Abstract
Attention Deficit Hyperactivity Disorder (ADHD) is a controversial diagnosis. There are several reasons for this, including potential difficulties in acknowledging that children can develop mental health disorders, professional and lay concern over diagnostic criteria and defining boundaries with normal functioning, and concern relating to prescribing psychoactive medication. Nevertheless, Australian research using a representative community sample has enshrined a one year ADHD prevalence of 11% in 6 to 17 year olds, more than three times the rate of either Depressive or Conduct Disorder [1], and a figure dissonant with prescribing rates [2]. We will consider assessment and management from the perspective that ADHD is now out of step with conceptual thinking in the child and adolescent mental health field.
Developmental psychopathology and ecological– systemic child mental health perspectives share the assumptions that mental health outcomes are multidetermined and influenced by inherent protective, risk and vulnerability factors and by the transactions between such factors and environmental events. Environment is broadly defined and the concept is not dissimilar to a systemic perspective involving the interplay of family, ethnicity, cultural factors and variables such as poverty and unemployment. The stress-vulnerability model is consistent with this perspective. Thus, disorder follows interaction with an intercurrent stressor that leads to maladjustment or failure to negotiate developmental tasks. Vulnerability is hypothesized to be endogenous to the individual and latent, but exposed in response to an environmental challenge. Vulnerability factors are stable, especially biological, while affective, cognitive or psychosocial factors are more amenable to change [3]. Lastly, presentations are never interpreted as cross-sectional but rather as episodes in continuities linked to an earlier ecology or novel discontinuities.
Developmental psychopathology and assessment of ADHD
Assessment must consider diagnostic criteria to confirm the symptom domains of impulsivity, hyperactivity and inattention. However, reaching a diagnosis is necessary but not sufficient to assess and treat ADHD. Diagnosis allows communication with other health professionals and treatment informed by the research base that defines ADHD as an entity. However, a classificatory system like DSM-IV [4] must include developmental factors, for instance, whether symptoms are more frequent and severe than experienced by others of comparable age, whether disturbance occurs in many settings and whether functional impairment is present. DSM-IV also requires assessment of transactional considerations: the relationship of symptoms to intelligence and degree of setting stimulation, the prevalence of ADHD in first-degree relatives, medication adherence and cultural differences. This system relies heavily on the assessment and recording of diagnostic comorbidities to adequately describe the full symptomatology.
What of the stress-vulnerability model and ADHD assessment? Ingram et al. separate potential vulnerability factors into cognitive, affective, psychosocial and biological variables [3]. Neuropsychological research has been hampered by difficulties in defining the concept of attention and its relationship to working memory and executive functioning [5, 6]. However, in ADHD difficulty with more effortful cognitive tasks, but not involving language functions [6], and deficits in planning, organization and working memory are found [5].
Affective vulnerability factors, including affect dysregulation problems, possibly relate to insecure attachment, parental intrusiveness, over-stimulation and exposure to abuse [7]. Psychosocial vulnerability factors cover social incompetence and deficits in communication and self-control. Lastly, molecular and genetic research implicates potential biological vulnerabilities such as abnormalities in the dopamine transporter system and DRD 4 receptor genes.
A developmental approach considers the following during assessment: whether the presenting symptoms are related to issues noted in the first years of life and preschool experience and are continuities from these periods or are more recent; whether the child's selfregulation difficulties include mood regulation as well as impulsivity and activity; potential management issues stemming from relational issues with significant adults; the child's belief system about their difficulties and the diagnosis (e.g., do they consider their impairment to be non-malleable); and whether the child carries a familial– genetic or neuropsychological vulnerability. Knowledge of more far reaching vulnerability also gives rise to the appreciation that current neuropsychological testing, including computer-aided tests of attention, are not sufficiently sensitive. Furthermore, special investigations provide low yields and should not be undertaken unless indicated on medical history or examination [8].
A developmental perspective on management
An inevitable effect of the developmental perspective is that there can be no single treatment. Although children may display core psychopathology they arrive at this point via diverse pathways, with a mix of vulnerability, risk and maintaining (prognostic) factors. Further, referral filters make it likely that children managed in different settings will differ in terms of the severity and range of psychopathology. For instance, Western Australian research has found that inpatient and outpatient children differ in terms of internalizing and externalizing symptoms, family functioning, parental mental health and parental alcohol use [9]. Viewed from a developmental perspective the clinical presentation may reflect differences between children and families seen by paediatricians, psychiatrists, and those presenting at developmental and mental health clinics.
Developmentally based treatment examines for parental mental ill health, their resources and their own experience of parenting. Knowledge of the school enables behaviour modification like token economies and positive reinforcers [10], or remediation for comorbid learning disorders. Recent approaches to adverse peer influence encompass proactive efforts to assist the child to replace such relationships with more prosocial role models. Knowledge of neighbourhood factors facilitates identifying neighbourhood resources. Treatment also targets any functional impairment. Social skills training [10] may be indicated although its effectiveness is unclear [8].
Risk factors like poverty are not specific targets of developmental interventions. Vulnerability factors are targeted only if they are also persistent prognostic variables, for example, coercive parenting in the case of comorbid conduct disturbance. Use of medication is consistent with a developmental perspective, prescribing stimulants, antidepressants and Clonidine as an adjunct [10] is evidence-based. There is little evidence for anticonvulsant use. The side-effect-benefit ratio usually precludes neuroleptics [10]. Developmental issues influencing medication include caution prescribing for younger children and where possible using low doses, avoiding polypharmacy, considering the risk of substance abuse in adolescents and of their tablets being accessible to friends. Advances in pharmacogenomics may allow future individualized prescribing in order to maximize effectiveness and minimize side-effects.