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.
Thank you for another of your compassionate and above all willing to look at the person blogs.
Thanks Jem. Very kind of you to say so.
Interesting read. For childhood condition of ADHD substitute adult one of bipolar. For drug company-sponsored ADHD conference insert University of Cardiff Faculty of Psychiatry sponsored Bipolar UK conference (certainly for the one and only one I attended in 2010). Never again.
I would tend to agree with you here and add that teachers also seem to be contributing to the problem as they find themselves under increasing pressure to live up to standardized testing.
Reblogged this on Mentally Wealthy.
A very well balanced piece and it’s good to hear from someone who works with kids day on day out in an ADHD clinic. I have a few comments, mainly because it’s a big topic for me too.
Your points on aetiology are excellent and rarely discussed, are we using ADHD as a catch all descriptor for a collection of difficulties with varying causes? Many would argue yes, but that presents it’s own challenges I would argue. (as an aside, your comments re: genetic ’causes’ ring true for a lot of MH genetic ‘findings’)
One key issue for me especially as someone who works a lot with young people who are looked after (in the care system) is that affect regulation is a key task of attachment. If affect is dysregulated, inattention and impulsivity follow. I’m not saying that all with ADHD have attachment problems, I’m with you, there are some who have evidently some of these problems despite all other factors being stable. (another aside, I’m so glad to hear someone screening for head injuries, such a missed, bit issue in mental health services).
The key issue is for me how the diagnosis is utilised and how medication is utilised. ADHD suggests inattention, impulsivity and hyperactivity, but that in itself is misleading. Research indicates that ppl with ‘ADHD’ do not have attentional deficits (eg Huang Pollock and Nigg 2003). The deficits appear to be more around so called higher level cognitions and processes such as executive functioning (also common in yp with adverse early experiences).
At times, sadly, children can be the scapegoat for a family’s difficulties, not all the time by any means, but it does happen. At these times we must not localise this problem within the child as this affects not only the child’s and family’s understanding but society’s too.
I’m not anti-medication per se, but my concerns regarding it’s use are predominantly twofold.
1) Evidence for long-term efficacy is limited, some say kids grow out of ADHD others argue it’s life long. Short to medium term evidence appears pretty robust but this reduces over time.
2) What is know about the long-term impact on the developing brain. More and more evidence is pointing to the fact that the brain undergoes another significant period of development in adolescence (for eg see work by the completely excellent Sarah Jayne Blakemore @sjblakemore) what impact does stimulant medicaition have on this growth? We don’t know.
I know some would say that aetiology doesn’t matter, if they have a problem and medication fixes it then job done. But how we understand difficulties does matter.
My daughter was telling me about a boy at school a couple of years ago and he’d got removed out of the class, I asked why and she said ‘oh, he’s got that ADHD’.
Saying he does that because he has ADHD
He does that because he had a really difficult early life.
I think there is a difference and stigma is a big issue (eg http://link.springer.com/article/10.1007%2Fs12402-012-0085-3)
I agree with a lot of what you’re eloquently put across but those are just some of my concerns in what is a very complex and emotive area. Thanks for writing.
It’s nice to hear an unbiased opinion on this from someone who works in the field. Most discussions about this turn into heated debates where logic and facts get out of the window.
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Adhd does exist in the same way as any other psychiatric disorder, what can present a significant variant is poor diagnosis, yes it is represented by inattention, hyperactivity and impulsively however this is only relevant if no other explanation can be identified. In the case of trauma etc and the possible general response to methylphenidate, it is feasible that observed non compliance could decrease for various reasons including a homeopathic response, meaning people paying attention to the individual, adverse effect making it harder to focus on mischief due to unusual or possibly unpleasant sensations also as you say a typical stimulant response which is in some ways an over focus. Adhd is not a lack of attention it is a failing in managing attention, hyperactivity and impulsively are also failings or impacts of specific executive functions, these things are relatively easy to separate from other factors if you take the time to understand them. The problem Adhd presents to professionals, teachers parents etc is that it contradicts well established cultural understanding and individual predisposition, the doubt is not the diagnosis but the unskilled way in which it can be used or not used. In terms of the idea that anyone could benefit from a stimulant medication, in the long term I would predict that where the diagnosis is not relevant or aptly applied this will be discontinued later or go on to complicate other factors whereas when prescribed and managed properly in the context of a solid diagnosis this medication has a usefulness which is unmatched elsewhere In psychiatry in terms of positive vs negative overall effect