- Psychological Issues
In younger children, their usual demanding behaviour and any existing specific and global deficits, especially in language, make it more difficult to determine what is “developmentally inappropriate”. As preschool children learn, their mobility and curiosity is demanding and parents often complain of “hyperactivity”. Palfrey, Levine, Walker et al (1985) followed a cohort of children from birth to second year at school in a study which also emphasised personalised education and guidance of the child and parents. Of 174 children, 41 per cent had some attentional concern; this peaked at 42 months and was often minor or transient. Thirteen per cent were judged worthy of intervention, 8 per cent had definite problems which abated before kindergarten and 5 per cent had definite and persistent problems with attention. Persistent attention problems were associated with preschool social-emotional concerns, developmental lags, and single parent families. By second year at school, 45 per cent had reading problems (compared with 13 per cent with normal attention), 37 per cent had poor work output, and used support teaching and language therapy twice as often.
Communication disorders have a strong and persistent association with behavioural dysfunction. In a group of 3 year-olds with expressive language delay 59 per cent (compared to 14 per cent of controls) had behaviour problems and significant persistence to age eight years (Stevenson, Richman and Graham 1985). ADHD is a common diagnosis when speech and language problems are found in both clinic patients (16 per cent) (Baker and Cantwell 1987) and in population samples (30 per cent) (Beitchman, Wilson, Brownlie et al 1996b; Cohen, Davine, Horodesky et al 1993). Benasich, Curtiss and Tallal (1993) question this specific association with ADHD, though did not specifically study it. genetic associations between ADHD and speech, language and literacy problems are evident in the Australian twin study (Levy, Hay, McLaughlin et al 1996). ADHD populations at school demonstrate language dysfunction with academic and social impact (Tannock, Purvis and Schachar 1993; Sandler, Hooper, Watson et al 1993). It is crucial in the diagnosis and management of ADHD in young children to thoroughly assess and manage communication disorders.
Both Campbell’s review (1995) and the Dunedin cohort study (McGee, Partridge, Williams et al 1991) document the persistence of preschool hyperactivity and difficult behaviour into adolescence. Satterfield, Swanson, Schell et al (1994) re-examined their cohort from two decades earlier and demonstrate that defiance, not only aggression, in preschoolers has a poorer outcome. Preschoolers, in general, already disapprove of aggressive, hyperactive peers as shown by Milich, Landau, Kilby et al (1982).
Logically, treatment, including stimulant medication, might allow children with moderate to severe problems to achieve more successful behaviour, learning, social acceptance and self-esteem before school entry. Stimulants have been used in young children for twenty years (Schleifereifler, Weiss and Cohen 1975) and act similarly as in older children, although dosage, benefits and side-effects need more careful evaluation. Mayes, Crites, Bixler et al (1994) conducted a realistic standardised blinded trial of three daily methylphenidate doses with 69 children aged 22 months to 13 years, with IQs between 23 and 136. Of preschool children with ADHD alone, 88 per cent improved with methylphenidate, with no increased side-effects.
Behavioural management of all preschoolers is challenging. While severe ADHD may be less common in very young children, it does exist, often with strong effects on parental psychopathology. In some children, complex developmental, social and family adversity combine to produce severe problems in spite of all support services being engaged and high-dose or multiple medications being used. Such cases tax the control procedures for the prescription of stimulants, which demand clinical thoroughness and, in very young children, second opinions from appropriate professionals. With ADHD, particularly with defiant-aggressive behaviour, immediate tangible and structured rewards are essential, and parents require close support (Strayhorn and Weidman 1989).
There is no published controlled study of combined medication and behavioural management in very young children. There is no controlled scientific support for the efficacy and safety of other medications, such as clonidine, antidepressants or thioridazine, but these are often used to avoid the bureaucratic complexities of stimulant monitoring.
The management of ADHD, including that of medication, in preschool children is of growing significance in trying to deflect the poor outcome of moderate/severe ADHD with the developmental, emotional and family problems which accompany it. Complex interaction between intrinsic traits in, and environmental influences on, the child and parent (as discussed in Section 4.6.4 and 8.1) may result in a preschool child presenting with symptoms of ADHD, defiant and aggressive behaviour (Satterfield, Swanson, Schell et al 1994). Management of ADHD in preschoolers demands careful consideration of the interactive effects of severe child behaviour disturbance and parental responses, major relationships and evaluation of practical and emotional safety of the child. Parents require support in relation to behaviour management therapy for the developmental problems of their child/ren, especially that of communication. Alternative or respite care is also required.
The use of medication in children under three years is rare and is only indicated for severe symptoms. It demands comprehensive, intensive and integrated expertise. Medication is only used in infants under two years of age in extreme circumstances that are likely to be associated with significant brain impairment, major developmental problems and/or severe environmental disruption. Monitoring of medication for ADHD must be very thorough for such young children. This should particularly apply to the use of medications other than stimulants, as there is little scientific data on their efficacy and safety and no statutory guidance and monitoring.
The diagnosis of ADHD in toddlers and preschoolers is complicated by normal developmental changes and environmental factors. Behaviour management and parent guidance is essential, and medication should be used with caution.
Management of ADHD during adolescence must be considered in the context of the behaviour, learning and social characteristics of normal adolescent development, persistence of dysfunction from early childhood and into adulthood, co-morbidity (especially conduct disorders), the need for specialised approaches to adolescents and the shortage of services which promote adolescent wellbeing.
Normal adolescence brings major developmental advances in abstract reasoning and in physical growth and sexuality often with these changes poorly synchronised. Increased demands are made on cognitive and academic performance and personal and social insight and responsibility. Throughout the school day there may be several changes in teachers, subjects, styles of learning and performing. Large amounts of complex information must be analysed, synthesised and extrapolated with abstract and figurative interpretation, robust verbal reasoning and complex narrative skills.
Even if cognitive, behavioural and social skills are adequate they must be used with insight and organisation. Language, behavioural insight and control and social intuition need to be accurate, appropriate, sustained and planned. Adolescents must cope with the pressure of time limits, exams and competition with oneself and one’s peers. They are harnessed in an intense examination of self, peers, friends and family accompanied by egocentricity and acute self-consciousness. There is an intense desire for privacy and confidentiality. Individual and group relationships are experimental and intense.
Adolescents later develop mature interdependence, economic and vocational survival and direction, and ethical and moral values, with culturally responsible relationships, and comfort with one’s own body and sexuality. Choices are daunting enough and options of leaving school, friends and family can be very tempting but confusing. This journey is struggle enough for a competent adolescent.
Those with invisible handicaps, such as a learning disability or ADHD, may have years of failure, with or without help, which was often inexplicable, previously unrecognised, and not fully evaluated. Vulnerabilities in cognitive style and organisation are exposed by the challenge to assimilate rapidly to new fashions and achieve acceptability. Formal examinations and planning for future education, training or employment add to anxiety levels. Those of above average ability may perform well enough until the increasingly complex and sophisticated demands of adolescence overwhelm their abilities.
Acting out, aggression, anxiety, introspection, physical symptoms of anxiety or depression are generally seen as stereotypes of normal adolescence, but perhaps are reactions to the output “failure” of ADHD and associated problems. From the prospective Dunedin cohort, 6 per cent of 15 and 16 year-olds self-report inattention, impulsivity, and hyperactivity. This includes those with or without preexisting ADHD and may indicate other psychopathologies (Schaughnency, McGee, Raja et al 1994).
ADHD is usually portrayed by the media as dramatic and severe, with anecdotal reports for and against its existence and critical incidents in school caused by the most severe of aggressive behaviour and academic failure. Adolescents may not see in themselves these stereotypes of ADHD associated with conduct disorder. More are disabled by more subtle symptoms in the mild to moderate range or those of mainly inattentive type. Qualities of poor organisation, behavioural inhibition and difficulty with task completion are more significant in adolescence than marked hyperactivity. Restlessness, fidgetiness and impulsivity may be felt inwardly rather than overt hyperactivity which may have diminished or never have been a prominent symptom. Common belief and anecdote support a tendency to spontaneous resolution with the normal powerful developmental changes in activity level and insight. However, research into outcome of ADHD gives varying results from very different methodologies as reviewed by Hechtman (1992) and Klein and Mannuzza (1991).
There are few controlled prospective studies with follow-up over several years and no cohorts have received comprehensive, sustained, multimodal optimised management. Studies by Satterfield, Hoppe and Schell (1982); Klein (1987); Barkley, Fischer, Edelbrock et al (1990); Hellgren, Gillberg, Gillberg et al (1993); and Slomkowski, Klein and Mannuzza (1995) suggest that ADHD symptoms in adolescence are relatively stable. Around 20 per cent of adolescents with earlier ADHD have no problems and others with some degree of learning, behaviour or emotional problems may not continue in active management. In young children diagnosed with ADHD, Slomkowski, Klein and Mannuzza (1995) report that those with no ADHD or obvious mental disorder evident in adolescence report lower self-esteem than controls, with continuing mild to moderate effects on educational and later employment progress. Schachar, Tannock, Marriot et al (1995) suggest that pervasive and school-only, but not home-only, ADHD are related to deficient inhibitory control; this may be significant for management and outcome.
Hyperactivity which persists from early childhood, associated with defiance or aggression, increases the risk of conduct disorder, antisocial personality, substance abuse and criminality in adulthood (Satterfield, Swanson, Schell et al 1994). Barkley’s study found that 40 per cent at age 15 years had Conduct Disorder and higher rates of oppositional defiant disorder. The Dunedin cohort of around 1000 children followed throughout childhood shows the combined impact of difficult behaviour and language disorder on global learning and self-esteem and the much greater long-term effects when difficult behaviour persists.
Academic, behavioural and social difficulties (Szatmari, Offord and Boyle 1989a) contribute to other adolescent problems. Potential impact of ADHD may include feeling worthless, truancy, unemployment, homelessness, delinquency, crime, psychiatric morbidity, suicide, later vulnerable parenting of their own children and family breakdown. Mannuzza and Klein (1992) review studies on various predictors of outcome.
The Ontario population cohort in Canada has followed about 800 children up to 12-16 years of age. Neither ADHD, presumably treated in many cases with stimulants, nor emotional disorder was related to adolescent substance abuse. Conduct Disorder assessed by teachers predicted use of alcohol and hard drugs. Low levels of family support and poor school performance predicted use of tobacco (Boyle, Offord, Racine et al 1993).
Lynskey and Fergusson (1995) confirmed this in the Christchurch cohort in New Zealand. Moffitt’s (1990) birth cohort of 435 children found the interaction of ADHD and delinquency was most associated with lower verbal ability, poor reading skills and family adversity. Criminal offending stems from a very complex interaction between biological traits in the parent, parents’ style of interaction and many social and environmental influences, as reviewed extensively by Farrington (1995).
ADHD management in adolescence requires a multimodal approach with varied services from health, education and welfare agencies (Szatmari, Offord and Boyle 1989a). Satterfield, Satterfield and Cantwell (1980) showed that a multimodal management strategy must be sustained for two years to have any impact on later delinquency. There is a shortage of such services. From middle adolescence, schooling is optional and support resources are scarce. School may be increasingly irrelevant to individual strengths and interests compared with a job with income, or the hope of it. Truancy or early leaving avoid the misery of school but also diminish the opportunity of further help.
The stimulants, dexamphetamine or methylphenidate, have the same proven benefits for adolescents as for younger children on aggression and delinquency, work output, socialisation and family function. They enhance the effectiveness of support teaching, cognitive behaviour therapy and counselling (Mayes, Crites, Bixler et al 1994). Use of stimulants also increases the likelihood of ADHD adolescents remaining at school and later undertaking tertiary study (Klein 1987).
Insistence on a single diagnosis, simplistic management or on whether the problem is primary or secondary can bedevil understanding, compliance and professional collaboration. Coexisting anxiety, depression or aggressive impulsivity may make medications other than stimulants more appropriate and effective. The efficacy of medication, lack of multimodal services and recognition of the chronicity of ADHD have lead to increased prescription of medication to adolescents. Statistics gathered in New South Wales show the highest prescribing rate in early high school students, which is similar to North American trends (Safer and Krager 1994). This has major practical, personal and policy implications where in high school the observers change many times in the day, tasks are very varied and the advancing curriculum complicates monitoring to refine dosage and timing of treatment. Demands for self-reliance and self-medication conflict with ADHD symptoms as the next dose may be forgotten when the previous one wears off. Treatments are judged by benefits demonstrated while on medication compared with when it is interrupted. This is relative to all other variables, and must be documented regularly, at least yearly, by the prescribing doctor with information gathered from the adolescent, parents and teachers.
Interviewing adolescents requires particular sensitivity to their usual introspection, privacy, difficulty in talking with adults and their relationship with parents and peers, particularly after years of failure, frustration and demoralisation. Difficulty in understanding and accepting help may be further compromised by ADHD adolescents having problems with insight or abstract reasoning with associated language dysfunction rather than by impulsivity or oppositional disorders.
Confidentiality from peers is very personal and, being ridiculed about needing “smart pills” for being “dumb” or “different”, conflicts with the need of adolescents to feel invincible and to ‘belong’. Explaining how medication works and achieving adolescents’ cooperation needs patient negotiation and is necessary to ensure compliance. A supportive school may be very important in maintaining compliance, especially in adolescence. Though self-consciousness and denial of vulnerability are strong in adolescence, groups at school or in community health centres may give valuable support.
Normal adolescent behaviour and learning involves testing hypotheses, reality and independence. It is predictable that adolescents should evaluate the effect of their medication by interrupting it, just as they empirically evaluate everything else. They can be very aware of the physiological changes with doses, timing and subtle benefits of medication. Adolescents have many challenging questions about medication which need discussion, though not all have answers. For example, how can a useful treatment like dexamphetamine also be a widely used recreational drug, which attracts criminal sanctions and can be addictive when abused? Reassurance is needed that, with appropriate therapeutic use, there is no firm evidence of dependence or increased substance abuse. Compared to the untreated adolescent with poor impulse control, medication provides some protection.
Behavioural management concentrates on avoiding dangerous risks and behaviours which escalate conflict with peers, family and official systems. The emphasis is on conflict resolution, communication, negotiation, problem solving and strategies for daily living with peers, school and family (Hallowell and Ratey 1994a and b; Barkley, Guevremont, Anastopoulos et al 1992; Robin and Foster 1989).
The diagnosis of ADHD in adolescents is often complicated by co-morbid conditions, and the sequelae of long-standing dysfunction or other significant developmental changes. Therefore medication use should be carefully considered.
At present, the recognition and understanding of adult ADHD is rudimentary. Initial prescribing of medication in adulthood (after the age of 18 years), according to statutory Australian guidelines, requires opinion from a psychiatrist. More flexibility, allowing paediatricians to continue management into early adulthood, would be constructive. This now exists in NSW guidelines. Transfer from paediatric to psychiatric care carries with it many connotations and adolescents and their family must be sensitively prepared for this. Paediatricians report that they have inadequate training in learning and attention problems (Hutchins and Chee 1995; Chee, Simpson and Hutchins 1994). Psychiatrists may experience similar inadequacies in their training. Their general understanding of assessment and comprehensive management, particularly medication, grows mainly from successful experience. Long-term medication use and comprehensive treatment are yet to be followed thoroughly in large numbers of children and adolescents into adulthood.
Athletes with ADHD receiving stimulant medication
Participation in sport may give a child with ADHD enjoyment, peer approval and acceptance in the face of less competence in the academic or social arena. The traits of intensity, high activity, impulsivity and risk taking which predispose to ADHD may also allow natural sporting ability to lead to competitive success. Having ADHD, however, may also compromise participation in team sports and those which require understanding of complex rules and compliance with authority and training discipline. Treatment of a child, adolescent or adult athlete with stimulant (or any psychotropic) medication invokes complex issues of, and concerns for, the individual and for society. These include whether the medication normalises function to allow participation, compliance and benefits from coaching or enhances performance to give an unfair advantage and in extreme exertion increases the potential for side-effects. Stimulant medication was shown to improve participation but not specific sporting skills in baseball (Pelham, McBurnett, Harper et al 1990). Young people are often indifferent about taking medication (Bowen, Fenton and Rappoport 1991). They attribute better performance in standard testing to their effort or ability rather than to the medication (Borden and Brown 1989). Increased focus, effort and task application induced by medication may make children feel the task is harder (Milich, Licht, Murphy et al 1989). Although studies on the effects of stimulants do not demonstrate any major enhancement of sporting ability, there is a long history of abuse of stimulants by athletes; risks and effects are discussed by Lombardo (1987) and Fitch and Haynes (1995).
The prescribing of stimulants for athletes with ADHD has been considered formally by the International Olympic Committee (IOC) and by the Medical Advisory Panel (MAP) of the Australian Sports Commission. With the approval of the IOC Medical Commission, MAP advises that athletes with ADHD may continue their stimulant medication and compete in sports competitions until the age of 14 years. They propose, and are seeking IOC approval, to extend the age to 16 years. The MAP must adhere to IOC rules (IOC 1996) and are unable to recommend to any athlete of any age who wants to participate in national or international sporting competition, to compete while on stimulant medication, as they will incur severe penalties. It is recommended that 72 hours is an appropriate time to cease stimulant medication prior to competition. The MAP understands that the cessation of stimulant medication may expose an athlete with ADHD to inferior sports performance and to some the possible risk of injury.
The Australian Sports Drug Agency (ASDA) advises that individual national sporting organisations may deal differently with the taking of banned substances for medical purposes. ASDA focuses drug testing on athletes at the Žlite level. In other representative situations, the individual athlete’s medical information should be discussed with the appropriate sporting organisation and the use of medications should not be avoided through fear of being tested.
Scientific research into the effects of stimulant medication (and also its temporary cessation) on the performance of athletes with ADHD is strongly recommended.
The persistence of ADHD is now well recognised, with reports of ADHD diagnosed in and continuing throughout childhood. Poorer outcomes are associated with aggression/defiant behaviour and Oppositional and Conduct Disorder, compounded by many other possible coexisting cognitive, behavioural or mood disorders and environmental disruptions.
Some adults present when their children are diagnosed and treated; they may present a clear history of childhood ADHD and have adapted to this with varying success. Encouraged by more widely-available information (Hallowell and Ratey 1994a,b) and public support groups, vulnerable adults present self-diagnosed ADHD symptoms which may truly be ADHD or may be other disorders with similar symptoms. Within the conceptual limitations of ‘categorical’ psychiatric diagnosis, such differentials (and potential co-morbidities) of ADHD include depression, anxiety, obsessive-compulsive disorder, narcolepsy and personality disorders. Significant learning disabilities, especially language disorder, are common and often untreated in previous decades, even if recognised. The combination of ADHD and Conduct Disorder in the parent has strong negative influence on outcome of the child.
Abuse of alcohol and psychotropic substances should raise suspicions of coexisting ADHD. This particular challenge is complicated by recent case reports of adults with ADHD successfully overcoming substance abuse problems with stimulant treatment.
Diagnosis of ADHD in adults employs the same techniques as those used in children, involving reports gathered from various informants, especially parents and siblings, reports from school and developmental assessments, job history and evaluations and the effects of various treatments. Persistence, pervasiveness and dysfunction are reflected in rating scales from Utah (Ward, Wender and Reimherr 1993) and Massachusetts in the United States, and are discussed further in Weiss (1992), by Silver (1990) and by Hechtmann (1992). The Utah criteria have been evaluated for gender difference and factor composition (Stein, Sandoval, Szumowski et al 1995). Behaviours and dysfunctions of classical childhood symptoms may modify with time, maturity, public understanding and intervention. Symptoms may be more internalised feelings of tension, mental hyperactivity, intrusion and distractibility from focused thoughts. The deficit is defined by the context of the demand and adults may have made adaptations for their strengths and vulnerabilities. Strategies may be learned and supports be engaged as a result of professional guidance, trial and error and coincidence. Individuals with more intrinsic strengths and more environmental or socioeconomic advantages may find help more effectively.
Shaffer (1994) suggests a prevalence rate of ADHD of 3.3 per cent amongst children and adolescents, based on his own unpublished cross-national collaborative work. He suggests at least an adult prevalence rate of 0.3 per cent, from the stringent diagnostic criteria of Mannuzza, Klein, Bessler et al (1995) which showed 10 per cent persistence into adulthood. Murphy and Barkley (1995) suggest adult impairment at DSM-IV symptom cutoff points of 4/9 inattention; 5/9 hyperactive/impulsive (rather than 6/9 and 6/9 for children). Co-morbidity, accommodation by the individual and recollections and realities of the demands, and understanding and management of symptoms in childhood, decades earlier, will all influence diagnostic information.
The stimulant response of adults who had childhood onset of ADHD resembles that of children as do the effects of other medications, particularly for co-morbidities. The Utah group demonstrated the efficacy of methylphenidate twenty years ago (Wood, Reimherr, Wender et al 1976), which has since been confirmed in a few placebo-controlled studies. One recent study shows similar response rates to methylphenidate in adults as in children, with common co-morbidity, mood and anxiety disorders. Interestingly, a higher proportion of ADHD was identified in females (Spencer, Wilens, Biederman et al 1995). Co-morbidity and nonresponse to stimulants will require more rigorous trials of various medications in adults with ADHD. Pharmacotherapy of adult ADHD is comprehensively reviewed by Wilens, Biederman, Spencer et al (1995).
Information regarding medication use and psychiatric information may be legally required on formal applications for employment and use of machinery, for driving, life insurance and drug testing at work and in sport. Official systems will respond according to current knowledge of ADHD outcome (which is derived from cohorts studied in earlier decades when treatment was suboptimal). Few of these issues, such as driving while taking medication, have been systematically examined (Barkley, Guevremont, Anastopoulos et al 1993). In the case of sports at the national and international level, it has been ruled that at representative competition level, stimulant use by athletes with ADHD cannot be allowed, despite the advantages for individuals with ADHD achieving success and self-esteem.
A number of issues remain to be addressed in order to provide adequate services to adults with ADHD. These include:
research should be undertaken into lifestyle issues of ADHD such as participation in sport, employment, and eligibility for insurance.
Further research should be carried out on the management of adult ADHD.