The purpose of the present paper is to (1) provide an overview of the nature of attention-deficit hyperactivity disorder (ADHD) as it seems to be viewed by North American clinicians and clinical scientists; (2) describe its diagnostic criteria as they are applied in that region; (3) discuss the prevalence of ADHD in the region; and (4) briefly present a new theoretical model of the authors emerging from that North American perspective. Some of the critical issues related to these matters will be raised along the way. Given the thousands of scientific papers on this topic, however, an overview of these various topics is all that space here can afford. Readers wishing a more thorough treatment of these topics as well as those pertaining to history, developmental courses, associated risks, assessment, and treatments for ADHD are directed to other writings by the author (Barkley, 1990).

Many different reasons may account for the well documented relationship between attention deficit hyperactivity disorder and learning difficulties. Longitudinal Australian data support the earlier occurrence of behaviour problems than reading problems, especially for boys. Language, motivation, and biological mechanisms, and combinations of these factors, may contribute to this association. Current emphasis must be placed on early intervention for behaviour problems, assessment of LDs which are suspected by the Grade 2 or 7-year-old level, and a long-term perspective on the management of both conditions.

There is a pressing need for the development of effective early family intervention programs for children showing Attention Deficit Hyperactivity Disorder (ADHD) behaviours with Conduct Disorder (CD) or Oppositional Defiant Disorder (ODD) behaviours. Previous research has indicated that children with ADHD are at high risk of developing comorbid CD or ODD behaviours. In addition, it has been shown that ODD or CD behaviours in childhood tend to persist and to have adverse effects on later social adjustment. However, ODD or CD behaviours are not necessary concomitants of ADHD, and it has been demonstrated that behavioural intervention can have both short- and long-term beneficial effects for children showing early signs of ODD or CD behaviours. In the short term, behavioural family interventions may be able to reduce oppositional behaviour, particularly in the preschool years. In the long term, early intervention has been shown to reduce the incidence of later antisocial behaviour in children at risk for this developmental trajectory. In this paper, it will be argued that behavioural family interventions have not been effectively utilised or promulgated in the community for children with ADHD despite the demonstrated efficacy of these types of interventons. A model of a multilevel system of intervention that can be tailored to the individual family's needs is presented.

Nine children meeting DSM-III-R criteria for Attention Deficit Hyperactivity Disorder (ADHD) and eighteen normal children participated in this study. A screening assessment revealed significantly more behavioural and academic problems in the ADHD group. Subjects performed a low demand visual vigilance task (the reference task) and the AX version of the continuous perfonnance task (CPT), while the steady-state visually evoked potential (SSVEP) was continuously recorded from 64 scalp electrode sites. The topography of the SSVEP amplitude difference between the reference and AX tasks was examined. In the 3.5 second interval between the appearances of the “A” and the “X” normal children showed transient reductions in right prefrontal SSVEP amplitude and a sustained reduction in right parieto-occipital SSVEP amplitude. These reductions in SSVEP amplitude were not seen in ADHD subjects. These results suggest that the presentation of a priming stimulus is associated with increased activation of right prefrontal and parieto-occipital regions in normal children, whereas the absence of this pattern of activation suggests a deficit in these processes in ADHD.

This paper reviews some issues related to the doubts and complexities involved in diagnosis and treatment of Attention Deficit Hyperactivity Disorder. While some writers claim that it is clear that all children presenting with ADHD should be treated by pharmacological means, there are associated risks and politics. However, in the absence of well-established and research-supported alternative understandings of the etiology and treatment of the disorder, many practitioners feel unable to offer a useful service. Resulting frustrations have lead some parents to form their own support networks, which make strong demands for increased services. More creative and innovative therapeutic interventions focusing on the broader impact of ADHD must be developed to deal with this disorder.

The last five years in Australia have been marked by an explosion in the diagnosis and treatment of Attention Deficit Hyperactivity Disorder (ADHD). The use of stimulant medication for ADHD has increased exponentially across all states, raising questions about the appropriate role of drug treatment and its relationship to other therapies in these children. Despite widespread consensus that multimodal therapy is the preferred option for intervention, many treatments advocated for ADHD lack scientific evidence to support their use. Because no two children with ADHD or their families are the same, an individualised approach to management is advocated that targets both the primary symptoms of the disorder, its cornorbid pathology, and the secondary problems that have developed. Evidence indicates that stimulant medication used in conjunction with parent training, family support, and school based behaviour modification offers the best prospects for improving the disturbing long-term prognosis in these children.

The State Child Development Centre (SCDC) of Western Australia has been involved in the assessment and management of children with attention deficit hyperactivity disorders over the past twenty years. It is a Centre committed to the multimodal interdisciplinary approach to this and related developmental problems. Incorporated in this approach is the recognition that medication is likely to be an essential component in order to facilitate other measures being effective for a majority of children with well established attentional disorders. However, the Centre recognises that the concept of ADHD is not adequate to explain all the developmental problems of children, An alternative conceptualisation of ADHD as multiple stimuli disorganisation syndrome (MSDS) is proposed.

Diagnostic issues in ADHD are examined from two perspectives. Firstly the long-term outcome of ADHD is one indicator of predictive validity of the concept and of its importance. At the same time, the role of comorbid conditions is fundamental to the prognosis of children with ADHD and emphasises the need for thorough assessment and careful differential diagnosis. The range of adult sequelae of ADHD is so broad as to have major implications for the delineation of adult ADHD, and suggestions are made as to how it cannot just be seen as a direct translation of the childhood symptoms. Given the high genetic component to ADHD, our work in ATAP (the Australian Twin ADHD Project) is used to examine three issues in the diagnosis of ADHD, namely that it is inherited as a behavioural dimension, not as a discrete category that there is some genetic and behavioural independence of the Hyperactivity-Impulsivity and Inattention symptom clusters, and that ADHD should not be seen as a consequence of learning problems (or the reverse). Because the concept of ADHD has undergone so many revisions since 1980, there remains much scope for input to a more definitive formulation with particular reference to age and gender differences.

The final session of the Scientific Retreat on ADHD held by the CEDP at The University of Melbourne on September 1, 1995 was a roundtable discussion aimedat arriving at a consensus statement on issues related to ADHD in Australia. Dr Russell Barkley actedas devil's advocate and facilitator. Discussion was lively and wide ranging, but agreement was not always easy to achieve. Discussion topics ranged across its legitimate status as a disorder, its comorbid risks, its genetic and environmental aetiology, its prevalence and associated gender criteria, its multiprofessional diagnosis and psychological and behavioural assessment, treatment efficacy, andimportant Australian issues still to be addressed. Some major areas of agreement between the delegates, emerging trends, and foci of further investigation have been synthesised from a transcript of the final session.