The powers that be who publish the Diagnostic and Statistical Manual of Mental Disorders (DSM), including its latest offering published in 2013, have thus far given little credence to the importance of emotional symptoms in Attention Deficit Hyperactivity Disorder (ADHD). Nonetheless, parents and practitioners alike are all too aware of how commonly the symptoms of irritability, frustration intolerance, anxiety and defiance complicate the presentation of ADHD. And behind the scenes there is an increasing research focus being afforded to this matter.
Of course, the prototypical disorder of emotional regulation is Bipolar Disorder. What complicates matters is the marked degree of symptom overlap between this mood disorder and ADHD: inattentiveness, talkativeness and impulsivity occur in both. There is a long and raging transatlantic debate about the frequency of this diagnosis and the appropriate diagnostic criteria to use. Generally, the North Americans accept criteria which are broader, resulting in a greater number of diagnoses than in Europe, where a stricter definition is favoured. When I was training in child psychiatry my professor was once moved to issue a temporary ban on the Bipolar diagnosis, in an attempt to help us see beyond the face-value of presenting symptoms.
Current trainees now have another diagnosis to invoke for children who are particularly irritable and moody, namely Disruptive Mood Dysregulation Disorder (DMDD), which made its debut in the latest edition of the DSM. On the topic of new terminology, Russell Barclay, one of the leading international experts in the field, has introduced the term emotional impulsivity as an important symptom in many children with ADHD, describing their low frustration tolerance and quickness to anger.
Further evidence for the association between ADHD and emotional dysregulation comes from a fascinating face-emotion processing study. For some time now we have known that youths with Bipolar Disorder and severe mood dysregulation are deficient in their ability to identify and label facial emotions. In this recently published study, a group of ADHD subjects were also included. This group showed hyperactivity of the amygdala (an area of the brain known to be important in emotion processing) when completing subjective fear ratings of neutral faces, relative to healthy controls. I was always taught that the prefrontal cortex and cerebellum were the important neuroanatomical correlates of ADHD; it now seems that the amygdala must now be included in that list.
There is a well-described association between ADHD and Oppositional Defiant Disorder (ODD); in fact, around 40% of boys with ADHD meet criteria for ODD. Emotional dysregulation is implicit in several of the diagnostic criteria for ODD. Three subtypes of ODD have been described, namely irritable (temper outbursts, easily annoyed, angry/resentful), headstrong (argues with adults, rule violations, purposefully annoying others, blaming others) and hurtful (spiteful, vindictive). Further research has confirmed that these dimensions are stable across time and are also prognostically important. Specifically, the irritable type is predictive of depression in the teenage years, and headstrong with Conduct Disorder (a severe behavioural disturbance) in later adolescence. Separate research has flagged the co-occurrence of ADHD, Oppositional Defiant Disorder/Conduct Disorder and anxiety/depression at the age of six as being highly predictive of depression and suicidal behaviour in later life.
Where does all this leave us? Any ADHD assessment should routinely investigate for associated emotional symptoms. Even if there are no co-existing disorders per se, emotional dysregulation may very well be an important part of the clinical picture. Furthermore, symptoms such as low frustration tolerance, irritability and emotional impulsivity should be targeted and then specifically monitored once treatment is instituted. This requires education of parents and caregivers, who may not recognise that these symptoms are part of the broader landscape of ADHD. Both the stimulants (such as Ritalin and Concerta) and atomoxetine (Strattera) commonly alleviate the emotional dysregulation associated with ADHD, although both classes of medication can also aggravate emotional symptoms in certain children.
Finally, as we have seen, the co-occurrence of ADHD and emotional disorders has very important treatment implications, underscoring the importance of identifying comorbid (co-existing) emotional disorders in patients with ADHD. This should result in a more targeted management approach which could proactively address symptoms before they develop into more severe problems in later adolescence or adulthood.
Dr Brendan Belsham is a child psychiatrist and author. His book, What’s the Fuss about ADHD? is available from amazon(click here)
Autism is a developmental condition, present from early childhood, which affects how a person relates to others. People with autism have great difficulty communicating and forming relationships. It affects around 1% of the population, and is commoner in boys than in girls. The prevalence seems to be rising, for reasons which we don’t completely understand. There are milder forms of autism, such as Asperger’s disorder, which may only be recognised in middle childhood or later.
How can you tell that your child is autistic?
A child with autism will usually be showing concerning behaviours by as early as 12 -18 months of age. Children with autism commonly have delayed speech, but it is important to remember that not every child with delayed speech is autistic, it fact most aren’t. But what is always impaired in autism is the way these children use speech and language to communicate with other people. Autistic children struggle to form friendships, and tend to be loners. They are often simply not interested in being with other kids. They lack the social skills required to interact meaningfully with others, and battle to understand facial expressions and other non-verbal gestures. These children lack what is called ‘joint attention;’ what this means is that they don’t spontaneously seek to share enjoyment with their parents and significant others. This may be evident from as early as 18 months, and one of the signs is the failure of the child to point to objects of interest in their environment. It’s one thing pointing to the fridge if you’re thirsty, but pointing to share enjoyment is typically absent in children with autism.
Autistic children display a lack of imagination and pretend play in their games. For example, a little boy with autism may line up all his cars in a row rather than invent a game in which the cars race or drive ‘as if’ they were real cars. They will not use a stick as if it was a gun or a pretend that they are superman or batman. Children with autism often display unusual, repetitive behaviours, such as hand-flapping or rocking to and fro. These children also tend to have a very narrow range of interests. In fact, higher functioning autistic children may become extremely knowledgable about their particular area of interest.
What causes Autism?
Autism is a genetic disorder, but there is no single genetic abnormality which is responsible for the condition. Rather, there are a number of genes which are suspected to contribute to autism. It is thought that these genes act in combination with eachother and with the environment to give rise to the disorder.
Can it be prevented?
There is no prevention for autism. Perhaps in the future when we understand more about what causes it, we will have strategies to prevent it. There is much controversy about the potential role of the MMR (measles mumps rubella) vaccine in causing autism, and many parents have opted not to immunise their children for fear of increasing their child’s risk for the condition. However there is NO EVIDENCE that the MMR vaccine is responsible for autism and it is a mistake to deny your child this immunisation and increase your child’s risk for these potentially serious infections.
Can autism be treated?
There is no cure for autism, but there are many strategies to reduce the severity of the condition, and enable those affected to live the most fulfilling lives possible. The first step is choosing the correct school for the child. This will depend on their intellectual ability. Some children with autism have a normal IQ, and others may be severely handicapped. There is a spectrum of ability which we see with this condition. Certain schools are specially geared to cater for autistic children. The treatment of autism is multidisciplinary. This means that several different professionals are often involved. Besides the teacher, a speech therapist, occupational therapist, psychologist or child psychiatrist may all have important roles to play. Children with autism may present with many challenging behaviours, and there are various forms of behaviour modification which are used to reduce these behaviours, both in the classroom and at home. Many children with autism require medication to assist with associated symptoms of the condition, such as aggression, anxiety, or concentration difficulties. Again, medication is not a cure for autism, but may well relieve troublesome symptoms.
For further assistance and advice, there are many excellent advocacy groups, such as Autism South Africa ( www.aut2know.co.za).
This book is an encouragement to all fathers to step up to the plate and be what we are supposed to be. It is easy to read and enjoyable, yet conveys a profound message. These key points stuck with me:
1. The way we live speaks louder than anything we say
2. We can only impart to our children what we have inside us to impart
3. What we have inside us, both good and bad, WILL be imparted to our children.
Day after day in practice, concerned parents ask me why ADHD has suddenly become so prevalent. ‘Better recognition’ has been my standard response. But I am no longer satisfied with this reply, and nor are these parents. Let’s examine this question in more detail.
Attention Deficit Hyperactivity Disorder refers to a condition in which a child (or adult) displays excessive inattentiveness, hyperactivity and impulsivity. These symptoms can occur in varying combinations, giving us three subtypes of the condition, namely the inattentive, the combined, and the hyperactive-impulsive subtypes. It seems to affect boys more than girls. According to well-designed epidemiological studies, the prevalence of ADHD in school aged children is around 6%. This figure is constant across countries, ethnic groups and cultures, and has not increased over the years. Contrast these findings with the numbers of children actually receiving the ADHD diagnosis and/or treatment, and a very different picture emerges. In the United States, according to 2013 data from the Centre for Disease Control, 11% of children between the ages of 4 and 17 had received the diagnosis of ADHD compared to 5% in the early 1990’s. In Britain, the estimated prevalence of ADHD in school children has risen from around 2% in 2003, to 5% in 2013. Inaccuracies in diagnosis have been highlighted in several studies, such as the Great Smoky Mountain study in the USA. In this study, some 1422 children, their parents and their teachers were given structured interviews to ascertain the prevalence of various conditions in the community. The results were quite startling. A mere 57% of the children who had been prescribed stimulant medications actually met criteria for ADHD! Of the entire group who did not meet diagnostic criteria for ADHD, as many as 4.5% had received stimulants. What’s going on?
Part of the problem lies in the very nature of ADHD itself. Unlike other disorders in medicine, ADHD is a dimensional condition. The symptoms of inattentiveness, impulsivity and hyperactivity exist on a spectrum, without clear boundaries between normal and abnormal. We speak of a ‘zone of ambiguity’ between clear-cut cases and those who are obviously unaffected. This means that diagnostic rigour is required in the assessment of the condition, and one has to carefully appraise the frequency and impact of each symptom before it can ‘count’ as part of the diagnosis. Rushed assessments, and those based on quick checklists, will invariably lead to over-diagnosis. It is fairly commonplace these days for a doctor to casually write a script for a stimulant medication ‘to see if it helps,’ as if this was some sort of diagnostic test. There is now a large body of evidence attesting to the cognitive benefits of stimulant medications in those without the ADHD diagnosis. Indeed, there is growing international concern about the phenomenon of cognitive enhancement, defined as the amplification of core capacities of the mind through improvement of information processing systems through medical means without therapeutic intentions. And this phenomenon is now becoming more socially acceptable, fuelled no doubt by the greater importance given by contemporary society to tertiary education, and the increased competition for admission to degree courses. This cavalier approach to cognitive enhancement is a worrying trend on South African campuses. I have been approached by more than one concerned lecturer to provide some guidance on the matter, and a South African policy framework is urgently required to address this issue. Other sociological reasons have been put forward to explain the burgeoning number of stimulant scripts. As a society, we have become increasingly prone to find medical explanations for aberrant behavior. Whereas in the past we may have tended to moralize or criminalize such behavior, we now medicalise it, finding a suitable diagnostic home for the symptoms we see. Related to this is the phenomenon of ‘medical reductionism,’ whereby inherently complex issues are overly simplified to a one-dimensional diagnosis. Here is an excerpt from What’s the fuss about ADHD:
‘ Both doctors and parents can fall into this trap, for different reasons. The doctor, because it is easier and he has a treatment to offer for this diagnosis, and the parents, because they actually prefer a label which lets them off the proverbial hook, rather than implicating their parenting, family lifestyle or worse… ‘
The symptoms of ADHD are non-specific and can occur in a number of other neuropsychiatric conditions. All too often, these conditions are ignored in favour of the ADHD diagnosis. Learning disorders, sensory modulation disorders, anxiety disorders, childhood depression and bipolar disorder can all masquerade as ADHD. Unidentified hearing or visual impairments may present with what appears to be inattentiveness and disruptiveness. Sleep disorders such as obstructive sleep apnoea may not manifest with yawning or somnolence in the classroom, but rather with increased hyperactivity and inattentiveness, thus incorrectly invoking a diagnosis of ADHD. Special mention should also be made of the oft-neglected Adjustment Disorder, which refers to the presence of emotional or behavioural symptoms (including hyperactivity and inattentiveness) occurring within three months of an identifiable stressor in a child’s life. If a child’s parents have recently separated, and she becomes distractible in class, the correct diagnosis is an Adjustment Disorder, not ADHD. A script for Ritalin or Concerta is inappropriate in this situation, and treatment should rather be targeted at the environment, in this case the parenting system, surrounding the child.
Another overlooked area in psychiatry is that of attachment, which refers to the close emotional bonds of affection that develop between babies and their primary caregivers. Depending on what happens between the mother and child in these crucial early months, children may become either securely or insecurely attached. Healthy attachment requires a primary caregiver who is consistently present, and attuned enough to the child to respond appropriately to her needs for focused attention, physical affection and stimulation. This is why it is so important to recognise and treat postnatal depression, a condition in which the mother cannot provide the emotional availability which her child requires. Secure attachment leaves the child with an ‘internal working model,’ or template, which allows her to see herself as valued, and others as ‘basically good.’ This facilitates healthy relationships in childhood and later life. In addition, studies have shown that securely attached children have longer attention spans and show more persistence in tasks. Interesting findings, considering that children with ADHD show impairments in these very areas. There is actually very little in the scientific literature on this, but the few studies which have been published, support an association between insecure attachment and ADHD. This overlap has prompted some to refer to the condition, somewhat cynically, as Attachment Deficit Hyperactivity Disorder.
An ADHD epidemic? Better recognition? Neither. At least in certain communities, we are over-recognizing ADHD, which has emerged as a more palatable alternative to a deeper, thornier complex of societal and environmental issues. This has contributed to what Russell Barclay refers to as the ‘trivialisation’ of the ADHD diagnosis.
We urgently need to find a balance between proper recognition and treatment of this often debilitating condition, and accurate appraisal of the more subtle forces at play in our society.
(References available on request)
For more information and understanding of this complex topic, please order the book: “What’s the fuss about ADHD” by Dr Belsham