Skip to main content
NCBI home page
The BMJ logoLink to The BMJ
. 1998 Oct 31;317(7167):1250. doi: 10.1136/bmj.317.7167.1250b

Attention deficit hyperactivity disorder in children

Child psychiatrists should help parents with difficult children, not blame them

David Bramble 1
PMCID: PMC1114175  PMID: 9794878

Editor—Kewley reviews the current poor service provision and professional understanding of the group of disorders subsumed by the diagnostic category “attention deficit hyperactivity disorder.”1 Orford suggests in her accompanying commentary that the current nosological status of the disorder ignores important aetiological factors.

Her notion—that some underlying unspecified early emotional trauma is responsible for core symptoms of attention deficit hyperactivity disorder—must be challenged. As Kewley points out, the accumulating evidence that the disorder is primarily a genetically determined neurodevelopmental condition is extremely convincing. Orford’s view that early abuse and trauma later manifest as symptoms and that the detection of these symptoms in children clearly illustrates early trauma is a prime example of the logical fallacy that underpins all psychoanalytical theory and practice. There is no convincing empirical evidence to support her assertion that psychoanalytical psychotherapy is often effective since it addresses the original emotionally traumatic experience. In sharp contrast, as Kewley states, the evidence base for the efficacy of psychostimulant treatment in moderate to severe forms of attention deficit hyperactivity disorder is beyond any reasonable doubt. Moreover, this treatment can help to make more effective other modalities of treatment that by themselves are usually ineffective (family therapy, individual psychotherapy, and special educational provision).

Theory and practice derived from psychoanalysis have been extremely influential in child psychiatric training until the recent adoption of evidence based practices. This fact has helped to explain why many families with children who have attention deficit hyperactivity disorder still experience so much difficulty in finding child psychiatrists who can actually help them rather than effectively blame them for their children’s extreme difficulties. My recent survey finding that nearly half of Britain’s child psychiatrists do not use psychostimulant treatment in their current practice shows that there is still a pressing need to improve standards of care in this area.2

References

  • 1.Kewley GD. Personal paper: Attention deficit hyperactivity disorder is underdiagnosed and undertreated in Britain. [With commentary by E Orford.] BMJ. 1998;316:1594–1596. doi: 10.1136/bmj.316.7144.1594. . (23 May.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Bramble D. Psychostimulants and British child psychiatrists. Child Psychol Psychiatry Rev. 1997;2:159–162. [Google Scholar]
BMJ. 1998 Oct 31;317(7167):1250.

Benefits of adding other forms of treatment to medication remain unclear

Anne Klassen 1, Parminder Raina 1, Anton Miller 1, Shoo Lee 1

Editor—We need evidence to support the efficacy of combination treatment for attention deficit hyperactivity disorder. Kewley, in his paper on the disorder, concludes that drugs have an essential role when combined with educational, psychological, and other strategies as appropriate.1-1 This reflects the prevailing consensus among clinicians, but it is important to bear in mind the sparseness of evidence in the literature to support the efficacy of adding other modalities of treatment to drugs. Some research has shown a relative benefit in combining psychological and behavioural strategies with drug treatment,1-2 but other research has found no added benefit,1-3 and several experimental studies point to the major effect in combined interventions arising from the medical rather than the psychological and behavioural component.1-2,1-4

We have recently completed a systematic review of the evidence of the efficacy of stimulant drugs in relation to each other, and in relation to psychological and behavioural treatment and combined forms of treatment for children and youths with attention deficit hyperactivity disorder.1-5 Some of the obstacles in the literature facing those who would like to base treatment decisions on research evidence include the relative paucity of intervention studies other than studies of drug treatment and heterogeneity of various kinds that exist in the literature in relation to the disorder and its treatment, particularly in subject selection, control conditions, specific interventions, and the choice of outcome measures. The need for standards in intervention studies in attention deficit hyperactivity disorder and for carefully controlled prospective studies is clear. From the current published literature, there is abundant evidence of the clinical efficacy of psychostimulant drugs in controlling the core symptoms of the disorder and normalising behaviour, but the relative benefits of adding other modalities of treatment to drug treatment for the disorder remain unclear.

References

  • 1-1.Kewley GD. Personal paper: Attention deficit hyperactivity disorder is underdiagnosed and undertreated in Britain. [With commentary by E Orford.] BMJ. 1998;316:1594–1596. doi: 10.1136/bmj.316.7144.1594. . (23 May.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 1-2.Gittelman R, Abikoff H, Pollack E, Klein DF, Katz S, Mattes G. A controlled trial of behavior modifications and methylphenidate in hyperactive children. In: Whalen C, Henker B, editors. Hyperactive children: the social ecology of identification and treatment. New York: Academic Press; 1980. pp. 221–246. [Google Scholar]
  • 1-3.Abikoff H. An evaluation of cognitive behavior therapy for hyperactive children. Adv Clin Child Psychol. 1987;10:171–216. [Google Scholar]
  • 1-4.Pelham WE, Carlson C, Sams S, Vallano G, Dixon MJ, Hoza B. Separate and combined effects of methylphenidate and behavior modifications on boys with attention deficit-hyperactivity disorder in the classroom. J Consult Clin Psychol. 1993;61:506–515. doi: 10.1037/0022-006X.61.3.506. [DOI] [PubMed] [Google Scholar]
  • 1-5.Klassen A, Miller AR, Lee SK, Raina P, Olsen L. Relative efficacy of interventions for attention-deficit/hyperactivity disorder: can meta-analysis help? Pediatr Res. 1998;43:13A. [Google Scholar]
BMJ. 1998 Oct 31;317(7167):1250.

Danger is one of overdiagnosis

M S Thambirajah 1

Editor—Kewley’s paper on attention deficit hyperactivity disorder is misleading and inaccurate.2-1 It exemplifies an increasingly used approach to diagnosis and treatment of psychiatric disorders in childhood. Hyperkinetic disorder is a clinical diagnosis based on current and past biopsychosocial factors. It is not and should not be reduced to a count of symptoms made from a checklist. In the absence of objective tests, the symptom cluster of impulsivity, inattention, and hyperactivity needs to be subjected to differential diagnosis in the time honoured medical tradition. The lack of mention of causes of inattentive and hyperactive behaviour other than attention deficit hyperactivity disorder is a major failing of the paper. Early traumatic experiences, attachment disorders, current abuse, neglect, and maternal depression can lead to symptoms of attention deficit hyperactivity disorder as all clinicians know.2-2 By ignoring the history, current experiences, and other psychosocial factors the paper takes the problem out of context and chooses a cookbook approach to diagnosis and treatment of childhood problems that is risky and dangerous.

In the case of attention deficit hyperactivity disorder there are dangers in extrapolating from epidemiological studies. These surveys rely on checklists of symptoms and rating scales to make a diagnosis of the disorder. Tests of attention have consistently failed to show appreciable impairment of attention. These studies ignore past experiences of the child and current psychosocial factors. Overreliance on symptom clusters leads inevitably to overestimation of prevalence. Studies that depend exclusively on rating scales have reported rates as high as 15%. Hence care has to be exercised when conclusions are made on the basis of such estimates. Blind application of ICD-10 or DSM-IV criteria to a group of children in the care system, for example, is bound to produce high prevalence. I wonder whether the overzealous exponents of attention deficit hyperactivity disorder would treat these children with early trauma with stimulants.

Little evidence of specific brain dysfunction has been shown in children with the disorder. Functional brain imaging studies have been on small samples, and experts in the field have been cautious in their interpretation.2-3 It seems disingenuous to refer to one’s own book written for parents to support the idea of brain dysfunction. The question of what is being inherited, a trait or a disorder, is open to debate.

Most child psychiatrists in the United Kingdom would agree that hyperkinetic disorder is a small subgroup within the syndromal definition of attention deficit hyperactivity disorder and that children with this tightly defined disorder may need treatment with stimulants after other conditions have been excluded. The real danger at the moment is the attempt to broaden the definition, diagnose the condition using symptom checklists and rating scales to the exclusion of psychosocial factors, and treat it with drugs. This would be the equivalent of calling all four legged animals with a tail donkeys.

References

  • 2-1.Kewley GD. Attention deficit hyperactivity disorder is underdiagnosed and undertreated in Britain. [With commentary by E Orford.] BMJ. 1998;716:1594–1595. doi: 10.1136/bmj.316.7144.1594. . (23 May.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2-2.Haddad P, Garralda ME. Hyperkinetic syndrome and disruptive early experiences. Br J Psychiatry. 1992;161:700–703. doi: 10.1192/bjp.161.5.700. [DOI] [PubMed] [Google Scholar]
  • 2-3.Tannock R. Attention deficit hyperactivity disorder: advances in cognitive, neurobiological and genetic research. J Child Psychol Psychiatry. 1998;39:65–69. [PubMed] [Google Scholar]
BMJ. 1998 Oct 31;317(7167):1250.

Multidisciplinary approach to management is needed

Andrew Weaver 1

Editor—Kewley’s paper on attention deficit hyperactivity disorder and Orford’s response seemed to reflect the age old debate about biological versus psychological factors in mental illness.3-1 Kewley asserts that attention deficit hyperactivity disorder is a genetic, inherited condition and cites carefully selected articles to support his belief that it is caused by brain dysfunction. In her commentary Orford’s argument is that forgetfulness and poor concentration in a child can result from several causes, many of them psychological. She is critical of the current diagnostic criteria as being simply a list of symptoms, forgetting perhaps that our understanding of sickness has traditionally developed from categorising ill health in such a way.

Kewley has overstated his case. Evidence from twin studies that attention deficit hyperactivity disorder has a genetic component does not mean that it is inherited in all cases. An almost identical clinical picture can be found in children who have had disruptive early experiences.3-2 A more realistic theory is that the disorder is multifactorial; in some cases biological and genetic factors seem relevant whereas in others psychosocial issues are paramount. In the future it may even be necessary to refer to a range of attention deficit disorders once aetiological mechanisms are more clearly understood.

Drug treatment can be very effective but this does not necessarily imply that it is needed in all cases. More importantly, perhaps, there is as yet no evidence that treating the symptoms with stimulants reduces the likelihood of conduct disorder in adolescence or adult life.3-3 Kewley also dismisses psychosocial approaches as being equivalent to blaming the parents despite the fact that counselling for parents, educational advice, and behavioural therapy are valuable aspects of a comprehensive treatment package.

The child mental health team in which I work is, like many others, seeing increasing referrals of “possible attention deficit disorder.” We regularly meet parents who have read books on the subject or downloaded information from relevant websites. I would therefore hesitate to suggest to my colleagues that the disorder is underdiagnosed and undertreated. The parents, struggling to manage a child with difficult behaviour, are hoping that we will automatically prescribe drugs. Many of them are surprised when we inform them that methylphenidate is an amphetamine. Our response to the demand has been to provide a comprehensive assessment supplemented by the use of detailed questionnaires.3-4 We look for biological, psychological, and environmental precipitants and offer several interventions including drugs. Orford emphasises the need for a greater refinement of the diagnostic criteria. I believe that a multidisciplinary, multiagency approach to assessment and management is even more important.

References

  • 3-1.Kewley GD. Personal paper: Attention deficit hyperactivity disorder is underdiagnosed and undertreated in Britain. [With commentary by E Orford.] BMJ. 1998;316:1594–1596. doi: 10.1136/bmj.316.7144.1594. . (23 May.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3-2.Haddad PM, Garralda ME. Hyperkinetic syndrome and disruptive early experiences. Br J Psychiatry. 1992;161:700–703. doi: 10.1192/bjp.161.5.700. [DOI] [PubMed] [Google Scholar]
  • 3-3.Barkley RA, Fischer M, Edelbrock CS, Smallish L. The adolescent outcome of hyperactive children diagnosed by research criteria: an 8 year prospective follow up study. J Am Acad Child Adolesc Psychiatry. 1990;29:546–557. doi: 10.1097/00004583-199007000-00007. [DOI] [PubMed] [Google Scholar]
  • 3-4.Achenbach TM. Manual for the child behavior checklist. Burlington, VT: University of Vermont Department of Psychiatry; 1991. [Google Scholar]
BMJ. 1998 Oct 31;317(7167):1250.

Author’s reply

Geoffrey D Kewley 1

Editor—Bramble’s survey compares with the findings of my 1993 study—of lack of recognition of the condition and consequent underprescribing by child care professionals.

Klassen et al emphasise the importance of drug treatment. In Britain, however, evidence based management is hampered by a predominantly psychosocial approach. Symptoms must be viewed in the context of impairment, not just an epidemiological cut off point. Common late diagnosis with progressive comorbidity requires multiple interventions.

Thambirajah erroneously equates hyperkinetic disorder with attention deficit hyperactivity disorder. The wide variation and complexity require experienced comprehensive multiprofessional assessment, not reliance on checklists or questionnaires.

Haddad and Garralda’s article quoted by Thambirajah and Weaver to substantiate that early traumatic experiences cause symptoms is anecdotal and unscientific. Literature showing that early traumatic experiences cause—rather than aggravate—core symptoms is sparse. Most such studies do not consider attention deficit hyperactivity disorder. My own book contains an extensive research bibliography.

The real danger is not carefully broadening the definition. Many children’s difficulties are currently overlooked. Research indicates that impulsiveness—not hyperkinesis—is the key problem in the disorder. Thambirajah correctly asserts that the disorder is heterogeneous. Clinical experience shows that conduct disorder can be medically treated. Awaiting all the answers should not prevent treatment.

Although inattentiveness is a trait in the normal population, this and other symptoms of attention deficit hyperactivity disorder can cause severe impairment. Thambirajah and Weaver’s comments underappreciate the difficulty and distress caused. Often psychosocial approaches focus solely on presumed psychoanalytic reasons connected with parenting or emotions. These approaches are ineffective without an awareness of the condition. Twin studies support a strong genetic basis to attention deficit hyperactivity disorder,4-1 with environmental factors contributing little. A multidisciplinary approach ignoring biological issues is unhelpful and cost ineffective. Weaver’s comment that he informs parents that methylphenidate is an amphetamine is alarming. Methylphenidate is a sympathomimetic amine with no evidence of long term addiction.4-2 Children with untreated attention deficit hyperactivity and conduct disorder are more prone to substance misuse.4-3

At the Royal College of Physicians in 1902 George Still urged recognition of a group of children with possible biological deficit of moral control and behavioural inhibition.4-4 Psychosocial and psychoanalytical interventions in the United Kingdom have heavily influenced approaches since. Bias and ignorance allow patchy provision of unsatisfactory services. A government inquiry is needed to provide evidence based guidelines for the medical profession, education services, psychologists, and social services.

References

  • 4-1.Barkley RA. Gene linked to ADHD verified. The ADHD Report. 1998;6:1–5. [Google Scholar]
  • 4-2.Rosenberg D, Holttum J, Gershon S. Textbook for pharmacotherapy for child and adolescent psychiatric disorders. New York: Brunner/Mazel; 1994. [Google Scholar]
  • 4-3.Biederman J, Faraone S, Mick E, Faraone SV, Weber W, Curtis S, et al. Is ADHD a risk factor for psychoactive substance abuse disorders? J Am Acad Child Adolesc Psychiatry. 1997;36:21–29. doi: 10.1097/00004583-199701000-00013. [DOI] [PubMed] [Google Scholar]
  • 4-4.Still GF. The Goulstonian lectures on some abnormal psychical conditions in childhood. Lectures 1, 2 & 3. Lancet. 1902;1:1008–1012. ;1077-82;1163-68. [Google Scholar]

Articles from BMJ : British Medical Journal are provided here courtesy of BMJ Publishing Group

RESOURCES