FOOD FOR THOUGHT ON ADHD (Attention Deficit Hyperactivity Disorder)

I am aware that I am entering an insidious and very delicate path, but as I always hope to do in the articles of this blog, I will try to propose some considerations hoping to encourage human and professional reflections and comparisons.

I am convinced that anyone who chooses to work with children, who has been doing it for a long time or who only approaches more recently, have a common purpose: the well-being of the little ones and their health. Physics and psychics.

The first descriptions of behaviors associated with the current ADHD acronym date back to the mid-19th century where the German psychiatrist and writer Hoffmann described in short stories for children, of restless, inattentive and disobedient young people. Mainly he seemed to attribute problems of educational origin to these behaviors.

In 1902, the pediatrician George Still describes children with the same characteristics but attributes to these problems genetic origins and not educational deficiencies on the part of the surrounding context; he spoke of a deficit in moral control and an excessive liveliness and destructiveness.

In the second edition of the reference text of psychiatry worldwide, the DSM, this disorder enters the manual with the diagnostic label of “Hyperkinetic Reaction of the Child”.

DSM III will use the diagnostic term “Attention Deficit Disorder” which provided for two subtypes: with or without hyperactivity and a list of symptoms that, associated and / or added together, define the picture. The DSM IV will not differ much from the previous version and will include the deficit in behavioral disorders whose symptoms are to be detected before the age of seven.

In the DSM V ADHD is classified as a neurodevelopmental disorder, as the only difference from the previous manual (as regards the diagnosis) the symptoms must present before the age of twelve; a criterion that sees the diagnosis of ADHD significantly increase.

There are some differences between ICD 10 (treated by WHO) and DSM, particularly on the age of diagnosis and the combination of symptoms to carry it out, but both agree that in order to make a diagnosis, symptoms must be present in at least two different contexts and compromise the social and school / working life of the subject.

The diagnosis is clinical and includes nine signs and symptoms of inattention and nine of hyperactivity and impulsivity.

Symptoms include:

Doesn’t seem to listen when spoken to directly, gets distracted easily, has difficulty playing quiet activities, often answers even before questions are completed, often interrupts or acts intrusive, etc.

The assessment is clinical, based on the observation of the child’s behavior in multiple contexts; there are no diagnostic tests that allow to identify with certainty the presence of the disorder and one of the limitations of the questionnaires could be represented by the subjectivity of those who have to fill them in, parents and teachers.

Before making a diagnosis, the physician should encourage and recommend PTBM (Parent Training Behavior Management) to parents; this tool, defined as a primary intervention, could be useful for parents and help them to correctly assess: “… developmental expectations appropriate to the age of their children, behaviors that strengthen the parent-child relationship, ability to manage situations and / or problematic behaviors … “

Following the diagnosis, the proposed treatments are: Behavioral Therapy and Pharmacological Therapy

 Psycho-behavioral treatment, (adapted to the characteristics of the subject based on age, symptoms, associated disorders, family / social situation and his cognitive resources) aims to favor an adequate adaptation of the child within the various contexts and improve the quality of the relationships within them, with the aim of favoring inclusion in school / work environments; management and recognition of emotions, ability to evaluate and solve problems, are just a few examples.

This treatment includes “Parent Training”, where parents are provided with some information on ADHD and strategies to be adopted with the child in the case of certain behaviors are suggested; There are also meetings with teachers to train them to observe, understand / recognize, evaluate and contain any problematic behaviors.

Pharmacological treatment involves the use of psychostimulants (methylphenidate in particular) and is prescribed by the child neuropsychiatrist. The drug, not recommended for children under the age of 6, is prescribed to improve the ability to concentrate and attention, while reducing the subject’s impulsive behaviors. Sometimes antidepressants, antipsychotics and mood stabilizers are also administered.

Some studies support the use of drugs and find a reduction in symptoms and a consequent improvement in school performance and behavior in relation to peers and reference adults (parents and teachers); other studies believe that the pharmacological treatment is not yet completely clear and that this improvement is not attributable to all aspects and, more importantly, the long-term effect on the body and the possible consequences on psycho-physical development is not clear.

Different and opposing currents of thought on this subject; there are health professionals who see the drug as the only solution, those who associate cognitive behavioral therapies with the drug and those who argue that the drug is absolutely to be avoided due to the damage it irreversibly causes on the psycho-physical development of children.

Illustrated how the disorder is defined by the most common diagnostic manuals, I would like to open the second part of this article with the words of Dr. A. Bembina and D. Della Putta who pose the question on a very interesting point of view: “In history of human thought the child has been seen only as one who does not yet have what characterizes a human being. In fact, man possesses an upright position, the opponent of the thumb, articulated language and above all rational thought, (..) the child was a “non-man”, (..) “human identity consists above all in a unconscious psychic reality capable of a profound sensitivity in the inter-human relationship, the ability to -feel- the other ”.

In fact, the authors affirm how fundamental it is … “to highlight the mental reality of the child who seems to disappear among the pages of many of the epidemiological and diagnostic-statistical manuals, (..), it is necessary to base the theoretical elaborations and diagnostic considerations on a clinical practice intent on grasping the meaning of the behaviors manifested within the relationships in which they occur … “

At this point I would like to make some reflections together and ask some questions.

Children are not “little adults”, they are children! They have their own way of communicating which, even before verbal language, is expressed in different ways. They use behavior, it is true, but these manifestations originate in places much deeper than the surface where they manifest themselves.

The expression of a discomfort, a difficulty, a malaise, a sense of inadequacy, is different from that of an adult. Their emotional state is not always only the expression of their character or of a disease; it is their “feeling”, their sensitivity that does not know or cannot express itself in any other way.

We know well, as stated by psychology and pedagogy, that the cognitive development of the child and therefore the ability to learn, pay attention, remember, feel interest, are closely linked to the emotional aspects and to the affective ties with the reference adults. So why, at times, does it seem that all this takes a back seat?

The first difficulty that seems evident is that the vast bibliography available on the subject is often in contradiction; moreover, the very fact that the symptoms change from child to child, change over time, emerge in different ages and environments, raises some questions, many of which are present between the lines of this article.

In the absence of scientific data and considering how, by respecting the DSM criteria, ADHD is diagnosed (ie by observing the behavior), why do we only deal with the symptoms and not the causes that generate them?

Why is the genetic hypothesis underlying the disorder justified (because perhaps a sibling or parent presented the same symptoms) and not taking into account the influence that the surrounding environment may have in the occurrence of a certain symptomatology? Can’t a father or brother become a role model that influences a child’s development?

Furthermore, I find it incongruent to state that other pathologies may exist in comorbidity with ADHD and the same pathologies are used to make differential diagnoses, such as: oppositional-provocative disorder, obsessive-compulsive disorder, conduct disorder.

There are many possibilities that emerge by discussing, studying and analyzing this issue, but above all, in all currents of thought, what emerges overwhelmingly is the idea of ​​incurability, the disorder is in fact defined “chronic”, a term that is to indicate a condition that will accompany the person for the rest of his life. Whether genetic reasons are taken into consideration or not, these children seem predestined to be “different” and this is how they should be treated, helped to behave well to fit within the social standards of good education. However, some do not think so and wonder why. Even some parents wonder why their child reacts in some ways at school, in the family, when faced with certain situations?

We must certainly worry about the symptom, (because it exists, it exists) but the claim is to go back to the cause. Where science has not yet provided certain and incontrovertible data, we must ask why.

Are we sure that it is on behavior that we need to focus our intervention? And that this isn’t just the tip of the iceberg?

Some insights from recent times and the vision of a docu-film by Stella Savino “ADHD-Rush hour”, which I highly recommend to see, suggested that I write what you are reading. This documentary analyzes the risk of taking drugs (with testimonies from parents of children who use them and adolescents who use them independently); the questions that arise later are legitimate: What damage do drugs cause on children? And what is the risk of them creating an addiction in adolescence?

Why does the health system cover all costs for a drug (even a very expensive one) but does not bother to guarantee psychotherapy and speech therapy for those in need? Is it just a cultural problem? Or are there other interests that are hard to understand to me?

As always many questions. To which it is urgent to give answers.

In recent weeks, the Lazio Regional Council has approved the law of 11 August 2021, n.14 “Provisions connected to the 2021 regional stability law and amendments to regional laws” which in art. 35 provides for the commitment of the Lazio Region Council to approve the “Regional guidelines for taking care of subjects affected by attention deficit hyperactivity disorder”. I await them with great interest.

Valeria Verna