French and American Approaches to “ADHD”

Things have been changing fast here in France since David Cohen (20I3) and Conrad and Bergey (2014) looked at French approaches to ADHD treatment. It now looks as if the U.S. approach to mental health is fast gaining purchase in a country that formerly boasted a great, perhaps too sophisticated (Lacan et al.) psychoanalytic tradition, but also a holistic psychosocial tradition when dealing with psychological disturbance in children.

As Conrad and Bergey put it, U.S. behavioural norms are now being exported worldwide, crushing interventions that would be far more meaningful in a very different culture like France, where a multi-factorial perspective was predominant. The fact that Ciba-Geigy let its Ritalin licence lapse in 1985 because of low sales spoke volumes about the French approach to psychological distress and the general French opposition to drugging children. What is particularly interesting here is that France, a major pill-popping nation, has been traditionally loth to drug her children. Or used to be. Things are changing rapidly here, something not noticed by Conrad and Bergey in 2014 when they examined the current French treatment of paediatric ADHD. Before detailing this change, it is worth casting a comparative glance at the standard American and French approaches to ADHD symptoms and treatment.

The first thing that strikes one is just how philosophically bereft is Anglo-American biomedical psychiatry (BMP), which assumes, mirabile dictu, that biology is the sole determinant of growth and behaviour; that a small child lives in a vacuum, emerging into daylight through a virgin birth, then remaining unaffected by little matters like poverty, inequality, neglect, inadequate nourishment, abuse, loss and separation. Most American child psychiatrists consider ADHD to be mono-causal, a biological disorder with a biological cause within the child’s brain, requiring a biological treatment, preferably with stimulants such as Ritalin and Adderall — thus obviating the need for creative thinking, reflection on context and the exploration of other possible aetiologies.

It would probably amaze such psychiatrists to learn that “ADHD,” far from being a solid, universally accepted category of “neuro-developmental” biological disorder, has not traditionally been so in France, where psychiatrists chose to explore the child’s underlying psycho-social context, treating attention and hyperactivity problems in a holistic, now old-fashioned bio-social-psychological way — with psychotherapy or family counselling. Instead of treating children’s behavioural problems with drugs, French psychiatrists preferred to assume or look for the underlying issues causing the child distress not in the child’s brain, but in the child’s social context. This is a very different way of seeing things from that of American clinicians, who tend to automatically attribute all symptoms to a biological deficit or dysfunction in the child’s brain.

It may be fanciful to suggest it, but the strong presence of philosophy (and not biomedical psychiatry!) in French secondary schools could well be an important factor contributing to the holistic, sophisticated and multi-factorial approach of traditional psychiatry here. I am continually astonished at the complete absence of reflection in Anglo-American biomedical psychiatric research, even at the top: the intellectual impoverishment of studies like Lancet Psychiatry’s recent meretricious ADHD “mega-analysis” or the Paxil Study 329 would shock most French professionals.

Biomedical psychiatry is a thought-free zone, desperately in need of philosophically-minded practitioners who might ask the big questions, seeing through flimflam and circular thinking. Studies like these give easy cannon fodder to the real scientists and philosophers who scorn what passes for research in psychiatry. En passant, I often wonder why we have no official philosophers of medicine or psychiatry. Since psychiatric training itself almost guarantees simple pharmacological solutions to complex existential problems, would any radical, interdisciplinary overhaul here bring the very foundations of BMP crashing to the ground? Or are so many billions at stake here, as in the Wyeth vaccination trial, that the truth might scupper the Big Pharma bonanza, or even cause a recession? (In France, Coluche used to say that we never see the truth on TV because too many people are watching!)

As we know, the MIA forum and the UK Critical Psychiatry Network has many highly thoughtful, radical and philosophically-minded writers, but we need a lot more people versed in other disciplines, like Pat Bracken, David Cohen, James Davies, Jo Moncrieff, Phil Thomas, Sami Timimi, Manuel Vallée and Ben Goldacre, with his powerful media presence and formal philosophical training. Let’s hope that the Philosophy of Medicine & Psychiatry M.A. at KC London and Cambridge’s philosophy of psychiatry conference, to which some of us contributed last year, are harbingers of good things to come on this front.

French Classification of Mental Illnesses

Traditionally, French child psychiatrists were not shackled by the hyper-consumerist, anti-philosophical culture that spawned the pseudoscientific, mindless rigidity of the DSM and built a whole insurance and treatment system around it: they use the CFTMEA (Classification Française des Troubles Mentaux de L’Enfant et de L’Adolescent), first released in 1983, and updated in 1988 and 2000. According to sociologist Manuel Vallée of U. Auckland, the French Psychiatric Federation developed this alternative, more child-focused classification system as an act of resistance against the influence of the DSM-III in 1980!

Unlike the DSM, the CFTMEA concentrates on identifying and addressing the underlying psycho-social causes of children’s symptoms, not on finding the “best” — ie. the most coercive and profitable — pharmacological ways to ignore and silence symptoms. The upshot of all this was that until recently relatively few French children “qualified” for the ADHD diagnosis, whose definition was tight and rigorous, not beholden to PR and the research of corrupt but eminent medics like Joe Biederman. French clinicians did not rush to pathologize normal childhood activity and exuberant, impulsive behaviour. Back at the American ranch, however, in 1994, DSM-IV, not caring a fig for underlying causes, gave clinicians permission to whip out their prescription pads at the drop of a hat, leading to an exponential increase in ADHD diagnoses and stimulant prescription over the next twenty years.

That was then: now, however, things are changing so fast here, in the direction of a purely biological child psychiatry, that the French psychiatric watchdog, La Commission des Citoyens pour les Droits de l’Homme (CCDH), has called the prescribing of Ritalin to hundreds of thousands French schoolchildren a tragedy likely to unleash a new public health scandal. What troubles its leaders is that the official French body, La Haute Autorité de Santé (HAS), publishes good practice recommendations for GPs and medical personnel that are, like those of the NIMH, straight out of a biomedical, Big Pharma doxology, thus enabling the massive (70-80%) increase in French Ritalin prescriptions over the last eight years or so.

The French Prevalence of ADHD

It is extremely hard to get a firm purchase on the prevalence of ADHD in France, for, as I have discussed elsewhere, reliability scores for psychiatric “illnesses” are notoriously poor, few more so than for ADHD. In the year 2000, Scahill and Schwab-Stone found an alarming variability in the prevalence of “ADHD,” from 2% to 17%, suggesting that the dramatic differences in these estimates may have been due to the choice of informant, of sampling or data collection methods, but most probably to its ultra-loose definition. More recently, HAS reckons the French prevalence to be between 4% and 6%, about half the American rate, but other French studies tell a different story — one that underscores even more dramatically the highly subjective character of any ADHD diagnosis.

The prestigious, independent research institute, INSERM, found in 2002 that French rates of ADHD diagnosis ranged from 0.4% to 16% of the child and adolescent populations. In other words, for some professional researchers four children per thousand “have” ADHD, whereas for others, the incidence is 40 times this figure — 160 per 1000! Now what credibility would we put, say, in the diagnosis of diabetes if a major research institute like INSERM came up with such variability in the diagnosis? Wouldn’t we conclude either that it couldn’t do simple arithmetic, or that the diagnosis itself was as fuzzy as Donald Trump?

Risks

In America, the risk assessment and regulation of psychotropic drugs has been lax in the extreme, not to say shameful, but even the FDA, a highly compromised establishment organization, did finally issue its own Black Label warning about the multiple risks of methylphenidate ingestion — from drug abuse, psychotic episodes, aggressivity, suicide, to cardiac problems and growth hormone damage — though this seems to have had little effect on prescribing practices and consumer demand. In contrast, French law has taken these risks seriously, restricting initial Ritalin prescription rights to specialists in neurology, psychiatry and paediatrics.

Recent evidence now suggests, however, that France, too, is now sliding down the American slope, according to L’Agence Française de Sécurité du Médicament, which claims that this law is being routinely flouted, since more than 10% of prescriptions are now being illegally written by GPs. The paradigm shift in French psychiatry becomes even more evident when we learn that these doctors are not penalized by the health authorities and official public bodies, but are openly encouraged by the HAS to prescribe for a “disorder” whose very existence is more than doubtful.

French psychiatrists traditionally viewed medication as a last resort when it comes to their children, privileging a whole range of other potential aetiologies for ADHD-type symptoms, like psychosocial context, sleep disturbance and nutrition — sensible enough in a global culture overwhelmed by communications technology, information overload and junk-food rife with artificial colours, sugar, dangerous additives, preservatives and allergens. There are, after all, cases in which dietary interventions can eliminate a child’s “ADHD-type” symptoms overnight!

Structure and Discipline

French children are generally better-behaved than their American counterparts, according to Pamela Druckerman, whose book, Bringing Up Bébé, based on her lived experience in both countries, highlights their very different parenting styles. This is undoubtedly because in French culture the idea of structure and discipline is very important, especially after 1789, and while this can be used by centralizing reactionary forces to crush difference and minorities, it is crucial to the safe parenting of young children.

In French schools and homes there are strict meal times with limited random snacking, so kids have no automatic right to sugared foods and drinks on demand: aggressive, consumerist individualism is not encouraged! French parents run the show, supported by a culture which valorizes discipline far more than Americans do, especially in child rearing. For them, as for Peter Breggin, unconditional love, allied to consistency and clear, enforced limits, make children feel safe, secure and confident — in Winnicottian terms, well held — so that they can more easily separate, achieve autonomy and discover their own creativity. (The 2011 doctoral thesis of Evelyne Simon-Pezeshknia at U. Nancy is an invaluable source of comparative information and reflection on how ADHD is, or rather was, seen and treated in French and Anglo-Saxon psychiatry up to 2009.)

After Winnicott, Bowlby, Siegel, Schore et al. we should all be sharply aware that secure attachment will do far more to help kids achieve physical and emotional self-regulation than any drug. Indeed, I believe that early trauma and attachment deficits play a preponderant role in addiction and in much emotional disturbance, aka “psychiatric disorders,” particularly in ADHD. Any good modern therapist working with children, like the attachment adepts, knows that discipline, limits and unconditional love, not medication, are what children really need, not drugs. When we look at the classic French way of approaching ADHD, we can appreciate the benefits of bringing a minimal level of reflection and holistic, systems thinking into psychiatric practice, but can only lament its gradual erosion.