jake

Socio-educational and Biomedical Models in the Treatment of Attention
Deficit / Hyperactivity Disorder and related Neurobehavioural
Disorders in Childhood and Adolescence, and their Implications for
Adult Mental Health.
Ian N Ford BA DMS FRSH

--------------------------------------------------------------------------------

Introduction

This paper looks at the way in which the models used to describe and
define emotional and behavioural problems of childhood and adolescence
can affect social and educational development, and also have a bearing
on the future mental health of these young people as adults. In
particular it looks at the attitudes of educational and health
professionals to a series of neurobehavioural disorders,predominantly
Attention Deficit Disorder with or without Hyperactivity.

It is interesting that when one seeks to compare data on the incidence
of neurobehavioural disorders there are striking differences between
reports from England on one hand, and from North America and other
countries such as Australia on the other. In the USA it is estimated
that now maybe 5% of children, mainly boys, are diagnosed as having
AD/HD and many are taking medication. In contrast, the rate of
clinical diagnosis of AD/HD and/or Hyperkinetic Disorder in England is
estimated as approximately 1: 3000 or about 0.3 %.

Clearly a difference of this magnitude cannot be put down to the
quirks of epidemiology; evidently there must be other factors
affecting the level of diagnosis apart from any consideration of the
objective incidence of a given level of symptomatology, if one could
establish such an arbitrary measure. Partly the difference lies in the
interpretation of formalised diagnostic criteria, but we will suggest
that the real difference is a matter of philosophy and ideology. We
describe these ideologies in broad terms as socio-educational and
biomedical.

In the USA many more children who cannot pay attention in class, who
are disruptive, restless, easily distracted, disorganised and
forgetful receive a clinical diagnosis than in UK. American parents
and schools appear more ready to see educational and behavioural
problems as requiring " treatment " from doctors and psychologists
rather than leaving it as a problem for teachers to deal with.We will
look at the case for this biomedical model, possible cultural
explanations for its predominance in the USA, and its increasing
popularity with parents and some professionals in this country in
recent years.

We will suggest that many young people with neurobehavioural disorders
do not get specialised medical diagnosis in England, but rather that
childhood " problem behaviour " is defined as a social and educational
problem rather than one for which medical intervention would be sought
in any but extreme cases. In other words, many of these young people
remain in the mainstream educational system and in time are labelled
as chronic underachievers lacking in motivation or as having problems
dealing with authority, although a few who exhibit severe problems are
described as having " emotional and behavioural difficulties " (EBD)
and referred for specialist help. Most are dealt with through
educational and social work channels. Commonly attempts are made to
link problem behaviour to a specific event or series of events.
Negative behaviour may be ascribed to child abuse, family stress, or
negative life events such as parental separation or bereavement, or to
psychodynamic and sociological explanations such as sibling rivalry or
inappropriate parenting. There is a strong belief that attentional and
behavioural difficulties are symptoms of some deeper mental distress,
and that it is necessary to identify and address these problems in
order to understand the presenting problems. We will describe this
socio-educational model in greater detail later.

The biomedical model

The biomedical model draws on " biological sciences " including
genetics, biology, medicine and biological psychology. It is this
model that defines problem behaviours as " neurobehavioural " It
assumes that certain behaviours are caused by biological factors
inherent to the individual, or to external factors operating at a
biological level. Conditions such as ADD are seen as disorders and
disabilities that have biological aetiologies. Inherent is the medical
view that individuals are subject to conditions which are biologically
abnormal or pathological, and that these disorders can be identified
and treated by the application of the scientific method. Thus it is
that " problem " behaviour is a symptom caused by an underlying
biological abnormality that can be described by biological sciences
such as genetics, biochemistry and neuro-anatomy and treated mainly by
psychopharmacology and behavioural therapy.

Clinical literature on AD/HD in recent years shows developing
recognition that this is not just a problem of childhood
hyperactivity, but a significant neurobehavioural disability that
affects many adults, and which is largely undiagnosed.

" Unlike other flagrant psychiatric disorders whose symptoms are so
extreme, atypical, bizarre or grotesque that they may fascinate or
horrify and are highly obvious, ADHD expresses itself by its subtle,
pernicious impact upon the individual's ability to meet life's daily,
often petty, responsibilities - one's relationship to friends, family
and offspring; one's capacity to pursue productive and successful
work; the ability to engage in the process of education for self-
improvement ... Its effects over development may be glacially slow but
ever-present in eroding one's self-esteem ... often leading to a life
of dramatic under-achievement relative to one's actual creative,
intellectual and academic abilities. "

by Weiss and Hechtman (1993). This details a prospective follow-up of
hyperactive children from 1960 to the present day. Their fif****-year
follow-up reported that 66% of the hyperactive group complained of at
least one symptom ( restlessness, poor concentration, impulsivity,
explosiveness ) compared with 7% of controls. All hyperactive adults
were significantly poorer in social-skills tests than the control
group and showed significantly less self-esteem.

Interestingly, much of the early clinical work on ADD and associated
disorders came from England. In the early years of the twentieth
century the distinguished paediatrician G.F Still (Still, 1902) was
describing hyperactive behaviour in children. He ascribed this as a
"defect of moral control" but with a clear implication that this had a
medical cause, as yet undiscovered. Terms such as " moral control "
may seem alien to our current thought, but in the language of his time
Still was clearly recognised that certain individuals appear unable (
as opposed to unwilling ) to conform to societal norms, and that this
inability has a causation that is probably organic. At first it was
thought that the condition was caused by " minimal brain damage" But
research failed to locate any gross neurological damage to the brains
of affected children, and the brain damage theory was effectively
debunked by Rutter (1977).

Others maintained that hyperactivity was just the extreme end of a
spectrum of normal development, and terms such as Hyperactive Child
Syndrome were suggested. (Chess, 1960) In a sense both views are
compatible with a biomedical model, in that some individuals displayed
behaviours that were not novel or bizarre but represented a variation
from the normal frequency or intensity of behaviour that could be
considered dysfunctional.

"Hyperactive " children also had problems with sustained attention and
impulse control that were often more significant than their motor
hyperactivity. (Douglas, 1972) and by 1980 the APA had recognised
Attention Deficit Disorder with or without Hyperactivity, ADDH and ADD
respectively.

Clinical research by Zametkin A J, et al. (1990) using Positron
Emission Tomography showed that children diagnosed as having ADHD
exhibited significantly differences in the way that certain parts of
their brain, areas in the frontal cortex, took up glucose during tasks
requiring focussed attention. It was as though there were " cold
spots" that were not functioning properly. One hypothesis is that in
AD/HD there is a shortage of the neurotransmitter 5-HT (
5-hydroxytriptamine, also known as serotonin) his substance acts to
inhibit the effects of excitatory neurotransmitters such as
norepinephrine ( noradrenaline ) and also controls the metabolism of
glucose in the brain and elsewhere by affecting the production of
insulin.

The disinhibition resulting from reduced 5-HT levels is highly
significant, and in a recently published critique of both the ICD-10
and DSM-IV criteria for defining AD/HD, Anastopoulos, Barkley et al.
(1995) point out that behavioural disinhibition (impulsivity) accounts
for three items in DSM-IV and does not appear at all in ICD- 10 , yet
this element is critical in the differential diagnosis of AD/HD or
hyperkinetic disorder compared with other psychiatric disorders.

" In future, research must focus upon the executive functions which
are linked to behavioural inhibition, how they are impaired in AD/HD,
the staging of their emergence over development, and how they account
for the myriad of difficulties those with ADHD have in daily adaptive
functioning in society as adolescents and adults. "

If defining the terminology was controversial, the issue of diagnosis
and treatment was even more fraught with difficulty. The practical
dilemma is at what point symptoms that are a part of every child's
experience such as inattention, high activity levels and impulsivity
become " clinically significant ". Clearly some children display
behaviour that is clearly inappropriate for their age and environment,
and which most adults and even other children would recognise as "
abnormal ". Beyond this, what measures do one use to expand on the
bare skeleton of DSM-IV or ICD-10, and where should the cutoff point
be drawn? This is, of course, a fundamental dilemma for anybody trying
to define at what point variations in normal behaviour becomes a "
mental disorder ".

Individual differences are recognised against a framework of normal
variation and pathological deviation from a set of assumptions of
physical and psychological health. The individual is seen in the
context of society that defines and enforces certain behavioural
boundaries, and those boundaries will reflect cultural, social and
political values and norms. Psychologists seek to establish the
contextual normal ranges of behaviour and then developing strategies
to bring what is defined as abnormal within the accepted range.
Various treatments can be used to reinforce affective, social and
social responses that accord with the culturally defined view of "
normality " and to extinguish undesired behaviours.

Even where apparently objective measuring techniques do exist they are
often too ***bersome or expensive to use outside the research
environment. EEGs and magnetic imaging techniques can give some
indication of changes in brain function that suggest various
neurological disorders, but they are neither sufficiently accurate nor
convenient for routine diagnostic use. Psychometric testing can often
give useful indications of attentional problems and specific learning
disabilities, but effective testing needs to be done on an individual
basis and each assessment takes several hours, and no single test or
battery of tests can establish a definitive diagnosis. A clinician
needs to make a highly subjective assessment based on a combination of
direct observation, reports from teachers and parents, school records,
test results etc.

We have already stated that the difference between the reported
incidence of AD/HD and other neurobehavioural disorders between
England and North America is unlikely to be related to epidemiology,
nor even to differences in clinical practice alone; rather there must
be other social factors at work that reflect on the rates of clinical
referral. Ideus (1995) describes the role of the teaching profession
in the USA, which may be a partial explanation:

"American teachers are professionally socialised to pragmatically
accept the authority of medicine and psychology in matters such as
ADHD ... American education at all levels has been shaped in the last
century and a half to produce a citizenry socialised to fit neatly
into a mass industrial society - into the bureaucracy and the factory
floor, juxtaposed with values placed on individual freedoms such as
life liberty and the pursuit of happiness. ... For eighty years
American schools have been structured as a grid into which flows ' all
sorts', who are then melded into societal members who see and enact
the value of sustained attention to written tasks, curbing impulses to
gain rewards for deferred gratification, and working quietly at desks
and on assembly lines.

If one takes a historical perspective, while the teaching profession
in the USA was coming to terms with the latest developments in
defining, identifying and then treating AD/HD, back in England in the
seventies the political and social climate was such that the
philosophy of education and of child-rearing generally diverged from
that of the USA. We would suggest that historical factors and
political ideologies accounted for the predominance of the
socio-educational model in the UK.

The socio-educational model

to develop " naturally " and to develop language and concepts at his own pace. A highly influential report by the Department of Education, Plowden Report was stressing discovery learning and formal class teaching was discouraged. Consequently, in many junior schools children were not expected to sit still in the way that their
American counterparts were, and children who were actively moving around the classroom could be perceived as involved in active learning, even if they were not actually learning a great deal from the experience. Hyperactivity was not perceived as a problem unless it involved violent or frankly disruptive behaviour.

Where a child clearly displayed behavioural problems the Zeitgeist was
very much in favour of seeking alternate explanations. Whereas
American educationalists were looking at behaviourist explanations,
child psychology in England had taken a different track, and the
emphasis was very much on psychodynamic approaches. Phrases such as "
there are no bad children, just troubled children " echoed around the
staff room and the consulting room.

The redefinition of " dyslexia " as primarily an educational problem
rather than a clinical diagnosis effectively put the assessment of
specific learning disabilities effectively into the hands of teachers
and educational ( as opposed to clinical) psychologists. With the "
dyslexia " label now available to teachers the number of children
recorded as dyslexic rose to a new high. More perceptive teachers
noted that many young people with dyslexia also exhibited behavioural
problems, poor self-esteem, depression and various other psychological
difficulties. However, it was easy enough to accept that a child who
was failing at school, felt under pressure, had language and
coordination problems etc. was probably " acting out " these
frustrations, particularly if they also had adverse family
cir***stances.

Special classes and special schools began to be filled with children
with a label of " dyslexia". Where there was no suggestion of specific
learning disabilities the children who did poorly on intelligence
tests were classified as having " Moderate Learning Difficulties ".
Brighter children with behavioural problems were classified as having
" Emotional and Behavioural Difficulties " (EBD)

However, it soon became clear that there was a core of young people
with emotional and behavioural difficulties who could not be contained
in ordinary schools, who ended up either in special units or
truanting. Many of these got into trouble with the police, and found
themselves in touch first with Social Services and then with the
criminal justice system. These were the youngsters on whom the
educational system had given up.

Those who became involved with social workers found their problems
explained in a variety of ways, according to which of the prevalent
theories informed the caseworker's practice. Typically " conflict with
authority " could be explained by several theories. Marxist theories
speak of the oppression of a proletarian underclass by the capitalist
system, and regard nonconforming behaviour as a form of resistance to
a hostile and exploitative society. Liberal Reformist theories would
look at the young person in a social setting and highlight how
antisocial behaviour was a reaction to the way society regarded young
people, and that a delinquent subculture was due to the lack of
opportunities for disadvantaged youth within the mainstream of
education, leisure services or employment provision. The Radical
Non-Interventionist approach would be to say that many young people
commit antisocial acts, most are not caught and those that are tend to
outgrow this unfortunate phase in time. (Lishman, 1991)

Again, some Social Workers would take a psychodynamic approach and try
to identify underlying problems, but increasing pressure on Social
Workers and the mounting caseload has made their work ever more a
crisis intervention service. Few social workers would see it as their
role to look for psychological causes of negative behaviour, which
they would regard as the province of the clinician. Even now the
attitude of British teachers and social workers is very different to
their American counterparts, as shown in a statement issued in 1995 by
the Association of Workers for Children with Emotional and Behavioural
Difficulties (AWCEBD,1995) :

" What we agreed was that :

The vast majority of emotional and behavioural difficulties arise from
familial, social and educational factors and identification and
treatment should be based on this premise.
A very small number of children have a medical condition known as
Attention Deficit Disorder with or without Attention Deficit
Hyperactivity Disorder.
Stringent symptomatic criteria exist and require a diagnostic
partnership between all agencies with experience of the child.
Drug treatment should only be used after assessment by a specialist
and should be monitored carefully.
Sustained efforts will be needed to ensure that diagnosis does not
become purely a medical matter and to avoid conflict between
professional groups. "
This statement reinforces the belief that only a " very small number "
of children have AD/HD, and that the " vast majority " of EBD are
caused by socio-educational problems. Since for many children and
adults problems of inattention, impulsivity etc. have gone unnoticed
for months and years, any history of inattention will have been buried
in a host of other issues to do with poor self-esteem, depression etc.
The question is what is cause and what is comorbidity? Which is the
chicken, and which the egg?

The medication debate

Many parents' groups, informed about AD/HD from the USA, are insisting
that their children have a recognised medical disorder, a
neurotransmitter imbalance that can be treated by medication, and that
unless the medical problem is addressed any other intervention will
not be effective. The ****ogy in physical medicine would be to first
try physiotherapy for a broken leg, then when that did not work one
would try putting in plaster. There is a case for a combination of
treatments, and one approach to the medical model is described by
Taylor & Hemsley (1995)

"Specific treatment is indicated when simple general measures are not
enough. The most powerful is the use of stimulant drugs ... Doubt
persists about the long term efficacy, but clinical experience leaves
little doubt that, for selected patients, the treatment continues to
help psychosocial adjustment even after three or more years of
treatment ...

We need to develop good cooperation among health professionals from
different disciplines, with, for example, joint clinics between child
psychiatrists and psychologists working with paediatric developmental
services. Liaison with schools is essential to helping the assessment
of the underlying problems and the and the monitoring and delivery of
treatment. "

One parent ( Kirwan, P 1995) wrote of the effect of medication:

" Although I hadn't told anyone that Matthew had started taking the
tablets, his non-teaching assistant asked me how I had worked the
miracle on Matthew. I asked her what she meant and she said he had
worked solidly all morning. No fidgeting, no chatting, no wandering
around looking for paper, pencils or rulers. A miracle indeed. "

But the use of medication can cause problems for psychothe****utic
practitioners:

Drugs and psychotherapy derive from different theoretical realms and
should be neutral towards each other, but ideologically they are
competitive. Linkages and bridges between these treatments are few and
weak in their empirical support...In clinical practice, however, these
approaches are used simultaneously, usually in an eclectic, pragmatic
and inconsistent manner.

Little attention has been given to the possible interactions between
these two the****utic approaches. A number of questions should be
asked ... Under what conditions do drugs facilitate or retard
psychothe****utic communication? Will too rapid reduction of symptoms
remove the patient's motivation for insight? " ( Klerman, 1993)

Nor is medication a simple solution. Hallowell and Ratey (1994) give
the success rate of psychostimulant medication, the most common
psychopharmacological treatment, as about 70%, so just under a third
of patients will not respond to the first choice of medication. In
addition, psychotropic medication can have a range of side-effects.
Those for stimulants range from headaches and rebound hyperactivity to
exacerbation of tics and sometimes symptoms resembling psychosis.
Whilst severe reactions are uncommon and usually reversible they are
still a cause for concern. Writers such as Breggin (1991) have drawn
public attention to the negative effects of medication, and the use of
stimulants, particularly methylphenidate ( Ritalin) has been the
subject of critical press comment in the USA.

Discussion

We would suggest that there is evidence to support the existence of
AD/HD as a neurobiochemical disorder ( or a spectrum of related
disorders ) which has a significant impact upon children and adults,
affecting their ability to function effectively in a variety of
situations, social, intellectual and in education or employment.

These individuals respond best to pharmacological and behavioural
treatments, yet traditionally such treatments have been kept as a
second tier if not a last resort. One can say that there is not an "
objective clinical test " for AD/HD and that the diagnostic criteria
used are inadequate, inconsistent and confusing. But then all one has
to do is read a few sets of notes from a Child Guidance Clinic to
wonder if explanations of behavioural problems as due to " sibling
rivalry " or whatever stand up to similar examination.

It is easy to criticise American doctors for prescribing Ritalin
without proper investigation, and to blame the increase in diagnosis
of neurobehavioural disorder as an attempt by parents to seek a "
disability " that explains why their child is not academically gifted.
However, one has also to question whether the British establishment
has got it right either. Early identification and intervention can
reduce educational problems and long-term psychiatric morbidity. Weiss
(op.cit.) described the problems experienced by her cohorts of
hyperactive children as they reached adulthood in terms of depression,
substance abuse, antisocial behaviour and self-harm.

Similarly Moir & Jessell (1995) point to a high correlation between
childhood AD/HD and other behavioural disorders and subsequent adult
antisocial behaviour and criminality. In their controversial work they
link various neurochemical abnormalities to delinquency:

"The whole question of concentration and attention is emerging as
central to the question of delinquency ... we must never lose sight of
other predictors, such as low income, large family size, poor houses,
poor parental guidance, poor supervision or convicted brothers; but
the fact is that hyperactivity or conduct disorder predicted as well
as, or better than, all of the above.

While accepting that many children with a history of hyperactivity
grow up as law- abiding citizens, there is some merit to the argument
that antisocial and criminal behaviour is often related to a
biological need for high stimulation, and that early recognition and
treatment can often break a cycle of increasingly negative behaviour."

There is a need for a greater awareness among teachers, psychologists,
psychotherapists and medical practitioners of the existence of
Attention Deficit / Hyperactivity Disorder in children and adults is a
neurobiochemical disorder with an aetiology in a combination of
genetic and environmental factors, and that this condition is
treatable by multimodal methods including psychopharmacology,
behavioural techniques, and environmental structuring and coaching.
While comorbid conditions such as depression, low self-esteem etc. may
respond to psychotherapy, psychodynamic approaches alone have limited
effectiveness in dealing with primary AD/HD.

Above all, there is a need to recognise the distress that this
condition can cause through damaged relationships, under-attainment in
education and at work, and impairment in social functioning. These
problems continue to exist in adolescence and adulthood even in those
cases where hyperactivity and behavioural disruption were not present
or are in remission. Neither the biomedical nor the socio-educational
models represent the full explanation for attentional and behavioural
disorders. We would suggest that all professionals need to be more
aware of the incidence and impact of neurobehavioural disabilities
such as AD/HD, and to move from playing lip-service to " joint working
" to a genuine multidisciplinary approach to young people and adults
with problems of attention and impulse control.

Bibliography & References

AMERICAN PSYCHIATRIC ASSOCIATION (1994) Diagnostic and statistical
manual of mental disorders (4th Edn rev.) Washington DC

ANASTOPOULOUS, A D, BARKLEY, R A & SHELTON, T L (1995) ADHD history
and Diagnosis in Cooper, P & Ideus, K (eds) " AD/HD : Educational,
Medical & Cultural Issues " - AWCEBD, Maidstone 1995

AWCEBD (1995) - [ Bennathan, M (Ed.) ] Attention Deficit Disorder /
Attention Deficit Hyperactivity Disorder. AWCEBD National Newsletter,
November 1995 p.6

BREGGIN, P (1991) Toxic Psychiatry (UK Edn. 1993 ) Harper Collins,
London

CHESS, S (1960) Diagnosis and treatment of the hyperactive Child New
York State Jnl. Med. 60, 2379-2385

DOUGLAS, V I (1972) " Stop look and listen: The problem of sustained
attention and impulse control in hyperactive and normal children.
Canad. Jnl. Behavioral Science, 4, 259-282

HALLOWELL, E M & RATEY, J J (1994) Driven to Distraction. Pantheon, NY

IDEUS, K Cultural foundations of ADHD: A sociological ****ysis in
Cooper, P & Ideus, K AD/HD - Educational, Medical & Cultural Issues -
ACWEBD, Maidstone

KIRWAN, Patricia (1995) " Living with ADHD - The story of Matt, James
and Me" ADD-Vice 2: 1 (Spring 95) p26 LADDER, London
LISHMAN, I ., MOIR, A & JESSEL, D (1995) A mind to crime - the
controversial link between the mind and criminal behaviour. Penguin,
London (p.314)

RUTTER, M (1977) Brain damage syndromes in childhood: Concepts and
Findings. Jnl. Abnormal Child Psychol. 18, 1-21

STILL, G F (1902) Some abnormal psychical conditions in children
Lancet, i 1008-12, 1077-82, 1163-68

STRAUSS, A & LEHTINEN (1947) Psychopathology and education of the
brain- injured child Grune & Stratton, NY

TAYLOR, E & HEMSLEY, R Treating Hyperkinetic Disorders in Childhood
BMJ 310 : 24 June 1995 pp 1617-8

WEISS, G & HECHTMANN, L T (1993) Hyperactive children grown up (2nd
edn.) Guildford Press, NY

WENDER, P H (1971) Minimal brain dysfunction in children Wiley, NY

WORLD HEALTH ORGANISATION (1990) International Classification of
Diseases (10th Edn ) Geneva

ZAMETKIN A J, NORDAHL, T E, GROSS, M et al. (1990) Cerebral Glucose
Metabolism in adults with hyperactivity of childhood onset. New
England J M 323 :20 pp 1361-66

--
‘All policymakers must be vigilant to the possibility of research data being manipulated
by corporate bodies and of scientific colleagues being seduced by the material charms of
industry.

Trust is no defence against an aggressively deceptive corporate sector.’

Editorial (2000). Resisting smoke and spin. Lancet 355, 1197.

markasurusio probertasaurusio

Thank you for posting this paper. Ian had been a ADAD regular for many
years, and his keen insights, and British perspective, were always most
appreciated byt the regulars and visitors.

child-centred" approaches. These drew on philosophical views of childhood
such as that of Rousseau and the theoretical work of child psychologists
such as Piaget. In primary education in particular the aim of education was
not to teach knowledge but to help the child

pace. A highly influential report by the Department of Education, Plowden
Report was stressing discovery learning and formal class teaching was
discouraged. Consequently, in many junior schools children were not expected
to sit still in the way that their

the classroom could be perceived as involved in active learning, even if
they were not actually learning a great deal from the experience.
Hyperactivity was not perceived as a problem unless it involved violent or frankly disruptive behaviour.

jake

you are welcome..
he outlines the issues succintly IMO .

markasurusio probertasaurusio

Succinct was always one of his trademarks. That, and being a gentleman.