ADHD expert, Dr. Nikos Myttas, discusses the myth of ADHD and bad parenting, the history of ADHD, and the diagnosis and treatment of childhood ADHD.

Key Points

• ADHD is a genetically determined, neuropsychiatric condition.
• ADHD constitutes a major educational, social, cognitive and emotional handicap for those affected.
• The major symptoms of ADHD persist throughout life in most people who are affected. People with ADHD run a high risk of alcohol and substance abuse, criminal behaviour, poor psychosocial functioning and psychiatric disorders.
• Early intervention and treatment significantly reduces the risk of further psychosocial complications.

The Myth of ADHD and Bad Parenting

A distinct group of children exists who have trouble staying with any task for any length of time unless they receive constant feedback, stimulation and reward or have close, one-to-one supervision. They fleet from activity to activity, hardly ever completing any. They are either distractible or hyperfocused and they lose their train of thought easily. They get muddled up and they have difficulty getting back on track. They daydream, they appear not to listen, they lose or misplace their things and they forget instructions. They procrastinate, avoiding tasks that demand attention and sustained concentration. They have a poor sense of time and priorities. They are moody and constantly complaining of boredom, yet they have trouble initiating activities. They are full of energy as if 'driven by a motor', restless, constantly fidgeting, tapping, touching or fiddling with something and they may have difficulty getting off to sleep. They speak and act without thinking, they cut across the conversations of others, they have difficulty waiting for their turn, they shout out in class, they disrupt others and they rush through their work making careless mistakes. They misjudge social situations, they dominate their peers, and they are loud and act silly in crowds to the embarrassment of their parents. They are demanding and cannot take 'no' for an answer. Putting off immediate rewards for delayed, but larger, ones sets them off in a spin.

These children are repeatedly described as 'lazy', 'underachievers', 'not reaching their potential', 'unpredictable', 'disorganized', 'erratic', 'loud', 'unfocused', 'scatterbrained', 'undisciplined' and 'uncontained'. Their teachers' reports are testimony to these labels. At the same time, they can be bright, creative, articulate, lateral thinkers, imaginative and loving.

What is often implied but not stated is that their parents are to blame. These parents are thought to be ineffective, uncontaining of their children, with pathological attachment, unable to exercise discipline or teach manners, harbouring unconscious repressed feelings of hatred against their children, often the result of their own deprived childhood. Yet the same parents may be bringing up several other children with no signs of distress or maladjustment in them. Guilt is almost synonymous with parenthood and it is extremely rare that a parent will resist such an attack and challenge it, especially if it comes from a professional.

History of ADHD

The restless, overactive and fidgety child who stands out from his peers has been around, presumably, as long as children have been around. The first known reference to a hyperactive child or one with attention deficit hyperactivity disorder (ADHD) occurs in the poems of the German physician Heinrich Hoffman, who in 1865 described 'fidgety Philip' as one who 'won't sit still, wriggles, giggles, swings backwards and forwards, tilts up his chair... growing rude and wild'.

In 1902 the paediatrician, George Still, presented a series of three lectures to the Royal Society of Medicine describing 43 children from his clinical practice who were often aggressive, defiant, resistant to discipline, excessively emotional or passionate, who showed little inhibitory volition, had serious problems with sustained attention and could not learn from the consequences of their actions. Still proposed that the deficits in inhibitory volition, moral control and sustained attention were causally related to each other and to the same underlying neurological deficit. He speculated that these children had either a low threshold for response inhibition or a cortical disconnection syndrome where intellect was dissociated from will, possibly due to nerve cell changes. The children described by Still, and by Tredgold (1908) soon after, would today be diagnosed as suffering from ADHD with associated oppositional defiant disorder or conduct disorder.

Clinical presentation of Childhood ADHD

Although ADHD is a heterogeneous condition occurring along a continuum of severity, a fairly typical presentation is a child who has been difficult to handle, often since birth and certainly before school entry. As infants, some may have been extremely difficult to settle at night. They may have had their parents pacing up and down the room for hours while holding them, in order for them to fall asleep. Their parents may even have taken them in the car and driven them around to get them to sleep. Many would sleep in short bursts, be full of energy upon waking, extremely demanding of constant stimulation and needing to be picked up and held for long periods of time.

As soon as these children can walk they may be into anything, sometimes clumsily. They climb, run about and get into accidents. At preschool they stand out as restless. They are unable to sit down during story time, they fight with others, spit, scratch, take unnecessary risks without a sense of fear and fail to respond to punishment.

At the start of formal education they might be, in addition to the above, messy and disorganized with their work, overtalkative in class and forgetful. They may interrupt the lesson and interfere with the work of others, get up from their seats, walk about, rock on their chairs, make noises, constantly fiddle, be unable to pay attention or be in a daze. During playtime they may have difficulty sharing and negotiating relationships with their classmates. They tend to dominate the game, be inflexible and particularly loud, and break up the games of others if not allowed in. Some would have such difficulty making and keeping friendships and they would rarely get invited to parties, if at all.

At home they may wind up their brothers or sisters, refuse to help out or comply with demands, complain of boredom, get into mischief, set fires or engage in other dangerous activities in the pursuit of excitement.