J.H.K.C. Psych. (1993) 3, Spl, 17-21

ORIGINAL PAPER

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TERMINOLOGIES

Hyperkinetic Syndrome of childhood, called the Hyperkinetic disorder CT.C.D.10) in the United Kingdom (W.H.0., 1990) or the Attention Deficit Hyperactivity Disorder in the States (American Psychiatric Association, 1987), is not an unique problem in the West.. It was at one time called the 'Minimal Brain Dysfunction' (Strauss & Lebtiner, 1974), a term Chinese psychiatrists used until recently (Shen, Wang & Yang, 1985). Besides overactivity, the syndrome is also characterised by a deficient attention span and impulsivity (Garfinkel, 1986).

CLINICAL EPIDEMIOLOGY

PREVALENCE

The prevalence of this syndrome in U.K. clinics was 1to 2% of children, but tl1e rate in the community would be much higher, as much as 5 to 10% (Rutter, Tizard & Whitmore, 1970). The variation was partly due to differences in the diagnostic criteria, especially the inclusion of children with conduct disorder as hyperkinetic (Greenberg & Lipmann, 1971; Stewa1t et al, 1981). One note of caution is that the high rate detected by the above study could be an indication of behavioural deviance only and not of exact clinical diagnosis. In fact Taylor (1991), using a two-stage design, rep01ted a much lowered prevalence rate of 1.7%.

In Hong Kong, the prevalence of a psychiatric clinic was 2.1% (Luk & Lleh-Mak, 1985). In the community, tl1e rate among p1imary school children was 5.2% (Luk, 1989), using the Conners' Teacher's Rating Scale (Conners, 1969), which was similar to 5.8% of primary school children in Beijing, China (Shen, Wang & Yang, 1985). Another study of 718 p1imary two to four in a local school, using the Rutter's A2 & B2 scales and a battery of probing questions (Wong & Lau, 1992), gave a 3% hyperkinetic syndrome witl1 an additional 1% with hyperkinetic conduct disorder. All the above studies among the Chinese children showed a predominance of boys over girls. Furthermore, students up to the age of 13 also exhibited marked symptoms of hyperactivity (Luk, 1989). In ce1tain sense, the rate reflects the culture's tolerance of such hyperactive behaviour in the children. For the Chinese people, tl1ey tend to have a more suppressive attitude towards motor activity, but an unwillingness to seek medical help unless the condition becomes serious.

The exact age of onset is not clear cut, but the common presenting ages is from 7 to 11(Gelder, Gath & Mayou, 1983).

DETERMINANTS

The exact cause of this disorder is not known, and the various rates reflect the use of different diagnostic criteria or even concept of this syndrome. “Various theories have been put forward, including genetic (Biederman et al, 1990; Wender, 1971; Monison & Stewart, 1971), trauma (Streissguth et al, 1984), neurotoxins especially lead, maternal smoking and drinking (David, Hoffman & Syerd, 1977), diet especially food additives and preservatives (Varley, 1984; Feingold, 1975), florescent lighting (O'Leary, Rosenbaum & Hughes, 1978), etc. The most. probable cause is a genetic predisposition with disrupted metabolism of neuro-transmitters, especially in the pre frontal areas and the limbic system (Shaywiiz et al, 1983; Zametkin & Rapoport, 1986; Lou et al, 1989).

Though T12ard & Hodges (1978) found that the disorder was disproportionately common in institutionalised children, Barkley (1990) concluded that there is no evidence to support that the cause is due purely to social or environmental factors such as poverty, family chaos, or poor management of child.

TREATMENT AND PREVENTION

So far, treatment for this syndrome is more symptomatic tl1an curative. Fortunately, as the brain matures with age, some of tl1e symptoms would also improve. The main emphasis is in the treatment of both the core symptoms of hyperactivity and the associated symptoms such as learning problem, motor coordination, language problems. The current method of choice is pharmacotherapy, supplemented by psychotherapy (Greenhill, 1989). Drug treatment consists mainly the use of amphetamine-like psycho-stimulants such as methyphenidate and pemoline (Dulcan, 1985; Abikoff & Gittelman, 1985) which were useful not only to curtail the symptoms (Klorman et al, 1990), but to improve academic and social behaviour (Pelham et al, 1985), including aggression (Ceadow, et al, 1990). As regard psychotherapy, the most. useful method involves some behavioral modification techniques (Pelham, 1986). TI1ese measures are often supplemented by social skill training and remedial teaching of the handicapped children, and involving the parents (Horn et al, 1991). In Hong Kong, besides medical treatment, tl1ere are some psychiatric day centres under the Hospital Authority which offered specific individual cognitive-behavioural therapy and dyad training for the patients and tl1eir parents.

In certain sense, the above irea1ment especially in the prevention of comorbidity such as conduct disorder can be considered secondary prevention. As the exact cause is not known, no p1imary prevention is possible. The advocation in the early 1980s of special dieting (the Feingold diet), without any artificial food additives, is already out of fashion (Biederman et al 1990· Conners, 1980). Instead there are reports of over-dieting result ing in malnutrition. One real possibility of lowering this incidence is to the improvement of obstetric care and to discourage smoking and drinking during pregnancy.

PROGNOSIS

It has now been found that, besides the long-term educational, vocational and social handicaps, untreated children are more prone to future accidents, substance abuse, delinquency and anti-social behaviour (Barkley et al, 1990; Fischer et al, 1990; Gittelman et al, 1985; McGee et al, 1991; Weiss & Hechtman, 1986). The presence of such chronic mental health problems would surely pose a severe stress on the family, both psychologically and financially. It should be noted that the studies above concerned mostly of treated cases in the clinic population, those of the untreated children remained uncertain.

PUBLIC HEALTH SIGNIFICANCE

PSYCHO-SOCIAL IMPORTANCE

Despite its unknown cause, Hyperkinetic Disorder is a significant psychiatric condition because .of its enormous psycho-social implications. firstly, this syndrome is underdetected and underdiagnosed, and is often misunderstood by others as a form of naughtiness or conduct problem in the children. 1his results in unnecessary shame and guilt of their parents who tried very hard to discipline their kids. Over-punitive measures have sometimes been given by parents and teachers, leading to broken parent-child and teacher-pupil relationships, and psychological trauma to all concerned.

Secondly, given its high prevalence, its persistence and the great need for diagnostic clarity, Hinshaw (1987) opined that the disorder is of major theoretical, empirical and clinical concern.

Thirdly, successful trea1ment is much affected by early detection and remedial trea1ment. Taking into account the young age of onset of these sufferers, the potential costs to the society in the long run (loss of productivity to the patients and their carers, costs in care, etc.) can be very significant.

SERVICE PROVISION

In order to properly cater for the real and potential sufferers of this disorder, the following services are of great practical importance, viz.:

1. Basically, there should be an universal agreement among the various medical and paramedical professionals about the diagnostic criteria, so that it may not be over restrictive or over inclusive. Any major psychiatric illness (e.g. schizophrenia) and mental retardation should initially be excluded (American Psychiatric Association, 1987).
2. Research, be it clinical or epidemiological, into this area should be For example, atypical cases should be thoroughly investigated to rule out any treatable underlying medical condition. A practical system suitable for detection of cases at school home or other situation should be applied; and valid, standardised screening instruments suitable for the various culture (e.g. the Chinese) should be developed (Luk, 1989).
3. Assessment should not be limited to diagnosis alone, but should include the wider educational, vocational, social and economic disabilities incurred by the disorder.
4. Public health education through the mass media should be stressed. By informing the public (especially those child carers such as parents, school teachers, family workers, ) about the characteristics of this syndrome, earlier detection and diagnosis may thus be possible.
5. With wide publicity, there may also be a danger of over-diagnosis of the disorder. False positive cases of over-activity e.g. the restlessness of anxiety, the hyperkinesia of autism, (Rutter, 1989) have to be This means an adequate provision of qualified staff to do the screening tests is needed. Properly trained nurses at maternity and child units or child guidance centres can play a very important role, but they should be supervised by experienced child psychiatrists who can examine the children and render a more comprehensive assessment.
6. Clinical out-patient services, and day hospitals for more severe cases, should also be provided region wide to cater for problem children, backed up by clinical psychologists and other paramedical staff (teachers and occupational therapists, etc.) Fortunately, in-patient beds are rarely needed for this
7. Further rehabilitation includes an 'inter-sectoral' co-operation between various agencies of the government and of society (Lawson, 1991). This approach would involve particularly the Health Department, the Hospital Authority, the Social Welfare Department (especially the family services), the Education Department (especially the special education section), and the various voluntary agencies providing services to children and adolescents, including parents
8. Lastly, as there may be a genetic component in the etiology of 'this disorder, some surveillance of the at-risk groups (e.g. the younger siblings or even the children of patients) could be established, to allow early diagnosis and intervention.

CURRENT SITUATION IN HONG KONG

So far in Hong Kong, there is no specific service to help detect and manage children with this disorder. The Health Department has a number of child assessment centres where parents can bring their children for assessment if they consider their children abnormal either physically or psychologically. When confirmed by the professional team (which includes a clinical psychologist), such hyperkinetic children are referred to child psychiatric out-patient clinics (as discussed above) for further management. Some primary care doctors, paramedical personnel working with children, and teachers are also able to detect the disorder and refer these children for care. However, there is so far no systematic plan to provide comprehensive service for such disorder as discussed above.

A PUBLIC HEALTH MODEL OF IMPLEMENTATION

Taking the conservative estimated prevalence of 3% of primary school children from Wong & Lau (1992), the projected number of children suffering from different degrees of severity of the disorder in Hong Kong is 30,000, with an extra 12,000 potential cases if preschool children are included (Census & Statistics Department, Hong Kong, 1989). This is an overwhelming figure that the current health services with limited resources can cater for. Therefore, implementation of the above strategies should be directed initially towards those with serious learning or conduct handicaps which can lower the target number by 50% (Barkley, 1990), lest false hope be aroused in the community, resulting in more long-term despair.

Considering the worldwide limitation of health resources and the demand on efficient public spending, the following 'incremental' decision making and planning (Ham & Hill, 1984) may be more practicable:

1. Stage I: this stage should concentrate on case detection among those children during their most disturbed period of life (e. the primary school age population). Close co-operation with the education department and the health education of the primary school teachers should be emphasised at this stage. There should be a strengthening of professional manpower at the child psychiatric service.
2. Stage II: this is the stage for public attention and concem, aiming at earlier detection of More child guidance should be set up, community wide. The target population should extend to pre-school age, though subsyndromal cases could be exempted in the beginning. The proper use of the mass media is important to attain this goal, but precautions should be tai<en to avoid undue alarm. Involvement and training of family members as co-therapists is important (Anastopoulos & Barkley, 1990).
3. Stage III: this is the remedial stage, where rehabilitation services should be developed for those grown-up patients. At this stage, the problems are mainly psycho-social and medication is perhaps less useful than psycho-beliavioural. Proper adolescent and even adult units staffed by multi--disciplinary teams knowledgeable about the disorder should be developed to provide remedial care and management, backed up by other occupational and social resources such as sheltered workshop, social clubs, etc.

COSTS AND BENEFITS

There has not been much cost-benefit studies in child psychiabic service, not to mention this disorder. There was one 'cost-benefit analysis' of a diagnostic system (Milich, Pelham & Hinshaw, 1986), and another one on the prices of psychotropic drugs for children (Greenberg et al, 1991).

Despite this paucity of information, the estimated costs for such implementation is obviously not low, as it involves training and employment of staff which has a high turnover rate when 1997 is approaching. Though hospitalisation is rarely needed, the multi-dimensional approach mentioned above can be quite "expensive-to-run" (Sagvolden & Archer, 1989). Fortunately, there is no special equipment needed for this disorder, and the needed medicines are not expensive. However, some labora- tory tests to rule out brain diseases could be costly, and should therefore be 'planned individually' rather than as ·a uniform programme' (Schachar & Taylor, 1986). The training of relatives is relatively cheap but quite time consuming, depending on their education standard. When the community is involved, there is the additional costs of public education and advertisement. Lastly, provisions and programmes of rehabilitation are very costly as the demand usually lasts a long time.

On the other side of the balance, the gains from early diagnosis and intervention are also obvious especially in the long run, through a decrease in educational and social handicaps among the patients and the future decrease in consumption of remedial services. The savings from a decrease in anti-social behaviour and criminal offenses, and the improved chance of gainful or sheltered employment must also be considered. Rnally, as parents do pay a high price in the care of the handicapped children at home (Chetwynd, 1985), the improved quality of life among the young sufferers and their relatives makes these preventive measures worthy of its costs.

INTEGRATION, IMPLEMENTATION & EVALUATION

In order to minimise the costs and to ensure success in the long run, the above plan could be incorporated into other psychiatric services for the young. As the Government is currently looking into the needs of the autistic children (Hong Kong Government, 1991), any provision in this direction should also consider the problem of hyperkinetic disorder which can be viewed as a developmental disorder similar to but of a much higher prevalence to that of childhood autism. By so doing, duplication of service and wastage of manpower may be avoided.

On the other hand, there are bound to have some unpredictable problems during the implementation of a new service. Therefore, the provision of such services could initially start off on a regional basis. Only when the initial efforts are properly evaluated, and the mistakes or problems properly dealt with, a territory-wide service could then be developed.

Lastly, in order to provide an efficient service provided to the community, continuous monitoring and evaluation of the activities should be incorporated right from the beginning of service provision. The monitoring of performance is of greatest importance where it is an intrinsic part of the planning process (Palmer, 1973).

CONCLUSION

As Hong Kong b2conias more developed, the mental health aspects of the community, especially the younger generation, should be attended lo. ·The hyperkinetic syndrome is one of the more common a... d yet serious enough childhood mental health problem encountered. Despite the present lack of information on the exact cause, it is of important concern to the society, especially in the 'Jong run. Therefore, it is the ripe time to implement strategies to prevent this 'tantalizing lifetime disorder' (Rome, 1989).

ACKNOWLEDGEMENT

The author is grateful to Drs. S.L Luk, T.P. Ho and C.H. Chan for their valuable advice and suggestions, especially with regard to the local scene.

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K.Y. Mak M.B.B.S., M.R.C.Psych., D.P.M., M.H.A. Senior Lecturer,Department of Psychiatry, The University of Hong Kong. Queen Mary Hospital,Pokfulam Road,Hong Kong.