Book Review

Attention Deficit Disorder: The Unfocused Mind in Children and Adults

N Engl J Med 2006; 354:2198-2199May 18, 2006

Article

Attention Deficit Disorder: The Unfocused Mind in Children and Adults
(Yale University Press Health & Wellness.) By Thomas E. Brown. 360 pp. New Haven, Conn., Yale University Press, 2005. $27.50. ISBN: 0-300-10641-6

Brown's book, written for adults and parents of children with attention deficit–hyperactivity disorder (ADHD), addresses controversies concerning the disorder and affirms the human experience of living with ADHD. The use of vignettes and of the words of children, adolescents, and adults clearly illustrates the effect that ADHD has on growth, development, and the quality of life.

In accessible terms, Brown explains the neurobiology that underlies ADHD and describes the scientific research in both neuropsychology and neuroradiology that contributes to our present understanding of ADHD. He captures the developmental problems faced by preschool children and young and middle-aged adults as they adapt to life with an impairment that is often poorly managed. Families will recognize their own struggles in the words of the patients whom Brown presents.

The description of the diagnostic process outlines the recommendations of all professional groups. The cornerstone of the diagnosis is history taking, but Brown also discusses standardized instruments used to collect ratings of behavior. He implies that diagnostic rigor is not possible without the involvement of an experienced clinician, particularly in the suggestion that the threshold for diagnosis and treatment may justifiably be varied for those who do not meet all the diagnostic criteria. The discussion of medication is superb, laced with nuance and evidence. However, in offering only one case description of the simultaneous use of atomoxetine and stimulants and in giving weight to the appropriateness of multiple medications for ADHD and coexisting conditions, Brown assigns a value to treatment that is unsupported by evidence.

The chief shortcoming of the book is its advancement of a new concept of ADHD, which the author calls the “attention deficit disorder syndrome” (ADD). Brown makes the point that patients with many conditions have symptoms of ADD that may well respond to medication and that physicians should not be constrained from the use of a medication that is safe and effective simply because a patient does not have a primary diagnosis of ADHD. Nowhere is this more strongly evident than in the case of children with mental retardation, for whom it is now well documented that treatment for inattention and impulsivity may improve the quality of life. However, Brown's delineation of ADD is not thorough enough to clarify for the general reader how his concept differs from the currently accepted definition of ADHD. The professional reader will want to see more evidence for such a new concept, a level of detail that the intended audience would probably not enjoy. Hence, the new concept of ADHD seems a distraction within an otherwise rich portrayal.

Brown astutely points out that the most radical critics of ADHD do not believe that medicine can alleviate the patient's suffering and that mental health and illness have a spiritual dimension. Therefore, the assault on the diagnosis and treatment of ADHD that the public has witnessed in recent years is not entirely about this disorder but also about a suspicion and mistrust of medicine. Brown's observation provides a very helpful context for young people and families who live with ADHD as they confront the undermining of faith in the medical understanding, diagnosis, and treatment of ADHD.

I would ask the families, young people, medical residents, and students with whom I work in my clinic to read this book. I would likewise invite teachers, social workers, and others who want to learn more about this condition to read it. Those who work with people with ADHD will hear about the nature of the disorder in the true voices of patients themselves — and about the potentially severe consequences associated with the mismanagement of this condition.

Marsha D. Rappley, M.D.
College of Medicine at Michigan State University, East Lansing, MI 48864
rappley@msu.edu

Citing Articles (2)

Citing Articles

1. 1

   Robert M. Hamilton, Eric Rosenthal, Martin Hulpke-Wette, John G. I. Graham, Joseph Sergeant. (2011) Cardiovascular considerations of attention deficit hyperactivity disorder medications: a report of the European Network on Hyperactivity Disorders work group, European Attention Deficit Hyperactivity Disorder Guidelines Group on attention deficit hyperactivity disorder drug safety meeting. Cardiology in the Young1-8
   CrossRef

2. 2

   KENNETH TOWBIN. (2008) Paying Attention to Stimulants. Journal of the American Academy of Child & Adolescent Psychiatry 47:9, 977-980
   CrossRef