Point of View: The Multiplicity of Etiologies in the Hyperkinetic Child
Reading Dr. Jaso’s 30-year-old talk is akin to opening a time capsule. It is delightful to look back at where we were, and to speculate about what progress we have made, if any, in the treatment of attention deficit hyperactivity disorder (ADHD). The “cortical stimulants” he refers to in 1972 are amphetamine, and methylphenidate. Even though each now has multiple preparations to choose from, these continue to be the first-line medications in the treatment of ADHD. His admonition that we look at the entire child and his living situation before medicating the youngster with “hyperkinesis” is just as valid today as it was 30 years ago. We continue to have children with learning disabilities, children who don’t fit in the classroom, children with a temperament that does not match his or her parents, and children with language or cultural differences that end up being labeled with ADHD and treated with stimulants. And we continue to have children who could benefit dearly from treatment be lost in the system. It is somehow reassuring to know that children we see today are not that different from those Dr. Jaso treated. However, it would be nice to think we were not making the same mistakes 30 years later.
-Thomas A. Roesler, MD e-mail: TRoesler@lifespan.org
Thomas A. Roesler, MD, is Associate Professor, Psychiatry and Human Behavior, Division of Child Psychiatry, Brown Medical School.
Recently reviewing my documents I found that in May of 1972 I moderated a meeting of the New England Pediatric Society on “The multiplicity of etiologies in the Hyperkinetic Child” (currently known as Attention Deficit Disorder) My current concerns continue to be the same today as they were expressed in my presentation then. The November 2nd issue of TIME magazine cover asks “ARE WE GIVING KIDS TOO MANY DRUGS?”emphasizes the need to concern ourselves with an ever increasing problem.
The text of my 1972 presentation brought into focus the need to include in our evaluation, diagnosis and treatment of these children the whole variety of causes.
THE MULTIPLICITY OF ETIOLOGIES IN THE HYPERKINETIC CHILD
Paper presented at the New England Pediatric Society Meeting, May 17, 1972 [edited version]
The Diagnostic and Statistical Manual of the American Psychiatric Association classifies the hyperkinetic reaction of childhood as a behavior disorder characterized by over-activity, restlessness, distractibility and short attention span. It suggests: “if this behavior is caused by organic brain damage, it should be diagnosed under the appropriate non-psychotic organic brain syndrome.”
Many clinicians concede the occurrence of minimal brain damage in a number of hyperkinetic children, and have seen the frequent response of this problem to cortical stimulants. Dr. Edward F. Hase of Tufts University School of Medicine states that when hyperkinesis is of organic etiology “the child needs the medication….”
The over-utilization of drugs with many children whose behavior has the above characteristics, but who do not present manifestations of brain damage or brain dysfunction, is a concern. These children may be surrounded by upsetting environmental conditions (e.g., one-parent family, death in the family, neglect, environmental deprivation, social-cultural deprivation, depression, etc., alone or in combination) – factors frequently not investigated in the evaluation of the case.
Much of the current literature fails to even mention these factors as primary in the causation of the hyperkinetic syndrome, sometimes only mentioning emotional factors as secondary to the child’s condition, in terms of parents’ response to the difficult child. Dr. Barbara Fish of the New York University School of Medicine [reference] states, “To perpetuate the simplistic idea that all hyperactive children simply require stimulant medication is to neglect the fact that many of these children require specific remediation for learning disabilities, that others require more potent medication and that still others need attention to social and psychological problems which are impeding normal growth and development.”
Elsewhere (Arch Gen Psych 1971;25), she concludes that “the myth of ‘one child, one drug’ is that a ‘stimulant is the drug for the hyperactive child.’ There is no one hyperactive child. There are many types of hyperactive children…Children with other behavior disorders may also be hyperactive…A stimulant is the drug of choice for only some hyperactive children…Some may need no medication.”
Much of the confusion seems to be because the hyperkinetic syndrome, characterized by over-activity, restlessness, distractibility and short attention span, has been elevated to the category of a nosological entity; and the expectation of a single etiology tends to divide, rather than unify, the problem.
The 1967 Third World Health Organization Seminar on Psychiatric Disorders (J Child Psychiat 1969;10:41-61) proposed a triple axis classification scheme. The first axis concerns the clinical psychiatric syndrome; the second axis refers to the child’s level of intellectual functioning; and the third axis notes the associated or etiological factors. By separating the clinical syndrome from the etiology, it permits agreement on the diagnosis, while allowing for variation in etiologic formulation, single or multiple.
B. Fish adds another factor, further compounding the contusion: the numbers of words used interchangeably: “… the term ‘hyperactive reaction’ is used interchangeably with ‘minimal brain dysfunction’ although they are hardly synonymous.” To this, I add the frequency of other interchangeable terms, such as learning disability, post-encephalitic behavior disorder, organic drivenness, etc.
Martin Bax of the Salomons Centre, Guy’s Hospital, London (Developmental Med Child Neurol 1972; 14:85-6) identifies several main groups of over-active school children, whom he distinguishes from “the small group of hyperkinetic children.”
1. Children with psychiatric disturbance, usually neurotic or antisocial. Childhood depression may present in this way. It is possible, he adds, that the difficulty of interpreting the paradoxical effect of stimulants on “hyperactive children relates to the fact that in a proportion of them the stimulant, far from controlling their hyperkinesis, is affecting their state of depression.”
2. Children with specific learning difficulties, which the teacher fails to recognize.
3. Children who are poorly taught. Those children become bored, inattentive and disruptive.
4. Children from social backgrounds that differ from that of the teacher. A child who has spent much of his time out in yards or around the streets has rarely experienced being sequestered with 30 to 40 other children, and will often react with “bad” behavior.
5. Children from cultural backgrounds that differ from that of the teacher. Sometimes the child enters school following the family’s change of country, often after separation from one or both parents, away from the extended family, with different climate, different language, and different child-rearing customs.
6. Children with high energy levels.
Dr. Mary C. Howell of Harvard Medical School (Clin Ped 1972; 11:30-9) adds to the list “secondary activity: “some children who are described as …hyperactive…are in fact aggressive.” She also mentions children whose behavior is within normal limits but the parents find it difficult to cope with their playfulness – “because the apartment is small and has thin walls, because there is no outside playground, because the child’s siblings were more quiet than this child, etc.”
Hector Jaso, MD, with an Introduction by Thomas A. Roesler, MD
Hector Jaso, MD, is a retired child psychiatrist, previously at the Child Development Center of Rhode Island Hospital, at Butler Hospital, at the Institute of Living (Hartford), and Director of the Providence Child Guidance Clinic.
Hector Jaso, MD
Copyright Rhode Island Medical Society Jan 2004
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