The Complete Guide to ADHD

Nature, Diagnosis, and Treatment

Katerina Maniadaki, Efhymios Kakouros

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781315316024
• Edition: 1
• Topic: Psychology
• Subtopic: Attention-Deficit Disorder (ADD-ADHD)
• Index: Psychology

This exciting new resource offers a comprehensive guide to ADHD, the most frequently diagnosed neurodevelopmental disorder and one of the most researched areas in child mental health. It brings together high-level research with the latest scholarship and applies them to practice, providing a unique and innovative perspective. Inside readers will find a critical presentation of current scientific knowledge regarding the nature, etiology, diagnosis, and management of the disorder. The book covers ADHD from infancy to adulthood and presents the whole range of possible comorbidities. The authors explore the topic from the perspective of researchers, academics, and clinicians while also offering a structured assessment procedure, a complete early intervention and treatment program, as well as illuminative case studies and practical tools for educators.

Part I
The Nature of ADHD

1 The History of ADHD

1.1 Introduction

Knowledge of the historical background of a disorder is essential for any scientist who wishes to study it in depth and gain a global understanding of the factors that have influenced the current conceptualization of the disorder. In clinical practice, history taking, which informs on the evolution of an individual, is indispensable for the establishment of a diagnosis. Similarly, knowledge on the evolution of scientific thought regarding a specific disorder over time is vital for better understanding the disorder.

The study of the appearance of ADHD as a diagnostic category contributes to a better comprehension of prevalent cognitions in different eras, on the basis of which different kinds of interventions have been proposed for its treatment. The importance of this study is also reinforced by the fact that over the course of a century of scientific research, many views of the pioneers in the investigation of the disorder reappear in the forefront and have a direct impact on the formulation of contemporary theories of ADHD.

Since the first reports on symptoms currently considered typical of ADHD, there has been ongoing controversy over its nosological structure and empirical validity (Insel, 2013). Various terms have been used to describe the range of symptoms that appear under the umbrella of the disorder. In some cases, this range was extended to include more symptoms while, in other cases, it was shortened on the grounds that some of the symptoms were considered as more relevant to other disorders. These changes in nomenclature were closely associated with the symptoms that were regarded as predominant in each era, as well as with the theories that prevailed regarding the etiology of the disorder.

1.2 The Historical Roots of ADHD: The Period Until 1900

Sporadic references to individuals with characteristics currently attributed to ADHD can be found even in ancient times. For instance, the Greek physician Galen often used to prescribe opium for restless, hyperactive children (Goodman & Gilman, 1975). Furthermore, relevant reports are also encountered in literature. For example, Shakespeare made reference to a malady of attention experienced by one of the characters of his play, Henry VIII (Barkley, 1996). In medical and broader scientific literature, however, the history of the disorder spans two and a half centuries.

For many years, the first scientific reports on symptoms of this disorder were accredited to the British physician George Still (1902) and, particularly, to the lectures he delivered at the beginning of the 20th century. These reports will be thoroughly discussed in Section 1.3.1.

Recently, however, Barkley and Peters (2012) discovered a medical textbook dated back to 1775, a century prior to Still’s descriptions, under the authorship of the German physician Melchior Adam Weikard. This discovery was made owing to a report by the Australian chemist John Gould, and is believed to be the first known scientific reference to ADHD symptoms. In this book, there was a chapter on “Attention Deficits” (Attentio Volubilis) as part of a wider section on “Sicknesses of the Spirit” (Geisteskrankheiten). This chapter described adults and children who were inattentive, hyperactive, and impulsive, also characterized by poor effort and low persistence. According to Barkley and Peters, most of Weikard’s descriptions show considerable overlap with attention problems believed to exist in ADHD, as it is currently conceptualized in contemporary diagnostic manuals. Weikard implied that the aforementioned difficulties could result from poor upbringing or child-rearing, but he also accepted biological predisposition. For their treatment, he recommended sour milk, steel powder, horse riding, and even seclusion for severe cases.

The next known reference to symptoms associated with ADHD appears in a book of the Scottish physician Alexander Crichton, dealing with an inquiry into the nature of mental disorders (Crichton, 1798). This textbook included a chapter on ‘attention disorders’ and was discovered by Palmer and Finger (2001). In this book, Crichton claimed that attentional problems were a consequence of either hereditary factors or accidental diseases to which the person has been exposed. These diseases affect the nerves and the brain. Crichton argued that early education of children could serve to enhance attention, especially if tailored to individual variation in personal interests and motivation.

In 1809, John Haslam provided a case history of a 10-year-old boy who was indulged, mischievous, and uncontrollable. He was considered “the terror of the family” (p. 199). Three years later, the famous American physician Benjamin Rush (1962/1812) described a syndrome involving the inability to focus attention and speculated on the “defective organization in those parts of the body which are occupied by the moral faculties of the mind” (p. 339).

In the middle of the 19th century, the German pediatrician Heinrich Hoffman (1865) published a children’s book of didactic poems based on his clinical observations, and described various psychological conditions among children (see Stewart, 1970). In this book, there is a poem titled Fidgety Philip, which seems to portray the case of a child with disruptive behavioral problems. Presently, this child could easily be diagnosed as having ADHD, Hyperactive/ Impulsive Presentation, using DSM-5 criteria (Martinez-Badía & Martinez-Raga, 2015). There is also a second one, titled Johnny-Head-in-Air, which describes a boy who is constantly distracted by external stimuli and is highly inattentive over a broad range of activities. However, these descriptions cannot be acknowledged as medical descriptions. As Taylor (2011) notes, Hoffman “presents an interesting and influential picture of children as active agents, making their own lives, and as complex beings, in contrast to the age’s contradictory and polarized views of children as angels or as savages” (p. 71). Fidgety Phil has nevertheless become a commonly used allegory for ADHD.

Representative excerpts of these two poems are cited below:

The story of Fidgety Philip

“Let me see if Philip can

Be a little gentleman;

Let me see if he is able

To sit still for once at table.”

Thus spoke, in earnest tone,

The father to his son;

And the mother looked very grave

To see Philip so misbehave.

But Philip he did not mind

His father who was so kind.

He wriggled

And giggled,

And then, I declare,

Swung backward and forward

And tilted his chair,

Just like any rocking horse;—

“Philip! I am getting cross!”

The Story of Johnny Head-in-the-Air

As he trudged along to school,

It was always Johnny’s rule

To be looking at the sky

And the clouds that floated by;

But what just before him lay,

In his way,

Johnny never thought about;

So that everyone cried out,

“Look at little Johnny there,

Little Johnny Head-in-Air!”

Running just in Johnny’s way

Came a little dog one day;

Johnny’s eyes were still astray

Up on high,

In the sky;

And he never heard them cry

“Johnny, mind, the dog is nigh!”

Bump!

Dump!

Down they fell, with such a thump,

Dog and Johnny in a lump!

Two years later, in 1867, the British psychiatrist Henry Maudsley published his book The Physiology and Pathology of the Mind, where he described the case of a child who manifested strong impulsivity and destructive behavior. In the United States, the American philosopher, psychologist, and physician William James (1890/1950) described a normal variant of character—which he called “explosive will”—in his textbook Principles of Psychology. This variant was characterized by difficulties similar to those observed in individuals with ADHD. In 1899, the Scottish psychiatrist Sir Thomas Clouston reported three cases of children who presented hyperexcitability, hypersensitiveness, mental explosiveness, and learning difficulties.

In France, the concept of ADHD has its roots in the description of children and adults with attention problems by Jean-Etienne Dominique Esquirol (1845). Furthermore, Désiré-Magloire Bourneville (1895) noted that some children and adolescents who were treated at the Bicêtre Hospital in Paris suffered from attention and behavioral problems. Finally, according to Bourneville (1895), one of his students, Charles Baker, provided in his 1892 thesis a clinical description of four children with symptoms of hyperactivity and impulsivity.

1.3 The Period 1900–1960

1.3.1 George Still’s Descriptions and Viewpoints

In 1902, George Still, the founder of pediatrics in England, presented a series of three lectures to the Royal College of Physicians under the name Goulstonian lectures. The same year, these lectures were published in the Lancet. This is considered as the scientific starting point of the history of ADHD (Lange, Reichl, Lange, Tucha & Tucha, 2010). In this seminal paper, Still described 43 children who presented with severely impaired sustained attention and self-regulation. Most of these children were also hyperactive and impulsive. Many were often aggressive, defiant, resistant to discipline, and excessively emotional. They seemed to be entirely driven by emotion and not at all by intellect. They had difficulty controlling their behavior, and one of their main characteristics was their proneness to immediate gratification. This problem resulted in the children’s inability to internalize rules and boundaries. Therefore, they seemed to be insensitive to punishment, even physical, and unable to learn from the consequences of their actions. Intellectual ability of this population varied from mental retardation to normal levels.

According to Still, these children displayed a major defect in “inhibitory volition” and “moral control.” In fact, this view is consistent with James (1890), the prominent American philosopher, psychologist, and physician who supported that sustained attention constitutes an important part of the moral control of behavior. James indicated that “effort of the attention is the essential phenomenon of will.” This view might have provided the philosophical foundation of current ADHD conceptualization (Martinez-Badía & Martinez-Raga, 2015). Still (1902) believed that moral control derives from a cognitive comparison between a person’s action and an action that conforms to “the idea of the good of all” (p. 1008). Therefore, these children have great difficulty inhibiting a behavior that is inappropriate with reference to moral rules due to deficits in this cognitive mechanism of comparison that Still called “moral consciousness.”

According to Barkley (1998a), this idea of comparing an individual action to a general rule involves two capacities: first, understanding the long-term consequences of one’s actions and, second, keeping in mind information about oneself and one’s actions along with information about the moral rule against which these actions must be compared. These views are closely associated with the contemporary concepts of self-awareness, working memory, and rule-governed behavior, which constitute central concepts in contemporary theories of ADHD.

Still considered that volition and moral control of behavior develop gradually in children, hence these mechanisms are less developed in younger children. He proposed the use of age-referenced criteria in order to determine if these mechanisms are adequately developed in a child. During this assessment, we should take into account individual differences in development, which are influenced by both environmental and inherent factors. Still was the first to suggest a developmental approach to the diagnosis of this disorder.

In Still’s opinion, the causes of the disorder were biological. In accord with James’s theory, he assumed that there is a causal relationship among inhibitory volition, moral control, and sustained attention and that their insufficient or deficient development is the result of the same underlying neurological impairment. He contended that the disorder could be either the result of hereditary predisposition or of prenatal or postnatal injury. In some cases, this behavior was secondary to an acute brain disease that had caused some type of brain dysfunction and was likely to improve upon recovery from the disease. However, this pattern of behavior could also lead to chronic impairment, thus raising the risk for manifestation of criminal acts during adulthood. Therefore, Still believed that any biological dysfunction that could cause significant brain damage might, in its milder form, lead to deficient development of moral control.

Although many of the children described by Still came from a chaotic family environment, others came from families who provided a seemingly proper upbringing. Still believed that children growing up in dysfunctional families should be exempt from the category of lack of moral control; he reserved it for children who displayed failure of moral control despite the positive impact of a favorable family environment (Barkley, 2015a).

Still’s descriptions constitute a significant milestone in the conceptualization of the constellation of symptoms that are nowadays identified as ADHD. Although Still’s work did not seem to have any influence at the time, several of his observations were corroborated 50 years later (Taylor, 2011). Still was the first to observe that in most cases the disorder occurred before 8 years of age, with a ratio of 3:1 in favor of males.

Additionally, he noted that conditions like alcoholism, criminality, and affective disorders were more commonly present among the biological relatives of these children. According to Still’s reports, some of these children manifested Tic Disorders (TDs). This was perhaps the first time that comorbidity between ADHD and TDs had been recognized. The preceding observations were bolstered by numerous subsequent studies (see Chapter 7). Finally, Still’s demonstration of a connection between brain damage and deviant behavior was highly influential. However, Still did not refer exclusively to children who would receive an ADHD diagnosis nowadays, but he included the full range of current externalizing disorders in his descriptions (Conners, 2000a).

Later, Tredgold (1908) and Pasamanick, Rogers, and Lilienfeld (1956) would return to Still’s views, supporting that learning and behavioral problems may be caused by some form of mild undiagnosed brain damage. Both Still and Tredgold concluded that medications or alterations in the environment could lead to temporary improvement in the symptoms of the disorder. However, they considered them as developmentally static conditions. The need for special education environments for these children was specifically emphasized at the time.

Around the same time period, in Spain, the physician Rodriguez-Lafora (1917) described a group of children with psychopathic constitutions whom he called “the unstables.” These children presented with intense inconstancy of attention, excessive activity, impulsive behavior, and the tendency to get carried away by their “adventurous temperament.”

To conclude, the origins of many current notions about ADHD, Oppositional Defiant Disorder (ODD), Conduct Disorder (CD), and Specific Learning Disorder (SLD), diagnoses that would probably be given today to the children described by Still and Tredgold, can be traced in the relevant scientific views that developed at the beginning of the 20th century. However, it took the scientific community almost 70 years to return to some of them. One of the main reasons for this delay was the prevalence of the psychodynamic views, which emphasized the role of upbringing in the development of behavioral problems in children (Barkley, 2015a).

1.3.2 Minimal Brain Damage (MBD)

In 1917–1918, following a world outbreak of encephalitis epidemic, clinicians were called in to deal with the numerous cases of children who had survived but exhibited remarkably abnormal behavior with major cognitive and behavioral deficits (Cantwell, 1981; Kessler, 1980). These deficits included impaired attention, impulsivity, excessive motor activity, learning difficulties, impairment in cognitive functions (including memory), emotional instability, and antisocial behavior (Ebaugh, 1923; Stryker, 1925). This pattern of behavior, which has notable similarities with the current notion of ADHD, was clearly the result of brain damage, and was described as postencephalitic behavior disorder. The prognosis of these children was rather pessimistic. However, interventions developed on the basis of simple behavioral techniques reported significant improvement (Bender, 1942; Bond & Appel, 1931).

The assumption of a causal connection between brain damage and deviant behavior led researchers to study other potential causes of brain injury in children, including birth trauma (Shirley, 1939), epilepsy (Levin, 1938), and exposure to toxic substances (Byers & Lord, 1943). These conditions were associated with a great number of cognitive and behavioral impairments. Many of these children also had mental retardation and more severe behavioral problems compared to children diagnosed with ADHD today. During this era, however, researchers did not attempt to differentiate the impact of mental retardation, learning disabilities, or other neuropsychological disorders from the impact of behavioral problems on the maladjustment of these children (Barkley, 2015a).

Other researchers (Blau, 1936; Levin, 1938) noted a resemblance in behavior between hyperactive children and monkeys with a frontal lobe ablation. Some researchers relied on this similarity to postulate that severe hyperactivity in children might be the result of frontal lobe damage, even if this could not be demonstrated neurologically (Levin, 1938). Such evidence was, however, provided by subsequent studies (Chelune, Ferguson, Koon, & Dickey, 1986; Lou, Henriksen, & Bruhn, 1984; Lou, Henriksen, Bruhn, Borner, & Nielsen, 1989). On the other hand, milder forms of hyperactivity were attributed to psychological causes, such as negative child-rearing practices and pathogenic family structures.

The Second World War also gave many researchers the opportunity to study a vast number of people with head traumas, among other wounds. It was discovered that injury to any part of the brain often resulted in hyperactivity, restlessness, and overaroused behavior (Goldstein, 1942).

Under these circumstances, the theory of MBD was born (Strauss & Lehtinen, 1947). This diagnosis was given to children on the basis of their behavioral characteristics, even when neurological evidence of such damage was insufficient or even absent (Dolphin & Cruickshank, 1951). However, the most notable contribution of this approach to understanding psychopathology lies in the fact that it prompted researchers to realize that at least some disorders might be associated with organic causes.

As far as intervention is concerned, in their influential paper, Strauss and Lehtinen (1947) recommended alterations in the educational environment of these children and placement in smaller, better controlled classrooms, with limited distracting stimuli such as bright colors and pictures on the walls. As a result, strikingly austere classrooms were developed in the United States. Teachers were instructed to avoid jewelry or colorful clothes, and walls did not have any posters or pictures, despite the fact that scientific proof of the efficacy of this practice has never been provided (Zentall, 1985).

Around this time period (1937–1941), a series of clinical reports were published concerning medical treatment of child psychopathology in general and behavior disorders in particular (Bradley, 1937; Bradley & Bowen, 1940). In 1937, Charles Bradley, a Rhode Island psyc...