Erectile dysfunction (ED) is a medical term that describes the inability to achieve and or maintain an erect penis adequate for sexual function. This condition is one of the most common sexual problems for men and the number of men suffering from ED increases with age. Approximately 25 million American men suffer from ED, although not all men are equally distressed by the problem.

What happens under normal conditions?

Achieving a normal erection is a complex process involving psychological impulses from the brain, adequate levels of the male sex hormone testosterone, a functioning nervous system, and adequate and healthy vascular tissue in the penis. The simplest way to describe the process of erection is to think of a washing machine. The "on-off" switch (the brain) initiates the process; the wires in the washing machine (the nerves) carry the electrical signal to the pipes (the blood vessels), when an appropriate signal arrives a valve opens to allow water to flow in (the arteries carry blood into the penis) and the drain shuts (the penile veins close). Water flows in and fills the tank (the penis fills with blood and becomes erect) and the wash cycle begins (enjoys sexual activity). At the end of the wash cycle this process reverses, the switch goes to the off position (the brain terminates erection), the valve closes (the arteries markedly decrease blood inflow) and the drain opens draining the wash tank of water (the veins open, blood leaves the penis and erection subsides).

What are the risk factors for ED?

There are risk factors for the development of ED. As men age, the level of circulating testosterone decreases, which may interfere with normal erection. While a low testosterone level itself is rarely the cause of ED (5 percent or less), low testosterone can be an additional contributing factor in many men who have other risk factors for ED. Low levels of sexual desire, lack of energy, mood disturbances and depression can all be symptoms of low testosterone. A simple blood test can determine if the testosterone level is abnormally low, and testosterone can be replaced using a number of different delivery systems (e.g., shots, skin patches, gels, pills placed under the tongue).

What are some causes of ED?

By far, the most important cause of the development of ED is the presence of illnesses like high blood pressure, diabetes mellitus, high cholesterol levels and cardiovascular disease. These processes, acting over time, can lead to a degeneration of the penile blood vessels, leading to restriction of blood inflow through the arteries and also to leakage of blood through the veins during erection.

The choices we make in life can lead to degeneration of the erectile tissue and the development of ED. Smoking, drug or alcohol abuse, particularly over a long period of time, will compromise the blood vessels of the penis. Lack of exercise and a sedentary lifestyle will contribute to the development of ED. Correction of these conditions will contribute to overall health and may in some individuals correct mild ED. Treatment of many medical conditions can interfere with normal erections. Drugs used to treat these risk factors listed above may also lead to or worsen ED. Patients undergoing surgery or radiation therapy for cancer of the prostate, bladder, colon or rectum are at high risk for the development of ED.

How is ED diagnosed?

For most patients, the diagnosis will require a simple medical history, physical examination and a few routine blood tests. Most patients do not require extensive testing before beginning treatment. The choice of testing and treatment depends on the goals of the individual. If erection returns with simple treatment like oral medication and the patient is satisfied, no further diagnosis and treatment are necessary. If the initial treatment response is inadequate or the patient is not satisfied, then further steps may be taken. In general, as more invasive treatment options are chosen, testing may be more complex.

What are some non-surgical treatments?

The first line of therapy for uncomplicated ED is use of oral medications known as phosphodiesterase-5 inhibitors (PDE-5) -- , or tadalafil (Cialis). Men with ED take these pills before beginning sexual activity and the drugs boost the natural signals that are generated during sex, thereby improving and prolonging the erection itself. These medications are safe and fairly effective, with improvement in erection in nearly 80 percent of patients using these drugs. Early concerns about possible bad effects on the heart have not proven true; after extensive testing and five years of use, sildenafil citrate can be used safely by all heart patients except those using medications called nitrates because of an interaction between these two classes of drugs. The side effects of PDE-5 inhibitors are mild and usually transient, decreasing in intensity with continued use. The most common side effects are headache, stuffy nose, flushing and muscle aches. In rare cases, sildenafil can cause blue-green shading of vision due to high blood levels of sildenafil exerting a brief effect on the retina of the eye. This is of no long-term risk and is gone within a short time as the amount of sildenafil in the blood decreases. It is important to follow the instructions for using these medications in order to get the best results. Tests have shown that 40 percent of men who do not respond to sildenafil will respond when they receive proper instruction on medication use.

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For men who do not respond to another drug, alprostadil, is approved for use in men with ED. This drug comes in two forms: injections that the patient places directly into the side of the penis and a transurethral suppository. Success rates with self-injection can reach 85 percent. Modifying alprostadil to allow transurethral delivery avoids the need for a shot, but reduces the effectiveness of the agent to 40 percent. The most common adverse effects of alprostadil use are a burning sensation in the penis and the risk of overcorrecting the problem, resulting in a prolonged erection lasting over four hours and requiring medical intervention to reverse the erection.

For men who cannot or do not wish to use drug therapy, an external vacuum device may be acceptable. This device combines a plastic cylinder or tube that slips over the penis, making a seal with the skin of the body. A pump on the opposite end of the cylinder creates a low-pressure vacuum around the erectile tissue, which results in an erection. To keep the erection once the plastic cylinder is removed a rubber constriction band goes around the base of the penis, which maintains the erection. With proper instruction, 75 percent of men can achieve a functional erection using a vacuum erection device.

There are some men who have severe degeneration in the tissues of the penis, which makes them unable to respond to any of the treatments listed above. While this is a small number of men, they usually have the most severe forms of ED. Patients most likely to fall into this group are men with advanced diabetes, men who suffered from ED before undergoing surgical or radiation treatment for prostate or bladder cancer and men with deformities of the penis called Peyronie's disease. For these patients, reconstructive prosthetic surgery (placement of a penile prosthesis or "implant") will restore erection, with patient satisfaction rates approaching 90 percent. Surgical prosthetic placement normally can be performed in an outpatient setting or with one night of hospital observation. Possible adverse effects include infection of the prosthesis or mechanical failure of the device.

What can be expected after treatment?

All of the treatments above, with the exception of prosthetic reconstructive surgery, are temporary and meant for use on demand. The treatments compensate for but do not correct the underlying problem in the penis. So it is important to follow-up with your doctor and report on the success of the therapy. If your goals are not reached, if your erection is not of sufficient quality or duration and you are still distressed, you should explore the alternatives with your doctor. Because the medications used are not correcting the problems leading to ED, your response over time may not be what it once was. If such should occur again, have a repeat discussion with your physician about the remaining treatment options.

Frequently Asked Questions

How do I know my ED is not in my head?

Many years ago most men with ED were thought to have psychological problems. This was the result of our ignorance of the normal mechanism of erection and the causes of ED. We now realize that most men have underlying physical causes.

If I worry about my ability to get an erection can I make a bad condition worse?

Nothing happens in the body without the brain; worrying about your ability to get an erection can itself interfere with the process. This condition is called performance anxiety and can be overcome with education and treatment ("Is It Erectile Dysfunction from Diabetes or Performance Anxiety?").

Can I combine treatment options?

This is often done but because of the risk of prolonged erections with drug therapy, it should only be performed under physician supervision. Ask your doctor for proper instructions.

I was fine until I began taking this new drug, what should I do?

Many drugs can cause ED, but some cannot be changed because the benefits outweigh the adverse effects. If you are fairly certain that a specific drug has caused the problem, discuss the possibility of a medication change with your doctor. If you must remain on the specific medication causing the problem, the treatment options outlined above can still be used in most cases.

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Glossary Terms

arteries: Blood vessels that carry blood from the heart to various parts of the body.

bladder: The balloon-shaped pouch of thin, flexible muscle in which urine is temporarily stored before being discharged through the urethra.

cancer: An abnormal growth that can invade nearby structures and spread to other parts of the body and may be a threat to life.

cholesterol: A fat-like substance important to certain body functions but which, in excessive amounts, contributes to unhealthy fatty deposits in the arteries that may interfere with blood flow.

citrate: A salt of citric acid.

colon: Large intestine.

constriction: The process of becoming narrower.

diabetes: A medical disorder that can cause kidney failure.

diabetes mellitus: A condition characterized by high blood sugar resulting from the body's inability to use sugar (glucose) as it should. In type 1 diabetes, the pancreas is not able to make enough insulin; in type 2 diabetes, the body is resistant to using available insulin.

ED: Also known as erectile dysfunction or impotence. The inability to get or maintain an erection for satisfactory sexual intercourse.

erectile: Capable of filling with blood under pressure, swelling and becoming stiff.

erection: Enlargement and hardening of the penis caused by increased blood flow into the penis and decreased blood flow out of it as a result of sexual excitement.

flushing: Fitting two things so they are completely level and form an even surface.

gene: The basic unit capable of transmitting characteristics from one generation to the next.

high blood pressure: Medical term is hypertension.

hormone: A natural chemical produced in one part of the body and released into the blood to trigger or regulate particular functions of the body. Antidiuretic hormone tells the kidneys to slow down urine production.

infection: A condition resulting from the presence of bacteria or other microorganisms.

invasive: Having or showing a tendency to spread from the point of origin to adjacent tissue, as some cancers do. Involving cutting or puncturing the skin or inserting instruments into the body.

ions: Electrically charged atoms.

liver: A large, vital organ that secretes bile, stores and filters blood, and takes part in many metabolic functions, for example, the conversion of sugars into glycogen. The liver is reddish-brown, multilobed, and in humans is located in the upper right part of the abdominal cavity.

penis: The male organ used for urination and sex.

Peyronie's disease: A plaque (hardened area) that forms on the penis, preventing that area from stretching. During erection, the penis bends in the direction of the plaque, or the plaque may lead to indentation and shortening of the penis.

prostate: In men, a walnut-shaped gland that surrounds the urethra at the neck of the bladder. The prostate supplies fluid that goes into semen.

prosthesis: Artificial body part.

radiation: Also referred to as radiotherapy. X-rays or radioactive substances used in treatment of cancer.

radiation therapy: Also referred to as radiotherapy or radiation. X-rays or radioactive substances used in treatment of cancer.

rectum: The lower part of the large intestine, ending in the anal opening.

testosterone: Male hormone responsible for sexual desire and for regulating a number of body functions.

tissue: Group of cells in an organism that are similar in form and function.

transurethral: Through the urethra. Several transurethral procedures are used for treatment of BPH. (See TUIP, TUMT, TUNA or TURP.)

urethra: In males, this narrow tube carries urine from the bladder to the outside of the body and also serves as the channel through which semen is ejaculated. Extends from the bladder to the tip of the penis. In females, this short, narrow tube carries urine from the bladder to the outside of the body.

urethral: Relating to the urethra, the tube that carries urine from the bladder to outside the body.

urge: Strong desire to urinate.

vacuum erection device: A device used for treatment of impotence that features a pump that draws air from a plastic cylinder placed over the penis and creates a vacuum that allows increased blood flow to the penis which causes and erection.

vas: Also referred to as vas deferens. The cordlike structure that carries sperm from the testicle to the urethra.

vascular: Having to do with blood vessels.

vascular disease: Disease that occurs in the blood vessels.

vein: Blood vessel that drains blood away from an organ or tissue.

Is there a direct relationship between a child's learning disability and his or her disruptive or delinquent antisocial behaviors?

Jeff

Jeff is in trouble at school...again. His mother was called.... again. "There was another fight. He raised his scissors to another student and threatened him," states the school principal. "Jeff is an at-risk student. He's headed for delinquency, school drop-out, and other emotional problems."

Jeff has a learning disability (LD) that interferes with his ability to read. "His LD," states the principal, "is the cause of this behavior." Jeff's mother feels helpless hearing these words. She does not know how to stop Jeff's aggressive behavioral outbursts. She does not know, either, if she believes the principal.

Policy

Policy makers, too, are in a quandary. As school violence seems to escalate with events such as the Columbine shootings increased requests for a "zero tolerance" policy are voiced. This means that some parents, teachers, and lawmakers are requesting legislation to assure that children who engage in violent behaviors that threaten others are expelled from school.

Others ask, "If Jeff's learning disability contributes to the antisocial behavior should he be disciplined in a manner similar to non-disabled students?" Answers are complicated. School may make Jeff feel more anxious and tense due to his disability. Rigid discipline structures make these feelings worse possibly escalating his antisocial behaviors. Expulsion further limits his chances for success.

The Classroom

Teachers trained to help students with learning disabilities are essential to Jeff's positive transition to adulthood. Two facets of their roles are especially critical:

1. understanding causative relationships between a student's LD and his or her antisocial behaviors
2. developing "risk preventative strategies" to help a child with LD achieve resiliency that can prevent future antisocial behaviors

These facets will, or course, interact with a child's inborn traits (personality, cognitive ability, and degree of disability) family and community structures, supports, and beliefs.

Is there a direct causative relationship between a child's learning disability and his or her disruptive or delinquent antisocial behaviors? Children with learning disabilities may misread social cues or act impulsively. Their "social scanners" that help them read the intent of another's behaviors; that is, their information processing systems, do not work as efficiently as those of other children. A classmate borrows another's pencil without asking. A child without effective social scanners may see only the "pencil taking." S/he does not consider intent and responds aggressively.

Children with LD also often find themselves, by virtue of their disability, in the lower rungs of the academically defined social status among their peers. Even though a teacher assigns labels such as "bluebirds" or "robins" to reading groups, children know who are the best readers, best spellers, and prized students. Students with LD often feel the pain of not being among those students. They know they try so much harder. They see little benefit from effort and worry about disappointing parents, teachers and themselves.

Disadvantaged social position, combined with inability to accurately read social cues, and a sense that no matter how hard you try you cannot achieve in school as well as other classmates, or your siblings, creates a recipe for frequent disruptive antisocial behaviors. Acting out releases feelings of frustration. It gives a time-out from anxiety. Thus it can be self-reinforcing. It also distracts an audience of peers, parents and teachers, from the real problems of LD. Jeff can define himself as the "best trouble maker" not the poorest student!What makes this even more frustrating for Jeff, his parents and his teachers is the fact that Jeff may really not know what caused the fight. Redl (1968) identified a classroom counseling/crisis intervention approach, a life-space interview, that offers teachers "here and now" strategies to help a child understand the origin of problem behaviors so that behavior change can begin. Through a technique of "emotional first aid on the spot", the teacher helps the student drain off the frustration in order to be ready to understand the causes of the disruptive behavior by using a technique called reality rub-in. The teacher helps the student discover new ways to handle a precipitating event. This also involves helping the child understand self-boundaries. Children who feel disadvantaged among peers will often allow others to take advantage of them. In so doing they seek to gain peer favor. When this does not follow the urgency of frustration escalates.

Jeff, I saw that Bill picked up your special pencil. It made you very angry... so angry that you hit him and threatened to 'kill him' with your scissors. This worried the other kids. They were scared because that is not how they would have acted. Jeff, you play so well on the playground with your friends. I bet Bill did not know how really important that pencil was to you. Let's look to see if we can find how the fight began. OK? Then we can see if we can practice other ways to solve it.

The teacher identifies the behavior that Jeff knows got him in trouble, the fight; helps Jeff know where there may have been a misperception; gives a positive self-statement that Jeff can use to anchor his self-esteem in some way; and says that s/he is there to help Jeff solve the problem. The teacher knows, too, it may take many times before Jeff will begin to put solution into practice. Family factors, too, influence a child's behaviors. Children develop best when there is a consistently supportive family structure. When a family is troubled there is a disequilibrium that will cause most children stress.

Parents

Additionally, parents of children with a learning disability may experience feelings of helplessness, or despair, that can impact their perceptions of their child. This can result in low expectations for achievement, inconsistent parenting, and sadness because a child is not "normal." Children internalize their parents' perceptions. Such perceptions can further increase anxiety and augment the cycle of antisocial behavior.

Teachers that collaborate effectively with parents help produce resilience in students with LD. Overwhelmed parents need reassurance and help re-framing their perception of their child. They see a disruptive child who is always in trouble. Teachers can direct focus to a child's strengths and how to develop those strengths. Some parents need more help. In such cases a trained professional is an important ally.

In Summary

Children with learning disabilities may be at greater risk for disruptive antisocial factors. Several interactive factors explain this. These include internal dispositions, school, family, and community factors. Teachers can provide a critical preventative role by helping a child understand the cause of disruptive behaviors, establishing positive collaborations with the family and by knowing when to help the parent seek further professional help.

About the author: Dr. Ross-Kidder is a faculty member of the Department of Psychology at The George Washington University, a former teacher in both private and public education and a licensed school psychologist who has worked extensively in public education and private practice helping children with learning disabilities and/or ADHD and their parents.

When disciplining a child with ADHD, what works? A mother of two ADHD children talks about behavior management through the use of consequences.

Being the parent of an ADHD child can be very stressful. I happen to be a single ADHD mom to three daughters and 2 of them have it as well. I can tell you from personal experience that I never in a million years thought my stress level could get so high. As your life spins out of control for the umpteenth time you find that help is hard to find from friends and family. They look at you and your children like their behavior is all your fault. It's pretty hard to convince someone that hasn't walked a mile in your shoes just what is really going on. So I won't even try anymore to explain it to a non-ADDer. I will tell you what I have learned though.

I had a unique chance to see my theory work just this week. One of my children had an issue that needed immediate resolution. The school met with me to explain their rules and consequences and that they would start using it with her. They called me a week later to see what else they could do since their method wasn't working. I explained the fact that purely negative consequences don't work with my daughter and she needed a positive consequence to go along with it. It worked IMMEDIATELY.

Why it worked:

Behavior management through the use of consequences is an important part of the treatment program when working with children with ADHD. We change our behavior according to the consequences that result. If I do something and as a consequence, I get hurt, the chances are that I will stop doing it. If I do something that brings satisfaction, the chances are I will keep doing it.

If we do not experience consequences for our behavior we are unable to make effective changes. We learn behaviors best when consequences are clearly related to specific behavior.

For most children, abstract rewards work very well and brief reprimands do the job. However, for children with ADHD, specific and tangible consequences are needed to encourage positive behavior in order to change disruptive or non-compliant behavior.

While talking may be effective with many children, for children with ADHD "doing" provides better results than "talking".

Two key factors in using consequences are Consistency and Timing. Rules should be firm and consistently enforced. Consequences should occur as soon as possible after the behavior you are attempting to change.

Examples of Positive Consequences:

• Special treat for dinner
• Special time with father and/or mother
• An additional story at bedtime
• Specific tangible reward (small toy)
• Take him/her places
• Rent a movie to watch together
• Let him/her select the menu for the next lunch or dinner
• A star or check is earned to be 'cashed' in later for a reward

Examples of Negative Consequences

• Missing a favorite TV show
• Time-out for a short period of time (2-5 minutes)
• Removal of some privileges
• TV is off earlier than usual
• Go to bed earlier

Ineffective Consequences

• Endless groundings
• Consequences without warning
• Inconsistent consequences (given one day but not the next)

About the author: Megan Dlugokinski is an ADD/ADHD coach and was diagnosed with ADHD in 2003. She is a single mother of three young daughters.

Being a parent of an ADHD child is a challenge. Here are 30 tips on managing Attention Deficit Disorder (ADHD) at home.

Based on 50 Tips on the Classroom Management of Attention Deficit Disorder by Edward M. Hallowell, MD and John J. Ratey, MD

These tips are directly from Hallowell and Ratey with only slight modifications in wording as they apply to the home situation.

According to Hallowell and Ratey:

• There is no one syndrome of ADD, but many.
• ADD rarely occurs in "pure" form by itself, but rather it usually shows up entangled with several other problems such as learning disabilities or mood problems.
• The face of ADD changes with the weather-- inconstant and unpredictable.
• The treatment for ADD, despite what may be serenely elucidated in various texts, remains a task of hard work and devotion.

There is no easy solution for the management of ADD in the home. After all is said and done, the effectiveness of any treatment for this disorder depends upon the knowledge and the persistence of the parent.

Needed: structure, education, and encouragement

1. Make sure what you are dealing with really is ADD.

Make sure someone has tested the child's hearing and vision recently, and make sure other medical problems have been ruled out. Make sure an adequate evaluation has been done. Keep questioning until you are convinced.

2. Build your support.

Make sure there is a knowledgeable person with whom you can consult when you have a problem (learning specialist, child psychiatrist, social worker, school psychologist, pediatrician -- the person's degree doesn't really matter. What matters is that he or she knows lots about ADD, has seen lots of kids with ADD, knows his or her way around a classroom, and can speak plainly.) Make sure the teachers are working with you.

3. Know your limits.

Don't be afraid to ask for help. You should feel comfortable in asking for help when you feel you need it.

4. Remember that ADD kids need structure.

They need their environment to structure externally what they can't structure internally on their own. Make lists. Children with ADD benefit greatly from having a table or list to refer to when they get lost in what they're doing. They need reminders. They need previews. They need repetition. They need direction. They need limits. They need structure.

5. Post rules.

Have them written down and in full view. The children will be reassured by knowing what is expected of them.

6. Repeat directions.

Write down directions. Speak directions. Repeat directions. People with ADD need to hear things more than once.

7. Make frequent eye contact.

You can "bring back" an ADD child with eye contact. Do it often. A glance can retrieve a child from a daydream or just give silent reassurance.

8. Set limits, boundaries.

This is containing and soothing, not punitive. Do it consistently, predictably, promptly, and plainly. DON'T get into complicated, lawyer-like discussions of fairness. These long discussions are just a diversion. Take charge.

9. Have as predictable a schedule as possible.

Post it on the refrigerator, the child's door, bathroom mirror. Refer to it often. If you are going to vary it, give lots of warning and preparation. Transitions and unannounced changes are very difficult for these children. They become discombobulated. Help the kids make their own schedules for after school in an effort to avoid one of the hallmarks of ADD: procrastination.

10. Take special care to prepare for transitions well in advance.

Announce what is going to happen, then make repeat announcements as the time approaches.

11. Allow for escape valve outlets.

Finding the right outlet will allow the child to leave the room rather than "lose it," and in so doing begin to learn important tools of self-observation and self- modulation.

12. Provide frequent feedback.

It helps keep them on track, lets them know what is expected of them and if they are meeting their goals, and can be very encouraging. Notice the positive steps no matter how small and tell the child what you see.

13. Break down large tasks into small tasks.

This is one of the most crucial of all training techniques for children with ADD. Large tasks quickly overwhelm the child and he recoils with an emotional "I'll-NEVER-be-able- to-do-THAT" kind of response.

By breaking the task down into manageable parts, each component looking small enough to be do-able, the child can sidestep the emotion of being overwhelmed. In general, these kids can do a lot more than they think they can. By breaking tasks down, the child can prove this to himself or herself.

With small children, this can be extremely helpful in avoiding tantrums born of anticipatory frustration. And with older children, it can help them avoid the defeatist attitude that so often gets in their way. And it helps in many other ways, too. You should do it all the time.

14. Loosen up. Act silly.

Let yourself be playful, have fun, be unconventional, be flamboyant. Introduce novelty into the day. People with ADD love novelty. They respond to it with enthusiasm. It helps keep attention -- the kids' attention and yours as well. These children are full of life -- they love to play. And above all they hate being bored. So much of their "treatment" involves boring stuff like structure, schedules, lists, and rules, you want to show them that those things do not have to go hand in hand with being a boring person. Every once in a while, if you can let yourself be a little bit silly, that will help a lot.

15. But watch out for overstimulation.

Like a pot on the fire, ADD can boil over. You need to be able to reduce the heat in a hurry. The best way of dealing with chaos is to prevent it in the first place.

16. Seek out and underscore success as much as possible.

These kids live with so much failure, they need all the positive handling they can get. This point cannot be overemphasized: these children need and benefit from praise. They love encouragement. They drink it up and grow from it. And without it, they shrink and wither. Often the most devastating aspect of ADD is not the ADD itself, but the secondary damage done to self-esteem. So water these children well with encouragement and praise.

17. Use tricks to improve memory.

They often have problems with what Mel Levine calls "active working memory," the space available on your mind's table, so to speak. Any little tricks you can devise -- cues, rhymes, code and the like -- can help a great deal to enhance memory.

18. Announce what you are going to say before you say it. Say it. Then say what you have said.

Since many ADD children learn better visually than by voice, if you can write what you're going to say as well as say it, that can be most helpful. This kind of structuring glues the ideas in place.

19. Simplify instructions. Simplify choices.

The simpler the verbiage the more likely it will be comprehended. And use colorful language. Like color-coding, the colorful language keeps attention.

20. Use feedback that helps the child become self-observant.

Children with ADD tend to be poor self-observers. They often have no idea how they come across or how they have been behaving. Try to give them this information in a constructive way. Ask questions like, "Do you know what just happened?" or "How do you think you might have said that differently?" or "Why do you think that other girl looked sad when you said what you said?" Ask questions that promote self-observation.

21. Make expectations explicit.

Don't assume anything or leave anything to chance.

22. Children with ADD respond to rewards and incentives.

A point system is a possibility as part of behavior modification or a reward system for younger children. Many are little entrepreneurs.

23. Try discreetly to offer specific and explicit advice as a sort of social coaching.

Many children with ADD are viewed as indifferent or selfish when in fact they just haven't learned how to interact. This skill does not come naturally to children, but it can be taught or coached.

If the child has trouble reading social cues -- body language, tone of voice, timing, and the like -- For example, say, "Before you tell your story, ask to hear the other person's first."

24. Make a game out of things when possible.

Motivation improves ADD.

25. Give responsibility back to the child when possible.

Let kids devise their own method for remembering what needs to be done, or let them ask you for help rather than your telling them they need it.

26. Praise, stroke, approve, encourage, nourish.

Praise, stroke, approve, encourage, nourish. Praise, stroke, approve, encourage, nourish.

27. Be like the conductor of a symphony. Get the orchestra's attention before beginning.

You may use silence, or the equivalent of tapping your baton, to do this. Keep the child "in time," pointing to things that need to be done as you ask for their help.

28. Expect to repeat, repeat, repeat.

Do it without getting angry. Anger won't increase their memory.

29. Provide for exercise.

One of the best treatments for ADD, in both children and adults, is exercise, preferably vigorous exercise. Exercise helps work off excess energy, it helps focus attention, it stimulates certain hormones and neurochemicals that are beneficial, and it is fun. Make sure the exercise IS fun, so the child will continue to do it for the rest of his or her life.

30. Always be on the lookout for sparkling moments.

These kids are far more talented and gifted than they often seem. They are full of creativity, play, spontaneity and good cheer. They usually have a "special something" that enhances whatever setting they're in.

About the author: Elaine Gibson is a writer, has a degree in educational psychology (M.A.), and counseling experience. She is also the mother of a "difficult child." 

Adult ADHD and time management are two concepts that don’t naturally go together. However, you can learn how to manage your time and stay on schedule with ADHD.

Organization and focus can be challenging because of the way the ADHD brain approaches tasks. It’s not that people with ADHD can’t manage their time. They can. It’s just that some things are more challenging for people with ADHD than they are for those without this added difficulty. The good news is that time management isn’t an inherent ability that you either have or you don’t. Time management and scheduling are learned skills.

ADHD and Time Management Difficulties

Perhaps you’ve experienced one or more of these time-management problems common in ADHD:

• Being late for appointments and other plans because you didn’t allow yourself enough time to get there
• Writing important notes on sticky notes or other pieces of paper and then losing said notes
• Similarly, making lists and losing them—or never using them
• Forgetting dates and appointments
• Addressing interruptions, then not getting back on track

ADHD makes it difficult to focus, pay attention, attend to minute details, and organize. All of these are part of effective time management. When you experience these symptoms, staying on schedule is difficult, but it’s not impossible. ADHD time management strategies are tactics you can learn and develop. As you do so, you’ll likely find this aspect of your life far less frustrating.

Time Management Tips for Adult ADHD

These tried-and-true ADHD time management strategies can teach you how to manage your time and stay on schedule:

• Use a planner. It can be digital or paper or even wall-based. Color code it and highlight the most important items. Experiment until you have a planner system that works, and then stick with it. Creating a consistent system trains your brain to recognize it and work with it.
• From your planner, create master to-do lists, and then prioritize them. To-do making is effective when it becomes part of your daily routine. Many people with ADHD find that writing the next day’s to-do list as part of their bedtime routine helps them sleep. Rather than ruminating and worrying about the next day, they have it planned and on paper and can more easily quiet their mind.
• Create deadlines for your tasks, no matter how minor. Deadlines increase focus and time on task.
• Eliminate items from your schedule. It’s okay to say no to avoid overscheduling yourself. You’ll be better able to stay on schedule, and you won’t feel as overscheduled and stressed.
• Use timers and alarms to help you keep track of time. This can be a practical ADHD time management technique if you frequently find yourself needing “just a few more minutes” but then remain in what you’ve been doing for hours. Set a wristwatch or other alarm to remind you when you need to transition to something different, and when it sounds, do so right away.
• Give yourself a break—and transition time. Switching gears from one activity to another can be difficult with ADHD because you have to refocus and attend to something different. When you use the timer system, give yourself extra time so you can gather your thoughts and prepare for a new task. Allow a mini-break to move and to do something you enjoy for a brief amount of time before diving into the new activity. While it might seem like you don’t have time for this, giving yourself this space will refresh you and actually make you more productive. Plus when you schedule for breaks, they become part of your time management program.

These practical techniques work with your ADHD brain rather than against it. Select from some of them, or employ all of them. Of course, tailor them to your personality and needs so they’re the most useful for you. Also, because these are learned skills, they take time to become an automatic routine. Be patient with yourself. These time management tips for adult ADHD can make a positive difference in your life.

ADHD and how to focus? It’s a problem many ADHD adults have. If you live with ADHD and have difficulty focusing at work, it’s not because you are incompetent or unqualified. It just might be a matter of building skills for how to be more productive with ADHD. There are a number of techniques you can develop to be successful at work.

ADHD and How to Focus on the Job without Medication

ADHD is a brain-based disorder that involves neurochemistry, especially unbalanced levels of dopamine and norepinephrine. Medication for ADHD can regulate these neurotransmitters and works very well for some people. If medication isn’t for you, you can still be productive at work. It’s a matter of learning how to focus with ADHD without medication.

Specific techniques help you manage your ADHD symptoms and beyond. Take control of your productivity with ADHD focus exercises.

5 Ways to Stay Focused and Productive at Work with ADHD.

You have ADHD and need ways to stay focused. It isn’t a matter of chance. Focus and concentration at work (or school or anywhere else, for that matter) are skills. Skills are learned and can be developed and honed. You can learn concentration techniques for ADHD.

Here are five ways to decrease ADHD impulsivity in order to increase productivity:

1. Minimize distractions before they start. A huge component of doing that is to find the right setting. The “right setting” is personal. ADHD is a very individualized disorder, and people focus in different ways and settings. If you have the flexibility, work in places like a coffee shop or a library. If not, make adjustments in your work setting. Make your space you-friendly. Create the right kind of stimulation by adding colors, a white noise machine, fidget objects, and anything else that helps you pay attention to the tasks at hand.
2. Break down tasks into small components or steps. Having one giant task in front of you can be overwhelming. It can shut you down and cause you to procrastinate (ADHD and Procrastination: How to Get Stuff Done). Avoid this by chunking. Attach deadlines to each small component to keep yourself on task. Both the project itself and your thoughts and feelings about the project will become less overwhelming and easier to deal with.
3. Create an organizational system that works for you. Using schedules helps you meet deadlines. How you create those schedules makes time-management easier for people with ADHD. Some people with ADHD find success with adult ADHD apps, programs like Evernote, or other electronic-based calendar systems. Others find such scheduling systems to be a nightmare because of alluring distractions. Large wall calendars, desk calendars, and planners can keep you productive. Whiteboards, too, help you brainstorm and plan. Devise a color-coded system for your calendars, planners, and whiteboard. Finally, ask for requests and instructions in writing so your to-do list is clear and easy to remember.
4. Remove digital distractions as much as possible. The digital world can be the bane of the existence of someone living with ADHD. Alluring temptations are at your fingertips. Mobile phones, tablets, and computers are a distraction for almost everyone who has access to them. For the ADHD brain, these are far worse. Because they offer instant gratification and fun, they impact the brain’s dopamine system. The dopamine rush experienced is problematic given that low levels of dopamine are implicated in ADHD. The brain wants more, so these devices become a habit, possibly an addiction. To be focused and productive at work, control your access to them as much as is practical for your job. Put your phone out of reach. Develop a routine for when you access social media. Minimizing digital distractions make focusing easier.
5. Work with your brain by rewarding yourself throughout the day. Reinforcing the completion of tasks with a small reward is a useful productivity technique for ADHD. Take breaks. Do something you like to do, such as taking a walk or just moving. This would be a good time to use your phone or otherwise go online. Whatever you do, set a timer, and return to work the moment it sounds.

These five tips are proven and practical for ADHD and are great ways to improve concentration at work. One overarching principle solidifies it all: Know your purpose. Why do you do what you do? What is your greater goal? Think of your roles in life beyond the mundane tasks. Apply the five ways to stay focused at work to your purpose, and you will create success with ADHD.

What are the best jobs for people with ADHD? Before we get to that, let’s talk about why finding a job or career suited for someone with adult ADHD is key to your success.

It’s important for you to find the best job for your ADHD brain, because a job is a significant part of life. People spend a great deal of time at work, so jobs play a role in our mental health and wellbeing. ADHD can make a lot of jobs very frustrating, and it’s not uncommon for someone with ADHD to jump from job to job. Just because you have ADHD, it doesn’t mean you’re doomed to struggle in the realm of work. ADHD friendly jobs exist, and you can find them.

Characteristics of Great Jobs for People with ADHD

ADHD can seem to interfere in all areas of life. The symptoms of adult ADHD, such as difficulty focusing and paying attention, distractibility, disorganization, and more can get in the way of job performance. It’s not that you’re incapable of working. It’s more likely that your own unique ADHD-related characteristics don’t match the characteristics of some jobs.

The best jobs for adults with ADHD have qualities that fit well with the disorder. If you have ADHD, look for job qualities like:

• Variety of tasks and duties
• Fast pace
• Intellectual stimulation
• Movement
• Opportunities to multitask
• Flexible scheduling
• Interactions with different people
• Support from coworkers, an assistant, etc.
• Clear expectations

In addition to looking for ADHD-friendly job characteristics, know yourself and your own unique traits. When considering the best jobs for someone with ADHD, keep in mind that, as with anything else, ADHD isn’t one-size-fits-all. Some people need a great deal of structure to stay on task, and an ideal job for them would be one with a clear hierarchy and regular, structured supervision. Other people with ADHD need freedom, independence, and flexibility in their job in order to thrive.

To find a job you can enjoy, know yourself. Do you do well under pressure and find stressful tasks to be challenging and rewarding? Or do you prefer variety without high pressure? What is your own unique style of working? When you know yourself and your ADHD characteristics, you can describe, and then seek, your ideal job.

Some of the Best Careers for People with ADHD

The jobs on this list are some of the best careers for people with ADHD. Collectively, they fit well with ADHD traits. Again, know yourself so you can identify which careers fit you. Hallowell & Ratey (2010) and Weiss (2005) suggest specific jobs for people with ADHD:

• Firefighter
• Waiter/waitress
• Teacher
• Trial lawyer
• Military
• Small business owner
• ER physician, surgeon, nurse
• Cab, Uber, or Lyft driver
• Athlete
• Politician
• Entertainment industry
• Airline pilot
• Chef

This is a sampling of ADHD-friendly careers. All are highly stimulating and allow freedom of movement. Some are flexible, some are structured.

Successful careers for people with ADHD are those that are motivating. What excites you and appeals to you? When you’re in a job that you like, you are more likely to be motivated to succeed. This interest and motivation are far stronger than your ADHD.

Tips for Finding an ADHD-Friendly Job You Love

If you have a tendency to become bored easily or to become frustrated easily, you might find yourself leaving jobs frequently. To increase your chances of success in your ideal career, avoid impulsively quitting one job and jumping into another job that might be just as terrible. Instead, try these tips to help you find and keep the right job:

• Think of your ideal job, and look at your unique strengths, skills, passions, and purpose and consider how your ADHD traits will help and hinder you in the job
• Look at your values and define what is important to you. What type of job do you need to meet your values?
• Volunteer to try out your different interests and work environments
• Connect with people online, such as in forums or groups for people with ADHD; what has worked for others?
• Talk to people in careers or jobs you’re interested in and learn specific aspects of the job for which ADHD might be an asset or a detriment
• People with ADHD can experience remarkable career success. The key is to find a job that you enjoy and that works with, rather than against, your ADHD traits. Find a good fit, and you’ll experience mental- and occupational health.

Learn about ADHD symptoms that women specifically report along with treatment of ADHD in women.

The Facts

The Mayo Clinic reports that 7.5% of school-aged children have ADHD. The great majority of these children grow up to be adults with AD/HD, which means that there are between 4.5 to 5.5 million women in the USA alone with AD/HD.

If one thinks of the core symptoms of AD/HD: distractibility, impulsivity, and hyperactivity, is it no wonder that woman struggle with seemingly simple tasks such as picking out clothes, keeping their home in order, handling the paperwork at their jobs, maintaining healthy relationships, etc? We often forget the many AD/HD symptoms that aren't usually described in clinical journals and books, but which I've observed in countless women.

Not all AD/HD presents the same. Some people are hyperactive; others are sluggish. Some love having a lot of commotion and stimuli in their lives; others need to retreat to a quiet space to re-charge.

Symptoms Appearing in Women with ADHD

Consider the list of symptoms below that are not often described in the ADHD literature but which I hear described over and over again from the ADHD women I talk to. Is it any wonder that one's daily activities can be so overwhelming?

• Hypersensitive to noise, touch, smell
• Low feeling of self-worth
• Easily overwhelmed
• Hypersensitive to criticism
• Poor sense of time- often runs late
• Emotionally charged; easily upset
• Starts projects but can't seem to finish them
• Takes on too much
• Difficulty remembering names
• Says things without thinking, often hurting others' feelings
• Appears self-absorbed
• Poor math and;/or writing skills
• Doesn't seem to hear what others are saying
• Addictive behaviors: shopping, eating
• Problems with word retrieval
• Poor handwriting
• Has difficulty with boring, repetitive tasks
• Ruminates
• Difficulty making decisions
• Clumsy; poor coordination
• Tires easily or conversely, can't sit still
• Has problems falling asleep and difficulty waking up the next morning

Effects of Living with AD/HD

For some women with ADHD, just holding their own in a conversation can be a real challenge. Others avoid social gatherings because they miss social cues, making them feel out of step, thereby shutting down in order to save themselves possible embarrassment.

Many feel unable to entertain at home because the piles of clothes, papers and assorted knickknacks keep them away from inviting people over.

Relationships, work situations, parenting- all can become huge challenges for women living with undiagnosed and untreated AD/HD. The result of living for years with these difficulties often produces depression, anxiety, low self-esteem, substance abuse, and other co-morbid difficulties.

Treatment of AD/HD in Women

Surprisingly, much of the treatment that is used for AD/HD in children is often the treatment of choice for adults as well. Studies have shown that a combination of counseling, psychoeducation (learning more about AD/HD and how it impacts one's life), ADD coaching, support groups and medication (if recommended by a physician), is the most successful treatment approach for women.

The most common medications used are the stimulants (Ritalin, Adderall, Dexedrine and Concerta are currently the most popular) and a newer non-stimulant medication, Strattera.

However, many women, because of their life-long struggle with AD/HD, may find themselves anxious, depressed or both. Approximately 50% of AD/HD adults do experience a co-morbidity which then needs to be medically addressed by adding perhaps an anti-depressant or anti-anxiety medication to their regime.

Special Considerations

Research is beginning to show that AD/HD women have special issues throughout their lifespan that cause extra difficulties in their living with this disorder. As hormonal changes shift, so do their AD/HD symptoms.

On the one hand, some girls may find that their hyperactivity improves during puberty, yet they may experience an increase in mood instability before and during their menstrual cycles.

Peri-menopause and menopause can create it's own set of problems. Women often report an increase in AD/HD symptoms, particularly memory loss and difficulty with word retrieval. Some notice an increase in depressive symptoms. It's important for women to work closely with their physicians during these times, so that changes in medications can be discussed. Often, hormonal treatment can alleviate these aggravated symptoms.

Check your AD/HD "temperature"

Whether you are a teenager, or a post-menopausal woman, it's important to regularly check your "AD/HD temperature" and discuss any changes in your symptoms with your health care provider.

About the Author

Terry Matlen, MSW, ACSW is a psychotherapist and consultant in private practice in Birmingham, MI, specializing in ADHD. She is also the author of "Survival Tips for Women with ADHD" and is the director of ADD Consults at www.addconsults.com. Terry serves on the board of directors for ADDA Assoc (ADDA), and is past coordinator of the E. Oakland County Chapter CHADD chapter. A popular presenter at local and national conferences, Terry has a special interest in women with ADHD and parenting ADHD children when one or both parents also have ADHD.

ADHD makes getting and staying organized challenging. Restlessness, impulsivity, focusing difficulties, and other symptoms of adult ADHD get in the way of someone’s ability to concentrate on a tedious task like organizing. However, when your life and surroundings are cluttered and disorganized, important things are hard to find, it’s hard to complete tasks, it feels chaotic, and ADHD symptoms are intensified.

It’s a horrible cycle: ADHD makes organization difficult, but disorganization worsens ADHD symptoms, and those make it even more difficult to organize. That doesn’t mean you have to give up and live in frustration. There are organization tips for ADHD adults that can help.

Getting Organized When You Live with ADHD

For adults with ADHD, inattention and problems focusing interfere in organization. Organizing, and then staying organized, isn’t always the most exciting task on your to-do list, so attending to the job and focusing on all that needs to be organized can be a problem. You can solve this particular problem by jazzing up your organizational system.

Getting organized with adult ADHD doesn’t have to be boring. Create ways to manage your clutter, your desk, your papers, your calendar and more that appeal to you. Color-code a filing system so you can store and access important papers efficiently. Create logical spots for everything. Keys, for example, are best kept by the door so you don’t have to search frantically for them, making you run late. Use strategically placed baskets or jars to keep things in. Buy them at a craft store or thrift shop and paint or decorate them to make them appealing to you. This makes staying organized with ADHD easier.

Staying Organized with ADHD

Staying organized doesn’t have to be a Sisyphean challenge. One of the best ways to stay organized when you have ADHD is to keep up with it. It’s tempting to forgo sorting and decluttering in favor of something more fun. However, spending a short amount of time each day putting things in their proper place, will help you stay organized almost effortlessly.

Tackle bite-sized bits each day. Create an organization routine, doing it at the same time each day so it becomes automatic. Make it fun by playing music or turning it into a game. Set a timer for 10 or 15 minutes and challenge yourself to get a certain amount of items organized. When the timer sounds, you can stop and be done for the day. If you met your goal, reward yourself.

Perhaps the best way to stay organized when you have ADHD is to think about why organization is important to you. Many people with ADHD think in terms of a bigger picture rather than minute details. Organization involves minute details, but it also involves a grander scope.

Staying organized can positively impact the way you live. It helps you function better, feel on top of things rather than always a step behind, and gives you a sense of competence and confidence. When you spend your brief amount of time each day organizing and decluttering, think of your greater purpose: feeling good and moving forward.

Sometimes, even when you’re motivated by your purpose for organization, it can be hard to know how to go about it. There are things you can do to help yourself be organized.

Organization Tips for Adults with ADHD

When organization seems daunting, it’s hard to keep up with it. The following ADHD organization and time management tips for adults can help you not just stay afloat but swim powerfully ahead.

• Establish a structure that works for you. To function easily and smoothly, have a logical place for everything. Incorporate ADHD organization charts, color coding, and more.
• Lists are one of the most useful ADHD organization tools. Keep track of things you need to do, important dates, and more.
• Set your phone or computer to notify you with reminders of appointments, events, etc.
• Have a notebook with you at all times to work on your lists and write down important thoughts so you don’t forget them. Having multiple notebooks that you keep in strategic places can be helpful.
• Use bulletin boards or whiteboards to pin up or write reminders to yourself.
• Find one planner system that works for you, and use it.
• Use ADHD organization apps. Multiple apps to help with organization and time management are available. Explore the various options, and select an ADHD app to help yourself. Find one that has the features and style you like.
• Use an ADHD coach or organization consultant. These professionals come to your home or office to teach you ADHD organization skills.

Getting and staying organized with ADHD can be challenging but very rewarding. When you know how to stay organized, you will reduce ADHD struggles and free yourself to move forward and thrive.

Feeling overwhelmed, disorganized, scattered? Is it just stress, or could you be a woman struggling with undiagnosed ADHD?

Most of us are familiar with hyperactivity and attentional problems in kids, and the debate over whether Ritalin is being over-prescribed. You may have also read an article here or there about Attention Deficit Disorder (ADD) in adults. John Ratey and Ned Hallowell's book on ADD - Driven to Distraction - made its way to The New York Times bestseller's list. But chances are that you haven't read much about girls or women with ADD. Why not? Because ADD has long been considered a male problem that affects only a few girls and women.

All that's beginning to change, however, and ADDvance Magazine: A Magazine for Women with ADD has been received with excitement by women across the country, women who are finally beginning to understand that the problems they have struggled with all of their lives are related to a very treatable, but misunderstood disorder: ADD in females.

What are the signs of ADD in women?

ADD in females can often be masked. Women with ADD are most often diagnosed as depressed. And many women with ADD do struggle with depression, but that is only part of the picture. As Sari Solden, author of Women With Attention Deficit Disorder, describes it, ADD in women is "the disorder of dis-order." In other words, for most women with ADD, their lives are filled with disorder which can feel overwhelming - piles and clutter out of control.

There are some women with ADD who have successfully compensated for their ADD, but the price they pay is to expend most of their waking energy combating their natural tendency to be disorganized. Many women with ADD feel a powerful sense of shame and inadequacy. They feel constantly behind, overwhelmed and frazzled. Some women with ADD feel that their lives are so out of control that they rarely invite others into their home - too ashamed to allow anyone to see the disorder, too overwhelmed to combat the disorder that pervades their lives.

ADD can be mild, moderate or severe. Some women are able to cope with the demands of daily life until they become mothers. For other women, their coping abilities don't collapse until baby number two comes along.

The job of housewife and mother is especially difficult for women with ADD because of its very nature. To raise children and to run a household well, women are required to function in multiple roles at the same time, to cope with constant, unpredictable interruptions, to function with little structure, little support or encouragement, and to not only keep ourselves on track, but also be the schedule for everyone else in the family. Who has soccer practice? Who has a dentist appointment? Who needs new shoes? Who needs a permission slip signed? Where is the permission slip? Who needs to go to the library? Who needs mom to drop everything this minute because they skinned their knee or because they have an earache and want to come home from school? And in the midst of all this, we are supposed to keep on track - planning meals, doing housework and laundry, planning social events, and for the majority of mothers, working full-time.

ADD has become a more challenging problem for women as the demands in our late-20th-century lifestyles become greater and greater. Now women are expected to juggle homemaking, child care, and full-time employment, along with a full complement of extra-curricular activities for our children. What is highly stressful for a woman without ADD becomes a continuing crisis for a woman with ADD. These women frequently suffer from anxiety, depression and low self-esteem because they find they can't live up to the superwoman image that so many women attempt today.

What is the difference between ADD and stress?

Stress is temporary or cyclical. A woman who feels disorganized and overwhelmed due to stress will heave a huge sigh of relief when the holidays are over or when the crunch at work has passed and will set about returning her life to order. For a woman with ADD, the stressful times are bad, but even in the best of times there is a feeling that the wave of "to do's" is about to crash over her head.

You may have ADD if you

• have trouble completing projects and jump from one activity to another;
• were told by parents and teachers that you should have tried harder in school;
• are frequently forgetful; have trouble remembering to do the things you intended;
• are frequently rushing, over-committed, often late;
• make impulsive purchases, impulsive decisions;
• feel overwhelmed and disorganized in your daily life;
• have a disorderly purse, car, closet, household, etc;
• are easily distracted from the task you are doing;
• go off on tangents in conversations - may tend to interrupt;
• have trouble balancing your checkbook, have difficulty with paperwork

Having difficulty with one or two of these things doesn't mean you have ADD. This list isn't meant as a questionnaire for self-diagnosis; but if you find yourself answering "yes" to many of the questions listed above, it may be very helpful to seek an evaluation from a professional very experienced in diagnosing ADD in adults. (A good place to begin your hunt for such a professional is to call the ADD experts in your community who work with children.)

If you are a woman with ADD who has not been officially diagnosed, help could be just around the corner. Women who have blamed themselves, calling themselves lazy or incompetent, have received help through ADD-oriented psychotherapy, medication and ADD coaching, and are now feeling and functioning much better.

About the author: The editors of ADDvance: A Magazine for Women with Attention Deficit Disorder - Patricia Quinn, MD and Kathleen Nadeau, Ph.D. - are both women with ADHD, as well as nationally recognized specialists in Attention Deficit Hyperactivity Disorder.

Resources for women with ADD - ADHD

Books:

• Women With Attention Deficit Disorder
  by Sari Solden, Underwood Press.
• First Star I See
  by Jaye Caffrey, Verbal Images Press.

© Copyright 1998 Kathleen G. Nadeau, PhD