- IN DEBATE
ADHD is best understood as a cultural construct
+ Author Affiliations
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Edited and introduced by Mary Cannon, Kwame McKenzie and Andrew Sims.
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Declaration of interest
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None.
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Declaration of interest
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E.T. has received menaces from an anti-psychiatry organisation, which may have biased him against their views. He and his department have received fees for lecturing at educational meetings and scientific conferences that had sponsorship from pharmaceutical companies – including Eli Lilly and Janssen-Cilag, who manufacture drugs used in ADHD. He is a lead clinician in a National Health Service trust, so could have an interest in keeping costs of treatment down.
INTRODUCTION
Attention-deficit hyperactivity disorder (ADHD) has received significant
research attention and is a problem that is rarely out of the news –
whether it is concerns about treating children with amphetamines, its over- or
underdiagnosis, or the long-term outcomes.
Despite all the research it has been difficult to gain and maintain
professional agreement on what ADHD is or what should be done about it. In
2002 an eminent group of psychiatrists and psychologists published the first
consensus statement on the science, diagnosis and treatment of ADHD
(
Barkley et al, 2002).
However, the statement could probably best be described as a position
statement because the diverse views of what ADHD is and what should be done
about it were not reflected or represented. Fundamental to the discussion are
questions about whether the diagnosis of ADHD actually holds water and what it
is that psychiatrists are trying to treat. Are differences in the rate of ADHD
a reflection of changes in its incidence or in society’s tolerance for
behaviour that does not conform? We asked Dr Sami Timimi, a child and
adolescent psychiatrist and author of Pathological Child Psychiatry and
the Medicalization of Childhood, and Professor Eric Taylor, a child
psychiatrist from the Institute of Psychiatry and researcher into the
aetiology, outcome and treatment of ADHD, to discuss the proposition that ADHD
is best understood as a cultural construct.
FOR
There are no specific cognitive, metabolic or neurological markers and no
medical tests for ADHD. Because of uncertainty about definition,
epidemiological studies produce hugely differing prevalence rates: from 0.5%
to 26% of children. Despite attempts at standardising criteria, in
cross-cultural studies major and significant differences between raters from
different countries in the way they rate symptoms of ADHD, as well as major
differences in the way children from different cultures are rated for symptoms
of ADHD, are apparent. More than 30 neuroimaging studies have been published;
however, researchers have yet to compare unmedicated children diagnosed with
ADHD with an age-matched control group. Sample sizes in these studies have
been small and have produced a variety of inconsistent results. In no study
were the brains considered clinically abnormal, nor is it possible to work out
whether any differences seen are caused by (rather than being the causes of)
different styles of thinking, or are the result of the medication the children
had taken. What we end up with is a modern version of the long-discredited ‘
science’ of phrenology. Genetic studies show that ADHD is linked
with being male (boys are four to ten times more likely to get this diagnosis
in practice) and is associated with the normal genetic variation found with
traits such as height. Comorbidity is extremely high, throwing doubt on the
specificity of the diagnosis. There are no specific treatments for ADHD, with
the most widely debated treatment (methylphenidate) being known to have
similar effects on otherwise normal children. There is no established
prognosis, and association and cause frequently are confused in the
literature. ADHD has generated huge profits for the pharmaceutical industry
against a background of poor-quality research, publication bias and payments
to some of the top academics in this field. Thus, the mainstream dogma on ADHD
is contaminated and misleading (
Timimi,
2002).
To explain the recent rise, to epidemic proportions, of rates of diagnosis
of ADHD, a cultural perspective is necessary. The immaturity of children is a
biological fact, but the ways in which this immaturity is understood and made
meaningful is a fact of culture. In modern Western culture many factors
adversely affect the mental health of children and their families. These
include loss of extended family support, mother blame (mothers are usually the
ones who shoulder responsibility for their children), pressure on schools, a
breakdown in the moral authority of adults, parents being put in a double bind
on the question of discipline, family life being busy and ‘
hyperactive’, and a market economy value system that emphasises
individuality, competitiveness and independence
(
Prout & James, 1997).
Throw in the profit-dependent pharmaceutical industry and a high-status
profession looking for new roles and we have the ideal cultural preconditions
for the birth and propagation of the ADHD construct.
Is a medical model of ADHD therapeutically helpful? Quite the opposite; it
offers a decontextualised and simplistic idea that leads to all of us –
parents, teachers and doctors – disengaging from our social
responsibility to raise well-behaved children. We thus become a symptom of the
cultural disease we purport to cure. It supports the profit motive of the
pharmaceutical industry, which has been accused of helping to create and
propagate the notion of ADHD in order to expand its own markets. By acting as
agents of social control and stifling diversity in children, we are
victimising millions of children and their families by putting children on
highly addictive drugs that have no proven long-term benefit
(
Timimi, 2002) and have been
shown in animal studies to have brain-disabling effects
(
Moll et al, 2001;
Sproson et al, 2001;
Breggin, 2002). By
conceptualising problems as medically caused we end up offering interventions
(drug and behavioural) that teach ADHD-type behaviour to the child. ADHD
causes ‘tunnel vision’ in the system, making it more difficult to
think about context, leading to interpersonal issues being marginalised. ADHD
scripts a potentially life-long story of disability and deficit, resulting in
an attitude of a ‘pill for life’s problems’. We create
unnecessary dependence on doctors, discouraging children and their families
from engaging their own abilities to solve problems. ADHD is de-skilling for
us as a profession as there is minimal skill involved in ticking off a
checklist of symptoms and reaching for the prescription pad.
AGAINST
Hyperactivity is neither a social construct nor a genetic disease. The
professional task is to understand how genetic and social influences interact,
not to simplify into a polemic.
Individual differences in hyperactivity have known physical counterparts:
in brain structure and function and DNA composition
(
Schachar & Tannock, 2002).
Genetic influences are strong and some molecular genetic variations
(especially of genes affecting dopamine systems) have been robustly
replicated. They work in interaction with the environment, and the
psychological environment helps to set the course into adjustment or disorder.
Consistent associations with changes in brain structure have been found, even
in unmedicated children, with neuroimaging.
Severe hyperactivity is a strong predictor of poor psychosocial adjustment
(
Taylor et al, 1996).
The developmental risk is not trivial. Even those who are not diagnosed or
medicated are more prone to accidents, conduct disorder, psychiatric problems
in adolescence, educational and occupational failure, and a lack of
constructive occupations or satisfactory relationships. This is why mental
health services get involved.
Some authorities suggest that the institutions of society can actually
cause the problem. For example, the decay of the family, or the school, or
social cohesion, or leisure activity can be blamed for children going ‘
out of control’. (Different countries vary in the choice of
scapegoat according to their perceived social problems.) Evidence for this is
lacking. Indeed, twin studies indicate that individual differences are very
little influenced by the shared environment. If there were a social
determinant of hyperactivity, it would need to be seen as making the whole
population more hyperactive; that is, the prevalence of a diagnostic category
such as ADHD would have to be increasing over time and be related to social
structures. In the UK, this is probably not so. Two epidemiological studies 20
years apart have produced very similar prevalence rates for ‘
hyperkinetic disorder’ (
Taylor
et al, 1991;
Meltzer
et al, 2000). Powerless groups such as immigrants do not
have markedly increased rates, and ‘ADHD’ affects all classes.
Social factors can probably influence the degree of hyperactivity that is
seen as a problem. Children do not usually refer themselves for help (although
they often try); they are dependent upon others to determine their caseness.
Families, schools and cultures vary somewhat in their tolerance. For example,
epidemiological research in Hong Kong used the same measures as had been used
in London, England, and found a higher rate of hyperactivity in Hong Kong when
ratings were used, but a lower rate when more objective measures were
employed. The likely interpretation is that hyperactive behaviour had a
greater impact in the Hong Kong environment, which attaches particular
importance to academic success.
This interaction between the child and the expectations of the adult world
is important clinically. It is a reason to take more pains in making a
diagnosis than just accepting a rating from a parent or teacher. Impairment
and risk are as important as symptomatology. An assessment should be thorough
enough to clarify the interaction in the individual case (as well, of course,
as to be able to detect the emotional problems and the relationship
difficulties that can both mimic hyperactivity and result from it).
Could these social influences lead to the condition being overdiagnosed?
This carries particular weight because of the frequent use of stimulant
medication. If there is overdiagnosis, then children treated will often be
found to fall short of rigorous diagnostic criteria. In the USA, this may
sometimes happen. There is some evidence there for a patchy mixture of
undertreatment and overtreatment, and a high rate of medication in preschool
children suggests that some practitioners are going beyond guidelines.
In the UK, however, the chief evidence is for undertreatment. Most children
with markedly hyperactive behaviour are still not identified, referred or
treated; yet they remain at risk. The obstacle probably lies largely in
medical attitudes rather than public ones
(
Sayal et al, 2002).
This is a pity, because there are several good ways of supporting children
with severe hyperactivity.
In short, broad social influences probably contribute to the recognition of
disorder rather than its presence. But these do not amount to a social
construction of disorder – rather, in the UK at least, they work against
recognition of a treatable risk.
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