Disorders of Attention and Activity 61overt brain damage, and terms such as ‘minimal brain damage’ are un-
helpful. If neurobiological explanations are to be useful, they need to
be as specific and testable as possible. There is growing support from
neuroimaging and neuropsychological studies for the idea that ADHD
sometimes results from impaired executive functioning linked to structural
and functional abnormalities of the prefrontal cortex and basal ganglia.
Other evidence links ADHD to delay aversion, that is, a preference for
small immediate rewards rather than larger delayed rewards. Executive
dysfunction and delay aversion may be alternative routes into ADHD;
difficulties regulating arousal may be a third route. It is important to
remember that just as a physical syndrome such as hepatitis can have
many possible causes (for example, alcohol, viral infections), so too may a
psychiatric syndrome such as ADHD.
Despite popular stereotypes, it is not common for ADHD to result from
exposure to environmental toxins such as lead, or to be due to pregnancy
and birth complications – with the exception that very premature births
are more likely to lead to problems with inattention. However, there is
rather more evidence for the widely held view that ADHD can be triggered
by adverse reactions to specific foods or drinks.
Psychosocial as well as biological factors influence ADHD symptoms, as
indicated by the link with deprivation and institutional rearing. The re-
sponses of parents, teachers and peers may influence the prognosis. There
is growing evidence that parents and teachers who respond to ADHD with
criticism, coldness and lack of involvement thereby increase the chance of
the affected individual becoming defiant, aggressive and antisocial.
Treatment
Education
The nature of the disorder needs to be explained to the affected individual,
the family and the school. ADHD is neither the parents’ fault nor their
child’s fault. Since children and adolescents with ADHD can be extremely
exasperating, they often come in for much criticism and little praise. The
balance may improve, however, once adults accept that the problems are
not just wilful naughtiness. Rules about unacceptable behaviours should
be clear, consistently and calmly enforced, and backed up by immediate
(but not harsh) sanctions. A key objective of treatment is to reduce the
chances of the child acquiring an additional behavioural disorder. Special
learning problems may need remedial help, and all teaching will need to
take account of the child’s limited attention span.
Psychological treatments
Behavioural management is often useful, and may be the only treatment
needed for the mildest cases. The most suitable targets are the sorts of dis-
ruptive behaviours described in more detail in Chapter 6. Parent-training
programmes can improve parents’ child-management skills and thereby