. Second, the 1.9% rate for physician- identified ADHD in 1996 is still substantially below actual prevalence rates that have been determined from a number of different studies. Overall, therefore, it may be that many instances of ADHD continue to go undiagnosed and untreated.

* Important changes are occurring in medication management

The percentage of visits for children with ADHD during which stimulants were prescribed increased from about 55% in 1989 to about 75% in 1996. During that time, there was a corresponding decline in the prescription of other medications to treat ADHD from about 15% in 1989 to about 7.5% in 1996.

Note: Because stimulant medication has been shown to be an effective treatment for most children with ADHD, the fact that more children are receiving it may reflect physicians' greater use of an empirically validated treatment approach. Unfortunately, no data is available on the quality and care of the medication treatment being practiced. As you may recall from the results of the MTA study (http://www.helpforadd.com/mta.htm) (i.e. the largest and most comprehensive treatment study of ADHD conducted to date) there is good reason to believe that children treated with medication in the community typically do not derive as much benefit as they might were careful and systematic procedures followed. I think it is encouraging that the rate of prescribing non-stimulant medications for children with ADHD has been cut dramatically.

The reason for this is that non-stimulant meds are typically less effective and less is known about their long-term safety. In the MTA study, however, almost none of the children with ADHD required medications other than stimulants to effectively manage their symptoms. This suggests that in many cases where other meds are prescribed, it may be because careful efforts to obtain the greatest possible benefits from stimulant medications were not used. Thus, the 7.5% figure may still reflect a greater use of alternative medications than is really necessary.

* There has been an important decline in important follow-up care for children with ADHD

Between 1989 and 1996, the percentage of visits where follow-up care was recommended declined from 91% to 75%. Thus, as recently as 1996, 25% of children identified as having ADHD are not scheduled for any follow-up care.

Note: I am very concerned about this finding. Because ADHD typically affects children over many years, one of the most important aspects of treatment is carefully monitoring a child's development over time. Just because a child's symptoms are being managed effectively at one point in time does not, unfortunately, mean that this will persist. Difficulties often emerge and require that adjustments to a child's treatment be made. It is virtually inconceivable that effective care could be provided in the absence of regular and periodic follow-ups. (The ADHD Monitoring System by Dr. David Rabiner can be an effective tool to help you monitor your child's progress and functioning over time, although this gets more difficult to do when children move into middle school and begin to have multiple teachers. If you do not have the monitoring system, just mail to: monitor@helpforadd.com.

The authors also examined how the type of services that children with ADHD received varied according to whether the provider was a pediatrician, family physician, or psychiatrist. These results are based on the most recently available data, which was from 1996.

The major findings here are that family physicians are more likely than the other providers to prescribe stimulant medication for treating ADHD (i.e. 95% vs. about 75% for pediatricians and psychiatrists). Conversely, family physicians were less likely to utilize any type of formalized diagnostic services in their visits with children identified as having ADHD (i.e. 33% vs. 64% for pediatricians and about 80% for psychiatrists). Family physicians were also less likely to recommend specific follow-up care (i.e. 46% vs. 79% for pediatricians and 89% for psychiatrists). Family physicians were also far less likely to provide any type of mental health/behavioral counseling services during visits - only 7% of the time - than were pediatricians (44%) or psychiatrists (67%).

Note: Although this study does not include any data that enables one to determine the appropriateness of services being provided, it does appear that the care a child receives depends greatly on the type of physician doing the treatment. In particular, although family physicians were more likely to prescribe stimulant medication, they were less likely to use any formalized diagnostic services, to provide any type of counseling, or to even recommend follow-up care. Even among pediatricians and psychiatrists, follow- up care often failed to be recommended, and it seems highly unlikely that this was because no such care would have been needed.

Overall, the authors conclude that in at least 50% of the cases, guidelines for care that have been recommended by the American Academy of Child and Adolescent Psychiatry for the treatment of ADHD are not being followed. This is not good news.

Barriers to Care

The final issue examined in this study concerned what primary care physicians (i.e. pediatricians and family physicians) perceived as the major obstacles to making mental health referrals they may have felt were needed for their patients with ADHD. Listed below are some of the barriers they identified along with the % of the physicians surveyed who reported each barrier:

• Barriers % reporting
• Lack of specialists 64%
• Difficulty getting appt. 64% Restrictions on who could be 48% referred to because of insurance company
• Authorization procedures 39%
• Financial disincentives 35%
• Burdensome paperwork 30%

The two most commonly reported barriers, mentioned by nearly two-thirds of participating physicians, reflect the perceived lack of clinicians who are specially trained to work with child behavior problems (e.g. child psychiatrists , child psychologists, developmental pediatricians). The other commonly reported barriers to care appear to be direct outgrowths of the restrictions placed on mental health treatment by many of today's health maintenance organizations. It is particularly striking to me that over one-third of the physicians surveyed reported that financial disincentives limited the number of mental health referrals they made for children. Although these data do not provide direct evidence that the quality of care that children receive as a result of HMO regulations has been compromised, it is certainly consistent with this hypothesis.

Summary and Implications

The most important implication of this study according to the authors is as follows:

"Although at least 2 professional associations have written guidelines or parameters of practice with these children (American Academy of Child and Adolescent Psychiatry and American Academy of Pediatrics), and though evidence-based reviews have been completed, these guidelines are not yet influencing care as delivered in real-world practices."

To this conclusion I would add that these data strongly suggest that changes in the insurance industry and the restrictions these changes have placed on many physicians is likely to be having a negative effect on the quality of care that many children with ADHD - as well as children with other types of emotional and behavioral problems - receive. To me, this highlights how important it is for parents to be as informed as possible about how ADHD can affect children's development and what are the best ways to promote the long-term success of children with ADHD.

Classroom Tips

Tips on the Classroom Management of Young Children with Attention Deficit Hyperactivity Disorder (ADHD).

As many caregivers and teachers know, ADHD can manifest itself in many forms in young children. Some children may appear highly overactive while others may seem "spacey". Often ADHD later appears entangled with several other problems such as learning disabilities, mood problems, or personality difficulties. ADHD features and their severity are also often unpredictable. Furthermore, the treatment for ADHD, continues to be a task of hard work and devotion.

There is no easy solution for the management of ADHD in the classroom, or at home for that matter. The bottom line is that the effectiveness of any treatment for this disorder at school depends upon the knowledge and the persistence of the school, individual teacher/caregiver, and parents.

Below are tips for the school management of children with ADHD. The following suggestions are intended for teachers of young children. The overall themes of structure, proactive measures, education, and encouragement pertain to all of the strategies. These tips represent a combination of several sources of information which are included at the end as references for more in-depth information.


1. Keep in mind that the diagnosis of ADHD in young children (particularly below age 5) is a complex process. It is definitely not up to the teacher to diagnose ADHD, but you can and should raise questions. Most importantly, inquire (tactfully) if the problem behaviors have been brought to the attention of a qualified health/mental health professional. The responsibility for seeing to this is the parents', not the teacher's, but the teacher can support the process.

2. Distinguish incompetence from noncompliance: If the child can't control his/her behavior it is not noncompliance, therefore, you can't blame.

3. Break down large tasks into small tasks. This is one of the most crucial of all instructional techniques for children with ADHD. Large tasks quickly overwhelm the child and he recoils with an emotional "I CAN'T DO THAT" kind of response. By breaking the task down into manageable parts, each component looking small enough to be do-able, the child can sidestep the emotion of being overwhelmed. In general, these kids can do a lot more than they think they can. By breaking tasks down, the teacher can let the child prove this to himself or herself. With small children this can be extremely helpful in avoiding tantrums born of anticipatory frustration. And with older children it can help them avoid the defeatist attitude that so often gets in their way. And it helps in many other ways, too. You should do it all the time.

4. Be sure to give positive feedback when appropriate. This is so important because children with ADHD often hear so much negative feedback.

5. Provide Extra Time for completing tasks: Permitting additional time can allow for the difficulties with attention common to many students with ADHD.

6. Build support for yourself. Being a teacher in a classroom where there are two or three kids with ADHD can be exhausting. Make sure you have the support of the parents. Consult when you have a problem (learning specialist, child psychologist, social worker, school psychologist, or pediatrician. Make sure the parents are working with you.

7. Know your limits. Don't be afraid to ask for help. You, as a teacher, cannot be expected to be an expert on ADHD. You should feel comfortable in asking for help when needed.

8. Ask the child what will help. These young people are often very intuitive. They can tell you how they can learn best if you ask them. They are often too embarrassed to volunteer the information, but try to sit down with the child individually and ask how he or she learns best. By far the best "expert" on how the child learns is the child himself or herself.

9. Remember that ADHD kids need structure. They need their environment to structure externally what they can't structure internally on their own. Make lists. Liberally give repetition, direction, set limits and structure.

10. Remember the emotional part of learning. These children need special help in finding enjoyment in the classroom, mastery instead of failure and frustration, excitement instead of boredom or fear. It is essential to pay attention to the emotions involved in the learning process.

11. Repeat directions. Write down directions. Speak directions. Let them hear things more than once.

12. Make frequent eye contact. You can "bring back" an ADHD child with eye contact. Do it often. A glance can retrieve a child from a daydream or give permission to ask a question of just give silent reassurance.

13. Seat the ADHD child near the teacher most of the time. This helps prevent drifting away..

14. Set limits and boundaries but not in a punitive way. Do it consistently, predictably, promptly, and plainly. DON'T get into complicated, lawyer-like discussions of fairness.

15. Have as predictable a schedule as possible. Post it on the blackboard or the child's desk. Refer to it often. If you are going to vary it, as most interesting teachers do, give lots of warning and preparation. Transitions and unannounced changes are very difficult for these children. They become discombobulated around them. Take special care to prepare for transitions well in advance. Announce what is going to happen, then give repeat warnings as the time approaches.

16. Allow for escape valve outlets such as leaving class for a moment. If this can be built into the rules of the classroom, it will allow the child to leave the room rather than "lose it," and in so doing begin to learn important tools of self-observation and self-modulation.

17. Monitor progress often. Children with ADHD benefit greatly from frequent feedback. It helps keep them on track and lets them know what is expected of them.

18. Use Time Out: Remove the child from opportunities for reinforcement. Be sure the "time out" environment is not reinforcing. This is important because ADHD children "heat up" and time out procedures provide an opportunity to "cool down".

19. Let yourself be playful, have fun, and be unconventional. Introduce novelty into the day. Children with ADHD love novelty. They respond to it with enthusiasm. It helps keep attention -- the kids' attention and yours as well. These children are full of life -- they love to play. And above all they hate being bored. So much of their "treatment" involves boring stuff like structure, schedules, lists, and rules, you want to show them that those things do not have to go hand in hand with being a boring person, a boring teacher, or running a boring classroom. Every once in a while, if you can let yourself be a little bit silly, that will help a lot.

20. Seek out and underscore success as much as possible. These kids live with so much failure, they need all the positive handling they can get. This point cannot be overemphasized: these children need and benefit from praise. They love encouragement. They drink it up and grow from it. And without it, they shrink and wither. Often the most devastating aspect of ADHD is not the ADHD itself, but the secondary damage done to self-esteem. So water these children well with encouragement and praise.

21. Memory is often a problem with these kids. Teach them little tricks-- cues, rhymes, code and the like -- can help a great deal to enhance memory.

22. Announce what you are going to say before you say it. Say it. Then review what you have said. Since many ADHD children learn better visually than by voice, if you can write what you're going to say as well as say it, that can be most helpful. This helps "glue" the ideas in place.

23. Simplify instructions. Simplify choices. Simplify scheduling. The simpler the verbiage the more likely it will be comprehended. And use colorful language. Like color coding, colorful language keeps attention.

24. Use feedback that helps the child become self-observant. Children with ADHD often have no idea how they come across or how they have been behaving. Be constructive. Ask questions like, "Do you know what you just did?" or "How do you think you might have said that differently?" or "Why do you think that other girl looked sad when you said what you said?" Ask questions that promote self-observation.

25. Make expectations explicit.

26. A point system is a possibility as part of a behavioral modification or reward system for younger children. Children with ADHD respond well to rewards and incentives.

27. If the child seems to have trouble reading social cues -- body language, tone of voice, timing and the like -- try discreetly to offer specific and explicit advice as a sort of social coaching. For example, say "Before you tell your story, ask to hear the other person's first," or, "Look at the other person when he's talking." Many children with ADHD are viewed as indifferent or selfish, when in fact they just haven't learned how to interact.

28. Make a game out of things. Motivation improves ADHD.

29. Separate pairs and trios, whole clusters even, that don't do well together.

30. Pay attention to "connectedness". If engaged, ADHD kids will less likely to tune out.

31. Enforce the home-to-school-to-home notebook. This can really help with the day-to-day parent-teacher communication and avoid the crisis meetings. It also helps with the frequent feedback these kids need.

32. Try to use daily progress reports.

33. Encourage a structure for self-reporting, self-monitoring. Brief exchanges at the end of class can help with this. Consider also timers, buzzers, etc.

34. Prepare for unstructured time. These kids need to know in advance what is going to happen so they can prepare for it internally. Spontaneous unstructured time can be over-stimulating.

35. Praise, stroke, approve, encourage, and nourish.

36. Explain and normalize the treatment the child receives to avoid stigma.

37. Meet with parents often. Avoid the pattern of just meeting around problems.

38. Recommend exercise. One of the best treatments for ADHD is exercise, preferably vigorous exercise. Exercise helps work off excess energy, helps focus attention, stimulates certain hormones and neurochemicals that are beneficial, and it is fun. If it is fun, the child will more likely continue to do it.

39. Always be on the lookout for sparkling moments. These kids are far more talented and gifted than they often seem. They are often highly creative. They tend to be resilient but still need much support.

The above information was adapted from the following resources:
Crutsinger, M.S. & Moore, D. ADD Quick Tips: Practical Ways to Manage Attention Deficit Disorder Successfully.
Nadeau, G. N.& Briggs, S. H. School Strategies for ADD Teens
Pfiffner, L. J. All About ADHD: The Complete Practical Guide for Classroom Teachers.
Reif, S. F.: How to Reach and Teach ADD/ADHD Children

For Further Information you may contact Dr. Jeffrey Bernstein and/or :
1). C.H.A.D.D National Office
499 Northwest 70th Avenue, Suite 101
Plantation, Florida 33317
(800) 233-4050
http://www.chadd.org

2). A.D.D. WAREHOUSE
(800) 233 - 9273
http://www.addwarehouse.com

When ADHD Combines with Depression

Depression Can Often Co-exist with AD/HD

Studies suggest that between 10-30 percent of children with AD/HD, and 47 percent of adults with AD/HD, also have depression. ADHD and depression can be a very harmful combination that interferes with effective coping for life's inevitable challenges. Both genetics and environment play a role. AD/HD children may not be invited to play at other children’s homes because of past difficulties with disruptive behavior or accidents, or may not be chosen to be on sports teams or to participate in games. They often may be ignored or teased by peers. This can squash the AD/HD child’s self-esteem, leaving the AD/HD child discouraged. About one in four may become clinically depressed. While all children have bad days where they feel down, depressed children may be down or irritable most days. Children with AD/HD and depression may also withdraw from others, stop doing things they once enjoyed, have trouble sleeping or sleep the day away, and lose their appetite. A big problem associated with depression is toxic thinking where individuals criticize themselves excessively ("I never do anything right!"), and talk about dying ("I wish I were dead"). Adults with ADHD may feel rejected and become depressed from being negatively treated by spouses, peers, and co-workers who are frustrated with them.

Based on my clinical experience, it gets complicated for the ADHD individual, parents, and loved ones when trying understand if problems are due to CHOOSE NOT or CANNOT (e.g., sustain attention, study in a linear, organized manner, and keep things in order). Too often ADHD children, teens, and adults are viewed as Choosing Not and they are negatively labeled as LAZY or IRRESPONSIBLE. This can contribute to depressed feelings. Individual counseling and family counseling can be of help for improving self-esteem, putting problems in perspective, gaining appropriate expectations, and arriving at new solutions. Negative self-talk needs to be challenged and countered with more positive thinking. In some cases, stimulants (such as Ritalin) can be combined safely with antidepressants such as fluoxetine (Prozac) — these children not only feel better but also function better at school. Newer antidepressants such as bupropion (Wellbutrin) and venlafaxine (Effexor) have been found effective in some individuals with AD/HD alone and may additionally benefit those individuals with both AD/HD and depression.



References/Related Reading

CHAAD FACT SHEETS at CHADD.org

The ADHD-Autism Connection : A Step Toward More Accurate Diagnoses and Effective Treatments
by Diane Kennedy, Rebecca Banks (2002)


When Your Child is Hyperactive: New Ways to Cope with ADHD in Your Family
by David B. Hawkins (2002)

Driven to Distraction : Recognizing and Coping With Attention Deficit Disorder from Childhood Through Adulthood
by Edward M. Hallowell, John J. Ratey (1994)

Pliszka, S.R. (1998). Comorbidity of Attention-Deficit/Hyperactivity Disorder with Psychiatric Disorder: An Overview. Journal of Clinical Psychiatry 59 (Supplement 7): 50-5B.

Wachtel, A. (1998). The Attention Deficit Answer Book. New York: Plume (Penguin).