ATTENTION-DEFICIT/HYPERACTIVITY DISORDER

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CHAPTER TWO ATTENTION-DEFICIT/HYPERACTIVITY DISORDER

INTRODUCTION

In 1845, the German physician, Hoffinan, described, in a children’s storybook, a little boy who never learnt from his mistakes, was always abuzz with activity and always in trouble (Barabasz & Barabasz 1996:1). The Story of Fidgety Philip, one of these stories, highlights the fact that ADHD is not a new disorder. The debilitating symptoms of ADHD, and the consequences thereof, are accurately described in the poem. The rnisperception that the problems stern from naughtiness is clearly underscored. Today, more than one hundred and fifty years later, despite the vast amount of literature readily available for study, the symptoms of ADHD continue to be perceived in this negative light by many (Goldstein & Goldstein 1998:6).
A personal interest in ADHD was greatly enhanced by the extremely negative behavioural phenomena which manifested in certain children. The question arose: Why do some children with ADHD function reasonably well, at home and at school, whereas others are completely disruptive and aggressive? In a therapeutic setting, the latter group appeared to be sensitive, approachable children, and positive behavioural changes were noted. Yet, these positive changes did not transfer to the school and home environments, and their behaviour, in the classroom, playground and at home, continued to pose a challenge for teachers and parents alike.
An analysis of the above situation led to the conclusion that, in families where there is little emotional support, or there is instability or inconsistency, the behavioural problems are far greater. Goldstein and Goldstein (1998:xiii-xiv) reinforce this finding. They have come to recognise the symptoms of ADHD as a catalyst. They believe that, when these children are placed in a protective, nurturing environment, they may cause problems, but are not viewed as the « twentieth century equivalent of the devil ». Yet, in a chaotic, high-risk setting, the qualities of ADHD act catalytically, to further worsen the child’s outcome. Thus they argue, « that successful treatment of ADHD requires a balance between symptom relief and building in protective factors that enhance resilience, defined as the capacity to recover from stress and lead children to successful transition into adulthood ».
The focus of this chapter is on the historical background, the nature, aetiology and the assessment of ADHD, as well as associated disorders. The aim is to supply a scientifically balanced view of the problems associated with ADHD.

HISTORICAL BACKGROUND

« What is already passed is not more ftxed than the certainty that what is future will grow out ofwhat has already passed, or is now passing » George B. Cheever (Barkley 1990: 106). Earlier writings serve as antecedents to the current conceptualizations of the disorder and its treatments. They provide insight into this important developmental disorder and an appreciation of why our perspective on these children has arrived at its current status. Goldstein and Goldstein (1998:6) claim that the earliest referral to the symptoms of ADHD is possibly provided by John the Baptist in Luke 1:41, where John describes foetal hyperactivity as « the babe leapt in her womb ». They point out that similar childhood problems are alluded to in the early civilizations, and mention that the Greek physician, Galen, prescribed opium for « restless, colicky infants ».
At the tum of the century, behavioural problems were associated with brain damage. In 1902, in the United Kingdom, Dr George Still claimed that children whose behaviour was impulsive, hyperactive and inattentive, and who tended to be troublemakers, were suffering from organic disorders of the brain. He described these children as having « a lack of moral control ». Barkley (1990:5) states that today, these children would probably be diagnosed with Oppositional Defiant Disorder or Conduct Disorder, and would most likely also have some sort oflearning disability.
The notion that hyperactive children had suffered « minimal brain damage » or « minimal brain dysfunction » was reinforced by other researchers over the next three decades. Firstly, the effects on behaviour of encephalitis, a viral infection of the nervous system, were noted. Then, observations of brain injured soldiers who presented with behavioural problems also lent support to the assumption. This concept was reinforced in the late 1950s, when a study of these children revealed that their mothers suffered more complications during pregnancy than the mothers of children without behavioural problems. Unlike many other medical mysteries, where a large number of,possibilities are considered one by one, until, through a process of elimination, they are excluded as the central problem becomes clearer, researchers have moved from this narrowly defined conception to a broader notion. No longer is it considered\reasonable to explain the behavioural difficulties associated with ADHD as arising from brain damage, but rather, the idea of multiple possible causes and modes of treatment is entertained (Bain 1991 :41-42 In the 1960s, medical professionals started to take an interest in specific behaviours, and described the hyperactive child syndrome. Green (1995: 14-17) points out that the concept of hyperactivity remained the focus in the United Kingdom for many years.
In 1973, Dr Ben Feingold suggested a relationship between diet and hyperactivity. Green (1995:14-16) believes that the obsessive interest in diet over the next few years distracted attention from the complexity of the problems associated with ADHD, and from the well-proven benefits of stimulant medication. Whilst the use of stimulants rapidly increased thereafter, it was frequently impeded by media misrepresentation. Another assault on the use of stimulant medication which set back appropriate treatment by years, in Green’s opinion, was made by the Church of Scientology, who asserted that Ritalin was a dangerous and addictive drug. Rather than review the research literature, frightened parents, educationalists, psychologists, psychiatrists, paediatricians and policy-makers were swayed by what was printed in the press.
Goldstein and Goldstein (1998:7) acclaim Still’s insight, in that he not only noted that the pattern of behaviour found in children with ADHD was the possible result of injury, but that it may also be from heredity or environmental experience. The idea that symptoms of impulsivity, hyperactivity and inattention were biologically based became popular in the 1980s. The 1980s closed with most professionals viewing ADHD as a developmentally handicapping condition, generally chronic in nature, and with a strong biological or hereditary predisposition. It was felt that a significant negative impact was made on academic and social outcomes for many children. Its severity, comorbidity, and outcome were viewed as significantly affected by environment, especially family. « Critics blamed parents, schools and society at large for the increase in ADHD symptoms » (Goldstein and Goldstein 1998: 18). There were growing doubts about the central cause of attention deficits, and an increasing interest arose in possible motivational factors as the core difficulty in ADHD. It was recognised that effective treatment required multiple methods and professional disciplines working in concert, over longer periods of time. The view that environmental causes were involved was weakened by increasing evidence of the heritability of the condition and its neuroanatomical localization. Still, the belief that environmental/familial factors were associated with the type of outcome was strengthened. Treatment was extended to include parents and family, as well as to control children’s anger and improve their social skills. Tricyclic antidepressant medications were found to be effective in the treatment.
Bain (1991 :42) suggests that, as solutions have become more complex, « they have also become better designed to address the total needs of children with ADHD and their families ». Through the eighties and nineties, the idea became popular that ADHD is a lifetime disorder, affecting all areas of an individual’s functioning (Goldstein & Goldstein 1998: 19). « Today when the term ADHD is used, it refers to a child who has a small but definite difference in normal brain function which causes the child to underachieve academically, and to behave poorly, in spite of excellent parenting (Benn et al. Undated: I). Whist ten years ago, most ADHD children were « depicted as whirling dervishes who careened through life, leaving a swath of destruction in their wake », we know now that quite a large number are daydreamers, who find it difficult to organise themselves or to focus on the task at hand, making it difficult for them to meet the demands of everyday life (Ingersoll 1998:1).

THE NATURE OF THE  DISORDER

There continues to be disagreement about terminology and many researchers are of the opinion that the DSM-V may reconceptualise the disorder, perhaps as an impulse disorder. The consensus among practitioners is that the symptoms of ADHD affect a significant minority of the population, who « represent a poor fit between society’s expectations and these individuals’ abilities to meet these expectations » (Goldstein & Goldstein 1998:5 & 15). Furthermore, Goldstein and Goldstein (1998:3-4) point out that significant and pervasive impairment in a child’s day-to-day interaction with the environment is caused by the symptoms of ADHD. This ineffective interaction and the inability to meet expectations within one’s surroundings results in a long history of negative feedback, which impacts forcefully on the child’s emerging personality. The lack of success and consequent positive feedback from teachers and parents, which motivates other children, as well as rejection by their peers, who may, in fact, shun them, leads to them feeling fiustrated, angry and bad (Bain 1991:9). Train (1996:27-28) points out that the inability to focus, which is common to both the children with hyperactivity and without, hinders their capacity to form relations, and leads to a deterioration of behaviour, exacerbated when they commence school, since they find the work difficult.
Some researchers have argued that the problems with inattention, hyperactivity, and impulsivity are the result of cultural phenomena, whilst others point out the changing view that ADHD is a cross-cultural disorder (Goldstein & Goldstein 1998:9). Goldstein and Goldstein emphasise the biopsychosocial nature of the problem, and stress that « the severity of the child’s problems results from the interaction of temperamental traits and the demands placed upon the child by the environment.  » They suggest that, in earlier years, children with behavioural and scholastic difficulties would have been taken out of school and sent out to work, where their impulsive qualities may have driven them to success. Winston Churchill, Albert Einstein, Woody Allen (Green 1995:11), Mozart, Edison and Dustin Hoffman (Hallowell & Ratey 1995:268) are some of the influential people who channelled their activity, drive and single-mindedness to achieve greatness. Today, however, there is an increasing emphasis on the importance, from an early age, of controlling impulses, sitting still, paying attention and finishing tasks. Thus, children compromised in their ability to do so, are unable to integrate into and meet the expectations of our educational system. Nevertheless, there is no doubt that the problems vary across cultures.
Debroitner and Hart (1997:12) point out that the terms ADD and ADHD do not refer, scientifically speaking, to a specific disease, but rather to a cluster of symptoms, the definition of which depends on the subjective opinion of observers. Barkley (1995 :40) refers to the chronic difficulties in the area of inattention, impulsivity and overactivity as the « holy trinity ofADHD ». According to Parker (1994:4), ADHD is a neurobiological disorder. Some people with ADHD are exceptionally hyperactive and impulsive, others are most notably inattentive, and still others have a combination of all three traits. These different types of the disorder are described in the Fourth Edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV) published by the American Psychiatric Association in 1994:

• Attention-deficit/Hyperactivity Disorder, Predominantly Inattentive Type
• Attention-deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type and
• Attention-deficit/Hyperactivity Disorder, Combined Type.

The predominantly hyperactive-impulsive type, along with the combined type, make up the majority of children with attention-deficit/hyperactivity disorder. Probably a third of all children with the disorder are the predominantly inattentive type and do not show signs of impulsivity or hyperactivity. In order to qualify for a diagnosis, the individual must present with the symptoms of inattention, hyperactivity, or impulsivity, before the age of seven, and impairment must be present in two or more settings, (i.e. at school, playground, at home). There must be evidence of impairment in social, academic, or occupational functioning, and the symptoms must not be the result of another psychiatric disorder.

Characteristics

Parker (1994:5-6) describes the characteristics of ADHD, as published in the Fourth Edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV).

CHAPTER1 INTRODUCTION, ORIENTATION AND STATEMENT OF THE PROBLEM
1.1 INTRODUCTION
1.2 AWARENESS OF THE PROBLEM
1.3 EXPLORATION OF THE PROBLEM
1.4 STATEMENT OF THE PROBLEM
1.5 PURPOSE OF THE STUDY
1.6 DEFINITION OF CONCEPTS
1.7 LIST OF ABBREVIATIONS
1.8 METHOD OF RESEARCH
1.9 PROGRAMME OF THE STUDY
CHAPTER2 ATTENTION-DEFICIT/HYPERACTIVITY DISORDER
2.1 INTRODUCTION
2.2 HISTORICAL BACKGROUND
2.3 THE NATURE OF THE DISORDER
2.4 DIAGNOSIS OF ADHD
2.5 AETIOLOGY
2.6 AS SOCIA TED PROBLEMS/DISORDERS
2.7 CONCLUSION
CHAPTER3 INTERVENTION
3.1 INTRODUCTION
3.2 MEDICAL MANAGEMENT
3.3 PSYCHOLOGICAL MANAGEMENT
3.4 EDUCATIONAL MANAGEMENT
3.5 ALTERNATIVE TREATMENTS
3.6 CONCLUSION
CHAPTER4 DESCRIPTION OF THE EMPIRICAL STUDY
INTRODUCTION
HYPOTHESES
PURPOSE OF THE STUDY
RESEARCH DESIGN
CONCLUSION
CHAPTER5 THE IDEOGRAPHIC RESEARCH
INTRODUCTION
METHOD RESEARCH
RESULTS OF THE PROGRAMME
CONCLUSION
CHAPTER6 SUMMARY, CONCLUSION AND RECOMMENDATIONS
6.1 INTRODUCTION
6.2 MOTIVATION FOR THE STUDY
6.3 THE PURPOSE OF THE STUDY
6.4 METHOD OF RESEARCH
6.5 THE RESULTS OF THE EMPIRICAL STUDY 164
6.5.l Hypotheses
6.6 RECOMMENDATIONS FOR FURTHER RESEARCH
6.7 CONCLUSION
LIST OF APPENDICES
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