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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
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. "
Thus wrote Russell Barkley in his foreword to what is probably the classic study of adults with AD/HD, " Hyperactive Children Grown Up " by Weiss and Hechtman (1993). This details a prospective follow-up of hyperactive children from 1960 to the present day. Their fifteen-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 cumbersome 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
From the late 1960s colleges of education were influenced by " 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 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 circumstances.
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 analogy 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 psychotherapeutic 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 therapeutic approaches. A number of questions should be asked ... Under what conditions do drugs facilitate or retard psychotherapeutic 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.
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.
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© Priory Lodge Education Ltd., 1994,1995,1996. First
Published December 1996