Intended for healthcare professionals


Attention deficit hyperactivity disorder in children

BMJ 1998; 317 doi: (Published 31 October 1998) Cite this as: BMJ 1998;317:1250

Child psychiatrists should help parents with difficult children, not blame them

  1. David Bramble, Senior lecturer in child and adolescent psychiatry
  1. Department of Child and Adolescent Psychiatry, Nottingham University School of Medicine, Nottingham NG7 2UH
  2. Faculty of Medicine, University of British Columbia, Vancouver, British Columbia V6H 3V4, Canada
  3. Child and Family Consultation Centre, Foundation NHS Trust, Stafford ST16 1PD
  4. Child and Adolescent Mental Health Service, Macclesfield District General Hospital, Macclesfield, Cheshire SK10 3BL
  5. Learning Assessment Centre, Horsham, West Sussex RH12 2PD

    EDITOR —Kewley reviews the current poor service provision and professional understanding of the group of disorders subsumed by the diagnostic category “attention deficit hyperactivity disorder.”1 Orford suggests in her accompanying commentary that the current nosological status of the disorder ignores important aetiological factors.

    Her notion—that some underlying unspecified early emotional trauma is responsible for core symptoms of attention deficit hyperactivity disorder—must be challenged. As Kewley points out, the accumulating evidence that the disorder is primarily a genetically determined neurodevelopmental condition is extremely convincing. Orford's view that early abuse and trauma later manifest as symptoms and that the detection of these symptoms in children clearly illustrates early trauma is a prime example of the logical fallacy that underpins all psychoanalytical theory and practice. There is no convincing empirical evidence to support her assertion that psychoanalytical psychotherapy is often effective since it addresses the original emotionally traumatic experience. In sharp contrast, as Kewley states, the evidence base for the efficacy of psychostimulant treatment in moderate to severe forms of attention deficit hyperactivity disorder is beyond any reasonable doubt. Moreover, this treatment can help to make more effective other modalities of treatment that by themselves are usually ineffective (family therapy, individual psychotherapy, and special educational provision).

    Theory and practice derived from psychoanalysis have been extremely influential in child psychiatric training until the recent adoption of evidence based practices. This fact has helped to explain why many families with children who have attention deficit hyperactivity disorder still experience so much difficulty in finding child psychiatrists who can actually help them rather than effectively blame them for their children's extreme difficulties. My recent survey finding that nearly half of Britain's child psychiatrists do not use psychostimulant treatment in their current practice shows that there is still a pressing need to improve standards of care …

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