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ADHD: the facts
  1. E V J Webb

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    Edited by Mark Selikowitz. Oxford: Oxford University Press, 2004, pp 235 £11.99. ISBN 0 19 852628 8

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    This book opens badly, with two long histories that, for some reason, are presented in tiny font size. Already irritated I was then dismayed to find the cases described maintaining the tired stereotypes of the dreamy inattentive girl and the hyperactive, impulsive boy. The boy is, disappointingly, also violent and aggressive. There are girls who are hyperactive and impulsive, and hyperactive, impulsive children of both sexes who are neither violent nor aggressive. Unfortunately the media stereotype, reinforced here, is not a helpful one for most children with ADHD trying to make sense of themselves.

    The relation between real and administrative prevalence, or the political and social factors which can influence both, are not discussed. ADHD is, at the severe end of the scale, a disabling disorder with clear neurobiological deficits. However it is also a dimensional disorder with no boundary between “normal” and “ADHD”; at the cusp it becomes, in part, a socially constructed disorder. This has such profound implications for the appropriateness of how we treat and teach all children that it should at least have had some mention.

    The book attempts, with considerable success, to explain simply the neurodevelopmental basis of ADHD. But there is confusion between the neuropsychological deficits found in ADHD and those found in other disorders with which it may be occasionally co-morbid. For example, the book fails to explain the role of attentional difficulties in the aetiology of social clumsiness found in ADHD, which is quite different in character to the primary socialisation difficulties of autism, arising as they do from deficits in communication, empathy, and theory of mind. To add to this, Asperger’s syndrome is described within a section on emotional disorders characteristic in ADHD, which is highly misleading. Indeed, throughout the book core and non-core symptomatology are muddled. The introductory section makes no distinction between the core symptoms of inattention, hyperactivity, and impulsiveness, and co-morbidity such as clumsiness and inflexibility—core for developmental coordination disorder and ASD respectively, but not for ADHD. In section 2, core deficits are again described with the same emphasis as, for example, defiance and emotional disorders. I think this can only confuse readers as to the true nature of ADHD.

    Subsequent chapters, on diagnosis, treatment, school and home management, and adult ADHD, provide a useful and well balanced source of information, although recent developments result in the comments on SSRIs being now out of date.

    The author appears to explain all behaviours in children with ADHD using exclusively neuropsychological, rather than behavioural, theory with no discussion of the impact of a child’s developmental context on how both personality and disorder are manifest. For example, chapter 7 (“Low self esteem”) discusses this phenomenon as having an entirely neuropsychological basis arising from faulty self appraisal mechanisms (although these theoretically could provide one with a super-ego instead). Only in chapter 9, in an aside, is the impact of negative experiences, of which these children have plenty, acknowledged in the development of poor self esteem. The quality of attachment, maternal depression, exposure to violence are all known to have a profound impact on how children develop, whether or not they have neurodevelopmental problems. It may be that children with ADHD are even more susceptible to the impact of early adverse experiences, but nowhere in this book is this explored. This is, presumably, an understandable but over-reaction to the still pervasive tendency to blame ADHD on poor parenting. But we need a more balanced view than that provided here.

    The blurb on the back claims this book to be useful to parents and professionals alike. Unfortunately the tabloid approach and lack of referenced primary sources really preclude its relevance to a professional audience. Although it does provide a wealth of useful information for a lay audience, it would have been much improved if there was at least some indication in the text of when a statement made is well supported by good quality research, for example, the high heritability of ADHD, from another which sets down a “fact” with, as far as I can ascertain, no research base at all. For example, page 47: “adolescent boys with ADHD are particularly averse to taking instruction from a woman teacher”. With some reservations this book will be useful for parents and other carers wanting a fairly detailed text they can dip into as the need arises but it is not one I could recommend to colleagues.