What’s the fuss about ADHD?

Attention deficit hyperactivity disorder (ADHD), to use its full title, refers to a condition in which a child (or adult) displays excessive inattentiveness, hyperactivity and impulsivity.

These symptoms can occur in varying combinations, giving us three subtypes of the condition, namely the inattentive, the combined, and the hyperactive-impulsive subtypes. Studies suggest a worldwide prevalence of around 6% of school-going children. It seems to affect boys more than girls.

When I first joined the ranks of child psychiatry, I saw ADHD as a ‘grudge condition,’ something I had to study but couldn’t get excited about. I viewed it as dry and mundane, favouring the rarer, more exotic conditions, as many students do. But several years of private practice have changed my mind.

At international meetings, it is not uncommon to be assailed by organised demonstrations voicing opposition to our conference, our ‘pseudoscience’ and our profession, which ‘drugs children with mind-altering chemicals’.

This initially shocked me, cocooned as I was within the cloistered confines of my university training. Clearly, these people did not sing from the same hymn sheet. Far from being dry and mundane, ADHD has increasingly become the touchstone for many issues in child psychiatry and for matters pertaining to children in general.

Working with parents

When working with parents – largely educated, intelligent people – I spend as much time unraveling rhetoric as I do addressing the condition. I find this both challenging and frustrating; challenging because such questions force me to sharpen my own understanding of the current research, and frustrating because a typical consultation doesn’t allow me to do justice to a parent’s need for proper information. My book is an attempt to meet this need by providing unbiased information about the condition, information which is neither oversimplified at the one extreme, nor obscured by scientific jargon at the other.

This frustration, coupled with the idea (or shall I say necessity?) of taking a writing sabbatical, laid the foundation for What’s the fuss about ADHD? The book is an attempt to answer the pertinent questions around the disorder in a manner which is honest, taking due cognisance of the extant scientific research. It is supposed to be readable and informative at the same time. There are eight chapters, each inspired by a commonly posed question or controversy surrounding the condition. It is not a textbook, but I hope it is educational for both the layperson and the professional.

Fidgety Philip and the history of ADHD

Many parents ask me why ADHD was not around when they (or at least their grandparents) were at school. They are suspicious of a diagnosis which seems to be a recent fad, and alarmed at how many children are being prescribed medication for concentration difficulties. Indeed there have been accusations levelled at the pharmaceutical industry of having ‘invented’ the condition, after the fortuitous discovery of the cognitive benefits of the amphetamines. Chapter one deals with this myth, exploring the history of the disorder and tracing its earliest descriptions back to the time of Shakespeare! Furthermore, clinical descriptions of what we now know as ADHD, notwithstanding several name changes, are evident in the medical literature from as long ago as the eighteenth century.

Please test him for ADHD

There is something vaguely unsatisfactory about not having a ‘sciency’ test to diagnose a condition – which no doubt contributes to the proliferation of gimmicks such as the latest fad, the so-called quantitative electroencephalography or qEEG – but unfortunately that is where we stand.

The diagnosis of ADHD involves a checklist of symptoms which should be evident in more than one setting and which should be causing significant impairment in his or her daily functioning. Chapter two addresses the diagnosis of ADHD, making reference to the accepted Diagnostic and Statistical Manual criteria. This chapter highlights the common symptoms of the condition and stressing the importance of collateral information (from teachers and parents) and functional impairment as a necessary concomitant to confirming the diagnosis. The latter is particularly important as the symptoms commonly seen in ADHD can occur as part of normal childhood development, and can overlap with immaturity.

Orchids and dandelions

Chapter three covers the aetiology of ADHD. It is well established that ADHD is highly heritable. Family studies, twin studies and adoption studies all attest to the genetic underpinnings of the condition, although there is no specific genetic variant which can explain the expression of the ADHD phenotype.

Rather, there are several genetic variants, each with a relatively small contribution, acting in concert with one another and the environment, which is thought to underly the disorder. The environment thus plays an important role in the pathophysiology of the condition, and this section gives special attention to the importance of mother-infant attachment as a risk factor for ADHD.

There is a strong association between post-natal depression and ADHD, and the impact of maternal depression on attachment is at least one explanation for this link. The title of the chapter comes from a relatively new theory of genetics, called the orchid hypothesis.

The concept of ‘dandelion children’ has been around for a while, describing kids who are resilient and will cope in most circumstances. In contrast, ‘orchid children’ are particularly sensitive to their rearing conditions.

Given the right environment, they bloom spectacularly, but if neglected they quickly wither and wilt. Orchid kids are at higher genetic risk, including for ADHD, but these same risky genes carry with them a potential upside, which comes to the fore at certain crisis moments in the life of the individual or society. It’s an interesting evolutionary (and somewhat dissident) view of ADHD.

False positives and false negatives

There is much conjecture, in both the scientific literature and the lay press, about the perceived increase in the frequency of the ADHD diagnosis, and the widespread use of stimulant medications. There has in fact been a well-documented surge in rates of diagnosis of ADHD and in that of prescriptions for ADHD medications, so much so that is not uncommon to hear of the ADHD epidemic in current discourse.

Chapter four explores the possible reasons for this phenomenon, emphasising differential diagnosis of the condition, and how several conditions can masquerade as ADHD, including sensory impairments and other medical disorders, anxiety, depression, bipolar disorder and adjustment disorders.

Furthermore, there is increasing use of stimulants for cognitive enhancement, where there is no disorder at all. The chapter concludes with a reminder that, in poorer communities, ADHD is still widely under-recognised, thus denying many children potentially life-changing treatment.

Prevention is better than cure

Can ADHD be prevented? This may be a somewhat ambitious assertion at this stage, but given the extreme burden to society associated with this disorder, it would certainly be highly cost-effective if there were strategies available to prevent the development of ADHD in at-risk children, or at least modify its progression to the full ADHD phenotype.

Certain environmental risk factors are well-documented, such us smoking or alcohol use in pregnancy, insecure mother-infant attachment and early exposure to electronic screens. Given these known risk factors, it seems plausible and cost-effective to target antenatal classes in particular in order to dissemminate this important information.

My personal experience educating expectant parents is that they are a highly motivated and responsive target audience. The chapter also highlights a recent study conducted in preschoolers which demonstrates how the symptoms of ADHD can be modified in early childhood by an inexpensive and sustainable parenting intervention.

Dietary strategies for ADHD (and other ineffective treatments)

Despite the tongue-in-cheek title (I couldn’t resist), this chapter nonetheless addresses a serious theme. I am the first to advocate a balanced, healthy diet, together with other lifestyle factors such as regular exercise, sufficient sleep and minimising electronic screen time.

But unfortunately there is a constant stream of faddy, pseudoscientific remedies purported to address the symptoms of ADHD, including various dietary manipulations and supplements. Many desperate parents are lured into these plausible-sounding alternatives, in an attempt to avoid prescribed medications.

This has the effect of delaying much needed treatment for countless children with ADHD, with unnecessary morbidity the consequence. The basic outline of a randomised placebo-controlled trial is explained in layperson’s terms, in order to better equip the average parent in sifting through the proliferation of dubious ADHD ‘cures.’

What’s the fuss about medication?

It seems to me that in the field of medicine, there are few more emotive issues than this one. This is important to acknowledge, because emotions can distort our thinking. No parent takes kindly to negative feedback of any sort about their child.

We are naturally defensive about our offspring. When a teacher declares that a child ‘should go onto drugs,’ as often happens, one can understand how this suggestion will be met with parental resistance. The media also tends to sensationalise rather than provide a balanced (more boring?) account of an issue.

There is a silent majority of children and families for whom ADHD medication is life-changing, but these stories don’t seem to be heard. Perhaps they are less newsworthy? And of course, anyone can post anything on the internet.

But underneath the hype and hysteria, ADHD is a real condition associated with significant morbidity, for which there are evidence-based treatments. This chapter summarises the available medications for ADHD, their common side-effects and long-term safety profile. The available research around growth concerns, cardiovascular safety and substance abuse is summarised.

The reader is reminded that ADHD is itself associated with an increased risk for substance abuse, and that treatment of the condition, including the use of stimulants, in no way increases this risk, in fact several studies suggest the opposite, that treatment protects against later substance abuse.

Another important consideration is the rationale for continuous treatment versus drug holidays. There is some interesting research in the educational literature which speaks to this question, highlighting how school holidays influence overall academic progress. Other commonly asked questions are also explored, such as how to explain the need for medication to a minor child, and how long medication will need to continue before it is weaned.

Parenting a child with ADHD

Recent advances in our understanding of ADHD as a biological condition have, I suspect, had an unfortunate if unintended consequence. Armed with a steady stream of information about the neurochemical underpinnings of the disorder, too many parents and professionals have thrown the proverbial baby out with the bathwater. This overly reductionistic approach dismisses any parenting or lifestyle interventions in favour of psychopharmacology alone.

This is a concerning trend in many sectors of the community. Whilst we understand that ADHD is not caused by poor parenting, there remains a very important role for parents to play in the overall management of their child’s condition, and possibly even in the prevention of ADHD in the first instance, as discussed earlier.

In this chapter I stress the importance of parents leading by example. This might entail treatment of their own psychopathology (including ADHD) where relevant, but at least involves creating a conducive atmosphere in the home. The use of positive reinforcement and incentives is discussed, and there are some practical guidelines for notoriously difficult times of the day, such as early mornings before school and homework times.

Time to get off the soapbox?

On the front cover of this book is a man with a megaphone. He symbolises the strong emotions people feel about ADHD and its management. The book concludes with an exhortation to all of us: Doctors, therapists, teachers and parents, to get off our proverbial soapboxes, consider the established facts and focus on the needs of the individual children entrusted to us.

Fellow parent or professional colleague, I trust you will find these pages helpful in navigating the myriad of opinions and debunking the misinformation surrounding ADHD. My hope is that our children – present and future – will be the ultimate beneficiaries of better knowledge and understanding of this disorder.

Author: Dr Brendan Belsham, Child and adolescent psychiatrist, Johannesburg

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