Hyperactive ADD:

The treatment of choice for children with moderate to severe hyperactive ADD is still stimulant medication. Stimulants have been used successfully and safely for decades. In spite of recent negative publicity and some medical concerns, the drugs are safe and effective for the vast majority of children, especially those with hyperactive ADD. Cardiac and seizure problems are the most serious, but rare risks. Tic disorders, which are involuntary muscle contractions often in facial muscles, can also rarely occur. Some mild reduction in height and weight gain over time has been noted. On the short- term basis, loss of appetite at midday is common. Sleep problems have been noted, but I have seen relatively little of that in cases where children or adults have been properly evaluated and confirmed to have hyperactive ADD.

Stimulants are often used in managing hyperactive ADD. The two major classes of stimulants are amphetamines (Dexedrine and Adderall) and methylphenidate (Concerta, Metadate, Focalin, Ritalin). If there are problems with one class of medication, sometimes the other will be better tolerated. Typical problems that can lead to discontinuing medication are anger, moodiness, headaches, severe appetite loss, restlessness, agitation etc. When the medications work well, these "stimulants" actually physically calm the child or adult down, along with improving attention and concentration. Many of the emotional and behavioral problems disappear rather quickly. There's also little time needed to establish effectiveness. These medications work quickly, often the first dose. Rare adverse reactions may develop later. All medication side effects or adverse effects should be reported to your doctor immediately.

Typical co-occurring problems with fairly straightforward, uncomplicated hyperactive ADD include: mild academic and developmental delays. Hyperactive children don't work patiently with fine motor activities. They tend to be awkward and even clumsy and they are prone to have accidents. Handwriting is often poor. Impatience and lack of frustration tolerance tends to make them quit tasks and not practice basic academic skills. Hyperactive ADD children may be a bit behind in basic reading, writing and math skills. Many children with mild deficits remit to average or above average functioning with normal activities and normal development with no intervention. Children with moderate or severe ADD may need remediation help to build skills, in and outside of school.

Counseling for hyperactive children and adults will often help build damaged self-esteem. These children and adults often underestimate their intellectual potential and that in turn tends to steer them away from challenges. Counseling can address coping strategies. Children and adults need to learn appropriate coping strategies, and not just rely solely on medication. The medication is not likely to fix 100% of the ADD and there will be times between doses or after medication has begun to wear off when new strategies will be needed. Counseling will be more necessary in cases of moderate to severe hyperactive ADD. These children and adults have endured almost continuous negative feedback, punishment and rejection in and outside of the family because of the side effects of their ADHD. Counseling will encourage self-monitoring and self-regulating.

Hyperactive ADD children and adults literally wear out others, and they know it. Most of these children and adults have developed significant negative behaviors as a coping strategy. These may include oppositional behavior and in later years conduct disorder and anti-social behavior. They are at very high risk of school failure. They are at a high risk of alcohol and drug abuse. They have become desensitized and even immune to the effects of routine discipline and punishment. Rewards mean little because they rarely achieve them. Early intervention is best, but treatment anytime is very helpful and usually necessary for this severely hyperactive population.

Non-hyperactive ADD:

The treatment of non-hyperactive or inattentive ADD is relatively new. As noted in the ADD types section of this website this disorder is primarily a processing disorder. It involves a very broad array of cognitive systems. Managing incoming information at lightning speed is not easy. Since processing incoming information is very complex it is not surprising that there is less success with medication management for this type of ADD. These ADD individuals are good candidates for cognitive/behavioral treatments, though medications can help reduce some symptoms. Non-hyperactive children often tolerate low dose stimulants. Many take medication primarily for school use only with breaks over weekends, vacations and summer. Medications that step up norepinephrine, a neurotransmitter, may also have beneficial effects (e.g. Prozac, Zoloft, Paxil).

Typical co-occurring problems with non-hyperactive ADD include mild academic weaknesses, failure to complete work, shyness, fatigue and low motivation. These problems occur not out of laziness, but because of the genuine effort needed to accomplish routine work. If you recall how tired you can be after straining to hear a TV show at low volume, then giving up and going to bed, you'll know how these children feel. It is a strain and effort every day. These children and adults are generally not disruptive. They tend to be invisible, on the sidelines. If they can accomplish average or close to average work, nobody bothers them. They often slip below the radar for many years until work demands increase. Still, they may struggle with poor coping skills, underachievement and problems interacting with others. Self-esteem may seem fine since the child may not complain openly, but many of these children suffer internally. They feel inadequate for the job and retreat.

Children and adults with non-hyperactive ADD need to learn to monitor and coach themselves in various academic and social situations.

Counseling will often focus on:

These children don´t wear out others as easily as hyperactive ADD children. They generally just retreat quietly. Problems develop when the pile of unfinished work, failure notices, lateness, etc. finally gets too much for the teacher or adult.

Complex ADD:

Some children and adults may have significant emotion issues along with the ADD. They may look like a simple, classic hyperactive child or adult, but they may also struggle with severe emotion management issues or broad neurological issues that may include auditory processing problems or receptive / expressive / pragmatic language problems. Receptive language problems involve poor understanding of incoming information and also poor understanding of the subtleties of language, i.e. the meaning behind the tone or gesture. Since much of our interpersonal communication is based on visual cues, it stands to reason that children and adults with ADD, who have trouble focusing, would be at a disadvantage. In some cases the child or adult is frustrated trying to get the right words out. They may think faster than their words and actually forget what they were just saying. Pragmatic language problems are subtle. These children and adults don´t read facial expressions or situations accurately. They don´t see the cues or demands of a particular situation. They intrude, cross others´ boundaries, do and say inappropriate things, etc. The emotion problems may involve externalizing behavior- such as anger management issues or internalizing issues- such as anxiety disorder, obsessive-compulsive problems, or withdrawal. The general communication and social skills of such ADD children and adults is often poor. These difficult ADD cases fit into a category I call complex ADD. They require much more intensive treatment. Working with the ADD alone will be insufficient.

Included in this group of complex ADD children and adults are those with pervasive developmental disorders and Asperger's, a form of mild autism. These individuals often struggle with a wide range of problems such as obsessive-compulsive symptoms in addition to learning disabilities. Fine and gross motor coordination is often impaired. The combination of all of these issues often results in significant functional problems in all areas of life, not just school. Children often struggle in isolation, unable to communicate well with others. They often give up on interacting unless they do so in an inappropriate way to get attention and control. Counseling with the child and management counseling with parents, teachers and care- givers are often essential.