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In cognition, mood and motor function children
are more capable and can exert more control than infants, but less so
than adults. The ADHD child is capable in these three areas of mental
function, but has problems in their control.
Attention-deficit/hyperactivity disorder refers
to problems with governing attentional resources (sustained, selective,
executive), and appropriately directing / inhibiting behaviour. The
feature of impulsiveness may cover both of these abilities (risk taking,
tantrums, gratification). The first signs usually appear
by the age of 6y (i.e. are often evident in pre-schoolers), symptoms
are maximal between the ages of 8 and 14y and attenuate
through adolescence. However, in a few of these areas of function the
effects may remain in some adults. There is evidence suggesting that
such a residuum underlies later social instability
(e.g. in partnerships, occupation, interactions with the authorities).
Any child can aggravate and frustrate the parent(s)
or care-giver according to these characteristics. It is their quantity,
quality and pervasiveness
that makes the distinction and offers grounds
for considering the descriptive term and diagnosis ADHD. To be successful
therapeutic help should be offered not only to the child, but to the
adults inevitably involved in supporting the child in his or her development
(e.g. care-giver, parent, teacher).
There are three
aspects of the use of the term ADHD
that can be a source of controversy and are of concern to researchers,
therapists and parents alike, albeit to varying degrees.
- · One
is the need to agree on and to be able to communicate about the
types of diagnosis possible
in different societies. In North America use of the Diagnostic and
Statistical Manual of the American Psychiatric Association (DSM-IV)
allows for an inattentive type, a hyperactive-impulsive type and a
combined type. It is therefore possible to have a diagnosis of ADHD
without being inattentive. In the International classification of
diseases (ICD-10) inattentiveness is necessary for a diagnosis, although
the disorder is called 'hyperactivity disorder' or hyperkinetic syndrome!
Gradually this gap is being bridged with the development of new instruments
for use in Europe and the Americas (e.g. 'hypescheme').
- · Second,
an area of current active investigation concerns the other features
that frequently occur alongside "ADHD" (the technical term is
'comorbidity').
These can come in three 'types': a)
with features of aggression in terms of verbal
or non-verbal behaviour against people, their 'rights' or property
[externalising features called oppositional or conduct problems],
b) with
features of emotional withdrawal (internalising features that
can include depression) and c)
other rather different disorders where hyperactivity
and problems with attention can be marked (e.g. complex tics, childhood
autism). The presence of such additional features must have an influence
on the form of therapy a clinician should offer, and thus it is a
matter of concern for current scientific investigation whether comorbidity
reflects a variant or a separate entity with separate aetiologies
and bases (a separate phenotype).
- · Third
no one should overlook that some of the overt features of "ADHD" can
reflect a quite different origin
or different problems from those embedded in
the developmental history, family or social environment of the ADHD
child. At a first look some ADHD-like symptoms can emerge as a result
of individual exposure to environmental toxins, allergic-like responses
to some diet characteristics, or reflect the very first signs of the
emergence of other illnesses (e.g. bipolar disorder).
This is why the pervasive problems of a child should be meticulously
examined by a Health-Services professional.
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