Abstract
Attention Deficit Hyperactivity Disorder (ADHD) has become the most prevalent child psychiatric diagnosis, and the Editor is to be praised for devoting a whole symposium to it [1].
Children have only a limited repertoire for expressing continuing distress. An eminent authority has compared the diagnosis of ADHD to the diagnosis of fever: it merely signals the need for a thorough assessment [2]. McDermott and Gibbon, in their excellent article on developmental assessment, make the case well.
The data presented by Sawyer et al. shows the unsuitability of DSM's categorical approach. With the support of a parent at home, a child might manage without medication, whereas an unsupported child may need it. So far as stimulants are concerned, Levy makes a point in passing which some would want engraved in stone. Stimulant medication may quieten any child, hyperactive or not, just as it may activate any adult. Trial of medication to ‘confirm the diagnosis’ is a nonsense!
Both Halasz and Vance underline the indispensability of dealing with family and school contexts. As Hazell says, in some cases we must advocate for medication in the face of parental opposition. More often we have to resist pressure for a quick fix and raise awareness of emotional needs – of the child, and of the parents too. Parents need to feel understood, to have their experience validated. Often we find that a parent is having difficulties with the emotional holding and containing of the child.
I have found a family therapy perspective valuable. Where deficient parental limit setting has been an important factor, children can respond markedly in the assessment sessions to our own limit setting – sometimes showing clear relief that can be very moving. Parents may need continuing help to model limit-setting and train them in its use. Teachers need to be heard as well, and sometimes then, advice for simple changes in classroom arrangements will make sufficient difference.
As Halasz says, adequacy of time is a crucial ethical issue: enough for a parent or teacher to deal with a child's difficulties; enough for a doctor to get to know the child, and to assess development and context. It will always be improper to ‘manage’ a child's behaviour without listening to the child [3, 4].