Attention-Deficit/ Hyperactivity Disorder Russell A

2. Attention-Deficit/Hyperactivity Disorder 75 CHAPTER TWO Attention-Deficit/ Hyperactivity Disorder Russell A. Barkley It is commonplace for children (especially pre- self-destructive ways have captured public and schoolers) to be active, energetic, and exuberant; scientific interest for more than a century. Diag- to flit from one activity to another as they explore nostic labels for inattentive, impulsive children their environment and its novelties; and to act have changed numerous times over the last cen- without much forethought, responding on im- tury; yet the actual nature of the disorder has pulse to events that occur around them, often changed little, if at all, from descriptions nearly with their emotional reactions readily apparent. a century ago (Still, 1902). This constellation of But when children persistently display levels of behavior problems may constitute one of the activity that are far in excess of their age group; most well-studied childhood disorders of our when they are unable to sustain attention, inter- time. Yet these children remain an enigma to est, or persistence as well as their peers do to their most members of the public, who struggle to ac- activities, longer-term goals, or the tasks assigned cept the notion that the disorder may be a bio- to them by others; or when their self-regulation logically rooted developmental disability when lags far behind expectations for their develop- nothing seems physically, outwardly wrong with mental level, they are no longer simply express- them. ing the joie de vivre that characterizes childhood. Children possessing the above-described attri- They are instead highly likely to be impaired butes to a degree that is deviant for their devel- in their social, cognitive, academic, familial, and opmental level sufficient to create impairments eventually occupational domains of major life in major life activities are now diagnosed as activities. having attention-deficit/hyperactivity disorder Highly active, inattentive, and impulsive young- (ADHD; American Psychiatric Association, 1994). sters will find themselves far less able than their Their problematic behavior is thought to arise peers to cope successfully with the universal de- early in childhood, and to be persistent over developmental progressions toward self-regulation, velopment in most cases. This chapter provides cross-temporal organization, and preparation for an overview of the nature of this disorder; briefly their future so evident in our social species. And considers its history; and describes its diagnostic they will often experience the harsh judgments, criteria, its developmental course and outcomes, punishments, moral denigration, and social ostra- and its causes. Current critical issues related to cism reserved for those society views as lazy, un- these matters are raised along the way. Given the motivated, selfish, thoughtless, immature, and thousands of scientific papers on this topic, this willfully irresponsible. These heedless risk-taking chapter must of necessity concentrate on the children with the devil-may-care attitudes, and most important topics in this literature. Readers 75 76 II. BEHAVIOR DISORDERS interested in more detail can pursue other familial predisposition to the disorder, likely of sources (Accardo, Blondis, Whitman, & Stein, hereditary origin; and yet (5) the possibility of the 2001; Barkley, 1998; Weiss & Hechtman, 1993). disorder’s also arising from acquired injury to the My own theoretical model of ADHD is also pre- nervous system. sented, providing a more parsimonious account- Interest in these children arose in North ing for the many cognitive and social deficits America after the great encephalitis epidemics of in the disorder; this model points to numerous 1917–1918. Children surviving these brain infec- promising directions for future research, while tions had many behavioral problems similar to rendering a deeper appreciation for the develop- those seen in contemporary ADHD (Ebaugh, mental significance and seriousness of ADHD. As 1923; Hohman, 1922; Stryker, 1925). These cases will become evident, continuing to refer to this and others known to have arisen from birth disorder as one involving attention deficits under- trauma, head injury, toxin exposure, and infec- states a more central problem with inhibition, tions (see Barkley, 1998) gave rise to the concept self-regulation, and the cross-temporal organiza- of a “brain-injured child syndrome” (Strauss & tion of social behavior. Lehtinen, 1947), often associated with mental retardation, that would eventually be applied to children manifesting these same behavior fea- HISTORICAL CONTEXT tures but without evidence of brain damage or retardation (Dolphin & Cruickshank, 1951; Literary references to individuals having serious Strauss & Kephardt, 1955). This concept evolved problems with inattention, hyperactivity, and into that of “minimal brain damage” and eventu- poor impulse control date back to Shakespeare, ally “minimal brain dysfunction” (MBD), as chal- who made reference to a malady of attention lenges were raised to the label in view of the in King Henry VIII. A hyperactive child was dearth of evidence of obvious brain injury in most the focus of a German poem, “Fidgety Phil,” by cases (see Kessler, 1980, for a more detailed his- physician Heinrich Hoffman (see Stewart, 1970). tory of MBD). William James (1890/1950), in his Principles of By the late 1950s, focus shifted away from eti- Psychology, described a normal variant of char- ology and toward the more specific behavior of acter that he called the “explosive will,” which hyperactivity and poor impulse control character- resembles the difficulties experienced by those izing these children, reflected in labels such as who today are described as having ADHD. But, “hyperkinetic impulse disorder” or “hyperactive more serious clinical interest in children with child syndrome” (Burks, 1960; Chess, 1960). The ADHD first occurred in three lectures of the disorder was thought to arise from cortical over- English physician George Still (1902) before the stimulation, due to poor thalamic filtering of Royal Academy of Physicians. stimuli entering the brain (Knobel, Wolman, & Still reported on a group of 20 children in his Mason, 1959; Laufer, Denhoff, & Solomons, clinical practice whom he defined as having a 1957). Despite a continuing belief among clini- deficit in “volitional inhibition” (p. 1008), which cians and researchers of this era that the condi- led to a “defect in moral control” (p. 1009) over tion had some sort of neurological origin, the their own behavior. Described as aggressive, pas- larger influence of psychoanalytic thought held sionate, lawless, inattentive, impulsive, and over- sway. And so, when the second edition of the active, many of these children today would be Diagnostic and Statistical Manual of Mental Dis- diagnosed as having not only ADHD but also op- orders (DSM-II) appeared, all childhood disorders positional defiant disorder (ODD) (see Hinshaw were described as “reactions,” and the hyperactive & Lee, Chapter 3, this volume). Still’s observa- child syndrome became “hyperkinetic reaction of tions were quite astute, describing many of the childhood” (American Psychiatric Association, associated features of ADHD that would come 1968). to be corroborated in research over the next cen- The recognition that the disorder was not tury: (1) an overrepresentation of male subjects caused by brain damage seemed to follow a simi- (ratio of 3:1 in Still’s sample); (2) high comorbidity lar argument made somewhat earlier by the with antisocial conduct and depression; (3) an prominent child psychiatrist Stella Chess (1960). aggregation of alcoholism, criminal conduct, and It set off a major rift between professionals depression among the biological relatives; (4) a in North America and those in Europe, which 2. Attention-Deficit/Hyperactivity Disorder 77 continues (to a lessening extent) to the present. Even so, concern arose within a few years of Europe continued to view hyperkinesis for most the creation of the label ADD that the important of the latter half of the 20th century as a relatively features of hyperactivity and impulse control rare condition of extreme overactivity, often asso- were being deemphasized,when in fact they were ciated with mental retardation or evidence of critically important to differentiating the disorder organic brain damage. This discrepancy in per- from other conditions and to predicting later spectives has been converging over the last de- developmental risks (Barkley, 1998; Weiss & cade, as evident in the similarity of the DSM-IV Hechtman, 1993). In 1987, the disorder was criteria (see below) with those of the International renamed “attention-deficit hyperactivity dis- Classification of Diseases, 10th revision (ICD-10; order” in DSM-III-R (American Psychiatric World Health Organization, 1993). Nevertheless, Association, 1987), and a single list of items in- the manner in which clinicians and educators corporating all three symptoms was specified. view the disorder remains quite disparate; in Also important here was the placement of the North America, Canada, and Australia, such chil- condition of ADD without hyperactivity, re- dren are diagnosed with ADHD (a developmen- named “undifferentiated attention-deficit dis- tal disorder), whereas in Europe they are viewed order,” in a separate section of the manual from as having a conduct problem or disorder (a be- ADHD, with the specification that insufficient

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