Now we're going to turn to attention deficit hyperactivity disorder or ADHD and dyslexia and the tension is intertwined with dyslexia for two important but very different reasons. First, dyslexic readers are not automatic. To them, reading remains effortful, and I have referred to them as quote manual leaders. This means that they have to dip into, and she'll use up their reservoir bucket of attention in order to read so that they become attention deprived, and as a result, they appear to have an attentional deficit so after reading a short time, they become easily distracted. Second, there is a very large overlap of comorbidity between ADHD and dyslexia. How does ADHD express itself in a student who is dyslexic? Let's talk about Sofia. Sofia was in the seventh grade and had been diagnosed with dyslexia. Reading how to improve dramatically with the help of tutors, the provision of extra time on tests, and her grades had also improved as well. At the same time though, for teachers had noticed that she was becoming inattentive in class and was easily distracted. They described her as not being focused, not being able to follow instructions. These behaviors were also noted by her parents at home and when they ask Sofia about her day, her mind would wander and she would take a long time to answer straightforward questions. Both her parents and her teachers noticed that she was often sidetracked when she was asked to complete an assignment or task and would take a long time to do it if she completed it at all. Sofia was disorganized at home, often losing or misplacing her schoolwork and after many months without any improvement, her parents with a recommendation from the school sought a consultation with a child psychiatrist. This child psychiatrist spoke at length with Sofia as well as her parents, and with her parent's consent, she also spoke with officials at the school and gave Sofia two rating scales to complete and to help with the diagnosis of ADHD. The ADHD rating scale was one and the second was Conner's rating scale. After reviewing the information, she told Sofia and her parents, who is most likely that Sofia had a form of ADHD, predominately inattentive type, and Sofia's parents were told that the co-occurrence or co-morbidity of dyslexia and ADHD is quite common in our own studies when we considered a sample based on children referred to a clinic for learning disability, 40 percent of children with dyslexia were also found to have symptoms of ADHD and over 50 percent of the children with ADHD were found had dyslexia. Again, I'm going to reiterate that's 40 percent of children with dyslexia were also found to have symptoms of ADHD and over 50 percent of the children with ADHD were found to have dyslexia. The psychiatrist explained to Sofia and her parents that ADHD is characterized by three cardinal symptoms. Inattention, impulsivity, and hyperactivity. Clinicians have come to recognize that the hyperactivity and impulsivity seem to track together and inattention often appear separately and then they also, clinicians have recognized three different types of ADHD, inattentive, hyperactive or impulsive, and a combined type where children have all three symptoms. Then looking at Sofia and her symptoms, she most likely had ADHD, predominately inattentive type, and this type of ADHD is usually not apparent until the child is eight or nine years of age and usually is lifelong and the symptoms, according to the new DSM-5, include where an individual often fails to give close attention to details or makes careless mistakes in schoolwork at work or doing other activities, often has difficulty sustaining attention and tasks or play activities often does not seem to listen when spoken to directly. Often does not follow through on instructions and fails to finish schoolwork, chores or duties often has difficulty organizing and avoids dislikes or is reluctant to engage in tasks that require more sustained mental effort and often loses things necessary for tasks or activities and is easily distracted and finally, it's forgetful in daily activities. It's important to know ADHD, the clinical diagnosis, and caution that at present, while rating scales are helpful, there is no evidence-based test that will reliably diagnose ADHD. The parents were urged to be skeptical of any measures claiming to identify ADHD, despite claims of EEG measures or experimental psychological measures such as continuous performance tests. Psychiatrists also told Sofia and her parents that good interventions had been developed and that there is a long successful history of therapy for ADHD, both using medications and behavioral interventions. The main pharmacotherapy treatment options include stimulants, atomoxetine, antidepressants and Alpha-2 agonists. The behavioral treatment strategy for children and young adults with ADHD includes working with the child, working with the parents, and working with the school. The child and the parents need to strive to maintain a daily schedule and reward positive activities. Set small but realistic goals and use checklists for the child to stay focused. The school can also help by providing accommodations. These accommodations can include extra time to complete the assignments and taking tests in a separate room to avoid distractions. The school can also arrange to have the child sit close to the teacher and provide note-takers to help her organize assignments and work. There are other behavioral treatment strategies as well. They include physical activity as well as mindfulness. In terms of the medications for ADHD, stimulants begin to work immediately, and they include methylphenidate, which is ritalin, amphetamines such as Adderall, and come in both short and long-term preparations. The short-acting preparations can last up to up to six hours. While the longer-acting preparations such as methylphenidate, ER or [inaudible] or amphetamine, dextroamphetamine, XR, Adderall XR, and lisdexamfetamine, which is why Vyvanse can last from ten or 12 hours. Then it's important to know, well generally said, the stimulants can cause anorexia. They can cause growth retardation in children, jitteriness, and they can exacerbate existing ticks and increase heart rate and blood pressure. In looking at the different classes, the med [inaudible] the amoxicillin is a non stimulant. Is a class used to treat ADHD, and its mechanism of action includes increasing the amount of available norepinephrine. Unlike the stimulants, which work, the onset is immediate, it can take up to 2-3 weeks to begin to act. It can also last up to 12 hours and can cause dry mouth, constipation. Also it can cause headaches and palpitations. Antidepressants, or a third-class medication options used to treat ADHD. As we talked about earlier, bupropion, or Wellbutrin is the selected dopaminergic re-uptake inhibitor is the most common among them, the effects can last up to 15 hours, though it can cause seizures, hypertension, and increased anxiety. The fourth class of psychotropic medications include the Alpha-2 agonists, such as clonidine or catapres, which works by indirectly increasing the amount of norepinephrine and their benefits can last up to 12 hours. Their side effects include low blood pressure, dry mouth, and sedation. It's also classified as a category C medication, meaning that there can be some potential detrimental effects on fetal development. After careful consideration and review with her parents and psychiatrists, Sofia selected the long-acting stimulant conservative and what's prescribed 18 milligrams a day. She found that medication extremely helpful in helping her focus. Her teachers and parents notice a positive change in her behavior at home and at school. She tolerated the medication very well, but did notice a decrease in her appetite and feeling jittery when she first started the medication. Because she took the medication in the morning, it did not affect her asleep and she took drug holidays and weekends when there was no school, which she found helpful as well. Sofia work with her parents and the school psychologists and behavioral techniques, including setting daily schedules and making lists to help complete assignments. She was granted accommodations by the school, including extra time on exams, which she was able to also do in a separate room. It's important to keep in mind with all this that dyslexia often does not come alone, but rather as accompanied by either or both anxiety and ADHD. This means that these conditions must be looked for an individual who dyslexic and treat it.