The ADHD Dilemma: Looking Beyond Big Pharma

Claudia Gold, MD
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Alan Schwarz aligns himself with the current mental health paradigm by opening his new book ADHD Nation: Children, Doctors, Big Pharma and the Making of an American Epidemic with this statement: “Attention deficit hyperactivity is real. Don’t let anyone tell you otherwise.” (The book will be released September 6th- this article draws on the New York Times book review of August 22nd)

However, later on in the book he captures the fallacy of this disease model when he quotes a clinician:

“We’ve decided as a society that it’s too expensive to modify the kid’s environment. So we have to modify the kid.”

Contemporary research shows us that efforts to locate a problem either in the child or in the environment are misguided. We now have detailed knowledge of the complex interplay of biology and environment that lead us to a new and different paradigm from the prevailing disease model of mental illness.

Sigmund Freud’s revolutionary ideas emerged out of the darkness of psychiatric care predominated by asylums and mostly ineffective, sometimes bizarre forms of treatment. His original insights, both that symptoms have unconscious meaning and that emotional suffering often has origins in early childhood, led a new generation of clinicians to listen carefully to their patients in the practice of psychoanalysis.

With the advent of the DSM, the so-called “bible of psychiatry” and modern psychopharmacology, the pendulum has swung back to a biological view of mental illness, supported by significant success of pharmacologic intervention. However, an exponential rise in psychiatric diagnoses and prescribing of psychiatric medication in adults and children indicates that a new paradigm is now needed.

Contemporary research validates Freud’s original observations, elucidating not only how adverse early childhood experiences result in long-term negative health consequences, but also the mechanism by which these experiences get into the body and brain. This research is subsumed under a new discipline—infant-parent mental health—that integrates current research at the interface of developmental psychology, genetics, and  neuroscience into a model of prevention, intervention, and treatment.

As I present in my forthcoming book The Developmental Science of Early Childhood, the infant mental health paradigm offers a model for understanding human experience from infancy through adulthood. The discipline represents a paradigm shift from treatment of disease to promotion of health and resilience. 

The DSM categories represent collections of behaviors or symptoms. While we have some knowledge of genetics and brain structure and function that underlie these behaviors, they are not well-defined biological processes.

Letting go of the need to make a diagnosis is not easy. Our entire system of health care is organized around the diagnostic model. However, as I argue in my book The Silenced Child, in our current climate of mental health care these diagnoses can get in the way of listening to a child’s communication. As we learn more about the developmental science, we increasingly recognize that psychiatric diagnoses as organized by the DSM are constructs in a conceptual framework that is outliving its usefulness.

When seen from this contemporary perspective, ADHD is no more “real” than any other so-called “disorder” described in the DSM.

The latest research by Peter Fonagy, psychoanalyst and director of the Anna Freud Centre in London, leads us to focus not on “what is the disorder” but rather “what makes us well?” In a brilliantly laid out argument, Fonagy and colleagues present the concept of a “p” factor that is common to all forms of mental suffering now categorized under the structure of mental health “disorders.”

Connection is central to our humanity. It regulates our physiology and protects against the harmful effects of stress. Its absence, the profound aloneness that accompanies difficulty in communicating with others, is the common factor underlying all forms of mental distress. As Fonagy writes:

“In that sense, many forms of mental disorder might be considered manifestations of failings in social communication.”

In a questioning of the current paradigm of mental health disorders he continues:

“The p factor concept convincingly explains why, so far, it has proved so difficult to identify isolated causes, consequences, or biomarkers and to develop specific, tailored treatments for individual psychiatric disorders.”

While medication may have role to play in alleviation of symptoms of inattention and hyperactivity, the real solution lies in recognizing our basic human need for connection. We need to shift our attention from diagnosis and treatment of disorders in children to insuring that all children and their parents feel heard and connected to the larger social world.

26 COMMENTS

  1. I agree with everything that you say except that I believe that you are prejudiced against understanding the plight of your clients based on your medical school education. Psychiatrists may know many details about “the complex interplay of biology and environment” but psychiatrists do not understand this interplay and it is wrong to imply otherwise. Distressful experiences especially during childhood cause emotional/mental suffering; this is natural, normal biology that affects some areas of the brain more than other areas. Pathologizing natural emotional suffering from distressful experiences seems like a bigger problem for emotional sufferers than identifying distressful experiences as the cause of emotional suffering.

    Best wishes, Steve

  2. Yes, Alan Schwarz “aligns himself with the current mental health paradigm…”. As does the author of this post when she says, “medication may have [a] role to play in [the] alleviation of symptoms of inattention and hyperactivity…”

    No. Powerful cocktails of psychotropic drugs should have NO “role to play” in the brains and bodies of children. Drugs treat and heal nothing, and are now (finally) being seen to cause lasting damage to the developing brain. Drugs are used on children simply to tranquilize so-called “hyperactivity” and control so-called “inattention”. Psychotropic drugs also pave the way for more drugs as years go on, and pharma consumers have been created anew.

    Very disappointing to read authors who support the drugging of children in MIA.

    MIA did publish an excellent, critical, thoughtful post by Patrick Landman, MD on the subject of “hyperactivity” and “inattention” here last year that is well worth a read:

    https://www.madinamerica.com/2015/11/hypermodern-hyperactives/

    Liz Sydney

    • The author also says, “With the advent of the DSM, the so-called “bible of psychiatry” and modern psychopharmacology, the pendulum has swung back to a biological view of mental illness, supported by significant success of pharmacologic intervention.”

      The “significant success of pharmacologic intervention” has been shown to be a total misrepresentation of the facts. Children do no better academically, their growth, development and self esteem suffer, and there is increased likelihood of all sorts of difficulties in later life.

      The closing paragraph, particularly, “While medication may have role to play in alleviation of symptoms of inattention and hyperactivity,….” falls back on the belief that these mind altering DRUGS (and that’s what they are) actually help the child….they don’t, they may help the adults who have failed to attend to the child’s needs adequately, but they damage children. They also help doctors perpetuate the belief they have something to offer in this field, and make lots of money for both them and pharmaceutical companies.

      As Liz states above, there are far better sources of information on the mythical “illness” of ADHD.

      Promoting the drugging of children is offensive.

    • Thank you! I was thinking the same thing about that phrase “While medication may have role to play in alleviation of symptoms of inattention and hyperactivity”

      Why do so many of the articles I read here, that are otherwise hopeful, include concession language about the drugs? Why do the authors feel the need to give the drugs a nod at all? I really don’t understand this.

  3. Sometimes the language in the articles and replies is hard to follow, but I think this article really captures what others on this website have said, that the social and emotional connections in childhood really are what causes later mental distress. And the distress is a reaction of the brain to an unnatural environment, and not something wrong with the “hardware.” And the point of trying to work at prevention is also very important. But it is hard for people to just read about how to provide the right environment for their children and then actually do it. And it seems very hard to provide a way to remedy mental problems once they happen, but I think that the social and emotional connection remedy, if it can be done, is vastly better than even considering medications. My own mother lived most of her life on several meds for schizophrenia. It is too bad that some other kind of help was not available. For some reason I will never fathom, it seems like we do just about anything for people with problems other than the one thing that will really help them, and I think this article kind of makes this point.

  4. Claudia Gold, Yes there is truth in what you say, but I still do not agree with what you are doing. Yes, you cannot separate nature and nurture, or biology and environment, and yes DMS and drugs are bad. But you also cannot try to prescribe a hygienic environment. Child development specialists are part of the problem, not part of the solution.

    There always needs to be a ready capacity to intervene in families, otherwise children are sacrificial victims. Sometimes this intervention can be moderate, and other times no, it must be extreme and it needs to be followed up with punitive actions against parents.

    Doctors can be fired. But punishing parents in the civil courts is rare. And so much of what effects children is well described as Munchausen’s by Proxy, scapegoating.

    Middle-class parents use pedagogy manuals, and they use child development theory, to make themselves right. And the thing which makes the middle-class different is that they have children deliberately, in order to gain for themselves prestige and power. And this is why we have pedagogy manuals and child development specialists. They serve the needs of the parents.

    Until we start holding these parents, and all the doctors who help them, accountable, it will still just be more child abuse.

    Nomadic

  5. “…supported by significant success of pharmacologic intervention. ” Not really. I’d say that the bio model was supported by billions of marketing dollars from the pharmaceutical industry, not from significant success of pharmacologic interventions. Unless you count success in elbowing out the competition and success in making more money in less time and success in drugging a significant portion of the “mentally ill” into inertia and an early grave.

    — Steve

  6. Regarding the supposed success of these drugs, suppressing distress is not “success”. The research for both antidepressants (e.g. Kirsch) and neuroleptics (e.g. Sohler) show that the most these drugs do is suppress severe distress over the short term, and that in the long-term, there is no solid evidence base showing they make people more functional or emotionally well.

    And for goodness sake, if you are going to write an article challenging the disease model, don’t call these drugs “medications.” They are not comparable in any way to insulin or penicillin, which treat specific disease processes and are thus medications in the true sense. These are drugs, tranquilizers, neuroleptics, etc.. but not medications.

    • Research also shows no significant improvement in ANY long-term outcome area for kids using stimulants vs. none, including educational, social, and emotional variables. The only “success” that stimulants have shown is that they successfully make active kids a lot less annoying for the adults who have to manage them. I know from personal experience (two of my three kids) how annoying that behavior can be, but that’s who these kids are, and the comment about changing environment vs. changing the kid quoted in the article really describes the direction we need to go.

      —- Steve

  7. I noticed that the savant regarded ADHD as a distinct diagnostic entity and not a syndrome, elements of which can be easily treatable, such as subclinical lead poisoning, which is diagnosed by hair mineral testing, or a d-pen challenge test and treated with chelating agents instead of stimulant drugs. There are also behavior-altering effects due to various dietary insults, which are also not treatable with stimulant drugs.

  8. “Connection is central to our humanity. It regulates our physiology and protects against the harmful effects of stress. Its absence, the profound aloneness that accompanies difficulty in communicating with others, is the common factor underlying all forms of mental distress.”

    Brilliant! The “aloneness” that comes to my mind is sensitively documented in the novel Steppenwolf.
    “I am in truth the Steppenwolf that I often call myself; that beast astray that finds neither home nor joy nor nourishment in a world that is strange and incomprehensible to him.” Hermann Hesse

  9. We don’t fail people through non, or a lack of, communication. We fail people through communication with people, in the same fashion in which we succeed people. We fail people with words. We have a number of words for this failing. Four of those words we use for failing human beings are attention hyperactive deficit disorder. There is also a variation for this failure made that involves the use of three of the words without the hyperactivity, but hyperactivity is mostly problematic when it comes with those who should be seen and not heard (i.e. children) or the adult variety of such (i.e. mental cases). It is apparently very important for us to fail people (the obverse of succeeding them.)

    Some people succeed pretty well at failing. Other people happen to succeed despite their being failed at one time or another, depending on how you define failure. We make a great deal out of our success stories, such as the story of the 40 billion dollar, now 80 billion dollar, man. An 80 billion dollar success story requires a multi-volume unwritten library of failure stories. You need much disability in order to finance such a great ability in other words. It is a failure system that doesn’t make a great deal of legitimate sense with all the official legitimacy there is to it.

    No, ADHD is not a disease. ADHD didn’t officially exist before 1980. ADHD is a drug company marketing ploy. Etc.

  10. ADHD is a made up, trumped up label that was created to benefit psychiatry and the drug companies. It is not real. Do some children have issues with the demands placed upon them by parents, schools, and society in general. Absolutely. But this does not make them ill and it doesn’t legitimate this created epidemic. I think that the person quoted at the beginning of this article is absolutely correct, since we refuse to modify the environment we will modify the poor kid. And we choose to do this by giving them meth, legal meth but meth none the same. This is absurd.

  11. sometimes suffering gets to be too much and drugs can help, for a season. I’m not big on long term drugs or horrible predictions of permanent disability and such, but I’m not anti-drugs, either.

    If a kid is suffering immensely and a pill helps for a while, OK. Stimulants aren’t ideal, but they’re better than,say, neuroleptics. Rx the pills and work on the problems. Oh wait…in the US, the problem isn’t just the family, the school, the community; the problem, for many kids (and adults) is a thoroughly messed up society.

    I think Mental Health, Inc., especially psychiatry, are well-funded because its easier to drug kids and grown ups than it is to take a look at what’s going wrong in 21st century American society and do something about it. ADHD isn’t a brain disease or neurological issue , but treating it as one lets families, schools, communities, and society off the hook and gives the Medical Establishment more power to (re)define “healthy” and “sick” and “treat” the rest of us accordingly.

    So…I guess I”m saying that personal-level and family-level observations, analyses, insights, changes, etc. are valuable and can be quite helpful, but I also think we should remember that “the personal is political” and do what we can to act accordingly.

  12. The author gives too much credit to Freud. Freud learned “both that symptoms have unconscious meaning and that emotional suffering often has origins in early childhood” from his studies with Charcot and Janet in Paris.

    A consummate opportunist, Freud claimed originality for much of what was described by those who came before him. This same opportunism caused Freud to declare that his patients’ stories of childhood sexual abuse were fabrications. For that alone, he deserves our condemnaiton, not our respect. http://www.susanrosenthal.com/articles/health-and-medicine/whats-wrong-with-sigmund-freud

  13. Yes, ADHD does exist, but it is not a disease or disorder. Ask any parent, Teacher or Clinician that deals with children diagnosed with ADHD, and they will tell you that something is wrong with their behavior. Years of research and millions of dollars expended to discover any empirical evidence that would qualify ADHD as a disease or disorder, and none has been found. Kids diagnosed with DSM 5 criteria for ADHD are perfectly normal kids, both physically and mentally….why….take away the DSM 5 behavior, and what you have left is a good kid. These kids are dancing to a different drummer. Any researcher out there, that has an interested in the drummer; we need to talk.

  14. Claudia, whether you believe that ADHD exists or not, you are still looking at it, and at the child who is considered to have it, as a problem to be solved, or as a disease to be cured.

    If you see that a child “has it”, and you believe that it is environmental, then this is why we have mandatory reporting laws. Doctors in public practice usually follow it. Those in private practice seem not to, as the understanding is that they can be hired by the parents to do their fixing job.

    Rather than looking at ADHD cases as a disease to be cured or a problem to be solved, rather how about as a child that needs to be Vindicated instead of being further Victimized by its parents, school teachers, and more doctors.

    I think we should set up a toll free phone number for juveniles who feel they are being Medically Exploited. And what we will do first is coach them in how to tell off doctors.

    Nomadic

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