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Attention‐Deficit Hyperactivity Disorder in Adults
BOOK
REVIEWS
Attention-Deficit Hyperactivity Disorder in Adults. By Paul H. Wender, M.D. New York: Oxjord University Press, 1995, 282 pp.. $30.00 (hardcover). Over the course of several decades, Dr. Paul H. Wender has studied the syndrome now known as attention-deficit/ hyperactivity disorder (ADHD). His research began in the days when the syndrome was known as minimal brain dysfunction and has continued into the current, DSM-/Vera. In Attention-Deficit Hyperactivity Disorder in Adults, Dr. Wender summarizes and distills his vast experience with this syndrome into a volume that is succinct , informative, and enjoyable to read . Attention-Deficit Hyperactivity Disorder in Adults is organized into eight chapters and six appendices. Chapter 1 begins by placing the current concept of ADHD in its historical context. This allows the author to set the stage for a description of his group's research into the adult syndrome of ADHD. This research began with Wender's recognition that the parents of many of his child ADHD patients presented childhood histories that were similar to those of their children. Through adulthood, the functioning of many of these adults continued to be compromised by signs and symptoms of the disorder, Chapter 2 contains a clinically rich description of the behaviors and impairments that characterize ADHD in chil dren and adults. This useful presentation goes far beyond a mere listing of descriptive features. Rather, the author focuses on IO dimensions of behavior ranging from attcnt ional difficulties and impulsivity to stress intolerance and response to medication . For each of these characteristics, he describes, in considerable detail, the ways in which childhood ADHD findings persist, attenuate, transmute, and weave themselves into the fabric of adult personality and adaptive functioning. Chapter 3, on the prevalence of ADHD in adults, was less satisfying to me. It seemed long and dry. It summarized material from many studies addressing the epidemiology of ADHD. Although important to the conceptual integrity of the book, this chapter offered the clin ician less relevant informanon. The next chapter, "Etiology," is better. Although also long, and at times dry, this chapter presents much material of interest in understanding the complex genetic and biological factors that underlie what is clearly a multifaceted syndrome. This chapter contains useful reviews of the dopamine and catecholamine systems. It ends with a brief section on the potential future role of molecular genetics in helping to
J. AM . ACAD. CHII.D ADOI. ESC. PSY CHIATRY, .\ 7: 7 . JUI.Y 1998
Assistant Editor: Dean X Parmelee, M.D.
understand the molecular abnormalities underlying various subtypes of ADHD. Chapters 5 , 6, and 7 were, for me, the heart of Dr. Wender's book. Chapters 5 and 6 deal with the diagnosis and treatment of ADHD in adults. Chapter 7 consists of detailed first-person accounts written by four adult patients describing their experiences of living with ADHD and being treated with stimulants. Dr. Wender's study of ADHD began in the early 1970s, and his diagnostic criteria have been refined over the years. The indexes contain some of the rating scales which the Utah group uses in their work. Wender's criteria for diagnosing ADHD in adults are rigorous and require sufficient information about the patient's childhood functioning to ensure that the patient would have met both narrow (DSM-/V) criteria and several broad criteria for the diagnosis in childhood. Then, as an adult, the patient has to retain characteristics of both "persistent motor hyperactivity" and "atrenrional difficulties. " In addition, two of five other inclusion criteria must be met. Exclusion criteria are listed as well. Beyond the listing of criteria, however, the book includes vivid descriptions of the life problems experienced by ADHD adults in their internal , interpersonal, and vocational lives. For those clinicians less experienced in treating ADHD in adults, these descriptions will help them recognize the more subtle forms of hyperactivity, impaired concentration, affective lability, stress intolerance, and the other "broad" criteria. Dr. Wender clearly believes that pharmacological management is the mainstay of treatment for ADHD in adults. His position is that ". . . drug-responsive adult ADHD patients . . . often function better than they ever have in their lives. Long-term treatment of patients responsive to stimulants often produces major changes in scholastic, vocational, and personal functioning" (p. 153). However, the author's presentation makes it clear that his prescription of medication (stimulant and otherwise) occurs in a context of patient education, support, and monitoring. Wender is also well aware of the medicolegal concerns over the long-term prescription of controlled substances. He suggests ways of mitigating these risks for clinicians who expect to treat substantial numbers of adult ADHD patients. Notwithstanding these concerns, when the author uses medications, he does so aggressively, with the recognition that stimulants are rapidly metabolized and that frequent doses are often required. Overall, I found Attention-Deficit Hyperactivity Disorder in Adults to be enjoyable and informative. Especially in the more
791
BO O K REV IEWS
clinical sec tio ns, I o ften fdt as if [ we re listen ing to a lec tu re presented by a n a rt icu la te a nd seaso ned teacher de scribing material with which he wa s intimately famil iar. I would particularly recommend thi s book to residents in both g~n~ral and child a nd ad o lescen t psychiatry. They w ill find that th e: clinical vign ettes transform th e AD H D synd ro me a nd the resu its o f its treatment into read ily acc essib le hu ma n experience . Thomas J. Schreiber, M.D. C lin ical Assista nt Profe ssor Unive rsi ty of Med icine and Dent istr y of N ew j ersey Newark
Dissociation in Children and Adolescents . By Frank W Putnam. M .D. New York. Loudon: The GuilfOrd Press. / 997. 42 / pp.. $38.95 (hardcover). Review ing books in thi s field is a he ad y experience . O ne m onth it is a d yn ami c st udy o f ado lesce n t path ology. T h is time it is a d et ailed st u dy of ch ild m altreatrn cnt a nd su b seq uent di sso ciation phenomena. Although d isso ciation W; \S kn own in th e 19th ce n tury through the work of Pierr e j an et. the recogn it ion of [aners "legacy occurs in the midst of a resurgence o f in terest in di ssoc iatio n th at began in th e lat e 1970s" (p, 3) . Sin ce: Frank Putnam wa s a p ioneer in looki ng at these clin ical activi ties and has been a lead er in pursu in g these studies, he is well placed to de scribe them in this closely w ritt en and der ailed text. Buttressin g hi s boo k w it h an o u tsta nd ing ly rich bibliograph y, Dr. Putnam rak es us t h ro ug h both t he hi story an d individual d evelopmen t of th e synd ro m es and sta tes o f th is pathology a nd its relat ion s to th e serio us tr aumati c en vironments of th ese children . T he thoroughn ess o f the te xt matches hi s interest, whi ch h e ex p r~ ss es at times in informal writing along with a certain amo u nt of m orali zing. Remembering the dram at ic rise o f stu d ies o f au tism in the 19 40s an d 19 50 s, o ne is tem p ted to ask, "w he re wer e th ese ch ild ren?" D r. Putnam clarifies so m e o f th e cli nic al and d iagnostic diffi culties and points o u t the ar eas that st ill need and lack stu dy. H is de velopment al ap p ro ac h lead s, w it h o ccasio n al rep et iti ons, to a well-defined p icture of t hese d issociative phenomena occurrin g not un commo n ly in qu ite: yo u ng ch ild ren as well as adolescents. Notabl y he d escribes simi lar nonparhol og ical symptoms and emphasizes th e resilience o f many traum ati zed children . Although the au th o r is at tim es immodest in hi s de scriptive m aterial an d co ncl usio ns, he is carefu l to no te the lim itations of th e rap y. M uc h of wh at he d escr ib es as meth od s esp ec ially ap p ro p ria te 1O th ese: d isorders m ir rors th e wo rk of m an y in th e field o f psych other ap y over the past few de cad es, He is m ost forcefu l in hi s p rescr iptions lor t h e m anner of
792
p lay th er apy a nd o f pl ayro oms. It is a n are a in ch ild psych iatric pr act ice th at fro m time to rime n eed s the rep et it ion that h e o ffers. But whil e disclaim in g his own kn owl edge of family dynami cs. Dr. Putnam includes an excellent chapter o n t:unil y tre atm ent as well as th e: vagaries of o u t-of-ho m e placements. No ti ng the: lack o f soc ietal o rga ni zatio n in th e a rea, the cha p ter is one o f th e m ost ins igh tfu l in the book. It might even bel o n g ea rlier in th e text , especially th e de scriptions of the families whence: th ese ch ild ren co m e: and, often, where they must return and abide. In m an y ways thi s is a wo rk-in -p rog ress. Readers will find that th e extensi ve b ibli ography (o n ly Sigmund is mis sin g) and the detail ed writing of th e clinical de scr iptions, along with appropriat e co ncern for th e requirements o f the "DSMs," ar e su fficie n t to help overlo ok the authoritar ian tone and th e chat ty lap ses. It is a so lid foundat ion for wo rk and study in th is field .
Henry H. Work, M.D. C lin ical Professor Ceo rge town a nd George Was hi ng to n Un iver sit ies Washington, D C
Sexually Aggressive Children: Coming to Understand Them. B)' Sharon Kay Araj i. Anchorage. A K SAGE Publica-
tions. / 997. 256 pp.. $22.95 (soficooer): available in hardcover. Pro fessor Araji's book is abo ut sexu ally agg ressive ch ild ren agrd 12 yea rs and yo u nge r. She has two o bjec tives for her book: "to co llect in o ne place th e availab le published and unpubl ish ed in fo rma tio n abo u t sexua lly agg ressive chi ld ren . . ." and "to expand cu rre nt publications that are primarily descripti ve" (p, xxvi). She u ses "psychol ogical, social psychological and sociological perspectives" for her "compreh en sive explanation" o f these chi ld ren's behavior (p. xxvii). She reviewed more than 22 0 publ icati ons, in ad di tio n to her own yea rs of experience in thi s ar ea, fro m her po stdo ctoral fell ow sh ip at NIMH an d workin g wi th D avid Finkelhor and Murray St raws to her ow n research at University o f Alaska in An ch orage. Th e b o ok sta rts wi t h a th oughtful fo re word b y W .N. Frudrick of the Mayo C linic, in whi ch he spea ks o f eight key issues for u nderstandin g th is population an d appreciating the diversity of sexu ally aggressive children and briefly revi ew s the inRuence of family, d evelopmental tasks, being abused , and the q u al it y of tr eatm ent programs. The book ha s si x cha p te rs and ad d resses different aspect s o f diagnosis, tr eat m ent , social. and legislat ive issues in thi s area. C ha p ter I is devoted to "id ent ifyin g, label in g, an d expl aining" th ese ch ild ren. The lack o f agree m ent o n term inology, n o rm a l an d a b n o r m a l sex ua l devel opm ent. co m pa riso n
J
A:-'I . ACAD . C H I l. D A IHll.ESC PSYC HI ATRY . .\7:7 . J U l.Y 1') ') 8
REVIEWS
Attention-Deficit Hyperactivity Disorder in Adults. By Paul H. Wender, M.D. New York: Oxjord University Press, 1995, 282 pp.. $30.00 (hardcover). Over the course of several decades, Dr. Paul H. Wender has studied the syndrome now known as attention-deficit/ hyperactivity disorder (ADHD). His research began in the days when the syndrome was known as minimal brain dysfunction and has continued into the current, DSM-/Vera. In Attention-Deficit Hyperactivity Disorder in Adults, Dr. Wender summarizes and distills his vast experience with this syndrome into a volume that is succinct , informative, and enjoyable to read . Attention-Deficit Hyperactivity Disorder in Adults is organized into eight chapters and six appendices. Chapter 1 begins by placing the current concept of ADHD in its historical context. This allows the author to set the stage for a description of his group's research into the adult syndrome of ADHD. This research began with Wender's recognition that the parents of many of his child ADHD patients presented childhood histories that were similar to those of their children. Through adulthood, the functioning of many of these adults continued to be compromised by signs and symptoms of the disorder, Chapter 2 contains a clinically rich description of the behaviors and impairments that characterize ADHD in chil dren and adults. This useful presentation goes far beyond a mere listing of descriptive features. Rather, the author focuses on IO dimensions of behavior ranging from attcnt ional difficulties and impulsivity to stress intolerance and response to medication . For each of these characteristics, he describes, in considerable detail, the ways in which childhood ADHD findings persist, attenuate, transmute, and weave themselves into the fabric of adult personality and adaptive functioning. Chapter 3, on the prevalence of ADHD in adults, was less satisfying to me. It seemed long and dry. It summarized material from many studies addressing the epidemiology of ADHD. Although important to the conceptual integrity of the book, this chapter offered the clin ician less relevant informanon. The next chapter, "Etiology," is better. Although also long, and at times dry, this chapter presents much material of interest in understanding the complex genetic and biological factors that underlie what is clearly a multifaceted syndrome. This chapter contains useful reviews of the dopamine and catecholamine systems. It ends with a brief section on the potential future role of molecular genetics in helping to
J. AM . ACAD. CHII.D ADOI. ESC. PSY CHIATRY, .\ 7: 7 . JUI.Y 1998
Assistant Editor: Dean X Parmelee, M.D.
understand the molecular abnormalities underlying various subtypes of ADHD. Chapters 5 , 6, and 7 were, for me, the heart of Dr. Wender's book. Chapters 5 and 6 deal with the diagnosis and treatment of ADHD in adults. Chapter 7 consists of detailed first-person accounts written by four adult patients describing their experiences of living with ADHD and being treated with stimulants. Dr. Wender's study of ADHD began in the early 1970s, and his diagnostic criteria have been refined over the years. The indexes contain some of the rating scales which the Utah group uses in their work. Wender's criteria for diagnosing ADHD in adults are rigorous and require sufficient information about the patient's childhood functioning to ensure that the patient would have met both narrow (DSM-/V) criteria and several broad criteria for the diagnosis in childhood. Then, as an adult, the patient has to retain characteristics of both "persistent motor hyperactivity" and "atrenrional difficulties. " In addition, two of five other inclusion criteria must be met. Exclusion criteria are listed as well. Beyond the listing of criteria, however, the book includes vivid descriptions of the life problems experienced by ADHD adults in their internal , interpersonal, and vocational lives. For those clinicians less experienced in treating ADHD in adults, these descriptions will help them recognize the more subtle forms of hyperactivity, impaired concentration, affective lability, stress intolerance, and the other "broad" criteria. Dr. Wender clearly believes that pharmacological management is the mainstay of treatment for ADHD in adults. His position is that ". . . drug-responsive adult ADHD patients . . . often function better than they ever have in their lives. Long-term treatment of patients responsive to stimulants often produces major changes in scholastic, vocational, and personal functioning" (p. 153). However, the author's presentation makes it clear that his prescription of medication (stimulant and otherwise) occurs in a context of patient education, support, and monitoring. Wender is also well aware of the medicolegal concerns over the long-term prescription of controlled substances. He suggests ways of mitigating these risks for clinicians who expect to treat substantial numbers of adult ADHD patients. Notwithstanding these concerns, when the author uses medications, he does so aggressively, with the recognition that stimulants are rapidly metabolized and that frequent doses are often required. Overall, I found Attention-Deficit Hyperactivity Disorder in Adults to be enjoyable and informative. Especially in the more
791
BO O K REV IEWS
clinical sec tio ns, I o ften fdt as if [ we re listen ing to a lec tu re presented by a n a rt icu la te a nd seaso ned teacher de scribing material with which he wa s intimately famil iar. I would particularly recommend thi s book to residents in both g~n~ral and child a nd ad o lescen t psychiatry. They w ill find that th e: clinical vign ettes transform th e AD H D synd ro me a nd the resu its o f its treatment into read ily acc essib le hu ma n experience . Thomas J. Schreiber, M.D. C lin ical Assista nt Profe ssor Unive rsi ty of Med icine and Dent istr y of N ew j ersey Newark
Dissociation in Children and Adolescents . By Frank W Putnam. M .D. New York. Loudon: The GuilfOrd Press. / 997. 42 / pp.. $38.95 (hardcover). Review ing books in thi s field is a he ad y experience . O ne m onth it is a d yn ami c st udy o f ado lesce n t path ology. T h is time it is a d et ailed st u dy of ch ild m altreatrn cnt a nd su b seq uent di sso ciation phenomena. Although d isso ciation W; \S kn own in th e 19th ce n tury through the work of Pierr e j an et. the recogn it ion of [aners "legacy occurs in the midst of a resurgence o f in terest in di ssoc iatio n th at began in th e lat e 1970s" (p, 3) . Sin ce: Frank Putnam wa s a p ioneer in looki ng at these clin ical activi ties and has been a lead er in pursu in g these studies, he is well placed to de scribe them in this closely w ritt en and der ailed text. Buttressin g hi s boo k w it h an o u tsta nd ing ly rich bibliograph y, Dr. Putnam rak es us t h ro ug h both t he hi story an d individual d evelopmen t of th e synd ro m es and sta tes o f th is pathology a nd its relat ion s to th e serio us tr aumati c en vironments of th ese children . T he thoroughn ess o f the te xt matches hi s interest, whi ch h e ex p r~ ss es at times in informal writing along with a certain amo u nt of m orali zing. Remembering the dram at ic rise o f stu d ies o f au tism in the 19 40s an d 19 50 s, o ne is tem p ted to ask, "w he re wer e th ese ch ild ren?" D r. Putnam clarifies so m e o f th e cli nic al and d iagnostic diffi culties and points o u t the ar eas that st ill need and lack stu dy. H is de velopment al ap p ro ac h lead s, w it h o ccasio n al rep et iti ons, to a well-defined p icture of t hese d issociative phenomena occurrin g not un commo n ly in qu ite: yo u ng ch ild ren as well as adolescents. Notabl y he d escribes simi lar nonparhol og ical symptoms and emphasizes th e resilience o f many traum ati zed children . Although the au th o r is at tim es immodest in hi s de scriptive m aterial an d co ncl usio ns, he is carefu l to no te the lim itations of th e rap y. M uc h of wh at he d escr ib es as meth od s esp ec ially ap p ro p ria te 1O th ese: d isorders m ir rors th e wo rk of m an y in th e field o f psych other ap y over the past few de cad es, He is m ost forcefu l in hi s p rescr iptions lor t h e m anner of
792
p lay th er apy a nd o f pl ayro oms. It is a n are a in ch ild psych iatric pr act ice th at fro m time to rime n eed s the rep et it ion that h e o ffers. But whil e disclaim in g his own kn owl edge of family dynami cs. Dr. Putnam includes an excellent chapter o n t:unil y tre atm ent as well as th e: vagaries of o u t-of-ho m e placements. No ti ng the: lack o f soc ietal o rga ni zatio n in th e a rea, the cha p ter is one o f th e m ost ins igh tfu l in the book. It might even bel o n g ea rlier in th e text , especially th e de scriptions of the families whence: th ese ch ild ren co m e: and, often, where they must return and abide. In m an y ways thi s is a wo rk-in -p rog ress. Readers will find that th e extensi ve b ibli ography (o n ly Sigmund is mis sin g) and the detail ed writing of th e clinical de scr iptions, along with appropriat e co ncern for th e requirements o f the "DSMs," ar e su fficie n t to help overlo ok the authoritar ian tone and th e chat ty lap ses. It is a so lid foundat ion for wo rk and study in th is field .
Henry H. Work, M.D. C lin ical Professor Ceo rge town a nd George Was hi ng to n Un iver sit ies Washington, D C
Sexually Aggressive Children: Coming to Understand Them. B)' Sharon Kay Araj i. Anchorage. A K SAGE Publica-
tions. / 997. 256 pp.. $22.95 (soficooer): available in hardcover. Pro fessor Araji's book is abo ut sexu ally agg ressive ch ild ren agrd 12 yea rs and yo u nge r. She has two o bjec tives for her book: "to co llect in o ne place th e availab le published and unpubl ish ed in fo rma tio n abo u t sexua lly agg ressive chi ld ren . . ." and "to expand cu rre nt publications that are primarily descripti ve" (p, xxvi). She u ses "psychol ogical, social psychological and sociological perspectives" for her "compreh en sive explanation" o f these chi ld ren's behavior (p. xxvii). She reviewed more than 22 0 publ icati ons, in ad di tio n to her own yea rs of experience in thi s ar ea, fro m her po stdo ctoral fell ow sh ip at NIMH an d workin g wi th D avid Finkelhor and Murray St raws to her ow n research at University o f Alaska in An ch orage. Th e b o ok sta rts wi t h a th oughtful fo re word b y W .N. Frudrick of the Mayo C linic, in whi ch he spea ks o f eight key issues for u nderstandin g th is population an d appreciating the diversity of sexu ally aggressive children and briefly revi ew s the inRuence of family, d evelopmental tasks, being abused , and the q u al it y of tr eatm ent programs. The book ha s si x cha p te rs and ad d resses different aspect s o f diagnosis, tr eat m ent , social. and legislat ive issues in thi s area. C ha p ter I is devoted to "id ent ifyin g, label in g, an d expl aining" th ese ch ild ren. The lack o f agree m ent o n term inology, n o rm a l an d a b n o r m a l sex ua l devel opm ent. co m pa riso n
J
A:-'I . ACAD . C H I l. D A IHll.ESC PSYC HI ATRY . .\7:7 . J U l.Y 1') ') 8