ADHD, Parental Stress, Stigma, and Mindfulness Training

Introduction

Attention Deficit Hyperactivity Disorder (ADHD) is the most commonly diagnosed behavioural disorder of childhood. Its core symptoms include developmentally inappropriate levels of attention, concentration, activity, distractibility and impulsivity. Children with ADHD usually have functional impairment across multiple settings including home, school and peer relationship. It has also been shown to have long-term adverse effects on academic performance, vocational success and socio-emotional development (NIH Consensus Development Conference Statement, 2000).

Attention Deficit Hyperactivity Disorder has a long history that spans over a century. The understanding of its nature, conceptualization and treatment has undergone a lot of changes and the current understanding of this disorder represents a varying developmental history. The first reference of hyperactivity could be traced back to a poem written by a German physician Heinrich Hoffman in 1865, which described the activities of a hyperactive or ADHD child named Fidgety Phil. George Still and Alfred Tredgold carried out the first scientific work on ADHD. Still, in 1902, described the clinical condition of 43 children who were similar to what is today known as ADHD and he attributed all these symptoms to ‘defect in moral control’, which could arise from defect of cognitive relation to the environment, defect of moral consciousness or defect in inhibitory volition. But later he proposed that early, mild and undetected brain damage could lead to such a condition. Tredgold (1908) and Pasamanick, Rogers and Lilienfeld (1956) supported the same conceptualization.

Studies focused on the relation between behavioural problems and brain lesions found an association between defects in forebrain structures and severe restlessness. Milder forms of hyperactivity were attributed to psychological causes such as ‘spoiled’ child-rearing practices or delinquent family environments. This gave way for the concept of ‘brain injured child’ (Strauss and Lehtinen, 1947) and it was modified as the concept of Minimal Brain Damage and Minimal Brain Dysfunction (MBD) by the 1950s and 1960s. Laufer, Denhoff and Solomons (1957a) coined the term ‘Hyperkinetic impulse disorder’ to refer to this disorder and they conceptualized that it could be caused by a central nervous system deficit occurring in the thalamic area due to the poor filtering of the stimulation. Laufer and Denhoff (1957) and Chess (1960) developed the concept of ‘Hyperactive child syndrome’, which emphasized hyperactivity as the major feature and thus the concept of a syndrome of hyperactivity was separated from the concept of a brain-damage syndrome. The disorder was included in the second edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-II) (American Psychiatric Association (APA), 1968) and it described the hyperkinetic reaction of childhood disorder as characterized by overactivity, restlessness, distractibility and short attention span, especially in younger children, which usually diminishes by adolescence. The difference in the conceptualization of ADHD between Europe and North America started during the 1960’s and it was reflected in the classification of the disorder in DSM and ICD (International Classification of Diseases, World Health Organization). Clinicians in Europe considered this disorder as a rare syndrome with excessive motor activity and a sign of brain damage but in North America, this disorder was considered relatively common and not necessarily associated with brain damage.

During the 1970’s, two different models to explain the nature of ADHD had developed-Wender’s theory of MBD and Douglas’ model of attention impulse control. Thus the emphasis was shifted from overactivity to the attention aspect of the disorder especially focusing on deficits in sustained attention as the core feature and the disorder was renamed Attention Deficit Disorder (ADD) with the publication of DSM-III (APA, 1980). The use of stimulant medication, special education programs, classroom behaviour `modification, dietary management and parent training were the treatment modalities employed during that period. Unhealthy environment was considered as the etiology of hyperactivity such as poor child rearing practices and child behaviour management. Studies also focused on the psychophysiology of hyperactivity in children and adult hyperactivity.