The third edition of the initial version, Hyperactive Children: A Handbook for Diagnosis and Treatment, retains its authoritative tone and a “one stop” information reservoir. Dr. Barkley has managed to bring many principal authors from the 1998 edition and added new research findings on all the chapters.
The book has three clearly divided sections named 1) the Nature of ADHD (Attention Deficit Hyperactivity Disorder); 2) Assessment; and 3) Treatment. These three sections house twenty-two chapters, each ending with a key clinical points list.
The book opens with a historical description of ADHD. As in the previous editions, the discussion of primary symptoms and diagnostic criteria retain central importance. Even in this chapter with many familiar facts and observations, there was new information. For example, there was a good description of a subtype of predominantly inattentive type as a heterogeneous group, and an updated review of prevalence research concerning ADHD.
Chapters two and three discuss associated and comorbid conditions with ADHD. The concept of associated reduced life expectancy in ADHD is a serious one, as is the impaired driving capacity of persons with ADHD. Another alarming factor discussed by the author is the greater utilization of the medical care system by children with ADHD. An important clinical observation that children with ADHD are more likely to have parents with ADHD is well discussed. In ADHD-PI, the subset with sluggish cognitive tempo (SCT) is more likely to manifest in internalizing disorders is another clinical reality that is affirmed.
The chapter on “etiologies” is well supported by empirical data. Of importance is the review of molecular genetic research suggesting the role of DRD4 in its 48-bp form and with 7 or more repeats. D5 dopamine receptor gene also has been associated with ADHD. Psychosocial factors are seen as non contributing as a causative factor for ADHD.
The sixth chapter covers ADHD in adults, and I thought it is sensitively written. Instead of merely focusing on the characteristics of adults with ADHD, it gives a balanced perspective of adults who were diagnosed as children with ADHD and self referred adults with ADHD. Two important points are made here: that adult ADHD is an authentic disorder and that neuropsychological functions are disturbed in self referring adults with ADHD. In this chapter key clinical points cover all ongoing risks in the life cycle of a person with ADHD. Risks such as academic, social risks, of having comorbid disorders, high risk sexual behaviors, accident proneness and risk taking behaviors reflected in adaptive functions are well described.
Chapter seven is difficult to read and conceptualize. It deals with “a theory of ADHD.” Dr. Barkley presents this theory or model as a hybrid between self regulation and executive functions. Fortunately, there are many diagrams explaining the different components of this theory. Behavioral inhibition on which four executive functions depend is tackled first. These four executive functions are nonverbal working memory, verbal working memory, the self regulation of affect and motivation/arousal, and reconstitution (page 331). The prominent discussion is about how these executive functions assume an important place in guiding outer behaviors by inner actions. The main tenet of theory is that behavioral inhibition deficits are important in ADHD as well as being a disorder of self–regulation. In my opinion this chapter should have been placed earlier, even before the phenomenology of ADHD is described.
The best part of this tedious chapter is when the implications of this theory for treatment of ADHD are explored. The discussion that ensues is useful in explaining what ADHD is doing to the affected person, rather than absolving the person from the consequences of ADHD. I loved Barkley’s idea of explaining ‘blindness to time is the ultimate yet nearly invisible disability afflicting those with ADHD.” (page 326). Most clinicians working in ADHD clinics already know about the veracity of this statement. No patient with ADHD consistently comes on time; some have arrived one week later or a few days earlier. The second idea is even more down to earth. He advocates that useful treatments should be offered at the point of performance. The goal of this endeavor is to assist persons with ADHD to exhibit the skills that they have and doing what one knows. There is a good rationale provided for the use of medications in ADHD. The author argues that the only treatment that would bring out improvement in inhibition is a medication treatment with psychostimulants and other medications that can help whilst the medication remains within the brain. Along with this approach, externalization of motivation is important. Finally, a chronic disability perspective is suggested in the overall management of ADHD.
With chapter eight we embark upon the assessment section. In the next four chapters, we learn about the interview techniques, rating scales, and observational measures useful in the assessment of ADHD. This chapter has a table that gives differential diagnostic tips for distinguishing other comorbid mental disorders from ADHD. I think all clinicians that diagnose and treat ADHD should have this table ready on their desks for quick reference. This chapter is definitely clinician friendly. It now gives us additional information on how to handle legal and ethical issues arising in treating persons with ADHD. Three main issues in this domain are guardianship/custody issues, disclosing of suspected physical and sexual abuse or neglect of the child, and the legal accountability of children with ADHD.
Chapter nine attests that psychological testing is not diagnostic of ADHD. The CPTs (continuous performance tests) are the most evidence based tests to diagnose ADHD.
Chapter ten is a must read. It provides ten actual clinical cases to illustrate fine points of applying theoretical knowledge to actual cases. Although most child psychiatrists can identify with these cases from their practices, these vignettes are important to young trainees and academicians involved in research to remind of the overall purpose of assessing and understanding the nature of ADHD; i.e. to help clinical cases.
An assessment of adults with ADHD is systematically explored in chapter eleven. Four central issues to the evaluation are defined: establishing the presence of symptoms before age of 12, documenting evidence of impairment across multiple domains, exploring other reasons for the presenting symptoms, and clarification of the existence of comorbid disorders.
The treatment section is the last section, but quite dense with eleven chapters. Parent training treatment format is explored in chapter 12. The next chapter, in contrast, describes parent training in large groups. A COPE model (community parent education program) is described in regards to the integration of principles involved and the structure of large groups, and with comments on cost efficacy and limitations of this model. I read the limitations with interest. The author describes problems of accessibility and reduced service utilization by families with affected members, and notes that not all the families will benefit from COPE programs. COPE however has been evaluated and compared to other interventions such as social learning parent training models.
Chapter 14 gives readers a solid tool to deal with adolescents with ADHD. The author gives a biobehavioral family systems model. I liked the focused style of this chapter which clearly outlines the principles for parenting the adolescent with ADHD and describes one intervention at a time, giving several clinical excerpts.
The next chapter targets teachers and the school system for treatment intervention. This chapter buzzes with lots of good information we could apply in assisting our patients. The two goals of school based interventions are to educate teachers about the nature of ADHD and to increase home/school collaboration. Authors recommend functional assessments of behavior and the nine management strategies. The core interventions include common sense approaches such as altering the physical layout of the classroom and modifying academic program to suit the child’s abilities.
An interesting twist to intervention is described in chapter 16 where peers are assisting children with ADHD in regulating impulsive behavior. The author describes this as student-mediated conflict resolution programs. Playground mediation is well described, along with its main purpose in reducing the bullying experiences.
Chapter 17 provides adequate information on the history, indications, basic pharmacology and clinical effects of stimulants. An interesting read in this chapter is about the treatment of comorbid symptoms in ADHD and the thorough discussion of acute side effects. In the brief, relevant next chapter (chapter 18) the treatment with antidepressants and SNRIs is described. The key clinical points made in chapter 19 are relevant to the difficult, hard-to-treat cases of ADHD. This chapter discusses the use of antidepressants, modafinil, and clonidine. The chapter also describes the use of anticonvulsants and special populations where antipsychotic medications might be indicated. Useful guidelines are provided for when clinicians have to use multiple drugs in treating ADHD (examples include Tourettes disorder and severe anxiety).
Chapter 20 advocates the use of combined child therapies to alleviate symptoms. Not all of the psychosocial treatments are without side effects. A phenomenon of behavioral contagion is described in a social skills training program for children with ADHD, as well as the escalation of conflicts during behavioral family therapy. The following two chapters describe psychological counseling and pharmacotherapy interventions for adults with ADHD.
This book is well referenced and has all the updated information. I had read the first edition and, to me, this book seemed more attractively presented. It is a good reference book to keep in one’s personal library, and a definite place needs to be found in departmental libraries.