determining child mental health

A symposium on Attention Deficit Hyperactivity Disorder (ADHD)

An ethical perspective

George Halasz

With remarkable ease diagnosis can turn the fright of chaosinto the comfort of the known; the burden of doubt intothe pleasure of certainty; the shame of hurting othersinto the pride of helping them; and the dilemma of moraljudgement into the clarity of medical truth. Because oftheir nature, functions, and meanings, diagnoses can dosuch things in efficient and powerful ways . . .

W. Reich (p.205) [1]

At the heart of the unfolding story of Attention DeficitHyperactivity Disorder (ADHD) are three questions: arethese children ill?; if not, why do children behave so?and why do they present now? In this paper, I suggestthat ethical considerations are paramount when dis-tinguishing between children’s ‘illness’ behaviour andbehaviour that communicates emotional states such asanxiety, panic, sadness, grief, frustration and resentment.Examples of ethical problems that lead to biased diag-nosis and non-rational prescribing highlight the chal-lenge the doctor faces to avoid turning ‘moral judgementinto . . . medical truth’.

Many researchers and clinicians accept ADHD asa valid diagnostic category unaware it is the focus of aUSA National Institute of Health (NIH) [2] consensus

statement: this states that ADHD remains of ‘unproven’status and ‘should give pause to both researchers andclinicians who may have reified ADHD as a “thing” or a“true entity” (rather than a

working hypothesis

thatserves scientific, communication, and clinical decisionmaking purposes)’. The statement is ‘independent, expertand credible’,

in spite

of the controversy surroundingADHD. Thirty-one experts provided scientific ‘testi-monies’ to a consensus panel, the scientific ‘jury’. Thedraft was subjected to rigorous revision attesting to theauthoritative nature of the final statement [3].

The NIH reminds developmentally minded child psy-chiatrists to assess and diagnose symptoms in childhoodon the understanding that ‘chaotic’, ‘acting out’, ‘out ofcontrol’ behaviours, as found in ADHD, can be ascribedto biopsychosocial factors. For example, Rutter [4] notesthat the ‘process of development constitutes the cruciallink between genetic determinants and environmentalvariables, between sociology and individual psychology,and between physiogenic and psychogenic causes.’ (p.1)Psychiatrists face special concerns with families, educa-tors and non-developmentally minded colleagues, sincethe nature of ADHD raises for each of these groupsinherently ambiguous perspectives.

Australian and New Zealand Journal of Psychiatry 2002; 36:472–487

We invited contributions on the ‘current state of the diagnosis and treatment of ADHD’ in thelight of the continuing controversy that envelopes this ‘clinical condition’.What follows are the seven accounts we received. If you have another view on the topic, douse the correspondence column. The debate is clearly far from over!

Honorary Senior Lecturer, Department of Psychological Medicine, Monash Medical Centre. (Correspondence) Burke Road Medical Suites, 30 Burke Road, EastMalvern, 3145, Victoria, Australia. Email: [email protected]

ATTENTION DEFICIT HYPERACTIVITY DISORDER 473

Eisenberg [5] points out two sources of ambiguity inchild psychiatry: ‘insufficiency of information on whichclinical decisions must be taken and (of) the frailty of thejudgement we can . . . bring to bear on the human prob-lems we face.’ Moreover, commonly occurring ‘flawedmental health care systems’ [6], introduce a duty forclinicians to make ethically clear judgements.

The child psychiatrist dealing with children withADHD faces no less than three ethical challenges: touphold the principle of acting in ‘the best interest ofthe child’; to respect ‘the rights of the child to beheard’; and to conduct rational diagnostic and prescrib-ing practices [7].

Let us turn to examples where dubious ethical conductthreatens not only standards of care but also erodes theintegrity of the ‘clinical process’ resulting in both over-and under-diagnosis of ADHD. I agree with the NIHsuggestion that frequency of prescribing medication‘may be due in part to the limited time spent making thediagnosis’ [3, p.186]. Such misdiagnosis, rather thandifferent rates of prevalence, could thus account for largevariations in prescribing throughout Australia (seeTable 1).

Categories of misdiagnosis

Reich [1] distinguishes between three categories ofmisdiagnosis: purposeful, non-purposeful and based onerror. Financial interests may lead to the first whileinherent limitations of DSM-IV can result in the second.Reich astutely observes that the third may derive from‘the humane transformation of social deviance intomedical illness’ (p.209).

On the other hand, we need to differentiate between‘misdiagnosis’ and valid diagnosis when ‘good enough’criteria inform the clinician. Before tackling this aspect,we should note a pervasive bias in child psychiatry. Irepeatedly see children presenting symptoms that ‘mask’a range of family conditions: acute stress; a crisis, such asdeath or divorce; long-standing dysfunction or mental

illness in a parent or sibling. Overlooking this results inassessment bias even with the use of ‘objective’ measures.

In the absence of an objective test for ADHD, DSM-IV relies on the interpretation of symptoms. Over- orunder-diagnosis, is determined by at least three factors:‘procedural validity’ (a concept introduced by Spitzerand Williams [8]) which revolves around the extent towhich DSM-IV ADHD, as a diagnostic procedure, yieldssimilar results to those of the DSM-III-R category andspeaks to the issue of the validity of the assessmentprocess. This is distinguishable from the validity of thediagnostic category itself (discussed previously). Thirdly,a potential ethical bias exists to which we now turn.

Intentional misdiagnosis and over-diagnosis

Reich observes that ‘. . . the ethical problem of diag-nosis stems from its capacity for misuse – that is, theknowing misapplication of diagnostic categories to personsto whom they do not apply, a misapplication that mayplace those individuals at risk for the harmful effects ofpsychiatric diagnosis’ [1, p.194].

In the USA, bias towards intentional misdiagnosisoccurs where children receive ‘cash benefits to a maximumof approximately $6000 per year per beneficiary’ as partof a disability programme. This has led Perrin

et al

. [9]to conclude that diagnosis can ‘reflect bias becauseproviders tend to code conditions and procedures thatare likely to be reimbursed. Therefore, the diagnosis onclaims may not accurately reflect the condition thatchildren have’. Reich continues ‘. . . these effects [ofmisdiagnosis] include not only the loss of personal free-dom, and not only the subjection to noxious psychiatricenvironments and treatments, but also the possibility oflife-long labelling . . .’(p.194). We are compelled to ask:who carries ethical and legal responsibility for possibleadverse effects on children’s development at ages threeor four, and even younger [10], when they are intention-ally misdiagnosed with ADHD and committed to a treat-ment programme that includes non-rational prescribing

Table 1. Dexamphetamine prescribing in Australia (Pharmaceutical Benefits Scheme (PBS)).Methylphenidate is not on PBS

New South Wales

Victoria Queensland South Australia

Western Australia

Tasmania Australian Capital

Territory

Northern Territory

1992–1993 6253 1590 2555 2250 3450 191 190 801999–2000 69 312 35 761 32 290 22 446 71 510 8226 2891 960

The figures show a virtual tenfold increase in South Australia to over 20 fold in Victoria and Western Australia. Yet Victoria has a much smaller per capita consumption.

474 ATTENTION DEFICIT HYPERACTIVITY DISORDER

in order that the family will qualify for a substantialdisability allowance?

In Australia this issue demands attention given theSouth Australian Parliament Social Development Com-mittee’s inquiry into ADHD [11] with its emphaticrecommendation ‘to determine a standard for best prac-tice in the diagnosis of ADHD’ be urgently implemented‘if we are to make any progress in tackling the complexissue of ADHD’ (p. 9).

Non-intentional misdiagnosis

Most clinical misdiagnosis is non-intentional, thisdefined by Reich as not resulting from wilful misappli-cation of psychiatric categories, but rather processes‘much more subtle and insidious, much more part of thefabric of the field itself, and much more difficult toidentify and stop’. The DSM-IV taskforce chair AllenFrances [12] observed that the classification perpetuatesinattention to a ‘developmentally sensitive, interactive orlongitudinal perspective . . . [and thus] limits the useful[sic] of the categories for both research and clinicalassessment and treatment of children and adolescents’(p. 164). This pervasive neglect is difficult to identifyand stop precisely because, as part of the fabric of theADHD picture, clinicians and researchers fail to recog-nize its insidious nature. Fortunately, the aforementionedParliamentary inquiry articulated serious concerns in thisregard.

Mistaken misdiagnosis

Jureidini and Mansfield [13], in highlighting the ethicsof the psychiatrist–pharmaceutical company relation-ship, recommend that practitioners as individuals and asa profession, need to develop a ‘more healthy scepti-cism’ about their links in order to benefit patients. Over-diagnosis of ADHD becomes more complex when thedoctor as prescriber is under the pervasive influence ofadvertising, combined with pressure from parents andteachers to ‘do something’ about a child’s ‘problem’behaviour.

Furthermore, the current ‘entrepreneurial ethos’ chal-lenges the notion of intellectual integrity and independ-ence of medical guidelines [14]. Relevant is theobservation that DSM ‘listed a mere 60 illnesses in1952; this grew to 145 in 1968 and in 1994 stood at 410,with strong potential for further growth’ [15]. Redneremphasizes ‘particularly badly affected by this constantlycreeping diagnostic expansion have been children, whose

least oddity or not quite normal (frequently confusedwith average) quirk is now assigned to some syndromeor other and treated with behaviour therapy and drugs.The ethics of all this is rarely called into question’(p.238).

Conclusion

No simple explanation accounts for the ADHD contro-versy. I contend that a valid diagnosis can only be madeafter comprehensive assessment of the child in a familycontext, with additional information obtained, if needed,from the school and related settings. Furthermore, avalid diagnosis is predicated on the observation thatchildrens’ ‘symptoms’ may be necessary but not suffi-cient criteria to label them as ‘patients’.

In our quest for a biopsychosocial understanding ofthis constellation of clinical features, an ethical impera-tive remains: to avoid turning ‘moral judgement into . . .medical truth’ through misdiagnosis, whatever its origin.

Acknowledgements

My thanks to the following for their helpful commentson earlier versions of this paper: Sid Bloch, ChrisBrowning, Don Grant, Andrew Firestone, Rachel Falk,Shirley Prager and Frances Thomson Salo.

References

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Psychiatric ethics

, 3rd edn. Oxford: Oxford University Press, 1999:193–224.

2. Jensen PS. Commentary: the NIH ADHD consensus statement. Win, Lose, or Draw?

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2000; 39:194–197.3. National Institutes of Health Consensus Development Conference

statement: diagnosis and treatment of Attention-Deficit/Hyperactivity Disorder (ADHD).

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6. Green SA, Bloch S. Working in a flawed mental health care system: an ethical challenge.

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7. Halasz G. ‘Voltaire’s bastards’ and the rights of the child. The manufacture of epidemics. In: Halasz G, Borenstein R, Buchanan J

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She STILL Won’t Be Right, Mate! Will managerialism destroy values based medicine? Your health care at risk!

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, Vol. I, 3rd edn. Baltimore: Williams & Wilkins, 1980.


9. Perrin JM, Kuhlthau K, McLaughlin TJ, Ettner SL, Gortmaker SL. Changing patterns of conditions among children receiving supplemental security income disability benefits.

Archives Pediatrics and Adolescent Medicine

1999; 153:80–84.10. Rappley MD, Mullan PB, Alvarez FJ, Eneli IU, Wang J,

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11. Social Development Committee.

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12. Frances AJ, Egger HL. Wither psychiatric diagnosis.

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1999; 33:161–165.13. Jureidini J, Mansfield P. Psychiatrists and the pharmaceutical

industry. Does drug promotion adversely influence doctors’ abilities to make the best decision of patients?

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research organisations: time for national action.

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Ethical life. The past and present of ethical cultures

. Lanham: Rowman & Littlefield, 2001.

‘Kid in the corner’

Philip Hazell

A recent British television drama titled ‘Kid in theCorner’ canvassed many of the issues surroundingAttention Deficit Hyperactivity Disorder (ADHD) andrelated problems that are of concern to parents, teachers,and health professionals. The first episode begins with atrip to the supermarket by Danny, a primary-school agedchild, and his parents. Danny is overstimulated by theexperience and his excitable behaviour quickly drawsdisapproval from other shoppers. His father comments,by way of an apology, that dietary control has beenineffective. Later, a lunch with family friends is dis-rupted after it is discovered that Danny has gone on acutting spree with a pair of kitchen scissors. At schoolDanny is teased because he has forgotten to bring hisgym shorts. The punishment for his forgetfulness andpoor organizational skills is to spend the gym classsitting on a mat. The teacher becomes very cross withDanny when she finds him, not only off the mat, buttrying to climb a rope. Danny assaults the teacher whenshe attempts to physically restrain him, leading to sus-pension from school. His parents consult their generalpractitioner, who is unsympathetic to their concern aboutADHD. Danny, after all, behaves perfectly well when hevisits the surgery. The implication is that Danny’sparents are pressuring for medication to compensate for

their disappointment that he is not a high achiever. WhatDanny needs is more quality time with his parents.Counselling sessions are abandoned because the thera-pist seems to focus more on the marriage than on Danny.A paediatric consultation does eventually lead to a trialof psychostimulant medication that helps to improveDanny’s concentration and reduce his hyperactivity.However, Danny remains oppositional and has otherproblems including deficits in social skills and low self-esteem. Following an episode of deliberate self-harmDanny is transferred to a residential treatment facility.

‘Kid in the Corner’ illustrates well the stress on familymembers when a young person is affected by ADHD. Italso illustrates the double standard present within thecommunity: ‘We do not approve of your child’s behav-iour, but we also do not approve of you invoking thediagnosis of ADHD to explain it’. Danny’s problems arenot restricted to poor attention and hyperactivity, and itis unlikely that psychostimulant medication alone will beenough to help him. Dysregulated affect is as much of aproblem to Danny’s parents and his teachers as hishyperactivity. There is a reciprocal interaction betweenDanny’s behaviour and his environment. Finally, antici-pation and a certain degree of flexibility on the part ofteachers and parents could go some way to alleviating

Conjoint Professor, Child and Adolescent Psychiatry, University of Newcastle, Callaginan, 2308, New South Wales, Australia. Email: [email protected]


Danny’s difficulties. If only the gym teacher hadaccepted Danny’s suggestion that he borrow a pair ofshorts from ‘lost property’ . . .

Attention Deficit Hyperactivity Disorder continues toreceive a disproportionate amount of media attentionrelative to other psychiatric disorders of childhood.Recurring themes include the concern that the medicalprofession may be pathologizing normal childhoodbehaviour, and reservations about the use of drugs thathave the potential for abuse as first line treatment. Evi-dence for ADHD being more than a benign self-limitingcondition comes from longitudinal research that showssymptoms persist into adolescence and adulthood in40–70% of cases [1]. Importantly, children with moder-ate to severe ADHD symptoms are also at increased riskof developing other problems such as anxiety, mooddisorder, antisocial behaviour, and substance abuse [2].The pattern of behaviour over time is probably the keyfeature in distinguishing children with ADHD fromthose with other disorders or no developmental prob-lems. If there is a criticism of current diagnostic practice,it is that too much emphasis is given to cross-sectionalassessment [3,4]. When there is uncertainty about thediagnosis, clinicians would be well advised to extend theassessment observation period over several months. Thisis especially true for preschool children, as research hasdemonstrated that the diagnosis of ADHD is unstable inthis age group [5]. General practitioners are in an excel-lent position to provide this longitudinal perspective, butare an underutilized resource.

A question often asked by parents is whether long-term exposure to psychostimulant medication willincrease the likelihood that their child will engage insubstance abuse. Despite recent concerns expressed inthe media, the evidence from a systematic review ofnaturalistic studies suggests not [6]. The authors of thereview concluded that, if anything, responsible treatmentof ADHD with psychostimulant medication protectsagainst subsequent substance abuse [6]. The mechanismis likely to be via a reduction in the risk of associatingwith youth with antisocial traits who may promote, andindeed supply the materials for substance abuse. Areprescribed psychostimulants misused by some patients,their families and associates? The answer is almost cer-tainly yes, but the extent of the problem is unknownowing to its covert nature. Personal communication fromparents suggests that some teenagers do give or sell theirtablets to peers, although the volume is likely to besmall. Where there is a suspicion of personal or familialsubstance abuse, clinicians obviously need to be wary ofprescribing psychostimulant medication. Slow releasepreparations of psychostimulant medication that are notpresently available within Australia would allow for

once daily dosing that could be better supervised byparents, and markedly reduce the need for teenagers totake their medications to school.

The short-term efficacy of psychostimulant medica-tion in reducing the target symptoms of ADHD is welldocumented [2]. The sixth edition of ‘Clinical Evi-dence’, which tends to be conservative in its conclu-sions, lists methylphenidate and dexamphetamine as oflikely benefit for ADHD [7]. At first glance this mayseem a case of the psychostimulants being damned byfaint praise. However, meta-analysis of data from mul-tiple trials, generally considered the highest order of clin-ical evidence, has been problematic owing to the lack ofan agreed statistical method for pooling data from cross-over trials to obtain a summary estimate of treatmenteffect. More controversial is the question of whetherpsychostimulant medication offers any long-term benefitto children. This is a difficult case to prove, as is the casefor the long-term benefit of intervention for any disorder,because there are many uncontrolled variables. How-ever, one randomized controlled trial of amphetamineadministered over 15 months found persistently lowerscores on parent and teacher ratings of the behaviour ofchildren receiving active treatment compared with thosereceiving placebo [8]. Placebo-controlled trials areunlikely to be conducted over periods longer than15 months, as it would be considered unethical to denychildren access to a treatment that has proven short-termbenefit.

Published practice guidelines generally advocate thatthe treatment of children with ADHD should incor-porate several modalities [3,4]. Typically this meansmedication combined with advice for parents aboutbehaviour management, and classroom support for thechild to facilitate learning and minimize disruptivebehaviour. The results of the Multimodal TreatmentStudy for ADHD (MTA study) conducted at multiplesites in North America challenge this view, becauseon the whole, children treated with psychostimulantmedication alone did as well as those receiving multi-modal treatment, and rather better than those receivingonly behavioural management [9]. Commentators havenoted that for the ‘medication-only’ group there wasstill substantial contact between the research clinicians,the children and their parents; the implication beingthat the families would have received considerablesupport and non-specific counselling. And so theyshould, as we would hope that clinician prescribersmaintain an active interest in the wellbeing of the childand family beyond the technical aspects of monitoringtreatment.

There is ample advice available to clinicians concern-ing the initiation of pharmacotherapy, but remarkably


little information about when and how to cease treat-ment. Data from a survey of parents of children in theHunter region of New South Wales treated withpsychostimulant medication suggest the obvious,namely that children continue with treatment when itis helpful, and discontinue when it is not [10]. There-fore, a reasonable approach is to allow the decisionabout the continuation of treatment to be guided by thechild and parent’s perception of benefit. Unfortunatelysome treatment non-responders are lost to follow-up,or resurface several years later with significant second-ary behavioural and educational problems. This can beprevented if adequate attention is given to establishingand maintaining a therapeutic alliance. Much emphasishas been given in practice guidelines to the technicalaspects of the management of children with ADHD.However, the survey of parents in the Hunter regionwhose children were treated with psychostimulantmedication found that good basic clinical practice suchas conducting a considered assessment, providinggood information to parents, and reviewing the patientat intervals of three months or less, were associatedwith a favourable treatment response [10]. These areclinician behaviours that facilitate rapport. There ismuch to be said for old-fashioned good doctoring.

References

1. Gillberg C, Hellgren L. Outcome. In: Sandberg S, ed.

Hyperactivity disorders of childhood

. Cambridge: Cambridge University Press, 1996;477–503.

2. Cantwell DP. Attention deficit disorder: a review of the past 10 years.

Journal of the American Academy of Child and Adolescent Psychiatry

1996; 35:978–987.3. Taylor E, Sergeant J, Doepfner M

et al.

Clinical guidelines for hyperkinetic disorder.

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1998; 7:184–200.4. Dulcan M. Practice parameters for the assessment and treatment

of children, adolescents, and adults with attention-deficit/hyperactivity disorder.


1997; 36:85S–121S.5. Hazell P.

Attention deficit hyperactivity disorder in preschool aged children

. Adelaide: Australian Early Intervention Network for Mental Health in Young People, 2000.

6. Wilens T, Faraone S, Biederman J. Pharmacological treatment of ADHD and later substance abuse: a review. In: Villani S, ed.

Proceedings of the 48th annual meeting of the American Academy of Child and Adolescent Psychiatry in conjunction with the 14th annual meeting of the Faculty of Child and Adolescent Psychiatry of the Royal Australian and New Zealand College of Psychiatrists.

Washington: American Academy of Child and Adolescent Psychiatry, 2001:97.

7. Joughin C, Zwi M, Ramchandani P. Attention deficit disorder in children. In: Barton S, ed.

Clinical evidence

, 6th edn. London: British Medical Journal, 2001:234–242.

8. Gillberg C, Melander H, von Knorring A

et al.

Long-term stimulant treatment of children with Attention-Deficit Hyperactivity Disorder symptoms: a randomized, double-blind, placebo-controlled trial.

Archives of General Psychiatry

1997; 54:857–864.

9. The MTA Cooperative Group. A 14-Month randomized clinical trial of treatment strategies for Attention-Deficit/Hyperactivity Disorder.


1999; 56:1073–1086.

10. Hazell PL, Lewin TJ, McDowell MJ, Walton JM. Factors associated with medium-term response to psychostimulant medication.

Journal of Paediatrics and Child Health

1999; 35:264–269.

Developments in treatment

Florence Levy

Lahey

et al

. [1] commented that ‘no term in the historyof childhood psychopathology has been subject to asmany reconceptualizations, redefinitions, and renamingsas the disorder referred to non-technically as hyper-activity’. Most recently, the DSM-IV has describedthree subtypes; Predominantly Inattentive, Predominantly

Hyperactive/Impulsive; and Combined types of AttentionDeficit Hyperactivity Disorder (ADHD). According toHill and Taylor [2], the DSM-IV identifies about 4% ofprimary school age children, which is four to five timesas prevalent as the ICD-10 condition of hyperkinetic dis-order, which has essentially the same symptom profile,

Senior Staff Specialist and Associate Professor, Prince of Wales Hospital and School of Psychiatry, University of New South Wales


but requires more stringent criteria. Although Levy

et al

.[3] showed that the unitary DSM-III-R ADHD could beconsidered as a highly heritable continuum, recent investi-gations suggest that while the three DSM-IV subtypesshow considerable genetic influences, different or addi-tional genes may operate at the extremes of behaviour.The DSM-IV subtypes also differ in their comorbidi-ties. Waldman

et al

. [4] utilized Australian Twin Study(ATAP) data to examine the causes of overlap andADHD, Oppositional Defiant Disorder (ODD) andConduct Disorder. They found considerable overlap ingenetic and environmental influences in these three dis-orders. At a genetic level, ADHD and ODD were closelyrelated (see MTA discussion below). Twin studies[5–7] have also shown that language and reading prob-lems are differentially related to ADHD subtypes. Thus,instruments based on the DSM-IV (National Health andMedical Research Council (NH & MRC) report, 1997)should provide the most useful diagnosis of ADHD andrelated disorders.

The use of ‘objective’ tests such as the ContinuousPerformance test (CPT) to diagnose ADHD, remainscontroversial. This is partly because the tests have variedconsiderably in different laboratories, in terms of length,interstimulous intervals and norms. Most recentlyConners [8] and colleagues reported a review of 20studies that had an experimental and a control group,rank ordering them separately in terms of effect size ofomission and commission errors. They found evidenceof ceiling effects in those tasks, which produced a smallnumber of errors. They have subsequently modified theConners CPT to use 75% targets and 25% non-targets toproduce a larger number of errors, and have reportedspecificity and sensitivity greater than 0.80.

Treatment

While the use of central nervous stimulant medicationssuch as methylphenidate and dexamphetamine is acceptedas the primary treatment for ADHD (NH & MRC Reporton ADHD, 1997) questions remain about differing prev-alence of medication use in the US versus UK and indifferent regions [9] in the US and Australia. Also,increased use of medication over the last decade [10] hasraised concerns.

Jensen

et al

. [9] examined data obtained from 1285children and their parents across four US communities.Analyses examined the frequency of ADHD diagnosis,the extent to which medications were prescribed, as wellas the provision of other services (e.g. psychosocialtreatments and school-based educational interventions).While 5.1% of children met full DSM-III-R ADHDcriteria during the previous 12 months, only 12.5% of

those meeting criteria were treated with stimulantsduring the previous 12 months. Some children who hadbeen prescribed stimulants did not meet full ADHDcriteria (8 of 16) but they manifested high levels ofsymptomatology. Jensen

et al

. concluded that while sub-stantial over-treatment was not occurring, the relativepaucity of school-based and/or psychotherapeutic serviceswas notable. Trials in stimulant prescribing in NSWhave recently been outlined in a NSW public healthbulletin supplement [10].

Another issue of concern has been the trend in pre-scribing psychotropic medications to preschoolers. Zitoand colleagues [11] reported a dramatic increase between1991 and 1995. Prescription records revealed a 1.7–3.1%increase in methylphenidate prevalence in 2–4 year olds,with sizeable elevations for clonidine and antidepressants.Unresolved questions involved the long-term safety ofpsychotropics, particularly in light of earlier ages ofinitiation and longer durations of treatment, with pos-sible impact on neurotransmitters.

The largest and most influential treatment study ofADHD was reported in 1999 by the MTA CooperativeGroup (Multimodal Treatment Study of Children withADHD) [12]. The multisite study assigned 579 children(aged 7–9.9 years) with ADHD combined type, to14 months of medication (titration followed by monthlyvisits), intensive behavioural treatment (parent, schooland child components), the above two combined andstandard community care. For ADHD symptoms carefulmedication management was superior to behaviouraltreatment and to routine community care. Combinedtreatment did not yield greater benefits than medicationfor core ADHD symptoms, but may have providedmodest advantages for non-ADHD symptoms (parent-reported internalizing symptoms, oppositional/aggres-sive symptoms and Wechsler Individual AchievementTest reading achievement score).

While the study is of great interest, several caveatsremain. First, Hyperactive/Impulsive and Inattentivesubtypes were not included. Second, treatment did notinclude separate learning and reading components, otherthan those routinely carried out by schools. Thus, thestudy did not investigate treatment implications for theimportant Predominantly Inattentive subtype, the groupmost implicated in the increased use of stimulants inrecent decades.

Another interesting finding is the beneficial effectsof medication on Aggression – ODD symptoms with areduction in mean score of 1.39 (SD = 0.92) to 0.65(SD = 0.68). Levy

et al

. (in press) have suggested thatthe genetic overlap between ADHD and ODD reportedby Waldman

et al

. [4] may, in part, account for thisfinding.


Hill and Taylor [2] have outlined an ‘auditable’ proto-col for treating ADHD, which attends to comorbidityand side-effects. Their parent and teacher side-effectquestionnaires appear on the

Archives of Disease inChildhood

website. More recently the American Academyof Child and Adolescent Psychiatry has publisheddetailed practice parameters for the use of stimulantmedications in the treatment of children, adolescents,and adults [13] using an evidence-based approach,detailed literature review and expert consultation.

A further issue relates to the use of slow-release stim-ulant medication. Slow-release methylphenidate anddexamphetamine preparations are freely available in theUSA, but only prepared by a few individual pharmaciesin New South Wales. The advantages are less need foradministration during the school day, and more evencoverage of symptoms, though clinical experienceindicates a need for immediate release boosters. A pos-sible disadvantage may be less sensitive control of thedose level.

What of the future? Winsberg and Commings [14]found that homozygosity of the 10 – repeat allele of thedopamine transporter (DAT-1) gene was characteristicof a non-response to methylphenidate. This is the firstpharmacogenomic study in child psychiatry, and maypredict future approaches to diagnosis and treatment.

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1999; 56:1073–1086.13. Practice parameter for the use of stimulant medications in the

treatment of children, adolescents, and adults.


2002; 41(Suppl):S26–S49.

14. Winsberg BG, Commings DE. Association of the dopamine transporter gene (DAT1) with poor methylphenidate response.


1999; 38:1474–1477.

Four pertinent issues in treatment

Ernest S.L. Luk

Research in the 1980s on Attention Deficit Hyper-activity Disorder (ADHD) focused on reliability in order

to establish that core symptoms could be observed underdifferent conditions [1]. Clustering was a consistent

Psychiatrist in private practice and Adjunct Associate Professor, Department of Psychiatry, Chinese University of Hong Kong. Room 1806, 70 Queen’s RdCentral, Hong Kong. Email: [email protected]


finding [2]. Syndromal status was established throughclinical, epidemiological and prospective follow-upstudies [3]. We now know that ADHD is a chronicdisorder that affects long-term social, emotional andeducational development [4].

DSM-III set out criteria for the diagnosis while threesubgroups emerged through DSM-IV and ICD-10: inat-tentive, hyperactive-impulsive, and combined. Subsequentresearch has covered neuropsychology, neurophysiology,behavioural genetics, molecular genetics and neuro-imaging [5]. Despite this work, diagnosis is still basedon a developmental history (using many informants) andcareful observation [6]. The diagnosis should never resultfrom questionnaire responses or the report of a singleobserver. The process involves detecting any comorbidconditions and developmental difficulties (e.g. Opposi-tional Defiant Disorder, Conduct Disorder, Anxiety andDepression Disorder, and Tourette Syndrome) [7]. Thelink between ADHD and anxiety is noteworthy in thatthe latter alters response to behavioural treatment [8].

The diagnosis in adolescents and adults is problematicinasmuch as it remains unclear how the criteria shouldbe modified to match developmental changes.

Diagnosis in girls is another concern. The ratio of boysto girls presenting to a clinic is much higher than thatfor children with ADHD in the community. Girls withADHD are often not recognized. They are silent suffer-ers. Prospective long-term follow up of girls is required.The question that needs to be answered is whether girlshave a prognosis similar to boys.

Attention Deficit Hyperactivity Disorder exists in dif-ferent cultures, but there is evidence that cross-culturaldifferences affect prevalence. The unanswered questionis whether the threshold for diagnosis is the same [2].

Treatment has made a big step forward as a result of alarge-scale trial [9]. The MTA study established theefficacy of stimulants both in the short and long term.Combining medication with behavioural treatment hadadditional benefits including improved general function-ing; combination treatment is likely to reduce the doseof stimulant required. The MTA study also highlightedthe importance of regular monitoring of medication.

The MTA study is the first large-scale random control-led trial in child psychiatry. Many more are needed.Until that happens, clinicians will continue to strugglewith the differences in opinions in the management ofchild psychiatric disorders in terms of the usefulness ofmedication and whether there is additional benefit incombining medication with other treatments.

There are four major issues in treatment. The first isabout early recognition and intervention. Children withADHD often are not recognized until they have startedprimary school. The delay puts pressure on the family

and perpetuates the negative interactions experienced bythe child. These secondary effects adversely affect thedevelopment, the parent–child and family relationships.

The second issue relates to non-responders. They oftenhave comorbid conditions or associated learning diffi-culties. Some have a history of abuse or difficult attach-ment. Controversies arise in terms of their diagnosis andtreatment. Comprehensive assessment by many profes-sionals is required to devise a plan of management [10].An inpatient programme may be required.

The third issue concerns training. The MTA studydemonstrated the low efficacy of treatment provided inthe community. Given the high prevalence of ADHDin the population and its significant morbidity, trainingprogrammes for primary health professionals, educa-tional staff and mental health professionals are crucial.

The fourth issue relates to treating adults with ADHD.Stimulants have been found to be helpful in adults withADHD in the short term [11]. However, their comparisonwith other treatments has not been made. A trial similarto the MTA is needed to answer this pivotal question.

One can equate the relevance of ADHD to child andadolescent psychiatry to that of psychosis to adult psy-chiatry. The suffering of people with psychosis has beenwell recognized by the community. The same cannot besaid about ADHD. Continuing controversies about ADHDabound. A continuum extends from it being a mythcreated by clinicians and educational staff on the oneend, to it being constructed as a scientifically establisheddevelopmental disorder that should be promptly treated.Seventy-five scientists in the field of child psychologyand psychiatry have recently called on these controver-sies to end and recognize ADHD as a disorder thatwarrants serious attention [12].

References

1. Luk SL, G.Thorley, E.Taylor. Gross overactivity – a study by direct observation.

Journal of Psychopathology and Behavioural Assessment

1987; 9:173–182.2. Luk SL. Cross-cultural aspects. In: Sandberg S, ed.

Hyperactivity disorders of childhood.

Cambridge University Press, 1996:350–381.

3. Taylor E, Sandberg S, Thorley G, Giles S. The epidemiology of childhood hyperactivity. In: Russell G, Anderton BH, eds.

Maudlsey monographs, number thirty-three.

London: Oxford University Press, 1991:148.

4. Taylor E, Chadwick O, Heptinstall E, Danckaerts M. Hyperactivity and conduct problems as risk factors for adolescent development.


1996; 35:1213–1226.5. Vance A, Luk ESL. Attention deficit hyperactivity disorder:

current progress and controversies.


2000; 34:719–730.6. American Academy of Pediatrics Clinical Practice Guideline.

Diagnosis and evaluation of the child with Attention-Deficit/Hyperactivity Disorder.

Pediatrics

2000; 105:1158–1170.


7. Pliszka SR. Comorbidity of Attention Deficit/Hyperactivity Disorder with Psychiatric Disorder: an overview.

Journal of Clinical Psychiatry

1998; 59:50–58.8. The MTA Co-operative. Moderators and mediators of treatment

response for children with Attention-Deficit/Hyperactivity Disorder.


1999; 56:1088–1096.9. The MTA Co-operative. A 14-month randomised clinical trial of

treatment strategies for Attention-Deficit/Hyperactivity Disorder.


, 1999; 56:1073–1086.10. Vance ALA, Birleson P, Luk ESL, Costin J. Tonge BJ, Maruff P.

The development of a clinic to manage Disruptive Behaviour

disorders not responding to conventional psychological and psychostimulant treatments.

Australasian Psychiatry

2001; 9:36–40.

11. Spencer T, Biederman J, Wilens T,

et al.

Efficacy of a mixed amphetamine salts compound in adults with Attention-Deficit/Hyperactivity Disorder.


2001; 58:775–782.

12. Barklay R.

ADHD Consensus Statement.

International Society for Research in Child and Adolescent Psychopathology 2002.

Embedding categorical constructs in contemporary child mental health approaches

Brett M. McDermott, Peter Gibbon

Attention Deficit Hyperactivity Disorder (ADHD) is acontroversial diagnosis. There are several reasons forthis, including potential difficulties in acknowledgingthat children can develop mental health disorders, pro-fessional and lay concern over diagnostic criteria anddefining boundaries with normal functioning, and concernrelating to prescribing psychoactive medication. Never-theless, Australian research using a representative com-munity sample has enshrined a one year ADHD prevalenceof 11% in 6 to 17 year olds, more than three times therate of either Depressive or Conduct Disorder [1], and afigure dissonant with prescribing rates [2]. We will con-sider assessment and management from the perspectivethat ADHD is now out of step with conceptual thinkingin the child and adolescent mental health field.

Developmental psychopathology and ecological–systemic child mental health perspectives share theassumptions that mental health outcomes are multideter-mined and influenced by inherent protective, risk andvulnerability factors and by the transactions betweensuch factors and environmental events. Environment isbroadly defined and the concept is not dissimilar to asystemic perspective involving the interplay of family,ethnicity, cultural factors and variables such as povertyand unemployment. The stress-vulnerability model is

consistent with this perspective. Thus, disorder followsinteraction with an intercurrent stressor that leads tomaladjustment or failure to negotiate developmentaltasks. Vulnerability is hypothesized to be endogenous tothe individual and latent, but exposed in response to anenvironmental challenge. Vulnerability factors are stable,especially biological, while affective, cognitive or psycho-social factors are more amenable to change [3]. Lastly,presentations are never interpreted as cross-sectional butrather as episodes in continuities linked to an earlierecology or novel discontinuities.

Developmental psychopathology and assessment of ADHD

Assessment must consider diagnostic criteria to confirmthe symptom domains of impulsivity, hyperactivity andinattention. However, reaching a diagnosis is necessarybut not sufficient to assess and treat ADHD. Diagnosisallows communication with other health professionalsand treatment informed by the research base that definesADHD as an entity. However, a classificatory systemlike DSM-IV [4] must include developmental factors,for instance, whether symptoms are more frequent andsevere than experienced by others of comparable age,

Brett McDermott, Professor (Correspondence); Peter Gibbon, Senior Research Officer, University Department of Paediatrics, Princess Margaret Hospital forChildren, GPO Box D184, Perth 6001,WA, Australia.


whether disturbance occurs in many settings and whetherfunctional impairment is present. DSM-IV also requiresassessment of transactional considerations: the relation-ship of symptoms to intelligence and degree of settingstimulation, the prevalence of ADHD in first-degreerelatives, medication adherence and cultural differences.This system relies heavily on the assessment and record-ing of diagnostic comorbidities to adequately describethe full symptomatology.

What of the stress-vulnerability model and ADHDassessment? Ingram

et al

. separate potential vulnerabilityfactors into cognitive, affective, psychosocial and bio-logical variables [3]. Neuropsychological research hasbeen hampered by difficulties in defining the concept ofattention and its relationship to working memory andexecutive functioning [5,6]. However, in ADHD diffi-culty with more effortful cognitive tasks, but not involv-ing language functions [6], and deficits in planning,organization and working memory are found [5].

Affective vulnerability factors, including affect dys-regulation problems, possibly relate to insecure attach-ment, parental intrusiveness, over-stimulation and exposureto abuse [7]. Psychosocial vulnerability factors coversocial incompetence and deficits in communication andself-control. Lastly, molecular and genetic researchimplicates potential biological vulnerabilities such asabnormalities in the dopamine transporter system andDRD

4

receptor genes.A developmental approach considers the following

during assessment: whether the presenting symptoms arerelated to issues noted in the first years of life andpreschool experience and are continuities from theseperiods or are more recent; whether the child’s self-regulation difficulties include mood regulation as well asimpulsivity and activity; potential management issuesstemming from relational issues with significant adults;the child’s belief system about their difficulties and thediagnosis (e.g., do they consider their impairment to benon-malleable); and whether the child carries a familial–genetic or neuropsychological vulnerability. Knowledgeof more far reaching vulnerability also gives rise to theappreciation that current neuropsychological testing,including computer-aided tests of attention, are not suf-ficiently sensitive. Furthermore, special investigationsprovide low yields and should not be undertaken unlessindicated on medical history or examination [8].

A developmental perspective on management

An inevitable effect of the developmental perspectiveis that there can be no single treatment. Although chil-dren may display core psychopathology they arrive at

this point via diverse pathways, with a mix of vulnerabil-ity, risk and maintaining (prognostic) factors. Further,referral filters make it likely that children managed indifferent settings will differ in terms of the severity andrange of psychopathology. For instance, Western Aus-tralian research has found that inpatient and outpatientchildren differ in terms of internalizing and externalizingsymptoms, family functioning, parental mental healthand parental alcohol use [9]. Viewed from a develop-mental perspective the clinical presentation may reflectdifferences between children and families seen by paedi-atricians, psychiatrists, and those presenting at develop-mental and mental health clinics.

Developmentally based treatment examines for paren-tal mental ill health, their resources and their own expe-rience of parenting. Knowledge of the school enablesbehaviour modification like token economies and pos-itive reinforcers [10], or remediation for comorbidlearning disorders. Recent approaches to adverse peerinfluence encompass proactive efforts to assist the childto replace such relationships with more prosocial rolemodels. Knowledge of neighbourhood factors facilitatesidentifying neighbourhood resources. Treatment alsotargets any functional impairment. Social skills training[10] may be indicated although its effectiveness isunclear [8].

Risk factors like poverty are not specific targets ofdevelopmental interventions. Vulnerability factors aretargeted only if they are also persistent prognostic vari-ables, for example, coercive parenting in the case ofcomorbid conduct disturbance. Use of medication isconsistent with a developmental perspective, prescribingstimulants, antidepressants and Clonidine as an adjunct[10] is evidence-based. There is little evidence for anti-convulsant use. The side-effect-benefit ratio usuallyprecludes neuroleptics [10]. Developmental issues influ-encing medication include caution prescribing for youngerchildren and where possible using low doses, avoidingpolypharmacy, considering the risk of substance abusein adolescents and of their tablets being accessible tofriends. Advances in pharmacogenomics may allowfuture individualized prescribing in order to maximizeeffectiveness and minimize side-effects.

References

1. Sawyer MG, Kosky RJ, Graetz BW

et al

. The mental health of young people in Australia: key findings from the child and adolescent component of the national survey of mental health and well-being.


2001; 35:806–814.2. Valentine J, Zubrick S, Sly P. National trends in the use of

stimulant medication for attention deficit hyperactivity disorder.

Journal of Paediatric and Child Health

1996; 32:223–227.


3. Ingram RE, Price JM.

Vulnerability to psychopathology risk factors across the lifespan

. New York: Guilford, 2001.4. American Psychiatric Association.

Diagnostic and statistical manual of mental disorders

, 4th edn. Washington, DC: American Psychiatric Association, 1994.

5. Karatekin C. Developmental disorders of attention. In: Nelson CA, Luciana M, eds.

Handbook of developmental cognitive neuroscience.

Cambridge, MA: MIT Press, 2001.6. Pennington BF, Ozonoff S. Executive functions and

developmental psychopathology.

Journal of Child Psychology and Psychiatry

1996; 37:51–87.7. Bradley SJ. Externalising disorders: the disruptive behavior

disorders. In: Bradley SJ, ed.

Affect regulation and the development of psychopathology

. New York: Guilford, 2000.

8. Zametkin AJ, Ernst M. Problems in the management of Attention-Deficit-Hyperactivity Disorder.

New England Journal of Medicine

1999; 340:40–46.9. McDermott BM, McKelvey R, Roberts L, Davies L. Severity

of children’s psychopathology and impairment and its relationship to treatment setting.

Psychiatric Services

2002; 53:57–62.

10. Practice parameters for the assessment and treatment of children, adolescents and adults with Attention-Deficit/Hyeractivity Disorder.


1997; 36 (Suppl):S85–S121.

Determining child mental health

Michael Sawyer, Brian Graetz, Peter Baghurst

A major decision for epidemiological studies of childmental health is determining the approach that should beused to identify children with mental health problems(for brevity, the term children is used to describe chil-dren and adolescents). The collaborating group respon-sible for the Child and Adolescent component of theNational Survey of Mental Health and Well-being inAustralia had to address this issue when designing thestudy [1]. Two alternatives were available. The dimen-sional approach was an attractive option since informa-tion can be collected using inexpensive self-report measures.The Child Behaviour Checklist [2] is an example of thistype of measure and was used in the survey to assessemotional and behavioural problems. It can be com-pleted independently by parents, adolescents or teachers.Identified problems are grouped as ‘externalising’ or‘internalising’ as well as in several narrower domains(e.g. aggressive behaviour, anxious/depressed). Higherscores reflect the presence of more problems. Recom-mended cut-off scores can be used to determine ‘case-ness’. A disadvantage of this approach is that results maybe difficult to interpret for those unfamiliar with thequestionnaires.

The alternative is the categorical approach employedin DSM-IV [3]. When this approach is used to identifymental disorders, structured interviews are conductedwith children and/or parents by trained lay interviewers.The advantages are familiarity with DSM-IV classifica-tion system in clinical services and the simple descrip-tors used to describe complex mental health problems.However, a disadvantage is the possibility that theapproach imposes a misleading dichotomy with childrenwho just fail to have the number of symptoms requiredto identify them as having a disorder, differing little fromthose who meet the criteria.

Boyle

et al

. [4] note that although DSM-IV is categorical,it acknowledges that disorders are dimensional by allowingsymptoms to be substituted for one another to achieve athreshold. For example, Attention-Deficit/HyperactivityDisorder, Inattentive Subtype (ADHD-I) requires at leastsix of nine inattention symptoms. In the Australiansurvey 5.8% of children were reported to have ADHD-Ion the basis of this criteria [1]. However, there wasconcern that the criteria may have been too broadleading to excessive numbers of children being identi-fied as having the disorder.

Michael Sawyer, Head, Research and Evaluation Unit (Correspondence); Brian Graetz, Project Manager, Research and Evaluation Unit; Peter Baghurst, Head,Public Health Research Unit Women’s and Children’s Hospital. 72 King William Road, North Adelaide, South Australia 5006. Email: [email protected]


Boyle

et al

. [4] suggest that case identification requiresrecommended thresholds which are sensible and non-arbitrary. This requires that children diagnosed withADHD-I on the basis of having 6 symptoms should bequalitatively different from those with 5 symptoms orless. We have examined the distribution of ADHD-Isymptoms and also determined the extent to which dif-ferent thresholds relate to parents’ perceptions of level ofimpairment and their perceptions of children’s need forhelp. This extends the approach we used to describe resultsfrom the Child Behaviour Checklist in the national childand adolescent mental health survey [1]. In the surveyreport we did not adopt a single cut-off score [1,2].Instead, we divided children into four groups with ‘veryhigh’, ‘high’, ‘moderate’ and ‘low’ levels of problems.We then compared functioning across the groups, andfound that as children experienced a greater number ofproblems, they also had increasing difficulties in otherareas such as suicidal ideation, health-related quality oflife and drug and alcohol use. There did not appear to bea threshold below which children did not have suchdifficulties.

Figure 1 shows the distribution of inattention symptomsreported by parents of children in the survey. A substantialnumber were identified as having no symptoms with anever-decreasing proportion having one or more symptoms.There is no obvious structure to this distributional patternwhich could be used to identify two subpopulations in thecommunity; one consisting of children considered to haveADHD-I and the other to be free of the disorder.

Figure 2 shows the percentage of children with eachsymptom level whose parents perceived that their symptomsimpaired children’s peer and school activities (defined asscoring in the lowest 10% of scores on the Child HealthQuestionnaire scale which assesses interference withschool and peer activities by emotional and behaviouralproblems) [5]. Lower levels of inattention symptoms areperceived by parents to have little impact on peer andschool activities with a steady increase in impact whenchildren experience higher levels of ADHD-I symptoms.However, there is no threshold at which there is a step-wise increase in the impact of symptoms on peer andschool activities that would suggest a subgroup experi-encing markedly greater problems than their peers. Fur-thermore, as the number of ADHD symptoms increases,so does the perception by parents that the children needhelp (see Fig. 2). Once again there was no point at whichchildren with fewer symptoms ceased to have a need forhelp. Rather, there was a steady increase in perceivedneed for help as the number of symptoms increased.

Although we have chosen for the sake of simplicity toshow these patterns using only symptoms which definethe ADHD-I, a similar pattern emerged when the focus

was on hyperactive-impulsive symptoms or on the fullset of 18 symptoms which comprise the Combined Sub-type. Our findings highlight the arbitrary nature of thethreshold used to identify ADHD-I in DSM-IV [3] aswell as the limitations of using a categorical approach todescribe mental health problems in the community.

It is not solely the role of researchers to determinethresholds above which children are considered to haveADHD and need help. Instead, they should identify the

Figure 2. Percentage of children who are impaired and percentage needing help. Bars represent per cent

needing help;

�

, per cent impaired.

Figure 1. Distribution of inattention symptoms


pattern of symptoms, the degree of impairment experi-enced by children with various levels of symptomatol-ogy, and parents’ perceptions of the need for help. It isthen the shared responsibility of clinicians, researchersand policy makers, to determine what level of symp-tomatology and impairment warrants help.

References

1. Sawyer MG, Arney FM, Baghurst PA

et al.

The mental health of young people in Australia

Canberra: Mental Health and Special Programs Branch. Commonwealth Department of Health and Aged Care, 2000.

2. Achenbach TM.

Manual for the Child Behavior Checklist/4–18 and 1991 profile

Burlington, VT: University of Vermont Department of Psychiatry, 1991.

3. American Psychiatric Association.

Diagnostic and statistical manual of mental disorders

, 4th edn. Washington, DC: American Psychiatric Association, 1994.

4. Boyle MH, Offord DR, Racine Y, Szatmari P, Fleming JE, Sanford M. Identifying thresholds for classifying childhood psychiatric disorder: issues and prospects.

Journal of American Academy of Child and Adolescent Psychiatry

1996; 35:1440–1448.

5. Landgraf JM, Abetz L, Ware JE Jr. Child health questionnaire (CHQ): a user’s manual. Boston, MA: The Health Institute, New England Medical Centre, 1996.

Towards an integrative developmental model

Alasdair L.A. Vance

Many dilemmas confront the clinician’s assessmentand treatment of children with ADHD. I wish to explorethese and also note the models that have attempted toaddress them. This may lead to an innovative model withpotential heuristic value and testable hypotheses.

Core symptom dimensions constitute an initial dif-ficulty. The relationship between hyperactive, impul-sive and inattentive symptoms remains unclear [1]. Isthe inattentive type distinct from the combined type; adifferent expression of the same disorder; or both atdifferent stages of development and in different con-texts in particular individuals? The age of onset ofthese core symptoms and their progression also variesconsiderably.

Comorbid conditions are increasingly recognized,regardless of subtype [2,3]. Oppositional Defiant Dis-order (ODD) is evident in up to half of the children witha combined type ADHD-CT; conduct disorder occurs in2–3% of children with pre-existing ADHD-CT andcomorbid ODD. Children with ADHD-CT and either ofthese comorbid conditions have worse verbal and visu-ospatial skills, lower full scale and verbal IQ and pooreracademic achievement. In addition, 20–30% of children

with ADHD, Inattentive or Combined type, have spelling,reading, writing and/or arithmetic learning difficulties.Anxiety occurs in a similar proportion, while depression,primarily dysthymic disorder, alone or co-occurring withmajor depressive disorder (so called ‘double depres-sion’), affects 15–30% of children with ADHD-CT. Incontrast, a vaguely defined ‘juvenile’ form of bipolar dis-order with marked irritability has been described. Fourcomments can be made about these comorbid patterns:they are common; parent and child reports are discordantand vary within individuals at different stages of develop-ment and in different contexts; the greater the numberof conditions, the more severe the ADHD-CT; and theresponse of ADHD-CT symptoms to short-term (upto 6 weeks duration) and/or longer-term (greater than3 months duration) psychostimulant medication and/orpsychotherapy targeting home and/or school environ-ments maybe diminished by comorbidity, particularlyanxiety.

Risk factors are either individual, interpersonal, familyor social [4]. Individual risk factors include the infant’stemperament (for example, decreased rhythmicity, adapt-ability, span and persistence of attention, and increased

Senior Lecturer, Consultant Child and Adolescent Psychiatrist, Department of Psychological Medicine, Monash University. Email: [email protected]


threshold of responsiveness and intensity of reaction);reduced verbal and visuospatial working memory andresponse inhibition executive function abilities; increasedsensitivity to noradrenergic activity; and decreasedself-esteem. Interpersonal risk factors include impairedrelationships with peers, parents and siblings. Familyfactors over the life cycle are parental psychopathology,decreased flexibility, adaptability, confiding, and nurtur-ing and increased hostile criticism and over-involvement.Social factors include lower socioeconomic statusand increased rigidity and inflexibility of attitudes andbeliefs about appropriate, responsible and accountablehuman behaviour, emotional expression and cogni-tion. These factors are not the cause of ADHD. Indeed,they vary in a given child at different points in devel-opment.

Psychostimulant and behavioural interventions havebeen the most studied treatments for ADHD-CT [5].Psychostimulant medication is a primary treatment modal-ity for children with ADHD-CT. In the short term (up to4–6 weeks), the core behavioural features of ADHD-CTand executive functions, such as response inhibition andverbal and non-verbal working memory performance,improve in 80%. In the longer-term (greater than3 months), this improvement may lessen; in contrast,improved executive functions persist. Therefore, con-structs of cognition such as executive function mayhelp us understand the reasons behind the poor behav-ioural response of a subgroup of children who are treatedwith medication in the longer-term [3]. These reasonsmay include the complex interplay of the interdependentvulnerabilities of executive functioning deficits, comor-bid conditions and psychosocial risk factors that repre-sent a final common pathway of a number of biologicaland psychosocial disturbances evident at particularperiods in early, middle and late childhood, resultingin ADHD-CT. Teacher and parent training programmesthat involve reinforcement of positive behaviour andresponse-cost procedures for undesired behaviour havebeen associated with short-term improvements in coresymptoms, academic performance, social skills, aggres-sion, and oppositional defiant behaviour. In addition, thepotential synergistic effect of behavioural interventionswith psychostimulants has been reported in the shortterm; in the longer-term, lower doses of medication wererequired in the combined medication and behaviourtherapy group compared to the medication alone groupin the 14 month NIMH Collaborative Study [6]. Futureresearch will need to aid the clinician to tailor validatedtreatments to the nature and severity of a child’s definedimpairments and disabilities, which vary in their relativecontribution at particular stages and within particularcontexts.

Contemporary conceptual models and a potential innovative approach

Four models have been used to address the dilemmasnoted above. (i) Pervasiveness of core symptoms hasbeen emphasized through the use of categorical anddimensional measures, to decrease sample heterogeneityand thereby to ensure study of the ‘true’ disorder. Highrates of comorbid conditions have limited the success ofthis approach. (ii) Equifinality and multifinality constructsfrom the developmental psychopathology discourse [7]and (iii) heterogeneity and pleiotropism models frombehavioural genetics [8] have been suggested to deal withthe confounding effects of the context- and development-dependent interplay of core and comorbid symptoms,risk factors and treatment response. (iv) Vulnerability,risk [9] and resilience [10] have also been proffered as aheuristic model that reflects the interplay of core symp-toms, comorbid conditions, risk factors and medicationand psychological treatment response in different con-texts and at different stages of development. While thesehelp cross-sectional description work, they are limited intheir power to determine the most appropriate priority ofkey symptoms, comorbidity, risk factors and treatmentresponse longitudinally. This limitation arises in partfrom the inability to address the greater degree of inter-dependence of the four key domains in ADHD com-pared to other disorders such as schizophrenia. Similarly, afactor of certain severity may be a risk factor in a givenpatient but be a resilience factor at a lower level ofseverity. Resilience factors were originally conceptual-ized as intra-individual in nature, whereas intra-individualand interpersonal aspects may apply.

A logical extension of the former three modelsaddresses the relatively greater degree of interdepend-ence of core symptoms, comorbid symptoms, risk/resilience factors and treatment response longitudinallyin a given child. Although this requires complex correla-tional statistics and large sample sizes, the advantagesfor clinician and researcher would be considerable. Justas chaos mathematics has demonstrated that complexorders of relationships can exist within apparent random-ness, a more useful pattern of significant statistical effectsmay exist in the relationships between core symptoms,comorbid conditions, key risk/resilience factors and med-ication and psychological treatment response than in thefour domains themselves.

References

1. Levy F, Hay DA, McStephen M, Wood C, Waldman I. Attention-deficit hyperactivity disorder: a category or a continuum? Genetic analysis of a large-scale twin study. Journal of the American Academy of Child and Adolescent Psychiatry 1997; 36:737–744.


2. Eiraldi RB, Power TJ, Nezu CM. Patterns of comorbidity associated with subtypes of Attention-Deficit/Hyperactivity Disorder among 6- to 12-year-old children. Journal of the American Academy of Child and Adolescent Psychiatry 1997; 36:503–514.

3. Vance ALA, Luk ESL. Attention Deficit Hyperactivity Disorder: progress and controversies. Australian and New Zealand Journal of Psychiatry 2000; 34:719–730.

4. Sandberg S, Day R, Trott GE. Clinical aspects. Olson S. Developmental aspects. Kado S, Takagi R. Biological aspects. Sandberg S, Garralda ME. Psychosocial contributions. In: Sandberg S, ed. Hyperactivity disorders of childhood. Cambridge: Cambridge University Press, 1996:69–110, 149–194, 46–279, 280–328.

5. Schachar R, Tannock R, Cunningham C. Treatment. In: Sandberg S, ed. Hyperactivity disorders of childhood. Cambridge: Cambridge University Press, 1996:433–476.

6. The MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for attention deficit hyperactivity disorder. Archives of General Psychiatry 1999; 56:1073–1086.

7. Cicchetti D. Reflections on the past and future of developmental psychopathology. In: Green J, Yule W, eds. Research and innovation on the road to modern child psychiatry, Vol. 1. Glasgow: Gaskell and the Association of Child Psychology and Psychiatry, 2001:37–53.

8. Skuse DH. Behavioural neuroscience and child psychopathology: insights from model systems. Journal of Child Psychology and Psychiatry 2000; 41:3–31.

9. Zubin J, Spring B. Vulnerability: a new view of schizophrenia. Journal of Abnormal Psychology 1977; 86:103–126.

10. Rutter M. Resilience in the face of adversity: protective factors and resistance to psychiatric disorder. British Journal of Psychiatry 1985; 147:598–611.

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