In recent years, different experts, as well as representatives of the associations of users of psychiatry, have increasingly been arguing – with ever-greater insistence – that the French system struggles with an abnormal delay in diagnosis; particularly with regards to autism, bipolar disorder, and ADHD. This opinion is often voiced in public lectures, found on websites and information leaflets and – to make it more convincing – is usually accompanied by diagrams and statistical data. A delay in diagnosing these conditions means that certain opportunities are missed and thus patients suffer. The problem allegedly mostly concerns the state-run outpatient therapy centers for children (CMPP) and adults (CMP), which often use as their reference the classic psychiatric clinic, the French CFTMEA classification, and psychoanalytic theory.
Although they are not always named explicitly, it is precisely these references that are accused of causing the diagnostic lag. The argument is often supported using patient and parent testimonials; sometimes the accusations are more straightforward, targeting the “psychoanalytic lobby” directly. I would like to examine the strength of this argument by taking ADHD as an example.
ADHD is a mental disorder which was first included in the third version of the DSM. It replaced the old categories of instability, hyperkinesia, and hyperactivity. It emphasizes quality of attention – primarily attention that can be associated with hyperactivity and impulsivity.
There are several reasons for this focus on attention (Though I am only going to look at those that I find most important): Attention as a pedagogical value (student attention); As an economical value (consumer and client attention); As it allows us to expand the disorder to include girls, teenagers and adults who are less concerned by hyperkinesia; As it is studied by modern neuropsychology and, most importantly, As it responds to methylphenidate (Ritalin, Quasym, Concerta) or, in some countries, Vyvanse.
The concept of ADHD has not been given any scientific proof and despite the hundreds of millions of dollars spent on research, its proponents are not ashamed to say “we have found nothing, but there is a consensus about the delay in the maturation of certain areas of the brain.” In other words, they produce laughably general claims, which are simply ideological and completely lack scientific rigor. Although the diagnosis of ADHD is not based on any scientific foundations, it has been presented as a neurodevelopmental and often simply neurological disorder. Hypotheses presented as reality.
And yet, why only neurodevelopmental, rather than psycho-developmental, educational-developmental or context-developmental? It is probably to “naturalize” the disorder; to suggest that everything has to do with the brain, and is therefore likely to respond to drugs as well as pedagogical and psychological support measures. The latter two are nevertheless seen as secondary – or at least increasingly so in everyday practice – despite all the safety precautions and official claims.
But allow me to return to the question of diagnosis.
What happens when parents are told their child has ADHD? Generally – but of course not always – the first reaction is relief (though I see many parents who later become disappointed or worried), especially if prior to this they were sent from one practitioner to another without receiving any clear information or if the previous form of care did not suit them – in other words, if the transference of therapeutic alliance failed to emerge. They are now seen by professionals — who seem to work in a scientific manner, using assessment tests, neuropsychological exams or even brain imaging — and who are therefore perceived as competent and up-to-speed.
Finally, as a result of being told which “illness” their child suffers from, the parents understand that they are not “bad parents” but only had been seen by the “wrong people,” which is what caused the diagnostic delay. This – somewhat simplified – is what happens in most cases.
How should we understand this feeling of relief?
On the one hand, the diagnosis acknowledges the suffering of both the child and the parents. However, it also objectifies it, thereby relieving any feelings of guilt. In addition, it produces a placebo effect – our child can be helped by science – creating an expectation and a therapeutic alliance. Nevertheless, this placebo effect of the diagnosis would not last very long if it were not for synergy with a drug that “works”: methylphenidate. However, this medication is simply a legal and controlled drug; it is not a remedy in the sense of curing a disorder. Strictly speaking, we should understand it as a kind of comfort solution, more like a study drug. Yet for a third of the children diagnosed with ADHD, its short-term efficacy is undeniable.
This means that what ADHD proponents present as validation of a diagnosis of a real and treatable disorder is in fact a placebo effect caused by an ostensibly scientific label, which exists in synergy with an efficient, legal drug.
The ADHD label produces this placebo effect because its diagnosis is based on behavior that in reality could be observed by anyone. What is observed sounds “scientific”; it is easily understandable and highly obvious. When the diagnosis is turned into an action plan, we forget that there is nothing scientific about it and that its evaluation is purely subjective and clinical; that it creates a great many false positives, and that a drug prescribed in half of the cases indeed does have serious side effects.
ADHD works — as a social construction. Telling parents that their child suffers from a neurosis would either mean nothing to them or, worse, they would feel incriminated — which would prevent the transference relationship from forming, with no hope of a placebo effect. The behavioral diagnosis clearly has an advantage here, especially because what today’s society increasingly demands from child psychiatry is to simply sedate certain types of behavior. To deny this dogmatically, as some would like to do, changes nothing and instead prevents us from reacting appropriately; for example, creating the impression that we wish to blame the parents who have agreed to their children being medicated.
When we speak about a delay in diagnosis, the diagnosis in question is a behavioral diagnosis, with its placebo effect and its legally sanctioned drug use.
But, after all, what should our answer be?
In his 1979 Closing remarks, published in Lettres de l’Ecole 25, Lacan said:
“So how does it happen that through the operation of the signifier, there are some people who are indeed cured? Because that is precisely what happens. It is a fact that some people do get better. Freud emphasized that the analyst should not be possessed by a desire to cure; but it is a reality that there are people who indeed are cured, cured of their neurosis or even perversion. How is it possible?
“Despite all that I may have said about it on different occasions, I have no idea. It is a question of trickery. How do we whisper to a subject who comes for analysis something that has the effect of curing him is a question of experience, which involves what I have called the subject supposed to know. A supposed subject is a doubling. A subject supposed to know is someone who knows; he knows the trick, because I have on occasion spoken about tricking; he knows the trick, the way one cures a neurosis.”
To conclude, we could say that the advocates of ADHD and of the biological-behavioral current in psychiatry have found their trick. It is their own kind of trickery, but as opposed to Lacan’s approach, they do not attempt to theorize it, but instead simply to deny it. The doubling that happens here is of the “subject supposed to know” that the trick – the drug – works.