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Children and "Attention Deficit Hyperactivity Disorder (ADHD)" - An overview

 
 

Maybe your child has been diagnosed as having ADHD.  If so, you will probably have a number of questions, such as: How best can I help my child? Are the medications safe?  Is ADHD a life-long problem? But before we get to these very practical and important questions, I think we need to be clearer about what ADHD is (or isn't).

Although so-called adult Attention Deficit Hyperactivity Disorder (ADHD) is increasingly being talked about, in this website I will focus primarily on children and ADHD.

Much has been written about ADHD and variations such as Attention Deficit Disorder (ADD).  Researchers and authors are far from agreed on what it is and how it should be treated.  Part of the confusion is simply that ADHD has not actually been shown to be a specific medical disorder.

  Questions about ADHD  
     
 
 
   

Think about it this way - there are many reasons to have a headache - it could result, for example, from a sports injury, a night out partying, sinus problems, traumatic brain injury, a brain tumour, too much sleep, or its time to have your eyes tested.  ‘Headache’ is not a disorder, but symptomatic of other problems. Similarly with ADHD, there are countless reasons why a child can be excessively hyperactive, impulsive and inattentive – and extremely difficult to manage.  That does not make it a medical disorder.  We will see later on that there are a variety of non-medical reasons that lead to ADHD type behaviour and resorting to medicines in these situations would be as meaningless as using a painkiller when what you really need are new glasses.  And as we will see, ADHD drugs come at a cost – with potentially serious side-effects.

It is likely that you have been searching the internet for information on ADHD and may have come across various ADHD support groups. It may be helpful to realise that these are often heavily funded by drug companies making ADHD medications - as such, their views are not independent and they tend to uncritically support the drug treatments. You can read more about this here.

ADHD has not been shown to be a single neurobiological disorder

ADHD as we now know it is an American term that is used in the main book that categorises what the American Psychiatric Association classifies as mental disorders – The Diagnostic and Statistical Manual, DSM-IV. (DSM-5 replaced DSM-IV in 2013).  The term as it currently stands was introduced in 1987 on the basis of a committee decision rather than on supporting scientific evidence.  In fact, ADHD has not been shown to be a specific neurobiological disorder; hence diagnosis of any youngster is based on a check list of behaviours as there are no real objective scientific tests (such as blood tests, brain scans) to support it. The ADHD diagnosis is just one way of trying to account for lively and distracted children.

Lively and difficult to manage children have been given a whole series of mental diagnoses over the years. Back in the 1940s hyperactive behaviour was diagnosed as Minimal Brain Dysfunction (MBD).  Theorists (such as Dr Alfred Strauss) were convinced that this was caused by brain damage but research failed to show a link between hyperactivity and brain damage with these children.  Today a similar stalemate has been reached: claims that ADHD has a definitive neurological cause have not been proven to be true. Please note that I am not questioning the difficulties children and their parents face: I am simply challenging the misleading and unfounded idea that there is a single neurological and medical condition that can rightly be called ADHD; hence, I sometimes write "so-called ADHD", as I personally don't find the term helpful or meaningful.

Claims that specific defective genes associated with ADHD have been discovered have reached the popular press.  However, a closer look at the research reveals wishful thinking, not scientific discovery.  To date there are no anatomical, genetic, or biochemical markers to differentiate those children with the ADHD diagnosis from other children.  In the words of Professor Steven Rose, “There are no manifest structural or biochemical abnormalities in [the brains of] those diagnosed with ADHD 1”.

Beware of misleading press reports making unfounded claims

The popular press love a story that claims to show a genetic link to mental health issues. A study published in the Lancet here was covered in many newspapers and scientific magazines across the world. Headlines based on the press release included this Mirror one: “Kids inherit ADHD from mum and dad”.

Professor Thapar, one of the study authors, is quoted as saying: "Now we can say with confidence that ADHD is a genetic disease and that the brains of children with this condition develop differently to those of other children". Did this study really demonstrate that so-called ADHD is a genetic disorder? Let’s take a closer look.

The study claimed that children diagnosed as ADHD were more likely to have duplicate or missing segments of DNA. Although these chromosomal duplications and deletions (known as “copy number variants” - CNVs) were present in just 16% of the children diagnosed with ADHD, it was claimed that the study established a genetic basis for ADHD.  

Dr Oliver James made clear in a BBC radio interview that almost 9 out of 10 of the children did not have the gene supposed to cause it. In fact, only 57 of the 366 children diagnosed with ADHD in the study had the genetic variant assumed to be a cause of the disorder. And, as The Guardian’s columnist Dr Ben Goldacre pointed out: “What many reports did not tell you – including the Guardian – is that this same pattern of CNV was also found in 8% of the children without ADHD.”

Johnjoe McFadden, professor of molecular genetics, summarised the study conclusions this way: “Of 100 children who inherit the kind of mutation identified by the Cardiff group, only 4 of them will develop ADHD. The study is clearly not strong evidence for ADHD being a genetic disease…all diseases are caused by ‘a complex mix of genes and environmental factors’.  Claiming that a particular disease is genetic when the evidence is, at best, suggestive is misleading and potentially dangerous.”

One further factor: we do not know if (or to what extent) the genetic mutations could have been due to ADHD drug treatments, bearing in mind that “researchers have found that after just three months, every one of a dozen children treated for attention deficit/hyperactivity disorder (ADHD) with the drug methylphenidate [Ritalin] experienced a threefold increase in levels of chromosome abnormalities - occurrences associated with increased risks of cancer and other adverse health effects...Most of the abnormalities found in the studied blood cells consisted of chromosome breaks."

The wish to attribute ADHD-type behaviours to biology and/or genetics is understandable

It can can come as a welcome relief for a desperate parent to be told that their child's problems are biological and/or genetic. This is partly because it is often wrongly assumed that if it is not a medical condition it must be the parent's fault. I have no interest in blame. Within families countless interactions and events occur: what we each say and do affects one another. Learning how and when we affect one another does not have to be done with blame, guilt and shame.

Are some of these children simply especially gifted?

Gifted children are often distractible and up-and-about children; in fact, displaying similar tendencies to those diagnosed as ADHD. Take a look at this list of behaviours describing gifted children (taken from here):

BEHAVIORS ASSOCIATED WITH GIFTEDNESS (WEBB, 1993)

  • Poor attention, boredom, daydreaming in specific situations
  • Low tolerance for persistence on tasks that seem irrelevant
  • Judgment lags behind development of intellect
  • Intensity may lead to power struggles with authorities
  • High activity level; may need less sleep
  • Questions rules, customs and traditions

This is reminiscent of the great 18th century inventor Richard Trevithick whose brilliance led to the invention and production of the first steam locomotive. One of his school reports stated that he was "a disobedient, slow, obstinate, spoiled boy, frequently absent and very inattentive". I guess today he might have been considered "ADHD"!

All we like sheep have gone astray

In some ways, the ADHD diagnosis tells us as much (if not more) about our attitudes as a society and our tolerance (or intolerance) for active and distracted children. It's the difference between sheep and lambs. Every watched sheep? They spend most of their time eating, follow each other for no obvious reason, and when their lambs get curious and want to explore they are quick to call them back. But lambs are fun! They play together in groups, are curious to investigate other animals (such as my dog) and have "life is wonderful" written all over them (well, not literally!). As adults we tend to lose that spontaneity so typical of children (and lambs). We live in very different worlds and some of the ADHD concerns are, I think, a clash between these worlds.

NHS doctors questioning current thinking on ADHD

There are those working within the NHS who have serious reservations over the increasing diagnosis of children as having "ADHD". Among these, Dr Nick Radcliffe (Clinical Psychologist) and Prof. Dr Sami Timimi (Clinical Psychiatrist) question the way we think about and treat so-called ADHD in this chapter here. 2

Problem behaviour or just lively children?

It's fair to say that some children are hyperactive and distracted for very little reason other than that is the way they are. Anyone with two or more children will appreciate the wonder that children are so different, even from (maybe before) the moment of birth. It is, however, important to be clear that we are considering extremes of behaviour when referring to "ADHD" - bearing in mind that children and young people are by nature taken to being lively, impulsive and inattentive. Healthy children can of course be curious and distracted and this is not necessarily problem behaviour.

Essentially, the diagnosis for ADHD focuses on three main criteria: hyper-activity, impulsivity and inattention. Next we will take a look at some possible causes of hyper-activity, impulsivity and inattention here. We will then consider ADHD medications. Finally, we will put our thoughts to what might helpful, here.

 

References - Bibliography - Further reading

1 Rose, S. (2006) The 21st Century Brain: Explaining, Mending and Manipulating the Mind. UK: Vintage Books

2 Timimi, S. & Radcliffe, N. (2005) "The Rise and Rise of Attention Deficit Hyperactivity Disorder", Journal of Public Mental Health, Vol. 4 Iss: 2, pp.9 - 13. Chapter available here.

     
               
                 
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