Four Types of Hyperkinesis (Attention Deficit Disorders)

Four Types of Hyperkinesis (Attention Deficit Disorders) Philip G. Ney, MD, FRCP(C) The Problem Methodology Constitutional Hyperkinesis Conditioned Hyperkinesis Chemical Hyperkinesis Chaotic Hyperkinesis Summary Epilogue The Problem Hyperactivity is one of the most frequent and yet one of the most elusive diagnostic categories facing child psychiatrists. Studies have shown that up to 5 percent of the public school population are hyperkinetic - over 25% of the diagnoses used by 40% of child psychiatrists. There is a wide variety of classification, managements and etiologies, mainly because, although hyperactivity is a diagnosis used by physicians, parents and teachers, the term is vague and ill-defined What has been established is the male to female sex ratio of hyperkinetic children of approximately 9:1. Hyperactivity seems to diminish with age and is more frequent among those who are culturally deprived. Any classification of the hyperkinesis and any hypothesis concerning their etiology must account for these facts. Methodology All those children considered to be hyperactive or restless by parents or teachers were selected for this study and, on the basis of hypotheses regarding their etiology, they were grouped into four categories: Genetic (constitutional) - children who were hyperactive from a very early age but where the pregnancy for the mother and the perinatal events for the child were normal. Behavioural (conditioned) - hyperactive children whose parents were responding with attention selectively to their active distracting behaviour. Minimal Brain Dysfunction (chemical) - children with early and continuous hyperactivity and histories of abnormal pregnancies or perinatal events. Reactive (chaotic) - children from home environments in which there was little agreement on discipline or where there was considerable marital turmoil. An independent rater using the same history and diagnostic findings tabulated the presence of 40 signs, symptoms, test findings, or factors of psychiatric significance in the history. It was predicted that: The constitutional and chemical types of hyperkinetic children have a higher male/female sex ratio. The constitutional child would have more behavioural difficulties at school than at home. He would do fairly well academically, be relatively devoid of neurotic signs and symptoms and would be treated less frequently with biochemicals. The conditioned hyperactive child would more often have depressed single parents, have a high incidence of neurotic problems, have fewer behaviour and academic problems, be more frequently distressed within himself and more often treated with biochemicals. The chaotic hyperkinetic child would be less of a problem at school than at home, have a high incidence of antisocial behaviour and be given corporal punishment more frequently. Constitutional Hyperkinesis It is hypothesized that the constitutional type of hyperkinesis is due either to a sex-linked genetic transmission or to an extreme biological variation. Anthropologically the male child has learned in a situation where his survival depended upon his ability to pick up stimuli in the periphery of his visual field and to react rapidly, otherwise he would miss his game or his enemy. Girls, on the other hand, have learned by attending to the weaving or cooking immediately in front of them. To be distracted would possibly mean starting all over again. This would accord with the findings of Campbell, who pointed out that hyperactive children make rapid decisions and cannot ignore intrusive information. The constitutional hyperkinetic child usually has a parent who remembers being hyperactive and therefore he is more likely to obtain affection and less likely to be a scapegoat. A parent who was hyperactive may want to correct his child in order that he may avoid many of the difficulties encountered by that parent as he grew up. However, the teachers do not understand why he will not sit still, and correct or criticize him more often. The management of the constitutionally hyperactive child is mainly one of rearranging and re-educating his environment. He should be placed in a class where the teacher is able to tolerate activity and distraction. Psychotherapy which is aimed at helping him understand why people become irritated with him goes a long way to prevent him becoming reactively aggressive. Parents can increase his attention span by using behaviour modification, reinforcing ‘on task’ attention, sitting, and the completion of his work. It was found that out-of-seat responses of hyperactive children in a classroom can be suppressed by reinforcing increasing amounts of sitting still. Behaviour modification can also improve the child’s ability to complete school tasks. Conditioned Hyperkinesis This group of children have parents, usually single mothers, who are depressed. The ‘bad’ hyperactive child reminds the mother of her lost spouse and thus is a scapegoat for her hostility. While the mother is depressed and withdrawn she is unaware of the child’s normal play and only interacts when he knocks something over, hits his sister or runs across the street. The child, being deprived of normal emotional contact contingent upon quiet behaviour is reinforced with attention only when he is hyperactive, thus increasing his hyperactivity. The mother becomes increasingly depressed as she considers the child’s behaviour worsening. The more depressed she becomes the less likely she is to notice her child or attend to him except when he is on the move. In time the mother is not only depressed but angry with her child. The anger alienates the child and he tends to look to his peers for approval. He becomes involved in exciting group behaviour. Unlike the constitutional variety, this child is usually reported by his teacher to be quiet and conscientious. He is looking desperately for approval and often finds it from her. Management of the conditioned hyperactive child is aimed at first treating the parent’s depression. The mother’s outside interests should be reactivated and she should be given time away from her problem child. The parent should be taught to recognize and react to any attempt on the part of the child to please her. She is told to be aware of and reinforce the child whenever he is playing quietly and to ignore him when he is flitting about. Concentrating on the improvement of one behaviour, she gradually becomes convinced she is a capable mother and begins to enjoy her child. As her depression improves, she becomes more alert to the child’s quiet behaviour and consequently his behaviour improves. The prognosis is usually good, but depends upon the treatment of the mother’s depression. Chemical Hyperkinesis It is still not known whether there was biochemical derangement or neuronal degeneration consequent upon the child’s difficulty during pregnancy or delivery. Wender has evidence that there is an abnormality in the metabolism of monoamines which impairs both the reward mechanism and the activating system. The underactivity of the caudate nucleus is responsible for the hyperactivity, and this was relieved by amphetamines. A possible alternative hypothesis is that because of low concentrations of the monoamines at the diencephalon, the brains of these children are relatively deprived of stimulus. The chemical hyperactive child must then engage more actively with the environment to provoke more auditory and visual stimuli. Bender believes that the hyperkinetic child must “…continually contact the physical and social environment to re-experience and reintegrate perceptual experience in an effort to gain some orientation in the world.” It may not be so much a matter of orientation as it is one of absolute amounts of stimulus. When the child engages in the new activity or picks up another toy, his level of sensory stimulus rises but then quickly drops. He must then go on to another toy. He is very aware of any new stimulus since the old one provides relatively less input. Sympathomimetics increase the amount of stimulus getting through the diencephalon and thus the child need not be so active. If anxiety is added to further raise his level of alertness he may begin hallucinating, sensing auditory or visual stimuli where there is none from the environment. When young these children are clumsy and at school they cannot sit still, have specific academic difficulties and are thought by the teacher to be immature, maladjusted or to have learning disabilities. Physicians find a greater proportion of this group respond to medication. The recommended treatment is with methylphenidate starting at 0.2 mg per kg and increasing until side effects of anorexia and insomnia are noted, then decreased slightly. The greatest benefit seems to be an increased ability to attend to sitting-down tasks, and therefore the teacher is usually the first to report an improvement. The child becomes better organized and more diligent, and consequently he is viewed with appreciation by his parents and peers. The positive feedback from them improves his self-image and lessens his tendency to provoke a quarrel. Remedial education should be aimed at any specific disability but also at improving the motivation. The child’s motivation often rapidly falls because of aversive conditioning, resulting from constant reminders by parents and teachers to finish his work. A special class of similar children helps him feel that he is not so unusual and unlovable. Robins has pointed out that, although in many of these children, hyperactivity does diminish, there has been such a long history of hostile interactions with adults that the children often become serious social problems. Psychotherapy aimed at helping the child resolve his hostility is very pertinent. Chaotic Hyperkinesis In an environment of intense conflict these children have learned to adapt and to avoid at least some of the friction by always being on the move. Their parents usually do not agree on discipline so the child uses an increasing number and variety of behaviours to find out which will meet with a predictable response from them. Because his social environment is so unpredictable, the child’s level of anxiety rises. As it rises, he becomes more restless, and as he becomes more restless, the chaos in his environment increases. The inconsistency of his parents usually reflects a contest for control between spouses. It is not only a control for household management but also a striving for control of their own impulses. The child’s restlessness activates within them the anxieties and hostilities which they have difficulty managing. The parent may then resort to harsh measures as he desperately tries to control the child’s behaviour which evokes in him the impulses he is barely able to manage. These children are often beaten severely. The hostility thus provoked in the child results in some devious retaliation which further shakes the parents’ own impulse control. The child then becomes even more anxious because of his own hostility. Night terrors and hypnogogic hallucinations involving threatening monsters are common. As the child becomes more hostile, he becomes more devious, threatening his parents by stealing and lying. With the occurrence of these behaviours the parents become even more divided and more inconsistent. The treatment is often to remove the child for at least a short period of time so that the parents may have respite during which they can start resolving their own interpersonal problems. To deal with their own punitive parents or intolerable job situations, are some of the more specific aims of conjoint psychotherapy. The child in our residential treatment setting, is given an opportunity to ventilate his anxieties, learn the origins of his conflicts and be instructed in more appropriate ways of expressing his hostility. Parents should be taught to spend time with the children individually, thus giving the child an opportunity to show more agreeable characteristics. The prognosis depends on how effectively chaos in the home can be resolved. Summary Although the prevalence of hyperactive children in schools and in physicians’ offices is high, there is little agreement regarding etiology and treatment. This study predicted the characteristics of four types: constitutional, conditioned, chemical and chaotic. Hyperactivity was the common feature but these groups were different with respect to: sex ratio, family history, type of parenting, learning disability and response to treatment. These groups are sufficiently distinct to warrant specific diagnosing and treating. The chemical type respond best to medication. Epilogue Although this article was published in the Canadian Psychiatric Association Journal (1974), I believe it is still relevant. Hopefully it will help physicians decide which of all the hyperactive children that are brought to his/her attention will respond to which type of medication. 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