Not long ago, a mother told me about her child's plight. He was bringing unfinished work home from school nightly. For a time, this schoolwork masqueraded as assigned homework, but she soon realized that the rest of the class completed this work at school. This family, which—like most of us—had only a few hours each evening to enjoy each other, was now embroiled in fighting over homework that was in actuality schoolwork, unfinished by a child with Attention-deficit Hyperactivity Disorder (ADHD). The frustrated mom wrote a catharsis letter to vent her feelings. (Catharsis letters are for journals, not to be sent.) She wrote to his teacher: "Since it appears that I am going to be doing at least two hours of your job each evening, I'm going to start sending Jake's laundry on Mondays and Thursdays. Please don't mix the colors with the whites."

        Children with ADHD are a unique group of individuals. They require unique strategies for parenting. Remember what life was like before you started to have children? At the Neurology, Learning, and Behavior Center, we call that period B.C., which doesn't stand for Before Children; it stands for Before Chaos. The children who come to see us are having trouble meeting the expectations of adults. According to the adults, they don't behave right, or feel right, or think right, or learn right. Because they don't fit the system that we adults have designed for them, life has become chaotic for everyone.

        When you envisioned the kind of parent you were going to be—patient and calm, never angry, doing things democratically, and so forth—and compare that to what has happened along the way, especially if you've had a child who differs a bit from the norm, I predict that you have learned a lot. For one thing, you may have discovered that children with ADHD have more power to control you than vice versa. For another, you will have discovered that mental illness is inherited—we get it from our children! My purpose is to provide some helpful suggestions for parents of children with ADHD. I'll begin with a general framework for understanding ADHD.

        In taking client histories, I ask parents to bring me pictures of their children. One mom showed me a family photo she had just taken at her daughter's preschool graduation. It was mid-August. These children would be in kindergarten in a few days. They were outside singing a song, lined up in straight rows, teachers standing tall, parents watching. This mom's rather active little girl was not mean or nasty, just one of those children who get asked to leave preschools because they don't sit on their carpet squares the way they are supposed to. So I asked, "Which one of these little girls is yours?" She said, "Oops, she's not in this one." I thought, Oh my, it's only preschool, and this child's in time-out already. The mother produced a second picture, scrutinized it briefly, and said, "Oh, there she is. See her—way up on the hill?" She explained that her daughter had agreed never to get out of sight. As long as she was in sight, the teachers allowed her to wander; they had given up trying to get her to keep her body in one place. I thought, Too bad. This behavior, which was labeled as acceptable in preschool, a week from now in kindergarten is going to be labeled as bad. The teacher is going to say, "This is bad. You can't do this."

        How we label a child's behavior powerfully influences our thoughts and behavior toward that child. If I call a child "careful," I like what he is doing. If I call him "slow," I have a very different response to the same behavior. If I decide that a child is creative and energetic, I deal very differently with her than if I regard the child as hyperactive and difficult. So, we have not only to think about what we want for our children and how to help them get there, but we have to think about what we think about our children and why we label some behaviors good or bad.

        Children with ADHD commonly display multiple and varied problems, but the core problem is impulsivity. Impulsivity leads to difficulty in three other skill areas: an impulsive child has difficulty paying attention and is easily distracted; an impulsive child has difficulty delaying rewards; an impulsive child tends to be excessively active and emotional.

        Let's consider the emotional factor in more depth. Children with ADHD express the extremes of their emotions faster and with greater intensity than is normal for their age. They also become frustrated quickly, often over minor events. Everyone around a child with ADHD is well aware of the child's presence and current feelings. Another problem with impulsivity is threshold. Little things get big reactions, but ten minutes after a major blowout over some minor event, children with ADHD can't understand why you are so upset—they've moved on to something else. Think about what life is like for these children. Imagine yourself with their extremes of emotion. When you are happy, you are so happy people tell you to calm down. When you're unhappy, you're so unhappy people tell you to calm down. Think about what they learn about emotions and feelings. Too often their feelings are what get them into trouble rather than being qualities to cherish in human interaction.

        So impulsivity can lead to problems, but is being impulsive bad? Why isn't it good? Children who exemplify, as educator Rick Lavoie has said, the OTM-OTM syndrome—"on the mind, out the mouth"—take higher risks, act without thinking, and have difficulty separating thought from feeling. These children learn from their experiences but have trouble acting on that knowledge because immediate needs overwhelm their limited capacity for self-control. But is this behavior, the tendency to act without thinking, bad in a moral sense? No. It is a morally neutral quality, a normal variant of human behavior. Some people are very reflective; some are not. Children with ADHD are not. Some people are typically calm; some are volatile and exuberant. Children with ADHD are not among the calm.

        In our modern, competitive society, we tend to look at everything, including children's behavior, on a scale from the best to the worst. If your child is in the top 5 percent for how fast he runs, the soccer coach wants him on the team. If she is in the bottom 5 percent, the soccer coach says, "Go play with dolls." If she is in the top 5 percent for how well she reads, she's in the gifted readers class that puts on a play at the end of the year; if he is in the bottom 5 percent, he gets to do remedial phonics exercises and maybe watch the play—if he's not in time-out. Which activity will teach a child that learning to read is fun and worthwhile? In our society, children and adults in the bottom 5 percent for how well they manage their impulses—how well they control their emotions, stop and think, do the right thing, or learn from experiences—are in trouble.

        What I want to suggest is that we look at ADHD and identify the core deficit. Children with ADHD don't have any trouble paying attention when the task is something they have chosen to do. Give the child with ADHD a roll of quarters. Send him to the noisiest, loudest, most distracting video arcade you can find. Offer him a favorite machine. He's not inattentive. He pays attention just fine. He has trouble paying attention when tasks are repetitive, uninteresting, effortful, and not of his choosing. Now I've just defined half of what children have to do in school. If we identify what ADHD children have trouble with, those four factors will determine their level of difficulty. The more these qualities come into play, the more trouble these kids will have.

        When most children make a mistake, a parent asks, "What were you thinking when you did that?" We want to understand their motives or correct their thinking. When children with ADHD make a mistake, a parent must ask, "What weren't you thinking when you did that?" Their problems occur not because they don't know better, have a mean streak, or are inherently bad, but because they don't think before they act. They often know what to do, but they don't do what they know. A child with ADHD becomes distracted by his own thoughts and desire for immediate reward. In these instances, the child acts impulsively.

        Although the child may have been punished numerous times for similar misbehavior—"Don't run out in the street without looking first!"—and is able to clearly explain the rule, when the moment arises, she acts impulsively and does not follow the rule. The problem isn't in acquiring knowledge but in the follow-through. Children with ADHD are not clueless but cueless. Let me explain. When a pedestrian gets to a street corner, the corner curbing is a cue to look both ways. If the pedestrian forgets to act on the cue, understanding that traffic is dangerous doesn't help.

        Impulsive children often don't pick up on cues. Punishment for yesterday's trouble seems to be enough for most children, faced with the same choice, to trigger the thought, "Oh, I'm not going to do that again." But a child with ADHD doesn't recall what happened yesterday without a reminder cue. These children have trouble learning to do repetitive things because they don't pick up on cues. After a month of practicing tooth brushing, Norman doesn't have to be rewarded anymore. He goes into the bathroom, and the bathroom is a cue: Oh, brush my teeth. After a month of practicing brushing teeth, Jed, a child with ADHD, the day I don't remind him or give him a reward, goes in the bathroom, looks around, thinks, Why am I here?—and out he goes. Now, does he know what to do? Yes. Does he do what he knows? No. If you assume this is deliberately obstinate or "bad" behavior, you're buying into trouble, because it is not. Jed simply needs more repetition, more practice, to adequately reinforce those cues. As a parent, you can adjust your expectation and say, "This kid needs more practice."

        If it takes most children thirty days to learn to remember to brush their teeth, the ADHD child may need three hundred. Now, that's not three hundred days of trying. That's three hundred days of establishing the habit, of developing an internal cueing system. All children eventually learn to look both ways when they reach traffic and to brush their teeth. So it is not hopeless. These children are not morally, emotionally, or psychologically diseased. They do not have some terrible problem as human beings. They're simply at the bottom for certain qualities that our society increasingly values: Hurry up. Move quickly. Do it fast. Catch on quick. Don't waste time. Let's go.

        The first lesson, as we talk about what to do, is to make the task more interesting because if the task is more interesting for these kids, they stick with it better. The second lesson is to make the payoff more rewarding. This group of children, because they need more practice, seem to need more immediate, frequent, predictable, and meaningful payoffs than other kids. They don't like punishment; they like rewards just like anybody else. But they seem to need more rewards. If I am going to continue asking my child to practice brushing his teeth five times as long as his brother, I'd better make that task five times more interesting. And I'd better make the payoff five times as enticing. So make the task interesting, make the payoff enticing, adjust your expectations, and allow more practices. Or if that's more energy and creativity than you can devote to this particular task, expect it to take longer and be more patient. Eventually everybody learns to brush his teeth.

        As for speeding up the learning process using appropriate medications, let me clear up a couple of misunderstandings. First, stimulants are performance enhancers. Divide any group of ordinary people and give one half a stimulant and the other half nothing. The half receiving a stimulant will make fewer mistakes on boring, repetitive tasks than the half without a stimulant. In one study some years ago, entire classrooms of children were given low-dose stimulants. These were not children who had significant problems—nor does the study say that the teacher was given a stimulant. But every teacher reported after the trial that all the children paid attention better and did better work. That's not a reason to add low-dose stimulants to school lunch. It's a reason to recognize that the brains of children with ADHD, in fact, operate in basically the same way as the brains of the rest of us. Stimulants work the same way for everyone. Some individuals, however, have a lot more room for improvement in attending to boring, repetitive tasks than others.

        About medicine, my second point is that pills won't substitute for skills. We shouldn't overstate the benefits or understate the liabilities. Not a single study indicates that if you take your Ritalin today, you'll turn out to be a better adult. About six hundred studies, however, suggest that if you take your Ritalin today, your mother and your teacher will be less likely to be angry with you today. So what the medicine provides is relief from symptoms. I want this message to thread through everything else I have to say about the benefits of medicine for behavior modification. Relief of symptoms is not enough. We can do a lot of things to relieve the symptoms of children with ADHD and give them survival tools, but giving them life skills requires something more than treatments for ADHD. If a child's mother is an untreated depressive who cycles in and out and his father is an antisocial alcoholic or a never-home workaholic, then with or without medicine, behavior modification, or school intervention, that child's chances for a happy, successful future are slim. That will be true for any child, with ADHD or without.

        For any child, the best predictor of what therapists call "life outcome" is the quality of family life. That is true for any child, including those with ADHD. The good news, then, is that biology is not destiny. It affects probability. A family's genetic risk factors—or lack of them—do not guarantee that every child in that family is going to turn out a certain way, good or bad. How you rear your children and the quality of your relationships with them determine on what field the risk factors are played out.

        Also, at some point, at a certain age, the child has to be in charge. The child must tell the parent if the medicine makes a difference. What I tell children is, "The medicine is a tool. It doesn't fix you. And it doesn't fix the world to make it go better for you. If you pick up the tool and use it effectively, life will be better. If you choose not to use it, it's not going to make any difference for you." The child should be in control, not the medicine.

        Now let me provide some general information about how children with ADHD fare in school settings. First, let's look at intelligence and achievement. It has been argued that children with ADHD are innately less intelligent than their peers who do not have ADHD. Careful research suggests that this is not the case; rather, we are observing the effect of impulsive, inattentive behavior on test performance. As a group, children with ADHD appear to be as intelligent as their peers without ADHD.

        So why do report cards of elementary school children with ADHD, as a group, characteristically look worse than those of their peers without ADHD? Achievement testing suggests that most are learning adequately. They simply are not performing. Although there appears to be a greater incidence of specific learning disabilities among children with ADHD, most appear to have intact learning skills. Over time, however, the cumulative effect of lack of attention and completion of work takes its toll. By adolescence, a significant number of students with ADHD begin to lag behind their peers in at least one academic subject.

        Two other traits trouble teachers of children with ADHD: (1) their uneven and unpredictable ability to perform a given academic task, and (2) daydreaming. Let's consider the first factor: performance. A third grader with ADHD may successfully rattle off the complete times tables in ninety seconds one day and find most of those facts have vanished the next day. A mother drilling spelling words will breathe a sigh of relief to find the list already mastered by Tuesday only to be dumbfounded when the child can't spell those same words on Thursday. She feels sure the child "just isn't concentrating" or isn't "trying"—but that's not the problem. Uneven performance extends to skills as well as retention of facts. Teachers frequently reassure children with ADHD that they can do it "if they try" and "they did it yesterday so they should be able to do it today." This is somewhat analogous to telling a child he hit a home run the last time at bat, and, therefore, he should be able to hit a home run every time at bat. Frequently, completing work for the child with ADHD is equivalent to hitting a home run.

        Children with ADHD are also frequently described as daydreamers. Studies suggest that they are not as much daydreaming as they are interested in something other than what the teacher is focusing on. Children with ADHD appear to engage in a significantly greater degree of nonproductive behavior than do their peers who do not have ADHD. Most elementary school age children find something productive to do during unstructured activities. Children with ADHD characteristically engage in unproductive activities, such as zipping and unzipping their coats or rearranging the clutter in their desks.

        What about teaching styles? The best teacher is one who can adjust and find the best in every child. Beyond that, I don't think any particular qualities are essential. Should kids with ADHD have teachers with ADHD? Probably not. Nobody would know what time it was, when to start or stop an activity, or what happened to the homework. But that might be better than an unreasonable teacher reared by authoritarian parents who shames and blames a child who loses homework.

        What do teachers need to be able to teach? Put yourself in the shoes of the child with ADHD. What do your teachers want from you? Basically, they want you to stop, start, and think along with everybody else. They want you to think about what everybody else is thinking about. They don't want your mind on the beach in the Bahamas somewhere. They want you to start working when everybody else starts and to stop when everybody else stops. Don't start before; don't stop after. When everybody else comes in from recess, you come in.

        Can children with ADHD do that, or do they need a special educational setting? If parents step in as advocates for their children, I think adaptations can be made. These children learn best when they talk and move and question and interact with their learning environment. Does that mean there is something wrong with them? When I ask a teacher to make an adjustment so a child can move a little bit or have his hands on the learning materials, teachers will sometimes say, "I just don't have the time." My response is, "You know, hands-on, interactive learning is good for everybody. You don't need to set up a separate curriculum for one child. Do it for the whole class." Again, the principle is: what's good for kids with ADHD is good for everyone, and what's bad for everyone is extra bad for kids with ADHD.

        Above else, the child with ADHD needs compassionate understanding, both at home and at school. Parents and teachers should not pity, tease, attack, be frightened of, angered by, or overindulge this child. They must understand the condition is real; it involves critical skill deficits; it is primarily a disorder of competence, not defiance. In other words, the child did not cause or want the condition.

        So in working with schools, identify your child's strengths. Be proud. What works best? Schools tend to quickly gloss over strengths: "Oh, he's a nice kid. He smiles," and then they spend all their time on what's wrong. No. I want to see his strengths. Tell me his academic strengths and how you are going to make them stronger, so he feels like he is really good at something academically. That's what will get him through life. As my friend and colleague Bob Brooks says, "If you've got a big sea of dysfunction, you'd better have big islands of competence to rest on."

        Unfortunately, although some people may eventually learn to make ADHD an asset, in our society being given a diagnosis of ADHD at ten years of age has zero assets. I'm not talking about treasuring your child as a family member. I'm not discussing your relationship with your child. I'm referring to his or her ability to deal with the world we've designed for children, and ADHD is a liability, period. If the world would make some adjustments, these children would function better. The world is not about to do that, however, so we must focus on how we can adjust the child. What I ask children is, "What is it we don't understand about how you learn, about what you need?"

        One day a mother came in obviously upset. "Help me. I'm losing my child," she begged. At first I thought she was talking about divorce. She wasn't. She had a third-grader with not just ADHD but learning problems as well, and she devoted two hours of every afternoon to working with her child. She had overheard him tell his friend that he didn't care if he ever saw her again because if she left, he wouldn't have to spend his afternoons doing this work. That's not worth it. If you're going to spend an hour working on what's wrong with this child, you'd better spend an hour reinforcing what's right. Balance.

        Most children with ADHD exhibit impulsivity, hyperactivity, and inattention. A smaller group, about 10 percent, are inattentive without hyperactivity. They respond to Ritalin but not quite as well. Theirs is a different problem. Those kids have different risks, different life outcome probabilities, and a low probability of substance abuse. Whenever I mention substance abuse, parents' alarm bells go off. Let me emphasize: these are not "bad kids." People will say, "Oh, ADHD? Substance abuse. ADHD? Criminal behavior." Not so. If you take a group of children with ADHD, and they do not develop beyond being just a pain in the neck (meaning plenty of irritation but no serious problems with delinquent behavior, depression, or anxiety), then they have no greater risks for substance abuse as teenagers or seriously dysfunctional futures than anybody else. ADHD doesn't dispose a child to the disease of addiction. ADHD is a catalyst. A child with ADHD is more likely to try something on an impulse. Placed in a bad environment, impulsive children are more likely to get themselves into trouble, especially if they don't have parents willing or able to struggle with them during the teen years, setting limits and boundaries, hanging in there and loving children when they are hard to like.

        My message to parents comes down to this: you can make the difference for your children, not just by giving them medicine and by understanding ADHD but in the way you live your lives. Children don't do what we say; they do what we do. You are the best model for your children. The way you go about living your life, day in day out, is the best insulator for children with ADHD.