INTERVIEW - WITH SAMI TIMIMI FROM PIM KLASSEN'S DOC PHIL,CAMBRIDGE UNIVERSITY 2007

' A NICE CASE OF ADHD'

Interview with Dr. Sami Timimi, 15.05.2007

PK Do you work with people who are referred to you because they have ADHD?

ST I work with people who are referred to me with behaviours that would be described

as ADHD, but the idea of them having ADHD would depend on how you interpret

that. From my point of view ADHD simply describes a number of behaviours. So if you

talk about people who have ADHD, for me that simply means that you’re describing people,

in my case children and young people, who present with certain types of behaviour.

And that’s all that it means. And from that point of view, I get plenty who are referred

with the sorts of behaviours that are described as ADHD. And I see plenty of people who

are referred where a parent or a teacher or a doctor are asking for us to exclude or assess

for a diagnosis of ADHD. The problem is in terms of the whole construct of ADHD; the

kind of other meanings that get woven into ADHD. ADHD has come to define not just a

description of behaviours, but also it has become a syndrome and a cause all at once, which

has kind of left it in a complete muddle. So that you have got this kind of circular situation

where we have something like a child who is presenting with something that would be described

as hyperactive and with poor concentration. And then you ask the question “well,

what is causing that?” and then somebody might answer who believes in the construct and

interprets it in a very narrow way may answer, “they have that because they have ADHD”.

So then you have to ask the question “why do they have ADHD? How do you know they

have ADHD?” That question will be answered “because they present with hyperactivity and

poor concentration”. So we have got this problem with these other meanings that get woven

into the ADHD construct. So in my own practice, I don’t go down that very narrow path.

Even though people are referred to me with these behaviours and with that question, my

assessments are not based around making a diagnosis. And my subsequent treatment is not

based around a diagnosis. So from that point of view, none of the kids I see have ADHD.

PK I have read some of your articles, in which you describe ADHD as a social construct.

Could you explain what you mean by that?

ST That’s the kind of question I could spend the next few hours on, because there

are many different aspects to that question. And there are many ways of misinterpreting

the answer. The first point to make about the idea of ADHD as a social construct is to

make sure that when talking about that I’m not saying that these types of behaviours are

not behaviours that are problematic, and their not behaviours for which we shouldn’t be

trying to provide good service and to try and help people with it. Having said that, if we

look at the history of how the whole concept of ADHD developed, what we find is that it

is not predicated on any particular discovery. There is no scientific discovery that led to the

syndrome coming into existence.

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PK Maybe it was in 1937 when Bradley first successfully used psychostimulants on

children? So that we first see the cure, and then a formulation of the problem.

ST That history is similar to the history of most psychiatric drugs. But that does not

equate with scientific evidence of an abnormality that is cured. That is sometimes referred to

as allopathic evidence: that because something changes something, you assume that therefore

an abnormality is cured. And we have many examples in medicine that that is not necessarily

the case. You don’t take aspirin because there is some identifiable biochemical abnormality

which aspirin corrects. It creates a certain type of difference in the brain, but it does not

correct an abnormal brain state. There is no such thing as an aspirin-deficiency syndrome

that is corrected by taking aspirin. In the same way, we know that it creates a different brain

state. And some people report getting social courage, for example. But that does mean that

if it cured that social problem of shyness, that alcohol is reversing some abnormal chemical

brain state. So it doesn’t quite equate with evidence with a biochemical abnormality.

And of course the kids that Bradley was using, the majority of them had been effected

by an epidemic of encephalitis a few years earlier. So they did have evidence that they had

suffered neurological insult. And that is where the kind of problem with the idea of brain

damage first came into existence. And if you look at the history of ADHD, basically it is

a mutation of constructs that has resulted in ADHD. In almost a very concrete way you

can see that the history of the definition has been socially constructed. At no point has it

been backed by any real discovery in the biological realms. Which is where the problems

start to occur for me with the whole ADHD construct, because it has come to be classified

as a neurodevelopmental disorder: a disorder of the development of the brain. And for me

this does not follow any logic or evidence. You need to demonstrate concretely that there

is some disorder of the development of the nervous system in order to class something like

that. And there is nobody who demonstrated that.

But what has happened, going back to Bradley, the idea of Minimal Brain Damage,

which is the forerunner of ADHD, gradually took hold. But it was always a small number

of children. It was a very rare disorder, and there was not much interest in it within psychiatry

or paediatrics. And the Minimal Brain Damage gradually lost interest anyway, because

nobody was coming up with any evidence of Brain Damage. And in fact children who do

have brain damage, are at risk of psychiatric disorder across the board. Not any specific

psychiatric disorder, they have a high risk of all sorts of psychiatric disorders. So there was

never any good concrete evidence that these particular behaviours were specifically linked

to brain damage. But if you look at what other gradual things that were happening, then

there is the gradual move to defining syndromes behaviourally; there is the changing in the

way that medicine was managed; there is the whole thing of the DSM changing in power

balance from psychoanalytic models in DSM I, by DSM III had gone over to the biological;

there is the whole changes in the managed healthcare in America, where having a service got

connected to having a diagnosis and the movement to treatment packages; the drug industry

came in and pumped a lot of money in it. For this is not a new drug, it has been around for

fifty-odd years. But there has been no interest in it. There is changes going on in the education

system with regard to certain disability and special needs, and how do you get access

to that, how you’re being recognised as having a ticket to various such services. There are

other wide changes taking place in the culture such that there is a gradual increase in almost

a moral panic about children’s development, and particularly about boys’ development. Remember

that this is a boy-disorder. This has to do with the behaviour of boys, as opposed

to their emotional state. It is about the behaviour of boys. And if you look at the history

of childhood, we see concern about children and their development and how we construct

them and how we conceive of them and how we go about the task of supporting them and

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parenting and so on. It seems to happen at times of greater social change, it seems to often

reflect times where the adults population are in some state of anxiety about what’s going on

in their lives. And children are often the arena where you see these things. See you this in a

small way in families, your unfulfilled wishes are often projected onto your children. . .

So there are lots of these cultural factors which are coming into play as to why,

despite so little biological evidence being around to back this idea, this becomes a problem.

There are all these aspects to talk about when we think about why this is a social construct,

and why it has become so popular, and why is it in particular countries that it has become

so popular. I’m half Iraqi, I grew in Iraq. The behaviours that are classified as ADHD at the

moment certainly from my knowledge of growing up in Iraq and from speaking to others

who come from that part of the world, that sort of behaviours are not considered the sorts

of things that, one, you would get too concerned about and, two, if you did get concerned

about them, you would not go to a doctor.

PK That’s in a lot of countries, not just culturally very different countries—also in

Spain in Italy, for example. But do you think that the management of inattentive, hyperactive

and impulsive behaviour should not belong to the medical jurisdiction at all?

ST My concern is that at the moment it belongs to paediatrics, and I do not think it

should belong to paediatrics at all. In some ways child psychiatry has been shooting itself

in the foot. Because once it began to classify these types of behaviour problems, which

has been the arena of child psychiatry for a long time, as neurodevelopmental problems,

neurodevelopmental disorders are the arena of paediatrics. What happened in the U.S. is

that paediatrics became a big growth area for diagnosing ADHD, and there is a similar

dynamics going on with Autism Spectrum Disorder, this is another boy thing. And that has

caught on in this country. So in the last five to ten years, all new ADHD clinics, or behaviour

clinics, have been run by community paediatricians. Child psychiatry, in this country and in

North America, traditionally grew out of the child guidance movement. The child guidance

movement used to have its clinics in community settings where there would be a mixture of

educational, social services and psychiatrists. So it sat in the interface, traditionally, of these

various childcare organisations, which I think is in some way quite logical. Because child

psychiatry, more then any other branch of medicine, reflects the interface between your

biology, your psychology, your social situation, because all children have to be cared for by

others, by adults around them, and have to have decisions made on their behalf. So it was

always going to be a bit different from adult psychiatry and it was always going to be a bit

different from the rest of medicine.

But what they have tried to do in child psychiatry when this biological model took

off, it has tried to become more doctory. And doing so has a say on what they [. . . ] because

now conditions like ADHD are being dealt with by paediatricians. And the problem there

is that, unlike child psychiatrists, who should better than paediatricians be able to deal with

a more broad range of perspectives, paediatricians stick to a very narrow model of ADHD.

They don’t have the training—unless individual paediatricians have decided to seek that out

themselves—in the assessment of broader factors such as school, peer relationships, trauma,

family history, family dynamics, behaviour management. . . And they don’t have the services

usually set up to offer more broad-ranged interventions. So what happens with paediatrics

quite often is that people will go and the service will be geared around making a diagnosis.

And if the diagnosis is made, putting in place a treatment plan, which often is medication

and medication only. Perhaps a bit of psycho-education about what ADHD is, that it is

caused by a problem of your brain, that you can have it for the rest of your life, that you

have to treat your son of daughter a bit differently and that you have to talk to the school

about special educational provisions to support this disability, etc. etc. And that, to me, is

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not helpful and that’s the bit that I think is wrong. I think medicine will likely always have

a role to play within people with these problems, particularly modern cultures that want

to organise their cosmology and society around rational scientific methodologies—medicine

will always have a very high status in that. So in those sorts of societies like ours we will

always have quite a high status.

But also there is a role because various physical conditions can cause behaviour problems,

and so you need to be able to recognise those. There is a lot of evidence about different

types of nutritional states, and we know that in the last twenty to thirty years the types of

food we consume have changed enormously—for the worse. And we know that quite a few

other childhood disorders—such as asthma and various kind of allergy states like hay fever,

often to do with the immune system—have also increased dramatically. So it is likely that

biology does play a role, but not in the way many people think today.

The temptation is always to try and live in a world with moral certainties, where

we can divide things quite clearly and where we can say that this is the problem, we simplify

it down, and this is our solution. And actually what I think has gone missing is an

ability to be a bit more reflective and a bit more thoughtful about the individual situation

of the particular child and their family. And I think the whole concept of ADHD has a neurodevelopmental

disorder has been particularly unhelpful, because it effectively treats huge

differences with the same [. . . ]. One child I work with might be helped with a behavioural

intervention, the next one might have educational things at school they’re not happy about,

the next one might be more nutritional type of problem, and the next by a combination of

all sorts of things, depending on what I find.

PK Do you expect that the guideline NICE is developing will alleviate the situation?

ST I was invited to speak to the Guideline Development Group [GDG], and my

concern is that whilst their intentions might be to improve the situation, the whole idea

of guidelines for ADHD is ripe with the potential to make matters even worse. If they are

properly going to grasp the nettle, then they actually need to take seriously the possibility

that a diagnosis and the culture of diagnosis is counterproductive, and actually leads you

away from understanding the particular cases or making a good stab at having different ways

of conceptualising the problem. My problem, and this is what I got from the day that I was

invited, is that they are trying to work out thresholds at which you would activate a process

to get a diagnosis. And that I think, when it comes to mental health or human subjective life

in general, is a nonsense. That is not the way you’re going to be able to develop, inmy view, a

system properly fit for the twenty-first century. Because we’re meant to be in a time in which

we’re trying to create partnerships with people, where we’re trying to understand their

narratives, etc. This is stuff that in the rest of medicine they’re taking serious now. We’ve

got narrative-based medicine, we’ve got values-based medicine, we’ve got the importance of

understanding the context of stories peoples are telling, the meanings they put on the various

things. And a sophisticated clinician should be able to work with these systems of meaning

and have big toolbox of ideas and approaches and be able to find—particularly when we’re

leaving in multi-cultural societies, where there are people who might have very different

believe-systems and different value systems about what the development or the trajectories

of children are, what their roles are in the family, what the roles of parents are, and so on—

so we need to be able to have different systems of knowledge that we can helpfully apply to

different situations. And we need to be able to use that flexibly. But this creating algorithms

by NICE is effectively pending that down. What it does what they’re trying to do is like

quality control in factories. In quality control in factories, when you’re producing washing

machines, you try to reduce human impact as much as possible by standardising processes

as much as possible. So that each washing machine is of the same standard—that’s what

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quality control is. You can’t do that when you’re dealing with mental health, with human

social relationships. Because the whole point of this type of work is that it is predicated on

relationships.

PK You said that in medicine are introducing and working with value-based medicine

and things like that, attaching value to the meaning people ascribe to their own conditions.

NICE is very proud to be working in a strictly evidence-based environment and the number

one tool of EBM is the Randomized Controlled Trial, in which all individual differences are

abstracted away from.

ST Some kinds of evidence are not appropriate for child psychiatry. That does not

mean that we should ignore the evidence base. In fact, what I’m saying is that from my

point of view entirely consistent with EBM. When EBM first came into practice, what it was

trying to do, which I fully support, was to reduce the amount of maverick interventions.

That was the whole thing, for example, about Bristol heart transplants, that were some

surgeons in Bristol who had an incredibly high death-rate. Examples like that have to do

with why the reasons why we have EBM, and the postcode-lottery. I can understand all of

that. The problem is that, just like any system you put in place, it can become a dogma.

Because this was applied by humans in various social relationships, essentially, it became the

watchword. As long as you could say that you were doing EBM you could produce a paper.

That became a kind of a dogma in itself. Which is exactly the opposite of what EBM was

meant to do. EBM was actually meant to get you to question you own assumptions. And

if you go back and look at the evidence, there is very little evidence to support the notion

that ADHD is a neurodevelopmental disorder. It is not up to me, as critics of my view come

up and say, to present the evidence on the disorder, it is up for the people who support that

idea to present the evidence, because that is the way science works.

PK These people are all on the GDG.

ST Exactly, that is the problem. They had a particular idea of what evidence is, I have

summarised the evidence, as have many people I know. One of the projects that I’m involved

in at the moment is that we’ve just completed a book which contains fifteen chapters

from various very well-know critics, it’s called Re-thinking ADHD, and it is critiques on the

construct from all different sorts of angles. From genetics, from the neuroimaging research,

from the cultural points of view, from the intervention point of view—the effects of stimulants

etc. There is a whole literature out there that points out the problem in the current

dogma about ADHD. So from a purely evidence-based perspective, the evidence about the

long-term effects about stimulants are not good. They do not produce long-lasting positive

outcomes in education, they do not produce long-lasting positive outcomes in relationships

with parents, in peer relationships, possibly in some behavioural trait. But there also appears

to be a whole set of negative things, from exposure to drugs that may have long-lasting effects

on your personality, on your cognitive functioning, on all sorts of things. On growth.

And the biggest concern at the moment is on the cardiac system, because it is a cardio-toxic

drug, and if you take it for several decades, what is the long-term impact of that? And that

is like a big experiment we’re carrying out.

PK A big experiment with a lot of people.

ST With a lot of people. So I have grave concerns about the way the evidende is

being interpreted in this group, and what their conclusions will be. Because to me, a thoroughly

evidence-based approach to the problem would have to start with what we call a

null-hypothesis.

PK It would have to start with questioning the validity of the diagnosis.

ST Yes, exactly. So I am very suspicious of the idea of an algorithm.

PK You have been to one of NICE’s meetings?

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ST Yes, I have been invited to one of the conferences of the GDG.

PK So you know the people who are on the GDG?

ST I know some of them.

PK Given that you know who they are, given that you have seen something of the

process so far, you don’t have much confidence that your view will be represented?

ST I have made it quite clear to them, for that was my concern, I was very close to

saying that I wouldn’t come along because I didn’t want to thick a box to say, yes, we’ve had

him.

PK Just as a lipservice.

ST Yes. I have nonetheless done that, and I know that another colleague of mine who

is critical has been included in the review process. It is hard to know how much influence

critical opinions will have until the guidelines come out. But my concern is that the chairperson

of the GDG is somebody who is very committed to the idea. I don’t think he is one

of the people who are slave to the drug companies, I think he is a genuine, or attempts to be,

a genuine scientist. But he has put together a life-time’s work, he has a lot of personal and

cognitive investment in this idea.

PK And professional investment as well.

ST And professional investment as well; he set up services, and he has argued for a

long time that ADHD is underdiagnosed and under-treated. And he is chairing. He cannot

be in an unbiased position, as a chair of that group. Because he has a very strong and very

public position about what ADHD is.

PK And he has had that position for about twenty years.

ST And he is not about to change his mind. Let’s put it that way. Which does make

you wonder, if the GDG—because not everybody in that group was averse to what I was

saying in my presentation—if the rest of the GDG were concluding that ADHD is overdiagnosed

and overtreated, would he feel able to leave that unchallenged? Would he be able to

agree with that, given that he has put so much energy and investment in the position that it

is underdiagnosed and undertreated. Those are my concerns.

PK To come back to something you said earlier about the development of the concept

of ADHD, you mentioned that in the change from DSM-I or DSM-IV, psychiatric

classification became, in a sense, more biologically prone, but diagnoses also became more

on behavioural symptoms. There is a bit of a tension there, as I see it. Can you say something

about that?

ST When DSM was originally conceive, and particularly when DSM-III was conceived—

which was the one that marked the shift towards “operationally defined”, which is a thicklist

of symptoms, which is a peculiar way to think about it. In the rest of medicine, we

have symptoms and signs. Signs is your physical signs, and that’s all they are. So you try put

together all your symptoms and signs, and then based on that you do whatever investigations

you think is needed to throw up your differential diagnosis and you come up with a possible

diagnosis that would fit these particular symptoms and signs. But you’re eventually trying

to decipher an underlying pathological process.

PK Aetiology.

ST Yes, that what it is based on, it is an aetiological based system. This is a rather

peculiar way of trying to deal with the shortcomings of not being able to do something like

that in mental health. And whilst the DSM [III] originally set out that it was going to be

an a-theoretical manual, it was going to divide phenomena according to operational criteria,

which was a thick-list of symptoms, and these were effectively done [. . . ]. It went out to

consultation psychiatrists across America, and various groups met in committees, and then

you submitted your data to the committees, and then eventually these committees voted.

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And what happened over the years is that the number of diagnoses in each manual started

increasing. That a whole other system came built around them, so that they become more

than just diagnostic categories. One of the big things about DSM-III is that it was the kind

of killer-challenge to psychoanalysis in American psychiatry. So it was kind of a victory for

the biological ones. And it pretty quickly got tied into the pharmaceutical industry, because

now pharmaceutical industry got into selling diseases. Because that is how they actually sell

drugs; if they sell the concept of depression, and if they popularise the concept of depression

among doctors and among the public, then people who are unhappy come more and more

to think that they need help.

PK How is that in the UK, are pharmaceutical companies allowed to act directly on

consumers?

ST In America they are allowed to act directly on consumers. In the UK they’re not.

But of course they do all the time, because we have got the internet. And companies set

up lots of internet sites. And they’re internet sites which have to do with diseases rather

than drugs. And they also support various pressure groups, consumer groups, and so on.

So that’s the way they’re acting directly on consumers. And of course they’re constantly

lobbying doctors. So there is that factor in there.

The shift to using operational criteria cleared the path for biological psychiatry to

take the upper hand. And it is not because of any new evidence. We have had the decade of

the brain, in which psychiatrists had all sorts of new tools to play with. And the promise of

the finding of the pathology was always just around the corner. Now we’ve got MRI, we’ve

got CAT-scans, we’ve got molecular genetics—the will o’ the wisp: you often think you

see something, but every time you approach it suddenly disappears. And there is actually

nothing there. Every time they look, they can’t find it.

PK Genetics is the contemporary example I guess, but many people are already realising

that there is nothing there, or at least not enough.

ST That it is more complicated than that it can be reduced to it, as you can have an

idea with other medical genetics. Something we clearly know is due to a pathological process

such as diabetes mellitus type 1. We know that is kind of genetic, and yet we know there is

huge environmental thing going on there which we don’t yet understand. Because rates of

insulin-dependent diabetes type 1 have increased and they seem to be presenting at younger

ages. And it is quite hard to know what combination of things is causing it. And the genetics

of that is quite complicated, it is not just one gene, but we know what protein is at issue.We

know that we need to look at the proteins that code for insulin, for that is the protein that

malfunctions. Or the proteins that code for the islands in the pancreas that make. . . and so

on. So we kind of know where we’re looking. It’s a huge step to go from vague behaviours

to genes. It’s an impossible leap.

PK Still, there is a molecular geneticist on the GDG for ADHD.

ST Is that Chris Hollis.

PK Yes, it is.

ST He is at Nottingham University, and he does a lot of research on genetics and so

on, and again, he is a hard-line ADHD supporter, and he does get drug-company money.

And the evidence on the genetics has been summarised by several people, probably the best

one is J. Joseph, he has written several articles and a couple of books. And basically, the

evidence is not there.

PK Except for twin-studies?

ST The twin-studies are an interesting case in point, because they actually provide no

more support for the genetic hypothesis than family-studies. Because so many psychological

studies have shown that identical twins are psychologically very different, because they’re

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very often reared as a unit, they often report identity confusion, they often swap roles, they

have an intense relationship. There is lots of studies out there that say you can’t differentiate

the psychological from the biological. So the twin-studies provide no more support than the

family-studies. Just because things run in families doesn’t mean that they’re genetic. It might

be genetic, but it could be entirely psychological. Simply that technique will not be able to

differentiate.

PK The eventual goal of any guideline is to make clinical practice more equal. What

are your expectations on that if that happens with the guideline on ADHD that is being

produced right now?

ST Depending on what the guideline produces, I think it has the potential to cause

more problems. It could also become a cause for the good. [. . . ]

It could actually become a warning about the early use of diagnosis and the ease

with which diagnosis can be a dumping ground for a whole manifold of problems. And if

it became something that actually encouraged clinicians to look more widely. And if it did

that, it would essentially be shooting down the concept of ADHD. That’s probably what I

would expect it to do, because eventually somewhere along the line a guideline will have to

address the question of the validity of the diagnosis.

PK Do you think this guideline will do that?

ST No, I don’t think so. It might still be a cause for good if it produces a guideline

that is quite strict about the overdiagnosis. Because in some ways I had a big problem with

the guideline on childhood depression, because it never questioned the concept. However,

there were some positive thing about it, which was that it did evaluate the evidence about

anti-depressants and it went further than I thought it would in terms of not recommending

it as a first-line treatment. Nevertheless I think it doesn’t go far enough, because actually

the evidence on anti-depressants for children says that non of them are particularly effective,

and they all have a potential, a small rate, but a potential of quite serious danger of inducing

suicidal thought. But it went a lot further than I thought.

PK It is very careful with respect to mild depression, for example. Do you think that

this might happen with the ADHD guideline as well?

ST The problem is, again, the devil is in the detail. Because different clinicians have

very different ideas on what is mild depression, what is medium depression, what severe

depression? Or what does depression mean? How do you differentiate it from unhappiness?

These kind of more conceptual problems. But nonetheless, it set a scenario that said that

we were using too much anti-depressants in children and that we have to stop using them

all the time. And that was helpful. It didn’t go far enough, but it was a step in the right

direction. These guidelines on ADHD could do the same. It might not be enough, in terms

of the proper critique of it. For in a way what the childhood depression was virtually saying

was that childhood depression was not that useful as a concept, in a roundabout way. It

couldn’t quite say that, but it was virtually saying that. And if the ADHD guideline moves

in a direction saying that we need to be much more cautious than we are being, then that

could be helpful. And that would be the most I could hope. But we need to wait and see.

If the algorithm is treated to concretely and if it remains in the arena of paediatricians

to treat it, because that is the other helpful thing this guideline could do: it could take it away

from paediatricians.

PK And move it to psychiatry entirely?

ST Exactly.

PK Actually I think you sound quite hopeful. I maybe expected that you’d be less

optimistic about this guideline, for example because of the people who are on the GDG.

ST I am concerned about what will come out. However, I do think the tide has been

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turning slowly. And a lot of it has been after the negative publicity about anti-depressants

in children. The climate is sceptical again. For a while biological models and the use of

medications were just going full speed ahead. But there is a sceptical attitude again, the press

is sceptical, a lot of the public is sceptical, in my interaction with them. And there are certain

elements within the profession that are sceptical. One thing that is of interest to me is that I

have had a number of times where I’ve had debates where there were no child psychiatrists

or paediatricians—I know lots of child psychiatrists and paediatricians who are actually very

much in agreement with the thoughts that I expressed—but I’ve had some debates with

hospital doctors in general, who are not part of the [ADHD community]. And when we

have a show of hands at these debates, the majority of doctors are actually in agreement

with ADHD being a social question and not a biological one. So I think there is actually a

silent majority even within medicine.

PK But the rise of ADHD diagnoses doesn’t really support your point.

ST I can only comment on the doctors I have had contact with in this country.

PK I’m talking about the UK. The prescription rates for methylphenidate are still

rising.

ST Yes, but you have to understand that a certain dynamics is happening, and that

there are certain interested parties. For example, community paediatrics is an interested

party that has expanded its role hugely. And all it takes, for example, in Lincolnshire we have

quite high rates in certain parts of the county and it is accounted for, more or less, by two

doctors who have clinics that are almost pumping children out. I don’t know how much,

but I would estimate hundreds of children are going through these two particular clinics,

having short appointments, being diagnosed, being put on medication, review every six

months, medication repeated. I know another paediatrician, in another part of the county

who works very differently. This paediatrician diagnoses much more rarely, she still uses

medication. Even within a small area like that, you might find that a county with a high

amount of prescribing, and it is accounted for by three or four doctors. I was working for

a while in North-East Lincolnshire and they had the same problem there. They had one

doctor there with a case-load of over seven hundred children on psychostimulants. And

you’ve got the drug companies in there, you’ve got certain parent support groups, but my

experience is actually that if you took doctors as whole in this country and I wouldn’t be

surprised, although I don’t know for sure, my straw pole as it were for times that I have

done debates with people is that in terms of doctors in general are sceptical. Certainly other

professions in mental health, like psychologists, social workers, nurses, psychoterapists.

PK It’s all a bit of guesswork, but you don’t think there is a chance that the GDG

might say that ADHD needs to be moved to primary care.

ST My god, I hope not. Have you picked up that there might be a chance that they’d

do that? I know that it happens in America.

PK It happens in America, that is one reason, another is that atomoxetine is being

prescribed by GPs, so it might be that also methylphenidate moves to their range.

ST Up until now the guidelines that have been produced have been saying thatADHD

has to be seen by a specialist. But I would hope that at least that would not happen.

PK Because you think there might even be more restriction when it comes to who is

in charge of ADHD?

ST There might be; I don’t know. And certainly I have the feeling that some members

on the panel are sensitive to that. I did hear this. They produced a draft after that day that

I have been there, and it went through nine revisions, because the members of the panel

couldn’t agree. So it sounds like there is some interesting internal politics going on. Maybe

they regretted having invited me afterwards. It might have stirred the pot a bit.

76 E j Interview with Dr. Sami Timimi

PK With respect to the internal politics, I find it very interesting that there is a group

of five people within the GDG—which in total doesn’t consist of much over twenty people—

who all published together.

ST That has been mine concern about the group from the start, when I was first

invited and I knew who was on the group. The chair-person is responsible for deciding who

is on the group. And, without being argument, why wasn’t I invited? I published widely,

I’ve written several books, I present at conferences regularly and internationally, I do regular

clinical practice, I’ve actually run an ADHD clinic before.

I was invited for a one-day thing.

PK And it is not just that you are not on the GDG, but no one like you is on the

GDG.

ST Exactly. Why did they not have a critic on that GDG? Depending on what they

produce—because I also have contacts in the press—I will certainly be contacting my contacts

in the press to make that very point about the membership of the GDG which is

fundamentally flawed.

PK Is that something you think, that it is fundamentally flawed?

ST Absolutely. They can’t magic away the fact that this is a controversial realm. That

it is controversial. There is a very large critical literature, and it needs to be fully incorporated

into their thinking, if they are to produce an evidence-based guideline.

PK So for you that would mean not just reading all the critical literature, but actually

importing the critical people into the GDG. And even though not all the people on

the GDG have been former students of Professor Taylor, no one on the panel has written

anything critically about ADHD.

ST Absolutely. And that is the fundamental failure, which was evident from the start.

There might actually be some people on the panel who are actually trying to take seriously

the critical literature, because I also submitted a series of articles and various things that I

wanted them to read. But that is not good enough in my opinion. It will be interesting to

see how much of that criticism actually gets taken on board