(Editor's note: In order to protect privacy and confidentiality, the names of individuals in this article have been changed and some descriptions of events have been modified)

"We're getting daily reports from Brian's teacher. He refuses to follow directions and do what he's told, unless it's something that he wants to do. She has to remind him constantly to stop bothering the other kids and get back to work. We're having the same problem with Brian at home; we have to ask him ten times before he does what he's told! Trying to get him started on homework turns into a battle every night. Honestly, this is wearing us out. It's wearing him out too!"

Shay and Stanley Lipton were sitting in my office describing their nine-year-old son, Brian. The complaints from his fourth grade teacher were only getting worse as the semester progressed. Was it possible, they wondered, that he might have ADHD? The thought filled them with apprehension, but clearly something had to be done.

Everyone knew that Brian was a bright child and quite capable of learning. However he kept getting into trouble at school and was not getting the academic work done. Even worse, Brian was starting to hate school and seemed increasingly frustrated with himself. He was making many negative comments about himself, such as "I can't do it" and "nobody likes me, I'm a jerk."

An evaluation confirmed what the parents suspected: Brian did indeed have ADHD, Combined Type. Treatment options were discussed, along with school accommodations. During the process of Brian's evaluation and discussions about the biology and genetics of ADHD, Shay gained some surprising insights about the effects of ADHD on other members of her biological family. This would lead to additional ADHD evaluations for herself and her father, Buck, and to concerns about other family members.

The most powerful diagnostic indicator in the evaluation of ADHD is a comprehensive history that shows the impact of ADHD on behavior and on a person's life over the course of many years. The personal stories of several individuals in this family, including Shay, Buck, Sharon, Barry, and Brian, present a graphic example of the impact ADHD can have on the lives of individuals and families over many generations. For the purpose of this article, their stories will be told along a time chronology that spans more than 60 years.

Buck's Story

Buck was born in 1940, the oldest of three sons of an autoworker and a housewife in Michigan. He has a clear and detailed recollection of the problems he experienced growing up that led him to drop out of high school, resulted in many job failures, and made for a rather tumultuous young adulthood.

Since grade school, Buck felt frustrated and bored in his classes to the point that he became the class clown. His classroom routines were entertaining his friends, but primarily Buck needed to entertain himself. His clowning behavior also hid the fact that he struggled severely to keep up with his academic work. He could not stay focused long enough to read textbook assignments, complete homework assignments, or study for tests. Failing grades led to truancy, which led to more failing grades.

Shortly after beginning his senior year in high school, Buck stopped going to classes and got a job in an auto repair shop. He loved working on cars and certainly had no problems focusing on that work. When the auto shop closed, Buck went through a number of short-lived jobs — "anything I could find." After six to twelve months in one job he either quit out of boredom or was fired for various reasons. He was never on time, never organized, and quick to get upset and get into conflicts with his bosses and co-workers.

Buck's father pulled some strings to get him a job working on the assembly line at the auto plant where the father also worked. Buck found the repetitive, monotonous nature of this work so unbearable that he quit after only one week. This decision led to a very angry confrontation with his understandably embarrassed father, and shortly after Buck moved out of his parents' house.

In his late 20's Buck went to work for his uncle, who needed help managing his commercial landscaping business. He found himself poorly suited for office managerial work due to problems with organization and planning and difficulties managing paperwork. In addition he was, once again, getting bored silly with his job but did not want to quit and betray his uncle's confidence in him.

Buck requested the position of lead salesman for the company and responsibility for training and supervising the sales team. His lively enthusiasm and excellent people skills made him very effective in this new area of responsibility. Within several years he helped build the business into the largest commercial landscaper in the state. Buck also got married during that period, became a father to his first daughter, Shay, and settled into a more stable lifestyle. Eventually he purchased the business when his uncle retired.

In providing additional family background, Buck described the histories of his two younger brothers, George and Barry. George was always well behaved and studious. He graduated from college with honors and became an actuary for a large insurance company. He currently holds a managerial position with the company.

Barry's Story

Buck's youngest brother, Barry, went through a childhood that was even more problematic than Buck's. Barry was restless, impulsive, and rebellious. He had a quick temper and got into numerous fights. He was a thrill seeker, for example hitching rides on passing freight train cars and then jumping off after a while. Barry had a love-hate relationship with Buck and George, but when they needed him he was a very loyal and caring brother.

Barry had problems similar to Buck's when it came to staying focused in class and completing schoolwork. He was expelled in the 11^th grade for repeatedly fighting at school and possession of marijuana. He never returned to complete his high school education or obtain a diploma. Relationships with his parents were understandably strained due to his school problems, drinking and drug use, and disregard for rules or consequences.

The family conflicts ended when Barry was drafted into the army. He enjoyed being in the military, was considered very good at his duties, and apparently benefited from the structure that military life provided. Barry's army unit was shipped to Vietnam in 1968, and he was killed in combat later that year. He was 22 years old.

Shay's Story

Shay is a 36-year-old mother of three and a graphic arts designer. She put her career on hold until the children are older. Shay describes her childhood as being happy and uneventful. She was a "huge daydreamer" throughout her grade school years, and spent much of her free time drawing and writing poetry.

Shay recalls problems with poor attention and concentration dating back to early childhood. She was a severe procrastinator since grade school with homework, school projects, and studying for tests. Shay did well in classes she liked, but had to work extremely hard to complete the work in classes that did not hold a strong interest for her.

Shay's grades were inconsistent from semester to semester, and often from one report card to the next. Studying for tests was an exercise in frustration because even after studying for hours, on the day of the test she would forget what she had studied. In general, trying to keep up with schoolwork was an exhausting and frustrating experience for her. "Even when I did well," she says with some sadness, "I never felt as smart as the other kids."

Shay still has difficulties with maintaining concentration on the task at hand. She finds it difficult to read for more than 15 or 20 minutes without her mind wandering. In school, and all through college, she would find herself reading the same page in a textbook two or three times because she would get distracted and forget what she had just read. The exceptions are when "it's a book I really like, then I can read for hours."

Shay very rarely had problems focusing when engaged in her graphic arts work. Unfortunately, this is not the case when it comes to most housework. The responsibilities involved in raising three young children and managing a household are more demanding and stressful for her than her job duties had been. There are endless plans to make and details to manage. Disorganization remains a problem, she says: "I've read every book on being organized, and I'm still not organized!" Her struggles with maintaining a household are raising doubts in her mind about her competence and taking a toll on self-esteem. After being diagnosed with ADHD, Predominantly Inattentive Type, Shay is able to make more sense of her behavior, sees solutions to her problems, and has gained a newfound sense of hope and optimism for the future.

Sharon's Story

Shay's sister, Sharon, is five years younger. Although the sisters are close, they grew up with very different interests and different circles of friends. Shay describes Sharon as highly distractible, impulsive, and forgetful. "She's a lot like me, but she's very hyper." Sharon lives with her boyfriend and is still trying to decide what career, if any, she wants to pursue. She went to three colleges over the course of six years, but quit in frustration after only earning two years worth of credits.

Sharon enjoyed the social aspects of school but ignored the academic side, according to Shay. She became involved with a heavy partying crowd during her sophomore year, and started drinking alcohol and smoking marijuana on a regular basis all through high school. Sharon was diagnosed with severe depression after dropping out of college and was treated with antidepressant medication. Her medication, along with the work of several different therapists, did not provide significant benefits for her. She went though an inpatient treatment program for substance abuse at age 24, but had a relapse shortly after. She continues to struggle with substance abuse problems. "I think she probably has ADHD," Shay guesses, "but nobody said anything to her about it."

Lost Opportunities, New Hopes

ADHD was not understood in its current definitions until publication of the DSM-IV diagnostic guidelines in 1994. When Buck and Barry grew up in the 1940s and 1950's, ADHD did not even exist as a concept. When Shay and Sharon attended school in the 1970's and 1980's, our understanding of ADHD was still very limited and focused primarily on hyperactive young boys. The availability of accurate diagnostic protocols and effective treatment methods was still many years away.

At age 63, Buck wonders what might have happened if he and his brother had been diagnosed and treated when they were growing up. Certainly the school failures and many of the behavioral and family problems might have been prevented. He wonders if Barry's short, troubled life might have been happier.

Shay also asks herself how her life might have been different if she knew 25 years ago what she knows today about ADHD. She might not have had to struggle so mightily in school, and perhaps would have made more of her education. Not being one to live in the past, she is now focusing her energies on helping herself in the present. Her newfound knowledge gives her the opportunity to learn how to manage her ADHD better, and to improve the quality of life for herself and her family.

In particular, Shay has strong concerns about her sister Sharon and has been discussing issues related to ADHD with her. How might things have been different if Sharon's suspected ADHD had been diagnosed and treated five years ago, along with her depression and substance abuse? Could the years of struggling, pain, and treatment failures have been averted? The question makes her angry, but she also realizes that there is still much Sharon can do to help herself. The ball is now in her sister's court.

Much remains to be done in furthering our knowledge base about ADHD and improving treatment options. When looking at the subject in a larger time perspective, however, it is almost startling to realize how rapidly advances have been achieved in knowledge and treatment. Brian's parents have options available to help him that were not available to help Shay and Sharon during their childhood, and were undreamed of for Buck and Barry in their childhood. Brian, and other children like him, are the fortunate ones. Adults with ADHD like Buck, Shay, and Sharon, although sometimes wondering "what if," also have new opportunities and many reasons to count their blessings.