Introduction

1.1 Understanding Attention Deficit Hyperactivity Disorder

(ADHD)

Attention Deficit Hyperactivity Disorder (ADHD) is a childhood psychiatric condition

characterized by symptoms of inattention, hyperactivity, and impulsivity (American
Psychiatric Association [APA], 2000). The dominant view on ADHD typifies ADHD as an
executive dysfunction disorder (i.e., Barkley, 1997), because children with ADHD
encounter difficulties with tasks regarding inhibition, working memory, and task-
switching (e.g., Geurts, Verte, Oosterlaan, Roeyers, & Sergeant, 2004) However, children
with ADHD apparently react differently to reward and punishment than normally
developing children (Luman, Oosterlaan, & Sergeant, 2005). The disorder represents one
of the most common reasons children are referred for behavioral problems to medical and
mental health practitioners in the United States and is one of the most prevalent childhood
psychiatric disorders.

The study of ADHD in children in India is unavoidably necessary since India has the
largest child population in the world. There were about 190 million children in the age
group of 6-14 years according to Economic Survey of India, 2004; ADHD call for in-
depth analysis and varied intervention strategies. Another aspect is the discrepancy in the
actual and estimated prevalence of ADHD in children. The prevalence of ADHD is around
one per cent of total general population in India, whereas 3-3.5 per cent of children may
suffer with ADHD. In India there is very little systematic research in ADHD in children
(Singhi P, Malhi P, 1998). The few studies that are available report prevalence rates
ranging from 10 to 20% (Bhatia MS, 1999). Most studies have shown that ADHD is more
common in males than females with estimates of gender incidence ratios ranging from 2:1
to 9:1 depending on the subset of ADHD and the setting, however, studies in adults with
ADHD show a similar prevalence in both genders. Another factor that influences the
greater number of males diagnosed with ADHD are the parents’ educational level.

1
In India there is very little systematic research in ADHD in children. The few studies that
are available report prevalence rates ranging from 10 to 20%. While the Western world is
attending to ADHD issue seriously, in India this has not yet received much attention.
Moreover, child psychiatry as a specialty has developed mainly during the last century in
Europe and in the United States and the developing world is lagging behind in keeping
pace with the latest developments.

Children with ADHD are characterized as having poor behavioral inhibition

(Barkley, 1997). Their symptoms include poor planning and anticipation, reduced
sensitivity to errors, poor organization, impaired verbal problem-solving and self-directed
speech, poor rule-governed behavior, poor self-regulation of emotions, and problems
developing, using and monitoring organizational strategies.

One of the first references to a child with hyperactivity or ADHD (“Fidgety Phil”)
was in the poetry of the German physician Heinrich Hoffman in 1865, who penned poems
about many of the childhood maladies he saw in his medical practice (Stewart, 1970). But
scientific credit is typically awarded to George Still and Alfred Tredgold for being the first
authors to focus serious clinical attention on the behavior-al condition in children that
most closely approximates what is today known as ADHD. This disorder was first termed
"hyperactivity," then "Attention-Deficit Disorder" (ADD), and then, to differentiate
between children who had ADD but did not exhibit hyperactivity, either (plain) ADD or
ADD-H. The new "official" term, Attention-Deficit Hyperactivity Disorder (ADHD)
has been chosen by psychiatric experts, and its symptoms have been published by the
American Psychiatric Association in its Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV). The definitions in the manual are widely acknowledged and are used
among doctors, in research, and administratively for purposes of insurance. ADHD affects
an estimated 3% of school-age children. Boys are about three times more likely than girls
to be diagnosed with it, though it's not yet understood why.

Children mature at different rates and have different personalities, temperaments,

and energy levels. Most children get distracted, act impulsively, and struggle to
concentrate at one time or another. Sometimes, these normal factors may be mistaken for

2
ADHD. Therefore it is important to realize that symptoms of inattention and hyperactivity
–impulsivity must be consistent with the child’s developmental level. The difference with
ADHD is that symptoms are present over a longer period of time and occur in multiple
contexts. They impair a child's ability to function socially, academically, and at home. A
child cannot be diagnosed with ADHD if he only shows symptoms with parents but never
with teachers and adults outside the home. Furthermore, the symptoms of ADHD are easy
to confuse with other problems—including learning disabilities and emotional issues—
that require totally different treatments. The diagnosis of ADHD is a difficult task because
there is no single test to determine the disorder.

It is really encouraging to know that with proper treatment, kids with ADHD can
learn to successfully live with and manage their symptoms. Along with an increasing
awareness of the problem of ADHD, a better understanding of its causes and treatment
has developed. Treatments can relieve many of the disorder’s symptoms, but there is no
cure. With treatment, most people with ADHD can be successful in school and lead
productive lives. Researchers are developing more effective treatments and interventions,
and using new tools such as brain imaging, to better understand ADHD and to find more
effective ways to treat and prevent it.

The purpose of the study was to create awareness amongst parents and teachers and the
society as a whole regarding ADHD and the problems that such children have to face due
to ignorance on the part of the teachers and parents. The study targeted ADHD children
with special emphasis on the need to change the attitude of their stakeholders towards
them because such children face punitive measures at the hand of their caretakers. They
need to understand the reason behind problem behaviour and to realize that the cure is not
in reprimanding them but in understanding the real cause of their behaviour. India’s socio-
economic status and human development indicators are a pointer to the way children are
looked after in this country. In a country where primary needs, such as malnutrition,
prenatal mortality and illiteracy are still a grave cause of concern, the mental health of
children obviously becomes secondary.

3
1.1.2 Barkley's Model of ADHD

Russell Barkley (1997, 1998 & 2000) has been instrumental in conceptualizing ADHD as
primarily a problem in behavioral inhibition, which then leads to a faulty sense of time
awareness and management. And for Barkley, it is the deficit in time awareness and
management that is the most detrimental for persons with ADHD.

4
Barkley notes that persons with ADHD have difficulties with executive
functions. Executive functions involve a number of self-directed behaviors, such as
working memory, inner speech, and self-regulation of emotions. Working memory is the
ability to hold things in mind while also engaging in other cognitive tasks. Problems in
working memory can affect the ability of the person with ADHD to have hindsight and
foresight (Barkley, 2000). Hindsight enables us to learn from prior experiences, which we
can then apply when formulating plans for new experiences. Foresight allows us to "see"
ahead and anticipate events, so that they may guide our behavior. Together, hindsight and
foresight create a window on time (past, present, and future) of which the individual is
aware. The temporal opening of that window probably increases across development, at
least up to age 30 years. This might suggest that across child and adolescent development,
the individual comes to organize and direct behavior toward events that lie increasingly
distant in the future. (Barkley, 2000)

Inner speech, another executive function, develops in young children and helps them
regulate their behavior. Inner speech is the inner "voice" we use to "talk" to ourselves
when faced with difficult problems. For those with ADHD, the almost seamless border
between inner speech and thought fails to occur naturally, and this interferes, among other
things, with their ability to follow rules or instructions.

Self-regulation of emotions also presents problems for many students with ADHD. They
often overreact to emotionally charged situations. Barkley hypothesizes that such
problems in regulating emotions contribute to motivational problems for individuals with
ADHD. They are unable to channel their emotions to help them persist in the pursuit of
future goals.

1.1.3 Clinical Feature of ADHD

According to Ross and Ross (1982), briefly in the classroom, children with ADHD
have difficulty staying with task and have difficulty organizing and completing the work.
Classroom and playroom observation found them frequently off task. Written work is
often sloppy and is characterized by impulsive, careless errors that are a result of not

5
following directions or guessing without considering all of the alternatives. Children often
seem not to be listening to adult considerations. Group situations and those that require
sustained attention are the most difficult.

Attentional problems at home are shown by failure to follow through parental

request and relative inability for age to stick to activities, including play. Adults describe
them as always on the go, “running like a motor”, or having difficult sitting still. Older
children and adolescents may be extremely fidgety and restless.

1.1.4 Diagnostic criteria for Attention-Deficit/Hyperactivity Disorder

(ADHD)

A. Either (1) or (2):

(1) Inattention: six (or more) of the following symptoms of inattention have persisted for
at least 6 months to a degree that is maladaptive and inconsistent with developmental
level:

(a) often fails to give close attention to details or makes careless mistakes in schoolwork,
work, or other activities
(b) often has difficulty sustaining attention in tasks or play activities
(c) often does not seem to listen when spoken to directly
(d) often does not follow through on instructions and fails to finish school work, chores, or
duties in the workplace (not due to oppositional behavior or failure to understand
instructions)
(e) often has difficulty organizing tasks and activities
(f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental
effort (such as schoolwork or homework)
(g) often loses things necessary for tasks or activities (e.g., toys, school assignments,
pencils, books, or tools)
(h) is often easily distracted by extraneous stimuli
(i) is often forgetful in daily activities

6
(2) hyperactivity-impulsivity: six (or more) of the following symptoms of hyperactivity-
impulsivity have persisted for at least 6 months to a degree that is maladaptive and
inconsistent with developmental level:

Hyperactivity

(a) often fidgets with hands or feet or squirms in seat

(b) often leaves seat in classroom or in other situations in which remaining seated is
expected
(c) often runs about or climbs excessively in situations in which it is inappropriate (in
adolescents or adults, may be limited to subjective feelings of restlessness)
(d) often has difficulty playing or engaging in leisure activities quietly
(e) is often "on the go" or often acts as if "driven by a motor"
(f) often talks excessively

Impulsivity

(g) often blurts out answers before questions have been completed
(h) often has difficulty awaiting turn
(i) often interrupts or intrudes on others (e.g., butts into conversations or games)

B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were

present before age 7 years.

C. Some impairment from the symptoms is present in two or more settings (e.g., at school
[or work] and at home).

D. There must be clear evidence of clinically significant impairment in social, academic,

or occupational functioning.

E. The symptoms do not occur exclusively during the course of a Pervasive

Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better
accounted for by another mental disorder (e.g., Mood Disorder, Anxiety
Disorder, Dissociative Disorders, or a Personality Disorder).

7
 DSM-IV-TR conceptualizes ADHD as a disorder that emerges in early childhood.
In order to be diagnosed with ADHD, individuals must have at least some symptoms of
inattention and hyperactivity-impulsivity before age seven.

1.1.5 Subtypes of ADHD

The current definition of ADHD includes a list of 18 behaviuoral symptoms

divided in two sets (inattention and hyperactivity- impulsive) of nine symptoms each
(American Psychiatric Association, 2000). There are three subtypes of ADHD: combined
type (ADHD-CT) predominantly inattentive type (ADHD-IA) and predominantly
hyperactive-impulsive type (ADHD-HI).

1). ADHD, Combined Type: Both inattention and hyperactivity-impulsivity symptoms

Children with Combined Type show significant inattentive and hyperactive-

impulsive symptoms. Parents and teachers describe them as sloppy, impulsive, distractible,
rushed, irresponsible and high rate (Lahey et al., 1997). Most experts believe that children
with ADHD –CT have underlying behavioural inhibition. Disinhibition causes them to
have difficulty with sustained attention and behavioural regulation at home, at school, and
with peers.

2. ADHD, Predominantly Inattentive Type: Inattention, but not enough (at least 6 out of 9)
hyperactivity-impulsivity symptoms

Children with ADHD-IA represent a heterogeneous mix of youngsters who display

significant inattentive symptoms but subthreshold problems hyperactive-impulsive
symptoms. This person has a problem organizing and finishing work but may not be
hyperactive. He or she is easily distracted and has trouble following instructions and
conversations or paying attention to details. This is often the child who stares out the
window during class.
3. ADHD, Predominantly Hyperactive-Impulsive Type: Hyperactivity-impulsivity, but not
enough (at least 6 out of 9) inattention symptoms
Children with ADHD-HI show significant hyperactive – impulsive symptoms but
only subthreshold problems with inattention. They are usually described as “driven by a

8
motor” or “constantly running” and on the go.”This child can’t sit still long enough to eat
dinner. He or she may be talkative and fidgety. Their restlessness leads to impulsive
behaviors such as blurting out answers without being called upon, interrupting others as
they speak, being unable to wait for his turn or to listen to directions without letting his
mind wander or get distracted. This child often can’t pick up body language and social
cues and therefore does not make friends easily.

1.2. Associated Features and Disorders of ADHD

1.2.1 Comorbid Disorders

Comorbid psychiatric disorders are common among children with ADHD. In one
large epidemiological study, 44% of children with ADHD had one or other psychiatric
disorder, 32% had at least two other disorders, and 11% had at least three other disorders

(Szatmari, Offord, & Boyle 1989).

Figure 1.1 Comorbidity in Children with ADHD

9
1.2.2 Conduct Problems

Conduct disorder and oppositional defiant are the most common comorbid
disorders found in both clinical and epidemiological samples of children with ADHD.
These children display argumentativeness, temper outbursts, defiance of authority and
rules, and aggressive, antisocial behavior in addition to symptoms of ADHD. Rates of
oppositional defiant disorder in samples of children with ADHD reportedly average 35
percent; when oppositional defiant disorder and conduct disorder are combined, rates of
comorbidity with ADHD rise to about 50 to 60 percent. A variety of influences may shape
this association. For example, school-age children with oppositional defiant disorder or
conduct disorder almost invariably meet criteria for ADHD. Conversely, adolescents with
conduct disorder without ADHD are more common. Other influences include greater
symptom severity, reading disorder, school impairment, and lower socioeconomic status in
comorbid ADHD–conduct disorder children. Children with ADHD associated with other
disruptive behaviors are particularly challenging and require intensive intervention to
prevent greater morbidity and impairment. This condition includes behaviors in which the
child may lie, steal, fight, or bully others. He or she may destroy property, break into
homes, or carry or use weapons.
On the other hand, both ADHD and conduct problems are characterized by
difficulties in executive functioning, that is ability to plan, prioritize, and regulate
behavior. Indeed some experts believe that the strong co occurrence of ADHD and conduct
problems in childhood and adolescence is due to abnormalities in the development of
executive functioning (Coolidge, Thede, & Young 2000)

1.2.3. Substance Use Problems

ADHD appears to place the children at greater risk for substance use problems
during adolescence (Biederman & Faraone 1999). Anxiety Disorder occurs in up to 30%
of children with ADHD, but half of the children never tell their parents! Patients are beset
most days by painful worries not due to any imminent stressor. Children may appear edgy,
stressed out, tense, or sleepless. There may be panic attacks or an incomplete (or negative)
response to stimulants.

10
 When an individual presents with both substance abuse and ADHD, clinicians
should first attempt to stabilize and treat the substance abuse disorder. Depression should
subsequently be treated followed lastly by treatment of the ADHD. A common concern is
that the treatment of children with stimulants will increase the rates of substance abuse
over the long term. In a 4-year follow-up study of ADHD and non-ADHD families,
Biederman and colleagues observed the patients with untreated ADHD had much higher
rates of later substance abuse compared with both treated ADHD patients and controls.
Untreated ADHD is also associated with higher rates of alcohol use at 15-year follow-up.

1.2.4. Anxiety and mood disorders

Significant comorbidity exists with ADHD and mood and anxiety disorders.
Estimates of the co-occurrence of ADHD and mood disorders have ranged from 15 to 75
percent, with an average comorbidity of about 25 to 30 percent; association with anxiety
disorders has been reported in up to 25 percent. Studies of comorbidity of ADHD with
mood disorders have found common co-occurrence of ADHD with both dysthymic
disorder and major depressive disorder. In general, comorbid depression and ADHD does
not appear to affect the manifestations of either disorder. With the early onset of ADHD,
most mood disorder diagnoses are made following the emergence of ADHD, which
suggests that some instances of ADHD–mood disorder comorbidity are secondary to the
experience of a chronic impairing disorder such as ADHD. Whether ADHD and mood
disorders share vulnerability factors is under active investigation.

11
Figure 1.2 Conceptual Model of the Impact of Attention Deficit Hyperactivity
Disorder

1.3 Associated Characteristics

1.3.1 Problems in Parent – Child Relationship

Parents usually realize their children are hyperactive from a very young age. But the
excess of activity problem is only the most apparent one and it usually is not the most
difficult one. In the beginning it might be, since parents think their child is a bit of a
“rascal”, a child who does not stop, who is a troublemaker. If the hyperactivity is very
marked from the beginning, they might complain that their child is disobedient, that he or
she does not listen, nor pay attention to what is being said. The child does not seem to
react whether punished or rewarded; the child’s reasoning is not appropriate for its age,
coming across as immature in many respects and skilful in others. Because on some
occasions the child behaves properly, and yet the child disobeys what he or she finds is
harder to carry out, parents tend to think their child acts on a whim and is spoiled. From

12
their frustration, parents start to blame and hold the child fully responsible for its behavior,
sending out an implicit and explicit message that s/he is a disaster, vile, ungrateful, etc.
which is to the more terrible for the development of the child’s own image, identity and
self-esteem.

Undisciplined conduct calls so much of the parent’s attention and requires such constant
effort on their part regarding control, supervision, correction that it is extenuating and if
they don’t stop to think about it, might altogether miss the child’s virtues, capacities, skills
and talents. And if parents don’t notice this, the child will notice it least of all. The way in
which parents see the child is an important part of the child’s self-image and self-esteem.

Children with ADHD often have problematic interactions with their parents. One
way psychologist study parent – child interactions in young children is to observe dyads
playing or performing a structured task. During these interactions, mothers of children
with ADHD are more negative and hostile and less sensitive and responsive to their
children than are mothers of children without ADHD. Their children, in turn, engage in
more aversive and noncompliant behavior (Barkely 1988). Researchers believe that these
parents – child behaviours are reciprocal: Parents engage in more hostile intrusive
parenting tactics because they are frustrated by their children’s high rate behavior; children
engage in more disruptive behaviours because of their parent’s punitive discipline
(Chronis & others 2003).

Parenting stress is generally understood to arise from characteristics of the parent,

the child, and the environment, and interactions among these factors. For families with a
child with ADHD the characteristics of the child are thought to be the primary contributor
to parenting and family stress.

1.3.2. Problems with Peers

Peer relationships are unique in that both parties involved in the relationship are of
equal status. Hence, peer relationships are the primary context in which children learn
cooperation, negotiation, and conflict resolution—skills that are critical for effective social
functioning throughout life. Viewed from this perspective, it is not surprising that
childhood peer problems predict a wide variety of later negative outcomes including

13
delinquency, dropping out of school, substance abuse, academic difficulties, truancy, and
psychological maladjustment. In fact, evidence indicates that views of one's peers are more
predictive of later psychological functioning than other variables typically used in mental
health research, such as teacher ratings, grades, achievement scores, IQ, or absenteeism.

Unfortunately, children with ADHD are frequently disliked by peers. Their

hyperactive and impulsive behavior often interferes with their ability to behave properly
during peer interactions. Children’s ADHD symptoms often cause peers to reject them
quickly. Children with ADHD were mostly, not only unpopular, but are actively rejected
by classmates. Although of children with ADHD sought friendships with their classmates,
especially popular children, these high status popular children were most likely to reject
and avoid them. The tendency for children with ADHD to be rejected was not merely due
to comorbid problems such as oppositional and defiant behavior. Children were rejected
based on their ADHD symptoms alone. Peers rejection occurred to children as young as
seven years of age.

1.3.3. Academic Difficulties

Children with ADHD have academic difficulties. Their behavioural symptoms of

inattention, hyperactivity and impulsivity indicate lack of concentration in children with
ADHD, due to which they have problems in academic domains. Children with ADHD
often show difficulties across academics, with particular problems in reading and math.
Compared to typically developing youth, children with ADHD are more likely to earn
failing grades, to be retained in school, and to drop out before graduation.
Distinct from the academic underachievement and slightly lower (intelligence
quotient) I.Q. test scores found in groups of ADHD children, learning disorders and
reading disabilities also commonly occur in children with ADHD. Use of rigorous criteria
has shown that learning disorders are more frequent in children with ADHD than in either
psychiatric controls of normal children, but this comorbidity is modest (15 to 30 percent).
Compared with conduct disorder, several studies find ADHD to be more strongly
associated with reading disorders than with mathematics disorder. The co-occurrence of

14
learning disability and ADHD has been suggested to result in poorer outcomes. This
overlap may also relate to the association of ADHD with other disruptive behavior
disorders, such as conduct disorder.
1.3.4. ADHD children in school environment

The functioning of hyperactive children in their school environment is also a sign that the
child has difficulties that deserve attention. The performance of these children is often
very irregular and certainly does not equal their apparent ability. They could have very
different results in the same subject within days of each other. They can make many
mistakes due to not paying attention and they are always the same mistakes. This
exasperates parents. They are disordered in the presentation of their work. They leave
everything to the last minute. They lose their books (in addition to their sweater, pencils,
etc.). And they never remember to write down their homework and the feedback from
teachers is: "He/She is very distracted," "He/She could do more if he/she wanted to" etc.

The school experience, the activity in which children spend the most time, may be an
important source of recognition, validation, identification, and a lot of the aspects needed
to develop a happy, safe and positive attitude toward work and toward a responsible and
independent life. Or it may be just the opposite.

1.4. Causes of ADHD

Although ADHD among children are most commonly diagnosed disorder in psychiatric
clinic, and a large number of studies are being conducted in the area of ADHD, it is still
not sure what exactly causes ADHD. Like many other psychological disorders in children,
ADHD probably results from a combination of factors. In addition to genetics, researchers
are looking at possible environmental factors, and are studying how brain injuries,
nutrition, and the social environment might contribute to ADHD.

15
1.4.1. Genetics

Research into the cause of ADHD has continued to indicate some substantial
genetic contributions. ADHD is a neuro - developmental disorder with a strong genetic
basis. Although the exact gene underlie ADHD have not been identified, genetics factors
may explain as much as 80% of the variance in ADHD among children with the disorder.

Reviews of the literature leave no doubt that genes influence the etiology of
attention-deficit/hyperactivity disorder (ADHD) (Faraone et al., 1998). Notably, twin
studies show the heritability of ADHD to be about 0.80, indicating that the effect of genes
is substantial. These genetic epidemiological studies have motivated molecular genetic
studies of ADHD that have produced intriguing but conflicting results (Faraone and
Biederman, 1998). Two genes that have been intensively studied are the dopamine
transporter gene (DAT) and the dopamine D4receptor gene (DRD4). Some studies of these
genes strongly suggest that they influence susceptibility to ADHD.

Twin studies suggest that ADHD is heritable. ADHD runs in families Genes.
Inherited from our parents, genes are the “blueprints” for who we are. Results from
several international studies of twins show that ADHD often runs in families. Researchers
are looking at several genes that may make people more likely to develop the disorder.
Knowing the genes involved may one day help researchers prevent the disorder before
symptoms develop. Learning about specific genes could also lead to better treatments.

Pharmacologic and animal studies have strongly implicated the norepinephrine

transporter (NET) in the pathophysiology of attention-deficit/hyperactivity disorder
(ADHD) (Sengupta SM, Grizenko N, Thakur GA, others 2012). Family-based association
tests were conducted with the categorical diagnosis of ADHD, as well as quantitative
phenotypes of clinical relevance (Conners Global Index for Teachers and Parents, and
Child Behavior Checklist measures). Sliding window haplotype analysis was conducted
with screening based on conditional power using PBAT. A previously reported association
with rs3785143 was confirmed in this study. Further, extensive association was observed
with haplotype blocks, with a differential pattern observed based on sex and subtype. The

16
5' region of the gene (encompassing haplotype block 1 and including a functional promoter
SNP, rs28386840) showed an association with ADHD in girls (irrespective of subtype). A
different region of the gene was associated with distinct behavioural phenotypes in boys.
The results obtained in this family-based study suggest that haplotype blocks within
different regions of SLC6A2 show differential association with the disorder based on sex
and subtype. Susan Sprich (2000) reported that six percent of the adoptive parents of
adopted ADHD probands had ADHD compared with 18% of the biological parents of
nonadopted ADHD probands and 3% of the biological parents of the control probands.
Results of this study lend support to the hypothesis that ADHD has a genetic component.

14.2. Brain structure and functioning

Relative to controls, children with ADHD show an average 5% reduction in cerebral

volume. This reduction includes grey and white matter and tends to be more pronounced
in the right hemisphere. Various studies have investigated differences in specific brain
regions. Some studies have found an overall reduction in the size of prefrontal cortex
among children with ADHD. Two subdivisions of prefrontal cortex seem to underlie these
deficits in executive functioning: the orbital frontal region and the dorsolateral prefrontal
region. The orbital frontal region is responsible for inhibition and impulse control. The
dorsolateral prefrontal region plays a role in organizing, planning and attending. Both
regions tend to be smaller in children with ADHD than in controls. Furthermore, children
with ADHD show under activity in both of these brain regions during tasks requiring
behavioural inhibition and memory.

1.4.3. Environmental factors

Studies suggest a potential link between cigarette smoking and alcohol use during
pregnancy and ADHD in children. In addition, preschoolers who are exposed to high
levels of lead, which can sometimes be found in plumbing fixtures or paint in old
buildings, may have a higher risk of developing ADHD. Exposure to lead, which is found
mainly in paint and pipes in older buildings, has been linked to disruptive and even violent

17
behaviour and to a short attention span. Exposure to PCBs in infancy may also increase a
child's risk of developing ADHD.

1.4.3. Sugar and Food additives

The idea that refined sugar causes ADHD or makes symptoms worse is popular,
but more research discounts this theory than supports it. In one study, researchers gave
children foods containing either sugar or a sugar substitute every other day. The children
who received sugar showed no different behavior or learning capabilities than those who
received the sugar substitute. Another study in which children were given higher than
average amounts of sugar or sugar substitutes showed similar results.
Recent British research indicates a possible link between consumption of certain food
additives like artificial colors or preservatives, and an increase in activity. Research is
under way to confirm the findings and to learn more about how food additives may affect
hyperactivity.

1.4.4. Parental ADHD

Family studies of the aggregation of psychiatric disorders among the biological

relatives of children with ADHD clearly demonstrate an increased prevalence of ADHD
among the parents of these children (Barkley, 2006). In general, there seems to be at least
a 40–50% chance that one of the two parents of the defiant child with ADHD will also
have adult ADHD (15–20% of mothers and 25–30% of fathers). Adults with ADHD have
been shown to be more likely to have problems with anxiety, depression, personality
disorders, alcohol use and abuse, and marital difficulties; to change their employment and
residence more often; and to have less education and socioeconomic status than adults
without ADHD. Greater diversity and severity of psychopathology among parents is
particularly apparent among the subgroup of ADHD children with comorbid ODD or CD.
More severe ADHD seems to also be associated with younger age of parents (Murphy &
Barkley, 1996), suggesting that pregnancy during their own teenage or young adult years
is more characteristic of parents of ADHD than non-ADHD children. It is not difficult to
see that these factors, as well as the primary symptoms of ADHD as well, could influence

18
the manner in which child behavior is managed within the family as well as the quality of
home life for such children more generally. Some research in our clinic suggests that when
the parent has ADHD, the probability that the child with ADHD will also have ODD
increases markedly. A recent clinical case (Evans, Vallano, & Pelham, 1994) suggests that
ADHD in a parent may interfere with the ability of that parent to benefit from a typical
behavioral parent training program. Treatment of the parent’s ADHD (with medication)
resulted in greater success in subsequent retraining of the parent. These preliminary
findings suggest of the importance of determining the presence of ADHD and even ODD
in the parents of children undergoing evaluation for the disorder.

1.4.5. Marital Discord

Many instruments exist for evaluating marital discord in parents. The one most
often used in research on childhood disorders has been the Locke–Wallace Marital
Adjustment Scale (Locke & Wallace, 1959). Marital discord, parental separation, and
parental divorce are more common in parents of ADHD children. Parents with such
marital difficulties may have children with more severe defiant and aggressive behavior
and such parents may also be less successful in parent training programs. Screening
parents for marital problems, therefore, provides important clinical information to
therapists contemplating a parent training program for such parents. Clinicians are
encouraged to incorporate a screening instrument for marital discord into their assessment
battery for parents of children with defiant behavior.

1.4.6. Parental Depression and General Psychological Distress

Parents of ADHD children, especially those with comorbid ODD or CD, are
frequently more depressed than those of normal children, which may affect their
responsiveness to behavioral parent training programs. The Beck Depression Inventory
(Beck, Steer, & Brown, 1996; Beck, Steer, & Garbin, 1988) is often used to provide a
quick assessment of parental depression. Greater levels of psychopathology generally and
psychiatric disorders specifically also have been found in parents of children with ADHD,
many of whom also have ADHD (Barkley, 2006; Lahey et al., 1988). One means of

19
assessing this area of parental difficulties is through the use of the Symptom
Checklist.This instrument not only has a scale assessing depression in adults but also has
scales measuring other dimensions of adult psychopathology and psychological distress.
Whether clinicians use this or some other scale, the assessment of parental psychological
distress generally and psychiatric disorders particularly makes sense in view of their likely
impact on the child’s course and the implementation of the child’s treatments typically
delivered via the parents.

1.4.7. Parental Stress

Research over the past 15 years suggests that parents of children with behavior
problems, especially those children with comorbid ODD and ADHD, report more stress in
their families and their parental role than those of normal or clinic-referred non-ADHD
children. One measure frequently used in such research to evaluate this construct has been
the Parenting Stress Index (Abidin, 1995). The original PSI is a 150-item multiple-choice
questionnaire which can yield six scores pertaining to child behavioral characteristics
(distractibility, mood, etc.), eight scores pertaining to maternal characteristics (e.g.
depression, sense of competence as a parent, etc.), and two scores pertaining to situational
and life stress events. These scores can be summed to yield three domain or summary
scores: Child Domain, Mother Domain, and Total Stress. A shorter version of this scale is
available and clinicians are encouraged to utilize it in evaluating parents of defiant
children.

1.5. Neuropsychology of ADHD in Children

Initial conceptualizations of performance differences between ADHD children and

normal controls on laboratory tests of cognition emphasized difficulties in sustained
attention in ADHD. The application of newer cognitive test paradigms has revealed more-
specific patterns of weakness in samples of children with ADHD. To assess the cognitive
functioning of children with ADHD, Cognitive Assessment System (CAS) was used by the
researcher. This test is designed to provide a nuanced assessment of the individual’s
intellectual functioning, providing information about cognitive strengths and weaknesses

20
in each of the four processes. This emphasis on processes (rather than abilities) makes it
useful for differential diagnosis; unlike traditional full-scale IQ tests, the CAS is capable
of diagnosing Learning disabilities and Attention Deficit Disorder, Autism, Mental
Retardation, cognitive changes in aging and Downs Syndrome, and more recently changes
due to brain impairment in Stroke. Its usefulness as a theory and measurement instrument
for Planning and Decision making in management has also been demonstrated. The test
which utilizes the PASS theory of intelligence, loads heavily on those areas of functioning
that are most affected by ADHD. The PASS theory (Naglieri & Das, 2005) is rooted in the
work of A.R. Luria, and was used by Naglieri and Das (1997) as a blue-print for defining
core components of human intelligence that are assessed in the Cognitive Assessment
System (CAS) (Naglieri & DAS, 1997). There are four basic cognitive processes that the
CAS examines: Planning is a cognitive process that provides cognitive control, use of
knowledge, intentionality, and self-regulation. Planning is critical to all activities where
the person has to determine how to solve a problem, which includes self-monitoring and
impulse control as well as generation, evaluation, and execution of strategies for problem
solving. Attention is a cognitive process that provides focused, selective cognitive activity
over time and resistance to distraction. Attention is involved when a person selectively
focuses on particular stimuli and inhibits responses to competing stimuli. The process
provides focused and selective attention over time. Focused attention involves directed
concentration toward a particular activity and selective attention is important for the
inhibition of responses to distracting stimuli. Simultaneous Processing is a cognitive
process used to integrate stimuli into groups. An essential aspect of simultaneous
processing is the conceptualization of interrelated elements into a whole, which is why
this process is often tested using visual spatial tasks. Successive Processing is a cognitive
process used when stimuli are arranged in a specific serial order to form a chain-like
progression. This process is required when information must follow a strictly defined
order where each element is only related to those that precede it and these stimuli are not
interrelated.

In summary, utilizing the PASS theory to and the CAS to uncover weaknesses in one or
more basic psychological processes allows for a better understanding and more targeted

21
way to educate and treat individuals with attention deficits. Psychologists who are
working with ADHD persons need to be aware of the cognitive issues briefly outlined
herein, in order to optimally care for children with ADHD.

1.5.1 Luria’s Neuropsychological Theory

The Planning, Attention, Simultaneous, Successive (PASS; Naglieri & Das, 1997)
theory is rooted in the work of A. R. Luria (1973, 1980) whose research on the functional
aspects of brain structures formed the basis of the theory (Das, Naglieri, & Kirby, 1994).
Das and Naglieri and their colleagues used Luria’s work as a blueprint for defining the
important components of human intelligence (Das, Naglieri & Kirby, 1994). Their efforts
represent the first time that a specific researched neuropsychological theory was used to
reconceptualize the concept of human intelligence.
Luria theorized that human cognitive functions could be conceptualized within a
framework of three separate but related “functional units” that provide four basic
psychological processes. The three brain systems are referred to as “functional” units
because the neuropsychological mechanisms work in separate but interrelated systems.
Luria (1973) stated “each form of conscious activity is always a complex functional
system and takes place through the combined working of all three brain units, each of
which makes its own contribution”. This means that the four processes form a “working
constellation” of cognitive activity. A child may, therefore, perform the same task with
different contributions of the PASS processes along with the application of a child’s
knowledge and skills.
Although effective functioning is accomplished through the integration of all
processes as demanded by the particular task, not every process is equally involved in
every task. For example, tasks like math calculation may be heavily weighted, or
dominated, by a single process, while reading decoding strongly related to another.
Effective functioning, for example, processing of visual information, also involves three
hierarchical levels of the brain. Consistent with structural topography, these can be
described in a simplified manner as the projection area where the modality characteristic
of the information is intact. Above the projection area lies the association areas. As
information reaches this area, it loses part of its modality tag. Above this area is the

22
tertiary area, or overlapping zone, where information is amodal. This enables information
to be integrated from various senses and processed at a higher level. This also illustrates
that modality is most important at the level of initial reception and less at the level where
information is integrated.

1.5.2 Three functional Units Described

The function of the first unit provides regulation of cortical arousal and attention;
the second codes information using simultaneous and successive processes; and the third
provides for strategy development, strategy use, self-monitoring, and control of cognitive
activities.
The second functional unit is associated with the occipital, parietal and temporal
lobes posterior to the central sulcus of the brain. This unit is responsible for receiving,
processing, and retaining information a person obtains from the external world. This unit
involves Simultaneous processing and Successive processes. Simultaneous processing
involves integrating stimuli into groups such that the interrelationship among the
components is understood. For example, in order to produce a diagram correctly when
given the instruction, “draw a triangle above a square that is to the left of a circle under a
cross”, the relationships among the different shapes must be correctly comprehended.
While Simultaneous processing involves working with stimuli that are interrelated,
Successive processing involves information that is linearly organized and integrated into a
chain-like progression. For example, successive processing is involved in the decoding of
unfamiliar words, production of syntagmatic aspects of language, and speech articulation.
Following a sequence such as the order of operations in a math problem is another
example of successive processing. In contrast, simultaneous processing involves
integration of separate elements into groups.
The third functional unit is associated with the prefrontal areas of the frontal lobes
of the brain (Luria, 1980). Luria stated that “the frontal lobes synthesize the information
about the outside world . . . and are the means whereby the behavior of the organism is
regulated in conformity with the effect produced by its actions” (Luria, 1980). This unit
provides for the programming, regulation, and verification of behavior, and is responsible
for behaviors such as asking questions, solving problems, and self-monitoring (Luria,

23
1973). Other responsibilities of the third functional unit include the regulation of
voluntary activity, conscious impulse control, and various linguistic skills such as
spontaneous conversation. The third functional unit provides for the most complex
aspects of human behavior, including personality and consciousness (Das, 1980).

1.5.5. Pass Profiles

Glutting, McDermott, Konold, Snelbaker, and Watkins (1998) suggested that
research concerning profiles for specific children are typically confounded because the
“use of subtest profiles for both the initial formation of diagnostic groups and the
subsequent search for profiles that might inherently define or distinguish those groups”
results in methodological problems. They further suggested that researchers should “begin
with unselected cohorts (i.e., representative samples, a proportion of which may be
receiving special education), identify children with and without unusual subtest profiles,
and subsequently compare their performance on external criteria”. Naglieri (2000)
followed this research methodology using the PASS theory and his (Naglieri, 1999)
concepts of “Relative” and “Cognitive” weaknesses.

1.5.6. Application of Pass Theory on ADHD Children

In contrast to an attention deficit, a Planning deficit is hypothesized to be the
distinguishing mark of ADHD within the constraints of PASS theory. A recent study by
Naglieri, Goldstein, Iseman & Schwebach (2003) is exemplary. The part of the study that
is relevant here concerns the comparison between a sample of ADHD children and the
normative groups on two tests, CAS and WISC- III. The purpose was to examine the
assumption that the PASS theory and its derivative CAS may be particularly sensitive to
the cognitive difficulties of children with ADHD, whereas the general intelligence test
WISC III is inadequate for diagnosis of ADHD. Specifically a low Planning mean score
was expected for the ADHD sample. The results showed a large effect-size for Planning
between the ADHD and the standardization samples. However, in regard to Attention
scale, a small effect-size was observed. The differences between the two samples in
Simultaneous and Successive scales were not significant at all.
Naglieri (2000) confirm the weakness of Planning, but not Attention, among
ADHD in a recent report. Participants in the study were forty-eight children (38 males and

24
10 females) referred to an ADHD clinic. The contrast group consisted of forty-eight
children (38 males and 10 females) in regular education. Their results indicate that the
children in regular education settings earned mean PASS scores that were all above
average, ranging from 98.6 to 103.6. In contrast, the ADHD group earned mean scores
close to the norm on the Attention, Simultaneous, and Successive scales (ranging from
97.4 to 104.0) but a significantly lower mean score on the Planning scale (90.3).
The low mean score in planning for the ADHD found in this study is consistent
with poor performance in planning reported in the previous study (Naglieri et al 2003) for
children identified as ADHD hyperactive/impulsive or combined types (Barkley 1997).
The consistency across these various studies suggests that some of these children have
difficulty with planning rather than attentional processing as measured by the CAS. In
some ways, PASS theory is an attempt to revive the intentions of early intelligence tests
developers and define ability using a multidimensional approach. The most important
difference between traditional IQ and PASS, therefore, lies in the use of cognitive
processes rather than general ability. The multidimensional, as opposed to a
unidimensional view of intelligence that the PASS theory provides is one of its
distinguishing aspects (Das & Naglieri1992). It is a theory for which research has
increasingly demonstrated utility and practitioners have noted its consistency with more
modern demands placed on such tests. We suggest that PASS is a modern alternative to 'g'
and IQ, based on neuropsychology and cognitive psychology, which is designed to meet
the needs of psychologists practicing in the 21st century.

1.6 Children with ADHD and their I Q

Research that uses samples drawn from clinics often report lower IQ. For example,
Barkley (1991) reviewed evidence to indicate that students with ADHD were about 7 to 15
points below comparison samples on standardized IQ tests, including samples of siblings.
Others have concluded that lower IQ and academic deficits may be a consequence of
ADHD rather than a core feature. The fact that lowered IQ may be an outcome explains
lower scores documented in later but not earlier grade levels. In sum, when differences in
IQ are found, they are most likely due to the selection of more severe cases of children
from clinical samples with some evidence suggesting that the IQ of children with ADHD

25
decreases as they age (Loney, 1978). When children with ADHD have been referred for
special education services, it has been associated with poor classroom achievement but not
typically with low IQ. Bright students are not immune from the cognitive difficulties that
plague other children and adolescents with attention deficit disorder, a new Yale study has
found. Often children and adolescents with IQ scores in and above the superior range are
brought by their parents for evaluation and treatment of chronic impairments related to
symptoms of ADHD.

1.7.1. Assessment Issues in Children with ADHD

Clinicians should bear in mind several goals when evaluating children for ADHD.
A major goal of such an assessment is the determination of the presence or absence of
ADHD as we1ll as the differential diagnosis of ADHD from other childhood psychiatric
disorders. This differential diagnosis requires extensive clinical knowledge of these other
psychiatric disorders and readers are referred to the DSM-IV (American Psychiatric
Association, 2000) for diagnostic criteria.

A second purpose of the evaluation is to begin delineating the types of

interventions needed to address the psychiatric disorders and psychological, academic, and
social impairments identified in the course of assessment. These may include individual
counseling, parent training in behavior management, family therapy, classroom behavior
modification, psychiatric medications, and formal special educational services, to name
just a few.

Another important purpose of the evaluation is to determine conditions that often

coexist with ADHD and the manner in which these conditions may affect prognosis or
treatment decision making.

A further objective of the evaluation is to identify the pattern of the child’s

psychological strengths and weaknesses and to consider how these strengths and
weaknesses may affect treatment planning. This identification may also include gaining
some impression as to the parents’ own abilities to carry out the treatment program as well

26
as the family’s social and economic circumstances and the treatment resources that may
(or may not) be available within their community and cultural group.

1.7.2 Parent Interview

The interview, particularly a semi structured interview, allows the clinician in a sense to
become another instrument in the assessment process. Although scorable data are
obtained, the small details and nuances of parent and child report resonates with clinician-
acquired knowledge (from previous interviews, research, readings, workshops, etc.) in
such a way as to flesh out and support final diagnostic conclusions.

The parental interview often serves several purposes. It establishes a necessary rapport
among the parents, the child, and the examiner that will prove invaluable in enlisting
parental cooperation with later aspects of assessment and treatment. The interview is an
obvious source of highly descriptive information about the child and family, revealing the
parents’ particular views of the child’s apparent problems. The initial parent interview can
help to focus the parent’s perceptions of the child’s problems on more important and more
specific controlling events within the family. Generally, those areas of importance to an
evaluation include demographic information, child-related information, school-related
information, and details about the parents, other family members, and community
resources that may be available to the family.

1.7.3. Demographic Information

If not obtained in advance, the routine demographic data concerning the child and family
(e.g., ages of child and family members; child’s date of birth; parents’ names, addresses,
employers, and occupations; and the child’s school, teachers, and physician) should be
obtained at the outset of the appointment.

1.7.4. Review of Major Developmental Domains

The examiner should review with the parents potential problems that might exist in
the developmental domains of motor, language, intellectual, academic, emotional, and

27
social functioning. Such information greatly aids in the differential diagnosis of the child’s
problems. To achieve this differential diagnosis requires that the examiner have an
adequate knowledge of the diagnostic features of other childhood disorders, some of
which may present as ADHD. Questioning about inappropriate thinking, affect, social
relations, and motor peculiarities may reveal a more seriously and pervasively disturbed
child.

1.7.5. School, Family, and Treatment Histories

The examiner should also obtain information on the school and family histories. The
family history must include a discussion of potential psychiatric difficulties in the parents
and siblings, marital difficulties, and any family problems centered around chronic
medical conditions, employment problems, or other potential stress events within the
family. Of course, the examiner will want to obtain some information about prior
treatments received by the child and his or her faily for these presenting problems.
Information about the child’s family is essential for two reasons. First, while ADHD is not
caused by family stress or dysfunction, such adverse family factors can contribute to
oppositional behavior or frank ODD. Therefore, the family history can help to clarify
whether the child’s attentional or behavioral problems are developmental or actually a
reaction to or product of stressful events that have taken place. Second, a history of certain
psychiatric disorders in the extended family might influence diagnostic impressions or
treatment recommendations. For example, because ADHD is hereditary, a strong family
history of ADHD in biological relatives lends weight to the ADHD diagnosis, especially
when other diagnostic factors are questionable.

The examiner should ask parents open-ended questions: “What did his teachers
have to say about him?”, “How did he do academically?”, or “How did he get along
socially?” The examiner should avoid pointed, leading questions (e.g., “Did the teacher
think he had ADHD?”). Examiners should allow parents to tell them their child’s story and
listen for the red flags (e.g., the teacher thought he was immature, he had trouble with
work completion, his organizational skills were terrible, he could not keep his hands to
himself, or he would not do homework).

28
 Gathering a reliable school history gives the clinician two crucial pieces of the
diagnostic puzzle. First, is there evidence of symptoms or characteristics of ADHD in
school previous to adolescence? Second, is there evidence of impairment in the child’s
academic functioning as a result of these characteristics?

1.7.6. Review of Childhood Psychiatric Disorders

As part of the general interview of the parent, the examiner must cover the symptoms
of the major child psychiatric disorders likely to be seen in ADHD children. A review of
the major childhood disorders in the fourth edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 2000) in some
semi-structured or structured way is imperative if any semblance of a reliable and
differential approach to diagnosis and the documentation of comorbid disorders is to
occur.

1.7.7. Psychosocial Functioning

A clinical diagnosis of ADHD requires impairment in the child’s functioning in at least

two important areas. This area could certainly be one of them. In addition, evidence of
impaired peer relationships may lead to important treatment recommendations such as
participation in a peer social skills training group or a peer support group.

Parents are asked if the child has trouble making or keeping friends, how the child
behaves around other children, and how well the child fits in at school. Parents are also
asked if they have concerns about the friends with whom their child spends time (e.g., do
parents view them as “troublemakers”). Finally, they are asked about recreational
activities in which the child participates outside school and any problems that occurred
during those activities.

The parental interview can then conclude with a discussion of the children’s positive
characteristics and attributes as well as potential rewards and reinforcers desired by the
children that will prove useful in later parent training on contingency management
methods. Some parents of ADHD children have had such chronic and pervasive

29
management problems that upon initial questioning they may find it hard to report
anything positive about their children. Getting them to begin thinking of such attributes is
actually an initial step toward treatment as the early phases of parent training will teach
parents to focus on and attend to desirable child behaviors (Barkley, 1997).

1.7.7 Child Interview

Some time should always be spent directly interacting with the referred child. The length
of this interview depends on the age, intellectual level, and language abilities of the
children. For preschool children, the interview may serve merely as a time to become
acquainted with the child, noting his or her appearance, behavior, developmental
characteristics, and general demeanor. For older children and adolescents, this time can be
fruitfully spent inquiring about the children’s views of the reasons for the referral and
evaluation, how they see the family functioning, any additional problems they feel they
may have, how well they are performing at school, their degree of acceptance by peers and
classmates, and what changes in the family they believe might make life for them happier
at home. As with the parents, the children can be queried as to potential rewards and
reinforcers they find desirable which will prove useful in later contingency management
programs.

Children below the age of 9–12 years are not especially reliable in their reports of their
own disruptive behavior.

1.7.8. Teacher Interview

Many ADHD children have problems with academic performance and classroom behavior
and the details of these difficulties need to be obtained. Initially this information may be
obtained by telephone; however, when time and resources permit, a visit to the classroom
and direct observation and recording of the children’s behavior can prove quite useful if
further documentation of ADHD behaviors is necessary for planning later contingency

30
management programs for the classroom. The teacher interview also should focus on the
specific nature of the children’s problems in the school environment, again following a
behavioral format. The settings, nature, frequency, consequences, and eliciting events for
the major behavioral problems also can be explored. Given the greater likelihood of the
occurrence of learning disabilities in this population, teachers should be questioned about
such potential disorders. When evidence suggests their existence, the evaluation of the
children should be expanded to explore the nature and degree of such deficits as viewed
by the teacher. Even when learning disabilities do not exist, children who have ADHD are
more likely to have problems with sloppy handwriting, careless approaches to tasks, poor
organization of their work materials, and academic underachievement relative to their
tested abilities. Time should be taken with the teachers to explore the possibility of these
problems.

1.7.9 Child Behavior Rating Scales for Parent and Teacher Reports

Child behavior checklists and rating scales have become an essential element in the
evaluation and diagnosis of children with behavior problems. The availability of several
scales with excellent reliable and valid normative data across a wide age range of children
makes their incorporation into the assessment protocol quite convenient and extremely
useful. Such information is invaluable in determining the statistical deviance of the
children’s problem behaviors and the degree to which other problems may be present.
Numerous child behavior rating scales exist, (Barkley, 1988, 1990) Despite their
limitations, behavior rating scales offer a means of gathering information from informants
who may have spent months or years with the child. Apart from interviews, there is no
other means of obtaining such a wealth of information with so little investment of time.

The clinician should also examine the pervasiveness of the child’s behavior problems
within the home and school settings as such measures of situational pervasiveness appear
to have as much or more stability over time than do the aforementioned scales (Fischer et
al., 1993).

31
One of the most common problem areas for ADHD children is their academic
productivity. The amount of work that ADHD children typically accomplish at school is
often substantially less than that done by their peers within the same period.
Demonstrating such an impact on school functioning is often critical for ADHD children
to be eligible for special educational services (DuPaul & Stoner, 2003).

1.8.1 Role of Parents of Children with ADHD

Given the numerous attentional and behavioral symptoms ADHD children exhibit,
including frequent displays of noncompliance, these children typically impose increased
care taking demands on their parents. As a result, parenting children with ADHD may
present a considerable challenge. Mothers of children with ADHD, compared with
mothers of nondiagnosed children, report higher levels of psychological distress and
marital dissatisfaction. Also, mothers of boys with ADHD are more likely to have a major
depressive episode and/or marked anxiety symptoms than comparison mothers (Brown &
Pacini, 1989; Nigg & Hinshaw, 1998).
Families that include a child with ADHD experience an alteration in their
communication patterns and dynamics, in addition to stress on family resources. Cohen
suggested that parent’s emotional resources become drained due to continuing confusion
about the appropriate way to manage the child and criticism of the child by others. Since
the ADHD child often monopolizes a significant amount of family time, other family
relationships, such as the marital relationship, can also become strained (Cohen). In
addition to decreased family functioning with ADHD children, investigators consistently
report increased parenting stress among these families.

1.8. Educational Rights for Children with Attention Deficit

HyperactivityDisorder
Because many children with ADHD/ADD experience significant academic difficulties, it
is very important for parents to be aware of the special educational services that public
schools are required to provide. Unfortunately, many children with ADHD/ADD do not

32
receive the services they are entitled to, and parents are often unaware of the assistance
their child should be receiving.
Prior to 1991, children with ADHD/ADD were not eligible to receive special
educational services unless they were determined to have some other disability (e.g. a
specific learning disability). Lobbying efforts to rectify this situation were successful,
however, and children with ADHD/ADD who require special assistance must now receive
access to special education and/or related services according to two federal laws.
Children with ADHD/ADD may be eligible for special services under Part B of the
Individual with Disabilities Education Act (IDEA). This would apply when a child's
ADHD/ADD is determined to be a "chronic or acute health problem which adversely
affects educational performance." When this condition is true - as it will be for many
children with ADHD/ADD - the child can be classified as "Other Health Impaired" (OHI),
and the school must develop an Individual Education Plan (IEP) that is designed to meet
the child's unique educational needs.
An IEP is a plan to educate your child based on your child's individual needs. Ideally, the
IEP should take into account a childish unique abilities and disabilities, and identify
specific educational goals for the child, procedures for attaining those goals, and methods
to evaluate whether the goals are being met. The IEP is developed after a child has been
evaluated and found to require special educational services. In the best circumstances, the
plan is developed in a collaborative meeting involving parents, teachers, and other school
personnel (e.g. guidance counselor, school psychologist, etc.) Parents are also free to bring
along anyone (e.g. child psychologist) that they feel would be helpful to have at the
meeting.
Special services for children with ADHD/ADD may also be obtained under Section 504, a
civil rights law that prohibits discrimination against individuals with disabilities. Like
IDEA, Section 504 requires schools to provide children who have disabilities with a free
and appropriate public education. Unlike IDEA, however, which stipulates that a child has
disabilities that require special education services, Section 504 identifies a qualified
person as anyone with a physical or mental impairment that substantially limits one or
more major life activities, such as learning. This means that children who do not require
special education are still guaranteed access to related services under Section 504 if the

33
child is deemed to have an impairment that "substantially limits one or more major life
activities" such as learning, and the school must try to adapt instructional methods to the
needs of children with ADHD.
As learning is considered a major life activity, children diagnosed with AD/HD are entitled
to the protections of Section 504 if the disability is substantially limiting their ability to
learn. It is up to the local school district to make the determination of whether this
condition is met and children who are not eligible for special education may still be
guaranteed access to related services if they meet the Section 504 eligibility criteria.
If the child is eligible under Section 504, the school district must develop a Section 504
plan. This plan would include accommodations/adaptations that are designed to meet the
child's educational needs and may include things such as the following:
-reducing the length of homework assignments;
- allowing the child extra time on tests;
- simplifying instructions about assignments;
- providing specific assistance with planning and organizational skills;
- or using behavioral management techniques in the classroom;
- use of tape recorders
- computer-aided instructions
In general, Section 504 provides a faster and more flexible procedure for obtaining some
accommodations and services for children with disabilities and some children may receive
protection who are not eligible for services or protection under IDEA. Thus, Section 504
can provide an efficient way to obtain limited assistance without the stigma and
bureaucratic procedures attached to IDEA.
The advantage of obtaining services under IDEA, however, is that it offers a wider range
of service options, the procedures for parent participation and procedural safeguards are
far more extensive, and the degree of regulation is far more specific than that found in
Section 504.
1.9 Awareness of ADHD
One of the prime reasons for conducting the study was to create awareness among
people living in Allahabad especially those persons who are the stakeholders of children
having ADHD, parents and teachers. In the process of data collection it was discovered by

34
the researcher that the teachers of the schools were not aware of the possibility of children
in their classes can be affected by ADHD, a neurobehavioural disorder. It is necessary to
identify such children because the disorder affects their day to day life academic
performance. Instead of giving them proper treatment they are ill-treated punished and
sometimes even beaten up by the teachers in schools and by parents at home. They are
often compared with their peers and siblings. The researcher was motivated with the inner
will to provide help to children having ADHD. Disorders like ADHD and SpLD are
prevalent in India; however, one of the major obstacles is lack of awareness of these
disorders. The higher the awareness among health-care professionals and school
authorities, the earlier the identification of affected children and referral for appropriate
intervention can begin and the fewer children will remain undetected.
These averages can be compared to those found by Parr et al (2003) who reported that the
mean age at diagnosis for 391 children with ADHD was 8.7 years and that girls were more
likely to have been diagnosed prior to age 8. The delay between symptoms first being
noticed and the child being diagnosed with SpLD and ADHD was nearly 6 years on
average for the children studied by Karande et al (2007). Thus, it is not surprising that all
of the children in their study demonstrated poor school performance by the time they were
assessed in the authors' clinic. Problems in school performance, as opposed to specific
symptoms of ADHD, are common complaints and common reasons for referral to child
development centers in India. (Wilcox CE., 2007) Some researchers have suggested that
attempts to raise awareness of, and access to, interventions for children with SpLD and/ or
ADHD should be made using locally acceptable models, focusing more on educational
and religious interventions as opposed to the medications and psychiatric labels of the
biomedical model.

35