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Attention Deficits

Andrew Rowland

Hyperactivity Disorders of Childhood. Seija Sandberg, ed. 517 pp. Cambridge University Press, 1996. $95.

The study of attention and hyperactivity problems among children is at an important crossroads. Although much of the lay public and many health professionals believe that hyperactivity is a socially constructed disorder, a substantial body of research has begun to accumulate suggesting that, for many children, it is a very real biological condition—one that has profound impacts on their lives. For the first time, a consensus is emerging among researchers that there is a core of children whose brains and nervous systems may really be different. This does not negate the fact that many children with hyperactivity or attention deficit hyperactivity disorder (ADHD as it is now called in the U.S.) are misdiagnosed. The label includes a heterogeneous group of children, including some who are primarily inattentive and others who are primarily hyperactive and impulsive.

In some American elementary schools, more than 10 percent of the children have been diagnosed with ADHD. A large proportion of these, perhaps as many as 75 percent, are being treated with stimulant medications such as Ritalin. For a condition of such apparent frequency, we know surprisingly little about its origins, how it is distributed in the population, how to best identify it and how to treat it most effectively.

This text successfully uses a multidisciplinary group of expert reviewers to guide the reader through a large volume of often-contradictory literature. They identify what is known about the disorder, where the research gaps are and what is being done to address some of the gaps. Overall, this is the best synthesis of the hyperactivity research literature that I have read. The book is not intended as a popular text, but I think any researcher interested in the etiology and treatment of attention or behavior problems in children will find reading it rewarding. There are excellent chapters on the historical development of our current understanding of hyperactivity, on epidemiological approaches, developmental perspectives, clinical aspects, sex differences and their significance, and on hyperactivity's cross-cultural aspects. The value of using a multidisciplinary approach is illustrated by the discussion of how the frequency and pattern of ADHD symptoms typically change with age. This is one of the characteristics of ADHD that has made understanding it elusive. Both the chapter on developmental perspectives and another that summarizes the longitudinal studies of hyperactive children address these issues thoughtfully from two different vantage points. The chapter on treatment is compelling because it both discusses the huge gaps in our understanding of the risks and benefits of long-term stimulant treatment and succinctly summarizes the literature on various behavioral interventions.

I do have two reservations about the book. The first is that, although the chapter on biologic aspects gives an excellent review of the literature up to 1993, it was outdated before the book was published, because this area of research has been changing so quickly. My second reservation is that because there has been a historic schism between American and European psychiatry about how to classify attention and behavioral problems—which is apparent in the differences between the two classification manuals, the European ICD-10 and the American DSM-IV—it would have been helpful to the reader to have had an American expert present that side of this debate. British clinicians typically classify most of the children that American clinicians call ADHD as "conduct disordered." Active dialogue about the implications of these two approaches is critical for the development of better standardized research criteria for both conditions. Despite these two reservations, I highly recommend this book.—Andrew S. Rowland, Epidemiology Branch, National Institute of Environmental Health Sciences, Research Triangle Park, N.C.

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