ADHD in France and America

David Cohen
20
1210

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.

20 COMMENTS

  1. As an adult who firmly believes in the existence of ADHD IN ME, who was NOT medicated as a child because my “behavior” was not the problem, my ability to work up to the potential indicated by my intelligence was — no one suffered from my (primarily inattentive) ADHD but ME, so the medical establishment didn’t give a rats ass at the time — I am pissed off by people like this who, by make it harder for me to get medication that HELPS ME subjectively: helps me not feel overwhelmed, indecisive, unable to stay on task and not be distracted, unable to prioritize when I lack appropriate mental or neurological filters that would make some things recede into background. It pisses me off when people who DONT have ADHD deny the reality of those who do. I’m not saying the medications aren’t inappropriately prescribed sometimes, and I tend to dislike ANY psych medications being given to children under 6 (but if you ask me, the REAL crisis we should be paying attention to is this insane push to put preschoolers on HEAVYDUTY ANTIPSYCHOTICS AND SO-CALLED MOOD-STABILIZERS for alleged “bipolar disorder” when these drugs have far worse permanent damaging effects on the brain and metabolism).
    This kind of anti-ADHD propaganda just perpetuates discrimination against people who need stimulant medication to be able to cope with a society that is set up for people who think quite unlike the ways I think; society is not going to change, and I don’t WANT to change myself PERMANENTLY, I just want to be facilitated in *dealing with society the way you jerks have set it up to suit people like YOU.*
    There are some ways in which my ADHD contributes to my creativity, which is why I would not want to be “cured” of it. But as long as I am forced to live in a society set up along lines that favor a very different kind of brain, you’re damn straight I want access to stimulant medication so I can do things “your way” when necessary.

    • I’m sure you find it hard to concentrate at times on things that either you or others think you should concentrate on.

      I have no evidence this is a disease or a disorder.

      I’m sure stimulant medication helps you concentrate. It does that for everyone, though at some cost.

      I am not convinced Dr’s should be prescribing drugs for this.

      You may find Lucy Johnstone’s posts on formulation as an alternative to diagnosis interesting. Her basic argument is that as hardly any mental illnesses have any bio markers and are themselves open to interpretation, so people end up with different diagnosis from different Dr’s why not merely describe the problem the person has, when it started, what the person thinks caused it, what makes it worse and what might help. From this a treatment plan or at least, further conversation might evolve.

    • Appreciate the perspective, and I’ve heard the same from many individuals. But I’m with John on this one – just because a drug helps you with a situation or condition doesn’t mean you’re ill. I raised two “ADHD” type boys and used alternative schooling and some creative discipline to help them succeed drug-free. It can definitely be done, but trying to force “square pegs into round holes” is a specialty of our school system, and is IMHO the main reason for the “ADHD” epidemic.

      You might also want to note that a good percentage of those preschoolers and school-aged kids started out on stimulants before they were diagnosed with “bipolar disorder.” Stimulants make a lot of kids agitated and/or aggressive by boosting their dopamine levels up too high. Rather than realizing they’ve created a monster, most psychiatrists will respond by using “atypical antipsychotics,” which bizarrely enough LOWER the dopamine levels that they’ve provided the stimulants to increase. So we raise dopamine with one hand, lower it with the other, and blame the kid if it doesn’t work out as we’d hoped. Not a formula for success!

      My personal belief is that we need to have a range of classrooms so those who can’t do it “your way” have another way that they can learn and be successful. It worked for my kids. I wish you’d had the chance to be in such an environment yourself, so your real strengths could have been valued instead of diagnosed as a “disorder.”

      —- Steve

      • Steve

        Being a former junior high and high school teacher for fifteen years I have to agree with you about the condition of our educational system in this country. It’s boring as hell. There is little room for individuality and you’d better not act up and cause a bother for the teacher or you’ll end up getting a referral for ADHD drugs.

        I have to say that all through my own journey through the school system as a child I never saw any of the behavior out of my fellow classmates that could be described as “ADHD behavior.” Also, as a teacher who taught for 15 years I didn’t see this kind of behavior out of my students. I had students who wanted to “march to a different drummer” but nothing that would constitute a label of “ADHD.” I always thought that it was normal for high school students to march to a different drummer. Frankly, I don’t believe in ADHD at all. Certainly, there are people who have difficulty concentrating on certain things, and people who are easily distracted and like to think about other things other than what’s in front of them to be worked on. But I don’t see this as an “illness.” It’s just a difference in human beings. Once again, I feel that this is just another example of psychiatry and the drug companies’ pathologizing human behavior for their own benefit. It’s a widening of the “net” that they’ve cast to catch as many people as they can.

        I hope that your boys appreciate what a great dad they have because you refused to put them on the drugs.

    • No, Emma – she said she’s against it.

      “and I tend to dislike ANY psych medications being given to children under 6 (but if you ask me, the REAL crisis we should be paying attention to is this insane push to put preschoolers on HEAVYDUTY ANTIPSYCHOTICS AND SO-CALLED MOOD-STABILIZERS for alleged “bipolar disorder” when these drugs have far worse permanent damaging effects on the brain and metabolism).”

    • I think ADH (not paying attention to what someone else wants them to concentrate on and running around a lot) is what someone does.

      D (disorder) is what the Dr’s and drug companies make their money on

      Dorothy Rowe wrote that when she was an educational psychologist a long time ago before this diagnosis existed she got sent children, mainly boys, who had this sort of behaviour. She said they split into two groups:
      1 didn’t fit into school and were entertaining themselves by being naughty
      2 from troubled homes (eg from refugee homes with traumatised parents)

      there are other eplanations but it’s line I quite like.

      Incidntely, the Beat writters used speed to help them concentrate and write – often for hours at a time (I saw the best minds of my generation…etc etc etc)

  2. What happened to self-discipline and self-control? We were taught both by our parents and teachers when I grew up in the forties and fifties in refugee camps in Germany and later on in France. Nobody ever thought there was anything wrong with our brains when we misbehaved. I was quite a loose cannon at the age of five and my grand mother spent a lot of time to get across to me- lovingly- that this will not do and it is up to me to take control of my behaviour. One of the problems is that parents haven’t got time to bring up their children: they have their careers to think of. Mothers are actively encouraged to go out to work in the UK and those who decide to stay at home and bring up their children are looked down upon. I don’t envy the modern child. We had much more freedom to run around when I was a child

  3. I would like to clarify a few points about France.

    You say:

    “I would say that most mental health professionals and much of the public in France appreciate theories of human development.”

    Or rather, they used to. France had a long tradition of supporting a psychoanalytic approach, with a vibrant community of psychologists and psychotherapists who work as Jungians, Freudians, Lacanians etc. Many people seeking help would still choose their therapists accordingly. In the UK (where I now live) this has disappeared, you get what you get in the public system, and you need to know your stuff to choose a particular approach in the private sector.
    Today, behavioural “tools” (Ah the dreaded toolbox!) are used increasingly. It suffices to see the debate (war) that has taken place around autism and children in France.
    For as long as I can remember the French system has lived alongside the influence of the pharmaceutical industry (I grew up in a medical family) but a healthy distance was maintained. Now psychoanalytical approaches are under severe attack and pressure, partly because of strong stances for more pragmatic approaches (the sooner the person is active again, the better… glorification of productive-tax paying man, some coming from EU programmes for mental health (the cost of “mental illness” is a leitmotiv in the discourse).
    My psychoanalytical friends tell me they are struggling to survive in their profession and my colleague user-survivor friends tell me that as patients, the bio medical approach in psychiatry has pretty much won the upper hand.

    “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.”

    I would take this out of the debate, it is irrelevant to how the medical system views ADHD and other forms of distress. Besides, France’s ranking has been challenged by some. It is meaningless in many respects.

    “Also, it reimburses virtually every drug prescribed to its citizens.”

    Wow, this is another of those rose-tinted views. The French social security system is extremely complex with a base rate of reimbursement and for some, the possibility of not having to advance the cost of seeing a doctor/treatment/medication.
    However, there is a significant and growing proportion of the population still only gets the social security base rate which, at best is 75% of the original cost, but can go as low as 20% for some medication, or nothing at all as not every meds is reimbursed.
    This is because they cannot afford, or can no longer afford, the infamous “mutuelle” a private health care supplementary insurance that compensate for the difference between the social security rate and the actual cost of doctor/treatment/meds etc. Some employers offer the “mutuelle” as part of the contract package, but that is not the norm.

    “In child mental health, the DSM is barely used, but this appears to be changing.”
    The DSM is barely used because they have been using the CFTMEA or Classification française des troubles mentaux de l’enfant et de l’adolescent (French lassification of children and adolescent mental disorders), developed by Prof Misès. It is no better than the DSM or ICD and uses those as a starting point.

  4. ADHD is not a made up disease or syndrom. It does exist. I suffered from it most of my life, and I can tell you it’s had very concrete negative effects. It’s not only about what you do, but mainly about how you perceive and process information both from the inside and from the outside…Which eventually will lead about how you globally interact with the whole world, including yourself. And yes, methylphenidate did improve greatly my condition when I took it….But it also had some very bad side-effects that negated the good.

    I had to stop taking methylphenidate and start looking for some other ways of relief.

  5. David

    I support what you are doing and the thrust of your position on this question.

    I don’t believe in the diagnosis of ADHD but I do believe for some people a more severe presentation of the symptoms may be present. I believe it is much more connected to problems of excessive anxiety. It is not just children being children.

    What is missing from this discussion is identifying the influence of trauma on young people and the long term effects this can cause on children’s ability to concentrate and control behavior. Both witnessing or directly experiencing trauma can set off a chain reaction of very uncomfortable symptoms of distress. Psychiatric drugs are not a solution but part of the problem.

    In addition to trauma there also may be things in the environment such as toxic chemicals or allergies to certain foods or chemicals within food products that may also cause some of these symptoms.

    The ADHD diagnosis is a creation of Biological Psychiatry but some of the symptoms do exist and we need to acknowledge that and find different solutions to what the current mental health system has to offer.

    Richard

    • So basically, what you say is : there’s no such thing as ADHD but some people suffer from it. That is : there are a set of symptoms (=a syndrom), but let’s be careful this cannot be called ADHD. Fair enough, give it any other name you like.

      And above all, please, tell me what can be done to alleviate its manifestation because after years of psychotherapy, nothing came close to the results I experimented with methylphenidate. Unfortunately, this was very short lived due to the toxicity of ritalin.

      If you know of a way of improving the life of people who suffer from ADHD (or from the syndrom wrongly labelled ADHD, I don’t care)please let us know.

  6. Tyler

    I would not pretend that I could offer you specific solutions to the problems you mention in an internet posting. One would have to know details about your life experience,including if there was evidence of trauma or other difficult experiences and related thought patterns that cause underlying anxiety problems.

    All this would have to be combined with a full medical workup by a knowledgeable physician to rule out some type of underlying medical problem. This would have to include tests for hormonal imbalances, allergies or sensitivity to food or other things in your environment.

    Possible solutions would flow out of the above conditions, perhaps combined with consistent healthy food, exercise (perhaps including yoga and walking),daily meditation, and good sleep.

    Having faith in a good medical doctor and therapist who can coach you through this journey would be a good place to start. While internet sources of information and dialogue can be helpful, satisfactory and more complete solutions to your problems is a process that can not be fully realized in this type of forum.

    P.S. Dr. Gabor Mate wrote an excellent book on addiction and he also has a book titled: “Scattered: How Attention Deficit Disorder Originates and What You can Do About It;” it might be worth checking out.

    I wish you the best, Richard

  7. Thanks for your time, thanks for your answer.

    What brought about my slightly agressive comment to your original post is the repetitive denial people suffering from ADHD will encounter. Quite often they can hear that ADHD does not exist. Really ? What could this mean ? Do we fake our shortcomings ? Are we so bored that we want to waste our time in doctors’ places ? So unruly that we are ready to ruin our careers, relationships and lives just because we don’t have self-discipline ? That’s what these denials seem to imply. And that’s most upsetting. Obviously, that is not what you mean.
    Obviously that is far from the truth. I’m going through this and I can tell you that ADHD is far more complex than “lack of discipline” or “ill will”. I struggle every day with a deficient sense of time and space for instance. This is very much real and has nothing to do with “lack of will”.

    And as I said, during a few months, ritalin seemed like a miracle to me. Unfortunately that medication is dangerous and I had to give it up.

    If ADHD “does not exist” then there is a need for another name more accurately descriptive of the syndrom I suffer from as there is a need for more appropriate and efficient treatment. Until then what I could read about it seem to describe fairly well my plight, although I cannot be sure of its etiology.

    Thanks for your attention
    Tyler

  8. Well, may be ADHD is not the right name….But surely a name is needed to understand what is to be adressed and how to deal with it ?

    I don’t know about all this alternative to diagnosis stuff. All I wonder is how to take into account the reality of the disease and how to treat better people plagued with severe adhd symptoms.

    As for doing what you said, that is “more accurately describe the problems you face why not just describe these problems, talk over what might have caused it, when things get worse and when they get better and then think about what might help”, I’ve been trying to do it for years and some symptoms just won’t go. When I got diagnosed with adhd, ritalin quickly helped me recover some “common sense” concerning time, space and organisation when nothing else had helped that way.

    So once again I wonder : how getting rid of the ADHD label is going to help improve sufferers’lives ? What solutions can be put forwards then ?

  9. I was wondering if I can be forced to give drug to my kid? The school been pressuring me since the grade 2 and he’s now in grade 7. I ‘ve been reading your post and it’s been a real help. My son does well academically but the complaints from the school is that he is fidgety and sometimes talk without the right to talk( impulsive) and have a hard time to stay on task for a long period of time. I really don’t want to medicate him and my son don’t want either. Each year,, at the end of the school year ,the school ask for a meeting and they go on and on ,how he is disturbing the class ect….making me feel like i’m a terrible mother and making it so obvious to me that their goal is to try to change my mind. The psychologist last year compared ADHD to diabetes and that if I don’t medicate him he would probably ;quit school, get into illegal drugs and be more at risk for suicide. Using this fear tactic almost worked,,,, because what mother wouldn’t do anything to prevent that outcome right??She also said that the information that i’ve been reading are false( witch she does not know the information I’d read in the first place) and said that parents like me that don’t want to medicate is because of misinformation. At the end of the meeting she offered me ‘” her “trustable “website information that I refused , because I said to her I do have trustable studies from different pediatrician and neurologue. Through the years I been changing the diet, given supplements and involving him in sports . The change that made the greatest change for him was the elimination of colorant and also the magnesium supplement. I just starting him on Zinc recently I ‘m hoping it will help too as alot swears by it . Sorry for the lenght of my post . Thank you to take the te to read it and give your opinion 😉