The ADHD Book of Lists: A Practical Guide for Helping Children and Teens with Attention Deficit Disorders

Copyright © 2015 by Sandra F. Rief. All rights reserved.

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Library of Congress Cataloging-in-Publication Data

Rief, Sandra F.

The ADHD book of lists : a practical guide for helping children and teens with attention deficit disorders / Sandra F. Rief.—Second edition.

pages cm

Includes bibliographical references and index.

ISBN 978-1-118-93775-4 (paperback), ISBN 978-1-118-93777-8 (ePDF), ISBN 978-1-118-93776-1 (ePub)

1. Attention-deficit-disordered children—Education—United States—Handbooks, manuals, etc. 2. Hyperactive children—Education—United States—Handbooks, manuals, etc. I. Title.

LC4713.4.R53 2015

371.94—dc23

2015014589

Cover design: Wiley

Cover image: © Top Row (left to right): Thinkstock/Jupiterimages; Thinkstock/Andrei Malov Center Row (left to right): Thinkstock/AKIRA/amanaimagesRF; Thinkstock/Nanette_Grebe Bottom Row (left to right): iStockphoto.com/SanneBerg; Thinkstock/Jani Bryson; carlosalvarez/iStockphoto.com; Thinkstock/Fuse

SECOND EDITION

Acknowledgments

My deepest thanks and appreciation to the following people:

My precious, wonderful family (that has grown and blossomed since the first edition of this book): Itzik, Gil, Sharon, Daniella, Raquel, Jackie, Jason, Maya, Jonah, Ezra, Ariel, and Anna. I love you all so much.

All of my former students and the other children who have touched my heart and challenged me throughout the years to keep learning and seeking the best ways to help them

The special families who have shared with me their struggles and triumphs and have been such an inspiration to me

All the outstanding, dedicated educators I have had the great fortune to work with and meet over the years; thank you for sharing with me your creative strategies, ideas, and insights

The extraordinary parents (especially the wonderful volunteers in CHADD and other organizations worldwide) whose tireless efforts have raised awareness about ADHD and as a result, significantly improved the care and education of our children

Tracy Gallagher, my wonderful editor at Jossey-Bass, for your help and guidance on this new edition, as well as the rest of the J-B team; it is always such a pleasure to work with you

All of the researchers and practitioners in the different fields dedicated to helping children and families with ADHD, LD, and other disabilities, from whom I have learned so much

Ariel Rief, my wonderful son, illustrator of this book and the 2003 first edition, who always takes the time to help me and others

Itzik Rief, Julie Heimburge, Abigail Roldan, Janet Poulos, Amanda Gerber, Alison Finberg, and Earl Chen for creating and sharing some of the charts found in the appendix of this book

About the Author

Sandra Rief, MA, is an internationally known speaker, educational consultant, and author who specializes in practical and effective strategies for helping students with ADHD and learning disabilities (LD) succeed in school. She has written several books and presented numerous seminars, workshops, and keynote speeches nationally and internationally on this topic. Sandra has trained thousands of teachers in the United States and throughout the world on best practices for helping students with ADHD and has worked with many schools in their efforts to provide interventions and supports for students with learning, attention, and behavioral challenges.

Among some of the books she has authored (published by Jossey-Bass/Wiley) are How to Reach & Teach Children with ADD/ADHD: Practical Techniques, Strategies, and Interventions, Second Edition (2005); The ADD/ADHD Checklist: An Easy Reference for Parents and Teachers, Second Edition (2008); The Dyslexia Checklist: A Practical Reference for Parents and Teachers (coauthored with J. Stern, 2010); How to Reach & Teach All Children in the Inclusive Classroom: Practical Strategies, Lessons, and Activities, Second Edition (coauthored with J. Heimburge, 2006); and How to Reach & Teach All Children through Balanced Literacy (coauthored with J. Heimburge, 2007). Sandra also wrote these laminated guides (published by National Professional Resources, Inc.): ADHD & LD: Classroom Strategies at Your Fingertips (2009); Dyslexia: Strategies, Supports & Interventions (2010); Section 504: Classroom Accommodations (2010); and Executive Function: Practical Applications in the Classroom (2015).

Sandra developed and presented these acclaimed educational DVDs: ADHD & LD: Powerful Teaching Strategies and Accommodations (with RTI); How to Help Your Child Succeed in School: Strategies and Guidance for Parents of Children with ADHD and/or Learning Disabilities; ADHD: Inclusive Instruction and Collaborative Practices; and together with Linda Fisher and Nancy Fetzer, Successful Classrooms: Effective Teaching Strategies for Raising Achievement in Reading and Writing and Successful Schools: How to Raise Achievement & Support At-Risk Students.

Sandra is a former award-winning special education teacher with San Diego City Schools (California Resource Specialist of the Year), with a few decades of experience teaching in public schools. Presently, Sandra is an instructor for continuing education and distance learning courses offered through a few universities on instructional and behavioral strategies and interventions for reaching and teaching students with ADHD, LD, and other mild to moderate disabilities. She received her BA and MA degrees from the University of Illinois. For more information, visit her website at www.sandrarief.com.

About This Book

Every elementary school teacher most likely has at least one or two students with ADHD in his or her classroom. Middle and high school teachers may teach several students who have ADHD each day. It is important that educators understand the nature of the disorder, its impact on school functioning, and the most effective strategies for reaching and teaching these students.

To make well-informed decisions on how to best help their son or daughter, parents of children with ADHD must learn as much as they can about the disorder and research-validated treatments. They must also be equipped with the skills and strategies that help in managing their child's ADHD symptoms and often challenging behaviors.

The purpose of this book is to help parents and teachers gain insights into and better understanding of children and teenagers with ADHD as well as the kinds of intervention, practical strategies, and supports that will help them succeed. Although the book is written primarily for parents and educators, many others (physicians, mental health professionals, relatives, for example) should find the information and tools useful as well.

I have had the privilege of presenting seminars and speaking at conferences on ADHD in several countries (Brazil, Canada, Costa Rica, Israel, Colombia, South Africa, Spain, Guatemala, China, Singapore, Philippines, Iceland, and Sweden). ADHD most definitely is not just an American disorder; it is one that significantly affects the lives of children and families in countries around the world. Teachers, parents, and clinicians everywhere share the same challenges and frustrations in getting the proper treatment and education for children with ADHD and are seeking the best strategies and interventions that will help them. Fortunately, our understanding of ADHD keeps developing over time, and there is much that can be done to help children, teens, and adults with this disorder.

This new edition of my original ADHD Book of Lists, first published in 2003, has been completely updated with the most current information on the disorder and interventions. I also included additional new lists on various topics: managing children's difficulty with emotional control and regulation, working memory weaknesses and supports, Response to Intervention (RTI), ADHD coaching, ADHD and gifted (dual exceptionalities), and research-based instructional approaches and intervention resources.

This book contains ninety lists and is designed to be an easy-to-use reference; it also has an appendix full of management forms, charts, and tools. The appendix contains illustrations that can be used as visual cues and prompts of behavioral expectations or other graphic reminders. Appendix materials are also available online at www.wiley.com/go/adhdbol2. The password is the last five digits of the book's ISBN, which is 37754. By accessing the appendix materials online, the illustrations are able to be printed in larger size and some charts can be customized to your needs.

Throughout the book are also numerous resources you may wish to explore for further ideas and information.

The lists are divided into seven sections.

Section 1 provides information about the disorder (the neurobiological differences, likely causes, executive function impairment) as well as diagnosis, treatment, common coexisting conditions, and more. We have learned a lot in the twelve years since the first edition of this book. The information in this section explains our new understanding of ADHD, which has evolved as a result of the tremendous amount of brain research and genetic studies in the past decade.

Section 2 addresses behavior: preventing or minimizing behavioral problems at home, in the classroom, and other environments; behavior-modification techniques and incentive systems (group and individual); increasing children's focused attention, on-task behavior, listening, and compliance; managing challenging behaviors (impulsive, hyperactive, argumentative, oppositional); and social skills interventions.

Section 3 explains the difference between accommodations and modifications and shares lots of instructional strategies teachers can implement to engage the attention and participation of students, keep them on task, increase work production, accommodate learning style differences and sensory needs, and more.

Section 4 provides numerous practical strategies for parents and teachers to help children and teens with executive function impairments. There are lists that explain working memory weaknesses and the difficulties that students with ADHD commonly have with organization, time management, and homework. There are hundreds of strategies and recommended resources provided in these lists that address how to improve those important skills and compensate for weaknesses.

Section 5 describes the common academic weaknesses that students with ADHD (and learning disabilities) often have in reading, math, and written language. The lists throughout this section provide numerous practical strategies, supports, accommodations, and resources for building skills and circumventing weaknesses in reading, writing, and mathematics.

Section 6 addresses the educational rights of students with ADHD under federal laws IDEA and Section 504. Since the first edition of this book, there have been significant changes in these laws as per the reauthorization of IDEA by Congress in 2004 and the 2008 amendments that were made to the Americans with Disabilities Act (ADA), which affected, in turn, Section 504. Lists throughout section 6 explain these laws, the special education process and IEPs, the difference between 504 plans and IEPs, and systems of support that parents and teachers should find within their schools (RTI and others).

Section 7 covers a lot of other important topics necessary for the success of children and teens with ADHD: teamwork, collaboration, and communication; advocacy; the benefits of exercise, outdoor green time, music, mindfulness, and other healthy, fun, and therapeutic ways to help manage ADHD; a very extensive list of websites and resources; and much more.

It is my hope that readers will find this book to be a valuable resource in teaching, parenting, or treating children and teens with ADHD—one that you will refer to frequently. I do want to point out that I am aware that with so many strategies and suggestions provided throughout this book, it can be overwhelming. Parents and teachers are advised that it is best to choose a few reasonable and doable new strategies or interventions and then evaluate how well they seem to be working. Introduce other strategies into your repertoire a few at a time as you feel comfortable doing so. Trying to implement too many new things at once is hard to follow through with and is often counterproductive. Fortunately, there are always things to try if something doesn't work or stops working. There is always plan B, C, D, and so forth.

I wish you success and all the best. Please feel free to contact me at www.sandrarief.com.

A Note from the Author

The official term for the disorder at this time is attention-deficit/hyperactivity disorder, which is abbreviated as ADHD. You may see it in print as ADHD or AD/HD (with a slash). The term ADD is also used by many people either interchangeably with ADHD or when referring to individuals with the predominantly inattentive presentation or type of the disorder—those who do not have the H characteristics associated with hyperactivity.

Throughout this book, I use only ADHD, which is inclusive of all types or presentations of the disorder:

Predominantly inattentive

Predominantly hyperactive-impulsive

Combined (inattentive and hyperactive-impulsive)

See List 1.3 for a thorough explanation of these three presentations of ADHD.

For your convenience, I have provided numerous cross-references to related lists throughout the book. These are indicated by the list numbers in parentheses following individual items or topics. You will find that these cross-references are useful for finding related topics in The ADHD Book of Lists.

In memory of my beloved son, Benjamin, and to all of the children who face struggles in their young lives each day with loving, trusting hearts, hope, and courage

Section 1

Understanding, Diagnosing, and Treating ADHD

Contents

1.1 ADHD: Definitions and Descriptions

1.2 ADHD and the Executive Functions

1.3 The Official Diagnostic Criteria for ADHD (DSM-5)

1.4 What Is Currently Known and Unknown about ADHD

1.5 Signs and Symptoms of ADHD

1.6 ADHD Statistics: Prevalence and Risk Factors

1.7 Causes of ADHD

1.8 ADHD and Coexisting Disorders

1.9 ADHD Look-Alikes

1.10 Positive Traits and Strengths

1.11 Developmental Course of ADHD across the Life Span

1.12 Girls with ADHD

1.13 ADHD and Its Effects on the Family

1.14 Pursuing an Evaluation for ADHD: Tips for Parents

1.15 Diagnosing ADHD in Children and Teens

1.16 The School's Role and Responsibilities in the Diagnosis of ADHD

1.17 If You Suspect a Student Has ADHD: Recommendations for Teachers and Other School Personnel

1.18 School-Based Assessment for ADHD

1.19 Multimodal Treatment for ADHD

1.20 Medication Treatment for Managing ADHD

1.21 If a Child or Teen Is Taking Medication: Advice for School Staff and Parents

1.22 Behavior Therapy (Psychosocial Interventions) for Managing ADHD

1.23 Alternative and Complementary Treatments

Please note that a lot of the content of these lists has been adapted and updated from my other books, published by Jossey-Bass/Wiley, which you may be interested in exploring for further information, tools, and strategies:

Rief, S. (2003). The ADHD book of lists: A practical guide for helping children and teens with attention deficit disorders. San Francisco: Jossey-Bass.

Rief, S. (2005). How to reach & teach children with ADD/ADHD: Practical techniques, strategies and interventions (2nd ed.). San Francisco: Jossey-Bass.

Rief, S. (2008). The ADD/ADHD checklist: A practical reference for parents and teachers (2nd ed.). San Francisco: Jossey-Bass.

1.1 ADHD: Definitions and Descriptions

Some of the definitions and descriptions of attention-deficit/hyperactivity disorder (ADHD) have been changed or refined as a result of all that we have learned in recent years from neuroscience, brain imaging, and clinical studies, and likely will continue to do so in the future. Until recently, ADHD was classified as a neurobehavioral disorder, characterized by the three core symptoms of inattention, impulsivity, and sometimes hyperactivity.

It is now recognized that ADHD is a far more complex disorder, involving impairment in a whole range of abilities related to self-regulation and executive functioning (Lists 1.2, 1.4). This more recent understanding of ADHD is reflected in some of the following descriptions, as shared by leading ADHD authorities Dr. Russell A. Barkley, Dr. Thomas E. Brown, Dr. Sam Goldstein, and others. Some of the following descriptions are from Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD), as well as the National Institute of Mental Health (NIMH), and other expert sources.

What Is ADHD?

ADHD (attention-deficit/hyperactivity disorder) is the term now used for a condition that has had several names over the past hundred years.

ADHD is a chronic neurobiological disorder affecting children and adults that causes difficulty with self-control and goal-directed behavior.

ADHD is one of the most common and most studied neurodevelopmental disorders of childhood. It is usually first diagnosed in childhood or adolescence and often lasts into adulthood.

ADHD is a neurobiological disorder characterized by chronic and developmentally inappropriate degrees of inattention, impulsivity, and in some cases hyperactivity, and is so pervasive and persistent that it interferes with a person's daily life at home, school, work, or other settings

ADHD is a disorder of self-regulation and executive functions.

ADHD is a brain-based disorder involving a wide range of executive dysfunctions that arises out of differences in the central nervous system—both in structural and neurochemical areas.

ADHD is a neurobiological disorder characterized by a pattern of behavior, present in multiple settings, that can result in performance issues in social, educational, or work environments.

ADHD represents a condition that leads individuals to fall to the bottom of a normal distribution in their capacity to demonstrate and develop self-control and self-regulatory skills.

ADHD is a developmental impairment of the brain's self-management system. It involves a wide range of executive functions linked to complex brain operations that are not limited to observable behaviors.

ADHD is a performance disorder—a problem of being able to produce or act on what one knows.

ADHD is a neurological inefficiency in the area of the brain that controls impulses and is the center of executive functions.

ADHD is a dimensional disorder of human behaviors that all people exhibit at times to certain degrees. Those with ADHD display the symptoms to a significant degree that is maladaptive and developmentally inappropriate compared to others at that age.

ADHD is a common although highly varied condition. One element for this variation is the frequent co-occurrence of other conditions.

ADHD is a medical condition caused predominantly by genetic factors that result in certain neurological differences. It comes in various forms.

Lists throughout this book, particularly Lists 1.2, 1.4, and 1.7, will clarify what these definitions mean and explain our understanding at this time about ADHD, executive functions, and the neurodevelopmental brain differences previously referred to.

Descriptions of ADHD: Explaining It to Children

As noted, ADHD is a disorder of executive functions. Of the executive functions (List 1.2), the primary one is inhibition—a person's behavioral brakes. Poor inhibition is seen in the inability to resist or ignore distractions (inattention), to delay gratification, be able to stop long enough to think about possible consequences before acting or reacting (impulsivity), and slow down or stop physical activity (hyperactivity).

One way to explain ADHD to children is through the analogy of a race car with poor brakes.

Dr. Edward (Ned) Hallowell (n.d.) tells children with ADHD: You have an amazing brain with a Ferrari engine. It's very powerful. You are a champion in the making. But there's one problem . . . you have bicycle brakes. He then explains that he is a brake specialist and together they are going to strengthen those brakes so in time the child will be able to slow down or stop when he or she needs to and win races instead of spinning out at the curve.

Dr. Patricia Quinn and Judith Stern (2009) tell children to imagine a sleek sports car speeding around the curves of a track. But, the race car has no brakes. It can't slow down or stop when it wants to and may get off the track or even crash. They explain that with ADHD, they may be like that racing car—with a good engine (lots of thinking power), a strong body, but brakes that don't work very well. The poor brakes cause problems being able to keep still, stay focused, or stop themselves from doing something, even when they know they should.

Sources and Resources

American Academy of Child & Adolescent Psychiatry. (n.d.). Frequently asked questions. ADHD Resource Center. Retrieved from www.aacap.org/cs/ADHD.ResourceCenter/adhd_faqs

Barkley, Russell A. (2005). ADHD and the nature of self-control. New York: Guilford Press.

Barkley, Russell A. (2013). Taking charge of ADHD: The complete authoritative guide for parents (3rd ed.). New York: Guilford Press.

Brown, Thomas E. (2000). Attention deficit disorders and co-morbidities in children, adolescents, and adults. Washington, DC: American Psychiatric Press.

Brown, Thomas E. (2013). A new understanding of ADHD in children and adults. London: Routledge.

Centers for Disease Control and Prevention. (n.d.). Attention-deficit/hyperactivity disorder. Retrieved from www.cdc.gov/ncbddd/adhd/

Hallowell, Ned. (n.d.). Explaining ADHD to a child. Kids in the House: The Ultimate Parenting Resource. Retrieved from www.kidsinthehouse.com/special-needs/add-and-adhd/parenting-tips/explaining-adhd-child

National Institute of Mental Health. (n.d.). Attention deficit hyperactivity disorder. Retrieved from www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd/

National Resource Center on AD/HD. (2008). The disorder named ADHD. What We Know, 1. Retrieved from http://help4adhd.org/documents/WWK1.pdf

National Resource Center on AD/HD. (n.d.). What is ADHD or ADD? Retrieved from http://help4adhd.org/en/about/what

Quinn, Patricia O., & Stern, Judith M. (2009). Putting on the brakes: Understanding and taking control of your ADD or ADHD (2nd ed.). Washington, DC: Magination Press.

1.2 ADHD and the Executive Functions

Based on extensive research, ADHD is now recognized as a disorder in the development of executive functions—a person's self-management and self-regulatory abilities. The current belief is that impairment of executive functions is the underlying problem causing the symptoms associated with ADHD. People with ADHD experience a wide range of executive dysfunction issues that can vary from person to person. What are the executive functions, and how is executive function (EF) impairment related to ADHD?

Definitions of Executive Function (EF)

EFs have been described in many ways:

The management functions (overseers) of the brain or the management system of the brain

Cognitive control skills

The self-directed actions individuals use to help maintain control of themselves and accomplish goals

The range of central control processes in the brain that activate, organize, focus, integrate, and manage other brain functions and cognitive skills

The higher-order cognitive processes involved in the self-regulation of behavior

A term used to describe the complex nature of cognitive processes involved in identifying, setting, maintaining through, and meeting goals despite distractions and problems along the way

Cognitive processes or brain functions that enable a person to engage in problem-solving and goal-directed behaviors

The brain's control center that orchestrates resources in memory, language, and attention to achieve a goal

Broad set of cognitive skills used to organize, self-monitor, control, and direct our behavior toward purposeful goals

The neuropsychological processes needed to sustain problem-solving toward a goal

EF Analogies and Metaphors

Conductor of a symphony orchestra. Thomas E. Brown and others use this popular analogy of EFs having a role like that of the conductor of a symphony orchestra—responsible for integrating and managing all of the different components for a successful performance. If the conductor fails to do his or her job well, even with very skilled musicians, the performance will be poor.

Chief executive officer (CEO). Many experts explain the role of executive functions as being similar to that of a successful corporate CEO: analyzing a task, planning, prioritizing, being flexible, making mid-course corrections as needed, being able to assess risk, able to delay immediate gratification to achieve long-term goals, keeping an eye on the big picture, making informed decisions, and completing tasks in a timely way (Silver, 2010; Willis, 2011).

Iceberg. Chris Zeigler Dendy (2002, 2011), Dr. Martin Kutscher (2010), and others share the analogy when describing ADHD as an iceberg with the visible core symptoms (inattention, impulsivity, hyperactivity) just the tip. Looming under the surface are often the most challenging aspects of ADHD: the executive function impairment and co-occurring conditions.

Air traffic control center. Just like air traffic control coordinates all of the different planes coming and going, the executive functions involve managing a lot of information, resisting distractions, inhibitory control, mental flexibility, and so forth. (Center on the Developing Child, Harvard University, n.d.).

EF Components

It has not as yet been determined exactly what constitutes all of the executive functions. However, most experts agree they involve the following:

Inhibition (impulse control, ability to stop, put on the brakes, and think before making a response, being able to resist temptations and distractions); this is considered by many to be the main executive function because inhibitory control is necessary for all of the other EFs to adequately develop

Working memory (holding information in mind long enough to act on it, to complete a task or do something else simultaneously, a mental desk top for holding information active while working with other information)

Planning and prioritizing (thinking through what needs to be done, structuring an efficient approach to accomplish those tasks, and making good decisions about what to focus on)

Organization (imposing order and structure to manage information, efficiently communicate one's thoughts, carry out goal-directed behavior)

Arousal and activation (being able to arouse effort and motivation to start or initiate tasks and activities, particularly those that are not intrinsically motivating)

Sustaining attention (maintaining alertness and focus, resisting distractions, especially when the task is tedious or not of interest)

Emotional self-control (modulating or self-regulating one's frustrations and emotions)

Time awareness (being aware of how much time has passed, how long things take, keeping track of time and planning and acting accordingly)

Goal-directed persistence (perseverance, maintaining the effort and motivation to follow through with actions needed to achieve goals)

Shifting and flexibility (adaptability and making adjustments when needed, mentally shifting information around, making transitions, ending one task to move to the next)

Self-monitoring and metacognition (being aware of and self-checking one's own behavior, thought processes, strategies, and comprehension; evaluating one's own performance, strategy monitoring, and revising)

Self-talk and private speech (using your inner voice, mentally talking to yourself to control and guide your behavior, work through a problem)

EF Dysfunction in ADHD

Research has found that children and teens with ADHD lag in their development of EF skills by approximately 30 percent compared to other children their age. So, expect that a ten-year-old with ADHD will have the EF maturity of a seven-year-old, and a fifteen-year-old to have the EF skills of a ten- or eleven-year-old. It is very important for teachers and parents to be aware of this developmental delay in executive skills and adjust their expectations for self-regulation and self-management accordingly.

EF weaknesses can be expected to cause some academic and work-related challenges to varying degrees (mild to severe), irrespective of one's intelligence.

The frontal lobes (particularly the prefrontal cortex and extended neural networks) are the primary center of executive functions. This region of the brain has been found to be underactive, smaller, and less mature in people with ADHD than in those without ADHD (Lists 1.4, 1.7).

For all people, the prefrontal cortex (PFC) matures and develops gradually from childhood into adulthood (the late twenties), with most rapid development occurring during school years. The PFC is the last part of the brain to fully mature, and for those with ADHD, it is delayed in development by a few years.

It is not just the prefrontal cortex that is involved in executive functions. The brain's executive system is complex as other regions of the brain and neural networks interact with the PFC. (Lists 1.4, 1.7).

Kutscher (2010) explains that the ability to modulate our behavior comes largely from our frontal and prefrontal lobes. In ADHD, the frontal lobe brakes and other executive functions are asleep on the job.

Models Explaining Executive Function Impairment in ADHD

Russell Barkley and Thomas Brown, two world-renowned researchers and authorities on ADHD, have been key leaders in the field and their work and teachings have fundamentally changed our understanding of ADHD to being that of a disorder of executive functioning—our self-management system. Both Barkley and Brown have developed their own conceptual models of ADHD as a disorder of executive functions, which are best understood by going directly to their books, websites, and other resources, some of which are provided in the Sources and Resources section of this list.

Barkley's Model of EF and ADHD

According to Barkley, each of the executive functions is actually a type of self-regulation—a special form of self-directed action that people do to themselves (usually mentally and not visible to others). These self-directed actions are what people do in order to modify their own behavior so that they are more likely to attain a goal or change some future consequence to improve their welfare.

Barkley says that there are five or six things people do to themselves for self-regulation:

Self-direct their attention (self-awareness)

Visualize their past to themselves

Talk to themselves in their minds

Inhibit and modify their emotional reactions to events

Restrain themselves (self-discipline)

Play with information in their mind (take it apart, manipulate it in various ways, and recombine it to form new arrangements)

See Barkley (2005, 2011a, 2011b, 2012, 2013) in the Sources and Resources section of this list and his website at www.russellbarkley.org/.

Brown's Model of EF and ADHD

Brown's conceptual model is that of six clusters of executive functions that are impaired in ADHD. These symptoms of impairment often appear and work together in various combinations in people with ADHD.

Activation. Organizing, prioritizing, and activating work

Focus. Focusing, sustaining, and shifting attention to task

Effort. Regulating alertness, sustaining effort, and processing speed

Emotion. Managing frustration and modulating emotions

Memory. Using working memory and accessing recall

Action. Monitoring and self-regulating action

See Brown (2005, 2008, 2013) in the Sources and Resources section of this list and his website at www.drthomasebrown.com.

Both doctors have also developed executive function assessment tools: Barkley Deficits in Executive Functioning Scale—Children and Adolescents (BDEFS-CA) and Brown ADD Rating Scales for Children, Adolescents and Adults. See these, along with the Behavior Rating Inventory for Executive Function (BRIEF) in List 1.15.

Other Interesting Information about Executive Functions

Executive dysfunction is not exclusive to ADHD. EF impairment to some degree is also common in learning disabilities, autism spectrum disorders, obsessive-compulsive disorder, bipolar, and some other developmental or psychiatric disorders, and can also be acquired by damage to the prefrontal cortex, such as by traumatic brain injury or strokes.

Studies have shown that self-discipline has a bigger effect on academic performance than does intellectual talent (Duckworth & Seligman, 2005; Tangney, Baumeister, & Boone, 2004).

A growing body of research has demonstrated that children's EFs (along with their skills in modulating emotion) are central to school readiness in early childhood (Raver & Blair, 2014).

EFs may be a better predictor of school readiness than one's IQ or entry level reading or math skills (Diamond, Barnett, Thomas, & Munro, 2007).

There is growing evidence that because of neuroplasticity, a person's self-regulation and executive skills can be strengthened with practice.

Tools of the Mind is one early childhood school program that has been studied by researchers and has shown impressive results. In this program, teachers spend most of each day promoting EF skills with their preschool and kindergarten children (Diamond, Barnett, Thomas, & Munro, 2007). See www.toolsofthemind.org and Lists 2.15 and 7.4.

School-Related EF Difficulties

EF weaknesses interfere with most all aspects of school success and result in a number of challenges. Weak executive skills are the reason that students with ADHD often struggle with the following:

Controlled attention (focusing and resisting distractions, maintaining on-task behavior, and shifting attention as needed)

Time awareness and time management (significantly underestimating how much time is needed to perform tasks, missing deadlines and due dates or scrambling last minute to complete homework and projects, tardiness to class, chronic lateness)

Organization (messy papers, notebooks, desks, and lockers; unprepared with needed materials and supplies; losing homework and belongings; lack of organized flow and sequence on essays and other assignments)

Planning and follow-through (failing to think through systematically all of the steps or components of a task, experiencing great difficulty with long-term assignments and projects)

Self-control and inhibition (blurting out in class, curbing inappropriate behavior or speech, not putting on the brakes long enough to think things through or get things done)

Memory and forgetfulness (not following all parts of the directions, not turning in homework even when they have it in their notebook or backpack completed, poor recall of information)

Work production (requiring a high degree of positive feedback, cues, and structural supports and incentives to keep on task and motivated, far more than needed by other students)

Handling negative emotions (having low frustration tolerance, getting stuck on things that are bothering them, overreacting when upset, dealing with anger, and other feelings)

Homework, independent classwork, study, and test-taking skills

Making many careless errors (not checking work, not noticing details such as punctuation marks, math processing signs, and decimal points)

Reading comprehension, written expression, mathematical problem solving (and other complex or lengthy academic tasks that require a heavy working memory load, planning and organization of thoughts and information, and self-monitoring or self-correction throughout the process)

Processing speed (being very slow, taking a lot longer than average time to process information or complete tasks and assignments)

See Lists 1.5, 4.1, 4.4, 5.1, 5.6, and 5.13 for related executive dysfunction symptoms and manifestations.

What Parents and Teachers Should Keep in Mind

EF weaknesses cause academic challenges to some degree (mild to severe), irrespective of one's intellectual and academic capabilities. Every individual with ADHD will be affected differently in EF areas of strength and weakness.

Many highly intelligent, gifted children and teens with ADHD (even those who manage to get good grades) struggle in their daily functioning because of their EF impairment (List 7.10).

Most students with ADHD will need supportive strategies and some accommodations to compensate for their deficit in EF, whether they are part of a formal plan (IEP or 504 accommodation plan) or not (Lists 6.3, 6.4, 6.5).

Every aspect of schooling involves a high level of EF. From the beginning of a school day to the end, a student is employing EF in order to get to school on time, respond appropriately to peers and adults, follow directions, initiate work, recall and organize information, find and organize materials, comprehend and complete assignments, and meet deadlines.

When students have executive dysfunctions, support from teachers and parents and efforts to teach and strengthen EF skills are critical for school success. There are many proactive strategies and interventions that can be helpful—supporting the development of their executive functions as well as compensate for their weaknesses.

Many students with ADHD manage to do well in elementary school because of the high degree of support provided by teachers and parents (who often take on the role of the younger child's prefrontal cortex). But by middle and high school, the executive demands for organizing, planning, time management, problem solving, and other EF skills can become overwhelming. As students with ADHD move up in the grades, the expectations for self-management and independence are often unrealistic, and many teens who did well in elementary school fall apart at this time.

Dendy (2011) reminds us that, unfortunately, kids with ADHD and EF deficits are often mistaken for being lazy because it can seem as if he or she has chosen not to get started on or complete work; and they are often admonished to try harder. In reality, these children and teens may work very hard, but because of attention and executive function deficits, their productivity does not match their greater level of effort (p.39).

What Parents, Teachers, and Other Supportive Adults Can Do to Help

Numerous strategies, supports, and accommodations for helping students with ADHD compensate for their EF impairments and strengthen skill development are found throughout this book. The following points describe a few general ways to help:

Environmental structuring to provide a great deal of external structure, such as visual and auditory cues, prompts, reminders, and clear organization of the classroom and home environment (Lists 2.1, 2.2, 2.3, 2.6, 2.12, 2.13, 2.15, 2.16, 3.2, 3.3, 3.4, 3.7, 4.1, 4.2, 4.5, 4.6, 4.7, 4.8, 4.9, 4.10, 7.4, 7.5, 7.8, and examples in appendix).

Explicit teaching of executive skills to model and provide a high degree of guided and independent practice with clear feedback and reinforcement. Executive skills such as planning, organizing, time management, goal setting, and self-monitoring need to be taught with lots of practice opportunities. The same applies for explicitly teaching of learning strategies and study skills that are typically affected by EF weaknesses, such as note taking, test-taking strategies, and memorization (Lists 4.1, 4.2, 4.3, 4.5, 4.6, 4.7, 4.8, 4.9, 4.10).

Management techniques and strategies that enable procedures, routines, and transitions to become smooth and automatic; clear rules and expectations that are effectively taught, practiced, and reinforced at the point of performance—each environment, task, or activity where and when those rules and expectations are expected to be used (Lists 2.1, 2.2, 2.4, 2.6, 2.8, 2.10, 2.12, 2.13, 2.15, 2.16, 2.17)

Supports and accommodations to compensate for memory weaknesses, such as use of checklists, recorded messages, visual aids, tools of technology (Lists 3.5, 4.1, 4.2, 4.5, 4.6, 4.7, 4.8, 4.9, 4.10)

Academic assistance or intervention in areas affected by working memory or other EF weaknesses (Lists 4.1, 4.2, 4.3, 4.5, 4.6, 4.7, 4.8, 4.9, 4.10, 5.3, 5.4, 5.5, 5.7, 5.8, 5.9, 5.11, 5.12, 5.13, 5.14, 7.6)

Reenergize the brain by providing frequent breaks in activities (brain breaks) and physical exercise to avoid cognitive fatigue (Lists 2.12, 2.13, 3.2, 3.3, 3.4, 3.6, 3.7, 4.9, 7.7)

Strategies and supports for focusing attention, initiating tasks, and maintaining on-task behavior (Lists 2.12, 3.2, 3.3, 3.4, 3.5)

Supports and strategies for dealing with frustrations, regulating emotions, and for teaching, practicing, and motivating use of self-control (Lists 2.9, 2.13, 2.15, 2.16)

Supports and accommodations as needed for organization, time management, classroom work production, and homework difficulties, particularly for long-term projects and assignments (Lists 4.5, 4.6, 4.7, 4.8, 4.9, 4.10)

Sources and Resources

ADHD Partnership, Fairfax County Public Schools, VA. (2008). Powerpoint: Executive function deficits. Free download retrieved from http://adhdpartnership.com/

Barkley, Russell A. (2005). ADHD and the nature of self-control. New York: Guilford Press.

Barkley, Russell A. (2011, January 20). The importance of executive function in understanding and managing ADHD. CHADD and the National Resource Center on ADHD. Ask the Expert Chat Series. http://www.chadd.org/Portals/0/AM/Images/Support/Ask%20The%20Expert/2011_January_Barkley.pdf

Barkley, Russell A. (2012a). Executive functions: What they are, how they work and why they evolved. New York: Guilford Press.

Barkley, Russell A. (2012b). Fact sheet: The important role of executive functioning and self-regulation in ADHD. Retrieved from www.russellbarkley.org/factsheets/ADHD_EF_and_SR.pdf

Barkley, Russell A. (2013). Taking charge of ADHD: The complete, authoritative guide for parents (3rd ed.). New York: Guilford Press.Bertin, Mark (2012, May 15). ADHD goes to school. Huff Post Parents Blog. Huffington Post. Retrieved from www.huffingtonpost.com/mark-bertin-md/adhd_b_1517445.html

Brown, Thomas. (2005). Attention deficit disorder: The unfocused mind in children and adults. New Haven, CT: Yale University Press.

Brown, Thomas E. (2008). Executive functions: Describing six aspects of a complex syndrome. Attention Magazine,15(1), 12–17.

Brown, Thomas E. (2013). A new understanding of ADHD in children and adults: Executive function impairments. New York: Routledge.

Center on the Developing Child, Harvard University. (n.d.). Key concepts: Executive functions. Retrieved from http://developingchild.harvard.edu/key_concepts/executive_function/

Cooper-Kahn, Joyce, & Dietzel, Laurie. (2008). Late, lost, and unprepared: A parent's guide to helping children with executive functioning. Bethesda, MD: Woodbine House.

Dawson, P., & Guare, Richard. (2010). Executive skills in children and adolescents: A practical guide to assessment and intervention (2nd ed.). New York: Guilford Press.

Dawson, Peg, & Guare, Richard. (2009). Smart but scattered. New York: Guilford Press.

Dendy, Chris A. Ziegler. (2002). 5 components of executive function. Attention (February), 26–31

Dendy, Chris A. Zeigler. (2011). Teaching teens with ADD, ADHD & executive function deficits (2nd ed.). Bethesda, MD: Woodbine House.

Diamond, A., Barnett, W. S., Thomas, J., & Munro, S. (2007). Preschool program improves cognitive control. Science, 318(5855), 1387–1388. Retrieved from www.ncbi.nlm.nih.gov/pmc/articles/PMC2174918/

Duckworth, Angela A., & Seligman, Martin E. P. (2005). Self-discipline outdoes IQ in predicting academic performance of adolescents. Psychological Science,16, 939–944.

Horowitz, Sheldon H. (n.d.). What's the relationship between ADHD and executive function? National Center for Learning Disabilities. Retrieved from www.ncld.org/types-learning-disabilities/executive-function-disorders/relationship-adhd-attention-deficit

Katz, Mark. (2014). Executive function: What does it mean? Why is it important? How can we help? The Special Edge: Student Behavior, 27(3), 8–10.

Kaufman, Christopher. (2010). Executive function in the classroom. Baltimore, MD: Paul H. Brookes.

Kutscher, Martin L. (2010). ADHD: Living without brakes. Philadelphia: Jessica Kingsley.

Mauro, Terri. (2013). Executive function. About.com. Retrieved from http://specialchildren.about.com/od/behaviorissues/g/executive.htm

Meltzer, Lynn. (2010). Promoting executive function in the classroom. New York: Guilford Press.

Moyes, Rebecca A. (2014). Executive function dysfunction: Strategies for educators and parents. London: Jessica Kingsley.

National Center for Learning Disabilities (NCLD) Editorial Team. (n.d.). Executive function fact sheet: What is executive function? Retrieved from www.ncld.org/types-learning-disabilities/executive-function-disorders/what-is-executive-function

Oregon Developmental Disabilities Coalition. (n.d.). Executive functioning: Skills, deficits, and strategies. Retrieved from http://oregonddcoalition.org

Raver, C. Cybele, & Blair, Clancy. (2014). At the crossroads of education and developmental neuroscience: Perspectives on executive function. Perspectives on Language and Literacy, 40(2), 27–29.

Rief, Sandra. (2011). Executive function: Practical applications in the classroom. Port Chester, NY: National Professional Resources.

Silver, Larry. (2010). Not your father's ADHD. ADDitude Magazine, 10(3), 47–48.

Tangney, J. P., Baumeister, R. F., & Boone, A. L. (2004). High self-control predicts good adjustment, better grades, and interpersonal success. Journal of Personality,72(2), 271–324.

Tools of the Mind. (n.d.). What is self-regulation? Retrieved from www.toolsofthemind.org/philosophy/self-regulation/

Wikipedia. (n.d.). Executive dysfunction. Retrieved from http://en.wikipedia.org/wiki/Executive_dysfunction

Willis, J. (2011, June 13). Understanding how the brain thinks. Edutopia blog. Retrieved from www.edutopia.org/blog/understanding-how-the-brain-thinks-judy-willis-md

1.3 The Official Diagnostic Criteria for ADHD (DSM-5)

The cornerstone of an ADHD diagnosis is meeting the criteria as described in the most current edition at this time of the Diagnostic and Statistical Manual of Mental Health Disorders, published by the American Psychiatric Association. The DSM is the source for diagnosing ADHD as well as other developmental and mental health disorders. The DSM has been updated and revised over the years, with different editions. The fifth edition (DSM-5) is the most current at this time, published in 2013 and replacing DSM-IV and text-revised DSM-IV-TR.

Although much remains the same in DSM-5, there were some significant changes to the diagnostic criteria in the fifth edition, which are explained in Changes to the DSM.

For a diagnosis of ADHD, a person must show a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development.

When evaluating for ADHD, the doctor, mental health professional, or other qualified clinician must collect and interpret data from multiple sources, settings, and methods to determine if DSM-5 criteria are met.

DSM-5 Criteria

The DSM-5 (as in previous editions) lists nine specific symptoms under the category of inattention and nine specific symptoms under the hyperactive-impulsive category.

To be diagnosed with ADHD, the evaluator must determine that the person often presents with a significant number of symptoms in either the inattentive category or the hyperactive-impulsive category or in both categories.

Children through age sixteen must often display six out of nine symptoms (in either one or in both of the categories). For individuals seventeen years old and above, only five symptoms out of the nine must be present.

Nine Inattentive Symptoms

Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities

Often has trouble holding attention on tasks or play activities

Often does not seem to listen when spoken to directly

Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (for example, loses focus, gets sidetracked). Note: This is not because of oppositional behavior or failure to understand instructions.

Often has trouble organizing tasks and activities

Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework)

Often loses things necessary for tasks and activities (for example, school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones)

Is often easily distracted

Is often forgetful in daily activities

Nine Hyperactive-Impulsive Symptoms

Often fidgets with or taps hands or feet or squirms in seat

Often leaves seat in situations when remaining seated is expected

Often runs about or climbs in situations when it is not appropriate (adolescents or adults may be limited to feeling restless)

Often unable to play or take part in leisure activities quietly

Is often on the go, acting as if driven by a motor

Often talks excessively

Often blurts out an answer before a question has been completed

Often has trouble waiting his or her turn

Often interrupts or intrudes on others (for example, butts into conversations or games)

Three Presentations of ADHD

Based on the specific symptoms, three types or what are now called presentations of ADHD can occur:

Predominantly inattentive presentation. If enough symptoms of inattention but not hyperactivity-impulsivity were present for the past six months

Predominantly hyperactive-impulsive presentation. If enough symptoms of hyperactivity-impulsivity but not inattention were present for the past six months

Combined inattentive and hyperactive-impulsive presentation. If enough symptoms in the category of inattention and in the category of hyperactivity-impulsivity were present for the past six months

Note: Because symptoms can change over time, the presentation may change over time as well. For example, a young child may be diagnosed with predominantly hyperactive-impulsive ADHD and later be reclassified as having the combined presentation of the disorder as inattentive symptoms become more significantly out of norm compared to other children the same age.

Other Criteria That Must Be Met

Several symptoms need to be present in two or more settings (for example, at both home and school or other settings).

The symptoms are inappropriate for their developmental level (compared to others their age).

Symptoms are to the degree that they interfere with or reduce the quality of their functioning (for example, school, social, or work functioning).

Other disorders (such as anxiety or depression) or conditions do not better account for these symptoms.

Changes in the DSM Criteria

In the previous editions of the DSM, the criteria was designed to help clinicians diagnose ADHD in children. As the research has proven that ADHD is not just a childhood disorder, it became clear that the criteria did not reflect adequately the experiences of adults with the disorder. DSM-5 adapted the criteria to more effectively diagnose adults, as well as children.

ADHD is no longer in the Disruptive Behavior Disorders section of the DSM. It is now found in the Neurodevelopmental Disorders section.

As symptoms tend to be reduced with age, DSM-5 accounts for this by reducing the number of required symptoms for diagnosis in individuals over seventeen to five out of nine (rather than six out of nine).

The age of onset changed in the criteria, reflecting our understanding that not all symptoms are evident at a young age. Now symptoms need to occur by age twelve, instead of the previous requirement that symptoms must occur before seven years old. (See List 1.12 about the common later onset of symptoms in girls.)

The impairment criteria and wording changed. It used to be a requirement that symptoms must cause impairment in at least two settings. This has been changed to ". . . clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning."

Although the nine symptoms in each category stayed the same, DSM-5 added additional descriptions to the symptoms—including what the symptoms may look like in teens and adults. Examples in DSM-IV were only of what symptoms may look like in children.

Instead of being referred to as the three types of ADHD, the wording is now three presentations of ADHD.

Now people with Autism Spectrum Disorder can also be diagnosed with ADHD. It is now recognized that Autism Spectrum Disorder can be a coexisting disorder with ADHD (List 1.8).

There is now a severity level of ADHD (mild, moderate, severe) that is to be specified under the new DSM-5 criteria.

See List 1.15 for information about the diagnostic process for ADHD in determining if DSM-5 criteria is met.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Association.

American Psychiatric Association. (2013). DSM-5 Attention-deficit/hyperactivity disorder fact sheet. Retrieved from http://www.dsm5.org/documents/adhd%20fact%20sheet.

Centers for Disease Control and Prevention. (n.d.). Attention-deficit/hyperactivity disorder: symptoms and diagnosis. Retrieved from www.cdc.gov/ncbddd/adhd/diagnosis.html

National Resource Center on AD/HD. (2014). ADHD awareness month: ADHD and the DSM-5. Retrieved from www.adhdawarenessmonth.org/wp-content/uploads/ADHD-and-the-DSM-5-Fact-Sheet1.pdf

Rabiner, David. (June 2013). New diagnostic criteria for ADHD: Subtle but important changes. Attention Research Update. Retrieved from www.helpforadd.com/2013/june.htm

1.4 What Is Currently Known and Unknown about ADHD

We Know…

ADHD has been the focus of a tremendous amount of research, particularly during the past three decades. Literally thousands of studies and scientific articles have been published (nationally and internationally) on ADHD.

ADHD is very common not just in the United States but throughout the world. On average it affects 5 percent of school-age children around the world and 4 percent of adults. In the United States, prevalency rate of ADHD in school-age children is estimated to range between 5 and 11 percent (List 1.6 ).

There is no quick fix or cure for ADHD, but it is treatable and manageable.

ADHD is not a myth. It has been recognized as a very real, valid, and significant disorder by the US Surgeon General, the National Institutes of Health, the US Department of Education, the Centers for Disease Control and Prevention, and all of the major medical and mental health associations.

Proper diagnosis and treatment can substantially decrease ADHD symptoms and impairment in functioning (Lists 1.15, 1.19, 1.20, 1.22).

ADHD is a neurobiological disorder that is a result of different factors—the most common cause by far being genetic in origin (1.7).

Regardless of the underlying cause, there are on average differences in both the size and function of certain areas of the brain in individuals with ADHD (Wolraich, & DuPaul, 2010).

ADHD exists across all populations, regardless of race, ethnicity, gender, nationality, culture, and socioeconomic level.

ADHD symptoms range from mild to severe.

There are different types or presentations of ADHD with a variety of characteristics. No one has all of the symptoms or displays the disorder in the exact same way (Lists 1.3, 1.5).

Approximately 75 percent of individuals with ADHD have additional coexisting disorders or conditions. People with ADHD commonly have other mental health disorders, for example, oppositional defiant disorder, anxiety disorder, or depression; developmental disorders, such as dyslexia or other learning disabilities; and other conditions, such as sleep disorders (List 1.8).

Many children, teens, and adults with ADHD slip through the cracks without being identified or receiving the intervention and treatment they need. This is particularly true of racial and ethnic minorities and girls.

ADHD is diagnosed at least two to three times more frequently in boys than girls, although many more girls may actually have ADHD. Because they often have less disruptive symptoms associated with hyperactivity and impulsivity, girls are more likely to be overlooked (List 1.12).

The challenging behaviors that children with ADHD exhibit stem from neurobiological differences. Their behaviors are not willful or deliberate. Children with ADHD are often not even aware of their behaviors and their impact on others (List 1.7).

The prognosis for ADHD can be alarming if it is not treated. Without interventions, those with this disorder are at risk for serious problems in many domains: social, emotional, behavioral, academic, health, safety, employment, and others (List 1.6).

Children with ADHD are more likely than their peers to be suspended or expelled from school, retained a grade or drop out of school, have trouble socially and emotionally, and experience rejection, ridicule, and punishment (List 1.6).

ADHD is typically a lifelong disorder. The majority of children with ADHD (approximately 80 percent) continue to have the disorder into adolescence, and 50 to 65 percent will continue to exhibit symptoms into adulthood. In the past, ADHD was believed to be a childhood disorder. We now know that this is not the case (Lists 1.6, 1.11, 7.5).

Although ADHD is most commonly diagnosed in school-age children, it can be and is diagnosed reliably in younger children and adults (Lists 1.3, 1.15, 7.4 ).

The prognosis for ADHD when treated is positive and hopeful. Most children who are diagnosed and provided with the help they need are able to manage the disorder. Parents should be optimistic because ADHD does not limit their child's potential. Countless highly successful adults in every profession and walk of life have ADHD.

ADHD has been recognized by clinical science and documented in the literature since 1902 (having been renamed several times). Some of the previous names for the disorder were minimal brain dysfunction, hyperactive child syndrome, and ADD with or without hyperactivity.

Children with ADHD can usually be taught effectively in general education classrooms with proper management strategies, supports, and accommodations, and engaging, motivating instruction.

ADHD is not the result of poor parenting.

ADHD is not laziness, willful misbehavior, or a character flaw.

Medication therapy and behavioral therapy are effective