The current DSM-IV characterization of ADHD provides for three types: Inattentive, Hyperactive-Impulsive, and Combined. A fourth characterization, Not Otherwise Specified Type, in which a number of symptoms present with impairment, but there are an insufficient number of symptoms for one of the first three diagnoses. Children must meet six of nine criteria to qualify for an ADHD diagnosis. Inattentive symptoms include failure to give close attention to details, difficulty sustaining attention, problems listening when being spoken to, difficulty following through with instructions, poor organization, avoiding sustained effort, being easily distracted, or forgetful. Hyperactive and impulsive symptoms include fidgeting, restlessness, excessive movement, talking excessively, acting without thinking, and having difficulty delaying impulses. Symptoms must be present prior to age 7, although DSM-IV field studies suggest age 12 is likely a better cutoff. Symptoms must occur in at least two settings and cause impairment in social, academic, or occupational functioning.

Goldstein and Goldstein (1998) proposed a practical size-part definition to facilitate understanding of this group of children and provide effective management and intervention. This practical definition contains five components with the first, impulsivity, considered to be the major contributing force in shaping the other components. The five components are briefly described below:

1. Impulsivity.

ADHD children have difficulty thinking before they act. They know what to do, but they do not do what they know. They have difficulty weighing the consequences of their actions before acting and do not reasonably consider the consequences of their past behavior. Their difficulty following rule-governed behavior (Barkley, 1981) appears to result directly from their inability to separate experience from response, thought from emotion, and action from reaction. Although they may be well aware of a rule and able to explain it to you, in their environment they are unable to control their actions or to think before they act in the same way as their same-aged peers. This results in impetuous, unthinking behavior in children who seemingly do not appear to learn from their experiences. In actuality, they will learn from their experiences, but have difficulty acting efficiently upon that knowledge. Consequently, they are frequent repeat offenders of age appropriate behavioral norms. They appear to require more parental and teacher supervision. They frustrate parents and teachers due to their seeming inability to benefit from experience. As one parent explained years ago, 29 times he asked his child not to get into his tools. Nevertheless, the child got into the tools again. The child was able to explain what had been requested, but the child’s immediate need for gratification overwhelmed his limited capacity for self-control. Frequently, parent and teacher perspective of this problem is to label the behavior as purposeful, non-caring, and oppositional, which in reality it does not accurately describe what is taking place and often leads to punitive, ineffective interventions

2. Inattention.

ADHD children have difficulty remaining on task and focussing attention in comparison to non-ADHD children of similar chronological age (American Psychological Association, 1994). It has been suggested that as children get older they become more efficient in their ability to sustain attention. 2-year-olds are typically capable of sustaining attention on the average of a few minutes and 5-year-olds are able to sustain attention for much longer periods (Caul, 1985). From that point on, children’s attention span continues to increase with age. This increase mimics the ongoing brain development of a child. By first grade we expect children to be able to sit and work for one half hour at a time. In is increasingly recognized, however, that the capacity to attend is intrinsically tied to multiple environmental factors. Thus, the measurement of attention as a unitary phenomena has not provided very much benefit in the conceptualization and understanding of as well as the assessment and intervention of ADHD. At one time it was also suspected that distractibility was the core problem (Strauss and Kephart, 1955). We are now aware that distractibility represents a minimal part of the ADHD child’s problem. It is the inability to invest in the task rather than distractions that is primarily responsible for off-task behavior. From an attention perspective, it has been increasingly recognized that repetitive, effortful, uninteresting, and un-chosen tasks are the most difficult ones for ADHD children to stick with. Not surprisingly, these characteristics define the most difficult tasks for everyone to engage. This reinforces an important point. ADHD represents an exaggeration, on a dimensional basis, of normal problems. Unfortunately, children with ADHD demonstrate too much or not enough of what is described as acceptable ranges of behavior. These children represent the extreme of what adults expect. Increasingly, it is recognized that this child’s impulsiveness results in inability to sustain attention under various circumstances.

3. Over arousal.

Children of ADHD tend to be excessively restless, overactive, and easily aroused emotionally. Their difficulty in controlling bodily movements is especially noted in situations in which they are required to sit still or stay put for long periods of time. The same motoric over arousal accounts for the ADHD child’s difficulty with handwriting. Moreover, the deficit in improving as tasks become proceduralized is represented in ADHD children’s handwriting difficulty. Whether happy or sad, the standard intensity with which ADHD children move to the extreme of their emotions is much greater than that of their same-age peers. This problem very clearly reflects their impulsivity and ability to separate thought and emotion. This pattern of behavior frequently frustrates parents because 15 minutes after becoming extremely upset, the child has forgotten the upsetting event and has moved on to something else. Meanwhile, parents remain frustrated. Parents have great difficulty reconciling this discrepancy between their own thoughts, attitudes, and behavior, and their ADHD child. Indeed, the child is then accused of lacking guilt. As one parent has aptly put it, children of ADHD children wear their emotions on their coat sleeves, but their coat sleeves are always changing.

4. Difficulty with Gratification.

As a result of impulsivity, children with ADHD require immediate, frequent, and predictable/meaningful rewards. Once again we are at excess or exaggeration in comparison to same-age peers in regards to these variables. They experience greater difficulty working towards long-term goals for these reasons. They frequently require praise and repeated payoffs rather than a single long-term reward. They also do not appear to respond to rewards in a manner similar to other children (Haenlein and Caul, 1987). Rewards to not appear to be effective in changing their behavior on a long-term basis. Frequently once the reward and accompanying structure of the behavior change program is removed, the ADHD child regresses and again exhibits behavior that was the target of change. Parents then perceive this child as manipulative, accusing him of blackmail or extortion. Increasingly it has been recognized that due to impulsiveness, children with ADHD appear to require more trials to consistently demonstrate mastery of behaviors which they clearly possess. It is the proceduralized mastery of behaviors which is often the core of frustration for teachers and parents. Plus, as noted, it is not that they do not learn what to do as quickly as others, it is that they do not exhibit those behaviors as consistently and effectively. Problems result from missing the cue necessary to self-direct the behavior. Thus, they arrive at a street corner, forget to remember that the corner is a cue to look both ways and despite the fact that they understand traffic safety, may blindly walk out into the street before looking. Because of their impulsiveness, their behavior remains bound by consequences. However, it also appears that given a sufficient number of trials and opportunity for generalization, their behavior, that is the capacity to do what one knows consistently, is shaped in a very similar way as children without ADHD. For children with ADHD in regards to consequences and behavior development, the issue is not so much behavior modification, but rather behavior management. The provision of a sufficient number of civilized, structured, and reinforced trials for everything from simple tooth brushing behavior to social skills development is essential.

5. Emotions and **Lack of Self-Control.

To the original four components of this definition, the fifth component is an added consideration. Due to impulsiveness and emotional over arousal, children with ADHD are often on a roller coaster ride of emotions throughout their childhood. When they are happy, they are extremely happy. People tell them to calm down. When they are unhappy, they are extremely unhappy, people tell them to calm down. They frequently learn that emotions are to be changed as opposed to accepted. Emotions, they tend to learn, often leads to trouble. The combination of these qualities, feedback received for emotionality, lack of ability to develop the skills necessary to control emotions, and the disruption in relationships these qualities cause exerts a significant impact on children’s emergent sense of self, *lack of self-control, and likely subsequent personality. It has been argued children with ADHD appear more prone to develop an external *lack of self-control, projecting blame on others and being unwilling to recognize and accept the role they play in their own behavior. They appear more vulnerable to developing certain personality problems, especially those related to social difficulties. They may also be more prone to depression as a lack of balance between successful and unsuccessful experience on a daily basis. It is important for practitioners to recognize this emotional impact, not just because it holds importance for current developmental patterns, but because it is increasingly recognized as the quality of children’s emotional lives which shapes their adult outcome.