Education and debate

Personal paper: Attention deficit hyperactivity disorder is underdiagnosed and undertreated in Britain

Commentary: Diagnosis needs tightening

Personal paper: Attention deficit hyperactivity disorder is underdiagnosed and undertreated in Britain

Geoffrey D Kewley, consultant paediatrician. 

Learning Assessment Centre, Horsham, West Sussex RH12 2PD

achorsham{at}aol.com

Attention deficit hyperactivity disorder is a condition of brain dysfunction ^{1 2} that is misunderstood and under-recognised in Britain. Research shows that it is a genetic, inherited condition that can be effectively managed. Studies of twins suggest an exceptionally high concordance,³ and genetic studies show a likely polygenetic basis for inheritance.⁴ Evidence of brain dysfunction has been found in cerebral imaging studies, including functional magnetic resonance imaging, quantitative electroencephalography, and positron emission tomography.⁵ If untreated the disorder may interfere with educational and social development and predispose to psychiatric and other difficulties. There is much myth and misinformation, fuelled by personal bias and the media, surrounding the existence and treatment of the condition, which has led to an assumption that it is overdiagnosed and overtreated in Britain.

Psychosocial approaches encourage the belief that poor parental discipline causes most children's behaviour problems. Such approaches generally ignore a biological basis to difficulties in self control, concentration, and hyperactivity. Widespread ignorance exists about attention deficit hyperactivity disorder and the need for drugs as a component of treatment. Trite and simplistic explanations for the symptoms of the disorder are perpetuated which encourage the view that merely naughty children are being diagnosed to absolve parental responsibility. Considerable care and expertise is essential in assessing children's emotional and behavioural problems to ensure accurate diagnosis. There are three main myths that need to be overcome: what constitutes attention deficit hyperactivity disorder, that the disorder is the same as hyperkinesis, and that the drugs used for treatment have serious side effects.

Confusion over nature of attention deficit hyperactivity disorder

Attention deficit hyperactivity disorder is a common but complex medical condition characterised by excessive inattentiveness, impulsiveness, or hyperactivity that significantly interferes with everyday life. The continuing presence of symptoms is essential for diagnosis. The condition manifests in many ways. For example, some children may be only inattentive; others may be persistently hyperactive; for some, hyperactivity may lessen with time. The wide range of possible presentations can be confusing. There are also many complications that may mask or overshadow the underlying core symptoms and worsen with time (box).

The core symptoms needed to be assessed both at home and school as does the functional impact of the complicating features. Children who are untreated and have conduct disorder are at much higher risk of later criminal activity.

Hyperkinesis versus attention deficit hyperactivity disorder

British professionals have traditionally used the more restrictive World Health Organisation and ICD 10 term "hyperkinesis," which means severe, persistent hyperactivity. Many people wrongly believe that attention deficit hyperactivity disorder is the less severe form of hyperkinesis. In fact, hyperactivity is just one possible feature of the disorder.

The DSM IV criteria of the American Psychiatric Association provide a broader, more realistic concept and include all possible manifestations of the disorder. Reliance on hyperkinesis as a benchmark of diagnosis excludes many children displaying other manifestations of attention deficit hyperactivity disorder, and these children are often denied appropriate management of their problems. Rutter et al noted 30 years ago that hyperactivity lessened with time but that it was often replaced by other problems, especially antisocial and learning difficulties.⁶

Myths about medical management

Ignorance of the role of drugs such as methylphenidate (Ritalin) as an essential component of multidisciplinary management of attention deficit disorder has encouraged further controversy. Drugs are highly effective in improving concentration and impulsiveness and lessening hyperactivity. Often an associated improvement occurs in many of the other difficulties, although second drugs may be needed. Methylphenidate has a dopaminergic effect; each dose lasts about four hours. Experienced adjustment of dose and timing is essential for optimum treatment. The media have greatly exaggerated the side effects. The incidence of side effects is low. They are transient and dose related. Research indicates that concern about long term tolerance, addiction, or growth suppression is unfounded.

View larger version (21K): [in this window] [in a new window]   Proportion of children receiving psychostimulants in United Kingdom, Australia, and United States

Children do not usually grow out of attention deficit hyperactivity disorder by puberty and treatment is indicated for as long as benefit is obtained. About 60% of sufferers still have the condition in adulthood.

Substantial national differences exist in rates of treatment in Britain, Australia,⁷ and North America⁸ (figure). British government data show that in 1995 up to 6000 children were being treated with psychostimulants.⁹ This equates to 0.03% of UK schoolchildren. As the incidence of severe hyperactivity in Britain is 0.5-1%,¹⁰ this demonstrates considerable undertreatment of the disorder.

Overseas experience shows that both paediatricians and child psychiatrists have a role in effective multidisicplinary management of attention deficit disorder. Cooperation with general practitioners and educational and counselling services is esssential for effective service provision.

Previous reports on provision and purchasing of community paediatric and child and adolescent mental health services have failed adequately to recognise the importance of attention deficit disorder in such services.¹¹ Professionals must understand the reality of the disorder and its importance as a public health issue for children and adults. Drugs have an essential role when combined with educational, psychological, and other strategies as appropriate.

References

1. Barkley RA. Attention deficit hyperactivity disordera handbook for diagnosis and treatment. New York: Guilford Press , 1991.
2. Cantwell DP. Attention deficit disorder: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry 1996; 35: 978-987[Medline].
3. Levy F, Hay DA, McStephen M, Wood C, Wildman I. Attention deficit hyperactivity disorder: a category or a continuum? Genetic analysis of a large scale twin study. J Am Acad Child Adolesc Psychiatry 1997; 36: 737-744[Medline].
4. Smalley SL. Genetic influences in childhood on psychiatric disorders. Autism and attention deficit-hyperactivity disorder. Am J Hum Genet 1997; 60: 1276-1282[Medline].
5. Kewley GD. ADHDa guide for parents and professionals. London: LAC Press (in press).
6. Rutter M, Graham P, Yule W. A neuropsychiatric study in childhood. London: Spastics International Medical Publications, Heinemann , 1970.
7. Australian National Health and Medical Research Council. Report of working party on ADHD. Canberra: Australian Government Publishing Service , 1996.
8. American Academy of Child and Adolescent Psychiatry. Practice parameters for the assessment and treatment of children, adolescents and adults with ADHD. J Am Acad Child Adolesc Psychiatry 1997; 36(suppl): 1311[Medline].
9. Parliamentary Office of Science and Technology. Treating problem behaviour in children. POST Tech Rep 1997; 92: 1-8.
10. Taylor E, Hemsley R. Treating hyperkinetic disorders in childhood. BMJ 1995; 310: 1617-1618[Full Text].
11. Williams R, Richardson G. Child and adolescent mental health services. Together we standthe commissioning, role and management of child and adolescent mental health services. London: HMSO , 1995.

Commentary: Diagnosis needs tightening

Eileen Orford, consultant child psychotherapist. 

Child Psychotherapy Trust, London NW5 4BD

cpt{at}globalnet.co.uk

Problems with the diagnosis of attention deficit hyperactivity disorder arise, at least partly, from the criteria for its diagnosis set out in Diagnostic and Statistical Manual of Mental Disorders (DSM IV) and ICD-10 (international classification of diseases).¹ These criteria are basically a list of symptoms. No indication of any underlying state is given. It is true that the criteria have been tightened up since earlier recognition of the condition and its original inclusion in DSM IV. However, Rutter's strictures as to diagnosis on the basis of a list of symptoms remain relevant, particularly with regard to those aspects of the criteria which pertain to attention deficit.²

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Many reasons exist for children being forgetful, preoccupied, and unable to attend to school work or indeed anything else. These include depression and anxiety about problems such as family, school, relationships with peers, and undisclosed and unresolved traumatic experiences, which may include abuse. Children whose difficulties arise from such situations will not respond to treatments which do not address the underlying reasons for the symptoms. Anyone considering a diagnosis of attention deficit hyperactivity disorder must thoroughly assess the child's situation at home and school and his or her state of mind. Investigation by questionnaire (as may be undertaken in some situations) is a blunt instrument unlikely to provide sufficiently sensitive information about a child's state of mind and behaviour.

Evidence is emerging from neurobiological investigations of patterns of hyperactivity linked to traumatic experience in infancy.³ Such experience establishes neural pathways in infancy analogous to those evoked in trauma, which then persist into later life. If these patterns are established (with their consequent effect on children's neurological and biochemical functioning and on their emotional development) a more substantial diagnostic category may come to be recognised. However, Perry et al's work suggests that pharmacological intervention alone is not adequate for treatment of the condition, and they and others suggest a package of measures which importantly include psychological therapies. ^{3 4} Such therapies involve work with parents and individual work with children. Psychoanalytic psychotherapy is often effective since it addresses the original emotionally traumatic experience and offers the child an opportunity to relearn and integrate new ways to manage his or her behaviour. Neurobiological theorists such as Schore stress the importance of recognising the emotional concomitants of the original experience if primitive neural pathways are to be superseded by higher level cortical functioning.⁵

Is attention deficit hyperactivity disorder overdiagnosed? The answer has to be yes if the condition of hyperactivity is confused with more widespread difficulties emanating from a variety of causes. If the disorder were redefined more closely in terms of hyperactivities dating from early life and seen in neurobiological and socioemotional terms, then progress could be made towards a more effective programme of treatment. In refining the diagnostic criteria and separating out problems in attending and concentrating from those of hyperactivity, we might be able to address both sorts of disturbance more effectively by taking account of their origins.

References

1. American Psychiatric Association. DSM IV. Diagnostic and Statistical Manual of Mental Disorders. Washington, DC: APA , 1994.
2. Rutter M. Syndromes attributed to minimal brain dysfunction in children Am J Psychiatry 1982;139:21-33.
3. Perry BD, Poland RA, Blakely TL, Baker WL, Vigilante D. Childhood trauma, the neurobiology of adaptation, use-dependent development of the brain, flaw states become traits. Infant Mental Health J 1995; 16: 271-291.
4. Taylor S, Samberg S, Thorley G, Giles S. The epidemiology of childhood hyperactivity. Oxford: Oxford University Press , 1991.
5. Schore A. Affect regulation and the origin of self. Hillsdale, NJ: Erlbaum , 1994.