Download Myths vs. Facts – Reflections on ADHD

Myths vs. Facts – Reflections on ADHD
Richard Lougy, LMFT
Licensed Marriage and Family Therapist
School Psychologist
&
David Rosenthal, M.D.
Child, Adolescent and Adult Psychiatrist
Published Authors and Lecturers on ADHD
ADHD: A Survival Guide for Parents and Teachers (Hope Press/2002)
Teaching Young Children with ADHD: Successful Strategies and Practical Interventions for PreK-3 (Corwin Press/2007)
The School Counselor’s Guide to ADHD: What to Know and What to Do to Help Your Students (Corwin Press/March/2009)
www.thesekidsaredrivingmecrazy.com
IS ADHD A MYTHICAL DISORDER?

ADHD is not just a temporary state a child will outgrow.

ADHD is not a mythical disorder recently fabricated by drug
companies or the American Psychiatric Association –
descriptions go back to 1902.

ADHD has been researched both in the United States and in
the international mental health community.
THEORY VERSUS SCIENTIFIC FACT

Some educators and parents become confused when ADHD
is described as “just a theory”.

In popular usage the concept of “a theory” often implies
rather weakly supported thoughts.

In science, theories are proposed, then tested and
tentatively accepted or discarded.

If attempts to falsify a theory fail, the theory is considered
likely to be correct, but it is still called a theory.
ADHD IS A COMPLEX SET OF BEHAVIORS

Research has shown that a complex set of behaviors has
been observed in children and adolescents identified with
ADHD.

Core Symptoms: “Holy trinity” - Inattention, hyperactivity, and
impulsivity.

In addition to core symptoms, they can have difficulty
following rules and display tremendous variability in task
performance.

Current research suggests behavioral inhibition or poor
regulation of behavior is the hallmark of ADHD.
DIAGNOSTIC CRITERIA

Essential feature is a persistent pattern of inattention
and/or hyperactivity-impulsivity that is more frequent and
severe than is typically observed in other children of
comparable level of development.

To be diagnosed with ADHD, some impairment must be
present in at least two settings and there must be evidence
of interference with developmentally appropriate social,
academic, or occupational functioning (DSM-IV-TR 2000).
DIAGNOSTIC CRITERIA
Diagnostic Criteria cont.

Signs of the disorder may be minimal or absent:
1.
2.
3.
4.
When the child is under strict control, is in a novel
setting
Is engaged in especially interesting activities
Is in a one-on-one situation
When experiencing frequent rewards for appropriate
behavior.
MANIFESTATIONS OF ADHD
The current diagnosis of ADHD is divided into four categories.
ADHD:
ADHD:
ADHD:
ADHD:
Combined Type
Predominantly Inattentive Type
Predominantly Hyperactive-Impulsive Type
Not Otherwise Specified (NOS)
MANIFESTATIONS OF ADHD
ADHD: Combined Type

A child who presents with predominantly inattention and
hyperactivity, but not significantly impulsivity.

The fidgety child who has difficulty staying in his seat,
difficulty finishing assignments, often loses assignments,
easily distracted by classroom noises, and often forgets daily
routines without reminders.
MANIFESTATIONS OF ADHD
ADHD: Predominantly Inattentive Type

Applies to a child who presents with inattention, but neither
hyperactivity nor impulsivity.

Child is often seen as a daydreamer or an underachiever,
inattentive and unfocused.

Distractibility can be both internal and external.

Child can struggle with organizational skills and has difficulty
finishing work.
MANIFESTATIONS OF ADHD
ADHD: Predominantly Hyperactive-Impulsive Type
•
Child who presents hyperactivity and impulsivity that is
maladaptive and inconsistent with his or her
developmental level.
•
Population of children who bring most challenges to
schools and outside agencies.
•
In the classroom, seem always on the go.
MANIFESTATIONS OF ADHD
ADHD: Not Otherwise Specified (NOS)
•
•
Prominent symptoms of inattention or
hyperactivity/impulsivity that does not meet the criteria for
ADHD.
This population, typically adolescents and adults, still
present with symptoms that are often diagnosed “ADHDNOS” or “ADHD in Partial Remission”.
MANIFESTATIONS OF ADHD
ADHD: Not Otherwise Specified (NOS) cont.
•
•
Even though no longer meeting the criteria for ADHD, they
still can present functional impairment in school and work.
“Late-onset ADHD”: all criteria are met except for onset prior
to 7 years of age. Symptoms may not become apparent
until puberty when teacher demands and expectations in
school are more challenging.
PREVALENCE OF ADHD

Most experts accept a range of 3% to 7% as the percentage of
the population diagnosed with ADHD. Similar percentage in
New Zealand, Canada, and Germany (Hoagwood, et. al., 2000).

Approximately 4.4 million children ages 4-17 years in the
United States have a history of ADHD (Bukstein, 2006).

Male to female ratio: 4:1 for the predominantly hyperactive
type, and 2:1 for the predominantly inattentive type.
PREVALENCE OF ADHD

Over the last three decades, the numbers of children with
ADHD has been increasing.
 250 % increase from 1990 to 1998.
 9.2 % of children in 1996 compared to 1.4% of
children in 1979, an increase of 657%.
 5% among adults in the U.S. population.
 50% to 70% of adolescents continue to show
symptoms into adulthood.
 90% to 95% of adolescents and adults with ADHD
manifesting the inattention component of their
disorder (et. al. Lougy, 2007).
WHAT CAUSES ADHD?

ADHD is a neurodevelopmental disorder with strong
evidence of family genetic risk factors.

ADHD is often described as a “hypodopaminergic
disorder”, or a disorder of self-regulation, often called an
“executive function dysfunction”.

Most current studies suggest that ADHD symptoms are
the result of diminished function of the prefrontal
executive centers of the brain cortex.
WHAT CAUSES ADHD?

An imbalance of dopamine and norepinephrine, two primary
neurotransmitters systems most directly involved in ADHD,
contribute to the symptoms we see in ADHD (Asma, J.,
2007).

These neurotransmitter systems work in concert with each
other to control attention, inhibition, and motor planning

Other parts of the brain thought to be involved are the frontostriatal complex, basil ganglia, and the right anterior frontal
lobe (Asma, J. 2007).
SIGNIFICANT GENDER RELATED DIFFERENCES

There is a difference in symptoms patterns between boys
and girls.

Girls are generally less impulsive while boys present with
more discipline problems.

There is a difference in distribution of ADHD subtypes. Girls
are more likely to have the inattentive type.

There is a gender difference in associated conditions. Girls
are less likely to have a learning disability; lesser risk for
depression, conduct disorder, and oppositional defiant
disorder than boys with ADHD.
PRIMARY SYMPTOMS AND COMMON
IMPAIRMENTS
ADHD probably represents the extreme end of a spectrum
of human traits that we all posses and, as with other human
traits, ADHD undergoes developmental changes with
maturity.

Primary Symptoms:
1. Inattention
2. Hyperactivity
3.Impulsivity
PRIMARY SYMPTOMS AND COMMON
IMPAIRMENTS
Inattention

Divided Attention: A student having difficulty taking notes
and paying attention to the teacher simultaneously would
have a problem with divided attention.

Focused Attention: A student who is described as a
daydreamer, preoccupied with other activities instead of
what is being talked about, would have a problem with
focused attention.

Selective Attention: A student who is distracted by outside
noises, such as a door closing or a student walking down
the aisle to the front of the room, would have a problem
with selective attention.
PRIMARY SYMPTOMS AND COMMON
IMPAIRMENTS
Inattention cont.

Sustained Attention: A student who is unable to remain on a
task long enough to sufficiently complete that task would have
a problem with sustained attention or persistence.

Vigilance: A student who is unable to wait for the next spelling
word to be presented by the teacher would have a problem with
vigilance or readiness to respond (Sam and Michael
Goldstein/1990).
PRIMARY SYMPTOMS AND COMMON
IMPAIRMENTS
Inattention cont.

Research suggests that deficits in attention are particularly
evident under repetitive or boring conditions.

Difficulty maintaining effort is closely aligned with difficulty
maintaining concentration and effort, especially with school
work and instruction that is non-engaging.

Inattention can also present itself at the opposite end of the
spectrum – “hyperfocusing”. Tendency to focus on discrete
things often leads to the child not hearing or seeing that the
class is transitioning to another content area or getting ready
for recess or class dismissal.
PRIMARY SYMPTOMS AND COMMON
IMPAIRMENTS
Inattention cont.

During complex tasks, attention can be described as
comprising of three processes related to self-regulation (Teeter,
P., 1998).



Maintaining attention over time.
Organizing and self-directing attention
Investing effort to attend to tasks.
PRIMARY SYMPTOMS AND COMMON
IMPAIRMENTS
Hyperactivity

Research suggests that hyperactivity and impulsivity are
different expressions of impaired behavioral inhibition.

Hyperactivity is not just high activity, but disorganized and
purposeless activity.

The classic overactivity found in younger children is often
diminished or transformed by adolescence –transformed into
“subjective feelings of restlessness” (Robin, 1998).
PRIMARY SYMPTOMS AND COMMON
IMPAIRMENTS
Hyperactivity cont.

Adolescents often will describe feeling confined if asked to sit
in a classroom for too long, or when seated at a desk to study
for a long period of time.

Teachers often will find nonstop talking (especially in girls) and
badgering as two common manifestations of hyperactivity in
adolescents.
PRIMARY SYMPTOMS AND COMMON
IMPAIRMENTS
Hyperactivity cont.

They seem to manage their great energy by channeling their
energy into many activities.

ADHD children struggle getting to sleep because of their “racing
mind” and can get as little as 4-5 hours of sleep a night.
PRIMARY SYMPTOMS AND COMMON
IMPAIRMENTS
Impulsivity


Impulsivity is often seen as difficulty waiting one’s turn,
blurting out before thinking, and interrupting or intruding on
others’ time and space – behaviors that are essentially
unacceptable in most classrooms.
The adolescent can continue to demonstrate high
impulsivity



Behaviorally
Cognitively
Emotionally
PRIMARY SYMPTOMS AND COMMON
IMPAIRMENTS
Impulsivity cont.

Behaviorally:
 Often driven by the moment and have a great
difficulty with delayed gratification.
 Often opt for short-term gratification despite longterm pain for not completing a homework assignment
or getting their chores done at home.
 Can be seen as irresponsible, selfish, immature, lazy,
and outright rude.
PRIMARY SYMPTOMS AND COMMON
IMPAIRMENTS
Impulsivity cont.

Cognitively:
 The impulsive adolescent rushes through schoolwork,
tests, overlooking crucial details, making careless
mistakes, and writing sloppily.

Emotionally:
 Impulsive teenagers can become easily frustrated,
agitated, moody, and lose their temper quickly –
sometimes accompanied by aggressive and verbal
responses directed at either others or themselves
(Robin, 1998)
PREDOMINANTLY INATTENTIVE TYPE OF ADHD

Predominantly inattentive-type child may sit and quietly zone
out, as they are often internally rather than externally
distracted.

They are often underactive, foggy, and cognitively sluggish.

Younger children with predominantly inattentive type are
unlikely to be referred for professional evaluation of ADHD
because they do not display commonly recognized disruptive
behavior.
PREDOMINANTLY INATTENTIVE TYPE OF ADHD

Fewer problems than the hyperactive-impulsive child in making
friends and keeping same age friends or getting along with
teachers and other adults.

These children have difficulty attending to one thing because
they often pay attention to everything!

Often make more mistakes than other children in following oral
and written instructions.

Difficulty sorting out relevant from the irrelevant and can
struggle with tasks involving perceptual-motor speed or eyehand coordination.
CLOSING THOUGHTS

ADHD children are asked to interface with a system that makes
day-to-day tasks nearly impossible for them.

This can be especially frustrating and debilitating for a student
if his or her struggles are not understood or appreciated by
their teacher, peers or other school staff.
ASSOCIATED DISORDERS SOMETIMES PRESENT
WITH ADHD

Oppositional Defiant Disorder (ODD)

Conduct Disorder (CD)

Anxiety Disorders

Mood Disorders

Bipolar Disorder

Learning Disability

Execute Function Dysfunction (EFD)
DISORDERS ASSOCIATED WITH ADHD

ADHD is a disorder that presents itself uniquely in each
affected child.

Some children will present with what professionals refer to
as “clean ADHD” – that is ADHD without associated
disorders - “comorbid disorders”.

For the majority of children referred for psychiatric evaluation
have ADHD complicated with comorbidity.

These associated disorders tend to adversely influence a
child’s academic and emotional development.
OPPOSITIONAL DEFIANT DISORDER (ODD) AND
CONDUCT DISORDER (CD)

Recent research suggests that approximately 2% to 16% of the general
population has ODD.

Up to 50% to 60% of children with ADHD, especially ADHD-HI, meet the
criteria for ODD (Bloomquist, 1996)

Most affected children develop ODD prior to the age of 8 years.

Up to 70 % of children with ADHD referred to clinics are diagnosed with
ODD.

The longer ODD behaviors persist, the more difficult they are to eliminate.
OPPOSITIONAL DEFIANT DISORDER (ODD) AND
CONDUCT DISORDER (CD)

Symptoms: (DSM-IV-TR 2000)
 Lose their temper
 Swear
 Often angry or resentful
 Easily annoyed by others
 Extremely stubborn
 Rarely accept blame for their actions
 Some ODD children go onto CD

The longer ODD behaviors persist, the more difficult they are
to eliminate.
CONDUCT DISORDER (CD)

Conduct Disorder presents a serious pattern of antisocial
behavior and violation of rights of others.

Symptoms: (DSM-IV-TR 2000)
 They often bully or intimidate others.
 Can be physically cruel to people and animals.
 Can lie or break promises to get what they want.
 They may steal, run away from home, skip school
 Deliberately destroy others’ property and set fires.
CONDUCT DISORDER (CD)

CD is rarely diagnosed in children younger than the ages of
five or six years.

There is some evidence suggesting that CD, unlike ODD,
may have a genetic factor which can be expressed through
environmental risk factors and stressors.

Children with ODD and CD are at risk for developing low
self-esteem, being expelled from school, isolating
themselves from peers, and for being drawn to other
children with similar challenges.
CONDUCT DISORDER (CD)

While medications can be effective in extreme cases to
decrease the severity of ODD and CD, medication alone will
not completely eliminate core behaviors related to ODD and
CD.

Treatment requires home, school, and psychiatric
interventions to find maximum benefit.

ADHD does not directly cause ODD and CD, but the
presence of ADHD greatly increases the risk for developing
ODD and CD.
ANXIETY DISORDERS

Anxiety disorders can manifest a broad range of signs
and symptoms and stem from a number of causes.

When a problem, young children tend to fear monsters
and ghosts and separation from caretakers.

Older children usually focus on possible natural disasters
and family concerns, or have home and school related
worries.

Secondary anxiety disorder is reported to be present in
34% of the ADHD population.
ANXIETY DISORDERS

Separation anxiety is the only anxiety disorder that is
specific to childhood. In young children separation anxiety
is triggered by a life stress such as a death of a pet, moving
to a new home, or a major illness in the family.

There is a high probability of finding ADHD-I children with
comorbid anxiety disorder.

Stimulant medications can at times help with an anxiety
disorder if the primary cause is related to ADHD. However,
if anxiety is a separate disorder associated with ADHD,
stimulants will often elevate the anxiety symptoms.

Anxiety can impact on school related tasks such as test
taking, homework, and social interactions (especially with
Social Anxiety Disorder).
MOOD DISORDERS

Studies find that children with ADHD and a diagnosis of
ODD and CD show a higher rate of depression and
anxiety, 30% and 34% respectively (August, et. al., 1996).

ADHD-I type are at more risk for depression than those
children with ADHD-C (Anastopoulos & Shelton, 2001).

Mood disorders often present themselves differently in
children than adults. Children typically display severe
irritability, underachievement in school, and an
exacerbation of their underlying ADHD features.
MOOD DISORDERS

Contributing Factors Leading to Depressive and Anxiety
Disorders:

ADHD children often experience less academic success in
school.

They often receive more negative feedback and disciplinary
consequences than unaffected children.

ADHD traits such as lacking perseverance in the face of
failure.

Poor behavior inhibition that makes it hard for them to
pause and think.

Their difficulty regulating their ongoing emotional
reactions.
BIPOLAR DISORDER

There is a tremendous overlap of symptoms in children with
severe ADHD and in those children diagnosed with bipolar
disorder (BD, or manic depression).

It is not uncommon for children to be initially diagnosed with
ADHD and later with BD. Because the symptoms of these
disorders overlap so much, a child can sometimes meet the
criteria for both diagnosis.

Children may show some of the same symptoms as adults
diagnosed with BD; however younger children commonly
display a mixed state, presenting with symptoms of mania and
depression.

Manic state can present itself as uncharacteristic behaviors of
extreme enthusiasm, irritability and anger.
BIPOLAR DISORDER

A child with manic symptoms is sometimes referred to as
having “bad ADHD” because the most common
disturbance in manic children is irritability and affective
storms, with prolonged and aggressive outbursts.

Because the symptoms of irritability can vary in degree
and result from a number of causes, the disorder can be
mistaken for depression, CD, or ADHD.

Clinicians recommend great caution in diagnosing
preschool and early school age children with BD.
LEARNING DISABILITIES

Estimate that 10% to 40% of children with ADHD have
associated learning disorders that meet the criteria for a
specific learning disability (Batshaw/2002).

Typically children with ADHD and learning disabilities exhibit
academic underachievement with the most difficulty with
reading and written language.
.
LEARNING DISABILITIES

ADHD children also have high incidence of central auditory
processing disorders and visual-motor functioning problems

Many affected children can be accommodated through Section
504 when they do not meet the criteria for placement in special
education.
LEARNING DISABILITIES

New IDEA 2004 regulations now allow states to discontinue the
use of the discrepancy model in lieu of Response to
Intervention (RTI) model.

Under the New IDEA/2004, ADHD children can be placed in
special education under Other Health Impaired (OHI). ADHD is
today seen as other health impairments such as asthma –
when the medical condition impacts on a child’s educational
performance, the child can qualify for special services under
OHI.
EXECUTIVE FUNCTION DYSFUNCTION
“I sometimes forget to turn in my homework. Am
I stupid? My science teacher told the class that:
“I always had an excuse for doing poorly in his
class because I had ADHD, but the rest of you
don’t”. My teacher thinks I don’t care and I use
ADHD as an excuse.”
- Ryan, eighth grade student
Educators can, because of misinformation, contribute to
an atmosphere where ADHD children are:
“in danger of being emotionally traumatized by being called
lazy, unmotivated, irresponsible, and other such words
implying moral turpitude instead of neurodevelopmental
disability or immaturity. Probably the greatest value in
recognizing the neurodevelopmental/neurocognitive domain
called EF is to protect a sizable minority of children from
being traumatized by what amounts to adult name-calling.”
(Denckla, M.B., 2007).
Snap Shot Overview of Executive Function Processes
(Meltzer, L., & Krishnan, K., 2007)

Selecting relevant task goals

Planning and organizing information and ideas.

Prioritizing and focusing on relevant themes rather than
irrelevant details.

Initiating and sustaining activities
Snap Shot Overview of Executive Function Processes
(Meltzer, L., & Krishnan, K., 2007)
Cont.

Holding information in working memory

Shifting strategies flexibly

Inhibiting competing actions

Self-monitoring, checking, and regulating behavior
WHAT ARE EXECUTIVE FUNCTIONS?

The term executive functions refers to an individual’s selfdirected actions that are used to help that person regulate his
or her behavior, that is, actions a person performs that help
him or her exert more self-control and better reach his or her
goals. Executive functions represent the internalization of
behavior that helps us anticipate changes in the environment
and events that lie ahead in time. It provides a sense of
readiness, the ability to inhibit habitual responses, delaying
gratification, and adjusting ones actions to changing
conditions. It is, in some ways, a cognitive process that serves
as a kind of supervisor or scheduler that helps one select a
strategy to integrate information from different sources (Lougy,
et. al., 2009).
Executive Functions Work Together in Various
Combinations (Thomas Brown, Ph.D.)
Cluster 1: Organizing, Prioritizing, and Activating Tasks

Difficulty getting started on tasks (completing homework,
doing chores, classroom assignments)

Procrastinating is often a major problem, particularly with
tasks not intrinsically interesting.
Executive Functions Work Together in Various
Combinations (Thomas Brown, Ph.D.)
Cluster 1, cont.

Difficulty attending to what is most important to attend to.

Report recurrent failure to notice critical details (putting name at
top of paper, noticing (+) versus (-) in a math quiz.

Difficulty figuring out how long a project will take or prioritizing
and putting items ahead of others.
Executive Functions Work Together in Various
Combinations (Thomas Brown, Ph.D.)
Cluster 2: Focusing, Sustaining, and Shifting Attention to Tasks

Difficulty sustaining attention long enough on a task to
complete it.

Difficulty with selective attention (listening on the telephone
or the words printed on a page).

Easily drawn away from a project by distractions.
Executive Functions Work Together in Various
Combinations (Thomas Brown, Ph.D.)
Cluster 2, cont.

Difficulty ignoring a myriad of thoughts, background noises,
or room distractions.

Unable to stop focusing on one thing so they can redirect
their attention to what is important.
Executive Functions Work Together in Various
Combinations (Thomas Brown, Ph.D.)
Cluster 3: Regulating Alertness, Sustaining Effort, and Processing Speed

Many children with ADHD complain they can hardly keep their
eyes open when they have to sit still and be quiet (especially
pronounced when classroom teacher uses a lecture format to
present information).

Affected children often are tired because of difficulty in getting a
good nigh sleep.
Executive Functions Work Together in Various
Combinations (Thomas Brown, Ph.D.)
Cluster 3, cont.

Difficulty completing certain school tasks because of slow
processing speed (particularly noticed in writing tasks)

Processing speed can be both too slow and too fast. When
too fast, they often perform poorly because of carelessness
and not attending to details.
Executive Functions Work Together in Various
Combinations (Thomas Brown, Ph.D.)
Cluster 4: Managing Frustration and Modulating Emotion

Affected children have a very low threshold for frustration
and chronic difficulty in regulating subjective emotional
experiences and expression.

Disproportionate emotional reaction to frustration, short
fuse, and low threshold for irritability.
Executive Functions Work Together in Various
Combinations (Thomas Brown, Ph.D.)
Cluster 4, cont.

Emotions are often described as flooding their mind and
leaving little room for any other thought.

Can be overly sensitive and react strongly to even minor
slights or criticism.

Chronic problems in managing frustration and other
emotions.
Executive Functions Work Together in Various
Combinations (Thomas Brown, Ph.D.)
Cluster 5: Utilizing Working Memory and Accessing Recall

ADHD children seem to have chronic difficulties with memory.
Impairment is generally not in long term memory, but in
“working-memory”: holding one bit of information active while
working with another. Remembering a telephone number you
just heard so you can call the number.

Communication is hard between individuals when working
memory is impaired. It can interfere both in expressive as well
as receptive aspects of communication.
Executive Functions Work Together in Various
Combinations (Thomas Brown, Ph.D.)
Cluster 5, cont.

ADHD individuals often complain that they have difficulty
retrieving information from long-term memory that they need to
do a task.

Proper functioning of working memory is an important
component in mastering many school academic core areas:
reading, math, and written expression.
Executive Functions Work Together in Various
Combinations (Thomas Brown, Ph.D.)
Cluster 6: Monitoring and Self-Regulating Action

ADHD children and adults tend to act without much
forethought, can be restless and hyperactive, and find it very
difficult to slow down and control their actions.

Brown notes that in addition to having difficulty “holding back”,
ADHD children also can have difficulty getting started.

Some children with ADHD can be excessively “focused on how
others are reacting and are excessively self-conscious” (Brown,
2007).
Executive Functions Work Together in Various
Combinations (Thomas Brown, Ph.D.)
Cluster 6, cont.

Social situations are often among the most challenging for
children with ADHD. They often do not measure or assess the
expectations or perceptions of others in order to behave
appropriately.

Their decisions and actions often seem random and/or a series
of guesses, rather than thought out responses. They often get
in trouble because they do not gauge the emotions or
intentions of others.
CLOSING THOUGHTS ON EXECUTIVE FUNCTION

Executive functions are very important in accomplishing many
daily task both at school and in the home.

Educational and positive peer relationships both depend to a
large degree on proper function of the executive function.

An important contribution to academic and social/emotional
adjustment in an ADHD child depends to a large degree on
providing academic accommodations and behavioral
interventions to minimize core ADHD symptoms.

Even though EF is very important in academic and
social/emotional development, important is not exclusive.
There may be other factors that may be impacting on an
affected child’s educational performance.
CLOSING THOUGHTS
We want to close with a thought from Melvin Levine:
“The more we involve ourselves with disappointing children, the
more we understand the risks they must take during childhood
. . . Their lives bear the scars of unjust accusation, chronic
feelings of inadequacy, and shamelessly untapped talent.
Understanding developmental variation, characterizing it
without oversimplifying it, and intervening vigorously on behalf
of developing humans experiencing inordinate failure –these
are urgent needs.” (Levine, 1993).
References






American Psychiatric Association. (2000). Diagnostic and
Statistical Manual of Mental Disorders (4th ed., text rev.).
Washington, DC: Author.
Anastopoulos, A. D., & Shelton, T.L. (2001). Assessing
Attention-Deficit/Hyperactivity
Disorder. New York: Kluwer Academic/Plenum.
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