Where's the hyperactive child going?

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VOLUME 57 . JANUARY 1976#{149}NUMBER 1

PEDIATRICS Vol. 57 No. 1 January 1976 1

Pediatrics

COMMENTARIES des he believes to be of particular interest to

Spanish

physicians.

If this venture is judged to be mutually success-ful, we hope that it will be but the first of several steps planned to bring Pediatrics to a wider

international audience.

J

EROLD F. LUCEY, M.D.

Where’s

the hyperactive

child

going?

Welcome

to our new Spanish

language

edition

Beginning with this month’s issue, Pediatrics

will be translated into Spanish. Angel Ballabriga,

M.D., Professor of Pediatrics in the Autonomous

University and Chairman of the Children’s

Hospital of the Seguridad Social, Barcelona,

Spain, will be the guest editor. Our Spanish

edition will be published and distributed by Ediciones Doyma in Spain to approximately 15,000 physicians caring for children.

We hope that our new readers in Spain will

find Pediatrics thseful in their practices. Professor Ballabriga will select, for highlighting, those

arti-Hyperactivity in childhood, and its correlates

of behavior problems and learning disorders, is a problem that pediatricians are facing with increasing frequency. Newspapers, magazines, scientific journals, and other media have popular-ized this topic and consequently parents,

teach-ers, psychologists, and just friends are looking at

children in a new light. As a result, physicians are frequently being asked how a child’s learning

abilities can be improved or maximized, what will

happen when he grows up, if medication is indicated, and a variety of related questions. In

this issue of Pediatrics Huessy and Cohen present

data on hyperkinetic children followed over a

seven-year period. Data like these are needed

at Viet Nam:AAP Sponsored on September 8, 2020

www.aappublications.org/news

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2 HYPERACTIVE CHILD

since the natural history of hyperkinesis is largely unknown. For a clinician the implications of these findings are especially important since he must decide how vigorously to treat such children. Their data suggest that the prognosis for those with “hyperkinesis” is quite serious. They state

“. . . many find their way into mental hospitals,

penal institutions, or are unable to successfully adapt to society in other ways.” Their references support this gloomy outlook. To many clinicians this will come as a surprise since they view most hyperkinetic, impulsive children as having im-maturity of the nervous system and consequently expect them to outgrow it in time. However, before clinicians change their view and accept these discouraging conclusions, they must criti-cally examine the data on which they are based.

Since a great many children are more active than seems “normal” or tolerable to their parents, teachers, or other adults, it becomes difficult to

define just what constitutes hyperactivity. The

classroom is often the first situation where the child is called upon to restrain himself, and consequently the first time inappropriate activity becomes obvious. Accordingly, in the current study hyperkinesis was assessed by a teacher questionnaire designed to measure “social maturi-ty, neuromuscular development, academic

per-formance, and general attitude and behavior.” The scores from this questionnaire were divided into percentiles and those in the upper 20th percentile designated as “hyperkinetic.” Al-though the teachers did not know the children’s final scores, it appears that similar judgments were used to define the outcome seven years later, namely, “poor social adjustment and

disci-plinary problems.” The sources for these data were again teachers’ comments and other official school documents. Thus, the possibility of falsely identifying a causative relationship by virtue of using similar information to define both the “dependent” and “independent variable” exists. This possibility is supported by the authors’ statement that “through various check-back procedures teachers were asked to identify problem children in their classes, and it was found that all the children they identified as problems did indeed have scores above the 80th percent-ile.” Thus, it would appear that the identification of hyperkinetic behavior is similar to that of poor social adjustment. Although the teachers were not the same at each of the intervals, it can be assumed that the basis for their judgments was similar.

In addition, the work of Werry and Quay1 raises some questions about this method. They

used a teacher questionnaire and found between 40% and 50% of boys in the Midwestern city school had restlessness, short attention span, disruptiveness, inattentiveness, and distractability. Although it is clear that this group is less socially acceptable, one wonders where the line is drawn between normal and abnormal. To the busy clinician who has tried to straighten his office after the visit of a hyperkinetic child, these

methods may seem a bit circuitous!

Assuming that hyperkinesis can be defined and

diagnosed with reasonable accuracy, what does it

indicate? Like most other symptoms, it is a part of, or results from, a variety of entities. It may be seen in children with psychosis, emotional prob-lems, learning disorders, diffuse cerebral damage, or minimal brain dysfunction (MBD). It is likely (and even probable) that the natural history for each of these is different. Most investigations dealing with this broad area fail to define the

children under consideration with sufficient

clar-ity. Moreover, the terms hyperkinetic syndrome, learning disorder, and MBD are often used inter-changeably. Consequently, there is considerable overlap between these diagnostic rubrics, and considerable confusion between cause and effect, particularly with regard to MBD which is

asso-dated with both hyperkinetic behavior and learning disorders in many instances. It is essen-tial, therefore, that investigators in this field make the utmost effort to define clearly the subgroups they are studying. Before we accept such a pessimistic long-term prognosis, it is important

that the categories studied be more carefully delineated. Failure to do so cannot help but add

confusion to an already chaotic scene.

Once the physician fits the child into one of these categories, a new problem arises. This is the danger of “labeling” a child and thus setting into motion what may prove to be a self-fulfilling prophecy. The work of Rosenthal and Jacobson2 has shown that a child’s classroom performance is

significantly influenced by the teacher’s expecta-lions. In the current study efforts were made to minimize this, and the authors wisely caution

against including the diagnosis in the school

records. This, however, may not be possible if any

active educational intervention is contemplated.

Because they feel the prognosis is so serious, Huessy and Cohen recommend early identifica-tion and treatment. It would be easier to accept these recommendations if there was good evidence that long-term treatment is beneficial. Silvert recently reviewed this topic in relation-ship to learning disabilities. Under “acceptable”

therapies he lists special education, medication,

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COMMENTARIES 3

and psychotherapy. The latter two therapies appear to make the child more available for learning by lenthening his attention span, decreasing his frustration, and improving his self-image. However, the basic need for educational help still exists. But, beyond that, do medication or psychological help have any long-term influences on the child still evident when he

reaches adulthood? There are few hard data to answer this crucial question.

Physicians who read this article, or any of the

references given, must ask themselves whether more drastic attempts at “early diagnosis and therapy” are justified. But before this question

can be answered properly, they must also ask “diagnosis of what?” In our view, it makes a very

substantial difference if the diagnosis is the

syndrome first described by Heinrich Hoffmann

in 1845 consisting of hyperactivity, impulsivity,

distractibility, and excitability,4 or one of the

spectnim of more recently discovered “specific learning disabilities,” or an emotional problem.

Similarly, it makes a great deal of difference if the

presumed cause of these symptoms is anoxia at birth, some genetic influence, lead intoxication, or a disturbed family environment. In summary,

until investigators succeed in defining more clearly what they are studying, clinicians can hardly be expected to follow their recommenda-tions without a healthy degree of skepticism.

GARY

J.

MYERS, M.D.

Department of Pediatrics,

University of Rochester School of Medicine and Dentistry

601 Elmwood Avenue Rochester, New York 14642

I. BARRY PLESS, M.D.

Montreal Children’s Hospital

2300 Tripper Street Montreal, Quebec Canada

REFERENCES

1. Werry JS, Quay HG: The prevalence of behavior

symptoms in younger elementary school children.

Am J Orthopsychiatry 41:136, 1971.

2. Rosenthal R, Jacobson L: Pygmalion in the Classroom. New York, Holt Rinehart & Winston mc, 1968.

3. Silver LB: Acceptable and controversial approaches to treating the child with learning disabilities.

Pediat-rics 55:406, 1975.

4. Hoffmann H: Der Struwwelpeter: Oder lustige

geschichten und drollige bilder. Leipzig, Insel Verlag, 1845.

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1976;57;1

Pediatrics

Gary J. Myers and I. Barry Pless