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Jay J. Jones
Fresno, California
One of the greatest concerns in child education and treatment is that of attention deficit and associated dysfunctional behaviors. Diagnostically, these conditions are more precisely referred to as Attention Deficit Hyperactivity Disorder with Conduct Disorder or Oppositional Defiant Disorder (American Psychiatric Association, 1987). Yet, to so limit the scope of our concern would unavoidably cause many children to fall through the educational and therapeutic cracks.
This paper will be predominantly focused on Attention Deficit Disorder, with great emphasis given to the educational and therapeutic problems encountered when this disorder coexists with Conduct Disorder or Oppositional Defiant Disorder. The important purpose of this review will be to look at the problems associated with the education and treatment of children who have some combination of features from these disorders. With that objective in mind, although we know that diagnostic labeling can be useful, we also know that to become slaves to rigidly specific diagnostic categories can also result in undue labeling that is neither useful nor practical in the treatment of real children.
Therefore, throughout this paper, diagnostic labels will be used only with relative / practical precision. When such diagnostic terms are used, they will be identified as follows: Attention Deficit Hyperactivity Disorder (ADHD), Conduct Disorder (CD), and Oppositional Defiant Disorder (ODD). Aggression, while being a part of CD, will be identified separately, when it is important to distinguish it from possible confusion with other CD symptoms.
ADHD might will be called the disorder of multiples. Multiple children are affected by the symptoms of ADHD (APA, 1987, 1980; Barkley, 1981; Ross & Ross, 1976; Sattler, 1988). There have been multiple names used over the years to identify this disorder (Barkley, 1981; Garfinkel & Wender, 1989; Quay & Werry, 1986 ). Multiple factors are suspected of causing the disorder (Barkley, 1981; Ross & Ross, 1976). Multiple features characterize the disorder ( APA, 1987, 1980; Garfinkel & Wender, 1989; Henker & Whalen, 1986; Quay & Werry, 1986; Reeves & Werry, 1987). Multiple measures must be used in order to properly diagnose the disorder (Barkley, 1981; Gueuremont, DuPaul & Barkley, 1990; Wood & Reimherr, 1976). And adequate treatment requires multiple, and often simultaneous forms of intervention (Barkley, 1981; Cantwell, 1989; Kolko & Loar, 1990; Nichamin & Windell, 1984; Roberts, 1982; Satterfield, Satterfield & Schell, 1987).
Estimates of prevalence attempt to depict the total number of children who are affected by a particular disorder (Hallahan & Kauffman, 1988). Arriving at such estimates is an extremely difficult and tenuous process, the complications of which cannot be detailed here. Suffice it to say that evaluating the prevalence of ADHD and the associated disorders of CD and ODD can only be done in rough estimate terms.
The Diagnostic and Statistical Manual of Mental Disorders, 3rd revised edition (APA, 1987) simply indicates that ADHD is common, and may occur in as many as 3% of children; ADHD is thought to occur between three and nine times as often in boys than in girls. As for CD, the manual indicates that approximately 9% of boys and 2% of girls under the age of 18 have the disorder. No information is given on the prevalence of ODD.
Other informational sources estimate the prevalence of ADHD with wide variance. Studies in Great Britain have estimated that fewer than 1% of school age children are affected by ADHD, although it is unclear what degree of similarity between criterion was being used to diagnose these cases (Garfinkel & Wender, 1989). Barkley (1981) has pointed out that some estimates place the percentage of children affected by the disorder as high as 20%, although this figure would most likely reflect children who are affected by the symptoms of ADHD, but who may not meet the full criterion of the DSM-III-R.
For practical purposes, focus on the percentage of children who are significantly affected by ADHD symptoms is important. When we combine these children into a cluster of children who are also affected by the associated disorders of CD and ODD the numbers begin to grow remarkably. Garfinkel and Wender (1989) believe that children demonstrating problems with inattention and overactivity comprise up to 10% of the school aged population. Cantwell (1989) believes that as many as 15% of school age children have significant conduct problems. Many of these children are affected by both ADHD and CD type symptoms, a phenomenon that clouds the prevalence picture considerably. In one study (Gittelman & Manuzza, 1985) a history of CD was found in 43% of a group of children diagnosed with ADHD, while CD was only found in 16% of controls. According to Garfinkel and Wender (1989), 15% of the children diagnosed as ADHD require special education services because of behavioral problems; behavioral problems that are likely to be part of the symptom clusters of CD and ODD.
It is unlikely that any childhood disorder has been referred to by so many different names. ADHD symptoms have been called postencephalitic behavior disorder (Barkley, 1981; Garfinkel & Wender, 1989), Still's disease (Garfinkel & Wender, 1989), organic drivenness (Barkley, 1981), Strauss-Lehtinen syndrome (Garfinkel & Wender, 1989), brain damaged child syndrome (Barkley, 1981; Garfinkel & Wender, 1989), minimal brain damage (Barkley, 1981), minimal brain dysfunction (Barkley, 1981; Boudralt et al. 1988; Garfinkel & Wender, 1989; Quay & Werry, 1986; Satterfield, et al. 1987), hyperactive child syndrome, or hyperkinesis (Barkley, 1981; Garfinkel & Wender, 1989; Quay & Werry, 1986; Satterfield, et al. 1987), hyperactivity (Boudralt et al. 1988; Quay & Werry, 1986), hyperkinetic impulsive disorder (Garfinkel & Wender, 1989), attention deficit disorder (APA, 1980; Barkley, 1981; Boudralt et al. 1988; Garfinkel & Wender, 1989; Quay & Werry, 1986; Satterfield, et al. 1987), and even the "figity Phil's" (Barkley, 1981).
Last Modified: Tuesday, November 11, 1997 7:59:12 PM
Steven J. Foust, peregrin@enteract.com