1. When my child is deeply interested in an activity I have difficulty dragging her away.

2. My child does pay attention to things he wants to do.

3. My child has difficulty paying attention to things I want her to do.

4. My child has difficulty paying attention to things others (e.g., teachers) want him to do (e.g. instructions).

5. My child daydreams, drifts into her own little world, oblivious to what's going on.

6. My child notes unimportant details, which interest him, yet misses the main idea.

7. My child doesn't pay attention to important details and often makes careless mistakes in schoolwork. (e.g., + and - signs in math)

8. My child's school grades do not reflect her true ability - she underachieves.

9. My child is inconsistent in his work and behavior. He is fine one day but not the next.

10. It is hard for my child to follow routines, such as getting ready for school or getting ready for bed.

11. My child gets easily sidetracked from a task someone else asks her to do. (For example, she stops to examine a bug on the wall and forgets she was on her way to brush her teeth.)

12. My child honestly "forgets" to bring her assignments home. ("Forgetting" is NOT done in an angry or oppositional manner most of the time.)

13. My child needs a lot of supervision to complete assignments (school work, chores), which require sustained attention.

14. My child's attention span is getting worse relative to other children the same age.

15. My child fails to think through what he is about to do or say; that is, leaps without looking.

16. My child has difficulty waiting for a turn, (for example, interrupts others, blurts out answers before a question is completed.)

17. My child has difficulty waiting in line, sharing, and cooperating.

18. My child often gets into potentially dangerous situations.

19. My child has difficulty waiting for rewards, delaying gratification. (She wants the toy now!)

20. My child's ability to control impulses is not improving with age.

21. My child's schoolwork, belongings, time-management and personal functioning seem very disorganized.

22. When my child is working on his own hobbies or creating his own projects he is extremely organized.

23. My child overreacts to minor disturbances

24. My child is easily bored.

25. My child shows rapid mood swings.

26. My child has difficulty adjusting to sudden changes in routines.

27. My child's activity level is inappropriate for the situation, for example, she has difficulty sitting still in class, church, during meals.

28. My child is restless, fidgets, and squirms.

29. My child seems always on the go as if driven by a motor.

30. My child seems sluggish, lethargic and unmotivated,

TOTAL CHECKS FOR EACH COLUMN

SCORE: (the total number of checks in each column multiplied by 0, 1, 2, and 3)

x 0 = 0x 1= x 2= x 3 =TOTAL = _________ Interpretation:

This questionnaire is designed to help you organize your thinking about your child. You can use the total score to track your child's symptoms over time. If you have checks only in the "often" and "almost always" columns for positive items such as numbers 1, 2 and 22, then A.D.D. is probably not a problem. On the other hand, if you have a great many of the other items marked in the "often and "almost always" columns, then it may be advisable for you to take this questionnaire and discuss your observations with a professional. (Hyperactive children will have higher scores than children who don't have hyperactivity.) Remember, too, that your child's age may affect the score. Younger children usually have higher scores.

Why are there more items under the first two topics?"Attention Span" and "Spontaneity" cover the major symptoms of A.D.D. It becomes increasingly difficult to separate other behavior disorders from A.D.D. when we ask questions about organization and emotions. Activity level can be average or at either extreme, hyperactive or lethargic.

What about angry, defiant behavior?A.D.D. is a very different problem from Conduct Disorder and Oppositional Defiant Disorder. In the A.D.D.-Q, we want to emphasize A.D.D. but also recognize that your child's scores can be higher if your child is angry and has other behavioral difficulties. Some parents will want to rate their child on the degree to which the symptoms of A.D.D. are accompanied by an angry, defiant, and oppositional attitude or behavior. That is something more complex than A.D.D. alone, and behavior management becomes extremely important. These children are the ones who are at risk for getting into trouble with the law, especially if they grow up in difficult family situations. One frustrated parent opened a counseling session with Dr. Bill, pleading, "I just want to keep him out of jail."

(From The A.D.D. Book by Drs. William Sears and Lynda Thompson)

STEP 2: ASSESS THE SEVERITY OF THE PROBLEM. In addition to describing your child by completing the checklist, you should also think about how the problem behavior affects your child, you, and the rest of the family. Does it cause occasional inconvenience, or are the child and family under constant stress? Perhaps the child's differences are a minor problem that time and maturity will resolve. Or perhaps the child is an average kid, but he is in an academic setting that is a poor match for his abilities or learning style, making the difficulties really a situational problem. To help you assess whether this problem is a "biggie" or a "smallie" and to pinpoint where the child is having the most difficulty (home, school, play), complete the A.D.D.-Q Supplement.

THE A.D.D.-Q SUPPLEMENT: THE EFFECTS OF MY CHILD'S BEHAVIOR. The next section gives you an opportunity to think about your child's and your family's need to change things. How severe is the problem?Never or very rarelySome-timesA great dealAlmost always

1. My child's behavior keeps me from liking him.

2. My child's behavior is causing family problems

3. My child's behavior is interfering with our marriage.

4. My child's inattention is keeping her from learning.

5. My child's behavior makes it hard for him to keep friends.

6. My child seems to be bothered by her behavior

7. Underachievement is resulting in lower self-esteem

TOTAL CHECKS FOR EACH COLUMN

SCORE: (The total number of checks for each column multiplied by 0, 1, 2, and 3

x 0 = 0x 1= x 2= x 3 =

STEP 3: GET INFORMATION FROM SIGNIFICANT OTHERS. While parents are undoubtedly the experts on their child's behavior, they may find it hard to be objective. Love and constant proximity make parents more accepting of their child's quirks; yet the child has to function in a society that will be less tolerant. Some children function well at home but fall apart at school. Some children learn well with one teacher yet clash with another. Children with A.D.D. have cross-situational problems, that is, the difficulties occur at home, at school, and with peers. If problems occur in only one area or situation then it makes sense to change that situation rather than change the child. To get a broader perspective, ask for observations from your child's teachers, caregivers and any other person who spends time with your child and whose observations you value.

My child's teacher observes:

My child's caregiver and/or other adults observe:

My child's friends observe:

STEP 4: DISCOVER YOUR CHILD'S SPECIAL SOMETHING. If you have read and enjoyed Calvin and Hobbes comic strip, you'll agree that A.D.H.D. boys have a certain charm, even though they are a handful. If you haven't met Calvin and his stuffed tiger toy, we highly recommend you purchase one of the anthologies. This cartoon will teach you more about the imaginative and energetic side of A.D.D., as well as the challenges it presents at home and school than you would learn in the same time spent with a specialist. And laughter is, in our view, your most valuable survival tool!

Remember that A.D.D. is only a description of a difference. A child who has this difference needs to be recognized and helped before it becomes a disability. There are two sides of the coin for each special trait found in children with A.D.D. Each trait can be an asset or a liability; it can work to the child's advantage or disadvantage. A child's personality is like a flower. Parents and teachers are like the gardeners. They cannot change the color of the flower or when it blooms, but they can prune the plant so that it blossoms more beautifully.

What qualities make your child special, valuable and delightful? What positive things do you have to say about your child? Is she creative, enthusiastic, persistent or artistic? List the qualities in your child you don't want to change.

Recognizing the positive side of your child's personality lessens the chances of him being over treated, inappropriately treated, or simply drugged for a caregiver or teacher's convenience rather than for his own well-being. Consider the following example of a child who was medicated for A.D.D. with hyperactivity.

Billy's parents were divorced, and Billy lived with his mother during the week and with his father on weekends. During the week Billy's behavior was made tolerable by drugs. On weekends, his Dad refused to give his son the prescribed medication. A social worker doing a home visit found dozens of magnificent drawings that Billy had done at his father's house, when not under the influence of medication. His creativity had been masked by medication. At his mother's home he behaved "better" but was less creative.

The fundamental question that parents, teachers and professionals must ask, especially when considering medication, is whether the treatment is for the convenience of the caregivers or the well-being of the child. By looking at both sides of your child's personality you and your child's helpers, like gardeners, are more likely to focus on providing the right soil and careful training of the vines rather than on using heavy artificial fertilizers.

I could better accept my son's behavior once I began looking for progress, not perfection."

QUALITIES I DON'T WANT TO CHANGE 1. 2. 3. 4. 5.

STEP 5: ANALYZE HOW THE PROBLEM IS PROGRESSING. Is your child's learning or behavior problem getting better, worse, or staying the same? This is an important piece of the puzzle only you can provide. Is your child growing out of the problem, or is your child growing into worse problems? Pick out the problems that seem to cause the most difficulty for you and your child and chart the progression. Problem Getting Better Staying the Same Getting Worse

STEP 6: SELECT THE RIGHT PROFESSIONAL HELP. Some parents may decide that they need assistance from an A.D.D. specialist as they are working through the previous steps. A professional can help in the process of assessing your child's difficulties as well as in deciding what to do about them. Many A.D.D. specialists will have their own checklists or questionnaires for you to complete.

Management of a child with A.D.D. requires a multidisciplinary approach. Your child may visit a variety of specialists (psychologist, learning specialist, behavior therapist, neurologist, ears-nose-throat specialist, etc.) during the process of diagnosing and treating his difficulties. Yet you must have one team quarterback who looks at what's happening all over the field and decides on an overall plan of attack for your child, the teachers, and the family. In many cases, parents become the quarterback.

Sports can be either a positive or a negative experience for A.D.D. children. Exercise helps them burn off excess energy, yet some teen sports can be frustrating because these children have difficulty listening and following the rules. After-school sports are especially valuable in allowing a child to release penned up anxiety at the end of a stressful academic day and to tire the child out so they are more mellow and easier to live with during family time in the late afternoon and evening. Here are some tips for matching child and sport:

• Start early. A younger child develops more a positive attitude about sports because the rules for young children are simpler, and the games are less competitive.
• Match the child's temperament to the sport. Set your child up for success. If your child cannot handle group situations in swimming class, for example, get semi-private or private lessons first, until the child feels confident. Confidence goes a long way toward helping the child with A.D.D. settle down long enough to cooperate in-group instruction. If your child likes to move around, she will be better off playing soccer than baseball.
• Match the child with the right position on the team. As a Little League coach, Dr. Bill would place the children with A.D.D. on the infield rather than the outfield. When they play outfield, they literally acted as if they were out in left field. They would watch birds, pick dandelions, and pay attention to anything but the batter. On the infield, they had to pay attention because there was more action. On the other hand, he sometimes worries that the particularly spacey infielders might get hit with the ball.
• Be patient. Don't be too disappointed if the child's interests wane once he discovers he has to work at his skills. Many kids are like this, but it is more extreme with children who have A.D.D. Not only is their attention more difficult to hold, but they also lack the patience for gradual improvement. They want to be at the professional level instantly.
• Don't invest too much in equipment until you know that the child will stick with the sport.
• Practice with your child. Your child will maintain her interest if she has more skills before she joins a team. Practice a lot in the two or three weeks before official practice starts. Children who feel confident and succeed are much more likely to stick with a sport.
• Remember that hyperfocus can give an athlete with A.D.D. an edge. In team sports, the child with A.D.D. will usually prefer a position that allows them to lock on and be totally at the center of the action (e.g., a goalie or center in hockey, pitcher, catcher, or first base in baseball).
• Consider martial arts, such as tae kwan do or karate. These sports can be therapeutic for the child with A.D.H.D. because they allow the child to be aggressive but in a controlled way. The child must stand in a certain spot and listen to instructions. He is more attentive because the instructions make sense and have immediate relevance to him.

Think of neurofeedback as weight training for the brain. If you want to build up your muscles, you go to a gym and start an exercise routine. With neurofeedback, you go to a training center and build up your brain so that you can concentrate better. For a child, it's like going to gymnastics or piano lessons.

The procedure is simple. Sensors are placed on the scalp, held in place with a special gel. Fine wires from these sensors conduct electricity from the child's head to a recording instrument that registers the different frequencies and amplitudes of the brainwaves produced in the area of the brain being monitored. Changes in the patterns show whether the person is paying attention and sitting still (or more accurately, suppressing the impulse to move.) In an EEG, the brainwave tracing is shown as a wavy line. In neurofeedback training, the computer converts the brain waves into game-like displays, a fish moving through a maze, puzzles going together, or images like a rising sun. The colorful displays are paired with sounds to give auditory feedback as well. The child's attentiveness controls what happens on the screen. Children can play the game only by controlling their level of concentration.

If the child's mind wanders, as it does when he "spaces out" in class, the colors on the monitor screen change or the action stops. The better he sustains his attention, the faster the activity on the screen changes. With most neurofeedback systems, the child also gets points, which can be converted into rewards.

The games can be adjusted so that children can be successful no matter what level of concentration they begin with. They have fun. They may be doing things such as playing basketball on the screen ( the opponent scores if the child's attention wanders) or moving a fish through a maze. The child feels successful and, at the same time, he is altering his brain physiology. Just as an athlete uses weight training to build up his muscles needed for the sport, the child is exercising and producing beneficial changes in his brain (settling down, attending, concentrating), which will help him pay attention in school and elsewhere.

With neurofeedback the child is exercising the nerve pathways that control attention and mental processing. As these neural pathways are exercised, children develop a sense of what concentration feels like, and they get excited about it. After practicing these exercises over a period of time, the pathways involved in attention and learning seem to work more efficiently. This enhanced brain activity becomes a natural part of the child's functioning. (For more information about neurofeedback for A.D.D., See Resources for A.D.D.")

Whether your child complies or defies often depends on how you phrase your request. Children with A.D.D. require clear, concise instructions, presented in a way that will sink in.

1. Use a nice voice.

• Lower your tone. A high-pitched voice irritates and turns off listeners.
• Speak slowly. Speaking too fast causes the child to tune out.
• Be brief. Use simple words and simple sentences, otherwise your child may become parent-deaf.

Refuse to listen to a child that yells. Say "When you can speak in a friendlier tone or 'nice voice' come back and we'll try again." Respect is contagious. If you model it as something you expect, your child will learn that everyone should be respected, including him.

Settle yourself first. Talk to yourself before you unload on your child. When you're angry and upset, you'll show these feelings to your child, causing him to withdraw or react to your feelings and miss what you're trying to say. Get your emotions and body language under control before saying a word.

2. Settle your child. Your child cannot process your directives if he's upset. Calm your child until he is settled enough to be receptive to what you have to say. Show him how to take a deep breath. Let him count to ten, take a time-out to cool down, or take a walk around the block. This will be easy for him if he sees you model this coping skill when you get upset.

3. Looks speak louder than words. Your child is receiving messages even before you open your mouth. Your facial expressions and gestures can either open the child up to what you have to say or turn him completely off. If your body language says confrontation, don't expect cheerful compliance from your child. Use the "I mean business look.". Your raised eyebrow reminds her that she's off track and is not to proceed with this behavior. But be sure to give approving messages as well: a smile, a nod, a happy face, and an arm around the shoulder – all conveying praise for a job well done.

4. Connect before you direct. With young children, get down to the child's eye level. Engage your child in eye-to-eye and hand-to-shoulder contact. Begin doing this when your child is a toddler: "Mary, I need your eyes" or "Tommy, I need your ears." With practice you will learn how to engage your child appropriately: not so intense a gaze that you make your child uncomfortably withdraw, yet engaging enough to hold your child's attention, show her you really care, and underline the importance of what you have to say. An observant teacher and mother of an A.D.D. child related this connecting tip: Children take more in when you're on their "dominant side." If you don't know which it is, assume it's the right side (left for left-handers). Every little bit helps.

Dr. Bill notes: As a Little League coach, to get the attention of wandering little minds and eyes, I sit the team in the dugout and say, "I need your eyes. I need your ears."

Some teens perceive eye-to-eye contact as controlling rather than connecting, so you may find a more willing listener while you're doing dishes or driving together rather than in face-to-face conversation.

5. Use "I messages." Try non-threatening openers. Begin your request with "I" or "we" instead of "you." Instead of "You left your dirty dishes on the counter again," try "We put our dishes in the dishwasher so the counter stays neat." Or "I am so tired of tripping over this hockey stick" instead of "You never put your things away." "I" messages do not place blame, so they take pressure off the child and encourage him to look at the situation from another person's point of view. "You" messages put the child on the defensive, so that he's likely to clam up or fight you. "I" messages give him a gentle reminder to think through how his actions affect others. "I felt great when I came into the kitchen and the counter was clear." "I like it when you take out the garbage without being asked." "I felt relieved when you left a note saying what time you would be home."

6. Try the sandwich technique. The first slice of bread is a compliment; then feed your child the meat of the sandwich – which is the point you're trying to make; the second slice of bread is another pleasant, positive statement: "The cover on your homework project looks terrific. The teacher will want you to explain in words what you've drawn so beautifully. I know you have some great ideas."

7. Avoid negative words. Refrain from undermining your compliments. If you say, "The cover on your project looks terrific, but you didn't finish the write up," the "but" statement cancels out your positive opener. Give your child time to process your compliment, then state your directive positively, "….Now, let's finish the writing…"

8. Value your child's viewpoint. Some children with A.D.D. are verbally hyperactive ("motor mouth)," and parents may tune them out. Teens, especially, are put off when they perceive that you don't appreciate their viewpoint. You don't have to agree – often you won't, but your child expects you at least to listen. Children with A.D.D. need to know that their viewpoint is valued.

9. Legs first, mouth second. It's time for dinner and you call, "Turn off the TV and come for dinner!" Some children will immediately come, especially if they are hungry. The child with A.D.D., on the other hand, is probably in a state of hyperfocus in front of the computer game. Instead of hollering at him, walk into the room and watch the program with him for a few minutes. Then during a break in the action, tell him "It's time for dinner" and have him turn off the computer.

10. Give advance notice. Children with A.D.D. do not transition well. Because they are egocentric, they do not willingly switch from their agenda to yours. If they are in the state of hyperfocus, they have difficulty complying with your desires. If you are planning a family activity, tell your child the day before or that morning rather than suddenly springing it on him. If your child is deeply involved in his play activity, give him time to sign off: "We're leaving soon, say bye-bye to the toys, bye-bye to the balls, bye-bye to the trucks," etc. If you are ready for him to go to bed but he isn't, let him make the rounds to all the guests, "Say night-night to grandmother, night-night to grandfather, night-night to Aunt Nancy…" By getting behind the eyes of your child and respecting his need for gradual transitions, you avoid battles and encourage compliance. Most people readily give advance notice to toddlers, but older children and adolescents with A.D.D. also need to transition slowly.

1. Stop signals. It's not enough just to tell your child not to be impulsive. You've got to show him how to control his impulses. Give him some "think it through first" tools so he knows what the consequences of his actions will be. Plant this sequence in your child's mind: Before you do it:

• Say to yourself, stop!
• Count to ten
• Imagine what will happen if you do it.

2. Do it together. The school-age child with A.D.D. is more likely to cooperate with your request if you do the task together. The three-or four-year- old with A.D.D. is unlikely to complete even small tasks that you assign, since they often can't pay attention to one task for very long. Don't be upset! This is a wonderful opportunity to model "helping each other."

3. Count your messages. Remember what we said about how important it is to frame your child in a positive way. Here's an exercise to help you judge whether you are giving your child predominantly positive or negative messages. Choose a day where you will be spending a lot of time with your child and count the number of positive and negative messages you give. This can be done mentally, on paper, or by using the green counter / red counter technique. Get two golf-score counters, the kind you can wear on your wrist in two different colors. Put one color, say red, on the left wrist and use it to count every time you give a negative message with words, tone of voice, or your actions. Put another color, say green, on your right wrist and count every time you compliment or praise your child or give him any kind of positive message. You can also use this technique to see what kind of messages you and your spouse are giving each other to see what you are modeling for your child. At the end of the day, you may be shocked to see that you scored 20 to 50 red messages, yet only 5 to 10 were green. Now that you're aware of this, try to change your ways. With thought and effort, you can reverse this! Your child's self-image will improve, and so will your image of him.

4. Be specific. A child who has attention differences will experience trouble when given subtle directions, gentle persuasions, and reasoning techniques. Many children with A.D.D. simply do not understand communication that is not crystal clear and to the point. 5. Identify triggers. Parents of a child with A.D.D. have many job titles, and one of these is detective. Stake out your child's behavior and, based on your observations, list what situations encourage good behavior and what situations trigger bad behavior. For example, many children behave best in the morning, but behavior may deteriorate when dad goes out of town. Some children do well when playing with one or two friends, but become aggressive in crowds of three or more. Construct a behavior profile to help you recognize in what situations your child behaves best and worst. You might do a behavior profile on yourself. When are you at your best and worst? It helps to know both your child's limits, and your own.

6. Structure the day. From your child's behavior profile you know what situations bring out the best and worst. It's certainly easier to shuffle your daily schedule than to change the temperament of your child. If your child's behavior is best in the morning, plan activities such as playgroup, outings, shopping trips, and preschool in the morning. If your child falls apart in the supermarket at 4 p.m., don't even think about shopping at that time. If your child needs time to unwind after school, save homework for after supper.

Structure the child to fit the day. While it's often easier to change your plans than change your child, some situations are not very flexible. If dinner at grandma's house is scheduled for 6 p.m. and that's not negotiable, play ahead. Think about what you and your child will be doing during the visit and come up with a play-by-play plan for setting your child up for good behavior. Have your child take a late afternoon nap. Talk with your child about what kind of behavior you expect and what activities are going to occur that evening. Take along quiet toys, and be prepared to spend enough time interacting with your child and monitoring his activities, so that your expectations have some hope of being realized. Plan on leaving before your child's behavior starts to deteriorate.

Occasionally, you may need to lie out the child's whole day on paper, to create structure where the child sees none. Start with the attitude she has when she gets out of bed, how quickly she dresses herself, brushes her teeth, eats breakfast, gets ready for the school bus, or says "yes" to each of your requests throughout the day. With each step successfully completed, she gets a star or point on a reward chart. Once your child realizes how much happier you both are when a day goes smoothly, this feeling becomes self-motivating.

7. Structure the classroom to fit your child. If a visit to your child's classroom reveals distractions in the classroom, see what you can do to restructure his environment. Ask to have your child seated in a less distracting place, away from windows or a distracting classmate, and closer to the teacher. If you notice the classroom environment has a rowdy zoo-like atmosphere, ask to have your child transferred to a calmer classroom, where the teacher has a more structured disciplinary system.

8. Hire a model. When Peter was eight, I hired one of his friends to model some exemplary behavior for him, figuring that if he saw one of his friends acting a certain way, he would be more likely to model it.

9. Match playmates and personalities. Kids with A.D.D. often choose the wrong friends because they're attracted to colorful, flashy, interesting things – including people. If you notice Amy plays well with Sara but clashes with Becky, realize that she is not yet ready to cope with a child with Becky's personality. In time you can help your child play compatibly with a wide variety of children, but for now, limit play dates with Becky to times when you can supervise the children closely. Remember, circumstances in life are seldom ideal, and you must give your child the tools she needs to succeed. This requires being your child's facilitator.

10. Match child and toys. If Brian is a thrower, structure his toy choices. Brian would do best with foam blocks that can't be turned into dangerous projectiles. If he throws his wood blocks, they get "time out". If you don't like noisy gunplay, put the toy guns away, or reserve them for outside. If toy squabbles occur between siblings or playmates, time out the toy or teach the children to take turns using a timer.

11. Busy the bored child. A bored child, especially one with A.D.D., is a set-up for trouble. And a bored child with a busy parent is a high-risk mismatch. Many children with A.D.D. are unfairly labeled as behavior problems, when they are simply bored. Busy these bundles of energy with activities that sustain their interest before they deviate into undesirable alternatives. Recognize, too, that the announcement "I'm bored" may mean a child needs your attention, not just something to do.

12. Catch the child in the act of being good. This commonsense principle is the oldest behavior modification technique around: catch the child in the act of being good and praise him. Your grandmother probably used this technique; you may remember the warm feeling you got as a child when a parent or teacher recognized your good efforts. Yet, this simple technique is often neglected. It's our human nature to focus on the child's "bad" way of acting. Bad behavior draws more attention than good behavior. Parents and teachers are more likely to correct or punish misdeeds than they are to praise good ones. To a certain degree, this is defensible. Studies show that parents and teachers are more likely to react negatively to children with A.D.D. than to children without the A.D.D. style. Adults become worn down by the energetic and persistent characteristics of these children. They jump on the negatives, and the positives, which may be infrequent, go unnoticed.

Children must learn that good behavior is expected and that it's not always praised or rewarded. Yet, they must also learn to like the way they feel when they behave well. Your praise and recognition will help your child prefer good behavior, even when it's not easy. If only bad behavior draws attention to the child, he will behave badly just to get reassurance that someone is noticing him.The good news is you can change these messages by practicing a few well- chosen words: "Great job!""Way to go!""Yesss!""I like the way you used a lot of color in that picture""Thanks for helping with supper.""That makes me happy."Basically you are saying to the child, "I like you, I think you're great!" The child is getting a lot of positive messages from you in the form of genuine praise. And if your child feels that you like him, he will like himself.

13. Try rewards. Rewards capitalize on the pleasure principle: behavior that's rewarding continues; behavior that's unrewarding ceases. Pet trainers use this principle; so do dolphin trainers at Sea World. Kid trainers can use positive reinforcement, too. Yes, rewards are bribes. If the word "bribery" offends you, call them "incentives" or "motivators" instead. You may feel skeptical about reward systems, believing them to be external gimmicks that don't really change your child from within. This is a valid criticism, since the ultimate goal is to give the child inner motivation and points or prizes alone will not accomplish this. Yet, reward systems are useful as a starting point, especially when nothing else seems to be working. You can use a reward system to redirect a negative child and give him a taste of success. Eventually, the child gets used to the good feelings he gets from all those "points" or "treats". These good feelings then become the child's own internal reward and motivate continued good behavior. Eventually, you can reduce the external rewards and just rely on social rewards, like smiles and praise.

A child's behavior affects the parents' behavior. Undesirable behavior in children often leads to unrewarding behavior in the parents. You need to shift from that kind of negative spiral to a positive feedback loop. Once your children see how much happier you are when they behave, your attitude toward them becomes another social reward.

MATCHING THE RIGHT REWARD SYSTEM FOR YOUR CHILD

• Use social rewards more than material rewards. Choose rewards that bring you and your child together to do something fun. This prevents you from feeling like you're a behavioral scientist dangling bits of cheese in front of little rats to guide them through the maze, and your child will see that your family values people more than things. Toy rewards seem to be more popular with younger children. As they get older, either combine or replace them with social rewards. Keep the child connected to people (e.g., "This coupon is good for one lunch date with Mommy or Daddy" or "When you finish putting away your toys, we'll sit down and play a game together.")
• Let your child help choose the rewards. "If you could choose a special place to go or a special thing to do, what would you choose?"
• Choose immediate rewards. Children with A.D.D. can't wait. Rather than a big treat at the end of a week of agreed-upon behavior, issue smaller rewards sooner. You are likely to get better results. The younger the child, the more frequent the payoff should be. Toddlers may need hourly, or at least daily, rewards; preschoolers need daily rewards; school-age children need weekly rewards; teenagers can hit the jackpot at the end of the month.
• Use reward games that the child likes. Remember, the child with A.D.D. tends to get bored with the same game. Change the game, or the way you play it, as needed.
• Relate the reward to the behavior you want changed. "When you show me you can keep your room tidy for a week, then we'll get bedroom furniture for your dollhouse."
• Should you take away points? When you're using positive reinforcement to shape behavior, it's important to give your child the message that nothing detracts from the good he has done. If you're making an effort to give your child positive messages rather than negative ones, you may not want to take points off the reward chart. For some children, the two-steps-forward-one-step- back approach may be too frustrating. Others respond well to the "give and take" method. Using both give and take is more realistic in preparing your child for real life.

6 CREATIVE REWARDS THAT WORK

These are systems that we have used in our own families or suggested to parents of children with A.D.D..

1. Tickets and tokens. Depending on the age and motivation of your child, you may have to give reward tokens every few minutes, hourly, or at the end of the day. Tickets and tokens are particularly useful to keep the wandering little mind on task. Break up a job or a homework assignment into small parcels, and issue a "job done" ticket at the end of each step. Once the goal is reached, present your child with a special double-value ticket.

2. Connect the dots. This technique provides small, frequent rewards to keep a child on task and to give a visual gauge of how much progress is being made toward the long-term goal. After you have identified the behavior you want to change ("Each time you are dressed and ready for the school bus on time with no nagging…"), have your child draw a picture of the reward you have agreed on. It may be a bike, a toy boat, a doll, a ball or a special outing. Then use dots about an inch apart to outline the picture. With each good behavior, the child connects one of the dots. When all the dots are connected, she collects the treat. You can also use this reward technique to remind children of their responsibilities. Each time they remember to put away their toys, clean up their room, or take out the trash, they can connect a dot. Focus on positive behavior (erasing lines doesn't work very well). Display the picture in a high visibility location, such as on the refrigerator or on the kitchen cabinet, and at your child's eye level. This reminds the child of the expected behavior and allows her to proudly display her progress.

3. Happy and sad faces. Make or buy stickers with happy and sad faces. A grumble or negative response to a parental request gets a sad face on the chart . Cooperation, or a positive response merits a happy face. When happy faces outnumber the sad faces on a predetermined number of days, the child collects the prize. Do not use this approach unless you're sure the happy faces will prevail. 4. Happy hands. This motivator helps remind the child of his responsibilities and provides rewards for good behavior or a job well done. Place your child's hands on a piece of paper and draw an outline around each finger. Above each finger write or draw a job (or desired behavior) the child has to complete. The left hand could list morning jobs and the right hand after- school jobs. As the child completes the job he colors in a finger and gets a happy-face sticker above the fingertip. When both hands are filled in, your child gets a special treat for having "so many happy faces on his fingers." You could also dub this game, "Hands for remembering."

5. A behavior bus. Draw a big bus with square windows and write the job (or desired behavior) to be accomplished in each window. The goal is to get a happy face sticker on each window. Once the bus is filled with happy faces, the bus drives on to get the prize.

6. "Give-and-take" systems. A reward system can be used to accomplish two goals: to encourage desirable behaviors and to get rid of undesirable ones. The give-and-take technique accomplishes both. You put a dime in the jar or a point on the chart for desirable behavior, you take a dime out of the jar or a point off the chart for bad behavior. Or you could start the day with five dimes in the jar, and take one out for every "no" you get from your child and add one for every "yes." Just be careful you don't let your child get into a negative balance and end up owing you money.

THE GOOD BEHAVIOR CANDLE
As a Cub scout leader, here's a trick that I (Dr. Bill) has successfully used to hold the attention of a dozen rowdy nine-year-olds and keep them on task. At the beginning of our meeting, we light the good behavior candle. As long as there are no disruptions the candle stays burning. As soon as someone disrupts the meeting, the candle gets blown out. As soon as the candle burns all the way down the group gets a special treat. Naturally, it's in everyone's best interest to keep the candle burning, so they help keep each other in line. You can adapt this technique to get siblings to work together on a job or to improve family table manners at dinnertime. Don't use this technique, however, if one child is going to be frequently singled out.

14. Shopping strategies. Supermarket shopping and children with A.D.H.D. is not the best match. Even if you survive the trip up and down the aisles, avoiding the breakables and the junk food, waiting in the checkout line is bound to do you in. Appreciate a basic principle of behavior modification: If there is a major behavior you want to shape, begin with baby steps and progress gradually. Here's a sequence to set the child up for successful shopping.

Begin with a small store and look in the window before entering to see if it's busy. Go in the store to purchase one item, say a container of milk. Have the exact change ready when you enter the checkout line and have your child pay the cashier. When the child leaves without whining and has behaved in the store according to the prearranged agreement, he gets a point and a reward. The next day go to the same store and get two or three items.

Generalizing
Many children with A.D.D. have trouble transferring the rules learned in one situation to another situation; they have difficulty generalizing. Your child may know what she may not touch in your house, but don't expect her to respect the same "no touches" when she goes to Grandmother's house. You must make your rules exceptionally clear and simple and repeat them when the situation changes. "Just like at home, we don't put our feet on the furniture at Grandmother's house."

• Gradually increase the size of the store, the number of items you purchase, the number of points your child gets, and maybe even the size of the reward.
• Finally, try the supermarket. Select the time of the day when your child is at his best, usually the mornings. Tell him what you're going to be doing and the kind of behavior you expect in the store. Set up a point system on your shopping list. List the items you need to purchase on your shopping list in one column and categories of good behavior on the other. You can assign a certain number of points for aisle behavior, checkout counter behavior, and helping behavior. Agree on a reward before you enter the store and write it down and draw a picture of it on your shopping list. This helps prevent tantrums. Let your child help pick out the items, and also let him check off each item on the list. As he does this, award points for good behavior. When you reach the checkout counter, your child will have earned his treat.

Jill, mother of five-year-old Andrew, came in to my pediatric office for counseling and confided to me, "Our whole day is spent in conflict with each other. I find myself constantly saying "no" to him. Andrew won't obey even when I ask him to do the simplest things. I want to be a happy mother, but I find myself becoming increasingly cranky."

I suggested she try a reward system. I said, "Tell Andrew exactly the behavior you expect. Say to him: "I want to be a happy Mommy, not a cranky Mommy. Let's try to have more 'yes days.' Then Jill made a chart with Andrew to keep track of yeses and nos. She told him, "Every time I ask you to do something and you say "Yes, Mommy" we'll put a "yes" on the chart. At the end of the day if there are more yeses than no's, that's a "yes day" and we'll do something special together." Soon Andrew realized that the happy Mommy was more fun to be with than the cranky Mommy, and they began to have more "yes" days. Also, Jill found that Andrew absolutely hated to lose points, so occasionally she would add a "take-away" slant to the reward system. She began the day with a dish of ten dimes, and for each "no" she took one out. Varying the game and the approach held Andrew's interest and got more consistent results. Eventually, they were able to have "yes" days without the chart and the reward.

15. Give reminders. "She's twelve-years-old! Do I still have to remind her to brush her teeth?"Reminders are words, pictures, checklists, or brief notes that jog a child's lazy memory and keep them from forgetting rules and routines. Frequent verbal or visual cues can keep an active mind on task. If you know from experience that your child is likely to get sidetracked on the way upstairs to brush her teeth, when she reaches the top of the staircase, call out a gentle prompt, "teeth." A certain look may remind the about-to-mess-up child that he knows better, or a short verbal cue can steer him toward the expected behavior ("Where do jackets go?") Reminders could even be in the form of pictures. To remember what he has to take to school help your child draw or paste a picture of a backpack on a piece of paper, and around it draw or paste pictures of items that go into the backpack each day. Tack this poster next to the door he uses in the morning.

Every child needs a few of these prompts every day (so do spouses). The child with A.D.D. just needs more of them. Reminders are more likely to be followed than a barrage of daily orders because they don't provoke a power struggle. Your child already knows the rules. Your reminders just start the memory process going and prevent a behavior problem from occurring. As you enter the supermarket you say, "Remember, we walk down the aisles."

"But I forgot." As lame as this excuse sounds, all children forget. Children with A.D.D. forget more often, so they need more reminders. During a particularly intense day your child may need hourly, sometimes minute-by-minute, reminders. Use all the positive verbal and body language you can muster up: "I need your eyes," "You're forgetting…" "You know what to do…" Be sure the art of reminding doesn't deteriorate into the hassle of nagging. Keep your body language positive, your voice light and happy, and your manner more playful than authoritarian. Then your child is likely to perceive your constant prompts as help rather than nagging.

To avoid nagging, once your child can read, write your reminders on little post-it notes for your child. Try some humor: "Dress the bed, then dress yourself;" "Your lunch is packed and in the refrigerator asking to be eaten." If you have an artistic flair, illustrate the notes.

16. Count your child. During your early disciplining, you may have frequently used countdowns, such as, "I'm going to count to three…," expecting your child to behave positively by the time you hit three. Our four-year-old daughter "hops to" at just the mention of counting. She prefers to behave on her own. She knows that once "three" comes, she's going to be physically assisted in cooperating, and she will do anything to avoid being picked up and carried like a baby. You can also teach your child to use counting to control his own impulsive behavior. Counting can be a cue to help him "think before he acts." Help him learn to do this by catching him in the act: "Before you throw the toy, count to five, and then imagine what might happen." The next time your child is about to act impulsively, issue a reminder, such as, "Count to five," or "Wait a minute," or "Imagine what might happen." Repeat these drills so that eventually he will be able to use this skill on his own.

Remember, one of the main challenges for children with A.D.D. is to teach them to "look before they leap." Teach your child to internalize his own counting drills and use them to control his impulsive behavior. Psychologists call this process of having an inner dialogue to guide behavior "internal verbal mediation." Teaching your child to have a dialogue with himself is a useful skill in developing self-control. 17. Card your child. This technique is a sort of warning system that gives your child time and space to change disruptive behavior before it gets worse. It also buys an angry, impulsive parent time to plan a gentler strategy. Get three cards, each a different color, and draw a face on each card, each one sadder than the previous one. You can use these cards as they are, or you can glue a magnetic strip to the back of each one to stick them to the refrigerator. When your child begins a disruptive behavior, give him the first card or stick it on the refrigerator door. If the behavior continues, the second, sadder, card goes up. If this doesn't prompt him to change his behavior and you have not yet come up with a better strategy, the third and saddest face card goes up. If your child is still misbehaving after all three warning faces are on the refrigerator (or on the table) then it's time for "time-out" or, preferably, "time-in." One mother tried a very interesting variation on the three-card method. She let her son put the cards up for her, if she started yelling. She gave her son the message that we all can learn from each other. Big people make mistakes, and they also must correct their errors.

18. Try time-in . We have noticed that for many children with A.D.D (and other children, too) the classic "time-out" method of behavior modification doesn't work. Their anger escalates when they are sent to another room for time-out, and they become resentful at being sent away. Time-out reinforces all the negative messages they are accustomed to receiving about themselves. This is why the "time-in" chair works better for many, especially for younger children. In time-in the parent has the child sit in a chair or stand in a corner in the same room as the parent. The child must be silent for a short period of time, but is not isolated. This gives the message that although you will not tolerate the behavior, you are not rejecting your child. Children three and older can be given a count of three to sit down. If your child does not sit, state firmly the one-minute time-in is now two minutes. Repeat this procedure raising the number of minute until the child sits in the chair. Screaming or abusive arguing from the child while sitting adds minutes until it stops. You must decide beforehand how long time-in will last. Obviously, fifteen minutes is too long for younger children. We prefer short times, no more than five minutes.

With the time-in method you don't have to carry, drag, or otherwise force your child upstairs or into a room. Time-in also spares the child's room from being trashed out of anger and resentment. While the child is sitting in the time-in chair, stand next to him. This positioning makes it difficult for the child to suddenly move out of the chair. You may even stand behind your child with a hand firmly, but lovingly, on his shoulder. Or you may stand in front of him with your hand on his shoulder. (Some children with A.D.D get upset if they are touched.) The child will find it difficult to get up out of his chair with you standing in front of him. Young children, and particularly young children with A.D.D., dislike doing nothing, even for a very short time. Time-in will get the corrective message across very quickly. One minute for each year of life is a good guideline for the length of a time-in.

Occasionally, parents may have to tell a child in a time-in that they are going to help him by holding him. This gentle, but firm, holding reinforces closeness and caring, not anger and control. This can protect a child from throwing himself into an extreme temper tantrum in which he might hurt himself.

MORE TIME-IN TACTICS
With preschoolers, try the teddy bear chair technique. When a child needs time- in, have her put her teddy bear (or any other favorite doll or stuffed animal) in a chair. Then both of you can talk to the bear about behaving better. This bit of playacting uses "time-in" as simply a break in the action to allow her to think about her undesirable behavior and to change what she is doing. Time-in also gives parents a chance to cool off and plan a better discipline strategy.

The timer alternative. Use a kitchen timer. Tell your child he has to sit quietly for three minutes. Turn the dial on the timer to three minutes. If he fusses or doesn't sit down by the count of three, then start the timer again. Restart the 3-minute time-in every time the child starts to argue. Children tend to respond to the demonstrative action of restarting the time-in period. Eventually, some children, after acting out, go to their time-in seat and set the timer themselves.

Give bonus points if the child explains his point of view calmly after time- in. Tell your child that you want to understand why he did what he did, but he must sit quietly for one minute first. If he explains his reasons calmly, reward him with points. Then ask: "What would you like to do when we are through?" This may get both of you headed in a more positive direction.

19. Try take-aways. By the time your child is five years of age, you can increase time-ins to five minutes. Once you reach the five-minute mark, tell the child that you are going to take away something he likes (don't say what) if he doesn't sit by the time you count to three. If he continues to be unruly then you say: "I'm now going to take the first ten minutes of your favorite TV program away." You don't tell him ahead of time what he is going to lose, because if you do, he will often just snap back that he doesn't want what you threatened to take away anyway. Think ahead to what you have planned that day. If you are planning to make play dough, that won't happen. Leave yourself with a lot of ammunition. The privilege you take away should be small. Don't take away his bicycle for a week for a relatively minor infraction.

20. Assist the child. "I'm-going-to-do-it-with-you." Here's a technique to try that stops short of taking away privileges. If your child is not doing what you've asked, try counting to three. If this doesn't work, say to him, "Do it or I am going to help you do it!" Use a stern voice as if your doing it with him is a very significant happening. Count to three again, and then act by taking his arm or hand and doing the task that was to be done. This method avoids the trap of repeating your request over and over again and the need to make threats about taking things away. It works, in part, because children like to do things themselves and partly because your stern tone has conveyed some urgency.

21. Use consequences to curb impulsiveness. Choices have consequences, and children must learn this. Because of their impulsiveness, children with A.D.D. are less likely to think before acting. They act before considering the consequences. Making wise choices in life begins with learning one basic lesson: "Think through what you're about to do."

"When…then…" "When your teeth are brushed, then we'll begin the story.""When you finish your homework, then you can go out to play."

Learning from mistakes. Experience is the best teacher and it's often the one that makes the greatest impression. Children with A.D.D. often have to learn "the hard way." If despite your guidance, your child still chooses the wrong path, then let him experience the consequences (as long as there's no danger). For example, your child leaves his tricycle in the driveway despite repeated admonitions to store it in the garage. The bicycle gets backed over by a car. Let him go without a bike for a while. Your child is dawdling despite your frequent reminders that he is late for his baseball game. He sits on the bench for the first two innings.

Imagining the consequences. Help your child imagine what the consequences of a particular action might be. Natural consequences that you have not arranged are happening in everyday life. You can also set up parent-made consequences, customized for a particular situation, that you hope will have lasting learning value. Here is a logical consequence that parents in my pediatric practice tried:

Judy and Tom had just moved into a new house and their four-year-old son, Aaron, was given his own room. He was feeling very proud and grown-up enjoying the privacy of his new room, but door slamming was becoming a problem, especially when he got angry. His parents repeatedly told him that slamming the door was annoying and must stop. If it didn't, he would no longer enjoy the privacy of having a door: his dad would remove it. Aaron got a "Yeah, sure, Dad's going to take the door off" look of disbelief on his face. He continued to slam the door over the next day, so when he went out to play, off came the door. A week later Tom put the door back on, and it hasn't been slammed since.

22. Teach empathy. Teaching empathy means helping your child to understand that his deeds have consequences for others. Tell him about the feelings you have as a result of his actions. ("That makes me feel…") Be sure he makes the connection that positive behaviors from him result in positive feelings in others, and negative behaviors result in negative feelings: "I sure like it when you…" "I feel angry when you…" (Notice we don't say, "You make me so mad.") Help your child get behind the eyes of other people, especially those on the receiving end of his behavior. Give your child practice in thinking about his own and others' feelings: "Do you think she feels sad?" "How would you feel if someone hit you?" Look for the "teachable moments" that crop up nearly every day and give you an opportunity to help your child learn empathy.

One day I saw two eight-year-old neighbor boys perched on the hillside ready to toss water balloons onto cars passing below. Obviously, these children had not thought about the effect of their misbehaviors on the drivers of the cars. This was a teachable moment. I sat down with them and asked them to imagine how they would feel as the driver of a car if a water balloon exploded on their window. They needed to learn to put themselves in someone else's seat. An accumulation of many such lessons over time will truly "put the child in the driver seat" in terms of being in control of their behavior. You want them to get to the point that they think through what the consequences of their actions will be for others rather than being totally focused on their own immediate fun or needs. You may hear that children with A.D.D. are at increased risk for sociopathic behavior, or just plain winding up in jail. Statistically, this is true. Yet the main quality that separates the child who uses his traits to society's advantage and the one who gets into big trouble is the quality of empathy – the ability to understand and sympathize with the feelings of another.

23. Give responsibilities. Giving your child responsible jobs to do is a powerful way to shape behavior. Responsibilities give children direction. When they have jobs to do, they have fewer opportunities for bad behavior. Adults often find their value in their work. They call it "being of use." Children who are given chores feel they are part of a group. They are depended upon, and the family values them. The child with A.D.D., in particular, needs to feel busy and on the move. Give your child special jobs. The word "special" is a good marketing tool and is likely to promote cooperation. Try these tips:

• Give the preschool child jobs around the house: vacuuming, dusting, tearing lettuce for a salad, setting the table, helping with dishes.
• School-age children can do their own laundry, help with the cooking, and pack lunches.
• Create job charts: some jobs might be for pay, others are done for the privilege of living in the home. Give genuine praise for a job well done. Working alongside children is a useful way to keep them on task.

24. Withdraw privileges. Besides all the "gives" that shape behavior, taking away luxuries is another way to keep the child on track. For this technique to have the desired result, it's important that children do not view it as a punishment. If done correctly, what's taken away should be a logical or natural consequence of the child's actions: "If you ride your bicycle without a helmet, you lose the use of your bicycle for two days." Remember to withdraw privileges, not the necessities of life. You don't deprive the child of a hot meal or a warm, winter jacket, but turning off the TV has never caused lasting harm. Losing privileges teaches the child realistic lessons for later in life: privileges are based on responsibility (e.g., If you want to keep your credit card, you must pay the bills.)

Withdrawing privileges works best as a behavior shaper if you have worked out with your child beforehand a mutually agreed upon consequence: "After you finish your homework, you may watch TV." Then, if he does not finish his homework, he already knows that he will not be watching television. As your child gets older, the stakes get higher. With increasing maturity come greater responsibilities, which bring greater privileges; however, neglecting these responsibilities brings more serious consequences.

A.D.D. NOTE To parents and professionals: Consider medication in addition to, but not instead of, other treatments, such as behavior and learning strategies.

HOW RITALIN WORKS
Every time you think or act, messages travel from one nerve to another telling the brain what to do. The messages are carried by neurotransmitters, chemicals secreted at the junction between brain cells to facilitate transmission of messages. Neurotransmitters include the chemicals norepinephrine, dopamine, and serotonin, names you may have run across in reading about other mental and physical disorders. Stimulant drugs are thought to increase, or stimulate, the secretion of neurotransmitters.

Here's the theory that explains why stimulants help the child with A.D.D.: in children with A.D.D., the brain centers that influence attention (learning) and impulse control (behavior) are under aroused, and all the wiggling and counterproductive behavior these children engage in is actually an attempt to arouse these laid-back parts of the brain. By increasing the levels of neurotransmitters in the brain, stimulant medications arouse these learning and behavior control centers so that the child can pay appropriate attention and control inappropriate behavior. Stimulants work on centers of the brain whose function is to inhibit impulsive behavior. This explains the paradox of giving a stimulant to calm the child down. The drug acts like a disciplinarian reinforcing "yes, you may not do that" messages. Stimulant medications are often described as "putting brakes on the brain," but in fact, what they really do is make the brain work better, so the child doesn't have to daydream or bounce around in his seat to keep his brain waves working. Stimulants provide sort of a "zoom lens" that helps the child narrow his focus from general arousal to the task at hand.

ARE STIMULANTS SAFE?
Stimulants are generally regarded as safe drugs. They were first used for hyperactive children in the 1930's, so they have been in use now for more than sixty years. Yet, like all medication, they are not a problem-free pill. I first began prescribing Ritalin for A.D.D. in 1972. Thirty years and hundreds of prescriptions later, I am impressed by how few undesirable side effects occur. When side effects do occur, they are minor and wear off quickly when the drug is stopped. Other physicians have different experiences, and some have observed complications severe enough that they have virtually stopped prescribing these medications. Prescribing and administering Ritalin is a decision parents, teachers, and health professionals must take seriously. The United States Drug Enforcement Administration (DEA) certainly does.

Because of the low incidence of side effects, it is tempting to regard using Ritalin as no big deal. It is even jokingly referred to as "Vitamin R," a sort of "It can't do any harm and it might help" classification. But the DEA lists Ritalin as a Schedule II drug, which means prescriptions for it are carefully regulated. Along with other drugs in this category, such as morphine and barbiturates, it is considered at high-risk for abuse. (The street drug culture would classify Ritalin as speed.) Doctors who prescribe it are required to obtain an expensive narcotic license, renew it every two years, and write the prescription (with annoying perfection) on special triplicate prescription pads provided by the DEA. The doctor retains a copy, the pharmacy retains a copy, and the DEA retains a copy. To further avoid "prescribing abuse" the doctor is limited by law to prescribing a one-month supply and the child must be reevaluated each month. A prescription for Ritalin cannot be called into the pharmacy over the phone; instead, the completed official prescription form must be mailed or handed directly to the patient. If the doctor forgets to cross a "t" or dot an "i" the pharmacist sends it back for fear that someone may have tampered with the prescription. The point is everyone involved with prescribing Ritalin takes it seriously, especially the doctor, the pharmacist, and the DEA, and so must everyone else.

It would be great if these medications worked selectively, that is, only on the brain functions concerned with attention or focusing ability (A.D.D.) or the areas that control movement and impulsiveness (A.D.H.D.), but they don't. Ritalin and other stimulants have a wider action in the brain, which is clear from the four side effects that have been identified by placebo-controlled research: decreased appetite, insomnia, headaches, and stomachaches. Stimulants affect the whole brain, causing both desirable and undesirable neurological effects. Two to four percent of children cannot tolerate stimulant medication because of severe side effects. In addition to what is known, or at least theorized, about how stimulants work, there is a great deal that science does not know. Stimulant drugs change the neurochemistry of the brain, but the long- term effects are unknown. When the action of neurotransmitters is artificially stimulated for a long time, might the brain eventually slow down its own production of these chemicals? By giving a child stimulant medication, you are "fooling" the brain into thinking it makes more neurotransmitters than it really does. Might this interfere with the neurological system's ability to regulate itself?

Normally, neurological systems work on a supply/demand or dose/response biological principle. During the thought process or physical activity the brain processes just enough neurotransmitters to make the right thought or perform the right activity. There is an internal self-regulating system. The problem with pills is they are not self-regulating.

Even though the party line among A.D.D. professionals is that stimulant medications are non-addictive, the attitudes about drugs we are giving our children may have long-term undesirable effects. Also, even though some stimulant medications are listed in the "controlled substances" category, in reality the control walks out the door when the parent leaves the pharmacy. "Control" simply means controlling the doctor and the pharmacy. There is no way you can control what the parent or child does with the drug.

7 SIDE EFFECTS OF STIMULANTS

1. Insomnia. Sleep in adequate quality and quantity is important for anyone's well being. Double that for children who have A.D.D. Individuals with A.D.D. have a low arousal and alertness level when they are involved in boring, repetitive activities, which accounts for adolescents and adults reporting that they have a great deal of trouble staying awake during lectures. This problem is worse for individuals who did not sleep well the previous night. Difficulties with going to sleep and staying asleep can be minimized by giving the last dose of Ritalin no later than 1 p.m., which allows the peak effect to occur during the afternoon school hours yet wear off by bedtime.

2. Diminished appetite. Of course, this is a side effect of stimulants. After all, the stimulant Dexedrine was once used as a popular appetite suppressant. The good news is appetite suppression can be minimized by:

• Feeding the child before giving the pill. Give your child breakfast before the pill begins to take effect. Start your child off with a breakfast high in proteins, calories, and complex carbohydrates that will reach his stomach before the medication reaches his brain. Your doctor or the package insert may recommend giving Ritalin "on an empty stomach" or "a half hour before a meal" because the drug is better absorbed this way. However, if the drug reaches the brain before the food reaches the stomach, the child may neither start nor finish his breakfast. So, in a child in whom appetite suppression is a problem, forget the empty stomach rule. When Ritalin is taken before meals, the child may need to take a higher dose. Discuss this with your doctor. (See)
• Encourage nutrient-dense foods. These are foods that pack a lot of nutrition in a small volume. Examples of good nutrient- dense foods are: avocado, yogurt (regular rather than nonfat), fish (salmon, tuna, cod), granola cereal, cottage cheese, kidney beans, cheese, eggs, nut- butter, whole-grain pasta, brown rice, tofu, and turkey.
• Encourage grazing. Children under the influence of appetite suppressants may be uninterested in big meals and big platefuls. Be more flexible about your child's mealtimes. Allow him to eat when he is hungry. Small, frequent feedings or grazing on nutritious snacks all day long is actually more biologically correct for the human body anyway. Besides, grazing is friendly to the food-mood connection characteristic of some of these children, as it prevents blood sugar swings and the moody behavior that goes with them.
• Drink the meals. High protein shakes, yogurt shakes, smoothies, or whatever nutritious blend your child likes is a fun way to get a lot of nutrition into your child. 3. Growth delay. Is the worry about stimulants stunting growth warranted? (Weren't you always told that coffee would "stunt your growth?") It is generally accepted that in most children stimulants have only a small effect on growth in height and weight. However, children differ, and some children may be affected more than others. Your child's physicians should keep a careful record of height and weight if stimulant medications have been prescribed. Most children who may temporarily have a slowdown in growth catch up when the medication is stopped, such as over the summer months. Nevertheless, parents worry. If stimulants diminish appetite, causing the child to get insufficient nutrition, naturally growth will suffer. There is also some evidence that stimulants directly affect growth by upsetting the balance of growth hormones. High doses given uninterrupted over several years are more likely to suppress growth than lower doses, especially if the child is not given drug holidays during school and summer vacations.

The truth is, the stimulant-growth connection is hard to study, and statistical studies are not applicable to individual children. What would the child's height have been a year later had he not been taking medication? This is an unanswerable question. We are left to use our common sense. Any drug that has a possibility of affecting growth hormones has the risk of aff