It is always gratifying
to see Australians writing books, and the above authors between them are
frequent gratifiers of all Australians, publishing as frequently as they do in
the journals and books representative of their interests.  Dr Anderson is
particularly prolific, in the child neuropathology field, and Melbourne in particular has spawned the
likes of Kevin Walsh and Jennie Ponsford, as well as the trio above, and the
contributions from the Melbourne school in neuropsychology have been awesome.

It’s a tough series
of acts to follow, but the authors above do not let us down.

The tiny book is
packed with crisp and clear analyses of the nature of the problem. 
References to such luminaries in the field as Russ Barkley abound, and overall
there must be more than 350 references in the 23 pages at the end of the book,
as well as a comprehensive index.

Their approach
homogenises a variety of thoughts we all have on this contentious issue, in
many ways akin to the controversies in the autism spectrum, or perhaps any
condition in childhood which presents somewhere between average behaviour and
grossly unusual behaviour.

As the coming
epidemic of mental illness threatens progress in the modern world, all of us in
the West have come to question if the demands of modern capitalist life are not
incompatible with wellness.

In 1995 and again
in 1997, Christopher Green and Kit Chee wrote, in their best-selling volume Understanding
ADHD (London: Vermillion):

Play therapy, with
an inattentive unthinking child, (is) of little value.  Certainly the
‘talking cures’ have a place in managing the emotional problems of some
parents, but not in treating ADHD.  Formal family therapy is generally
unhelpful, though clever psychiatrists use a less structured approach to help
all members of a family work together to support their ADHD child€¦.(p 118)

A programme on
which they appeared, on Granada
television in the UK, logged
over 7000 phone calls immediately.  Such was the concern of parents
then.  But since then, as the Australian authors note, several truths have
emerged:

• ADHD aetiology has no Royal Road, but a multitude of paths
  lead to a common symptom
• Its not a syndrome, its too variable,
  resulting in variable rates of diagnosis
• Different cultures see the problem
  difficulty
• Even tight DSM-IV and ICD-10 formulations
  still allow for interpretation and subjectivity, with different rates of
  diagnosis
• Stimulant medication improves performance
  in all children, not just ADHD, the extent of the improvement is what
  varies, not whether there is or isn’t change
• These changes do not reliably have an
  outcome in the school setting
• The primacy of the medical model has
  retarded progress in treatment, with no objective diagnostic methodology
  holding true
• Current treatment approaches have run the
  risk of isolating the child, disempowering the parents, and ultimately the
  misdirection of treatment
• Various forms of attempted diagnostic
  tools have proved unreliable and with questionable validity
• There are gender issues in the
  historical, feminisation of society
• There is a bias towards diagnosis of
  minorities and lower socio-economic status groups
• ‘Talking Cures’ are a valid part of the
  treatment, not just the disabilities that flow from the impairment
• Medication is more readily dispensed to
  those in institutional care
• Geographic area appears to influence
  diagnosis statistics
• Small numbers of practitioners account
  for disproportionately large numbers of prescriptions for stimulants
• As an illness of our time, ADHD may
  indeed reflect child rearing practice in a society which has changed
  considerably under the influence of modern capitalist demographics,
  including dependence on day care which may not meet the understood needs
  of children at various stages in their lives, depending on various stages
  of brain development.

The authors quote
a leading Australian commentator who notes that the minute you see such
variations like this in medicine and mental health, you are looking at
opinion-based, not evidence-based medical practice.

 

What the authors
do in this book is try to move away from linear approaches such as the narrowly
defined medical model, to a more cybernetic, second order system which would
see the psycho or neuropathology as embedded within the interactions between
child and social substrate, not within the skin of the child.  Hence the
blind application of a germ or disease-centred medical model, using curative
medication or intervention, would fail, given the multifactorial picture they
paint.

 

Instead, and in
keeping with modern psychiatric philosophy, they advocate for a
bio-psycho-social model in the Engel sense.  This would answer the
questions differently, viz:

Not what single
causative agent makes this child ill? (what diagnosis?), but rather:

Why has this child,
produced these symptoms, at this stage of his/her life?

I have argued for
years that the central question in psychiatry is diagnosis in its
original form: literally dia-gnosis , or ‘through knowledge’.  Dr
Leslie Koopowitz, in Adelaide,
a teacher in psychiatry, makes the same point in the three-question approach
about the child, the symptom, and timing of the emergence of these symptoms in
this child at this time of their development.  In many ways, the
three-question approach typifies the biological, psychological, sociological,
approach.  What is within the skin, what is within the mind,
and what is within the world of this person that compels the production
of these signs, NOW?

However, the
authors make it plain that we should not fall into the linear epistemological
trap of assuming that the environment causes the child to become ill, or
its genes cause it to become ill, or some milieu events cause it
to become ill.  This is again, linear, cause-effect relationship,
anathematic to circular second order cybernetic feedback thinking.

In the interaction
of the genes, the family, the school, the world, the thoughts, the endocrines,
the stem cells, the cytokines, the chandelier cells, the loud words, absence,
separation, working parents, lousy child care, rapid-fire stimulation, grief,
emigration, loud TV, and any one of the hundreds of causal chains and context
markers, a pattern connects which represents how this child, at this time of
its life, demonstrates the symptoms of ADHD, and communicates this in producing
symptoms.

The medical or
other linear models thus produce and represent punctuation points, or rather
focal points in a complex system, descriptions, not explanations, which result
from a cross-sectional slice approach to diagnosis, rather than a developmental
framework.  The authors here are advocating a much more comprehensive
series of interventions.  The epistemology above certainly represents the
thinking of Family Therapy, of a more global determinism than the biology, or
social or psychological domains of development would represent.  We must
remember that in neuropsychology, a concatenation of symptoms does not
represent a syndrome, nor does linear definition of test outcomes provide
meaningful data.

Arthur L Benton
(1987) wrote:

The unfortunate
consequences of this combination of ignorance with delusion are numerous,
including the inappropriate application of tests to probe for evidence of
cerebral abnormality, the uncritical interpretation of test findings and, most
important from the standpoint of the patient or client, the drawing of
unwarranted conclusions about the state of his whole brain or some
geographically labelled part of it (page 8: Evolution of a clinical
specialty.  The Clinical Neuropsychologist 1, 5-8).

The authors here write:

The complex
presentation of ADHD lends itself particularly well to an exploration that can
move beyond the linear thinking of symptom and syndrome, allowing us to look
for patterns of interrelationship within a broader context.  It is for
this reason that we introduce an attempted integration of neuropsychological
and psychodynamic approaches to understanding ADHD, a condition that appears to
operate on the boundary between brain function (the realm of neuropsychology
and neurology) and the child’s emotional and social relationships within the
family and the outside world (p 11).

The implications
of such thinking of course go wider than the application here to ADHD, but of
course have an impact on thinking in the wider, broader spectrum of all
childhood conditions seen in context.  The dynamic relationship between
families and the lesser and greater facets of the units of social structure
can, must, and do colour the presentation of any organic substrate, as
Neurologist, Bill Blessing of Adelaide has suggested, when he asserts that we
cannot dissociate the feeling of thirst from the subsequent search for water.

Not only that, the
overall effect of strain-inducing stress on the brain is well documented in
other conditions, altering the way DNA is expressed, suppressing
hypothalamic-pituitary-adrenal axis functions, and rendering the organism even
more exquisitely sensitive to stresses in turn, and hence making ongoing
stresses even more excitotoxic (see the works of Marin Teicher, Danya
Glaser, John Ratey, J Douglas Bremner, Michael De Bellis, Bruce Perry and
others).

This is not war on
the medical model, but a call for intervention from multidisciplinary
teams.  If one cannot eliminate the complex chain of events ending with
the phenotype of impairment represented by ADHD, then one must intervene within
society, avoiding a disposal diagnosis, recognising that medication is not
cure, avoiding coalitions against the child, containing their anxiety,
accepting psychodynamic principals that all, including bad, behaviour is
meaningful, the need for appropriate authority and the knowledge of the
importance of containing and supporting boundaries, working as partners with
parents and teachers, improving child care arrangements, bridging the gap
between home and school, dealing with separation and divorce, making positive
changes in the school environment, supporting boys in the face of the demands
of modern and future societies, an most critical, working with prevention in
the wider social and political context.

This is a most
important work, and with a wide audience, readable by everyone, even the damned
parents.  It really is crucial reading, given its evidence base, that
psychiatrists, psychologists, teachers, general practitioners, magistrates,
judges and politicians become aware of the problems facing those who rear and
mind children in the 21^st Century, not just for ADHD, but the whole
wide and varied spectrum of mental disorders.

This book is really
well done.  The last chapters need a great deal more detail and planning
if the advocacy of such an approach is to go ahead. The post-modern view is
really overdue, and the deconstruction of the terms we use is now a demand of
the biopsychosocial model, and of the consumer.

 

© 2004 Roy Sugarman

 

Roy Sugarman,
PhD, is post of Clinical Director of the Clinical Therapies Programme in Liverpool (Sydney) and Clinical
Associate Professor at the University of New South Wales.

Categories: ChildhoodDisorders, Psychology