Getting organized is serious business for students with attention deficit disorder

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It's back to school soon for one creative, quick and highly verbal 10-year-old. The trouble is, he rarely gets A's on his report cards. His parents and teachers are frustrated that such a bright kid is so sloppy, careless and irresponsible. At times they wonder if he is just bored with it all.


Annie O'Neill, Post-GazetteDr. Craig Liden -- "Identifying ADD at an early stage makes it possible to begin treatment before the children enter a destructive cycle of failure that can interfere with their successful growth and development."
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The same dilemma once perplexed another mother, Pam, who was concerned about her son Tim, now 13.

"My son was having so much trouble paying attention at school and struggling in many areas despite being a really bright kid," said Pam, 40, a marketing consultant. She asked that their last name not be used for privacy reasons.

It was only after learning that the two boys have attention deficit disorder that their parents and teachers could begin to help them. Without expert support, the start of a new school year is daunting.

"School is a nightmare. I start to dread it," Pam said, but she added that parents can meet with teachers in August and make a plan for services and accommodations that the children are eligible for.

Her son, going into the eighth grade at South Fayette Middle School, will be getting organized and prepared, she said, complete with color-coded notebooks. Middle school marks a time of increasing demand for independence and organizational skills along with higher academic demands -- a challenge for any child, but particularly so for children with ADD.

Many people know that loved ones have chronic inattention, impulsivity or distractibility, and may think they will grow out of it. But the condition affects between 3 and 7 percent of school-age children and between 2 and 4 percent of adults and lasts a person's whole life. Adding to its effects is a lack of awareness and understanding, and misconceptions.

ADD is linked to inborn differences in the parts of the brain that control paying attention, which appear to involve the neurotransmitting chemicals dopamine and norepinephrine, according to the Pittsburgh ADD expert Dr. Craig B. Liden, 60, who has treated more than 9,000 patients with ADD.

People with ADD are less alert and are frequently fidgety, often make careless mistakes and do or say inappropriate things, have difficulty focusing their attention, thinking clearly and organizing and expressing themselves as they are more easily distracted, have difficulty staying focused on a project or an activity for sustained period, and fail to check themselves or critically evaluate their behavior.

Knowing that her son never fit the standard hyperactivity trait, Pam was always so perplexed when she would read about hyperactivity in available materials, which she found to be "so one-dimensional."

When Dr. Liden, then serving as pediatric resident in training at Children's Hospital Medical Center in Boston more than 30 years ago, was deliberately looking for reading materials on ADD, he also did not find any standard reference book. It was only "superficially described" in his textbooks.

The difficulty he himself faced made him undertake a mission to produce good resources and work out a method for proper diagnosis, treatment and personal understanding of ADD.

After completing a fellowship on ADD at Harvard, he started a program, the Child Development Unit, at Children's Hospital of Pittsburgh. While trying to develop and research his own testing procedures there, he found a tendency among medical students and residents to diagnose ADD as if it were a simple problem that would respond to neat technological approaches. He found family doctors, pediatricians or mental health professionals had little training or experience in ADD.

Also troubled by his own son's similar problem, Dr. Liden then left the hospital and organized a team of professionals -- including teachers, speech-language pathologists, psychologists, counselors and nurses -- to begin TRANSACT Health Systems in Monroeville. Dr. Liden's practice with his associates is now in Gibsonia, still using the TRANSACT diagnosis system.

"Although our initial focus was children and adolescents with ADD, we found ADD among parents and grandparents of many of the children we see," Dr. Liden said.

Saying that 40 percent of the 9,000 people he has treated since 1975 are adults, he added, "I've found that more than 90 percent of the parents of children with ADD can identify another family member with a similar problem."

Without depending totally on medication, the team started a three-pronged treatment -- counseling the individual, working with parents, spouses, teachers, co-workers and use of medical therapy -- and quickly found significant results.

Although it is inborn, diagnosing ADD before a child enters school is often difficult: Some of the "red flags" indicating ADD can be normal in preschool-age children.

Since there are misconceptions and a lack of understanding surrounding the problem, a comprehensive ADD assessment should include a medical, educational, vocational and behavioral history, survey of daily activities and independent functioning, general physical and neurological examinations, sensory screening and neuro-developmental assessment.

"Identifying ADD at an early stage makes it possible to begin treatment before the children enter a destructive cycle of failure that can interfere with their successful growth and development," Dr. Liden said.

If ADD is not identified and treated in childhood, unhealthy living patterns and behaviors, chronic stress and failure associated with ADD can result in alcoholism, obesity, sleep disorders, hypertension, depression, allergies, hypercholesterolemia, accidents, unplanned pregnancy, child and spousal abuse, chronic constipation, recurrent headaches and pain syndrome, premenstrual syndrome, bipolar disorder and poor treatment compliance.

Due to a lack of awareness, many families wait to seek treatment until after the children start doing "really bad" in school, Dr. Liden said.

"It is not only because the parents do not find adequate easy-to-understand materials. When the possibility of ADD enters our consciousness, it shakes our wish that everything would be perfect for our child."

So people tell themselves that their children are indeed perfect -- it is just that the teacher is too demanding or that the other kids are unfair. And when the kids sometimes pull it all together, people hold on to their stance.

"It's really hard to say that my son has this problem, and I made the problem worse thus. His self-esteem started to go down," Dr. Liden was saying about his 31-year-old son, "But once he was diagnosed and started being treated, everything dramatically turned around. He has been a very successful person."

To encourage people to appreciate the problems and understand the condition, Dr. Liden and his trans-disciplinary team published a book "Pay Attention!" in 1989.

Apart from helping set up similar programs in Reading, Harrisburg, Lancaster, Erie and Du Bois, he helped establish an ADD clinic with the Servyr health system in El Salvador.

The El Salvador group has translated the book in Spanish.

Besides writing 30 books and articles on ADD, Dr. Liden has conducted workshops for medical, psychological and education professionals in Central America and Israel. Doctors from different parts of the United States come and spend a few days to learn his method to take home.

After getting a request to include ADD in adults in "Pay Attention!" the team published a second edition in September.

"Understanding the dynamic between my son's intense temperament and his attentional difference was the turning point for us," Pam said, explaining that the book finally brought her clarification "of a very misunderstood condition that has been marginalized by society with the sound bite."

ADD cannot be cured totally. While some aspects of attention can improve with development of the nervous system, ADD persists and accompanies an individual throughout his or her life, Dr. Liden said.

"Unlike most other physicians who try to solve the problem traditionally with medication, Dr. Liden addresses each person with all his individual characteristics. He empathizes with him and makes him think that he is not the only one in his society. It's a common problem," said Tom D'Erminio, director of Affinity Center, an ADD clinic in Cincinnati.

After reading "Pay Attention!" and having a meeting with Dr. Liden 15 years ago, Mr. D'Erminio opened the clinic modeled after Dr. Liden's program.

"Even now, if you go to the Internet, unless you are a very sophisticated consumer, there is not a lot of really good reliable information," Dr. Liden said.

Although "Pay Attention!" provides in-depth information about symptoms and causes of ADD, the book strongly suggests readers consult with their physician or healthcare professionals before acting upon any of the ideas in it. Getting a good diagnosis leads to the best treatment.

What does Dr. Liden advise for school-age children?

Parents and teachers can encourage a child's success in school this fall with appropriate "structuring," he says.

"Structuring is a method of managing behavior, promoting responsibility, encouraging independent functioning by changing the physical surroundings or by providing the organization necessary for completion of a task," he writes.

He goes on to explain the importance of a balance: not too little nor too much structuring.

"As a rule of thumb, to avoid this, we all should only use structuring that is practical and applicable to the real world. Our children and students with ADD must cope with the demands of a world where we are not always present."

Helping the ADD child. Dear Doctor, Page F-3


The book "Pay Attention!" costs $25. Visit www.translationspress.com to learn more. The nonprofit organization TRANSHealth supports educational activities, clinical research and provides ADD health scholarships to needy individuals, and is seeking funds for free distribution of the book. Jill Daly contributed to this report. Shamim Ashraf is the Post-Gazette's 2007 Alfred Friendly Fellow. He can be reached at sashraf@post-gazette.com or 412-263-1198.


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