The Hyperkinetic
Child Syndrome:
The Need for Reassessment
S h e r w o o d O. Cole, PhD S a m u e l F. Moore, PhD Rutgers University, Camden
T h e d r a m a t i c increase in t h e i n c i d e n c e of h y p e r k i n e s i s w i t n e s s e d in r e c e n t years c o n s t i t u t e s a growing c o n c e r n for t h e c h i l d r e n so classified. S o m e relevant issues are discussed in t e r m s of (a) diagnostic practices, (b) t r e a t m e n t practices, a n d (c) c h a n g i n g views a b o u t t h e n a t u r e o f t h e d i s o r d e r itself. R a t h e r t h a n f o c u s i n g o n t h e child as a source of t h e p r o b l e m (as has t y p i c a l l y b e e n t h e case), f u t u r e research a n d p r a c t i c e s need t o d e m o n s t r a t e a b r o a d - b a s e d perspective o n t h e a d j u s t m e n t p r o b l e m s of these c h i l d r e n t h a t e x a m i n e s " s i t u a t i o n a l " d e t e r m i n a n t s a n d i n s t i t u t i o n a l policies.
ABSTRACT:
In recent years, a dramatic increase in the incidence of hyperkinesis has been witnessed. Whether such a p h e n o m e n o n reflects an actual increase in the occurrence of maladaptive s y m p t o m a t o l o g y or merely a sharpening of our clinical tools of observation and classification is difficult to say. It is also quite possible, as pointed out by Schrag and Divoky [1 ], that the current social and educational ideology, which increasingly defines " n o r m a l c y " in terms of " c o n f o r m i t y , " has created a new statistical population of " d i s t u r b e d " children heretofore u n k n o w n in our society. With the implementation of such an ideology, children who demonstrate any degree of atypical behavior become likely candidates for being classified (hyperkinetic or otherwise), mainly because they do not meet the expectations of those in positions of authority. Regardless of the many factors that may have contributed to the current prevalence of the " h y p e r k i n e t i c " syndrome, the affected children constitute a social and educational problem of major proportion. Although figures vary somewhat depending Dr. Cole is Professor of Psychology, a n d Dr. M o o r e is A s s i s t a n t Professor of Psychology, R u t g e r s University, C a m d e n , New Jersey 0 8 1 0 2 . R e p r i n t queries s h o u l d be d i r e c t e d to t h e senior a u t h o r . Child Psychiatry and Iturnan Development
Vol. 7(2), Winter 1976
103
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upon the source, it is estimated that anywhere from 3% to 10% of schoolchildren demonstrate enough traits (mild or severe) to be classified as hyperkinetic [2, 3], with more males than females apparently being affected [2]. While these figures are, in themselves, astounding, they become even more so when it is realized that only a decade ago hyperkinesis was a relatively u n k n o w n syndrome. In the current identification of the hyperkinetic child, two major symptoms appear to predominate: hyperactivity of a "driven" nature and attention difficulties or distractibility [2, 4]. In an extensive comparison of hyperkinetic children with normal control children, Douglas [5] concluded that, in practical terms, many of the performance deficits (as well as other problems) of hyperkinetic children are due to their inability to "stop, look, and listen." While the identification of such adjustment problems is essential in order to ensure the genuine welfare of the child, the use of such symptomatology to reinforce the ideologies of social and educational institutions is morally questionable. The failure to make such a basic distinction in the purpose of " s y m p t o m identification" (along with changing views about the nature of the disorder itself) constitutes just cause for the growing concern for the children so classified. These issues are discussed in the following sections. Diagnostic Practices The practice of translating the adjustment problems of the hyperkinetic child into pseudoscientifically labeled disorders is increasing at an epidemic rate. As a result, misleading terms are increasingly being used to identify the hyperkinetic child, in that some authors make no clear distinctions between "hyperkinesis," " M B D " (minimal brain dysfunction), and " L D " (hyperactivity accompanied by learning disabilities) [6, 7, 8]. In fact, hyperkinesis (along with many other poorly understood syndromes) is typically grouped under the one roof of MBD [1 ]. Although genetic variations, events surrounding the birth process, neurological dysfunction, and biochemical imbalance have been proposed as contributing to hyperkinesis, little is really known about the causative factors underlying the disruptive behavior [9]. Until such potential explanations are more clearly understood, it would seem appropriate to avoid the global and indiscriminate use of such labels as brain dysfunction (minimal or otherwise) and LD, which have pseudo-explanatory or etiological implications. The implied etiological assumptions of the MBD diagnostic category, in particul~r, can prematurely preclude the examination of situational and environmental causative factors that may contribute to the sympto-
S h e r w o o d O. Cole and Samuel F. Moore
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matology. Of course, in those instances where hyperkinesis is accompanied by known central nervous system damage, a proper recognition of the relationship is essential and may have important implications for treatment practices. Another problem associated with labeling the hyperkinetic child as MBD or LD is the lack of professional agreement as to what clinical s y m p t o m s are to be subsumed under such labels. Certainly, adjustment problems other than those resulting from hyperactivity per se and attention difficulties are frequently included, in spite of the fact that such problems may have little or no relationship to the adjustment needs that initially led to the labeling. As pointed out by Schrag and Divoky [1], attempts to identify the multitude of s y m p t o m s underlying these labels merely become "sophisticated statements of ignorance" and provide the occasion for numerous subjective judgments made by persons in positions of authority to be translated into pseudoscientific language. While there may be professional disagreement a b o u t the s y m p t o m s underlying the MBD and LD syndromes, the application of such diagnostic labels may still have serious consequences for the child so labeled. As with any diagnostic label, the impact of the labels MBD and LD can lead to what Lemert [10] terms "secondary deviance." The labeled child becomes selectively reinforced for any and all behaviors that have been associated with the diagnostic label; thus, the expectations for the child's subsequent behavior, as viewed by significant others (teachers and other professionals), are influenced [ 11]. Even more distressingly, the label can be internalized by the child in his own behavioral expectations and become a "self-validating hypothesis" [12]. The potential for these effects being present in the application of diagnostic labels has led to the proposed abolishment of all labeling of behavioral disorders [13]. While such a recommendation may be somewhat overstated, diagnostic labels that are only ambiguously defined and understood, and that prematurely exceed symptom-descriptive statements to include etiological assumptions, can mask the true nature of the adjustment problems of the hyperkinetic child. Particularly when misapplied, such labels serve to propagate institutional and professional ideas about the nature of disorders, while the unique and individual needs of the child are ignored [14]. Treatment
Practices
Of the treatment practices currently being employed with hyperkinetic children, the use of stimulant drugs is, by far, the most prevalent. The effectiveness of the sympathomimetic amines d-amphetamine
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(Dexedrine) and methylphenidate (Ritalin) in reducing the activity level and improving the attentive behavior of hyperkinetic children has been reviewed elsewhere [15]. While stimulants appear to "normalize" the behavior of such children, an explanation of the efficacy of such treatment is still incomplete. In addition to the chemical treatment of hyperkinesis, behavior modification (systematic reinforcement of desirable behavior) has demonstrated some effectiveness in reducing the activity [16, 17] and improving the attentive behavior [4] of such children. Although it has not received wide publicity, there also seems to be some trend toward an increased use of psychosurgery (surgical interruption of emotion-regulating areas of the central nervous system) with hyperkinetic children [18]. However, as children on whom such surgery is performed typically demonstrate violent and destructive behavior (as well as hyperactivity and poor concentration), it appears that these practices are directed primarily at broader problems of adjustment, not hyperkinetic symptomatology only. Observations on such children following a m y g d a l o t o m y (lesions that destroy only part of the nucleus) indicate that the child is not only quieter and more obedient but shows a reduction in activity and an improvement in attention [19]. In spite of the evidence that apparently documents the effective treatment of hyperkinetic symptomatology with chemicals, behavior modification, and psychosurgery, some of these practices serve as unfortunate examples of the process whereby the pressures for ameliorating problems encourage shortsighted solutions. This appears to be particularly true in the case of chemical treatment and psychosurgery, both of which are apparently more concerned with the immediate alleviation of disruptive symptomatology than with the long-term impact of such practices. While there is general agreement that stimulant drugs decrease disruptive hyperactivity, serious doubts exist regarding benefits beyond those of making the child more compliant. Certainly, a primary objective for the use of stimulants should be that of enabling the treated child to profit from academic experiences; yet, in a recent review of drug treatment studies, Sroufe [20] concluded that there is no compelling evidence that such treatment facilitates reasoning, nonrote learning, problem solving, or actual educational achievement. It is also the case that the chronic treatment of hyperkinetic symptomatology with stimulant drugs may diminish the appetite, increase the resting heart rate, and retard the growth rate of such children (see review by Cole [15] ). Furthermore, the possibility that such chronic drug treatment of children will encourage later addictive behavior
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must remain an open issue until more longitudinal data are available on the topic [21]. Despite the lack of conclusive evidence for any benefits of stimulants beyond the suppression of hyperactivity, the use of chemicals remains the predominant treatment practice with hyperkinetic children. In the case of psychosurgery, the distinction between the immediate alleviation of disruptive symptomatology and the long-term impact of the treatment becomes even more crucial. All such operations mutilate some nondiseased tissue and may blunt the overall emotional and intellectual responsiveness of the child [22]. Thus, while psychosurgery may have some immediate effectiveness in reducing the disruptive symptomatology of hyperkinesis, such an irreversible treatment may have serious deleterious effects on the future development of the child. One of the basic issues encountered in all of the t r e a t m e n t practices used in dealing with hyperkinetic s y m p t o m a t o l o g y is t h a t they tend to be " c o n t r o l " or " m a n a g e m e n t " oriented. Such an orientation expresses a greater concern for the day-to-day suppression of symptomatology than for an honest examination of the varied and complex problems that may have given rise to the disruptive behavior. The day-to-day control of hyperkinetic s y m p t o m a t o l o g y with stimulant drugs requires that the affected child be almost constantly under the influence of the drug (drug-state condition). Yet busy parents and overworked school administrators find such a practice to be a relatively simple solution to a complex problem. In spite of some evidence that the beneficial effects of stimulants on disruptive hyperactive behavior may carry over into drug-free periods [3, 23], an emphasis on control or management does not encourage one to experiment with interruptions or alterations in the child's drug regimen. To suggest that the practice of psychosurgery has any primary objective other than control or management of disruptive symptomat o l o g y is to be naive indeed. The use of this technique assumes that we know much more than we do about brain functioning, when, in fact, the actual history of psychosurgery is one of vagueness and uncertainty regarding the specificity of its immediate effects (other than simply management) and even less clarity about its long-range consequences. The fact that some investigators using psychosurgery refer to it as "sedative neurosurgery" [24] indicates clearly that this practice is concerned with the suppression (control) of disruptive symptomatology, not with the intellectual and emotional development of the child. Behavior modification techniques can be equally control or man-
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agement oriented in their application, as documented by Winett and Winkler [25 ]. Typical applications of behavior modification programs with hyperkinetic children have focused primarily on the reduction of disruptive s y m p t o m a t o l o g y w i t h o u t an accompanying concern for establishing new, more adaptive behaviors [26]. Although such practices emphasize the need for modifying social behavior, the equally important emphasis on the establishment of new social attitudes and the necessity of the child being aware of the long-term advantages of such changes is frequently missing. Numerous moral issues are raised by any treatment practice that demonstrates more concern for the suppression of disruptive symptomatology than for the welfare of the affected child. Of course, the importance of these issues is much greater for those practices where the control or management of behavior cannot be reversed or undone (psychosurgery) than it is in any practice where the treatment can be terminated or altered (stimulant drugs or behavior modification). According to Schrag and Divoky [1 ], important issues are also raised by t h e fact that control or management practices are typically used to reinforce the present-day ideology which increasingly defines normalcy in terms of conformity. This being the case, control or management becomes tighter as normalcy demands more and more conformity. The result is that the right of any child (hyperkinetic or otherwise) to be different and to demonstrate atypical behavior is rapidly disappearing [ 1 ]. Changing Views about the Nature o f the Disorder For many years it has been assumed that hyperkinetic symptomatology constitutes a childhood syndrome, with the child outgrowing the symptoms or learning better adjustment by the time of puberty [2]. However, recent evidence [27, 28, 29] suggests that the hyperkinetic child may continue to be in academic difficulty and demonstrate problems of social adjustment into adolescence and adult life. The prolongation of such adjustment problems must be dealt with, which, in turn, has serious implications for treatment practices as well as for diagnostic labeling practices. The assumption that hyperkinesis is a childhood disorder has provided an accepted safeguard against the treatment of such symptomatology with stimulant drugs resulting in later addictive behavior [30]. In all likelihood, the treatment would be prescribed for only a limited number of years (probably until the child reaches puberty) and would typically be terminated prior to the period of peak social pres-
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sure for drug abuse (late adolescence and early adulthood). However, if the adjustment problems of the hyperkinetic syndrome are not restricted to childhood, treatment of such children with the chronic use of stimulant drugs has the potential for encouraging a lifelong "chemical style" of dealing with affective and behavioral problems. Such practices could result in many young adults perceiving a large percentage of their life through "drug-state eyes." A case in point is that of a 26-year-old patient who was on stimulant m e d i c a tion from the age of 8 and whose personality, perceptions, and interactions with reality developed almost totally under the influence of the drug [21]. While it might appear, on the surface, that the changing views about hyperkinetic s y m p t o m a t o l o g y justify the use of psychosurgery as a treatment (i.e., prolonged adjustment problems require more drastic, perhaps even permanent solutions), the issue must be examined more closely. First of all, the evidence suggesting that the hyperkinetic child may continue to demonstrate adjustment problems into adolescence and adulthood does not spell out the specific nature of such problems, that is, whether they continue to be hyperactive and attention-deficit symptoms or learned maladaptive behaviors. If, in fact, they are learned, there may be more appropriate and less permanent ways to cope with the adjustment needs of the child. Secondly, to suggest that the adjustment problems of the hyperkinetic child continue beyond the period of puberty does not necessarily imply that they remain lifelong concerns. Therefore, the use of psychosurgery in the treatment of such problems defies logic, in that no irreversible practice is justified in dealing with adjustment problems that, at a n y stage, may be reversible or remit of their own accord. While the changing views about the nature of the hyperkinetic disorder may appear to have little impact on the use of behavior modification in the treatment of such symptomatology, such is not the case at all. Rather, the evidence suggesting that the adjustment problems of hyperkinesis may continue into late adolescence and adulthood provides the strongest possible argument for establishing adaptive behaviors rather than merely suppressing disruptive ones. Concomitantly, it is imperative that the external reinforcements of desirable behaviors be adopted by the child as internalized controls of his behavior, and that the child be aware of their long-term advantages. As Bandura [31] suggested, such awareness is the necessary precursor to the development of self-monitoring which should predominate in adult functioning. Changing views about the nature of the hyperkinetic disorder also
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have some impact on diagnostic labeling practices. Such labels as MBD and LD have typically been used (either implicitly or explicitly) to explain the "adjustment lag" of children who present management problems in school or other institutional contexts. While such labels provide an aura of understanding that may be comforting to parents and institutional authorities in the short run, they provide no clear basis for explaining or effectively coping with the long-term problems of adjustment into late adolescence and adulthood. Labels that encourage a view that only a temporary adjustment lag is involved are, at best, euphemistic, and may very well impede advances in our understanding of the long-term needs of the hyperkinetic child. To suggest that we should avoid such diagnostic labels does not, however, imply that we should discard the practice of identifying all disruptive symptomatology. Some identification of the adjustment needs of such children is still essential in dealing both with their short-term (childhood) and long-term (late adolescence and adulthood) welfare. However, the avoiding of such labels as MBD and LD may provide an appropriate incentive for a more comprehensive assessment of the problems of hyperkinetic symptomatology, including an examination of our institutional policies. Concluding Comments Professional responsibility in the identification and treatment of the hyperkinetic child is indeed awesome. Nothing less than a continuing and intensified research program of the total situation surrounding the problems of hyperkinesis will suffice. While it will continue to be essential to identify the problematic symptoms of affected children in order for such research to progress, it is imperative t h a t practitioners ensure that the use of the diagnostic category of hyperkinesis is in the interest of recognizing and dealing with the individual needs of the child rather than in the interest of excluding and/or controlling the child. Subsuming the diagnostic category of hyperkinesis under the more generic (and ambiguous) labels of MBD and LD would appear to be premature, given the many potential etiologies of the symptomatology. Such labels are frequently not in the best interest of the child, to the extent that they encourage a perspective that focuses solely on the child as the source of the adjustment problems. Future research and practices must demonstrate a more broadbased perspective on the adjustment problems of the hyperkinetic chiId, by recognizing the importance of the child's interaction with the environment and the treatment regimen. With such a recognition,
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it t h e n b e c o m e s possible t o e x a m i n e " s i t u a t i o n a l d e t e r m i n a n t s " as viable factors in disruptive s y m p t o m a t o l o g y and t o c o n s i d e r m o r e individualized t r e a t m e n t practices. F u r t h e r m o r e , in t h e design o f individualized t r e a t m e n t s , m u c h remains to be a c c o m p l i s h e d b e y o n d t h e mere m a n a g e m e n t or c o n t r o l of t h e h y p e r k i n e t i c child's disruptive behavior. Far m o r e i m p o r t a n t is the e s t a b l i s h m e n t o f basic a c a d e m i c and social skills t h a t the child will u l t i m a t e l y need to f u n c t i o n as a p r o d u c t i v e and i n d e p e n d e n t adult in society. A b o v e all else, t h e m o r a l j u d g m e n t o f the p r a c t i t i o n e r m u s t ensure t h a t the h y p e r k i n e t i c child does n o t b e c o m e the victim or p a w n o f standard diagnostic and t r e a t m e n t practices t h a t c o n f o r m t o institutional ideologies and policies. In t h e long run, o n l y a b r o a d e r - b a s e d perspective t h a n has h e r e t o f o r e been practiced will g u a r a n t e e such p r o t e c t i o n o f the child and will provide a s o u n d basis for selecting t r e a t m e n t s t h a t will increase the efficacy o f m e e t i n g l o n g - t e r m goals as well as dealing with the i m m e d i a t e behavioral p r o b l e m s o f these children.
References 1. Schrag P, Divoky D: The Myth o f the Hyperactive Child and Other Means o f Child Control. New York, Pantheon Books, 1975. 2. Office of Child Development, Department of Health, Education, and Welfare: Report o f the Conference on the Use o f Stimulant Drugs in the Treatment o f Behaviorally Disturbed Young School Children. Washington, D.C., United States Government Printing Office, 1971. 3. Sleator EK, yon Neuman A, Sprague RL: Hyperactive children. JAMA 229: 316-317, 1974. 4. Allen KE, Henke LB, Harris FR, et al: Control of hyperactivity by social reinforcement of attending behavior. J Ed Psychol 58:231-237, 1967. 5. Douglas VI: Are drugs enough? To treat or to train the hyperactive child. Int J Ment Health 4:199-212, 1975. 6. Berlin IN: Minimal brain dysfunction. JAMA 229:1454-1456, 1974. 7. Feingold BF: Why Your Child Is Hyperactive. New York, Random House, 1975. 8. Witter C: Drugging and schooling. Transaction 8:31-34, 1971. 9. Dubey DR: Organic factors in hyperkinesis: A critical evaluation. A m e r J Orthopsychiat 46:353-366, 1976. 10. Lemert EW: Human Deviance, Social Problems, and Social Control. Englewood Cliffs, NJ, Prentice-Hall, 1967. 11. Rosenthal R, Jacobson L: Teachers' expectancies: Determinants of pupils' I.Q. gains. Psychol Rep 19:115-118, 1966. 12. Ullmann LP, Krasner L: A Psychological Approach to Abnormal Behavior. Englewood Cliffs, NJ, Prentice-Hall, 1969. 13. Menninger K: The practice of psychiatry. Digest Neurol Psychiat 23:101, 1955. 14. Hobbs N: Editor's introductory comments. In N Hobbs (Ed), Issues in the Classification o f Children (Vol 1). San Francisco, Jossey-Bass, 1975.
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15. Cole SO: Hyperkinetic children: The use of stimulant drugs evaluated.Amer J Orthopsychiat 45:28-37, 1975. 16. Doubros SG, Daniels GJ: An experimental approach to the reduction of overactive behavior. Behav Res Ther 4:251-258, 1966. 17. Patterson GR, Jones R, Whittier J, et ah A behavior modification technique for the hyperactive child. Behav Res Ther 2:217-226, 1965. 18. Breggin P: Underlying a method. Ment Hygiene 58:19-21, 1974. 19. Narabaysahi H: Stereotaxic amygdalotomy. In BE Eleftheriou (Ed), The Neurobiology o f the Amygdala. New York, Plenum Press, 1972. 20. Sroufe LA: Drug treatment of children with behavior problems. In F Horowitz (Ed), Review o f Child Development Research (Vol 4). New York, Russell Sage Foundation, 1975. 21. Vonder Harr TA: Chaining children with chemicals. The Progressive 39:1317, 1975. 22. Breggin PR: The second wave. Ment Hygiene 57:10-13, 1973. 23. Cohen NJ, Douglas VI, Morgenstern G : The effect of methylphenidate on attentive behavior and autonomic activity in hyperactive children. Psychopharmacol 22:282-294, 1971. 24. Balasubramaniam V, Kanaka TS, Ramanujam PV, et ah Sedative neurosurgery. J Indian Med Assoc 53: 377-381, 1969. 25. Winett RA, Winkler RC: Current behavior modification in the classroom: Be still, be quiet, be docile. J A p p l Behav Anal 5:499-504, 1972. 26. Simpson DD, Nelson AE: Attention training through breathing control to modify hyperactivity. J Learn Disabil 7:274-283, 1974. 27. Huessy HR, Metoyer M, Townsend M: 8-10 year follow-up of 84 children treated for behavioral disorder in rural Vermont. Acta Paedopsychiat 40: 230-235, 1974. 28. Mendelson W, Johnson N, Stewart M: Hyperactive children as teenagers: A follow-up study. J Nerv Ment Dis 153:273, 1971. 29. Menkes M, Rowe J, Menkes J: A twenty-five year follow-up study on the hyperkinetic child with minimal brain dysfunction. Pediat 39:392-399, 1967. 30. Cole SO, Moore SF: Stimulants and hyperkinesis: Drug use or abuse; JDrug Ed 5:371-379, 1975. 31. Bandura A: Behavior theory and the models of man. A m e r Psychol 29:859869, 1974.
Child Syndrome:
The Need for Reassessment
S h e r w o o d O. Cole, PhD S a m u e l F. Moore, PhD Rutgers University, Camden
T h e d r a m a t i c increase in t h e i n c i d e n c e of h y p e r k i n e s i s w i t n e s s e d in r e c e n t years c o n s t i t u t e s a growing c o n c e r n for t h e c h i l d r e n so classified. S o m e relevant issues are discussed in t e r m s of (a) diagnostic practices, (b) t r e a t m e n t practices, a n d (c) c h a n g i n g views a b o u t t h e n a t u r e o f t h e d i s o r d e r itself. R a t h e r t h a n f o c u s i n g o n t h e child as a source of t h e p r o b l e m (as has t y p i c a l l y b e e n t h e case), f u t u r e research a n d p r a c t i c e s need t o d e m o n s t r a t e a b r o a d - b a s e d perspective o n t h e a d j u s t m e n t p r o b l e m s of these c h i l d r e n t h a t e x a m i n e s " s i t u a t i o n a l " d e t e r m i n a n t s a n d i n s t i t u t i o n a l policies.
ABSTRACT:
In recent years, a dramatic increase in the incidence of hyperkinesis has been witnessed. Whether such a p h e n o m e n o n reflects an actual increase in the occurrence of maladaptive s y m p t o m a t o l o g y or merely a sharpening of our clinical tools of observation and classification is difficult to say. It is also quite possible, as pointed out by Schrag and Divoky [1 ], that the current social and educational ideology, which increasingly defines " n o r m a l c y " in terms of " c o n f o r m i t y , " has created a new statistical population of " d i s t u r b e d " children heretofore u n k n o w n in our society. With the implementation of such an ideology, children who demonstrate any degree of atypical behavior become likely candidates for being classified (hyperkinetic or otherwise), mainly because they do not meet the expectations of those in positions of authority. Regardless of the many factors that may have contributed to the current prevalence of the " h y p e r k i n e t i c " syndrome, the affected children constitute a social and educational problem of major proportion. Although figures vary somewhat depending Dr. Cole is Professor of Psychology, a n d Dr. M o o r e is A s s i s t a n t Professor of Psychology, R u t g e r s University, C a m d e n , New Jersey 0 8 1 0 2 . R e p r i n t queries s h o u l d be d i r e c t e d to t h e senior a u t h o r . Child Psychiatry and Iturnan Development
Vol. 7(2), Winter 1976
103
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Child Psychiatry and Human Development
upon the source, it is estimated that anywhere from 3% to 10% of schoolchildren demonstrate enough traits (mild or severe) to be classified as hyperkinetic [2, 3], with more males than females apparently being affected [2]. While these figures are, in themselves, astounding, they become even more so when it is realized that only a decade ago hyperkinesis was a relatively u n k n o w n syndrome. In the current identification of the hyperkinetic child, two major symptoms appear to predominate: hyperactivity of a "driven" nature and attention difficulties or distractibility [2, 4]. In an extensive comparison of hyperkinetic children with normal control children, Douglas [5] concluded that, in practical terms, many of the performance deficits (as well as other problems) of hyperkinetic children are due to their inability to "stop, look, and listen." While the identification of such adjustment problems is essential in order to ensure the genuine welfare of the child, the use of such symptomatology to reinforce the ideologies of social and educational institutions is morally questionable. The failure to make such a basic distinction in the purpose of " s y m p t o m identification" (along with changing views about the nature of the disorder itself) constitutes just cause for the growing concern for the children so classified. These issues are discussed in the following sections. Diagnostic Practices The practice of translating the adjustment problems of the hyperkinetic child into pseudoscientifically labeled disorders is increasing at an epidemic rate. As a result, misleading terms are increasingly being used to identify the hyperkinetic child, in that some authors make no clear distinctions between "hyperkinesis," " M B D " (minimal brain dysfunction), and " L D " (hyperactivity accompanied by learning disabilities) [6, 7, 8]. In fact, hyperkinesis (along with many other poorly understood syndromes) is typically grouped under the one roof of MBD [1 ]. Although genetic variations, events surrounding the birth process, neurological dysfunction, and biochemical imbalance have been proposed as contributing to hyperkinesis, little is really known about the causative factors underlying the disruptive behavior [9]. Until such potential explanations are more clearly understood, it would seem appropriate to avoid the global and indiscriminate use of such labels as brain dysfunction (minimal or otherwise) and LD, which have pseudo-explanatory or etiological implications. The implied etiological assumptions of the MBD diagnostic category, in particul~r, can prematurely preclude the examination of situational and environmental causative factors that may contribute to the sympto-
S h e r w o o d O. Cole and Samuel F. Moore
105
matology. Of course, in those instances where hyperkinesis is accompanied by known central nervous system damage, a proper recognition of the relationship is essential and may have important implications for treatment practices. Another problem associated with labeling the hyperkinetic child as MBD or LD is the lack of professional agreement as to what clinical s y m p t o m s are to be subsumed under such labels. Certainly, adjustment problems other than those resulting from hyperactivity per se and attention difficulties are frequently included, in spite of the fact that such problems may have little or no relationship to the adjustment needs that initially led to the labeling. As pointed out by Schrag and Divoky [1], attempts to identify the multitude of s y m p t o m s underlying these labels merely become "sophisticated statements of ignorance" and provide the occasion for numerous subjective judgments made by persons in positions of authority to be translated into pseudoscientific language. While there may be professional disagreement a b o u t the s y m p t o m s underlying the MBD and LD syndromes, the application of such diagnostic labels may still have serious consequences for the child so labeled. As with any diagnostic label, the impact of the labels MBD and LD can lead to what Lemert [10] terms "secondary deviance." The labeled child becomes selectively reinforced for any and all behaviors that have been associated with the diagnostic label; thus, the expectations for the child's subsequent behavior, as viewed by significant others (teachers and other professionals), are influenced [ 11]. Even more distressingly, the label can be internalized by the child in his own behavioral expectations and become a "self-validating hypothesis" [12]. The potential for these effects being present in the application of diagnostic labels has led to the proposed abolishment of all labeling of behavioral disorders [13]. While such a recommendation may be somewhat overstated, diagnostic labels that are only ambiguously defined and understood, and that prematurely exceed symptom-descriptive statements to include etiological assumptions, can mask the true nature of the adjustment problems of the hyperkinetic child. Particularly when misapplied, such labels serve to propagate institutional and professional ideas about the nature of disorders, while the unique and individual needs of the child are ignored [14]. Treatment
Practices
Of the treatment practices currently being employed with hyperkinetic children, the use of stimulant drugs is, by far, the most prevalent. The effectiveness of the sympathomimetic amines d-amphetamine
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(Dexedrine) and methylphenidate (Ritalin) in reducing the activity level and improving the attentive behavior of hyperkinetic children has been reviewed elsewhere [15]. While stimulants appear to "normalize" the behavior of such children, an explanation of the efficacy of such treatment is still incomplete. In addition to the chemical treatment of hyperkinesis, behavior modification (systematic reinforcement of desirable behavior) has demonstrated some effectiveness in reducing the activity [16, 17] and improving the attentive behavior [4] of such children. Although it has not received wide publicity, there also seems to be some trend toward an increased use of psychosurgery (surgical interruption of emotion-regulating areas of the central nervous system) with hyperkinetic children [18]. However, as children on whom such surgery is performed typically demonstrate violent and destructive behavior (as well as hyperactivity and poor concentration), it appears that these practices are directed primarily at broader problems of adjustment, not hyperkinetic symptomatology only. Observations on such children following a m y g d a l o t o m y (lesions that destroy only part of the nucleus) indicate that the child is not only quieter and more obedient but shows a reduction in activity and an improvement in attention [19]. In spite of the evidence that apparently documents the effective treatment of hyperkinetic symptomatology with chemicals, behavior modification, and psychosurgery, some of these practices serve as unfortunate examples of the process whereby the pressures for ameliorating problems encourage shortsighted solutions. This appears to be particularly true in the case of chemical treatment and psychosurgery, both of which are apparently more concerned with the immediate alleviation of disruptive symptomatology than with the long-term impact of such practices. While there is general agreement that stimulant drugs decrease disruptive hyperactivity, serious doubts exist regarding benefits beyond those of making the child more compliant. Certainly, a primary objective for the use of stimulants should be that of enabling the treated child to profit from academic experiences; yet, in a recent review of drug treatment studies, Sroufe [20] concluded that there is no compelling evidence that such treatment facilitates reasoning, nonrote learning, problem solving, or actual educational achievement. It is also the case that the chronic treatment of hyperkinetic symptomatology with stimulant drugs may diminish the appetite, increase the resting heart rate, and retard the growth rate of such children (see review by Cole [15] ). Furthermore, the possibility that such chronic drug treatment of children will encourage later addictive behavior
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must remain an open issue until more longitudinal data are available on the topic [21]. Despite the lack of conclusive evidence for any benefits of stimulants beyond the suppression of hyperactivity, the use of chemicals remains the predominant treatment practice with hyperkinetic children. In the case of psychosurgery, the distinction between the immediate alleviation of disruptive symptomatology and the long-term impact of the treatment becomes even more crucial. All such operations mutilate some nondiseased tissue and may blunt the overall emotional and intellectual responsiveness of the child [22]. Thus, while psychosurgery may have some immediate effectiveness in reducing the disruptive symptomatology of hyperkinesis, such an irreversible treatment may have serious deleterious effects on the future development of the child. One of the basic issues encountered in all of the t r e a t m e n t practices used in dealing with hyperkinetic s y m p t o m a t o l o g y is t h a t they tend to be " c o n t r o l " or " m a n a g e m e n t " oriented. Such an orientation expresses a greater concern for the day-to-day suppression of symptomatology than for an honest examination of the varied and complex problems that may have given rise to the disruptive behavior. The day-to-day control of hyperkinetic s y m p t o m a t o l o g y with stimulant drugs requires that the affected child be almost constantly under the influence of the drug (drug-state condition). Yet busy parents and overworked school administrators find such a practice to be a relatively simple solution to a complex problem. In spite of some evidence that the beneficial effects of stimulants on disruptive hyperactive behavior may carry over into drug-free periods [3, 23], an emphasis on control or management does not encourage one to experiment with interruptions or alterations in the child's drug regimen. To suggest that the practice of psychosurgery has any primary objective other than control or management of disruptive symptomat o l o g y is to be naive indeed. The use of this technique assumes that we know much more than we do about brain functioning, when, in fact, the actual history of psychosurgery is one of vagueness and uncertainty regarding the specificity of its immediate effects (other than simply management) and even less clarity about its long-range consequences. The fact that some investigators using psychosurgery refer to it as "sedative neurosurgery" [24] indicates clearly that this practice is concerned with the suppression (control) of disruptive symptomatology, not with the intellectual and emotional development of the child. Behavior modification techniques can be equally control or man-
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agement oriented in their application, as documented by Winett and Winkler [25 ]. Typical applications of behavior modification programs with hyperkinetic children have focused primarily on the reduction of disruptive s y m p t o m a t o l o g y w i t h o u t an accompanying concern for establishing new, more adaptive behaviors [26]. Although such practices emphasize the need for modifying social behavior, the equally important emphasis on the establishment of new social attitudes and the necessity of the child being aware of the long-term advantages of such changes is frequently missing. Numerous moral issues are raised by any treatment practice that demonstrates more concern for the suppression of disruptive symptomatology than for the welfare of the affected child. Of course, the importance of these issues is much greater for those practices where the control or management of behavior cannot be reversed or undone (psychosurgery) than it is in any practice where the treatment can be terminated or altered (stimulant drugs or behavior modification). According to Schrag and Divoky [1 ], important issues are also raised by t h e fact that control or management practices are typically used to reinforce the present-day ideology which increasingly defines normalcy in terms of conformity. This being the case, control or management becomes tighter as normalcy demands more and more conformity. The result is that the right of any child (hyperkinetic or otherwise) to be different and to demonstrate atypical behavior is rapidly disappearing [ 1 ]. Changing Views about the Nature o f the Disorder For many years it has been assumed that hyperkinetic symptomatology constitutes a childhood syndrome, with the child outgrowing the symptoms or learning better adjustment by the time of puberty [2]. However, recent evidence [27, 28, 29] suggests that the hyperkinetic child may continue to be in academic difficulty and demonstrate problems of social adjustment into adolescence and adult life. The prolongation of such adjustment problems must be dealt with, which, in turn, has serious implications for treatment practices as well as for diagnostic labeling practices. The assumption that hyperkinesis is a childhood disorder has provided an accepted safeguard against the treatment of such symptomatology with stimulant drugs resulting in later addictive behavior [30]. In all likelihood, the treatment would be prescribed for only a limited number of years (probably until the child reaches puberty) and would typically be terminated prior to the period of peak social pres-
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sure for drug abuse (late adolescence and early adulthood). However, if the adjustment problems of the hyperkinetic syndrome are not restricted to childhood, treatment of such children with the chronic use of stimulant drugs has the potential for encouraging a lifelong "chemical style" of dealing with affective and behavioral problems. Such practices could result in many young adults perceiving a large percentage of their life through "drug-state eyes." A case in point is that of a 26-year-old patient who was on stimulant m e d i c a tion from the age of 8 and whose personality, perceptions, and interactions with reality developed almost totally under the influence of the drug [21]. While it might appear, on the surface, that the changing views about hyperkinetic s y m p t o m a t o l o g y justify the use of psychosurgery as a treatment (i.e., prolonged adjustment problems require more drastic, perhaps even permanent solutions), the issue must be examined more closely. First of all, the evidence suggesting that the hyperkinetic child may continue to demonstrate adjustment problems into adolescence and adulthood does not spell out the specific nature of such problems, that is, whether they continue to be hyperactive and attention-deficit symptoms or learned maladaptive behaviors. If, in fact, they are learned, there may be more appropriate and less permanent ways to cope with the adjustment needs of the child. Secondly, to suggest that the adjustment problems of the hyperkinetic child continue beyond the period of puberty does not necessarily imply that they remain lifelong concerns. Therefore, the use of psychosurgery in the treatment of such problems defies logic, in that no irreversible practice is justified in dealing with adjustment problems that, at a n y stage, may be reversible or remit of their own accord. While the changing views about the nature of the hyperkinetic disorder may appear to have little impact on the use of behavior modification in the treatment of such symptomatology, such is not the case at all. Rather, the evidence suggesting that the adjustment problems of hyperkinesis may continue into late adolescence and adulthood provides the strongest possible argument for establishing adaptive behaviors rather than merely suppressing disruptive ones. Concomitantly, it is imperative that the external reinforcements of desirable behaviors be adopted by the child as internalized controls of his behavior, and that the child be aware of their long-term advantages. As Bandura [31] suggested, such awareness is the necessary precursor to the development of self-monitoring which should predominate in adult functioning. Changing views about the nature of the hyperkinetic disorder also
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have some impact on diagnostic labeling practices. Such labels as MBD and LD have typically been used (either implicitly or explicitly) to explain the "adjustment lag" of children who present management problems in school or other institutional contexts. While such labels provide an aura of understanding that may be comforting to parents and institutional authorities in the short run, they provide no clear basis for explaining or effectively coping with the long-term problems of adjustment into late adolescence and adulthood. Labels that encourage a view that only a temporary adjustment lag is involved are, at best, euphemistic, and may very well impede advances in our understanding of the long-term needs of the hyperkinetic child. To suggest that we should avoid such diagnostic labels does not, however, imply that we should discard the practice of identifying all disruptive symptomatology. Some identification of the adjustment needs of such children is still essential in dealing both with their short-term (childhood) and long-term (late adolescence and adulthood) welfare. However, the avoiding of such labels as MBD and LD may provide an appropriate incentive for a more comprehensive assessment of the problems of hyperkinetic symptomatology, including an examination of our institutional policies. Concluding Comments Professional responsibility in the identification and treatment of the hyperkinetic child is indeed awesome. Nothing less than a continuing and intensified research program of the total situation surrounding the problems of hyperkinesis will suffice. While it will continue to be essential to identify the problematic symptoms of affected children in order for such research to progress, it is imperative t h a t practitioners ensure that the use of the diagnostic category of hyperkinesis is in the interest of recognizing and dealing with the individual needs of the child rather than in the interest of excluding and/or controlling the child. Subsuming the diagnostic category of hyperkinesis under the more generic (and ambiguous) labels of MBD and LD would appear to be premature, given the many potential etiologies of the symptomatology. Such labels are frequently not in the best interest of the child, to the extent that they encourage a perspective that focuses solely on the child as the source of the adjustment problems. Future research and practices must demonstrate a more broadbased perspective on the adjustment problems of the hyperkinetic chiId, by recognizing the importance of the child's interaction with the environment and the treatment regimen. With such a recognition,
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it t h e n b e c o m e s possible t o e x a m i n e " s i t u a t i o n a l d e t e r m i n a n t s " as viable factors in disruptive s y m p t o m a t o l o g y and t o c o n s i d e r m o r e individualized t r e a t m e n t practices. F u r t h e r m o r e , in t h e design o f individualized t r e a t m e n t s , m u c h remains to be a c c o m p l i s h e d b e y o n d t h e mere m a n a g e m e n t or c o n t r o l of t h e h y p e r k i n e t i c child's disruptive behavior. Far m o r e i m p o r t a n t is the e s t a b l i s h m e n t o f basic a c a d e m i c and social skills t h a t the child will u l t i m a t e l y need to f u n c t i o n as a p r o d u c t i v e and i n d e p e n d e n t adult in society. A b o v e all else, t h e m o r a l j u d g m e n t o f the p r a c t i t i o n e r m u s t ensure t h a t the h y p e r k i n e t i c child does n o t b e c o m e the victim or p a w n o f standard diagnostic and t r e a t m e n t practices t h a t c o n f o r m t o institutional ideologies and policies. In t h e long run, o n l y a b r o a d e r - b a s e d perspective t h a n has h e r e t o f o r e been practiced will g u a r a n t e e such p r o t e c t i o n o f the child and will provide a s o u n d basis for selecting t r e a t m e n t s t h a t will increase the efficacy o f m e e t i n g l o n g - t e r m goals as well as dealing with the i m m e d i a t e behavioral p r o b l e m s o f these children.
References 1. Schrag P, Divoky D: The Myth o f the Hyperactive Child and Other Means o f Child Control. New York, Pantheon Books, 1975. 2. Office of Child Development, Department of Health, Education, and Welfare: Report o f the Conference on the Use o f Stimulant Drugs in the Treatment o f Behaviorally Disturbed Young School Children. Washington, D.C., United States Government Printing Office, 1971. 3. Sleator EK, yon Neuman A, Sprague RL: Hyperactive children. JAMA 229: 316-317, 1974. 4. Allen KE, Henke LB, Harris FR, et al: Control of hyperactivity by social reinforcement of attending behavior. J Ed Psychol 58:231-237, 1967. 5. Douglas VI: Are drugs enough? To treat or to train the hyperactive child. Int J Ment Health 4:199-212, 1975. 6. Berlin IN: Minimal brain dysfunction. JAMA 229:1454-1456, 1974. 7. Feingold BF: Why Your Child Is Hyperactive. New York, Random House, 1975. 8. Witter C: Drugging and schooling. Transaction 8:31-34, 1971. 9. Dubey DR: Organic factors in hyperkinesis: A critical evaluation. A m e r J Orthopsychiat 46:353-366, 1976. 10. Lemert EW: Human Deviance, Social Problems, and Social Control. Englewood Cliffs, NJ, Prentice-Hall, 1967. 11. Rosenthal R, Jacobson L: Teachers' expectancies: Determinants of pupils' I.Q. gains. Psychol Rep 19:115-118, 1966. 12. Ullmann LP, Krasner L: A Psychological Approach to Abnormal Behavior. Englewood Cliffs, NJ, Prentice-Hall, 1969. 13. Menninger K: The practice of psychiatry. Digest Neurol Psychiat 23:101, 1955. 14. Hobbs N: Editor's introductory comments. In N Hobbs (Ed), Issues in the Classification o f Children (Vol 1). San Francisco, Jossey-Bass, 1975.
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15. Cole SO: Hyperkinetic children: The use of stimulant drugs evaluated.Amer J Orthopsychiat 45:28-37, 1975. 16. Doubros SG, Daniels GJ: An experimental approach to the reduction of overactive behavior. Behav Res Ther 4:251-258, 1966. 17. Patterson GR, Jones R, Whittier J, et ah A behavior modification technique for the hyperactive child. Behav Res Ther 2:217-226, 1965. 18. Breggin P: Underlying a method. Ment Hygiene 58:19-21, 1974. 19. Narabaysahi H: Stereotaxic amygdalotomy. In BE Eleftheriou (Ed), The Neurobiology o f the Amygdala. New York, Plenum Press, 1972. 20. Sroufe LA: Drug treatment of children with behavior problems. In F Horowitz (Ed), Review o f Child Development Research (Vol 4). New York, Russell Sage Foundation, 1975. 21. Vonder Harr TA: Chaining children with chemicals. The Progressive 39:1317, 1975. 22. Breggin PR: The second wave. Ment Hygiene 57:10-13, 1973. 23. Cohen NJ, Douglas VI, Morgenstern G : The effect of methylphenidate on attentive behavior and autonomic activity in hyperactive children. Psychopharmacol 22:282-294, 1971. 24. Balasubramaniam V, Kanaka TS, Ramanujam PV, et ah Sedative neurosurgery. J Indian Med Assoc 53: 377-381, 1969. 25. Winett RA, Winkler RC: Current behavior modification in the classroom: Be still, be quiet, be docile. J A p p l Behav Anal 5:499-504, 1972. 26. Simpson DD, Nelson AE: Attention training through breathing control to modify hyperactivity. J Learn Disabil 7:274-283, 1974. 27. Huessy HR, Metoyer M, Townsend M: 8-10 year follow-up of 84 children treated for behavioral disorder in rural Vermont. Acta Paedopsychiat 40: 230-235, 1974. 28. Mendelson W, Johnson N, Stewart M: Hyperactive children as teenagers: A follow-up study. J Nerv Ment Dis 153:273, 1971. 29. Menkes M, Rowe J, Menkes J: A twenty-five year follow-up study on the hyperkinetic child with minimal brain dysfunction. Pediat 39:392-399, 1967. 30. Cole SO, Moore SF: Stimulants and hyperkinesis: Drug use or abuse; JDrug Ed 5:371-379, 1975. 31. Bandura A: Behavior theory and the models of man. A m e r Psychol 29:859869, 1974.
