By Dr. Jennifer-Ann Shillingford

Imagine you're Dorothy. You're in the calm of Auntie Em's farmhouse, but inside you cyclone winds are swirling cows and witches in all directions. Now try to focus on your math homework. That's what it can sometimes feel like when you've got ADD.
When Johnny goes on Ritalin
By Dr. Susan Rhodes

As a family practitioner, I get at least one or two parents a week landing in my office; concerned parents of children who might possibly have attention deficit disorder. "Johnny's teacher has sent us here, Dr. Rhodes. She thinks he has ADD and wants him to be on drugs!"
    ADD is a common disorder, estimated to affect up to 10 percent of the entire population, so the average classroom may have two or three children like Johnny. Today teachers are more knowledgeable about it and would likely be the first ones to recognize it in a child.
    Research indicates that ADD is caused by a physical difference in the area of the brain that enables information to cross from one side to the other. It's not that sufferers don't have enough attention, but rather they have too much attention. Without ADD, a person's brain sifts out all the background information it's constantly receiving – my socks are itchy, it's hot in here, there's a bird singing outside – and concentrates on the task at hand: the math problem, the story being read, the conversation going on. With ADD, the brain perceives all the information it receives as equally important, making it very difficult to focus on the task assigned. Medication, such as Ritalin, allows the ADD brain to function "normally".
    The beneficial effect of Ritalin is often dramatic. A child previously unable to sit still long enough to learn anything can focus and acquire the skills necessary for academic success. Many parents are understandably reluctant to put their child on medication. But since ADD is caused by a physical disorder in the brain, its treatment with medication should be no more alarming than treating diabetes with insulin or an underactive thyroid with thyroid hormone. The goal of treatment is to allow the child to learn and function as easily as his peers, freeing him from the frustration and low self-esteem untreated ADD can create.

Dr. Susan Rhodes is a general practitioner in Oakville, Ont.
He doesn't follow directions. She talks excessively during class. He's constantly leaving his seat and wanders around the classroom. She's distracted by the least thing. He never listens to what's being said to him. She's always fidgeting. These are the symptoms of attention deficit/hyperactivity disorder (ADHD), a condition more commonly known as ADD.

    As a child develops and acquires new skills, parents may become aware that he or she appears to be more restless, impulsive or more active than usual. Teachers may start commenting that a child has difficulty focusing. It's not just in the classroom. A child may also appear inattentive and/or restless during after-school activities, as well as at home. Ordinarily, behavioural changes in a child diminish after a few days or weeks. However, if they persist for at least six months to a degree that is inconsistent with a child's developmental level, attention deficit/hyperactivity disorder could be the cause.

    The key features of ADD are hyperactivity, short attention span and impulsiveness that are developmentally inappropriate and persist for at least six months. To varying degrees, these symptoms appear in each affected child, and, for diagnosis, must have been evident before age seven. If a child starts showing signs of ADD, consult a pediatrician, general practitioner or psychologist who is knowledgeable about the condition.

    These specialists will often refer to three separate types of ADD: inattentive, hyperactive/impulsive and combined – a combination of symptoms from the two.

    Typically, symptoms of ADD become evident before or during early elementary school. At school, children with this diagnosis may have problems listening to directions, completing assignments or working alone without being distracted. In the classroom, they may fidget and fuss, fall off their chairs, disrupt conversations, blurt out answers and have problems waiting their turn. Their grades may suffer because of these behaviour difficulties. Children with ADD may also demonstrate impairments in motor, math or reading skills. And tend to be socially immature.

    These symptoms may stem from other conditions that range from anxiety and mood disorders like depression and mania, to conduct, development and medical disorders. Restlessness can also be caused by chronic-use medications, including stimulating medications and sedating medications, which can produce a paradoxical response in children.

    Careful differential diagnosis is crucial. It's important to know what is normal at each age level and how children behave in a variety of environments. In addition, because other conditions frequently occur with ADD, in 1991 the American Academy of Child and Adolescent Psychiatry (AACAP) recommended that children suspected of having ADD should be referred to test for IQ, psychological, speech, language and learning disabilities, if clinically indicated.

    Treatment for ADD should be multi-modal and target a child's strengths and weaknesses. Some of the more common interventions include parent training, cognitive therapy, behaviour modification, medication, educational programming and social skills training.

The AACAP recommends the following:
•    Individual and/or group therapy to address low self-esteem and peer problems
•    Family therapy if there's family dysfunction
•    Social skills training and cognitive therapies for inattention and impulsiveness (one goal is to get children to verbalize or think before they act)
•    Parent behaviour training to develop the child's ability to set appropriate and consistent limits, and behaviour modification programs

    Stimulants such as dextroamphetamine and methylphenidate (Ritalin) diminish overactivity, impulsiveness, irritability and emotional fluctuations; they also increase vigilance, attention span and general sociability.

    These medications can work in a couple of days, but often require one to two weeks. Children should be monitored regularly for changes in blood pressure, pulse, height, weight, appetite, mood and possible side effects, like tics.

    Since no single medication always works for every child, parents' and teachers' input to the prescribing physician is vital. Medicines are also available in longer-acting doses, which enable the child to get through lunch without having to take a dose.

    Even if a child is already taking medication, still more can be done. Special techniques developed by psychologists, such as behaviour modification and cognitive therapy, can help the child recognize and modify his or her behaviour. Most ADD children do best under a combination of medication and psychological techniques.

    Always remember when children are diagnosed with ADD that they are still, first and foremost, children. Avoid the tendency to see them as they've been labelled. Every child has his or her own unique strengths and weaknesses.

Dr. Jennifer-Ann Shillingford is the consulting psychologist at the ADD Clinic at First Canadian Medical Centre in Toronto.

Inattentive ADD
•    failure to pay close attention to details
•    difficulty sustaining attention in tasks
•    doesn't seem to listen
•    doesn't follow instructions
•    has problems organizing
•    avoids work that requires attention for long periods of time
•    often loses things
•    easily distracted
•    often forgetful

Hyperactive/impulsive ADD
•    often fidgets with hands or feet
•    can't sit still
•    difficulty playing quietly
•    restless
•    blurts out answers before questions have been completed
•    finds it hard to await turn
•    talks excessively
•    often interrupts conversations
•    is always "on the go"