ATTENTION DEFICIT HYPERACTIVITY DISORDER In Children & Adolescents

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ATTENTION DEFICIT HYPERACTIVITY DISORDERIn
Children Adolescents
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What is ADHD?The Current Clinical View

• A disorder featuring age-inappropriate
• Inattention
• Poor persistence of responding
• Impaired resistance to distraction,
• Deficient task re-engagement following disruption
• Hyperactivity-Impulsivity (Disinhibition)
• Impaired motor inhibition,
• Poor sustained inhibition
• Excessive and often task-irrelevant motor and
  verbal behavior
• Restlessness decreases with age, becoming more
  internal, subjective by adulthood
• Most cases are developmental and involve delays
  in the rate at which these two traits are
  maturing
• Some cases are acquired (20 mainly males)
• These may represent pathology and may differ in
  severity, recovery, possibly treatment response

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Essential Features

• ADHD presents as impairment in
• Persistence
• Resistance to distraction
• Working memory

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Persistence

• ADHD Individuals do not have problems with such
  perceptual aspects of attention as
• arousal or alertness
• focus or selective attention
• span of apprehension or divided attention
• Rather have an inability to sustain action toward
  a goal for an adequate period of time which is a
  motor problem
• Persistence is on the motor side of attention, it
  is an output disorder.
• Output is the problem
• Most people think of attention as an input
  problem how you perceive, select filter and
  process information

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Resistance to Distraction

• Related to persistence opposite sides of the
  same coin.
• If you can persist it is because you can resist
  distraction If you can resist distraction you
  can persist One requires the other
• Not a perception problem, ADHD kids are not
  overly perceptive they do not perceive
  distractions any better the difference is that
  they respond to the distracting events
• Most of us are able to inhibit our responses to
  distracting events, ignore them even though we
  detect them.
• ADHD is not a problem of perception but inhibition

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Working Memory

• Once distracted ADHD individuals are far less
  likely to return to the original goal or task
• task re-engagement is a major problem for this
  population
• This is modulated by working memory information
  held in mind that guides us toward a goal.
• People with ADHD are likely to have serious
  difficulties with working memory.
• Once distracted they are gone, off on another task

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Inattention Symptoms (DSM-IV)

• Failure to give close attention to details
• Difficulty sustaining attention
• Does not seem to listen
• Does not follow through on instructions
• Difficulty organizing tasks or activities
• Avoids tasks requiring sustained mental effort
• Loses things necessary for tasks
• Easily distracted
• Forgetful in daily activities
• Symptoms must occur Often or more frequently

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Hyperactive-Impulsive Symptoms

• Fidgets with hands or feet or squirms in seat
• Leaves seat in classroom inappropriately
• Runs about or climbs excessively
• Has difficulty playing quietly
• Is on the go or driven by a motor
• Talks excessively
• Blurts out answers before questions are completed
• Has difficulty awaiting turn
• Interrupts or intrudes on others
• Symptoms must occur Often or more frequently

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DSM-IV Criteria for ADHD

• Manifests 6 symptoms of either inattention or
  hyperactive-impulsive behavior
• Symptoms are developmentally inappropriate
• Have existed for at least 6 months
• Occur across settings (2 or more)
• Result in impairment in major life activities
• Developed by age 7 years
• Are not better explained by another disorder,
  e.g. Severe MR, PDD, Psychosis
• 3 Types Inattentive, Hyperactive, or Combined

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ADHD Varies by Setting

• Better Here Worse Here
• Fun Boring
• Immediate Delayed Consequences
• Frequent Infrequent Feedback
• High Low Salience
• Early Late in the Day
• Supervised Unsupervised
• One-to-one Group Situations
• Novelty Familiarity
• Fathers Mothers
• Strangers Parents
• Clinic Exam Room Waiting Room

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Prevalence (United States)

• 7-8 of children (using DSM-IV) (3-4 million)
• Varies by sex, age, social class, urban-rural
• 31 Males to females in children (51 in clinical
  samples)
• Somewhat more common in middle to lower-middle
  classes
• More common in population dense areas
• No evidence for ethnic differences to date that
  are independent of social class and urban-rural

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Co-Occurring DSM-IV Disorders

• More than 80 have one additional disorder
• More than 60 have two additional disorders
• Oppositional Defiant Disorder (Average of 55)
• Conduct Disorder (Average of 45)
• Anxiety Disorders (20-35)
• Major Depression (25-35)
• Bipolar Disorder (0-27 likely 6-10 max.)
• (97 of those Diagnosed w/ Bipolar also have ADHD)

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Medical Risks

• Sleep problems (39-56) mainly delayed onset and
  greater night waking leading to shorter sleep
  time
• Developmental Coordination Disorder (50)
• Reduced Physical Fitness, Strength, Stamina
  (using physical fitness tests)
• Accident Proneness 57
• 1.5 to 4x risk of injuries (greater in ODD)
• 3x risk for accidental poisonings
• Due to Impulsivity, risk-taking, impaired
  coordination, oppositionality, and poor parental
  monitoring

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Causes of ADHD

• Disorder arises from multiple causes
• All currently recognized causes fall in the realm
  of biology (neurology, genetics)
• Causes may compound each other
• Common neurological pathway for ADHD appears to
  be the areas of the brain controlling Executive
  Functions and Physical Activity (Smaller / Less
  Developed)
• Social causes have poor evidence

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Acquired Cases Prenatal

• Maternal smoking in pregnancy (odds 2.5)
• Maternal alcohol drinking in pregnancy (same)
• Prematurity of birth, especially if brain bleeds
  (45 have ADHD)
• Total increased pregnancy complications
• Maternal high phenylalanine levels in blood (?)
• High maternal anxiety in second trimester (?)
• Cocaine/crack exposure not a risk factor after
  controlling for the above factors

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Acquired Cases Post-Natal (7-10)

• Head trauma, brain hypoxia, tumors, or infection
• Lead poisoning in preschool years (0-3 yrs.)
• Survival from acute leukemia (ALL)
• Treatments for ALL cause brain damage
• Post-natal Streptococcal Bacterial Infection
• triggers auto-immune antibody attack of basal
  ganglia
• Post-natal elevated phenylalanine (dietary amino
  acid related to PKU)
• Prenatal hyperactivity
• Post-natal inattention

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Heredity Family Studies

• Familial Expression of ADHD
• - 25-35 of siblings
• - 78-92 of identical twins
• - 15-20 of mothers
• - 25-30 of fathers
• - If parent is ADHD, 20-54 of offspring
• (odds 8)

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Heredity Twin Studies

• Heritability (Genetic contribution)
• 57-97 of individual differences (Mean 80)
• (91-95 using DSM criteria)
• Shared Environment (common to all siblings)
• 0-6 (Not significant in any study to date)
• Unique Environment (events that happen only to
  one person in a family)
• 15-20 of individual differences
• (but includes unreliability of measure used to
  assess ADHD)

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Etiologies of ADHDFrom Joel Nigg (2006), What
Causes ADHD?
Other
Perinatal
Smoking
Lead
FASD
LBW
Heritable (Genetics)
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ADHD Evaluation Core Considerations

• Are the symptoms of inattention, impulsiveness,
  and overactivity, present. MOST Importantly Is
  there clear evidence of an impulsive style?
• Is there evidence that these symptoms
  significantly interfere with the childs
  functioning both at school and at home?
• Did these symptoms have a reasonably early onset?
  (If not, is there a good explanation?).
• Have these symptoms been an enduring and
  consistent feature of the childs behavior
  throughout their development and in the majority
  of contexts?
• Is there evidence that the child wishes to
  perform well but cannot?
• Are there better explanations for the
  underachievement?
• Is there a pattern or specific triggers to the
  problem behaviors?

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6 Step Diagnostic Process

• Review of Home Behavior
• Review of School Bx and Collateral Information
• Review of Developmental History
• Review of Family/Marital Situation
• School / Natural Environment Observation
• Interview of Child

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Psychodiagnostic Evaluation

• A psychodiagnostic Evaluation may be necessary if
  the assessment produces mixed/inconsistent
  results or has uncovered possible evidence of any
  of the following
• Suicidality
• Significant Developmental Delays
• Intellectual limitations
• Learning disabilities
• Serious Psychiatric disturbance
• Significant family problems
• Other reasons to refer for testing
• Child was moderately to severely premature
• Prenatal exposure to toxins especially ETOH
  Nicotine
• Low birth weight
• Complicated pregnancy and/or birth
• Reports that child had trouble grasping
  concepts/acquiring new skills
• Reports that child has trouble with major
  academic subjects even when attentive.

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Ruling out Depression

• Later onset than ADHD
• Usually preceded by excessive anxiety
• Not uncommon to have both as a result of the
  negative outcomes due to ADHD behaviors.
• Must treat both
• When comorbid, associated with a 4x increase in
  suicidal ideation and 2x increase in attempts
• Appears to be connected to same genes associated
  with ADHD.
• Best differential EARLY HISTORY

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Ruling Out Anxiety

• Onset later than ADHD
• Associated with a particular event or in
  accordance with a time pattern (anniversary).
• Restlessness is not a primary manifestation of
  Anxiety (usually a habit, style, or boredom)
• Usually characterized by panic or dread along
  with worry.
• Best measure for presence of anxiety is childs
  report (parents and teachers under report).

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Ruling Out PTSD

• Must look closely at developmental and early
  school history.
• PTSD will stem from a specific event
• Children with ADHD are at greater risk for PTSD
  from abuse and risky behaviors.

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Ruling Out Bipolar Disorder

• Childhood BPD manifests as severe and chronic
  irritability (rather than episodic mania)
• Also characterized by Disjointed thinking,
  capricious mood, destructiveness, and dysphoria.
• BPD usually starts as ADHD in childhood
• ADHD itself does not develop into BPD
• One-way Comorbidity
• 3-6 of ADHD have BPD
• 80-97 of BPD have ADHD

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Ruling Out ODD

• In many cases ADHD is at the root of ODD
• There is a high degree of co-occurrence
• Early onset of ADHD symptoms is the differential

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TreatingATTENTION DEFICIT HYPERACTIVITY
DISORDERIn Children Adolescents
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Current Perspective

• ADHD creates a kind of Myopia for future events
  or Time Blindness.
• ADHD individuals live in the Moment
• ADHD is a Disorder of
• Performance, not skill
• Doing what is known, not knowing what to do
• The when where, not the how or what
• Using representations of the past at the
  appropriate place time (Point of Performance)
• ADHD is better characterized as an Intention
  Deficit

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ADHD Executive Functioning

• Executive Functioning is responsible for two
  types of sustained attention (SA)
• Contingency-shaped (Externally maintained)
• Video Games
• Goal-directed (Internally guided motivated)
• Homework
• Goal-directed (SA) is impaired in ADHD
  individuals which creates problems with
• Delayed responding intrinsic motivation
• Doing the opposite of what is suggested in
  sensory fields
• Time, waiting, delays, and future orientation
• Problem solving, strategy development,
  flexibility
• Increases in complexity with age development

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Treatment Implications

• Teaching skills is ineffective (As is insight)
• Treatment must occur at the point of performance.
• Medications are likely to be essential for most
  but not all cases.
• Diminished capacity does not excuse
  accountability (The problem is time and timing
  not consequences).
• Behavioral treatment is essential but does
  generalize or endure after removal.
• Treatment success depends on the compassion and
  willingness of others to make accommodations.
• Maintaining a Chronic Disability perspective is
  most effective.

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Unproven / Disproved Therapies

• Elimination Diets Sugar, Additives, etc. (Weak
  Evidence)
• Megavitamins, Anti-oxidants, Minerals (No strong
  evidence or disproved)
• Sensory Integration Training (Disproved)
• Chiropractic Skull Manipulation (No Evidence)
• Play / Psychotherapy (Disproved)
• Neurofeedback (Experimental)
• Cognitive Self-Control Therapies (Effective in
  Clinic)
• Social Skills Training (Effective in Clinic
  Setting)
• Better for Inattentive (SCT) Type and anxious
  cases

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Empirically Proven Treatments

• Parent Education
• Psychopharmacology
• Parent Training in Child Management
• 65-75 of Children under 11 respond
• 25-30 of Adolescents show reliable changes
• Family Therapy for Adolescents
• Problem-Solving and Communication Training
• 30 show change (best combined with BMT)
• Teacher Education
• Train Teachers in Classroom Bx Management
• Special Ed (IDEA, 504)
• Regular Physical Exercise
• Residential Treatment (5-8)
• Parent Family Services (25)
• Parent/Patient Support Groups

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Managing ADHD

• Time is critical reduce delays
• Externalize a many processes as possible
• Time (Clocks, Timers, Calendars, PDAs etc.)
• Important information (Lists, reminders,
  instruction cards, etc.)
• Motivation (Token economy, tangible rewards)
• Problem Solving (use paper and pencil or dry
  erase board)
• Give immediate feedback
• Increase frequency of consequences
• Increase accountability to others
• Use salient artificial rewards

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General Recommendations

• Change rewards periodically
• Minimize talking, maximize communicative touch
• Corollary Act dont Yak
• Maintain a sense of humor
• Emphasize rewards over punishments (reward first)
• Anticipate problem situations and make a plan
• Keep a sense of priorities (pick your battles)
• Hold to the perspective of ADHD as a Disability
• Be forgiving (of child, self, and others)

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Give Effective Commands

• Initially give heavy praise to high compliance
  commands
• Dont use questions, use Imperatives
• Use eye contact and touch
• Have child recite request
• Break complex tasks into simpler ones
• Make chore cards for Multi-Step tasks
• List all steps involved on a 3x5 card
• Stipulate the time period on the card
• Reduce time delays for consequences
• Make use of Timers at the Point of Performance
• Avoid assignment of multiple tasks all at once
• Praise initiation of compliance
• Provide rewards throughout the task
• Have child evaluate their performance at the end

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Time-Out

• Target time-out to focus on one problem
• Act quickly after infractions
• Violations of household rules get instant time
  out
• Immediate commands
• Give Command ( count backwards from 5)
• Give Warning with raised voice (repeat count of
  5)
• Initiate time-out
• Release from time-out contingent on
• Completion of minimum time period (1-2
  minutes/year of age)
• Becoming quiet
• Consenting to command
• Reward next good behavior
• Best to use Bedroom for Time-out
• Remove all major play activities (Sanitize)

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Psychopharmacology
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Stimulant Medications

• These are the most well studied drugs in
  psychiatry
• In use for over 40 years
• Over 350 studies
• Thousands of cases

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StimulantsBehavioral Effects

• Increased concentration and persistence
• Decreased Impulsivity hyperactivity
• Increased work productivity
• Better emotional control
• Decreased aggression and defiance
• Improved compliance
• Better working memory internalized language
• Improved handwriting and motor coordination
• Improved self-esteem
• Decreased punishment
• Improved peer acceptance and interactions
• Better awareness in sports
• Improved driving performance

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Stimulants Side Effects

• Most tolerate well
• 5 discontinue due to negative effects
• Side effects are dose dependent
• Most common side effects
• Insomnia (50 )
• Loss of Appetite (50 )
• Headaches (20-40)
• Stomach Aches (20-40)
• Irritability, tearfulness (lt10)
• Nervous Habits Mannerisms (lt10)
• Tics (lt3) and Tourettes (Rare)
• Mild Weight Loss (Average 1-4 pounds transient)
• Small effect on height during 1st year (Approx
  1cm) Increased heart rate (3-10 bpm)
• Increased blood pressure (1.5-14 mmHg)
• Psychosis (lt3)

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StimulantsCommon Myths

• Addictive when used as prescribed
• No, Must be inhaled or injected
• Over Prescribed
• 7.8 prevalence rate, only 4.3 on stimulants
• Creates Aggressive, Assaultive Behavior
• No, decreases aggression and antisocial actions
• Increases the likelihood of Seizures
• Only at very very high doses
• Causes Tourettes Syndrome
• Can increase tics in 30 decreases it in 35
• Increases risk of later substance abuse
• No, 14 studies have found no such result, some
  found that it decreased risk if continued
  throughout teens

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Strattera

• Selective Norepinepherine reuptake inhibitor
• Not Schedule II no abuse potential
• Effective for children, adolescents, and adults
• Equal efficacy with Methylphenidate with
  previously unmedicated cases (75 positive
  response)
• Slightly lower efficacy with those previously on
  stimulants (55 positive response)
• Sustained response for up to 3 years
• Increasing improvement over time
• Can be given once daily (morning) or split (am/pm)

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Benefits of Strattera

• Reduces ADHD, ODD, aggression
• Reduces internalizing symptoms
• Increases school productivity
• Improved peer social behavior
• Improved self-esteem
• Improved parent-child relations
• Improved dry nights among bed-wetters
• Better morning after behavior
• Less insomnia and faster onset of sleep than
  Methylphenidate
• No emotional blunting

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Academic and Occupational Interventions for the
Treatment of ADHD
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Classroom ManagementBasic Considerations

• One of the major impairments of children with
  ADHD is functioning in the educational setting.
• More children with ADHD are receiving services in
  public schools now than at any other time in
  history.
• Despite the success of medication management and
  parent training, psychoeducational interventions
  are needed to ensure academic success and
  maintain positive behavior in children with ADHD.

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Classroom ManagementBasic Considerations

• The first goal of school-based interventions is
  to improve basic knowledge among educators about
  the nature, causes, course and treatment of ADHD.
• The second goal is to increase home and school
  collaboration to ensure that the treatment plan
  is consistent, and effective across settings.
• Third, effective interventions should include
  strategies to improve academic and social
  functioning in children and adolescents and
  occupational functioning in adults.

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ADHD BasicsTraining for Educators

• ADHD is biologically based and is treatable but
  not curable. Goal is to manage symptoms and
  reduce secondary harm (e.g., grade retention,
  peer rejection, disciplinary actions).
• ADHD is not due to a lack of skill or knowledge,
  but is a problem of sustaining attention, effort,
  and motivation and of inhibiting behavior. It is
  a disorder of performing what one knows, not of
  knowing what to do.
• Treatment is most effective when applied
  consistently at the place and time where a
  behavior is expected to be performed (e.g., at
  school).

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ADHD BasicsTraining for Educators

• It is harder for students with ADHD to do the
  same academic work and exhibit the social
  behavior expected of other students. Thus, these
  students need more structure, frequent positive
  consequences, consistent negative consequences,
  and accommodations to assigned work.
• To maximize behavior change proactive
  interventions involve manipulating antecedent
  events to prevent challenging behaviors from
  occurring reactive interventions involve
  implementing consequences following a target
  behavior.

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Classroom Interventions 9 Key Principles

• Rules and instructions provided to children with
  ADHD must be clear, brief and often delivered
  through more visible and external modes of
  presentation than required for the management of
  their peers.
• Consequences used to manage the behavior of those
  with ADHD must be delivered more swiftly
  (ideally, immediately) than with their peers.
• Consequences must also be applied more frequently.

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Classroom Interventions 9 Key Principles

• Consequences must often be of a higher magnitude,
  or more powerful, than that needed to manage the
  behavior of typical children.
• An appropriate degree of incentives must be
  provided within a setting or task to reinforce
  appropriate behavior before punishment can be
  implemented.
• Reinforcers/rewards that are employed must be
  changed or rotated more frequently than typical
  to avoid habituation or satiation.

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Classroom Interventions 9 Key Principles

• Anticipation is key. Thus, teachers must plan
  ahead and ensure that children with ADHD are
  cognizant of an upcoming transition or change in
  rules or routine before it occurs. Think aloud,
  think ahead.
• Children with ADHD must be held more publicly
  accountable for their behavior and goal
  attainment than typical children.
• Behavioral interventions only work while they are
  being implemented and require modification over
  time for effectiveness.

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Classroom ManagementAccommodations

• 10 core areas of intervention
• Decrease workload to fit the childs attentional
  capacity
• Alter teaching style and curriculum
• Make rules external
• Increase frequency of rewards and fines
• Increase immediacy of consequences
• Increase the magnitude/power of rewards
• Set time limits for work completion
• Develop a hierarchy of classroom punishments
• Coordinate home and school consequences
• Modifications for teens adults

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Classroom ManagementAccommodations

• Decreasing the workload
• Give smaller quotas of work
• Allow frequent, shorter work periods
• Target productivity and effort first accuracy
  and completion of assignments later
• Post work instructions on the board provide a
  schedule of assignments weekly and send home to
  parents.
• Reduce the amount of homework to 10 mins. per
  grade level (e.g., 1st grade 10 mins.)

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Classroom ManagementAccommodations

• Modifying the classroom and curriculum
• Be animated, flexible and responsive
• Reward incentive systems and clear consequences
  for misbehavior are crucial
• Use participatory teaching strategies have child
  write on board, point, use counters
• Sit child close to the teachers area
• Allow for restlessness, short stretching and/or
  exercise breaks
• Intersperse low interest with high interest tasks

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Classroom ManagementAccommodations

• Make rules external
• Post schedule and rules
• Use color-coded materials for instructions and
  organization
• Have child re-state the instruction to ensure
  understanding
• Use verbal prompts such as stay in seat, keep
  on working, etc.

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Classroom ManagementAccommodations

• Use a reward incentive system
• Combine positive consequences (praise, rewards,
  token economies) and negative consequences
  (response cost, time out), with positive
  consequences tending to make the most impact
• Use strategic teacher attention smiles, nods,
  pats on the back, active ignoring

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Classroom ManagementAccommodations

• Consequences must be immediate
• Avoid lengthy reasoning over misbehavior. Simply
  state the misbehavior and the consequence (should
  be posted as a rule)
• Use a daily report card or sticker chart.
• Variations of time out go to the chill area of
  classroom complete a given number of worksheets
  (drills) depending on the severity of the
  misbehavior
• Use mild, private, specific reprimands although
  punishment should be used sparingly

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Classroom ManagementAccommodations

• Rewards must be tangible and desirable
• Vary rewards to keep interest high
• A videogame (especially, educational type) or
  computer program can be used as an incentive
• Have parents donate preferred toys and games
• Try group rewards
• Use a home-school based reward program (e.g. good
  behavior points from school transfer to rewards
  at home)

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Classroom ManagementAccommodations

• Set time limits for work completion
• Use timers or a bell to signify the end of a work
  period use a signal about five minutes before
  the end as well
• Generally, extra time is not beneficial. Focus
  on developing a distraction-free work setting and
  provide breaks after short work periods.

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Classroom ManagementAccommodations

• Use a punishment hierarchy
• Head down on desk quiet time
• Response cost (loss of tokens)
• Time out in a corner/chill location
• Time out at school office where childs behavior
  can be monitored
• Suspension to the office (in school, not at
  home)--punishment is immediate and brief and does
  not include rewarding activities

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Classroom ManagementAccommodations

• Coordinate home and school consequences
• Daily school behavior report card/rating form and
  point system
• Daily home-school journal to communicate with
  parents and/or provide a reminder to child when
  completing homework
• Gradually, move to weekly monitoring

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Classroom ManagementAccommodations

• Specifically, for teens with ADHD
• Use a daily assignment notebook/planner with
  teacher verification and cross-checking
• Create a private, in-class cueing system for
  off-task behavior and disruption
• Use a daily or weekly school report card
  coordinate w/ home rewards (e.g. for grades)
• Assign a daily case manager or organizational
  coach to help monitor, organize and motivate
• Permit music during homework
• Require note-taking to pay attention
• Keep an extra set of books/materials at home

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Classroom ManagementAccommodations

• More tips for teens
• Learn SQ4R for reading comprehension
• Survey material, draft Questions, Read, Recite,
• Write, Review
• -- Study with buddy after school
• -- Swap phone numbers and email addresses with
  classmates to call in the event of lost or
  missing assignment sheets and instructions
• -- Attend after school help/tutoring sessions
• -- Schedule parent-teacher review meetings every
  6 weeks

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OccupationalAccommodations

• College-bound teens and young adults may require
  assistance with
• Employment
• Independent Living
• Managing money
• Organization
• Time management
• Accommodations/resources for college and
  occupational success

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OccupationalAccommodations

• CHADD (Children and Adults with
  Attention-Deficit/Hyperactivity Disorder) offers
  several resources to assist adults in handling
  these and other important issues. Please visit
  www.chadd.org for more information.

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Summary

• Education of teachers and other professionals
  working with children and adults with ADHD is
  crucial to helping these individuals receive the
  accommodations needed to ensure success
  academically and occupationally.
• Interventions are effective as long as they are
  being implemented and must be maintained over
  extended time periods.
• Collaboration between school and home appears to
  ensure greater success in the classroom.
• There are many resources available offering a
  wealth of advice to professionals who help those
  with ADHD.

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Resources

• www.chadd.org offers scientifically reliable
  information in English and Spanish about ADD in
  children, adolescents, and adults. Sponsored by
  Children and Adults with ADHD (CHADD), the
  largest ADHD support and advocacy organization in
  the United States, it has downloadable fact
  sheets of science-based information for parents,
  educators, professionals, the media, and the
  general public. The site also includes contact
  information for two hundred local chapters of
  CHADD throughout the United States.
• www.help4adhd.org presents evidence-based
  information in English and Spanish about ADD in
  children, adolescents, and adults. This national
  clearing house of downloadable information and
  resources concerning many aspects of ADHD is
  funded by the U.S. government's Centers for
  Disease Control and Prevention and operated by
  CHADD. New material is added frequently, and
  questions directed to the site are responded to
  by knowledgeable health-information specialists.
• www.add.org is a resource in English for adults
  with ADD. Sponsored by Attention Deficit Disorder
  Association (ADDA), the world's largest
  organization for adults with ADHD, it provides
  information, resources, and networking
  opportunities.