Treatment of attention deficit hyperactivity disorder

Editor, – Dr P. Hazell (Aust Prescr 1995;18:60-3) and Professor R. Adler (Aust Prescr 1995;18:64), writing on stimulant treatment for ADHD, demonstrate the 'medical model' approach to the problem.

Further consideration of the DSM-IV Dr Hazell refers to, may enable one to determine some common characteristics of personality amongst the parents in these cases. This then becomes a delicate matter. Having brought their child for treatment to various medical specialists authorised to prescribe methylphenidate and amphetamines for ADHD, parents may not take kindly to any suggestion that the origins of the problem of the child are rooted in their personalities and that the child's best chance of staying out of gaol as an adult, or being killed or seriously injured in a motor accident, or becoming psychotic, lies in the parents entering therapy as well.

This is hardly a popular concept and an even less popular option. It can be applicable for a myriad of 'medical' problems, with not only parents, but also often medical practitioners, loathe to consult appropriately trained psychologists. Whilst, as Dr Hazell says, there is evidence of brain injury in some cases, remember ADHD was also known as 'minimal brain dysfunction' before the euphemism 'ADHD' was invented to make parents and child and others more comfortable with the diagnosis.

The realistic possibility of schizophrenia in early adulthood is better faced at the outset. Whilst I see no value in causing patients or their relatives undue concern, they might better appreciate some indication of what the future might hold.

Karl R. Wood
Pharmacist and Member
Psychologists' Association of Australia
Cabramatta, N.S.W.

Dr P. Hazell, the author of the article, comments:

Mr Wood has raised concern about schizophrenia being overlooked as a differential diagnosis in ADHD, and the possibility that the child's problems may be due to other problems in the family. While there are individual case reports of children diagnosed with ADHD developing schizophrenia¹,and some retrospective evidence that adults with schizophrenia may have childhood histories of attentional problems², longitudinal research has found ADHD children to be no more likely than control subjects to develop schizophrenia in adulthood.³ Since the possibility of schizophrenia is remote in most ADHD children, I would not recommend that clinicians raise with parents schizophrenia as a potential outcome. Conduct, emotional and educational difficulties are of greater concern.³

Family difficulties must be considered in the assessment and management of ADHD children⁴; however, it is unlikely that these problems cause ADHD. Parent psychopathology, including personality disturbance, seems to be of greater relevance to the development of conduct problems than to ADHD.⁵ Any association of ADHD with parent psychopathology is almost certainly due to the common co-occurrence of ADHD with conduct problems. ADHD children may be more vulnerable than their non-affected siblings to the pathogenic effects of living with a disturbed parent.