Most epidemics are the result of a contagious disease. ADHD – Attention Deficit Hyperactivity Disorder – is not contagious, and it may not even be a genuine malady, but it has acquired the characteristics of an epidemic. New data has revealed that UK prescriptions for Ritalin and other similar ADHD medications have more than doubled in the last decade, from 359,100 in 2004 to 922,200 last year. In America, the disorder is now the second most frequent long-term diagnosis made in children, narrowly trailing asthma. It generates pharmaceutical sales worth $9bn (£5.7bn) per year. Yet clinical proof of ADHD as a genuine illness has never been found.
Sami Timimi, consultant child psychiatrist at Lincolnshire NHS Trust and visiting professor of child psychiatry, is a vocal critic of the Ritalin-friendly orthodoxy within the NHS. While he is at pains to stress that he is “not saying those who have the diagnosis don’t have any problem”, he is adamant that “there is no robust evidence to demonstrate that what we call ADHD correlates with any known biological or neurological abnormality”.
The hyperactivity, inattentiveness and lack of impulse control that are at the heart of an ADHD diagnosis are, according to Timimi, simply “a collection of behaviours”. Any psychiatrist who claims that a behaviour is being caused by ADHD is perpetrating a “philosophical tautology” – he is doing nothing more than telling you that hyperactivity is caused by an alternative name for hyperactivity.
There is still no diagnostic test – no marker in the body – that can identify a person with ADHD. The results of more than 40 brain scan studies are described by Timimi as “consistently inconsistent”. No conclusive pattern in brain activity had been found to explain or identify ADHD.
The diagnosis, in other words, is simply a label to attach to certain behaviours – not an explanation for what may have caused those behaviours, or an indicator of any physiological difference to a non-sufferer.
Matthew Smith, senior lecturer in history at the University of Strathclyde, and author of Hyperactive: The Controversial History of ADHD, goes even further in his criticism of the medical orthodoxy. He believes the diagnostic threshold is now so low that it has led us to a place where we have pathologised naughtiness as a mental disorder requiring medication. “And not just naughtiness,” he adds. “All sorts of children, simply those that daydream and don’t pay attention, could now be diagnosed with ADHD and placed on medication.”
Timimi sees it specifically as a pathologisation of maleness (boys tend to find it harder to sit still in a confined classroom), while a report in Time magazine cited a psychologist describing the symptoms of ADHD as “everything that adults don’t like about children”.
The most popular remedy is methylphenidate hydrochloride, or Ritalin, which is by no means a mild medical intervention. Professor Tim Kendall, consultant psychiatrist and member of the group that developed NICE’s clinical guidelines on ADHD, has said: “If you take Ritalin for a year, it’s likely to reduce your growth by about three-quarters of an inch… I think there’s also increasing evidence that it precipitates self-harming behaviour in children, and we have absolutely no evidence that the use of Ritalin reduces the long-term problems associated with ADHD.”
So why, if the evidence for the disorder is so shaky, and if the medication has significant drawbacks, with NICE explicitly not recommending drugs as a first-line treatment for school-age children, is Ritalin prescription on an ever-increasing curve?
Scepticism towards ADHD as a phenomenon tends to be silenced with a simple retort: “Ritalin works.”
And it does. A child who is inattentive, impulsive, and struggling at school, given Ritalin or another similar stimulant, will often demonstrate a marked improvement in behaviour and academic attainment within days.
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This explains the popularity of these drugs with teachers, parents and the majority of child psychiatrists. The benefits are plain to see. Doesn’t this easily observable effect destroy the delicate caveats and philosophical objections of the anti-ADHD argument?
Timimi’s response to this is nuanced, but persuasive. “It depends what you are looking for. If you’re looking for a short-term improvement in concentration, then with Ritalin, you will meet with an 80 per cent success.” Ritalin works similarly on the human body to other, more powerful stimulants such as speed or cocaine. It produces “psychological tunnel vision – you get absorbed in whatever you are doing – which is why coca leaves were traditionally chewed by manual labourers in South America, and why people are drawn to recreational drugs at a rave”. This explains the seeming paradox of why a stimulant can cure hyperactivity, and accounts for rapid improvements in focus from easily distractable children.
Timimi doesn’t discount the short-term “success” of these drugs, but points to long-term follow-up studies which have looked at adolescents and young adults eight years on from a prescription of ADHD medication. These found “no advantages on any outcomes” compared to non-medicated children, while the medicated subjects had ended up both shorter and lighter (these drugs are appetite suppressants), and with marginally higher rates of delinquency.
Matthew Smith adds that a stimulant drug wouldn’t just improve the educational performance of those with an ADHD diagnosis. Every student would show improved focus and productivity. Equally, if we all took steroids, every one of us would be better at athletics. But nobody seems to be advocating that.
This is why Ritalin has a value for students who want to cram for exams. A University of Maryland School of Public Health study has stated that 31 per cent of college students now resort to the “non-medical use of prescription stimulants” to help with their studies, and this problem is known to be spreading to the UK. Drug cheats in sport are universally vilified; in academia – where results actually matter – the practice is silently tolerated.
The marketing might of Big Pharma has successfully swept aside these objections and concerns. The short-term “Ritalin works” argument has prevailed, initially in the USA, then across Europe, now increasingly among the aspirational middle classes of China and India. The geographical spread of ADHD points to a cultural change in attitudes towards childhood that goes hand in hand with the victory of neo-liberal economics.
Sami Timimi sees ADHD as a “cultural barometer” of society’s attitudes towards children. We think of ourselves as being increasingly tolerant towards children, but the rise in medication for the young is an indication of the opposite trend. “In some cultures, children are loved unconditionally,” he says, but in the West we have a more “performance-oriented approach, where children are valued primarily for their achievements. At the same time, educational demands on children are rising”.
This is an approach that we are now exporting to the East, and with it, a medical “solution” for those children who can’t keep up with the rising pressures.
Matthew Smith points to Finland as a rare instance of a country moving in the other direction. Formal schooling there starts at seven. The country has a very low rate of ADHD. When the behaviours that we identify as ADHD are displayed by a Finnish child, they are likely to be treated behaviourally, without drugs. Finland is usually within the top three on international tables of school-leaving attainment.
As British schools become more standardised, and British schoolchildren more frequently tested, with their teachers under ever-increasing pressure to meet “value added” targets for their pupils, it is to be expected that inattentiveness will be greeted with rigid intolerance. In an educational environment where somebody must be blamed for any underperformance, it is hardly surprising that teachers are keen to find an “additional needs” label to attach to the child who won’t conform in the schoolroom. In a judgmental world, where parenting is now almost a competitive sport, parents, too, can find absolution in an ADHD diagnosis, which points the finger of blame for educational underperformance away from the parent and the child, and on to the child’s genes.
The more obsessed a culture becomes with attainment and success, the more afraid we are of the blame that will be apportioned to those children (and their parents) who fail to triumph. An ADHD diagnosis points the finger of blame away from diet, food additives, excessive screen time, emotional problems, distracted parenting, conformist and unimaginative schooling, peer pressures, social media-exacerbated friendship anxiety, lack of exercise, or any of the other multitude of factors that might be causing a child to become disruptive, aggressive, or uncooperative.
All the avenues of help that might come the way of a child in, say, Finland, who is exhibiting behavioural signs of distress, are shut down by the quick and convenient solution of slapping on the ADHD label and prescribing a stimulant.
Sami Timimi’s clinic in Lincolnshire advocates a group therapy approach that focuses on “relationship building” rather than “behavioural control”, using some of the techniques of NHA (Nurtured Heart Approach) therapy, which involves teachers and parents in a process of developing strategies to transform negative behaviours into positive behaviours. Timimi hasn’t prescribed Ritalin to a single child for five years, and claims a 76 per cent “clinically significant improvement” rate among those patients he discharges.
But within the UK, he is a rarity. Most parents stand little chance of finding an NHS physician who will take a comparable approach to their child’s difficulties. Nobody denies the reality of those behaviours that are currently labelled as ADHD, nor of the challenges of helping a child to overcome them. The question is simply one of how these children should be helped.
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We must also question not just the behaviour of the children in question, but the behaviour of adults towards those children, and how that may be exacerbating the problem. Those people who find as adults that they dislike desk work, and are better suited to practical, physical or outdoor employment are respected, valuable and often well-paid members of our society. Yet as children in today’s education system they are likely to be labelled as inadequate or, under the banner of ADHD, mentally defective. This casts a shadow, in terms of expectations and self-esteem, that can last a lifetime.
“Faulty genes” is a quick and easy explanation that often satisfies parents, teachers and even children in the short term, but once you internalise the idea that your brain is endemically faulty, your sense of self may be changed for ever. A recent parody on the satirical website The Onion superbly crystallised this medical demonisation of unusual behaviour, with the headline “Ritalin Cures Next Picasso”, and a story in which delighted parents say: “The cured child no longer tries to draw on everything in sight, calming down enough to show an interest in television.”
This makes the serious point that daydreaming, distractable children may be highly creative. Their own thoughts might seem more interesting than the words of their teachers and parents because, in fact, they are. To medicate this away is nothing short of cruelty.
A BMJ article in 2012 posed the question, “Has Ritalin replaced the rod?”, pointing out that the children who are being drugged today would have been beaten 50 years ago. Could it be that our “cures” for ADHD are just the latest in a history of strategies for forcing children to comply with adult demands?
Yet none of these doubts about the ADHD juggernaut come close to the greatest scandal of all. I was originally drawn to this topic as a novelist following a single conversation with a consultant child psychiatrist who related to me a professional worry of hers. She was concerned that some families might be pushing for a Ritalin prescription for their child not because of genuine medical worries, but because an ADHD diagnosis makes a family eligible for Disability Living Allowance.
This statement horrified me. I had to confirm that I hadn’t misheard, and that she was genuinely telling me we live in a state that effectively pays parents to drug misbehaving children. This sounded to me more like science fiction than a political reality, but she confirmed this was the case, adding that she had occasionally encountered parents who refuse to accept medical advice to diminish the dosage for their child, which aroused suspicion that they feared the concomitant reduction of their DLA payments.
This discovery led me towards writing Concentr8, a novel set in a seemingly fantastical London where a mayor has instituted a programme to push out a behaviour-modifying drug on increasing numbers of misbehaving children and teenagers. Non-fiction extracts open each chapter, slowly revealing this world to be far closer to reality than one would like to believe.
Experts like Timimi lay the blame for the epidemic on a “cultural colonisation”. When he first trained, there was an extremely rare ailment named “hyperkinetic disorder”, now ADHD in common parlance, with coverage appearing everywhere in magazines, newspapers and, in the last month, even a Coronation Street storyline. This has a huge effect on diagnostic rates.
Highly authoritative voices, particularly in America, back up all the Big Pharma claims, their authority barely diminished by numerous scandals exposing undeclared pay-offs. It takes inside knowledge to tell drug marketing from impartial medical advice when leading experts in the field, such as Joseph Biederman of Massachusetts General Hospital and Harvard University, are exposed as having earned $1.6m (£1.02m) in consulting fees from drug companies between 2000 and 2007. There is also Dr Frederick Goodwin, former director of the National Institute of Mental Health, who, as James Davies has reported in Cracked: Why Psychiatry is Doing More Harm Than Good, “was reported to have earned at least $1.3m between 2000 and 2007 for marketing lectures to physicians on behalf of drug companies. He did not disclose this to relevant parties such as national media outlets, where he’d been invited to speak publicly about drugs.”
There can be little hope that the ADHD epidemic will abate. The voices telling parents to medicate are powerful, respected, and backed up by supremely well-financed marketing. The ADHD sceptics are a quiet sideshow by comparison, but they are presenting an argument that should be more widely circulated.
The pharmaceutical/medical industry teaches us that whatever the problem, a pill is the answer. This notion is becoming so all-powerful, and so locked together with a pressurised, exam-centred, conformist educational system, that every parent who has a misbehaving or inattentive child may now find themselves pushed towards a diagnosis of ADHD. If you haven’t encountered the anti-medication argument elsewhere, you are unlikely to hear it from a doctor.
The behaviours associated with ADHD are real, and the problems they cause can be very hard to live with. Yet however desperate they are for help, all parents should be cautious and sceptical about the “cure” they are likely to be offered. Equally, children should be reminded that “failing” at school is not failing as a human being. Many of the most creative and successful people only find their path through life in adulthood. Being different is not an illness.