I remember all too well the dread that I used to feel as the start of school drew near.

 I did not always have to drag my child from bed, but if he was already awake, there was no telling where he would be or what he would be doing first thing in the morning. Getting him through morning routines in time to get to the school bus stop was always a major challenge. Every step of getting dressed, eating breakfast, brushing teeth, packing the knapsack, and getting out the door had to be strictly supervised. Once he was at the bus stop, an adult had to make sure that he did not bound out into traffic on the street.

 Then there were a few hours of quiet while he was in the care of school personnel. At the end of the school day, he would arrive home declaring how much he hated school, his teachers, and most of his classmates. He would have no idea of whether he had any homework. Sometimes a list of spelling words or a blank worksheet would be jammed into the knapsack along with a note from the teacher saying that he did not turn in his homework for the last week. Of course, that homework that had been done under great duress, was wadded into the bottom of the knapsack. He had “forgotten” to turn it in. The homework battle would begin. Once something resembling a completed assignment is finished, he would shoot off to his video game where he spends several hours almost perfectly still and with rapt attention. When you call him for supper, he cannot break away from his “screen”. He is cranky, maybe even has a meltdown when a parent finally shuts down the video game. When bedtime comes around, he cannot wind down to get to sleep and he keeps the whole household up late.

 At some point, the teacher notes, emails, and conferences would come nearly every day. He is constant fidgeting and making inappropriate noises; he won’t stay in his classroom seat; he plays too roughly; he interrupts lessons by speaking out or talking with classmates; he does not finish his classwork; the schoolwork he does is poorly organized and difficult to read; he did not follow the directions; he does not follow school rules; he doesn’t wait his turn; he acts out and “shows off”; he is immature; he seems unable to make friends.

 The family is expending huge resources, mentally and physically, trying to help the child get through each day. As a parent, you hurt for him, but realize that he needs to learn to perform age appropriate activities even though progress seems to be small or even non-existent.

 “Have you had him evaluated for attention deficit disorder?”

 Here are the official DSM 5 criteria for ADD/ADHD:

 DSM-5 Criteria for ADHD
 

People with ADHD show a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development:

1. Inattention: Six or more symptoms of inattention for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level:
   • Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.
   • Often has trouble holding attention on tasks or play activities.
   • Often does not seem to listen when spoken to directly.
   • Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).
   • Often has trouble organizing tasks and activities.
   • Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).
   • Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
   • Is often easily distracted
   • Is often forgetful in daily activities.

2. Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level:
   • Often fidgets with or taps hands or feet, or squirms in seat.
   • Often leaves seat in situations when remaining seated is expected.
   • Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).
   • Often unable to play or take part in leisure activities quietly.
   • Is often “on the go” acting as if “driven by a motor”.
   • Often talks excessively.
   • Often blurts out an answer before a question has been completed.
   • Often has trouble waiting his/her turn.
   • Often interrupts or intrudes on others (e.g., butts into conversations or games)


In addition, the following conditions must be met:

• Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.
• Several symptoms are present in two or more setting, (e.g., at home, school or work; with friends or relatives; in other activities).
• There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning.
• The symptoms do not happen only during the course of schizophrenia or another psychotic disorder. The symptoms are not better explained by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).


Based on the types of symptoms, three kinds (presentations) of ADHD can occur:

Combined Presentation: if enough symptoms of both criteria inattention and hyperactivity-impulsivity were present for the past 6 months

Predominantly Inattentive Presentation: if enough symptoms of inattention, but not hyperactivity-impulsivity, were present for the past six months

Predominantly Hyperactive-Impulsive Presentation: if enough symptoms of hyperactivity-impulsivity but not inattention were present for the past six months.

Because symptoms can change over time, the presentation may change over time as well.

 Unfortunately, many issues and conditions besides ADD/ADHD can be manifested by these or similar brain-based symptoms. Medical conditions like allergic rhinitis, asthma, thyroid problems, infections, lead toxicity, malnutrition, medication reactions, and visual or hearing impairment can appear to be an attention disorder. Environmental conditions can be implicated: improper learning environments, sociocultural factors, social skills issues, parenting issues, bullying, and child neglect or abuse. Neurological problems like seizures, brain injury, developmental delays, learning disabilities, language processing problems, intellectual disabilities, and sleep disorders can be implicated. Lastly, psychiatric problems such as anxiety, conduct disorder, depression, obsessive-compulsive disorder, posttraumatic stress disorder, and substance abuse can appear to be attention problems.

 To complicate things further, many of these conditions can coexist with ADD/ADHD. It is particularly common to find anxiety, conduct disorder, developmental disorder, mood disorder, oppositional defiant disorder, substance abuse, and tics with ADD/ADHD. Additionally, I usually find that the effects of ADD/ADHD extend deeply in a patient’s family and psychosocial milieu. This sets off a cascade of issues that need attention and remediation.

 In my practice, I try to identify as many concerns as possible with each patient and help to prioritize efforts to find remedies. One of my major tools is the use of EEG neurofeedback because of its potential to help on a global basis. Its effects in encouraging cooperation of brain networks not only help with the symptoms of ADD/ADHD, but EEG neurofeedback also helps with many of the other issues that complicate the patient’s ability to successfully navigate their environment. As their brain begins to work better for them, family, work, school, and social interactions improve. Relationships begin to normalize and become self-sustaining in healthier patterns.

 EEG neurofeedback has been approved by the American Academy of Pediatrics as having the Best Level of Support for efficacy for treating ADD/ADHD. Unfortunately, medication not only wears off in a few hours, and it has a long list of potential negative effects. Medication does not seem to affect most psychosocial issues associated with ADD/ADHD. Patients on medication tend to lapse into old behavior patterns once medication is stopped. EEG neurofeedback and behavioral therapies are individualized to each patient. They take time to be effective, but have truly significant and long-lasting positive effects.