Evolution in clinical practice

Clinical practice in North America and the United Kingdom diverged markedly in the 1940s. In North America, the presence of the behavioural manifestations of the syndrome alone was considered sufficient for the diagnosis of minimal brain damage or dysfunction.(!4) Coexisting disorders such as conduct disorder and mental retardation (learning disability) were thought to be manifestations of the syndrome. (!5) In the United Kingdom, clinicians required evidence of documented neuropathology, such as a history of head injury or seizure disorder, (!6) significant behavioural disturbance in multiple settings (pervasive hyperactivity), and the absence of significant comorbid psychopathology, including conduct disorder. In many European countries, clinicians emphasized the need for evidence of neurological dysfunction, along with deficits in attention and motor control. (!7>

These differences in diagnostic practice have had a profound impact on estimates of the prevalence of the disorder and its treatment, initiating a debate about the overinclusiveness of the diagnosis that continues today. (!8) In the United Kingdom, for example, HD was diagnosed in only 0.001 per cent of children during the 1960s,(!9 whereas in North America, ADHD was thought to apply to between 5 and 10 per cent of children.(20) Recent revisions of both North American (DSM-IV)(19 and European (ICD-10)(21 criteria have resulted in a much more unified set of diagnostic criteria, although differences remain (see below for discussion and Table 1).

Table 1 Diagnostic criteria

The most important development in the history of the treatment of AD-HKD occurred in 1937: Bradley's chance discovery(22,) of the beneficial effect of dextroamphetamine on attention and behaviour among children with behavioural problems. The growing awareness of the positive effects of medication, coupled with the waning influence of psychoanalytical theory and practice, resulted in a marked increase in the popularity of the diagnosis.

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