Rachel Klein,
Ph.D., New York State Psychiatric Institute
The concept of ADHD has
been noted since the 19th century. It was largely ignored until the middle
of the 20th century, when the concept of minimal brain dysfunction was
introduced. It encompassed a multitude of pychopathology, with the inference
that they all shared abnormal brain function, in the absence of abnormal
anatomical findings. In 1968, the DSM-II for the first time in the history
of psychiatric nosology, included a category that is at the origin of the
current disorder, i.e. Hyperkinetic reaction of childhood. The subsequent
versions of the DSM (DSM-III, III-R and IV) have modified the definitional
content of the disorder. The reasons for renaming the disorder Attention
Deficit Disorder, and for the changes introduced by each version of the DSM
will be summarized.
ADHD, as a separate
diagnostic entity with discrete clinical features, has been largely a U.S.
phenomenon. However, in the U.S. and abroad, it has stimulated controversy
regarding its validity. The history of the controversy will be reviewed
briefly.
The symptoms associated
with the disorder and its subtypes will be noted. The introduction of the
Inattentive subtype has raised some important questions as to its
relationship to the overall category of ADHD.
There is general
consensus that ADHD is a relatively common disorder, but prevalence rates
vary considerably across investigations. The factors that may contribute to
these variations will be noted. These include, among others, the source of
information (parent alone, or parent and teacher); the type of evaluation
(layman or clinician), rating scale versus direct interviews.
The therapeutics of ADHD
are the best studied of all childhood psychiatric disorders. Several classes
of pharmacological interventions have been systematically assessed in
randomized placebo controlled trials. They include psychostimulants,
neuroleptics, tricyclics, MAO inhibitors, and others. Several of these
compounds have established efficacy in ADHD, but evidence for improvement of
associated dysfunction seems restricted to the psychostimulants. In
addition, various theoretical views regarding the origin of ADHD have
stimulated the development of other interventions, such as cognitive
training and behavior therapy. In addition, the expectation that the
combination of effective medication with non-medical interventions would
yield optimal outcome has prompted several informative clinical
investigations. The overall status of treatment efficacy will be summarized.
To conclude, noted will
be the remaining challenges in the management of ADHD.
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