Understanding Attention Deficit Disorder

Christopher Green is a specialist paediatrician, Head of the Child Development Unit at the Royal Alexandra Hospital for Children, Sydney and clinical lecturer at the University of Sydney. Over the last 15 years Dr Green has been prominent in introducing modern attitudes towards treatment of ADHD to Australia.

He is the well known author of two bestsellers books on childcare, Toddler Taming (1984, 1990) and Babies! (1988). Dr Green runs parenting seminars which reach over 20,000 Australians and New Zealand and United Kingdom parents every year. He is a presenter with Australia’s top-rating day-time television programme, the ‘Midday Show’ and has made a ten-part childcare series ‘Growing Pains’ for Granada Television, UK.

Chris is married to Hilary, a part-time general practitioner and full-time mum. They have two sons. When not working he enjoys sailing, swimming and outdoors Australia with his family.

Kit Chee is a paediatrician specialising in the behavioural and learning problems of children. She is honorary physician at the Royal Alexandra Hospital for Children, Sydney and consultant at the Sydney Learning Clinic.

Kit has a research interest in children’s learning, language, ADHD and the effect of stimulant medication. Kit is married to Arthur, also a paediatrician. Outside work every minute is taken up looking after her two young children, but she still finds time to enjoy classical music, the arts and exploring Sydney.

Important note

The author’s work is not intended to be exhaustive and matters of opinion are often expressed. This book describes conditions commonly presented and it is not intended that this work be substituted for the benefits obtained from the consultation with, and treatment by, a professional practitioner. Where drugs or prescriptions are referred to care should be taken to note same in conjunction with specifications issued from time to time by the relevant drug houses.

In this book there may seem to be an overuse of the word ‘he’. The truth is that ADHD mostly affects ‘hes’ and when it comes to extremes of behaviour, the ‘hes’ usually get the gold medal.

There is also a certain amount of repetition, with the same information appearing in different lists and chapters. We have aimed to create a book that is useful to those who don’t wish to read from cover to cover. For this reason each section is as complete as possible, but this has necessitated some duplication of text.

The authors believe the information contained in this publication to be accurate at the time of publishing, but emphasise that it is not intended that the work be a substitute for the individual professional opinion obtained from consultation with a qualified medical practitioner. Nor should parents or sufferers self-prescribe Medication or dosages. Where drugs or prescriptions are reffered to, care should be taken to note recommendations in conjuction with current and ongoing specifications issued by the relevant drug manufacturers.

A NOTE TO PARENTS

THE LAST FEW years have been an exciting time for our parent support groups. Enlightenment has now replaced the overwhelming ignorance of ADHD that was once so common. Parents, doctors and teachers have pushed knowledge of this important disorder into the limelight and British ADHD support groups have developed as a force to be reckoned with.

Despite this new understanding, an immense amount of pain and anger still surrounds the families of the sufferers, whether children, adolescents or adults. ‘Why so long?’ is a frequent question we hear from parents, dismayed that their child has suffered so very badly at the hands of misguided professionals.

From Cornwall to the Isles of Orkney, from the Isle of Wight to Northern and Southern Ireland, many hands now reach out to parents who have just discovered that their child has ADHD. The support groups distribute thousands of information packs and help parents find the short cuts to the best medical and educational help.

Families have now come together, united in their determination to get the best possible professional care for their children. Parents are asking for consistent, high quality, medical treatment and educational interventions that are appropriate to the needs of ADHD children. They want to receive the correct medical and educational help now, not intervention from the welfare services in the future. They want to put a stop to the put-downs and negativity that has previously surrounded these families.

Today’s children are tomorrow’s society and, as their parents, we are not prepared to let their attributes go to waste. Their talents cannot be overlooked, we must protect their self esteem and mental health.

The support groups are working hand in hand with parents and professionals to lay down better paths for our children and grandchildren. We do this for one reason, because we unashamedly love and want the best for our children.

Gillian Mead

President and founder member The ADD/ADHD Family Support Groups UK

FOREWORD

SINCE THE PUBLICATION of the first edition of this book there has been a great increase in awareness of ADHD in the UK. Parent groups and professionals have worked together to show that ADHD is an important yet under-recognised biological condition, affecting children’s mental health and educational progress.

Despite this there continues to be a great difference in the diagnostic and management approaches in North America, South Africa and Australia when compared to this country. Here traditional views have shown a reluctance to consider biological and genetic factors when addressing educational and behavioural problems in children. This has meant that thousands of children and families have failed to receive the help that they need. Accusations of inadequate parenting have frequently aggravated the situation and have served only to exacerbate parental guilt and low morale.

There continue to be misguided notions as to the nature and basic facts of ADHD. There is also a failure to appreciate that this is a genuine and sometimes severely distressing condition for those affected and their families. ADHD is too broad and too complex a disorder to be owned by any one professional group. it requires us to work together to achieve the best result for the child, with the most cost effective delivery of service.

Chris Green’s updated book comes as a breath of fresh air and provides essential facts and data on ADHD. Chris in his clear and easily readable style, helps untangle the various confusions and provides simple treatment strategies. In correcting many misguided notions Understanding ADHD will enable whole families and children to be helped more effectively. This new edition is most welcome.

Geoffrey D Kewley MB BS FRCP FRACP DCH

Consultant Paediatrician

Learning Assessment Centre

Horsham, Sussex

INTRODUCTION

TWO AND A half years ago the first edition of this book was published in London. Though it was initially met with some professional disbelief, parents knew what we were talking about. Throughout the promotion the interest was immense. One brief television appearance on Granada’s ‘This Morning’ resulted in seven thousand requests for information, a record response for that programme.

This demand for information has snowballed over the last two years and there is a new community awareness of the importance of ADHD. Now most professionals have accepted that ADHD is a genuine condition which causes clever children to underachieve at school and behave unexpectedly badly at home. With the current interest in ADHD, professionals and parents are wanting practical, up to the minute information on how to help these children and this major update aims to fulfil that need.

Understanding ADHD presents a clear overview of a far from simple condition. This new edition tries to emphasise that ADHD is not just about attention and over-activity, it is a four part problem. The first part concerns attention, memory and academic underachievement. The second, the active, impulsive, poorly controlled behaviours. Then there is a third part, the associated comorbid conditions (e.g. dyslexia, Oppositional Defiant Disorder, Conduct Disorder). These are not true parts of ADHD but in many children they add to the problem. The fourth part is the influence of the child’s living environment, where the child who is accepted and nurtured will do much better than those who are met with force, hostility and criticism.

There is still a lot we don’t know about the nature of ADHD, but despite this we must all pursue the same goal. To start when children are young and steer them towards adulthood with the best possible education, self confidence, useful life skills and intact family relationships. If we move away from highlighting controversy and focus on constructive help, the next decade will be a lot easier for these children and their stressed parents.

This book provides an easy to read text, full of well tried, practical suggestions, that work both in the home and classroom. For those who wish to take it further, the appendices at the end have additional information, such as summaries of the most recent research findings, current diagnostic criteria, parent/teacher questionnaires and where to get help.

It is unusual to undertake a major rewrite as early as two and a half years after a successful book is first published but we want to keep this information up with the most recent research. What you are about to read is a very personal, yet up to date, perspective of ADHD. There will be people who dispute some of our ideas. All we ask is that if you can relate to the text and it helps with a child in your care, please read on.

Christopher Green

Kit Chee

ONE

ADHD – The Facts

ATTENTION DEFICIT HYPERACTIVITY Disorder (ADHD) is not new: it was first described almost 100 years ago, and the beneficial effects of stimulant medication have been well known for over half a century.

Today when we talk about ADHD we refer to a slight but demonstrable difference in normal brain function that causes a clever child to underachieve academically and to behave poorly, despite receiving the highest standard of parenting. This cluster of behaviours was once called Hyperactivity, then Attention Deficit Disorder, and now Attention Deficit Hyperactivity Disorder.

With so much current interest in ADHD one might think that we are in the midst of an epidemic. But ADHD is occurring no more frequently than in the past – we have just become more skilful at recognising a very real condition that previously was missed and mis-diagnosed.

Despite our better knowledge of ADHD, many children still remain undiagnosed. Bewildered parents watch as their children underachieve at school and create immense tension in the home. Professionals are often equally unaware, some continuing to believe ADHD to be a trendy non-condition or a poor excuse for incompetent parenting.

A few of the old school of child psychiatrists still see ADHD as a sign of the dysfunction and troubled mind of the child’s parents. Fortunately, parent punishing is well on the wane with entrenched ideas being overtaken by science.

As ADHD is caused by a subtle difference in the normal brain, the seeds of ADHD are present at birth. The extent of the difficulty depends on the severity of the child’s problem and how well their behaviour and education are managed. We can’t change this inborn predisposition, but we can most certainly modify the home and school environment to help our children behave and achieve to their maximum potential.

The facts about ADHD

With so much misinformation still confusing today’s parents, let’s start this book by outlining the essentials of ADHD.

ADHD is a real condition which to some extent affects approximately 2 per cent to 5 per cent of all children.

The concept of ADHD is said to be controversial, but in the late 1990s there is controversy only in the media, not in reputable professional circles.

When the media describes some disastrous behaviour or criminal activity as typical of ADHD, they are misrepresenting the truth. ADHD, by itself, does not cause a child to be malicious or deliberately antisocial. The problems presented are severe Oppositional Defiant Disorder or Conduct Disorder. These can be associated with ADHD, but they are not a true part of the condition we describe.

ADHD is a biological, brain-based condition which is caused by a minor difference of fine tuning in the normal brain (a slight brain dysfunction).

The dysfunction of ADHD is thought to be due to an imbalance in the brain’s neurotransmitter chemicals, noradrenaline and dopamine. This imbalance is mostly found in those parts of the brain responsible for self-monitoring and putting the brakes on unwise behaviour (the frontal lobes and their deep connections, which are the basal ganglia circuits).

These areas of dysfunction are now being demonstrated by researchers who use the latest brain scanning techniques, Positron Emission Tomography (PET), and volumetric and functional Magnetic Resonance Imaging (MRI).

ADHD presents in two ways, impulsive, poorly self-monitored behaviour (referred to as hyperactive-impulsive behaviour) and in problems of attention, short-term memory and learning (attention deficit-learning weakness). A child may present with one of these in isolation, but most ADHD children have a mixture of both.

With age the active, impulsive behaviours tend to mellow, though the learning and organisational problems tend to linger on.

These behaviours and learning weaknesses are not exclusive to ADHD. They occur in all of us, but to a much lesser extent. To qualify for a diagnosis of ADHD, a child must be significantly out of step with others of the same developmental level and standard of parenting.

The cut-off point between a normal, but difficult, temperament and ADHD is not clearly definable in black and white. For a diagnosis of ADHD, six out of nine difficult behaviours should be present. (See Appendix I, The Criteria for Diagnosing ADHD (DSM-IV).) The child with four or five of these difficult behaviours may not fit the full criteria, but they will still be a handful to manage.

Factors in the child’s environment do not cause ADHD, but do affect its severity and outcome. A child with six difficult behaviours, who has an exceptional teacher and a saint for a mother, may not need to be treated for ADHD. The child with five out of nine characteristics officially does not qualify for diagnosis, but may come for treatment if they are being poorly managed in a non-coping home and school situation.

Diet is no longer seen as an important part of ADHD. A few children react adversely to some artificial and natural food chemicals. This can also occur in those who do not have ADHD. Food intolerance does not cause ADHD, though occasionally it makes it worse.

ADHD is a strongly hereditary condition. Most ADHD children have a close relative (usually male) affected to some degree by the same problem. Developmental Reading Disorder (dyslexia) which is often associated with ADHD is also a strongly hereditary condition.

ADHD is mostly a ‘boy’ problem. Boys are six times more likely to be referred for help than girls. It is suggested that the true ratio in the community is actually 3:1. Many girls remain undiagnosed as by nature they tend to be less disruptive and suffer more silently than the male of the species. They may not be referred to a clinic for bad behaviour, but they may still be failing at school.

ADHD is a long-term condition which affects learning and behaviour right through the school years. About 50 per cent of children will carry some of their ADHD with them into adulthood. With age ADHD tends to move away from the restless impulsive behaviours, towards those of inattention, inability to sustain work output, deficient short-term memory and frustration with learning. It is these residual features that cause most trouble to adolescents and adults with ADHD. The treatment of adult ADHD is an exciting success story in North America at this time.

It is believed that the incidence of ADHD is approximately the same in most countries and races. The rate of ADHD differs between areas depending on the level of professional vision or blindness. (See Appendix XV ADHD in other cultures.)

A few parents know their child is different from the moment the child is born or even when still in the womb. About half the parents say their child has been ‘non-stop and into everything’ from the moment they first walked.

Some preschoolers are incorrectly labelled as ‘hyperactive’. In fact they have no problem other than the normal ‘busyness’ and lack of commonsense one finds at this young age.

Most parents first suspect their ADHD child is out of step between the age of two-and-a-half and three years. However, due to the more laid-back, less demanding life of preschool, most of these children manage well until the first or second year of school.

A small minority of two, three and four year olds will present for treatment. At this age the behaviours that force us to intervene are low frustration tolerance, unpredictable outbursts, assaults on other children and suspension from preschool (see Chapter 18, ADHD in the Under-Fives).

Where ADHD is causing strife at a young age, this must be taken seriously. When parents find a three year old impossible to manage they lose confidence or become excessively punitive. The use of force, and hostile-critical parenting lead to resentment which sows the seeds for irretrievable relationship problems. If a difficult child finds early acceptance, nurture and support, this greatly reduces the risk of oppositional behaviour and other negative outcomes.

Teachers of ADHD children tell us that at school, ‘This child is distractable, disruptive and needs one-to-one supervision to achieve’. Teachers are confused when a clever child behaves poorly and underfunctions for intellect.

Playground problems are common as the child misreads social cues, ‘comes on too strong’, and overreacts to teasing. Sometimes teachers describe an ADHD child as ‘Known by all but liked by none’. This has immense implications for self-esteem.

Approximately half of the children who present with ADHD are also troubled by specific learning disabilities, for example dyslexia, Language Disorder or a weakness with mathematics. These are not caused by the ADHD but are associated or ‘comorbid’ conditions. The treatment of ADHD does not treat the specific learning disability, but it makes the child more receptive to remedial teaching.

At school the two parts of ADHD present in different ways. The hyperactive-impulsive, poor self-monitoring behaviours result in the child rushing through work, settling slowly after a break, tapping and fidgeting, calling out in class and failing to check work before it is handed in. The attention deficit learning problems affect organisation, getting started with work, listening skills, sustained work output, distractability and short-term memory.

Problems of short-term memory make memorising homework difficult. The information is locked in the night before but forgotten by the time of the test. Learning times tables is a particular hassle. The memory problems can cause a weakness in reading comprehension, where ADHD children forget what was at the beginning of the paragraph by the time they reach the end.

Most ADHD children present with a mix of the hyperactive-impulsive behaviours and attention deficit-learning problems. A surprisingly large number are now being diagnosed as ADHD – predominantly inattentive (ie having mostly problems learning). The extreme of this group, ADHD purely inattentive, are quiet, dreamy, slow moving, disorganised, inattentive and underachieving. They remain undiagnosed until about the age of 10 years, when self-motivation becomes vital for school success. They cause no behaviour concerns, they just ‘space out’ and sink silently.

Hyperactivity by itself is not a troublesome behaviour. In these hyperactive-impulsive children the difficulty comes from lack of impulse control and from incessant demand. It is not activity that makes them so unpredictable and hard to handle.

ADHD children are sought out by school bullies as they overreact to taunting. Though they did not start the incident, they are blamed for the fight that follows.

Poor impulse control leaves the ADHD child both physically and verbally accident-prone. They frequently trip, fall, act stupid and put their ‘feet in their mouth’. ADHD children nag at and demand of their parents from dawn to dusk. This incessant pressure generates great tension.

Most ADHD children have the social and emotional maturity of a child two-thirds their age. Lack of emotional understanding, independence and commonsense are frequent complaints.

Professionals are taught that poor parenting causes a child to develop bad behaviour. In ADHD it is the difficult child that makes good, competent parents appear inadequate.

Fathers are generally more effective in managing the ADHD child than are mothers. They are not a superior parent, they just have a louder voice and are less exploitable because they are not so often at home.

ADHD is a strongly hereditary condition. When it affects a parent, management of their own ADHD child may not be calm and considered. As mothers still tend to provide the consistent structure of most homes, behaviour management may be easier if the ADHD-affected parent is the father, not the mother.

Treatment of ADHD involves behavioural advice, support at school and the use of stimulant medication.

ADHD children act before they think, do not consider the implications of a sequence of events and are less satisfied with rewards. This makes the behavioural techniques that work so well on our other children much less effective when used on those with ADHD. As nothing seems to work parents often pull back on discipline, and this is then incorrectly blamed for causing the difficult behaviour that made the parents pull back in the first place.

Any behavioural expert who recommends a standard behaviour program or suggests a parent effectiveness course, probably has little experience with the management of ADHD.

Stimulant medication is pivotal in the treatment of ADHD. A major multi-centre study underway in North America is currently looking at the relative benefits of various combinations of medical, educational and psychological treatments for ADHD. Rumours at this stage suggest that without first priming with medication, most of the other techniques are relatively ineffective. Stimulants help a child to focus, listen and be reached. You have to reach before you can teach.

The benefits of stimulant medication are often misrepresented in the media and by misinformed professionals. When stimulant medication is used correctly it is both safe and remarkably free from side-effects. It is without doubt the single most effective form of therapy available for ADHD (see Appendix XVI, Recent Review Papers).

The stimulants Ritalin and dexamphetamine have been used for 40 years. At the last count there have been over 155 controlled trials which show their benefits and safety (see Spencer et al. 1996 in Appendix XVI). Between 80 per cent and 90 per cent of children with significant ADHD will be helped in the short term by one of the stimulants. Long-term benefits are presumed but as yet unproven.

Stimulant medication may be a relative of amphetamine, but it does not cause the ADHD child to substance-abuse or become addicted. Medication brings the unfocused child into full-focus reality. You don’t get addicted to reality.

Natural remedies are often promoted as safer than stimulants and equally effective in the ADHD child. These have not been subjected to the same scientific trials and safety checks that would be required for a medication. Because a product comes from a plant does not mean it is safe. Opium, digitalis, magic mushrooms and tobacco are all natural substances.

Medication is only given after a full explanation and the informed consent of the parents. If there is ever any doubt about benefits or any worrying side-effect, the parents must stop the preparation at once and talk to those who prescribed it. Parents are in charge, not doctors.

With any medical treatment the benefits must be carefully balanced against all potential risks. Critics of medication quote the obscure, small print side-effects but do not mention the major risk of failing to treat. Every year impulsive, unthinking ADHD children are injured or killed needlessly in accidents. Countless families of untreated children fall out of love with the difficult child and these wrecked relationships may never heal.

Oppositional Defiant Disorder (ODD) is a comorbid condition found in 40 per cent to 60 per cent of children with ADHD. The ADHD child acts impulsively, without thought, and is remorseful after the event. The ODD child is openly hostile and may show no regret. When ADHD and ODD exist together treatment will be much more difficult. The behaviours of ODD do not respond to stimulants nor to any other medication.

The ADHD child is not deliberately difficult, they just act before they think. Successful parents make allowances but still ensure that children with ADHD know they are responsible for their own actions. ADHD is an explanation, it is not an excuse.

ADHD needs to be taken seriously. It is no longer good enough for parents, psychologists, teachers and paediatricians to pretend it is a trivial non-condition. Whatever means we use, our aim should be to help these children enter adulthood with the best education, esteem, and life skills that are possible. It is also vital to keep family relationships intact. If we miss out here, all the rest of our efforts are pretty pointless.

TWO

ADHD – An Old Condition Rediscovered

ADHD HAS BEEN heavily promoted recently in the popular press. Although it has now become the behavioural ‘flavour of the month’ it is not a new condition. Churchill, Einstein and some of the most influential people of all time had one thing in common: they channelled their ADHD activity, drive and single-mindedness to achieve greatness.

The history of ADHD

ADHD was first described almost 100 years ago. Some of the earliest work was done by a famous English paediatrician, George Still. He remains a respected father figure who is now remembered, not for his work on ADHD, but for his classic description of arthritis in children, which continues to be called Still’s disease.

Others had seen these behaviours some years before, but it was Still who in 1902, was the first to recognise and describe the condition. He noticed a group of his patients, mostly boys, had difficult behaviours which had started before the age of eight. Most were inattentive, overactive and were different from other children in their resistance to discipline.

Still described these children as having a poor control of inhibition, being full of aggression and, in his Victorian language, suffering from ‘A lack of moral control’. Still saw this as a chronic condition, biological (inborn) in nature and not caused by poor parenting or adverse environment. What George Still described at the turn of the century is probably what would nowadays be called ADHD with Oppositional Defiant Disorder (ODD) or Conduct Disorder (CD).

It is interesting to note that at this time the United Kingdom led the world in its understanding of ADHD. Unfortunately, as the twentieth century moved along, British researchers became preoccupied with a more psychoanalytical style of psychiatry, which left the job of sorting out ADHD to the North Americans.

ADHD and brain damage

Interest in ADHD came next in the wake of the great influenza epidemic of 1918–19. This epidemic killed over 20 million people worldwide, and its associated encephalitis (an inflammation of the brain) left many people neurologically impaired. Some of these people went on to develop Parkinson’s disease (as described in the film Awakenings, starring Robin Williams), while others showed immediate signs of disinhibition and dysfunction that had some similarities to the problems first described by Still. From this experience, ADHD was now seen as being the result of brain damage.

It was a long time before this injured brain idea lost favour and research returned to the inbuilt, biological nature initially suggested by Still.

Stimulants and ADHD – a chance finding

In 1937 a group of behaviourally disturbed in-patients were subjected to an unorthodox treatment. They were given the drug amphetamine and to everybody’s surprise their difficult behaviours improved. It took almost another 20 years before stimulant medication became widely used, but this chance finding was to greatly influence the direction of future treatment.

Minimal Brain Damage – Minimal Brain Dysfunction

Researchers in the 1950s and 1960s began to realise that most of these ADHD children had never suffered any brain damage. They softened the name from Minimal Brain Damage to Minimal Brain Dysfunction (MBD). This implied that the brain was effectively normal, but there was some subtle malfunction which accounted for the behaviours.

Paediatricians then became obsessed with hunting for minor neurological differences. Until relatively recent times much of the assessment of ADHD consisted of looking at the flow of movement in the fingers, the dominance of eye, foot and hand and a multitude of other trivial tests. This form of assessment is still popular in some centres, but most have moved on from this unhelpful preoccupation with ‘soft neurological signs’.

Minimal Brain Dysfunction was never a satisfactory term, but at least it implied that ADHD was made up of a cluster of behaviours and it placed the blame on the brain, rather than the parents.

Hyperkinesis and Hyperactivity

During the time when the term Minimal Brain Dysfunction (MBD) was being used, other medical professionals were starting to look at specific behaviours. In the early 1960s the Hyperactive Child Syndrome was first described. The symptoms were somewhat unclear, but the condition was seen as being part of the child’s individual make-up and not caused by brain damage. Through the 1960s and 1970s the terms MBD and Hyperactivity were both used, Hyperactivity being the name that caught the attention of the public and the press.

Hyperactivity and the Feingold Diet

Dr Ben Feingold, a former Professor of Allergy in San Francisco, first suggested a relationship between diet and Hyperactivity in 1973. He claimed that the reported rates of Hyperactivity were increasing in proportion to the number of additives which legally polluted our food. Feingold was quickly championed by the press and such was the overreaction, the American government was obliged to set up committees, and detailed research projects, to investigate the claims.

Feingold believed that 50 per cent of Hyperactive children might be helped by his diet. When the results of carefully controlled trials were analysed, it appeared that no more than 5 per cent of these children were adversely affected by food. (See Chapter 13 for an up-to-date overview of diet and ADHD.)

These years of obsessive interest in diet distracted professional attention from the complex package of problems that made up ADHD, and from the already proven benefits of stimulant medication.

Stimulants – in and out of fashion

The beneficial effects of stimulant medication have been well known for over half a century. The benefits of amphetamines were clearly documented in the late 1930s, but stimulants were not widely used until the late 1950s and 1960s. The main breakthrough came with the introduction in 1957 of a new stimulant, methylphenidate (Ritalin), and in the next decade many carefully controlled studies showed that stimulants were both safe and effective.

The use of stimulants increased rapidly, impeded only by the occasional media panic. In one early 1970s article, which is still often quoted, the rate of prescribing was misrepresented by 10 times its correct level. This media misinformation helped the sale of newspapers but it also frightened parents from a form of therapy that for some would have revolutionised their relationship with their children.

The greatest assault on stimulants was made in the late 1980s from an unexpected source, the Church of Scientology. This organisation sent press releases to the media through its lobby group ‘the Citizens’ Commission on Human Rights’. Most of their activities took place in the United States, but the group’s actions also affected many families elsewhere.

Newspapers and radio stations were quick to transmit the Commission’s dramatic claims. Ritalin, it was asserted, was a dangerous and addictive drug, often used as a chemical straitjacket to subdue normally exuberant children because of intolerant educators, parents and money-hungry psychiatrists. Ritalin could result in violence, murder, suicide, Tourette syndrome, permanent brain damage, emotional disturbance, seizures, high blood pressure, confusion, agitation and depression. Great controversy was said to exist among the scientific and professional communities concerning the use of medication (see R.A. Barkley, Attention Deficit Hyperactivity Disorder, A Handbook for diagnosis and treatment, Guilford Press, New York, 1990).

This unexpected assault by a religious subgroup set back the appropriate treatment of ADHD by years. Parents believed what they read in the press and refused to put their children on the medication. Even worse was the attitude of many top educationalists, psychologists, psychiatrists, paediatricians and policy-makers. They were swayed by what they saw in the media rather than reviewing the numerous studies in the scientific literature.

It was only at the start of the 1990s that a country such as Australia was able to shake off these antistimulant attitudes. In the meantime, thousands of children had been prevented from receiving the treatment they needed.

Parents must still be on their guard as even today press releases and ‘letters to the Editor’ continue to come from Scientologists with antimedication attitudes.

From Hyperactivity to Attention Deficit Hyperactivity Disorder

In the early 1970s a Canadian, Virginia Douglas, promoted the view that attention deficit was a more important symptom than hyperactivity. By the end of the 1970s her publications were so impressive that the American Psychiatric Association in 1980 used the term ‘Attention Deficit Disorder’ in their diagnostic and statistical manual (DSM-III). In 1987 the American Psychiatric Association put out DSM-III-Revised, which now talked of Attention Deficit Hyperactivity Disorder. In 1994 the Association released its latest classification DSM-IV, which describes Attention Deficit Hyperactivity Disorder (ADHD) without active, impulsive behaviours; ADHD with active, impulsive behaviours; and ADHD with a combination of both. Many parents, teachers and legislators now use the popular term ADD, but to be strictly correct this condition should be referred to as ADHD.

Conclusion

In this century, our definition of ADHD started with Still’s cluster of behaviours which were of biological (inborn) origin and had a poor prognosis. This was followed by a time of presumed brain damage. Next all the focus was on hyperactivity. Then diet seemed all-important in a condition that was believed to resolve itself before high school age. The current definition describes a cluster of inbuilt behaviours of which inattention is paramount and impulsivity and overactivity are usual. The problems are long term and symptoms often continue into adulthood. Medication is now accepted as an important part of therapy.

We have come a long way, but ADHD remains a highly variable, complex and imprecisely defined condition. The danger for today’s parents and professionals is to become lost in the uncertainties, rather than focusing on what we know to be true and using this information to help our children.

THREE

ADHD – The Cause

RESEARCHERS STILL DISAGREE on the exact cause of ADHD, but two things are certain. First, it is an hereditary condition. Second, the problems of ADHD result from a subtle difference in the fine tuning of the brain.

Most of the current debate centres around the exact nature of this brain difference. Some doctors see ADHD as a part of the normal spectrum of temperament, but the majority believe that it is a syndrome which is separate from temperament. Most researchers now believe that it is due to the underfunctioning of those areas of the brain that put the brakes on unwise behaviour, the frontal lobes and their close connections, the basal ganglia circuits. In addition to this, there seems to exist an unusual imbalance in the message-transmitting chemicals of the brain, the neurotransmitters.

Whatever the rights and wrongs of these theories, two old ideas have certainly outlived their day: this condition is definitely not caused by diet or by poor parenting.

Heredity/genes and ADHD

When we look carefully at families in our practice, we notice most children with ADHD seem to have a close relative with a similar problem. Often we see a father who found his early school years difficult or who underfunctioned academically for his abilities. Some of these adults have done well in life but are still restless, inattentive, and fitted with a dangerously short fuse.

There is good research evidence to prove this genetic influence. Identical twins are created sharing the same genetic material. If one twin suffers ADHD, research shows an almost 90 per cent chance the other will also have this problem.

Unidentical twins have the same risk of ADHD as the brother or sister of any ADHD child. The risk between siblings is somewhere between 30 per cent and 40 per cent depending on who you believe. These are high figures when compared with a rate of ADHD in the general population which is somewhere between 2 per cent and 7 per cent. An ADHD child of a parent with both ADHD and dyslexia often inherits both the attentional and reading problems.

There is no doubt that genes play an important part in the inheritance of both ADHD and specific learning disabilities, but why one child in a family inherits and another does not, remains a mystery.

The brain difference

In this noisy world, most of the unimportant messages that come into the brain are screened out at a low level without ever reaching the attention of ‘middle management’. Important information is taken in and looked at by the specialist parts of the brain, which interact together to give a properly coordinated response. Finally, the chief executive (frontal lobe) takes an overview of the middle management decisions, approving or disapproving on the grounds of appropriateness, priorities, future implications and their effect on others.

In the ADHD child’s brain it seems that the information rushes in without much filtering, which leaves the television screen of the mind in a bit of a buzz. The information is integrated, but action is often taken before the chief executive has approved the decision.

This is an oversimplification of a complicated process, but there is no doubt that these children do become distracted with too much competing stimulation and they tend to respond without giving proper consideration. Though the research emphasis is all on frontal lobes and the basal ganglia circuits, it is probable that many other areas of the brain are also involved.

Brain research in ADHD

At present the main research interest is in four areas: assessing frontal lobe function (the seat of executive control); investigating areas of under- and overfunction (SPECT, PET and functional MRI scans); measuring levels of activity; and studying the message-transmitting brain chemicals (neurotransmitters).

Assessing frontal lobe function – neuropsychology

A more specialised breed of psychologists, the neuropsychologists, are constantly developing ways to study the subtle workings of the brain. One area of special interest is the executive control which resides in the frontal lobes.

Most knowledge of this part of the brain comes from studies of adult accident victims. When their frontal lobes have been injured, they may respond to situations without proper consideration. Most of the tests of frontal lobe function focus on ‘response inhibition’, ‘planning’ and ‘mental flexibility’, as these seem to be the hallmark of problems in the frontal lobe.

In testing, the child is bombarded with a flood of distracting information, and in the midst of this they are repeatedly challenged to see if they will make a considered, not reflex, response. The ADHD child shows a weakness in knowing when to react, when to hold back and when to modify their response.

This poor performance in response inhibition, planning and mental flexibility confirms a weakness in frontal lobe function. Children who have ADHD without the hyperactive-impulsive behaviours, the ‘inattentive only’ group, have this same weakness and, on top of this, their speed of processing information is very slow. These dreamy ADHD children have frontal lobe dysfunction and also show ‘slow moving cogs’ in their brain.

Brain imaging

SPECT and PET Until recently medical methods of imaging the brain did little to help us understand ADHD. Skull X-rays showed problems in the skull bones but not the brain. Routine CAT (Computer Axial Tomography) scans showed the anatomy in detail, but in ADHD the brains were essentially normal.

In the late 1980s two exciting new developments arrived, firstly Single Photon Emission Computed Tomography (SPECT) and then Positron Emission Tomography (PET scans). These techniques assess the level of activity in the various parts of the brain, where they show function rather than anatomy (see also Appendix IX).

The SPECT measures blood flow to different parts of the brain and emits much less radiation than a PET scan. In the PET scan a sugar is tagged with a radioactive marker and injected into the body. The sugar accumulates in the areas of the brain that are doing most of the work, which ‘light up’ with high levels of the tagged radioisotopes.

Due to the amount of radiation used and the expense, these scans are not routinely used in children with ADHD, but research scans have come up with some fascinating findings:

The frontal lobes and their close connections are found to underfunction in ADHD.

The areas of the brain that collect auditory and visual input seem overloaded in ADHD, suggesting that they are being bombarded by a lot of unnecessary, inappropriate information.

When stimulant medication is administered, the ADHD difference seen in the brain scan can be largely reversed. This exciting finding shows that the effects of stimulant medication are certainly no figment of the imagination; they normalise the brain difference that is presumed responsible for ADHD. (See Appendix XV for details of studies)

MRI scans The Positron Emission Tomography (PET) and Single Photon Emission Computed Tomography (SPECT) studies had their limitations, due to the levels of radiation. Researchers have recently moved to the techniques of volumetric and functional Magnetic Resonance Imaging (MRI). These give out little radiation and the hard copy of the MRI picture can be assessed impartially by experts around the world. Volumetric MRI is not cheap, with about 30 hours of labour needed to measure each scan.

In ADHD each volumetric MRI scan is measured in minute detail. These studies will reliably pick up about 70 per cent of ADHD children due to a slight asymmetry in their frontal area and a constant difference in the caudate nucleus (part of the basal ganglia circuits). (See J. Rapoport.)

1902	Clear description of ADHD behaviours.Not caused by brain damage or poor parenting.
1930s	Brain damage causes ADHD behaviours.
1937	Stimulant medication first used.
1950s, 1960s	Now believed to be a brain dysfunction ‘Minimal Brain Dysfunction’. Psychoanalytical child psychiatrists see ADHD In terms of parent and environment problem (for some this attitude continued until the 1990s).
1957	Methylphenidate (Ritalin) Introduced.
1960–70	The ‘Hyperactive Child Syndrome’ becomes popular. Ritalin widely used and many research papers on stimulants.
1970–75	Inaccurate media claims raise concerns with medication. Feingold Diet becomes popular.
1975–80	Medication regains considerable popularity.
1980	American Psychiatric Association uses term ‘Attention Deficit Disorder’ (DSM-III).
1987	American Psychiatric Association uses term ‘Attention Deficit Hyperactivity Disorder’ (DSM-IIIR). Antimedication campaign misleads many parents and professionals.
1990	Positron Emission Tomography (PET scan) show significant difference in function between the ADHD brain and the non-ADHD brain.
1994	American Psychiatric Association redefines ‘Attention Deficit Hyperactivity Disorder’ DSM-IV.
1997	ADHD seen as an interplay of four factors: attention and learning; impulsive, poorly controlled behaviours; the presence or absence of comorbid conditions; nurture or hostility or the child’s environment.

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First published in 1995 by Vermilion, an imprint of Ebury Publishing This revised edition published by Vermilion in 1997

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Copyright text © Dr Christopher Green, 1994, 1997 Copyright illustrations © Roger Roberts, 1994, 1997

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