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The epidemiology of childhood hyperactivity
Electroencephalography and clinical Neurophysiology, 87 ( 1993 ) 167-168
167
#~ 1993 Elsevier Scientific Publishers lreland, Ltd. 0013-4694/93/$06.00
B o o k Reviews
Edited by E. Niedermeyer and P.M. Rossini Neurobehavioral problems in epilepsy. Advances in Neurology, Vol. 55. - D.B. Smith, D.M. Treiman and M.R. Trimble (Eds.) (Raven Press, New York, 1991, 496 p., Price: US $142.00)
Because numerous disciplines have associated epilepsy with disturbed behavior, a group of international experts in various fields were invited to present their views. The resultant treatise, divided into 5 sections with 29 different topics, is a fascinating collection of opinions of leaders in the field of epileptology. The first chapter on the neurophysiological basis of ictal behavioral changes, written by Dr. P. Gloor, discusses the extensive investigations of Penfield and his associates. He e n u m e r a t e s the responses evoked from surface and depth electrical excitation of the brain. These include various perceptual phenomena, confusional states and automatisms. Gloor believes that many of the perceptual, mnemonic and affective p h e n o m e n a elicited by temporal lobe excitation resemble everyday experiences as contrasted to the crude motor and sensory responses obtained by stimulation of the central gyri. These responses, he believes, result from activation of cortex involved in such processes normally, although he admits that this view is not shared by all investigators. In the following chapters of this section, Drs. Meldrum and Reynolds discuss the neurochemical alterations producing behavioral disturbances. That these may be the result of temporal lobe maldevelopment is propounded by Dr. Scheibel. The concluding paper is a discussion of temporal lobe dysfunction in various psychotic states - a subject which Dr. Stevens has emphasized in the past. The second section attempts the difficult task of assessing the role of epilepsy in misbehavior. Much of the discussion deals with epilepsy-induced behavior - a subject which Dr. Blumer takes up in the last paper of the section. Dr. Bennie and her associates noted in the records of epileptic patients, the frequent occurrence of subclinical spiking with "transitory cognitive impairment" in only 50% of the cases. In some epileptic patients when their behavior was unruly, the previously abnormal electroencephalogram became less dysrhythmic. Dr. P. Wolf of G e r m a n y discussed this state of "forced normalization." Such alternating psychosis and sanity was well known to attendants at mental hospitals who recognized that a known epileptic person was about to have a convulsion as he was becoming mean. The third section deals with the side reactions of anti-epileptic drugs upon behavior. The concluding two chapters discuss the behavioral changes after surgical procedures on the temporal lobe and corpus callosum. The fourth section, on behavioral syndromes of various types of epilepsy, should be of particular interest of electroencephalographers. Dr. H.-G. Wieser depicts in graphic form, the multiple clinical manifestations and the progression or march of temporal lobe attacks. More than half of the analyzed seizures remained unilateral; contralateral propagation occurred when the initial hemispbera[ activity had reached a certain but large critical mass. Such propagation was solely to the contralateral hippocampal formation in 77% of cases, but involved other contralateral sites in 95% of cases. The most common evoked response was arrest (9%) and the rarest, a recollection, dfijh vu or dreamy state (1%). Of 1665 stimulations, complex psychic p h e n o m e n a were elicited only on 17 occasions. Dr. Treiman critically analyzes the occurrences of violence in epileptic
attacks, concluding that it is very rare in persons with epilepsy, even of temporal lobe origin. The most common of the ictal amnestic and fugue states, transient global amnesia, Drs. Rowan and Rosenbaum believe is associated with a number of etiological or co-incidental conditions such as epilepsy, cerebrovascular disease, cerebral neoplasm, etc. Dr. T h o m p s o n discussed factors responsible for an embarrassing failure of memory in some patients upon developing epilepsy. In a detailed chapter, Halgren and associates at Los Angeles analyzed the medial temporal lobe seizure activity and memory aberrations using PET and E E G depth recording during psychological testing. Based on their findings, the authors concluded that "seizures hyperengage the same cells that are needed for ordinary memory." Dr. Benson discussed the medial temporal lobe dysfunction which was described by Gastaut and associates in the '50s, elaborated by Blumer in the '60s and slightly modified by Geschwind and associates in the "70s. Although Blumer and others atlempted to reconcile these alterations with those of the primate Kltiver-Bucy syndrome, not all investigators concurred. Even its designation as a syndrome would appear to be tenuous. In the fifth section, Berent analyzed the psychological testing of patients, and Mattson, the relationship of emotions to seizures. In the final chapter, J. G u n n of London, England, contrasted American and British legal reactions to problems related to epilepsy. Although written for and deserving to be in the library of every practicing neurologist and neurosurgeon, this book would be a useful and comprehensive reference source for professional and technical electroencephalographers to consult in the elucidation of behavioral problems in epilepsy. A.E. Walker, M.D.
Albuquerque. NM (USA) The epidemiology of childhood hyperactivity. - E. Taylor, S. Sandberg, G. Thorley and S. Giles (Oxford University Press, Oxford, 1991, 158 p., Price: US $46.75)
This research monograph is the 33rd volume of the Maudsley Monograph series summarizing work of the Institute of Psychiatry in London. Professor Taylor and colleagues have tackled the confusing and controversial overlapping relationships of childhood hyperactivity, antisocial conduct and disordered attention. They have approached the issue from a rigorous, data rich, epidemiological perspective with clear operational definition of clinical symptoms and subgroupings of children. The monograph describes a 2-stage epidemiological study of 2462 6- and 7-year-old boys in a geographically defined region of East London, an area the authors describe as a "stressed urban community." The sample comprised 77% of the boys of eligible age in the community and hence should not be encumbered by ascertainment bias as is the case in any referral p o p u l a t i o n An initial screening stage using parent and teacher questionnaires suggested that statistically distinct groups with " p u r e hyperactivity" (N = 91) and "pure conduct disorder" (N = 349) could be defined on the basis of reported symptoms. As would be expected, an overlabping "mixed hyperactivity and conduct disorder" group (N = 128) was also present.
168
BOOK REVIEWS
As a second stage, subgroups were selected for more intensive clinical study: pure hyperactivity, pure conduct disorder, mixed hyperactivity and conduct disorder, and a normal control group. The more detailed evaluations of these groups and their resulting characteristics and comparisons form the basis for most of the monograph. The authors demonstrate that a tightly defined "hyperkinetic disorder" exists with clear neuropsychological dysfunction. These children are more likely than controls or other clinical groups to have a history of perinatal problems, early language delay and early behavior problems. As a group they had lower IQ, were inattentive and reading delayed. The prevalence of this "hyperkinetic disorder" in the community studied was 1.72/100 6- and 7-year-old boys. By contrast, non-hyperactive boys with "'conduct disorder" had families with higher degrees of marital discord and antisocial conduct. However, the group had less perinatal difficulties, low IQ and early delay. Thus, the authors argue, "hyperkinetic disorder" appears to have a strong constitutional or neurodevelopmental basis whereas "conduct disorder" is more likely to be environmentally induced. The children with features of both disorders likely represent a complex interaction of both constitutional and family environmental factors. The monograph is thorough in its research description yet quite readable. Individual chapters describe separate aspects of the research. Each chapter attempts to suggest directions for future research based on the study's findings. With aid from an initial "Outline and Summary" chapter, most single chapters stand alone as research papers, not requiring detailed reading of the entire monograph. A "Discussion" chapter concludes the volume and addresses practical aspects of definition, diagnosis, treatment and biological mechanism. Overall the monograph concisely summarizes an extensive, rigorous epidemiological study while thoughtfully discussing its relationship to existing research, its potential contributions to clinical practice and to understanding of neurobiological mechanisms of hyperactivity. For example, a clear contrast is made between hyperactivity as an extreme on a continuous temperamental dimension and hyperactivity as a specific neurobiological disorder. The authors suggest their data supports both interpretations with the more severely hyperactive boys representing a distinct syndrome of neurodevelopmental impairment. The monograph is highly recommended for anyone with an academic interest in hyperactivity and related disorder. Its value lies in the important research summarized but also in the careful discussion of the studies' implications. F.B. Palmer
Developmental Pediatrics, Kennedy Krieger Institute, Johns Hopkins Hospital, Baltimore, MD (USA) Neuropsychologieal foundations of learning disabilities. - J.E. Obrzut and G.W. Hynd (Eds.) (Academic Press, Harcourt, Brace Jovanovich Publishers, San Diego, CA, 1991, 832 p., Price: US $155.00) This text, comprising 27 chapters, lives up to the comments noted in the preface - "a comprehensive summary of recent advances made in the neuropsychology of learning disabilities with regard to theory, diagnosis, and remediation." It addresses the neurobiological basis of learning disabilities, updating the recent theories and practice in the field. The contributors are well known and highly regarded experts representing neurology, psychiatry, genetics, development, education, audiology and speech pathology. While it is aimed for students at the graduate level, its contents are presented in a
comprehensible fashion with technical matters thoroughly explained. This text has a wide use both practically and theoretically for those professionals and students who are involved with children having learning problems representing central nervous system dysfunction. The wide heterogeneity of presentations of learning problems is especially highlighted. With federal legislation (Public Law 94-142 of 1975 and 99-547 of 1986) mandating the multidisciplinary approach to identification, evaluation, diagnosis and implementation of individual education programs for every child with a developmental disability, this book serves as a valuable resource for the disciplines who are a part of the neuroscience consortium addressing etiologies, as well as management. This volume is divided into 3 parts with part I covering the "'foundations and theoretical issues on the neuropsychology of learning disabilities," part I1 addressing "methodologies and assessment techniques in the diagnosis of learning disabilities," and part 111 highlighting the "neuropsychological syndromes and practice in learning disabilities." The chapters in part I include thc biological foundations of learning disabilities, updating the neurological background of them. They include developmental syndrome investigations (Duane); genetical basis of developmental dyslexia with an update of the current knowledge regarding genetic linkage (Lubs); critical review with definitional and assessment issues of learning disabilities addressed (Morrison and Siegel): with other chapters dealing with childhood psychology, demonstrating the relationships between academic underachievement and psychopathology (Nieves); and a chapter covering the cognitive models of developmental reading disorders (Chase and Tallal). Part II includes 8 chapters highlighting the methodologies and assessment techniques in the diagnosis of learning disabilities. Chapter presentations include the use of discretionary formulas in assessing learning disabilities (Heath and Kush); neuropsychological assessment of learning disabilities in children (Batchelor and Dean), as well as in adolescence and young adults (O'Donnell); chapters devoted to the neuropsychological subtypes of learning disabilities (Newby and Lyon) and the psychological prediction of learning disabilities (Felton and Brown): another chapter is devoted to brain imaging (Hynd, Semrud-Clikeman and Lyytinen) presenting the neurobiological theory utilizing neuroimaging studies, along with the brain electrical activity mapping (BEAM). Part III includes the remaining 10 chapters with this section devoted to the neuropsychological syndromes and practice in learning disabilities. The nature and diagnosis of reading disorders (Aaron and Simurdak) is presented; chapters are devoted to specific mathematics disorders (Keller and Sutton) and speech and language disorders (Stark, Montgomery and Windsor), giving definitions of language impairment; a chapter devoted to the remediation of reading disabilities (Wise and Olson). Also, the academic interventions with learning disabled children (Bos and VanReusen) is presented with a final chapter highlighting the relevance and neuropsychological data to learning disabilities (Hiscock and Hiscock). This volume will serve as an excellent resource and should be readily available for those professionals interested in the learning disabilities spectrum. Its subtitle seems most appropriate: "a handbook of issues, methods and practices." A.J. Capute
Department of Pediatrics, Kennedy Krieger Institute, Johns Hopkins Unicersity, Baltimore, MD (USA)
167
#~ 1993 Elsevier Scientific Publishers lreland, Ltd. 0013-4694/93/$06.00
B o o k Reviews
Edited by E. Niedermeyer and P.M. Rossini Neurobehavioral problems in epilepsy. Advances in Neurology, Vol. 55. - D.B. Smith, D.M. Treiman and M.R. Trimble (Eds.) (Raven Press, New York, 1991, 496 p., Price: US $142.00)
Because numerous disciplines have associated epilepsy with disturbed behavior, a group of international experts in various fields were invited to present their views. The resultant treatise, divided into 5 sections with 29 different topics, is a fascinating collection of opinions of leaders in the field of epileptology. The first chapter on the neurophysiological basis of ictal behavioral changes, written by Dr. P. Gloor, discusses the extensive investigations of Penfield and his associates. He e n u m e r a t e s the responses evoked from surface and depth electrical excitation of the brain. These include various perceptual phenomena, confusional states and automatisms. Gloor believes that many of the perceptual, mnemonic and affective p h e n o m e n a elicited by temporal lobe excitation resemble everyday experiences as contrasted to the crude motor and sensory responses obtained by stimulation of the central gyri. These responses, he believes, result from activation of cortex involved in such processes normally, although he admits that this view is not shared by all investigators. In the following chapters of this section, Drs. Meldrum and Reynolds discuss the neurochemical alterations producing behavioral disturbances. That these may be the result of temporal lobe maldevelopment is propounded by Dr. Scheibel. The concluding paper is a discussion of temporal lobe dysfunction in various psychotic states - a subject which Dr. Stevens has emphasized in the past. The second section attempts the difficult task of assessing the role of epilepsy in misbehavior. Much of the discussion deals with epilepsy-induced behavior - a subject which Dr. Blumer takes up in the last paper of the section. Dr. Bennie and her associates noted in the records of epileptic patients, the frequent occurrence of subclinical spiking with "transitory cognitive impairment" in only 50% of the cases. In some epileptic patients when their behavior was unruly, the previously abnormal electroencephalogram became less dysrhythmic. Dr. P. Wolf of G e r m a n y discussed this state of "forced normalization." Such alternating psychosis and sanity was well known to attendants at mental hospitals who recognized that a known epileptic person was about to have a convulsion as he was becoming mean. The third section deals with the side reactions of anti-epileptic drugs upon behavior. The concluding two chapters discuss the behavioral changes after surgical procedures on the temporal lobe and corpus callosum. The fourth section, on behavioral syndromes of various types of epilepsy, should be of particular interest of electroencephalographers. Dr. H.-G. Wieser depicts in graphic form, the multiple clinical manifestations and the progression or march of temporal lobe attacks. More than half of the analyzed seizures remained unilateral; contralateral propagation occurred when the initial hemispbera[ activity had reached a certain but large critical mass. Such propagation was solely to the contralateral hippocampal formation in 77% of cases, but involved other contralateral sites in 95% of cases. The most common evoked response was arrest (9%) and the rarest, a recollection, dfijh vu or dreamy state (1%). Of 1665 stimulations, complex psychic p h e n o m e n a were elicited only on 17 occasions. Dr. Treiman critically analyzes the occurrences of violence in epileptic
attacks, concluding that it is very rare in persons with epilepsy, even of temporal lobe origin. The most common of the ictal amnestic and fugue states, transient global amnesia, Drs. Rowan and Rosenbaum believe is associated with a number of etiological or co-incidental conditions such as epilepsy, cerebrovascular disease, cerebral neoplasm, etc. Dr. T h o m p s o n discussed factors responsible for an embarrassing failure of memory in some patients upon developing epilepsy. In a detailed chapter, Halgren and associates at Los Angeles analyzed the medial temporal lobe seizure activity and memory aberrations using PET and E E G depth recording during psychological testing. Based on their findings, the authors concluded that "seizures hyperengage the same cells that are needed for ordinary memory." Dr. Benson discussed the medial temporal lobe dysfunction which was described by Gastaut and associates in the '50s, elaborated by Blumer in the '60s and slightly modified by Geschwind and associates in the "70s. Although Blumer and others atlempted to reconcile these alterations with those of the primate Kltiver-Bucy syndrome, not all investigators concurred. Even its designation as a syndrome would appear to be tenuous. In the fifth section, Berent analyzed the psychological testing of patients, and Mattson, the relationship of emotions to seizures. In the final chapter, J. G u n n of London, England, contrasted American and British legal reactions to problems related to epilepsy. Although written for and deserving to be in the library of every practicing neurologist and neurosurgeon, this book would be a useful and comprehensive reference source for professional and technical electroencephalographers to consult in the elucidation of behavioral problems in epilepsy. A.E. Walker, M.D.
Albuquerque. NM (USA) The epidemiology of childhood hyperactivity. - E. Taylor, S. Sandberg, G. Thorley and S. Giles (Oxford University Press, Oxford, 1991, 158 p., Price: US $46.75)
This research monograph is the 33rd volume of the Maudsley Monograph series summarizing work of the Institute of Psychiatry in London. Professor Taylor and colleagues have tackled the confusing and controversial overlapping relationships of childhood hyperactivity, antisocial conduct and disordered attention. They have approached the issue from a rigorous, data rich, epidemiological perspective with clear operational definition of clinical symptoms and subgroupings of children. The monograph describes a 2-stage epidemiological study of 2462 6- and 7-year-old boys in a geographically defined region of East London, an area the authors describe as a "stressed urban community." The sample comprised 77% of the boys of eligible age in the community and hence should not be encumbered by ascertainment bias as is the case in any referral p o p u l a t i o n An initial screening stage using parent and teacher questionnaires suggested that statistically distinct groups with " p u r e hyperactivity" (N = 91) and "pure conduct disorder" (N = 349) could be defined on the basis of reported symptoms. As would be expected, an overlabping "mixed hyperactivity and conduct disorder" group (N = 128) was also present.
168
BOOK REVIEWS
As a second stage, subgroups were selected for more intensive clinical study: pure hyperactivity, pure conduct disorder, mixed hyperactivity and conduct disorder, and a normal control group. The more detailed evaluations of these groups and their resulting characteristics and comparisons form the basis for most of the monograph. The authors demonstrate that a tightly defined "hyperkinetic disorder" exists with clear neuropsychological dysfunction. These children are more likely than controls or other clinical groups to have a history of perinatal problems, early language delay and early behavior problems. As a group they had lower IQ, were inattentive and reading delayed. The prevalence of this "hyperkinetic disorder" in the community studied was 1.72/100 6- and 7-year-old boys. By contrast, non-hyperactive boys with "'conduct disorder" had families with higher degrees of marital discord and antisocial conduct. However, the group had less perinatal difficulties, low IQ and early delay. Thus, the authors argue, "hyperkinetic disorder" appears to have a strong constitutional or neurodevelopmental basis whereas "conduct disorder" is more likely to be environmentally induced. The children with features of both disorders likely represent a complex interaction of both constitutional and family environmental factors. The monograph is thorough in its research description yet quite readable. Individual chapters describe separate aspects of the research. Each chapter attempts to suggest directions for future research based on the study's findings. With aid from an initial "Outline and Summary" chapter, most single chapters stand alone as research papers, not requiring detailed reading of the entire monograph. A "Discussion" chapter concludes the volume and addresses practical aspects of definition, diagnosis, treatment and biological mechanism. Overall the monograph concisely summarizes an extensive, rigorous epidemiological study while thoughtfully discussing its relationship to existing research, its potential contributions to clinical practice and to understanding of neurobiological mechanisms of hyperactivity. For example, a clear contrast is made between hyperactivity as an extreme on a continuous temperamental dimension and hyperactivity as a specific neurobiological disorder. The authors suggest their data supports both interpretations with the more severely hyperactive boys representing a distinct syndrome of neurodevelopmental impairment. The monograph is highly recommended for anyone with an academic interest in hyperactivity and related disorder. Its value lies in the important research summarized but also in the careful discussion of the studies' implications. F.B. Palmer
Developmental Pediatrics, Kennedy Krieger Institute, Johns Hopkins Hospital, Baltimore, MD (USA) Neuropsychologieal foundations of learning disabilities. - J.E. Obrzut and G.W. Hynd (Eds.) (Academic Press, Harcourt, Brace Jovanovich Publishers, San Diego, CA, 1991, 832 p., Price: US $155.00) This text, comprising 27 chapters, lives up to the comments noted in the preface - "a comprehensive summary of recent advances made in the neuropsychology of learning disabilities with regard to theory, diagnosis, and remediation." It addresses the neurobiological basis of learning disabilities, updating the recent theories and practice in the field. The contributors are well known and highly regarded experts representing neurology, psychiatry, genetics, development, education, audiology and speech pathology. While it is aimed for students at the graduate level, its contents are presented in a
comprehensible fashion with technical matters thoroughly explained. This text has a wide use both practically and theoretically for those professionals and students who are involved with children having learning problems representing central nervous system dysfunction. The wide heterogeneity of presentations of learning problems is especially highlighted. With federal legislation (Public Law 94-142 of 1975 and 99-547 of 1986) mandating the multidisciplinary approach to identification, evaluation, diagnosis and implementation of individual education programs for every child with a developmental disability, this book serves as a valuable resource for the disciplines who are a part of the neuroscience consortium addressing etiologies, as well as management. This volume is divided into 3 parts with part I covering the "'foundations and theoretical issues on the neuropsychology of learning disabilities," part I1 addressing "methodologies and assessment techniques in the diagnosis of learning disabilities," and part 111 highlighting the "neuropsychological syndromes and practice in learning disabilities." The chapters in part I include thc biological foundations of learning disabilities, updating the neurological background of them. They include developmental syndrome investigations (Duane); genetical basis of developmental dyslexia with an update of the current knowledge regarding genetic linkage (Lubs); critical review with definitional and assessment issues of learning disabilities addressed (Morrison and Siegel): with other chapters dealing with childhood psychology, demonstrating the relationships between academic underachievement and psychopathology (Nieves); and a chapter covering the cognitive models of developmental reading disorders (Chase and Tallal). Part II includes 8 chapters highlighting the methodologies and assessment techniques in the diagnosis of learning disabilities. Chapter presentations include the use of discretionary formulas in assessing learning disabilities (Heath and Kush); neuropsychological assessment of learning disabilities in children (Batchelor and Dean), as well as in adolescence and young adults (O'Donnell); chapters devoted to the neuropsychological subtypes of learning disabilities (Newby and Lyon) and the psychological prediction of learning disabilities (Felton and Brown): another chapter is devoted to brain imaging (Hynd, Semrud-Clikeman and Lyytinen) presenting the neurobiological theory utilizing neuroimaging studies, along with the brain electrical activity mapping (BEAM). Part III includes the remaining 10 chapters with this section devoted to the neuropsychological syndromes and practice in learning disabilities. The nature and diagnosis of reading disorders (Aaron and Simurdak) is presented; chapters are devoted to specific mathematics disorders (Keller and Sutton) and speech and language disorders (Stark, Montgomery and Windsor), giving definitions of language impairment; a chapter devoted to the remediation of reading disabilities (Wise and Olson). Also, the academic interventions with learning disabled children (Bos and VanReusen) is presented with a final chapter highlighting the relevance and neuropsychological data to learning disabilities (Hiscock and Hiscock). This volume will serve as an excellent resource and should be readily available for those professionals interested in the learning disabilities spectrum. Its subtitle seems most appropriate: "a handbook of issues, methods and practices." A.J. Capute
Department of Pediatrics, Kennedy Krieger Institute, Johns Hopkins Unicersity, Baltimore, MD (USA)