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Attention-Deficit/Hyperactivity DisorderReview - Attention-Deficit/Hyperactivity Disorder
A Clinical Guide to Diagnosis and Treatment for Health and Mental Professionals
by Larry B. Silver
American Psychiatric Association, 2003
Review by Ruth Mark
Feb 9th 2005 (Volume 9, Issue 6)

Larry B. Silver's handbook, currently in its third edition, claims to be aimed at "health and mental health professionals." Written in a straightforward, if at times vague language, I'd nevertheless recommend this book to anyone concerned with Attention-Deficit/Hyperactivity Disorder (ADHD). Parents of such children and adolescents will find a wealth of information within the book's pages. They might even find ways to cope with their own inattention/distractibility, hyperactivity and impulsivity (the three cornerstones of ADHD). Silver clearly states that despite the belief that most children outgrow the disorder, approximately 50% take their difficulties into adulthood. Throughout, ADHD is clearly identified as a.) a neurological disorder (the brain is seen to be "wired differently" from a very early age) and b.) that it is a long-duration disorder.

On the whole, this is not a technical book, the author doesn't use a great deal of clinical jargon and when he does he explains it to enable non-medical parents to understand what he's saying. His usage of case studies, examples, anecdotes from his own private clinical practice (he's a child and adolescent psychiatrist in Washington, D.C.) make the book very relevant, accessible and current.

Divided into six principal sections: Introduction and Overview; Diagnosis; Associated Disorders; Treatment; Special Topics; and Conclusions, the author leads his readers deftly through the minefield that is ADHD. There is also a useful resources section and index at the end of the book. Concerned parents would do well to read the entire book and not be tempted to turn immediately to the treatment section. As Silver says himself -- education is crucial. Understanding the underlying reasons behind the presenting behaviors will give vital clues for the clinician to make a diagnosis. This is a book which advocates what I call a Holistic approach -- taking the individual's entire life -- their social skills, family, school, health etc. into account when attempting to diagnose and ultimately treat. Wise words. Each individual is different after all.

Silver blows stereotypes we might have about the disorder out of the water when he advocates awareness, education and being on the alert for controversial therapies. The fourth section on treatment is the longest section in the book and covers everything from the importance of finding the right medication for the client to behavioral therapies, education for schools, parents and relevant others, to controversial therapies (using herbs, vitamins, biofeedback etc.) The author also provides useful tables throughout (although the sheer quantity of DSM-IV-R tables may overwhelm the non-technical reader in the Diagnosis section, they are a nod towards the clinician though they might have been better placed in an index).

Silver highlights several important issues throughout the book namely:

a.)    the fact that ADHD rarely occurs alone but is accompanied by other neurologically-based disorders.

b.)     that the cause of the child's problems needs to be established before a diagnosis can be formulated.

c.)    that ADHD impacts all aspects of the child's life (the problems are not just apparent at school but also seen at home and elsewhere.)

d.)    that medication is recommended to cover all aspects of the child's day and that a mixture of Type 1 and Type 2 drugs might be required for optimal results.

e.)    the fact that the dosage of these drugs cannot be determined on body weight requires a great deal of trial-and-error in order to figure out the correct medication for each individual. Parents and other concerned persons should be made aware of this fact.

f.)      that there are huge individual differences in the behaviors exhibited by a sufferer of ADHD. They can't all be labeled in exactly the same way.

g.)    but labeling is useful when using the law to obtain all the advantages that the client is legally entitled to. This book is heavily American-oriented. People from other countries should be advised (but aren't) to look up the relevant laws in their own countries.

It has to be said that the book is very weak on a few topics -- brain anatomy, cell biology (in particular where/how the drugs prescribed work at a cellular level) and, as a clinician, I felt that this vagueness lets it down. There is for example a growing literature of Biofeedback/Neurofeedback and ADHD, both in America and elsewhere. Silver donates one vague, non-committal paragraph to this therapy and in his enthusiasm for medication at all costs turns his back on these, as he names them, controversial therapies. The jury is not yet out on the issue of Bio-/ Neurofeedback. The author also has a habit of mentioning research but gives few or no names within the text itself and only sometimes does he list which research he is referring to at the end of chapters. This leads to the growing sense of vagueness as you move through the pages. I think he may have been going for readability at the expense of completeness, but using numbers to denote research publications throughout the text doesn't break up its readability and interested readers can, in such a way, be directed to the appropriate, original papers.

To give Silver his due he does say: "I am using poetic license with anatomy and physiology." (pg 122) He also tries to qualify his statements throughout, a practice that introduced doubt into this reader's mind. Research into ADHD is a rapidly expanding field, one which many clinicians have trouble finding the time to keep abreast of, especially if they run busy clinics. Silver does attempt, with this book, to bring all the current relevant information together, his ultimate goal is:

"…that the information in this book helps you to be effective in working with individuals who have ADHD." (pg 228)

The greatest gift this book has to offer in my opinion however can be summed up in the author's words (italics added):

"Unless the total individual is understood and helped, progress might be limited. A complete evaluation should be done." (pg 227)

He also believes in trusting "parents' intuition" (pg 54) and he advocates a multimodal treatment approach. Throughout the book it is clear that Silver cares about young people and their parents who have to live with this disabling condition. I agree with him that education is the single most powerful tool in any ADHD sufferer's arsenal. Parents shouldn't be put off by the book's sub-title, it is actually (in my opinion) written for them.

It should be a standard text in staff rooms of schools and in relevant clinics and general medical practices across the world, with a relevant section on that country's law. Larry B. Silver's book is on the whole a useful edition to the growing literature that is available on ADHD. At the very least it should enhance awareness about this very disabling condition, never a bad thing when you consider that some clinicians and members of the public still doubt its very existence.

 

Link: Publisher's web page for book

 

© 2005 Ruth Mark

 

Ruth Mark is lecturer of neuropsychology at the University of Tilburg in the Netherlands. She specializes in Alzheimer's disease, stroke, epilepsy and other neurological disorders. Her personal website can be viewed at: www.remark.be


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