The ‘ESSENCE’ of child psychiatry: lumping and splitting ADHD and associated conditions

ADHD and Its Many Associated Problems

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Christopher Gillberg

Edited by: Published by: Oxford University Press ISBN: 978-0-19-993790-5 Retail price: £32.99; $49.95

Christopher Gillberg’s book ‘ADHD and Its Many Associated Problems’ offers a comprehensive overview of the condition as but one of many conditions lumped under the umbrella concept of ESSENCE (Early Symptomatic Syndromes Eliciting Neurodevelopmental Clinical Examinations).

In the 1970s, Professor Gillberg had a leading role in developing a similar concept, deficits in attention, motor control and perception (DAMP), primarily used in Scandinavia. DAMP is essentially a combination of attention-deficit hyperactivity disorder (ADHD) and developmental coordination disorder (DCD), and, according to Gillberg, constitutes a ‘subgroup of the diagnostic category of ADHD’ formerly known as minimal brain disorder (MBD), which represents about half of all cases of ADHD.

The severe form of DAMP is always clinically impairing, and usually leads to children attending at paediatric medical, psychiatric, neurological and/or speech therapy clinics before they reach 10 years of age. It also has severe repercussions in later life, as these children do become adults, heavily affecting on the afflicted person’s environment and quality of life.

Since DAMP was first defined, there has been considerable debate on how best ‘to deal with the conflict between splitting (ADHD plus DCD) and lumping (DAMP) ADHD and its associated conditions’. In this regard, the DAMP concept has recently proved helpful in identifying a group of children with ADHD and multiple needs that would not be self evident if the diagnosis were just ADHD or DCD.

However, in Gillberg’s view, the introduction of the ESSENCE mode of viewing problems related to deviations from normal child development should not be taken as support for lumping, as opposed to splitting, but does suggest the order in which these two aspects of diagnosis should be approached. Indeed, splitting would not be possible if there were nothing to split.

As well as reviewing the history of ADHD, its definitions, symptoms, aetiology, risk and protective factors, approaches to diagnosis and diagnostic work-up, outcomes and associated ESSENCE-related issues, Gillberg provides comprehensive intervention guidelines and highlights the fact that children with a combination of ‘disorders’ have many more problems and autistic-type behaviours than would be expected by merely combining the two separate conditions. He also devotes space to the possible causes of ADHD, albeit with only a very short chapter on genetic factors, although genetic susceptibility, genetic modifiers and very rare Mendelian inheritance are known to be influential.

Nevertheless, Gillberg reports several thorough and fascinating case histories, comprising detailed clinical descriptions of infants, children, adolescents, young adults, older adults and the elderly affected by ADHD and its many co-morbidities. He cites the physician to Catherine II, Empress of Russia, Melchior Adam Weikard, to whom we owe the term ‘attention deficits’, which he reported around 1770. From there he takes us on a journey through the history of medicine in these childhood conditions, complete with the many colourful clinical definitions used to describe ADHD over the centuries (from moral defect to brain injury), including the concept of minimal brain damage, or injury (MBD and MBI), which was introduced towards the end of 1940s and persisted for over 20 years.

Gillberg also illustrates the complexity of reaching a correct diagnosis by masterfully describing the main diagnostic concepts, and providing prevalence data for the various subgroups (from ESSENCE to psychiatric disorders), as well as clinical examples, and clear and plentiful schematics to shed light on each phenotype scenario. All aspects of care – from the first stages of disease, through the sensory (speech, language, reading, writing and dyscalculia) and motor control difficulties, to the mental, psychiatric or neurological ramifications – are discussed, with particular reference to the differential diagnosis criteria, and he points out that a holistic approach should be considered best practice for these patients. He also argues that the required multidisciplinary approaches need careful long-term planning, which can only stem from systematic knowledge and recognition of these conditions in clinical practice.

The book concludes with some valuable recommendations for all the stakeholders in the field, once again illustrating the key concepts with the aid of clinical cases. In our view it is a precious resource for both clinicians and those charged with planning long-term care for patients with a clinical diagnosis of ADHD. Moreover, it will doubtlessly inspire decision-makers to plan innovative approaches for dealing with such children, their families, and their complex and multifaceted needs. Of particular interest in this regard is the chapter on possible interventions, which describes the type of support, familial and social, that ADHD children may require. Indeed, alongside the well-established psychological, pharmacological and pedagogical interventions, motor training, yoga and martial arts are listed, as well as several alternative medicine options.

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Correspondence to Alessandra Ferlini.

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Ferlini, A., Neri, M. ADHD and Its Many Associated Problems. Eur J Hum Genet 24, 151 (2016). https://doi.org/10.1038/ejhg.2015.136

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