Does ADHD exist?

One of the joys of working in child and adolescent mental health services (CAMHS) is that I regularly get asked whether I think ADHD exists. It’s a topic that has two polarised camps. In one camp you get those who think it’s an attempt to medicate away all kinds of family and social problems, giving bad parents a handy excuse while lining the wallets of Big Pharma. In the other camp you have those who insist that those voices are simply pillshaming a debilitating but treatable condition.

I’m going to give my answer to that question, and it’s slightly more complicated than either pole. Quite possibly I might wind up sounding like Bill Clinton’s notorious comment that, “It depends what the meaning of the word ‘is’ is.”

To start off, what do we mean when we say that a child (or adult, since adult diagnoses are on the increase) has “got ADHD”? Well, the first thing to remember is that ADHD, as with most psychiatric diagnoses, is a descriptive statement about a collection of thoughts, feelings and behaviours that somebody happens to be displaying. There’s not a blood test or a scan for ADHD (or depression, or psychosis, or post-traumatic stress disorder etc etc).

At the risk of simplifying somewhat, ADHD is defined by three core symptoms: inattention, hyperactivity and impulsivity. If you’re inattentive, hyperactive and impulsive, you’ve “got ADHD.” If you don’t have those three things, you “haven’t got ADHD”. What that doesn’t tell you is why somebody is inattentive, hyperactive and impulsive.

Back in 2010 there was a big media hoo-hah after a Lancet paper was widely reported as having found a “gene for ADHD.” The media’s eye was particularly caught by a line in the abstract.

Our findings provide genetic evidence of an increased rate of large CNVs in individuals with ADHD and suggest that ADHD is not purely a social construct.

I don’t pretend to be an expert on genetics, but there’s a handy deconstruction of the paper by Neuroskeptic here. The upshot of it is that this particular piece of genetic evidence is likely only to account for 7% of individuals with ADHD. Fine, but what about the other 93%?

I guess some researchers would be keen to say “other genes”. But if ADHD is essentially a description of symptoms, why do we need to think either all or none of it is down to genetics?

We don’t assume that say, anxiety is caused by one single thing, be it biological or environmental. I see a lot of anxious children due to psychosocial events. I also worked a while back with an anxious child who turned out to have abnormal hormone levels. When the hormones corrected themselves, the anxiety disappeared.

I’m not an ADHD nurse specialist – I’m something of a CAMHS jack-of-all-trades – but I run a regular nurse-led ADHD clinic. In that there are children who, for no apparent reason, seem to have been hyperactive, inattentive and impulsive from birth, and for those children a genetic component to their behaviour certainly seems plausible. There are also children who developed those symptoms after a head injury.

And yes, there are children who have a strong history of being subjected to various psychological, family and social stresses.

A while back I was running one of my ADHD clinics. For confidentiality reasons I won’t go into the details of the cases. However, what I will say is that after reading the notes I discovered that every child booked into my clinic that morning had either been sexually abused or exposed to domestic violence during early infancy. A lot of people outside psychiatry and psychology tend to assume that this would be unlikely to affect the child later on, because they wouldn’t remember those very early experiences. It’s true that these children probably don’t consciously remember what happened to them. However, at that very early age their fight-or-flight responses would have been going off like the clappers, right at the time when they would be starting to form those early attachment bonds that go on to develop the basis of somebody’s personality.

What would a child be like if they developed an attachment style based on an aroused attunement to perceived danger? Jumpy? Fidgety? Finding it hard to sit still and focus on a schoolbook?

What childhood condition does that sound like, eh?

But here’s the thing. At every one of those appointments that morning, both the child and the parents agreed that he or she was benefiting from the medication. I don’t mean in a simple, “He’s behaving himself and not causing trouble” kind of way. As in they were coping better with the school day, able to progress in their education, able to make and sustain friendships. They were able to get on with being a child.

This isn’t entirely surprising when you think about the medication involved. There’s various ADHD medications on sale: atomoxetine (aka Strattera), lisdexamfetamine (aka Elvanse) but by far the most commonly-used is methylphenidate. You all know it by its more famous name Ritalin, but that’s a brand name one doesn’t often see these days. It’s more likely to be prescribed in various slow-release preparations – Equasym, Concerta, Medikinet – or as generic methylphenidate.

Methylphenidate is basically a performance-enhancing drug. One child psychiatrist (not one I work with) told me that when parents tell him that their child’s school grades have gone up since starting methylphenidate, he thinks back to his time at university, when he took speed to help with his exam revision. Methylphenidate is a stimulant that helps people to concentrate and stay on task, and can provide symptom relief to those who have trouble with that, regardless of why they have trouble with it.

Throughout human history, people have used pharmacological products to improve their functioning on a personal, social or cultural level. Anyone who says otherwise simply doesn’t own enough Beatles albums. Little Johnny might be taking methylphenidate. His Mum is being prescribed fluoxetine to help her cope with the drudgery of her life. Dad is medicating himself from the stress of work with some diluted liquid ethanol from his local pharmaceutical supplier at Thresher’s. Meanwhile, Johnny’s teenage sister deals with her anger at Dad by smoking some herbal tetrahydrocannabinol that she obtains from an amateur, unlicensed pharmacist. Along the way she discovers it has some interesting effects on her art A level coursework. As the song goes, it’s a chemical world.

 

 

 
If that sounds like a cynical way to put it, I should point out that methylphenidate is, unlike some of those other products mentioned, relatively safe. Not completely safe, but then no medication is. Even so, as long as there’s regular monitoring of fairly basic things such as height, weight, pulse and blood pressure the risks are low and manageable. Often those risks are much lower than simply allowing a child’s educational, emotional and social development to carry on being disrupted by whatever is causing them to become inattentive, hyperactive and impulsive.

So, to go back to the question, “Does ADHD exist?” If by that do we mean that children can become hyperactive, inattentive and impulsive and that this can be corrected with medication, then yes, it does exist.

If by that do we mean it’s a single condition with one single cause that affects every child who has it, I’d say not.

To paraphrase President Clinton, I suppose it depends on what we mean by “exists”.

Of course, this is not how the speakers would put it at a drug company-sponsored ADHD conference.

BACP closes regulatory loophole

A few weeks ago I wrote about a loophole that could enable an unscrupulous psychotherapist to evade a misconduct hearing. Of the various professional bodies, it usually isn’t possible to bring a complaint against a practitioner who has resigned their registration prior to the complaint being made. Admittedly this is true for other professions such as nursing. But there’s a difference in that “nurse” is a protected title and in order to practice you have to be registered with the Nursing and Midwifery Council. Any nurse who resigns in anticipation of a complaint is effectively striking themselves off.

This isn’t true of psychotherapy. “Psychotherapist” and “counsellor” are not protected titles, and although various professional bodies exist (the British Association for Counselling and Psychotherapy, the UK Council for Psychotherapy, the British Psychoanalytic Council etc) there’s no legal obligation to belong to one of them. So, if a counsellor or psychotherapist gets wind that a complaint of misconduct is about to be made, they can just resign from their professional body and carry on practising. No complaint can then be made, therefore there’s no record of any safeguarding concerns that could put vulnerable adults or children at risk.

Just so people know why I mentioned this particular loophole, it’s because the above scenario isn’t a hypothetical one. It’s happened. On more than one occasion by the sound of it.

I previously had an e-mail from the British Association for Counselling and Psychotherapy, which is the UK’s largest psychotherapy body. They said they were “currently engaged in the process of changing this procedure.” It now appears they’ve done exactly that.

The BACP have published the following amendment to their Professional Conduct Procedure.

1. Page 1, paragraph 1.3 ‘Complaints against non-members’ is now replaced with:

1.3 Complaints against non-members / former members

a) The Association cannot deal with complaints against individuals or organisations that were not member/registrants of the Association at the time of the alleged misconduct.

b) The Association can deal with complaints made against a former member/registrant if that former member/registrant was a member at the time to which the complaint relates, subject to the provisions of paragraph 1.5.

c) Members/registrants of the Association referred to herein will be deemed to include former members/registrants.

d) Paragraph 1.3 b) only applies to members/registrants whose membership was current at the time of the adoption of this revised paragraph 1.3 by the Association by resolution of its Board of Governors pursuant to 5.1 of the Standing Orders of the Association on the 20th day of September 2013.n [emphasis added]

That should prevent any unethical practitioners from thinking they can avoid a BACP hearing through a just-in-the-nick-of-time resignation. This is welcome news, and I hope the other professional bodies will follow suit.

There’s been a couple of other developments recently with regard to professional regulation in psychotherapy. Under the previous Labour government there were plans to make counselling and and psychotherapy state-regulated professions under the auspices of the Health Professions Council (now the Health and Care Professions Council) which already regulates clinical psychologists and arts therapists. This was shelved by the Conservative-Lib Dem coalition in favour of regulation-lite or “assured voluntary registration” where the existing professional bodies could apply to be accredited by the Professional Standards Authority. So far only the BACP has achieved this accreditation.

In July Geraint Davies MP tabled an early day motion, calling for the previous plan to be reinstated.

That this House notes that anyone can set themselves up as a counsellor or psychotherapist without training or experience with no recourse for the patient if something goes wrong; further notes that there are more than 50,000 registered counsellors or psychotherapists and an unknown number unregistered; further notes that millions of people, often with mental health problems who are therefore vulnerable and at risk, are being given therapy in an unregulated industry with no uniform code of conduct or ethics; and calls on the Government to regulate counsellors and psychotherapists by bringing them into the jurisdiction of the Health and Care Professions Council.

So far 53 MPs have signed it: mostly Labour, though with a fair sprinkling of MPs from the other parties.

Back when HPC regulation was first mooted, there was a small but very noisy campaign by certain psychotherapists who predicted that the sky would fall in if psychotherapists had to be accountable for their actions in the same way as doctors, nurses, social workers or just about any other profession that routinely works with vulnerable people.  I’ve previously (and only semi-jokingly) referred to those campaigners as “the worst bunch of malevolent hippies since the Dharma Initiative in Lost.”

Their argument was essentialy that state regulation would bring in “market values” to psychotherapy. If that argument sounds oxymoronic, then…well, that’s because it is. They used a lot of left-wing language to argue against regulation, but essentially what they were saying was that psychotherapists should be left to regulate themselves, much in the same way financial services and the tabloid media were. And we all know how well that ended.

If you’re wondering about the commitment of these anti-regulation campaigners to protecting the public from abuse, take a look at this beyond-parody article by Denis Postle, reporting on the hearings for Derek Gale, struck off by the HPC as an arts therapist for running a nasty therapy cult.

The imaginal universe of the human condition is ubiquitous. Since the Vedic traditions, Buddha, and Freud, we know we can’t turn it off. It runs. It leaps. We may hide from it but we can’t escape. We resonate with the world, the world reverberates through us. As practitioners we know that grasping the ‘real’ is matter of navigating multiple transferences and embodied foregone conclusions, this article included. The HPC as it seems to me stands in defiance, studied intentional defiance of this. The HPC has spectacles through which it sees only categories. Health. Standards. Competence. Treatment. Note-keeping. Effectiveness. This is a ‘hearing’ and in this room, as we were repeatedly reminded, what matters are ‘particularized facts’.

Also in defiance but of another order, from another paradigm, is Mr Gale, who for almost thirty years has had a private practice of individual psychotherapy and groupwork.

His defiance, as was apparent from the first three days proceedings, has its roots in Humanistic Psychology and the Human Potential movement, personal development traditions that stand outside the HPC’s medicalised models of healthcare.

I guess it was the HPC’s “medicalised models” that decided that Gale was sexually, physically, emotionally and financially abusing his clients. I’d attempt to deconstruct Postle’s article, but at this point we’re not talking about oxymoronic arguments. Just plain moronic.

Postle is a leading figure in the Alliance for Counselling and Psychotherapy, which helped coordinate the anti-regulation campaign. What are they doing now? Among other things, they’re crying foul about another development, in which the BACP has apparently applied for a royal charter. If they’re successful, this could mean that the BACP might bestow such titles as “chartered counsellor” or “chartered psychotherapist”.

The Alliance has written an open letter objecting to this.

We do not believe that BACP’s desire to bestow chartered status on its members will do anything for the field as a whole, nor do we think it in the interests of service users or of the public generally. On the contrary, we consider BACP’s move to be a potentially divisive and retrograde step which could be construed as a predatory attempt to steal a march on other organisations at a time when the government’s new voluntary register system, under the PSA, is just beginning to find its feet.

In due course, we will be writing to the Privy Council, the Department of Health, MPs and Peers, asking them to join with us in resisting this move by BACP. But we feel that the major membership organisations of counselling and psychotherapy should
join with us and we invite you to allow us to mention your names in whatever further communications we send out.

Or, to put it another way….

 

The BACP are of course entitled to apply for a royal charter. If other bodies feel that’s giving the BACP an unfair competitive advantage, then they could apply for one too, and take their place among such august organisations as Marylebone Cricket Club and the Worshipful Company of Lightmongers. Unless of course, such bodies simply aren’t good enough to meet the criteria for a royal charter.

If the BACP are successful, then that would be very good news for them indeed. It would mean that they’re the only psychotherapy body that could give a practitioner both chartered status and PSA accreditation. In other words they’d be the gold standard that any respectable counsellor or psychotherapist would be expected to be registered with.

These anti-regulation campaigners wanted to be free from the shackles of a single state regulator, so they could be left to set their own standards. Well, they got that. Now, for all their anti-market rhetoric they could well be about to discover exactly what happens in the marketplace when your product is visibly inferior to that of your competitor.

I can’t say I feel sorry for them.