| Attention Deficit Hyperactivity Disorder

NIH Publication No. 96-3572Printed 1994, Reprinted 1996
**Understanding the Problem**What are the symptoms of ADHD?Can any other conditions conditions produce these       symptoms?Can other disorders accompany ADHD?What causes ADHD?**Getting Help**How is ADHD identified and diagnosed?What are the educational options?What treatments are available?**Sustaining Hope**Can ADHD be outgrown or cured?What hope does research offer?What are sources of information and support?
| Home | Mental Disorder Info |

**Attention Deficit Hyperactivity Disorder**
Imagine living in a fast-moving kaleidoscope, where sounds,images, and thoughts are constantly shifting.  Feeling easilybored, yet helpless to keep your mind on tasks you need tocomplete.  Distracted by unimportant sights and sounds, your minddrives you from one thought or activity to the next.  Perhaps youare so wrapped up in a collage of thoughts and images that youdon't notice when someone speaks to you.
For many people, this is what it's like to have Attention DeficitHyperactivity Disorder, or ADHD.  They may be unable to sit still, planahead, finish tasks, or be fully aware of what's going on around them.To their family, classmates or coworkers, they seem to exist in awhirlwind of disorganized or frenzied activity.  Unexpectedly--on somedays and in some situations--they seem fine, often leading others tothink the person with ADHD can actually control these behaviors. As aresult, the disorder can mar the person's relationships with others inaddition to disrupting their daily life, consuming energy, and diminishing self-esteem.
ADHD, once called hyperkinesis or minimal brain dysfunction, is one ofthe most common mental disorders among children.  It affects 3 to 5percent of all children, perhaps as many as 2 million American children.Two to three times more boys than girls are affected.  On the average,at least one child in every classroom in the United States needs helpfor the disorder.  ADHD often continues into adolescence and adulthood,and can cause a lifetime of frustrated dreams and emotional pain.
But there is help...and hope.  In the last decade, scientists havelearned much about the course of the disorder and are now able toidentify and treat children, adolescents, and adults who have it. Avariety of medications, behavior-changing therapies, and educationaloptions are already available to help people with ADHD focus theirattention, build self-esteem, and function in new ways.
In addition, new avenues of research promise to further improvediagnosis and treatment.  With so many American children diagnosed ashaving attention disorder, research on ADHD has become a nationalpriority.  During the 1990s--which the President and Congress havedeclared the "Decade of the Brain"--it is possible that scientists willpinpoint the biological basis of ADHD and learn how to prevent or treatit even more effectively.
This booklet is provided by the National Institute of Mental Health(NIMH), the Federal agency that supports research nationwide on thebrain, mental illnesses, and mental health.  Scientists supported byNIMH are dedicated to understanding the workings and interrelationshipsof the various regions of the brain, and to developing preventivemeasures and new treatments to overcome brain disorders that handicappeople in school, work, and play.
The booklet offers up-to-date information on attention deficit disordersand the role of NIMH-sponsored research in discovering underlying causesand effective treatments.  It describes treatment options, strategiesfor coping, and sources of information and support.  You'll find outwhat it's like to have ADHD from the stories of Mark, Lisa, and Henry.You'll see their early frustrations, their steps toward getting help,and their hopes for the future.
*The individuals referred to in this brochure are not real, but theirstories are representative of people who show symptoms of ADHD.*
| Home | Mental Disorder Info | Top of Pub |

**UNDERSTANDING THE PROBLEM**
*Mark*
Mark, age 14, has more energy than most boys his age.  But then, he'salways been overly active.  Starting at age 3, he was a human tornado,dashing around and disrupting everything in his path.  At home, hedarted from one activity to the next, leaving a trail of toys behindhim.  At meals, he upset dishes and chattered nonstop.  He was recklessand impulsive, running into the street with oncoming cars, no matter howmany times his mother explained the danger or scolded him.  On theplayground, he seemed no wilder than the other kids.  But his tendencyto overreact--like socking playmates simply for bumping into him--hadalready gotten him into trouble several times.  His parents didn't knowwhat to do.  Mark's doting grandparents reassured them, "Boys will beboys.  Don't worry, he'll grow out of it."  But he didn't.
*Lisa*
At age 17, Lisa still struggles to pay attention and act appropriately.But this has always been hard for her.  She still gets embarrassedthinking about that night her parents took her to a restaurant tocelebrate her 10th birthday.  She had gotten so distracted by thewaitress' bright red hair that her father called her name three timesbefore she remembered to order.  Then before she could stop herself, sheblurted, "Your hair dye looks awful!"
In elementary and junior high school, Lisa was quiet and cooperative butoften seemed to be daydreaming.  She was smart, yet couldn't improve hergrades no matter how hard she tried.  Several times, she failed exams. Even though she knew most of the answers, she couldn't keep her mind onthe test.  Her parents responded to her low grades by taking awayprivileges and scolding, "You're just lazy.  You could get better gradesif you only tried." One day, after Lisa had failed yet another exam, theteacher found her sobbing, "What's wrong with me?"
*Henry*
Although he loves puttering around in his shop, for years Henry has haddozens of unfinished carpentry projects and ideas for new ones he knewhe would never complete.  His garage was piled so high with wood, he andhis wife joked about holding a fire sale.
Every day Henry faced the real frustration of not being able toconcentrate long enough to complete a task.  He was fired from his jobas stock clerk because he lost inventory and carelessly filled outforms.  Over the years, afraid that he might be losing his mind, he hadseen psychotherapists and tried several medications, but none everhelped him concentrate.  He saw the same lack of focus in his young sonand worried.
| Home | Mental Disorder Info | Top of Pub |

**What Are the Symptoms of ADHD?**
The three people you've just met, Mark, Lisa, and Henry, all have a formof ADHD--Attention Deficit Hyperactivity Disorder.  ADHD is not like abroken arm, or strep throat.  Unlike these two disorders, ADHD does nothave clear physical signs that can be seen in an x-ray or a lab test. ADHD can only be identified by looking for certain characteristicbehaviors, and as with Mark, Lisa, and Henry, these behaviors vary fromperson to person.  Scientists have not yet identified a single causebehind all the different patterns of behavior--and they may never findjust one.  Rather, someday scientists may find that ADHD is actually anumbrella term for several slightly different disorders.
At present, ADHD is a diagnosis applied to children and adults whoconsistently display certain characteristic behaviors over a period oftime.  The most common behaviors fall into three categories:inattention, hyperactivity, and impulsivity.
**Inattention.**  People who are inattentive have a hard time keeping theirmind on any one thing and may get bored with a task after only a fewminutes.  They may give effortless, automatic attention to activitiesand things they enjoy.  But focusing deliberate, conscious attention toorganizing and completing a task or learning something new is difficult.
For example, Lisa found it agonizing to do homework.  Often, she forgotto plan ahead by writing down the assignment or bringing home the rightbooks.  And when trying to work, every few minutes she found her minddrifting to something else.  As a result, she rarely finished and herwork was full of errors.
**Hyperactivity.**  People who are hyperactive always seem to be in motion.They can't sit still.  Like Mark, they may dash around or talkincessantly.  Sitting still through a lesson can be an impossible task.Hyperactive children squirm in their seat or roam around the room.  Orthey might wiggle their feet, touch everything, or noisily tap theirpencil.  Hyperactive teens and adults may feel intensely restless.  Theymay be fidgety or, like Henry, they may try to do several things atonce, bouncing around from one activity to the next.
**Impulsivity.**  People who are overly impulsive seem unable to curb theirimmediate reactions or think before they act.  As a result, like Lisa,they may blurt out inappropriate comments.  Or like Mark, they may runinto the street without looking.  Their impulsivity may make it hard forthem to wait for things they want or to take their turn in games. Theymay grab a toy from another child or hit when they're upset.
Not everyone who is overly hyperactive, inattentive, or impulsive has anattention disorder.  Since most people sometimes blurt out things theydidn't mean to say, bounce from one task to another, or becomedisorganized and forgetful, how can specialists tell if the problem is ADHD?
To assess whether a person has ADHD, specialists consider severalcritical questions:  Are these behaviors excessive, long-term, andpervasive?  That is, do they occur more often than in other people thesame age?  Are they a continuous problem, not just a response to atemporary situation?  Do the behaviors occur in several settings or onlyin one specific place like the playground or the office?  The person'spattern of behavior is compared against a set of criteria andcharacteristics of the disorder.  These criteria appear in a diagnosticreference book called the DSM (short for the *Diagnostic and StatisticalManual of Mental Disorders*).
According to the diagnostic manual, there are three patterns of behaviorthat indicate ADHD.  People with ADHD may show several signs of beingconsistently inattentive.  They may have a pattern of being hyperactiveand impulsive.  Or they may show all three types of behavior.
According to the DSM, signs of 
inattention
include:
becoming easily distracted by irrelevant sights and sounds
- failing to pay attention to details and making careless mistakes  rarely following instructions carefully and completelylosing or forgetting things like toys, or pencils, books, and      tools needed for a task
Some signs of **hyperactivity** and **impulsivity**are:
feeling restless, often fidgeting with hands or feet, or squirming
- running, climbing, or leaving a seat, in situations where sitting      or quiet behavior is expected blurting out answers before hearing the whole question having difficulty waiting in line or for a turn
Because everyone shows some of these behaviors at times, the DSMcontains very specific guidelines for determining when they indicateADHD.  The behaviors must appear early in life, before age 7, andcontinue for at least 6 months.  In children, they must be more frequentor severe than in others the same age.  Above all, the behaviors mustcreate a real handicap in at least two areas of a person's life, such asschool, home, work, or social settings.  So someone whose work orfriendships are not impaired by these behaviors would not be diagnosedwith ADHD.  Nor would a child who seems overly active at school butfunctions well elsewhere.
| Home | Mental Disorder Info | Top of Pub |

**Can Any Other Conditions Produce These Symptoms?**
The fact is, many things can produce these behaviors.  Anything fromchronic fear to mild seizures can make a child seem overactive,quarrelsome, impulsive, or inattentive.  For example, a formerlycooperative child who becomes overactive and easily distracted after aparent's death is dealing with an emotional problem, not ADHD.  Achronic middle ear infection can also make a child seem distracted anduncooperative.  So can living with family members who are physicallyabusive or addicted to drugs or alcohol.  Can you imagine a child tryingto focus on a math lesson when his or her safety and well-being are indanger each day?  Such children are showing the effects of otherproblems, not ADHD.
In other children, ADHD-like behaviors may be their response to adefeating classroom situation.  Perhaps the child has a learningdisability and is not developmentally ready to learn to read and writeat the time these are taught.  Or maybe the work is too hard or tooeasy, leaving the child frustrated or bored.
Tyrone and Mimi are two examples of how classroom conditions can elicitbehaviors that look like ADHD.  For months, Tyrone shouted answers outin class, then became disruptive when the teacher ignored him.  Hecertainly seemed hyperactive and impulsive.  Finally, after observingTyrone in other situations, his teacher realized he just wanted approvalfor knowing the right answer.  She began to seek opportunities to callon him and praise him.  Gradually, Tyrone became calmer and morecooperative.
Mimi, a fourth grader, made loud noises during reading group thatconstantly disrupted the class.  One day the teacher realized that thebook was too hard for Mimi.  Mimi's disruptions stopped when shewas placed in a reading group where the books were easier and she couldsuccessfully participate in the lesson.
Like Tyrone and Mimi, some children's attention and class participationimprove when the class structure and lessons are adjusted a bit to meettheir emotional needs, instructional level, or learning style.  Althoughsuch children need a little help to get on track at school, theyprobably don�t have ADHD.
It's also important to realize that during certain stages ofdevelopment, the majority of children that age tend to be inattentive,hyperactive, or impulsive--but do not have ADHD.  Preschoolers have lotsof energy and run everywhere they go, but this doesn't mean they arehyperactive.  And many teenagers go through a phase when they are messy,disorganized, and reject authority.  It doesn't mean they will have alifelong problem controlling their impulses.
ADHD is a serious diagnosis that may require long-term treatment withcounseling and medication.  So it's important that a doctor first lookfor and treat any other causes for these behaviors.
**What Can Look Like ADHD?**
- Underachievement at school due to a learning disability Attention lapses caused by petit mal seizuresA middle ear infection that causes an intermittent hearingproblem
- Disruptive or unresponsive behavior due to anxiety ordepression | Home | Mental Disorder Info | Top of Pub |

**Can Other Disorders Accompany ADHD?**
One of the difficulties in diagnosing ADHD is that it is oftenaccompanied by other problems.  For example, many children with ADHDalso have a specific learning disability (LD), which means they havetrouble mastering language or certain academic skills, typically readingand math.  ADHD is not in itself a specific learning disability.  Butbecause it can interfere with concentration and attention, ADHD can makeit doubly hard for a child with LD to do well in school.
A very small proportion of people with ADHD have a rare disorder calledTourette's syndrome.  People with Tourette's have tics and othermovements like eye blinks or facial twitches that they cannot control.Others may grimace, shrug, sniff, or bark out words.  Fortunately, thesebehaviors can be controlled with medication.  Researchers at NIMH andelsewhere are involved in evaluating the safety and effectiveness oftreatment for people who have both Tourette's syndrome and ADHD.
More serious, nearly half of all children with ADHD--mostly boys--tendto have another condition, called oppositional defiant disorder. LikeMark, who punched playmates for jostling him, these children mayoverreact or lash out when they feel bad about themselves.  They may bestubborn, have outbursts of temper, or act belligerent or defiant. Sometimes this progresses to more serious conduct disorders.  Childrenwith this combination of problems are at risk of getting in trouble atschool, and even with the police.  They may take unsafe risks and breaklaws--they may steal, set fires, destroy property, and drive recklessly.It's important that children with these conditions receive help beforethe behaviors lead to more serious problems.
At some point, many children with ADHD--mostly younger children andboys--experience other emotional disorders.  About one-fourth feelanxious.  They feel tremendous worry, tension, or uneasiness, even whenthere's nothing to fear.  Because the feelings are scarier, stronger,and more frequent than normal fears, they can affect the child'sthinking and behavior.  Others experience depression.  Depression goesbeyond ordinary sadness--people may feel so *"down"* that they feelhopeless and unable to deal with everyday tasks.  Depression can disruptsleep, appetite, and the ability to think.
Because emotional disorders and attention disorders so often go hand inhand, every child who has ADHD should be checked for accompanyinganxiety and depression.  Anxiety and depression can be treated, andhelping children handle such strong, painful feelings will help themcope with and overcome the effects of ADHD.
(Graphic Omitted:  Diagram showing the overlapping of other disorderswith ADHD.)
Of course, not all children with ADHD have an additional disorder.  Nordo all people with learning disabilities, Tourette's syndrome,oppositional defiant disorder, conduct disorder, anxiety, or depressionhave ADHD.  But when they do occur together, the combination of problemscan seriously complicate a person's life.  For this reason, it'simportant to watch for other disorders in children who have ADHD.
| Home | Mental Disorder Info | Top of Pub |

**What Causes ADHD?**
Understandably, one of the first questions parents ask when they learntheir child has an attention disorder is *"Why?  What went wrong?"*
Health professionals stress that since no one knows what causes ADHD, itdoesn't help parents to look backward to search for possible reasons.There are too many possibilities to pin down the cause with certainty.It is far more important for the family to move forward in finding waysto get the right help.
Scientists, however, do need to study causes in an effort to identifybetter ways to treat, and perhaps some day, prevent ADHD.  They arefinding more and more evidence that ADHD does not stem from homeenvironment, but from biological causes.  When you think about it, thereis no clear relationship between home life and ADHD.  Not all childrenfrom unstable or dysfunctional homes have ADHD.  And not all childrenwith ADHD come from dysfunctional families.  Knowing this can remove ahuge burden of guilt from parents who might blame themselves for theirchild's behavior.
Over the last decades, scientists have come up with possible theoriesabout what causes ADHD.  Some of these theories have led to dead ends,some to exciting new avenues of investigation.
One disappointing theory was that all attention disorders and learningdisabilities were caused by minor head injuries or undetectable damageto the brain, perhaps from early infection or complications at birth.Based on this theory, for many years both disorders were called *"minimalbrain damage"* or *"minimal brain dysfunction."*  Although certain types ofhead injury can explain some cases of attention disorder, the theory wasrejected because it could explain only a very small number of cases.Not everyone with ADHD or LD has a history of head trauma or birthcomplications.
Another theory was that refined sugar and food additives make childrenhyperactive and inattentive.  As a result, parents were encouraged tostop serving children foods containing artificial flavorings,preservatives, and sugars.  However, this theory, too, came underquestion.  In 1982, the National Institutes of Health (NIH), the Federalagency responsible for biomedical research, held a major scientificconference to discuss the issue.  After studying the data, thescientists concluded that the restricted diet only seemed to help about5 percent of children with ADHD, mostly either young children orchildren with food allergies.
**ADHD Is Not Usually Caused by:**
- too much TV  food allergies excess sugar 
- poor home life  poor schools
In recent years, as new tools and techniques for studying the brain havebeen developed, scientists have been able to test more theories aboutwhat causes ADHD.
Using one such technique, NIMH scientists demonstrated a link between aperson's ability to pay continued attention and the level of activity inthe brain.  Adult subjects were asked to learn a list of words.  As theydid, scientists used a PET (positron emission tomography) scanner toobserve the brain at work.  The researchers measured the level ofglucose used by the areas of the brain that inhibit impulses and controlattention.  Glucose is the brain's main source of energy, so measuringhow much is used is a good indicator of the brain's activity level.  Theinvestigators found important differences between people who have ADHDand those who don't.  In people with ADHD, the brain areas that controlattention used less glucose, indicating that they were less active.  Itappears from this research that a lower level of activity in some partsof the brain may cause inattention.

The next step will be to research WHY there is less activity in theseareas of the brain.  Scientists at NIMH hope to compare the use ofglucose and the activity level in mild and severe cases of ADHD.  Theywill also try to discover why some medications used to treat ADHD workbetter than others, and if the more effective medications increaseactivity in certain parts of the brain.
Researchers are also searching for other differences between those whohave and do not have ADHD.  Research on how the brain normally developsin the fetus offers some clues about what may disrupt the process.Throughout pregnancy and continuing into the first year of life, thebrain is constantly developing.  It begins its growth from a fewall-purpose cells and evolves into a complex organ made of billions ofspecialized, interconnected nerve cells.  By studying brain developmentin animals and humans, scientists are gaining a better understanding ofhow the brain works when the nerve cells are connected correctly and incorrectly.  Scientists at NIMH and other research institutions aretracking clues to determine what might prevent nerve cells from formingthe proper connections.  Some of the factors they are studying includedrug use during pregnancy, toxins, and genetics.
Research shows that a mother's use of cigarettes, alcohol, or otherdrugs during pregnancy may have damaging effects on the unborn child.These substances may be dangerous to the fetus's developing brain.  Itappears that alcohol and the nicotine in cigarettes may distortdeveloping nerve cells.  For example, heavy alcohol use during pregnancyhas been linked to fetal alcohol syndrome (FAS), a condition that canlead to low birth weight, intellectual impairment, and certain physicaldefects.  Many children born with FAS show much the same hyperactivity,inattention, and impulsivity as children with ADHD.
Drugs such as cocaine--including the smokable form known as crack--seemto affect the normal development of brain receptors.  These brain cellparts help to transmit incoming signals from our skin, eyes, and ears,and help control our responses to the environment.  Current researchsuggests that drug abuse may harm these receptors.  Some scientistsbelieve that such damage may lead to ADHD.
Toxins in the environment may also disrupt brain development or brainprocesses, which may lead to ADHD.  Lead is one such possible toxin.  Itis found in dust, soil, and flaking paint in areas where leaded gasolineand paint were once used.  It is also present in some water pipes.  Someanimal studies suggest that children exposed to lead may developsymptoms associated with ADHD, but only a few cases have actually been found.
Other research shows that attention disorders tend to run in families,so there are likely to be genetic influences.  Children who have ADHDusually have at least one close relative who also has ADHD.  And atleast one-third of all fathers who had ADHD in their youth bear childrenwho have ADHD.  Even more convincing:  the majority of identical twinsshare the trait.  At the National Institutes of Health, researchers arealso on the trail of a gene that may be involved in transmitting ADHD ina small number of families with a genetic thyroid disorder.
| Home | Mental Disorder Info | Top of Pub |

**GETTING HELP**
*Mark*
In third grade, Mark's teacher threw up her hands and said, *"Enough!"* In one morning, Mark had jumped out of his seat to sharpen his pencilsix times, each time accidentally charging into other children's desksand toppling books and papers.  He was finally sent to the principal'soffice when he began kicking a desk he had overturned.  In sheerfrustration, his teacher called a meeting with his parents and theschool psychologist.
But even after they developed a plan for managing Mark's behavior inclass, Mark showed little improvement.  Finally, after an extensiveassessment, they found that Mark had an attention deficit that includedhyperactivity.  He was put on a medication called Ritalin to control thehyperactivity during school hours.  Although Ritalin failed to help,another drug called Dexedrine did.  With a psychologist's help, hisparents learned to reward desirable behaviors, and to have Mark take"time out" when he became too disruptive.  Soon Mark was able to sitstill and focus on learning.
*Lisa*
Because Lisa wasn't disruptive in class, it took a long time forteachers to notice her problem.  Lisa was first referred to the schoolevaluation team when her teacher realized that she was a bright girlwith failing grades.  The team ruled out a learning disability butdetermined that she had an attention deficit, ADHD withouthyperactivity.  The school psychologist recognized that Lisa was alsodealing with depression.
Lisa's teachers and the school psychologist developed a treatment planthat included participation in a program to increase her attention spanand develop her social skills.  They also recommended that Lisa receivecounseling to help her recognize her strengths and overcome her depression.
*Henry*
When Henry's son entered kindergarten, it was clear that he was going tohave problems sitting quietly and concentrating.  After severaldisruptive incidents, the school called and suggested that his son beevaluated for ADHD.  As the boy was assessed, Henry realized that he hadgrown up with the same symptoms that specialists were now finding in hisson.  Fortunately, the psychologist knew that ADHD can persist inadults.  She suggested that Henry be evaluated by a professional whoworked with adults.  For the first time, Henry was correctly diagnosedand given Ritalin to aid his concentration.  What a relief!  All theyears that he had been unable to concentrate were due to a disorder thatcould be identified, and above all, treated.
| Home | Mental Disorder Info | Top of Pub |

**How Is ADHD Identified and Diagnosed?**
Many parents see signs of an attention deficit in toddlers long beforethe child enters school.  For example, as a 3-year-old, Henry's sonalready displayed some signs of hyperactivity.  He seemed to loseinterest and dart off even during his favorite TV shows or while playinggames.  Once, during a game of "catch," he left the game before the balleven reached him!
Like Henry's son, a child may be unable to focus long enough to play asimple game.  Or, like Mark, the child may be tearing around out ofcontrol.  But because children mature at different rates, and are verydifferent in personality, temperament, and energy level, it's useful toget an expert's opinion of whether the behaviors are appropriate for thechild's age.  Parents can ask their pediatrician, or a childpsychologist or psychiatrist to assess whether their toddler has anattention disorder or is just immature, has hyperactivity or is just exuberant.
Seeing a child as "a chip off the old block" or "just like his dad" canblind parents to the need for help.  Parents may find it hard to seetheir child's behavior as a problem when it so closely resembles theirown.  In fact, like Henry, many parents first recognize their owndisorder only when their children are diagnosed.
In many cases, the teacher is the first to recognize that a child ishyperactive or inattentive and may consult with the school psychologist.Because teachers work with many children, they come to know how"average" children behave in learning situations that require attentionand self control.  However, teachers sometimes fail to notice the needsof children like Lisa who are quiet and cooperative.
Types of Professionals Who Make the Diagnosis
School-age and preschool children are often evaluated by a schoolpsychologist or a team made up of the school psychologist and otherspecialists.  But if the school doesn't believe the student has aproblem, or if the family wants another opinion, a family may need tosee a specialist in private practice.  In such cases, who can the familyturn to?  What kinds of specialists do they need?

  
**Speciality****Can diagnose ADHD****Can prescribe medications, if needed****Provides counseling or training****Psychiatrists****yes****yes****yes****Psychologists****yes****no****yes****Pediatricians or family physicians****yes****yes****no****Neurologists****yes****yes****no**
 

The family can start by talking with the child's pediatrician or their family     doctor. Some pediatricians may do the assessment themselves, but more often     they refer the family to an appropriate specialist they know and trust. In     addition, state and local agencies that serve families and children, as well     as some of the volunteer organizations listed in the back of this booklet,     can help identify an appropriate specialist. 

Knowing the differences in qualifications and services can help the family     choose someone who can best meet their needs. Besides school psychologists,     there are several types of specialists qualified to diagnose and treat ADHD.     Child psychiatrists are doctors who specialize in diagnosing and treating     childhood mental and behavioral disorders. A psychiatrist can provide therapy     and prescribe any needed medications. Child psychologists are also qualified     to diagnose and treat ADHD. They can provide therapy for the child and help     the family develop ways to deal with the disorder. But psychologists are not     medical doctors and must rely on the child's physician to do medical exams     and prescribe medication. Neurologists, doctors who work with disorders of     the brain and nervous system, can also diagnose ADHD and prescribe medicines.     But unlike psychiatrists and psychologists, neurologists usually do not provide     therapy for the emotional aspects of the disorder. Adults who think they may     have ADHD can also seek a psychologist, psychiatrist, or neurologist. But     at present, not all specialists are skilled in identifying or treating ADHD     in adults. 

Within each specialty, individual doctors and mental health professionals     differ in their experience with ADHD. So in selecting a specialist, it's important     to find someone with specific training and experience in diagnosing and treating     the disorder. 
Steps In Making a Diagnosis
 Whatever the specialist's expertise, his or her first task is to gather     information that will rule out other possible reasons for the child's behavior.     In ruling out other causes, the specialist checks the child's school and medical     records. The specialist tries to sense whether the home and classroom environments     are stressful or chaotic, and how the child's parents and teachers deal with     the child. They may have a doctor look for such problems as emotional disorders,     undetectable (petit mal) seizures, and poor vision or hearing. Most schools     automatically screen for vision and hearing, so this information is often     already on record. A doctor may also look for allergies or nutrition problems     like chronic "caffeine highs" that might make the child seem overly     active.   
 Next the specialist gathers information on the child's ongoing behaviorin order to compare these behaviors to the symptoms and diagnosticcriteria listed in the DSM *(Diagnostic and Statistical Manual of MentalDisorders)*.  This involves talking with the child and if possible,observing the child in class and in other settings.
The child's teachers, past and present, are asked to rate theirobservations of the child's behavior on standardized evaluation forms tocompare the child�s behaviors to those of other children the same age.Of course, rating scales are subjective--they only capture the teacher'spersonal perception of the child.  Even so, because teachers get to knowso many children, their judgment of how a child compares to others isusually accurate.
The specialist interviews the child's teachers, parents, and otherpeople who know the child well, such as school staff and baby-sitters.Parents are asked to describe their child's behavior in a variety ofsituations.  They may also fill out a rating scale to indicate howsevere and frequent the behaviors seem to be.
In some cases, the child may be checked for social adjustment and mentalhealth.  Tests of intelligence and learning achievement may be given tosee if the child has a learning disability and whether the disabilitiesare in all or only certain parts of the school curriculum.
In looking at the data, the specialist pays special attention to thechild's behavior during noisy or unstructured situations, like parties,or during tasks that require sustained attention, like reading, workingmath problems, or playing a board game.  Behavior during free play orwhile getting individual attention is given less importance in theevaluation.  In such situations, most children with ADHD are able tocontrol their behavior and perform well.
The specialist then pieces together a profile of the child's behavior.Which ADHD-like behaviors listed in the DSM does the child show?  Howoften?  In what situations?  How long has the child been doing them?How old was the child when the problem started?  Are the behaviorsseriously interfering with the child's friendships, school activities,or home life?   Does the child have any other related problems? Theanswers to these questions help identify whether the child'shyperactivity, impulsivity, and inattention are significant andlong-standing.  If so, the child may be diagnosed with ADHD.
Adults are diagnosed for ADHD based on their performance at home and atwork.  When possible, their parents are asked to rate the person'sbehavior as a child.  A spouse or roommate can help rate and evaluatecurrent behaviors.  But for the most part, adults are asked to describetheir own experiences.  One symptom is a sense of frustration.  Sincepeople with ADHD are often bright and creative, they often reportfeeling frustrated that they're not living up to their potential. Manyalso feel restless and are easily bored.  Some say they need to seeknovelty and excitement to help channel the whirlwind in their minds.Although it may be impossible to document when these behaviors firststarted, most adults with ADHD can give examples of being inattentive,impulsive, overly active, impatient, and disorganized most of their lives.
Until recent years, adults were not thought to have ADHD, so many adultswith ongoing symptoms have never been diagnosed.  People like Henry gofor decades knowing that something is wrong, but not knowing what it is.Psychotherapy and medication for anxiety, depression, ormanic-depression fail to help much, simply because the ADHD itself isnot being addressed.  Yet half the children with ADHD continue to havesymptoms through adulthood.  The recent awareness of adult ADHD meansthat many people can finally be correctly diagnosed and treated.
A correct diagnosis lets people move forward in their lives. Once thedisorder is known, they can begin to receive whatever combination ofeducational, medical, and emotional help they need.
An effective treatment plan helps people with ADHD and their families atmany levels.  For adults with ADHD, the treatment plan may includemedication, along with practical and emotional support.  For childrenand adolescents, it may include providing an appropriate classroomsetting, the right medication, and helping parents to manage theirchild's behavior.
| Home | Mental Disorder Info | Top of Pub |

**What Are the Educational Options?**
Children with ADHD have a variety of needs.  Some children are toohyperactive or inattentive to function in a regular classroom, even withmedication and a behavior management plan.  Such children may be placedin a special education class for all or part of the day.  In someschools, the special education teacher teams with the classroom teacherto meet each child's unique needs.  However, most children are able tostay in the regular classroom.  Whenever possible, educators prefer tonot to segregate children, but to let them learn along with their peers.
Children with ADHD often need some special accommodations to help themlearn.  For example, the teacher may seat the child in an area with fewdistractions, provide an area where the child can move around andrelease excess energy, or establish a clearly posted system of rules andreward appropriate behavior.  Sometimes just keeping a card or a pictureon the desk can serve as a visual reminder to use the right schoolbehavior, like raising a hand instead of shouting out, or staying in aseat instead of wandering around the room.  Giving a child like Lisaextra time on tests can make the difference between passing and failing,and gives her a fairer chance to show what she's learned.  Reviewinginstructions or writing assignments on the board, and even listing thebooks and materials they will need for the task, may make it possiblefor disorganized, inattentive children to complete the work.
Many of the strategies of special education are simply good teachingmethods.  Telling students in advance what they will learn, providingvisual aids, and giving written as well as oral instructions are allways to help students focus and remember the key parts of the lesson.
Students with ADHD often need to learn techniques for monitoring andcontrolling their own attention and behavior.  For example, Mark'steacher taught him several alternatives for when he loses track of whathe's supposed to do.  He can look for instructions on the blackboard,raise his hand, wait to see if he remembers, or quietly ask anotherchild.  The process of finding alternatives to interrupting the teacherhas made him more self-sufficient and cooperative.  And because he nowinterrupts less, he is beginning to get more praise than reprimands.
In Lisa's class, the teacher frequently stops to ask students to noticewhether they are paying attention to the lesson or if they are thinkingabout something else.  The students record their answer on a chart.  Asstudents become more consciously aware of their attention, they begin tosee progress and feel good about staying better focused.  The processhelped make Lisa aware of when she was drifting off, so she could returnher attention to the lesson faster.  As a result, she became moreproductive and the quality of her work improved.
Because schools demand that children sit still, wait for a turn, payattention, and stick with a task, it's no surprise that many childrenwith ADHD have problems in class.  Their minds are fully capable oflearning, but their hyperactivity and inattention make learningdifficult.  As a result, many students with ADHD repeat a grade or dropout of school early.  Fortunately, with the right combination ofappropriate educational practices, medication, and counseling, theseoutcomes can be avoided.
Right to a Free Public Education
Although parents have the option of taking their child to a privatepractitioner for evaluation and educational services, most children withADHD qualify for free services within the public schools.  Steps aretaken to ensure that each child with ADHD receives an education thatmeets his or her unique needs.  For example, the special educationteacher, working with parents, the school psychologist, schooladministrators, and the classroom teacher, must assess the child'sstrengths and weaknesses and design an Individualized EducationalProgram (IEP).  The IEP outlines the specific skills the child needs todevelop as well as appropriate learning activities that build on thechild's strengths.  Parents play an important role in the process.  Theymust be included in meetings and given an opportunity to review andapprove their child's IEP.
Many children with ADHD or other disabilities are able to receive suchspecial education services under the Individuals with DisabilitiesEducation Act (IDEA).  The Act guarantees appropriate services and apublic education to children with disabilities from ages 3 to 21.Children who do not qualify for services under IDEA can receive helpunder an earlier law, the National Rehabilitation Act, Section 504,which defines disabilities more broadly.  Qualifying for services underthe National Rehabilitation Act is often called "504 eligibility."
Because ADHD is a disability that affects children's ability to learnand interact with others, it can certainly be a disabling condition. Under one law or another, most children can receive the services they need.

  
**Some Coping Strategies for Teens and Adults with           ADHD**
**When necessary, ask the teacher or boss to repeat instructions             rather than guess.**

**Break large assignments or job tasks into small, simple tasks.             Set a deadline for each task and reward yourself as you complete each             one.**

**Each day, make a list of what you need to do. Plant the best             order for doing each task. Then make a schedule for doing them. Use             a calendar or daily planner to keep yourself on track.**

**Work in a quiet area. Do one thing at a time. Give yourself short             breaks.**

**Write things you need to remember in a notebook with dividers.             Write different kinds of information like assignments, appointments,             and phone numbers in different sections. Keep the book with you a             of the time.**

**Post notes to yourself to help remind yourself of things you             need to do. Tape notes on the bathroom mirror, on the refrigerator,             in your school locker, or dashboard of your car-- wherever you're             likely to need the remainder.**

**Store similar things together. For example, keep all your Nintendo             disks in one place, and tape cassettes in another. Keep canceled checks             in one place, and bills in another.**

**Create a routine. Get yourself ready for school or work at the             same time, in the same any, every day.**

**Exercise, eat a balanced diet and get enough sleep.**

***Adopted from: Weinstein, C. "Cognitive Remediation Strategies."           Journal of Psychotherapy Practice and Research. 3(1):44-57, 1994.***

 

| Home | Mental Disorder Info | Top of Pub |

**What Treatments Are Available?**
For decades, medications have been used to treat the symptoms of ADHD.Three medications in the class of drugs known as stimulants seem to bethe most effective in both children and adults.  These aremethylphenidate (Ritalin), dextroamphetamine (Dexedrine or Dextrostat),and pemoline (Cylert).  For many people, these medicines dramaticallyreduce their hyperactivity and improve their ability to focus, work, andlearn.  The medications may also improve physical coordination, such ashandwriting and ability in sports.  Recent research by NIMH suggeststhat these medicines may also help children with an accompanying conductdisorder to control their impulsive, destructive behaviors.
Ritalin helped Henry focus on and complete tasks for the first time.Dexedrine helped Mark to sit quietly, focus his attention, andparticipate in class so he could learn.  He also became less impulsiveand aggressive.  Along with these changes in his behavior, Mark began tomake and keep friends.
Unfortunately, when people see such immediate improvement, they oftenthink medication is all that's needed.  But these medicines don't curethe disorder, they only temporarily control the symptoms.  Although thedrugs help people pay better attention and complete their work, theycan't increase knowledge or improve academic skills.  The drugs alonecan't help people feel better about themselves or cope with problems. These require other kinds of treatment and support.
For lasting improvement, numerous clinicians recommend that medicationsshould be used along with treatments that aid in these other areas.There are no quick cures.  Many experts believe that the mostsignificant, long-lasting gains appear when medication is combined withbehavioral therapy, emotional counseling, and practical support.  Somestudies suggest that the combination of medicine and therapy may be moreeffective than drugs alone.  NIMH is conducting a large study to check this.
Use of Stimulant Drugs
Stimulant drugs, such as Ritalin, Cylert, and Dexedrine, when used with medical supervision, are usually considered quite safe.  Although theycan be addictive to teenagers and adults if misused, these medicationsare not addictive in children.  They seldom make children *"high"* orjittery.  Nor do they sedate the child.  Rather, the stimulants helpchildren control their hyperactivity, inattention, and other behaviors.
Different doctors use the medications in slightly different ways.Cylert is available in one form, which naturally lasts 5 to 10 hours.Ritalin and Dexedrine come in short-term tablets that last about 3hours, as well as longer-term preparations that last through the schoolday.  The short-term dose is often more practical for children who needmedication only during the school day or for special situations, likeattending church or a prom, or studying for an important exam.  Thesustained-release dosage frees the child from the inconvenience orembarrassment of going to the office or school nurse every day for apill.  The doctor can help decide which preparation to use,and whether a child needs to take the medicine during school hours onlyor in the evenings and on weekends, too.
Nine out of 10 children improve on one of the three stimulant drugs.  Soif one doesn't help, the others should be tried.  Usually a medicationshould be tried for a week to see if it helps.  If necessary, however,the doctor will also try adjusting the dosage before switching to adifferent drug.
Other types of medication may be used if stimulants don't work or if theADHD occurs with another disorder.  Antidepressants and othermedications may be used to help control accompanying depression oranxiety.  In some cases, antihistamines may be tried.  Clonidine, a drugnormally used to treat hypertension, may be helpful in people with bothADHD and Tourette's syndrome.  Although stimulants tend to be moreeffective, clonidine may be tried when stimulants don't work or can't beused.  Clonidine can be administered either by pill or by skin patch andhas different side effects than stimulants.  The doctor works closelywith each patient to find the most appropriate medication.
Sometimes, a child's ADHD symptoms seem to worsen, leading parents towonder why.  They can be assured that a drug that helps rarely stopsworking.  However, they should work with the doctor to check that thechild is getting the right dosage.  Parents should also make sure thatthe child is actually getting the prescribed daily dosage at home or atschool--it's easy to forget.  They also need to know that new orexaggerated behaviors may also crop up when a child is under stress.The challenges that all children face, like changing schools or enteringpuberty, may be even more stressful for a child with ADHD.
Some doctors recommend that children be taken off a medication now andthen to see if the child still needs it.  They recommend temporarilystopping the drug during school breaks and summer vacations, whenfocused attention and calm behavior are usually not as crucial.  These"drug holidays" work well if the child can still participate at camp orother activities without medication.
Children on medications should have regular checkups.  Parents shouldalso talk regularly with the child's teachers and doctor about how thechild is doing.  This is especially important when a medication is firststarted, re-started, or when the dosage is changed. 
The Medication Debate
As useful as these drugs are, Ritalin and the other stimulants havesparked a great deal of controversy.  Most doctors feel the potentialside effects should be carefully weighed against the benefits beforeprescribing the drugs.  While on these medications, some children maylose weight, have less appetite, and temporarily grow more slowly.Others may have problems falling asleep.  Some doctors believe thatstimulants may also make the symptoms of Tourette's syndrome worse,although recent research suggests this may not be true.  Other doctorssay if they carefully watch the child's height, weight, and overalldevelopment, the benefits of medication far outweigh the potential sideeffects.  Side effects that do occur can often be handled by reducingthe dosage.
It's natural for parents to be concerned about whether taking a medicineis in their child's best interests.  Parents need to be clear about thebenefits and potential risks of using these drugs.  The child'spediatrician or psychiatrist can provide advice and answer questions.
Another debate is whether Ritalin and other stimulant drugs areprescribed unnecessarily for too many children.  Remember that manythings, including anxiety, depression, allergies, seizures, or problemswith the home or school environment can make children seem overactive,impulsive, or inattentive.  Critics argue that many children who do nothave a true attention disorder are medicated as a way to control theirdisruptive behaviors.
Medication and Self-Esteem
When a child's schoolwork and behavior improve soon after startingmedication, the child, parents, and teachers tend to applaud the drugfor causing the sudden change.  But these changes are actually thechild's own strengths and natural abilities coming out from behind acloud.  Giving credit to the medication can make the child feelincompetent.  The medication only makes these changes possible.  Thechild must supply the effort and ability.  To help children feel goodabout themselves, parents and teachers need to praise the child, not thedrug.
It's also important to help children and teenagers feel comfortableabout a medication they must take every day.  They may feel that becausethey take medicine they are different from their classmates or thatthere�s something seriously wrong with them.  CH.A.D.D. (which standsfor Children and Adults with Attention Deficit Disorders), a leadingorganization for people with attention disorders, suggests several waysthat parents and teachers can help children view the medication in apositive way:
- Compare the pills to eyeglasses, braces, and allergy medications    used by other children in their class.  Explain that their    medicine is simply a tool to help them focus and pay attention. Point out that they're lucky their problem can be helped.    Encourage them to identify ways the medicine makes it easier to do    things that are important to them, like make friends, succeed at    school, and play.
Myths About Stimulant Medication
- **Myth:**   Stimulants can lead to drug addictionlater in life. **Fact:**
  Stimulants help many children focusand be more successful at school, home, and play. Avoidingnegative experiences now may actually help prevent addictions andother emotional problems later.
**Myth:**
  Responding well to a stimulant drugproves a person has ADHD.
**Fact:**
  Stimulants allow many people to focusand pay better attention, whether or not they have ADHD.  Theimprovement is just more noticeable in people with ADHD.
**Myth:**
  Medication should be stopped when thechild reaches adolescence.
**Fact:**
  Not so!  About 80 percent of those whoneeded medication as children still need it as teenagers.  Fiftypercent need medication as adults.
Treatments To Help People With ADHD and TheirFamilies Learn To Cope
Life can be hard for children with ADHD.  They're the ones who are sooften in trouble at school, can't finish a game, and lose friends.  Theymay spend agonizing hours each night struggling to keep their mind ontheir homework, then forget to bring it to school.
It's not easy coping with these frustrations day after day.  Somechildren release their frustration by acting contrary, starting fights,or destroying property.  Some turn the frustration into body ailments,like the child who gets a stomachache each day before school.  Othershold their needs and fears inside, so that no one sees how badly they feel.
It's also difficult having a sister, brother, or classmate who getsangry, grabs your toys, and loses your things.  Children who live withor share a classroom with a child who has ADHD get frustrated, too.They may feel neglected as their parents or teachers try to cope withthe hyperactive child.  They may resent their brother or sister neverfinishing chores, or being pushed around by a classmate.  They want tolove their sibling and get along with their classmate, but sometimesit's so hard!
It's especially hard being the parent of a child who is full ofuncontrolled activity, leaves messes, throws tantrums, and doesn'tlisten or follow instructions.  Parents often feel powerless and at aloss.  The usual methods of discipline, like reasoning and scolding,don't work with this child, because the child doesn't really choose toact in these ways.  It's just that their self-control comes and goes.Out of sheer frustration, parents sometimes find themselves spanking,ridiculing, or screaming at the child, even though they know it's notappropriate.  Their response leaves everyone more upset than before.Then they blame themselves for not being better parents.  Once childrenare diagnosed and receiving treatment, some of the emotional upsetwithin the family may fade.
Medication can help to control some of the behavior problems that mayhave lead to family turmoil.  But more often, there are other aspects ofthe problem that medication can't touch.  Even though ADHD primarilyaffects a person's behavior, having the disorder has broad emotionalrepercussions.  For some children, being scolded is the only attentionthey ever get.  They have few experiences that build their sense ofworth and competence.  If they're hyperactive, they're often toldthey're bad and punished for being disruptive.  If they are toodisorganized and unfocused to complete tasks, others may call them lazy.If they impulsively grab toys, butt in, or shove classmates, they maylose friends.  And if they have a related conduct disorder, they may getin trouble at school or with the law.  Facing the daily frustrationsthat can come with having ADHD can make people fear that they arestrange, abnormal, or stupid.
Often, the cycle of frustration, blame, and anger has gone on so longthat it will take some time to undo.  Both parents and their childrenmay need special help to develop techniques for managing the patterns ofbehavior.  In such cases, mental health professionals can counsel thechild and the family, helping them to develop new skills, attitudes, andways of relating to each other.  In individual counseling, the therapisthelps children or adults with ADHD learn to feel better about themselves.  They learn to recognize that having a disability does notreflect who they are as a person.  The therapist can also help peoplewith ADHD identify and build on their strengths, cope with dailyproblems, and control their attention and aggression.  In groupcounseling, people learn that they are not alone in their frustrationand that others want to help.  Sometimes only the individual with ADHDneeds counseling support.  But in many cases, because the problemaffects the family as well as the person with ADHD, the entire familymay need help.  The therapist assists the family in finding better waysto handle the disruptive behaviors and promote change.  If the child isyoung, most of the therapist's work is with the parents, teaching themtechniques for coping with and improving their child's behavior.
Several intervention approaches are available and different therapiststend to prefer one approach or another.  Knowing something about thevarious types of interventions makes it easier for families to choose atherapist that is right for their needs.
***Psychotherapy*** works to help people with ADHD to like and acceptthemselves despite their disorder.  In psychotherapy, patients talk withthe therapist about upsetting thoughts and feelings, exploreself-defeating patterns of behavior, and learn alternative ways tohandle their emotions.  As they talk, the therapist tries to help themunderstand how they can change.  However, people dealing with ADHDusually want to gain control of their symptomatic behaviors moredirectly.  If so, more direct kinds of intervention are needed.
***Cognitive-behavioral therapy***helps people work on immediateissues.  Rather than helping people understand their feelings andactions, it supports them directly in changing their behavior.  Thesupport might be practical assistance, like helping Henry learn to thinkthrough tasks and organize his work.  Or the support might be toencourage new behaviors by giving praise or rewards each time the personacts in the desired way.  A cognitive-behavioral therapist might usesuch techniques to help a belligerent child like Mark learn to controlhis fighting, or an impulsive teenager like Lisa to think before she speaks.
***Social skills training***can also help children learn new behaviors.In social skills training, the therapist discusses and modelsappropriate behaviors like waiting for a turn, sharing toys, asking forhelp, or responding to teasing, then gives children a chance topractice.  For example, a child might learn to "read" other people'sfacial expression and tone of voice, in order to respond moreappropriately.  Social skills training helped Lisa learn to join ingroup activities, make appropriate comments, and ask for help.  A childlike Mark might learn to see how his behavior affects others and developnew ways to respond when angry or pushed.
***Support groups***connect people who have common concerns.  Manyadults with ADHD and parents of children with ADHD find it useful tojoin a local or national support group.  Many groups deal with issues ofchildren's disorders, and even ADHD specifically.  The nationalassociations listed at the back of this booklet can explain how tocontact a local chapter.  Members of support groups share frustrationsand successes, referrals to qualified specialists, and information aboutwhat works, as well as their hopes for themselves and their children.There is strength in numbers--and sharing experiences with others whohave similar problems helps people know that they aren't alone.
***Parenting skills training,*** offered by therapists or in specialclasses, gives parents tools and techniques for managing their child'sbehavior.  One such technique is the use of "time out" when the childbecomes too unruly or out of control.  During time outs, the child isremoved from the agitating situation and sits alone quietly for a shorttime to calm down.  Parents may also be taught to give the child"quality time" each day, in which they share a pleasurable or relaxedactivity.  During this time together, the parent looks for opportunitiesto notice and point out what the child does well, and praise his or herstrengths and abilities.
An effective way to modify a child's behavior is through a system ofrewards and penalties.  The parents (or teacher) identify a fewdesirable behaviors that they want to encourage in the child--such asasking for a toy instead of grabbing it, or completing a simple task.The child is told exactly what is expected in order to earn the reward.The child receives the reward when he performs the desired behavior anda mild penalty when he doesn't.  A reward can be small, perhaps a tokenthat can be exchanged for special privileges, but it should be somethingthe child wants and is eager to earn.  The penalty might be removal of atoken or a brief "time out."  The goal, over time, is to help childrenlearn to control their own behavior and to choose the more desiredbehavior.  The technique works well with all children, although childrenwith ADHD may need more frequent rewards.
In addition, parents may learn to structure situations in ways that willallow their child to succeed.  This may include allowing only one or twoplaymates at a time, so that their child doesn't get overstimulated.  Orif their child has trouble completing tasks, they may learn to help thechild divide a large task into small steps, then praise the child aseach step is completed.
Parents may also learn to use stress management methods, such asmeditation, relaxation techniques, and exercise to increase their owntolerance for frustration, so that they can respond more calmly to theirchild's behavior.
Controversial Treatments
Understandably, parents who are eager to help their children want toexplore every possible option.  Many newly touted treatments soundreasonable.  Many even come with glowing reports.  A few are purequackery.  Some are even developed by reputable doctors orspecialists--but when tested scientifically, cannot be proven to help.
Here are a few types of treatment that have not been scientificallyshown to be effective in treating the majority of children or adultswith ADHD:
- biofeedback restricted dietsallergy treatments
- medicines to correct problems in the inner ear megavitaminschiropractic adjustment and bone re-alignment
- treatment for yeast infection eye trainingspecial colored glasses
A few success stories can't substitute for scientific evidence.  Untilsound, scientific testing shows a treatment to be effective, familiesrisk spending time, money, and hope on fads and false promises.
| Home | Mental Disorder Info | Top of Pub |

**SUSTAINING HOPE**
*Mark*
Today, at age 14, Mark is doing much better in school.  He channels hisenergy into sports and is a star player on the intramural football team.Although he still gets into fights now and then, a child psychologist ishelping him learn to control his tantrums and frustration, and he isable to make and keep friends.  His grandparents point to him with prideand say, "We knew he'd turn out just fine!"
*Lisa*
Lisa is about to graduate from high school.  She's better able to focusher attention and concentrate on her work, so that now her grades arequite good.  Overcoming her depression and learning to like herself havealso given her more confidence to develop friendships and try new things.
Lately, she has been working with the school guidance counselor toidentify the right kind of job to look for after graduation.  She hopesto find a career that will bypass her attention problems and make thebest use of her assets and skills.  She is more alert and focused and isconsidering trying college in a year or two.  Her counselor reminds herthat she's certainly smart enough.
*Henry*
These days, Henry is successful and happy in his job as a shoe salesman.The work allows him to move around throughout the day, and theappearance of new customers provides the variety he needs to help himstay focused.  He recently completed a course in time management, andnow keeps lists, organizes his work, and schedules his day.  Now that hehas harnessed his energy, his ability to think about several things atonce allows him to be creative and productive.
He is proud that he and his wife have developed important parentingskills for working with their son, so that he, too, is doing better athome and at school.  Henry is also pleased with his new ability tofollow through on projects.  In fact, he just finished making his son abeautiful wooden toy chest for his birthday.
| Home | Mental Disorder Info | Top of Pub |

**Can ADHD Be Outgrown or Cured?**
Even though most people don't outgrow ADHD, people do learn to adapt andlive fulfilling lives.  Mark, Lisa, and Henry are making good lives forthemselves--not by being cured, but by developing their personalstrengths.  With effective combinations of medicine, new skills, andemotional support, people with ADHD can develop ways to control theirattention and minimize their disruptive behaviors.  Like Henry, they mayfind that by structuring tasks and controlling their environment, theycan achieve personal goals.  Like Mark, they may learn to channel theirexcess energy into sports and other high energy activities.  And likeLisa, they can identify career options that build on their strengths andabilities.
As they grow up, with appropriate help from parents and clinicians,children with ADHD become better able to suppress their hyperactivityand to channel it into more socially acceptable behaviors, like physicalexercise or fidgeting.  And although we know that half of all childrenwith ADHD will still show signs of the problem into adulthood, we alsoknow that the medications and therapy that help children also work foradults.
All people with ADHD have natural talents and abilities that they candraw on to create fine lives and careers for themselves.  In fact, manypeople with ADHD even feel that their patterns of behavior give themunique, often unrecognized, advantages.  People with ADHD tend to beoutgoing and ready for action.  Because of their drive for excitementand stimulation, many become successful in business, sports,construction, and public speaking.  Because of their ability to thinkabout many things at once, many have won acclaim as artists andinventors.  Many choose work that gives them freedom to move around andrelease excess energy.  But some find ways to be effective in quieter,more sedentary careers.  Sally, a computer programmer, found that shethinks best when she wears headphones to reduce distracting noises. Like Henry, some people strive to increase their organizational skills. Others who own their own business find it useful to hire support staffto provide day-to-day management.
| Home | Mental Disorder Info | Top of Pub |

**What Hope Does Research Offer?**
Although no immediate cure is in sight, a new understanding of ADHD maybe just over the horizon.  Using a variety of research tools andmethods, scientists are beginning to uncover new information on the roleof the brain in ADHD and effective treatments for the disorderSuch research will ultimately result in improving the personalfulfillment and productivity of people with ADHD.
For example, the use of new techniques like brain imaging to observe howthe brain actually works is already providing new insights into thecauses of ADHD.  Other research is seeking to identify conditions ofpregnancy and early childhood that may cause or contribute to thesedifferences in the brain.  As the body of knowledge grows, scientistsmay someday learn how to prevent these differences or at least how totreat them.
NIMH and the U.S. Department of Education are cosponsoring a largenational study--the first of its kind--to see which combinations of ADHDtreatment work best for different types of children.  During this 5-yearstudy, scientists at research clinics across the country will worktogether in gathering data to answer such questions as:  Is combiningstimulant medication with behavior modification more effective thaneither alone?  Do boys and girls respond differently to treatment?  Howdo family stresses, income, and environment affect the severity of ADHDand long-term outcomes?  How does needing medicine affect children'ssense of competence, self-control, and self-esteem?  As a result of suchresearch, doctors and mental health specialists may someday know whobenefits most from different types of treatment and be able to intervenemore effectively.
NIMH grantees are also trying to determine if there are differentvarieties of attention deficit.  With further study, researchers mayfind that ADHD actually covers a number of different disorders, eachwith its own cluster of symptoms and treatment requirements.  Forexample, scientists are exploring whether there are any criticaldifferences between children with ADHD who also have anxiety,depression, or conduct disorders and those who do not.  Otherresearchers are studying slight physical differences that mightdistinguish one type of ADHD from another.  If clusters of differencescan be found, scientists can begin to distinguish the treatment eachtype needs.
Other NIMH-sponsored research is examining the long-term outcome ofADHD.  How do children with ADHD turn out, compared to brothers andsisters without the disorder?  As adults, how do they handle their ownchildren?  Still other studies seek to better understand ADHD in adults. Such studies give insights into what types of treatment or services makea difference in helping an ADHD child grow into a caring parent and awell-functioning adult.
Animal studies are also adding to our knowledge of ADHD in humans.Animal subjects make it possible to study some of the possible causes ofADHD in ways that can't be studied in people.  In addition, animalresearch allows the safety and effectiveness of experimental new drugsto be tested long before they can be given to humans.  One NIH-sponsoredteam of scientists is studying dogs to learn how new stimulant drugsthat are similar to Ritalin act on the brain.
Piece by piece, through studies of humans and animals, scientists arebeginning to understand the biological nature of attention disorders. New research is allowing us to better understand the inner workings ofthe brain as we continue to develop new medications and assess new formsof treatment.
As we learn more about what actually happens inside the brain, weapproach a future where we can prevent certain brain and mentaldisorders, make valid diagnoses, and treat each effectively.  This isthe hope, mission, and vision of the National Institute of MentalHealth.
| Home | Mental Disorder Info | Top of Pub |

**What Are Sources of Information and Support?**
Several publications, organizations, and support groups exist to helpindividuals, teachers, and families to understand and cope withattention disorders.  The following resources provide a good startingpoint for gaining insight, practical solutions, and support.  Otherresources are outpatient clinics of children�s hospitals, universitymedical centers, and community mental health centers.  Additionalprinted information can be found at libraries and book stores.
- **Books for Children and Teens:**  Galvin, M.  *Otto Learns about his Medication.*  New York: Magination Press, 1988.  (for young children)
Gehret, J.  *Learning Disabilities and the Don't Give UpKid.* Fairport, New York:  Verbal Images Press,  1990.  (forclassmates and children with learning disabilities and attentiondifficulties, ages 7-12)
Gordon, M.  *Jumpin' Johnny, Get Back to Work!  A Child's Guideto ADHD/Hyperactivity.*  DeWitt, New York:  GSI Publications,1991. (for ages 7-12)
Meyer, D.; Vadasy, P.; and Fewell, R.  *Living with a Brotheror Sister with Special Needs:  A Book for Sibs.*  Seattle: University of Washington Press, 1985.
Moss, D.  *Shelly the Hyperactive Turtle.*  Rockville, MD: Woodbine House, 1989. (for young children)
Nadeau, K., and Dixon, E.  *Learning to Slow Down and PayAttention.* Annandale, VA:  Chesapeake PsychologicalPublications, 1993.
Parker, R.  *Making the Grade:  An Adolescent's Struggle withADD.* Plantation, FL:  Impact Publications, 1992.
Quinn, P., and Stern, J.  *Putting on the Brakes:  YoungPeople's Guide to Understanding Attention Deficit HyperactivityDisorder.* New York:  Magination Press, 1991.  (for ages 8-12)
Thompson, M.  *My Brother Matthew.*  Rockville, MD: Woodbine House, 1992.
**Books for Adults With Attention Disorders:**
Adelman, P., and Wren, C.  *Learning Disabilities, GraduateSchool, and Careers:  The Student's Perspective.*  LakeForest, IL: Learning Opportunities Program, Barat College, 1990.
Hallowell, E., and Ratey, J.  *Driven to Distraction.*  NewYork: Pantheon Books, 1994.
Hartmann, T.  *Attention Deficit Disorder:  A NewPerception.* Lancaster, PA:  Underwood-Miller, 1993.
Kelly, K., and Ramundo, P.  *You Mean I'm Not Lazy, Stupid, orCrazy?!* Cincinnati, OH:  Tyrell and Jeremy Press, 1993.
Weiss, G., and Hechtman, L. (eds).  *Hyperactive Children GrownUp.*  2d ed.  New York:  Guilford Press, 1992.
Weiss, L.  *Attention Deficit Disorder in Adults.*  Dallas,TX: Taylor Pub. Co., 1992.
Wender, P.  *The Hyperactive Child, Adolescence, and Adult: Attention Deficit Disorder Through the Lifespan.*  New York: Oxford University Press, 1987.
**Books for Parents:**
Anderson, W.; Chitwood, S.; and Hayden, D.  *Negotiating theSpecial Education Maze:  A Guide for Parents and Teachers.* 2d ed. Rockville, MD:  Woodbine House, 1990.
Bain, L.  *A Parent's Guide to Attention Deficit Disorders.*New York: Dell Publishing, 1991. 
Barkley, R.  *Defiant Children.*  New York:  Guilford Press,1987.
Child Psychopharmacy Center, University of Wisconsin. *Stimulants and Hyperactive Children.*  Madison:  1990. (Order by calling (608) 263-6171.)
Copeland, E., and Love, V.  *Attention, Please!:  AComprehensive Guide for Successfully Parenting Children withAttention Disorders and Hyperactivity.* Atlanta, GA:  SPIPress, 1991.
Fowler, M.  *Maybe You Know My Kid:  A Parent's Guide toIdentifying, Understanding, and Helping your Child with ADHD.*New York:  Birch Lane Press, 1990.
Goldstein, S., and Goldstein, M.  *Hyperactivity:  Why Won't MyChild Pay Attention?*  New York:  J. Wiley, 1992.
Greenberg, G.; Horn, S.; and Wade F.  *Attention DeficitHyperactivity Disorder:  Questions & Answers for Parents.* Champaign, IL:  Research Press, 1991.
Ingersoll, B., and Goldstein, S.  *Attention Deficit Disorderand Learning Disabilities:  Realities, Myths, and ControversialTreatments.* New York:  Doubleday, 1993.
Kennedy, P.; Terdal, L.; and Fusetti, L.  *The HyperactiveChild Book.* New York:  St. Martrin's Press, 1993.
Moss, R., and Dunlap, H.  *Why Johnny Can't Concentrate: Coping with Attention Deficit Problems.*  New York:  BantamBooks, 1990.
Silver, L.  *Dr. Silver's Advice to Parents onAttention-Deficit Hyperactivity Disorder.*  Washington, DC: American Psychiatric Press, 1993.
Vail, P.  *Smart Kids with School Problems.*  New York:  EPDutton, 1987.
Wilson, N.  *Optimizing Special Education:  How Parents CanMake a Difference.*  New York:  Insight Books, 1992.
Windell, J.  *Discipline:  A Sourcebook of 50 FailsafeTechniques for Parents.* New York:  Collier Books, 1991.
**Other Resources:**
For individuals with a computer and modem, there are on-linebulletin boards where parents, adults with ADHD, and medicalprofessionals share experiences, offer emotional  support, andask and respond to questions.
Two such on-line services include CompuServe [(800) 848-8990] andAmerica Online [(800) 827-6364].  You may also wish to check withother national and local on-line communications companies to seeif they offer similar services.
- **Resources for Teachers and Specialists:**  Barkley, R.  *Attention Deficit Hyperactivity Disorder*(four 40-minute videocassettes in VHS format).  New York: Guilford Publications, 1990.
Copeland, E., and Love, V.  *Attention Without Tension:  ATeacher's Handbook on Attention Disorders.*  Atlanta, GA:  3C's of Childhood, 1992.
Harris, K., and Graham, S.  *Helping Young Writers Master theCraft.* Cambridge, MA:  Brookline Books, 1992.
Johnson, D.  *I Can't Sit Still-Educating and AffirmingInattentive and Hyperactive Children:  Suggestions for Parents,Teachers, and Other Care Providers of Children to Age 10.* Santa Cruz, CA:  ETR Associates, 1992.
Parker, H.  *The ADD Hyperactivity Handbook for Schools.*Plantation, FL:  Impact Publications, 1992.
**Related Materials Available from NIH:**
Attention Deficit Disorder Information Packet and "Know YourBrain Fact Sheet."  Both are available from NIH NeurologicalInstitute, P.O. Box 5801; Bethesda, MD  20824  (800) 352-9424.*Learning Disabilities* (NIH Pub. No. 93-3611) and "PlainTalk about Depression' (NIH Pub. No. 93-3561).  These areavailable by contacting:  NIMH, 6001 Executive Boulevard, Rm. 8184, MSC 9663Bethesda, MD  20892-9663.
Support Groups and Organizations
Attention Deficit Information Network (Ad-IN)475 Hillside AvenueNeedham, MA  02194(781) 455-9895
*Provides up-to-date information on current research,regional meetings.  Offers aid in finding solutions to practicalproblems faced by adults and children with an attentiondisorder.*
ADD Warehouse300 NW 70th AvenuePlantation, FL  33317 (800) 233-9273
*Distributes books, tapes, videos, assessment  on attentiondeficit hyperactivity disorders.  A central location for orderingmany of the books listed above.  Call for catalog.*
Center for Mental Health ServicesOffice of Consumer, Family, and Public Information5600 Fishers Lane, Room 15-105Rockville, MD  20857(301) 443-2792
*This national center, a component of the U.S. Public HealthService, provides a range of information on mental health,treatment, and support services.*
Children and Adults with Attention Deficit Disorders (CH.A.D.D.)499 NW 70th Avenue, Suite 101Plantation, FL  33317(800) 233-4050
*A major advocate and key information source for peopledealing with attention disorders.  Sponsors support groups andpublishes two newsletters concerning attention disorders forparents and professionals.*
Council for Exceptional Children11920 Association DriveReston, VA  22091(703) 620-3660
*Provides publications for educators.  Can also providereferral to ERIC (Educational Resource Information Center)Clearinghouse for Handicapped and Gifted Children.*
Federation of Families for Children's Mental Health1021 Prince StreetAlexandria, VA  22314 (703) 684-7710
*Provides information, support, and referrals throughfederation chapters throughout the country.  This nationalparent-run organization focuses on the needs of children withbroad mental health problems.*
HEATH Resource CenterAmerican Council on Education1 Dupont Circle, Suite 800Washington, DC  20036 (800) 544-3284
*A national clearinghouse on post-high school education forpeople with disabilities.*
Learning Disabilities Association of America4156 Library RoadPittsburgh, PA  15234(412) 341-8077
*Provides information and referral to state chapters, parentresources, and local support groups.  Publishes news briefsand a professional journal.*
National Association of Private Schools for Exceptional Children1522 K Street, NW, Suite 1032Washington, DC  20005          (202) 408-3338
*Provides referrals to private special education programs.*
National Center for Learning Disabilities99 Park Avenue, 6th FloorNew York, NY  10016(212) 687-7211
*Provides referrals and resources.  Publishes Their Worldmagazine describing true stories on ways children and adults copewith LD.*
National Clearinghouse for Alcohol and Drug InformationP.O. Box 2345Rockville, MD  20847(800) 729-6686
*Provides information on the risks of alcohol duringpregnancy, and fetal alcohol syndrome.*
National Information Center for Children and Youth with Disabilities (NICHCY)P.O. Box 1492Washington, DC  20013(800) 695-0285
*Publishes free, fact-filled newsletters.  Arrangesworkshops.  Advises parents on the laws entitling children withdisabilities to special education and other services.*
Sibling Information NetworkA.J. Pappanikou Center1776 Ellington RoadSouth Windsor, CT  06074(203) 648-1205
*Publishes a newsletter for and about siblings of childrenwith special needs.*
Tourette Syndrome Association42-40 Bell BoulevardBayside, NY  11361(718) 224-2999
*State and local chapters provide national information,advocacy, research, and support.*
MESSAGE FROM THE NATIONAL INSTITUTE OF MENTAL HEALTH
Research conducted and supported by the National Institute of MentalHealth brings hope to millions of people who suffer from mental illnessand to their families and friends.  In many years of work with animal aswell as human subjects, researchers have advanced our understanding ofthe brain and vastly expanded the capability of mental health professionals to diagnose, treat, and prevent mental and braindisorders.
Now, in the 1990s, which the President and Congress have declared the"Decade of the Brain," we stand at the threshold of a new era in brainand behavioral sciences.  Through research, we will learn even moreabout mental and brain disorders such as depression, bipolar disorder,schizophrenia, panic disorder, obsessive-compulsive disorder, andattention deficit hyperactivity disorder.  And we will be able to usethis knowledge to develop new therapies that can help more peopleovercome mental illness.
The National Institute of Mental Health is part of the NationalInstitutes of Health (NIH), the Federal Government's primary agency forbiomedical and behavioral research.  NIH is a component of the U.S.Department of Health and Human Services.
All material in this publication is free of copyright restrictions andmay be copied, reproduced, or duplicated without permission from NIMH; citation of the source is appreciated.
Credits
This booklet was written by Sharyn Neuwirth, M.Ed., an education writerand instructional designer in Silver Spring, MD.  Scientific informationand review was provided by NIMH staff members L. Eugene Arnold, M.D.; F.Xavier Castellanos, M.D.; and Alan J. Zametkin, M.D.  Also providingreview and assistance were Russell A. Barkley, Ph.D., University ofMassachusetts Medical School; Eileen Weiner-Dwyer, Ph.D., and KevinDwyer, M.A., N.C.S.P., of the Montgomery County (Maryland) Schools;JoAnne Evans, R.N., Children and Adults with Attention DeficitDisorders; Jane Hauser, U.S. Department of Education; Reid Lyon, Ph.D.,National Institute of Child Health and Human Development; Harvey C.Parker, Ph.D., A.D.D. Warehouse; Larry B. Silver, M.D., GeorgetownUniversity.  Editorial direction was provided by Lynn J. Cave, NIMH.
U.S. Department of Health and Human ServicesPublic Health Service
National Institutes of HealthNational Institute of Mental Health
NIH Publication No. 96-3572Printed 1994, Reprinted 1996  
 This publication is available for purchase from the U.S. Government Printing Office S/N 017-024-01543-1 -- $45.00 package of 25 copies. | GPO Order Form |         |
|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|