ADHD in France and America
Recently, a Canadian journalist researching the topic of ADHD in France asked me a few questions by email. This is an expanded version of the exchange.
Can you explain your views on ADHD diagnosis and medication?
Today, a diagnosis of ADHD given to a child or an adult is first and foremost a socio-legal justification to give that person a stimulant drug. Concerning children specifically, the DSM ADHD diagnosis is just the name given to the inconvenient behaviors of children in settings that expect them to stay on task and to perform on time. These behaviors were supposed to identify children whose brains are diseased, but they haven’t. Still, many experts and many parents believe that children who don’t conform this way are actually sick rather than merely different, under-achieving or not well-suited to schools. They also believe that these children should be changed by drugs until a better cure comes along — but they fail to recognize how drugs don’t appear to change children in the desired directions at all in the long term. Experts also seem unconcerned that the head of the DSM-IV Task Force publicly confessed to “creating a false epidemic” of ADHD by hugely expanding the definition of ADHD in 1994.
Are you concerned about over diagnosis? Why or why not?
Because I see the diagnosis of ADHD as an example of medicalizing a series of ordinary problems faced by schools and families, and because I think that medicalization’s main effects are undesirable — for example, it weakens the vitality of a culture — then yes I am very concerned. We now have 40-plus years of diagnosing and medicating children for ADHD in the US, and at a population level there’s no evidence that US kids are mentally or cognitively “healthier” than kids in other societies: on virtually every outcome of child well-being and education, the US lags behind many other modern nations. Many factors are at play here, of course, but I suspect this relative decline started with the introduction of the ADHD label in DSM-III in 1980. How that evolving label intertwined with the changing nature of education in the US is a story that has yet to be written.
In any case, societies differ in how they respond to globalizing trends to diagnose and drug children to change behavior. So there is no over- or under-diagnosis: just different ways to raise and socialize children and different ways to identify and manage those who don’t fit well in the main institution designed just for them.
Do you believe any children have ADHD?
I don’t believe anyone “has” ADHD because ADHD is not a property of a living system. It’s an attribution. There has never been a single objective biological sign in the criteria used to diagnose ADHD, like there is say in the criteria used to diagnose influenza. People diagnosed with ADHD share only the fact that someone at some point believed they needed a stimulant drug or some extra educational or other attention, or excuse, that required being recorded formally somewhere.
You recently spent some time in France. How does their view of ADHD, and perhaps mental health in general, differ from ours?
I would say that most mental health professionals and much of the public in France appreciate theories of human development that situate a problem behavior in context, rather than see it mainly as a sign of a disordered brain. I think that most professionals there would see distractibility and inattention of a child in school as saying less about the child than about the responsiveness of the school to that child or the family’s adaptation to the demands of school and society. In France, no stimulant prescriptions are allowed to children under six years, while first prescriptions must be from hospital-based specialists. Prescription to youths only began in 1995; it’s grown much since then, but remains at around 1.5%, compared to about 10-20% in the US and Canada.
Does that differ from Europe as a whole?
Europe today includes about 45 countries, each one arguably with a distinct main culture. Different educational systems exist, different degrees of penetration of pharmaceutical company marketing, different impacts of parent groups promoting drugs discussed in world media, different support for women and for families, and so on. Italy seems to share the dominant French view of ADHD as indicating a malaise in family, school, and social systems. It allowed prescription starting only in 2004, rates today are even lower than in France. The UK is another story altogether: although prescriptions started there in the mid-1990s, like France, they’re five times higher. The Scandinavian countries appear quite accepting of medication and have a strong biological orientation to developmental problems, but this is compensated by highly evolved social welfare and educational systems. The former Eastern Europe may be in a state of ferment about ADHD, probably due to major pushes by drug companies. Around the world, the ADHD scene is constantly mutating and what we see today may be obsolete tomorrow.
Why is the French view so different?
Here are some factors that I believe contribute to the French difference, but no list may be exhaustive. To appreciate why I call this a cultural difference, keep in mind that France has the most accessible and best performing health care system in the world. Also, it reimburses virtually every drug prescribed to its citizens. And, French adults use more psychoactive drugs than most of their neighbors. Yet they sharply draw the line at medicating kids with such drugs.
In France, parental leaves for childbirth are generous. An extensive early child care system is in place. Every legal employee enjoys several weeks’ paid vacation each year. All this promotes bonding of parents and children throughout the early years. Schools, for their part, are very protective of what they see as their mission: educating children and shaping citizens. This makes them disregard parents’ demands, I think. There is also plenty of recess in elementary schools. Nutrition is taken quite seriously in school cafeterias. In child mental health, the DSM is barely used, but this appears to be changing. Finally, and very important, a public infrastructure is in place, staffed mostly by psychologists, for providing psycho-social interventions for children and families facing various hardships, so that medication almost never appears as a first option. Diagnosing a seemingly specific problem as residing inside a child is simply unnecessary to secure some assistance for that child or family.
Are there any anecdotes that stand out from your time in France?
In 1995, I remember that the elementary school gate where my daughter was starting pre-school had a prominent sign on it that read, “No medications allowed on school grounds” (and they were referring to regular meds, as stimulants were barely a whisper then). In 1998, when controversies about Ritalin were raging in Canada and the US, I recall that the main health journalist of a leading French daily had never heard of the drug. When she looked it up in the official drug reference book on her shelf, there was a skulls-and-crossbones icon next to its name to highlight its dangers. Last year, when I interviewed a child psychiatrist in Poitiers on how she assessed children referred to her, she stated that, given French law forbidding prescriptions to pre-school children, “the issue of medication just doesn’t come up at all when I work with families. It’s all about helping parents work effectively with their child.”
You’re from Canada but live in the States – do you have a sense of how Canada and the States differ in their views towards ADHD? And why are they different?
My own reading is that there’s little difference between the two countries in views about ADHD (“a neurobiological disorder”) general patterns of medicating children with psychoactive drugs, or in teachers’ lack of critical thinking about the ADHD propaganda they have been fed for decades. The discourse about it in professional and popular media also seems fairly similar in both countries. If so, the explanation might be simple: although Canadian health and welfare policies may be more advantageous to kids at a population level compared to the US, Canada remains the first and most willing recipient of US trends and ideas in all fields, and the US remains the epicenter of the ADHD enterprise.
I get the impression you believe American parents should be concerned. Should Canadians be concerned as well? Or does Canada have it right?
Everyone should be concerned because the way a society treats its children expresses what it believes is important for its own future. Just over a century ago, we were still sending young children to work in factories, because we believed that nothing was more important than manufacturing goods and that everything in a society should be harnessed to that goal. Eventually we smartened up, passed child labor laws and today we look upon child labor as institutional child abuse. That American and Canadian societies are drugging at least one tenth of their children to change their behavior in schools and homes saddens me and scares me because it suggests that we believe everything in society should be harnessed to minimize performance and temperament differences between individuals. Not so long ago we were celebrating individuality. We’re now engaging in suppression and negation of individuality on a mass scale.
This field is rapidly changing – has your view on the issue changed since you wrote your first book?
It’s unclear to me how much the field really has changed. You know the adage, “The more things change…” For instance, stimulants have again become the rage among young adults in the US.
I’ve gained a deeper appreciation that the urge to medicalize annoying behavior fulfills so many interests: from corporate pharmaceutical interest in expanding markets, to schools’ interest in managing kids without kicking them out of school, to parents’ interest in avoiding blame for their kids’ mismatch in school, and other interests. Everyone gains (at least in the short term), except the children. But I still think that stimulant drugs have long held a privileged place as performance enhancers in many societies, and always will. Many people like them, and today many parents obviously want to give them to their children.
Probably, we should more openly discuss the desire for performance enhancement by drugs or other means as a social and ethical phenomenon. In sports, we ban them outright. Should we do so in education? Or do we make stimulants even more widely available, like we’re doing in some places with hallucinogens like cannabis? This complex societal decision-making involves coming to terms with the morality of psychoactive drug use for its own sake, as well as adults’ access to drugs in a democracy. We muddle and delay this coming to terms, we create contradictions that have huge consequences, when we invoke pseudo-medical justifications like the ADHD diagnosis to justify access to stimulants.